Clinical Case Study: The “Non-Healing” Ulcer
Patient Presentation:
A 68-year-old male presents with a 4-month history of dull, aching epigastric pain that worsens shortly after eating. He has noticed a 5kg weight loss and occasional early satiety. He has no history of NSAID use but was a heavy smoker for 30 years.
Endoscopic Findings:
Upon endoscopy, a 2.5 cm ulcer is found on the greater curvature of the stomach, showing heaped up nodular margins, and clubbed mucosal folds around it, that appear to flatten as they approach the ulcer.
Immediate Action: "We see this irregular ulcer. What is the next immediate step?"Answer: Take 6–8 biopsies from the ulcer rim and base.
Pharmacology: "While waiting for pathology, we start a PPI. If the patient feels better in 2 weeks, can we assume it was benign?"Answer: No. Malignant ulcers can partially heal or show symptomatic improvement with PPIs. This is known as “pseudocicatrization.”
Follow-up: "The biopsy comes back 'negative for malignancy' but show chronic inflammation. Are we done?"Answer: No. Because of the high risk of “sampling error,” a repeat endoscopy is mandatory in 8–12 weeks to confirm the ulcer has completely disappeared. If it persists, re-biopsy or surgical consultation is required.
Discussion Points
| Feature Observed | Significance |
| Location: Greater Curvature | Benign ulcers are usually on the lesser curvature; greater curvature ulcers are more suspicious for malignancy. |
| Margins: Heaped-up, nodular | Suggests tissue infiltration and neoplastic growth rather than a clean inflammatory break. |
| Mucosal Folds: “Clubbed” and stopping early | In benign ulcers, folds radiate cleanly to the edge. In malignancy, the tumor interrupts these folds. |
| Weight Loss/Age | These are “Red Flag” (alarm) symptoms that shift the suspicion heavily toward gastric adenocarcinoma. |
Final Summary
- Duodenal Ulcers: “Peace of mind”—Rarely malignant, no biopsy needed.
- Gastric Ulcers: “Proceed with caution”—Always biopsy, always follow up to complete healing.