Teaching Case

48 year old female with metastatic breast carcinoma, taking non steroidal anti-inflammatory agents, presents with abdominal pains.

48 year old female with metastatic breast carcinoma, taking non steroidal anti-inflammatory agents, presents with abdominal pains.

Gastric ulcers are a common medical problem with significant morbidity and mortality. Predisposing factors include Helicobacter pylori, non steroidal anti-inflammatory drugs, stress, tobacco and alcohol. Most cases are now diagnosed by endoscopy. Double contrast barium meal still has a role in the diagnosis of peptic ulcer disease in patients unsuitable for or failed endoscopy. Most benign ulcers are located on the lesser curve with only 3-11% on the greater curvature. Benign greater curvature ulcers are usually in the distal half of the stomach. These are more likely to be related to ingestion of aspirin like agents which tend to lie at this location due to gravity. Giant ulcers are defined as greater than 3 cms. They are more likely to be benign, but are more likely to be complicated by bleeding or perforation. Radiologic features of an ulcer that favor benignity include ulcer crater that protrudes beyond the expected contour of the stomach; is deep relative to its size; has a smooth and symmetric ulcer mound; has a smooth ulcer collar; folds radiating from the ulcer are smooth without nodularity; heals completely. Features that favor malignancy are the opposite to that of benignity, that is, a shallow ulcer crater; does not protrude beyond the stomach contour; appears to sit on an irregular, nodular mass; is irregular in contour; the folds radiating from the ulcer are irregular and nodular; and failure to heal completely. The radiologic features in this case favor a benign ulcer, but all cases require histologic confirmation. In this case, histology confirmed benignity and she was successfully treated.