Endoscopic signs of duodenal ulceration

Acute ulcers of the duodenum. They usually develop secondarily, with the necrotic process affecting the mucous membrane and submucous layer. They are clinically manifested mainly with complications. Of the complications, bleeding is most common - in 10-30% of cases. Endoscopy gives a positive result in 98%. It should be performed on all patients with a risk of developing an acute ulcer.

Acute ulcers can be in any part of the duodenum, but most often in the bulb. They can be single or multiple. Often there is a combination - both in the stomach and in the duodenum. Isolated lesions in the duodenum are 5 times less common than in the stomach.

Endoscopic picture of acute duodenal ulcer.The ulcers are small - up to 1.0 cm, round in shape, but can merge and take on irregular outlines. The bottom is shallow, smooth, without granulation, covered with fibrin or hemorrhagic plaque. The edges are sharp, even, soft, clearly defined, hyperemic, with petechiae. Edema and hyperemia are not pronounced. There is no convergence of folds. Biopsy shows pronounced bleeding.

Stages of the course of acute ulcers of the duodenum.

1. Hyperemia and hemorrhages in the mucous membrane (first hours, several days).
2. Superficial erosions.
3. Formation of one or more ulcers.
4. Bleeding from an ulcer.

Acute ulcers are characterized by the prevalence of necrobiotic processes over inflammatory ones. They heal quickly - within 2-4 weeks with the formation of a delicate epithelialized scar, which becomes invisible as the process subsides.

Chronic ulcers of the duodenum. Chronic ulcers of the duodenum are a local manifestation of peptic ulcer disease. They affect the muscular, submucous and mucous layers. Most often they are localized in the bulb, within 3 cm from the place where the pyloric canal of the stomach passes into the duodenum. They mainly develop in working age. Compared to gastric ulcers, they form faster. They are more often located on the anterior wall - in 60%. Extrabulbar ulcers occur in 2-7% of cases and are localized mainly in the area of the upper flexure of the duodenum or in the upper third of the descending branch. Multiple ulcers occur in 5-25% of cases.

Stages of development of chronic duodenal ulcer.

1. Acute stage.
2. The stage of incipient healing.
3. Stage of complete healing (scar stage).

Acute stage.A mucous defect of a round or oval shape. In case of recurrent exacerbation, it is often irregular in shape - linear, polygonal, etc. The ulcer bottom is shallow, covered with a white or yellow fibrin coating. The edges are edematous, uneven, with granular protrusions, bleed easily. The sizes are usually within the range of 0.3 to 1.0 cm. The mucous membrane around the ulcer is hyperemic, edematous, easily injured. Convergence of folds is characteristic. Inflammatory changes can be limited to one zone, several zones and capture the entire bulb.

The stage of incipient healing. Similar to the stage of the inflammatory process subsiding. The ulcer size decreases. It may retain its shape, or it may become linear, polygonal or slit-like. Its edges become flatter, smoother, less edematous, the ulcer seems to flatten, the bottom is cleared of plaque. Epithelialization occurs from the edges or from the bottom. After epithelialization, a red spot remains at the site of the ulcer, duodenitis symptoms subside, erosions may remain.

Stage of complete healing.A bright red linear or star-shaped scar with convergence of folds and a zone of moderate hyperemia is formed at the site of the former ulcer - a fresh scar. After 2-3 months, the scar becomes whitish, there are no inflammatory phenomena, convergence of folds and deformation are reduced. Ulcers heal on average from 4 to 12 weeks. A favorable morphological sign is the restoration of the villous epithelium at the site of the white former ulcerative defect of the intestine or epithelialization of the scar. If a non-epithelialized fibrous scar is formed and inflammatory changes persist - an unfavorable sign - the ulcer can reopen in 4-6 months.

Giant ulcers of the duodenum.Ulcers larger than 2 or 3 cm are considered giant, according to different authors. They are found mainly in older people, mainly on the back wall.

There are 2 types of giant duodenal ulcers.

• Type I. With a deep niche of large size, resembling a diverticulum.
• Type II. The ulcer bottom is the pancreas due to penetration. The wall of the duodenum is absent here. There may be massive bleeding.

In both types, cicatricial changes are expressed up to stenosis of the duodenum. The duration of the course and frequent relapses are characteristic. Giant ulcers are subject to surgical treatment.

Complications of peptic ulcer disease.

1. Bleeding - 12-34% of patients.
2. Penetration and perforation - 5-10%.
3. Pyloric stenosis - in 10-40% of patients with a long-term course of the disease.

In the acute stage, ulcers located in the proximal parts of the bulb and in the pylorus area can cause obstruction. When the inflammation subsides, the passage is restored. In case of relapses, when fibrous changes occur, true pylorus stenosis develops.

Among patients with ulcers, it occurs in 1% of cases, and in 10% of cases with a long course. It was first described in 1955. It is characterized by tumor growth of the insular zone of the pancreas. The tumor produces mainly gastrin - gastrinoma. It is a round formation, usually small in size - 0.3-0.5 cm, located in the tissue of the pancreas, but can be located in the submucosal layer of the wall of the stomach and duodenum. Morphologically, the tumor is similar to carcinoid. Benign course in 30-40% of cases, malignant - in 60%.

Clinically manifests as an intractable ulcer located in the distal part of the bulb or in the postbulbar part, combined with high production of hydrochloric acid. Ulcers can be in the stomach, duodenum, esophagus, small intestine. They can develop rapidly, but more often they exist for years.

Endoscopic picture. There is a large amount of fluid in the stomach, its folds are hypertrophied, atony of the stomach is noted. Ulcer defects are often multiple, large in size with a deep bottom, surrounded by a large inflammatory shaft.

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