A. First part of Esophagus
B. First part of Duodenum
C. Stomach ,usally antrum
D. Within the margins of a gastrojejunostomy.
Ans:A. Fisrt part of Esophagus.
The patient in question is suffering from Peptic Ulcer Disease.
Image shows: Chronic peptic ulcer. Histologic zones of the ulcer are illustrated in the diagram. The photomicrograph on right shows necrotic debris, ulceration and inflammation on the mucosal surface,and scarring.
- Peptic ulcers are chronic , most often solitary lesions that occur in any protion of the gastrointestinal tract exposed
- to the aggressive action of acid / peptic juice .
- Peptic ulcers located in the following sits, in order of decreasing frequency :
- Duodenum, 1′ portion
- Stomach ,usally antrum
- At the gastro – esophageal junction in the setting of gastroesphageal reflux or Barrett’s esophagus.
- Within the margins of a gastrojejunostomy.
- In the duodenum, stomach or jeunum of patients with Zollinger -Ellison Syndrome. Within or adiacent to Meckels diverticulum that contains ectopic gastric mucosa.
- Gross and microscopic changes in gastric and duodenal ulcers are similar and quite characteristic.
- Gastric ulcers are found predominantly along the lesser curvature in the region of pyloric antrum, more commonly on the posterior than the anterior wall.
- Most duodenal ulcers are found in the first part of the duodenum, usually immediate post-pyloric, more commonly on the anterior than the posterior wall.
- Uncommon locations include ulcer in the cardia, marginal ulcer and in the Meckel’s diverticulum .
- Grossly, typical peptic ulcers are commonly solitary (80%), small (1-2.5 cm in diameter), round to oval and characteristically ‘punched out’.
- Benign ulcers usually have flat margins in level with the surrounding mucosa.
- The mucosal folds converge towards the ulcer. The ulcers may vary in depth from being superficial (confined to mucosa) to deep ulcers (penetrating into the muscular layer).
- Chronic duodenal ulcer never turns malignant, while chronic gastric ulcer may develop carcinoma in less than 1% of cases.
- Malignant gastric ulcers are larger, bowl-shaped with elevated and indurated mucosa at the margin .
- Microscopically, chronic peptic ulcers have 4 histological zones. From within outside, these are as under :
- Necrotic zone—lies in the floor of the ulcer and is composed of fibrinous exudate containing necrotic debris and a few leucocytes.
- Superficial exudative zone—lies underneath the necrotic zone. The tissue elements here show coagulative necrosis giving eosinophilic, smudgy appearance with nuclear debris.
- Granulation tissue zone—is seen merging into the necrotic zone. It is composed of nonspecific inflammatory infiltrate and proliferating capillaries.
- Zone of cicatrisation—is seen merging into thick layer of granulation tissue. It is composed of dense fibrocollagenic scar tissue over which granulation tissue rests.
- Thrombosed or sclerotic arteries may cross the ulcer which on erosion may result in haemorrhage