Considerations on the diagnosis of large gastric ulcers and implications as to treatment

Summary

From the above discussion, it is evident that large gastric ulcers are significantly more often malignant than are smaller lesions. The hazards confronting the clinician, roentgenologist, and gastroscopist in the differential diagnosis of large gastric ulcers are great and this fact needs to be re-emphasized. The results of this study of large gastric ulcers, extending over a period of 10 years, support similar previous reports (9) showing that there is nothing in the history, physical examination, laboratory tests, findings on X-ray study gastroscopy, or in the results of medical treatment which wilhunfailingly differentiate a benign from a malignant gastric ulcer. In some cases only the histologic examination of the excised lesion will lead to correct diagnosis.

The therapeutic implications of the foregoing considerations would seem to be clear. To the writer, as to many others (10), the observations here reported suggest the advisability of resecting every large gastric ulcer. As pointed out in a previous paper (11), resection of large gastric ulcers is advisable not only because of the danger of misdiagnosing a malignant lesion as benign, but also because the complications of these large gastric ulcers make them in a way malignant when they are histologically benign. We advise surgery for large gastric ulcers even though we are aware of Bloomfield’s (12) conclusion that errors in differential diagnosis do not exceed the mortality rate of resection. This conclusion seems inapplicable to the clinic where I work where the mortality from operation is not high.

For years I followed the plan of closely observing our patients with large gastric ulcers until the lesion was completely healed. The results, however, were not entirely satisfactory inasmuch as even when the lesion was not malignant, we frequently saw recurrences and complications after apparent complete healing and finally we often had to operate. From such observations, I would hesitate to say that there is such a thing as complete healing of a large gastric ulcer on medical treatment. The excellent paper by Palmer (13) and his associates supports this view. Considering, therefore, the complications that may arise from large gastric ulcers, even when they are benign, and the possibility that they may be carcinomatous, it seems to me that one can never rest content until such a lesion is resected.