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The importance of gastroscopy in surgical diagnosis
THE IMPORTANCE
OF GASTROSCOPY DIAGNOSIS*
EDWARD B. BENEDICT, BOSTON,
IN SURGICAL
M.D.
MASSACHUSETTS
G
ASTROSCOPY is now a we11 recognized diagnostic procedure. It is safe, easy to perform, and gives information not obtainabIe by any other method. This discussion is based on a series of 456 gastroscopies performed at the Massachusetts Genera1 HospitaI, where the Wolf-Schindler AexibIe gastroscope1’2 has been in use since earIy in 1933. In this series there has been one minor compIication, but no major compIication. PreIiminary x-ray examination of the esophagus is aIways carried out before gastroscopy in order to ruIe out esophagea1 disease that wouId contraindicate the bIind passage of the gastroscope. PreIiminary esophagoscopy is unnecessary, however, for the AexibIe gastroscope aIways passes readiIy through an esophagus that appears normal to x-ray examination. Gastroscopy is conducted as an offIce or out-patient department procedure. As the patient must be fasting, earIy morning is the best time. PreIiminary gastric Iavage is usuaIIy unnecessary and inadvisabIe as it may iriitate the mucosa, but preIiminary drainage by lowering the patient’s head with a Iarge stomach tube in pIace wiI1 frequentIy yield from I to 2 ounces of retained secretions and resuIt in a more compIete and satisfactory view of the mucosa. For anesthesia of the throat a 2 per cent soIution of pantocaine, used as a gargIe, has been found suflicient. Codeine, I$ gr., may be used for sedation.
During the examination the patient Iies on the left side with the head extended on piIIows or heId in the hands of a trained assistant. OnIy a very few minutes are necessary for complete gastroscopic study, and the patient may go home immediateIy afterwards. He may eat within an hour of the examination, or as soon as the IocaI anesthesia wears off. Except for sIight sore throat, there wiI1 be no unpIeasant aftermath. Gastroscopy permits a minute study of aImost a11 the gastric mucosa, but certain bIind areas shouId be mentioned. The duodenum cannot be seen. The pylorus is usuaIIy we11 visuaIized, but an uIcer Iying within the pyIoric cana wiI1 probabIy not be visibIe. In a J-shaped stomach it may be impossibIe to see the Iesser curvature of the antrum near the pyIorus. This gastroscopic bIind spot is due to anguIation and is not aIways present; during the passage of a peristaItic wave the whoIe lesser curvature may become visibIe even in a diff%uIt case. Owing to the fact that the objective Iens Iooks at right angIes to the axis of the instrument there is a bIind spot on the greater curvature where the tfp of the g&troscope impinges on the muscosa. Bv manipulation of the instrument this &ea beiomes very smaI1. The portion of the fundus above the cardiac orifice and adjacent to the esophagus is aIso invisibIe, but is a reIativeIy unimportant area. Except for these smaI1 areas, which are of varying visibiIity and importance in
* From the Massachusetts 4
General HospitaI.
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Benedict-Gastroscopy
different stomachs, the entire gastric mucosa is usuaIIy very we11 seen. Indications for gastroscopy incIude a11 diseases of the stomach, for there is no intrinsic gastric pathoIogy in which direct endoscopic examination of the mucosa may not give information impossibIe to obtain by any other method. If gastroscopy were done routineIy on a11patients with stomach compIaints much vaIuabIe information wouId be obtained. Gastroscopy is easier to perform than cystoscopy and shouId bear much the same reIationship to gastroenteroIogy that cystoscopy bears to urology. In genera1 we may say that gastroscopy is indicated in many cases of benign tumor, maIignant tumor, gastric uIcer, duodena1 ulcer, gastritis, unexplained gastric symptoms, such as indigestion, dyspepsia, sour stomach, etc., gastric neurosis, hematemesis, meIena, pernicious anemia, post-operative gastritis, and gastrojejuna1 uIcer. Benign Tumor. Gastroscopy in benign tumor of the stomach wiI1 indicate the location of the growth, its genera1 appearance, its basic attachment to the stomach waI1, and the condition of the surrounding mucosa. Thus assistance wiI1 be obtained in determining whether the tumor is reaIIy benign, or possibIy aIready maIignant, and in deciding the question of operabiIity and extent of operation necessary. SmaII tumors with a broad base or an uIcerated surface are IikeIy to be maIignant. Adenomatous poIypi, aIthough benign in their earIy stages, are IikeIy to become maIignant3p4 and, if not resected at once, shouId be carefuIIy observed gastroscopicaIIy. OccasionaIIy cases thought to be benign tumor wiI1 be shown by gastroscopy to be due to foreign body. Malignant Tumor. In maIignant neopIasm of the stomach gastroscopy aids in making an earIy diagnosis, in confirming a diagnosis aIready made, in differentiating benign from maIignant lesions, and in determining the extent and operabiIity of a malignant tumor. 5*6,7The earIy diagnosis of cancer is a goa toward which we are a11
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striving, and wiI1 be definiteIy hastened when more patients have a gastroscopic examination at the first sign of stomach troubIe. Gastroscopy to confirm a diagnosis may occasionaIIy show no Iesion at a11 in the area suspected, in which case further x-ray examination must be carried out, but, on the other hand, it may revea1 a much more extensive process than was anticipated. In such cases surgica1 pIans wiI1 be In some instances materiaIIy aItered. gastroscopy has been of definite assistance when the question arose as to whether a mass cIose to the stomach waI1 was intrinsic or extrinsic. When other types of gastric maIignancy, as Iymphoma or sarcoma, are suspected cIinicaIIy or roentgenoIogicaIIy, gastroscopic examination may be of very great importance in excIuding or conhrming the diagnosis. Gastric Ulcer. Contrary to the cIinica1 impression in America that duodena1 uIcer is more common than gastric uIcer, a recent study8 of 457 peptic uIcers at necropsy reveaIed 240 gastric uIcers, 215 duodena1 uIcers, and 2 jejuna1 uIcers. In Europe as weI1, gastric uIcer is reported to be more common than duodena1 uIcer. It may be anticipated that, with the more frequent use of the gastroscope in this country, the cIinica1 diagnosis of gastric uIcer wiI1 be much more frequent. AIthough it is not possible to see a11 gastric uIcers,9 the direct endoscopic observation of a gastric uIcer gives much vaIuabIe information not otherwise obtainabIe regarding (I) the benign or maIignant nature of the uIcer, (2) its abiIity to heal, and (3) the amount of associated gastritis. An uIcer with sharp margins and a cIean base is 1ikeIy to be benign, but an uIcer with a sIightIy noduIar margin and a dirty base is IikeIy to be maIignant. SchindIer5 has emphasized that the gross differentiation between benign and maIignant gastric uIcer is easier by gastroscopic observation of Iiving tissue than by pathoIogic observation of dead tissue, for in the former the presence of the circuIating bIood and the
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direct inspection of the tissues in their normaI coIors is of great assistance. OnIy by gastroscopy can the complete heaIing of a gastric uIcer be shown. The disappearance of the niche by x-ray examination does not necessariIy mean that epitheIiaIization has taken pIace, for the crater may be fiIIed with mucus and so may fai1 to fiI1 with barium, or a very smaI1 crater may not be demonstrable roentgenoIogicaIIy. The amount of gastritis associated with gastric uIcer is variabIe. In my experience there is usuaIIy evidence of gastritis in the neighborhood of the uIcer. This may manifest itseIf by the presence of mucosa1 hemorrhages, pigment spots, verrucous elevations in the mucosa, and mucosa1 erosions. In the presence of a severe generaIized hypertrophic gastritis associated with a gastric ulcer, good resuIts cannot be expected from a IocaI excision of the uIcer. In fact, even with extensive gastric resection Iarge areas of gastritis may remain and the surgica1 resuIt wiI1 be probIematica1. When surgery becomes imperative due to faiIure of medica treatment, danger of maIignant degeneration, or hemorrhage, the surgeon shouId know the amount of gastritis present so that he may decide on the type and extent of the operation to be performed. Duodenal Ulcer. An uIcer in the duodenum is not visibIe by gastroscopy, but in duodena1 uIcer, as in gastric uIcer, there is usuaIIy an associated gastritis. lo The degree of gastritis varies from a sIight amount of superficia1 gastritis to very severe hypertrophic gastritis with erosions. The usua1 Iocation of the process is in the body of the stomach, but when there is pyIoric obstruction, superficia1 gastritis of the antrum is common, and the gastroscopist wiI1 frequentIy demonstrate increased reddening, mucosa1 hemorrhages, pigment spots, and hemorrhagic erosions. When a severe hypertrophic gastritis is present, with verrucous eIevations in the mucosa, erosions, and superficia1 ulcerations, it must be recognized that we are deaIing with
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more than a simpIe duodena1 uIcer, and the treatment must be pIanned accordingIy. Gastric uIcer is a not infrequent accompaniment of duodena1 uIcer, and may be demonstrated gastroscopicaIIy. The treatment of duodena1 uIcer may thus be considerabIy modified after a detaiIed study of the gastric mucosa by gastroscopy. Chronic Gastritis. In this disease, the commonest of a11 gastric disorders, gastroscopy is recognized as the best method of examination,“‘12’13 for only by direct inspection of the mucosa can we demonstrate the finer changes seen in chronic gastritis. In generaI, chronic gastritis may be subdivided into three types, superficia1, hypertrophic, and atrophic, but sometimes more than one type wiI1 be present in the same stomach, and a strict adherence to cIassification wiI1 be impossibIe. Superficial Gastritis. The changes seen in superficia1 gastritis are increased reddening of the mucosa, edema, and exudate. SmaII erosions may be present. There may be bleeding from the inffamed mucosa, or from the erosions. It is important for the surgeon to reaIize that hemorrhage may occur in superficia1 gastritis. Gastroscopic examination in such cases wiI1 therefore save unnecessary surgica1 expIoration. Hypertrophic Gastritis. The changes seen by gastroscopy in hypertrophic gastritis consist in eIevations in the mucosa varying in degree from granuIar or verrucous, to a noduIar or even poIypoid size. IrreguIar creases are visible in the mucous membrane and the rugae may have a beaded or caterpiIIar-Iike appearance, sometimes ending abruptIy or in a buIbous manner. The mucosa itself, normaIIy gIistening with many highIights, appears duI1, with few or Erosions and superficia1 no highIights. uIcerations are very frequently present. Hypertrophic gastritis is a very important disease from a surgica1 standpoint because it may be the source of severe hemorrhage.5’14~15~16”7 Massive, even fata hemorrhage has occurred from gastritis aIone. Gastroscopic examination in such cases not infrequentIy reveaIs the exact
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source of the bIeeding, or may show a very diffuse inflammatory hemorrhagic process. Surgery is contraindicated. In the past many patients have suffered a fruitIess surgica1 expIoration because of unexpIained hematemesis or meIena under the erroneous supposition that a peptic uIcer had been overIooked, whereas in reaIity the bIeeding was coming from a severe chronic gastritis with muItipIe erosions.‘* The surgeon must aIso be famiIiar with the fact that chronic hypertrophic gastritis may simuIate peptic ulcer in symptomatoIogy, or may present a very variabIe picture. A positive gastroscopic diagnosis of hypertrophic gastritis is often a satisfactory solution to the case with vague and otherwise unexpIained gastric symptoms, such as indigestion, gas, heartburn, dyspepsia, sour stomach, etc. Such cases, often given an unjust and erroneous diagnosis of gastric neurosis in the past, wiI1 require medica treatment, but the surgeon wiI1 frequentIy be caIIed upon to direct the methods used in differentia1 diagnosis. Atrophic Gastritis. The mucosa in atrophic gastritis is very paIe, and so thin that the bIood vesseIs of the submucosa are pIainIy seen. The gastroscopic picture is UnmistakabIe. It is a condition seen in dehciency diseases, notabIy pernicious anemia. Liver therapy improves the condition of the gastric mucosa.lg The surgica1 significance of atrophic gastritis Iies in the fact that gastric neoplasm probabIy arises more commonIy from an atrophic mucosa than from apparentIy norma mucosa.20*21~22Because of our interest in atrophic gastritis, severa cases of deficiency disease have been examined here gastroscopicaIIy, and in two of them the other (one a: pernicious anemia, a PIummer-Vinson syndrome) poIypoid tumors of the stomach have been discovered, conhrmed by x-ray examination, and resected. Both were thought to be maIignant, and were so proved on pathologic examination. Post-Operative Gastritis. Gastroscopists are generaIIy agreed that chronic gastritis
in Diagnosis
APRIL,1938
is to be found frequently after gastric operations, whether pyIoropIasty, gastroenterostomy, or partia1 gastric resection. Whether this is due to the aItered gastric physioIogy is not known. Many stomachs before operation exhibit more or Iess chronic gastritis in association with the peptic uIcer or carcinoma for which the operation was undertaken. This gastritis may persist foIIowing operation, further inflammatory changes may take place, or, if no gastritis was evident before operation, it may deveIop after operation. Any of the mucosal changes already described in superIicia1 or hypertrophic gastritis may be found in post-operative gastritis. When intractabIe symptoms persist and gastroscopy shows the presence of a severe gastritis, further surgery may be necessary, undoing of a gastroas, for exampIe, enterostomy, or further gastric resection. Gastro-Jejunal Ulcer. MarginaI uIcers are sometimes, but not aIways, we11 seen by gastroscopy. It is not to be expected that jejunal uIcers far removed from the stoma wiI1 be seen. Gastroscopy shouId be done in cases of suspected gastrojejuna1 ulcer, for in addition to a direct inspection of the ulcer, gastritis and perhaps muItipIe uIcerations may be found, and the treatment of the disease modified accordingly. CASE
REPORTS
In the folIowing case, in which autopsy showed carcinoma of the stomach, more attention shouId have been paid to the gastroscopic report: CASE I. E. D. S. (M.G.H. g233), a white American male of 68, first entered the hospita1 in August 1934, because of 20 pounds’ weight Ioss in three months. There were no symptoms whatever referable to the gastrointestinal tract. Past History. This was not remarkable except for an excessive use of aIcoho1 for a thirty year period as a young man, urethral stricture, and a miId diabetes of three years’ duration. It was thought possibIe that the diabetic diet might be responsibIe for the weight 10s~. Physical examination was essentialIy negative.
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Laboratory Findings. R.B.C. 5.6 miIIion. HemogIobin go. The stoo1 was guaiac-positive on three examinations. Gastric anaIysis showed no free acid in the fasting content or one hour after histamine. The fasting bIood sugar was 171 mg. per I00 C.C. X-ray Examinations. On seven different examinations done over a two year period from August 1934, to July 1936, it was impossible to make a positive diagnosis. There was a deformit.y in the prepyIoric region, but it was impossibIe to say whether this was due to neopIasm, ulcer, or inffammation. An earIy report suggested a smaI1 neoplasm; Iater reports, whiIe showing much the same lesion, indicated slight improvement and tended toward a nonmaIignant diagnosis. Gastroscopy. In October 1934, gastroscopy showed very irreguIar areas on the Iesser curvature and posterior waI1, consistent with marked hypertrophic gastritis or with infiItrating maIignancy. Exploratory Iaparotomy was urged by the gastroscopist unless malignancy could be positiveIy excluded by x-ray. The patient gained weight and strength and continued symptom-free. In December 1934, a repeated gastroscopy showed irreguIar and sIightIy noduIar appearance of the Iesser curvature, consistent with hypertrophic gastritis but not excIuding neopIasm. Clinical Course. The patient continued to do we11 as regards his stomach, and attention was focused on his diabetes and hypertrophied prostate, for which prostatectomy was performed in September 1935. In March 1936, it was noted that his appetite was poor and his weight was six pounds Iower than it had been a year previousIy, ahhough at Ieast ten pounds higher than it had been after prostatectomy. Anorexia was again noted in February 1937, but in April the onIy symptom referabIe to the gastrointestinal tract was a Iittle indigestion. There had, however, been marked weight 10s~. In May 1937, he died at another hospital. The autopsy showed conffuent bronchopneumonia and extensive carcinoma of the stomach with regiona extension and metastases to the lungs, Iiver, mesenteric and periaortic Iymph nodes, and ileum. Comment. Gastroscopy here was more accurate than any other method of examiMore weight should have been nation.
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pIaced on the gastroscopic findings. The age of the patient, absence of symptoms, sIow rate of growth, and complication of diseases were, however, extenuating circumstances. In the folIowing case of severe gastric hemorrhage, gastroscopy demonstrated gastric ulcer with superficial and hypertrophic gastritis : CASE
II.
M. (M.G.H. ISOIS), a truck driver, entered the hospital in September 1937, because of hematemesis. There had been two severe episodes of bIeeding, one eight months prior to admission, when he vomited about a pint of bIood, and the other two days before admission, when he had repeated hematemesis of a cupfu1 or more of changed bIood. The past history was negative. Physical Examination. There were marked paIIor and dehydration. Blood pressure was 108 systoIic, 68 diastoIic. Laboratory Findings. R.B.C. 2.5 miIIion, hemogIobin 50 per cent. W.B.C. 18,000. The stools were positive for guaiac on three occasions. X-ray examination eight months previous, three weeks after the first episode, was negative except for moderate hypertrophic gastritis. Severe hematemesis continued for severa days after admission, and the red count feI1 to 1.5 million. A repeated x-ray examination tweIve days after the second episode was inconcIusive. Gastroscopy two days Iater showed a superficia1 I X 2 cm. ulcer on the anterior waI1 of the stomach near the cardia. Marked superficial and hypertrophic gastritis of the upper part of the body and fundus of the stomach was aIso demonstrated. Clinical Course. In view of these findings it was feIt that surgery was definiteIy contraindicated. Under medica treatment he became asymptomatic about one month after admission, at which time x-ray examination showed unusuaIIy marked hypertrophic gastritis and active duodena1 ulcer. Two months after discharge from the hospita1 this patient was entireIy symptom-free and able to go back to work. M.
E.
35 year oId American
Comment. Gastroscopy strated a very extensive hypertrophic gastritis of
here demonsuperficia1 and the body and
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fundus of the stomach with a gastric ulcer high up near the cardia. These gastroscopic findings constituted a detinite contraindication to surgery in this case. The following case shows how important gastroscopy may be in a case of duodenal uker : CASE III. P. S. (M.G.H. g1374), a 43 year old Greek housewife, entered the hospital November IO, 1937, compIaining of epigastric pain and vomiting. Two months previous the epigastric pain had begun, usuaIIy relieved by milk. Three weeks before admission, there was fulness, with vomiting of sour material at two or three day intervals. The past history was negative, and physica examination was aIs negative except for epigastric fulness. Laboratory Findings. Urine, bIood, stools, and gastric analysis were essentiaIIy normaI. X-ray examination on two occasions demonstrated a 0.5 cm. duodenal ulcer without other pathoIogy. Clinical Course. Because of obstinate obstructive symptoms it was feIt that surgery was indicated, but this was delayed. Gastroscopy demonstrated superficia1 and hypertrophic gastritis, a gastric ulcer near the cardia, and multiple gastric erosions with active hemorrhage. Under medica management, incIuding psychotherapy, this patient showed a striking improvement and was discharged home without operation. Comment. In view of the gastroscopic findings surgery was contraindicated in this case. In the foIlowing case no satisfactory diagnosis was reached until gastroscopy showed chronic gastritis with erosion : CASE IV. J. G. L. (B.M.H. 78062), a married American housewife of 6g, entered the hospital on September 8, 1937, as a patient of Dr. B. T. Guild. There had been occasional irreguIar attacks of duI1 epigastric pain, nausea, and vomiting of fifteen years’ duration, anorexia, debiIity, and loss of 30 pounds in weight in the past two years, and very dark stooIs for the past month.
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The past history was non-contributory. PhysicaI examination revealed a pale and undernourished woman. Laboratory Findings. R.B.C. 3.0 million. Hemoglobin 50 per cent. The smear was normal
except for moderate achromia. The urine was negative. The stoo1 was guaiac-negative on three examinations. X-ray Examination. A gastrointestinal series was negative except for diverticuIi of the fundus of the stomach and the second portion of the duodenum. A barium enema gave negative results. The Graham test was negative. Gastroscopy showed a 3 mm. erosion just proximal to the muscuIus sphincter marked superficial and hypertrophic
antri with gastritis.
Comment. In this case gastroscopy not only revealed the source of the hemorrhage, but ako indicated that a severe gastritis was the cause of the long-standing gastric complaints. CONCLUSIONS
Gastroscopy with the fIexible gastroscope is safe and easy to perform. Gastroscopic examination gives information not obtainable by any other method. Indications for gastroscopy incIude benign and maIignant gastric neoplasm, gastric, duodenal, and jejunal ulcer, and hypertrophic, atrophic, and superficial, post-operative gastritis. In many cases of gastrointestinal hemorrhage, vague gastric compIaints, gastric neurosis, and deficiency disease, gastroscopy shouId be performed. REFERENCES I. SCHINDLER, R. Ein vollig ungefiihrliches fiexibles Gastroskop. Miincben. med. Wcbnscbr., 79: 1268 (Aug.) 1932. 2. BENEDICT, E. B. Examination of the stomach by means of a flexible gastroscope: A preliminary report. New England J. Med., 210: 669 (Mar. 29) 1934. 3. BENEDICT, E. B.,
and ALLEN, A. W. Adenomatous polypi of the stomach. Surg., Gynec. Ed Obst., 58: 79, 1934. 4. ~IILLER, T. G., ELIASON, E. L., and WRICIIT, V. W. M. Carcinomatous degeneration of polyp of the stomach. Arch. Int. Med., 46: 841, 1930. 5. SCHINDLER, R. Gastroscopy. The Endoscopic Study University of Chicago of Gastric Pathofogy. Press, 1937.
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6. BENEDICT, E. B. Gastroscopic observations in neopIasm. New England J. Med., 214: 563 (Mar. rg) 1936. 7. SCHINDLER,R., and GIERE, N. Gastric surgery and gastroscopy. Arch. Surg., 35: 712 (Oct.) 1937. 8. PORTIS, S. A., and JAFF~, R. H. A study of peptic uIcer based on necropsy records. J. A. M. A., IIO: 6 (Jan. I) 1938. 9. SCHINDLER, R. The vaIue of gastroscopy in diagnosis and surgica1 treatment of chronic gastroduodena1 ulcer. Surgery, 2: 692 (Nov.) 1937. 10. SCHLOSS, J., ET~INGER, A., and PRATT, J. H. Diagnosis of diseases of the stomach by gastroscopic and x-ray reIief studies. Am. J. M. SC., 193: 171
15. KORBSCH, R. Uber Hamatemesis bei chronischer Gastritis. Miincben. med. Wcbnscbr., 722: 1558,
(Feb.) 1937. r I. SCHATZKI, R. Gastroscopy and roentgen examination. Radiology, 29: 488 (Oct.) 1937. I 2. BENEDICT, E. B. The vaIue of gastroscopy in diagnosis. Radiology, 29: 480 (Oct.) 1937. I 3. BENEDICT, E. B. Chronic gastritis: A cIinica1 discussion based on gastroscopic examination. New England J. Med., 212: 468 (Mar. 14) 1935. 14. HENNING, N. Die Entziindung des Magens. Barth, Leipzig, 1934.
1935. 20. HURST, A. F. Schorstein lecture on precursors of carcinoma of stomach. Lancet, 2: 1023 (Nov. 16)
1925. 16. FABER, K. Gastritis and Its Consequences. New York. Oxford Universitv Press. 19%. 17. BENEDI’C~, E. B. Hemorrhage from- gastritis: A gastroscopic study. Am. J. Digest. Dis. & Nutrition, 4: 657 (Dec.) 1937; aIso Tr. Am. Castroent. Assn., 1937. 18. MEANS, J. H. Upper gastrointestina1 hemorrhage. Med. Clin. Nortb America (in press). rg. JONES, C. M., BENEDICT,E. B., and HAMPTON, A. 0. Variations in the gastric mucosa in pernicious anemia: gastroscopic, surgical and roentgenologic observations. Am. J. M. SC., Igo: 596 (Nov.)
1929. 21. KONJETZNY, G. E. Uber die Beziehungen der chronischen Gastritis mit ihren FoIgierscheinungen und des chronischen MagenuIcus zur EntwickIung des Magenkrebses. Beitr. z. klin. Cbir., 85: 455, 1913. 22. MOUTIER, F. Trait& de gastroscopie. Masson et Cie. Paris, 1935.
ACTINOMYCOSIS may be primary in the [saIivary] gIand itseIf, after gaining entrance through the duct, but usuaIIy it is secondary to invoIvement of neighboring infected tissues. From-“SurgicaI Diseases of the Mouth and Jaws” by Ear1 CaIvin Padgett (Saunders).
OF GASTROSCOPY DIAGNOSIS*
EDWARD B. BENEDICT, BOSTON,
IN SURGICAL
M.D.
MASSACHUSETTS
G
ASTROSCOPY is now a we11 recognized diagnostic procedure. It is safe, easy to perform, and gives information not obtainabIe by any other method. This discussion is based on a series of 456 gastroscopies performed at the Massachusetts Genera1 HospitaI, where the Wolf-Schindler AexibIe gastroscope1’2 has been in use since earIy in 1933. In this series there has been one minor compIication, but no major compIication. PreIiminary x-ray examination of the esophagus is aIways carried out before gastroscopy in order to ruIe out esophagea1 disease that wouId contraindicate the bIind passage of the gastroscope. PreIiminary esophagoscopy is unnecessary, however, for the AexibIe gastroscope aIways passes readiIy through an esophagus that appears normal to x-ray examination. Gastroscopy is conducted as an offIce or out-patient department procedure. As the patient must be fasting, earIy morning is the best time. PreIiminary gastric Iavage is usuaIIy unnecessary and inadvisabIe as it may iriitate the mucosa, but preIiminary drainage by lowering the patient’s head with a Iarge stomach tube in pIace wiI1 frequentIy yield from I to 2 ounces of retained secretions and resuIt in a more compIete and satisfactory view of the mucosa. For anesthesia of the throat a 2 per cent soIution of pantocaine, used as a gargIe, has been found suflicient. Codeine, I$ gr., may be used for sedation.
During the examination the patient Iies on the left side with the head extended on piIIows or heId in the hands of a trained assistant. OnIy a very few minutes are necessary for complete gastroscopic study, and the patient may go home immediateIy afterwards. He may eat within an hour of the examination, or as soon as the IocaI anesthesia wears off. Except for sIight sore throat, there wiI1 be no unpIeasant aftermath. Gastroscopy permits a minute study of aImost a11 the gastric mucosa, but certain bIind areas shouId be mentioned. The duodenum cannot be seen. The pylorus is usuaIIy we11 visuaIized, but an uIcer Iying within the pyIoric cana wiI1 probabIy not be visibIe. In a J-shaped stomach it may be impossibIe to see the Iesser curvature of the antrum near the pyIorus. This gastroscopic bIind spot is due to anguIation and is not aIways present; during the passage of a peristaItic wave the whoIe lesser curvature may become visibIe even in a diff%uIt case. Owing to the fact that the objective Iens Iooks at right angIes to the axis of the instrument there is a bIind spot on the greater curvature where the tfp of the g&troscope impinges on the muscosa. Bv manipulation of the instrument this &ea beiomes very smaI1. The portion of the fundus above the cardiac orifice and adjacent to the esophagus is aIso invisibIe, but is a reIativeIy unimportant area. Except for these smaI1 areas, which are of varying visibiIity and importance in
* From the Massachusetts 4
General HospitaI.
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different stomachs, the entire gastric mucosa is usuaIIy very we11 seen. Indications for gastroscopy incIude a11 diseases of the stomach, for there is no intrinsic gastric pathoIogy in which direct endoscopic examination of the mucosa may not give information impossibIe to obtain by any other method. If gastroscopy were done routineIy on a11patients with stomach compIaints much vaIuabIe information wouId be obtained. Gastroscopy is easier to perform than cystoscopy and shouId bear much the same reIationship to gastroenteroIogy that cystoscopy bears to urology. In genera1 we may say that gastroscopy is indicated in many cases of benign tumor, maIignant tumor, gastric uIcer, duodena1 ulcer, gastritis, unexplained gastric symptoms, such as indigestion, dyspepsia, sour stomach, etc., gastric neurosis, hematemesis, meIena, pernicious anemia, post-operative gastritis, and gastrojejuna1 uIcer. Benign Tumor. Gastroscopy in benign tumor of the stomach wiI1 indicate the location of the growth, its genera1 appearance, its basic attachment to the stomach waI1, and the condition of the surrounding mucosa. Thus assistance wiI1 be obtained in determining whether the tumor is reaIIy benign, or possibIy aIready maIignant, and in deciding the question of operabiIity and extent of operation necessary. SmaII tumors with a broad base or an uIcerated surface are IikeIy to be maIignant. Adenomatous poIypi, aIthough benign in their earIy stages, are IikeIy to become maIignant3p4 and, if not resected at once, shouId be carefuIIy observed gastroscopicaIIy. OccasionaIIy cases thought to be benign tumor wiI1 be shown by gastroscopy to be due to foreign body. Malignant Tumor. In maIignant neopIasm of the stomach gastroscopy aids in making an earIy diagnosis, in confirming a diagnosis aIready made, in differentiating benign from maIignant lesions, and in determining the extent and operabiIity of a malignant tumor. 5*6,7The earIy diagnosis of cancer is a goa toward which we are a11
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striving, and wiI1 be definiteIy hastened when more patients have a gastroscopic examination at the first sign of stomach troubIe. Gastroscopy to confirm a diagnosis may occasionaIIy show no Iesion at a11 in the area suspected, in which case further x-ray examination must be carried out, but, on the other hand, it may revea1 a much more extensive process than was anticipated. In such cases surgica1 pIans wiI1 be In some instances materiaIIy aItered. gastroscopy has been of definite assistance when the question arose as to whether a mass cIose to the stomach waI1 was intrinsic or extrinsic. When other types of gastric maIignancy, as Iymphoma or sarcoma, are suspected cIinicaIIy or roentgenoIogicaIIy, gastroscopic examination may be of very great importance in excIuding or conhrming the diagnosis. Gastric Ulcer. Contrary to the cIinica1 impression in America that duodena1 uIcer is more common than gastric uIcer, a recent study8 of 457 peptic uIcers at necropsy reveaIed 240 gastric uIcers, 215 duodena1 uIcers, and 2 jejuna1 uIcers. In Europe as weI1, gastric uIcer is reported to be more common than duodena1 uIcer. It may be anticipated that, with the more frequent use of the gastroscope in this country, the cIinica1 diagnosis of gastric uIcer wiI1 be much more frequent. AIthough it is not possible to see a11 gastric uIcers,9 the direct endoscopic observation of a gastric uIcer gives much vaIuabIe information not otherwise obtainabIe regarding (I) the benign or maIignant nature of the uIcer, (2) its abiIity to heal, and (3) the amount of associated gastritis. An uIcer with sharp margins and a cIean base is 1ikeIy to be benign, but an uIcer with a sIightIy noduIar margin and a dirty base is IikeIy to be maIignant. SchindIer5 has emphasized that the gross differentiation between benign and maIignant gastric uIcer is easier by gastroscopic observation of Iiving tissue than by pathoIogic observation of dead tissue, for in the former the presence of the circuIating bIood and the
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direct inspection of the tissues in their normaI coIors is of great assistance. OnIy by gastroscopy can the complete heaIing of a gastric uIcer be shown. The disappearance of the niche by x-ray examination does not necessariIy mean that epitheIiaIization has taken pIace, for the crater may be fiIIed with mucus and so may fai1 to fiI1 with barium, or a very smaI1 crater may not be demonstrable roentgenoIogicaIIy. The amount of gastritis associated with gastric uIcer is variabIe. In my experience there is usuaIIy evidence of gastritis in the neighborhood of the uIcer. This may manifest itseIf by the presence of mucosa1 hemorrhages, pigment spots, verrucous elevations in the mucosa, and mucosa1 erosions. In the presence of a severe generaIized hypertrophic gastritis associated with a gastric ulcer, good resuIts cannot be expected from a IocaI excision of the uIcer. In fact, even with extensive gastric resection Iarge areas of gastritis may remain and the surgica1 resuIt wiI1 be probIematica1. When surgery becomes imperative due to faiIure of medica treatment, danger of maIignant degeneration, or hemorrhage, the surgeon shouId know the amount of gastritis present so that he may decide on the type and extent of the operation to be performed. Duodenal Ulcer. An uIcer in the duodenum is not visibIe by gastroscopy, but in duodena1 uIcer, as in gastric uIcer, there is usuaIIy an associated gastritis. lo The degree of gastritis varies from a sIight amount of superficia1 gastritis to very severe hypertrophic gastritis with erosions. The usua1 Iocation of the process is in the body of the stomach, but when there is pyIoric obstruction, superficia1 gastritis of the antrum is common, and the gastroscopist wiI1 frequentIy demonstrate increased reddening, mucosa1 hemorrhages, pigment spots, and hemorrhagic erosions. When a severe hypertrophic gastritis is present, with verrucous eIevations in the mucosa, erosions, and superficia1 ulcerations, it must be recognized that we are deaIing with
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more than a simpIe duodena1 uIcer, and the treatment must be pIanned accordingIy. Gastric uIcer is a not infrequent accompaniment of duodena1 uIcer, and may be demonstrated gastroscopicaIIy. The treatment of duodena1 uIcer may thus be considerabIy modified after a detaiIed study of the gastric mucosa by gastroscopy. Chronic Gastritis. In this disease, the commonest of a11 gastric disorders, gastroscopy is recognized as the best method of examination,“‘12’13 for only by direct inspection of the mucosa can we demonstrate the finer changes seen in chronic gastritis. In generaI, chronic gastritis may be subdivided into three types, superficia1, hypertrophic, and atrophic, but sometimes more than one type wiI1 be present in the same stomach, and a strict adherence to cIassification wiI1 be impossibIe. Superficial Gastritis. The changes seen in superficia1 gastritis are increased reddening of the mucosa, edema, and exudate. SmaII erosions may be present. There may be bleeding from the inffamed mucosa, or from the erosions. It is important for the surgeon to reaIize that hemorrhage may occur in superficia1 gastritis. Gastroscopic examination in such cases wiI1 therefore save unnecessary surgica1 expIoration. Hypertrophic Gastritis. The changes seen by gastroscopy in hypertrophic gastritis consist in eIevations in the mucosa varying in degree from granuIar or verrucous, to a noduIar or even poIypoid size. IrreguIar creases are visible in the mucous membrane and the rugae may have a beaded or caterpiIIar-Iike appearance, sometimes ending abruptIy or in a buIbous manner. The mucosa itself, normaIIy gIistening with many highIights, appears duI1, with few or Erosions and superficia1 no highIights. uIcerations are very frequently present. Hypertrophic gastritis is a very important disease from a surgica1 standpoint because it may be the source of severe hemorrhage.5’14~15~16”7 Massive, even fata hemorrhage has occurred from gastritis aIone. Gastroscopic examination in such cases not infrequentIy reveaIs the exact
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source of the bIeeding, or may show a very diffuse inflammatory hemorrhagic process. Surgery is contraindicated. In the past many patients have suffered a fruitIess surgica1 expIoration because of unexpIained hematemesis or meIena under the erroneous supposition that a peptic uIcer had been overIooked, whereas in reaIity the bIeeding was coming from a severe chronic gastritis with muItipIe erosions.‘* The surgeon must aIso be famiIiar with the fact that chronic hypertrophic gastritis may simuIate peptic ulcer in symptomatoIogy, or may present a very variabIe picture. A positive gastroscopic diagnosis of hypertrophic gastritis is often a satisfactory solution to the case with vague and otherwise unexpIained gastric symptoms, such as indigestion, gas, heartburn, dyspepsia, sour stomach, etc. Such cases, often given an unjust and erroneous diagnosis of gastric neurosis in the past, wiI1 require medica treatment, but the surgeon wiI1 frequentIy be caIIed upon to direct the methods used in differentia1 diagnosis. Atrophic Gastritis. The mucosa in atrophic gastritis is very paIe, and so thin that the bIood vesseIs of the submucosa are pIainIy seen. The gastroscopic picture is UnmistakabIe. It is a condition seen in dehciency diseases, notabIy pernicious anemia. Liver therapy improves the condition of the gastric mucosa.lg The surgica1 significance of atrophic gastritis Iies in the fact that gastric neoplasm probabIy arises more commonIy from an atrophic mucosa than from apparentIy norma mucosa.20*21~22Because of our interest in atrophic gastritis, severa cases of deficiency disease have been examined here gastroscopicaIIy, and in two of them the other (one a: pernicious anemia, a PIummer-Vinson syndrome) poIypoid tumors of the stomach have been discovered, conhrmed by x-ray examination, and resected. Both were thought to be maIignant, and were so proved on pathologic examination. Post-Operative Gastritis. Gastroscopists are generaIIy agreed that chronic gastritis
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is to be found frequently after gastric operations, whether pyIoropIasty, gastroenterostomy, or partia1 gastric resection. Whether this is due to the aItered gastric physioIogy is not known. Many stomachs before operation exhibit more or Iess chronic gastritis in association with the peptic uIcer or carcinoma for which the operation was undertaken. This gastritis may persist foIIowing operation, further inflammatory changes may take place, or, if no gastritis was evident before operation, it may deveIop after operation. Any of the mucosal changes already described in superIicia1 or hypertrophic gastritis may be found in post-operative gastritis. When intractabIe symptoms persist and gastroscopy shows the presence of a severe gastritis, further surgery may be necessary, undoing of a gastroas, for exampIe, enterostomy, or further gastric resection. Gastro-Jejunal Ulcer. MarginaI uIcers are sometimes, but not aIways, we11 seen by gastroscopy. It is not to be expected that jejunal uIcers far removed from the stoma wiI1 be seen. Gastroscopy shouId be done in cases of suspected gastrojejuna1 ulcer, for in addition to a direct inspection of the ulcer, gastritis and perhaps muItipIe uIcerations may be found, and the treatment of the disease modified accordingly. CASE
REPORTS
In the folIowing case, in which autopsy showed carcinoma of the stomach, more attention shouId have been paid to the gastroscopic report: CASE I. E. D. S. (M.G.H. g233), a white American male of 68, first entered the hospita1 in August 1934, because of 20 pounds’ weight Ioss in three months. There were no symptoms whatever referable to the gastrointestinal tract. Past History. This was not remarkable except for an excessive use of aIcoho1 for a thirty year period as a young man, urethral stricture, and a miId diabetes of three years’ duration. It was thought possibIe that the diabetic diet might be responsibIe for the weight 10s~. Physical examination was essentialIy negative.
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Laboratory Findings. R.B.C. 5.6 miIIion. HemogIobin go. The stoo1 was guaiac-positive on three examinations. Gastric anaIysis showed no free acid in the fasting content or one hour after histamine. The fasting bIood sugar was 171 mg. per I00 C.C. X-ray Examinations. On seven different examinations done over a two year period from August 1934, to July 1936, it was impossible to make a positive diagnosis. There was a deformit.y in the prepyIoric region, but it was impossibIe to say whether this was due to neopIasm, ulcer, or inffammation. An earIy report suggested a smaI1 neoplasm; Iater reports, whiIe showing much the same lesion, indicated slight improvement and tended toward a nonmaIignant diagnosis. Gastroscopy. In October 1934, gastroscopy showed very irreguIar areas on the Iesser curvature and posterior waI1, consistent with marked hypertrophic gastritis or with infiItrating maIignancy. Exploratory Iaparotomy was urged by the gastroscopist unless malignancy could be positiveIy excluded by x-ray. The patient gained weight and strength and continued symptom-free. In December 1934, a repeated gastroscopy showed irreguIar and sIightIy noduIar appearance of the Iesser curvature, consistent with hypertrophic gastritis but not excIuding neopIasm. Clinical Course. The patient continued to do we11 as regards his stomach, and attention was focused on his diabetes and hypertrophied prostate, for which prostatectomy was performed in September 1935. In March 1936, it was noted that his appetite was poor and his weight was six pounds Iower than it had been a year previousIy, ahhough at Ieast ten pounds higher than it had been after prostatectomy. Anorexia was again noted in February 1937, but in April the onIy symptom referabIe to the gastrointestinal tract was a Iittle indigestion. There had, however, been marked weight 10s~. In May 1937, he died at another hospital. The autopsy showed conffuent bronchopneumonia and extensive carcinoma of the stomach with regiona extension and metastases to the lungs, Iiver, mesenteric and periaortic Iymph nodes, and ileum. Comment. Gastroscopy here was more accurate than any other method of examiMore weight should have been nation.
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pIaced on the gastroscopic findings. The age of the patient, absence of symptoms, sIow rate of growth, and complication of diseases were, however, extenuating circumstances. In the folIowing case of severe gastric hemorrhage, gastroscopy demonstrated gastric ulcer with superficial and hypertrophic gastritis : CASE
II.
M. (M.G.H. ISOIS), a truck driver, entered the hospital in September 1937, because of hematemesis. There had been two severe episodes of bIeeding, one eight months prior to admission, when he vomited about a pint of bIood, and the other two days before admission, when he had repeated hematemesis of a cupfu1 or more of changed bIood. The past history was negative. Physical Examination. There were marked paIIor and dehydration. Blood pressure was 108 systoIic, 68 diastoIic. Laboratory Findings. R.B.C. 2.5 miIIion, hemogIobin 50 per cent. W.B.C. 18,000. The stools were positive for guaiac on three occasions. X-ray examination eight months previous, three weeks after the first episode, was negative except for moderate hypertrophic gastritis. Severe hematemesis continued for severa days after admission, and the red count feI1 to 1.5 million. A repeated x-ray examination tweIve days after the second episode was inconcIusive. Gastroscopy two days Iater showed a superficia1 I X 2 cm. ulcer on the anterior waI1 of the stomach near the cardia. Marked superficial and hypertrophic gastritis of the upper part of the body and fundus of the stomach was aIso demonstrated. Clinical Course. In view of these findings it was feIt that surgery was definiteIy contraindicated. Under medica treatment he became asymptomatic about one month after admission, at which time x-ray examination showed unusuaIIy marked hypertrophic gastritis and active duodena1 ulcer. Two months after discharge from the hospita1 this patient was entireIy symptom-free and able to go back to work. M.
E.
35 year oId American
Comment. Gastroscopy strated a very extensive hypertrophic gastritis of
here demonsuperficia1 and the body and
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fundus of the stomach with a gastric ulcer high up near the cardia. These gastroscopic findings constituted a detinite contraindication to surgery in this case. The following case shows how important gastroscopy may be in a case of duodenal uker : CASE III. P. S. (M.G.H. g1374), a 43 year old Greek housewife, entered the hospital November IO, 1937, compIaining of epigastric pain and vomiting. Two months previous the epigastric pain had begun, usuaIIy relieved by milk. Three weeks before admission, there was fulness, with vomiting of sour material at two or three day intervals. The past history was negative, and physica examination was aIs negative except for epigastric fulness. Laboratory Findings. Urine, bIood, stools, and gastric analysis were essentiaIIy normaI. X-ray examination on two occasions demonstrated a 0.5 cm. duodenal ulcer without other pathoIogy. Clinical Course. Because of obstinate obstructive symptoms it was feIt that surgery was indicated, but this was delayed. Gastroscopy demonstrated superficia1 and hypertrophic gastritis, a gastric ulcer near the cardia, and multiple gastric erosions with active hemorrhage. Under medica management, incIuding psychotherapy, this patient showed a striking improvement and was discharged home without operation. Comment. In view of the gastroscopic findings surgery was contraindicated in this case. In the foIlowing case no satisfactory diagnosis was reached until gastroscopy showed chronic gastritis with erosion : CASE IV. J. G. L. (B.M.H. 78062), a married American housewife of 6g, entered the hospital on September 8, 1937, as a patient of Dr. B. T. Guild. There had been occasional irreguIar attacks of duI1 epigastric pain, nausea, and vomiting of fifteen years’ duration, anorexia, debiIity, and loss of 30 pounds in weight in the past two years, and very dark stooIs for the past month.
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The past history was non-contributory. PhysicaI examination revealed a pale and undernourished woman. Laboratory Findings. R.B.C. 3.0 million. Hemoglobin 50 per cent. The smear was normal
except for moderate achromia. The urine was negative. The stoo1 was guaiac-negative on three examinations. X-ray Examination. A gastrointestinal series was negative except for diverticuIi of the fundus of the stomach and the second portion of the duodenum. A barium enema gave negative results. The Graham test was negative. Gastroscopy showed a 3 mm. erosion just proximal to the muscuIus sphincter marked superficial and hypertrophic
antri with gastritis.
Comment. In this case gastroscopy not only revealed the source of the hemorrhage, but ako indicated that a severe gastritis was the cause of the long-standing gastric complaints. CONCLUSIONS
Gastroscopy with the fIexible gastroscope is safe and easy to perform. Gastroscopic examination gives information not obtainable by any other method. Indications for gastroscopy incIude benign and maIignant gastric neoplasm, gastric, duodenal, and jejunal ulcer, and hypertrophic, atrophic, and superficial, post-operative gastritis. In many cases of gastrointestinal hemorrhage, vague gastric compIaints, gastric neurosis, and deficiency disease, gastroscopy shouId be performed. REFERENCES I. SCHINDLER, R. Ein vollig ungefiihrliches fiexibles Gastroskop. Miincben. med. Wcbnscbr., 79: 1268 (Aug.) 1932. 2. BENEDICT, E. B. Examination of the stomach by means of a flexible gastroscope: A preliminary report. New England J. Med., 210: 669 (Mar. 29) 1934. 3. BENEDICT, E. B.,
and ALLEN, A. W. Adenomatous polypi of the stomach. Surg., Gynec. Ed Obst., 58: 79, 1934. 4. ~IILLER, T. G., ELIASON, E. L., and WRICIIT, V. W. M. Carcinomatous degeneration of polyp of the stomach. Arch. Int. Med., 46: 841, 1930. 5. SCHINDLER, R. Gastroscopy. The Endoscopic Study University of Chicago of Gastric Pathofogy. Press, 1937.
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6. BENEDICT, E. B. Gastroscopic observations in neopIasm. New England J. Med., 214: 563 (Mar. rg) 1936. 7. SCHINDLER,R., and GIERE, N. Gastric surgery and gastroscopy. Arch. Surg., 35: 712 (Oct.) 1937. 8. PORTIS, S. A., and JAFF~, R. H. A study of peptic uIcer based on necropsy records. J. A. M. A., IIO: 6 (Jan. I) 1938. 9. SCHINDLER, R. The vaIue of gastroscopy in diagnosis and surgica1 treatment of chronic gastroduodena1 ulcer. Surgery, 2: 692 (Nov.) 1937. 10. SCHLOSS, J., ET~INGER, A., and PRATT, J. H. Diagnosis of diseases of the stomach by gastroscopic and x-ray reIief studies. Am. J. M. SC., 193: 171
15. KORBSCH, R. Uber Hamatemesis bei chronischer Gastritis. Miincben. med. Wcbnscbr., 722: 1558,
(Feb.) 1937. r I. SCHATZKI, R. Gastroscopy and roentgen examination. Radiology, 29: 488 (Oct.) 1937. I 2. BENEDICT, E. B. The vaIue of gastroscopy in diagnosis. Radiology, 29: 480 (Oct.) 1937. I 3. BENEDICT, E. B. Chronic gastritis: A cIinica1 discussion based on gastroscopic examination. New England J. Med., 212: 468 (Mar. 14) 1935. 14. HENNING, N. Die Entziindung des Magens. Barth, Leipzig, 1934.
1935. 20. HURST, A. F. Schorstein lecture on precursors of carcinoma of stomach. Lancet, 2: 1023 (Nov. 16)
1925. 16. FABER, K. Gastritis and Its Consequences. New York. Oxford Universitv Press. 19%. 17. BENEDI’C~, E. B. Hemorrhage from- gastritis: A gastroscopic study. Am. J. Digest. Dis. & Nutrition, 4: 657 (Dec.) 1937; aIso Tr. Am. Castroent. Assn., 1937. 18. MEANS, J. H. Upper gastrointestina1 hemorrhage. Med. Clin. Nortb America (in press). rg. JONES, C. M., BENEDICT,E. B., and HAMPTON, A. 0. Variations in the gastric mucosa in pernicious anemia: gastroscopic, surgical and roentgenologic observations. Am. J. M. SC., Igo: 596 (Nov.)
1929. 21. KONJETZNY, G. E. Uber die Beziehungen der chronischen Gastritis mit ihren FoIgierscheinungen und des chronischen MagenuIcus zur EntwickIung des Magenkrebses. Beitr. z. klin. Cbir., 85: 455, 1913. 22. MOUTIER, F. Trait& de gastroscopie. Masson et Cie. Paris, 1935.
ACTINOMYCOSIS may be primary in the [saIivary] gIand itseIf, after gaining entrance through the duct, but usuaIIy it is secondary to invoIvement of neighboring infected tissues. From-“SurgicaI Diseases of the Mouth and Jaws” by Ear1 CaIvin Padgett (Saunders).