Endoscopic signs of gastric ulcers

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

During gastric endoscopy it is necessary to determine the location, quantity, shape, size, and stage of development.

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Acute gastric ulcer

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

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Flat acute gastric ulcer

The diameter is from 0.5 to 2.0 cm, usually about 1.0 cm. Rounded, the edges are low, smooth, clearly defined, around a bright red rim. The bottom is covered with a hemorrhagic coating or fibrin coating, which can be from whitish-yellow to dark brown. The mucous membrane around the ulcer is moderately edematous, slightly hyperemic, it often has erosions, soft on instrumental palpation, contact bleeding is increased.

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Deep acute gastric ulcer

It looks like a cone-shaped defect, usually 1.0 to 2.0 cm in diameter. The raised edges of the ulcer are clearly visible. The bottom is covered with a brown coating or a blood clot.

Biopsy: zone of necrotic tissue with periulcerous leukocyte infiltration, vascular changes (dilation, stasis), leukocyte impregnation, fibrinous plaque at the edges and bottom, unlike a chronic ulcer, there is no proliferation of connective tissue, no structural reorganization with mucosal metaplasia and glandular atrophy.

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Dieulafoy's ulceration

Refers to acute ulcers. Rarely encountered and accompanied by massive bleeding from the arteries. Localized in the vault of the stomach with a transition to the body along the greater curvature of the upper third of the body of the stomach. Never occurs on the lesser curvature and in the pyloric section (areas of predominant localization of chronic ulcers). Massive bleeding from the ulcer is due to the peculiarities of its localization. Parallel to the lesser and greater curvatures 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 dividing, 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 muscular layers depart retrogradely. This zone was called by Voth (1962) "the vascular Achilles heel of the stomach." When acute ulcers form in this zone, erosion of a large arterial vessel can occur and massive bleeding can occur. If acute ulceration with bleeding is detected in this area, emergency surgery is indicated. Conservative treatment is futile.

Chronic gastric ulcer

Depends on the localization, stage of healing, frequency of exacerbation. Localization: more often along the lesser curvature (50%), in the angle of the stomach (34%), in the pyloric zone. Rarely along the greater curvature - 0.1-0.2%. More often single (70-80%), less often - multiple. Diameter from 0.5 to 4.0 cm, but can be larger - up to 10 cm. Large ulcers are located on the lesser curvature and the posterior wall.

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Acute stage of gastric ulcer

The ulcer is round, the edges are high, clearly defined, the slopes of the ulcer crater are broken off. The mucous membrane is edematous, hyperemic and around the ulcer has the appearance of a raised ridge, which is clearly delimited from the surrounding mucous membrane and rises above it. The bottom can be smooth or uneven, clean or covered with a fibrin coating from yellow to dark brown. The bottom is uneven in deep ulcers. The proximal edge of the ulcer is most often undermined, and the distal edge, facing the pylorus, is smoothed, terrace-like (food leads to mechanical displacement of the mucous membrane). With pronounced edema of the gastric mucosa, the entrance to the ulcer may be closed. In this case, converging folds of the mucous membrane indicate the site of the ulcer. The depth of the ulcer depends on the inflammatory ridge and edema of the mucous membrane around the ulcer. With pronounced edema, the ulcer appears deeper. Sometimes food stagnation forms under the proximal edge, the food decomposes, which leads to the fact that part of the ulcer seems to deepen.

As the inflammatory process subsides, hyperemia decreases, the shaft flattens, the ulcer becomes less deep, granulations appear at the bottom, the ulcer shape becomes oval or slit-like. The ulcer can be divided into several. The presence of converging folds running towards the ulcer is characteristic. Healing is often accompanied by the rejection of fibrinous plaque, while granulation tissue is formed and the ulcer acquires a characteristic appearance - a "pepper-salt" ulcer (red-white). (converging folds).

When an ulcer defect heals, the inflammatory changes in the mucous membrane around the ulcer first disappear, and then the ulcer itself heals. This is used to determine the prognosis: when the inflammatory changes around the ulcer disappear, it shows that it is in the process of healing. Conversely, if gastritis has not disappeared, the probability of healing the ulcer is insignificant and an exacerbation can be expected.

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Post-ulcer scar

Most often, ulcer healing is accompanied by the formation of a linear scar, less often - a stellate scar. They look like delicate, shiny, pink, drawn into the mucous membrane. A fresh hyperemic ulcerative scar - the stage of an immature red scar - recurs more often. When granulation tissue is replaced by fibrous connective tissue, the scar becomes whitish - the stage of a mature white scar. Convergence of the folds of the mucous membrane towards the scar is noted. Rarely, the healing of a chronic ulcer is not accompanied by deformation of the gastric mucosa. Usually, scarring leads to a pronounced disturbance of the relief: deformations, scars, narrowing. Gross deformations are the result of frequent exacerbations.

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

Callous ulcer of the stomach

Long-term non-healing ulcers become callous. This diagnosis can only be made after long-term observation. The edges are high, rigid, undermined, as if calloused, the bottom is uneven, bumpy, with necrotic plaque. The mucous membrane is bumpy, infiltrated, often localized on the lesser curvature. The larger the diameter, the more likely its malignancy. A biopsy is necessary. The diagnosis is not made at the first examination. If the ulcer does not heal within 3 months, a diagnosis is made and a biopsy is taken.

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Senile gastric ulcers

Occur against the background of atrophic gastritis. Most often on the back wall of the middle third of the stomach. Single. Flat. Inflammatory changes are weakly expressed. Under the influence of therapy, they heal quickly and after a short time appear in the same place.

Perforated ulcer

Perforation occurs more often during an exacerbation. It is often preceded by physical exertion, neuropsychic overstrain, etc. Steep whitish edges and a hole without a bottom are visible. The ulcer is limited by rigid callous edges, has the shape of a cylinder or a truncated cone facing the lumen of the stomach. It is often filled with pieces of food or necrotic plaque.

Penetrating ulcer

This is an ulcer that extends beyond the stomach wall into surrounding organs and tissues.

There are three stages in the course of a penetrating ulcer:

1. Penetration of the ulcer (necrosis) through all layers of the stomach wall.
2. Fibrinous adhesion to an adjacent organ.
3. Complete perforation and penetration into the tissue of the adjacent organ.

Gastric ulcers penetrate into the lesser omentum and the body of the pancreas. They are round, less often polygonal, deep, the crater is steep, the edges are high, in the form of a shaft, clearly delimited from the surrounding mucosa. Sizes from 0.5 to 1.0 cm. On the walls and in the depth of the ulcer there is a dirty gray coating.

Syphilitic ulcer

The pain syndrome is less pronounced. Often accompanied by gastric bleeding. Secretion is reduced to the point of acholica. A fresh ulcer formed from gummas is characterized by greater penetration into the submucosal layer, eroded edges and thickening. The bottom is covered with a dirty yellow, jelly-like coating, gummas are visible along the periphery, separating the ulcer from the normal mucosa. There are many of them. With a long course, the edges are roughly thickened, sclerosed, the bottom is cleared, in this period it is difficult to distinguish a syphilitic ulcer from a callous one. In the scraping - pale spirochete.

Tuberculous ulcer

Rarely encountered. Always present with other signs of tuberculosis. Size up to 3.0 cm. 2-3 ulcers located one after another. The stomach does not straighten with air well. Peristalsis is sluggish or absent. The edges are lace-like from the center to the periphery. The bottom is covered with a dull dirty yellow coating.

Giant stomach ulcers

There is no consensus on what ulcer is considered giant: from 7 to 12 cm and more. They are localized mainly along the greater curvature. The tendency to malignancy is high. An ulcer larger than 2 cm becomes malignant in 10% of cases, larger than 4 cm - up to 62%. Differential diagnosis is carried out with cancer. Mortality is 18-42%. Bleeding in 40% of cases. Treatment is surgical.