Endoscopic signs of a stomach ulcer

An ulcer is a limited defect in the wall of the stomach that seizes the mucous membrane and some other layers (submucosal, muscular, sometimes serous).

With endoscopy of the stomach, it is necessary to determine the localization, quantity, shape, size, stage of development.

[1], [2], [3], [4], [5]

Acute Stomach Ulcer

More often multiple (60%). Appear more often against a background of superficial and hypertrophic gastritis. Usually small sizes (0.5-1.0 cm in diameter), the edges are even, smooth, the bottom is shallow, often with a hemorrhagic coating. Acute ulcers epithelize within 2-4 weeks with the formation of a tender scar and are not accompanied by deformation of the stomach. Localization: a small curvature and a posterior wall of the middle third of the body of the stomach and in the region of the angle of the stomach. Acute ulcers of the stomach can be flat and deep, the shape is more often rounded, less often polygonal (fusion of several ulcers).

[6], [7], [8]

Flat acute gastric ulcer

Diameter from 0.5 to 2.0 cm, often about 1.0 cm. Round shape, the edges are low, even, clearly defined, around a bright red rim. The bottom is covered with hemorrhagic plaque or fibrin plaque, which can be from whitish-yellow to dark-brown in color. Mucous around the ulcer is moderately edematous, slightly hyperemic, it is often eroded, with instrumental palpation soft, increased contact bleeding.

[9], [10], [11], [12], [13]

Deep acute ulcer of stomach

It looks like a cone-shaped defect more often from 1.0 to 2.0 cm in diameter. The raised edges of the ulcer are well pronounced. The bottom is covered with a brown coating or a clot of blood.

Biopsy: a zone of necrotic tissue with periulcerous leukocyte infiltration, a change in blood vessels (expansion, stasis), leukocyte impregnation, fibrinous plaque in the edges and bottom, unlike chronic ulcers, there is no proliferation of connective tissue, there is no structural rearrangement with metaplasia of the mucosa and atrophy of glands.

[14], [15], [16], [17]

Ulceration of Djelafua

Refers to acute ulcers. It is rare and accompanied by massive bleeding from the arteries. Localized in the arch of the stomach with the transition to the body along the large curvature of the upper third of the body of the stomach. Never occurs on a small curvature and in the pyloric section (areas of preferential localization of a chronic ulcer). Massive bleeding from the ulcer is due to the peculiarities of its localization. In parallel with the small and large curvature of the stomach, at a distance of 3-4 cm from them there is a zone 1-2 cm wide, where the primary branches of the gastric arteries pass, without separating, through their own muscular membrane into the submucosal layer. There they bend in the form of an arc and form a plexus, from which the vessels that feed the muscle layers retrograde. This zone is called Voth (1962) "vascular Achilles heel of the stomach". With the formation of acute ulcers in this zone, an artery of a large arterial vessel may occur and massive bleeding may occur. If acute ulceration is detected in this area with bleeding, an emergency operation is indicated. Conservative treatment is futile.

Chronic Stomach Ulcer

Depends on localization, healing stage, frequency of exacerbation. Localization: more often with a small curvature (50%), in the angle of the stomach (34%), in the pyloric zone. On a large curvature it is rare - 0,1-0,2%. Most often single (70-80%), rarely - multiple. Diameter from 0,5 to 4,0 cm, but can be even more - up to 10 cm. Large ulcers are located on the small curvature and back wall.

[18], [19], [20], [21]

Acute stage of stomach ulcer

The ulcer is of rounded shape, the edges are high, clearly outlined, the slopes of the ulcer crater are cut off. The mucous membrane is edematous, hyperemic and around the ulcer looks like a raised shaft, which is clearly delimited from the surrounding mucosa and rises above it. The bottom can be smooth or uneven, clean or covered with a fibrin coating from yellow to dark brown. Uneven bottom occurs with deep ulcers. The proximal edge of the ulcer is most often dug, and the distal, facing the gatekeeper, is flattened, terrazoobrazny (food leads to a mechanical shift of the mucous membrane). If the edema of the gastric mucosa is severe, the ulcer inlet may be closed. In this case, the convergent folds of the mucous membrane indicate the place of the ulcer. The depth of the ulcer depends on the inflammatory shaft and the mucus edema around the ulcer. With severe swelling, the ulcer looks deeper. Sometimes, under the proximal margin, stagnation of food is formed, food decomposes, which leads to the fact that part of the ulcer becomes deeper.

When the inflammation subsides, the hyperemia decreases, the shaft flatens, the ulcer becomes less deep, granulation appears on the bottom, the ulcer becomes oval or slit. Ulcer can be divided into several. It is characteristic that there are converging folds that go towards the ulcer. Healing is often accompanied by the rejection of fibrinous plaque, at the same time granulation tissue is formed and the ulcer acquires a characteristic form - "pepper-salt" ulcer (red-white). Folds).

With the healing of the ulcerative defect, first the inflammatory changes in the mucosa near the ulcer disappear, and then the ulcer itself heals. This is used to determine the prognosis: when the inflammatory phenomena around the ulcer disappear, it shows that it is in the process of healing. Conversely, if gastritis has not disappeared, the probability of curing ulcers is negligible and one can expect an exacerbation.

[22], [23]

Staggered cicatrix

More often healing of ulcers is accompanied by the formation of a linear scar, rarely - a scar of a star. They look like gentle, shiny, pink, drawn into the mucous membrane. Fresh hyperemic ulcerous scar - stage of immature red scar - recurs more often. When the granulation tissue is replaced by a fibrous connective scar, it becomes whitish - the stage of a mature white scar. There is a convergence of folds of the mucous membrane towards the rumen. Rarely, healing of a chronic ulcer is not accompanied by deformation of the gastric mucosa. Usually scarring leads to a pronounced disturbance of the relief: deformities, scars, narrowing. Rough deformations are the result of frequent exacerbations.

Through the stage of the linear scar, perpendicular to the small curvature. Separation of ulcers into kissing. Healing through a linear scar, parallel to a small curvature (usually giant ulcers).

Callous ulcer of the stomach

Long-lasting non-healing ulcers become callous. This diagnosis can be made only with prolonged follow-up. The edges are high, rigid, dug, as if omozolelnye, the bottom is uneven, hilly, with necrotic plaque. Mucous tuberous, infiltrated, more often localized on a small curvature. The larger the diameter, the more likely its malignancy. A biopsy should be performed. At the first examination, the diagnosis is not made. If the ulcer does not heal within 3 months - a diagnosis is made and a biopsy is taken.

[24], [25], [26], [27]

Stomach ulcers of the stomach

Appear against a background of atrophic gastritis. More often on the back of the middle third of the body of the stomach. Single. Flat. Inflammatory changes are weak. Under the influence of therapy, they quickly heal and in a short time appear there.

Perforated ulcer

Perforation occurs more often during exacerbation. Often, it is preceded by physical stress, neuro-psychic overstrain, etc. You can see sheer whitish edges, a hole without a bottom. The ulcer is limited by the stiff callous edges, has the form of a cylinder or a truncated cone, turned into the lumen of the stomach. Often filled with slices of food or necrotic plaque.

Penetrating ulcer

It is an ulcer that spreads beyond the walls of the stomach into surrounding organs and tissues.

There are three stages of the flow of the penetrating ulcer:

1. Penetration of the ulcer (necrosis) through all layers of the stomach wall.
2. Fibrinous fusion with the adjacent organ.
3. Completed perforation and penetration into the tissue of the adjacent organ.

The gastric ulcer penetrates into the small omentum and body of the pancreas. They have a rounded, rarely polygonal shape, deep, the crater is steep, the edges are high, in the form of a shaft, clearly delimited from the surrounding mucosa. Dimensions from 0.5 to 1.0 cm. On the walls and in the depths of ulcers a dirty-gray plaque.

Syphilitic ulcer

Pain syndrome is less pronounced. Often accompanied by gastric bleeding. The secretion is reduced right up to acholia. A fresh ulcer formed from gummas is distinguished by a great penetration into the submucosal layer, edging of the edges and thickening of them. The bottom is covered with a dirty yellow, jelly-like coating, along the periphery, there are gums separating the ulcer from normal mucosa. A lot of them. With a long course, the edges are grossly thickened, sclerosed, the bottom is cleaned, in this period the syphilitic ulcer is difficult to distinguish from callous. In soskobe - pale spirochaeta.

Tuberculosis ulcer

It is rare. There are always other signs of tuberculosis. Dimensions up to 3.0 cm. 2-3 ulcers are located one after another. Stomach badly spreads the air. Peristalsis sluggish or absent. Edges in the form of laces from the center to the periphery. The bottom is covered with a dull, dirty yellow coating.

Giant Stomach Ulcers

There is no consensus about what a giant ulcer is, no: from 7 to 12 cm or more. Localize mainly in large curvature. The tendency to malignancy is great. An ulcer more than 2 cm is malignant in 10% of cases, more than 4 cm - up to 62%. Differential diagnosis is performed with cancer. Mortality rate is 18-42%. Bleeding in 40% of cases. Treatment is surgical.