BENIGN ULCERS OF THE GREATER CURVATURE OF THE STOMACH Report of Two Cses CHARLES H. BROWN, M.D. Deprtment of Gstroenterology nd ANTHONY D. INTRIERE, M.D.* BENIGN ulcertion long the greter curvture of the prs medi of the stomch is uncommon. Levin nd ssocites 1 collected from the literture 2 cses of histologiclly proven benign ulcers of the greter curvture nd dded one cse of their own in 1949. Griffin 2 found 2 cses of proven benign ulcertion long the greter curvture in the literture to 1954, nd dded three cses: two of which were in the ntrum nd one in the prs medi of the stomch. Dnstrom, Lowry nd Colvert recently reported five cses, ll verified by microscopic study. This mkes totl of 4 cses of benign, histologiclly proven, gstric ulcer long the greter curvture, exclusive of utopsy studies, which hve been reported. The percentges of gstric ulcers long the greter curvture tht prove to be mlignnt vry considerbly in different series. Silk nd ssocites 4 reported 18 ptients with ulcers long the greter curvture, 1 of which were benign nd 8 mlignnt. They commented tht benign ulcer long the greter curvture often is ssocited with duodenl ulcer or with benign ulcer long the lesser curvture of the stomch. Boudrel nd ssocites 6 in study of utopsy mteril reported tht 47 of 247 gstric ulcers were on the greter curvture nd tht 2 of these (49 per cent) were mlignnt. Smith nd ssocites 6 reported tht of 12 ulcers described by the pthologist s being long the greter curvture, 8 were mlignnt; thirteen dditionl ulcers, however, were described by the roentgenologist s being long the greter curvture. These reports suggest tht there is high rtio of mlignncy in ulcertive lesions long the greter curvture of the stomch. Recently we hve observed two ptients with benign ulcertion long the greter curvture of the prs medi of the stomch. Becuse of the uncommon occurrence of such lesions, nd becuse of the problem s to whether tretment of these lesions should be medicl or surgicl, we re reporting these two cses. * Fellow in the Deprtment of Internl Medicine. Volume 22, Jnury 1955 '27
BROWN AND INTRIERE CASE REPORTS Cse 1. A 54-yer-old mn ws first seen t the Clevelnd Clinic on Mrch 9, 1951, becuse of epigstric distress tht occurred one hour postprndil. The discomfort hd been consistendy relieved by food nd ntcids. Ten dys prior to exmintion, the ptient hd noted two blck stools. The pst history reveled tht in 194 thyroidectomy hd been performed for hyperthyroidism, nd tht in 1947 he hd hd duodenl ulcer tht hd responded promptly to medicl tretment. Findings on physicl exmintion were norml. Lbortory studies reveled the hemoglobin to be 14 Gm./lOO ml. Gstric nlysis, with lcohol s stimulnt, showed 2 units of free nd 46 units of totl cidity. On roentgenogrphic exmintion of the stomch n ulcer crter, 1.2 cm. in dimeter nd.7 cm. in depth, ws visulized long the greter curvture of the prs medi; there ws n incisur opposite the ulcer crter nd the duodenl bulb ws deformed (Fig. 1, nd b). An ulcerting neoplsm ws suspected. Surgicl tretment ws dvised, nd on Mrch 26, 1951, 15 dys fter initil exmintion, subtotl gstric resection ws performed. At opertion, two gstric ulcers, ech 8 mm. in dimeter, were pprent. Ech ulcer ws "punched out" with concve, yellowish-tn, irregulr bses nd with the mucos heped up t the edges. A bndlike re of depressed, congested, gstric mucos connected the two ulcers, one of which ws situted 1 cm. from the lesser curvture on the posterior wll, nd the other of which ws locted long the greter curvture. Multiple microscopic sections disclosed no evidences of mlignncy. The ptient hd n uneventful postopertive course until two months fter the gstric resection when he suddenly developed cute ppendicitis. A gngrenous ppendix ws immeditely removed. When the ptient ws lst seen on September 12,1954, more thn three yers fter the gstric resection, he ws well lthough he hd some dietry idiosyncrsies. Comment: In view of the observtion of Silk nd his ssocites 4 tht benign ulcer of the greter curvture often is ssocited with duodenl ulcer or with benign ulcer of the lesser curvture, the history of duodenl ulcer nd the second ulcer ner the lesser curvture in this ptient re interesting. Cse 2. A 6-yer-old womn ws dmitted to the hospitl on Mrch 19, 1954, with two-month history of postprndil bloting nd belching. Three weeks before dmission she hd developed nuse nd vomiting. Her ppetite hd been poor nd she hd lost 2 pounds in weight. Findings on physicl exmintion were essentilly norml but the blood pressure ws 2/12 mm. Hg. Lbortory studies showed moderte nemi: hemoglobin ws 9.2 Gm./lOO ml.; red blood cell 4,14,, nd white blood cell count 74 per cu. mm. Stools were positive for occult blood. Gstric nlysis, with lcohol s stimulnt, showed 26 units of free nd 6 units of totl cidity. Roentgenogrphic studies (Fig. 2, nd b) were reported s follows: the chest ws norml except for slight crdic enlrgement. The stomch ws distended nd contined food. The distl prt of the stomch, for n re of bout 5 cm. ws mrkedly constricted in its entire circumference. A smll ulcertion ws thought to be present t the proximl prt of this constricted re on the greter curvture. Diverticulosis of the colon ws the only bnorml finding on cholecystogrms nd brium enem studies. The preopertive dignosis ws: nnulr ulcerting neoplsm of the prepyloric prt of the stomch. Surgicl tretment ws dvised, nd subtotl gstric resection ws performed on Mrch 25, six dys fter dmission. Gross exmintion of the stomch reveled four 28 Clevelnd Clinic Qurterly
BENIGN ULCERS
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BENIGN ULCERS ulcers. Two ulcers (2 cm. nd 2.5 cm. in dimeter, respectively) were situted on the greter curvture of the stomch just proximl to the ntrum. The other two ulcers, ech. cm. in dimeter, were "kissing" ulcers, one locted on the nterior wll nd the other on the posterior wll just proximl to the ntrum. Multiple sections of the ulcers reveled no evidence erf mlignncy, nor ws there ny evidence of mlignncy in the ntrum or in the pylorus. The ptient ws dischrged from the hospitl ten dys fter the opertion. She hd n uneventful postopertive course nd when lst seen, six months fter surgery, ws entirely symptomtic. Comment: The deformity in the ntrum of the stomch, which on roentgenogrphic study ws, strongly suggestive of mlignnt neoplsm, resulted from spstic phenomen secondry to the four gstric ulcers. Mrked spsm of the ntrum of the stomch, nd even gstric retention, cn occur in ssocition with n ulcer higher in the stomch. We hve seen severl ptients ech of whom hd gstric retention cused by spsm of the pylorus nd ntrum tht ws ssocited with gstric ulcertion ner the crdi of the stomch. Of the four ulcers in this ptient, only one hd been roentgenogrphiclly visulized. DISCUSSION Ech of these ptients hd benign ulcertion long the greter curvture of the prs medi of the stomch, nd ech hd multiple gstric ulcers, one hving two nd the other four. In ech cse, the multiplicity of the ulcers ws discovered only t opertion nd their benign nture subsequently ws estblished by histologic study. Both ptients hd been dvised to undergo surgery becuse of indictions of possible mlignncy on roentgenogrphic nd other clinicl exmintions. Gstroscopic exmintions were not performed becuse we believed tht, on the bsis of other evidence, surgery ws wrrnted regrdless of possible gstroscopic findings. We hve shown previously tht mlignnt trnsformtion of benign gstric ulcers does occur, but tht such trnsformtion is rre. 7 The problem of gstric ulcers is not whether specific ulcer will become mlignnt, but whether it is mlignnt now tht is, the differentil dignosis of benign nd mlignnt ulcers. For typicl benign ulcers long the lesser curvture, we believe tht tril of dequte medicl tretment with creful follow-up is indicted. 8 Mny uthors, (e.g. references 9, 1, 11) dvocte surgicl tretment for every lesion of the greter curvture of the stomch becuse of the high incidence of mlignncy. Bockus 11 stted tht benign ulcer niche rrely projects from tht region in the usul roentgenogrms, nd he dvocted considering nd treting ll such lesions s mlignnt. Kennedy nd Beck 9 stted tht only fter histologic exmintion of the resected lesion is it possible to determine dignosticlly tht ulcertion of the greter curvture of the stomch is benign. The possibility of gstric mlignncy of the greter curvture cnnot be excluded or confirmed by roentgenogrphic exmintion, by gstroscopic exmintion, or even by inspection of the stomch t opertion. We hve seen severl cses in which frozen sections t the time of opertion showed no evidence Volume 22, Jnury 1955 1
BROWN AND INTRIERE of neoplsm, but permnent sections lter disclosed the crcinom. Consequently, if ny findings from clinicl, roentgenogrphic or gstroscopic exmintion re suggestive of neoplsm, surgicl tretment should be dvised. The high incidence of crcinom long the greter curvture necessittes tht ll such lesions be regrded nd treted s mlignnt. SUMMARY AND CONCLUSIONS 1. Benign ulcer long the greter curvture of the prs medi of the stomch is uncommon. 2. Two cses of benign ulcer of the greter curvture re presented. Both ptients hd multiple gstric ulcers.. Becuse of the high incidence of neoplsm nd the low incidence of benign ulcer long the greter curvture of the stomch, we believe tht surgery is indicted for ll lesions locted in tht region. References 1. Levin, E., Kirsner, J. B., Clrk, D. nd Plmer, W. L.: Benign ulcer of the greter curvture of the stomch (report of histologiclly proven cse). Gstroenterology 1: 166-169 (August) 1949. 2. Griffin, B. G.: Benign ulcer of the greter curvture of the stomch. Gstroenterology 27: 178-182 (August) 1954.. Dnstrom, J. R., Lowry, D. C. nd Golvert, J. R.: Benign gstric ulcer of the greter curvture. Am. J. Roentgenol. 72: 426-41 (Sept.) 1954. 4. Silk, A. D., Blomquist. O. A. nd Schindler, R.: Ulcer of the greter gstric curvture. J.A.M.A. 152: 5-7 (My 2) 195. 5. Boudrel, R. P., Hrvey, J. P., Jr. nd Robbins, S. L.: Antomic study of benign nd mlignnt gstric ulcertions. J.A.M.A. 147: 74-77 (Sept. 29) 1951. 6. Smith, F. H., Boles, R. S., Jr. nd Jordn, S. M.: Problem of the gstric ulcer reviewed: study of 1 cses. J.A.M.A. 15: 155-158 (Dec. 26) 195. 7. Brown, C. H., Fisher, E. R. nd Hzrd, J. B.: Reltion between benign ulcer nd crcinom of stomch; report of eight cses of mlignnt trnsformtion. Gstroenterology 22: 1-111 (Sept.) 1952. 8. Brown, G. H.: Benign ulcer nd crcinom of the stomch. J. Am. Geritrics Soc. 1: 177-189 (Mrch) 195. 9. Kennedy, G. R. nd Beck, E.: Benign ulcer of the greter curvture of the stomch. Am. J. Surg. 76: 429-4 (Oct.) 1948. 1. Mtthews, W. B.: Peptic ulcers involving the greter curvture of the stomch. Ann. Surg. 11: 844-855 (Mrch) 195. 11. Bockus, H. L.: Gstro-enterology. Vol. 1, Phildelphi, Sunders nd Co., 1946, p. 42. 2 Clevelnd Clinic Qurterly