Radiological presentation of a benign ulcer
During barium fluoroscopy, the ulcer can be assessed in profile or en-face (en-face). Most benign defects measure between 5 and 10 mm.
During en-face examination:
- Barium pools in the crater on the underlying wall.
- The shape of the ulcer is usually round or oval.
- «Ring» sign: visible when contrast coats the edges of the ulcer without filling it (if the ulcer is located on a non-gravity-dependent surface).
- A smooth edema mound (circular filling defect) is often noticeable around the crater.
- Upon healing, the mucosal folds remain smooth and extend directly to the edge of the crater.
During profile examination:
- Ulcer niche: projects beyond the contours of the gastric lumen.
- Hampton line (Hampton line): a thin radiolucent line at the base of the ulcer formed by overhanging mucosa. This is a pathognomonic sign of benignancy.
- Ulcer collar: a thicker (2–4 mm) smooth radiolucent rim.
- Ulcer mound: a symmetrical elevation caused by edema.
Differential diagnosis of ulcers
The radiologist's primary task is to distinguish a benign ulcer from a malignant one. If there is any doubt, the patient is strictly referred for endoscopy with biopsy.
| Sign | Benign ulcer | Malignant ulcer |
|---|---|---|
| Contour | Projects beyond the gastric wall | Does not extend beyond the wall contour |
| Hampton line | Present | No |
| Folds | Smooth, regular, converge toward the center | Irregular, nodular, abrupt termination |
| Carman's meniscus sign | No | Present (lenticular barium accumulation) |
| Mass lesion | No | Present |
| Shape | Round, oval | Irregular, angular |
Computed tomography (CT) in gastric ulcer
CT is used to assess the gastric wall, plan treatment, and detect complications. The method includes virtual gastroscopy and multiplanar reconstruction (MPR).
- Benign changes on CT: smooth crater, smooth edema fold, normal wall stratification. Contrast enhancement of the wall does not exceed that of adjacent areas.
- Malignant changes on CT: asymmetric edges, uneven base, club-like thickening of folds. The wall around the ulcer shows strong contrast enhancement, stratification is lost. Fat tissue infiltration and lymphadenopathy are possible.
- Signs of perforation: leakage of water-soluble contrast beyond the organ contour, local wall thickening, and adjacent fat stranding.
Erosions and gastritis
Erosions (aphthous ulcers) are superficial defects that do not extend deeper than the muscularis mucosae. They heal without scarring. On radiographs, "complete" erosions appear as small (1–2 mm) barium accumulations with a radiolucent edema rim.
In gastritis, radiological and endoscopic findings are similar. The most frequent sign is gastric fold thickening (more than 5 mm). A combination of thickened folds and enlarged gastric areas (areae gastricae) is considered specific for H. pylori infection.
Briefly: answers to topical questions
What radiological signs are characteristic of gastric ulcer perforation?
Gastric ulcer perforation is characterized by the presence of free gas in the abdominal cavity and specific changes in the gastric wall.
- Pneumoperitoneum (pneumoperitoneum) — free gas visualized on an upright plain radiograph as a crescent-shaped layer between the diaphragm and the liver or stomach.
- Cupola sign (Cupola sign) — confluence of free gas beneath the right and left domes of the diaphragm along the midline.
- Contrast leakage (leaking contrast) — beyond the gastric contour on CT.
- Tissue changes (fat stranding) — local wall thickening and adjacent adipose tissue stranding on CT.
Lung window settings are used on CT to detect small volumes of gas.
What complications of peptic ulcer disease are detected by diagnostic imaging methods?
Diagnostic imaging methods detect the following complications of peptic ulcer disease:
- Perforation (perforation) — transmural wall destruction with content leakage into the abdominal cavity, detected by CT and plain radiography.
- Acute haemorrhage (acute haemorrhage) — diagnosed using CT angiography (without oral contrast, in three phases) or traditional angiography.
- Penetration (penetration) — extension of the ulcer into surrounding tissues (pancreas, lesser omentum, gallbladder), confirmed radiologically and by MSCT.
- Obstruction (obstruction) — narrowing or deformation of the antrum during ulcer healing, as well as cicatricial pyloric stenosis.
Profile differences: Benign ulcer has a "plus-tissue" appearance (the niche projects BEYOND the contour). Malignant ulcer has a "minus-tissue" appearance (ulcer within the wall, does not project beyond the contour).
Class and exam questions
What is Hampton's line?
This is a thin radiolucent line at the base of the ulcer, visible in profile. It indicates overhanging preserved mucosa over the submucosal defect and is a pathognomonic sign of benignancy.
Where are NSAID-induced ulcers most commonly localized?
Nonsteroidal anti-inflammatory drug-induced ulcers are more frequently located on the greater curvature and in the gastric antrum.
What does Carman's meniscus sign indicate?
This is a sign of a malignant ulcer. It represents a lenticular accumulation of barium with elevated margins that appears convex relative to the gastric lumen upon compression.
How do benign ulcers heal?
Usually they heal within 8 weeks. The shape changes from round to a linear slit. Mucosal folds evenly converge toward the scar site.
What else to study on this topic
- Flow technique in fluoroscopy
- Complications of ulcer scarring (antral narrowing)
- Differences between complete and incomplete erosions
- CT limitations in the differential diagnosis of ulcers
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