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Roentgenologic Diagnosis of Gastric Ulcer
M edical Clinics of North America
July, 1941. Mayo Clinic Number
ROENTGENOLOGIC DIAGNOSIS OF GASTRIC ULCER
B. R.
KIRKLIN
Until scarcely more than two decades ago diagnosticians canvassing the grave lesions of the stomach that might be present in a given case gave first consideration to gastric ulcer. This can be accounted for perhaps by the fact that at that time the anatomic and pathologic lines separating benign gastric ulcer from ulcerous carcinoma and from duodenal ulcer were drawn less often and less sharply than they now are, and thus gastric ulcer received unwarranted emphasis in the practice and literature of medicine. It is now well known that the incidence of gastric ulcer is far below that of ulcerous carcinoma and much farther below that of duodenal ulcer, but impressions derived from the past still make it difficult sometimes for clinicians and roentgenologists to approach the diagnosis of gastric ulcer with the degree of caution appropriate for the relative infrequency with which this lesion occurs. Pathology.-The favorite seat of gastric ulcers is on the posterior wall near, sometimes immediately on, the lesser curvature in the vicinity of the angular incisure. But often they are situated on the posterior wall distant from the curvature, or near the pylorus, and exceptionally they may occur on the anterior wall or greater curvature or elsewhere, but they are seldom, if ever, found above the plane of the esophageal opening. As a rule ulcers are single, but rarely there may be two or more. With respect to their morbid anatomy as discerned roentgenologically, gastric ulcers may be classed in two groups; namely, penetrating ulcers that have excavated the gastric wall to varying depths, and perforated ulcers that have burrowed through the wall and into organs or tissues outside the stomach, thus producing an extragastric pocket. Penetrating ulcers vary in diameter from 1 or 2 mm. to 2 cm. or 1117
1118
B. R. KIRKLIN
more. Perforated ulcers may become sealed off at the serosa and are then indistinguishable roentgenologically from penetrating ulcers. Accessory pockets resulting from perforation are extremely rare. Most often the pocket is in the liver, but it may be in the pancreas, spleen or abdominal wall. Pockets vary in size, but their greatest diameter seldom exceeds 3 or 4 cm.
Fig. 129.-Niche of benign ulcer on lesser curvature just above the angle. Considerable antral spasm.
Roentgenologic Signs of Ulcer.-The basic and indispensable roentgenologic sign of ulcer is the barium filled crater of the ulcer, the niche, or its exaggerated form, the accessory pocket. When the internal surface of the stomach is thinly coated with barium, the niche appears in the face view as a dense spot amid the mucosal relief. Even ulcers that are mere shallow erosions are likely to be visible as persisting flecks on the mucosal pattern. After the stomach is filled with the sus-
ROENTGENOLOGIC DIAGNOSIS OF GASTRIC ULCER
1119
pension of barium, the niche of a penetrating ulcer, if favorably situated, can be seen as a budlike prominence on the gastric silhouette, projecting beyond the normal line of the lumen, or if the ulcer is on the posterior or anterior wall distant from either curvature (Figs. 129, 130, 131 a~d 132), a face view of the niche may be obtained by compressing the stomach to thin out its opaque content. As a rule, the mucosal margin of a benign ulcer is rather evenly rounded, and the base of the
Fig. 130.-Niche of benign ulcer on lesser curvature above angle. Rather marked prepyloric spasm with hypertrophy of the pyloric muscle.
crater is smoothly hemispherical. Usually, also, the accessory pocket of a perforated ulcer is rather regularly ovoid or spherical, and when ovoid it is likely to be pendulous. Often the suspension exhibits an upper fluid level with an air bubble above, and barium may remain in the pocket after the stomach is empty. Secondary manifestations that commonly accompany gastric ulcer stimulate the examiner to search for their cause and are .of considerable value in differential diagnosis. Often the
1120
B. R. KIRKLIN
rugae in the field about the ulcer are accentuated and converge toward the crater. Usually the ulcer is tender to pressure over the niche. Almost invariably the stomach is of hook form, and often the pyloric end is curled toward the median line (Fig. 132). In most cases peristalsis is fairly active and sometimes
Fig. 131.-Niche of benign ulcer rather high on lesser curvature with spastic hour-glass deformity.
disorderly as a result of the increased irritability of the stomach. Gastrospasm in its varied forms is a striking and common accompaniment of ulcer. One form, a deep and narrow indentation of the greater curvature in the plane of the ulcer (Fig. 131), was at one time regarded as a good index, but it occurs
ROENTGENOLOGIC DIAGNOSIS OF GASTRIC ULCER
1121
only rarely and is not always significant of ulcer. A much more common variety of gastrospasm, regardless of the situation of the ulcer, is manifested by narrowing of the antrum and blurring of the antral shadow (Figs. 129 and 130). Often the pylorus also is spastic; it opens less freely and less frequently than under normal conditions, and evacuation of the stomach is retarded (Fig. 132).
Fig. 132.-Rather large ulcer niche on lesser curvature with marked gastrospasm. Spastic contraction of lesser curvature producing snail form of stomach. Obstruction due to pylorospasm.
In arriving at a diagnosis of ulcer the first task of the examiner is to confirm the presence of a niche or pocket and exclude simulants of either. The shadow of a niche or pocket is constant as to size and form and persists or recurs at: the same site. The bulge on the lesser curvature between two peristaltic waves resembles a niche only momentarily for it progresses with the waves. A small mass of barium .in the small bowel near the stomach may imitate a niche, but its position changes when the angle of view is altered or the stom-
1122
B. R. KIRKLIN
ach is manipulated. Secondary signs without a niche never warrant a diagnosis of ulcer, for they may result from other diseases or functional disorders. Differentiation from Malignant Disease.-When it is clear that an ulcerous lesion is present, the differential diagnosis of benign ulcer from ulcerating carcinoma and malignant ulcer becomes highly important. A small, deeply ulcerated carcinoma has some resemblance to a benign ulcer, but the
Fig. 133.-Large malignant ulcer on lesser curvature at the angle of the stomach.
former is characterized by demonstrable elevation of the border around the ulcerous excavation, the latter of which is within the gastric lumen, and by absence of the secondary signs that accompany benign ulcer. (See section on Gastric Cancer.) Distinction of benign from malignant ulcers in which the element of tumefaction is not apparent frequently occasions difficulty. In general, benign ulcer is characterized by regularity of the base and mucosal margin of the crater, accentuation and convergence of rugae adjacent to the ulcer, tenderness to pres-
ROENTGENOLOGIC DIAGNOSIS OF GASTRIC ULCER
1123
sure and spastic accompaniments. In contrast, malignant ulcer commonly is marked by irregularity of the crater (Fig. 133), effacement of adjacent rugae, lack of tenderness to pressure and absence of gastrospasm. Ulcers with craters having a diameter exceeding 2.5 cm. usually, but not invariably, prove to be malignant (Fig. 134). Perforated ulcers with accessory pockets are seldom malignant. Most ulcers on the greater
Fig. 134.-Large malignant ulcer on . lesser curvature below angle.
curvature are found to be malignant. Ulcers on the posterior wall remote from the lesser curvature and ulcers near the pylorus are more likely to be malignant than those seated in t~e vicinity of the angular incisure. Ulcer near the pylorus is especially hard to identify; often its niche cannot be discerned clearly, and the deformity of the antrum resembles that produced by early carcinoma (Fig. 135). From 10 to 12 per cent of ulcers that seem roentgenolog-
1124
B. R. KIRKLIN
ically to be benign prove nevertheless to be malignant, and both clinician and surgeon should understand thoroughly that a roentgenologic diagnosis of gastric ulcer, implying that the lesion appears to be benign, is never to be construed as an assertion that malignancy can confidently be excluded. The effect of medical management on ulcers as indicated by subsequent roentgenologic examination is a valuable test of
Fig. 13S.-Benign prepyloric ulcer with marked spasm.
their character, for diminution or disappearance of the crater is strong evidence that the ulcer is benign. However, the test cannot be relied on implicitly, for occasionally the crater of a malignant ulcer fills with granulations or detritus and thus is obliterated. Hence, every patient who has apparently benign ulcer should be kept under observation until the nature of the lesion is established beyond reasonable doubt.
July, 1941. Mayo Clinic Number
ROENTGENOLOGIC DIAGNOSIS OF GASTRIC ULCER
B. R.
KIRKLIN
Until scarcely more than two decades ago diagnosticians canvassing the grave lesions of the stomach that might be present in a given case gave first consideration to gastric ulcer. This can be accounted for perhaps by the fact that at that time the anatomic and pathologic lines separating benign gastric ulcer from ulcerous carcinoma and from duodenal ulcer were drawn less often and less sharply than they now are, and thus gastric ulcer received unwarranted emphasis in the practice and literature of medicine. It is now well known that the incidence of gastric ulcer is far below that of ulcerous carcinoma and much farther below that of duodenal ulcer, but impressions derived from the past still make it difficult sometimes for clinicians and roentgenologists to approach the diagnosis of gastric ulcer with the degree of caution appropriate for the relative infrequency with which this lesion occurs. Pathology.-The favorite seat of gastric ulcers is on the posterior wall near, sometimes immediately on, the lesser curvature in the vicinity of the angular incisure. But often they are situated on the posterior wall distant from the curvature, or near the pylorus, and exceptionally they may occur on the anterior wall or greater curvature or elsewhere, but they are seldom, if ever, found above the plane of the esophageal opening. As a rule ulcers are single, but rarely there may be two or more. With respect to their morbid anatomy as discerned roentgenologically, gastric ulcers may be classed in two groups; namely, penetrating ulcers that have excavated the gastric wall to varying depths, and perforated ulcers that have burrowed through the wall and into organs or tissues outside the stomach, thus producing an extragastric pocket. Penetrating ulcers vary in diameter from 1 or 2 mm. to 2 cm. or 1117
1118
B. R. KIRKLIN
more. Perforated ulcers may become sealed off at the serosa and are then indistinguishable roentgenologically from penetrating ulcers. Accessory pockets resulting from perforation are extremely rare. Most often the pocket is in the liver, but it may be in the pancreas, spleen or abdominal wall. Pockets vary in size, but their greatest diameter seldom exceeds 3 or 4 cm.
Fig. 129.-Niche of benign ulcer on lesser curvature just above the angle. Considerable antral spasm.
Roentgenologic Signs of Ulcer.-The basic and indispensable roentgenologic sign of ulcer is the barium filled crater of the ulcer, the niche, or its exaggerated form, the accessory pocket. When the internal surface of the stomach is thinly coated with barium, the niche appears in the face view as a dense spot amid the mucosal relief. Even ulcers that are mere shallow erosions are likely to be visible as persisting flecks on the mucosal pattern. After the stomach is filled with the sus-
ROENTGENOLOGIC DIAGNOSIS OF GASTRIC ULCER
1119
pension of barium, the niche of a penetrating ulcer, if favorably situated, can be seen as a budlike prominence on the gastric silhouette, projecting beyond the normal line of the lumen, or if the ulcer is on the posterior or anterior wall distant from either curvature (Figs. 129, 130, 131 a~d 132), a face view of the niche may be obtained by compressing the stomach to thin out its opaque content. As a rule, the mucosal margin of a benign ulcer is rather evenly rounded, and the base of the
Fig. 130.-Niche of benign ulcer on lesser curvature above angle. Rather marked prepyloric spasm with hypertrophy of the pyloric muscle.
crater is smoothly hemispherical. Usually, also, the accessory pocket of a perforated ulcer is rather regularly ovoid or spherical, and when ovoid it is likely to be pendulous. Often the suspension exhibits an upper fluid level with an air bubble above, and barium may remain in the pocket after the stomach is empty. Secondary manifestations that commonly accompany gastric ulcer stimulate the examiner to search for their cause and are .of considerable value in differential diagnosis. Often the
1120
B. R. KIRKLIN
rugae in the field about the ulcer are accentuated and converge toward the crater. Usually the ulcer is tender to pressure over the niche. Almost invariably the stomach is of hook form, and often the pyloric end is curled toward the median line (Fig. 132). In most cases peristalsis is fairly active and sometimes
Fig. 131.-Niche of benign ulcer rather high on lesser curvature with spastic hour-glass deformity.
disorderly as a result of the increased irritability of the stomach. Gastrospasm in its varied forms is a striking and common accompaniment of ulcer. One form, a deep and narrow indentation of the greater curvature in the plane of the ulcer (Fig. 131), was at one time regarded as a good index, but it occurs
ROENTGENOLOGIC DIAGNOSIS OF GASTRIC ULCER
1121
only rarely and is not always significant of ulcer. A much more common variety of gastrospasm, regardless of the situation of the ulcer, is manifested by narrowing of the antrum and blurring of the antral shadow (Figs. 129 and 130). Often the pylorus also is spastic; it opens less freely and less frequently than under normal conditions, and evacuation of the stomach is retarded (Fig. 132).
Fig. 132.-Rather large ulcer niche on lesser curvature with marked gastrospasm. Spastic contraction of lesser curvature producing snail form of stomach. Obstruction due to pylorospasm.
In arriving at a diagnosis of ulcer the first task of the examiner is to confirm the presence of a niche or pocket and exclude simulants of either. The shadow of a niche or pocket is constant as to size and form and persists or recurs at: the same site. The bulge on the lesser curvature between two peristaltic waves resembles a niche only momentarily for it progresses with the waves. A small mass of barium .in the small bowel near the stomach may imitate a niche, but its position changes when the angle of view is altered or the stom-
1122
B. R. KIRKLIN
ach is manipulated. Secondary signs without a niche never warrant a diagnosis of ulcer, for they may result from other diseases or functional disorders. Differentiation from Malignant Disease.-When it is clear that an ulcerous lesion is present, the differential diagnosis of benign ulcer from ulcerating carcinoma and malignant ulcer becomes highly important. A small, deeply ulcerated carcinoma has some resemblance to a benign ulcer, but the
Fig. 133.-Large malignant ulcer on lesser curvature at the angle of the stomach.
former is characterized by demonstrable elevation of the border around the ulcerous excavation, the latter of which is within the gastric lumen, and by absence of the secondary signs that accompany benign ulcer. (See section on Gastric Cancer.) Distinction of benign from malignant ulcers in which the element of tumefaction is not apparent frequently occasions difficulty. In general, benign ulcer is characterized by regularity of the base and mucosal margin of the crater, accentuation and convergence of rugae adjacent to the ulcer, tenderness to pres-
ROENTGENOLOGIC DIAGNOSIS OF GASTRIC ULCER
1123
sure and spastic accompaniments. In contrast, malignant ulcer commonly is marked by irregularity of the crater (Fig. 133), effacement of adjacent rugae, lack of tenderness to pressure and absence of gastrospasm. Ulcers with craters having a diameter exceeding 2.5 cm. usually, but not invariably, prove to be malignant (Fig. 134). Perforated ulcers with accessory pockets are seldom malignant. Most ulcers on the greater
Fig. 134.-Large malignant ulcer on . lesser curvature below angle.
curvature are found to be malignant. Ulcers on the posterior wall remote from the lesser curvature and ulcers near the pylorus are more likely to be malignant than those seated in t~e vicinity of the angular incisure. Ulcer near the pylorus is especially hard to identify; often its niche cannot be discerned clearly, and the deformity of the antrum resembles that produced by early carcinoma (Fig. 135). From 10 to 12 per cent of ulcers that seem roentgenolog-
1124
B. R. KIRKLIN
ically to be benign prove nevertheless to be malignant, and both clinician and surgeon should understand thoroughly that a roentgenologic diagnosis of gastric ulcer, implying that the lesion appears to be benign, is never to be construed as an assertion that malignancy can confidently be excluded. The effect of medical management on ulcers as indicated by subsequent roentgenologic examination is a valuable test of
Fig. 13S.-Benign prepyloric ulcer with marked spasm.
their character, for diminution or disappearance of the crater is strong evidence that the ulcer is benign. However, the test cannot be relied on implicitly, for occasionally the crater of a malignant ulcer fills with granulations or detritus and thus is obliterated. Hence, every patient who has apparently benign ulcer should be kept under observation until the nature of the lesion is established beyond reasonable doubt.