Ulcers

Clinical

GI ulcerations are common occurrences, with reportedly up to 15% of the adults affected at some point during their life. The vast majority occur in duodenum and stomach, and are caused by H. pylori, NSAIDS. Clinical presentations of ulcers usually include epigastric pain.  Given that uncomplicated ulcers have such a strong association with H. pylori, the mainstay of medical management includes both mucosal protection and bacterial eradication.

When multiple ulcers or ulcers in atypical locations (i.e. esophagus, jejunum) are discovered, other (less common) etiologies must be entertained. Other etiologies include neoplastic, inflammatory, and infectious processes, as well as certain drugs and radiation exposure.

The most common complications of ulcers (and those that require surgical intervention) include hemmorhage, perforation, obstruction, and intractable pain.

Radiological

Fluoroscopy, using either single or double contrast, is the imaging study of choice for evaluating small bowel ulcerations. Barium pools in the ulcer base, seen as a radiopaque collection outside the confines of the small bowel. Ulcers can have a variety of appearances, ranging from aphthoid to linear to “punched-out” to “bull’s-eye,” depending on the etiology. In addition , pancreatic pseudocysts and diverticula may mimic the appearance of ulcers.

Differentiating a benign ulceration from one associated with malignancy is difficult, and biopsy is often needed for confirmation, especially in the stomach. Imaging findings used to help differentiate apply most appropriately to gastric ulcers, and are discussed in more detail in the Stomach section.

Plain films and CT are often used to evaluate for complications of ulcers, such as perforation or obstruction, as well as to search for less common etiologies, such as neoplasms.

Ulceration.  This image demonstrates barium pooling in the base of an ileal ulceration. The atypical location of this ulcer should raise the suspicion for something other than an uncomplicated ulcer. Other complicating features include luminal narrowing and fold thickening. This turned out to be lymphoma.