Cirrhosis of the Stomach

Minor Organic Affections of the Stomach.

(Cirrhosis; Hypertrophic Stenosis of Pylorus; Atrophy; Anomalies in the Form and the Position of the Stomach; Rupture; Gastromalacia.)

BY W. H. WELCH, M.D.

DEFINITION.—Cirrhosis of the stomach is characterized by thickening of the walls of the greater part or of the whole of the stomach in consequence of a new growth of fibrous tissue, combined usually with hypertrophy of the muscular layers of the stomach. The cavity of the stomach is usually contracted, but sometimes it is of normal size or even dilated.

SYNONYMS.—Fibroid induration of the stomach; Hypertrophy of the walls of the stomach; Chronic interstitial gastritis; Sclerosis of the stomach; Plastic linitis.

HISTORY.—The writings of the seventeenth and eighteenth centuries contain many records of extremely contracted stomachs with uniformly and greatly thickened walls (Butzen, Löseke, Storck, Portal, Lieutaud, Pohl, etc.). In the works of Lieutaud and of Voigtel may be found references to many such cases. Doubtless, some of these cases were examples of cirrhosis of the stomach, but in the absence of microscopical examination it is not possible to separate these from cancer.

Lieutaud, Historia anat.-med., t. i. p. 8, Venet., 1779; Voigtel, Handb. d. Path. Anat., Bd. ii. p. 450, Halle, 1804. Here it may be mentioned that Diemerbroeck's case, which is so often quoted to prove that polyphagia instead of causing gastric dilatation may produce hypertrophy of the muscular coat of the stomach, with contraction, was probably an instance of cirrhosis of the stomach.

Andral was the first to describe fully and systematically hypertrophy of the walls of the stomach. He attributed the lesion to chronic inflammation. He erroneously supposed that scirrhus of the stomach was only hypertrophy of the gastric walls. Cruveilhier distinguished between scirrhous induration and hypertrophy, which he considered to be a final result of the irritation accompanying chronic diseases of the stomach. Rokitansky's description of fibroid induration of the stomach, although brief, is accurate. He says that the process usually involves the whole stomach, and that it originates in an inflammation of the submucous connective tissue. This inflammation may occur either independently or in combination with gastritis mucosa. Rokitansky emphasizes the error of confounding the disease with scirrhous cancer. Bruch made an elaborate study of hypertrophy of the walls of the stomach, which he considered to be the final stage of various chronic diseases of the stomach. Fibrous or scirrhous cancer he considered to be nothing but this hypertrophy.

Précis d'Anat. path., Paris, 1829.

Anatomie pathologique, Paris, 1830-42.

Lehrb. d. Path. Anat., Wien, 1855-61.

Zeitschr. f. rat. Med., Bd. vii., 1849.

The best descriptions of cirrhosis of the stomach have been furnished by English writers, by most of whom it is properly regarded as an independent disease. Brinton first employed the names cirrhosis of the stomach and plastic linitis. Excellent descriptions of the disease have been given by Hodgkin, Budd, Brinton, Habershon, H. Jones, Wilks, Quain, and Smith.

Diseases of the Stomach.

While in former times cirrhosis of the stomach was confounded with cancer, in recent times it has not been separated by many from chronic catarrhal gastritis. In German systematic works the disease receives, as a rule, only passing mention in connection with chronic catarrhal gastritis.

ETIOLOGY.—Cirrhosis of the stomach is rare, but it is not so exceptional as to be without any clinical importance. I have met with three cases at post-mortem examination.

The disease is more frequent in men than in women. A considerable number of cases have occurred between thirty and forty years of age, but the greatest frequency is after forty. At an earlier age than twenty the disease is very rare.

The causation of cirrhosis of the stomach is obscure. Nearly all writers upon the subject have emphasized the abuse of alcohol as an important cause in this as in other diseases of the stomach. Intemperance cannot, however, be the only cause; and here, as elsewhere, it is not easy to say what importance is to be attached to it as an etiological factor. In only one of the three cases which I examined post-mortem could it be determined that the patient was an immoderate drinker, and in one case intemperance could be positively excluded. Other cases have been recorded in which the abuse of spirits could be positively excluded. In one of my cases syphilis existed, as was established by the presence of gummata in the liver. In some cases the disease has been attributed to cicatrization of a gastric ulcer. In a case reported by Snellen the disease followed an injury to the epigastric region.

Canstatt's Jahresbericht, 1856, iii. 302.

Cirrhosis of the stomach, as well as cancer, ulcer, and most other chronic structural diseases of this organ, is usually associated with chronic catarrhal gastritis. There is, however, no proof of the prevalent idea that chronic catarrhal gastritis is the cause of the enormous new growth of fibrous tissue which characterizes typical cases of this disease.

SYMPTOMATOLOGY AND DIAGNOSIS.—The symptoms of cirrhosis of the stomach are not sufficiently characteristic to warrant a positive diagnosis. Sometimes the disease pursues a latent course. Like cancer of the stomach, it may put on various disguises. Thus, in a case of cirrhosis of the stomach reported by Nothnägel the symptoms were typically those of progressive pernicious anæmia. Association with ascites or with chronic peritonitis may lead to a false diagnosis. Thus, in one of the cases which I examined after death, and in which there was chronic peritonitis with abundant fluid exudation, the disease during life was diagnosticated as cirrhosis of the liver. Most frequently, however, cirrhosis of the stomach is mistaken for gastric cancer, from which, in fact, it can rarely be positively diagnosticated.

Deutsches Arch. f. kl. Med., Bd. 24, p. 353.

The symptoms are usually those of chronic dyspepsia, which sooner or later assumes a severity which leads to the diagnosis of some grave structural disease of the stomach, usually of cancer.

Indigestion, loss of appetite, oppression in the epigastrium, vomiting, are the common but in no way characteristic symptoms of cirrhosis of the stomach. There may be severe gastralgia, but in general the disease is less painful than either ulcer or cancer of the stomach. The inability to take more than a small quantity of food or of drink at a time, with the sense of fulness which even this small quantity occasions, has been considered somewhat characteristic of cirrhosis of the stomach, but this symptom is too inconstant, and occurs in too many other affections of the stomach, to be of much service in diagnosis. The symptoms of dyspepsia are often of much longer duration than in cancer, existing sometimes for many years (up to fifteen years), but on the other hand there have been cases in which the clinical history of gastric cirrhosis was as rapid in its progress as cancer. Moreover, cancer may be preceded by dyspeptic symptoms of long duration, but long duration is the exception with cancer and the rule with cirrhosis of the stomach.

As the disease progresses the patient loses flesh and strength, and usually dies in a condition of marasmus. Blood is rarely present in the vomit, but in a few cases the vomiting of coffee-ground material has been noted.

By physical examination sometimes a tumor in the region of the stomach can be felt. Under favorable circumstances it can sometimes be determined that this tumor is smooth, elastic, tympanitic on percussion, and presents more or less distinctly the contours of the stomach. By administering effervescing powder it may be possible to obtain further evidence that the tumor corresponds in its form to the stomach. The diagnosis of contraction of the cavity of the stomach is not easy. Some information may be afforded by noting the length to which the inflexible stomach-tube can be passed. The quantity of water which can be poured into the stomach until it begins to run out of the stomach-tube may also bring some confirmatory evidence as to the existence of contraction of the stomach.

Even should the physical signs suffice to determine that the tumor is the thickened and contracted stomach, still cancer cannot be excluded, for this also may grow diffusely in the gastric walls and may cause contraction of the cavity of the stomach. With our present means of diagnosis, therefore, the most which can be said is, that a special combination of favorable circumstances may render probable the diagnosis of cirrhosis of the stomach, but a positive diagnosis is impossible.

MORBID ANATOMY.—In most cases of cirrhosis of the stomach the stomach is contracted. The cavity of the stomach has been found not larger than would suffice to contain a hen's egg, but such extreme contraction is very rare. When the stomach in this disease is found dilated, either the thickening involves only or chiefly the walls of the pyloric portion, or the morbid process probably began there and was followed by dilatation.

In typical cases the walls of the entire stomach are thickened, but frequently the thickening is most marked in the pyloric region. The walls may measure an inch and even more in thickness. The thickened walls are dense and firm, so that often upon incision the stomach does not collapse.

Upon transverse section the different coats of the stomach can be distinguished. The mucous membrane is least affected, being sometimes thickened, sometimes normal or atrophied. The muscularis mucosæ is hypertrophied, and is evident to the naked eye as a grayish band. The submucous coat is of all the layers the most thickened, being sometimes ten to fifteen times thicker than normal. It appears as a dense white mass of fibrous tissue. The main muscular coat is also, as a rule, greatly hypertrophied; the grayish, translucent muscular tissue is pervaded with streaks of white fibrous tissue prolonged from the submucous and subserous coats. This last coat resembles in appearance the submucous coat, which, however, it does not equal in thickness, although it is, proportionately to its normal thickness, much hypertrophied. The free peritoneal surface usually appears opaque and dense.

To the naked eye it is apparent that the new growth of fibrous tissue is most extensive in the submucous coat, which it is probably correct to regard as the starting-point of the disease. The hypertrophy of the muscular layers is also in most cases an important element in the increased thickness of the gastric walls.

Microscopical examination shows sometimes a nearly normal mucous membrane. The tubules, however, are usually more or less atrophied. In the case reported by Nothnägel tubules could be found only in the pyloric region of the stomach. The essential lesion is the new growth of fibrillated connective tissue pervading all of the coats of the stomach. In an interesting case reported by Marcy and Griffith, which was believed to be caused by an extensive cicatrized ulcer, a new formation of smooth muscular tissue was found not only in the main muscular tunic and the muscularis mucosæ, but also throughout the submucosa. This peculiarity was probably referable to the cicatrization of the ulcer.

Microscopical examination is always necessary for a positive diagnosis of cirrhosis of the stomach. In a case which I examined post-mortem of double ovarian cancer, with multiple secondary deposits in the peritoneum and with chronic peritonitis, the stomach presented the typical gross appearances of cirrhosis, but here and there were to be found nests of cancer-cells in the prevailing new growth of fibrous tissue in the walls of the stomach.

Am. Journ. of the Med. Sci., July, 1884, p. 182.

Not infrequently adhesions exist between the stomach and surrounding organs. Exceptionally, a diffuse growth of fibrous tissue may invade the greater part of the peritoneum, particularly the visceral layer, and cause a thickening similar to that existing in the stomach. In such cases ascites is usually a marked symptom.

PROGNOSIS.—The prognosis of cirrhosis of the stomach is grave. The disease runs a chronic course, and usually terminates in death by asthenia. There is no reason to believe that the stomach can ever be restored to its normal condition. Still, cases have been reported in which it has been supposed that cirrhosis of the stomach has terminated in recovery. The diagnosis, however, in such cases must remain doubtful.

Lesser, Cirrhosis Ventriculi, Inaug. Diss., Berlin, 1876; Smith, "Cirrhosis of the Stomach," Edinb. Med. Journ., 1872, p. 521.

TREATMENT.—The treatment is symptomatic, and is to be guided by the general principles developed in previous articles concerning the regulation of the diet and the administration of remedies.