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.
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.