the following is a medical media production from
W.R.A.M.C.T.V.
Gastric ulceration is a
pretty widely discussed topic.
I'm sure you've all heard more than you really don't like
to hear about it.
But despite the fact that
it's been written about and discussed very frequently,
we still find that our
residents have problems with the individual ulcers.
And it's not uncommon that we have a case referred from
another institution where a an
erroneous diagnosis has been reached.
It's really a rather simple problem.
And I think for purposes of this discussion
we'll see if we can't reduce it to the
most simple common denominator and
hopefully you'll be able to use it in the future.
There have been a lot of criteria
advanced for the differential diagnosis
and many of them are really not too useful but
they persist in the textbooks and we'll see if we can't dispose
of a few of them.
It's been said,
for example,
that the larger gastric ulcers are
almost invariably uh
malignant and that's not uh
correct
speaking in a general sense it might be
true.
But for practical purposes so far as the individual
crater is concerned,
it does not apply.
Here's an ulcer that starts at this point runs all the
way down past the inside.
Sure,
angular across the inside,
sure.
Almost to the pile or a ring
a huge crater.
Another criteria which has been postulated is
not regularity of the base of the crater.
If there are nodules in the base of the crater,
this is supposed to represent tumor
and therefore provides differential
between a benign and malignant ulceration and here you see a
very large nodule
uh in the base of this crater,
if we look at the uh
crater with spot compression devices,
we see that this is real,
it doesn't move,
it stays there all of the time and there is
an obliteration of the mucous membrane pattern around the
margins of this particular ulcer.
All of these things would suggest a malignant
process.
However,
here is the gross specimen and you
see that it has an intact
mucous membrane surrounding it and its entirety.
This is a Dema and this this
nodule in the center of the crater represents
granule ation tissue.
Some other smaller areas are scattered throughout the base
also.
So in this particular instance,
size not regularity and the absence of the
peripheral mucosal pattern is of no
value in making the differential diagnosis is a
completely a benign process.
Another criterion that has been stated,
and you'll find it even in books published within the last
year,
is that greater curvature ulcers are almost
invariably malignant.
And here is a crater on the posterior
aspect of the stomach,
greater curvature and in fact it's within the
confines of the stomach.
If we projected out the normal gastric outline,
it would be to this point.
So this would be mass with central
ulceration.
Both findings supposedly
indicative of malignant
ulceration.
However,
the gastric opic photograph on this individual
shows a rather innocuous looking crater with a
heaped up margin around it's uh
it's uh edges which represents
lymphoid hyperplasia,
uh sub mucosal process intact
mucous membrane overline and it is on the greater
curvature.
So again,
this criterion does not help insofar as
differential diagnosis is concerned
as in the last case,
and also in this one,
the fact that the ulcer crater does not project
beyond the gastric wall is
assumed to be an indicator of an
ulcerated neo plasm that is projecting into the
gastric lumen as opposed to the peptic ulcer which
should lie out here somewhere beyond
the margin of the stomach
here is one edge of the stomach here another.
And if we project uh the
non existent edge,
we see that this should probably all be mass.
The stomach should be out to here somewhere.
And therefore this large ulceration
should probably be within mass and
therefore of the malignant variety.
But once again we look at the gastro topic
photograph and we see a very sharply punched out
typically benign ulcer in an
individual.
Obviously a chronic ulcer in view of the
deformity of the stomach.
That's sick attritional scarring which is
responsible for the depression of the crater rather
than mass.
So the depth of the crater,
the location of the crater,
the size of the crater modularity of the base of
the crater,
all of these things at least so far as I'm concerned,
mean nothing.
Now if we've thrown those away what's left.
Well,
an ulceration represents primarily a break in the
mucous membrane that lines the stomach.
And if it's within mass,
there should be destruction of that mucous membrane.
In addition to the ulcer crater itself,
there should be the formulation of mass
in the vicinity of the ulcer crater.
In contradistinction to that,
the uninvolved ulcer should be
associated with intact mucous membrane.
And I think that represents
the basics in making the differential diagnosis
between benign and malignant ulceration.
If you can show integrity of the
mucous membrane surrounding that ulceration,
then there's no problem.
Usually as to what you're dealing with.
And here's a case in point here is a very well defined ulcer
crater,
several different projections of it.
And as best we can tell on all of these.
Uh there is uh mucous
membrane in the vicinity of the crater which
runs right up to the margin.
There's no interruption of it.
And this should be taken as an indicator
of a probable benign process.
Now,
remember That here we are in essence,
are seeing a crater in profile.
We're not seeing 360° around the margin of that
crater.
And it's not impossible,
for example,
that normal mucous membrane lies on this side,
but the opposite side of the crater actually
shows infiltration representing an early,
superficial spreading type of tumor.
So we're never possible.
We should try to identify the
mucous membrane around the entire periphery of the crater,
this is not always possible.
But when we can it's a very useful
uh differential diagnostic
tool.
Now,
this really represents
rather gross um
detail insofar as the differential is
concerned,
we're looking at the major mucosal pattern of the
stomach and this is seen
particularly well on the single contrast
study.
We see it here without any difficulty on
the double contrast study.
But you notice as we get into the region of the
crater itself,
there's a tendency for obliteration
of the the mucous membrane
pattern.
Now,
this is in part a function of the optimum
technique of the double contrast study.
Because what we try to do with the properly
done double contrast examination is to
distended stomach uh to the point that
the mucus membrane,
the major mucous membrane pattern is effaced
and we do this because we want to see
the uh surface
characteristics of the mucous membrane without
any intervening folds.
We want to be able to determine whether or not it's one
smooth flowing hole or whether there
are minor areas of uh
rigidity uh or destruction,
small mass and so forth,
and so on.
So that in the double contrast study,
although from time to time,
you can establish this mucosal integrity.
It is not optimum from the standpoint of
differential diagnosis,
what is particularly useful is something that is
neglected.
Nowadays,
I'm afraid to say.
And that is the use of your hand under the fluoroscope
to palpate the ulcer crater.
And to determine whether or not there is flexibility of
the gastric wall and the adjacent mucous membrane
pattern.
This ulcer creator very easily seen.
And you see the mucous membrane running right up to the
margins and by taking the glove finger
and pal painting this area,
we can establish that this bends with the
pressure and snaps back into a normal position when you
relieve the pressure.
And that is worth a great deal in making a differential
diagnosis.
That is something that can satisfy most
questions about the arch of an ulcer very graphically.
And because you are working under the fluoroscope,
you can rotate the patient and have a better
appreciation of the entire circumference
of the crater than you can with the
static single projection film.
Now,
assuming that one can't show
the major mucous membrane,
what can be done well if you take the
stomach specimen
and paint it with a thin
uh solution of barium,
wipe off the excess and radiographic.
You'll see the usual
guy that we're also familiar with,
but both on the surface of the rue guy and
between a small mesh like
pattern that represents the so called area
gastric or the minor
mucous membrane pattern of the stomach.
Uh These represent clusters of
gastric glands which are separated by little
salsa.
The so called salsa gastric a in effect they're little
islands of mucous membrane
separated by these very thin valleys,
each one of which represents or contains
multiple uh little
orifices which are the point
of of the emptying of the of the
gastric glands.
Now,
these are useful to us because if you can
demonstrate these in a
single or double contrast study,
you know that your technique is pretty good.
You are able to to conclude that you
are seeing just about everything that need to be seen in that
particular area of the stomach and that there is no
intrusion of motion,
improper radiographic factors and so on.
In addition,
the very fact that these can be demonstrated
straight ID indicates that you are dealing with an
intact mucous membrane at least insofar
as tumor tissue is concerned.
If you see them,
you can pretty well for that particular area,
exclude the presence of a tumor.
And here they are in vivo.
You see this little mesh work pattern throughout the Antrim and
this is the area where they're most readily
visualized.
And this because the guy are
relatively few in the Antrim as you get back into the
body and fungus of the stomach,
the large folds tend to interfere with the
visualization of the area.
But they're there.
And you can convince yourself of this.
If you just take a look at the gross specimen there
just as large in the fund this as they are in the
Antrim.
It's a matter of of ease with
which they can be visualized rather than their presence or
absence in different parts of the,
of the stomach.
Now to show an example of how these may
be used in identifying
uh whether a gastric
ulceration is of the benign or malignant
variety.
This is a rather bizarre crater.
You can just about see it here as a double
contrast with this
displacement around it.
Uh This is actually uh a demo
this mucous membrane,
but there's no way of telling that from this
radiograph,
that's what it was proven to be eventually,
but it could easily be mistaken
for mass and this ulcer crater
for uh necrosis within a
rather large infiltrating tumor.
However,
with the double contrast technique,
we've obliterated the major mucosal
pattern.
And here we can see quite clearly the
individual area gastric running right up to the
margin of that crater.
In addition,
if you look at the periphery here,
you see a slight scalloping little
speckles in between.
These represent the area
seen in profile with the little
speckles,
barium within the individual soul side
gastric.
And this is a convenient way of identifying the minor
mucosal pattern as well as seen it.
Uh in foss as you do here again,
we can see them here,
but there's relatively little information on this
portion of the crater and you have to again
go through multiple positions to
establish the fact that all of the
uh ulceration is indeed surrounded by
intact area gastric.
When you do.
However,
you can rest assure for practical purposes that you
are dealing with a benign process and you do not have to worry
about the presence of a gastric carcinoma.
Now,
unfortunately,
on Many,
many patients,
it's not possible to either show
the major mucosal pattern reaching
the edge of the ulcer creator or for that matter,
to demonstrate the area gastric.
We have been able to show the area in about 50% of
all of our G.
I.
series,
it's there in all the rest,
but factors that we are not entirely
cognizant of uh
apparently interfere with the visualization in every case,
probably mucus is the most common
cause,
but we really haven't been able to either
show conclusively that that's the case or to control
it this being.
So what can you do in the
differential diagnosis of gastric ulceration
to supplant the information that you would
normally derive from the mucous membrane?
Well,
a variety of so called signs have been
described,
which are quite useful once
again when they are present here,
we see a very obvious ulcer crater.
The mucous membrane itself is difficult to
see in this case obliterated by
Dema.
But if we look at the margins of that crater,
we see two little tabs of tissue and this
of course,
is the so called Hampton's line named
after Aubrey Hampton,
who was in Washington for so many years and
represents a morphological characteristic of a
gastric ulcer,
namely the tendency of the benign
peptic ulcer to undermine its mucosal
margins,
in other words,
to be recessed beyond
the apparent margins of the crater
as we see it in Fox looking at the gross specimen.
If this is the case then occasionally we should be able
to visualize these overhanging tabs of mucous
membrane and that is precisely what we're seeing there.
Now this being the case.
If you have these little flexible thin tabs
there really cannot be mass in the vicinity of this
crater.
The fact that those tabs are present
effectively eliminates the presence
of mass and about 98% of
individuals in whom you can demonstrate this
particular finding.
Now it's not always possible or necessary to
demonstrate it on both sides of the crater.
Occasionally you will see it only on one such as
as a parent here.
Or you may show it on
both sides or bridging the entire
mouth of the crater.
However size of the crater
doesn't necessarily have any
relationship to it.
You can see it with very small ulcers as well as well as some of
the large ones that I've demonstrated to you.
And also if you don't see it
first crack out of the box when you're examining the patient.
If other findings indicate a probable
benign process.
If you treat the patient for a week,
10 days,
two weeks.
Very commonly you'll find that
where it could not be demonstrated on the initial
examination it has appeared following
decrease in the size of the ulcer.
Here's of course a very obvious crater.
And after about 10 days of therapy,
the same patient,
we now are able to see Hamptons line without any
difficulty substantiate.
In our original opinion that we were
indeed dealing with benign
process.
It's very easy however,
to talk yourself into a Hamptons line when actually what you're
seeing with say compression techniques is uh
an overlapping margin of the stomach on the other
side of the crater.
And occasionally you'll get vegetable
fibers in the crater base
itself.
And these can be mistaken for Hampton's line
here,
for example,
with one,
here's another,
here's something running almost
vertically to the axis
of the office of the crater.
And with juggling this patient around little
bit,
you see that all of the things that we were
considering on this projection as possible.
Hampton's lines are gone and we're left with this which may or
may not be Hamptons line itself.
So it can be sort of misleading and you have to be careful
that you're not looking at debris only
Rather rarely.
Probably in about one or 2% of patients either a
Hamptons line will coexist with an
ulcer rating neo plasm or will be
simulated by an ulcerated Nia plasm.
This looks for all the world uh like
Hamptons line but you notice this rather
angular configuration of the adjacent
gastric wall.
And of course on this uh greater curvature
side,
an angular in drawing with a suggestion of mass
and this is infiltrating cancer.
Regardless of the fact that we have this
apparent sign of dignity.
So one must be careful not to rest
entirely on this finding.
Now it's
difficult.
I really don't have a figure,
I've never compiled one as to how frequently
you can demonstrate Hampton's line in a
given ulceration.
But I would say certainly not more than half the time.
And you have to work at it pretty diligently to get that figure.
Uh that being the case,
what can we substitute for Hampton's line as the
98% accurate criteria?
And after all,
that's pretty good.
But if you can't if you can't see it,
uh then its accuracy is really of
no great moment.
And the next question is,
what can we substitute for it?
Just as Hampton's line itself was a substitute for
being able to demonstrate the mucous membrane.
Well,
in all of the text,
you are usually told that one of the characteristics of a
benign ulcer is the fact that it will hold
material in the erect position.
The contents of the stomach.
Whether it happens to be barium uh gastric
juice or whatnot will spill into the ulcer
crater and will be held there
by the usual dumbbell configuration of the
crater.
This is a particularly nice demonstration of it.
Where And we have the heavier barium at the bottom.
Gastric juice uh
occupying roughly the next third of the crater.
And here air trapped within it in the erect
position.
Well,
this is a rather tenuous criterion.
and I don't like to use it as such simply because
uh it doesn't really explain what's going
on.
I don't like to talk about
a radiographic finding as purely
descriptive wherein we don't
understand the underlying cause and the
reason for these,
for the ability of the ulcer crater to trap this
liquid material.
And air is really quite simple and readily
explain If we take
this schematic of an ulcer crater.
And this goes all the way back to uh
for shell in the late 1920s when
he pounded his magnificent
theories on the auto plasticity of the mucous
membrane.
We see that he noted that in the
vicinity of an ulcer crater there was a tendency for
the mucous membrane to swell to heap
up and to overlap the mouth of
the crater.
And this was a gradual process.
But I think you can see how it would tend to obliterate the
mucous membrane with this sub mucosal
swelling and this layer represents the muscular is
appropriate.
This represents the mucous membrane and it's sub
mucosal uh space
with this gradual distension of the sub mucosal space.
There's a tendency to obliterate the
major mucosal pattern,
however,
uh be that as it may,
it's basically an intact process.
It's just distended.
And there is a tendency on the part of this mucous
membrane to try and overlap the mouth of this
ulcer.
Now whether this is a function of just the swelling itself
with the extra bulk of the mucous membrane
produced,
or whether it's a function of the mucous
membrane trying to cover the
crater and thereby uh
present a protective mechanism insofar as
gastric juices concern is open to question.
However,
it does overlap the entire crater and
this fact does displace barium
and the displacement of barium by this overlapping
mucous membrane has been described by dr
Marshak and dr Wolfe as the so called
ulcer collar and its just as useful
in its own way as Hampton's line and has
exactly the same significance.
Here are some cases in point a large crater
which is apparently entirely separate from the general lumen of
the stomach.
We have this black band running between them.
Now,
if we milk the barium around a little bit with our
fingers were able to demonstrate of course that this is
not separate from it,
but that there is a relative
bulk of tissue between the crater and the general
lumen,
which is displacing barium.
And here we can see uh the gradual
uh transition from the crater
to the general lumen of the stomach by
this intervening mass.
Whatever it may be.
If we look at it in another projection,
we can see the crater itself and very faintly
see that surrounding collar
displacing barium in the double contrast
view as well.
Now this represents that heaped up mucus
membrane surrounding the ulcer crater,
the so called ulcer collar and a double
contrast study shows it rather beautifully.
Here we can see the crater itself and here
the Mucous membrane riding
toward the ulcer crater overlapping it.
And indeed extending throughout the
360° of the ulcer periphery
and notice that this is quite smooth.
There's no hint of destruction,
infiltration,
ulceration.
It's a gradual process.
It has approximately the same width throughout and
above all.
The mucous membrane periphery
is absolutely smooth.
Now this again bespeaks mucosal integrity
and therefore it has the same significance as these other
findings that we were talking about
Now,
every once in a while,
the so called ulcer collar can be so
large that it has to be referred to
by another name.
And it has been called the ulcer mound.
And I guess that's as good as any.
The primary significance is that when they are so
large,
they're apt to be mistaken for tumors.
And here we see a case in point if we projected this
gastric outline here again,
this presumably would represent tumor and
this represent ulceration within the
tumor.
However,
I'd like to call your attention the configuration of
that ulcer.
The ulcer has not
a dumbbell appearance in this instance,
not a stele eight appearance,
but rather is flattened.
And if you would like to be
fanciful,
you might say it looks a little bit like a flying
saucer.
Now this is a useful observation.
If we go to this crater in the immediate
pre pile oric area,
we see an ulcer
collar surrounding it.
And in the double contrast projection we see
integrity of the mucous membrane on either side.
No question about it.
Nice and smooth,
radiates right up to the margin of the ulcer.
And once again we see this saucer like
appearance.
Now this is what dr Sydney nelson has referred to
as the corner sign,
and what it is,
of course,
is the adam entous mucous membrane on either side of
the ulcer creator,
plus the undermine mucosa producing this
recess.
And again,
we're looking at the tendency of the
benign ulceration to undermine
itself to extend beyond its
orifice.
Is seen when you're looking down at the mucous membrane proper.
So the corner sign so called.
Or if you will,
the flying saucer sign has exactly the
same significance as Hampton's line
or the ulcer collar.
It indicates that you are dealing
morphological e with benign ulceration and
that the mucous membrane in the vicinity of the ulcer creator
is intact.
Another example of it very nicely shown here where
you can see this little tip
coming out and projecting above the margin of the
adjacent gastric wall.
This is also demonstrable in small craters,
just as Hampton's line and actually there's a combination of
the corner sign and Hampton's line there.
But again,
note the basic flat configuration
of that ulcer and that's
very helpful.
I have been able to separate in some instances
suspected malignant processes
uh from
benign processes by just the
configuration of this crater.
I find it a very useful observation.
So this being the case.
What uh is
reliable from the standpoint of benign
ulceration?
Well,
what is reliable is integrity of the mucous membrane and
integrity of the mucous membrane may be demonstrated either
by seeing the major or the minor mucosal
folds or in the absence of those folds.
Anyone of the three
observations that further
document integrity,
namely Hamptons,
line the ulcer collar
or the corner sign.
And I think these last three can all be
described as simply by
saying that you couldn't
have any of them if the mucous membrane were not
intact.
If the little tab of mucous membrane
that constitutes Hamptons line were destroyed
by tumor,
you wouldn't be able to see it.
If the mucous membrane surrounding the ulcer
crater were not flexible,
you would not get the adama which permits you to
see that smooth enrolling that is so
characteristic of that particular observation.
And without integrity of the mucous membrane,
allowing the formation of the little tab and the
concomitant flexibility is demonstrated by
adama,
The corner sign would not exist.
So all of those three things show
exactly what the major and minor mucosal
patterns show you,
namely integrity of the mucous membrane.
If it's present,
it's a benign process as opposed to
malignant.
Now,
just briefly,
there are other types of gastric ulceration which occur.
They usually cause no problem from the standpoint of differential
diagnosis here are multiple small ulcers
scattered throughout the entire body of the stomach and a
patient with flag minutes gastritis.
We don't see this very often,
but when we do it's readily recognizable.
And of course all of us are aware of the fact that multiple
ulcers can occur.
Multiple benign ulcers and here is
123 and four.
Uh This particular individual happened to be
receiving steroids for
carcinoma of the breast and this of course
is particularly prone to cause multiple alterations.
But be that as it may,
the multiplicity uh does not
necessarily suggest process such as
lymphoma.
It may be entirely on a benign basis
now that we've discussed all these things about
benign ulcers.
The next thing to consider is what
constitutes uh
a malignant ulcer.
And I will start this
by simply saying that there is one
classic description of
a malignant ulcer
that you all should be aware of.
And then having major aware of it,
we can forget all about it because the
cholera area,
what I've told you so far is if you can demonstrate
integrity of the mucous membrane,
you have a benign process.
If you can't demonstrate integrity or if you can demonstrate any
suggestion of mass you have a malignant process and it's
really rather useless to talk about signs and so
forth.
When you can boil something down to a simple
statement such as that.
However,
I'm sure all of you have read about carmen sign
as being indicative of the presence of a
gastric cancer.
And it's true and it does not necessarily have to be
associated with an advanced gastric cancer.
Carmen sign can occur in
very early cancers.
It's commonly regarded as advanced disease,
but that's not.
So there has been an inordinate
amount of misunderstanding of this sign.
And if you go back and read Dr Carmen's original article,
you can understand it because he is not too precise
about what he's saying in terms of
describing that finding.
It was subsequently uh discussed
that greater extent by dr burrow Kirkland of the Mayo
clinic.
And actually I suppose it would be proper to
refer to this as the Carmen Kirkland
complex,
since both of them had a hand in
defining its components be that as it
may.
This little uh throwaway ashtray I
think pretty well explains what it
is.
We see with carmen sign this of
course,
is the dish part of the ashtray.
And this cremated margin here can be considered
tumor and the dish part and ulceration.
Now,
if we bend that in half and
consider this as uh say
on the lesser curvature of the stomach,
we can see that barium could be trapped
within this disproportion and that would represent the ulcer
and the cremated portion would represent
mass.
And then of course barium would surround this.
So what we would see in the radiograph then
would be barium in the proper in the
lumen of the stomach proper barium then
displaced by irregular mass,
a cuff of irregular mass and then barium
trapped within the ulcer crater.
So this would be dense,
this would be dense and this would be relatively radio loosened.
And that's the Carmen Kirkland complex.
It's ulcerated mass.
And when you view it properly in the
stomach with proper grades of compression and so forth,
you see the barium trapped within the ulcer and
surrounded by the mass of the non
ulcerated portions of the tumor.
And this is very easily seen radiographic lee.
And here's a rather typical one scene in foss.
Here's the mass,
if you will,
the Nagy ular margins of the ashtray.
And here is that this part of the ashtray or in this
instance,
the irregular ulcer.
Now,
if we saw that in profile instead of in
foss,
this would be overlapping so that we have sort of a
saddle ulcer and it would be surrounded by
a radio loosen.
See such as you see here,
here is the crater and here
is the surrounding mass.
This of course,
is the general Newman of the stomach doesn't differ a
great deal from the appearance of
some of the ulcer collars and so on that I've been
showing you accept that this margin is not
smooth,
it is not regular and the nodule clarity
is of course a significant
This does not have to occur.
It's not confined to the stomach alone,
you can see a carmen sign anywhere in the
gastrointestinal track.
And it makes sense,
since it's nothing more than ulcer rating mass.
And here you see a carcinoma of
the recto sigmoid,
it's displacing barium.
Here's a ser pigeon is ulcer in it
and this therefore represents the surrounding
cuff of non necrotic tissue,
the ulcer and the general lumen of the colon.
Another example of it here,
an apparent uh area of
rigidity on the lesser curvature of the stomach just
before the polaris.
We see this flat saddle like double
density here surrounded by a faint radio loosen.
See uh if we follow that through
here is the crater remaining complete
destruction of the mucous membrane
around it and relatively intact mucous membrane on
the greater curvature side where infiltration has not occurred.
This is the classic serial,
a graphic appearance of the Carmen Kirkland complex
and all of you should be able to recognize this and make an instant
diagnosis of ulcerated gastric cancer.
When you see it,
it has been generically stated for purposes of
differential diagnosis that in the benign
crater,
the margins,
the mucous membranes surrounding the margin has a tendency
to roll in and overlap the mouth of the crater
as we described and to parallel
the long axis of the crater.
Whereas in the tumor uh,
the uh
access of the indentation has a tendency to be
at right angles to the crater.
And that is generally so although not
sufficiently frequently seen to
permit it to be an absolute
criterion.
Now,
usually when we see an
individual who has an insight shura
opposite an ulcer,
we tend to regard it as a benign
crater.
And uh this is proper as I will show you in a moment.
But beware because
cancers can infiltrate the
wall opposite a crater and produce an
apparent insight shura and uh I have
seen misdiagnoses on this basis,
a case in point,
an ulcer crater,
apparent mucous membrane integrity
surrounding it.
Uh and an insight sure on the opposite
wall but there is mass here,
there's mass here and this is infiltrating
cancer opposite this ulceration.
The tumor probably extends to here as well.
And if we look at gas Trask optically here is this
large ridge of tumor
representing mass,
which is restricting the
sensibility of the wall by infiltration and has nothing to
do with an inside shore at all.
Just bear in mind about inside.
Sure,
is that they are probably related to the oblique
fibers or the internal muscle layer of the
stomach and that the true spastic
inside shura occurs only along the
distribution of these fibers.
And as you can see,
they're draped around the esophageal gastric junction,
much like a scarf come down on either
side of the esophageal gastric junction,
along the lesser curvature of the stomach and fan out
to eventually join with the
circular layer,
at about the mid portion of the stomach,
they're indistinguishable from about this point on.
But they are there and they terminate insofar as
the long axis of the stomach is concerned at about the
level of the inside.
Sure angularity.
It has been postulated that these are not a
supportive bundle of muscles but are actually
akin to the muscles,
the bundles of hits in the heart.
It's a conducting system and therefore,
when they're involved by processes such as
ulceration,
there's a spastic contracture that results uh
and produces the deformity that we're so aware of
be that as it may.
Uh These two inside sures occur only over this
area.
This of course,
is opened along the greater curvature.
And when you see inside assures beneath this
point.
Beware particularly
because there are no oblique fibers distal to the
inside.
Sure,
angular.
Now here is a case in point of an individual
who has a parent
integrity of the mucous membrane folds superficially
these could be regarded as foals running right up to the margin of
this crater.
And here is presumably an insight.
But remember,
they don't develop like this distal to the
inside your angular
far more reliable than this observation,
therefore,
is the integrity of the mucous membrane.
And this is the same patient with a double contrast technique
here we see the inside which actually
represents infiltrating cancer.
You notice that there is irregular obliteration
of the mucous membrane throughout this area of
ulceration.
This obliteration involves incoming mucous
membrane folds and there are points where these folds are
pinched and there are points where the folds widen.
This of course,
again,
is indicative of infiltrating tumor all around the
margins of the crater and clearly makes the diagnosis.
And you can see in the gastric opic photo the irregular
crater.
And here the infiltrating mass that in the single
contrast view,
to some extent simulated uh
peripheral,
intact peripheral folds.
So in this instance,
the double contrast study demonstrating
interruption and distortion of the mucous membrane is the
far more reliable study uh
than the single contrast
or observation of adjacent
in say sure and so on.
The shape of the ulcer crater is also useful.
Dr Marshak has made this point and I think it's valid by
and large.
Benign ulceration is oblong
circular,
pretty sharply defined,
smooth margins.
When you see diamond shaped or otherwise irregular
craters.
Beware.
And here's a very nice point in
the question.
This is very irregular multiple,
Sir pigeon.
Isse extensions into the surrounding tissue
and is readily recognizable as a
malignant process.
In addition,
you notice that the mucous membrane is visualized
throughout the majority of the adjacent stomach till you
get into the area immediately surrounding the
crater.
And then it's totally obliterated.
Not only is it totally obliterated,
you might say,
well,
that could be a Dema that's true.
But look at this fold,
for example,
this is not only obliterated suddenly widen and then
abruptly goes back to a more normal size and that does
not occur with the Dema their gradual transitions with the
demon.
This is not regularity.
And if you see modularity it's tumor that you're dealing with
guest risk optically.
It's not uncommon for
benign peptic ulceration is to
show Sir pigeon is extensions such as this but we
do not see them radiologic lee for practical
purposes.
There is no radiologic counterpart when we see it.
It usually indicates that we're dealing with some
type of ulcerated neo plasm.
We can carry this a little farther as I indicated
earlier by absence of the area.
Gas tricky.
And here we notice in this rather innocuous looking
crater which is not particularly bizarre and shape
uh that the adjacent major
mucosal pattern is irregular,
partially effaced.
It comes down say to about this point and suddenly stops.
Here's one that comes down to here and abruptly stops and
so on.
And if we look at this rather closely there are area
gastric A here here here here but they're totally
absent in this area.
This happens to be in this instance a lymphoma
with rather extensive involvement of this
portion of the stomach but it's really not appreciable
except by this observation of the
mucosal findings with the stomach
distended.
It was virtually impossible to detect.
Now one last finding Insofar
as uh malignant
gastric ulceration is concerned.
Occasionally.
We will see gastric ulcers which are
not ulcers.
Uh This paradoxical statement is
related to the methods by
which superficial carcinomas are prone to
develop.
This is a staged drawing made by
dr Albert Jutras of Montreal who described
this process many years ago.
And we see in essence what takes place,
there is initially a very slight
atrophy or flattening of the mucous membrane.
This gradually becomes more marked and
finally there is a tendency for this
particular portion of the involved mucous
membrane to be tacked down by proliferating
cells.
While this bulge is centrally,
this becomes more and more demonstrable as a
fibra genic reaction is instituted by the
cells until you have what seems to be
a carmen Kirkland complex.
But actually there is no ulceration.
It's just the proliferating cells
in conjunction with the fiber genic reaction,
tacking down this portion of the mucous membrane and
producing,
if you will,
a pseudo ulcer.
Now,
these may go on later to ulceration
themselves.
But if you look at it here,
in the superimposed drawing,
you can see the apparent ridge representing tumor.
You can see the interruption of the mucosal folds and here
the seeming ulcer crater.
And here's a case in point.
You notice the folds all radiate towards this point.
They're suddenly interrupted here,
there's loss of the falls and here is an ulcer which
has a rather bizarre shape to it but
otherwise is not too significant.
Very obvious.
However,
this is the gross specimen on this individual and there is no
ulcer.
This is the flattening that I just described to you,
a depression produced by the combination of
the proliferating tumor cells and the fiber genic
tissue,
pulling these mucous membrane folds toward
it,
eventually obliterating them but actually
producing no ulcer.
Now,
of course,
these will go on to ulceration at a later
date.
But the japanese with this type of tumor are
experiencing five year survival rates on the order of
90 or 95% assuming
that the type of cancer that they see in japan is
similar to our own gastric cancers.
And some people dispute that be that as it may,
this is a very early manifestation of
gastric cancer and much more subject to queue to
cure than when frank ulceration develops.
These are merely the types of
cancers that are
encountered fun gating uh
uh,
infiltrating the superficial
spreading and of course the line itis plastic
type.
These are probably the most difficult types to
diagnosed,
but they're the ones that are analogous to the
uh series that I just showed you and
does represent the type that we can be most helpful with
when they're detected early on.
Now,
other forms of gastric ulceration in tumor that occur
are well known to you.
Of course,
here's an obvious crater in the gastric fungus and
the tip off in this is not only the shape of the crater,
but also the fact that the margins of this
mass are so smooth.
In fact,
they are covered by intact mucous membrane with the exception of
that this bespeaks a sub mucosal origin
and is of course indicative of a
mesenchymal tumor here when seen in profile,
that crater has a characteristic punched out appearance.
And again,
we're dealing with intact mucous membrane surrounding the
crater,
all of which makes the diagnosis rather easy.
It does not,
however,
tell you particularly what type of tissue is involved in that
statistically it's most often um
A oh my Oma
or li'l mouse sarcoma.
But it may be a lymphoma.
Excuse me,
A lymphoma or Anura genic tumor
and so forth.
The ulceration for any of these is quite characteristic
however,
and directly represents what we saw on the
radiograph.
There's excellent correlation between the two.
Finally,
in the terms of benign sub mucosal
ulceration is beware every once in a while.
A fun gating cancer will mimic them rather closely.
This is a cancer.
Notice the serrated edges of this which you should not
have with the sub
mucosal lesion.
Uh and the central ulceration has not got the sharply
punched out appearance that we demonstrated in the
true benign process.
Now,
this covers the criteria that I wanted to
mention and I think that having
stated them uh as though they
were entirely reliable.
Uh One might get the impression that it's
possible in every instance to make a precise
differentiation and this is not the case.
Uh probably
with Very
exquisite technique and with the help of our gastric
opic friends,
we can make the diagnosis
correctly in about 95% of
cases.
Uh however,
there are some times when we just can't do it and we're going
to have to have depend upon the gas tras copyist and
even some of those cases they are not
always able to help.
This is a case in point insofar as the radiologic
diagnosis is concerned,
this was an elderly woman in her late sixties
with positive tools positive for blood,
Occult blood,
an upper gastrointestinal series was done and she had
this obvious deformity of the duodenum and the diagnosis
of of duodenal ulcer was made uh
and she was treated for about a week or
10 days and the gastrointestinal series repeated.
This hasn't changed one iota,
but this time somebody was a little more careful
and here we see actually the
source of her bleeding.
There is an ulceration on the lesser curvature side
and there is complete obliteration of the mucous
membrane pattern sarai And
obviously it wasn't a very big ulcer to start
with and it apparently hadn't responded to that week or 10 days of
therapy.
So surgery was carried out immediately and this
was a superficial carcinoma
with ulceration.
The obliteration of the mucous membrane pattern
represented combination of infiltrating tumor and fibra
genic response.
So in this instance one would have to
say in the complete interruption of
the mucous membrane pattern here as well as this sir pigeon this
extension that you were dealing with a cancer but
usually cancers of the stomach are reputed not to
occur in conjunction with peptic ulceration elsewhere.
And this is a case in point where in fact uh they
did occur in the same individual.
Another individual with an ulcer in approximately the
same area seen in foss.
Couldn't get it in profile because of its location.
There's the crater there surrounding mass.
Benign or malignant,
we couldn't tell the mucous membrane was
destroyed or absent.
Therefore we thought we had to call it uh
uh a malignant process,
but it was a benign peptic ulcer.
The point of these two,
this is the same individual by the way,
same crater.
And here is the surrounding
absence of mucous membrane.
The point of these two cases is that
with certain types of ulceration,
with absence of the mucous membrane pattern,
you have no choice but to regard it as a malignant
process.
And if it turns out to be benign and the
patient uh has an
unnecessary gastrectomy.
It's unfortunate,
but better that that be done uh than
a tumor left in sight.
To another
example here is a flat ulcer
limited distance ability of the gastric wall
probable infiltration of the
adjacent gastric wall when
seen in another projection,
there is most certainly interruption of the mucous membrane
pattern in the most disorganized haphazard
way.
This may well be mass in this
uh area and uh
when this patient was operated on.
That was a benign chronic peptic ulcer with
extensive fibrosis in its base.
This is a counterpart of the hand of the of
the carmen Kirkland complex that I showed you earlier
mass ulceration surrounding
cuff of tissue.
Another view of it,
the double contrast where not only is their
absence of the mucous membrane but
apparent modularity in the periphery of the
crater,
there is this usual uh
uh flattening of the crater that I mentioned to
you a little while ago,
but that was not felt to
offset the apparent modularity of the mucous
membrane.
The patient was subjected to surgery.
This was a benign peptic ulcer
with surrounding fibrosis.
The reasons for this are seen in this series
of histological slides.
Usually once an ulcer crater heals,
the mucous membrane is reconstituted over it
and although you usually can so some residual,
it's difficult.
However,
if it's a chronic ulcer,
they frequently will not heal and if they
don't heal uh the individual
is prone to develop a lot of fibers tissue,
not only in the base of that crater,
but for considerable distances surrounding it.
And that fibrous tissue in an individual with a
chronic ulcer can produce exactly the same
type of deformity as one anticipates with cancer
and from the radio logic standpoint,
it can be virtually impossible to tell the difference between them.
If you try a therapeutic test,
they frequently do not heal because of the
poor vascular supply in the region and that is of no
help also.
So that very commonly these people come to
surgery.
And all you can say under those circumstances is you were glad
you were wrong and that the patient turned out to have a curable
process.
Uh The surgery was necessary in either
instance,
not only for diagnosis,
but also because of the propensity of these
craters not to heal.
Now I've indicated that the true test of
the accuracy
of rank and diagnosis or gastric opic diagnosis for
that matter is one of healing.
And let us say that in any case you
analyze it and you decide
that the factors favoring Bennett
nitty over uh ride
those favoring malignancy and you elect
to to treat the patient.
If this is done,
the patient should be in the hospital and it should be a carefully
controlled course of therapy.
And certainly there should be ample progress toward
healing within two weeks of this type of
treatment.
If it does not occur,
then one should go ahead and
uh advocate
surgical treatment.
Since the probabilities are even if it is a benign
creator,
it's of the refractory variety that I just mentioned
Here is one where we decided that it was
probably benign despite a rather bizarre
regional mucous membrane pattern.
And this is after two weeks of therapy with total
healing.
The fact that the mucous membrane pattern is
obliterated here is probably a function
of sub mucosal fibrosis rather than any
other thing.
Suffice it to say that for practical purposes,
99 and 90 100
of all times malignant alterations will
not respond to therapy.
They may show some reduction in size but they
don't heal completely.
And that is the center
of diagnosing the benign versus the malignant
ulceration insofar as the eventual
outcome is concerned,
the therapeutic test,
these ulcers will not respond a case in point
small ulcer radiologic lee.
We thought it was benign gastric optically.
I thought it was benign gastric opic biopsy.
Benign patient looked at gas risk
optically.
This is this little tiny crater with intense zone of
adama.
The biopsy was taken right from this point,
the patient was treated for 10 days.
Here's the crater hasn't gone away,
hasn't changed one iota
gassed risk optically,
it looked a little better.
The edema had decreased but the crater was still there.
The patient was operated on this was all
benign tissue,
but it was a penetrating carcinoma.
On the bottom of that crater.
In the final uh permanent
tissue sections,
malignant cells were found and also rating carcinoma
did not respond to therapy.
In summary,
then mucosal integrity is a
basis for differential diagnosis of these
uh craters.
Uh If you can demonstrate integrity,
you're probably dealing with a benign process if you cannot,
you have no alternative.
But to regard it as malignant and then
weigh the pros and cons of a therapeutic
test,
as opposed to immediate surgery In all
probability.
The therapeutic test ought to be used more frequently
simply because in most of these individuals,
an additional week or 10 days is not going to make a
significant difference in the outcome.
And if you can save a patient a
relatively crippling procedure,
namely a sub total gastrectomy,
it's best to do so.
Thank you
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