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Current radiological methods can be used for the differential diagnosis of stomach ulcers. In the presence of relatively large (15 mm and over) ulcers, double-contrast radiology can reliably differentiate between malignant and benign ulcers. In cases of ulceration due to infiltrative-ulcerous cancer, the double-contrast method or inflation of the stomach with air alone (pneumogastrography) reveals the »ring« sign [44]. The X-ray picture in such cases shows a ridge of tumor infiltration around the ulcer crater against the background of air in the stomach cavity. No other ulcers of non-tumor origin, including the so-called callous ulcers, the frequency of which should also be revised, show the pattern of the infiltration ridge. We are absolutely sure that only »cartilaginous« firmness of the epithelial tumor can give a shadow on a roentgenogram showing the infiltration ridge. In cases of benign ulcers of the same size and localization, the X-ray image of a tightly filled stomach (double contrast) demonstrates a spot or drop. This can be explained by the fact that barium sulfate suspension is retained only in the ulcer crater, and it assumes irregular rounded shapes with distinct outlines, because the first ridge of infiltration, characteristic ofblastomatous ulceration, is absent. Meanwhile, an inflammatory ridge, which is elastic, is distended on adequate inflation of the stomach [1, 58, 71, 182].

▲ Fig. 104 a.

□ Fig. 104a-f. Patient H., age 49. Diagnosis: gastric cancer. From anamnesis: peptic ulcer for 6 years. Last complaints included marked epigastric pain. Loss of 8 kg. Endoscopy of the pyloric part of the stomach revealed rough cicatricial ulcerous deformation with an ulcer defect (8 x 3 cm) on the upper part of the posterior wall. Conclusion: Coarse cicatricial-ulcerous deformation of the pyloric part of the stomach with an ulcer. Histological examination of the bioptates failed to discover tumor cells. a Stomach roentgenogram (tight filling, vertical position, right quarter-oblique projection): the pyloric part of the stomach is unevenly narrowed, the sinus and the antral part are ectatic, evacuation is severely upset. b Stomach roentgenogram (tight filling, vertical position, anterior projection): the pyloric part of the stomach is strongly disfigured, the pylorus is elongated, its contours are uneven (arrows). c Stomach roentgenogram (tight filling, vertical position, anterior projection) after evacuation of the pyloric part: a depot of contrast medium in the disfigured pyloric part of the stomach (arrow). Conclusion: Roentgenologic picture of minor infiltrative-ulcerous cancer of the pyloric part of the stomach. In the absence of histological verification of gastric cancer, the patient was given MRI examination of the stomach. d MRI of the stomach (stomach cavity is filled with water, axial projection, position on the right side, T2 image): markedly thickened wall of the pyloric part of the stomach due to intramural infiltration. The inner contour of the affected wall is uneven, the outer contour is distinct with visualization of a thin hypoin-tense stripe (arrow). The MR signal from the affected wall is heterogeneous and of low intensity. e MRI of the stomach

(stomach filled with water, axial projection, position on the right side, T2 image): circular constriction of the prepyloric part due to intramural infiltration over about 15 cm. The outer contour of the involved wall is distinct, signs of infiltration spread onto the pancreas head are absent. Distinct visualization of a hypo-intensive stripe between the affected stomach wall and the pancreas head (arrow). Conclusion: Initial signs of intramural blastomatous infiltration of the pyloric part of the stomach. Despite the absence of histological confirmation of the stomach tumor the patient was operated in view of radiological indications. f Fragment of a macrospecimen (strip): the wall of the pyloric part of the stomach is thick due to tumor infiltration of white color (arrows). Histologically, signet-ring cell carcinoma.

We were able to check the reliability of these two symptoms in dynamics in patients with peptic ulcer using control X-ray studies supplemented by the double-contrast method. In patients with ulcer of tumor origin, whose operation was postponed because of their refusal or the absence of histological confirmation of carcinoma, we observed enlarge ment of the ridge of infiltration around the ulcer. As the stomach filled with barium sulfate suspension, we observed enlargement of the ulcer crater. In control studies of patients with benign ulcers, the drop (spot), which is characteristic of peptic ulcer, diminished in size but preserved its shape and distinct contour. After 45 days, double-contrast radiology

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