Diagnosis

The diagnosis of peptic ulcer disease is best verified by upper endoscopy. Esophagogastroduodenoscopy is greater than 95% sensitive and near 100% specific in identifying peptic ulcers of both the duodenum and stomach. There are several endoscopic features, additionally, of gastric ulcers that can help to distinguish between peptic ulceration and malignant ulceration. Benign ulcers typically appear as round lesions with slightly raised, smooth borders. The surrounding mucosal folds are symmetric and taper evenly toward the edge of the ulcer. In addition, benign ulcers often have a smooth base covered with a fibrous layer. Although these characteristics may suggest a benign ulcer the only way to truly distinguish is with multiple biopsies at the ulcer edge. Malignancy must be ruled out with biopsy upon the discovery of a gastric ulcer.

Subtypes of Gastric Ulcers

Gastric ulcers are classified into one of four different subtypes:

• Type I ulcers occur along the lesser curvature, in the body of the stomach, just above the incisura angularis. These ulcers account for about 40-50% of gastric ulcers and as such are the most common type of gastric ulcer. Gastric acid output is within the normal range. Surgical therapy consists of a distal gastrectomy with gastrojejunostomy. Vagotomy is not necessary since these ulcers are not associated with acid hypersecretion. In

fact, the addition of a vagotomy does not decrease the ulcer recurrence rate, which is about 3%.

• Type II ulcers also occur along the lesser curvature, in the body of the stomach, and again are found just above the incisura. These ulcers, however, are associated with the simultaneous presence of a duodenal ulcer. They account for about 25% of gastric ulcers. Type II ulcers are associated with gastric acid hypersecretion. Surgical therapy generally consists of a truncal vagotomy with either antrectomy or pyloroplasty.

• Type III ulcers are prepyloric ulcers. They account for about 25% of gastric ulcers. These ulcers are also associated with gastric acid hypersecretion. Surgical therapy consists of truncal vagotomy with either antrectomy or pyloroplasty. Parietal cell vagotomy is associated with higher rates of ulcer recurrence when used for the treatment of type III ulcers.

• Type IV ulcers occur high on the lesser curvature, near the GE junction. They account for less than 10% of gastric ulcers. Type IV ulcers are associated with normal levels of gastric acid secretion. Surgical therapy is more complicated than with the other types of gastric ulcers and depends on the proximity of the ulcer to the GE junction. Esophagogastrectomy may be necessary for ulcers too close to the distal esophagus to allow for preservation of the GE junction.

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