Radiography
Image from an upper gastrointestinal series. A 5-cm ulcer crater in the lesser curve of the stomach is depicted en face. The filling defects in the ulcer crater are caused by a blood clot from recent bleeding.
This erect chest radiograph shows free gas under the diaphragm from a perforated gastric ulcer.
This radiograph depicts a subphrenic collection resulting from a perforated gastric ulcer.
Image from an upper gastrointestinal series. A 1-cm lesser-curve ulcer is depicted en face. Note the radiating mucosal folds.
Findings
Technique of double-contrast barium study
The biphasic technique of double-contrast barium study combines double-contrast views of the stomach obtained using effervescent granules and a high-density barium suspension with subsequent prone or erect single-contrast compression views obtained using a low-density barium suspension. Glucagon 0.1 mg is administered intravenously as a hypotonic agent. Ulcers in the posterior wall or lesser curve are depicted well on double-contrast supine or oblique views. However, prone compression views are required to visualize anterior wall ulcers because they do not fill on supine or oblique projections.
Radiologic features
Gastric ulcers are usually seen as round or ovoid collections of barium (see Images 7-9), but they can also be linear or rod or star shaped. Linear ulcers are often observed in the healing stages.
Ulcers smaller than 5 mm may not be detected on barium studies. The availability of effective medical therapy, commenced before barium study, has been associated with a prevalence of ulcers smaller than 10 mm. Ulcers may vary from 3 mm to > 5 cm in diameter. Giant ulcers (>3 cm) have a greater risk of complications such as bleeding and perforation (see Images 1-2). A gastric diverticulum, which usually arises from the posterior wall of the fundus (see Image 10), should not be confused with a large ulcer.
Most benign ulcers are located in the lesser curve or posterior wall of the antrum or body of the stomach. Only about 5% of benign ulcers are located in the anterior wall or greater curve. Antral ulcers are associated with younger patients and upper lesser-curve ulcers associated with the elderly.1
The incidence of multiple gastric ulcers varies with the imaging technique. Single-contrast studies are associated with an incidence of 2-8%; double-contrast studies, about 20%; and endoscopy, as high as 30%.1 Multiple ulcers are more common in patients using aspirin or NSAIDs. Multiple gastric ulcers are usually located in the antrum or body.
Lesser-curve ulcers
The smooth, round, or oval ulcer crater projects beyond the contour of the adjacent gastric wall (see Image 8). Areae gastricae adjacent to the ulcer may be enlarged because of edema, and undermining of the mucosa in the base of the ulcer results in the appearance of a thin radiolucent line called the Hampton line, dividing the barium in the ulcer crater from that in the body of the stomach. If the rim of mucosa becomes edematous, a wider radiolucent band or ulcer collar may be observed. Less commonly, the edema and swelling around the ulcer may produce an ulcer mound with poorly defined outer borders.
This image (same patient as in Image 7 in Multimedia) shows a small, lesser-curve gastric ulcer in profile.
This image from an upper gastrointestinal series shows a small lesser-curve ulcer with regular radiating mucosal folds. Histologic evaluation revealed no evidence of malignancy.
Hourglass deformity caused by fibrosis. This large lesser-curve ulcer is healing, with fibrosis dividing the body of the stomach into 2 compartments.
Another image obtained in the same patient as in Image 12 in Multimedia.
Hampton lines, ulcer collars, and ulcer mounds are classic features of benign gastric ulcers, but they are observed in only a minority of lesser-curve ulcers. Retraction of the gastric wall adjacent to the lesser-curve ulcers may lead to the formation of smooth, symmetrical folds that radiate from the ulcer crater (see Image 11). The opposite wall may also be retracted, producing an incisura of the greater curve and, ultimately, an hourglass stomach (see Images 12-13).
Greater-curve ulcers
Benign greater-curve ulcers are usually located in the distal half of the stomach and are strongly associated with aspirin and NSAID use; the dissolving aspirin tablets collect in the most dependent part of the stomach and cause focal ulceration and gastric erosions (see Image 14).
This image from an upper gastrointestinal series shows aspirin-induced gastric erosions in the body and antrum.
The ulceration and erosions may appear intraluminal because of associated muscle spasm and retraction of the adjacent gastric wall and are usually associated with thickened irregular folds and edema. An upper greater-curve ulcer suggests malignancy. Endoscopy and biopsy are required to exclude malignancy.
Posterior wall ulcers
Posterior wall ulcers may fill with barium and have the typical appearance of an ulcer crater; shallow ulcers may appear as ring shadows.
This image from an upper gastrointestinal series shows a small lesser-curve ulcer with regular radiating mucosal folds. Histologic evaluation revealed no evidence of malignancy.
The surrounding mucosa is best assessed with en face views; the areae gastricae may be enlarged because of edema, and an ulcer collar is seen as a radiolucent halo surrounding the ulcer. Mucosal folds may radiate from the ulcer crater (see Image 11).
Anterior wall ulcers
Anterior wall ulcers are depicted as ring shadows; barium coats the rim of the unfilled ulcer crater. These ulcers fill in when the patient is in the prone position.
Pyloric channel ulcers
Most pyloric channel ulcers are smaller than 1 cm in diameter and are located in the lesser-curve aspect or anterior wall of the pylorus (see Images 15-16).
This image from an upper gastrointestinal series shows a pyloric canal ulcer.
This image (same patient as in Image 15 in Multimedia) shows the pyloric canal ulcer in detail.
They may be associated with marked edema and spasm of the pylorus and distal antrum and may resemble an ulcerated carcinoma. New ulcers must be differentiated from pseudodiverticula caused by scarring from previous ulcers; mucosal folds are present in pseudodiverticula but not in ulcers. Healing of pyloric channel ulcers may lead to gastric outlet obstruction as a result of scarring and narrowing or angulation of the pyloric canal.
Appearances suggestive of a benign ulcer
About 95% of gastric ulcers are benign.1 The double-contrast technique allows differentiation between benign and malignant gastric ulcers in most cases.
The following features are associated with a benign ulcer:
- The ulcer projects beyond the healthy lumen on the profile view (see Image 8).
- The margin of the ulcer crater is sharply defined and smooth en face (see Image 11 and Image 13).
- Any filling defect that surrounds the ulcer, as a result of edema, is smooth and symmetrical and merges with the healthy mucosa (see Image 11).
- The mucosal folds radiate to the edge of the ulcer (see Image 11).
Benign ulcers that do not have these typical features are classified as indeterminate, and endoscopy and biopsy are required, as they are for ulcers that appear malignant. Reports of single-contrast studies before 1975 showed that 6-16% of gastric ulcers with benign appearances were actually malignant.1 This finding accounts for the common practice of performing endoscopy and biopsy for gastric ulcers that appear benign despite the low incidence of malignancy (5%).1
Appearances suggestive of malignancy
The following features are associated with a malignant ulcer:
- The ulcer crater has an intraluminal location. Exceptions are ulcers in the antrum or greater curve, where benign ulcers are often drawn inward because of muscle spasm in the adjacent stomach wall.
- The margins of the ulcer crater may be irregular and nodular.
- The ulcer crater is surrounded by an asymmetrical mass that has an abrupt outer border with the healthy mucosa.
- Clubbed mucosal folds terminate short of the ulcer crater (see Image 17).
- Ulcers in the fundus are rare, and almost all are malignant.
Ulcer healing and scarring
Ulcer healing is demonstrated at follow-up studies as a decrease in ulcer size and, often, a change in shape from round to linear. Complete healing or disappearance of the ulcer is usually observed 8 weeks after medical treatment and confirms its benign nature. Endoscopy and biopsy are indicated if any residual nodularity or irregularity is present.
Posterior wall ulcers are often associated with radiating mucosal folds that converge to form a shallow pit. This appearance may be mistaken for an ulcer crater; however, its margins slope more gradually than that of an ulcer crater, and its appearance does not change on follow-up images.
Hourglass deformity caused by fibrosis. This large lesser-curve ulcer is healing, with fibrosis dividing the body of the stomach into 2 compartments.
Another image obtained in the same patient as in Image 12 in Multimedia.
Healing of antral ulcers is associated with narrowing and deformity that may mimic malignancy. The hourglass stomach results from the healing of a lesser-curve ulcer and marked retraction or deformity of the opposite wall (see Images 12-13).
Degree of Confidence
Single-contrast views have a sensitivity of about 75%, as compared with the combined double-contrast technique, which has a sensitivity of 95% (Levine, 2000). Although most benign ulcers may be identified with double-contrast studies, as many as 6-16% of ulcers diagnosed as benign with single-contrast studies before 1975 were actually malignant. An ulcerating gastric carcinoma must not be mistaken for a benign gastric ulcer, and endoscopy and biopsy are mandatory whenever the radiographic appearances are indeterminate or suggestive of malignancy.1
False Positives/Negatives
Ulcers smaller than 5 mm may be missed with both single- and double-contrast techniques.
Large gastric diverticulum in the fundus.
A gastric diverticulum should not be confused with a large ulcer (see Image 10).
Computed Tomography
Findings
CT scanning has no part in the primary detection of gastric ulcers8 ; however, this modality has a role in the detection of subphrenic and other collections that may occur after a perforation of a gastric ulcer (see Image 6).
Multidetector row CT (MDCT) scanning9 and three-dimensional (3-D) imaging are expected to overcome the limitations in cancer staging by offering rapid and accurate information for space perception, detailed hemodynamics, and real-time 3-D processing of volumetric data sets. In particular, virtual endoscopic imaging may be helpful for detecting early gastric cancer.
Ultrasonography
Findings
The main role of ultrasonography is in the detection of other causes of upper abdominal pain, such as gallstones and pancreatitis. Sonograms depict subphrenic and other collections resulting from a perforated gastric ulcer.
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 Imaging: Gastric Ulcer |
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References
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Levine MS, Rubesin SE. The Helicobacter pylori revolution: radiologic perspective. Radiology. Jun 1995;195(3):593-6. [Medline].
Lanas A, Serrano P, Bajador E, et al. Evidence of aspirin use in both upper and lower gastrointestinal perforation. Gastroenterology. Mar 1997;112(3):683-9. [Medline].
Lanza FL. NSAIDs and the gastrointestinal tract. Abdom Imaging. Jan-Feb 1997;22(1):1-4. [Medline].
Bas G, Eryilmaz R, Okan I, Sahin M. Risk factors of morbidity and mortality in patients with perforated peptic ulcer. Acta Chir Belg. Jul-Aug 2008;108(4):424-7. [Medline].
Koivisto TT, Voutilainen ME, Färkkilä MA. Symptoms, endoscopic findings and histology predicting symptomatic benefit of Helicobacter pylori eradication. Scand J Gastroenterol. 2008;43(7):810-6. [Medline].
Uppalapati SS, Boylan JD, Stoltzfus J. Risk Factors Involved in Patients with Bleeding Peptic Ulcers: A Case-Control Study. Dig Dis Sci. Jul 22 2008;[Medline].
Grassi R, Romano S, Pinto A, Romano L. Gastro-duodenal perforations: conventional plain film, US and CT findings in 166 consecutive patients. Eur J Radiol. Apr 2004;50(1):30-6. [Medline].
Kim HJ, Kim AY, Oh ST, et al. Gastric cancer staging at multi-detector row CT gastrography: comparison of transverse and volumetric CT scanning. Radiology. Sep 2005;236(3):879-85. [Full Text].
Wayne JD, Bell RH Jr. Limited gastric resection. Surg Clin North Am. Oct 2005;85(5):1009-20, vii.
Yee YK, Cheung TK, Gu Q, Chan P, But D, Hung IF, et al. Factors affecting physicians' practices related to Helicobacter pylori infection: effect of experience and mode of practice. Digestion. 2008;78(2-3):77-81. [Medline].
Zippi M, Febbraro I, De Felici I, Mattei E, Traversa G, Occhigrossi G. [Diagnosis and treatment of bleeding peptic ulcer: our experience]. Clin Ter. Jul-Aug 2008;159(4):249-55. [Medline].
Befrits R, Sjostedt S, Tour R, et al. Long-term effects of eradication of Helicobacter pylori on relapse and histology in gastric ulcer patients: a two-year follow-up study. Scand J Gastroenterol. Nov 2004;39(11):1066-72. [Medline].
Glickman MG, Szemes G, Loeb P, Margulis AR. Peptic ulcer of the pyloric region. Am J Roentgenol Radium Ther Nucl Med. Sep 1971;113(1):147-58.
Levine MS. Erosive gastritis and gastric ulcers. Radiol Clin North Am. Nov 1994;32(6):1203-14. [Medline].
Levine MS, Creteur V, Kressel HY, et al. Benign gastric ulcers: diagnosis and follow-up with double-contrast radiography. Radiology. Jul 1987;164(1):9-13. [Medline].
Lim CH, Chalmers DM. Upper gastrointestinal haemorrhage. Postgrad Med J. Aug 2004;80(946):492, 494. [Medline]. [Full Text].
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Peek RM Jr, Blaser MJ. Pathophysiology of Helicobacter pylori-induced gastritis and peptic ulcer disease. Am J Med. Feb 1997;102(2):200-7. [Medline].
Peura DA. Prevention of nonsteroidal anti-inflammatory drug-associated gastrointestinal symptoms and ulcer complications. Am J Med. Sep 6 2004;117 (suppl 5A):63S-71S.
Schulman A, Simpkins KC. The accuracy of radiological diagnosis of benign, primarily and secondarily malignant gastric ulcers and their correlation with three simplified radiological types. Clin Radiol. Jul 1975;26(3):317-25.
Further Reading
Related eMedicine topics
Gastric Ulcers (from Gastroenterology)
Gastritis and Peptic Ulcer Disease
Peptic Ulcer Disease
Peptic Ulcer: Surgical Perspective
Perforated Peptic Ulcer
Clinical guidelines
Peptic Ulcer Disease
Dyspepsia: A National Clinical Guideline
Clinical studies
Healing Effects of Rebamipide and Omeprazole in Helicobacter pylori–Positive Gastric Ulcer after Eradication Therapy
A Comparative Efficacy and Safety Study of Nexium Delayed-Release Capsules (40mg qd and 20mg qd) versus Ranitidine 150mg bid for the Healing of NSAID-Associated Gastric Ulcers When Daily NSAID Use Is Continued
Keywords
gastric ulcer, peptic ulcer, stomach ulcer, Helicobacter pylori, H pylori, mucosal break, nonsteroidal anti-inflammatory drugs, NSAIDs
