Unusual manifestations of peptic

Transcription

1 Unusual manifestations of peptic ulcer disease William M. Thompson, M.D. George Norton, M.D.* Frederick M. Kelvin, F.R.C.R., M.R.C.P. R. Kristina Gedgaudas, M.D. Robert A. Halvorsen, M.D. Reed P. Rice, M.D. The radiologist may be the first to identify the less frequent manifestations ofpeptic ulcer disease and should be familiar with their appearances. Among gastrointestinal diseases, peptic ulcer disease is one of the most Introduction frequently encountered by the radiologist. A great deal has been written about the usual radiographic manifestations of peptic ulcers as well as about the various techniques by which they may be demonstrated. Despite the considerable attention that has been focused on the radiographic demonstration, appearances and differential diagnosis of peptic ulcer disease, there has been little mention of the unusual manifestations of this common entity. The following discussion presents a variety of. important but relatively uncommon manifestations of peptic ulcer disease. The entities illustrated are (1) multiple ulcers, (2) Zollinger-Ellison syndrome, (3) giant gastric ulcer, (4) gastric outlet obstruction, (5) stomal ulcer, (6) retained gastric antrum, (7) gastric stump cancer, (8) perforation, (9) double pylorus, (10) gastrocolic fistula, (1 1) choledochoduodenal fistula, (12) giant duodenal ulcer, and (13) post-bulbar ulcer. From the Department of Radiology Duke University Medical Center and Durham Veterans Administration Hospital. * St. Vincent s Hospital, Little Rock, Arkansas. Address correspondence and reprint requests to: William M. Thompson, M.D., Department of Radiology, Duke University Medical Center, Box 3808, Durham, N. C Volume 1, Number 1, May 1981 RadioGraphics

2 Multiple ulcers 4 Multiple ulcers occur in 10-20% of patients with peptic ulcer disease. The majority of multiple ulcers are gastric. Concurrent gastric and duodenal ulcers are rare, but this association strongly suggests that the gastric ulcer is benign. The majority of multiple gastric ulcers are benign, but each ulcer should be evaluated individually; in one series, 18% of multiple ulcers were malignant. Figure 1 Two large benign gastric ulcers (arrows) well shown by double contrast technique. Figure 2 Two large benign antral ulcers (arrows). A large antral mass is present simulating malignancy. 2 RadioGraphics May 1981 Volume 1, Number 1

3 Zollinger-Ellison syndrome is due to a gastrin secreting non-b islet cell tumor. Ninety percent or more of these tumors are located in the pancreas, but ectopic tumors have been described in the medial wall of the duodenum. The patients usually present with recurrent peptic ulcer disease despite therapy. Approximately 10-15% of Z-E patients have chronic diarrhea as their primary complaint. The classic radiographic features of multiple ulcers or ulcers in unusual locations are infrequent. In our experience, the most typical radiographic features of Zollinger-Ellison syndrome are: (1) enlargement of the folds in the stomach, duodenum and small bowel and (2) increased fluid in the small bowel. These findings in a patient with a peptic ulcer are highly suggestive of Zollinger-Ellison syndrome. Approximately / of the patients with the Zollinger-Ellison syndrome have no radiographic abnormality other than a typical benign peptic ulcer, usually in the duodenum. The specific diagnosis is based on the demonstration of a secretin. markedly elevated serum gastrin level especially after stimulation by intravenous Zollinger- Ellison syndrome2 57 Figures 3 & 4 Upper gastrointestinal examinations of two different patients with Zollinger-Ellison syndrome, each showing a duodenal ulcer (arrows), enlarged folds in the stomach, duodenum and small bowel, as well as evidence of increased secretions and mild dilatation of the duodenum and jejunum. Volume 1, Number 1, May 1981 RadioGraphics 3

4 Giant gastric ulcer2 A giant gastric ulcer is arbitrarily defined as an ulcer greater than 3 cm in diameter. Previously, ulcers of this size were thought to be malignant. It has been well documented, however, that ulcer size is of no significance in distinguishing between benign and malignant ulcers. Giant gastric ulcers are frequently associated with a walled off perforation. There is usually little difficulty in differentiating a large benign gastric ulcer from an ulcerating malignant neoplasm because the malignancy will almost always have a large mass associated with the ulcer. 5 6 Figure 5 This upper gastrointestinal examination performed after esophagogastrectomy for esophageal cancer, shows a benign giant gastric ulcer (arrows) in the thoracic stomach. Figure 6 Upper gastrointestinal examination showing a benign giant gastric ulcer (arrows) of the antrum. 4 RadioGraphics May 1981 Volume 1, Number 1

5 Gastric outlet obstruction occurs in 5-10% of patients with peptic ulcer disease. In 80% of these patients the obstruction is due to a duodenal ulcer. Outlet obstruction due to gastric ulcer occurs much less frequently. Other causes of gastric outlet obstruction include carcinoma of the stomach, adult hypertrophic pyloric stenosis, gastric antral diaphragm, surgical scarring, Crohn s disease, and caustic ingestion. Specific diagnosis may be impossible radiographically unless the stomach has been decompressed prior to the examination; and even after nasogastric decompression, the radiologist may be able to identify only the level of obstruction, not the underlying cause. Gastric obstruction2 outlet Figure 7 Upper gastrointestinal examination showing gastric outlet obstruction due to pyloric scarring (arrows) from peptic ulcer disease. The stomach had been decompressed by nasogastric suction prior to performing the upper gastrointestinal examination. Volume 1, Number 1, May 1981 RadioGraphics 5

6 Stomal ulcer 2 Stomal ulcers are reported to occur in 1-10% of patients following surgery for peptic ulcer disease. In the past, in patients who had a gastrojejunostomy without a vagotomy, the incidence was reported to be as high as 30%. This operation is rarely performed today, and thus, the overall stomal ulcer incidence is now less than 10%. Stomal ulcers may occur in patients who have a retained gastric antrum, an incomplete vagotomy, Zollinger- Ellison syndrome, or an improperly placed gastroenterostomy stoma. It may be difficult accurately to localize the position of a stomal ulcer radiographically. They are usually on the jejunal side of a gastrojejunostomy and in the efferent loop. Stomal ulcers may also occur after a Billroth I anastomosis. A double contrast upper gastrointestinal examination may be more reliable than a single contrast technique for detecting a stomal ulcer in a patient who has had gastric surgery for peptic ulcer disease. Figure 8 Double contrast examination demonstrates a stomal ulcer (arrow) following a Billroth I anastomosis. Figure 9 Large stomal ulcer (arrows) on the jejunal side of the anastomosis following a Billroth II resection. 6 RadioGraphics May 1981 Volume 1, Number 1

7 The retained gastric antrum syndrome occurs when a segment of antrum is left intact during a partial gastrectomy and gastrojejunostomy. The antrum is the site of gastrin secretion. Normally gastrin secretion by the antrum is controlled by gastric acidity. With a gastrojejunostomy, however, the retained gastric antrum is bathed by alkaline duodenal secretions. This leads to increased gastrin secretion which causes excess acid production in the remaining stomach. The retained gastric antrum may result in an elevated serum gastrin. This can be distinguished biochemically from the Zollinger-Ellison syndrome because in patients with a retained gastric antrum, the serum gastrin level does not rise following the intravenous administration of secretin as it does in patients with Zollinger-Ellison syndrome. Radiologic examination is of value if the entire afferent loop can be filled. This may reveal whether or not the base of the duodenal bulb and distal antrum have been surgically removed. Recent reports indicate that the technecium 99m pertechnetate scan may show retained gastric mucosa in the base of the duodenal bulb or the antrum. Thus, this test may be helpful in evaluating patients suspected of having a retained gastric antrum. gastric Retained antrum Figure 10 Upper gastrointestinal examination demonstrating a retained gastric antrum (double arrows). The pylorus is marked with an arrowhead. (Case courtesy of Dr. Thomas Beneventano, Montefiore Hospital, New York) Volume 1, Number 1, May 1981 RadioGraphics 7

8 Gastric cancer stump Gastric stump cancer is a primary carcinoma occurring in a gastric remnant at least five years after operation for benign peptic ulcer disease. The incidence in the United States is approximately two percent in patients who have had gastric surgery for benign peptic ulcer disease. This is significantly higher than the incidence of carcinoma in the population at large or in patients who have had peptic ulcer disease without gastric surgery. Gastric stump cancer usually occurs years after the surgery. Most stump cancers have occurred following antrectomy and Billroth II anastomosis, but they have also occurred following Billroth I procedures and gastrojejunostomies without gastric resection. The radiographic features of gastric stump cancer are similar to those of any primary gastric malignancy. Many of these tumors diffusely infiltrate the stomach. Figure 11 This diffuse infiltrating gastric stump cancer developed fifteen years after an antrectomy and Billroth II anastomosis for peptic ulcer disease. Figure 12A This study performed ten years after partial gastrectomy and Billroth I anastomosis is normal apart from thick folds. Figure 12B Three years later, this study shows marked diminution of the gastric pouch which is due to an infiltrating gastric stump cancer. 8 RadioGraphics May 1981 Volume 1, Number 1

9 Perforation occurs in 5-10% of patients with peptic ulcer disease. The most common site of duodenal perforation is the anterior wall. Sixty percent of gastric ulcer perforations occur along the lesser curvature. Most (75%) of the patients with acute perforation of gastric or duodenal ulcers, have evidence of extraluminal air on survey abdominal radiographs. In cases of suspected perforation in which there is no radiographic evidence of pneumoperitoneum, a contrast study with a water soluble medium may reveal a leak into the peritoneal cavity. Five to 10% of peptic ulcer perforations from the stomach and duodenum occur posteriorly and these may cause pancreatitis or a lesser sac abscess. Perforation2 Figure 13 Upper gastrointestinal study employing a water soluble contrast agent shows perforation of a marginal ulcer. There is obvious extravasation of contrast material into the peritoneal cavity, extending into the right lower quadrant (arrows). Survey abdominal radiographs made in both supine and upright positions were normal. Figure 14 Upper gastrointestinal examination showing a large duodenal ulcer (arrows) perforating into the pancreatic duct. Volume 1, Number 1, May 1981 RadioGraphics 9

10 Double pylorust2 13 Double pylorus is the term used to describe a fistula between the antrum and the base of the duodenal bulb. The entity is better referred to as a gastroduodenal fistula. The fistula usually occurs from the lesser curvature of the distal stomach to the superior fornix of the duodenal bulb. Occasionally, however, the fistula arises from the greater curvature aspect of the stomach. Most proved cases of double pylorus are due to a penetrating gastric ulcer. The mass effect associated with the fistula may result in confusion with antral carcinoma, Crohn s disease, lymphoma, or metastatic carcinoma. Patients with a gastroduodenal fistula caused by peptic ulcer disease usually do not require surgery. Some authors have suggested that the development of this type of fistula may be a sign of healing of the peptic ulcer. Figure 15 Upper gastrointestinal examination of a patient with a proved double pylorus. The true pylorus is marked by an arrowhead and the fistulous channel by arrows. 10 RadioGraphics May 1981 Volume 1, Number 1

11 Approximately 10-20% of gastrocolic fistulas are caused by a benign peptic ulcer. The majority are due to a malignant neoplasm arising from the colon or stomach and extending to the other viscus via the gastrocolic ligament. A gastrocolic fistula caused by a peptic ulcer should be considered in any patient with typical ulcer pain, diarrhea and feculent vomiting. A history of steroid or aspirin usage is also often elicited. The ulcer is usually located along the greater curvature of the stomach and extends through the gastrocolic ligament to the transverse colon. A barium enema will usually show the fistula; in most cases, however, an upper gastrointestinal series is needed to show its cause. Gastrocolic fistula 4 _ LATER ST 16A Figure 16A Early film from a barium enema showing filling of the transverse colon which is partly in spasm because of the adjacent inflammatory process. Figure 16B Later spot film from the barium enema showing a gastrocolic fistula. ST-Stomach, U-Gastric Ulcer (only partially filled) TC-Transverse Colon (in marked spasm). Figure 16C Upper gastrointestinal examination of same patient showing large benign gastric ulcer (arrows) arising from the greater curvature. 16C Volume 1, Number 1, May 1981 RadioGraphics 11

12 Choledochoduodenal fistula 5 6 The most common cause of spontaneous biliary enteric fistula is cholecystoduodenal communication resulting from gallstone erosion, but 5-20% of all biliary enteric fistulas involve the common bile duct. The majority of choledochoduodenal fistulas are secondary to peptic ulcer perforation. Patients may have minimal symptoms from such a fistula, but can develop severe cholangitis. An upper gastrointestinal examination will usually demonstrate the fistula and the underlying peptic ulcer. Figure 17 Upper gastrointestinal examination showing a choledochoduodenal fistula. Figure 18 Upper gastrointestinal examination of a patient with a post-bulbar ulcer (arrow). Note marked narrowing of the second portion of the duodenum and barium in the biliary tract. 12 RadioGraphics May 1981 Volume 1, Number 1

13 Giant duodenal ulcer is defined as an ulcer greater than cms in diameter arising within the duodenal bulb. Giant duodenal ulcer is associated with a high mortality (18-41%) and high morbidity related to the frequency of complications including massive gastrointestinal hemorrhage, obstruction, and perforation. The ulcer can easily be missed on an upper gastrointestinal examination because these giant ulcers may simulate the normal bulb. The characteristic radiographic features are: 1, consistency in size and shape; 2, loss of normal mucosal pattern; 3, constriction of the gastrointestinal tract proximal and distal to the ulcer; 4, nodularity in the ulcer crater; 5, prolonged barium retention in the crater; 6, ulcer within the giant ulcer, and 7, a surrounding mass. The total lack of change in shape and size of a giant duodenal ulcer is the single feature most useful in distinguishing it from a normal duodenal bulb. Giant duodenal ulcer 7, 8 Figures 19,20,21,22 Four examples of giant duodenal ulcers (arrows). Note the post-ulcer constriction (arrowheads), the absence of mucosal pattern and the presence of nodularity within the craters. Volume 1, Number 1, May 1981 RadioGraphics 13

14 Post-bulbar ulcer 9 2#{176} Post-bulbar ulcers make up three to five percent of all duodenal ulcers. Almost all post-bulbar ulcers occur in the preampullary region. Many are associated with significant spasm, display poor coating and occur in patients with posterior duodenal bulbs. As a result, the radiologist may fail to recognize an acute post-bulbar ulcer. Most are on the medial wall of the duodenum and result in an incisura on the lateral wall. This characteristic asymmetric ring stricture may help identify the location of the ulcer. The ulcer crater itself may not be visualized due to the spasm associated with the inflammatory narrowing. Post-bulbar ulcers are reported to be associated with a higher incidence of complications than duodenal bulbar ulcers. Figures 23 & 24 Different patients with post-bulbar ulcers. Note the marked duodenal deformity, proximal and distal constriction and the obvious ulcer (arrows). 14 RadioGraphics May 1981 Volume 1, Number 1

15 Summary The radiologist may be the first to identify the less frequent manifestations of peptic ulcer disease and should be familiar with their appearances. Important individual points concerning these entities include the following: 1. Multiple gastric ulcers must be evaluated individually since up to 20% may be malignant. Multiplicity of ulcers in the stomach is not necessarily a sign of benign disease. 2. A typical duodenal ulcer is the only radiographic abnormality in up to one-third of patients with the Zollinger-Ellison syndrome. Important radiographic features of the Zollinger-Ellison syndrome are evidence of hypersecretion and enlargement of the folds in the stomach, duodenum, and small bowel. 3. Gastric ulcers greater than three centimeters in diameter (giant gastric ulcers) are not necessarily malignant. The size of a gastric ulcer is not useful in differentiating benign from malignant disease. 4. Gastric outlet obstruction is usually due to a duodenal or pyloric ulcer. Fewer than ten percent of patients with gastric outlet obstruction have gastric ulcers. 5. Stomal ulcers are best evaluated by the double contrast technique. They usually occur in the efferent loop. 6. The radiologist should make an effort to fill the afferent loop in all patients who have had a Billroth II anastomosis. Retained gastric antrum can be identified on the barium study only if the afferent loop is filled. The technetium 99m pertechnetate scan may be a useful technique for identifying patients with a retained gastric antrum. 7. Gastric stump cancer is an important delayed complication of peptic ulcer surgery usually occurring years after the operation. It represents a further reason for employing double contrast radiography in post-gastrectomy patients. 8. Only 75% of patients with acute ulcer perforation will have demonstrable free air on plain abdominal radiographs. If ulcer perforation is suspected, an upper gastrointestinal series with a water soluble contrast agent will usually show the site of perforation. 9. The double pylorus (gastroduodenal fistula) rarely requires surgical intervention and may be a sign of healing of the ulcer. This abnormality may mimic malignancy. 10. Gastrocolic fistulas are usually due to malignancy. A small percentage are due to benign peptic ulcer disease. A barium enema will usually show the fistula, but an upper gastrointestinal examination may be needed to identify the cause. 11. Most spontaneous choledochoduodenal fistulas are due to peptic ulcer. 12. Giant duodenal ulcers are important to recognize because they have a very high morbidity. Their constant appearance distinguishes them from a normal duodenal bulb. RadioGraphics May 1981 Volume 1, Number 1 15

16 13. Many post-bulbar ulcers are difficult to recognize on upper gastrointestinal examinations because of the spasm and associated narrowing at the site of the ulcer. 1. Laufer I: Double contrast gastrointestinal radiology with endoscopic correlation. Phila- References delphia, W. B. Saunders Co., Sleisenger HM, Fordtran JS: Gastrointestinal disease. Philadelphia, W. B. Saunders Co., Taxin RN, Livingston PA, Seaman WB: Multiple gastric ulcers: A radiographic sign of benignity. Radiology 114:23-27, Bloom SM, Paul RE Jr, Matsue H, et al: Improved radiographic detection of multiple gastric ulcers. AJR 128: , Zboralske FF, Amberg J: Detection of the Zollinger-Ellison syndrome: The radiologist s responsibility. AJR 104: , Regan PT, Malagelada JR: A reappraisal of clinical, roentgenographic and endoscopic features of Zollinger-Ellison syndrome. Mayo Clin Proc 53:19-23, Deveney CW, Deveney KS, Way LW: The Zollinger-Ellison syndrome-23 years later. Ann Surg 188: , Beneventano TC, Glotzer P, Messinger NH: Retained gastric antrum. Am J Gastroenterol 59: , Dunlap JA, McLame RC, Roper TJ: The retained gastric antrum. Radiology 117: , Feldman F, Seaman WB: Primary gastric stump cancer. AJR 115: , Eberlein TJ, Lorenzo FV, Webster MW: Gastric carcinoma following operation for peptic ulcer disease. Ann Surg 187: , Hegedus V, Paulsen PE, Reichardt J: The natural history of the double pylorus. Radiology 126:29-34, Rappoport AS: Gastroduodenal fistula and double pyloric canal. Gastrointest Radiol 2: , Laufer I, Tornley GB, Stolberg H: Gastrocolic fistula as a complication of benign gastric ulcer. Radiology 119:7-11, Hoppenstein JM, Medoza CB, Watre AL: Choledochoduodenal fistula due to perforating duodenal ulcer disease. Ann Surg 173: , Constant E, Turcotte, JG: Choledochoduodenal fistula: The natural history and management of an unusual complication of peptic ulcer disease. Ann Surg 167: , Eisenberg RL, Margulis AR, Moss AA: Giant duodenal ulcers. Gastrointest Radiol 101: , Rosenquist CJ: Clinical and radiographic features of giant duodenal ulcer. Clin Radiol 20: , Bilbao MK, Frische LH, Rosch J, et al: Postbulbar duodenal ulcer and ring stricture. Radiology 100:27-35, Rodriguez HP, Aston JK, Richardson CT: Ulcers in the descending duodenum. AJR 119: , Volume 1, Number 1, May 1981 RadioGraphics