Stomach ulcers

Modern conceptions of peptic ulcer with localization ulcers in the stomach significantly deepened and clarified thanks to x-ray study not only confirms the clinical diagnosis of stomach ulcers, but can give exhaustive information about localization and size of it, on the secondary changes distorting nature, communication with neighboring organs, and so on, Finally, an x-ray promotes the recognition of ulcers, when clinically often don't have any suspicion of its existence. These "dumb" ulcers are not so rare. However, modern x-ray diagnostics with its rich technical equipment does not give more recognition capabilities stomach ulcers in all cases without exception. As for the reliability of the installed x-ray diagnosis of stomach ulcers, it is very high and according to surgical associations reaches 95-97%.
X-ray signs of stomach ulcers can be divided into two groups: 1) consequential, indirect indicators of functional disorders of ulcers, and 2) an anatomical, direct characteristics, which include: ulcerative niche related ulcer reactive changes in the mucous membrane and cicatricial deformations.
Indirect signs, which are indicators of functional disorders, have little value for the diagnosis of stomach ulcers. Changes in the tone, evacuation, secretion, and pain sensitivity are not pathognomonic for ulcers and occur in many diseases of the abdominal cavity.
Peristalsis when gastric ulcer is often enhanced, especially in the localization sores have pyloric or duodenal bulb. Often, however, peristalsis keeps quiet type, and even sometimes weakened, so to evaluate the nature of peristalsis as one of the characteristics that contribute to the diagnosis, is not possible due to insufficient reliability. Peristalsis may diminish or even disappear in the very place of ulceration. This is especially clearly speaks at a chart on which there is a lack of intersection peristalsis due to infiltration and rigidity of the stomach wall. However, this should be treated with a critical assessment, as the same character peristalsis may be affected and when the so-called "small forms" of stomach cancer.
Often delay the evacuation. But this is not the rule, and it is often necessary to note the very rapid gastric emptying even under these plagues that are identified on the basis of direct symptoms.
Especially important place among the indirect signs of ulcer process takes local spasm circular muscles of the stomach. This symptom appears as a deep retraction in the greater curvature (symptom De-quervain's). Often opposite such retraction observed ulcerative niche on the lesser curvature.
Pain sensitivity is important in determining ulcers, but the value of this attribute is weakened by the fact that very often the patients either do not celebrate pain sensitivity or pain point is found outside of the stomach, mostly in the solar plexus.
For diagnosis of stomach ulcers on the basis of indirect systems can have a value of the whole complex of functional disorders.
Not being enough diagnostically valuable, indirect signs are of great importance when repeated x-ray observations in cases of ulcers, established on the basis of anatomical changes. Registration of functional deviations in x-ray picture of gastric ulcer gives the possibility to determine the disease dynamics under the influence chosen for the patient therapy.
Direct signs. The main x-ray symptom of ulcers of the stomach is the so-called niche (Fig. 86). Niche match the anatomic integrity of the stomach wall and is usually crateriform form. It barium depot in place of the defective tissue. Thus, the "minus fabric" radiographically is expressed in "plus the shadow". Surface, flat ulcers that do not have more or less deep seabed, the so-called "niche on the terrain, especially difficult to recognize, as anatomical abnormalities when they are expressed in a small degree.

Fig. 86. Stomach ulcer (x-rays).
a - niche on the lesser curvature of the convergence of the mucous; b - a niche on the lesser curvature of the shaft swollen mucosa.

Diagnosis of ulcerative niche is facilitated by the fact that she accompany changes in the elevation of the mucosa. The niche is often possible to observe a convergence of folds, or the so-called convergence. Sores around formed a circle roller, protruding above the surface of the mucous. This roller occurs at soil infiltration of the mucous membrane, thus helping to develop ulcer crater. Thus, the depth of the niche depends not only on the degree of destruction of the stomach wall, but also on the shaft protrusion of the mucous over it. Therefore, the depth of the niche often does not correspond to the flaw depth of the wall. A shaft, surrounding the ulcer called ulcerative shaft", represents the expression of nasal mucous and functional changes of spastic nature of the muscles submucosal layer. This shaft is of great diagnostic value and not only contributes to the identification of niches, but allows for repeated studies to assess the evolution of ulcers. Often found this picture, in which the reaction from the mucous becomes pronounced. Then the swelling of the mucous leads to the formation of massive shaft covers the entrance to the ulcerative defect - crater than difficult diagnosis ulcers at primary research. Only later, as the remission of such reactive process can be clearly identified niche.
There are cases when appropriate clinical syndromic and in the presence of pronounced changes mucous membrane in the form of significant swelling and deformation of relief at primary research you cannot identify the niche. While improving the overall state of the investigated or after conducting anti training in a few days niche becomes clearly visible.
When the ulcer is celebrated infiltration of the walls of the stomach, often reaching large size and sometimes even apparently under the screen as some swelling.
Changes in the mucous important when they are localized in the antrum. It is here that most often it is necessary to observe the emergence niche in losing jet
nasal mucous. In some cases, small in size niche, find primary research is becoming more with clinical improvement. This paradoxical dynamics" niches (C. C. Reinberg, I. M. Yakhnich, G. A. Kosterin, B. M. stern) is observed in the reduction of swelling around the ulcer and indicates a favourable throughout the process.
More difficulties arise in identifying preprocessing and especially the pyloric ulcer. But now ulcers and this localization revealed quite often (Fig. 87). Most rarely recognized and difficult to differentiate ulcer along the greater curvature of the body of the stomach, especially when expressed signs of swelling of the mucous. But here is a typical picture of changes on the part of the relief of the mucous membrane in the form of convergence folds has a significant help in the diagnosis of these ulcers. Often large alcove separated from his mother" basis, separated by a narrow isthmus, sometimes reaching considerable length. This typically occurs when penetrating ulcers or covered the perforations, but may also be due to inflammatory infiltrative changes at the edges of the ulcer. Niche that has sporgobrino shape or form sharp thorns, characteristic ulcers, accompanied expressed peripateticism changes.

Fig. 87. Stomach ulcer (x-ray).
Arrow denotes a niche gatekeeper.

In some cases around the ulcer can be observed so dramatically manifested infiltration that formed small defects of filling due to wrap contrast lot of these ledges of walls of the stomach and folds of mucous membrane. This niche gets scalloped appearance with uneven and sometimes with indistinct contours. Such large niches with those changes are very suspicious for cancer transition, especially if they are located in subcardial or the antrum (Gutman, 1950; Massa, 1958). Patients with such niches require purely a thorough clinical and x-ray observations, so that when the time was taken surgical treatment.
X-ray examination, re-conducted in the process of treatment of patients, gives the opportunity to form a judgment about the effectiveness of treatment and reverse the development of ulcers on changes from its main characteristic - niches. A decrease in the niches in the proper treatment often is. It should be noted that such a reduction may depend not only on the immediate impact of treatment interventions on the ulcer in General. Reducing the size of the niche may be associated with improved functional background. There may be also a manifestation of a "paradoxical dynamics". Hence, reduction of a niche does not indicate trends for healing ulcers.
In the process of monitoring and treatment outcomes in assessing the effectiveness of its great importance is the study of changes from the side elevation of the mucous. If for dynamic monitoring revealed losing associated edema before detected reducing the size of the niche, then in such cases, you can expect a positive effect of treatment.