Pathologic anatomy ulcer disease

Pathological anatomy. Initial ulcers do not penetrate deeper mucosa. Chronic ulcer may spread to the muscle and serous membranes. Kallusnoi called the plague with solid rising edges. Ulcer, exciting all layers of the gastric wall, could cause a rupture. Ulcer, penetrating into neighboring organs, most often in the pancreas, is called penetrating. After healing ulcers occur scars, sometimes deforming the stomach (the"hourglass", the stomach in the form of a snail or causing narrowing (stenosis) of the pylorus of the stomach. Inflammation of the serous membranes in the location of the ulcer causes perigastric or peridotite and the formation of adhesions and nearby organs.

Acute ulcers are usually round or oval shape. The edges of the ulcer clear, the bottom is generally clean, no overdubs. Acute ulcers may cause perforation of the stomach wall and deadly stomach bleeding.
Chronic ulcer, according to most researchers, is the outcome of acute and differs from it by a significant development of fibrous tissue in the bottom and edges. Chronic ulcer usually round or oval, less often it is the wrong shape. Cardiac region ulcers as if saped, pyloric - flat. The bottom is covered with a dirty-gray overlay in the bottom of penetrating ulcers visible body to which occurred penetration. Stomach ulcers are usually more of duodenal ulcers. The size niches defined by x-ray, not always correspond to the size of the ulcers. Due to the swelling of the edges, fill ulcer crater slime, the exudate or food masses ulcerative defect may not completely filled with barium. Most stomach ulcers is located on the small curvature and pyloric Department. Duodenal ulcer is usually localized in 1-2 cm from the gatekeeper, equally often on the front and back walls of the colon. Less frequent are postularse ulcers. Chronic ulcers are usually single, but there are multiple lesions. When gastroscopy near large sores are sometimes several small, not detected x-ray. In patients with gastric ulcer sometimes simultaneously detected duodenal ulcer. Multiple ulcers duodenal ulcers often located on opposite walls of the colon ("kissing" ulcers). Most scarce ulcers in the stomach are the cardiac Department, bottom and large curvature.
Microscopic examination at the bottom of ulcer distinguish four layers. On the inner side you can see the fibrinous-necrotic overlay, endothelial cells, leukocytes, erythrocytes and hydrochloric gelatin, coloring the bottom of the ulcer in grey or dark brown. Under this layer is a layer of fibrinoidnogo necrosis, educated disorganized and nekrotizirovanne collagen fibers. In quickly and rapidly progressing ulcers, this layer can be up to several millimeters in width. Deeper down granulation tissue. Often it is not detected, as is fully involved in the destructive process. Granulation tissue passes in the following, the most developed layer - scar tissue, which is made of soft and dense fibrous connective tissue. There are minor lymphoid follicles with severe reactive centers. When relapse ulcers scars, you can see a lot of fat cells with signs of enhanced secretory activity. Scar tissue grows muscle layers, submucosa, the amount considerably exceeds the size of the ulcers.
When the ulcers usually occur necrosis of granulation tissue and collagen fibers, inflammatory reaction in the surrounding tissues, rejection necrosis areas and due to this increase of the ulcer. Y. M. Lazovsky believes that the progressive growth of fibrous tissue at the bottom of the ulcer is not linked to the transformation in the rumen of granulation tissue, and with immediate formation of collagen fibers of the basic substance.
In the area of the ulcer usually there are changes in blood vessels with the development of inflammatory and necrotic processes, sites fibrinoidnogo necrosis of the walls of arteries, brain arteries and veins, and the subsequent recalibration of them. These secondary lesions vessels violate the tissue trophism and serve as one of the reasons hindering the healing of chronic wounds. In the bottom of ulcer meet immured in scar tissue, nerve trunks and expansion of nerve fibers type amputation of navrom. In the ganglion cells intramural nerve nodes are observed dystrophic changes and phenomena irritation (C. S. Weil, P. C. Sipovsky).
When ulcers occur change all of the mucous membrane of the stomach and duodenum. At the edges of stomach ulcers observed the proliferation of epithelial that can grow in depth and mucous on the surface of it, taking the form of polyps. Pyloric glands geneclinics, they can see the signs of enhanced mukodni secretion. Secret appear missing in the norm of acid mucopolysaccharides. With long-term existence ulcers occur atrophic changes glands, secretion of them is waning. In fundic gland paintings are marked atrophy, intestinal metaplasia, formed the so-called pseudoperichaeta cancer stern containing mukodni secret. In stroma, you can see a diffuse lymphoplasmacytoid infiltrates, large lymphoid follicles, the proliferation of smooth muscle fibers. When duodenal ulcer significantly increase the number of obkladochnykh cells that detect even in the pyloric Department.
Healing of chronic ulcers by scarring. Before healing come swelling and inflammatory infiltration edges of ulcers. The edges are smoothed, approach the bottom of necrotic masses covering the bottom, rejected. In the bottom and edges appear granulation, which gradually fill the crater of an ulcer. Surface epithelium, rich RNA, grows on granulation tissue lined with her. Muscular layer of the mucosa, gastric and duodenal cancer't regenerate. In the healing of ulcers great importance is the accumulation of acid mucopolysaccharides. For healing ulcers with mild severe fibrosis bottom and edges takes about 5-7 weeks. Sometimes complete healing occurs within 10 days, it sometimes takes several months. In the result of healing deep, especially penetrating, ulcers can occur deformation of the stomach. Healing scar ulcer pyloric can lead to pyloric stenosis. Between healed duodenal ulcer and gatekeeper can develop diverticula (ulcus diverticulum).


Complications. C. M. Samsonov identifies five groups of complications from ulcers.
1. Complications ulcerous-destructive origin: perforation, arrozivnym bleeding and penetration. The perforation of the ulcer is one of the most severe complications. Most often perforation occurs in the second half of the day. The diameter of perforation holes about 0.5 see histological study found a picture of exacerbation of ulcer disease, necrosis and leukocytic infiltration edges and bottom of the ulcer, the imposition of fibrin in serous cover.
Arrozivnym bleeding from large vessels of the bottom of the ulcer. M. K. Dal and others have found that arrosee vessel may be preceded by a limited necrosis wall with the formation of the aneurysm and its subsequent break. Especially dangerous bleeding from chronic ulcers, vessels which are fixed scar tissue preventing the contraction of the arteries. Ulcers of the lesser curvature of the stomach usually penetrates into small gland, duodenal ulcer in the pancreas.
When penetration of ulcers in hollow organs arise gastric fistula (gastrocolic, gastro-intestinal, gastric-gelceutical). Ulcers cardiac and subcatalog departments can panettiruling in the diaphragm. In the future there may come a breakthrough such ulcers in the pleural cavity, in the pericardial cavity.
2. Complications of inflammatory nature: gastritis, duodenitis, perigastric, perioodina, cellulitis stomach, gepathology.
3. Complications of ulcer-scar of origin: stenosis of the gastric cardia, gatekeeper, duodenal ulcer, shortening the lesser curvature, deformation of the stomach in the form of "hourglass", diverticula of the stomach and duodenum.
4. A malignancy of stomach ulcers, according to A. I. Abrikosov, occurs in 8-10% of cases. The lack of consensus about the frequency of malignization ulcers difficult differential diagnosis zlokacestvennoe ulcers and primary ulcer cancer. A malignancy of duodenal ulcers observed extremely seldom.
5. Combined complications.