Linear Niches in the Duodenal Bulb

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941 Albert de Roos1 J. Odo Op den Orth1 Received September 14, 1 982; accepted after revision December 1 3, 1982. I Department of Radiology, 5t. Elisabeth s of Groote Gasthuis, P.0.B.

1 941 Albert de Roos1 J. Odo Op den Orth1 Received September 14, 1 982; accepted after revision December 1 3, I Department of Radiology, 5t. Elisabeth s of Groote Gasthuis, P.0.B. 41 7, 2000 AK Haarlem, The Netherlands. Address reprint requests to J. 0. Op den Orth. AJR 140: , May x/83/ American Roentgen Ray 5ociety Linear Niches in the Duodenal Bulb #{149}... S..,... Twenty-three linear niches in the duodenal bulb were found in 22 patients out of a series of 314 patients with radiographically demonstrated duodenal ulcers (incidence 7%). Double-contrast and single-contrast graded-compression views were effective in depicting the linear niche in four cases. In 14 cases only double-contrast films showed the abnormality, while in four cases the diagnosis could be made only on positivecontrast graded-compression films. Optimal distension proved to be essential in both techniques. All niches were transversely oriented in the duodenal bulb. In 18 cases the niche occurred in a deformed bulb, and in four cases there was no deformity. Radiologic differentiation between a thin, active, linear ulcer and a linear scar was not possible. Linear niches in the duodenal bulb are common endoscopic findings. The reported endoscopic and pathologic incidence ranges from 4.3% to 26% out of all duodenal ulcers [1-3]. Linear ulcers are clinically important because of their tendency toward poor healing [4]. Reports of radiographic visualization and diagnosis of this lesion are rare [1, 5, 6]. There is no agreement on the relative value of double-contrast and single-contrast graded-compression studies. In the leading article in this field Shirakabe, a distinguished authority on double-contrast techniques, diagnosed linear niches in the duodenal bulb only with singlecontrast graded-compression studies; the double-contrast studies were not diagnostic [1]. Others, however, favor double-contrast techniques [5]. There is agreement that linear niches occur almost exclusively in a deformed duodenal bulb and that optimal duodenal distension is essential for a correct diagnosis [1, 6]. We undertook this study to evaluate the relative value of double-contrast and singlecontrast graded-compression studies in the diagnosis of linear niches in the duodenal bulb. Other purposes were to find out whether bulban deformity is essential in obtaining the diagnosis. Materials and Methods Radiologic reports over a 2-year period were reviewed, and 31 4 patients having a duodenal ulcer were found in a group of about 3,300 radiologic studies of the upper gastrointestinal tract. The radiologic study consisted of the standard biphasic-contrast examination routinely used at our institution [7, 8]. This examination was preceded by an intravenous injection of 0.5 mg of glucagon. If the first dose wore off after the gastric examination (which usually preceded the duodenal study), a second dose of 0.5 mg of glucagon was administered. In the second half of the 2-year period, the techniques were slightly changed: Instead of 0.5 mg of glucagon, usually 0.1 mg of glucagon was administered. This dose of 0.1 mg of glucagon decreased our costs and examination time and was usually effective for the first and the eventual second injection [9, 1 0. Only exceptionally we needed an injection of 0.5 mg of glucagon to obtain full distension of the descending duodenum. Further, we successfully modified our technique at the suggestion of Lotz [1 1 ]: At the beginning of the examination, the patient takes one swallow (30 ml) of a high-.

942 DE ROOS AND OP DEN ORTH AJR:140, May 1983 Fig. 1 -A, Supine double-contrast study, left posterior oblique view. Round ulcer niche in posterior wall of duodenal bulb.

density barium suspension (250% w/v). The patient is then rotated on the right and left side for mucosal coating.

In our experience this modification improved the barium coating on double-contrast films.

that permits transparency of the single-contrast graded-compression studies. Results Twenty-three linear niches in the duodenal bulb were found in 22 patients.

2 942 DE ROOS AND OP DEN ORTH AJR:140, May 1983 Fig. 1 -A, Supine double-contrast study, left posterior oblique view. Round ulcer niche in posterior wall of duodenal bulb. B, Erect single-contrast gradedcompression study, left posterior oblique view. Linear extension of ulcer toward greater curvature. Thickened folds converge toward this linear extension. density barium suspension (250% w/v). The patient is then rotated on the right and left side for mucosal coating. Thereafter we continue the examination with our medium-density barium suspension (90% w/v) containing CO2 ( bubbly barium ). In our experience this modification improved the barium coating on double-contrast films. The two barium suspensions mix perfectly well and the mixture of a small dose of high-density barium suspension with a large dose of medium-density barium suspension results in an ultimate density that permits transparency of the single-contrast graded-compression studies. Results Twenty-three linear niches in the duodenal bulb were found in 22 patients. The patients were 1 1 men and 1 1 women aged years (average, 45 years). In 1 4 cases only double-contrast films were effective in obtaining the Fig. 2.-A, Erect single-contrast graded-compression study, left postenor oblique view. Two ulcer niches in duodenal bulb. Double-contrast supine films showed that one was in anterior wall and other in posterior wall (kissing ulcers). B, After 8 weeks of treatment. There are now kissing linear niches. diagnosis. In four cases the diagnosis could only be made on single-contrast graded-compression films. In four cases the linear niche could be seen by means of both methods. In one case there was a round ulcer with a linear extension (racket ulcer). The round ulcer could easily be seen by both techniques, but its linear extension could only be demonstrated by single-contrast graded-compression studies (fig. 1 ). In two cases of linear niches, there was a coexistent round ulcer in the opposite wall of the duodenal bulb. In one case there were two linear niches, one in the anterior wall and the other in the posterior wall of the bulb (kissing linear niches) (fig. 2). In each case the diagnostic films appeared to be made in optimal distension of the duodenal bulb and all niches were found to be transversely oriented. In 10 cases the linear niches were diagnosed in a unilaterally deformed bulb, and in eight cases in a bilaterally deformed

AJR:140, May 1983 LINEAR NICHES IN DUODENAL BULB 943 Fig. 3.-A, Supine double-contrast study, left posterior oblique view. Rodlike ulcer in posterior wall of deformed bulb.

Sharply demarcated barium line transversely oriented in bilaterally deformed duodenal bulb. This linear niche was considered to be caused by scar, but thin active linear ulcer could not be excluded.

Round ulcer that is probably predecessor of linear niche in A. bulb. In four cases the bulb did not show any deformity at all.

We believe that this is not necessary because a duodenal ulcer has no tendency to malignant degeneration.

3 AJR:140, May 1983 LINEAR NICHES IN DUODENAL BULB 943 Fig. 3.-A, Supine double-contrast study, left posterior oblique view. Rodlike ulcer in posterior wall of deformed bulb. B, After 3 months, under same conditions. Linear niche where previously rodlike ulcer was demonstrated. Fig. 4.-A, Supine double-contrast study, left posterior oblique view. Sharply demarcated barium line transversely oriented in bilaterally deformed duodenal bulb. This linear niche was considered to be caused by scar, but thin active linear ulcer could not be excluded. Endoscopy showed linear scar. B, Erect single-contrast graded-compression study, left posterior oblique p0- sition, done several years earlier. Round ulcer that is probably predecessor of linear niche in A. bulb. In four cases the bulb did not show any deformity at all. At our institution radiologic follow-up and/on endoscopy are not routinely used if a duodenal ulcer has been diagnosed. We believe that this is not necessary because a duodenal ulcer has no tendency to malignant degeneration. Furthermore, disappearance of symptoms under medical management is accepted as an indication of the healing process. In six cases, however, we had earlier films. In all cases these films showed a round, oval, or nodlike niche which we considered the predecessor of the linear niche (figs. 2-4). We asked for duodenoscopy in three cases of linear niches because a linear scar was considered, but a thin, active, linear ulcer could not be excluded (figs. 4 and 5). These linear niches were found to be linear scars at endoscopy. Discussion Our study demonstrates that linear niches in the duodenal bulb were found in 0.7% of all examinations and in 7% of all duodenal ulcers. In a previous report, the incidences were 0.2% and 6%, respectively [6]. It is also demonstrated that a biphasic-contrast examination-combining the advantages of double-contrast and single-contrast graded-compression studies-is mandatory to obtain a correct diagnosis of linear niches in the duodenal bulb. As only films made with optimal bulbar distension were diagnostic, we are convinced that glucagon has been of great help. Furthenmore, it is shown that demonstration of a niche does not mean that an active ulcer exists. We therefore disagree with a previous report which stated that when a line persists, an ulcer crater exists rather than just a scar [6]. We are not

4 944 DE ROOS AND OP DEN ORTH AJR:140, May 1983 aware of definite radiologic criteria to differentiate a linear scar from a thin, active, linear ulcer. In these cases endoscopy may be indicated. We found that all linear niches were transversely oriented. This is in agreement with a study of Shirakabe et al. [1 ]. The predictable orientation of the niche was of significant help in the recognition of the lesion. Bulbar deformity is an indication that a linear niche may be present and usually leads to the search for a linear niche. Our study, however, indicates that linear niches may occur in bulbs without any deformity. Finally, we found, by comparison with previous films, that at least some of the instances of linear niches represent part of a healing process. This is in agreement with an endoscopic follow-up study which, however, also demonstrated the tendency of linear niches to heal poorly [4]. Thus the nadiologic detection of linear niches seems to be of great importance. REFERENCES 1. Shirakabe H, Nishizawa M, Kobayashi 5, Maruyama T. L ulcera lineare del bulbo duodenale. In: La radiologia de!l esofago, de!lo stomaco e del duodeno. Cittadella (Padova), Italy: Bertoncello Artigrafiche, 1 978: Fig. 5.-A, Supine double-contrast study, left posterior oblique view. Linear niche transversely oriented in unilaterally deformed duodenal bulb. B, Erect single-contrast graded-compression study, left posterior oblique view. Linear niche cannot be identified. Endoscopy showed that linear niche was caused by linear scar. 2. Brandst#{228}tter G, Kratochvil P: Endoscopie beim Ulcus duodeni. MedK!in 1978;73:ii76-1i78 3. Kawai K, Ida K, Misaki F, Akasaka Y, Kohli Y. Comparative study for duodenal ulcer by radiology and endoscopy. Endoscopy 1973;5: Kohli Y, Misaki F, Kawai K. Endoscopical follow-up observation of duodenal ulcer. Endoscopy 1 972;4 : Poplack W, Paul RE Jr, Goldsmith M, et al. Linear and rodshaped peptic ulcers. Radiology 1 977; 122: Braver JM, Paul RE Jr, Philipps E, Bloom S. Roentgen diagnosis of linear ulcers. Radiology 1 979;1 32 : Op den Orth JO, Ploem S. The standard biphasic-contrast gastric series. Radiology 1 977;i 22 : Op den Orth JO. The standard biphasic-contrast examination of the stomach and duodenum; method, results and radiologica! at/as, 1 St ed. Boston (Lingham): Martinus Nijhoft Medical Division, Maglinte D, Caudill U, Krol K, Brown D. The use of a small dose of glucagon in upper gastrointestinal radiography (abstr). Gastrointest Radio! 1 980;5 : Miller RE, Chernish SM, Greenman GF, Maglinte DOT, Rosenak BO, Brunelle AL. Gastrointestinal response to minute doses of glucagon. Radiology 1982;143:3i Lotz W. Verbesserte rontgenologische Magendiagnostik durch weiterentwickelte Kontrastmittel und Untersuchungstechnik. Rontgenblatter 1982;35:

5 This article has been cited by: 1. Stephen E. RubesinCase [CrossRef] 2. Marc S. LevinePeptic Ulcers [CrossRef]

gastric lesions CASE 1 (M.A., 85/65) A woman aged 61 was admitted to

gastric lesions CASE 1 (M.A., 85/65) A woman aged 61 was admitted to Gut, 1969, 10, 436-442 Double-contrast method for the evaluation of gastric lesions TORIOLA F. SOLANKE,1 KENJI KUMAKURA, MASAKAZU MARUYAMA, AND NAIKI SOMEYA From the Department of Internal Medicine, Cancer