PATHOLOGY AND PATHOGENESIS OF PEPTIC ULCER. DR. SAMPURNA ROY M.D. Ulcers are defined as a breach in the mucosa of the alimentary tract, which extends through the muscularis mucosa into the submucosa or deeper. ( An erosion differs from an ulcer in being partial thickness mucosal defect).
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DR. SAMPURNA ROY M.D.
( An erosion differs from an ulcer in being partial thickness mucosal defect).
Peptic ulcers are produced by an imbalance between the gastro-duodenal mucosal defense mechanisms and damaging forces of gastric acid and pepsin, combined with superimposed injury from environmental or immunologic agents.
H. pylori infection is present in almost all patients with duodenal ulcers and 70% cases with gastric ulcers.
Duodenal ulcers - Usually associated with gastritis confined to the antrum.
Gastric ulcers - Usually associated with pangastritis.
Eg - Antrum
- Junction of antral and body- fundic mucosa (division between the inflamed antral mucosa and normal acid secreting mucosa).
Peptic ulcer caused due to high gastrin level and excess acidproduction. Gastrinoma may cause multiple peptic ulceration as in Zollinger Ellison syndrome. There is increased parietal cell mass.
Peptic ulcers caused due to impaired mucosal defense . The gastric acid and pepsin levels are normal and no H.pylori are present.
Lesions less than 0.3 cm are likely to be shallow erosions.
Giant ulcers are usually greater than 3cm in diameter.
May also reach upto 10cm (particularly on lesser curvature ).
Mortality rate is higher in these patients.
Size does not differentiate benign from malignant ulcer.
Some carcinomatous ulcers are less than 4cm and 10%
of benign ulcers are more than 4cm .
Depth of penetration :
to the pancreas, omental fat or liver. Free perforation into peritoneal cavity may occur.
Base of ulcer:
Surrounding gastric mucosa:
radiates from the crater in a spoke- like fashion.
Scarring involve the entire thickness . Subserosal
fibrosis and inflammation present.
Regional lymphnodes are enlarged.
Four distinct layers are present in a peptic ulcer.
at the ulcer edge : loss of apical portion of cells,
dropout of epithelial cells,
erosion, cellular tufts.
Cellular atypia may be present in ulcers caused by arterial infusion chemotherapy.
Criteria for reduction of the size of ulcer crater.
Reduction of crater size by 50% over 6-8 weeks of intensive medical management.