Case 11: Chronic gastric ulcer

This specimen is from a 68 year old lady who had a partial gastrectomy for chronic peptic ulcers. She would probably have presented with intermittent burning epigastric pain coming on shortly after meals and unrelieved by eating. She would have come to surgery following failure of medical treatment.

Macroscopic pathology

Microscopic pathology

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Macroscopic examination of the tissue section shows a strip of stomach wall including mucosa, sub-mucosa, muscularis propria, and serosal connective tissue. At the top of the section is an area of ulceration involving the surface mucosa, sub-mucosa and muscularis propria which extends down to involve the serosal tissues. Close examination shows that the muscularis propria is pulled up towards the ulcer base. The sub-mucosa appears thickened. Dark blue nodules representing lymphoid collections are seen immediately beneath the gastric mucosa and the ulcer.

Microscopic examination shows the typical features of a chronic peptic ulcer. The ulcer is located in the antrum. At the ulcer base the 4 zones of Askanazy can be seen. The 4 zones, labelled 1 to 4, are numbered from the ulcer base. The most superficial zone is one of cellular debris (1), (2), (3) containing numerous viable and degenerate polymorphs. Beneath this is a zone of fibrinoid necrosis (1), (2), (3) containing inflammatory cells and granulation tissue. Next, the third zone of Askanazy is one of granulation tissue (1), (2), (3) and here variable sized capillary channels are separated by fibroblastic connective tissue heavily infiltrated with lymphocytes, neutrophils, and eosinophils. Beneath this is a zone of mature fibrous scar tissue (4) replacing the muscularis propria and entrapping large nerves and muscular arteries. There are large aggregates of lymphocytes in this region. One of the arteries is occluded by organising thrombus (6). Haemorrhage from these vessels in the base of gastric ulcers can be life-threatening.

The mucosa adjacent to an ulcer crater should always be examined carefully under the microscope to rule out the presence of dysplasia/carcinoma. In this case the mucosa shows prominent histological abnormalities. These include intestinal metaplasia (5) with the presence of goblet cells in the surface epithelium and in the underlying glands and a prominent active chronic gastritis with numerous inflammatory cells (5) within the lamina propria.

Normal gastrointestinal system tissues

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Micro 1 of 6

Micro 2 of 6

Micro 3 of 6

Micro 4 of 6

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Micro 6 of 6

Test yourself on the pictures of this case - Link to the gastrointestinal system test pictures (Cases 9-14) - (Cases 15-21)

Learning objectives

1. Identify a gastric ulcer
2. Understand and locate the four zones of Askanazy