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Gastroscopy in the diagnosis of gastric disease
GASTROSCOPY IN THE DIAGNOSIS OF GASTRIC DISEASE HERMAN J. MOERSCH, M.D. AND ALBERT M.
SNELL, M.D.
Division of Medicine, The Mayo Chic ROCHESTER,
MINNESOTA
OR many years there has been a constant effort on the part of the medical profession to deveIop instruments by which the various hoIIow organs of the body couId be directIy visuahzed. Such efforts have been we11 rewarded since the deveIopment of such methods has aIways been associated with an increased knowledge of the function of the organ concerned and the pathoIogic changes which may be present. WhiIe the interior of the stomach was one of the first portions of the body to be examined by direct visualization, the procedure was a very formidabIe one and did not come into genera1 favor because of mechanica and optica di&uIties. Interest in the probIem Iagged, for obvious reasons, after the deveIopment of the Roentgen rays as an eficient diagnostic agent. KussmauI,l in 1868, probabIy made the first attempt at direct visuaIization of the interior of the stomach; he used a sword swaIIower as his subject, with indifferent success. MikuIicz2 is credited with having performed the first satisfactory gastroscopy, in I 881. Although he was successfu1 in his effort, he apparentIy reahzed the dangers and shortcomings of his instrument as he discontinued its use. Since then, sporadic efforts have been made to improve on the gastroscope and to extend its heId of usefulness. During the era of transition, the greatest advances were made by Sussman,s who in rgr I used an instrument which consisted of a AexibIe tube that couId be converted into a rigid one after its introduction in the stomach, and by SchindIer,d who in rgzz used a rigid gastroscope. This Iatter instrument was used at The Mayo CIinic between 1923 and 1933 and whiIe it afforded a very excehent view of the interior of the stomach and per-
F
521
mitted recognition of pathoIogic conditions in certain cases, it was not regarded as an entireIy satisfactory instrument, chiefly because it afforded onIy a partia1 view of the interior of the stomach and the most important areas were not discernibIe in a majority of cases. Furthermore, the procedure entaiIed some slight risk, aIthough when the examination was performed with care the danger was minimaI. For these reasons, the use of gastroscopy as a diagnostic procedure was generahy negIected unti1 the development of the AexibIe gastroscope by WoIf6 and SchindIer,6 in 1932. With this instrument it is possibIe to obtain a satisfactory view of the greater portion of the interior of the stomach in a high percentage of cases, and the examination can be carried out with a minimum of discomfort and risk to the patient. The technique for the introduction of the AexibIe gastroscope and the contraindications to its use have been so we11 described by SchindIer’ and by Henning* that further eIaboration on these points seems unnecessary. The question which we propose to consider is the present vaIue of gastroscopy as a diagnostic aid. GASTRITIS Gastroscopy has probably done more than any other procedure to awaken interest in this controversia1 subject. In spite of the interesting and comprehensive work of Faber,g Konjetzny,‘O and many others, the subject of gastritis has not received the attention it deserves. This is to be attributed primariIy to the fact that there has been no ready method avaiIabIe by which the diagnosis couId be estabIished with certainty. Since gastroscopic examinations have been more frequentIy performed in this country and abroad, the interest
522
American Journal of Surgery
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of surgeons and pathologists in the subject has been stimuIated and instances of the condition have been reported with increasing frequency. That gastritis is a reaI pathoIogic condition which deserves the greatest consideration may be gIeaned from the fact that Gutzeit,” in his cIinic, observed that chronic gastritis was tweIve times as common as gastric uIcer and three times as common as duodena1 uIcer. While these figures may be questioned by many physicians, they do indicate that gastritis may be a common cause of symptoms. From the standpoint of the gastroscopist, one of the most diffIcuIt probIems that presents itseif is to know where the borderIine exists between norma gastric mucosa and that affected by gastritis. In the we11 marked examples of the condition, no such doubt exists and in the discussion which wiI1 foIIow we have concerned ourseIves onIy with cases in which there was no reasonabIe doubt regarding the pathoIogic change. It is not within the scope of this paper to consider the cIinica1 features of gastritis, but rather to emphasize the vaIue of the gastroscope as a diagnostic aid and to describe briefly the visua1 picture of certain common forms of the disease process. Three types of gastritis are described by most investigators, aIthough the terminoIogy has by no means been standardized. These types are usualfy designated as superficia1, acute or catarrha1 gastritis; chronic or hypertrophic gastritis; and atrophic gastritis. While for purposes of cIassification they have been divided into separate groups, the differentiation is not aIways cIear-cut or definite, as one type of Iesion may bIend into the other and exampies of a11 three types may be found in the same stomach. The superficia1, acute or “ catarrha1” gastritis apparentIy invoIves onIy the uppermost Iayers of the gastric mucosa. They mucous membrane appears to be edematous and congested and there is an excess of mucus between and over the
MARCH, 1938
gastric folds. The process may be associated with smaI1 patches of erosion with a minima1 amount of adjacent inflammatory reaction. This type of gastritis is of an evanescent nature and tends to disappear rapidIy under treatment, but in some cases it may progress to the hypertrophic stage. Chronic or hypertrophic gastritis has been divided into many subgroups but for genera1 descriptive purposes a11 of these may be cIassified under one heading, as they bIend one with another. In this type of gastritis the appearance of the mucosa may present a simpIe sweIIing and congestion of the gastric foIds, which Iose their norma siIky appearance, or some thickening of the gastric mucosa may be apparent and mucopuruIent secretion may be present between the foIds. In cases in which the disease is of moderate severity, the mucosa may assume a noduIar or cobbIestone appearance and, if the disease is advanced, there may be marked hypertrophy of the gastric rugae, patches of ulceration and surrounding edema, infihration, and a Ioss in the norma elasticity of the gastric wall. (Fig. I.) This Iatter type of gastritis is a variety in which the roentgenoIogist is deveIoping an increased aptitude in recognition. Atrophic gastritis occurs with Iess frequency than the other forms of gastritis and is characterized by an extreme thinning of the gastric mucosa. The gastric rugae tend to disappear and the submucosa1 vesseIs, which are not normaIIy visibIe, come into view. The mucous membrane has a grayish-green coIor, in contrast to its norma orange-red coIor. Jones, Benedict and Hampton12 have described this same mucosa1 appearance in cases of pernicious anemia, and have demonstrated the changes that occur when Iiver therapy is used. WhiIe some cavi1 at the cIinica1 diagnosis of gastritis in genera1 or question the pathoIogic significance of the changes observed, sufficient evidence has been accumuIated to estabIish the authenticity of the diagnosis in many cases. It has been our good fortune to observe many such
3
FIG. I. MiId degree of gastritis. FIG. 2. Gastroscopic appearance of an acute ulcer of stomach. FIG. 3. Gastroscopic appearance of a carcinoma near the cardiac end of the stomach. FIG. 4. Inflammatory reaction about stoma formed by PoIya type of anastomosis.
NEW Smuaa VOL. XXXIX.
No.
Moersch,
3
SneII-Gastroscopy
cases in which operation is performed and to have the diagnosis confirmed by micro. scopic examination. The present diffIcuIty to be surmounted is obviousIy the proper correIation of gastroscopic, cIinica1 and pathoIogic studies, and much study wiI1 be required to determine the true significance of gastritis as an independent cIinica1 entity and its reIationship to other organic or functiona gastric diseases. GASTRIC
ULCER
The use of the gastroscope in the diagnosis of gastric uIcer must assume a pIace secondary to roentgenoIogic examination. However, roentgenoIogic diagnosis is not infaIIibIe and there is aIways the chance that a smaI1 uIcer may be overIooked during the course of a routine examination. Gastroscopy shouId aIways be considered in cases in which roentgenoIogic examination does not revea1 any abnormaIity or in cases in which the cIinica1 history is strongIy suggestive of an intrinsic gastric Iesion. It shouId be emphasized that gastroscopy shouId be considered in every case of unexpIained hematemesis as it may occur from either an area of gastritis or an uIcer. Great stress has been pIaced on the vaIue of gastroscopy as an aid in foIIowing the therapeutic management of a gastric uIcer. Both Schindler’ and Gutzeit” have pointed out that the heaIing of the uIcer as seen through the gastroscope does not keep pace with the ciinical and roentgenoIogic improvement; visibIe uIceration persists Iong after roentgenoIogic examination faiIs to reveal any abnormality. Gutzeit was of the opinion that this Iatter fact is of the utmost importance in the proper treatment of gastric uIcer and in the prevention of recurrence. The greatest vaIue of gastroscopy in this fieId, next to the demonstration of an uIcer, p?obabIy is the differentiation of a benign gastric uIcer and a maIignant uIcer, a matter which wiI1 be considered in a Iater paragraph. The appearance of a gastric uIcer on direct visuaIization is very striking. Such
American Journal of Surgery
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uIcers are usuaIIy found aIong the Iesser curvature, or adjacent to it. Their appearance varies somewhat with the stage of their activity. In the acute uIcer there is usuaIIy edema, marked congestion of the surrounding mucosa, and the rim of the crater is very sharp. The base of the ulcer is usuaIIy covered with a whitish or goIdenyeIIow dbbris; bIeeding may occasionaIIy be noted, aIthough this is unusual. (Fig. 2.) In the heaIing and quiescent uIcer, the border is Iess edematous and congested than when the uIcer is in the acute phase, and the edges of mucous membrane seem to be puIIed into the center, Iike the spokes of a whee1. Great care must be exercised to ruIe out a so-caIIed phantom uIcer, which may easiIy be mistaken for a true one by the inexperienced gastroscopist. This phenomenon is due to a pecuIiar conformation of the gastric rugae, which has the appearante of a crater. It can be readiIy differentiated by the absence of the characteristic base of the true uIcer, whiIe the supposed crater can be obIiterated by inffation of the stomach with air. There exist marked differences of opinion among observers as to the association and reIationship of gastritis and gastric ulcer. SchindIer’3 expressed the opinion that there is no reIationship between the two, and noted that he had observed Iarge ulcers without any trace of associated gastritis. Gutzeit,l’ Korbsch,14 and Konjetzny,IOhowever, emphasized the frequent association of gastritis and gastric uIcer. Th e exact reIationship between the two is not cIear, but gastritis has been thought b y some investigators to be the forerunner of uIcer Gastroscopy is of onIy secondary vaIue in the diagnosis of duodena1 uIcer, unIess the condition is associated with greatIy retarded emptying of the stomach. When obstruction is present, a marked and definite gastritis wiI1 often be found, but gastritis is by no means a necessary or frequent finding in cases of uncompIicated duodenal uIcer.
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American Journal of Surgery
CARCINOMA
OF
THE
Moersch,
SneII-Gastroscopy
STOMACH
The diagnosis of carcinoma of the stomach in its moderateIy advanced stage is usuahy readiIy made by roentgenoIogic examination. In the earIy stage, however, diffrcuIty may occasionaIIy exist in the differentia1 diagnosis of benign and maIignant Iesions. In a case of this type, gastroscopy may be of definite vaIue in estabIishing the nature of the Iesion, and may offer vaIuabIe information as to its probabIe operabihty. WhiIe the accuracy of roentgenoIogic diagnosis of carcinoma of the stomach is admittedIy high, there is aIways a chance that a smaI1 Iesion or one situated.high in the stomach may be overIooked, or that marked hypertrophy of the gastric mucosa may be misinterpreted as carcinoma. The endoscopic picture of a carcinoma of the stomach varies considerabIy with the nature of the growth, but it nevertheIess is usuaIIy striking and can hardIy be mistaken for the appearance of a benign uIcerating Iesion or one of the rare benign tumors of the stomach. The appearance of a carcinoma with its bIood suppIy intact is entireIy different from the appearance of a growth that has been excised. In a carcinomatous uIcer the base of the Iesion is not so cIean and bright as that of a benign uIcer. The edge is irreguIar and ragged and IocaI infiItration and rigidity of the gastric waI1 are present. Gross irreguIar patches of deep infiltration, marked changes in the overIying mucosa1 pattern, and the presence of an intraIumina1 mass are usuaIIy indicative of carcinoma. In association with these findings, there may be bIeeding, whiIe the grayish-white appearance of the growth itself is further substantiating evidence of carcinoma. In the diffuse non-uIcerating type of carcinoma and in Iymphosarcoma, the gastroscopist may encounter as much diffrcuIty in differentia1 diagnosis as does the roentgenoIogist. This is especiaIIy true if the growth invoIves the entire stomach and if there is no tissue avaiIabIe to indicate
MARCH. 1938
contrast in coIor between norma and pathoIogic structures. (Fig. 3.) SchindIeP was of the opinion that carcinoma can be diagnosed with aTmost compIete accuracy by gastroscopy and that it can be distinguished from benign Iesions with great certainty. WhiIe there is reason to beIieve that this is true in most cases, we are in agreement with Henning,s who said that in not a few cases the final diagnosis must rest on the histoIogic examination. Since even experienced gastric surgeons encounter the same difficuIty, this implies no great criticism of gastroscopic diagnosis. BENIGN
TUMORS
AND
FOREIGN
BODIES
Benign tumors of the stomach may offer the greatest difhcuIty in differentia1 diagnosis, even after carefu1 roentgenoIogic examination of the stomach and adequate gastroscopic visualization. They are, as a ruIe, readiIy distinguished from the ordinary carcinoma by the absence of an irreguIar surface and surrounding infihration. This ruIe does not, of course, aIways hoId true, as it is notorious that gastric poIyps may undergo secondary malignant change. It is seIdom indeed that foreign bodies in the stomach come under the scrutiny of the gastroscopist since most smaI1 and readiIy swaIlowed objects wiI1 pass the pyIorus without difhcuIty. When this does not occur, endoscopic remova may be attempted and, if successfu1, gastrostomy may be avoided. In one case which was seen recentIy, it was possibIe to examine a Iarge phytobezoaP through a gastrothe gastroscopic findings were scope; the same as the findings at subsequent operation. The gastroscopic appearance of syphihs of the stomach has been described by Schindler16 and Moutier,l’ and whiIe the condition is not infrequentIy seen at the cIinic, no patient who has had this condition has as yet been subjected to gastroscopic examination.
NEW SERIES VOL. XXXIX,
No.
POST-OPERATIVE
3
GASTRIC
Moersch, SneII-Gastroscopy LESIONS
One of the most difFicuIt probIems for the cIinician, surgeon, and roentgenoIogist is the proper interpretation of the symptoms which may at times foIIow operations on the stomach. In such cases gastroscopy may be of assistance, but it is essentia1 that the observer have knowIedge of the particuIar type of operation performed, if he is to evaIuate the findings properIy. The stoma formed by a gastroenterostomy, by a PoIya type of operation, or by various modifications of these procedures, usuaIIy is readiIy discernibIe. One quickIy Iearns to recognize a properIy functioning gastroenteric stoma, as it drains weI1, the Iumen is of good caIiber, and the stoma opens and cIoses properIy. At times, it is possibIe to observe the rhythmic opening and cIosing of the stoma and pyIorus in the same gastroscopic fieId. The jejunum is generaIIy visibIe through the new stoma and can readiIy be distinguished from gastric mucosa by the character of its foIds. Gutzeit” has said that the most marked forms of gastritis are found in the stomach previously operated on; this may be true if there is evidence of obstruction, but it is equaIIy certain that many such stomachs present an entireIy norma appearance. Gastroscopy may at times be of assistance in estabIishing the presence or absence of a gastrojejunal uIcer. In certain cases, rather than a true anastomotic uIcer, one may find definite evidence of IocaI gastritis and jejunitis which may account for the presenting symptoms. Such Iesions are easiIy discernibIe by roentgenologic examination. Another type of Iesion which may be encountered in certain cases consists of smaI1 IocaIized regions of uIceration adjacent to the gastiic side of the stoma, a condition which undoubtedIy may Iead to interference with proper function of the stoma. (Fig. 4.) As Henning8 and others have pointed out, the type of case in which post-operative symptoms deveIop after a gastric operation is not infrequentIy one in which
American Journal ofSurgery
525
there is visibIe evidence of gastritis. It is conceivabIe that, if a11 patients who were to undergo gastric operations for uncomplicated benign uIcer first were subjected to gastroscopy and that if those who had gastritis were subjected to a preIiminary course of medica treatment, a decrease in post-operative compIications might ensue. Paschoud,l* who worked on this hypothesis, said that gastroscopy has been of vaIue to him in better and more skiIIfu1 surgica1 care of his patients who had Iesions of the stomach. In any case, gastroscopy has a distinct fieId of usefuIness in the study of compIications which may arise after gastric operations, and we know of numerous diagnoses which were made by this method after other means had been exhausted. The nature of post-operative gastritis, its relation to recurrent uIcer, its occurrence, its reIation to the observed symptoms, and the effects of treatment are IargeIy unsettIed probIems, and it is to be expected that the gastroscopic study of post-operative complications wiI1 contribute greatIy to their soIution. COMMENT
From the foregoing paragraphs it may be inferred that the principa1 fieIds in which gastroscopy is of vaIue are many in number. In cases in which there is a concIusive history suggesting organic disease, but in which the roentgenologic findings are normal, the diagnosis shouId be a probIem of primary importance for the gastroscopist. We have records of such cases in in which gastritis, gastric uIcer, and even carcinoma have been demonstrated and successfuIIy treated. The second most important group comprises those cases in which there is a demonstrabIe gastric Iesion of uncertain nature; direct visuaIization of the stomach aIso may estabIish a correct diagnosis in these cases. Observation of the progress of gastric lesions under medica treatment constitutes the third fieId; some recent experiences with patients who were suffering from benign gastric uIcer make it cIear that a gastroscopic
526
American Journd of Surgery
Moersch,
SneII-Gastroscopy
examination of supposedIy “cured” patients may not be amiss. FinaIIy, in cases in which there are persistent post-operative symptoms but the resuIts of roentgenoIogic examination are negative or inconcIusive, the patients shouId not be dismissed from consideration or toId that their symptoms are of functiona origin unti1 gastroscopic examination has been performed. is of SchindIer13 said that gastroscopy such vaIue that it shouId be used as a routine procedure in a11 gastric examinations. Whether time wiI1 justify such a view is doubtfu1; there is no doubt, however, that direct visuaIization of the interior of the stomach shouId be attempted in any case in which clinical and roentgenoscopic evidence is inconcIusive or of a negative nature, but in which there is symptomatic evidence of intrinsic gastric disease. Gastroscopy does not replace carefu1 cIinica1 or roentgenoIogic study, but is rather an adjunct to diagnosis and therapy. Used in this way, gastroscopy has a pIace in the diagnosis of Iesions of the upper digestive tract. SUMMARY
Gastroscopy is a procedure which shouId be an adjunct to the cIinica1 and roentgenoIogic study of seIected cases of known or suspected gastric disease. Direct visuaIization of the stomach is of vaIue in the examination in cases in which the cIinica1 and roentgenoscopic evidence of gastric disease is uncertain or absent. It is particuIarIy usefu1 in those cases in which symptoms persist foIIowing an operation on the stomach. It has stimulated renewed interest in the probIem of gastritis, and thereby has increased the interest of cIinicians and roentgenoIogists in an effort to deveIop criteria by which they may determine the presence of such lesions with greater accuracy. Further studies must be carried out to determine the sism&cance. imoortance. and reIationshin
MARCH, 1938
of gastritis to other clinica and pathoIogic findings; this is a fieId in which gastroscopy may be of paramount importance. REFERENCES KUSSMAUL, ADOIF. Uber die Behandlung der Magenerweiterung durch eine neue Methode mittelst der Magenpumpe. Deutscb. Arch. f. klin. Med., 6: 455y500, 1869. und Oesopha2. MIKULICZ, J. Uber Gastroskopie goskopie. Wien. med. Presse., 22: 1405-1408, 1881. 3. SUSSMAN,M. Ein biegsames Gastroskop. Tberap. d. Gegenw., 52: 433-441, IgI I. 4. SCHINDLER, R. Die diagnostische Bedeutung der Gastroskopie. Miincben. med. Wcbnscbr., 69: 535-537 (April 14) 1922. 5. WOLF, Quoted by Schindler.G 6. SCHINDLER, RUDOLF. Ein vollig ungeflihrliches, Aexibles Gastroskop. Miincben. med. Wcbnscbr.. 79: 12681269 (Aug. 5) 1932. 7. SCHINDLER,RUDOLF. Diagnostic gastroscopy; with special reference to the Aexible gastroscope. _ 6. A. M. A., 105: 352-355 (Aug. 3) 1935. NORBERT. Lehrbuch der Gastroskooie. 8. HENNING, Leipzig; J. A. Barth 1935. 9. FABER, KNUD. Gastritis and Its Consequences. New York, Oxford University Press, 1935. IO. KONJETZNY,G. E. Zur Klinik der Gastritis (Magenblutung und peritonitische Erscheinungen bei der einfachen Gastritis). Arch. j. Verdauungskr., 43: 262-273 (March) 1928. II. GUTZEIT, KURT. Die Bedeutung der Gastroskopie (Unter besonderer Beriicksichtigung der Gastritis). Die Ergebnisse der Gastroskopie. Verbandl. d. deutscb. Gesellscb. j. innere Med., 47: 368-378, 1935. 12. JONES, C. M., BENEDICT, E. B., and HAMPTON, A. 0. Variations in gastric mucosa in pernicious anemia: gastroscopic, surgical and roentgenologic observations. Am. J. M. SC., 190: 596-610 (Nov.) ‘935. ‘3. SCHINDLER,RUDOLF. On the clinical value of gastroscopy. Proc. Staff Meet., Mayo Clin., I I : 747750 (Nov. 18) 1936. van ausgesuchten 14. KORBSCH, R. Demonstration gastroskopischen Aquarellen. Verbandl. d. deutscb. Gesellscb. j. here Med., 47: 378-383, 1935. ‘5. MOERSCH, H. J. and WALTERS, WALTMAN. Phvtobezoar with visualization by means of gastroscopy. _” Am. J. Digest. Dis. @ Nutrition.. ,_2: I,t-17 (March) 1936. 16. SCHINDLER,R. Gastroscopy. Chicago, University of Chicago Press, 1937. 17. MOUTIER, FRAN~OIS. Trait& de gastroscopie et de pathologie endoscopique de l’estomac. Paris, Masson et Cie, 1935. und der 18. PASCHUND, HENRI. Die Gastroskopie Chirurg. Verbandl. d. deutscb. Gesellscb. j. innere Med., 47: 383-385, 1935. I.
I
SNELL, M.D.
Division of Medicine, The Mayo Chic ROCHESTER,
MINNESOTA
OR many years there has been a constant effort on the part of the medical profession to deveIop instruments by which the various hoIIow organs of the body couId be directIy visuahzed. Such efforts have been we11 rewarded since the deveIopment of such methods has aIways been associated with an increased knowledge of the function of the organ concerned and the pathoIogic changes which may be present. WhiIe the interior of the stomach was one of the first portions of the body to be examined by direct visualization, the procedure was a very formidabIe one and did not come into genera1 favor because of mechanica and optica di&uIties. Interest in the probIem Iagged, for obvious reasons, after the deveIopment of the Roentgen rays as an eficient diagnostic agent. KussmauI,l in 1868, probabIy made the first attempt at direct visuaIization of the interior of the stomach; he used a sword swaIIower as his subject, with indifferent success. MikuIicz2 is credited with having performed the first satisfactory gastroscopy, in I 881. Although he was successfu1 in his effort, he apparentIy reahzed the dangers and shortcomings of his instrument as he discontinued its use. Since then, sporadic efforts have been made to improve on the gastroscope and to extend its heId of usefulness. During the era of transition, the greatest advances were made by Sussman,s who in rgr I used an instrument which consisted of a AexibIe tube that couId be converted into a rigid one after its introduction in the stomach, and by SchindIer,d who in rgzz used a rigid gastroscope. This Iatter instrument was used at The Mayo CIinic between 1923 and 1933 and whiIe it afforded a very excehent view of the interior of the stomach and per-
F
521
mitted recognition of pathoIogic conditions in certain cases, it was not regarded as an entireIy satisfactory instrument, chiefly because it afforded onIy a partia1 view of the interior of the stomach and the most important areas were not discernibIe in a majority of cases. Furthermore, the procedure entaiIed some slight risk, aIthough when the examination was performed with care the danger was minimaI. For these reasons, the use of gastroscopy as a diagnostic procedure was generahy negIected unti1 the development of the AexibIe gastroscope by WoIf6 and SchindIer,6 in 1932. With this instrument it is possibIe to obtain a satisfactory view of the greater portion of the interior of the stomach in a high percentage of cases, and the examination can be carried out with a minimum of discomfort and risk to the patient. The technique for the introduction of the AexibIe gastroscope and the contraindications to its use have been so we11 described by SchindIer’ and by Henning* that further eIaboration on these points seems unnecessary. The question which we propose to consider is the present vaIue of gastroscopy as a diagnostic aid. GASTRITIS Gastroscopy has probably done more than any other procedure to awaken interest in this controversia1 subject. In spite of the interesting and comprehensive work of Faber,g Konjetzny,‘O and many others, the subject of gastritis has not received the attention it deserves. This is to be attributed primariIy to the fact that there has been no ready method avaiIabIe by which the diagnosis couId be estabIished with certainty. Since gastroscopic examinations have been more frequentIy performed in this country and abroad, the interest
522
American Journal of Surgery
Moersch, SneII-Gastroscopy
of surgeons and pathologists in the subject has been stimuIated and instances of the condition have been reported with increasing frequency. That gastritis is a reaI pathoIogic condition which deserves the greatest consideration may be gIeaned from the fact that Gutzeit,” in his cIinic, observed that chronic gastritis was tweIve times as common as gastric uIcer and three times as common as duodena1 uIcer. While these figures may be questioned by many physicians, they do indicate that gastritis may be a common cause of symptoms. From the standpoint of the gastroscopist, one of the most diffIcuIt probIems that presents itseif is to know where the borderIine exists between norma gastric mucosa and that affected by gastritis. In the we11 marked examples of the condition, no such doubt exists and in the discussion which wiI1 foIIow we have concerned ourseIves onIy with cases in which there was no reasonabIe doubt regarding the pathoIogic change. It is not within the scope of this paper to consider the cIinica1 features of gastritis, but rather to emphasize the vaIue of the gastroscope as a diagnostic aid and to describe briefly the visua1 picture of certain common forms of the disease process. Three types of gastritis are described by most investigators, aIthough the terminoIogy has by no means been standardized. These types are usualfy designated as superficia1, acute or catarrha1 gastritis; chronic or hypertrophic gastritis; and atrophic gastritis. While for purposes of cIassification they have been divided into separate groups, the differentiation is not aIways cIear-cut or definite, as one type of Iesion may bIend into the other and exampies of a11 three types may be found in the same stomach. The superficia1, acute or “ catarrha1” gastritis apparentIy invoIves onIy the uppermost Iayers of the gastric mucosa. They mucous membrane appears to be edematous and congested and there is an excess of mucus between and over the
MARCH, 1938
gastric folds. The process may be associated with smaI1 patches of erosion with a minima1 amount of adjacent inflammatory reaction. This type of gastritis is of an evanescent nature and tends to disappear rapidIy under treatment, but in some cases it may progress to the hypertrophic stage. Chronic or hypertrophic gastritis has been divided into many subgroups but for genera1 descriptive purposes a11 of these may be cIassified under one heading, as they bIend one with another. In this type of gastritis the appearance of the mucosa may present a simpIe sweIIing and congestion of the gastric foIds, which Iose their norma siIky appearance, or some thickening of the gastric mucosa may be apparent and mucopuruIent secretion may be present between the foIds. In cases in which the disease is of moderate severity, the mucosa may assume a noduIar or cobbIestone appearance and, if the disease is advanced, there may be marked hypertrophy of the gastric rugae, patches of ulceration and surrounding edema, infihration, and a Ioss in the norma elasticity of the gastric wall. (Fig. I.) This Iatter type of gastritis is a variety in which the roentgenoIogist is deveIoping an increased aptitude in recognition. Atrophic gastritis occurs with Iess frequency than the other forms of gastritis and is characterized by an extreme thinning of the gastric mucosa. The gastric rugae tend to disappear and the submucosa1 vesseIs, which are not normaIIy visibIe, come into view. The mucous membrane has a grayish-green coIor, in contrast to its norma orange-red coIor. Jones, Benedict and Hampton12 have described this same mucosa1 appearance in cases of pernicious anemia, and have demonstrated the changes that occur when Iiver therapy is used. WhiIe some cavi1 at the cIinica1 diagnosis of gastritis in genera1 or question the pathoIogic significance of the changes observed, sufficient evidence has been accumuIated to estabIish the authenticity of the diagnosis in many cases. It has been our good fortune to observe many such
3
FIG. I. MiId degree of gastritis. FIG. 2. Gastroscopic appearance of an acute ulcer of stomach. FIG. 3. Gastroscopic appearance of a carcinoma near the cardiac end of the stomach. FIG. 4. Inflammatory reaction about stoma formed by PoIya type of anastomosis.
NEW Smuaa VOL. XXXIX.
No.
Moersch,
3
SneII-Gastroscopy
cases in which operation is performed and to have the diagnosis confirmed by micro. scopic examination. The present diffIcuIty to be surmounted is obviousIy the proper correIation of gastroscopic, cIinica1 and pathoIogic studies, and much study wiI1 be required to determine the true significance of gastritis as an independent cIinica1 entity and its reIationship to other organic or functiona gastric diseases. GASTRIC
ULCER
The use of the gastroscope in the diagnosis of gastric uIcer must assume a pIace secondary to roentgenoIogic examination. However, roentgenoIogic diagnosis is not infaIIibIe and there is aIways the chance that a smaI1 uIcer may be overIooked during the course of a routine examination. Gastroscopy shouId aIways be considered in cases in which roentgenoIogic examination does not revea1 any abnormaIity or in cases in which the cIinica1 history is strongIy suggestive of an intrinsic gastric Iesion. It shouId be emphasized that gastroscopy shouId be considered in every case of unexpIained hematemesis as it may occur from either an area of gastritis or an uIcer. Great stress has been pIaced on the vaIue of gastroscopy as an aid in foIIowing the therapeutic management of a gastric uIcer. Both Schindler’ and Gutzeit” have pointed out that the heaIing of the uIcer as seen through the gastroscope does not keep pace with the ciinical and roentgenoIogic improvement; visibIe uIceration persists Iong after roentgenoIogic examination faiIs to reveal any abnormality. Gutzeit was of the opinion that this Iatter fact is of the utmost importance in the proper treatment of gastric uIcer and in the prevention of recurrence. The greatest vaIue of gastroscopy in this fieId, next to the demonstration of an uIcer, p?obabIy is the differentiation of a benign gastric uIcer and a maIignant uIcer, a matter which wiI1 be considered in a Iater paragraph. The appearance of a gastric uIcer on direct visuaIization is very striking. Such
American Journal of Surgery
523
uIcers are usuaIIy found aIong the Iesser curvature, or adjacent to it. Their appearance varies somewhat with the stage of their activity. In the acute uIcer there is usuaIIy edema, marked congestion of the surrounding mucosa, and the rim of the crater is very sharp. The base of the ulcer is usuaIIy covered with a whitish or goIdenyeIIow dbbris; bIeeding may occasionaIIy be noted, aIthough this is unusual. (Fig. 2.) In the heaIing and quiescent uIcer, the border is Iess edematous and congested than when the uIcer is in the acute phase, and the edges of mucous membrane seem to be puIIed into the center, Iike the spokes of a whee1. Great care must be exercised to ruIe out a so-caIIed phantom uIcer, which may easiIy be mistaken for a true one by the inexperienced gastroscopist. This phenomenon is due to a pecuIiar conformation of the gastric rugae, which has the appearante of a crater. It can be readiIy differentiated by the absence of the characteristic base of the true uIcer, whiIe the supposed crater can be obIiterated by inffation of the stomach with air. There exist marked differences of opinion among observers as to the association and reIationship of gastritis and gastric ulcer. SchindIer’3 expressed the opinion that there is no reIationship between the two, and noted that he had observed Iarge ulcers without any trace of associated gastritis. Gutzeit,l’ Korbsch,14 and Konjetzny,IOhowever, emphasized the frequent association of gastritis and gastric uIcer. Th e exact reIationship between the two is not cIear, but gastritis has been thought b y some investigators to be the forerunner of uIcer Gastroscopy is of onIy secondary vaIue in the diagnosis of duodena1 uIcer, unIess the condition is associated with greatIy retarded emptying of the stomach. When obstruction is present, a marked and definite gastritis wiI1 often be found, but gastritis is by no means a necessary or frequent finding in cases of uncompIicated duodenal uIcer.
524
American Journal of Surgery
CARCINOMA
OF
THE
Moersch,
SneII-Gastroscopy
STOMACH
The diagnosis of carcinoma of the stomach in its moderateIy advanced stage is usuahy readiIy made by roentgenoIogic examination. In the earIy stage, however, diffrcuIty may occasionaIIy exist in the differentia1 diagnosis of benign and maIignant Iesions. In a case of this type, gastroscopy may be of definite vaIue in estabIishing the nature of the Iesion, and may offer vaIuabIe information as to its probabIe operabihty. WhiIe the accuracy of roentgenoIogic diagnosis of carcinoma of the stomach is admittedIy high, there is aIways a chance that a smaI1 Iesion or one situated.high in the stomach may be overIooked, or that marked hypertrophy of the gastric mucosa may be misinterpreted as carcinoma. The endoscopic picture of a carcinoma of the stomach varies considerabIy with the nature of the growth, but it nevertheIess is usuaIIy striking and can hardIy be mistaken for the appearance of a benign uIcerating Iesion or one of the rare benign tumors of the stomach. The appearance of a carcinoma with its bIood suppIy intact is entireIy different from the appearance of a growth that has been excised. In a carcinomatous uIcer the base of the Iesion is not so cIean and bright as that of a benign uIcer. The edge is irreguIar and ragged and IocaI infiItration and rigidity of the gastric waI1 are present. Gross irreguIar patches of deep infiltration, marked changes in the overIying mucosa1 pattern, and the presence of an intraIumina1 mass are usuaIIy indicative of carcinoma. In association with these findings, there may be bIeeding, whiIe the grayish-white appearance of the growth itself is further substantiating evidence of carcinoma. In the diffuse non-uIcerating type of carcinoma and in Iymphosarcoma, the gastroscopist may encounter as much diffrcuIty in differentia1 diagnosis as does the roentgenoIogist. This is especiaIIy true if the growth invoIves the entire stomach and if there is no tissue avaiIabIe to indicate
MARCH. 1938
contrast in coIor between norma and pathoIogic structures. (Fig. 3.) SchindIeP was of the opinion that carcinoma can be diagnosed with aTmost compIete accuracy by gastroscopy and that it can be distinguished from benign Iesions with great certainty. WhiIe there is reason to beIieve that this is true in most cases, we are in agreement with Henning,s who said that in not a few cases the final diagnosis must rest on the histoIogic examination. Since even experienced gastric surgeons encounter the same difficuIty, this implies no great criticism of gastroscopic diagnosis. BENIGN
TUMORS
AND
FOREIGN
BODIES
Benign tumors of the stomach may offer the greatest difhcuIty in differentia1 diagnosis, even after carefu1 roentgenoIogic examination of the stomach and adequate gastroscopic visualization. They are, as a ruIe, readiIy distinguished from the ordinary carcinoma by the absence of an irreguIar surface and surrounding infihration. This ruIe does not, of course, aIways hoId true, as it is notorious that gastric poIyps may undergo secondary malignant change. It is seIdom indeed that foreign bodies in the stomach come under the scrutiny of the gastroscopist since most smaI1 and readiIy swaIlowed objects wiI1 pass the pyIorus without difhcuIty. When this does not occur, endoscopic remova may be attempted and, if successfu1, gastrostomy may be avoided. In one case which was seen recentIy, it was possibIe to examine a Iarge phytobezoaP through a gastrothe gastroscopic findings were scope; the same as the findings at subsequent operation. The gastroscopic appearance of syphihs of the stomach has been described by Schindler16 and Moutier,l’ and whiIe the condition is not infrequentIy seen at the cIinic, no patient who has had this condition has as yet been subjected to gastroscopic examination.
NEW SERIES VOL. XXXIX,
No.
POST-OPERATIVE
3
GASTRIC
Moersch, SneII-Gastroscopy LESIONS
One of the most difFicuIt probIems for the cIinician, surgeon, and roentgenoIogist is the proper interpretation of the symptoms which may at times foIIow operations on the stomach. In such cases gastroscopy may be of assistance, but it is essentia1 that the observer have knowIedge of the particuIar type of operation performed, if he is to evaIuate the findings properIy. The stoma formed by a gastroenterostomy, by a PoIya type of operation, or by various modifications of these procedures, usuaIIy is readiIy discernibIe. One quickIy Iearns to recognize a properIy functioning gastroenteric stoma, as it drains weI1, the Iumen is of good caIiber, and the stoma opens and cIoses properIy. At times, it is possibIe to observe the rhythmic opening and cIosing of the stoma and pyIorus in the same gastroscopic fieId. The jejunum is generaIIy visibIe through the new stoma and can readiIy be distinguished from gastric mucosa by the character of its foIds. Gutzeit” has said that the most marked forms of gastritis are found in the stomach previously operated on; this may be true if there is evidence of obstruction, but it is equaIIy certain that many such stomachs present an entireIy norma appearance. Gastroscopy may at times be of assistance in estabIishing the presence or absence of a gastrojejunal uIcer. In certain cases, rather than a true anastomotic uIcer, one may find definite evidence of IocaI gastritis and jejunitis which may account for the presenting symptoms. Such Iesions are easiIy discernibIe by roentgenologic examination. Another type of Iesion which may be encountered in certain cases consists of smaI1 IocaIized regions of uIceration adjacent to the gastiic side of the stoma, a condition which undoubtedIy may Iead to interference with proper function of the stoma. (Fig. 4.) As Henning8 and others have pointed out, the type of case in which post-operative symptoms deveIop after a gastric operation is not infrequentIy one in which
American Journal ofSurgery
525
there is visibIe evidence of gastritis. It is conceivabIe that, if a11 patients who were to undergo gastric operations for uncomplicated benign uIcer first were subjected to gastroscopy and that if those who had gastritis were subjected to a preIiminary course of medica treatment, a decrease in post-operative compIications might ensue. Paschoud,l* who worked on this hypothesis, said that gastroscopy has been of vaIue to him in better and more skiIIfu1 surgica1 care of his patients who had Iesions of the stomach. In any case, gastroscopy has a distinct fieId of usefuIness in the study of compIications which may arise after gastric operations, and we know of numerous diagnoses which were made by this method after other means had been exhausted. The nature of post-operative gastritis, its relation to recurrent uIcer, its occurrence, its reIation to the observed symptoms, and the effects of treatment are IargeIy unsettIed probIems, and it is to be expected that the gastroscopic study of post-operative complications wiI1 contribute greatIy to their soIution. COMMENT
From the foregoing paragraphs it may be inferred that the principa1 fieIds in which gastroscopy is of vaIue are many in number. In cases in which there is a concIusive history suggesting organic disease, but in which the roentgenologic findings are normal, the diagnosis shouId be a probIem of primary importance for the gastroscopist. We have records of such cases in in which gastritis, gastric uIcer, and even carcinoma have been demonstrated and successfuIIy treated. The second most important group comprises those cases in which there is a demonstrabIe gastric Iesion of uncertain nature; direct visuaIization of the stomach aIso may estabIish a correct diagnosis in these cases. Observation of the progress of gastric lesions under medica treatment constitutes the third fieId; some recent experiences with patients who were suffering from benign gastric uIcer make it cIear that a gastroscopic
526
American Journd of Surgery
Moersch,
SneII-Gastroscopy
examination of supposedIy “cured” patients may not be amiss. FinaIIy, in cases in which there are persistent post-operative symptoms but the resuIts of roentgenoIogic examination are negative or inconcIusive, the patients shouId not be dismissed from consideration or toId that their symptoms are of functiona origin unti1 gastroscopic examination has been performed. is of SchindIer13 said that gastroscopy such vaIue that it shouId be used as a routine procedure in a11 gastric examinations. Whether time wiI1 justify such a view is doubtfu1; there is no doubt, however, that direct visuaIization of the interior of the stomach shouId be attempted in any case in which clinical and roentgenoscopic evidence is inconcIusive or of a negative nature, but in which there is symptomatic evidence of intrinsic gastric disease. Gastroscopy does not replace carefu1 cIinica1 or roentgenoIogic study, but is rather an adjunct to diagnosis and therapy. Used in this way, gastroscopy has a pIace in the diagnosis of Iesions of the upper digestive tract. SUMMARY
Gastroscopy is a procedure which shouId be an adjunct to the cIinica1 and roentgenoIogic study of seIected cases of known or suspected gastric disease. Direct visuaIization of the stomach is of vaIue in the examination in cases in which the cIinica1 and roentgenoscopic evidence of gastric disease is uncertain or absent. It is particuIarIy usefu1 in those cases in which symptoms persist foIIowing an operation on the stomach. It has stimulated renewed interest in the probIem of gastritis, and thereby has increased the interest of cIinicians and roentgenoIogists in an effort to deveIop criteria by which they may determine the presence of such lesions with greater accuracy. Further studies must be carried out to determine the sism&cance. imoortance. and reIationshin
MARCH, 1938
of gastritis to other clinica and pathoIogic findings; this is a fieId in which gastroscopy may be of paramount importance. REFERENCES KUSSMAUL, ADOIF. Uber die Behandlung der Magenerweiterung durch eine neue Methode mittelst der Magenpumpe. Deutscb. Arch. f. klin. Med., 6: 455y500, 1869. und Oesopha2. MIKULICZ, J. Uber Gastroskopie goskopie. Wien. med. Presse., 22: 1405-1408, 1881. 3. SUSSMAN,M. Ein biegsames Gastroskop. Tberap. d. Gegenw., 52: 433-441, IgI I. 4. SCHINDLER, R. Die diagnostische Bedeutung der Gastroskopie. Miincben. med. Wcbnscbr., 69: 535-537 (April 14) 1922. 5. WOLF, Quoted by Schindler.G 6. SCHINDLER, RUDOLF. Ein vollig ungeflihrliches, Aexibles Gastroskop. Miincben. med. Wcbnscbr.. 79: 12681269 (Aug. 5) 1932. 7. SCHINDLER,RUDOLF. Diagnostic gastroscopy; with special reference to the Aexible gastroscope. _ 6. A. M. A., 105: 352-355 (Aug. 3) 1935. NORBERT. Lehrbuch der Gastroskooie. 8. HENNING, Leipzig; J. A. Barth 1935. 9. FABER, KNUD. Gastritis and Its Consequences. New York, Oxford University Press, 1935. IO. KONJETZNY,G. E. Zur Klinik der Gastritis (Magenblutung und peritonitische Erscheinungen bei der einfachen Gastritis). Arch. j. Verdauungskr., 43: 262-273 (March) 1928. II. GUTZEIT, KURT. Die Bedeutung der Gastroskopie (Unter besonderer Beriicksichtigung der Gastritis). Die Ergebnisse der Gastroskopie. Verbandl. d. deutscb. Gesellscb. j. innere Med., 47: 368-378, 1935. 12. JONES, C. M., BENEDICT, E. B., and HAMPTON, A. 0. Variations in gastric mucosa in pernicious anemia: gastroscopic, surgical and roentgenologic observations. Am. J. M. SC., 190: 596-610 (Nov.) ‘935. ‘3. SCHINDLER,RUDOLF. On the clinical value of gastroscopy. Proc. Staff Meet., Mayo Clin., I I : 747750 (Nov. 18) 1936. van ausgesuchten 14. KORBSCH, R. Demonstration gastroskopischen Aquarellen. Verbandl. d. deutscb. Gesellscb. j. here Med., 47: 378-383, 1935. ‘5. MOERSCH, H. J. and WALTERS, WALTMAN. Phvtobezoar with visualization by means of gastroscopy. _” Am. J. Digest. Dis. @ Nutrition.. ,_2: I,t-17 (March) 1936. 16. SCHINDLER,R. Gastroscopy. Chicago, University of Chicago Press, 1937. 17. MOUTIER, FRAN~OIS. Trait& de gastroscopie et de pathologie endoscopique de l’estomac. Paris, Masson et Cie, 1935. und der 18. PASCHUND, HENRI. Die Gastroskopie Chirurg. Verbandl. d. deutscb. Gesellscb. j. innere Med., 47: 383-385, 1935. I.
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