Kissing ulcers | Radiology Signs

Answer:

Kissing ulcers are paired ulcer craters sitting on directly opposing walls of the same segment, most often the anterior and posterior walls of the duodenal bulb and, in the stomach, on the lesser and greater curvature of the antrum or on apposed antral walls. They arise where mucosal surfaces are in continuous contact, so the same acid-peptic or drug injury acts on both surfaces simultaneously. On double-contrast studies they are seen as two barium-filled collections that project in profile and as ring shadows en face, and their identification matters for two reasons: paired posterior wall bulbar ulcers are the ones that erode into the gastroduodenal artery and bleed, and anterior wall ulcers are the ones that perforate. The features that indicate a benign ulcer are a crater projecting beyond the expected lumen line, smooth symmetrical folds radiating to the edge of the crater, a Hampton line or ulcer collar, and a smooth surrounding oedematous mound. Malignant ulceration is suggested by a crater that stays within the lumen line, nodular, clubbed or amputated folds that stop short of the crater, and an eccentric ulcer within a mass, the Carman meniscus complex. The underlying causes are Helicobacter pylori infection and NSAIDs, with Zollinger-Ellison syndrome and Crohn disease considered when ulcers are multiple, postbulbar or refractory. Because radiographic criteria cannot exclude gastric carcinoma reliably, gastric ulcers require endoscopic biopsy and documented healing.

Why is it called so?

The two craters face each other across the lumen and touch when the walls appose, so they are described as kissing.

Pathophysiology

Ulceration follows a breakdown in the balance between aggressive factors, acid, pepsin, Helicobacter pylori infection and prostaglandin inhibition by NSAIDs, and mucosal defence by mucus, bicarbonate and mucosal blood flow. In a narrow, collapsible segment such as the duodenal bulb the anterior and posterior mucosal surfaces are apposed for much of the time, so the same acid load and the same infected mucosa are exposed on both walls and injury develops in mirror-image positions. Continued digestion of the ulcer base deepens the crater until it reaches the submucosal vascular plexus or the serosa, which determines whether the ulcer bleeds or perforates.

Alternative names: Mirror-image ulcers; paired ulcers

Other associated named signs: Hampton line, the ulcer collar and ulcer mound of benign ulceration, and the Carman meniscus sign of malignant ulceration

References

1. Op den Orth JO. Use of barium in evaluation of disorders of the upper gastrointestinal tract: current status. Radiology. 1989;173(3):601-8. PMID: 2682769.