Lactology Foundation

Late Complications of Ulcer Disease

It is important to note that gastric ulcers, much more
more commonly than duodenal ulcers, can be caused by
carcinoma. Histologic diagnosis is therefore man-
datory and the healing must be monitored endos-
copically.

Pyloric Stenosis
Pyloric stenosis is a late complication of chronic recurring ulcers. The character of ulcer pain is changed and loss of appetite occurs. Feelings of fullness and discomfort after meals, which are not present in uncomplicated ulcers indicate stenosis. A stenosis is very likely with vomiting that relieves or cures late pain and with vomiting of food from the previous day. If endoscopic examination identifies empty stomach secretion and food 12 hours after eating, this supports the diagnosis. Food and liquid retention can often be detected by sonography. The diagnosis is confirmed radiologically by slow pyloric passage, dilatation of the stomach, and marked dilution of the contrast agent by stomach secretion and food residues. The nature of the pyloric stenosis (benign or malignant) can generally be defined by endoscopy and histology.

Gastric Carcinoma
Epidemiology and Risk Factors. 85% of malignant tumors in the stomach are adenocarcinomas. They can grow as space-filling processes or diffusely infiltrate the stomach wall (linitis plastica). Non-Hodgkin lymphoma and leiomyosarcoma are malignant gastric tumors. Nitrates in food, which are converted to carcinogenic nitrites by bacteria, play an important role in the development of gastric carcinoma. Hp infection also seems to play a significant role. Patients with chronic atrophic type A gastritis are at particular risk for carcinoma. Gastric carcinomas are more frequent in patients with blood group A.
Clinical Features. In contrast to ulcers, the symptoms of gastric carcinoma are less typical. They start slowly, are uncharacteristic, and are not periodic. There is generally no history of stomach complaints. Typical features are the persistence or progression of the complaints and the appearance of general symptoms, particularly weakness (anemia) and weight loss.
Iron-deficiency anemia frequently precedes the local symptoms by weeks or months. In contrast to ulcer symptoms, carcinoma pain
is not relieved by antacids and is not periodic. In about one-quarter of cases there is no pain, but rather unspecific complaints (feeling of fullness, discomfort, belching, nausea). In other cases the complaints are more diffuse, e. g., loss of appetite and weight loss. Vomiting is typical for tumors in the antrum or cardia. Cardiac carcinoma extending to the esophagus typically causes dysphagia.

Exophytically growing ulcerated carcinoma in the prepyloric antrum (moderately differentiated adenocarcinoma).

Diagnosis. The carcinoma is generally palpable only in advanced cases. The early cases are either not sensitive to palpation or present with diffuse pain. A Virchow gland above the left clavicle is typical for advanced gastric carcinoma.
Endoscopy and histology are usually diagnostic. If endoscopy suggests gastric carcinoma, a negative biopsy does not rule out a carcinoma. Close endoscopic-histologic monitoring is necessary for early detection of gastric carcinoma. Failure of an ulcer to heal after four to eight weeks of medical therapy or early recurrence are indications for a malignant or complicated ulcer.
Detection of early cancer by endoscopy improves prognosis. Early cancer, defined as carcinoma restricted to mucosa and submucosa, is generally cured by surgery.

Hematemesis
Causes. Hematemesis indicates a bleeding mucosal lesion proximal to the duodenojejunal flexure. The main causes of acute upper gastrointestinal bleeding are:
➤ peptic ulcers
➤ erosive gastritis
➤ Mallory−Weiss syndrome
➤ esophageal varices.
In 80-90% of all cases one of these four diseases is present.
Mallory-Weiss syndrome is caused by tears in the mucosa in the cardia region at the gastroesophageal junction, which generally occur during massive, cramp-like vomiting.
Other uncommon causes of hematemesis are:
➤ esophagitis
➤ tumors of the gastroduodenal region
➤ hemorrhagic diathesis
➤ hemobilia
➤ haemosuccus pancreaticus
➤ hemangioma
➤ Osler disease
➤ aortointestinal fistula
➤ mesenteric arterial occlusion
➤ pseudoxanthoma elasticum.
Hemobilia must be suspected in hematemesis in association with biliary colic or jaundice. The main cause is an abdominal trauma with central or subcapsular liver rupture. In some cases hemobilia may occur months after the trauma. Liver abscess, echinococcus infection, vascular anomalies, liver tumors, and gallstone penetration are other causes of hemobilia.

Melena
Causes. Massive tarry stools generally have the same causes as hematemesis.
These are mainly:
➤ peptic ulcers
➤ erosive gastritis and Mallory−Weiss syndrome
➤ esophageal varices
➤ tumors.
Hematemesis concurrent with melena indicates that the source of the bleeding must be proximal to the jejunum.
Hematemesis may also be absent in bleeding from the upper gastrointestinal tract. Among others, NSAID therapy must be considered as the cause of hemorrhage.
Stress ulcers (particularly after surgical procedures, burns) and hemorrhage due to anticoagulant therapy must be considered.
If melena and no hematemesis are present, all rare sources of bleeding distal from the jejunum must be included in the differential diagnosis.
Various factors affect the occurrence of melena: volume of blood (> 50 mL), intestinal transition time (< 8 h), and effect of hydrochloric acid and intestinal flora on hemoglobin. Rectal bleeding with bright red blood indicates hemorrhage from the colon or distal small intestine (e.g., tumors, diverticula, Crohn's disease, ulcerative colitis, angiodysplasia). A massive hemorrhage in the upper gastrointestinal tract may also be associated with bright red rectal bleeding in cases of accelerated intestinal passage. Tarry stools are observed in some cases with hemorrhage from the proximal colon, particularly in cases of slow intestinal passage. An hemorrhagic diathesis, mesenteric arterial and venous thrombosis, or other vascular diseases (e. g., aneurysms, cavernoma, hemangioma) may cause intestinal bleed-
Eng.
The effects of specific drugs, particularly iron formulation, charcoal preparations, or certain foods in large quantities (e. g., red beets, blueberries) may imitate melena.

Non-Hodgkin lymphoma of the stomach. Extensive
ulceration in the gastric antrum and body; 70-year-old woman.

Diagnosis. Endoscopy is the method of choice for detection and, if necessary, therapy. An esophagogastroduodenoscopy followed by, if necessary, a colonoscopy is generally indicated. Angiography for the detection of abdominal hemorrhage is restricted to cases with continuous blood loss of 0.5−2.0 mL/min.
Small intestinal lesions, particularly tumors of the small intestine, are difficult to detect. In cases of intestinal bleeding with negative endoscopic results, tumors of the small intestine should be considered (e.g., schwannoma, leiomyoma, malignant lymphoma, carcinoma). Capsule endoscopy and double balloon enteroscopy are becoming increasingly important in addition to radiologic small intestine imaging, CT and MRI.
Uncommonly recurring blood loss from the pancreas, particularly from a pancreatic pseudocyst in chronic pancreatitis, can be a diagnostic challenge (he-mosuccus pancreaticus).

CT view of the pseudocyst in the head of the pancreas filled with contrast agent. The thin arrow points to a calcification, the thick arrows point to the pseudoaneurysm.

Rare Gastric Diseases
Malignant Lymphoma. Malignant lymphoma is similar to gastric carcinoma. Primary gastric lymphoma is rare. However, the stomach is the most common extranodal localization of a non-Hodgkin lymphoma. The prognosis of malignant lymphoma is significantly better than that of gastric carcinoma. Infection with Hp is associated with the development of gastric lymphoma, particularly the MALT lymphoma. The eradication of the Hp infection causes a regression of the MALT lymphoma in about 50% of patients.
Lymphoma of the small intestine can also be a complication of sprue
Leiomyoma. This tumor is rare (approximately 1% of all tumors). The most important clinical symptom is hemorrhage. Endoscopy and radiography show a semispherical, well-circumscribed tumor with central ulceration.
Gastrointestinal Stromal Tumors (GIST).
GIST are mesenchymal tumors of the gastrointestinal tract, 60−
70% of which are localized in the stomach. They were until recently frequently classified as leiomyomas or leiomyosarcomas, but have a specific cellular origin and a specific pathogenesis. GIST are identified by mutations of the cKIT protooncogene and activation of the KIT receptor tyrosine kinase, and like chronic lymphatic leukemia, respond to treatment with the specific ty-
rosin kinase inhibitor imatinib mesylate.
Intestinal Polyposis. In contrast to Ménétrier disease, gas-
tric mucosa with intestinal polyposis shows a predominantly normal, smooth aspect with diffusely distributed individual polyps at endoscopy. Gastric polyps are more frequent in patients with chronic atrophic gastritis, particularly in pernicious anemia. The complaints are uncharacteristic. Depending on the extent and location of the tumors, the polyps may be asymptomatic, may present as gastritis, or result in sudden stenosis. The tumors often bleed, resulting in anemia that may dominate the clinical picture. The diagnosis must be histologically confirmed.
Hamartomatous polyps occur in the colon and the small intestine in Peutz-Jeghers syndrome and juvenile polyposis. Malignancy is rare compared to familiar adenomatous polyposis, Gardner and Turcot syndromes, and hereditary nonpolyposis colorectal carcinoma.
Very Rare Gastric Diseases. Syphilis, tuberculosis, sarcoidosis, Crohn disease, eosinophilic gastritis, or phlegmonous gastritis are extremely rare causes of gastric complaints. Endoscopy and biopsy are generally diagnostic. With many diseases the diagnosis can only be confirmed if organs other than the stomach are affected (e. g., sarcoidosis, Crohn's disease, tuberculosis).
Duodenal Diverticulitis. Duodenal diverticulitis is generally harmless. Sometimes, however, it may cause complaints similar to duodenal ulcers. Annular pancreas must be considered in the differential diagnosis. Periampullar or intraduodenal diverticula originating from the common bile duct may be a rare cause of pancreatitis or cholangitis.