Peptic ulcer disease
Peptic ulcer disease is a mucous ulceration accompanied by pain, secondary to the effects of gastric acid. Risk factors: H. pylori, severe stress, NSAIDs and corticosteroids.
Four stages:
- Ulcus simplex: erosion of the mucosa only. Do endoscopy to visualise it and take a biopsy for H. pylori.
- Ulcus callosum: involves the muscular layer and submucosa.
- Ulcus penetrans: a chronic condition in which the stomach changes shape.
- Ulcus perforans: a complication; the ulcer penetrates past the serosa to adjacent structures, e.g. liver, small intestine, pancreas.
Barium meal with double contrast is used when endoscopy is contraindicated or refused by the patient. A defect under 2 mm is called an erosion; over 2 mm it is called a 'crater', towards which the gastric folds radiate inward. A radiolucent ring of oedema surrounding it is called the line of Hampton.
Ulcer on upper GI study:
- it collects barium;
- the rim is oedematous and smooth;
- punctate ulcerations = pinpoint contrast collections;
- ulcers: central opaque, low-density rim.
Complication: pneumoperitoneum
Pneumoperitoneum is a radiolucent shadow (free gas) under the diaphragm, which is radiopaque. The amount of gas depends on the size of the perforation. It is not seen in old perforations or if the perforation is covered by omentum. Air can also be introduced on purpose after laparoscopy, flushing of the fallopian tubes in female infertility, or during examination of Chilaiditi syndrome or pneumatosis intestinalis.
DDx of pneumoperitoneum, pneumatosis intestinalis: intramural gas in the bowel wall from necrosis. Most easily identified by CT and plain radiography.
DDx of pneumoperitoneum, Chilaiditi syndrome: anterior interposition of the colon to the liver, reaching the under surface of the right hemidiaphragm. Haustra can be seen on X-ray and the patient has upper abdominal pain.