Gastroscopy in the Evaluation of Patients with Peptic Ulcer

The object of this paper is to discuss the value and limitations of gastroscopy as a diagnostic aid and as a guide to the efficacy of therapy in patients with duodenal, gastric, and stomal ulcers.

A gastroscopic study may readily be made in fasting patients on an ambulatory basis, with local anesthesia of the pharynx. While the patient lies on his left side, the instrument, which is flexible and covered with rubber in the portion which lies in the lower esophagus and stomach, is inserted. A prism at the distal end enables various areas of the gastric mucosa to be seen at right angles to the axis of the instrument. A series of convex lenses allows a clear image to be maintained if the flexible portion is deviated not more than 30° at any single point. During the procedure the stomach is inflated with air through a passage inside the instrument.

Upon the initial insertion of the gastro-scope, the pylorus should be sought as a major landmark and should be seen in 90 per cent of undistorted stomachs (1). A second landmark, the incisura angularis, is an arch-like fold on the lesser curvature which separates the antrum from the body of the stomach. This fold, caused simply by the angulation of the stomach, corresponds roughly to the incisura demonstrated radiologically. Deep peristaltic waves may be seen to cross the antrum associated with contractions of the pylorus.

Three zones of the stomach are not visible gastroscopically: the posterior wall on which the instrument lies, the lowermost lesser curvature behind the incisura angularis, and the cardiac portion of the stomach which domes above the entrance of the esophagus. No portion of the esophagus can be seen gastroscopically. Radiographic studies made by Ould and Dailey (2) demonstrated that the gastroscope clings closely to the posterior wall near the lesser curvature. This is the reason why it is frequently difficult or impossible to visualize lesions of the posterior wall, since the focal distance of the lens of the instrument is approximately 1.5 cm.

The contraindications to gastroscopy include esophageal diverticula, varices, and neoplasms; cardiospasm; aortic aneurysm; severe deformities of the thoracic spine ; gastric tumors which encroach upon the cardia. Age is not a contraindication, our oldest patient being eighty-six years of age. Nearly all patients are entirely cooperative when the procedure is explained to them and they are assured of the absence of pain.

Several studies have been made which compare the accuracy and relative value of competent radiographic and gastroscopic examination of the stomach; that of Benedict (3) is one of the most recent, objective, and comprehensive appraisals. Since a major gain from gastroscopy is the evaluation of radiographic findings, it is evident that an appreciation of the value and limitations of each method of examination is desirable.