Gastric Ulcer

Published on 19/07/2015 by admin

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Last modified 22/04/2025

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 Sharply defined mucosal defect (ulcer); smooth, even, radiating folds to edge of ulcer crater

image Projects beyond expected contour of stomach (on upper GI and CT imaging)
image Usually on lesser curve, posterior wall, or antrum
image CT may show extravasation of gas and oral contrast (lesser sac or greater peritoneal cavity)
• Malignant ulcer

image Uneven shape; irregular or asymmetric edges; interruption and clubbing of radiating folds
image Does not project beyond contour of stomach
image CT may show metastasis to nodes, peritoneum, liver
• Imaging for diagnosis

image Upper GI series to show ulcer
image CT to show complications (± ulcer itself)
image CT gastroscopy in experienced hands may compete with endoscopy
• Sump ulcers: Distal 1/2 of greater curvature (NSAIDs)
• Incisura defect: Smooth or narrow indentation on curvature opposite ulcer (muscle contraction)

TOP DIFFERENTIAL DIAGNOSES

• Gastritis
• Gastric GIST
• Gastric metastases and lymphoma
• Artifactual

PATHOLOGY

• 2 major risk factors: H. pylori (60-80%) and NSAIDs (20%)

CLINICAL ISSUES

• Benign (95%), malignant (5%)
• Often multiple: 20-30% prevalence
• Complications: Hemorrhage, perforation, gastric outlet obstruction, and fistula
image
(Left) Graphic shows a gastric ulcer with smooth gastric folds radiating to the edge of the ulcer crater. Note the infolding of the gastric wall “pointing” toward the ulcer, known as the incisura sign.

image
(Right) Film from an upper GI series shows an ulcer niche image projecting off the lesser curve of the antrum. Note the smooth gastric folds that radiate to the edge of the ulcer crater.
image
(Left) CECT of a perforated gastric ulcer shows thickening of the antral wall and submucosal edema image, along with free intraperitoneal gas image and ascites image. The patient was taken to surgery where a perforated antral ulcer was oversewn along with an omental patch.

image
(Right) A subsequent upper GI series in the same patient shows a large prepyloric ulcer image as a fixed outpouching of barium. The antrum and pylorus are distorted.

TERMINOLOGY

Abbreviations

• Gastric ulcer (GU)

Definitions

• Inflammatory erosion of gastric mucosa ± submucosal or deeper penetration

IMAGING

General Features

• Best diagnostic clue

image Sharply marginated barium collection with folds radiating to edge of ulcer crater on upper GI series
• Location

image Benign GU

– Most common on lesser curvature or posterior wall of antrum or body
– 3-11% on greater curvature, 1-7% on anterior wall
image Malignant GU

– Usually on greater curvature
• Size

image Most diagnosed ulcers are > 1 cm
image Giant (> 3 cm) ulcers are usually benign but have increased risk of complications (e.g., perforation)
• Morphology

image Same criteria are used for findings on upper GI series, CT virtual gastroscopy, and endoscopy
image Benign GU

– Sharply defined mucosal defect (ulcer); smooth, even, radiating folds to edge of ulcer crater
– Ulcer projects beyond expected contour of stomach (on upper GI and CT imaging)
image Malignant GU

– Uneven shape; irregular or asymmetric edges; interruption and clubbing of radiating folds
– Does not project beyond contour of stomach

Radiographic Findings

• Upper GI series

image Benign GU, profile view

– Ulcer crater: Round or ovoid collections of barium
– Hampton line: Thin radiolucent line separating barium in gastric lumen from barium in crater
– Ulcer mound: Smooth, bilobed hemispheric mass projecting into lumen on both sides of ulcer; outer borders form obtuse, gently sloping angles with adjacent gastric wall (edema or inflammation)
– Ulcer collar: Radiolucent rim of edematous mucosa around ulcer
– Ulcer projecting beyond gastric wall
– Smooth, symmetric radiating folds to edge of ulcer crater
– Incisura defect: Smooth or narrow indentation on curvature opposite ulcer (muscle contraction)
– Enlarged areae gastricae in adjacent mucosa (edema or inflammation)
– Sump ulcers: Distal 1/2 of greater curvature (due to NSAIDs)
– Linear barium-coated ulcer: Decreases in depth with healing
– Splitting of 1 ulcer to 2 smaller collections (healing)
– Central pit or depression, radiating folds, or retraction of adjacent gastric wall (scarring)
– Hourglass stomach: Marked narrowing of body (scarring)
image Benign gastric ulcer, en face view

– Ring shadow: Shallow ulcer on anterior or posterior wall (barium-coated rim and unfilled crater)
image Malignant GU, profile

– Carman meniscus sign: Ulcer crater and radiolucent elevated border
– Does not project beyond expected gastric contour
– Discrete tumor mass forms acute angles
image Malignant GU, en face view

– Irregular crater eccentrically located within tumor mass
– Focal nodularity, distortion, or obliteration of adjacent areae gastricae (tumor infiltration)
– Nodular, clubbed, fused, or amputated folds

CT Findings

• CECT (use water or water-soluble oral contrast, with oral gas granules to optimally distend stomach)

image May visualize ulcer itself as outpouching
image Associated signs

– Wall thickening ± luminal narrowing of stomach
– Submucosal edema
– Infiltration of surrounding fat or organs (pancreas, liver)
– Free air or oral contrast in abdomen or lesser sac

image Small amount to massive
– Malignant GU

image May detect local nodes, peritoneal and liver metastases
image Virtual gastroscopy

– Obtain thin axial sections with gas distention of lumen
– Construct MPR and 3D views of gastric lumen
– Reported to detect benign and malignant GU with accuracy comparable to endoscopy

Imaging Recommendations

• Best imaging tool

image Upper GI series to show ulcer
image CT to show complications (± ulcer itself)
image CT gastroscopy (in experienced hands) may compete with endoscopy
• Protocol advice

image Upper GI: Add prone compression views of gastric antrum and body in single contrast phase of exam (with additional thin barium by mouth)

DIFFERENTIAL DIAGNOSIS

Gastritis

• Markedly thickened gastric folds; shallow erosions
• Limited distensibility, usually of antrum
• Helicobacter pylori  gastritis

image Thickened gastric folds in antrum or body
image Enlarged areae gastricae (≥ 3 mm)

Gastric Stromal Tumor (GIST)

• Often more evident on CT, as much of mass is exophytic
• > 2 cm → ulcerated, central contrast-filled crater within smooth or slightly lobulated submucosal mass (bull’s-eye or “target” lesions)
• Upper GI: Submucosal mass with smooth surface, etched in white; borders form right angles or slightly obtuse angles with gastric wall

Gastric Metastases and Lymphoma

• Malignant melanoma

image Most common hematogenous metastasis to stomach
image Ulceration of mucosa over intramural mets → bull’s-eye or “target” appearance
• Kaposi sarcoma

image GI involvement in 50%, usually with skin lesions
image Elevated lesions; submucosal defects (0.5-3.0 cm)
image Often ulcerate: Bull’s-eye or “target” lesions
• Gastric lymphoma

image More frequent in stomach than other GI sites
image 50% of cases are confined to stomach
image Causes nodular or circumferential soft tissue density wall thickening

Artifactual

• Barium precipitates

image Resemble tiny ulcers; differentiated by lack of projection beyond wall
image Absence of mucosal edema or radiating folds
• “Stalactites”

image Hanging droplets of barium (on anterior wall)
image Differentiated by transient nature on double-contrast barium studies

PATHOLOGY

General Features

• Etiology

image 2 major factors: H. pylori (60-80%) and NSAIDs (20%)
image Other risk factors: Steroids, tobacco, alcohol, coffee, stress, reflux of bile, delayed gastric emptying
image Less common etiologies

– Zollinger-Ellison syndrome
– Hyperparathyroidism
– Cushing ulcer: Stress (especially from head injury)
– Curling ulcer: Burns
image Pathogenesis

– Normal or decreased levels of gastric acid
– Breakdown in mucosal defense by H. pylori or NSAID allows acid to erode mucosa
• Genetics

image Genetic syndromes

– Multiple endocrine neoplasia type 1 (MEN1)
– Systemic mastocytosis
image Greater concordance in monozygotic twins
image Increased incidence with blood type O
• Need for further evaluation

image Unequivocal benign gastric ulcers on double-contrast studies: No further testing may be needed
image Equivocal gastric ulcers (mixed features of benign and malignant)

– Endoscopy and biopsy to exclude malignancy
– If endoscopy and biopsy show no cancer, follow-up with upper GI series until complete healing
• Multiple ulcers

image 80% are benign; most likely cause: NSAIDs

Gross Pathologic & Surgical Features

• Round or oval; sharply punched-out and regular walls; flat adjacent mucosa

Microscopic Features

• Necrotic debris, zone of active inflammation, granulation and scar tissue

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

image Asymptomatic; may have anemia, GI blood loss
image Burning, gnawing, or aching pain in epigastrium
image Usually not relieved by food or antacids
image Pain that awakens patients from sleep (33%)
image Anorexia and weight loss (50%)
• Diagnosis: Endoscopy with biopsy

Demographics

• Age

image Usually > 40 years old
• Gender

image M = F
• Epidemiology

image Benign (95%), malignant (5%)
image Often multiple: 20-30% prevalence

Natural History & Prognosis

• Complications

image Hemorrhage, perforation, obstruction, and fistula
• Prognosis

image Good with medical treatment and surgery

Treatment

• Ulcer without H. pylori: H2-receptor antagonists (cimetidine, ranitidine, or famotidine) or proton-pump inhibitors (omeprazole or lansoprazole)
• H. pylori treatment: Metronidazole, bismuth plus clarithromycin, amoxicillin or tetracycline
• Ulcer with H. pylori: H. pylori treatment and H2-receptor antagonists or proton-pump inhibitors
• NSAID induced: Misoprostol and stop NSAIDs
• Other agent: Sucralfate
• Surgery required for

image Recurrent or intractable ulcers
image Ulcer complications
image Equivocal or suspicious findings on radiologic or endoscopic examinations
• Follow-up 6-8 weeks after medical treatment

image If not healed, suggests malignant gastric ulcer

DIAGNOSTIC CHECKLIST

Consider

• Rule out malignant gastric ulcers

Image Interpretation Pearls

• Benign gastric ulcers: Ulcer crater, Hampton line, ulcer mound and collar; smooth, radiating folds
• Malignant gastric ulcers: Carman meniscus sign; nodular, blunted folds

image
(Left) CECT of a penetrating gastric ulcer shows prominent folds along the greater curve and adjacent inflammatory changes in the mesenteric fat. Note the walled-off collection of fluid image immediately adjacent to the stomach.
image
(Right) Lateral view from an upper GI series in the same patient shows prominent gastric folds and an ulcer image projecting off the greater curve. This corresponds to the site of focal fluid and inflammation seen on CT.
image
(Left) NECT of a perforated gastric ulcer shows a thick-walled stomach and massive free intraperitoneal gas image. Extraluminal contrast material and gas are present near the anterior surface of the stomach image, representing the perforated ulcer.

image
(Right) In the same patient, the extravasated enteric contrast material mixes with ascites to result in high-attenuation ascites image. Note that gastric ulcers may perforate into the lesser sac or the greater peritoneal cavity, as in this case.
image
(Left) NECT of an alcoholic man with pain and hypotension shows diffuse low attenuation of the liver, compatible with steatosis or massive hepatic necrosis. A nasogastric tube image marks the dependent surface of the stomach. Contrast material spills into the lesser sac image through a perforated ulcer.

image
(Right) CT in the same patient shows the nasogastric tube image and the lesser sac collection of oral contrast medium image. The ulcer was confirmed and repaired at surgery, but the patient died of acute hepatic failure.
image
Lateral view of an upper GI series shows a deep posterior wall gastric ulcer image and a mound of edematous folds.

image
Axial CECT shows a posterior gastric wall ulcer with loculated fluid and gas in the lesser sac image.
image
Axial CECT shows a perforated gastric antral ulcer resulting in intraperitoneal air image, fluid, and enteric contrast medium image.
image
Axial CECT shows a large posterior wall gastric ulcer image. The gastric folds are thickened.
image
Upper GI series shows an ulcer crater image with radiating folds to the edge of the crater.
image
Upper GI series shows barium pool in an ulcer crater image with smooth folds radiating to the edge of the ulcer.

SELECTED REFERENCES

1. Dib, RA, et al. Ulcer and bleeding complications and their relationship with dyspeptic symptoms in NSAIDs users: a transversal multicenter study. Scand J Gastroenterol. 2014; 49(7):785–789.

2. Chen, CY, et al. MDCT for differentiation of category T1 and T2 malignant lesions from benign gastric ulcers. AJR Am J Roentgenol. 2008; 190(6):1505–1511.

3. Horton, KM, et al. Current role of CT in imaging of the stomach. Radiographics. 2003; 23(1):75–87.

 

Schroder, VT, et al. Vagotomy/drainage is superior to local oversew in patients who require emergency surgery for bleeding peptic ulcers. Ann Surg. 2014; 259(6):1111–1118.

Insko, EK, et al. Benign and malignant lesions of the stomach: evaluation of CT criteria for differentiation. Radiology. 2003; 228(1):166–171.

Pattison, CP, et al. Helicobacter pylori and peptic ulcer disease: evolution to revolution to resolution. AJR Am J Roentgenol. 1997; 168(6):1415–1420.

Fishman, EK, et al. CT of the stomach: spectrum of disease. Radiographics. 1996; 16(5):1035–1054.

Levine, MS, et al. The Helicobacter pylori revolution: radiologic perspective. Radiology. 1995; 195(3):593–596.

Jacobs, JM, et al. Peptic ulcer disease: CT evaluation. Radiology. 1991; 178(3):745–748.

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