Ques. 1 What are the different sites of peptic ulcer?
Ans. The different sites of peptic ulcer are :-
- Gastrojejunal ulcers following gastrojejunostomy.
- Peptic ulcers n Mekel’s diverticulum.
- In the terminal (introgastric part) of the oesophagus.
- Gastric ulcer – occurring in relation to lesser curvature and its adjacent anterior and posterior surfaces which normally corresponds with the food canal.
- Duodenal ulcer- occurring in the 1st part of duodenum commonly on its anterior surface.
Ques. 2 Describe the morbid anatomy of Gastric ulcer.
Ans. The morbid anatomy of Gastric ulcer is :-
- Floor : It is always deep, usually formed by the serous coat. The muscle coat at the floor is always destroyed and there is a circular gap in muscle coat. The floor feels indurated.
- Number : Usually single. In 5 to 10% of cases it may be multiple.
- Margin : They are always steep or may be sloping. The cardiac end of the ulcer is steeper than its pyloric end.
- Sharp : Usually it is funnel shaped. Superficial ulcers may be oval or round in shape.
- Site: Commonest site is in the region of lesser curvature and its adjacent surfaces at least 2” above the pyloric end ulcer may be situated in the pylorus.
- Corresponding serous coat : it looks pearly white in colour, hard and cartilaginous to feel (hence it is said that G.U. are better palpated then seen from outside). The thickened serous coat is puckered & tags of omentum. Adjacent coats of intestine etc. are usually seen adherent to it.
- Size : Usually less than I” in diameter (gastric ulcers having diameter larger than I” should be taken to be ulcerative type of carcinoma).
The Microscopical appearance of Gastric Ulcer:
A progressive chronic gastric ulcer has the following features:
- A zone of fibrous tissue proliferation at the base of the ulcer.
- The vessels show endarteritis obliterans.
- The muscle fibres spread out in fanwise manner from the periphery of the ulcer and ultimately fuse with the muscularis mucosa.
- Most superficially a zone of acute inflammatory cells consisting of polymorphs, mononuclear cells and there is breach in the continuitly of mucosal line.
- The muscle coat at the site.
Ques. 3 Write about the healing of peptic ulcer?
Ans. Healing of Peptic Ulcer:
Once the ulcer becomes chromic it shows better tendency for healing Healing is retarded because of the following factors:
- Necrotic slough present at the base of the ulcer covers, the granulation tissue and provides no footing for the growing epithelium. The dense layer of scar tissue interfers with healing preventing approximation of the edges of the ulcer.
- Endarteritis oblierans of the vessles interfere with blood supply so that the part becomes more and more devitalized.
- The part is constantly exposed to irritant acid gastric juice which sets up irritation.
Because of all these factors gastric ulcer once formed becomes gradually progressive, it may show some amount of healing just to recur within a short period.
Table: Difference between Ulcerative type of carcinoma & Gastric ulcer undergoing malignant change.
Ulcerative Type of Carcinoma i.e. Cancer Ulcer
G.U. Showing Malignant Change i.e. Ulcer Cancer
1) Site usually at the pyloric region.
1) Usual site is lesser curvature and its anterior and posterior surfaces about 2-4” above the pyloric region.
2) Size – Diameter of the ulcer is always larger than I”.
2) Size – It is usually less than I”.
3) The condition of the muscle coat at xthe floor – muscle fibres are present but are infiltrated with yellowish white streaks of tumour tissue producing gramentation of the muscle coat.
3) Muscles coat at the region is completely destroyed and there is a circular gap of deficiency in it.
4) Regional lymph glands – are involved. They are enlarged, hard to feel.
4) Less involved except in a late case where the glands have the features of metastatic lymph node.
A chronic gastric ulcer undergoing secondary carcinomatous change will show following positive features:
- Dense scar tissue at the floor.
- Endarteritis of blood vessels.
- It is the edge of the ulcer which is carcinomatous, not the base. So loops of malignant cells are present only at the edge and are seen infiltrating into the healthy area.
- Complete destructive of underlying muscle coat.
All these features are not in ulcerative type of carcinoma. Tissue taken from any part of the ulcer will show presence of carcinoma.
Ques. 4 What are the complications of peptic ulcer?
Ans. The complications of peptic ulcer are:-
- Perigastric adhesion : Adhesions are quite common with the pancreas, the greater omentum, liver, transverse colon etc. Due to retraction of these fibrous bands the stomach may get distorted in its shape.
- Honour glass deformity : This is invariably seen during healing up of gastric ulcer. The dense ring of scar tissue formed divides stomach into two segments. The pyloric segment is usually smaller than cardiac one. The communication between these two sacs through the narrow opening is never situated at the lowest point, because it is greater curvature which is approximated on to the corresponding part of lesser curvature at the site.
- Haemorrhage: Both haematemasis and malaena may be the result. It is due to erosin of blood vessels caused by desperation of the necrotic slough during formation of ulcer. Haematemasis is feature of gastric ulcer usually whereas malaena is a feature of duodenal ulcer.
- Pyloric obstruction : This is usually seen in duodenal ulcer when the duodenal bulb gets deformed, distorted. Gastric ulcer deep situated no doubt may give rise rarely to pyloric obstruction.
- Perforation : This is very common as the ulcers are very deep seated, floor being formed by the serous coat. The peritonitis resulting from perforation is at first non-infective & sterile but later on there is invariable bacterial infection due to reflex inbinition of gastric & secretion. The perforation may be either complete or may be leaking in type when there is a slow leakage of contents into the periforeum. Such leaking perforation is often closed by mental adhesion.
Some consider the presence of distorted proliferated glands present in deeper coats in stomach will be diagnostic of malignant change, others hold that such appearance of glands may be the usual feature of gastric ulcer undergoing healing & according to latter view limited number of cases of gastric ulcer (5% only) show real malignant change. This is never seen in duodenal ulcer. The frequency of malignant change in gastric ulcer usually seen in 5-25% of cases. About diagnosis of malignant changes there is lot of controversy.