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The gastrointestinal tract

Stomach and duodenum

Imaging techniques

Contrast studiesThe routine contrast examination for gastroduodenal disease is the double-contrastbariummeal (DCBM); thishas been found consistently superior to single contrast studies. There are many variations in technique forperformance of the DCBM, but a frequently used method is a biphasic one that incorporates elements of thesingle contrast examination. The single contrastbariummeal is occasionally justified in very elderly, sick orimmobile patients and can be used to answer specific questions, such as determining the presence of gastricoutletobstruction. Water-soluble iodinated contrast media are used where there is suspected perforation orwhere a recent anastomosis is being tested. The commonest such contrast is 76% sodium methylglucaminediatrizoate ("Gastrografin"). However, this is contra-indicated if there is a risk of airway aspiration or suspicion ofan oesophago-tracheal fistula, since its hyperosmolality can precipitatepulmonaryoedema.Non-ioniciodinatedcontrast media are then used (or, alternatively, low-density dilutebarium, with caution).

Figure 18.

Supinedouble contrast view of gastric body and antru

showing mosaic-like areae gastricae.

The aim of the DCBM is to see, by appropriate positioning, all parts of theoesophagus, stomach andproximalduodenumin double contrast with good mucosalbariumcoating, adequate gaseous distension andhypotonia. A measure of good coating is the visualisation of the areae gastricae, which are seen as a mosaic-likepattern in the stomach (Fig. 18). These represent the areas about 1-4 mm in diameter, in the centre of which, thegastric glands open. Their visualisation depends onradiographictechnique,bariumdensity and the amount ofmucus in the stomach. They are most often seen in the gastric antrum and body. Although controversial there isa suggestion that an increase in size of the areae and their presence in the proximal stomach are associatedwith increased acid production.Focalabnormalities of the areae are more important; distortion or enlargement

may be seen ingastritisaround an ulcer or due to superficialinfiltrationbycarcinoma, and may be the only subtlec1ue to this. Other anatomical features seen in the stomach on DCBM include the rugal folds and the cardia. Thefolds in the antrum are effaced with distension by gas; if they persist this suggests antral gastitis. The rugae in

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the fundus and proximal body should be smooth and relatively straight in the distended stomach. Theappearance of the cardia is variable; it may appear en face as a rosette which may be flat or have elevatedmargins; it may possess a hooded fold - the "burnaus sign"; or it may be seen as a crescentic line.The modem biphasicbariummeal should inc1ude double and single contrast oesophagograms, compressionviews of the gastric antrum and duodenal cap as well as double contrast images of the stomach andduodenum,and an assessment of oesophageal motility. As part of the DCBM it is important to ensure that the second andthird parts of theduodenumhave been outlined. It is possible to obtain good double-contrast distended views of

the descendingduodenum. It is rarely necessary nowadays toperformahypotonicduodenogram using a tubemethod.

If the examination is being performed for suspected gastroduodenal perforation, a water-soluble contrast is used.Profile views of the filled stomach are obtained. The patient is then turned onto the right side to allow duodenalfilling and turned through 360. If no obvious extravasation of contrast is seen, the patient should remain on theright side for ten minutes or so and then re-fluoroscoped. If no perforation is seen but is still strongly suspectedclinically, delayed films may show contrast excreted through the urinary tract, since Gastrografin is absorbedfrom the peritoneal cavity. However, this sign is not specific for perforation since inflamedorischaemicmucosacan allow absorption and thusrenalexcretion.

Computed tomography(CT)CTis useful in gastroduodenal disease for staging of neoplasms and assessment of extramural disease. Thepatient should be fasted so that solid food in thelumendoes not cause confusion withpathologicalfilling defects.Distension of the gut withoralcontrast medium is essential. Dilute (3 %) Gastrografin or dilutebariumsulphatesuspension is used. As well as positive contrast, a gas- forming agent can be given to distend the stomach

andduodenum. Sometimes this can be given in lieu of the final cup of contrast. Ahypotonicagent may also beadministered if gas is used. This distension allows recognition of wall thickening and intraluminal filling defects. Ifthere is a suspicion of wall thickening the patient can be rescanned in a decubitus or proneposition asappropriate to show the distended non-dependent wall of the viscus, for example right-side up for lesions at thecardia. Normally, adynamicsequentialscanfollowingintravenousbolus administration of contrast is used toshowvascularstructures and for the identification of liver metastases. RecentCTtechnological advances allowhelical (spiral)CTimages of the upperabdomento be obtained with a single breath-hold.

CTis also a useful technique in suspected gastroduodenal perforation, being able to detect very small volumesof free intraperitoneal gas or iodinated contrast.

Ultrasonography (US)Conventional US has little place in gastroduodenal disease in adults, although wall thickening due togastriccarcinomaand inflammatory disease in the antrum can often be seen.Real-timeUS can also be used tostudy antropyloric emptying and motility non- invasively.Endoscopicultrasound(EUS) is accurate in the T and N

staging of gastric adenocarcioma and the confirmation of linitis plastica. It may also be used to detect and stagegastriclymphoma, and image submucosal tumours such as smooth muscle lesions and distinguish them fromextrinsic impressions seen atendoscopyorbariumstudies.

Nuclearmedicine scintigraphyApplications ofnuclearmedicine techniques in the gastroduodenal region include gastric emptying studies and,occasionally, detection of duodenogastric bile reflux. The former is performed with either a solid or liquid phasetest meal or both. Serial imaging is performed with computer acquisition and time-activity curves are generated tocalculate gastric emptying rate. Bile reflux into the stomach is assessed by injecting intravenously a Technetium-labelled iminodiacetic acid derivative (e.g. HIDA). This tracer is excreted by the liver into the bile duct and thencetheduodenum. If there is significant retrograde passage of tracer into the stomach this can be quantitated.

Investigation of dyspepsiaDyspepsia means different things to different individuals. It has been carefully defined asintermittentor

continuous pain, discomfort or nausea that is referable to the upper gastrointestinal tract, which is present for atleast a month, is not precipitated by exertion and is unrelieved within five minutes by rest. This definition willinclude patients with organic gastroduodenal disease, GOR disease, various forms of non-ulcer dyspepsia andbiliary tract disease. If one considers patients with gastroduodenal dyspepsia of age greater than, say, 45 yearsor with symptoms that include one or more of constant daily pain, weight loss, vomiting, a past history of gastriculcer or gastric surgery, then these patients by virtue of their age and/or symptoms, may be expected to have anincreased probability of gastric pathology - eitherbenignormalignantcompared to younger patients whosesymptoms do not have any of the above features. Ifendoscopicand radiological services are of equal availabilityit is reasonable forendoscopyto be the primary investigation in the former group (since all of this group requireinvestigation and are likely to need biopsies). Whereendoscopicservices are limited, a carefulbiphasicbariummeal should be performed. Abariumstudy may be the initial examination in the latter group. Ithas been suggested that this latter group may not require initial investigation at all, and that it is acceptable totreat empirically for dyspepsia and to reserve investigation for those with refractory symptoms. In patients withbarium-negative dyspepsia consideration should be given to other causes of symptoms such as biliary orpancreatic disease (and US should be performed.) The relationship of non-uIcer dyspepsia to Hehobacter pylorigastric infection remains to be finally clarified. Some patients will respond to eradication of these organisms.

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Pathology

Hiatus hernias and gastric rotations

Sliding herniasThegastro-oesophagealjunction is above thediaphragm(Figs. 11, 19). The size of the herniated proximalstomach is variable. Small sliding hiatus hernias are a very common finding and are often asymptomatic. The

major association of sliding hiatus hernias isgastro-oesophagealreflux (see above).

Para-oesophagueal herniasThese are much less common (about 5%). In this case thegastro-oesophagealjunction lies belowthediaphragmbut all or part of the gastric fundus is above thediaphragmand lies adjacent to thedistaloesophagus- usually to the left. Most para-oesophageal hiatus hernias are non-reducible. They may berecognised on a chest radiograph by an air fluid level behind the heart, the nature of which may be confirmed byrepeating the radiograph after the patient takes a few mouthfuls ofbarium. Most patients with paraoesophagealhernias are asymptomatic, but

Figure 19.

Sliding hiatus hernia. Area of narrowing is arrowed at

level of diaphragmatic hiatus. There is abenigngastric

ulcer (small arrow) on the lesser curve, presumed due t

recurrent mechanicaltraumaat the hiatus.

complications are mechanical. Dysphagia may occur when the intrathoracic portion of the stomach fills during ameal and obstructs the distaloesophagus.Obstructionof the herniated portion of the stomach may causestrangulation and perforation. An acute torsion may occur.Mixed herniasIn this case the oesophagogastric junction is in the thorax but much of the rest of the stomach also lies in thechest adjacent to the distaloesophagus. A variant of this is the intrathoracic stomach. This is associated withpartial twisting of the stomach so that the fundus lies behind the heart, the greater curvature is cranial, and the

antrum passes through thediaphragm(Fig. 20). When the fundus lies at a level inferior to the body, distension ofthe former with food may causeobstructionto the antrum. Similarlyobstructionmay occur when a herniatedfundus returns into theabdomen(Fig. 21). Other viscera, particularly thetransversecolon, may also beherniated. Although the intrathoracic stomach isproneto volvulus, chronic volvulus usually only causes mildsymptoms. However, acute torsion presents as an emergency.

The stomach can undergo two main types of rotation and these are often associated withherniationof thestomach. Organo-axial rotation is a

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Figure 20.

lntrathoracic stomach. The GOJ is in the thorax (curve

arrow), the gastric fundus lies behind the heart, the

greater curve is upper-most, due to organo-axial rotati

and the antrum passes through thediaphragm(straight

arrow).

Figure 21.

Intrathoracic stomach with axial rotation, but fundus h

returned to infradiaphragmatic position with resulting

artialobstruction. The nasogastric tube demonstrates

the position of the GOJ (arrowed).

twist along the long organic axis of the stomach - that is the line drawn from the fundus to pylorus. The resultingconfiguration depends on the original orientation of the stomach. If the stomach was horizontally orientated, thenthe result is a reversal of the normal lesser and greater curves (Fig. 20). When the stomach is more verticallyorientated the fundus lies to the right and the antrum points to the left - so called "mirror-image" stomach.

Organo-axial rotation is only rarely associated with severe symptoms. Mesentero-axial rotation is less commonbut much more often

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Figure 22.

Varioliform erosivegastritis. Multiple punctate erosion

are seen in the gastric antrum and body, each

surrounded by a halo of oedema.

associated withobstructionand strangulation. The stomach rotates around an axis joining greater and lessercurves and perpendicular to its long organic axis so that the resulting configuration is an "upside-down" stomach.Total volvulus is a rotation greater than 180? withobstructionat GOJ and/or gastric outlet. The patient hassudden epigastric pain, retching without vomitus and collapse. Ischaemia and necrosis of the stomach result. Achest radiograph may show air-fluid levels in the upperabdomenand themediastinum. A contrast study showstaperingobstructionof the distaloesophagus.

GastritisRadiology is limited in the diagnosis ofgastritisand other superficial mucosal disease, but certain patterns arerecognisable based on the presence of erosions, thickening or atrophy of folds, hyper -rugosity and wall

thickening. Disturbance of the areae gastricae pattern is a further indication of mucosal disease.

Erosivegastritismay be acute or chronic and may be asymptomatic or accompanied by dyspeptic symptoms orbleeding. Causes include alcohol, aspirin and other non-steroidal anti-inflammatory drugs, but many areidiopathic. Two patterns of erosivegastritisare seen. The so-called varioliformgastritiscomprises multipleaphthous erosions surrounded by a mound of radiolucent oedema, usually orientated along the longitudinal foldsand tending to be concentrated in the antrum (Fig. 22). A similar appearance may be seen in Crohn's diseaseaffecting the stomach. The second pattern is of flat erosions without a halo of oedema, but tending to have thesame distribution of varioliformgastritis. This variety is more difficult to diagnose on DCBM. Distinction must bemade frombariumprecipitates.

Hypertrophic gastropathy is a group of entities characterised radiologically by hyper-rugosity of the stomach.Such conditions include hyperacidity states such as Zollinger-Ellison syndrome and chronicrenalfailure,Menetrier's disease and hypertrophicgastritis, and are mimicked byinfiltrationwithlymphomaor submucosalspread ofcarcinoma.

Gastric atrophy, such as occurs in pernicious anaemia, is associated with loss of folds on the greater curvatureand in the fundus and reduction of the areae gastricae.Eosinophilicgastritisis a condition characterised by peripheral eosinophilia, a history of allergy and protein-losingenteropathy. The stomach only is involved in about half the patients with eosinophilic gastroenteritis. The usualsite is the antrum and in the acute stage demonstrates enlarged rugal folds. In the chronic phase there is acontractednodularantrum.

CorrosivegastritisCorrosive damage to the stomach is usually due to acid ingestion, but sometimes alkalis can affect the stomachas well as, more typically, theoesophagus. The radiological findings depend on the stag e of damage. Acutelythere is gastric atony, rugal swelling,ulceration, pneumatosis or perforation. These may be visible on plainradiographs. Gradually scarring occurs with resultant deformity and contraction of the stomach (Fig. 23).

GastriculcerationOn double-contrastbariummeal (DCBM), gastric ulcers are seen as niches or collections ofbarium. When

viewed en face, ulcers on the posterior (dependent) wall are apparent asbariumcollections when full of contrast,or ring shadows when empty, with or without radiating folds (Fig. 25 a). On the non-dependent (anterior) surface

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they are seen en face

Figure 23.

Stomach of a young man approximately 3 weeks after

Formalin ingestion. The stomach is contracted with

sacculation andulcerationand antral narrowing. There ialso narrowing and spiculation of the proximalduodenu

GOJ and pylorus are arrowed.

Figure 24.

Benigngastriculceration. Two ulcers (arrowed); that on

lesser curve is empty ofbariumand seen almost in profile

a curvilinear outpouching - note that the edges (and those

the ulcer in Fig. 19) do not protrude into thelumen-

compare with Fig. 26. The posterior antral ulcercontainsbarium.

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a

Figure 25.

a)Benignposterior wall gastric ulcer showing radiating

olds extending to ulcer crater.

b)Malignantantral ulcer with thickened margin and fold

amputated short of the ulcer crater.

bas ring shadows.Anterior wall lesions may not be easilyseen without erect andpronecompression views. In profile ulcers areseen as barium-filled collections extending beyond thelumenor, if empty, curvilinear lines ofbarium(Figs. 19,24). The majority ofbenigngastric ulcers occur on the lesser curve or in the antrum (usually posterior wall).Greater curve ulcers are more suggestive of malignancy, but evenbenignulcers in this site may haveamalignantappearance. There appears to be an association between non-steroidal anti-inflammatory drugtherapy andbenigngreater curve ulcers which may progress to gastrocolic fistulae. Pyloric and prepyloric ulcersare usually

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Figure 26.

Gastric diverticulum just distal to the cardia. Note the

gastric folds running into thelesionaiding the distinctio

rom gastriculceration.

small andbenign. Size is not a good indicator ofbenignormalignantnature; giant ulcers are oftenbenign.Features onbariummeal that help distinguishbenignandmalignantgastric ulcers are listed in Table 4. As ulcerhealing occurs the crater diminishes in size and the oedematous edges disappear. The radiating folds become

more apparent as scarring progresses. As re-epithelialisation occurs the crater may end up as a small residualdepression (an ulcer scar) or as an area of flatmucosawith radiating folds.Gastric diverticula are not-infrequently misdiagnosed as gastric ulcers. These true (congenital) lesions occur onthe posteromedial wall just distal to the cardia (Fig. 26). The typical site and often the demonstration of gastricfolds running into them will help distinguish these non-consequential lesions from ulcers.

Figure 27.

Malignantgastric ulcer. Although a typical site (lesser

curve, incisural) for abenignulcer, note the margins

rotruding into thelumen, characteristic of

amalignantlesion(arrowed).

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Figure 28.

Malignantgastric ulcer seen en face. The ulcer crater is

empty ofbariumand the raised margins typical of

malignancy are clearly shown (arrows).

Table 4.Benignversusmalignantgastric ulcers (Figs. 19, 24-28)

Feature Benign Malignant

Size Not a good indicator Not a good indicator

Site majority lesser curve or antrum variable

Shape round, oval, linear irregular

Areae gastricae extend to crater* cease away from crater

Edges +/- ulcer mound/ collar

with central and

symmetrical niche.Margins of mound form

obtuse angle with

normal wall.

Hampton line

raised edges protruding intolumen

Radiating folds smooth, radiate to ulcer* clubbed,nodular

amputated, fused

* but not necessarily when the ulcer is surrounded by significantgastritis

If a gastric ulcer is diagnosed onbariummeal the question of further investigation prior to treatment will dependon a) the degree of radiological confidence that i t isbenign, and b) the prevalence of gastric cancer and,particularly, "early" gastric cancer in that community. Laufer introduced the concept of confidence levels inrelation to radiological diagnosis of abenigngastric ulcer and found that, if theradiologistis confident ofthebenignnature of an ulcer then he/she is rarely wrong. Subsequent studies have confirmed the reliability of aradiological diagnosis of abenigngastric ulcer by DCBM and have suggested thatendoscopyand biopsies canbe reserved for equivocal or malignant-appearing ulcers or those that do not completely heal on follow-upimaging after ulcer therapy. However, partly due to the oft-quoted ability ofmalignantulcers to heal on modemulcer therapy, many gastroenterologists prefer toperformendoscopyon all radiologically diagnosed gastriculcers. In communities where "early" gastric cancer is common, it is prudent to follow this policy. It must beremembered thatmalignantchange may be patchy and, therefore, multiple biopsies from all areas of the ulcerrim and crater and, preferably, cytological brushings should be obtained. Where "early" gastric cancer is notprevalent a reasonable costeffective policy for a radiographicallybenigngastric ulcer istoperformendoscopy/biopsywhere available prior to therapy and follow-up (if confirmedbenign) to complete

healing by subsequent DCBM examinations.

Gastriccarcinoma

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DiagnosisThe diagnosis of gastriccarcinomais usually made byendoscopyorbariummeal. "Early" gastric cancers (EGC),i.e. those limited tomucosa+/- submucosa regardless of the presence oflymphnode metastases) are prevalentin some communities, such as Japan, but are relatively uncommon in most Western societies. They can appearas Type I (polypoid), Type II (superficial; Type IIa elevated; Type IIb flat; Type IIc depressed), or Type III(excavated). Mixed types occur. The surface of earlypolypoidlesions on DCBM is lobular or granular andsimulates the areae gastricae. Differentiation is required from adenomas and hyperplastic polyps (see below).

Type H lesions are seen as flat mucosal elevations. Where a central depression is present (i.e. superficialerosion) this is irregular in outline with an uneven surface. Folds radiating towards

Figure 29.

Diffuseinfiltrative gastriccarcinoma.

causingobstructionat the antrum.

thelesionmay show evidence ofinfiltrationsuch as nodularity, amputation or fusion. Type III lesionsdemonstrate deeper excavations.Advanced gastric cancers are more common than EGC in Western societies. These involve the muscularispropria or deeper layers. They may be classified on gross radiological appearances aspolypoid, ulcerative withraised margins (Figs. 25 b, 27, 28), a larger infiltrative and ulcerating type, and adiffuseinfiltrative type(oftenseen as a constrictingtumourin the antrum) (Fig. 29). These correspond to Borrman types 1-4,respectively. Linitis plastica is adiffuseinfiltration, predominantly submucosal, which is manifest on contraststudies as a poorly distensible so-called "leather bottle"-stomach. This not infrequently may be overlookedendoscopically and, to a lesser extent, radiographically. Advanced ulcerative or raised cancers are often largeand obvious radiologically. All lesions needendoscopicbiopsyfor confirmation.

StagingThe need for staging of gastriccarcinomais less obvious than for oesophageal lesions. However, in communitieswhere EGC is prevalent, it is useful to help determine therapy and prognosis, particularly where non-surgicalendoscopictreatment is contemplated. Where advanced lesions are more prevalent it could be arguedthat surgery, whether for attempted cure or palliation, is the treatment of choice and that pre-operative stagingdoes not influence management. However, surgeons' practices differ; if staging is required then this is bestachieved byCTor EUS for local staging, anddynamicenhanced or helicalCT(or conventional US) for distantmetastases. EUS has been shown consistently superior toCTfor local staging, but is of limitedavailability.CTvisualises the thickened gastric wall and its relationship to adjacent structures, but is unable todetermine the depth of wall invasion.CTcan detectlymphnode enlargement but is non-specific, unable todistinguish reactive frommalignantnodes. The criterion for enlargement is usually taken as > 10 mm. Since

metastases can also be present in non-enlarged nodes,CTis not very sensitive. When performed optimallyCT,using either adynamicsequential technique with bolus contrast enhancement or the newer spiral (helical)techniques, is relatively accurate (probably in the region of 90%) at showing whether the patient has livermetastases or nor, but is significantly less sensitive at demonstrating all lesions in an individual patient. Mosshas suggested aCTstaging scheme for gastriccarcinoma(Table 5).

Table 5.CTStaging of gastriccarcinoma(after Mossetal)

Stage IIntraluminal mass without wall thickening (i.e. < 10 mm thick). No metastases.

Stage IlWall thickening > 10 mm withouttumourextension or metastases.

Stage IIIThickened wall with adjacent organ involvement but no distant metastases.

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StageIVDistant metastases with thickened wall.

The accuracy of EUS in T and N staging of gastriccarcinomais similar to its accuracy inoesophagealcarcinomaand significantly better thandynamicCT, being 80-90% for T and 75% + for N in mostseries. Once again, there is difficulty in distinguishingbenignfrommalignantnodes although positive andnegative predictive values of87.5 % and 82 % have been achieved for nodalmetastasis. EUS is highly accuratein distinguishing EGC from advanced cancer. In linitis plastica EUS demonstrates adiffusethickening of thesubmucosa and muscularis propria layers.

Figure 30.

Submucosal smooth muscletumourof the gastric body

(seen in single contrast) exhibiting

centralulceration(arrowed). Note otherwise smooth

surface and right angled conjunction with gastric walls.

Other gastric tumours

Submucosal tumoursAlthough many cell types can give rise to submucosal tumours in the stomach, thevastmajority are smoothmuscle lesions - leiomyomas, leiomyoblastomas and themalignantleiomyosarcomas. Radiology essentiallycannot distinguish these three lesions. Most smooth muscle tumours are fundal, rounded and often exhibitcentralulceration(Fig. 30). The latter accounts for the frequent presentation of bleeding. Size is variable. As forall submucosal lesions they appear on DCBM as smooth surfaced with normal overlyingmucosa. In profile themargins are at right angles or obtuse to the line of the gastric wall. Much of the bulk of the tumourmay beexophytic to the stomach - an "iceberg" phenomenon. EUS is useful for confirming the origin of thetumourfrommuscularis propria and distinguishing between a submucosal and an extrinsic mass (Fig. 31). For larger lesionswhere malignancy is suspected, EUS orCTare helpful in assessinginfiltrationof adjacent structures.Haematogenous metastases frommalignantmelanoma, breast and lungcarcinoma, phaeochromocytoma and,

in recent times, Kaposi sarcoma, may give rise to small submucosal tumours. These are usually multiple andhave a "bull's eye" or target appearance due to centralulceration. Breastcarcinomamay spread submucosallylike scirrhouscarcinoma.

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