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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