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Digital Library: Case Studies: The Gastrointestinal Tract: Case 2: Peptic Ulcer Disease 60-year old man with epigastric pain.
Chief complaint: Epigastric pain just before meals with some nausea and vomiting. Burning sensation in midepigastrium was relieved to some degree by antacids and over the counter H-2 antagonists. Clinical findings: Stool was positive for occult blood. Hemoglobin and hematocrit were decreased at 12g/dL and 37%, respectively. An upper GI endoscopic examinatinon revealed a crater in the proximal duodenum and a normal stomach. Follow-up: The patient died in an automobile accident soon after his evaluation. An autopsy was performed.
Endoscopic appearance of the duodenal ulcer. The diagnosis is duodenal ulcer. Note well circumscribed borders and depressed shaggy base. Duodenal ulcers are usually single and <2 cm in diameter.
Macroscopic appearance of the stomach and duodenum. Identify the lesion. Are ulcers more common in the proximal or distal duodenum? Most peptic ulcers (GI tract ulcers that persist as a function of acid-peptic activity in the gastric juice) occur in the lesser curvature of the stomach (distal antrum and prepyloric region) and the first few centimeters of the duodenum.
Low power (full thickness, trichrome stain) photomicrograph of the duodenal ulcer. Describe the histologic features. The ulcer bed is surrounded on both sides by duodenal mucosa with chronic duodenitis and is bounded inferiorly by fibrosis (light blue). Complications of peptic ulcers include hemorrhage, free perforation, penetration, and gastric outlet obstruction.
What is present closely opposed to the mucus layer in the gastric biopsy as highlighted in this Diffquick stain? What disorders has this bacterium been associated with? Helicobacter pylori is found as curved blue "seagull-like" rods in the mucus layer just above the gastric mucosa. It is able to survive in the normally sterile stomach by creating a more alkaline microenvironment in this location by the action of its urease. Approximately 80-95% of duodenal ulcers, and a lesser number (70-85%) of gastric ulcers, are associated with H. pylori-related chronic gastritis. In duodenal ulcer patients, H. pylori is also often found in the duodenum, always in association with metaplasia of surface duodenal mucosa to a gastric type. Eradication of this organism with antibiotics has revolutionized the therapy of peptic ulcer disease.
Macroscopic view of a benign gastric ulcer. What is the likely complication in this case? Can gastric ulcers be distinguished soley on macroscopic appearance from ulcerated gastric carcinomas? The diagnosis is benign gastric ulcer. Punched out or cookie cutter appearance of classic benign gastric chronic gastric ulcer with folds radiating uniformly to the ulcer ulcer crater which has smooth non-heaped up borders. Of great importance is the fact that benign gastric ulcers cannot be distinguished from ulcerating carcinomas based on size or macroscopic appearance alone.
Two examples of ulcerated gastric carcinomas. The large size (>3 cm) and heaped-up borders of the first ulcer are ceratinly quite suspicious for malignancy, while the small and innocuous gross appearance of the second ulcer belies its malignant nature. Early gastric cancer has a five-year survival of >70%, versus 10% for advanced gastric cancer.
Autopsy specimen of stomach from a 40-year old man with hematemesis (vomiting blood). What is your diagnosis? What are potential etiologies? The diagnosis is erosive gastropathy. Multiple hemorrhagic erosions (stress ulcers, erosive or acute gastropathy) are seen. They are most commonly found in association with the use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDS), which worldwide are prescribed more than any other group of medicines. This type of ulcer may also be seen with alcohol or other drugs, and in severely ill patients related to mucosal ischemia (stress ulcers).
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Question for Class Discussion