Giant Gastric Ulcer

Video Endoscopic Sequence 1 of 11.

Giant Gastric Ulcer

This 75 year-old male, who was referred to our endoscopic unit to evaluate, adynamia, anorexia and nauseas, had been with , aspirin, antihypertensives drugs and oral hypoglycemic agents.

Multiple biopsies were taken to ruled out malignancy, finding Helicobacter Pyloris. Given treatment with Proton-pump inhibitors (PPIs) for six weeks, but not at this moment to Helicobacter Pyloris, practicing new endoscopy finding the scar of ulcer.

For more endoscopic details download the video clips by clicking on the endoscopic images, wait to be downloaded complete then press Alt and Enter; thus you can observe the video in full screen.

All endoscopic images shown in this Atlas contain
video clips.

 

Endoscopy of Giant Gastric Ulcer

Video Endoscopic Sequence 2 of 11.

Endoscopy of Giant Gastric Ulcer

The giant stomach ulcer can be defined as a crater measuring more than 30 mm in diameter. This variety of stomach ulcer represents 10-15% of the whole range of gastric ulcers, but they are not quite different from the nosologic point of view. It appears effectively that no etiopathogenic clinical or evolving particular factors can distinguish this kind of ulcer from the niches of normal size.

See Endoscopic Animation concerning Gastric Ulcers in YouTube.

 

Pubmed

 

Endoscopy of Giant Gastric Ulcer

Video Endoscopic Sequence 3 of 11.

Endoscopy of Giant Gastric Ulcer

Multiple biopsies were obtained from different angles showing no malignancy.

Peptic ulcer disease (PUD) is a common problem.

Data from the pre-H. pylori, pre-proton pump inhibitor (PPI) era provide important to insights into the natural history of PUD. Untreated, peptic ulcers have a widely variable natural history]. Some heal spontaneously, but recur within months or sometimes within a year or two.

Other ulcers cause complications or remain refractory despite antisecretory therapy. The patient's prior ulcer history tends to predict future behavior; those with a history of complications have an increased risk of future complications. Ulcers that take longer to heal initially are more likely to recur rapidly and ulcers that have recurred frequently are likely to continue to do so, unless the underlying cause (eg, H. pylori or nonsteroidal antiinflammatory drugs [NSAIDs]) is removed. A long duration of symptoms prior to presentation is more likely to be associated with a poor response to medical therapy.

See in YouTube: Endoscopic Animation.


Giant gastric ulcer

Video Endoscopic Sequence 4 of 11.

Giant gastric ulcer is uncommon. Patients are more seriously ill than those with smaller ulcers. 

Distal antral ulcers, especially prepyloric ulcers (within 2 to 3 cm of the pylorus), may have a different pattern of healing than ulcers at or proximal to the incisura because of different levels of acid secretion and the distribution of gastritis. Many studies did not analyze gastric ulcers by location, and available data are conflicting. Nevertheless, prepyloric ulcers appear to heal more slowly and may be more likely to recur.

Giant ulcers are marked by higher operative mortality and the late-term results of surgical treatment of these patients yield to those in cases of usual gastric ulcers. Giant ulcers occur most frequently in the elderly.


Endoscopy of Giant Gastric Ulcer

Video Endoscopic Sequence 5 of 11.

More biopsies of ulcer edges

Treatment of H. pylori in infected individuals dramatically alters the incidence of ulcer relapse. In a meta-analysis that included 14 studies, duodenal ulcers recurred in fewer than 10 percent of patients successfully treated for H. pylori compared with 65 to 95 percent of those who remained infected. However, newer data from the United States suggest that recurrences after successful H. pylori antibiotic treatment may be more frequent. By contrast, relapse is the rule in the absence of successful anti-H. pylori therapy.


Endoscopy of Giant Gastric Ulcer

Video Endoscopic Sequence 6 of 11.

Another irregular area is observed at the incisura angularis biopsies were taken.

Upper GI endoscopy has largely replaced upper GI barium x-ray series for the evaluation of upper GI tract disease or symptoms because it allows direct visualization, tissue acquisition, and therapeutic interventions

 

 

Endoscopy of Giant Gastric Ulcer

Video Endoscopic Sequence 7 of 11.

In the gastric fundus shows an ulcerated nodule, also some biopsies were obtained.

The gastric ulcer are staged, by using of the endoscopic staging system of Sakita, into 3 stages (active, healing, scarring) as follows.

Stages

Manifestation
Active stage

A1 The surrounding mucosa is edematously swollen and no regenerating epithelium is seen endoscopically A2 The surrounding edema has decreased, the ulcer margin is clear, and a slight amount of regenerating epithelium is seen in the ulcer margin. A red halo in the marginal zone and a white slough circle in the ulcer margin are frequently seen. Usually, converging mucosal folds can be followed right up to the ulcer margin

Healing stage

H1 The white coating is becoming thin and the regenerating epithelium is extending into the ulcer base. The gradient between the ulcer margin and the ulcer floor is becoming flat. The ulcer crater is still evident and the margin of the ulcer is sharp. The diameter of the mucosal defect is about one-half to two thirds that of A1 H2 The defect is smaller than in H1 and the regenerating epithelium covers most of the ulcer floor. The area of white coating is about a quarter to one-third that of A1.

Scarring stage

S1 The regenerating epithelium completely covers the floor of ulcer. The white coating has disappeared. Initially, the regenerating region is markedly red. Upon close observation, many capillaries can be seen. This is called ‘‘red scar’’ S2 In several months to a few years, the redness is reduced to the color of the surrounding mucosa. This is called ‘‘white scar’’.

Endoscopy of Giant Gastric Ulcer

Video Endoscopic Sequence 8 of 11.

In addition small ulcer in the gastric fundus

In patients with NSAID-associated peptic ulcers, discontinuation of NSAIDs is paramount, if it is clinically feasible. For patients who must continue with their NSAIDs, proton pump inhibitor (PPI) maintenance is recommended to prevent recurrences even after eradication of H pylori. Prophylactic regimens that have been shown to dramatically reduce the risk of NSAID-induced gastric and duodenal ulcers include the use of a prostaglandin analog or a PPI. Maintenance therapy with antisecretory medications (eg, H2 blockers, PPIs) for 1 year is indicated in high-risk patients.


Endoscopy of Giant Gastric Ulcer

Video Endoscopic Sequence 9 of 11.

A follow up endoscopy was performed after six week of treatment, the scar was found.

Most peptic ulcers heal within 4 to 6 weeks of treatment.

The recommended primary therapy for H pylori infection is proton pump inhibitor (PPI)–based triple therapy. These regimens result in a cure of infection and ulcer healing in approximately 85-90% of cases. Ulcers can recur in the absence of successful H pylori eradication.


Gastric ulcers

Video Endoscopic Sequence 10 of 11.

Gastric ulcers usually undergo a repeat endoscopy to ensure that the ulcer has healed and to ensure that the ulcer does not contain cancer cells.

Most patients with PUD are treated successfully with cure of H pylori infection and/or avoidance of nonsteroidal anti -inflammatory drugs (NSAIDs), along with the appropriate use of antisecretory therapy.


Gastric ulcers

Video Endoscopic Sequence 11 of 11.

In this second endoscopy, multiple biopsies were obtained again , which also showed no malignancy. At this time the patient was prescribed with specific treatment for Helicobacter Pylori.


Gastric Ulcer

Video Endoscopic Sequence 1 of 8.

Gastric Ulcer

Case of big gastric ulcers and multiple ulcers at the gastric antrum as well as duodenal bulb with multiple scars.

67 year-old, male who was referred to our endoscopy unit to evaluate abdominal pain, nausea, vomiting and anorexia.

Endoscopy of a Gastric Ulkcer


Gastric Ulcer

Video Endoscopic Sequence 2 of 8.

Giant gastric ulcer is uncommon. Patients are more seriously ill than those with smaller ulcers. Most giant gastric ulcers heal with histamine H2-receptor antagonist treatment. The condition is a marker of poor general health, reflected by the high long term mortality.

 

Duodenal Ulcer

Video Endoscopic Sequence 3 of 8.

Duodenal Ulcer

Our patient also has a Duodenal Ulcer


The antrum is deformed with inflammatory reaction

Video Endoscopic Sequence 4 of 8.

The antrum is deformed with inflammatory reaction around the ulcer.


Video Endoscopic Sequence 5 of 8.

PEPTIC ULCER CAUSES

Peptic ulcers form when acid erodes the lining of the digestive tract. This can happen when there is excess acid in the system, or when the protective layer of mucus on the lining is broken down (making it more susceptible to damage).

There are two major causes of peptic ulcers, bacterial infection and the use of pain relievers called nonsteroidal anti-inflammatory medications (NSAIDs). NSAIDs include aspirin, ibuprofen (sample brand names: Advil, Motrin), and naproxen (sample brand name: Aleve).

H. pylori infection — Helicobacter pylori is a type of bacteria that lives in the digestive tract. H. pylori is very common; some data suggest that it is present in approximately 50 percent of people.

Most people who have H. pylori do not develop ulcers, but some do. This is because the bacteria can cause the following, all of which can contribute to peptic ulcer formation:

●An increase in the amount of acid in the stomach and small intestine
●Inflammation of the lining of the digestive tract
●A breakdown of the protective mucous layer
NSAIDs — The use of NSAIDs can also cause peptic ulcers in some people. They are commonly used to relieve pain and reduce inflammation. Many people also take low-dose aspirin daily to prevent heart attack or stroke.

NSAIDs can cause changes in the protective mucous layer of the digestive tract, leading to ulcers in some people. The risk of ulcer formation depends on multiple factors, including the NSAID type, dose, and duration of use.

Other risk factors — Neither the presence of H. pylori nor the use of NSAIDs causes ulcers in every case; there are other factors as well:

●Genetics likely play a role, as studies have shown that having a family member with peptic ulcers makes a person more likely to develop ulcers as well.
●People who smoke cigarettes are more likely than nonsmokers to develop peptic ulcers.
●While drinking alcohol does not appear to be a cause of ulcers, alcohol abuse can interfere with ulcer healing.
●Although certain foods and beverages can cause stomach upset, there is no good evidence that they cause or worsen ulcers. Still, eating a healthy diet with plenty of fruits, vegetables, and fiber may decrease the risk of ulcers.
●The role of psychological stress in the formation of ulcers is controversial. There is some evidence that psychological factors (such as stress, anxiety, and depression) may contribute to the development of ulcers as well as impaired healing and increased recurrence. However, this relationship is not fully understood, as there are many other variables involved (eg, the presence or absence of H. pylori; use of NSAIDS; other individual characteristics) and “stress” can be difficult to measure and study.
●Other (non-NSAID) medications and health conditions can also cause ulcers, but this is fairly uncommon


 

Video Endoscopic Sequence 6 of 8.

Multiple biopsies were obtained from all quadrants of the ulcer.

Video Endoscopic Sequence 7 of 8.

This image shows the status after taking some biopsies.


Video Endoscopic Sequence 8 of 8.

In the lesser curvature of pre-pyloric antrum, there is a scar and an ulcer in the bulb.



Video Endoscopic Sequence 1 of 3.

Endoscopic Image of Gastric Ulcer.

This 76 year-old male, smoker, presented nausea vomiting
and non-specific abdominal pain at endoscopy displays a
well circumscribed smooth, regular, rounded edge with a
flat smooth base and surrounding mucosa.

Video Endoscopic Sequence 2 of 3.

Multiple biopsies were taken to ruled out malignancy.

A gastric ulcer is a break in the normal tissue that lines the
stomach.

Ulcers develop when the normal defense and repair
mechanisms of the lining of the stomach or duodenum are
weakened, making the lining more likely to be damaged by
stomach acid.

By far, the two most common causes of peptic ulcer are
infection of the stomach with Helicobacter pylori bacteria
and use of certain drugs.


Video Endoscopic Sequence 3 of 3.

Ulcer in red Scar

A follow up endoscopy was performed after six week of treatment with PPI.

Smoking
Studies show smoking increases the chances of getting an ulcer, slows the healing process of existing ulcers, and contributes to ulcer recurrence.

Four stages of gastric ulcer healing have been established by correlating endoscopic findings with those obtained from stereoscopic microscopy and histologic observations: I. initial healing stage; II. proliferative healing stage; III. palisade scar stage; IV. cobblestone scar stage. The palisade scar and cobblestone scar stages roughly correspond to Sakita's red and white scar stages, respectively. It is suggested that healing is not complete until the cobblestone stage with attendant micropit formation is achieved.

 

Multiple Gastric Ulcers.

Video Endoscopic Sequence 1 of 10.

Case of Multiple Gastric Ulcers.

A 76 year-old, female, presented with a three day history
of melena without any abdominal pain. She had one episode
of hematemesis (about 100 ml blood) in the emergency
room, patient has a strong alcoholic drink abuse.
An upper endoscopy with magnification was performed.
multiple ulcers was detected across of the gastric camera,
esophageal varices was also detected.

Endoscopy of multiple gastric ulcers


Case of Multiple Gastric Ulcers.

Video Endoscopic Sequence 2 of 10.

The image displays a high magnification endoscopy
displaying one of the ulcers.

Symptoms of peptic ulcer disease include epigastric
discomfort (specifically, pain relieved by food intake or
antacids and pain that causes awakening at night or that
occurs between meals), loss of appetite, and weight loss.
Older patients and patients with alarm symptoms indicating
a complication or malignancy should have prompt
endoscopy.


Endoscopy of Multiple Gastric Ulcers.

Video Endoscopic Sequence 3 of 10.

Endoscopy of Multiple Gastric Ulcers.

The image and the video clip display several ulcers
across of the entire stomach.

For younger patients with no alarm symptoms, a
test-and-treat strategy based on the results of H. pylori
testing is recommended. If H. pylori infection is diagnosed,
the infection should be eradicated and antisecretory
therapy (preferably with a proton pump inhibitor) given for
four weeks.


Endoscopy of Multiple Gastric Ulcers.

Video Endoscopic Sequence 4 of 10.

Endoscopy of Multiple Gastric Ulcers.

Retroflexed image shows multiple ulcers.

Surgery is indicated if complications develop.
Administration of proton pump inhibitors and endoscopic
therapy control most bleeds. Perforation and gastric outlet
obstruction are rare but serious complications. Peritonitis
is a surgical emergency.

 

Endoscopy of Multiple Gastric Ulcers.

Video Endoscopic Sequence 5 of 10.

Endoscopy of Multiple Gastric Ulcers.

A panoramic view of the gastric body, retroflexed image.

 

 

Endoscopy of Multiple Gastric Ulcers.

Video Endoscopic Sequence 6 of 10.

Chromoendoscopy using indigo carmine.

 

 

Endoscopy of Multiple Gastric Ulcers.

Video Endoscopic Sequence 7 of 10.

A close up of generative epithelium at the border of the
ulcer, magnifying image.


Endoscopy of Multiple Gastric Ulcers.

Video Endoscopic Sequence 8 of 10.

More images and video clips of multiple ulcers with indigo
carmin stain.

Endoscopy of Multiple Gastric Ulcers.

Video Endoscopic Sequence 9 of 10.

Chromoendoscopy using lugol´s solution.

 

Endoscopy of Multiple Gastric Ulcers.

Video Endoscopic Sequence 10 of 10.

In addition of multiple ulcers, patient shows esophageal
varices.

Pre-Pyloric ulcer

Video Endoscopic Sequence 1 of 9.

Pre-Pyloric ulcer surrounding with regenerative epithelium.

 

Video Endoscopic Sequence 2 of 9.

More evident the regenerative epithelium is observed,
surrounding the ulcer using a magnifying endoscope.
Recently, magnifying endoscope has been used clinically
for its developments in amplifying power, definition and
operational capability.
Magnifying endoscopy is helpful for more correctly
distinguishing hyperplastic lesions from adenomatous and
cancerous lesions, and for improving detection of early flat
and depressed cancer.



Video Endoscopic Sequence 3 of 9.

A magnifying close up.

Magnifying endoscopy may have an obvious value in
diagnosing chronic atrophic gastritis, intestinal metaplasia
and H pylori infection.




Video Endoscopic Sequence 4 of 9.

Magnification chromoendoscopy dye-methylene blue.
The new detailed images seen with magnifying
chromoendoscopy are unequivocally the beginning of a ne
era where new optical developments will allow a unique
look on cellular structures.


Video Endoscopic Sequence 5 of 9.

High-resolution chromoendoscopy.

Chromoendoscopy, the intravital staining of gastrointestinal
epithelia, provides additional diagnostic information with
respect to the epithelial morphology and pathophysiology.
Based on experience gathered, chromoendoscopy is now in
more widespread use, in particular to identify preneoplastic
and neoplastic lesions.


Video Endoscopic Sequence 6 of 9.

Chromoendoscopy with methylene blue. Tissue staining during endoscopy (chromoendoscopy) is a technique used to study the fine details of the mucosa throughout the gastrointestinal tract.

Chromoendoscopy combines high resolution endoscopy with various methods of vital staining of epithelial structures. In these methods, during endoscopy, tissues are coloured by a stain introduced through a spray catheter. The staining techniques are technically simple, economical and easy to perform.

Various stains produce different optical effects. Contrast
staining with indigo carmine fills folds, villi and other
uneven areas and hence emphasises the structure. A
different image is obtained by using absorptive stains such
as methylene blue or Lugols solution which are directly
taken up by the cells, thus staining them.

An even more differentiated investigation is possible using
zoom or magnification endoscopy. This uses special
endoscopes capable of enlarging the endoscopic images up
to 150 times. It does not take much imagination to predict a
dynamic development of chromo- and zoom endoscopy.


Video Endoscopic Sequence 7 of 9.

For more endoscopic features download the video clip.


Video Endoscopic Sequence 8 of 9.

Multiple erosions are observed

 

Video Endoscopic Sequence 9 of 9.

Dye-Scattered picture (Methylene blue) multiple erosions
are appreciated.


Giant Gastric Ulcer.

Video Endoscopic Sequence 1 of 5.

Giant Gastric Ulcer.

91 year old female presented epigastric pain, nauseas and
vomiting for 3 months.

The biopsies were benign.


Giant Gastric Ulcer

Video Endoscopic Sequence 2 of 5.

Giant Gastric Ulcer

Retroflexed Image.

A peptic ulcer is a defect in the gastric or duodenal wall
that extends through the muscularis mucosa
(the lowermost limit of the mucosa) into the deeper layers
of the wall (submucosa or the muscularis propria). Signs
and symptoms of PUD include dyspepsia, GI bleeding,
anemia, and gastric outlet obstruction. Dyspepsia is a
nonspecific term denoting upper abdominal discomfort that
is thought to arise from the upper GI tract. Dyspepsia is
a common symptom, affecting 10% to 40% of the general
population.4,5 Although the majority of patients with
dyspeptic symptoms have functional dyspepsia for which no
organic etiology can be identified, PUD is found in 5%
to 15% of dyspeptic patients.


Video Endoscopic Sequence 3 of 5.

Giant Gastric Ulcer

Posterior wall of the gastric corpus.

 

Video Endoscopic Sequence 4 of 5.

Adenomatous polyp near of the giant ulcer.

 

See the video sequence of this polyps after six week of
treatment, of that ulcer is appreciated with magnifying
endoscopy with chromoscopy.


Video Endoscopic Sequence 5 of 5.

After six week of treatment, A follow up endoscopy was performed a scar was found.



Irregular gastric ulcers with scars

Video Endoscopic Sequence 1 of 7.

Irregular gastric ulcers with scars

This is the case of a woman of a 72 year-old, an endoscopy was practiced because of abdominal pain, multiple irregular ulcers was detected, initially thought that this endoscopic picture could be a MALT lymphoma, but two follow up endoscopies were performed one after 20 days and again at three months, despite multiple biopsies in the three endoscopies which were negative for malignancy.


Irregular gastric ulcers with scars

Video Endoscopic Sequence 2 of 7.

Irregular gastric ulcers with scars

In the incisura angularis multiple erosions are observed

Endoscopy of Irregular gastric ulcers with scars

Video Endoscopic Sequence 3 of 7.

Endoscopy of Irregular gastric ulcers with scars

Irregular ulcer "star-shaped" with edges lift due to healing is observed

 

Endoscopy of Irregular gastric ulcers with scars

Video Endoscopic Sequence 4 of 7.

Endoscopy of Irregular gastric ulcers with scars

Another image of endoscopy in which several irregular ulcers are displayed.



Endoscopy of Irregular gastric ulcers with scars

Video Endoscopic Sequence 5 of 7.

Endoscopy of Irregular gastric ulcers with scars

Endoscopy after three months of treatment with proton pump inhibitors (PPIs). Multiple scars are observed, After multiple biopsies in three endoscopies, showed no malignancy.

Endoscopy of Irregular gastric ulcers with scars

Video Endoscopic Sequence 6 of 7.

Endoscopy of Irregular gastric ulcers with scars

A scar is observed

Endoscopy of Irregular gastric ulcers with scars

Video Endoscopic Sequence 7 of 7.

Endoscopy of Irregular gastric ulcers with scars

Healing is observed with some elevation

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