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Treatment in General Practice

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Treatment in General Practice 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 mucous membrane 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 Stomach 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 small intestine. 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 peristalsis, 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 pylorus, 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 ulcerative colitis. -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.
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