Radiology And Endoscopy Diagnosis Of Peptic Ulcer

Abstract:

Background: In this study Radiological, and Endoscopy study of gastric and duodenal ulcer”. Endoscopy and radiography with the clinical picture is main procedures in diagnosis of peptic ulcer and other gastric pathology. Also in this study we discuss the values and accuracy of radiology and endoscopy in diagnosis of peptic ulcer. 

The study was applied in Gaza strip hospital, mainly European Gaza hospital.

Aim of work: The aims of the current study are:

·            Radiographic evaluation of patient suffering from peptic ulcer disease

·             Endoscopy evaluation of patient suffering from peptic ulcer disease.

·            Comparison between radiography and endoscopy in evaluation of peptic ulcer disease.

Material and methods: this is prospective study performed during period 2000 to 2005 in European Gaza hospital, Gaza, Palestine. The study included 200 cases complaining of upper gastro-intestinal symptoms as dyspepsia, heartburn, epigastric pain and other symptoms. They were subjected to radiological and endoscopic study. The age of the above patients ranged from 10-80 ys. Old, and include 130 male and 70 female.

Results: The results of this study show that the Endoscopy has an accuracy of 100 % in the diagnosis of gastric and duodenal ulcer and other pathology in comparison to 83 % accuracy of radiology. Double contrast study has an accuracy of 85%, while single contrast has an accuracy of 66 %.

Conclusion: Both tools (radiology and endoscopy), are still suitable for diagnosis of gastric and duodenal ulcer, and both tools are complementary to each others.

Introduction: Accurate diagnosis is the key to good medical and surgical practice. Over the last two decades, the introduction and increased a viability of new imaging modalities have made the diagnostic process easier.  Communication between the clinician and radiologist is vital for each to understand the clinical problem.

 X-ray was first discovered in 1895, by Wilhelm Corad Rontgen, professor of physics as University of Warzbug Germany during experiments with electrical current pass through vacuum tube ⁽¹⁾.

Endoscopy is a technique that allows examination of an area of body by means of endoscope, a tubelike instrument with lenses and light source attached.  In the early 1930, the first reports of laparoscopic intervention of semi-flexible gastroscope for viewing the stomach. Through 1960 and 1970, laparoscopy became a vital part of gynecology practice. Despite these technological advances, it was not until after 1986, following development of video computer chip that allow the magnification and projection of images onto television screen ^{(2) (3)}.   Generally, the development of endoscopy can be divided into the following    stages:

1-The stage of rigid - tube system,         2- Semiflexible instruments,

3-Fiberoptic endoscopy,                         4- Endoscopic ultrasonography and

5-Electronic endoscopy etc.

Now, endoscopy is not only used in diagnosis, but also in therapy ⁽⁴⁾.

DemirciS, Gohchi A. In comparative study for fiberoptic and video endoscopic suggested that video endoscopy may be more useful than fiberoptic endoscopy in the evaluation of minimal mucosal changes of GIT ⁽⁵⁾.

Material And Methods:

Material:. I applied my study on 200 cases, referred to radiology and Endoscopy departments, from medical and surgical department as well as out patient clinic in European Gaza hospital. This part includes a description of the methods and machines used in the study include Radiology and Endoscopy equipments

 Equipment: The radiological examination was applied by using Siemens fluoroscopic x-ray machine, fluoroscopy viewing system (TV chain), which transmitted to a television monitor for viewing ⁽⁶⁾.

Endoscopy unit and staff: Endoscopy unit formed with multiple procedure rooms, with space dedicated to preparation, recovery and reporting, in collaboration with teams of specially trained nurses and supporting staff ⁽⁷⁾.   With specific functions in mind, keeping nursing and doctor spheres of activity separate ⁽⁸⁾ .

Contrast Media:

I-Waters-soluble contrast media: e.g. Gastrografin—Iodine concentration 370 mg. ml. It has an osmotic pressure of more than 1800 mOsm, more than five times serum osmolarity ⁽⁹⁾.

II- BARIUM: Barium material is radio-opaque contrast material is swallowed, for purpose of demonstrating the anatomy and pathology of gastrointestinal tract using –x-rays. Barium suspension is made up from pure barium sulphate, the particles of barium must be small (0.1-3mic.m), since this makes them most stable in suspension.   

III. Pharmacological agents: Hypotonic drugs such as Buscopan or Glucagon may be administered prior to the examination to slow gastric empty by reduced bowel peristalsis during the examination, owing to the smooth muscle relaxant action ⁽¹⁰⁾.

VI-Gas-productive agent: Sodium bicarbonate is the basic ingredient, plus citric or tartaric acid. I also used 7-up material as gas- productive agent. This agent release carbon dioxide in the stomach quickly and consistently, and incorporate an antifoaming agent.

7- up is low  cost, good taste, palatable for patient, its used direct by drink 50 cc before barium sulphate suspension or may be mixed with barium suspension. Gag- productive agent product large volume of gas 200-400 ml. and its non interference with barium coating, rapid dissolution easily swallowed and low cost ⁽¹¹⁾.

Methods:

The methods used to achieves the research parameters which are;

I. Radiological examination.             II. Endoscopic examination.

1. Radiological examination includes:   

Barium meal: A barium meal is an x-ray examination of stomach and esophagus and first part of small intestine (the duodenum).

Patient preparation for barium and endoscopy must fast for at least 6- 8 hours.

 1-Single contrast or Barium-Filled Radiographs: The single-contrast upper gastrointestinal series invariably includes several views of the barium-filled stomach. The method, which is used in, very ill adult to demonstrate gross pathology and in children since it is usually not necessary to demonstrate mucosal pattern.

Double contrast: This is the method of choice to demonstrate mucosal pattern. High-density barium suspension is used to demonstrate fine mucosal detail, and double contrasts are achieved by means of a gas-producing agent. A hypotonic drug such as Buscopan or glucagons may be administered to maintain destination and inhibit peristalsis ⁽¹²⁾.

The bio physic examination: This modification of the double contrast technique was by additional quantity of dilute barium is given of the end of the examination and further films are obtained of the stomach and duodenum ⁽¹³⁾.

II. Endoscopic examination: for esophagus, stomach and upper duodenum. Biopsy taken by endoscopes for all cases, and Histopathology examination. 

Results:

 In this chapter we explain the data found after examining 200 cases of patients who came to the European Gaza hospital out patient clinic, medical department, and surgical department. The above patients complaining from signs and symptoms of upper gastrointestinal tract troubles. The entire above patients submitted to radiological examination and endoscopic examination.

The result obtained in this chapter going with the objectives of the current study which are:

 1. Radiographic evaluation of patient suffering from peptic ulcer disease

2. Endoscopy evaluation of patient suffering from peptic ulcer disease.

3. Comparison between radiography and endoscopy in evaluation of peptic ulcer disease.

Comparison between radiography and endoscopy in evaluation of peptic ulcer disease:

In this item we compare the result of both radiography and endoscopy examination; we put the comparative study in table1. 

Table 1:

Ulcer in lesser curvature of stomach

Ulcer niche

Discussion:

Discussion the results presented in the tables were obtained from current study and compare this result with other studies performed with researcher in the world.  In our study all the 200 patients were subjected to clinical examination, radiography examination and endoscopy examination.

The objective is radiography study of peptic ulcer by use single and double contrast barium meal study:   In table 1, we found that from 200 cases of peptic ulcer disease 165 (83%) cases were diagnosed by radiography while 35(17 %) cases are misses by radiography.  All cases examined by double contrast radiography which have high accuracy than single contrast barium meal. 85% ⁽¹⁴⁾ .

Double-contrast is very useful in detection of upper gastrointestinal pathology as well as detection of fine normal gastroduodenal anatomy ⁽¹⁵⁾.  

In study the percent of false positive and false negative result of both single contrast and double contrast and by use of endoscopy was used as the definitive diagnostic procedure. Large number of false positive findings of gastric and duodenal ulcer had been reported after radiological examination ⁽¹⁶⁾  

 2. The second and third objectives are to use endoscope to study the peptic ulcer disease and compare this study with the radiographic study.

In looking to the result of the study in the table which compare between the tow tools in diagnosis of peptic ulcer, we found that the tow procedure still available in diagnosis of upper GI tract pathology. Endoscopy result reach to 100% which is superior to radiography which result reach 83%, with high percent of false positive result.

 Endoscopy has become the recommended first test for confirming the present of peptic ulcer in patients with upper GI tract symptoms as dyspepsia.

Radiography barium contrast examination is can be used in patient with contraindication of endoscopy procedure, and when endoscopy not available for diagnosis or the patient afraid from rare minor complication of endoscopy ⁽¹⁷⁾. Both procedures are complementary to each other. ⁽¹⁸⁾.

 Endoscopic examination diagnosed the missed ulcer by radiography but missed 2 cases of gastric ulcer in first time due to small ulcer between thick gastric folds, the clinical picture of the 2 patients still suspected ulcer, so repeat gastroscopy after 3week, small ulcer seen between thick gastric folds. 

 In my study most of cases doe both procedures in diagnosis of peptic ulcer. Some time endoscopy done before radiography and vies versa. When endoscopy diagnosis occur no need to confirm by radiology, but if radiology diagnosis positive or negative also we need endoscopy to confirm ⁽¹⁹⁾.

Knowledge the results of prior to upper gastrointestinal endoscopy alter radiography results. But knowledge results of prior upper gastrointestinal radiography did not alter endoscopic results ⁽²⁰⁾.
 

Duodenal ulcer (DU):

As seen in above tables, the present of radiological positive (111 cases) 82.4% and there is (24cases) 17.6% radiology give false negative and theses cases are diagnosis by endoscopy. The endoscopy has high percent of accuracy 100%.

At first we found difficult to diagnosis  4 cases which not seen by endoscopy in first time is due to outlet obstruction and over distention of stomach and stomach full of secretion and residual food, and due to pyloric stenosis, due to spasm. Pyloric stenosis associated with duodenal ulcer is in the majority of cases the result of pyloric spasm, not of organic constriction or scar of sphincter. The mucosa in or around the pyloric ring is edematous. Repeated endoscopy examination can diagnosis the above cases.

Gastric Ulcer (GU): From 65 cases of gastric ulcer, (54 cases) 83% of the cases are diagnosis by radiography , and (11 cases ) 17 %, the radiology give false negative result, these cases are diagnosis by endoscopy which give high percent of positive result 100 %,  

 Radiological founding of GU and DU (peptic ulcer): The result of peptic ulcer diagnosis by radiography is approximately equal (GU 83%, DU 82.4%).  The above positive percent is low in comparison to endoscopy due false negative due to some ulcers is small, shallow or filled with residual mucus, blood , food or necrotic tissue that prevents barium from filling its ulcer crater. Similarly the margins of ulcer can be so edematous that barium cannot enter it, small ulcer may be obscured by large rugal folds. In contrast false –positive ulcer –like patterns may be caused by barium trapped between gastric folds. These false positive (non-ulcers) are most commonly noted along the greater curvature and the upper body and antrum of the lesser curvature. Careful technique, with graded compression and distention of stomach, usually permits obliteration of these non-ulcers.

Site of ulcers: gastric ulcers can involve any part of stomach, but most of ulcers 53 cases (81%) are located in lesser curvature. This result around the national result, which is 80% ^(21). Three radiographic features of ulcer seen on profile view Hampton line, and radiation mucosal fold seen in most cases diagnosed by radiology. Ulcer scar and deformity of seen in large number of duodenal ulcer than gastric ulcer, cases of perforated DU, diagnosis as air under diaphragm. The above radiologically benign gastric ulcer criteria differ from malignant ulcer which appears as irregular collection of barium within an intra-luminal mass, no project outside the lumen of stomach. The thick irregular folds surrounding ulcer crater are not smooth ⁽²²⁾.

Endoscopic appearance of DU, and GU: By endoscopy peptic ulcer typically appear as discrete, excavated lesions with whitish base due to fibrin. The edges of benign ulcers usually are smooth and regular, and symmetrically thickened fold typically radiate to the ulcer base. Erythema in surrounding mucosa. In some cases of DU when healed with scar and deformity occur and appear as psudo-diverticulum. The above signs with other signs. The ulcer usually associated with other pathology as gastritis or duodenitis. Inspite the above typical characters of benign peptic ulcers, also its non hundred percent sure ⁽²³⁾. Multiple biopsies specimens (at least six ) was taken from the edge of ulcer and from gastric mucosa at the edges of the gastric ulceration, because specimens obtain from ulcer base (crater) often show necrotic debris and granulation tissue.  

A number of studies have compared the accuracy of upper gastrointestinal radiology and upper gastrointestinal endoscopy for diagnosing of peptic ulcers disease.

 By comparing current results with Mokaram, ⁽²⁴⁾. Levine MS. ⁽²⁵⁾, Glick SN. ⁽²⁶⁾,    

Cotton PB. Shorvon PJ (27)

From table we found that current study and national studies results in both radiology and endoscopy in diagnosis of peptic ulcer is improved, as positive radiology in Mokaram study in 1978, 73.3%. In current study and in other national studies range 80-90%. Endoscopy results in Mokaram study is 85.7%. Endoscopy result in current study and national studies was 95-100%. We think that the difference in the results could be due to recent development of both radiology and endoscopy machines and the easiness and availability of the examination and improve endoscopist skill. 

In one of conclusion of our study and in recent studies have found that discourage routine follow-up endoscopy for gastric ulcer after an initial endoscopic evaluation of gastric ulcer that includes brush cytology and at least six biopsy specimens, repeat endoscopy to document healing should not be performed.

Conclusion and recommendations:

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Head of Radiology Department of
European Gaza Hospital,
  consultant of radiology