WEBVTT

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*This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.*

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the following is a medical media production from

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W.R.A.M.C.T.V.

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Gastric ulceration is a

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pretty widely discussed topic.

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I'm sure you've all heard more than you really don't like

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to hear about it.

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But despite the fact that

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it's been written about and discussed very frequently,

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we still find that our

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residents have problems with the individual ulcers.

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And it's not uncommon that we have a case referred from

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another institution where a an

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erroneous diagnosis has been reached.

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It's really a rather simple problem.

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And I think for purposes of this discussion

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we'll see if we can't reduce it to the

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most simple common denominator and

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hopefully you'll be able to use it in the future.

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There have been a lot of criteria

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advanced for the differential diagnosis

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and many of them are really not too useful but

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they persist in the textbooks and we'll see if we can't dispose

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of a few of them.

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It's been said,

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for example,

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that the larger gastric ulcers are

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almost invariably uh

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malignant and that's not uh

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correct

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speaking in a general sense it might be

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true.

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But for practical purposes so far as the individual

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crater is concerned,

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it does not apply.

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Here's an ulcer that starts at this point runs all the

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way down past the inside.

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Sure,

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angular across the inside,

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sure.

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Almost to the pile or a ring

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a huge crater.

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Another criteria which has been postulated is

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not regularity of the base of the crater.

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If there are nodules in the base of the crater,

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this is supposed to represent tumor

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and therefore provides differential

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between a benign and malignant ulceration and here you see a

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very large nodule

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uh in the base of this crater,

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if we look at the uh

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crater with spot compression devices,

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we see that this is real,

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it doesn't move,

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it stays there all of the time and there is

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an obliteration of the mucous membrane pattern around the

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margins of this particular ulcer.

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All of these things would suggest a malignant

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process.

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However,

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here is the gross specimen and you

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see that it has an intact

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mucous membrane surrounding it and its entirety.

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This is a Dema and this this

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nodule in the center of the crater represents

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granule ation tissue.

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Some other smaller areas are scattered throughout the base

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also.

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So in this particular instance,

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size not regularity and the absence of the

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peripheral mucosal pattern is of no

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value in making the differential diagnosis is a

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completely a benign process.

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Another criterion that has been stated,

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and you'll find it even in books published within the last

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year,

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is that greater curvature ulcers are almost

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invariably malignant.

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And here is a crater on the posterior

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aspect of the stomach,

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greater curvature and in fact it's within the

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confines of the stomach.

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If we projected out the normal gastric outline,

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it would be to this point.

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So this would be mass with central

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ulceration.

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Both findings supposedly

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indicative of malignant

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ulceration.

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However,

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the gastric opic photograph on this individual

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shows a rather innocuous looking crater with a

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heaped up margin around it's uh

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it's uh edges which represents

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lymphoid hyperplasia,

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uh sub mucosal process intact

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mucous membrane overline and it is on the greater

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curvature.

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So again,

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this criterion does not help insofar as

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differential diagnosis is concerned

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as in the last case,

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and also in this one,

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the fact that the ulcer crater does not project

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beyond the gastric wall is

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assumed to be an indicator of an

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ulcerated neo plasm that is projecting into the

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gastric lumen as opposed to the peptic ulcer which

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should lie out here somewhere beyond

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the margin of the stomach

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here is one edge of the stomach here another.

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And if we project uh the

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non existent edge,

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we see that this should probably all be mass.

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The stomach should be out to here somewhere.

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And therefore this large ulceration

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should probably be within mass and

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therefore of the malignant variety.

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But once again we look at the gastro topic

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photograph and we see a very sharply punched out

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typically benign ulcer in an

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individual.

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Obviously a chronic ulcer in view of the

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deformity of the stomach.

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That's sick attritional scarring which is

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responsible for the depression of the crater rather

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than mass.

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So the depth of the crater,

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the location of the crater,

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the size of the crater modularity of the base of

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the crater,

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all of these things at least so far as I'm concerned,

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mean nothing.

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Now if we've thrown those away what's left.

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Well,

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an ulceration represents primarily a break in the

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mucous membrane that lines the stomach.

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And if it's within mass,

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there should be destruction of that mucous membrane.

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In addition to the ulcer crater itself,

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there should be the formulation of mass

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in the vicinity of the ulcer crater.

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In contradistinction to that,

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the uninvolved ulcer should be

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associated with intact mucous membrane.

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And I think that represents

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the basics in making the differential diagnosis

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between benign and malignant ulceration.

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If you can show integrity of the

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mucous membrane surrounding that ulceration,

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then there's no problem.

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Usually as to what you're dealing with.

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And here's a case in point here is a very well defined ulcer

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crater,

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several different projections of it.

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And as best we can tell on all of these.

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Uh there is uh mucous

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membrane in the vicinity of the crater which

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runs right up to the margin.

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There's no interruption of it.

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And this should be taken as an indicator

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of a probable benign process.

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Now,

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remember That here we are in essence,

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are seeing a crater in profile.

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We're not seeing 360° around the margin of that

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crater.

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And it's not impossible,

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for example,

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that normal mucous membrane lies on this side,

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but the opposite side of the crater actually

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shows infiltration representing an early,

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superficial spreading type of tumor.

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So we're never possible.

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We should try to identify the

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mucous membrane around the entire periphery of the crater,

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this is not always possible.

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But when we can it's a very useful

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uh differential diagnostic

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tool.

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Now,

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this really represents

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rather gross um

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detail insofar as the differential is

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concerned,

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we're looking at the major mucosal pattern of the

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stomach and this is seen

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particularly well on the single contrast

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study.

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We see it here without any difficulty on

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the double contrast study.

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But you notice as we get into the region of the

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crater itself,

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there's a tendency for obliteration

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of the the mucous membrane

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pattern.

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Now,

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this is in part a function of the optimum

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technique of the double contrast study.

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Because what we try to do with the properly

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done double contrast examination is to

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distended stomach uh to the point that

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the mucus membrane,

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the major mucous membrane pattern is effaced

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and we do this because we want to see

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the uh surface

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characteristics of the mucous membrane without

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any intervening folds.

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We want to be able to determine whether or not it's one

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smooth flowing hole or whether there

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are minor areas of uh

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rigidity uh or destruction,

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small mass and so forth,

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and so on.

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So that in the double contrast study,

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although from time to time,

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you can establish this mucosal integrity.

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It is not optimum from the standpoint of

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differential diagnosis,

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what is particularly useful is something that is

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neglected.

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Nowadays,

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I'm afraid to say.

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And that is the use of your hand under the fluoroscope

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to palpate the ulcer crater.

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And to determine whether or not there is flexibility of

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the gastric wall and the adjacent mucous membrane

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pattern.

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This ulcer creator very easily seen.

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And you see the mucous membrane running right up to the

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margins and by taking the glove finger

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and pal painting this area,

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we can establish that this bends with the

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pressure and snaps back into a normal position when you

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relieve the pressure.

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And that is worth a great deal in making a differential

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diagnosis.

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That is something that can satisfy most

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questions about the arch of an ulcer very graphically.

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And because you are working under the fluoroscope,

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you can rotate the patient and have a better

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appreciation of the entire circumference

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of the crater than you can with the

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static single projection film.

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Now,

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assuming that one can't show

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the major mucous membrane,

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what can be done well if you take the

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stomach specimen

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and paint it with a thin

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uh solution of barium,

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wipe off the excess and radiographic.

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You'll see the usual

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guy that we're also familiar with,

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but both on the surface of the rue guy and

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between a small mesh like

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pattern that represents the so called area

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gastric or the minor

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mucous membrane pattern of the stomach.

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Uh These represent clusters of

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gastric glands which are separated by little

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salsa.

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The so called salsa gastric a in effect they're little

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islands of mucous membrane

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separated by these very thin valleys,

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each one of which represents or contains

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multiple uh little

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orifices which are the point

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of of the emptying of the of the

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gastric glands.

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Now,

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these are useful to us because if you can

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demonstrate these in a

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single or double contrast study,

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you know that your technique is pretty good.

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You are able to to conclude that you

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are seeing just about everything that need to be seen in that

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particular area of the stomach and that there is no

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intrusion of motion,

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improper radiographic factors and so on.

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In addition,

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the very fact that these can be demonstrated

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straight ID indicates that you are dealing with an

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intact mucous membrane at least insofar

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as tumor tissue is concerned.

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If you see them,

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you can pretty well for that particular area,

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exclude the presence of a tumor.

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And here they are in vivo.

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You see this little mesh work pattern throughout the Antrim and

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this is the area where they're most readily

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visualized.

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And this because the guy are

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relatively few in the Antrim as you get back into the

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body and fungus of the stomach,

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the large folds tend to interfere with the

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visualization of the area.

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But they're there.

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And you can convince yourself of this.

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If you just take a look at the gross specimen there

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just as large in the fund this as they are in the

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Antrim.

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It's a matter of of ease with

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which they can be visualized rather than their presence or

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absence in different parts of the,

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of the stomach.

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Now to show an example of how these may

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be used in identifying

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uh whether a gastric

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ulceration is of the benign or malignant

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variety.

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This is a rather bizarre crater.

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You can just about see it here as a double

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contrast with this

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displacement around it.

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Uh This is actually uh a demo

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this mucous membrane,

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but there's no way of telling that from this

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radiograph,

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that's what it was proven to be eventually,

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but it could easily be mistaken

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for mass and this ulcer crater

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for uh necrosis within a

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rather large infiltrating tumor.

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However,

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with the double contrast technique,

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we've obliterated the major mucosal

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pattern.

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And here we can see quite clearly the

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individual area gastric running right up to the

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margin of that crater.

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In addition,

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if you look at the periphery here,

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you see a slight scalloping little

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speckles in between.

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These represent the area

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seen in profile with the little

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speckles,

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barium within the individual soul side

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gastric.

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And this is a convenient way of identifying the minor

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mucosal pattern as well as seen it.

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Uh in foss as you do here again,

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we can see them here,

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but there's relatively little information on this

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portion of the crater and you have to again

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go through multiple positions to

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establish the fact that all of the

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uh ulceration is indeed surrounded by

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intact area gastric.

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When you do.

13:32.590 --> 13:33.100
However,

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you can rest assure for practical purposes that you

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are dealing with a benign process and you do not have to worry

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about the presence of a gastric carcinoma.

13:43.020 --> 13:43.300
Now,

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unfortunately,

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on Many,

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many patients,

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it's not possible to either show

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the major mucosal pattern reaching

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the edge of the ulcer creator or for that matter,

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to demonstrate the area gastric.

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We have been able to show the area in about 50% of

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all of our G.

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I.

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series,

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it's there in all the rest,

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but factors that we are not entirely

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cognizant of uh

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apparently interfere with the visualization in every case,

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probably mucus is the most common

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cause,

14:16.160 --> 14:18.550
but we really haven't been able to either

14:18.570 --> 14:21.530
show conclusively that that's the case or to control

14:21.530 --> 14:24.060
it this being.

14:24.060 --> 14:26.990
So what can you do in the

14:26.990 --> 14:29.610
differential diagnosis of gastric ulceration

14:29.620 --> 14:32.390
to supplant the information that you would

14:32.390 --> 14:34.900
normally derive from the mucous membrane?

14:35.730 --> 14:36.020
Well,

14:36.020 --> 14:38.510
a variety of so called signs have been

14:38.510 --> 14:39.320
described,

14:40.020 --> 14:42.680
which are quite useful once

14:42.680 --> 14:45.210
again when they are present here,

14:45.210 --> 14:47.340
we see a very obvious ulcer crater.

14:47.780 --> 14:50.700
The mucous membrane itself is difficult to

14:50.700 --> 14:53.030
see in this case obliterated by

14:53.040 --> 14:53.780
Dema.

14:53.860 --> 14:56.270
But if we look at the margins of that crater,

14:56.270 --> 14:59.240
we see two little tabs of tissue and this

14:59.240 --> 14:59.710
of course,

14:59.710 --> 15:02.640
is the so called Hampton's line named

15:02.640 --> 15:03.820
after Aubrey Hampton,

15:03.820 --> 15:06.720
who was in Washington for so many years and

15:06.720 --> 15:09.540
represents a morphological characteristic of a

15:09.540 --> 15:10.370
gastric ulcer,

15:10.370 --> 15:13.170
namely the tendency of the benign

15:13.170 --> 15:16.030
peptic ulcer to undermine its mucosal

15:16.030 --> 15:16.730
margins,

15:16.920 --> 15:17.640
in other words,

15:17.640 --> 15:19.900
to be recessed beyond

15:20.100 --> 15:22.950
the apparent margins of the crater

15:22.950 --> 15:25.950
as we see it in Fox looking at the gross specimen.

15:27.090 --> 15:30.050
If this is the case then occasionally we should be able

15:30.050 --> 15:32.900
to visualize these overhanging tabs of mucous

15:32.900 --> 15:35.450
membrane and that is precisely what we're seeing there.

15:35.650 --> 15:37.030
Now this being the case.

15:37.550 --> 15:40.510
If you have these little flexible thin tabs

15:40.510 --> 15:43.260
there really cannot be mass in the vicinity of this

15:43.260 --> 15:43.690
crater.

15:44.370 --> 15:46.320
The fact that those tabs are present

15:46.670 --> 15:49.590
effectively eliminates the presence

15:49.590 --> 15:52.250
of mass and about 98% of

15:52.250 --> 15:54.690
individuals in whom you can demonstrate this

15:54.690 --> 15:55.790
particular finding.

15:56.050 --> 15:58.810
Now it's not always possible or necessary to

15:58.810 --> 16:01.220
demonstrate it on both sides of the crater.

16:02.310 --> 16:05.310
Occasionally you will see it only on one such as

16:06.090 --> 16:07.290
as a parent here.

16:07.350 --> 16:09.560
Or you may show it on

16:10.080 --> 16:13.080
both sides or bridging the entire

16:13.220 --> 16:14.610
mouth of the crater.

16:15.270 --> 16:17.900
However size of the crater

16:17.910 --> 16:20.010
doesn't necessarily have any

16:20.130 --> 16:21.700
relationship to it.

16:21.710 --> 16:24.660
You can see it with very small ulcers as well as well as some of

16:24.660 --> 16:27.490
the large ones that I've demonstrated to you.

16:27.580 --> 16:30.460
And also if you don't see it

16:30.470 --> 16:33.430
first crack out of the box when you're examining the patient.

16:33.440 --> 16:36.020
If other findings indicate a probable

16:36.030 --> 16:37.340
benign process.

16:37.750 --> 16:39.620
If you treat the patient for a week,

16:39.630 --> 16:40.450
10 days,

16:40.460 --> 16:41.150
two weeks.

16:41.420 --> 16:43.780
Very commonly you'll find that

16:43.880 --> 16:46.700
where it could not be demonstrated on the initial

16:46.700 --> 16:49.270
examination it has appeared following

16:49.270 --> 16:50.950
decrease in the size of the ulcer.

16:50.960 --> 16:53.220
Here's of course a very obvious crater.

16:53.230 --> 16:55.520
And after about 10 days of therapy,

16:55.530 --> 16:56.450
the same patient,

16:56.640 --> 16:59.160
we now are able to see Hamptons line without any

16:59.160 --> 17:00.610
difficulty substantiate.

17:00.610 --> 17:03.110
In our original opinion that we were

17:03.110 --> 17:05.560
indeed dealing with benign

17:05.560 --> 17:06.200
process.

17:08.410 --> 17:09.730
It's very easy however,

17:09.730 --> 17:12.730
to talk yourself into a Hamptons line when actually what you're

17:12.730 --> 17:15.650
seeing with say compression techniques is uh

17:15.660 --> 17:18.410
an overlapping margin of the stomach on the other

17:18.410 --> 17:19.450
side of the crater.

17:19.660 --> 17:22.140
And occasionally you'll get vegetable

17:22.140 --> 17:24.940
fibers in the crater base

17:24.940 --> 17:25.510
itself.

17:25.510 --> 17:28.480
And these can be mistaken for Hampton's line

17:28.480 --> 17:28.670
here,

17:28.670 --> 17:29.250
for example,

17:29.250 --> 17:29.760
with one,

17:29.760 --> 17:30.490
here's another,

17:30.500 --> 17:32.570
here's something running almost

17:32.580 --> 17:35.050
vertically to the axis

17:35.060 --> 17:37.090
of the office of the crater.

17:37.220 --> 17:40.190
And with juggling this patient around little

17:40.190 --> 17:40.440
bit,

17:40.440 --> 17:42.810
you see that all of the things that we were

17:43.090 --> 17:45.590
considering on this projection as possible.

17:45.590 --> 17:48.510
Hampton's lines are gone and we're left with this which may or

17:48.510 --> 17:51.060
may not be Hamptons line itself.

17:51.060 --> 17:53.810
So it can be sort of misleading and you have to be careful

17:54.030 --> 17:56.030
that you're not looking at debris only

17:57.740 --> 17:58.630
Rather rarely.

17:58.630 --> 18:01.540
Probably in about one or 2% of patients either a

18:01.540 --> 18:04.400
Hamptons line will coexist with an

18:04.400 --> 18:07.190
ulcer rating neo plasm or will be

18:07.190 --> 18:09.660
simulated by an ulcerated Nia plasm.

18:09.660 --> 18:12.290
This looks for all the world uh like

18:12.290 --> 18:14.600
Hamptons line but you notice this rather

18:14.600 --> 18:17.170
angular configuration of the adjacent

18:17.170 --> 18:18.000
gastric wall.

18:18.000 --> 18:20.570
And of course on this uh greater curvature

18:20.570 --> 18:21.090
side,

18:21.270 --> 18:24.180
an angular in drawing with a suggestion of mass

18:24.180 --> 18:25.820
and this is infiltrating cancer.

18:25.940 --> 18:28.480
Regardless of the fact that we have this

18:28.490 --> 18:30.780
apparent sign of dignity.

18:30.780 --> 18:33.760
So one must be careful not to rest

18:33.760 --> 18:35.710
entirely on this finding.

18:37.370 --> 18:39.460
Now it's

18:39.460 --> 18:40.560
difficult.

18:40.570 --> 18:42.900
I really don't have a figure,

18:42.900 --> 18:45.870
I've never compiled one as to how frequently

18:45.870 --> 18:48.770
you can demonstrate Hampton's line in a

18:48.770 --> 18:50.600
given ulceration.

18:50.600 --> 18:53.550
But I would say certainly not more than half the time.

18:53.550 --> 18:56.400
And you have to work at it pretty diligently to get that figure.

18:57.330 --> 18:58.950
Uh that being the case,

18:58.950 --> 19:01.770
what can we substitute for Hampton's line as the

19:01.780 --> 19:03.770
98% accurate criteria?

19:03.770 --> 19:04.370
And after all,

19:04.370 --> 19:05.270
that's pretty good.

19:05.600 --> 19:08.150
But if you can't if you can't see it,

19:08.160 --> 19:10.860
uh then its accuracy is really of

19:10.860 --> 19:12.090
no great moment.

19:12.570 --> 19:13.880
And the next question is,

19:13.880 --> 19:15.540
what can we substitute for it?

19:15.550 --> 19:18.420
Just as Hampton's line itself was a substitute for

19:18.420 --> 19:20.690
being able to demonstrate the mucous membrane.

19:21.480 --> 19:21.970
Well,

19:21.980 --> 19:23.260
in all of the text,

19:23.430 --> 19:26.210
you are usually told that one of the characteristics of a

19:26.210 --> 19:28.840
benign ulcer is the fact that it will hold

19:28.840 --> 19:30.610
material in the erect position.

19:31.120 --> 19:32.750
The contents of the stomach.

19:32.750 --> 19:35.710
Whether it happens to be barium uh gastric

19:35.710 --> 19:38.560
juice or whatnot will spill into the ulcer

19:38.560 --> 19:41.380
crater and will be held there

19:41.390 --> 19:44.170
by the usual dumbbell configuration of the

19:44.170 --> 19:44.610
crater.

19:46.240 --> 19:48.780
This is a particularly nice demonstration of it.

19:48.780 --> 19:51.500
Where And we have the heavier barium at the bottom.

19:51.770 --> 19:54.130
Gastric juice uh

19:54.140 --> 19:56.860
occupying roughly the next third of the crater.

19:56.860 --> 19:59.410
And here air trapped within it in the erect

19:59.410 --> 20:00.000
position.

20:00.600 --> 20:00.970
Well,

20:00.970 --> 20:03.370
this is a rather tenuous criterion.

20:03.370 --> 20:06.190
and I don't like to use it as such simply because

20:06.590 --> 20:09.340
uh it doesn't really explain what's going

20:09.340 --> 20:09.780
on.

20:09.790 --> 20:12.790
I don't like to talk about

20:12.800 --> 20:14.990
a radiographic finding as purely

20:14.990 --> 20:17.240
descriptive wherein we don't

20:17.240 --> 20:19.890
understand the underlying cause and the

20:19.890 --> 20:21.250
reason for these,

20:21.770 --> 20:24.390
for the ability of the ulcer crater to trap this

20:24.850 --> 20:26.030
liquid material.

20:26.030 --> 20:28.520
And air is really quite simple and readily

20:28.520 --> 20:31.390
explain If we take

20:31.400 --> 20:33.300
this schematic of an ulcer crater.

20:33.300 --> 20:36.130
And this goes all the way back to uh

20:36.140 --> 20:38.990
for shell in the late 1920s when

20:38.990 --> 20:41.650
he pounded his magnificent

20:42.170 --> 20:44.870
theories on the auto plasticity of the mucous

20:44.870 --> 20:45.530
membrane.

20:45.880 --> 20:48.640
We see that he noted that in the

20:48.640 --> 20:51.550
vicinity of an ulcer crater there was a tendency for

20:51.550 --> 20:54.370
the mucous membrane to swell to heap

20:54.370 --> 20:57.320
up and to overlap the mouth of

20:57.320 --> 20:57.880
the crater.

20:58.830 --> 21:01.040
And this was a gradual process.

21:01.690 --> 21:04.560
But I think you can see how it would tend to obliterate the

21:04.560 --> 21:07.100
mucous membrane with this sub mucosal

21:07.100 --> 21:10.020
swelling and this layer represents the muscular is

21:10.020 --> 21:10.650
appropriate.

21:10.650 --> 21:13.440
This represents the mucous membrane and it's sub

21:13.440 --> 21:15.510
mucosal uh space

21:16.420 --> 21:19.270
with this gradual distension of the sub mucosal space.

21:19.270 --> 21:22.030
There's a tendency to obliterate the

21:22.040 --> 21:23.670
major mucosal pattern,

21:23.680 --> 21:24.480
however,

21:24.490 --> 21:26.880
uh be that as it may,

21:28.740 --> 21:31.000
it's basically an intact process.

21:31.000 --> 21:32.240
It's just distended.

21:32.250 --> 21:35.020
And there is a tendency on the part of this mucous

21:35.020 --> 21:37.910
membrane to try and overlap the mouth of this

21:37.910 --> 21:38.360
ulcer.

21:38.680 --> 21:41.600
Now whether this is a function of just the swelling itself

21:41.600 --> 21:43.860
with the extra bulk of the mucous membrane

21:44.110 --> 21:44.680
produced,

21:44.680 --> 21:47.200
or whether it's a function of the mucous

21:47.200 --> 21:49.980
membrane trying to cover the

21:49.990 --> 21:52.650
crater and thereby uh

21:52.660 --> 21:55.560
present a protective mechanism insofar as

21:55.560 --> 21:58.430
gastric juices concern is open to question.

21:59.060 --> 21:59.590
However,

21:59.590 --> 22:02.500
it does overlap the entire crater and

22:02.510 --> 22:04.920
this fact does displace barium

22:05.530 --> 22:08.380
and the displacement of barium by this overlapping

22:08.380 --> 22:10.740
mucous membrane has been described by dr

22:10.740 --> 22:13.370
Marshak and dr Wolfe as the so called

22:13.380 --> 22:16.210
ulcer collar and its just as useful

22:16.210 --> 22:19.210
in its own way as Hampton's line and has

22:19.210 --> 22:20.930
exactly the same significance.

22:21.970 --> 22:24.750
Here are some cases in point a large crater

22:25.420 --> 22:28.380
which is apparently entirely separate from the general lumen of

22:28.380 --> 22:28.870
the stomach.

22:28.880 --> 22:30.910
We have this black band running between them.

22:31.240 --> 22:31.460
Now,

22:31.460 --> 22:33.880
if we milk the barium around a little bit with our

22:33.880 --> 22:36.800
fingers were able to demonstrate of course that this is

22:36.800 --> 22:37.950
not separate from it,

22:38.090 --> 22:40.870
but that there is a relative

22:41.040 --> 22:43.970
bulk of tissue between the crater and the general

22:43.970 --> 22:44.350
lumen,

22:44.350 --> 22:45.840
which is displacing barium.

22:45.840 --> 22:48.660
And here we can see uh the gradual

22:48.960 --> 22:51.720
uh transition from the crater

22:51.890 --> 22:54.770
to the general lumen of the stomach by

22:54.780 --> 22:56.750
this intervening mass.

22:56.750 --> 22:58.000
Whatever it may be.

22:59.140 --> 23:01.180
If we look at it in another projection,

23:01.180 --> 23:04.030
we can see the crater itself and very faintly

23:04.030 --> 23:06.310
see that surrounding collar

23:06.660 --> 23:09.500
displacing barium in the double contrast

23:09.510 --> 23:10.440
view as well.

23:10.840 --> 23:13.670
Now this represents that heaped up mucus

23:13.670 --> 23:15.890
membrane surrounding the ulcer crater,

23:16.260 --> 23:18.770
the so called ulcer collar and a double

23:18.770 --> 23:21.040
contrast study shows it rather beautifully.

23:21.050 --> 23:23.930
Here we can see the crater itself and here

23:24.150 --> 23:27.080
the Mucous membrane riding

23:27.080 --> 23:29.540
toward the ulcer crater overlapping it.

23:29.660 --> 23:32.410
And indeed extending throughout the

23:32.410 --> 23:35.170
360° of the ulcer periphery

23:35.360 --> 23:37.470
and notice that this is quite smooth.

23:37.470 --> 23:39.480
There's no hint of destruction,

23:39.480 --> 23:40.250
infiltration,

23:40.250 --> 23:41.000
ulceration.

23:41.210 --> 23:42.960
It's a gradual process.

23:43.060 --> 23:46.060
It has approximately the same width throughout and

23:46.060 --> 23:46.770
above all.

23:46.770 --> 23:49.010
The mucous membrane periphery

23:49.760 --> 23:51.520
is absolutely smooth.

23:51.620 --> 23:54.500
Now this again bespeaks mucosal integrity

23:54.500 --> 23:57.480
and therefore it has the same significance as these other

23:57.670 --> 23:59.990
findings that we were talking about

24:02.360 --> 24:02.600
Now,

24:02.600 --> 24:04.040
every once in a while,

24:05.250 --> 24:07.570
the so called ulcer collar can be so

24:07.570 --> 24:10.510
large that it has to be referred to

24:10.510 --> 24:11.520
by another name.

24:11.520 --> 24:13.850
And it has been called the ulcer mound.

24:13.850 --> 24:15.520
And I guess that's as good as any.

24:15.940 --> 24:18.860
The primary significance is that when they are so

24:18.860 --> 24:19.300
large,

24:19.300 --> 24:21.090
they're apt to be mistaken for tumors.

24:21.530 --> 24:24.490
And here we see a case in point if we projected this

24:24.920 --> 24:26.750
gastric outline here again,

24:26.920 --> 24:29.840
this presumably would represent tumor and

24:29.850 --> 24:32.750
this represent ulceration within the

24:32.750 --> 24:33.180
tumor.

24:33.610 --> 24:34.270
However,

24:34.280 --> 24:37.200
I'd like to call your attention the configuration of

24:37.200 --> 24:37.750
that ulcer.

24:39.020 --> 24:41.860
The ulcer has not

24:41.870 --> 24:44.580
a dumbbell appearance in this instance,

24:44.590 --> 24:46.180
not a stele eight appearance,

24:46.180 --> 24:48.970
but rather is flattened.

24:49.000 --> 24:51.800
And if you would like to be

24:51.800 --> 24:52.490
fanciful,

24:52.490 --> 24:55.170
you might say it looks a little bit like a flying

24:55.170 --> 24:55.750
saucer.

24:56.720 --> 24:58.790
Now this is a useful observation.

24:58.790 --> 25:01.710
If we go to this crater in the immediate

25:01.710 --> 25:02.990
pre pile oric area,

25:03.330 --> 25:06.180
we see an ulcer

25:06.180 --> 25:07.330
collar surrounding it.

25:07.940 --> 25:10.780
And in the double contrast projection we see

25:10.780 --> 25:13.470
integrity of the mucous membrane on either side.

25:13.470 --> 25:14.440
No question about it.

25:14.440 --> 25:15.350
Nice and smooth,

25:15.350 --> 25:17.390
radiates right up to the margin of the ulcer.

25:17.750 --> 25:20.600
And once again we see this saucer like

25:20.600 --> 25:21.190
appearance.

25:21.880 --> 25:24.670
Now this is what dr Sydney nelson has referred to

25:24.670 --> 25:25.880
as the corner sign,

25:26.320 --> 25:27.180
and what it is,

25:27.180 --> 25:27.840
of course,

25:27.850 --> 25:30.810
is the adam entous mucous membrane on either side of

25:30.810 --> 25:31.780
the ulcer creator,

25:32.090 --> 25:35.020
plus the undermine mucosa producing this

25:35.020 --> 25:35.620
recess.

25:35.620 --> 25:36.200
And again,

25:36.200 --> 25:38.670
we're looking at the tendency of the

25:38.680 --> 25:41.460
benign ulceration to undermine

25:41.460 --> 25:44.030
itself to extend beyond its

25:44.030 --> 25:44.550
orifice.

25:44.550 --> 25:47.450
Is seen when you're looking down at the mucous membrane proper.

25:47.860 --> 25:50.520
So the corner sign so called.

25:50.630 --> 25:51.500
Or if you will,

25:51.500 --> 25:54.280
the flying saucer sign has exactly the

25:54.280 --> 25:57.110
same significance as Hampton's line

25:57.120 --> 25:58.310
or the ulcer collar.

25:58.650 --> 26:00.940
It indicates that you are dealing

26:00.940 --> 26:03.890
morphological e with benign ulceration and

26:03.890 --> 26:06.880
that the mucous membrane in the vicinity of the ulcer creator

26:07.050 --> 26:07.900
is intact.

26:10.020 --> 26:12.960
Another example of it very nicely shown here where

26:12.960 --> 26:15.780
you can see this little tip

26:15.780 --> 26:18.350
coming out and projecting above the margin of the

26:18.350 --> 26:19.660
adjacent gastric wall.

26:22.120 --> 26:24.910
This is also demonstrable in small craters,

26:25.300 --> 26:28.270
just as Hampton's line and actually there's a combination of

26:28.270 --> 26:30.460
the corner sign and Hampton's line there.

26:30.560 --> 26:31.280
But again,

26:31.280 --> 26:34.050
note the basic flat configuration

26:34.190 --> 26:37.010
of that ulcer and that's

26:37.010 --> 26:37.720
very helpful.

26:37.730 --> 26:40.350
I have been able to separate in some instances

26:40.370 --> 26:42.630
suspected malignant processes

26:42.640 --> 26:44.580
uh from

26:44.770 --> 26:47.140
benign processes by just the

26:47.140 --> 26:48.750
configuration of this crater.

26:49.100 --> 26:51.520
I find it a very useful observation.

26:53.230 --> 26:55.070
So this being the case.

26:55.080 --> 26:57.630
What uh is

26:57.640 --> 27:00.130
reliable from the standpoint of benign

27:00.130 --> 27:00.850
ulceration?

27:01.670 --> 27:01.990
Well,

27:01.990 --> 27:04.860
what is reliable is integrity of the mucous membrane and

27:04.860 --> 27:07.710
integrity of the mucous membrane may be demonstrated either

27:07.710 --> 27:10.420
by seeing the major or the minor mucosal

27:10.420 --> 27:13.380
folds or in the absence of those folds.

27:13.680 --> 27:15.700
Anyone of the three

27:15.910 --> 27:18.510
observations that further

27:18.510 --> 27:19.780
document integrity,

27:19.790 --> 27:20.810
namely Hamptons,

27:20.810 --> 27:22.990
line the ulcer collar

27:23.280 --> 27:25.310
or the corner sign.

27:25.970 --> 27:28.210
And I think these last three can all be

27:28.210 --> 27:31.010
described as simply by

27:31.010 --> 27:33.790
saying that you couldn't

27:33.830 --> 27:36.610
have any of them if the mucous membrane were not

27:36.610 --> 27:37.300
intact.

27:37.310 --> 27:39.930
If the little tab of mucous membrane

27:40.180 --> 27:43.050
that constitutes Hamptons line were destroyed

27:43.050 --> 27:43.670
by tumor,

27:43.670 --> 27:44.960
you wouldn't be able to see it.

27:45.330 --> 27:48.190
If the mucous membrane surrounding the ulcer

27:48.190 --> 27:50.010
crater were not flexible,

27:50.150 --> 27:53.110
you would not get the adama which permits you to

27:53.110 --> 27:55.560
see that smooth enrolling that is so

27:55.560 --> 27:58.390
characteristic of that particular observation.

27:58.750 --> 28:01.450
And without integrity of the mucous membrane,

28:02.250 --> 28:05.170
allowing the formation of the little tab and the

28:05.170 --> 28:07.780
concomitant flexibility is demonstrated by

28:07.780 --> 28:08.320
adama,

28:08.330 --> 28:10.220
The corner sign would not exist.

28:10.300 --> 28:12.660
So all of those three things show

28:12.660 --> 28:15.300
exactly what the major and minor mucosal

28:15.300 --> 28:16.390
patterns show you,

28:16.400 --> 28:18.440
namely integrity of the mucous membrane.

28:18.440 --> 28:19.200
If it's present,

28:19.210 --> 28:21.750
it's a benign process as opposed to

28:21.750 --> 28:22.280
malignant.

28:23.490 --> 28:23.730
Now,

28:23.730 --> 28:24.430
just briefly,

28:24.430 --> 28:27.080
there are other types of gastric ulceration which occur.

28:27.080 --> 28:29.930
They usually cause no problem from the standpoint of differential

28:29.930 --> 28:32.630
diagnosis here are multiple small ulcers

28:32.630 --> 28:35.360
scattered throughout the entire body of the stomach and a

28:35.360 --> 28:37.220
patient with flag minutes gastritis.

28:37.220 --> 28:38.840
We don't see this very often,

28:39.030 --> 28:41.540
but when we do it's readily recognizable.

28:41.620 --> 28:44.460
And of course all of us are aware of the fact that multiple

28:44.460 --> 28:45.650
ulcers can occur.

28:45.950 --> 28:47.720
Multiple benign ulcers and here is

28:47.720 --> 28:50.600
123 and four.

28:51.000 --> 28:53.800
Uh This particular individual happened to be

28:53.800 --> 28:56.300
receiving steroids for

28:56.310 --> 28:59.220
carcinoma of the breast and this of course

28:59.220 --> 29:01.780
is particularly prone to cause multiple alterations.

29:01.780 --> 29:03.160
But be that as it may,

29:03.220 --> 29:06.210
the multiplicity uh does not

29:06.210 --> 29:08.870
necessarily suggest process such as

29:08.870 --> 29:09.490
lymphoma.

29:09.490 --> 29:12.250
It may be entirely on a benign basis

29:13.430 --> 29:16.240
now that we've discussed all these things about

29:16.250 --> 29:17.210
benign ulcers.

29:17.210 --> 29:19.580
The next thing to consider is what

29:19.580 --> 29:22.260
constitutes uh

29:22.270 --> 29:24.410
a malignant ulcer.

29:24.580 --> 29:27.150
And I will start this

29:27.160 --> 29:29.930
by simply saying that there is one

29:29.930 --> 29:32.300
classic description of

29:32.310 --> 29:35.160
a malignant ulcer

29:35.170 --> 29:36.630
that you all should be aware of.

29:36.630 --> 29:38.010
And then having major aware of it,

29:38.010 --> 29:40.750
we can forget all about it because the

29:40.750 --> 29:41.470
cholera area,

29:41.470 --> 29:44.200
what I've told you so far is if you can demonstrate

29:44.200 --> 29:46.060
integrity of the mucous membrane,

29:46.120 --> 29:47.590
you have a benign process.

29:47.590 --> 29:50.580
If you can't demonstrate integrity or if you can demonstrate any

29:50.580 --> 29:53.470
suggestion of mass you have a malignant process and it's

29:53.470 --> 29:56.020
really rather useless to talk about signs and so

29:56.020 --> 29:56.590
forth.

29:56.640 --> 29:59.600
When you can boil something down to a simple

29:59.600 --> 30:00.850
statement such as that.

30:01.770 --> 30:02.360
However,

30:02.360 --> 30:05.030
I'm sure all of you have read about carmen sign

30:05.480 --> 30:08.350
as being indicative of the presence of a

30:08.350 --> 30:09.320
gastric cancer.

30:09.700 --> 30:12.420
And it's true and it does not necessarily have to be

30:12.420 --> 30:14.720
associated with an advanced gastric cancer.

30:14.720 --> 30:17.320
Carmen sign can occur in

30:17.320 --> 30:18.800
very early cancers.

30:19.510 --> 30:21.710
It's commonly regarded as advanced disease,

30:21.710 --> 30:22.440
but that's not.

30:22.440 --> 30:25.330
So there has been an inordinate

30:25.330 --> 30:27.440
amount of misunderstanding of this sign.

30:27.440 --> 30:30.090
And if you go back and read Dr Carmen's original article,

30:30.090 --> 30:32.700
you can understand it because he is not too precise

30:32.940 --> 30:35.480
about what he's saying in terms of

30:35.480 --> 30:36.740
describing that finding.

30:37.000 --> 30:39.890
It was subsequently uh discussed

30:39.890 --> 30:42.700
that greater extent by dr burrow Kirkland of the Mayo

30:42.700 --> 30:43.160
clinic.

30:43.160 --> 30:45.850
And actually I suppose it would be proper to

30:45.850 --> 30:48.060
refer to this as the Carmen Kirkland

30:48.060 --> 30:48.870
complex,

30:49.290 --> 30:51.810
since both of them had a hand in

30:51.810 --> 30:54.800
defining its components be that as it

30:54.800 --> 30:55.600
may.

30:55.740 --> 30:58.530
This little uh throwaway ashtray I

30:58.530 --> 31:01.360
think pretty well explains what it

31:01.360 --> 31:01.630
is.

31:01.630 --> 31:04.330
We see with carmen sign this of

31:04.330 --> 31:04.640
course,

31:04.640 --> 31:06.170
is the dish part of the ashtray.

31:06.170 --> 31:09.020
And this cremated margin here can be considered

31:09.030 --> 31:12.000
tumor and the dish part and ulceration.

31:12.470 --> 31:12.720
Now,

31:12.720 --> 31:15.310
if we bend that in half and

31:15.310 --> 31:17.980
consider this as uh say

31:17.980 --> 31:20.370
on the lesser curvature of the stomach,

31:20.820 --> 31:23.710
we can see that barium could be trapped

31:23.720 --> 31:26.660
within this disproportion and that would represent the ulcer

31:26.880 --> 31:29.550
and the cremated portion would represent

31:29.550 --> 31:30.060
mass.

31:30.090 --> 31:32.520
And then of course barium would surround this.

31:32.550 --> 31:35.260
So what we would see in the radiograph then

31:35.450 --> 31:38.240
would be barium in the proper in the

31:38.240 --> 31:41.130
lumen of the stomach proper barium then

31:41.130 --> 31:43.450
displaced by irregular mass,

31:43.460 --> 31:46.240
a cuff of irregular mass and then barium

31:46.250 --> 31:47.850
trapped within the ulcer crater.

31:47.850 --> 31:49.040
So this would be dense,

31:49.200 --> 31:52.180
this would be dense and this would be relatively radio loosened.

31:52.440 --> 31:54.860
And that's the Carmen Kirkland complex.

31:54.900 --> 31:56.590
It's ulcerated mass.

31:56.810 --> 31:59.720
And when you view it properly in the

31:59.720 --> 32:02.710
stomach with proper grades of compression and so forth,

32:02.720 --> 32:05.650
you see the barium trapped within the ulcer and

32:05.650 --> 32:08.440
surrounded by the mass of the non

32:08.440 --> 32:10.680
ulcerated portions of the tumor.

32:11.880 --> 32:14.470
And this is very easily seen radiographic lee.

32:14.470 --> 32:16.840
And here's a rather typical one scene in foss.

32:17.020 --> 32:18.260
Here's the mass,

32:18.870 --> 32:19.530
if you will,

32:19.530 --> 32:21.590
the Nagy ular margins of the ashtray.

32:21.800 --> 32:24.410
And here is that this part of the ashtray or in this

32:24.410 --> 32:24.860
instance,

32:24.860 --> 32:25.920
the irregular ulcer.

32:26.370 --> 32:26.570
Now,

32:26.570 --> 32:29.270
if we saw that in profile instead of in

32:29.270 --> 32:29.760
foss,

32:30.340 --> 32:33.000
this would be overlapping so that we have sort of a

32:33.000 --> 32:35.220
saddle ulcer and it would be surrounded by

32:35.550 --> 32:37.570
a radio loosen.

32:37.570 --> 32:38.940
See such as you see here,

32:38.950 --> 32:41.800
here is the crater and here

32:41.810 --> 32:43.200
is the surrounding mass.

32:43.210 --> 32:43.890
This of course,

32:43.890 --> 32:46.700
is the general Newman of the stomach doesn't differ a

32:46.700 --> 32:48.940
great deal from the appearance of

32:49.210 --> 32:51.970
some of the ulcer collars and so on that I've been

32:51.970 --> 32:54.780
showing you accept that this margin is not

32:54.780 --> 32:55.290
smooth,

32:55.290 --> 32:57.680
it is not regular and the nodule clarity

32:57.920 --> 33:00.000
is of course a significant

33:02.140 --> 33:04.020
This does not have to occur.

33:04.020 --> 33:06.390
It's not confined to the stomach alone,

33:06.390 --> 33:08.580
you can see a carmen sign anywhere in the

33:08.580 --> 33:09.890
gastrointestinal track.

33:09.890 --> 33:10.810
And it makes sense,

33:10.810 --> 33:12.820
since it's nothing more than ulcer rating mass.

33:13.090 --> 33:16.010
And here you see a carcinoma of

33:16.010 --> 33:17.190
the recto sigmoid,

33:17.200 --> 33:18.660
it's displacing barium.

33:18.670 --> 33:21.240
Here's a ser pigeon is ulcer in it

33:21.590 --> 33:24.500
and this therefore represents the surrounding

33:24.500 --> 33:26.620
cuff of non necrotic tissue,

33:26.720 --> 33:29.320
the ulcer and the general lumen of the colon.

33:31.740 --> 33:33.930
Another example of it here,

33:33.930 --> 33:36.820
an apparent uh area of

33:36.820 --> 33:39.680
rigidity on the lesser curvature of the stomach just

33:39.680 --> 33:40.760
before the polaris.

33:40.760 --> 33:43.550
We see this flat saddle like double

33:43.550 --> 33:46.180
density here surrounded by a faint radio loosen.

33:46.180 --> 33:48.810
See uh if we follow that through

33:48.820 --> 33:51.770
here is the crater remaining complete

33:51.770 --> 33:54.320
destruction of the mucous membrane

33:54.330 --> 33:57.300
around it and relatively intact mucous membrane on

33:57.300 --> 34:00.110
the greater curvature side where infiltration has not occurred.

34:00.430 --> 34:01.860
This is the classic serial,

34:01.860 --> 34:04.600
a graphic appearance of the Carmen Kirkland complex

34:04.730 --> 34:07.500
and all of you should be able to recognize this and make an instant

34:07.500 --> 34:09.630
diagnosis of ulcerated gastric cancer.

34:09.770 --> 34:10.720
When you see it,

34:11.550 --> 34:14.140
it has been generically stated for purposes of

34:14.340 --> 34:17.110
differential diagnosis that in the benign

34:17.110 --> 34:17.660
crater,

34:17.970 --> 34:19.520
the margins,

34:19.530 --> 34:22.510
the mucous membranes surrounding the margin has a tendency

34:22.510 --> 34:25.410
to roll in and overlap the mouth of the crater

34:25.410 --> 34:28.110
as we described and to parallel

34:28.430 --> 34:30.070
the long axis of the crater.

34:30.070 --> 34:32.570
Whereas in the tumor uh,

34:32.580 --> 34:34.550
the uh

34:35.590 --> 34:38.580
access of the indentation has a tendency to be

34:38.580 --> 34:40.420
at right angles to the crater.

34:40.430 --> 34:43.050
And that is generally so although not

34:43.050 --> 34:45.760
sufficiently frequently seen to

34:45.770 --> 34:48.030
permit it to be an absolute

34:48.040 --> 34:48.840
criterion.

34:50.900 --> 34:51.500
Now,

34:51.510 --> 34:53.850
usually when we see an

34:53.850 --> 34:55.960
individual who has an insight shura

34:56.160 --> 34:57.830
opposite an ulcer,

34:57.840 --> 35:00.480
we tend to regard it as a benign

35:00.490 --> 35:01.100
crater.

35:01.470 --> 35:04.470
And uh this is proper as I will show you in a moment.

35:04.590 --> 35:07.530
But beware because

35:07.530 --> 35:10.170
cancers can infiltrate the

35:10.170 --> 35:12.870
wall opposite a crater and produce an

35:12.870 --> 35:15.870
apparent insight shura and uh I have

35:15.870 --> 35:18.660
seen misdiagnoses on this basis,

35:18.660 --> 35:19.690
a case in point,

35:20.240 --> 35:21.260
an ulcer crater,

35:21.750 --> 35:24.750
apparent mucous membrane integrity

35:24.750 --> 35:25.630
surrounding it.

35:25.640 --> 35:28.540
Uh and an insight sure on the opposite

35:28.540 --> 35:30.460
wall but there is mass here,

35:30.470 --> 35:32.980
there's mass here and this is infiltrating

35:32.980 --> 35:35.650
cancer opposite this ulceration.

35:35.760 --> 35:38.290
The tumor probably extends to here as well.

35:38.330 --> 35:41.110
And if we look at gas Trask optically here is this

35:41.110 --> 35:43.230
large ridge of tumor

35:43.320 --> 35:45.110
representing mass,

35:45.250 --> 35:47.740
which is restricting the

35:47.880 --> 35:50.590
sensibility of the wall by infiltration and has nothing to

35:50.590 --> 35:52.920
do with an inside shore at all.

35:53.410 --> 35:55.390
Just bear in mind about inside.

35:55.390 --> 35:55.730
Sure,

35:55.730 --> 35:58.450
is that they are probably related to the oblique

35:58.450 --> 36:01.120
fibers or the internal muscle layer of the

36:01.120 --> 36:03.740
stomach and that the true spastic

36:03.740 --> 36:06.410
inside shura occurs only along the

36:06.410 --> 36:08.000
distribution of these fibers.

36:08.150 --> 36:09.170
And as you can see,

36:09.170 --> 36:11.630
they're draped around the esophageal gastric junction,

36:11.630 --> 36:14.280
much like a scarf come down on either

36:14.280 --> 36:17.220
side of the esophageal gastric junction,

36:17.270 --> 36:20.100
along the lesser curvature of the stomach and fan out

36:20.510 --> 36:23.030
to eventually join with the

36:23.040 --> 36:24.310
circular layer,

36:24.500 --> 36:26.960
at about the mid portion of the stomach,

36:26.960 --> 36:29.420
they're indistinguishable from about this point on.

36:29.640 --> 36:32.580
But they are there and they terminate insofar as

36:32.580 --> 36:35.560
the long axis of the stomach is concerned at about the

36:35.560 --> 36:36.550
level of the inside.

36:36.550 --> 36:37.650
Sure angularity.

36:38.190 --> 36:40.860
It has been postulated that these are not a

36:40.860 --> 36:43.520
supportive bundle of muscles but are actually

36:43.670 --> 36:45.400
akin to the muscles,

36:45.410 --> 36:47.260
the bundles of hits in the heart.

36:47.430 --> 36:49.680
It's a conducting system and therefore,

36:49.680 --> 36:52.090
when they're involved by processes such as

36:52.090 --> 36:52.880
ulceration,

36:53.040 --> 36:56.010
there's a spastic contracture that results uh

36:56.010 --> 36:58.820
and produces the deformity that we're so aware of

36:58.830 --> 37:00.080
be that as it may.

37:00.580 --> 37:03.410
Uh These two inside sures occur only over this

37:03.410 --> 37:03.770
area.

37:03.770 --> 37:04.310
This of course,

37:04.310 --> 37:06.000
is opened along the greater curvature.

37:06.030 --> 37:08.900
And when you see inside assures beneath this

37:08.900 --> 37:09.530
point.

37:09.540 --> 37:11.990
Beware particularly

37:11.990 --> 37:14.790
because there are no oblique fibers distal to the

37:14.790 --> 37:15.160
inside.

37:15.160 --> 37:15.440
Sure,

37:15.440 --> 37:15.940
angular.

37:17.400 --> 37:19.880
Now here is a case in point of an individual

37:19.940 --> 37:21.870
who has a parent

37:22.630 --> 37:25.630
integrity of the mucous membrane folds superficially

37:25.630 --> 37:28.540
these could be regarded as foals running right up to the margin of

37:28.540 --> 37:29.150
this crater.

37:29.150 --> 37:30.780
And here is presumably an insight.

37:31.390 --> 37:32.290
But remember,

37:32.470 --> 37:35.320
they don't develop like this distal to the

37:35.320 --> 37:36.660
inside your angular

37:37.980 --> 37:40.270
far more reliable than this observation,

37:40.270 --> 37:40.810
therefore,

37:40.820 --> 37:43.050
is the integrity of the mucous membrane.

37:43.050 --> 37:46.010
And this is the same patient with a double contrast technique

37:46.020 --> 37:48.640
here we see the inside which actually

37:48.640 --> 37:50.420
represents infiltrating cancer.

37:50.690 --> 37:53.590
You notice that there is irregular obliteration

37:53.590 --> 37:55.840
of the mucous membrane throughout this area of

37:55.840 --> 37:56.610
ulceration.

37:57.250 --> 37:59.800
This obliteration involves incoming mucous

37:59.800 --> 38:02.800
membrane folds and there are points where these folds are

38:02.800 --> 38:05.630
pinched and there are points where the folds widen.

38:06.120 --> 38:06.730
This of course,

38:06.730 --> 38:07.210
again,

38:07.210 --> 38:09.970
is indicative of infiltrating tumor all around the

38:09.970 --> 38:12.620
margins of the crater and clearly makes the diagnosis.

38:12.750 --> 38:15.690
And you can see in the gastric opic photo the irregular

38:15.690 --> 38:16.170
crater.

38:16.180 --> 38:19.160
And here the infiltrating mass that in the single

38:19.160 --> 38:20.050
contrast view,

38:20.050 --> 38:22.660
to some extent simulated uh

38:22.670 --> 38:23.360
peripheral,

38:23.360 --> 38:24.980
intact peripheral folds.

38:25.010 --> 38:26.820
So in this instance,

38:27.100 --> 38:29.390
the double contrast study demonstrating

38:29.390 --> 38:32.350
interruption and distortion of the mucous membrane is the

38:32.350 --> 38:35.200
far more reliable study uh

38:35.210 --> 38:37.040
than the single contrast

38:37.950 --> 38:40.580
or observation of adjacent

38:42.080 --> 38:43.680
in say sure and so on.

38:45.930 --> 38:48.460
The shape of the ulcer crater is also useful.

38:49.720 --> 38:52.670
Dr Marshak has made this point and I think it's valid by

38:52.670 --> 38:53.590
and large.

38:54.310 --> 38:56.590
Benign ulceration is oblong

38:56.590 --> 38:57.380
circular,

38:57.580 --> 38:59.040
pretty sharply defined,

38:59.050 --> 39:00.220
smooth margins.

39:00.380 --> 39:03.210
When you see diamond shaped or otherwise irregular

39:03.210 --> 39:03.700
craters.

39:03.700 --> 39:04.350
Beware.

39:04.510 --> 39:07.410
And here's a very nice point in

39:07.410 --> 39:08.060
the question.

39:08.300 --> 39:10.210
This is very irregular multiple,

39:10.210 --> 39:10.900
Sir pigeon.

39:10.900 --> 39:13.700
Isse extensions into the surrounding tissue

39:13.810 --> 39:16.690
and is readily recognizable as a

39:16.690 --> 39:18.010
malignant process.

39:18.020 --> 39:18.710
In addition,

39:18.890 --> 39:21.750
you notice that the mucous membrane is visualized

39:21.750 --> 39:24.710
throughout the majority of the adjacent stomach till you

39:24.710 --> 39:27.600
get into the area immediately surrounding the

39:27.600 --> 39:28.090
crater.

39:28.100 --> 39:29.680
And then it's totally obliterated.

39:30.000 --> 39:31.780
Not only is it totally obliterated,

39:31.780 --> 39:32.230
you might say,

39:32.230 --> 39:32.610
well,

39:32.660 --> 39:34.710
that could be a Dema that's true.

39:34.740 --> 39:36.280
But look at this fold,

39:36.280 --> 39:37.080
for example,

39:37.500 --> 39:40.120
this is not only obliterated suddenly widen and then

39:40.120 --> 39:43.070
abruptly goes back to a more normal size and that does

39:43.070 --> 39:45.800
not occur with the Dema their gradual transitions with the

39:45.800 --> 39:46.180
demon.

39:46.380 --> 39:47.620
This is not regularity.

39:47.620 --> 39:50.420
And if you see modularity it's tumor that you're dealing with

39:51.500 --> 39:52.680
guest risk optically.

39:53.130 --> 39:54.900
It's not uncommon for

39:55.880 --> 39:58.880
benign peptic ulceration is to

39:58.880 --> 40:01.870
show Sir pigeon is extensions such as this but we

40:01.870 --> 40:04.530
do not see them radiologic lee for practical

40:04.530 --> 40:05.140
purposes.

40:05.140 --> 40:07.950
There is no radiologic counterpart when we see it.

40:08.140 --> 40:10.930
It usually indicates that we're dealing with some

40:10.930 --> 40:12.710
type of ulcerated neo plasm.

40:13.770 --> 40:16.490
We can carry this a little farther as I indicated

40:16.490 --> 40:18.240
earlier by absence of the area.

40:18.240 --> 40:18.910
Gas tricky.

40:19.110 --> 40:21.890
And here we notice in this rather innocuous looking

40:21.890 --> 40:24.890
crater which is not particularly bizarre and shape

40:25.020 --> 40:27.530
uh that the adjacent major

40:27.530 --> 40:29.720
mucosal pattern is irregular,

40:30.010 --> 40:31.250
partially effaced.

40:31.690 --> 40:34.560
It comes down say to about this point and suddenly stops.

40:34.560 --> 40:37.560
Here's one that comes down to here and abruptly stops and

40:37.560 --> 40:38.170
so on.

40:38.180 --> 40:41.150
And if we look at this rather closely there are area

40:41.150 --> 40:44.090
gastric A here here here here but they're totally

40:44.090 --> 40:45.200
absent in this area.

40:45.350 --> 40:47.870
This happens to be in this instance a lymphoma

40:47.980 --> 40:50.720
with rather extensive involvement of this

40:50.720 --> 40:53.490
portion of the stomach but it's really not appreciable

40:53.600 --> 40:56.320
except by this observation of the

40:56.650 --> 40:59.470
mucosal findings with the stomach

40:59.470 --> 41:00.000
distended.

41:00.000 --> 41:01.980
It was virtually impossible to detect.

41:04.570 --> 41:07.460
Now one last finding Insofar

41:07.470 --> 41:10.150
as uh malignant

41:10.150 --> 41:12.160
gastric ulceration is concerned.

41:12.190 --> 41:13.080
Occasionally.

41:13.080 --> 41:15.880
We will see gastric ulcers which are

41:15.880 --> 41:16.620
not ulcers.

41:17.680 --> 41:20.620
Uh This paradoxical statement is

41:20.620 --> 41:23.610
related to the methods by

41:23.610 --> 41:26.170
which superficial carcinomas are prone to

41:26.170 --> 41:27.280
develop.

41:27.590 --> 41:30.310
This is a staged drawing made by

41:30.310 --> 41:33.240
dr Albert Jutras of Montreal who described

41:33.240 --> 41:34.950
this process many years ago.

41:35.230 --> 41:37.970
And we see in essence what takes place,

41:37.970 --> 41:40.610
there is initially a very slight

41:40.620 --> 41:43.290
atrophy or flattening of the mucous membrane.

41:43.790 --> 41:46.560
This gradually becomes more marked and

41:46.560 --> 41:49.370
finally there is a tendency for this

41:49.370 --> 41:52.300
particular portion of the involved mucous

41:52.300 --> 41:54.930
membrane to be tacked down by proliferating

41:54.930 --> 41:55.610
cells.

41:55.630 --> 41:58.210
While this bulge is centrally,

41:58.940 --> 42:01.540
this becomes more and more demonstrable as a

42:01.540 --> 42:04.140
fibra genic reaction is instituted by the

42:04.140 --> 42:07.140
cells until you have what seems to be

42:07.450 --> 42:09.430
a carmen Kirkland complex.

42:09.580 --> 42:11.790
But actually there is no ulceration.

42:11.800 --> 42:14.730
It's just the proliferating cells

42:14.850 --> 42:17.490
in conjunction with the fiber genic reaction,

42:17.500 --> 42:20.460
tacking down this portion of the mucous membrane and

42:20.460 --> 42:21.010
producing,

42:21.010 --> 42:21.600
if you will,

42:21.610 --> 42:22.580
a pseudo ulcer.

42:22.800 --> 42:22.970
Now,

42:22.970 --> 42:25.390
these may go on later to ulceration

42:25.390 --> 42:26.050
themselves.

42:26.270 --> 42:27.810
But if you look at it here,

42:27.810 --> 42:29.420
in the superimposed drawing,

42:29.530 --> 42:32.410
you can see the apparent ridge representing tumor.

42:32.560 --> 42:35.520
You can see the interruption of the mucosal folds and here

42:35.600 --> 42:36.950
the seeming ulcer crater.

42:37.800 --> 42:39.210
And here's a case in point.

42:39.680 --> 42:42.660
You notice the folds all radiate towards this point.

42:42.670 --> 42:44.320
They're suddenly interrupted here,

42:45.020 --> 42:47.810
there's loss of the falls and here is an ulcer which

42:48.300 --> 42:51.000
has a rather bizarre shape to it but

42:51.000 --> 42:53.480
otherwise is not too significant.

42:56.040 --> 42:56.970
Very obvious.

42:57.310 --> 42:57.770
However,

42:57.770 --> 43:00.640
this is the gross specimen on this individual and there is no

43:00.640 --> 43:01.030
ulcer.

43:02.030 --> 43:04.530
This is the flattening that I just described to you,

43:04.530 --> 43:07.300
a depression produced by the combination of

43:07.300 --> 43:10.220
the proliferating tumor cells and the fiber genic

43:10.220 --> 43:10.650
tissue,

43:11.120 --> 43:14.080
pulling these mucous membrane folds toward

43:14.080 --> 43:14.240
it,

43:14.250 --> 43:16.870
eventually obliterating them but actually

43:16.870 --> 43:17.900
producing no ulcer.

43:17.900 --> 43:18.030
Now,

43:18.030 --> 43:18.410
of course,

43:18.410 --> 43:21.410
these will go on to ulceration at a later

43:21.410 --> 43:21.830
date.

43:22.010 --> 43:24.410
But the japanese with this type of tumor are

43:24.410 --> 43:27.280
experiencing five year survival rates on the order of

43:27.430 --> 43:30.040
90 or 95% assuming

43:30.040 --> 43:33.040
that the type of cancer that they see in japan is

43:33.040 --> 43:34.860
similar to our own gastric cancers.

43:34.860 --> 43:37.710
And some people dispute that be that as it may,

43:37.740 --> 43:40.310
this is a very early manifestation of

43:40.310 --> 43:43.130
gastric cancer and much more subject to queue to

43:43.130 --> 43:46.080
cure than when frank ulceration develops.

43:47.860 --> 43:50.370
These are merely the types of

43:50.380 --> 43:52.650
cancers that are

43:52.660 --> 43:55.390
encountered fun gating uh

43:55.400 --> 43:55.910
uh,

43:55.920 --> 43:58.520
infiltrating the superficial

43:58.520 --> 44:01.280
spreading and of course the line itis plastic

44:01.290 --> 44:01.850
type.

44:02.100 --> 44:04.630
These are probably the most difficult types to

44:04.640 --> 44:05.660
diagnosed,

44:05.660 --> 44:07.900
but they're the ones that are analogous to the

44:07.910 --> 44:10.860
uh series that I just showed you and

44:10.860 --> 44:13.680
does represent the type that we can be most helpful with

44:13.690 --> 44:15.560
when they're detected early on.

44:18.700 --> 44:18.930
Now,

44:18.930 --> 44:21.840
other forms of gastric ulceration in tumor that occur

44:21.840 --> 44:22.610
are well known to you.

44:22.610 --> 44:23.130
Of course,

44:23.140 --> 44:26.080
here's an obvious crater in the gastric fungus and

44:26.080 --> 44:28.610
the tip off in this is not only the shape of the crater,

44:28.720 --> 44:31.420
but also the fact that the margins of this

44:31.420 --> 44:32.680
mass are so smooth.

44:32.680 --> 44:33.110
In fact,

44:33.110 --> 44:35.960
they are covered by intact mucous membrane with the exception of

44:35.960 --> 44:38.850
that this bespeaks a sub mucosal origin

44:38.860 --> 44:41.510
and is of course indicative of a

44:41.510 --> 44:44.150
mesenchymal tumor here when seen in profile,

44:44.150 --> 44:46.950
that crater has a characteristic punched out appearance.

44:47.110 --> 44:47.840
And again,

44:47.840 --> 44:50.440
we're dealing with intact mucous membrane surrounding the

44:50.440 --> 44:50.870
crater,

44:51.070 --> 44:53.560
all of which makes the diagnosis rather easy.

44:53.900 --> 44:54.860
It does not,

44:54.870 --> 44:55.370
however,

44:55.370 --> 44:58.180
tell you particularly what type of tissue is involved in that

44:58.180 --> 45:00.940
statistically it's most often um

45:00.950 --> 45:03.800
A oh my Oma

45:03.800 --> 45:05.090
or li'l mouse sarcoma.

45:05.090 --> 45:07.190
But it may be a lymphoma.

45:07.370 --> 45:08.330
Excuse me,

45:08.330 --> 45:11.290
A lymphoma or Anura genic tumor

45:11.290 --> 45:12.200
and so forth.

45:12.420 --> 45:15.090
The ulceration for any of these is quite characteristic

45:15.090 --> 45:15.570
however,

45:15.570 --> 45:18.090
and directly represents what we saw on the

45:18.090 --> 45:18.730
radiograph.

45:18.730 --> 45:21.370
There's excellent correlation between the two.

45:23.250 --> 45:23.920
Finally,

45:24.030 --> 45:27.030
in the terms of benign sub mucosal

45:27.030 --> 45:29.390
ulceration is beware every once in a while.

45:29.390 --> 45:32.090
A fun gating cancer will mimic them rather closely.

45:32.090 --> 45:33.020
This is a cancer.

45:33.290 --> 45:35.950
Notice the serrated edges of this which you should not

45:35.950 --> 45:38.440
have with the sub

45:38.440 --> 45:39.680
mucosal lesion.

45:39.880 --> 45:42.710
Uh and the central ulceration has not got the sharply

45:42.710 --> 45:45.680
punched out appearance that we demonstrated in the

45:45.690 --> 45:46.980
true benign process.

45:48.770 --> 45:49.180
Now,

45:49.260 --> 45:51.740
this covers the criteria that I wanted to

45:51.740 --> 45:54.670
mention and I think that having

45:54.670 --> 45:57.370
stated them uh as though they

45:57.370 --> 45:59.120
were entirely reliable.

45:59.130 --> 46:01.640
Uh One might get the impression that it's

46:01.640 --> 46:04.220
possible in every instance to make a precise

46:04.220 --> 46:07.010
differentiation and this is not the case.

46:07.020 --> 46:09.810
Uh probably

46:09.810 --> 46:12.140
with Very

46:12.380 --> 46:15.090
exquisite technique and with the help of our gastric

46:15.090 --> 46:15.860
opic friends,

46:15.860 --> 46:18.450
we can make the diagnosis

46:18.460 --> 46:21.260
correctly in about 95% of

46:21.270 --> 46:21.900
cases.

46:22.080 --> 46:23.790
Uh however,

46:23.790 --> 46:26.730
there are some times when we just can't do it and we're going

46:26.730 --> 46:29.390
to have to have depend upon the gas tras copyist and

46:29.390 --> 46:32.200
even some of those cases they are not

46:32.210 --> 46:33.930
always able to help.

46:34.930 --> 46:37.860
This is a case in point insofar as the radiologic

46:37.870 --> 46:39.340
diagnosis is concerned,

46:39.340 --> 46:41.660
this was an elderly woman in her late sixties

46:41.890 --> 46:44.690
with positive tools positive for blood,

46:44.690 --> 46:45.540
Occult blood,

46:45.770 --> 46:48.770
an upper gastrointestinal series was done and she had

46:48.770 --> 46:51.570
this obvious deformity of the duodenum and the diagnosis

46:51.570 --> 46:54.350
of of duodenal ulcer was made uh

46:54.350 --> 46:57.120
and she was treated for about a week or

46:57.120 --> 46:59.950
10 days and the gastrointestinal series repeated.

46:59.950 --> 47:01.640
This hasn't changed one iota,

47:01.820 --> 47:04.750
but this time somebody was a little more careful

47:04.850 --> 47:07.510
and here we see actually the

47:07.510 --> 47:08.630
source of her bleeding.

47:08.630 --> 47:11.550
There is an ulceration on the lesser curvature side

47:11.610 --> 47:14.290
and there is complete obliteration of the mucous

47:14.290 --> 47:16.450
membrane pattern sarai And

47:16.460 --> 47:19.380
obviously it wasn't a very big ulcer to start

47:19.380 --> 47:22.380
with and it apparently hadn't responded to that week or 10 days of

47:22.380 --> 47:22.800
therapy.

47:22.800 --> 47:25.560
So surgery was carried out immediately and this

47:25.560 --> 47:28.510
was a superficial carcinoma

47:28.520 --> 47:29.470
with ulceration.

47:29.710 --> 47:32.170
The obliteration of the mucous membrane pattern

47:32.250 --> 47:35.240
represented combination of infiltrating tumor and fibra

47:35.240 --> 47:36.310
genic response.

47:36.610 --> 47:39.380
So in this instance one would have to

47:39.380 --> 47:42.370
say in the complete interruption of

47:42.370 --> 47:45.230
the mucous membrane pattern here as well as this sir pigeon this

47:45.230 --> 47:48.040
extension that you were dealing with a cancer but

47:48.040 --> 47:50.930
usually cancers of the stomach are reputed not to

47:50.930 --> 47:53.580
occur in conjunction with peptic ulceration elsewhere.

47:53.840 --> 47:56.840
And this is a case in point where in fact uh they

47:56.840 --> 47:59.060
did occur in the same individual.

47:59.740 --> 48:02.710
Another individual with an ulcer in approximately the

48:02.710 --> 48:05.660
same area seen in foss.

48:06.000 --> 48:08.800
Couldn't get it in profile because of its location.

48:09.280 --> 48:11.800
There's the crater there surrounding mass.

48:11.810 --> 48:13.510
Benign or malignant,

48:14.290 --> 48:16.910
we couldn't tell the mucous membrane was

48:16.910 --> 48:18.640
destroyed or absent.

48:18.650 --> 48:21.070
Therefore we thought we had to call it uh

48:21.080 --> 48:23.210
uh a malignant process,

48:23.220 --> 48:26.020
but it was a benign peptic ulcer.

48:26.610 --> 48:28.430
The point of these two,

48:28.440 --> 48:30.760
this is the same individual by the way,

48:30.760 --> 48:31.500
same crater.

48:31.500 --> 48:33.970
And here is the surrounding

48:34.110 --> 48:35.960
absence of mucous membrane.

48:36.160 --> 48:38.770
The point of these two cases is that

48:38.840 --> 48:40.870
with certain types of ulceration,

48:40.880 --> 48:43.200
with absence of the mucous membrane pattern,

48:43.200 --> 48:46.090
you have no choice but to regard it as a malignant

48:46.090 --> 48:46.720
process.

48:46.810 --> 48:49.060
And if it turns out to be benign and the

48:49.060 --> 48:51.740
patient uh has an

48:51.740 --> 48:53.540
unnecessary gastrectomy.

48:53.550 --> 48:54.630
It's unfortunate,

48:54.630 --> 48:57.090
but better that that be done uh than

48:57.100 --> 48:59.790
a tumor left in sight.

48:59.790 --> 49:02.150
To another

49:02.150 --> 49:04.500
example here is a flat ulcer

49:05.350 --> 49:08.210
limited distance ability of the gastric wall

49:08.550 --> 49:11.460
probable infiltration of the

49:11.460 --> 49:14.330
adjacent gastric wall when

49:14.330 --> 49:15.750
seen in another projection,

49:15.750 --> 49:18.560
there is most certainly interruption of the mucous membrane

49:18.560 --> 49:21.100
pattern in the most disorganized haphazard

49:21.100 --> 49:21.790
way.

49:21.940 --> 49:24.230
This may well be mass in this

49:24.240 --> 49:27.150
uh area and uh

49:27.160 --> 49:29.030
when this patient was operated on.

49:29.040 --> 49:31.910
That was a benign chronic peptic ulcer with

49:31.910 --> 49:33.950
extensive fibrosis in its base.

49:35.100 --> 49:37.890
This is a counterpart of the hand of the of

49:37.890 --> 49:40.860
the carmen Kirkland complex that I showed you earlier

49:41.110 --> 49:43.950
mass ulceration surrounding

49:43.950 --> 49:45.630
cuff of tissue.

49:46.140 --> 49:47.640
Another view of it,

49:47.640 --> 49:50.050
the double contrast where not only is their

49:50.060 --> 49:53.030
absence of the mucous membrane but

49:53.030 --> 49:55.930
apparent modularity in the periphery of the

49:55.930 --> 49:56.430
crater,

49:56.850 --> 49:59.370
there is this usual uh

49:59.380 --> 50:02.090
uh flattening of the crater that I mentioned to

50:02.090 --> 50:03.590
you a little while ago,

50:03.780 --> 50:06.480
but that was not felt to

50:06.480 --> 50:09.290
offset the apparent modularity of the mucous

50:09.290 --> 50:09.920
membrane.

50:10.150 --> 50:12.560
The patient was subjected to surgery.

50:12.660 --> 50:15.260
This was a benign peptic ulcer

50:15.310 --> 50:17.300
with surrounding fibrosis.

50:18.740 --> 50:21.640
The reasons for this are seen in this series

50:21.640 --> 50:24.050
of histological slides.

50:24.250 --> 50:27.030
Usually once an ulcer crater heals,

50:27.130 --> 50:30.130
the mucous membrane is reconstituted over it

50:30.130 --> 50:32.570
and although you usually can so some residual,

50:32.580 --> 50:33.530
it's difficult.

50:33.620 --> 50:34.660
However,

50:34.880 --> 50:36.320
if it's a chronic ulcer,

50:36.410 --> 50:39.260
they frequently will not heal and if they

50:39.260 --> 50:42.170
don't heal uh the individual

50:42.170 --> 50:44.560
is prone to develop a lot of fibers tissue,

50:44.560 --> 50:46.460
not only in the base of that crater,

50:46.570 --> 50:49.110
but for considerable distances surrounding it.

50:49.210 --> 50:52.090
And that fibrous tissue in an individual with a

50:52.090 --> 50:54.990
chronic ulcer can produce exactly the same

50:54.990 --> 50:57.790
type of deformity as one anticipates with cancer

50:57.990 --> 50:59.980
and from the radio logic standpoint,

50:59.980 --> 51:02.920
it can be virtually impossible to tell the difference between them.

51:03.110 --> 51:05.010
If you try a therapeutic test,

51:05.210 --> 51:07.850
they frequently do not heal because of the

51:08.090 --> 51:11.070
poor vascular supply in the region and that is of no

51:11.070 --> 51:11.910
help also.

51:12.140 --> 51:14.670
So that very commonly these people come to

51:14.670 --> 51:15.270
surgery.

51:15.650 --> 51:18.600
And all you can say under those circumstances is you were glad

51:18.600 --> 51:21.570
you were wrong and that the patient turned out to have a curable

51:21.570 --> 51:22.220
process.

51:22.510 --> 51:25.110
Uh The surgery was necessary in either

51:25.110 --> 51:25.530
instance,

51:25.530 --> 51:26.790
not only for diagnosis,

51:26.790 --> 51:29.490
but also because of the propensity of these

51:29.490 --> 51:30.760
craters not to heal.

51:32.490 --> 51:35.280
Now I've indicated that the true test of

51:35.280 --> 51:38.270
the accuracy

51:38.270 --> 51:41.090
of rank and diagnosis or gastric opic diagnosis for

51:41.090 --> 51:43.840
that matter is one of healing.

51:44.100 --> 51:46.590
And let us say that in any case you

51:46.590 --> 51:49.340
analyze it and you decide

51:49.350 --> 51:52.240
that the factors favoring Bennett

51:52.240 --> 51:54.800
nitty over uh ride

51:54.810 --> 51:57.630
those favoring malignancy and you elect

51:57.630 --> 52:00.000
to to treat the patient.

52:00.770 --> 52:02.160
If this is done,

52:02.160 --> 52:04.720
the patient should be in the hospital and it should be a carefully

52:04.720 --> 52:06.180
controlled course of therapy.

52:06.180 --> 52:08.950
And certainly there should be ample progress toward

52:08.950 --> 52:11.460
healing within two weeks of this type of

52:11.470 --> 52:12.040
treatment.

52:12.270 --> 52:13.700
If it does not occur,

52:13.790 --> 52:15.500
then one should go ahead and

52:15.510 --> 52:17.930
uh advocate

52:17.930 --> 52:19.230
surgical treatment.

52:19.240 --> 52:21.980
Since the probabilities are even if it is a benign

52:21.980 --> 52:22.450
creator,

52:22.570 --> 52:25.250
it's of the refractory variety that I just mentioned

52:25.470 --> 52:28.070
Here is one where we decided that it was

52:28.070 --> 52:30.640
probably benign despite a rather bizarre

52:30.640 --> 52:32.320
regional mucous membrane pattern.

52:32.320 --> 52:34.990
And this is after two weeks of therapy with total

52:34.990 --> 52:35.390
healing.

52:35.610 --> 52:38.090
The fact that the mucous membrane pattern is

52:38.090 --> 52:40.170
obliterated here is probably a function

52:40.370 --> 52:43.330
of sub mucosal fibrosis rather than any

52:43.330 --> 52:44.150
other thing.

52:44.620 --> 52:47.320
Suffice it to say that for practical purposes,

52:47.490 --> 52:49.900
99 and 90 100

52:50.440 --> 52:53.350
of all times malignant alterations will

52:53.350 --> 52:54.720
not respond to therapy.

52:54.720 --> 52:57.460
They may show some reduction in size but they

52:57.470 --> 52:58.740
don't heal completely.

52:58.940 --> 53:00.780
And that is the center

53:01.730 --> 53:04.510
of diagnosing the benign versus the malignant

53:04.510 --> 53:07.420
ulceration insofar as the eventual

53:07.420 --> 53:08.510
outcome is concerned,

53:08.510 --> 53:09.760
the therapeutic test,

53:10.510 --> 53:13.310
these ulcers will not respond a case in point

53:14.150 --> 53:16.500
small ulcer radiologic lee.

53:16.500 --> 53:18.630
We thought it was benign gastric optically.

53:18.630 --> 53:21.130
I thought it was benign gastric opic biopsy.

53:21.130 --> 53:23.900
Benign patient looked at gas risk

53:23.900 --> 53:24.350
optically.

53:24.350 --> 53:27.270
This is this little tiny crater with intense zone of

53:27.270 --> 53:27.870
adama.

53:27.880 --> 53:30.000
The biopsy was taken right from this point,

53:30.210 --> 53:32.100
the patient was treated for 10 days.

53:32.110 --> 53:34.920
Here's the crater hasn't gone away,

53:34.930 --> 53:36.470
hasn't changed one iota

53:37.480 --> 53:38.940
gassed risk optically,

53:39.180 --> 53:40.260
it looked a little better.

53:40.260 --> 53:42.900
The edema had decreased but the crater was still there.

53:42.900 --> 53:45.550
The patient was operated on this was all

53:45.550 --> 53:46.560
benign tissue,

53:46.560 --> 53:48.330
but it was a penetrating carcinoma.

53:48.330 --> 53:49.460
On the bottom of that crater.

53:49.460 --> 53:52.350
In the final uh permanent

53:52.360 --> 53:53.190
tissue sections,

53:53.340 --> 53:56.150
malignant cells were found and also rating carcinoma

53:56.160 --> 53:58.250
did not respond to therapy.

53:59.580 --> 54:00.250
In summary,

54:00.250 --> 54:03.140
then mucosal integrity is a

54:03.140 --> 54:05.800
basis for differential diagnosis of these

54:05.810 --> 54:06.970
uh craters.

54:07.070 --> 54:09.780
Uh If you can demonstrate integrity,

54:09.780 --> 54:12.690
you're probably dealing with a benign process if you cannot,

54:12.700 --> 54:14.130
you have no alternative.

54:14.320 --> 54:17.020
But to regard it as malignant and then

54:17.020 --> 54:19.850
weigh the pros and cons of a therapeutic

54:19.850 --> 54:20.290
test,

54:20.410 --> 54:22.880
as opposed to immediate surgery In all

54:22.880 --> 54:23.780
probability.

54:24.100 --> 54:26.630
The therapeutic test ought to be used more frequently

54:26.870 --> 54:29.630
simply because in most of these individuals,

54:29.630 --> 54:32.240
an additional week or 10 days is not going to make a

54:32.240 --> 54:34.460
significant difference in the outcome.

54:34.560 --> 54:37.170
And if you can save a patient a

54:37.180 --> 54:38.740
relatively crippling procedure,

54:38.750 --> 54:41.280
namely a sub total gastrectomy,

54:41.290 --> 54:42.350
it's best to do so.

54:42.410 --> 54:43.210
Thank you

54:53.900 --> 54:56.710
a medical media production from w r e m

54:56.710 --> 54:57.600
c t v.