CHRONIC GASTRIC ULCER
The chronic gastric ulcer is almost invariably single, although scars of previous ulcers that have healed can be found in association with the sole active chronic lesion. Not infrequently, a duodenal ulcer develops simultaneously with a chronic gastric ulcer.
Most benign
chronic gastric ulcers occur at or near the lesser curvature of the
stomach in its midarea and, frequently, on the posterior wall near the lesser
curvature. They arise less commonly at the cardiac portion of the stomach or
near the pyloric ring. Only rarely does an ulcer on the greater curvature prove
to be benign.
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Chronic
gastric ulcers vary considerably in size, but about 80% of them are less than
1.8 cm in diameter. The ulcer is usually round, but at times it may be
elongated. The margins of a chronic ulcer are raised and, usually, considerably
undermined, as a result of the retraction of the muscular strata, whose continuity
has, in a chronic ulcer, always been interrupted. Fibrotic tissue, covered, at
times, by a fibrinous, purulent exudate, forms the floor of the ulcer. The penetrating
ulcerative process may also involve the serosa, which subsequently becomes
thickened by production of fibrotic tissue.
At times,
obliterative endarteritis appears in the blood vessels on the floor of the
chronic peptic ulcer. The associated veins sometimes show evidence of
thickening. Thrombosis of the veins and arteries may occur, sometimes with
endarteritis in the same vessel. The nerves at the floor of the ulcer
occasionally display perineural fibrosis.
The dominant
and also most characteristic symptom of chronic gastric ulcer is epigastric
pain, which the patient locates at some place between the xiphoid process and
the umbilicus, or somewhat left of this line toward the left costal margin. The
intensity and character of the pain, which the patient may describe as
“cutting,” “gnawing,” or “burning,” depend upon a variety of factors, such as
the location, size, and “activity” of the ulcer and the sensitiveness of the
individual patient. The pain may radiate to the back, usually to the level of
the 8th to 10th thoracic vertebrae. Rhythmic and periodic recurrence of pain is
rather typical, but is by no means absolutely pathognomonic of a chronic ulcer
(or sufficiently invariable as to exclude the possibility of a malignant
growth). Shortly after ingestion of food, the pain usually disappears, only to
recur ½ hour after the meal. It
may abate spontaneously before the next intake of food. This food-comfort-pain
rhythm, as it has been called, may persist or may respond more or less
satisfactorily to medical treatment. It may fade gradually and disappear
suddenly, failing to reappear for many months, or even years, if the
ulcerating, penetrating, or accompanying inflammatory processes have slowed to
a stop. If, on the other hand, the pain becomes more intense, or loses its
periodic rhythm and becomes persistent, this should always be taken as an ominous
sign of increasing danger of further complications.
Though the
patient’s history and complaints, as well as a careful physical examination,
will be helpful in diagnosing a gastric ulcer, the final diagnosis is generally
made endoscopically or by radiologic contrast studies. Radiologically, the
chronic gastric ulcer is characterized by a niche projecting from the
barium-filled stomach. As a rule, the niche is deeper than that of a subacute
ulcer, though it is not always possible to determine the exact depth of the
crater from the size of a niche, owing to the variability in the thickness of
the edematous and swollen
wall.
