Gastric Ulcers

Causes

• Stress

• Burns=Curling ulcer

• Cerebral disease=Cushing ulcer

• Uremia

• Steroid therapy

• Hyperparathyroidism (25% have ulcer disease)

Other facts

• Multiple in 2-8%

• Coexistent duodenal ulcer disease in 5-42%; duodenal:gastric ratio=3:1

• Multiple postbulbar duodenal ulcers should suggest Zollinger-Ellison

Location

• Lesser curvature aspect of body and antrum usually for benign ulcers

• Benign ulcers also occur on posterior wall; not usually anterior wall

• May be found in proximal half of stomach in geriatric patient

• Almost all lesser curvature gastric ulcers <1cm are benign

• Greater curvature benign ulcers are associated with considerable mass effect which erroneously leads to conclusion of malignancy

Two prerequisites for diagnosis of an ulcer:

l Collection

l Persistent

X-Ray Signs of a benign gastric ulcer

• Ulcer crater-collection of barium on dependent surface which usually projects beyond anticipated wall of stomach in profile (penetration)

• Hampton’s line-1 mm thin straight line at neck of ulcer in profile view which represents the thin rim of undermined gastric mucosa

• Ulcer collar-smooth, thick, lucent band at neck of ulcer in profile view representing thicker rim of edematous gastric wall

• Ulcer mound-smooth, sharply delineated tissue mass surrounding a benign ulcer

• Ring shadow-thin rim of contrast which represents an ulcer on the non-dependent surface of an air-contrast study

• Thickened folds radiating directly to the base of the ulcer en face

Healing

• Most gastric ulcers clear completely in 6-8 weeks.

• With healing, ulcer decreases in size and is more likely to appear linear

• Radiating folds become more prominent and extend to crater

• Between 50-90% of healed gastric ulcers produce visible scars on Double Contrast study

X-ray signs of malignant ulcers

• Ulcer projects within the anticipated wall of the stomach

• Ulcer is eccentrically located within the ulcer mound

• Irregularly shaped ulcer crater

• Nodular ulcer mound

• Abrupt transition between normal and abnormal mucosa several cms away from the ulcer crater

• Rigidity, lack of distensibility and lack of changeability

• Associated large mass

• Carmen meniscus sign-a relatively shallow gastric ulcerating malignancy projecting as an ulcer which is always convex inwards to the lumen and which does not project beyond the wall=Kirklin meniscus complex

Complications of ulcer disease

l Bleeding is slightly more common in the duodenum than the stomach

• About 17% of all ulcers are complicated by bleeding

• A filling defect in the ulcer crater may represent a blood clot

l Gastric outlet obstruction is less common than bleeding (5%)

• Stomach may have to be suctioned to get good study

• Benign ulcer disease at pylorus is a more likely to cause gastric outlet obstruction than ca

l Perforation in 5-11% is more common in duodenal than gastric ulcers

• Most gastric perforations are from lesser curve ulcers

• Free air is not detected by x-ray in 25-35% of perforated duodenal ulcers

l Penetration is the extension of the ulcer beyond the serosa in to adjacent structures

• Pancreas is most common site, but also biliary tree, colon