The surface pattern of the stomach and duodenum in a chronic renal failure cohort JOHN H. SCOTT, DD. Pottsville, Pennsylvania ROBERT R. ROSENBAUM, aa, FAOCR Philadelphia, Pennsylvania nostic imaging studies did not confirm the presence A retrospective review of 42 patients of malignant disease, and renal transplantation (60 examinations) with end-stage was successfully performed. This experience renal disease (ESRD) on dialysis prompted a review of the literature dealing with therapy was performed for evaluation the appearance of the upper gastrointestinal tract of the roentgenographic appearance in end-stage renal disease (ESRD) patients on di- of the upper gastrointestinal tract. alysis as well as a retrospective review of our mate- Many patients with chronic renal rial. The purpose of this report is to document our failure exhibited a variation in the findings. surface pattern of the stomach and Method duodenum during maintenance dialysis therapy. There was an Sixty upper gastrointestinal tract examinations, increased incidence of a cobblestone which had been performed for 42 ESRD patients configuration of the duodenal who were on maintenance dialysis between 1979 mucosa, predominantly within the and 1983, were evaluated retrospectively for the duodenal cap and proximal duodenal purpose of analyzing the following parameters: (1) loop. These nodular defects are quality of gastric surface pattern visualization; (2) probably representative of thickness of and presence or absence of nodular hypertrophy of Brunners glands and defects of the gastric mucosal folds; (3) presence, should not be mistaken for possible number, and size of nodular surface pattern defects malignant submucosal lesions. In the in the cap and duodenal loop; and (4) presence of patients who presented with similar gastric or cap ulcers. complaints of peptic ulcer disease, Of the 60 studies, 45 were performed by a stan- there was only a small incidence of dard double-contrast method. 1 The remainder were peptic ulcer in the ESRD cohort as single-contrast examinations, usually because of compared to the group without renal the inability of the patient to cooperate sufficiently failure. Because of the increase in for an adequate double-contrast procedure. incidence of maintenance dialysis A random control study was then performed therapy in ESRD patients, we suggest retrospectively in patients of similar age (40-65 that these findings are of importance years) who presented with complaints of peptic ul- in a radiographic assessment of the cer disease. Sixty patients were examined between upper gastrointestinal tract. September and December 1983; all 60 underwent double-contrast upper gastrointestinal examina- tions. The same parameters were utilized in the evaluation of these studies. Review of the literature References to the appearance of the upper gastroin- A patient who had been on a hemodialysis regimen testinal tract in ESRD (particularly as demon- for chronic renal failure was subjected to radiologic strated by double-contrast techniques) are sparse. assessment of the upper gastrointestinal tract in This is somewhat surprising in view of the increas- anticipation of a renal transplant procedure. The ing number of such patients. There is a large body study demonstrated multiple large nodular surface of literature dealing with the gross and microscopic pattern defects in the duodenal loop, which were pathology of the mucosa, endoscopic appearance of interpreted as possible malignant submucosal the mucosa, and physiologic parameters of acid masses (Fig. 1). Endoscopic and other diag- production, secretory activity, and so forth, with Surface pattern of the stomach and duodenum in a chronic renal failure cohort 162/75 thickened mucosal folds without nodules. Endo- scopic evaluation correlated directly with the radi- ographic findings of nodular duodenitis. Histologic characteristics of nodular duodenitis suggested this to be a form of duodenal inflammation. Of interest is the incidence of peptic ulcer disease in only 6 percent of these patients versus the overall incidence of peptic ulcer disease in 1-3 percent of the general population. 12 Zuckerman and col- leagues concluded that nodular duodenitis may be a variation in the clinical presentation of peptic ulcer disease in the patients with ESRD. Weiner, Vertes, and Shapiro° performed upper gastrointestinal tract studies on 48 patients, 14 of whom were on peripheral dialysis and 34 on hemo- dialysis. There were 10 abnormal examinations in Fig. 1 Double-contrast upper gastrointestinal study of a pre- the peritoneal dialysis group and 23 in the hemo- transplant patient with chronic renal failure demonstrates nodular defects in the duodenal loop ( arrows). dialysis patients. The listed abnormalities in- cluded the following: a "wet stomach" with prominent gastric folds in 11 patients; prominence some passing references to radiologic examina- and enlargement of duodenal bulb folds, usually tion.2-9 linear and irregular but occasionally vertical and/ Lewicki and associates l° reviewed 51 upper gas- or nodular in 21 patients; duodenal ulcer scarring trointestinal studies in a group of 235 patients, in 3 patients; and prominence of mucosal pattern some of whom were on pretransplant dialysis and with enlarged folds involving the proximal portion most of whom were post-transplant patients. Gas- of the descending duodenum in 8 patients. There trointestinal bleeding was the most common in- were no gastric or duodenal ulcers. dication for examination. Thirty-three studies King and coauthors" reported on 22 upper gas- were normal, and 15 patients had gastroduodenal trointestinal and small bowel studies in 18 patients ulcerations. A duodenal mucosal pattern resem- on hemodialysis. Fourteen studies had normal bling that associated with Brunners gland hyper- findings. The remaining studies demonstrated trophy was seen in 80 percent of the dialysis mucosal changes of the duodenum, jejunum, and patients and 60 percent of the post-transplant pa- ileum, including thickened but pliable valvulae tients. The authors called this a "cobblestone duo- conniventes. There were no gastric abnormalities. denal mucosa" and commented that "widened In a prospective study of 83 renal failure patients rugae and enlarged duodenal mucosal folds were on dialysis, Margolis and coworkers 15 observed en- common. Because of technical factors, it was gener- larged gastric folds in 12 percent and enlarged duo- ally easier to assess and grade this finding in the denal folds in 42 percent. No peptic ulcers were duodenum." In a group of randomly selected ulcer demonstrated. Correlative panendoscopy in 60 of patients without known renal failure, a distinct the 83 patients demonstrated gastritis in 22 per- cobblestone pattern was seen in 23 percent. The cent and nodular duodenitis in 60 percent. A highly threefold-increased incidence of such a pattern in significant correlation existed between endoscopic their renal failure groups led to the conclusion that and radiologic duodenitis. it could not be merely a secondary feature of ulcer Smith, Petersen, and Junor 16 demonstrated hy- disease, but that a mechanism related to altered pertrophy of gastric mucosa in 19 and hypertrophy renal function was responsible. of the duodenal mucosa in 11 of 31 patients who Zuckerman and colleagues 11 evaluated the duo- were on long-term hemodialysis. Three patients denum in patients with ESRD by radiographic and had questionable ulcer disease radiographically, endoscopic methods. Seventeen of 50 patients (34 but no ulcers were observed endoscopically. percent) had radiographic findings of "nodular duo- Dorph and associates 17 found a coarse mucosal denitis," which was defined as two or more discrete pattern in 65 percent of 84 studies in chronic renal nodules protruding into the duodenal lumen. Four failure patients. The most common location was in percent exhibited these findings in the general pop- the distal half of the duodenal bulb and in the ulation. An additional 15 patients (30 percent) de- proximal half of the descending duodenum. Only 1 picted findings of "non-nodular duodenitis," that is, peptic ulcer was seen. 163/76 March 1986/Journal of AOA/vol. 86/no. 3 Results Gastric surface pattern The double-contrast studies were evaluated for quality of surface pattern demonstration. Cur- rently acceptable criteria for a good surface pattern are based on sharpness of the areae gastricae pat- tern—sharpness and continuity of the "white line" marginal contour of the stomach and the area of the stomach throughout which the pattern is apparent (Fig. 2A). It is generally anticipated that a good surface pattern is obtained in about 50 percent of unselected double-contrast studies. The surface pattern was judged as poor, fair, or good. A surface pattern was judged as poor if no areae gastricae were visualized, or if only a small segment of the stomach contained identifiable areae gastricae, or if extensive puddling of barium occurred (Fig. 2B). A fair designation was given to an areae gastricae pattern that was somewhat more extensive but obviously limited to well under 50 percent of surface area without extensive pud- dling of barium (Fig. 2C). The 45 double-contrast studies presented 31 poor, 10 fair, and 4 good surface pattern (Table 1). In the population without renal failure, there were 46 good and 14 fair surface patterns. Mucosal folds The appearance of the gastric mucosal folds was evaluated in all 60 examinations, in an effort to assess prominence, nodularity,