Gastric and duodenal peptic ulcer - etiology, pathogenesis, microscopic & gross pathomorphology, complications
Ulcers are the continued process of gastritis, be that acute or chronic. Where gastritis occurs, it can then lead to an ulcer (defined as a defect extending through the muscularis mucosae), which in turn can lead to perforation.
Acute peptic ulceration
- A complication of therapy with NSAIDs and severe stress, there are three types of lesion
- Stress ulcers - commonly patients who are critically ill
- Curling ulcers - occur in proximal duodenum and associated with burns
- Cushing ulcer - in stomach, duodenum or esophagus, generally in patients with intracranial diseases
- Thought to be due to vagal stimulation causing gastric acid hypersecretion
NSAID induced ulcers are caused by direct chemical irritation and cyclooxygenase inhibition, while other conditions such as stress ulcers and sepsis are thought to relate to decreased blood circulation in the gut.
Morphologically, lesions vary in depth and shape, typically they are rounded and less than 1cm in diameter, blackened by acid with necrotic debris. Single lesions are possible but often multiple occur. Healing can take days or weeks after etiological factors are removed.
Peptic ulcer disease (chronic peptic ulceration)
- Associated with chronic NSAID use or H.pylori and is rapidly becoming the most common cause of ulcers
- Most common in proximal part of the duodenum or, less likely in gastric antrum
- May also occur in esophagus as part of GERD
- For full pathogenesis see PG of Chronic gastritis, this is the natural continuation
- 80% are solitary, lesions less than 0.3cm usually shallow, greater than 0.6cm in diameter generally deeper. The base of the ulcer is generally smooth and clean thanks to peptic digestion
- Ulcers are recurring, cause epigastric pain and can cause complications such as iron deficiency anemia, frank hemorrhage or perforation. Nausea, vomiting and bloating may all be present.
Remember: a chronic peptic ulcer is a round-oval, sharply punched-out crater with flat margins and mucosal folds radiating from it; heaped-up, rolled edges suggest an ulcerated carcinoma instead. Microscopically the base shows four layers: necrotic fibrinoid debris → neutrophilic infiltrate → granulation tissue → fibrous scar.