704 APRIL 4, 1936 OF BRtTISM 704 APRIL4,RADIOGRAPHS1936 OF THE -ALIMENTARYALIMENTARY TRACTTRACT. WTHEK,EDICA.BRITISH~~~~~~~~~~~~~JUIJI.AmTOURtNAL TREATMENT IN GENERAL PRACTICE

This article is onie of a series on the manlagemen1t of some diseases of the digestive system met with in general practice.

Niche or Pocket.-This is a projection of the barium shadow INTERPRETATION OF RADIOGRAPHS into the wall of the viscus or through it, and is nearly always OF THE ALIMENTARY TRACT due to an ulcer. is BY Incisura.-This a contraction of the circular muscle fibres or a cicatricial contracture indenting the barium shadow. E. XV. TWINING, M.R.C.S., L.R.C.P., D.M.R.E.Camb. In rare cases it may be due to a band or adhesion. (With Special Diverticulum.-This is a protrusion of the Plate) through a small gap in the muscular walls. Occasionally (" false " diverticulum) there is a protrusion of all layers of Radiographs of the alimentary tract should be studied the walls. with certain considerations in mind: 1. They represent a fluid cast of the internal surface, Oesophageal Lesions and show only profiles of that surface if the viscus is full. Nearly always malignant, oesophageal stricture shows 2. The actual walls of the viscus are, of course, in- an abrupt narrowing, emptying below by an irregular visible. It will be found extremely helpful, in studying channel; the dilatation above the stricture is rarely radiographs of the alimentary tract, to sketch in the extreme, though the dilated lumen may reach a breadth estimated outline of the peritoneal surface. Even allowing of about two inches. A tapered lower end often occurs for inevitable errors due to " guesswork" this method, with malignant disease, due to spasm just proximal to by bringing the thickness of the wall into consideration, the actual growth. A similar tapering is seen in fibrous gives a much clearer conception of the anatomical facts stricture and in simple spasmodic conditions. If the and of the shape and size of a pathological lesion than can growth is near the upper end, the valleculae, pyriform be gained from mere inspection of contours of the barium recesses, and the oesophagus are often dilated proximal shadow. The method is illustrated in the diagrams in to the stricture. In such cases the barium may " spill the text (I, II, III). over " into the trachea or enter it directly by an 3. If the viscus is only partly filled the apposition of oesophago-tracheal fistula. In either case the trachea and its mucous surfaces allows mucosal detail to be demon- bronchi are outlined by barium. strated, for the opaque material then lodges in the sulci, Cardiospasm eventually, owing to its chronic course, and the elevations of the mucosal ridges and folds appear produces dilatation and elongation of the oesophagus, with as translucent streaks and lines between the barium- hypertrophy of the walls. The dilated, elongated oeso- filled sulci. This method of showing " relief pattern " of phagus takes on an S-shape, ending below at the cardiac the mucous membrane has for many years been an im- orifice or at the diaphragm in a tapered extremity. It portant part of technique. By its means ulcer craters, may project to the right of the inediastinal shadow and small papillomata, and growths are often beautifully increase the apparent width of the latter in a radiograph and readily illustrated. of the chest. Retained food remnants may produce 4. The radiographic film or print conveys, by its fixed filling defects (clear areas) or irregularities simulating and static appearance, a very false impression of what carcinomatous nodules. is seen on the fluorescent screen-unless it be remem- bered that it is only a " snapshot " of appearances which The are rapidlv changing. Film and fluoroscopic examination In the normal stomach the mucosal rugae run longi- bear much the sarne relation to one another as a still tudinally, but may be more or less crumpled. On the snapshot of a football match does to a cinema film. greater curvature and fundus a notching is produced by This is particularly true of the oesophagus, stomach, and folds which curve away from the observer, in the line of . Much of the evidence which an experi- sight. When the stomach is completely filled the mucosal enced radiologist gains from his screen examination, upon ridges, except those on the greater curvature, are hidden which indeed he bases his diagnosis, must pass unrecorded from sight. (They are brought back' to view by local in films, though an effort is usually made to record the pressure of hand or a pad, which brings anterior and most significant phases of the constantly changing picture. posterior walls into apposition.) Such evidence includes , flexibility of the walls, Deeper notches (three to four in number) on the greater fixation, palpable tumour or induration, and tenderness curvature are due to peristaltic waves. Becoming deeper associated with organic lesions. By making a compre- towards the , they pass from their point of forma- hensive study of each viscus from ever-varying angles tion, about half-way down the greater curvature, to the and in various degrees of filling, the radiologist builds up pylorus in about twenty seconds. Very deep and numer- his conception, often very accurate, of the size, shape, ous rapidly moving waves occur in the hyperperistalsis and nature of the lesion. This article (restricted mainly of duodenal or pyloric ulcer, or in early pyloric obstruction. to those conditions disutssed in this series) deals only with those points which should be looked for in the films, GASTRIC ULCER The crater or niche is and with film appearances wlhich, so far as they go, may (Haudek) the cardinal sign of be considered " typical." ulcer (see Plate, Figs. 5 and 6). Projecting usually from the lesser curvature into the gastric wall, or through it, it Definitions presents in profile view a smooth, rounded contour; its The foUowing terms are often met vwith in radiological apparenit depth is increased by the heaping up of the reports. mucosa around its margins. On the greater curvature, Filling J)efect.-This signifies a transltucent arca in the opposite to it, a deep spasmodic or cicatricial " incisura " barium-filled viscus, due to a space-filling lesion of the wvall (Fig. 5) ofteni points like an accusing finger to the crater. projecting into the lumiien or to some object (food, clot, poly- Ulcer craters near the pylorus are less obvious: pus, hairball, etc.) in occurring thle lumen. on anterior or posterior wall they may only be visible as THz Bnmsz Ar 4, 19iS - MEDICA. JOMNAL E. W. TWINING: INTERPRETATION O1c RAIAbGRAPHS OF THE ALIMENTARY TRACT

FIG. 1.-Carcinoma of stomach. Flat, irregular filling FIG. 2.-Large malignant ulcer of stomach. Broad triangular edge defect on greater curvature. Note abrupt sharply projecting into lumen on either side of crater. defined edge of the filling defect. A

c Di

FIG. 3.-Duodenal ulcer. A. Anterior wall ulcer crater seen in profile. Note filling defect on either side of crater, due to thickened margins of ulcer. FIG. 4.-Duodenal ulcer. of cap. B. (Same case.) Ulcer crater seen " en face " with slight compression. Note ring of Typical deformity thickened mucosa surrounding crater. Gastric ulcer also present. C. Projecting crater on lesser curvature side. Incisura on opposite side. P Diverticular pocket arrowed. Scarring in duodenal cap. APRTL 4 1936 M TT BRITINAL E. W. TWINING: INTERPRETATION OF RADIOGRAPHS OF THE ALIMENTARY TRACT

..P- - ; FIG. 5.-Chronic gastric ulcer on lesser curvature FIG. 6.-Chronic penetrating gastric ulcer. C c-iater. Note the rolled-over with rolled edge. Incisura on greater curvature. edge on either side of tho crater.

7. and norinal small FIG. 8.--Ribbon-shaped colon in . -iHour-nglassintestine.stonach THE BRITTSH 705 APRTL 4, 1936 RADIOGRAPHS OF THE ALIMENTARY TRACT MEDICAL JOURNAL

I ien face '' pockets brought out by slight pressure on the They can occur anywhere in the stomach; the extent of abdominal wall, which traps the barium in the ulcer pocket the neoplasm is indicated by the abrupt edge of the filling between the opposing gastric walls thus brought into defect. contact. Carcinoma at the fundus often shows a shadow pro- Perforating ulcers may show a triple level-that is, a jecting inlto the gastric air bubble anid visible in it as a translucent air bubble above, a layer of fluid beneath this, "soft tissue shadow." This inay be verified by exam- and a layer of opaque barium at the bottom. These ination of the patient in the recumbent position, with the perforating ulcers are usually adherent to, and often head of the couch tilted downwards. The barium Inow excavate, the pancreas or liver. flows to the fundus, and a filling defect appears having The edge of the crater should be studied carefuilly. the same shape and contours as the previously noted soft A moderately chronic ulcer (Diagram I, A) shows a tissue shadow. Both are due to the actual tumnour mass. triangular edge, rounded off near the edge of the crater, Scirrhous carcinoma, usually beginning at the pyloric which rises gradually from the inner wall. The peritoneal end, produces a tapering and narrowing of the pre-pyloric surface, invisible in the radiograph, is outlined in the segment, which is rigid, inflexible, and palpable as a diagramii. Very chronic ulcers have a thickened, rolled- thickened mass which can be rolled beneath the hand. Pyloric insufficiency is often present; the food pours out A R C into the small intestine through the rigid pylorus in a characteristic manner. Later, pyloric stenosis leids to dilatation of the stomach with considerable retention of food after five hours. This dilatation with retention is more frequent and more marked in simple cicatricial stenosing lesions of the pylorus (pyloric or duodenal ulcer) than it is with neoplasm. To distinguish cicatricial pyloric stenosis from that due )I to growth is one of the principal difficulties of gastric examination-it demands patience and experience. The I /mI ,_ differential diagnosis depends almost entirely upon the DIAGRAxM I.-A,.Ulcer of stomach, wvith incisura. B, Rolled edge of chronic ulcer. C, Ilealing ulcer. patient screen observation, and on putting together of a number of visual observations of peristalsis, of flexibility over edge (Diagram I, B). During healing of a gastric and rigidity of the wall, of contour, and of variations in ulcer the crater becomes smaller and conical, and finally size of the lumen, together with the results of screen disappears (Diagram I, C). The heaped-up edges flatten palpation. Retained food and fluid secretions add to the out, but for some considerable time a rigid, flattened area difficulties. The subject cannot be fully dealt with here. remains after the disappearance of the niche, and an What must be emphasized is the absolute necessity for incisura may persist on the greater curvature after all screening, and the impossibility in most instances of getting, visible trace of the crater has disappeared. A single a certain result from films alone. The method adopted observation is insuifficient to distinguish a spasmodic by some observers of making diagnosis from routine filnms incisura from a cicatricial one. Variations in depth or is in my opinion bound to lead to serious error. Even constancy of the incisura point to a spasmodic origin. more difficult is the differentiation of various benign Frank hour-glass stomach (Fig. 7) showvs a very definite lesions from one another: for example, chronic hyper- biloculation of the stomach, the sacs being separated by trophic stenosis of the pylorus, without ulcer, may be a broad incisura onl the greater curvature. On the lesser extremely difficult to distinguish from submucous oedema, curvature side of this the food may be seen passing lues, or from simple spasm, with or without actual through the narrowed isthmus. This condition is much ulceration. less commonly seen nowadays than it was ten or twenty MALIGNANT ULCER years ago. When a carcinoma ulcerates a crater is visible. The ACUTE ULCERS distinguishing character is that it is a niche within a Cases of acute haematemesis, without previous symp- filling defect" (Diagram toms, rarely show an ulcer crater radiographically. This II). Careful observation has usually healed during the few weeks which elapse shows that the edges between the haemorrhage and the examination. Some of seen in profile are nearly these ulcers are extremely small and shallow, and even if always thicker and more unhealed would possibly remain undetected. triangular than those of a simple chronic ulcer, GASTRIC NEOPLASMS and that the crater is Neoplasms of the stomach are usually carcinomata. shallow and shelving. If Sarconma imiay occur, but it is rare. Lymphadenoima, the edges are traced out- fibroma, myoma, polypus, and other benign lesions are wards from the crater a , unicommon. The benign lesions are distinguished by their point is found where smo)other contouirs anid, when pedunculated, by their they rise abruptly from, mobility xx ithin the gastric lumenn. the stomach wall (Dia- _ Of all the cases of carcinoma of the stomach which gram II). This abrupt come to the radiologist only a very small proportion have rise indicates the true small or incipient lesions. The insidious onset and abseince edge of the malignant - of early symptoms account for the fact that the lesion is mass, which extends far ' nearly always of appreciable size when the patient is first the visible DIAGR\M IT.-'Ulcerating carci- bevond nomiia of stomiach. iNote the abrupt examined. The radiographic appearances are somewvhat crater. The behaviour edge of the filling defect in the different in the txx'o types of carciinoma-(a) hypertrophic, of the mucosal folds is barium shadoxv, anid the shallowv (b) scirrhous or infiltrating. In the former (Fig. 1 on also important. Ulcers crater xxithin the filling defect. Special Plate' there is found a filling defect projecting tend to cicatrize, and in this process contract. The into the lumen, often showing irregular, multiple, " finger- mucosal folds therefore converge towvards a benign chronic print " trasluhcenicies due to nodulation of the surface. ulker. Neoplasm spreads centrifugally and obliterates the 7O APRi 4, 196 RAtORAPHS OF THISALIMIENTARY ThACT mucous folds. These therefore cease abruptly at the edge the meal is found to have occurred. Very slight peri- of the malignant area, usually at some little distance from staltic movements are enough to enable the head of the the edge of the crater. meal to pass forward from one haustrum to another. A meal will usaally be followed by a distinct advance of Duodenal Ulcer the head of the opaque column, and by a striking clear- In the past a method of diagnosing duodenal ulcer was ance of the terminal . Most observers have seen, based upon indirect signs, and much importance was on rare occasions, a mass movement beginning near the attached to the triad " hypertonus, hypermotility, and hepatic flexure and rapidly sweeping the contents of the hyperperistalsis " of the stomach. Every one of these into the descending portion. signs is of secondary importance, and duodenal ulcer is, in fact, found associated with any type of stomach, NEW GROWTH showing widely different degrees of tonus, motility, and Carcinoma of the colon is shown as a filling defect. peristalsis. In no condition is careful and repeated filling Although this may be clearly in evidence in an examina- of the viscus so important or so essential. tion by barium meal as soon as the meal has reached Duodenal ulcer occurs most frequently in the first part its site, failure to demonstrate a growth by this method -the duodenal " cap " (Fig. 4). To understand the does not in any sense exclude a lesion, and it is abso- typical deformity of the caused by ulcer we lutely essential to examine by opaque enema (after may regard it as a stomach in miniature: on one wall thorough cleansing of the bowel by simple enemata), since we look for a projecting crater, on the opposite wall an the meal usually leaves several segments of the colon incisura may be found (Diagram III). The heapinig up unfilled in which a growth might.lurk. of the mucosa at the edges ,% of the crater produces in this COLITIS , , %% small space a much more There are no characteristic radiographical appearances pronounced narrowing of the in mucous colitis ; occasionally there are local areas of 1 :B) "%A lumen than it does in the spasm which persist, or an unusually irregular haustral stomach. Convergence of the segmentation. Ulcerative colitis, on the other hand, _c\t'', folds of mucosa towards the shows, with opaque enema, a very typical, narrow, ribbon- crater, combined with mucosal shaped colon (Fig. 8), with absence of haustral segmenta- The mucous membrane may show a mottled # thickening, may divide the tions. I% - cavity into a number of appearance (pseudo-polyposis) in either condition. (Accu- pockets. It must, however, mulations of mucus, actual ulcers, or hypertrophied be borne in mind that the mucosa may cause this mottled appearance.) ulcer. A, Crater, with ulcer crater may be very smal heaped - up margins. B, and itself invisible, and that Incisura, opposite ulcer. C, diagnosis depends on recog- PRESENTATION TO SIR ALMROTH WRIGHT Pylorus. nition of constant deformity due to some or all of the other factors enumerated above. Conversely a well-filled and normally shaped duodenal cap SIR HENRY DALE'S TRIBUTE often contains an ulcer, which is only brought into view In the library of the Inoculation Department of St. Mary's by slightly compressing its walls, under fluoroscopic Hospital on March 24th Sir Henry Dale unveiled a portrait control, until the crater shows as an " en face " niche, bust of Sir Almroth Wright, the work of Mr. Donald or by careful scrutiny of each part of the cap in profile Gilbert, and presented it to him, together with a small (Fig. 3, A, B, C, D). volume containing an engrossed address and the names Extra-luminal (penetrating and perforating) ulcer of about 250 colleagues who had participated in the pockets also occur, and often contain residual barium testimonial. The address read as follows: deposits when the viscus itself is empty. Tenderness on " On the attainment of your seventy-fifth year we, your deep pressure over the crater is often present, and is of colleagues, pupils, and friends, take this opportunity of offering some diagnostic value. you a token of our esteem and our warm personal affection. \Ve wish to commemorate your outstanding work in immuno- Small Intestine logy, your development of vaccine therapy, and your founding of the Inoculation Department of St. Mary's Hospital, where, It is rare to find radiographical evidence of organic so far as in us lies, your work shall continue. We would disease of the small intestine, since lesions of this part commemorate, in particular, that scientific humbleness of of the alimentary tract are uncommon. A very character- heart and that freshness of vision which have helped yoi istic picture is produced by obstruction of the small in unravelling the tangles of contemporary medical thought intestine. If the patient is examined standing a number and which, throughout your career, have been an inspiration of dome-shaped air bubbles are seen, grouped usually in to your fellow-workers and disciples. middle and abdomen. On " We wish you continued health and vigour to enable you the upper giving the patient still a it is that yet more to enlighten the dark places of our minds and barium meal found the normal feathery further to enrich those branches of medicine with which your appearance of the intestinal mucosa is replaced by a name will ever be linked." regular cross-striation, due to the stretched valvulae con- niventes, and the dilated loops of small bowel tend to Sir HENRY DALE, in performing the ceremony, said that arrange themselves in the well-known step-ladder forma- they were assembled to testify their admiration and affectionate regard for Almroth Wright. They were there tion. The obstructing iesion is usually found near the to tell him that they realized what it meant for science ileo-caecal junction, and may be due to neoplasm or to and humanity that he should have come through all adhesions. these years of tireless devotion to the increase of life-saving The Colon knowledge by research with his own skilful hands and his own ingenious mind. Some of those present had only a The normal colon, examined by the meal method, shows layman's appreciation of the practical results- of his work, a number of sacculations, the haustra, which remain un- These were not far to -seek-for example, the contrast changed over very long periods of time. Peristaltic between the tragic toll which enteric fever took of our movements are vrery rarely seen, though if the case is armies in the South African War, and the experience of examined from hour to hour a fairly steady progress of the much greater conflict two decades ago, when that