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X-RAY APPEARANCES OF GASTRIC, DUODENALAND JEJUNAL ULCER

by H. C. H. BULL, M.A., M.B., B.CH., M.R.C.P.(Lond.)Hon. Radiologist, Southend General Hospital

A gastric ulcer is first an erosion of the mucousmembrane which subsequently penetrates thedeeper layers of the submucosa, muscle and perito-neum. Radiology is shadow diagnosis and so theburrowing and eroding ulcer becomes to us a nicheor projection from the clearly defined stomach walldemonstrated in shadow by the contrast mediumfilling it.Of gastric ulcers go per cent. are found on or

about the lesser curvature above the incisuraangularis. The lesser curvature differs anatomi-cally from the rest of the stomach, and is the directpathway of food and fluids entering, but just whyit is the seat of ulceration is not known.Of the remaining io per cent. some are found

on the lesser curvature between the incisura andpylorus; the others-and they are few, probablyless than i per cent.-are on the anterior wall ofthe pyloric end of the stomach.

Simple ulcers have been recorded on the greatercurvature. I have not seen one other than a malig-nant ulcer, but there are a few published cases.The outstanding fact and diagnostic feature-

the ' direct evidence ' of gastric ulcer-is the nicheseen in profile or tangential view projecting out-wards from the cavity of the stomach illustratingin shadow picture the identical form seen in post-mortem pathology (Fig. i).

These gastric ulcers may be small or large, recentor of long standing. The size is some estimate ofchronicity, but any size above one inch diametercarries with it a suggestion of malignancy. Despitethe work, pathological and surgical, devoted tostudy of the early malignant changes in gastriqulcer there is direct evidence that chronic gastriculcers often develop malignant change. Whenlarge the ulcer is usually old and certainly pene-trating in the sense that it has broken through andpassed beyond the natural boundaries of thestomach. Once an ulcer has reached the peri-toneum, established adhesions between it and anadjacent viscus, usually the pancreas or the liver,and broken down the peritoneal boundary,erosion proceeds rapidly and the crater becomes alarge cavity of irregular outline. Such an ulcertends to show a relatively narrow passage at thepoint of exit through the peritoneum, expandinginto a large cavity beyond.

In shape gastric ulcers vary a good deal accord-ing to chronicity and position. The small ulcerproj'cs fromp the lesser curvature as a blunt point

or a rounded bud and its outline is relativelysmooth. The larger ulcer which has penetratedthrough the peritoneum will often show a fluidlevel with a gas bubble above when the patient isin the erect position.An ulcer situated between the incisura and

pylorus on the lesser curvature has the samegeneral characters as that above the incisura but,as gravity plays a part, it does not hold barium sowell in the erect position. Examined under thescreen, barium can be pushed up into the crater, butwhen the pressure is released a certain amount onlysticks on to the rough surface, and is better demon-strated on the films taken with the patient prone.

Carman, in 1920, described the saddle ulcerlying astride the lesser curvature between incisuraand pylorus, an ulcer with rolled edges holdinggutters of barium when pressure was applied sothat the appearance was that of detachment. Tothis he gave the name ' meniscus' and he said itwas always malignant. Such an ulcer is notcommon. Even a simple ulcer often has thickrolled edges, thus retaining barium, and it has beenmy experience that an innocent ulcer can show themeniscus sign. If we add to Carman's dictum thatthe meniscus sign in an ulcer of one inch or morediamreter spells malignancy, then we are approach-ing nearer the truth.

Thick rolled edges, to which mention has beenmade in connection with malignancy, is a featureof chronic ulcer and not necessarily a sign ofmalignancy.The radiologist, particularly whilst screening,

may find many indirect signs or accompanimentsof gastric and duodenal ulcer useful as pointers toshow that he is on the trail of an abnormal varia-tion. Such may be

i. Excess secretion.2. Thickening of the mucous membrane.3. Spasm.4. Alterations of peristalsis.

i. E'xcess Secretion. Normally the amount ofresting fluid in the empty stomach is so small itcan and does pass unnoticed when the initial bolusof barium tracks down the Iesser curvature topool in the most dependent part of the body ofthe stomach. For satisfactory radiological exam-ination of it, the stomach should be physiologicallyempty and to ensure this the patient must neithereat nor drink during the prior I2-hour period.There are always some patients unwilling or

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March i9o8 BULL: X-Ray Appearances of Gastric, Duodeial andYejuncal Ulcer I29

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Fie. i.-Large penetrating ulcer of the lesser curvaturewith spastic contraction of the greater curvatureopposite.

FIG. 2.-Ulcer near the lesser curvature WIh( Indrhedspastic incisura.

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FIG. 3.-Ulcer of the pyloric end of the stomach.C'

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PO'S'T" GRADUATE MEDICAL JOURNAL March 194

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FIG. 4.-Hyperperistalsis of the stomach with ulcer of the duodenum.

mentally unable to co-operate who will surrep-titiously eat or drink within that time. When theradiologist finds excess fluid he has to judgebetween physical and mental pathology since thesesinners do not always confess. Apart then fromfood or fluids introduced within the forbiddenlimit the amount of resting fluid should be insig-nificant. Excess fluid means pyloric obstruction,gastritis, prolonged alkaline treatment, duodenalulcer with partial obstruction or delay in the smallintestine. It becomes an indirect sign of gastriculcer because of the associated gastritis, or becauseit follows reflex pyloric spasm.

2. The next of the indirect signs is thickenina' ofthe folds of mucous membrane. We still do not knowthe real meaning of thick folds of mucous mem-brane, but the gastroscope suggests that they areinflammatory in nature. The folds are alwaysnmore or less thickened in the presence of ulcer ofthe stomach or duodenum, but often occur inconditions in which no ulcer can be demonstrated.

3. Spasm. Ulcers are inflammatory, and asspasm is the natural answer of unstriped muscleto inflammation, spasm is nearly always found withan ulcer. But since the stomach may go intospasm on behalf of its remote friends-gall-

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March 1948 BULL: X-RayI Appearances of Gastric, Dtiodenall andlejuntal Ulceir 131

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FIG. 5.-Mucous membrane of normal duodenal cap.

OR...

FIG. 6.-Duodenal ulcer, gross deformity of the catdeep peristaltic wave in stomach.

bladder, kidney, appendix and colon as well as onits own account, this sign is in no way diagnostic.

Spasm. accompanying gastric and duodenal ulcertakes many formns. The simrplest and rrmost helpfulis the local indrawing of the greater curvatureopposite an ulcer on the lesser curvature pointingfingerlike to the crater (Fig. 2). The spasm is notalways like that but there is nearly always somedegree of contraction, shallow or deep on thegreater curvature when an ulcer is situated on thelesser curvature above the incisura. Spastic con-traction of the pyloric end of the stomach iscommon, but only rarely does it mean an ulcer ofthe pyloric end of the stomach (Fig. 3). It mayaccompany an ulcer in the body of the stomachaway from the pylorus or an ulcer of the duo-denum. Even moen often the pyloric end of thestomach contracts because of some peritonealirritation not gastric in origin. True pyloric ulcersare a rarity and there is no difference in the typeof spasm to distinguish its origin. But when dueto an intrinsic lesion it is more fixed and lessyielding to the persuasion of massage or Bella-donna.. Spasm of the longitudinal and obliquemuscle bands can occur and it causes foreshorten-

ing of the stomach dividing it into two loculi atdifferent levels. Thus the barium enters the upperloculus and spills over, cascading into the lower.This form of spasm is nearly always reflex.

4. Peristalsis. Peristalsis is disturbed wheneverthere is gastritis from any cause. Deep andfrequent peristaltic waves to be seen in the stomachat the same t.m is called hyperperistalsis and isusually a sign of partial pyloric obstruction ofwhich duodenal ulcer is the commonest cause(Fig. 4).

Duodenal UlcerThe direct sign of ulcer of the duodenum is

deformity of the first part which from its shape andsmooth round outline is called the cap (Fig. 5).There are two causes of deformity-inflammationfrom within and inflammation from without.Ulcer, whether shallow or deep, recent or chronic,gives rise to a characteristic regional contractionwhich is in part spastic and in part fibrotic andpermanent. The vastly greater number of de-formed duodenal caps are due to ulcer fromwithin; the few which are deformed by inflamma-tion from without come from adhesions, sometimes

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1 32 1'OST GCRADUATE NIEDICAL JOUtRNAL, March 1948

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Fiu. 7.-Duodenal ulcer,deformity of the cap,the projecting niche mayor may not be theulcer crater.

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Frn. 8.-Gastric and duodenal ulcers.

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FIG. 9.-Large jejunalulcer adjacent to thestoma with gastritis onthe proximal and je-junitis on the distalsides.

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March I948 BULL: X-Ray Appearances of Gastric, Duodenal and Jejunal Ulcer 133

to an adjacent pathological gall-bladder, sometimesresidual from operation or peritonitis.The deformity assumes many forms from simple

linear spastic contraction of the wall to totaldestruction of shape so that the term of cap nolonger fits (Fig. 6). Most positive when it can bedemonstrated is the ulcer crater, but it must bedemonstrated in two views at right angles to eachother, and this can only be done in a few selectedcases. The irregularities of outline of a deformedcap are not necessarily craters and should not beaccepted as such (Fig. 7).The indirect signs are:-

i. Thickening of the mucous membrane ofthe duodenum and of the stomach.

2. Irritability of the duodenal cap.3. Excess secretion in the stomach.4. Dilatation of the stomach with hyperperi-

stalsis.i. Thickened mucous membrane. Besides being

thrown into folds by contraction the mucousmembrane of the duodenal cap is thick and thefolds coarser and deeper than those of a normalcap. In this the stomach suffers, too, as if fromcommon cause and invidious selection. Gastricand duodenal ulcers do occur together but areuncommon (Fig. 8). But to write of a commoncause is a loose expression since we have noreasqnable knowledge that gastritis or deep folds ofmucous membrane have anything to do with thecause ; it may equally well be due to treatment,such as habitual alkalinization.

2. Irritability. The normal duodenal cap whenfilled holds barium for a few seconds before spillingor syphoning over into the second part. The irri-table duodenal cap contracts quickly and fre-quently. Irritability is a sign of inflammation andin the presence of a deformed cap usually meansactive ulcer.

3. Excess Secretion in the Stomach.4. Dilatation and Hyperperistalsis. Excess secre-

tion may be just an expression of gastritis, butits importance is as a sign of partial obstruction.Progressive obstruction of the outlet of thestomach from fibrotic contraction of an ulcer withoedematous swelling of the mucous membrane is,perhaps, the gravest complication of ulcer but onethat can be cured by surgery. Where the excess ofgastric secretion is due to obstruction it is recog-nized by the difficulty of forcing barium throughthe pylorus under the screen, and by the frequentand deep waves of peristalsis, best seen in filmstaken with the patient prone. In these cases thestomach appears to the eye larger than normal, andindeed is so when absolute obstruction is approach-ing. Such stomachs may be three times the normalsize and retain half a meal for 24 hours.

3. Post-operative Ulcers. Ulcers may recur in

the stomach or duodenum after local excision orcautery and a small number develop about thestoma of a gastroenterostomy within the first12 months of operation. I have never seen an ulcerin the stomach or jejunum after successful partialgastrectoiny.

4. Gastrojejunal Ulcer. Gastrojejunostomy,popular 25 years ago, has not proved so universallysatisfactory in the long run. One reason, statis-tically the. least, is the appearance of a new ulcer inor about the stoma. These gastrojejunal ulcersdevelop within a few months of the operation andpersist with remissions and relapses, adhesionsto adjacent viscera and sometimes perforate intothe colon.

Radiologically they are difficult to detect, thedirect sign we want-the ulcer crater-is mostdifficult to identify with certainty. I used todepend on the niche of barium near the stomawhich retained its relationship in all positions,could not be displaced, and was locally tender.But I have made, and seen, mistakes and do notnow think the diagnosis of ulcer justified on thisevidence unless the niche can be seen projectingfrom, in continuity with, the barium filled stomachor jejunum (Fig. 9). This applies to the smallerulcers ; large ulcers are easier to identify but notso common to meet.The indirect signs of gastrojejunal ulcer are the

same as for gastric and duodenal ulcer-spasm andthickening of mucous membranes. Spasm ofthe stomach around the stoma may cause delayedpassage-the obstruction appearing absolute atfirst but relaxing later. Spasm of the jejunumbeyond the stoma is seen as a narrow contractionalternating with the spike-like appearance asso-ciated with jejunitis.

Thickening of mucous membrane of stomachand duodenum accompanies gastrojejunal ulcer,but is not really a significant sign since we find it tosome degree in all cases of gastrojejunostomy.

ConclusionIn the radiological diagnosis of gastrojejunal

ulcer we are conscious of our weakness and thenecessity of checking carefully against the clinicalevidence. With gastric and duodenal ulcers thereis more confidence and even a feeling by some thatthe X-ray findings alone will stand against theworld. It is, indeed, true that in most cases ofdiagnosis the clinician agrees, however modestlyretreating from the limelight. If he does notagree, maybe the clinician is wrong, or the radiolo-gist is wrong; in either case we are backing humanjudgment-and the camera can lie. One thing iscertain, if the clinical and radiological findingsdo not agree, one is at fault and both should berechecked.

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