Ultrasonography of Benign Gastric Ulcers Characteristic Features and Sequential Follow-ups

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Ultrasonography of enign Gastric Ulcers Characteristic Features and Sequential Follow-ups Yuji Tomooka, MD, Hideo Onitsuka, MDt Tomomochi Goya, MDt, Takefumi Koga, MD, Satoshi Uchida, MD, Walter ].

1 Ultrasonography of enign Gastric Ulcers Characteristic Features and Sequential Follow-ups Yuji Tomooka, MD, Hideo Onitsuka, MDt Tomomochi Goya, MDt, Takefumi Koga, MD, Satoshi Uchida, MD, Walter ]. Russell, MD, Motomichi Torisu, MOt Ultrasonography was performed for 15 patients with gastric ulcers, after tap water ingestion using 5 MHz andjor 7.5-MHz transducers. Sonographic signs of gastric ulcer were classified as gastric wall edema asso ciated with ulcer crater (six cases) and gastric wall edema only (nine cases). The latter nine included two cases of perforation of gastric ulcers that were depicted as gastric W ith the recent development of apparatus and diagnostic techniques, ultrasonography (US) has become an important diagnostic tool for detecting abdominal disease. Since treating a boy whose acute multiple gastric ulcers were diagnosed by US, 1 we have been using US to examine patients complaining of abdominal pain. This is a report of interesting US findings of patients with benign gastric ulcers and the application of US to the assessment of this disease. wall edema associated with fluid collection. Ultrasonography proved useful for detecting benign ulcerations and can be used to supplement follow up examinations, but it cannot replace endoscopy and contrast radiography. KEY woros: gastric ulcer, ultrasonography, gastric wall edema. (J Ultrasound Med :513, 199) years; the group consisted of 12 males and 3 females. Ultrasonography was performed using 5-MHz andjor 7.5-MHz transducers (U-Sonic, Model RT 2600, Yokogawa Medical Systems). Each US examination of the stomach was performed following the oral administra tion of 400 ml of tap water. The stomachs of 22 healthy subjects were also ultrasonographically examined; they served as normal controls. RESULTS MTERILS ND METHODS From November 195 to July 19, 15 patients with benign gastric ulcers were examined. US diagnoses were corroborated by endoscopic, radiologic, surgical, and biopsy findings. These patients' ages ranged from 9 to 2 Received October 3. 19, from the Departments of Pediatrics and Internal Medicine, Saga Koseikan Hospital, Saga, Japan; the Departments of 'fradiology and ;First Surgery. Faculty of Medicine, Kyushu University. Fukuoka, Japan; and the Department of Radiology, Radialion Effects Research Foundation, Hiroshima, Japan. Revised manu script accepted for publication March 2, 199. ddress correspondence and reprint requests to Dr. Tomooka: Ikidanchi. Nishi ku, Fukuoka, 14-01, Japan. Normal Controls. In 22 normal controls, the range of thickness of the gastric wall was 236 ± 0.49 mm (mean ± SD) after water ingestion. With contraction, the thickness changed to 3.47 ± 1.02 mm. Normal gastric walls showed a typical five-layer structure as illustrated in Figure 1. These findings resembled those of endoscopic ultrasonography as described by Strohm andciassen.2 Gastric Ulcer Cases. The clinical and laboratory findings of the 15 patients are summarized in Table 1. Thick ened gastric walls and loss of the five-layer structure b d G were o serve. astric wall thickness ranged from 7 to 1 mm. The sonographic signs of benign ulceration were 199 by the merican Institute of Ultrasound in Medicine J Ultrasound Med : , /$3.50

514 ENIGN GSfRIC ULCERS Figure 1 US lindings of a typical five-layer structure of normal gastric wall: the first echogenic and the second echo-poor layer correspond to the interface of the mucosa and

2 514 ENIGN GSfRIC ULCERS Figure 1 US lindings of a typical five-layer structure of normal gastric wall: the first echogenic and the second echo-poor layer correspond to the interface of the mucosa and the mucosa itself, the third echogenic layer to the submucosa, the fourth echo-poor layer to the muscularis propria, and the fifth echo genic layer to the serosa. classified as gastric wall edema associated with u lcer crater (six cases) and gastric wall edema without ulcer crater (nine cases). The latter group included two cases of perforated gastric ulcer associated with gastric wall edema and flu id collection. CSE REPORTS Case 3 25 year-old woman with a 2 week history of ab domina! discomfort was admitted with severe epigastric pain and vomiting of 4 hours' duration. On the second postadmission day, after the oral administration of 400 ml of tap water, US was performed using a 7.5 MHz transducer. Two ulcer craters were observed on the markedly thickened anterior and posterior gastric walls (Fig. 2). Subsequent endoscopy confirmed the presence of acute multiple gastric ulcers in the antrum. This patient received 40 mg famotidine daily and antacids; her clinical course was uneventful. Sequential US foijow-up findings concerning gastric waij edema and the ulcers are shown in Figure 2 (, C, and D). These sequential US changes correlated well with clinical improvement. Case year-old man complained of abdominal pain. fter he ingested tap water, US was performed using a 5-MHz transducer. Thickening of the gastric wall was observed (Fig. 3). Sequential endoscopy showed acute multiple hemorrhagic ulcers on the antral wall US findings during the convalescent phase are shown in Figure 3. Case year-old man was referred to our hospital for evaluation of right-sided epigastric pain of 22 days' duration. tentative diagnosis of liver abscess had been made on the basis of US (Fig. 4) and a computed tomography (CT) scan (Fig. 4) performed in another hospital. bdominal radiogra phy and an upper gastrointestinal (UGl) series were performed 3 days prior to admission. They revealed no free air, but there was a question of an extragastric mass near the lesser curvature. On the fourth postadmission day, the US was re peated using a 7.5-MHz transducer. collection of fluid ap peared as a discrete echo-free space, with string-like echogenicity representing air bubbles between the left lobe of the liver J Ultrasound Med : , 199 interface - /_roo.cosa oo:;-.==j::;.f -submuco_sa \... musculans propria serosa and the stomach. fter water ingestion, US was repeated. Of great interest was the fact that we could observe small gas bubbles in the stomach that repeatedly passed through the ulcer canaliculus into the fluid space, which we diagnosed as a perforated gastric ulcer (Fig. 4C). Subsequent endoscopy re vealed a linear ulcer; liver and fatty tissue were observed through a hole in the anterior wall. partial gastrectomy with a illroth n anastomosis was performed U days later. t surgery, adhesions were detected between the ulcer and the peritoneum. In this case, US provided useful preoperative infor mation for the benefit of the surgeon. DISCUSSION enign gastric ulcers are currently diagnosed by endoscopy, contrast radiography, and biopsy. US has contributed little to the diagnosis and follow-up of benign ulcerations. In the present study, US allowed visualization of benign ulcerations; they were always associated with gastric wall thickening and loss of the five-layer structure of the gastric wall. The lesions were successfully demonstrated, probably because they were severe, and located in the antrum. The US was performed repeatedly using 5-MHz andjor 7.5-MHz transducers. To obtain clear images, patients were examined in various positions, especially the erect position, with good distention of the gastric wall following water ingestion. Most of these cases presented here were large ulcers, and cases of superficial ulceration localized in the mucosa could not be demonstrated by US, presumably due to m ild thickening of the wall. Review of the literature disclosed several reports of gastric ulcer detected by US; namely, one case with focal dense echoes and strong distal acoustic shadows, 3 two as pericholecystic fluid collections and thickened gallbladder walls, 4 and others as showing only thickened gastric walls.5 9 Generally, perforated gastric ulcers are diagnosed by pneumoperitoneum on abdominal radiography.

3 Table 1: Clinical and Laboratory Findings in 15 Patients with Gastric Ulcers Symptoms Case ge bdominal no. (yr) Sex pain Vomiting 3 25 F + + Gastric Edema Only woe (per pi) 7,100,700 9,000 5,00 4,700 10,300 6,900 6,300 6,500 12,100 4,00 14,100,300 7,500 16,100 Hb (g/dl) Thickness of wall (mm) Ultrasound E-C junction Site with fluid collection with fluid collection Endoscopy and/or UGI series cute mutliple hemorrhagic ulcers Open ulcer, incisura Open ulcer, body Small open ulcer, prepylorus Small open ulcer, E-C junction Small open ulcer, antrum Small open ulcers, body Linear ulcer, antrum See text Giant open ulcer, antrum; penetration to pancreas._ g iii g "' :J D. 11) D. 9!1 w to a F= Ul '""' ""' Gastric Edema ssociated with Ulcer Crater 1 11 M M M F M M M M M M F M M M + WC, white blood cells; Hb. hemoglobin; UGI, upper gastrointestinal; E-C, esophagocardiac.

516 J Ultrasound Med :513-517, 199 ENIGN GSTRIC ULCERS c D Figure 2, On the second postadmission day.

4 516 J Ultrasound Med : , 199 ENIGN GSTRIC ULCERS c D Figure 2, On the second postadmission day. two ulcer craters (arrows) were observed on the anterior and posterior walls of the gastric antrum. The gastric wall is 16 mm thick and edematous. The five layer structure is poorly identified (UL, ulcer crater)., On the ninth postadmission day. one of the ulcer craters (arrows) is still seen and the gastric waji is mm thick (UL, ulcer crater). C, On the 16th postadmission day. there is no ev dence of ulcer and the gastric wall is 6 mm thick. non the 23rd postadmission day. the gastric wall is still 6 mm thick and its.llve layer structure is partially identified. Madrazo et al reported a patient with a perforated gastric ulcer and subphrenic fluid and a patient with adhesions between an antral ulcer and the pancreas and enlargement of the head of the pancreas, both demonstrated by US. 10 Our two patients with perforated ulcers had gastric wall edema and fluid coljections, but no pneumoperitoneum. Figure 3, On the first day after onset, the gastric wall is 12 mm thick (arrows)., On the seventh day after onset, the gas tric wall thickness (arrows) was reduced to 5 mm. lthough a relatively large portion of the stomach is inaccessible to US, numerous benign ulcerating lesions are located in the gastric antrum or body, 11 which is relatively easily assessed by US. Therefore, US is a useful means of detecting them. The sonographically demonstrable sequences correlated well with clinical symptoms and with endoscopic and x-ray contrast examinations. In about 3 weeks, there is no ulcer evident and the thickness of the gastric wall has reduced to almost normal on US examination, and US can be a substitute for contrast radiography. disadvantage of US is that subsequent endoscopy or UGI series cannot be easily made because of a stomach distended with water. The US findings described above are not only the characteristic features of benign ulceration; they are also observed in ulcerating carcinoma and differentiation between them is difficult on the basis of US findings alone. Further observation may resolve the problem. Differential diagnoses to be considered also include eosinophilic gastritis, polypoid lesions, and submucosal tumors. It is important to recognize that US is a supportive or supplementary method, not a substitute for endoscopy or biopsy. However, in patients with benign ulcerations, including children, elderly men, and those with histories of steroid use or aspirin ingestion, the use of endoscopy and/or contrast radiography as a follow-up study could be limited to a reasonable frequency by using US instead.

J Ultrasound Med :513-517, 199 TOMOO.K ET L 517 Figure 4, Using a 3.

5 J Ultrasound Med : , 199 TOMOO.K ET L 517 Figure 4, Using a 3.5-MHz transducer, a huge 11 X 7 X em mass (arrow) is visualized in the liver, with evenly granular internal echogenicity including gas bubbles (transverse scan; G, gallbladder)., The collection of fluid seen in the liver (arrows) was interpreted as a subhepatic abscess. C, On the fourth postadmission day, a collection of fluid is seen above the superior surface of the liver and connected with the thickened gastric wall, which is 11 mm thick. n ulcer canaliculus is clearly imaged. Ruid collection Stomach c Ulcer canaliculs REFERENCES 1. Tomooka Y, Koga T, Shimoda Y, et al: The ultrasonic demonstration of acute multiple gastric ulcers in a child. r J Radio! 60:290, Strohm WD, Classen M: enign lesions of the upper Gl tract by means of endoscopic ultrasonography. Scand J Gastroenterol 21(suppl 123):41, Rosenberg ER, Morgan CL, Trought WS, et al: The ultrasonic recognition of a gastric ulcer. r J Radio! 53:1014, Nyberg D, Laing FC: Ultrasonographic findings in peptic ulcer disease and pancreatitis that simulate primary gallbladder disease. J Ultrasound Med 2:303, Lutz HT, Petzoldt R: Ultrasonic patterns of space occupying lesions of the stomach and the intestine. Ultrasound Med ioi 2:129, luth El. Merritt CR, Sullivan M: Ultrasonic evaluation of the stomach, small bowel, and colon. Radiology 133:677, Yeh HC, Rabinowitz JG: Ultrasonography and computed tomography of gastric wall lesions. Radiology 141:147, 191. Miller JH, Kemberling CR: Ultrasound scanning of the gastrointestinal tract in children: Subject review. Radiology 152:671, Stringer D, Daneman, runelle F, et al: Sonography of the normal and abnormal stomach (excluding hypertrophic pyloric stenosis) in children. J Ultrasound Med 5:13, Madrazo L, Hricak H, Sandler M, et al: Sonographic findings in complicated peptic ulcer. Radiology 140:457, Levine MS, Creteur V, Kresse! HY, et a]: enign gastric ulcers: Diagnosis and follow-up with double-contrast radiography. Radiology 164:9, 197

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