Abstract
The pathogenesis of gastric ulcer has not been obscure yet, although several factors such as acidity, pepsin activity, local circulation, gastric mucin or hormones may be considered to contribute. The present paper deals with two cases with unusual giant ulcers of "trench" shape complicated with high ACTH level in serum. Case 1. A 72-year-old male was admitted to Osaka University Hospital with complaints of jaundice of four day duration, anorexia and epigastric discomfort over the preceding two months. He had been suffered from diabetes mellitus since these three years. At six hospital day melena was occurred. Urgent gastrofiberscopy was performed on nineth hospital day and two "trench" ulcers (wide and belt-shaped ulcers) from cardia to angle of the stomach, running in parallel onthe lesser curvature and posterior wall, were observed. Gastric bleeding continued and on 20 th hospital day a partial resection of the stomach and choledochojejunostomy were performed. Resected stomach showed two ulcers, one sized 6.0×2.8cm, the other 10.0×4.0 cm. Both ulcers were Ul-2 in depth. The patients died on 50th hospital day. At autopsy, oat cell carcinoma was found in the upper lobe of the right lung, and the choledochus was obstructed by metastatic tumor of the head of the pancreas. Diffuse and nodular hyperplasia of the adrenals were also seen. ACTH level in the serum of the patient was much higher than that of normal controls.Case 2. A 57-year-old male developed an episode of sudden substernal pain a week prior to admission and was diagnosed as having myocardial infarction and diabetes mellitus by his family physician. Two days before admission he complained of epigastric pain. Gastrofiberscopy was performed on 14th hospital day and two"trench" ulcers similar to those of case 1 were found. Moreover, an another deep ulcer was found at cardia. After three months the ulcers became linear red scar with convergence of mucosal folds and white scar after nine months. The level of ACTH in the serum was also high. These two cases had similarity in the shape of ulcers ("trench" shape) and in the location (the lesser curvature and the posterior wall from cardia to angle of the stomach), and therefore it might be suggested that same factors acted on the production of ulcer. Both cases had diabetes mellitus, and thinking of the presence of chronic hypoxemia due to lung cancer in case 1 and of myocardial infarction in case 2, it seems likely that the disturbance of the circulation in whole body and the local disturbance of the circulation in the stomach are very important factors. The administration of anti-inflammatory drugs and hormonal factors may, also, be responsible for these "trench" ulcers.
