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Chronic peptic ulcer

Reviewers: Elliot Weisenberg, M.D. (see Reviewers page)
Revised: 7 August 2012, last major update August 2012
Copyright: (c) 2003-2012, PathologyOutlines.com, Inc.


● Usually in pyloric-type mucosa along lesser curvature
● 20% have coexisting duodenal ulcer
● 5% are multiple
● Mean age 50 years, but may occur in children
● Multiple (~10) biopsies recommended to rule out malignancy

● Epigastric burning
● Pain worse at night, within 1-3 hours after meals
● Pain may decrease with food/alkali
● Perforation associated with pain in back, left upper quadrant, chest
● Usually impairs life but doesn’t shorten it
● Heals in 15 years without treatment versus weeks with treatment
● Complifcations: perforation, hemorrhage, obstruction, surgery


● H2 blockers, proton pump inhibitors

Gross description

● Usually sharply punched out defect with straight walls, NO heaped up margins
● Size doesn’t predict malignancy

Gross images

Various images

Micro description

● Muscle wall replaced by fibrous tissue
● Serosal fibrosis
● Hyperplasia of adjacent lymph nodes
● Proximal mucosa may be overhanging
● Distal mucosa may have ladder-like configuration
● Accompanied by active and chronic inflammation, unless NSAID related

Active ulcers have 4 prototypical zones:
(a) surface neutrophils, bacteria, necrotic debris and possibly Candida
(b) fibrinoid necrosis at base and margins
(c) granulation tissue with chronic inflammatory cells
(d) fibrous or collagenous scars in muscularis propria with thickened blood vessels showing endarteritis obliterans

Healing ulcers:
● Have regenerating epithelium over the surface
● May have intestinal metaplasia, marked reactive changes
● Rarely exhibits hyalinization (severe thickening, usually of submucosa (Arch Pathol Lab Med 1982;106:472)

Micro images

Various images

Differential diagnosis

● Acute gastric ulcers due to severe systemic stress
● Carcinoma (radiologically)

End of Stomach > Ulcers > Chronic peptic ulcer

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