An Analysis of X-Ray Findings in 405 Cases of Benign Gastric and Pyloric Ulcer

Abstract

The purpose of this study was primarily: (a) to determine the most frequent sites of benign gastric ulcers and (b) to discover the reasons for the differences in location as reported by the radiologist, surgeon, and pathologist. In the course of our investigation, however, we took advantage of a comprehensive follow-up of a large number of cases to evaluate the results obtained by medical and surgical treatment. We believe that this information is of enough interest and importance to warrant its inclusion in a radiological presentation. The material upon which the paper is based consists of 429 gastric and pyloric ulcers in 405 patients hospitalized during the past fifteen years. There are included in this number several chronic ulcers found incidentally at autopsy. Terminology A review of the literature reveals considerable confusion in anatomical terminology in reference to the stomach, particularly the distal portion, as shown in Figure 1. This confusion is shared by the anatomist, surgeon, pathologist, and roentgenologist. We feel that there is a definite need for standardization of nomenclature, and offer our suggestions in Figure 2. The term “antrum” we apply to that portion of the stomach between the incisura angularis and the pylorus. We have divided the antrum into two parts, calling the distal 2.5 cm. the prepyloric area. In our experience, the greatest confusion has arisen from the loose way in which the word “pylorus” is used. Actually, this term should be applied only to the aperture between the stomach and duodenum. Many, however, have referred to any portion of the stomach distal to the incisura angularis as the pylorus. For example, in locating an ulcer in the prepyloric area in one case, the surgeon reported as follows: “Inspection revealed an indurated area approximately 1.5 cm. in diameter on the anterosuperior surface of the pylorus just proximal to the ring.” In another case, the pathologist, in describing an ulcer at the pyloric ring, made the following statement: “The specimen consists of the pyloric portion of the stomach and part of the duodenum. Of the pylorus there is about 5 cm.; of the duodenum 3.5 cm. At the junction of the two, on the lesser curvature, there is a small deep ulcer 7 mm. in diameter.” Similar mistakes are frequently made by the radiologist. The term “parapyloric ulcer” is confusing and should not be used, since it may mean any one of three things: (a) an ulcer originating in the base of the duodenal bulb and extending to the pyloric and prepyloric regions; (b) an ulcer primary in the pylorus and extending to the stomach and duodenum; (c) ulceration in the prepyloric area which may involve both the pylorus and the base of the cap. For a similar reason the term “juxtapyloric ulcer” is often ambiguous.