Coarse Duodenal Folds in Patients with Peptic Ulcer
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Gut: first published as 10.1136/gut.9.5.609 on 1 October 1968. Downloaded from Gut, 1968, 9, 609-611 Coarse duodenal folds in patients with peptic ulcer J. RHODES, J. H. LAWRIE, AND K. T. EVANS From the Departments of Medicine, Surgery, and Radiology, Welsh National School of Medicine and United CardiffHospitals, Cardiff In 1964, Fraser, Pitman, Lawrie, Smith, Forrest, appearance was similar to that found in patients with and Rhodes reported a group of 33 patients with idiopathic steatorrhoea. typical ulcer dyspepsia in whom no ulcer could be In the 88 patients with duodenal ulcer, acid demonstrated radiologically. However, the mucosal secretion was 43 ± 4.6 milliequivalents per hour folds in the duodenum were unusually coarse and (normal 24-9 ± 2.2); 22 had coarse duodenal folds the pattern of gastric acid secretion was similar to (25%) and in six of them the folds were 'marked'. that in duodenal ulcer. We have recently reported In the patients who had normal folds, the secretion our findings in 40 patients with coarse duodenal of acid was 403 ± 13.8 m-equiv per hour; in those folds. Seventeen of these patients had an ulcer with coarse folds, it was 45.8 ± 10.1 m-equiv per when first seen or developed one subsequently hour. This difference was not significant (Fig. 2). (Rhodes, Evans, Lawrie, and Forrest, 1967). However, five of the six patients with 'marked' Because of the association of coarse duodenal coarse folds had an acid secretion greater than folds with a high acid secretion and sometimes with 57 m-equiv per hour. The sixth patient secreted duodenal ulcer, we have now examined the frequency 43 m-equiv per hour, but a diagnosis of Zollinger- of abnormal duodenal folds in a series of patients Ellison syndrome was suspected since his basal with duodenal or with gastric ulcer. secretion was 16 m-equiv per hour. Only three patients had both coarse duodenal and jejunal folds. METHODS In the 14 patients with gastric ulcer, the acid secretion was 20.8 - 62 m-eqiv per hour. Only http://gut.bmj.com/ Barium meal radiographs from 102 patients were reviewed: 88 had a duodenal ulcer and 14 a gastric ulcer. The patients were chosen at random from two groups: one group had been admitted to hospital because of severe symptoms and the other consisted of patients referred through the general practitioners' x-ray unit and studied as outpatients. Gastric acid secretion was measured by the histamine infusion on September 23, 2021 by guest. Protected copyright. technique (Lawrie, Smith, and Forrest, 1964). An attempt was made to assess the presence or absence of coarse folds. If the folds were thought to be large, they were recorded as moderate or marked. The radiographs were assessed by one observer who had no knowledge of the patients or of their acid secretion. RESULTS There are normally small folds of mucosa in the duodenal bulb. In many of the films reviewed, this appearance was replaced by irregular folds which distorted the outline of the bulb and in some cases gave the appearance of nodules protruding into the lumen (Fig. 1). The abnormal appearance often extended into the second and third part of the duodenum where the mucosal folds were large and FIG. 1. Radiograph from a patient with duodenal ulcer; gave a cobblestone appearance. Occasionally, the there are marked coarse folds in the bulb and secondpart proximal jejunum was also involved and then the of the duodenum. 609 Gut: first published as 10.1136/gut.9.5.609 on 1 October 1968. Downloaded from 610 J. Rhodes, J. H. Lawrie, and K. T. Evans DUODENAL D.U. & GASTRIC high acid output. In two patients with a gastric ULCER COARSE FOLDS ULCER ulcer and coarse folds, acid secretion was similar 70 to that in duodenal ulcer. The incidence of coarse * * mucosal folds in the duodenum in patients with chronic duodenal ulcer is very high in this series (25 Y.). This high figure is thought to be due to the 60 o fact that this group of patients had been investigated because of the severity of their symptoms. Burns I and Laws (1966) related the acid output to the size 0000~~~ of the mucosal folds in the stomach and duodenum 50 0o 0 in patients with miscellaneous forms of dyspepsia * 00 or anaemia. They had difficulty in grading patients who had radiological evidence of gastric ulcer because of resting gastric secretion and deformity _40 40 i:... ~~~0000 of outline due to the ulcer. However, they found a highly significant correlation between gastric folds .L S goo~~00 0 and acid secretion in patients with no focal gastric = t~~~~loe.. o 230 - 0~~~~ lesion. Our findings show that patients with a high 000 0 30 acid secretion may or may not have coarse mucosal folds. However, if a patient has very coarse folds in 00~~~~ the duodenum, his acid secretion will probably be * 0 very high. 20 The coarse mucosal appearance has been thought by Kirklin (1934) to be due to contraction of the muscularis mucosa as a result of high duodenal acidity. We believe that the abnormality is functional 10 - S rather than anatomical as the change is inconstant, continually varying when observed fluoroscopically. 10 There is a marked difference between the appearances shown radiologically and at operation (Rhodes http://gut.bmj.com/ et al, 1967). The appearance is well known to FIG. 2. Acid secretion in patients with peptic ulcer. occur in patients with the Zollinger-Ellison syndrome * Duodenal or gastric ulcer with normal mucosalfolds (Zollinger and Ellison, 1955; Zulrod, Pieper, O Duodenal or gastric ulcer with moderate coarsefolds * Duodenal ulcer with marked coarsefolds Hilbish, Smith, Dutcher, and Werner, 1958; Cooke, Fowler, Gaddie, Cox, Meynell, and Brewer, 1960). two had coarse duodenal folds and in both of them SUMMARY on September 23, 2021 by guest. Protected copyright. the acid output was high (Fig. 2). Coarse duodenal folds on radiological examination DISCUSSION are common in patients with duodenal ulcer, being A number of authors have reported coarse duodenal present in 25 % of 88 patients in this series. The acid folds on radiological examination and the appear- output in those with moderate coarse folds was ances have been attributed alternatively to duodenitis similar to those without coarse folds; the acid (Kirklin, 1934; Ritvo and Shaffer, 1952) or to secretion in those with marked duodenal folds was hypertrophy of Brunner's glands (Dodd, Fishler, very high. Only two of 14 patients with gastric ulcer and Park, 1953). It has been shown that patients had coarse duodenal folds and their acid output with coarse duodenal folds have a high acid was high. secretion and may also have a duodenal ulcer We wish to thank Professor H. Scarborough for his (Fraser et al, 1964; Burns and Laws, 1966; Rhodes helpful advice and Mr R. Marshall and his staff for the et al, 1967). illustrations. Our present findings show that coarse duodenal The work was carried out while Dr John Rhodes held folds are more commonly associated with duodenal a grant from the Medical Research Council. ulcer than with gastric ulcer. In patients with duodenal ulcer, the acid output was similar in REFERENCES with and without patients patients coarse folds, Burns, G. P., and Laws, J. W. (1966). The radiological assessment of but patients with markedly coarse folds had a very gastric acid secretion. Lancet, 1, 70-72. Gut: first published as 10.1136/gut.9.5.609 on 1 October 1968. Downloaded from Coarse duodenalfolds in patients with peptic ulcer 611 Cooke, W. T., Fowler, D. I., Gaddie, R., Cox, E. V., Meyncll, M. J., Rhodes, J., Evans, K. T., Lawrie, J. H., and Forrest, A. P. M. (1967). and Brewer, D. (1960). Multiple endocrine adenoma syndrome. Coarse mucosal folds in the duodenum. Quart. J. Med., 37, Gut, 1, 71-75. 145, 151-169. Dodd, G. D., Fishler, J. S., and Park, 0. K. (1953). Hyperplasia of R itvo, M., and Shaffer, A. (1952). Gastrointestinal X-ray Diagnosis Brunner's glands: report of 2 cases with review of literature. p. 327. Lea and Febiger, Philadelphia. Radiology, 60, 814-821. Zollinger, R. M., and Ellison, E. H. (1955). Primary peptic ulcerations Fraser, G. M., Pitman, R. G., Lawrie, J. H., Smith, G. M. R., of the jejunum associated with islet cell tumours of the Forrest, A. P. M., and Rhodes, J. (1964). The significance of pancreas. Ann. Surg., 142, 709-728. the radiological finding of coarse mucosal folds in the Zubrod, C. G., Pieper, W., Hilbish, T. F., Smith, R., Dutcher, T., duodenum. Lancet, 2, 979-982. Kirklin, B. R. (1934). Duodenitis and its roentgenologic characteristics. and Werner, P. (1958). Acromegaly, jejunal ulcers and Amer. J. Roentgenol., 31, 581-587. hypersecretion of gastric juice. In Clinical-Pathological Lawrie, J. H., Smith, G. M. R., and Forrest, A. P. M. (1964). The Conference, National Institutes of Health. Ann. intern. 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