Cocaine or Benzoylmethylecgonine is an alkaloid extracted from the leaves of the Erythroxylon plant, which can cause gastrointestinal ischemia from severe arterial vasoconstriction via stimulation of alpha-adrenergic receptors in the gastric and mesenteric arteries. We report this case of a 65-year-old man who presented with a single massive ulcer at the incisura of the stomach as a result of cocaine use. The size and location of this ulcer were atypical and illustrate the potential for serious gastrointestinal manifestations from cocaine use. 1. Introduction Recent estimates suggest that cocaine use is still rampant with almost 1.9% of population of North America indulging in it, the rate being highest in the world [1]. Cocaine is predominantly available in two forms: cocaine hydrochloride salt which is water soluble and can be injected intravenously and a water insoluble cocaine alkaloid, popularly known as crack cocaine [2, 3]. Cocaine has a very short plasma half-life (0.5 to 1.5 hours) but extended tissue half-life of up to 8 hours [2]. Cocaine has multisystem manifestation with well-recognized gastrointestinal manifestations ranging from gastroduodenal ulceration with perforation [4–8] to intestinal infarction with perforation [9]. Cocaine-associated gastroduodenal ulcers are frequently distributed in the greater curvature, prepyloric and pyloric canal regions of the stomach along with the first portion of the duodenum. We intend to report a rare instance of a cocaine-induced giant ulcer at the gastric incisura. 2. Case Report A 65-year-old African American man presented to the hospital with complaints of epigastric abdominal pain and melena of 3-day duration. The patient also reported progressively worsening fatigue over the preceding three months. His medical comorbidities included essential hypertension and gastroesophageal reflux disease. The patient reported no nonsteroidal anti-inflammatory drugs (NSAIDs) use. The patient admitted chronic heavy smoking for almost 50 years and using cocaine until the day before the presentation. Physical examination revealed a hemodynamically stable, cachectic man with minimal epigastric tenderness and melena upon digital rectal examination. Initial set of laboratory studies showed severe anemia (Hemoglobin of 5.6？g/dL). Patient received multiple packed red blood cell (PRBC) transfusions with appropriate improvement in Hemoglobin. He underwent an esophagogastroduodenoscopy (EGD) that revealed a single large 4？cm deep cratered gastric ulcer at the incisura. The base of the ulcer was partly necrotic with eschar
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