(RadioGraphics. 1981;1:1-16.)
© RSNA, 1981

Unusual manifestations of peptic ulcer disease

¹ From the Department of Radiology Duke University Medical Center and Durham Veterans Administration Hospital.
² St. Vincent's Hospital, Little Rock, Arkansas.

Address correspondence and reprint requests to: William M. Thompson, M.D., Department of Radiology, Duke University Medical Center, Box 3808, Durham, N.C. 27710.

The radiologist may be the first to identify the less frequent manifestations of peptic ulcer disease and should be familiar with their appearances. Important individual points concerning these entities include the following:

1. Multiple gastric ulcers must be evaluated individually since up to 20% may be malignant. Multiplicity of ulcers in the stomach is not necessarily a sign of benign disease.

2. A typical duodenal ulcer is the only radiographic abnormality in up to one-third of patients with the Zollinger-Ellison syndrome. Important radiographic features of the Zollinger-Ellison syndrome are evidence of hypersecretion and enlargement of the folds in the stomach, duodenum, and small bowel.

3. Gastric ulcers greater than three centimeters in diameter (giant gastric ulcers) are not necessarily malignant. The size of a gastric ulcer is not useful in differentiating benign from malignant disease.

4. Gastric outlet obstruction is usually due to a duodenal or pyloric ulcer. Fewer than ten percent of patients with gastric outlet obstruction have gastric ulcers.

5. Stomal ulcers are best evaluated by the double contrast technique. They usually occur in the efferent loop.

6. The radiologist should make an effort to fill the afferent loop in all patients who have had a Billroth II anastomosis. Retained gastric antrum can be identified on the barium study only if the afferent loop is filled. The technetium 99m pertechnetate scan may be a useful technique for identifying patients with a retained gastric antrum.

7. Gastric stump cancer is an important delayed complication of peptic ulcer surgery usually occurring 10-15 years after the operation. It represents a further reason for employing double contrast radiography in post-gastrectomy patients.

8. Only 75% of patients with acute ulcer perforation will have demonstrable free air on plain abdominal radiographs. If ulcer perforation is suspected, an upper gastrointestinal series with a water soluble contrast agent will usually show the site of perforation.

9. The double pylorus (gastroduodenal fistula) rarely requires surgical intervention and may be a sign of healing of the ulcer. This abnormality may mimic malignancy.

10. Gastrocolic fistulas are usually due to malignancy. A small percentage are due to benign peptic ulcer disease. A barium enema will usually show the fistula, but an upper gastrointestinal examination may be needed to identify the cause.

11. Most spontaneous choledochoduodenal fistulas are due to peptic ulcer.

12. Giant duodenal ulcers are important to recognize because they have a very high morbidity. Their constant appearance distinguishes them from a normal duodenal bulb.

13. Many post-bulbar ulcers are difficult to recognize on upper gastrointestinal examinations because of the spasm and associated narrowing at the site of the ulcer.