Pathologic anatomy stomach ulcers

A peptic ulcer is defined as the defect part of the stomach or duodenum spreads via tunica muscularis mucosae in submucosal shell. Postmortem should be distinguished: 1) acute ulcer and erosion, 2) chronic ulcers, 3) penetrating ulcers and 4) cicatricial changes in the ulcer.
Erosion and acute ulcers. Erosion, usually multiple represent a defect mucous membrane, which extends deeper t. muscularis mucosae; acute ulcer is distributed through submucosal shell on other layers of the stomach, sometimes up to the serous membranes. However, the anatomical location is purely formal distinction. Y. M. Lazovsky with employees (1947) believe that in the basis of development and erosion and acute ulcers is not an inflammatory process (Konjctzny, 1925), and the necrobiosis with distinct changes in blood vessels and connective tissue of the stomach.
Thus, the fundamental difference between erosion and acute ulcer does not exist (Y. M. Lazovsky al., 1947; I. C. Davydov, 1958).
Acute ulcers are of different sizes - from a point to 2 cm and more. The form of round, oval or elongated in clinico stomach. Acute ulcer is relatively small (not more than 1 cm), but a deep crater with sharp edges, without inflammatory peripheral reactions around. The bottom of acute ulcers or clean, or there is a dark-brown decay products. Are severe ulceration mainly the small curvature and pyloric division stomach.
Chronic ulcers. In the absence of tendency to heal and scarring acute ulcer becomes chronic. Sometimes it justifies its name (the"round ulcer") and actually has a round shape, but it can be oval, egg-shaped, elongated and with irregular shapes. The size of chronic ulcers range from 1-3 to 10 see the hallmark of chronic ulcers is (due to the proliferation of connective tissue) gradual, progressive seal the edges and bottom of it. Originally described seal is small, the disease is soft to the touch (ulcus simplex), but in the further development of connective tissue becomes more pronounced, the last sklerosiruta, and the edges of the ulcer becomes hard, dense (ulcus callosum).
The result is especially intensive proliferation of connective tissue may develop an inflammatory swelling (ulcus tumor), which (because of its similarities with malignant neoplasms of the stomach) cause diagnostic problems even on an operating table.
Microscopic examination of the bottom of chronic ulcers seems consisting of several layers: surface fibrinous-necrotic, fibrinoidnogo (thread fibrina, homogenized collagen fibers, blood, blood), granulation and connective tissue.
Peptic ulcers are located in different parts of the gastro-duodenal system not with the same frequency. Stomach ulcers most often found in small curvature and in the antrum, and only 5-10% of benign gastric ulcers occur in the greater curvature. Duodenal ulcer is usually formed by 1-2 cm away from the pyloric ring. 10% of duodenal ulcers are below bulbs - postularse ulcers. In 1/4 cases there are multiple ulcers in the front and the back of the bulb ("kissing sores").
Recently Oi al. (1969) spent a long analysis of the regularities of location ulcers on the resected stomach and put forward the concept of dual control mechanism of their origin.
In Fig. 25 presents the scheme of muscle bundles in the wall of the stomach. According to Oi, ulcers always located within the most pronounced kinetic muscle tension (Fig. 26, b), in the narrow area of the lesser curvature, where there are no slanted bundles of muscle fibers, near circular beams in the duodenum immediately after the sphincter, where muscle fibers break a connective tissue. Among 269 observations Oi in 96.3% of defects of mucous had such localization and only 3.7% of cases was the exception to the rule. The high degree of tension in these areas was confirmed electromyographic studies.

Fig. 25. Diagram of the locations of the muscular layers (1,2, 3) the wall of the stomach (Oi, 1969).
Fig. 26. Diagram of the locations of ulcers, depending on the structure of the mucous membrane (a) and location of muscle bundles (b) for Oi (1969). Explanation in the text.

On the other hand, it turned out that ulcers are always located on the border of 2 kinds of mucous membranes with different structure and different compositions of the cellular elements. In the stomach, it was a transition zone between the body and the pyloric Department, always on the side opposite fundic glands and mucous pyloric, and in the duodenum immediately for pyloric ring (Fig. 26, a). Even if the ulcers were formed in other regions of the mucous membrane, they were histologically presents cells actophilornis epithelium pyloric glands. On materials of Oi among 855 observations in 97% of cases met the above pattern of location of defects of mucous. According to the cumulative data, Oi, 95.2 percent ulcers are under a certain "control" of the mucous membrane and muscle membranes, and anatomic correlations are constantly that determines the chronic and relapsing nature of peptic ulcers. The area where double control mechanism can be very narrow, and for stomach ulcers it takes only small curvature at the corner of the stomach. The formation of ulcers in the stomach may occur at different distances from the pyloric ring and at the same distance to the duodenum ulcers.
The concept Oi logically and convincingly documented evidence.
Penetrating ulcers. These are the forms in which ulcerative process goes through all layers of the mucous membrane that is outside of the stomach and duodenum, but does not give the perforation in the free abdominal cavity. In this case the destruction process is slow and the bottom of the ulcer spaevaet with other neighbouring authorities. Is formed as a new bottom, consisting of other body tissues. Therefore, when the destruction of the serous membrane stomach, resp. duodenal ulcer, ulcer penetrates to the appropriate authority. Such is often the pancreas.
Cicatricial changes. Chronic stomach ulcer and duodenal ulcer inclined to heal, and not less than half the time it takes 4-6 weeks, except kallusnykh and perforated gastric ulcers. Usually formed characteristic linear or star-shaped scars. But in the process of scarring may occur puckering separate parts of the stomach. Then the latter takes various forms: lithobates, bipolar gastric or stomach hourglass.
Duodenal ulcer is located in 85-90% of cases in front of the bulb, do not stimulate the development of connective tissue and always heal without scarring.
Ulcers back wall of the duodenum are characterized by
a tendency to the formation of scars, but among them, more often penetration *.
Histopathological picture of the mucous membrane that can be derived from materials aspiration biopsy, some complements postmortem data, and facilitates the ability to answer a separate unclear questions clinic.

* I. Century Davydov. Pathology and pathogenesis of human disease. T. II. M., 1958; A. I. Apricots and A. And, Strukov. Pathological anatomy. H 2, M, 1954.