1.4 duodenal ulcer with achlorhydria i. sachs

8/2/2019 1.4 Duodenal Ulcer With Achlorhydria i. Sachs

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946 S .A. M ED ICA L JO UR NA LDUODENAL ULCER WITH ACHLORHYDRIA

REPORT OF A CASE1. SACKS, M.D. (ABERD.)

National Hospital, Bloemfontein

6 November 1954

The patient , a police officer, aged 45, married, was sent in forinvestigation for supposed attacks of angina pectoris.Complaint. Pain in the left arm accompanied by headache.Pain in the praecordium. Upper abdominal pain with flatulence.History. lIe was first seen on 22 July 1952. As a boy he usedto get attacks of lower abdominal colicky pain. Fo r some yearshe has had pain in the epigastrium with tenderness on pressure.Belching used to give him relief. In previous years he sufferedfrom heartburn but this has ceased. His epigastr ic pain is notdefinitely related to the taking of food and he has had no nauseaor vomiting. Some days before this examination, after attendinga rugby match where he had become very excited, he sufferedintense pain in the left upper arm and headache relieved by aspirin.Three nights later he woke with severe pain in the left arm, shoulderand elbow, headache and a feeling of illness. He perspired pro-fusely and this was followed by a jerky feeling in the left arm.He has had similar, though less severe, a ttacks since then. Thepraecordial pain was not related to effort or rest but he becameslightly dyspnoeic and tired on effort. He smokes 25 cigarettes aday.Examination. He does not look ill or distressed. The respiratory,urogenital, articular and cardiovascular systems are all normaland the cardiogram is normal. There is some tenderness onpressure over the gall-bladder and only slight tenderness in theepigastrium. 0 enlargement of the liver or spleen. It was feltthat a cholecystogram and a barium meal should be done before

Fig I . Bar ium meal. Ir ritable duodenal cap. No definite ulcerdemonstrated.

deciding that this was a case of angina pectons. The cholecystogram was normal and the barium meal showed nothing abnormalin the stomach. There was fairly marked pylorospasm and theduodenal cap filled and emptied fleetingly. The cap had smoothoutlines and no evidence of ulceration was found. The mucosalpattern of the small bowel visualized presented normal features(Fig. I). .In view of these X-ray reports I advised_that I was still morehesitant about diagnosing angina pectoris , especially as thisdiagnosis might handicap his future in the service. I t was thoughtthat the marked pylorospasm and irritability of the duodenal capmight be due to an underlying condition even though the ulcercould not be demonstrated radiologically. I t was suggested thatan ulcer regime be followed and the barium meal repeated at alater date. This treatment was applied and on 23 May 1952 thebarium meal showed that the stomach was normal, that there

was no pylorospasm and that the duodenal cap filled and emptiedfleetingly. Some difficulty was experienced in getting the duodenalcap filled; there was slight irregularity of contour but no ulcercrater could be demonstrated (Fig. 2).On 28 May 1952 the patien t said he felt better . He had lessupper abdominal pain and no praecordial pain. He had no feelingof constrict ion in the chest. Belching was still t roublesome. Onexamination he was found to have tenderness in the epigastriumand, for the first time, over McBurney's point. He was advised

-Fig. 2. Barium meal. Spastic duodenal cap with constant incisurabut no definite ulcer niche.


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November '1954 S . A . TYDSKRIF V I R G E N E E S K U N D E 947esume duties, but on 9 June 1952 he complained of flatulencer meals an d pain in the left ar m an d so he was advised tor hospital. Th e stool was found to be negative for occultd and parasites. The blood Eagle test was negative. Fractionalric analysis showed a histamine-fast achlorhydria. Only 1952 the barium-meal examination showed that the duoal cap was irritable an d a spastic incisura was found on theter curvature with an ulcer n i c ~ e bearing all the stigmata ofty present on the same sIde (FIg. 3).

3. Barium meal. Ulcer demonstrated on duodenal cap.

On 10 July 1952 the benzidine test for occult b lood was foundto be positive an d a repeat gastric analysis, with the tube shownby X-rays to be in the stomach, again showed a histamine-fastachlorhydria.On 13 July 1952 the barium meal was repeated by a differentradiologist, who reported that there was fairly marked pylorospasm an d a very definite ulcer niche on the greater curvatureside of the duodenal bulb, a nd t ha t the gastric analysis tube waspresent in the stomach. Sixteen localized projections of the duo-

Fig. 4. Barium meal. Duodenal cap. Constant incisura an ddefinite ulcer niche in the exact position previously noted in Fig. 3.

Fig. 5. Appendix meal a nd p ro of of gastric analysis tube in the stomach.


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948 S.A. MEDICAL JOURNAL 6 November 1954

Fig. 7. Gas tr ic analysis tube in posi tion in the stomach.denum showed that the constant incisura on the lesser curvature,previously repor ted, was absent , suggesting that the condi tionwas subsiding (Fig. 4). The appendix was found to be diseased

LFig. 6. Barium meal . Ulcer on duodenal cap subsiding. IncisurastiU present but less marked.

by clinical and radiological examination and appendicectomy wasdone. These films also confirmed that the gastric analysis tubewas in position (Figs. 5 and 7).

Fig. 8. Barium meal. Ulcer healed.


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Nov embe r 19 54 S.A. TYDSKRIF VIR GENEESKUNDE 94911 August 1952 a contro l barium meal showed that somer pylorospasm was still present and that there was a smaller niche in exactly the same posi tion as previously demonThe ulcer was smaller and the irritability of the duodenalless (Fig. 6). The pat ient was allowed to go home and cone the ulcer regime. One month later he said he felt well exceptflatulence, and the barium meal then showed that the duodenalfilled well and there was no irritability or deformity, but theiously-reported ulcer could no longer be detected (Fig. 8).

DISCUSSIONe feels that this is a proved case of duodenal ulcerthe presence of a histamine-fast achlorhydria. Thisthrough the var ious stages by X-rays, andtube has been proved to be in situ. X-ray healingesponded with the cessation of his symptoms asorted by his doctor on 3 February 1953. The lateArthur Hurst 1 stated that, in his opinion, pepticer with achlorhydria was qui te rare and that he hader seen a case of duodenal ulcer with achlorhydria.doubted whether a peptic ulcer ever developed inabsence of free hydrochloric acid.J. Kauver and L. W. Leiter 2 say that it is generallythat benign duodenal ulcer does not developthe presence of achlorhydria and they quote Washand Rosendal, Palmer and Nutter, and Rickets

al. They state that cases have been averred, f rome to time, and ment ion two cases diagnosed asenal ulcers, clinically and radiologically, bu t inoperation failed to disclose duodenal ulcers.ey say that in no case has adequate evidence beento substan tiat e such a condition. Monat is

quoted as saying that in 500 avy patients he saw severalcases but the reviewers add that he says noth ing of histechnique of gastric analysis or whether histamine wasinjected or not. Palmer and utter are quoted as statingthat in a series of 2,200 cases of proved gastric andduodenal ulcers no instance of persistent achlorhydriawas encountered. The reviewers state that i t is generallyrecognized that duodenal deformity, while most com-monly due to chronic duodenal ulcer, is not an acceptable criterion per se for the diagnosis, and certainlynot in the presence of achlorhydria, but that the presenceof a niche or crater is held to be pathognomonic ofactive ulcer (F. E. Templeton, M. Feldman, G. Rigler).

SUMMARYA case of duodenal ulcer in the presence of a histaminefast achlorhydria is presented notwithstanding theopinion of authorities. The achlorhydria has beenfully proved and t he tube has been proved to be in thestomach. Three different radiologists have taken theseries of X-ray films. Cessation of t he pat ien t' s sym-ptoms corresponded with radiological healing. Onenotes the length of t ime it took for the ulcer to heal.

I am greatly indebted to the late Dr. L. Morel for permissionto publish the case and to the radiologists Dr. Ross Gamer, Dr .P. Dreyer and Dr . R. Tahan for their help.REFERENCES

1. Hurst, A personal communication.2. Kauver, A. J. and Leiter, 1.. W. (1950): Amer. J. Gastro-enterol., p. 550.

A METHOD OF EXCRETORY UROGRAPHY IN CHILDREN.P. J. DENNEHY, M.B. , CH.B.(RAND), ER.C.S. (ENGLAND)

l J r o l o g ~ t , J o h a n n e s b u r g

e their introduction in 1923, techniques in excretoryaphy havemade many renal pathological conditionsThey consist in the intravenous, intraor subcutaneous administration of a dye whichexcreted and concentrated by the kidneys and isto X-rays. I t is in the adult that this methodrenal diagnosis is most useful; in children it is no tsatisfactory. A survey of excretory urography reportsng children shows an astonishingly high proportioncases where renal defination was so poor that noopinion could be given and resort had thereforebe had to subsequent ret rograde pyelography.it would appear that the ordinary techniques ofurography are no t really of much value inchildren.'major factors contributing to the poor visualizaof the renal out line which is obtained in the childthe following:The relatively high fluid-intake causes a greatof the dye in the urine, which militates againstquate concentration.The presence of loops of bowel filled with gas ores frustrates visualization (see Fig. 1).

3. Preparation of the child for pyelography is moredifficult than preparation of the adult . Prolonged limitation of fluids is no t practicable because thirst inducescrying and the swallowing of air. This results in gas inthe bowel, which further obscures the faint dye con-centration.4. After a painful injec tion i t is difficult to gain thefull co-operation of a child.5. I t is often difficult to find an adequate vein and inconsequence the intramuscular or subcutaneous routehas to be used for administering the dye.To improve the quality of visualization in childrenin spite of these difficulties the following methods havebeen used:1. Increasing the quantity of dye used.2. Various methods of diminishing the amount ofintestinal gas.3. Postural control of intestinal gas.4. The use of hyalase to increase the absorption of dyeafter subcutaenous or intramuscular administration.Though these methods were of some assistance, the

1.4 duodenal ulcer with achlorhydria i. sachs

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