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Peptic esophagitis with duodenal ulcer
Peptic
Esophagitis ASHER WINKELSTEIN,
From Tbe Mount Sinai Hospital, New York, New York. 1934, I discussed before the American MedicaI Association a new clinica entity, peptic esophagitis, previousIy undescribed [I]. The association of this Iower esophagea1 Iesion with hyperchlorhydria and peptic uIcer of the duodenum or stomach led to the theory that these cases were peptic in origin, i.e., they were due to the action of pepsin and hydrochloric acid on a susceptible mucosa. HamperI, the Viennese pathotogist then delivered a paper before the Deutschen Pathologischen GeseIIschaft entitled “Peptische Oesophagitis.” He described the postmortem features of a group of patients hvith an erosive, stenosing inff ammation of the lower esophagus [2]. Since these two earIy cJescriptions, many interesting papers on this subject Jrave appeared in the literature. Other types of esophagi& in which peptic activity (hyclrochIoric acid and pepsin) probably plays a prominent role are: (I) esophagitis with marginal ukeration at the cardia secondary to the hiatus hernias, associated with a short esophagus (studied by WoIf and others [3]); (2) esophagitis due to severe repeated vomiting, such as occurs frequentIy after abdominal operations and in pregnancy; (3) esophagitis due to proIonged esophagea1 intubation or frequent gastric Iavages; (4) esophagitis secondary to operations in which the esophagus is anastomosed to the stomach (seen frequentIy after the Heyrovsky operation for cardiospasm); and (5) the sobtary peptic uIcer of the lower esophagus, associated with persistent embryonic columnar epithehum. N
I
CLINICAL FEATURES ApparentIy the disease is uncommon, but Jackson has pointed out that esophagoscopies are usuaIIy performed onJy when there is an important indication. It is probabJe that in
with Duodenal
Ulcer
M.D., New York, New York
patients with gastric or duodena1 ulcer who have severe heartburn and acid regurgitation, evidence of a mild esophagitis wouId be reveaIed if esophagoscopy with biopsy were empIoyed in the study. Symptoms. The symptoms in my series of twenty cases were dysphagia (sixteen patients), heartburn (six patients), regurgitation and/or vomiting (seven patients), substernal pain (seven patients), Ioss of weight (ten patients) and hemorrhage. Dysphagia was the first and most prominent symptom in seventeen of the twenty patients. Regurgitation or vomiting of sour fluid with or without food was a common symptom. Lower substernal pain on swallowing, without radiation to the back, was noted occasionaIIy. Dysphagia seems to be the most constant and important symptom. Hyperchlorhydria occurred in 85 per cent of the cases. Three patients had a gastric acidity of 20 to 40 clinica units of free hydrochIoric acid, ten patients had an acidity of 40 to 80 units, and seven had an acidity of more than 80 units. The chief comphcations were stenosis, hemorrhage and perforation. Stenosis occurred in nine patients. The role of inflammatory swelling, spasm and fibrous stricture in the production of the stenosis couId be determined accurately only by a study of resected specimens or postmortem material. It is probable that a1J three factors are involved. Fibrous stenosing esophagitis occurs in the Iate stages of the severe cases. Massive hemorrhage occurred in four patients. In three it took place after the onset of dysphagia. In all cases it took the form of hematemesis. Perforation occurred in one patient and was found at the postmortem examination in a small hiatus hernia immediately below the area of stenotic peptic esophagitis. Previous Operations. Four patients had undergone previous operations for duodenal
Peptic
Esophagitis
with
ulcer. One had had an operation for closure of a perforation, two had had gastroenterostomies, and one had had subtotal gastrectomy. Fifteen Association with Ulcer and Hernia. patients had a duodenal uIcer and two had gastric ulcers. In one patient a gastric uIcer, and in another a duodenal ulcer, developed at a later date. One patient had a previous solitary peptic ulcer of the esophagus. In five cases a smaI1 hiatus hernia was found. These hernias are probably secondary, due to traction. In one case a Iarger hiatus hernia that may have been due to a pre-existing short esophagus was revealed. Paraesophageal hiatus hernias were not seen in this series. It has Association with Pyloric Obstruction. been suggested that peptic esophagitis is prone to occur in patients with pyloric obstruction. With this in mind, a review of the cases in this series reveaIed the presence of pyloric obstruction before the onset of the dysphagia in only one case. Peptic esophagitis is rarely encountered, at Ieast clinically, in large series of patients with pyIoric obstruction. RADIOGRAPHIC
DuodenaI
UIcer
minimum inflammatory changes show considerably less striking findings on the roentgenologic examination. The faiIure of normal distensibility of the lower third of the esophagus may be seen onIy after the examination of numerous films, including those with the patient in the erect position. It can then be noted that this portion of the esophagus does not dilate as much as wouId be anticipated normaIly. Instead, when maximalIy dilated, a tubuIar cylindric structure with paraIle1 side walls is visualized. Within this segment the contours of the involved portion ma)- show a fuzziness or a fine irreguIarity, and the mucosal pattern again cannot be clearly delineated. When partiaIIy empty, this segment may show irregular tertiary contractions. Prompt regurgitation of barium was noted in two patients. Careful studies of this refIux are not available for the entire series. The differential diagnosis from marginal or peptic ulceration above a large hiatus hernia is not difficult. Marginal ulceration immediateIy above a Iarge hiatus hernia associated with a short esophagus may be differentiated from the peptic esophagitis associated with duodenal or gastric ulcer by the foIIowing radiographic findings in cases of margina ukeration: (I) The esophagus is short. (2) The area of narrowing in the Iowermost end of the esophagus is short (I cm. usuaIIy). (3) The esophagus above this area is pliable. (4) A slit-Iike uIcer crater or an ulcer patch may be identified immediately proximal to the cardia. (5) TranscardiaI reff ux is marked and prompt. The differentiation from cardiospasm is usualI> simpIe radiographicaIIy. It may also be readily accomplished in most cases of carcinoma; however, in a smaI1 number of cases, differentiation cannot be made radiographically and esophagoscopy with biopsy is then necessary.
FEATURES
The roentgenologic tindings are essentiaIly of two varieties, namely, changes in distensibiIity or narrowing of the lower third of the esophagus and changes in the mucosal pattern. In severe cases the lack of distensibility may be so marked as to produce a Iong segment of considerable narrowing involving the lower third of the esophagus. The junction between the moderateIy dilated esophagus above and the narrowed portion beIow is gradual and symmetric. The mucosal pattern throughout the narrowed segment is distorted and may have a hazy irreguIar appearance. Discrete projecting uIcer craters are not seen; however, the margins of the narrowed segment may show a fine serration. Coarser irregularities are not common. The invoIved segment usuaIly shows no evidence of peristaItic activity. Slight changes in caliber on repeated examinations may be noted. In the diIated segment above the invoIved area there may be smaI1 irreguIar transitory contractions. In the type of case associated with prolonged peptic esophagitis, a very smaIl tent-like traction hiatus hernia may be seen. This occurred in five patients. In contrast to the severe cases of peptic esophagitis described previously, persons with
PATHOLOGY
The appearances on esophGross Pathology. agoscopy are marked edema and congestion of the affected mucous membrane. This usuaIIy invoIves a long segment occupying the Iower haIf or third of the esophagus, but occasionaIIy may spread upward to invoIve the entire esophagus to a Iesser degree. Multiple smalI superficia1 uIcerations may be seen on the surface of irreguIar foIds. OccasionaIIy, a Iarger narrow area of ffat uIceration runs IongitudinaIly immediateIy above the cardia on the 235
WinkeIstein posterior waI1. When the necrotic membrane is removed, a denuded area with an intensely red granuIar base becomes visible. Small noduIar excrescences or a diffuse granular appearance may be present. In addition, there may be adherent white exudates in small patches or larger plaques that are readily removed by suction, exposing an edematous mucosa. Rarely, smaI1 petechiae have been observed. There is marked narrowing of the Iumen in the lower esophagus that usually can be traversed by the esophagoscope, since the narrowing is most often due to spasm. In advanced cases, however, impassabIe organic stenosis due to Fibrous stricture formation may be encountered and require In the earIy cases the repeated diIatations. cardia seems competent, and gastric rellux is not seen. ReIIux has been observed in a few cases of Iong duration in which a fibrous repIacement of the card& has occurred. Microscopic Pathology. The microscopic features have been presented in considerable detai1 by HamperI. He mentions the foIIowing as earIy necrosis, epitheIia1 hyperIesions : epithelial pIasia, a hyaline mucosa1 zone spIitting the superficial epitheIia1 layer, poIynucIear inhltraand hypertrophy of the muscularis tion, mucosae. These changes are generaIIy accepted by pathoIogists as evidence of peptic inflammation, i.e., inflammation due to the destructive action of hydrochIoric acid and pepsin on a susceptible mucosa, and form perhaps the best diagnostic criteria of peptic esophagitis. FinaIIy, fibrosis and stenosis are seen. The erosions, as a rule, do not penetrate through the muscuIaris mucosae. This diffuse, superficia1 uIceration seen in peptic esophagitis does not, in my experience, eventuate in the deep, circumscribed solitary peptic ulcer of the Iower esophagus. THERAPY
Medical Tberapy. AI1 of these patients were given the conventional Sippy type of therapy with anticholinergic drugs, including methantheIine bromide (banthine@) in some cases, and aIkaIis. Six patients were treated with continuous intraesophageal miIk-soda drip therapy. Mechanica diIatation was empIoyed in six cases. This was usuaIIy started by passing graded ditators through the endoscope. When a No. 36 French dilator couId be passed, endoscopic diIatation was discontinued and a 236
No. 36 French Hurst mercury-weighted rubber esophagea1 bougie was substituted. The size of the tube is gradually increased if possible to a No. 40 French. The resuIts of this type of therapy are often remarkabIy good. These medical measures are usuaIIy successful and result in either a cure or a remission. I have seen a markedIy constricted esophagus widen to almost norma diameter after diIatation. Surgical Therapy. One patient underwent transthoracic biIatera1 vagotomy and four patients underwent subtota1 gastrectomy. In general, the resuIts of these operations have been disappointing. This may be due to the fact that surgery was instituted only in the most severe cases with marked stenosis, hemorrhage or intractable dysphagia. Whether the poor results are due to the persistence of free acid or to a continuation of the disease process into greater stenosis is conjectura1. The fact remains that subsequent dilatations were necessary to relieve these patients from progressive stenosis. Probably the surgica1 procedure of resection of the Iower esophagus and upper haIf of the stomach with bilateral vagotomy and esophagogastrostomy seems best. COURSE
AND
DIAGNOSIS
Sixteen patients seemed to have done we11 with medica or surgica1 therapy. Three still had symptoms despite therapy, and one died of a perforation. The most important disease to be differentiated is, of course, carcinoma of the Iower esophagus. The occurrence of peptic esophagitis in the oIder age group, the type of symptoms, the marked Ioss of weight and the radiographic features combine to suggest carcinoma strongIy. Although the radiographic features of peptic esophagitis are characteristic, they may be imitated exactIy in a few rare cases by a carcinoma. Endoscopy alone may aIso be inadequate for the differentiation; therefore, biopsy is imperativeIy indicated. Cardiospasm is usuaIIy easily differentiated radiographically and endoscopicaIIy. Other types of esophagitis may be diagnosed and separated from this group by the history and observations of definite causal agents. Such agents incIude proIonged vomiting, intubation, extensive burns, genera1 infections, cerebra1 Iesions and chemical agents. I have aIso encountered a few cases of peptic esophagitis
Peptic
Esophagitis
with
without any apparent etiologic explanation. These will perhaps be clarified by the occurrence of a peptic ulcer of the duodenum or stomach Iater in the history. SCMMARI
This disease is apparently one that afIlicts men in the older age groups. In the group under consideration, duodena1 uker or gastric ulcer (and in one case a previous peptic ulcer of the esophagus) were constantly associated. From this feature, the location of the lesion in the lower third of the esophagus and the hyperchlorhydria in most cases, the conclusion seems inescapable that this disease is peptic in origin. The response to medical and surgical antiulcer therapy is striking. What the ultimate, detailed mechanism of peptic esophagitis is seems purely conjectural at present. RefIux may result from the hypersecretion associated with duodenal ulcer or from an unexplained decrease in the tone of the cardial sphincter. Perhaps the characteristic nocturnal hypersecretion with the patient in the horizontal position leads to a prolonged bathing of the lower esophagus by the highIy
237
DuodenaI
Ulcer
As a result, localized acid gastric contents. peptic esophagitis occurs in the lower esophagus with a spastic narrowing. The disease is characterized by a Iong histoq of cluodenal or gastric ulcer with a subsequent shorter history of esophageal symptoms. The chief symptoms are dysphagia, heartburn, regurgitation, substernal pain and loss of weight. The complications are stenosis, hemorrhage and perforation. There is no evidence that this is a precancerous disease. The response to medical therapy and mechanical dilatation is usuaIIy good. In a smal1 percentage of the patients, surgical therapy is necessary. This condition is important not only as a disease entity but also in the differential diagnosis from carcinoma of the lower end of the esophagus. REFERENCES
I. WINKELSTEIN, A. Peptic csophagitis: new clinical entity. J. A. M. A., 104: 906-909, 1935. 2. HAMPERL, H. Peptische Oesophagitis. Verhandl. d. 1934. deutsch. path. G&ells&., 27: ;08-215, 2. WOLF. B. S.. MARSHAK. R. and SOM. M. L. Short esophagus with esophagogxstric or margina ulceration. Radiology, 61: 473-494, ,953.
Esophagitis ASHER WINKELSTEIN,
From Tbe Mount Sinai Hospital, New York, New York. 1934, I discussed before the American MedicaI Association a new clinica entity, peptic esophagitis, previousIy undescribed [I]. The association of this Iower esophagea1 Iesion with hyperchlorhydria and peptic uIcer of the duodenum or stomach led to the theory that these cases were peptic in origin, i.e., they were due to the action of pepsin and hydrochloric acid on a susceptible mucosa. HamperI, the Viennese pathotogist then delivered a paper before the Deutschen Pathologischen GeseIIschaft entitled “Peptische Oesophagitis.” He described the postmortem features of a group of patients hvith an erosive, stenosing inff ammation of the lower esophagus [2]. Since these two earIy cJescriptions, many interesting papers on this subject Jrave appeared in the literature. Other types of esophagi& in which peptic activity (hyclrochIoric acid and pepsin) probably plays a prominent role are: (I) esophagitis with marginal ukeration at the cardia secondary to the hiatus hernias, associated with a short esophagus (studied by WoIf and others [3]); (2) esophagitis due to severe repeated vomiting, such as occurs frequentIy after abdominal operations and in pregnancy; (3) esophagitis due to proIonged esophagea1 intubation or frequent gastric Iavages; (4) esophagitis secondary to operations in which the esophagus is anastomosed to the stomach (seen frequentIy after the Heyrovsky operation for cardiospasm); and (5) the sobtary peptic uIcer of the lower esophagus, associated with persistent embryonic columnar epithehum. N
I
CLINICAL FEATURES ApparentIy the disease is uncommon, but Jackson has pointed out that esophagoscopies are usuaIIy performed onJy when there is an important indication. It is probabJe that in
with Duodenal
Ulcer
M.D., New York, New York
patients with gastric or duodena1 ulcer who have severe heartburn and acid regurgitation, evidence of a mild esophagitis wouId be reveaIed if esophagoscopy with biopsy were empIoyed in the study. Symptoms. The symptoms in my series of twenty cases were dysphagia (sixteen patients), heartburn (six patients), regurgitation and/or vomiting (seven patients), substernal pain (seven patients), Ioss of weight (ten patients) and hemorrhage. Dysphagia was the first and most prominent symptom in seventeen of the twenty patients. Regurgitation or vomiting of sour fluid with or without food was a common symptom. Lower substernal pain on swallowing, without radiation to the back, was noted occasionaIIy. Dysphagia seems to be the most constant and important symptom. Hyperchlorhydria occurred in 85 per cent of the cases. Three patients had a gastric acidity of 20 to 40 clinica units of free hydrochIoric acid, ten patients had an acidity of 40 to 80 units, and seven had an acidity of more than 80 units. The chief comphcations were stenosis, hemorrhage and perforation. Stenosis occurred in nine patients. The role of inflammatory swelling, spasm and fibrous stricture in the production of the stenosis couId be determined accurately only by a study of resected specimens or postmortem material. It is probable that a1J three factors are involved. Fibrous stenosing esophagitis occurs in the Iate stages of the severe cases. Massive hemorrhage occurred in four patients. In three it took place after the onset of dysphagia. In all cases it took the form of hematemesis. Perforation occurred in one patient and was found at the postmortem examination in a small hiatus hernia immediately below the area of stenotic peptic esophagitis. Previous Operations. Four patients had undergone previous operations for duodenal
Peptic
Esophagitis
with
ulcer. One had had an operation for closure of a perforation, two had had gastroenterostomies, and one had had subtotal gastrectomy. Fifteen Association with Ulcer and Hernia. patients had a duodenal uIcer and two had gastric ulcers. In one patient a gastric uIcer, and in another a duodenal ulcer, developed at a later date. One patient had a previous solitary peptic ulcer of the esophagus. In five cases a smaI1 hiatus hernia was found. These hernias are probably secondary, due to traction. In one case a Iarger hiatus hernia that may have been due to a pre-existing short esophagus was revealed. Paraesophageal hiatus hernias were not seen in this series. It has Association with Pyloric Obstruction. been suggested that peptic esophagitis is prone to occur in patients with pyloric obstruction. With this in mind, a review of the cases in this series reveaIed the presence of pyloric obstruction before the onset of the dysphagia in only one case. Peptic esophagitis is rarely encountered, at Ieast clinically, in large series of patients with pyIoric obstruction. RADIOGRAPHIC
DuodenaI
UIcer
minimum inflammatory changes show considerably less striking findings on the roentgenologic examination. The faiIure of normal distensibility of the lower third of the esophagus may be seen onIy after the examination of numerous films, including those with the patient in the erect position. It can then be noted that this portion of the esophagus does not dilate as much as wouId be anticipated normaIly. Instead, when maximalIy dilated, a tubuIar cylindric structure with paraIle1 side walls is visualized. Within this segment the contours of the involved portion ma)- show a fuzziness or a fine irreguIarity, and the mucosal pattern again cannot be clearly delineated. When partiaIIy empty, this segment may show irregular tertiary contractions. Prompt regurgitation of barium was noted in two patients. Careful studies of this refIux are not available for the entire series. The differential diagnosis from marginal or peptic ulceration above a large hiatus hernia is not difficult. Marginal ulceration immediateIy above a Iarge hiatus hernia associated with a short esophagus may be differentiated from the peptic esophagitis associated with duodenal or gastric ulcer by the foIIowing radiographic findings in cases of margina ukeration: (I) The esophagus is short. (2) The area of narrowing in the Iowermost end of the esophagus is short (I cm. usuaIIy). (3) The esophagus above this area is pliable. (4) A slit-Iike uIcer crater or an ulcer patch may be identified immediately proximal to the cardia. (5) TranscardiaI reff ux is marked and prompt. The differentiation from cardiospasm is usualI> simpIe radiographicaIIy. It may also be readily accomplished in most cases of carcinoma; however, in a smaI1 number of cases, differentiation cannot be made radiographically and esophagoscopy with biopsy is then necessary.
FEATURES
The roentgenologic tindings are essentiaIly of two varieties, namely, changes in distensibiIity or narrowing of the lower third of the esophagus and changes in the mucosal pattern. In severe cases the lack of distensibility may be so marked as to produce a Iong segment of considerable narrowing involving the lower third of the esophagus. The junction between the moderateIy dilated esophagus above and the narrowed portion beIow is gradual and symmetric. The mucosal pattern throughout the narrowed segment is distorted and may have a hazy irreguIar appearance. Discrete projecting uIcer craters are not seen; however, the margins of the narrowed segment may show a fine serration. Coarser irregularities are not common. The invoIved segment usuaIly shows no evidence of peristaItic activity. Slight changes in caliber on repeated examinations may be noted. In the diIated segment above the invoIved area there may be smaI1 irreguIar transitory contractions. In the type of case associated with prolonged peptic esophagitis, a very smaIl tent-like traction hiatus hernia may be seen. This occurred in five patients. In contrast to the severe cases of peptic esophagitis described previously, persons with
PATHOLOGY
The appearances on esophGross Pathology. agoscopy are marked edema and congestion of the affected mucous membrane. This usuaIIy invoIves a long segment occupying the Iower haIf or third of the esophagus, but occasionaIIy may spread upward to invoIve the entire esophagus to a Iesser degree. Multiple smalI superficia1 uIcerations may be seen on the surface of irreguIar foIds. OccasionaIIy, a Iarger narrow area of ffat uIceration runs IongitudinaIly immediateIy above the cardia on the 235
WinkeIstein posterior waI1. When the necrotic membrane is removed, a denuded area with an intensely red granuIar base becomes visible. Small noduIar excrescences or a diffuse granular appearance may be present. In addition, there may be adherent white exudates in small patches or larger plaques that are readily removed by suction, exposing an edematous mucosa. Rarely, smaI1 petechiae have been observed. There is marked narrowing of the Iumen in the lower esophagus that usually can be traversed by the esophagoscope, since the narrowing is most often due to spasm. In advanced cases, however, impassabIe organic stenosis due to Fibrous stricture formation may be encountered and require In the earIy cases the repeated diIatations. cardia seems competent, and gastric rellux is not seen. ReIIux has been observed in a few cases of Iong duration in which a fibrous repIacement of the card& has occurred. Microscopic Pathology. The microscopic features have been presented in considerable detai1 by HamperI. He mentions the foIIowing as earIy necrosis, epitheIia1 hyperIesions : epithelial pIasia, a hyaline mucosa1 zone spIitting the superficial epitheIia1 layer, poIynucIear inhltraand hypertrophy of the muscularis tion, mucosae. These changes are generaIIy accepted by pathoIogists as evidence of peptic inflammation, i.e., inflammation due to the destructive action of hydrochIoric acid and pepsin on a susceptible mucosa, and form perhaps the best diagnostic criteria of peptic esophagitis. FinaIIy, fibrosis and stenosis are seen. The erosions, as a rule, do not penetrate through the muscuIaris mucosae. This diffuse, superficia1 uIceration seen in peptic esophagitis does not, in my experience, eventuate in the deep, circumscribed solitary peptic ulcer of the Iower esophagus. THERAPY
Medical Tberapy. AI1 of these patients were given the conventional Sippy type of therapy with anticholinergic drugs, including methantheIine bromide (banthine@) in some cases, and aIkaIis. Six patients were treated with continuous intraesophageal miIk-soda drip therapy. Mechanica diIatation was empIoyed in six cases. This was usuaIIy started by passing graded ditators through the endoscope. When a No. 36 French dilator couId be passed, endoscopic diIatation was discontinued and a 236
No. 36 French Hurst mercury-weighted rubber esophagea1 bougie was substituted. The size of the tube is gradually increased if possible to a No. 40 French. The resuIts of this type of therapy are often remarkabIy good. These medical measures are usuaIIy successful and result in either a cure or a remission. I have seen a markedIy constricted esophagus widen to almost norma diameter after diIatation. Surgical Therapy. One patient underwent transthoracic biIatera1 vagotomy and four patients underwent subtota1 gastrectomy. In general, the resuIts of these operations have been disappointing. This may be due to the fact that surgery was instituted only in the most severe cases with marked stenosis, hemorrhage or intractable dysphagia. Whether the poor results are due to the persistence of free acid or to a continuation of the disease process into greater stenosis is conjectura1. The fact remains that subsequent dilatations were necessary to relieve these patients from progressive stenosis. Probably the surgica1 procedure of resection of the Iower esophagus and upper haIf of the stomach with bilateral vagotomy and esophagogastrostomy seems best. COURSE
AND
DIAGNOSIS
Sixteen patients seemed to have done we11 with medica or surgica1 therapy. Three still had symptoms despite therapy, and one died of a perforation. The most important disease to be differentiated is, of course, carcinoma of the Iower esophagus. The occurrence of peptic esophagitis in the oIder age group, the type of symptoms, the marked Ioss of weight and the radiographic features combine to suggest carcinoma strongIy. Although the radiographic features of peptic esophagitis are characteristic, they may be imitated exactIy in a few rare cases by a carcinoma. Endoscopy alone may aIso be inadequate for the differentiation; therefore, biopsy is imperativeIy indicated. Cardiospasm is usuaIIy easily differentiated radiographically and endoscopicaIIy. Other types of esophagitis may be diagnosed and separated from this group by the history and observations of definite causal agents. Such agents incIude proIonged vomiting, intubation, extensive burns, genera1 infections, cerebra1 Iesions and chemical agents. I have aIso encountered a few cases of peptic esophagitis
Peptic
Esophagitis
with
without any apparent etiologic explanation. These will perhaps be clarified by the occurrence of a peptic ulcer of the duodenum or stomach Iater in the history. SCMMARI
This disease is apparently one that afIlicts men in the older age groups. In the group under consideration, duodena1 uker or gastric ulcer (and in one case a previous peptic ulcer of the esophagus) were constantly associated. From this feature, the location of the lesion in the lower third of the esophagus and the hyperchlorhydria in most cases, the conclusion seems inescapable that this disease is peptic in origin. The response to medical and surgical antiulcer therapy is striking. What the ultimate, detailed mechanism of peptic esophagitis is seems purely conjectural at present. RefIux may result from the hypersecretion associated with duodenal ulcer or from an unexplained decrease in the tone of the cardial sphincter. Perhaps the characteristic nocturnal hypersecretion with the patient in the horizontal position leads to a prolonged bathing of the lower esophagus by the highIy
237
DuodenaI
Ulcer
As a result, localized acid gastric contents. peptic esophagitis occurs in the lower esophagus with a spastic narrowing. The disease is characterized by a Iong histoq of cluodenal or gastric ulcer with a subsequent shorter history of esophageal symptoms. The chief symptoms are dysphagia, heartburn, regurgitation, substernal pain and loss of weight. The complications are stenosis, hemorrhage and perforation. There is no evidence that this is a precancerous disease. The response to medical therapy and mechanical dilatation is usuaIIy good. In a smal1 percentage of the patients, surgical therapy is necessary. This condition is important not only as a disease entity but also in the differential diagnosis from carcinoma of the lower end of the esophagus. REFERENCES
I. WINKELSTEIN, A. Peptic csophagitis: new clinical entity. J. A. M. A., 104: 906-909, 1935. 2. HAMPERL, H. Peptische Oesophagitis. Verhandl. d. 1934. deutsch. path. G&ells&., 27: ;08-215, 2. WOLF. B. S.. MARSHAK. R. and SOM. M. L. Short esophagus with esophagogxstric or margina ulceration. Radiology, 61: 473-494, ,953.