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Double-Contrast Upper Gastrointestinal Radiography: A Note: This copy is for your personal, non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, use the Radiology Reprints form at the end of this article. REVIEWS AND COMMENTARY Double-Contrast Upper Gastrointestinal Radiography: A Pattern Approach for Diseases of the Ⅲ Stomach1 REVIEW FOR RESIDENTS Stephen E. Rubesin, MD The double-contrast upper gastrointestinal series is a valu- Marc S. Levine, MD able diagnostic test for evaluating structural and functional Igor Laufer, MD abnormalities of the stomach. This article will review the normal radiographic anatomy of the stomach. The princi- ples of analyzing double-contrast images will be discussed. A pattern approach for the diagnosis of gastric abnormali- ties will also be presented, focusing on abnormal mucosal patterns, depressed lesions, protruded lesions, thickened folds, and gastric narrowing. ௠ RSNA, 2008 1 From the Department of Radiology, Hospital of the Uni- versity of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104. Received July 18, 2006; revision requested Sep- tember 20; revision received October 5; accepted Novem- ber 2; final version accepted January 2, 2007; final re- view by M.S.L. June 19. S.E.R. and M.S.L. are paid consultants for E-Z-Em, Westbury, NY. Address corre- spondence to M.S.L. (e-mail: [email protected] .edu ). ஽ RSNA, 2008 Radiology: Volume 246: Number 1—January 2008 33 REVIEW FOR RESIDENTS: Double-Contrast Upper Gastrointestinal Radiography Rubesin et al his article presents a pattern ap- ples of double-contrast image interpre- more undulating on the greater curva- proach for the diagnosis of dis- tation, we will consider abnormal sur- ture. The thickness of the rugal folds Teases of the stomach at double- face patterns of the mucosa, depressed varies with the degree of gastric disten- contrast upper gastrointestinal radi- lesions (erosions and ulcers), protruded tion (5). ography. After describing the normal lesions (polyps, submucosal masses, appearance of the stomach on double- and other tumors), thickened folds, and Areae Gastricae contrast barium studies and the princi- gastric narrowing. The mucosal surface of the stomach consists of flat polygonal-shaped tufts of mucosa, known as areae gastricae, sep- Essentials Normal Stomach arated by narrow grooves (6,7). The Ⅲ Protruded lesions (eg, polyps and areae gastricae are recognized on dou- cancers) on the dependent wall of Gastric Configuration and Rugal Folds ble-contrast studies as a reticular net- the stomach may appear as radi- The normal stomach is a J-shaped work of barium-coated white lines when olucent filling defects in the bar- pouch that lies in the left upper quad- barium fills the grooves between these ium pool, whereas protruded le- rant (Fig 1). The stomach has a fixed mucosal tufts (Fig 3). Individual muco- sions on the nondependent wall configuration created by the greater sal tufts of areae gastricae normally may appear as barium-coated length of the longitudinal muscle layer have a diameter of 2–3 mm in the gas- “ring shadows” due to barium on its greater curvature. The lesser cur- tric antrum and of 3–5 mm in the gastric coating the edge of these lesions. vature of the stomach is suspended body and fundus (Fig 3) (6,8). Areae Ⅲ Multiple small, round, uniform nod- from the retroperitoneum by the hepa- gastricae are detected on double-con- ules in the stomach are usually togastric ligament, a portion of the trast studies in nearly 70% of patients caused by lymphoid hyperplasia lesser omentum. The gastrosplenic liga- and are observed with greater fre- associated with Helicobacter pylori ment and gastrocolic ligament (ie, the quency in the elderly (8,9). gastritis, whereas irregular nonuni- proximal portion of the greater omen- form nodules may be caused by tum) are attached to the greater curva- Comparison of Histologic Anatomy with low-grade B-cell mucosa-associated ture of the stomach. The gastric cardia Macroscopic Anatomy lymphoid tissue lymphoma. is attached to the diaphragm by the sur- Abasicunderstandingofthehistologic Ⅲ Aspirin and other nonsteroidal rounding phrenoesophageal membrane. anatomy of the stomach is helpful for antiinflammatory drugs (NSAIDs) The stomach is arbitrarily divided understanding peptic ulcer disease, as are by far the most common into five segments: the cardia, fundus, well as other gastric abnormalities cause of erosive gastritis, a condi- body, antrum, and pylorus. The gastric (5,10). The stomach contains several tion manifested on double-con- cardia is characterized on barium stud- types of mucosa: cardiac-type mucosa, trast studies as punctate or slitlike ies by three or four stellate folds that body/fundic-type mucosa, and antral/ erosions surrounded by radiolu- radiate to a central point at the gastro- pyloric-type mucosa. Gastric foveolae cent mounds of edema or, in esophageal junction, also known as the (or pits) are conical depressions in the some patients taking NSAIDs, by cardiac “rosette” (Fig 2) (1,2). The gas- mucosal surface that communicate linear or serpiginous erosions on tric fundus is defined as the portion of with gastric glands (4,10). The glands or near the greater curvature of the stomach craniad to the gastric car- are long, straight, and tightly packed the gastric antrum or body. dia. The gastric body is defined as the structures. The foveolae in all parts of Ⅲ H pylori gastritis is by far the portion of the stomach extending from the stomach are lined by surface fove- most common cause of focally or the gastric cardia to the smooth bend in olar mucous cells. The cardiac-type diffusely thickened gastric folds, the mid lesser curvature known as the mucosa comprises a short (1 cm in which can be so large and lobu- incisura angularis. The gastric antrum is length) segment of the gastric mucosa lated (eg, polypoid gastritis) that defined as the portion of the stomach adjacent to the gastroesophageal junc- the radiographic findings resem- extending from the incisura angularis to tion (4). The distinguishing feature of ble those of Menetrier disease or the pylorus (a structure created by a the body-type mucosa is the presence lymphoma. muscle sphincter shaped like a figure Ⅲ On barium studies, scirrhous carci- eight). nomas of the stomach may produce Rugal folds are most prominent in Published online alinitisplasticaappearancewith the gastric fundus and body, whereas 10.1148/radiol.2461061245 diffuse narrowing or long- or short- the gastric antrum is often devoid of Radiology 2008; 246:33–48 segment narrowing of any portion folds (Fig 1). Gastric rugae are change- of the stomach; metastatic breast able structures composed of mucosa Abbreviations: cancer and lymphoma occasionally and submucosa (3,4). The rugal folds MALT ϭ mucosa-associated lymphoid tissue NSAID ϭ nonsteroidal antiinflammatory drug may produce a similar radiographic are relatively straight on the lesser cur- appearance. vature of the stomach but larger and Authors stated no financial relationship to disclose. 34 Radiology: Volume 246: Number 1—January 2008 REVIEW FOR RESIDENTS: Double-Contrast Upper Gastrointestinal Radiography Rubesin et al of parietal and chief cells in the glands. extending progressively higher on the (Fig 1). With air contrast, the luminal The parietal cells produce hydrochlo- lesser curvature. Peptic ulcers fre- contour appears as a smooth, continuous ric acid and intrinsic factor, and the quently develop on the lesser curva- barium-coated white line (Fig 1) (11). chief cells produce proteolytic en- ture at the transition zone (Fig 4). zymes. No parietal or chief cells are Barium Pool found in antral-type mucosa. The sur- The pool of high-density barium is the face foveolar mucous cells line both an- Principles of Image Analysis tool the radiologist uses to scrub and tral pits and glands. Body-type mucosa lines the ana- Appearance of the Stomach tomic gastric fundus and the gastric The radiologist first examines the over- Figure 3 body and extends into the gastric an- all position, shape, and size of the stom- trum along the greater curvature (4). ach. The gastric fundus abuts the left Antral-type mucosa lines the antrum hemidiaphragm. The cardia has a mid- along the lesser curvature from the py- line location, abutting the crus of the left lorus to the incisura angularis, but only hemidiaphragm. The stomach curves to lines a small amount of antrum along the the right across the midline, with the greater curvature. Thus, the histologic distal gastric antrum and duodenum ex- division of the stomach into body- and tending to the right of the spine. There antral-type mucosa does not correlate is considerable variation in the size of with the anatomic and radiologic divi- the stomach, depending on the amount sion of the stomach into fundus, body, of barium and effervescent agent ad- and antrum (5). ministered. The transition zone between body- Figure 3: Double-contrast spot image of stom- and antral-type mucosa is a line that Luminal Contour ach with patient in left posterior oblique position extends from the incisura angularis to In the barium pool, the contour is de- shows normal areae gastricae pattern in antrum as the distal greater curvature. The transi- marcated by a smooth edge of barium 2–3-mm polygonally shaped radiolucent tufts of tion zone migrates proximally with age, mucosa outlined by barium in grooves. Areae Figure 2 gastricae are slightly larger in distal gastric body than in antrum. Figure 1 Figure 4 Figure 1: Normal stomach. Double-contrast spot image of stomach with patient supine shows distal gastric body (B) and antrum (A). Greater curvature (white arrows) and lesser curvature Figure 2: Double-contrast spot image of gas- (black arrows) are coated by barium. Rugal fold on tric fundus with patient in right-side-down posi- posterior wall of gastric body is depicted as tubu- tion shows normal gastric cardia with smooth lar, slightly undulating, radiolucent filling defect folds radiating to central point (white arrow) at Figure 4: Double-contrast spot image of stom- (black arrowheads) in shallow barium pool.
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