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Gastroscopy of Peptic Ulceration
Symposium on Acid-Peptic Disease
Gastroscopy of Peptic Ulceration
John A. Higgins, M.D.
Since the introduction of the fiberoptic gastroscope by Hirschowitz in 1958, the endoscopist has become an increasingly active member of the diagnostic team evaluating the patient with complicated peptic ulcer disease. In theory, the availability of a flexible optical system for inspecting a well-illuminated field should have largely solved the problems of diagnosing conditions involving the mucosa of the esophagus and stomach. The structural inadequacies of the earlier fiberoptic equipment, however, left many important areas of the gastric interior (for example, cardia, lesser curve below the angle) relatively inaccessible for inspection, and the subjectiveness of visual diagnosis introduces sufficient error so that the anticipated accuracy of fiberoptic endoscopy has not been fully realized. Yet with broadening of experience and technical improvements in instrumentation, considerable progress has been made. Currently, one of the major problems confronting the practicing gastrointestinal endoscopist is that of keeping abreast with new developments in instrumentation. Naturally, he wants the greatest capacity for visualization, photography, biopsy, and cytologic study combined into a single instrument which can then be used to examine the esophagus, stomach, and duodenal cap. Efforts to develop such an ideal instrument have resulted in the rapid illtroduction of serial modifications, each possessing some improvement, though often at the cost of some other advantage. But recently available instruments do indeed have the length and flexibility for visualizing the esophagus, cardia, distal antrum, and proximal duodenum; and they have reasonably adequate biopsying devices and provide for photographic recording of the examination (Figs. 1 to 3). Therefore the majority of the mucosal lesions resulting from peptic disease in the upper digestive tract should be accessible and identifiable to the trained endoscopist, and his examination should be of great benefit in the investigation of such patients.
TECHNIQUE The obvious comfort and apparent safety provided the patient by flexible fiberoptic equipment seem to be associated, to a degree, with Surgical Clinics of North America- Vol. 51, No.4, August 1971
961
962
JOHN
A.
HIGGINS
Figure 1. A.C.M.1. Mark 87 fiberoptic gastroesophageal endoscope with straight forward visual system and biopsy capabilities.
some of its hazards as well. Surveys comparing the complications of gastroscopic examination with rigid and with flexible instruments 4 indicate a somewhat higher incidence of perforation and associated trauma with the flexible endoscope, although with either instrument the occurrence of significant injury was less than 0.1 %. The higher incidence of injury with the flexible instrument can only be explained
Figure 2. A.C.M.1. Mark 7 fiberoptic gastroscope with right-angle optical system and biopsy capabilities.
GASTROSCOPY OF PEPTIC ULCERATION
963
Figure 3. Olympus Model GFB fiberoptic gastroscope with right-angle optical system and maneuverable biopsy attachment.
by the false sense of security associated with its use-a feeling which may induce inadequately trained examiners to overreach their experience and the usually careful endoscopist to neglect necessary precautions. As with the semi-rigid endoscope, injuries appear to be most common on the posterior wall where the upper esophagus overlies the vertebral bodies of the cervical spine. The mechanical advantages of fiberoptic instruments do not allow the careful preparation of the patient to be neglected. The adequacy and acceptance of the procedure are significantly improved if the technique and the aim of the examination can be discussed previously with the patient, preferably by the physician who will perform it. Nearly always the patient's apprehension is more distressing than the examination itself. Even in an emergency situation, a calm, stepwise explanation of the procedure can allay unnecessary fears and make possible a more satisfactory examination and more certain result. If the patient is given the proper psychologic preparation, use of topical pharyngeal anesthesia and preexamination sedation may be considered optional. Most endoscopists, however, believe these measures add enough to patient comfort to offset the minimal risks of significant hypersensitivity reactions or respiratory depression. Pharyngeal swabbing, spraying, or gargling with topical anesthetic preparations is usual, but in cases that include a history of hypersensitivity to these agents the examination ordinarily can be completed satisfactorily without this preparation. Parenteral administration of meperidine and, more recently, intravenous administration of diazepam have been widely used to provide temporary sedation and a degree of amnesia for the examination. Normal attention to dose and administration should result in adequate relaxation without the risk of serious respiratory depression. Lavage of the stomach prior to the gastroscopic examination is no longer a routine procedure. Gastric secretions are rarely a significant hindrance to an essentially complete evaluation of the gastric mucosal surface. The maneuverability of the instrument and careful appropriate changes of the patient's position usually allow all areas of the body of the stomach to be seen adequately for diagnostic purposes. Anticholinergic drugs may be used routinely, although to a degree this may influence the interpretation of the contraction patterns of the stomach wall. Many endoscopists now advocate intravenous administration of propantheline bromide during the examination when careful evaluation
964
JOHN
A.
HIGGINS
of the transiently paralyzed and distended antrum is necessary in the search for possible mucosal erosions or ulcerations. To some extent, the advent of fiberoptic gastrointestinal endoscopes has influenced the concept of a standard technique in performing the examination. The flexibility of the instrument reduces the need for specific maneuvers for visualization of certain portions of the mucosal surface, and no two examinations proceed in exactly the same sequence. Some examiners prefer a stepwise approach, inspecting the esophagus, stomach, antrum, and prepyloric regions as they are reached. Others advance the instrument as directly as possible to the distal antrum and perform the detailed examination as it is being withdrawn. In a situation where a specific lesion is suspected from a prior x-ray study, it is often advantageous to inspect the area in question as soon as possible, while the patient's tolerance is still optimal, and to search for secondary factors after the primary lesion has been located and evaluated. But whereas technical improvements have produced a flexible fiberoptic instrument with a superb optical system and associated photographic, biopsy, or cytologic capabilities, the ultimate value of the procedure rests upon the interpretation of the examiner. It is his evaluation of his visual observations and his expertness in maneuvering the instrument and the patient which most influence the diagnostic accuracy , of the examination and therefore the decisions relating to management.
INDICATIONS The indications for gastroscopic examination in patients with pepticulcer disease and its complications can justly be considered to be either rather limited or nearly limitless, depending upon the availability and reliability of other diagnostic aids and the nature of the problem presented. In all cases it should be considered as complementary to other diagnostic resources, and in any given instance it may be of primary or of only secondary significance. In general, diagnostic efforts are best served by combining the techniques of the radiologist and the endoscopist and, in appropriate situations, the cytologist. The responsible physician, however, should not feel compelled routinely to perform all possible diagnostic studies if the nature of the problem is clearly evident from one or another of the procedures. In a case of nonspecific upper abdominal pain with a negative x-ray of the stomach and duodenum and no previous gastric surgery, there is little likelihood of benefit from a gastroscopic examination; but even with negative radiologic studies, the source of upper gastrointestinal bleeding frequently can be determined by endoscopic evaluation. The problems presented by the gastrectomized patient-usually pain or anemia-are particularly difficult for the radiologist, and the flexible fiberoptic gastroscope adds considerably to the evaluation of the gastrojejunal anastomotic area. It is best to consider the results of both roentgenographic and endoscopic examinations when making decisions on management of ulceration of the gastric mucosa.
GASTROSCOPY OF PEPTIC ULCERATION
965
EVALUATION The most common problem facing the gastroscopist is further evaluation of an ulcerating gastric lesion demonstrated by x-ray. The malignant potential of the lesion has been partially assessed by the character of the roentgenographic picture, and the aim of the endoscopic examination is to provide further evaluation of potential malignancy and to search for additional evidence of disease within the stomach. The benign gastric ulcer is characterized by a sharply demarcated edge and a smooth, clean white base in the crater. The inflammatory reaction in the adjacent mucosa is variable: edema, erythema, and friability may be prominent, or nearly normal mucosa may extend almost to the edge of the crater. If prominent mucosal edema is associated with a lesion, the thickening of the gastric wall may distort peristaltic contractions and thus suggest the presence of malignant infiltration. In general, the neoplastic ulcer is less inclined to be regular in outline, its edge is less clearly defined, its base often nodular and uneven, its color usually more gray than white. No single feature has certain diagnostic significance, but the composite has considerable accuracy. Combined with x-ray evaluation, the gastroscopic examination should yield a correct diagnosis of gastric ulceration in well over 90% of cases. 7 Judicious use of direct-vision biopsy from the edge of the lesion or cytologic study of gastric washings after an abrasive jet has been directed against the lesion under gastroscopic control also increases the accuracy of detecting malignancy. Separation of multiple ulcers by apparently normal mucosa favors benignancy, but the linking of several ulcers by nodularity or induration between them may be a manifestation of lymphoma or carcinoma. Gastroscopic reexamination is often of considerable value in the follow-up of ulcers during nonsurgical treatment. Direct observation of the lesion may indicate changes of malignant character even though the therapeutic program has mitigated symptoms and roentgenographic studies have indicated a reduction in the associated inflammatory reaction. Additionally, many antral gastric ulcers are accompanied, in both active and healing phases, by significant deformity. In such circumstances the endoscopic examination may be the only reliable way of following the influence of treatment. On rare occasions the center of a benign gastric ulcer may completely epithelize while the crater deformity persists. The radiologist may suspect this from absence of induration and spasm; however, the gastroscopist is usually in a better position to evaluate this probability by his direct view of the site of the lesion. A wide variety of ulcer-like dyspepsias are encountered in medical practice. X-ray studies in these conditions are equivocal or negative, and gastroscopic evaluation usually does not yield much additional evidence of diagnostic significance. Occasionally a definite inflammatory reaction of the distal antral mucosa with erythema, edema, and often increased friability provides a clue to adjacent duodenal ulceration or at least adds some degree of confidence to the recommendation for an ulcer management program. As noted previously, antral inflammatory disease may ,
366
JOHN
A.
HIGGINS
result in significant deformity which may be difficult to distinguish from a stenosing malignancy, particularly if previous films are not available for comparison. If gastroscopic examination shows the area is not ulcerated, peristaltic contractions are symmetric, and the narrowed segment can be distended by the insufflation of air, then the likelihood of malignancy is remote and a period of careful observation can be advised. The endoscopist may encounter special problems in bleeding from the upper gastrointestinal tract. Massive hemorrhage requires prompt diagnostic measures so that appropriate definitive treatment, as well as the necessary supportive therapy, may be instituted as soon as possible. Often the patient's condition does not allow satisfactory roentgenographic study, so the endoscopy is the only available means of diagnostic study. Inasmuch as determination of the bleeding site, or sites, significantly influences early management decisions, a gastroscopic examination should be performed as soon as the patient's hemodynamic status will allow. The relative ease and comfort of the fiberoptic examination facilitate its early use in emergency situations. Gastric lavage should be an early procedure in cases of acute upper gastrointestinal bleeding of any clinical significance. When endoscopic examination is anticipated, the lavage should be performed with a tube of large caliber so that clots may be thoroughly evacuated. Unless the gastric mucosa can be reasonably well cleansed, a gastroscopist is seriously hampered in his efforts to detect a specific bleeding site. Thus, in massive hemorrhage when bleeding cannot be even temporarily controlled, the localizing diagnostic value of any visual evaluation is significantly reduced. The most common cause of upper gastrointestinal bleeding is variously reported to be hemorrhagic gastritis or duodenal ulcer-depending, to a degree, upon the emphasis accorded the different diagnostic procedures. 5 , 6, 8 In centers where endoscopic techniques are pursued vigorously, gastritis is generally considered to be more frequent; where radiologic studies have primary importance, duodenal ulcer disease is reported more often. In almost every case, direct visualization of the gastric mucosa should provide a substantially reliable opinion as to whether the bleeding originates in the stomach. Observation of the reflux of blood through the pyloric canal into the antrum may occasionally provide a clue as to the duodenal origin of the hemorrhage, although typically the gastroscopic examination in cases of duodenal ulceration is not diagnostic. Bleeding as the result of drug use is becoming more frequent, and aspirin and related compounds remain the most common offenders. When drug ingestion is implicated in gastric bleeding, early gastroscopic examination is imperative. It has been shown repeatedly that the superficial, focal erosions related to salicylate ingestion, which may bleed with startling severity, heal within a few days. Prompt observation is essential if a diagnosis is to be made. Unfortunately, the patient with chronic duodenal ulceration may also develop a drug-induced gastritis and occasionally both lesions may be bleeding actively. The presence of hemor-
GASTROSCOPY OF PEPTIC ULCERATION
967
rhagic gastritis at gastroscopy, therefore, does not diminish the need for subsequent x-ray examination in search of an active duodenal inflammatory reaction. Similarly, patients with known portal cirrhosis are also prime candidates for hemorrhagic gastritis induced by a drug or alcohol. Upper gastrointestinal bleeding in cirrhotics frequently arises from sites other than esophageal varices.! Examination of the esophagus should always be included in the endoscopic evaluation of the bleeding patient. Gastroscopy is particularly helpful in critical illness with acute stress ulcer.2 These lesions are typically hemorrhagic in their presentation and often occur under circumstances where the usual diagnostic procedures cannot be readily performed because of the patient's precarious state. The differentiation between multiple gastric erosions and a single gastric or duodenal ulcer may be of great importance in decisions about management. The duodenal ulcer or single gastric lesion is often best treated by early surgical intervention. Gastroscopic examination with a flexible instrument may be of the most assistance in evaluation of the patient with symptoms following subtotal gastrectomy. In almost all cases the gastrojejunal anastomosis can be well visualized, and in most instances the instrument can be passed through the stoma for examination of the jejunal mucosa also. A mild degree of edema and erythema is a common finding on the gastric side of the anastomosis and is probably of little clinical significance. More pronounced signs of an inflammatory reaction in the peristomal mucosa often seem associated with digestive symptoms, usually of a nondiagnostic nature. Discrete ulcers are uncommon in this situation. Mucosal friability suggests that oozing from the inflamed surface may contribute the mild anemia so commonly associated with postgastrectomy symptoms. Actual anastomotic ulceration, which is primarily jejunal in location, may be difficult to view directly because of its proximity to the anastomosis with the associated mucosal folds, scarring, and fixation. Marked edema and inflammation often provide the clues of adjacent ulceration. It may be possible only to view a small portion of the actual ulcer crater, but even this degree of visualization will be adequate to confirm the diagnosis and direct therapy. A newly recognized postoperative complication, so-called alkaline gastritis, may not have distinctly characteristic gastroscopic features, yet endoscopic findings may serve to support the diagnosis. 9 In the reported cases, where the condition had been suspected and appropriate surgical procedures allayed the symptoms, the gastroscopic evidence was an intense, diffuse inflammatory reaction involving much of the mucosa of the gastric remnant. Diffuse mucosal oozing was common, and a constant feature was the regurgitation of an unusually large volume of bile-stained jejunal content into the gastric pouch. In the few patients who were reexamined after symptomatically successful surgery, the inflammatory reaction had cleared and the jejunal regurgitation was markedly reduced.
968
JOHN
A.
HIGGINS
CONCLUSIONS The endoscopic evaluation of the upper part of the digestive tract has become an increasingly more useful and reliable procedure in the differential diagnosis of conditions involving this system. It may be the decisive examination in establishing the cause of bleeding or pain or it may be employed to confirm the nature of an ulceration already detected by gastric x-ray. On occasion a negative finding may support the clinical impression that abdominal symptoms are not the result of organic gastric disease. In all circumstances the findings on the examination should be interpreted in the light of the clinical setting, and the technical and interpretive limitations of the procedure should be well understood by the physician responsible for the patient's care. Within this framework the gastroscopic examination can be of great benefit to the care of some patients with peptic ulceration.
REFERENCES 1. Conn, HO, Brodoff M: Emergency esophagoscopy in the diagnosis of upper gastrointestinal hemorrhage: a cirtical evaluation of its diagnostic accuracy. Gastroenterology 47:505512,1964 2. David E, McIlrath DC, Higgins JA: Clinical experiences with acute gastroduodenal ulcers. Mayo Clin Proc 46:15-24,1971 3. Hirschowitz BI, Curtiss LE, Peters CW, et al: Demonstration of a new gastroscope, the fiberscope. Gastroenterology 35:50-53, 1958 4. Katz D: Morbidity and mortality in standard and flexible gastrointestinal endoscopy. Gastroint Endosc 15:134-141, 1969 5. Katz D, Douvres P, Weisberg H, et al: Early endoscopic diagnosis of acute upper gastrointestinal hemorrhage: demonstration of relatively high incidence of erosions as a source of bleeding. JAMA 188:405-408, 1964 6. Lilly JO: Locating the source of gastrointestinal bleeding. Postgrad Med44:113-119, 1968 7. Palmer ED: Accuracy and errors in the diagnosis of gastric ulcer. Gastroint Endos 16: 117-118,1969. 8. Palmer ED: The vigorous diagnostic approach to upper-gastrointestinal tract hemorrhage: A 23-year prospective study of 1,400 patients. JAMA 207:1477-1480, 1969 9. Van Heerden JA, Priestley JT, Farrow GM, et al: Postoperative alkaline reflux gastritis: surgical implications. Amer J Surg 118:427-433, 1969
Gastroscopy of Peptic Ulceration
John A. Higgins, M.D.
Since the introduction of the fiberoptic gastroscope by Hirschowitz in 1958, the endoscopist has become an increasingly active member of the diagnostic team evaluating the patient with complicated peptic ulcer disease. In theory, the availability of a flexible optical system for inspecting a well-illuminated field should have largely solved the problems of diagnosing conditions involving the mucosa of the esophagus and stomach. The structural inadequacies of the earlier fiberoptic equipment, however, left many important areas of the gastric interior (for example, cardia, lesser curve below the angle) relatively inaccessible for inspection, and the subjectiveness of visual diagnosis introduces sufficient error so that the anticipated accuracy of fiberoptic endoscopy has not been fully realized. Yet with broadening of experience and technical improvements in instrumentation, considerable progress has been made. Currently, one of the major problems confronting the practicing gastrointestinal endoscopist is that of keeping abreast with new developments in instrumentation. Naturally, he wants the greatest capacity for visualization, photography, biopsy, and cytologic study combined into a single instrument which can then be used to examine the esophagus, stomach, and duodenal cap. Efforts to develop such an ideal instrument have resulted in the rapid illtroduction of serial modifications, each possessing some improvement, though often at the cost of some other advantage. But recently available instruments do indeed have the length and flexibility for visualizing the esophagus, cardia, distal antrum, and proximal duodenum; and they have reasonably adequate biopsying devices and provide for photographic recording of the examination (Figs. 1 to 3). Therefore the majority of the mucosal lesions resulting from peptic disease in the upper digestive tract should be accessible and identifiable to the trained endoscopist, and his examination should be of great benefit in the investigation of such patients.
TECHNIQUE The obvious comfort and apparent safety provided the patient by flexible fiberoptic equipment seem to be associated, to a degree, with Surgical Clinics of North America- Vol. 51, No.4, August 1971
961
962
JOHN
A.
HIGGINS
Figure 1. A.C.M.1. Mark 87 fiberoptic gastroesophageal endoscope with straight forward visual system and biopsy capabilities.
some of its hazards as well. Surveys comparing the complications of gastroscopic examination with rigid and with flexible instruments 4 indicate a somewhat higher incidence of perforation and associated trauma with the flexible endoscope, although with either instrument the occurrence of significant injury was less than 0.1 %. The higher incidence of injury with the flexible instrument can only be explained
Figure 2. A.C.M.1. Mark 7 fiberoptic gastroscope with right-angle optical system and biopsy capabilities.
GASTROSCOPY OF PEPTIC ULCERATION
963
Figure 3. Olympus Model GFB fiberoptic gastroscope with right-angle optical system and maneuverable biopsy attachment.
by the false sense of security associated with its use-a feeling which may induce inadequately trained examiners to overreach their experience and the usually careful endoscopist to neglect necessary precautions. As with the semi-rigid endoscope, injuries appear to be most common on the posterior wall where the upper esophagus overlies the vertebral bodies of the cervical spine. The mechanical advantages of fiberoptic instruments do not allow the careful preparation of the patient to be neglected. The adequacy and acceptance of the procedure are significantly improved if the technique and the aim of the examination can be discussed previously with the patient, preferably by the physician who will perform it. Nearly always the patient's apprehension is more distressing than the examination itself. Even in an emergency situation, a calm, stepwise explanation of the procedure can allay unnecessary fears and make possible a more satisfactory examination and more certain result. If the patient is given the proper psychologic preparation, use of topical pharyngeal anesthesia and preexamination sedation may be considered optional. Most endoscopists, however, believe these measures add enough to patient comfort to offset the minimal risks of significant hypersensitivity reactions or respiratory depression. Pharyngeal swabbing, spraying, or gargling with topical anesthetic preparations is usual, but in cases that include a history of hypersensitivity to these agents the examination ordinarily can be completed satisfactorily without this preparation. Parenteral administration of meperidine and, more recently, intravenous administration of diazepam have been widely used to provide temporary sedation and a degree of amnesia for the examination. Normal attention to dose and administration should result in adequate relaxation without the risk of serious respiratory depression. Lavage of the stomach prior to the gastroscopic examination is no longer a routine procedure. Gastric secretions are rarely a significant hindrance to an essentially complete evaluation of the gastric mucosal surface. The maneuverability of the instrument and careful appropriate changes of the patient's position usually allow all areas of the body of the stomach to be seen adequately for diagnostic purposes. Anticholinergic drugs may be used routinely, although to a degree this may influence the interpretation of the contraction patterns of the stomach wall. Many endoscopists now advocate intravenous administration of propantheline bromide during the examination when careful evaluation
964
JOHN
A.
HIGGINS
of the transiently paralyzed and distended antrum is necessary in the search for possible mucosal erosions or ulcerations. To some extent, the advent of fiberoptic gastrointestinal endoscopes has influenced the concept of a standard technique in performing the examination. The flexibility of the instrument reduces the need for specific maneuvers for visualization of certain portions of the mucosal surface, and no two examinations proceed in exactly the same sequence. Some examiners prefer a stepwise approach, inspecting the esophagus, stomach, antrum, and prepyloric regions as they are reached. Others advance the instrument as directly as possible to the distal antrum and perform the detailed examination as it is being withdrawn. In a situation where a specific lesion is suspected from a prior x-ray study, it is often advantageous to inspect the area in question as soon as possible, while the patient's tolerance is still optimal, and to search for secondary factors after the primary lesion has been located and evaluated. But whereas technical improvements have produced a flexible fiberoptic instrument with a superb optical system and associated photographic, biopsy, or cytologic capabilities, the ultimate value of the procedure rests upon the interpretation of the examiner. It is his evaluation of his visual observations and his expertness in maneuvering the instrument and the patient which most influence the diagnostic accuracy , of the examination and therefore the decisions relating to management.
INDICATIONS The indications for gastroscopic examination in patients with pepticulcer disease and its complications can justly be considered to be either rather limited or nearly limitless, depending upon the availability and reliability of other diagnostic aids and the nature of the problem presented. In all cases it should be considered as complementary to other diagnostic resources, and in any given instance it may be of primary or of only secondary significance. In general, diagnostic efforts are best served by combining the techniques of the radiologist and the endoscopist and, in appropriate situations, the cytologist. The responsible physician, however, should not feel compelled routinely to perform all possible diagnostic studies if the nature of the problem is clearly evident from one or another of the procedures. In a case of nonspecific upper abdominal pain with a negative x-ray of the stomach and duodenum and no previous gastric surgery, there is little likelihood of benefit from a gastroscopic examination; but even with negative radiologic studies, the source of upper gastrointestinal bleeding frequently can be determined by endoscopic evaluation. The problems presented by the gastrectomized patient-usually pain or anemia-are particularly difficult for the radiologist, and the flexible fiberoptic gastroscope adds considerably to the evaluation of the gastrojejunal anastomotic area. It is best to consider the results of both roentgenographic and endoscopic examinations when making decisions on management of ulceration of the gastric mucosa.
GASTROSCOPY OF PEPTIC ULCERATION
965
EVALUATION The most common problem facing the gastroscopist is further evaluation of an ulcerating gastric lesion demonstrated by x-ray. The malignant potential of the lesion has been partially assessed by the character of the roentgenographic picture, and the aim of the endoscopic examination is to provide further evaluation of potential malignancy and to search for additional evidence of disease within the stomach. The benign gastric ulcer is characterized by a sharply demarcated edge and a smooth, clean white base in the crater. The inflammatory reaction in the adjacent mucosa is variable: edema, erythema, and friability may be prominent, or nearly normal mucosa may extend almost to the edge of the crater. If prominent mucosal edema is associated with a lesion, the thickening of the gastric wall may distort peristaltic contractions and thus suggest the presence of malignant infiltration. In general, the neoplastic ulcer is less inclined to be regular in outline, its edge is less clearly defined, its base often nodular and uneven, its color usually more gray than white. No single feature has certain diagnostic significance, but the composite has considerable accuracy. Combined with x-ray evaluation, the gastroscopic examination should yield a correct diagnosis of gastric ulceration in well over 90% of cases. 7 Judicious use of direct-vision biopsy from the edge of the lesion or cytologic study of gastric washings after an abrasive jet has been directed against the lesion under gastroscopic control also increases the accuracy of detecting malignancy. Separation of multiple ulcers by apparently normal mucosa favors benignancy, but the linking of several ulcers by nodularity or induration between them may be a manifestation of lymphoma or carcinoma. Gastroscopic reexamination is often of considerable value in the follow-up of ulcers during nonsurgical treatment. Direct observation of the lesion may indicate changes of malignant character even though the therapeutic program has mitigated symptoms and roentgenographic studies have indicated a reduction in the associated inflammatory reaction. Additionally, many antral gastric ulcers are accompanied, in both active and healing phases, by significant deformity. In such circumstances the endoscopic examination may be the only reliable way of following the influence of treatment. On rare occasions the center of a benign gastric ulcer may completely epithelize while the crater deformity persists. The radiologist may suspect this from absence of induration and spasm; however, the gastroscopist is usually in a better position to evaluate this probability by his direct view of the site of the lesion. A wide variety of ulcer-like dyspepsias are encountered in medical practice. X-ray studies in these conditions are equivocal or negative, and gastroscopic evaluation usually does not yield much additional evidence of diagnostic significance. Occasionally a definite inflammatory reaction of the distal antral mucosa with erythema, edema, and often increased friability provides a clue to adjacent duodenal ulceration or at least adds some degree of confidence to the recommendation for an ulcer management program. As noted previously, antral inflammatory disease may ,
366
JOHN
A.
HIGGINS
result in significant deformity which may be difficult to distinguish from a stenosing malignancy, particularly if previous films are not available for comparison. If gastroscopic examination shows the area is not ulcerated, peristaltic contractions are symmetric, and the narrowed segment can be distended by the insufflation of air, then the likelihood of malignancy is remote and a period of careful observation can be advised. The endoscopist may encounter special problems in bleeding from the upper gastrointestinal tract. Massive hemorrhage requires prompt diagnostic measures so that appropriate definitive treatment, as well as the necessary supportive therapy, may be instituted as soon as possible. Often the patient's condition does not allow satisfactory roentgenographic study, so the endoscopy is the only available means of diagnostic study. Inasmuch as determination of the bleeding site, or sites, significantly influences early management decisions, a gastroscopic examination should be performed as soon as the patient's hemodynamic status will allow. The relative ease and comfort of the fiberoptic examination facilitate its early use in emergency situations. Gastric lavage should be an early procedure in cases of acute upper gastrointestinal bleeding of any clinical significance. When endoscopic examination is anticipated, the lavage should be performed with a tube of large caliber so that clots may be thoroughly evacuated. Unless the gastric mucosa can be reasonably well cleansed, a gastroscopist is seriously hampered in his efforts to detect a specific bleeding site. Thus, in massive hemorrhage when bleeding cannot be even temporarily controlled, the localizing diagnostic value of any visual evaluation is significantly reduced. The most common cause of upper gastrointestinal bleeding is variously reported to be hemorrhagic gastritis or duodenal ulcer-depending, to a degree, upon the emphasis accorded the different diagnostic procedures. 5 , 6, 8 In centers where endoscopic techniques are pursued vigorously, gastritis is generally considered to be more frequent; where radiologic studies have primary importance, duodenal ulcer disease is reported more often. In almost every case, direct visualization of the gastric mucosa should provide a substantially reliable opinion as to whether the bleeding originates in the stomach. Observation of the reflux of blood through the pyloric canal into the antrum may occasionally provide a clue as to the duodenal origin of the hemorrhage, although typically the gastroscopic examination in cases of duodenal ulceration is not diagnostic. Bleeding as the result of drug use is becoming more frequent, and aspirin and related compounds remain the most common offenders. When drug ingestion is implicated in gastric bleeding, early gastroscopic examination is imperative. It has been shown repeatedly that the superficial, focal erosions related to salicylate ingestion, which may bleed with startling severity, heal within a few days. Prompt observation is essential if a diagnosis is to be made. Unfortunately, the patient with chronic duodenal ulceration may also develop a drug-induced gastritis and occasionally both lesions may be bleeding actively. The presence of hemor-
GASTROSCOPY OF PEPTIC ULCERATION
967
rhagic gastritis at gastroscopy, therefore, does not diminish the need for subsequent x-ray examination in search of an active duodenal inflammatory reaction. Similarly, patients with known portal cirrhosis are also prime candidates for hemorrhagic gastritis induced by a drug or alcohol. Upper gastrointestinal bleeding in cirrhotics frequently arises from sites other than esophageal varices.! Examination of the esophagus should always be included in the endoscopic evaluation of the bleeding patient. Gastroscopy is particularly helpful in critical illness with acute stress ulcer.2 These lesions are typically hemorrhagic in their presentation and often occur under circumstances where the usual diagnostic procedures cannot be readily performed because of the patient's precarious state. The differentiation between multiple gastric erosions and a single gastric or duodenal ulcer may be of great importance in decisions about management. The duodenal ulcer or single gastric lesion is often best treated by early surgical intervention. Gastroscopic examination with a flexible instrument may be of the most assistance in evaluation of the patient with symptoms following subtotal gastrectomy. In almost all cases the gastrojejunal anastomosis can be well visualized, and in most instances the instrument can be passed through the stoma for examination of the jejunal mucosa also. A mild degree of edema and erythema is a common finding on the gastric side of the anastomosis and is probably of little clinical significance. More pronounced signs of an inflammatory reaction in the peristomal mucosa often seem associated with digestive symptoms, usually of a nondiagnostic nature. Discrete ulcers are uncommon in this situation. Mucosal friability suggests that oozing from the inflamed surface may contribute the mild anemia so commonly associated with postgastrectomy symptoms. Actual anastomotic ulceration, which is primarily jejunal in location, may be difficult to view directly because of its proximity to the anastomosis with the associated mucosal folds, scarring, and fixation. Marked edema and inflammation often provide the clues of adjacent ulceration. It may be possible only to view a small portion of the actual ulcer crater, but even this degree of visualization will be adequate to confirm the diagnosis and direct therapy. A newly recognized postoperative complication, so-called alkaline gastritis, may not have distinctly characteristic gastroscopic features, yet endoscopic findings may serve to support the diagnosis. 9 In the reported cases, where the condition had been suspected and appropriate surgical procedures allayed the symptoms, the gastroscopic evidence was an intense, diffuse inflammatory reaction involving much of the mucosa of the gastric remnant. Diffuse mucosal oozing was common, and a constant feature was the regurgitation of an unusually large volume of bile-stained jejunal content into the gastric pouch. In the few patients who were reexamined after symptomatically successful surgery, the inflammatory reaction had cleared and the jejunal regurgitation was markedly reduced.
968
JOHN
A.
HIGGINS
CONCLUSIONS The endoscopic evaluation of the upper part of the digestive tract has become an increasingly more useful and reliable procedure in the differential diagnosis of conditions involving this system. It may be the decisive examination in establishing the cause of bleeding or pain or it may be employed to confirm the nature of an ulceration already detected by gastric x-ray. On occasion a negative finding may support the clinical impression that abdominal symptoms are not the result of organic gastric disease. In all circumstances the findings on the examination should be interpreted in the light of the clinical setting, and the technical and interpretive limitations of the procedure should be well understood by the physician responsible for the patient's care. Within this framework the gastroscopic examination can be of great benefit to the care of some patients with peptic ulceration.
REFERENCES 1. Conn, HO, Brodoff M: Emergency esophagoscopy in the diagnosis of upper gastrointestinal hemorrhage: a cirtical evaluation of its diagnostic accuracy. Gastroenterology 47:505512,1964 2. David E, McIlrath DC, Higgins JA: Clinical experiences with acute gastroduodenal ulcers. Mayo Clin Proc 46:15-24,1971 3. Hirschowitz BI, Curtiss LE, Peters CW, et al: Demonstration of a new gastroscope, the fiberscope. Gastroenterology 35:50-53, 1958 4. Katz D: Morbidity and mortality in standard and flexible gastrointestinal endoscopy. Gastroint Endosc 15:134-141, 1969 5. Katz D, Douvres P, Weisberg H, et al: Early endoscopic diagnosis of acute upper gastrointestinal hemorrhage: demonstration of relatively high incidence of erosions as a source of bleeding. JAMA 188:405-408, 1964 6. Lilly JO: Locating the source of gastrointestinal bleeding. Postgrad Med44:113-119, 1968 7. Palmer ED: Accuracy and errors in the diagnosis of gastric ulcer. Gastroint Endos 16: 117-118,1969. 8. Palmer ED: The vigorous diagnostic approach to upper-gastrointestinal tract hemorrhage: A 23-year prospective study of 1,400 patients. JAMA 207:1477-1480, 1969 9. Van Heerden JA, Priestley JT, Farrow GM, et al: Postoperative alkaline reflux gastritis: surgical implications. Amer J Surg 118:427-433, 1969