Contents I MEDICAL RADIOLOGY. Diagnostic Imaging. Editors: A. L. Baert, Leuven M. Knauth, Göttingen K. Sartor, Heidelberg

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1 Contents I MEDICAL RADIOLOGY Dignostic Imging Editors: A. L. Bert, Leuven M. Knuth, Göttingen K. Srtor, Heidelerg

2 Contents III A. H. Freemn E. Sl (Eds.) Rdiology of the Stomch nd Duodenum With Contriutions y K. Bln A. B-Sslmh N. R. Crroll C. Cousins M. Dux T. Fork A. H. Freemn K. M. Hrris H.-U. Lsch D. Mrtin M. Memrsdeghi P. Pokieser M. Prokop J. W. A. J. Reeders E. Sl T.C. See P. J. Shorvon M. Uffmnn R. Zissin Foreword y A. L. Bert With 322 Figures in 588 Seprte Illustrtions, 129 in Color nd 9 Tles 123

3 IV Contents Aln H. Freemn, MB, BS, FRCR Consultnt Rdiologist Deprtment of Rdiology Addenrooke s Hospitl Box 219, Hills Rod Cmridge, CB2 2QQ UK Evis Sl, MD, PhD University Lecturer/Honorry Consultnt Rdiologist University Deprtment of Rdiology Addenrooke s Hospitl Box 219, Hills Rod Cmridge CB2 2QQ UK Medicl Rdiology Dignostic Imging nd Rdition Oncology Series Editors: A. L. Bert L. W. Brdy H.-P. Heilmnn M. Knuth M. Molls C. Nieder K. Srtor Continution of Hnduch der medizinischen Rdiologie Encyclopedi of Medicl Rdiology Lirry of Congress Control Numer: ISBN Springer Berlin Heidelerg New York This work is suject to copyright. All rights re reserved, whether the whole or prt of the mteril is concerned, specificlly the rights of trnsltion, reprinting, reuse of illustrtions, recittions, rodcsting, reproduction on microfilm or in ny other wy, nd storge in dt nks. Dupliction of this puliction or prts thereof is permitted only under the provisions of the Germn Copyright Lw of Septemer 9, 1965, in its current version, nd permission for use must lwys e otined from Springer-Verlg. Violtions re lile for prosecution under the Germn Copyright Lw. Springer is prt of Springer Science+Business Medi http// Springer-Verlg Berlin Heidelerg 2008 Printed in Germny The use of generl descriptive nmes, trdemrks, etc. in this puliction does not imply, even in the sence of specific sttement, tht such nmes re exempt from the relevnt protective lws nd regultions nd therefore free for generl use. Product liility: The pulishers cnnot gurntee the ccurcy of ny informtion out dosge nd ppliction contined in this ook. In every cse the user must check such informtion y consulting the relevnt literture. Medicl Editor: Dr. Ute Heilmnn, Heidelerg Desk Editor: Ursul N. Dvis, Heidelerg Production Editor: Kurt Teichmnn, Muer Cover-Design nd Typesetting: Verlgsservice Teichmnn, Muer Printed on cid-free pper 21/3180xq

4 Contents V To my wife Jckie for ll her ptience during the preprtion of this ook Aln H. Freemn To my son Pier nd my husnd Gezim Evis Sl

5 Contents VII Foreword Notwithstnding the mjor contriutions of endoscopy in the dignosis nd mngement of disorders of the stomch nd the duodenum, rdiology still hs n importnt role in specific disese settings. This volume provides up to dte informtion on multimodlity imging of this ntomic section of the upper gstrointestinl trct within the frmework of multidisciplinry pproch. The editors, A.H. Freemn nd E. Sl, judiciously selected the topics nd were very successful in engging the help of severl other interntionlly recognised experts in gstrointestinl rdiologicl imging. The ook comprehensively covers ll min res of interest, is superly illustrted nd the references include the most importnt recent pulictions in the field. I m confident tht this outstnding volume will find gret interest from generl s well s specilised gstrointestinl rdiologists ut lso from gstroenterologists nd dominl surgeons, who wnt to updte their knowledge nd ilities on the ctul vlue of rdiologicl imging for ptients with stomch or duodenl disorders. I hope tht it will meet the sme success s the previous volumes in our series. Leuven Alert L. Bert

6 Contents IX Prefce Following Roentgen s discovery of X-rys, erly experimenters quickly relised tht this new technology held promise for investigting the hitherto unknown re of the gstrointestinl trct. Only 1 yer fter the puliction of Roentgen s pper, W. Becher fed led sucette to guine pig nd thus performed proly the first contrst study of living stomch. Studies on humns soon followed, with Roux nd Blthzrd reporting their findings using ismuth sunitrte s contrst gent in Hermn Rieder in 1904 ws the first to stndrdise the gstric exmintion, using s contrst gent mixture of 40 g of ismuth sunitrte mixed with gruel henceforth known s the Rieder mel. However, it ws relised tht ismuth sunitrte hd toxic side effects so investigtors hd to serch for nother form of contrst gent. They soon relised tht rium sulphte, nturlly occurring minerl, possessed the idel prmeters of inertness, non-sorption from the gstrointestinl trct nd excellent X-ry diffrction properties, which mde it perfect contrst gent for opcifying the upper GI trct. Its potentil use hd een suggested y Wlter Cnnon ut it ws Bchem nd Gunter in 1910 tht first descried the use of rium sulphte in the stomch, nd thus ws orne the rium mel. Modifictions occurred over the yers, prticulrly with the introduction of doule contrst, in n ttempt to provide etter delinetion of the mucosl surfce. Although the principle of doule contrst in the colon hd een first dvocted y Fischer in 1923, its use in the stomch ws slow to ctch on in the Western world. The mjor stimulus for doule contrst studies cme from Jpn in the 1960s, when popultion screening progrmme ws strted to detect erly gstric cncer condition with very high prevlence in Jpn. Hikoo Shirke, in prticulr, populrised the technique which requires the dherence of thin film of high density rium sulphte to the gstric mucos whilst the stomch is inflted with gs usully CO 2. Improvements in rium preprtions, including the ddition of numerous gums nd nti-flocculting gents, ment tht y the lte 1970s excellent mucosl detil could e demonstrted of the entire stomch nd duodenum. And then long cme flexile endoscopy, with its ility not only to see ll the mucos in glorious technicolour, ut lso to tke iopsies of ny suspicious or doutful lesion. Here ws simple outptient procedure requiring miniml sedtion nd within decde the rium mel virtully died. However, conventionl exmintion of the upper GI trct is still performed, lthough now the indictions re different often for function s well s morphologicl detil. New indictions, such s studying the stomch fter surgery for morid oesity, hve come into vogue nd re likely to increse with the oesity epidemic in the Western world. It should lso e rememered tht endoscopy

7 X Prefce is not infllile point ddressed in Chpter 4 nd tht there re still occsions when ptient cnnot or will not tolerte n endoscopy. Whilst demnd for conventionl rdiology of the stomch hs sustntilly dropped, ided y the discovery of Helicocter pylori nd its reltionship to peptic ulcer disese, new technology hs introduced host of indictions for rdiologicl imging of the stomch nd duodenum. This prticulrly pplies to CT with the susequent development of multidetector CT (MDCT). Erly CT rpidly proved its worth in stging gstric crcinom, prticulrly in the sphere of distnt spred to nodes nd the liver. Delinetion of the wll of the stomch, however, proved difficult oth ecuse of durtion of scn time s well s lck of fine detil. These prolems hve een lrgely overcome with MDCT, which cn now offer exquisite detil of the gstric wll cquired in the spce of few seconds. Very fine detil of the distinction etween the mucos nd sumucos cn still only e chieved y the use of endoscopic US s is outlined in Chp. 8. It is interesting to speculte s to whether or not CT will eventully hve this cpility or will MRI possily supersede oth, ided y its rel time cpilities. The ltter clerly tkes the rdiologist into the role of functionl studies, sphere up to now dominted y Nucler Medicine exmintions. Rdiologicl intervention in the stomch nd duodenum is lso growing in importnce nd whilst it is helpful to hve endoscopic expertise, this is not essentil, s is shown in Chpter 11. Finlly, it goes without sying tht ccurte interprettion of rdiologicl imges (however they re cquired) requires full knowledge of pthologicl processes nd the wy tht they ffect the orgn. The principle of rdiologic/ pthologic correltion is now well estlished, ut it is lwys helpful to remind ourselves of the mcroscopic chnges nd how they come out from different disese processes. This we hve ttempted to do in Chptre 2. In conclusion, we would like to thnk Prof. A. Bert for entrusting us with the preprtion of this project in the Medicl Rdiology series, nd our prticulr thnks go to ll our uthors for contriuting to this volume. We hope tht it will provide useful nd informtive reding for ny rdiologist with n interest in the stomch nd duodenum. Finlly we wish to thnk Ms Ursul Dvis, Mr Kurt Teichmnn nd ll the production tem t Springer, whose tremendous help nd expertise rought the project to fruition. Cmridge Aln H. Freemn Evis Sl

8 Contents XI Contents 1 Introduction nd Clinicl Overview Aln H. Freemn Rdiologicl Pthologicl Correltion Jcques W. A. J. Reeders, Aln H. Freemn, nd Evis Sl Endoscopy of the Upper Gstrointestinl Trct Thoms Fork Prolems nd Pitflls of Gstrointestinl Endoscopy. Is There Still Role for Brium Mel? Philip John Shorvon Conventionl Rdiology of the Stomch nd Duodenum Evis Sl nd Aln H. Freemn CT of the Stomch Teik C. See, Nichols R. Crroll, nd Aln H. Freemn Multislice CT of the Stomch Ahmed B-Sslmh, Mrtin Uffmnn, Peter Pokieser, nd Mthis Prokop Mgnetic Resonnce Imging of the Stomch Mrkus Dux Endoscopic Ultrsound of the Stomch Keith M. Hrris CT of the Duodenum Rivk Zissin Rdionuclide Imging of the Stomch Kottekkttu Bln Rdiologicl Intervention in the Stomch nd Duodenum Derrick F. Mrtin nd Hns-Ulrich Lsch The Acute Stomch nd Duodenum Evis Sl nd Aln H. Freemn The Postopertive Stomch nd Duodenum Peter Pokieser, Ahmed B-Sslmh, nd Mzd Memrsdeghi Angiogrphy of the Stomch nd Duodenum Clire Cousins Suject Index List of Contriutors

9 Introduction nd Clinicl Overview 1 Introduction nd Clinicl Overview 1 Aln H. Freemn CONTENTS 1.1 Which Ptients Should Undergo Endoscopy? Is There Ever Role for the Upper Gstrointestinl Series (Brium Mel)? 3 References 4 Additionl Reding 4 Diseses of the stomch nd duodenum re immensely common, ccounting for 4% of fmily doctor visits per yer. The generic title indigestion encompsses collection of symptoms including herturn, nuse, loting, elching nd sometimes vomiting. All of these my rise from disorders of the lower oesophgus, stomch or duodenum. In ddition, disorders of the iliry tree my lso cuse such symptoms, resulting in dignostic nd tretment dilemms In mny instnces there my not e n underlying physicl normlity, so-clled functionl dyspepsi which is proly relted to motor disturnces of the stomch nd duodenum (Hmmer nd Tlley 2000). In prticulr, this my e relted to personl hits such s smoking, eting too much nd too quickly or drinking too much lcohol. When orgnic cuses re present, they most commonly relte to gstro-oesophgel reflux disese (GORD), gstritis nd duodenitis, s well s frnk ulcertion. Occsionlly, ominous symptoms such s loss of ppetite, incresed stiety nd loss of weight suggest more sinister cuse such s crcinom. Understndly, most ptients re wre of n ssocition etween indigestion nd excess gstric cid nd re therefore likely to self medicte s witness the lrge numer of proprietry ntcids ville cross phrmcy counters. If simple mesures A. H. Freemn, MB, BS, FRCR Consultnt Rdiologist, Deprtment of Rdiology, Addenrooke s Hospitl, Box 219, Hills Rod, Cmridge, CB2 2QQ, UK fil then the ptient is likely to consult his fmily doctor. Here, rief history is essentil, if only to rule out ominous symptoms s indicted ove. Physicl exmintion is lrgely unrewrding, unless there re ovious signs such s gstric mss, lymphdenopthy, etc. Agin in the first instnce tretment is likely to e symptomtic; for exmple, if GORD is suspected then simple mesures such s the voidnce of lrge mels lte t night, elevting the hed of the ed nd weight reduction re indicted. If symptoms persist, then considertion hs to e given to the prescription of proton pump inhiitor (PPI). This is usully dministered first thing in the morning over 4- to 8-week tril period. Filure to respond to this regime is common, proly in the order of qurter of the ptients, nd therefore the dose hs to e incresed. Usully this is douled so the mediction is tken efore rekfst nd efore dinner. Alterntively tril of nother mnufcturer s PPI is often dvocted nd it hs to e noted tht there re different genetic responses to the vrious PPIs. It is lso worth rememering tht there re other cuses of oesophgitis prt from GORD. Medictions such s doxycycline, tetrcycline, ledronte, potssium chloride, non steroidl nti-inflmmtory gents (NSAIDs) nd quinidine re ll well recognised cuses of oesophgitis. If the ptient remins symptomtic fter these mnoeuvres, nd confounding drug history hs een excluded, then it is time to consider endoscopy (see elow) nd proly ph testing. Endoscopy is lso necessry to exclude rrer cuses of oesophgitis such s eosinophilic oesophgitis in which the oesophgel wll ecomes infiltrted with eosinophils; usully without peripherl eosinophili. This condition typiclly responds to steroids. Diseses of the stomch nd duodenum ccount for out 50% of cses of dyspepsi, in the form of gstritis, duodenitis nd duodenl ulcer. Most of these conditions re linked to infection with Helicocter pylori (HP); for exmple it is shown to e present in 95% of cses of duodenl ulcer. Therefore, the gol here is the detection nd erdiction of this

10 2 A. H. Freemn orgnism. How should this e done? The ure reth test is the most ccurte method of HP detection. This test relies on the fct tht HP in the stomch produces urese. If the ptient ingests 13C lelled ure, this will rect with urese in the stomch nd thus relese 13C lelled CO2. In turn this is sored nd then exhled in the ptient s reth, whence it cn e quntified y mss spectrometry. Alterntively, rdioctive C14 my e used s the lelling gent nd will require scintilltion counter to mesure the resultnt C14CO2. The test hs sensitivity nd specificity of round 96% nd is simple to perform. Ptients need to stop tking PPIs for t lest 2 weeks prior to the test nd Histmine H2 receptor ntgonists for 3 dys efore. In ddition, ntiiotics should cese t lest 4 weeks efore the test. There re two other non-invsive tests for HP nd these include serology nd the stool ntigen test. Serology is less specific thn either of the other tests ecuse it will remin positive long fter the infection hs een erdicted, ut it is simple to perform nd requires no preprtion on the prt of the ptient. With sensitivity of 92% nd specificity of 91% the stool ntigen test is lmost s ccurte s the reth test. However, it requires the sme ptient preprtion s the reth test nd so cnnot e conducted instntly. The finl nd invsive test to scertin the presence of HP is endoscopy nd iopsy. The iopsies should e tken from the ntrum of the stomch which is the re most frequented y the orgnism, lthough there is evidence tht it colonises the more proximl ody in ptients who re tking PPIs. Histologicl exmintion revels the orgnism. Aprt from forml histology the iopsy specimens cn e instntly exmined for the presence of HP y the rpid urese test. This gin utilises the fct tht the orgnism secretes urese, ut in this instnce it is the conversion of ure to mmoni nd icronte which is the key. The specimen is plced in medium contining phenol red. Susequent production of mmoni rises the ph nd chnges the colour of the specimen, thus providing useful instnt dignosis. 1.1 Which Ptients Should Undergo Endoscopy? This will e determined y locl nd ntionl guidelines (Ntionl Institute for Helth nd Clinicl Excellence 2004). As generl rule it is impertive to endoscope ptients over the ge of 50 who hve persisting symptoms despite the use of PPIs, or whose dyspepsi is unexplined y other fctors such s NSAID ingestion. In ddition, there re numer of lrm fetures which should lwys led to urgent endoscopy. These include the following: difficulty in swllowing, vomiting, sudden nd unintentionl weight loss, chronic gstrointestinl leeding, epigstric mss, norml rium mel nd iron deficiency nemi. With the lst mentioned not only cn endoscopy exclude serious disese of the stomch nd duodenum, ut y otining iopsy mteril from the second prt of the duodenum will lso exclude celic disese. All gstric ulcers must e iopsied even if they exhiit chrcteristic enign ppernces; though it should e noted tht only out 2% of gstric ulcers will e mlignnt. The usul technique involves iopsies from ll four qudrnts plus or minus rushing for cytology. If the iopsies re negtive then repet endoscopy is indicted to confirm complete heling, though even tht my not e infllile s sometimes mlignnt ulcers cn hel over on tretment. Immedite prepyloric nd duodenl ulcers my e regrded s enign. If HP is present wht tretment regimes re recommended? The recommended tretment is tht of triple therpy comprising of full dose PPI together with metronidzole nd clrithromycin or moxicillin nd clrithromycin. This course is for 7-dy period though will need to e extended to 1 month if gstric ulcer hs een demonstrted. In some circumstnces it my e pproprite to consider such course of tretment in ptients who re symptomtic ut hrour HP. This group includes ptients who re on other drugs, prticulrly NSAIDS, s it is known tht out 10% 20% of ptients tking these drugs will develop peptic ulcer disese, sometimes with serious complictions(hippisley-cox et l. 2005) This issue prticulrly pplies to elderly ptients who re tking NSAIDs nd who my hve extensive other co-moridity fctors. 1.2 Is There Ever Role for the Upper Gstrointestinl Series (Brium Mel)? Whilst there hs een huge decline in the numers performed, this procedure, unlike the orl cholecystogrm, hs not pssed into history. Perhps the commonest indiction is the filed endoscopy. Despite

11 Introduction nd Clinicl Overview 3 sedtion nd/or locl nesthetic throt spry, there re still ptients who re unle to tolerte the procedure nd still require evlution of the stomch nd duodenum. It lso hs to e rememered tht endoscopy is not infllile (see Chpter 4).There re severl situtions where endoscopic interprettion my e prolemtic or downright erroneous. The first concerns ltertion in ntomy which my preclude full endoscopic interrogtion. Typiclly this results from lrge hitl hernis, n intrthorcic stomch or frnk gstric volvulus. All of these my prevent the pssge of the endoscope or oscure lrge res of the stomch. For this reson sptil reltionships of the stomch my e etter pprecited t rium mel. Secondly, endoscopic demonstrtion is lrgely tht of the mucosl surfce nd sumucosl lesions my e overlooked. Most typicl of these is linitis plstic or lether ottle stomch, which my completely escpe notice ecuse filure to distend the stomch is ttriuted to the ptient elching. Finlly, it must not e forgotten tht successful endoscopies inspect the duodenum down to the level of the inferior duodenl flexure nd disese in the third nd fourth prts my not e noted. The common endoscopic report of no normlity seen in the oesophgus, stomch or duodenum must on occsion e treted with cution, prticulrly if it does not fit with the clinicl picture. Dyspeptic symptoms my of course rise from structures other thn the stomch nd duodenum. The commonest of these is disese of the gll ldder nd iliry trct, with tumours of the pncres less frequent considertion. Mny of these conditions re well scertined y trns-dominl ultrsound; prticulrly diseses of the gll ldder. As the symptomtology often overlps it my e prudent in mny cses to perform this simple test, in the knowledge tht more sophisticted cross section imging, i.e. CT, my e required if there is excess ft, gs, etc. The dvent of multi-detector CT (MDCT) hs unquestionly enhnced its role in the dignosis of diseses of the stomch nd duodenum, (see Chps. 6.1, 6.2), ut it lso still retins mjor role in the stging of tumours. Whilst the overll incidence of crcinom of the stomch my e going down, there is good evidence of the increse of tumours of the gstro-oesophgel junction so-clled junctionl tumours. Thus history of dysphgi, prticulrly if llied to dyspepsi nd weight loss hs to e tken with extreme seriousness. Initil dignosis is mde y endoscopy nd iopsy, ut susequent mngement then requires ccurte stging. The following questions need to e nswered: Is the tumour menle to surgicl resection? If not, cn it e down-stged y chemotherpy? If still unresectle is it suitle for pllitive tretment such s stenting nd/or lser tretment? Is there extensive metsttic disese or re there other co-moridity fctors tht prevent intervention? Mny of these questions cn e nswered y MDCT which, of course, is prticulrly good t demonstrting loco-regionl nodes s well s locl invsion into djcent structures. Nturlly, it excels t demonstrting more distnt metsttic disese, prticulrly in the liver. However, the emerging role of PET/CT will chllenge it in severl of these res (lymph nodes nd the liver in prticulr), nd this will hve to e incorported into mngement protocols when importnt clinicl decisions hve to e mde. It must lso e rememered tht CT cnnot s yet compete with endoscopic ultrsound for T1/2 stging. Nturlly, CT plys mjor role in the followup of these ptients, whether they hve hd forml surgery or pllition in the form of stent. Tumour recurrence nd/or more distnt spred lwys will remin possiility nd the role of rdiology in the post-opertive sitution is reviewed in Chpter 13. The iggest prcticl issues following stent insertion is locl recurrence, which my e through the mesh if it is uncovered, or over the top of the stent if covered. However, covered stents re more prone to distl migrtion thn uncovered, which lso presents its own prolem. Tumour recurrence through the wll cn e delt with y lser therpy or, on occsion, y the insertion of second stent through the lumen of the originl. The prevlence of pncretic cncer is lso incresing nd its presenting fetures often overlp with those of gstro-duodenl origin. Of course, if the tumour is situted in the hed of the pncres then ostructive jundice is likely to e the first sign. However, tumours rising from the neck or ody of the glnd often hve more insidious nd occult mode of presenttion, usully with vgue epigstric discomfort, together with loss of ppetite nd weight. Urgent CT exmintion will usully revel the dignosis nd should e performed t the slightest suggestion, s it is the minsty of dignosis. In summry, it cn e seen tht the role of rdiology in investigting diseses of the stomch nd duodenum hs chnged. Endoscopy nd endoscopic techniques re now pre-eminent in the initil dignosis, ut rdiology, prticulrly in the vrious forms of cross sectionl imging, hs mjor nd incresing role to ply.

12 4 A. H. Freemn References Hmmer J, Tlley NJ (2000) Non-ulcer dyspepsi. Curr Opin Gstroenterol 16: Ntionl Institute for Helth nd Clinicl Excellence (2004) Mnging dyspepsi in dults in primry cre. NICE, London ( Hippisley-Cox J, Couplnd C, Logn R (2005) Risk of dverse gstrointestinl outcomes in ptients tking cyclo-oxygense-2 inhiitors or conventionl non-steroidl ntiinflmmtory drugs: popultion sed nested cse-control nlysis. BMJ 331: Additionl Reding British Society of Gstroenterology (2002) Guidelines for the mngement of oesophgel nd gstric cncer. BSG, London (

13 Rdiologicl Pthologicl Correltion 5 Rdiologicl Pthologicl Correltion 2 Jcques W. A. J. Reeders, Aln H. Freemn, nd Evis Sl Rdiology s discipline is one which is dominted y imges. Nowhere is this truer thn imging of the upper gstrointestinl trct, which ws the first re to experience the correltion of imges produced y indirect rdiologicl techniques with those produced y direct endoscopic methods. Knowledge of the mcroscopic ppernces s shown either y endoscopy or from pthologicl specimens is the key to interpreting rdiologicl imges. The following chpter ttempts to ring these fcets together so tht the reder is le to understnd etter the pthologicl se of the common nd not so common conditions ffecting the stomch nd duodenum, nd how these processes mnifest themselves on rdiologicl imges. Fig. 2.1,. Erosive Gstritis. Doule Contrst rium study () showing multiple erosions in the ody nd ntrum of the stomch. Note the typicl round lucencies with centrl pit of rium. Endoscopy () confirms the smll ulous elevtions with centrl ulcertions J. W. A. J. Reeders, MD, PhD Consultnt Rdiologist, Deprtment of Rdiology, St. Eliseth Hospitl Willemstd, Breedestrt 193(O), Curço, Netherlnds Antilles A. H. Freemn, MB, BS, FRCR Consultnt Rdiologist, Deprtment of Rdiology, Addenrooke s Hospitl, Box 219, Hills Rod, Cmridge, CB2 2QQ, UK E. Sl, MD, PhD, FRCR Univerity Lecturer/Honorry Consultnt Rdiologist, Deprtment of Rdiology, Addenrooke s Hospitl, Box 219, Hills Rod, Cmridge, CB2 2QQ, UK

14 6 J. W. A. J. Reeders, A. H. Freemn, nd E. Sl Fig. 2.2 c. Benign gstric ulcer. Doule contrst rium study () showing lrge deep penetrting ulcer t the incisur ngulris. Ultrsound of the wter-filled stomch () illustrtes the oedemtous order of the ulcer. Endoscopy (c) confirms deep ulcertion with thickening of the surrounding mrgin. Biopsy proved this to e enign ulcer c Fig. 2.3,. Benign gstric ulcer. Doule Contrst rium study () shows smll enign ulcer niche on the greter curve of the ody of the stomch, with folds rditing to the ulcer crter. Endoscopy () confirmed enign ulcer

15 Rdiologicl Pthologicl Correltion 7 Fig. 2.4,. Mlignnt gstric ulcer. Doule Contrst rium study () nd single contrst study () show lrge deep penetrting mlignnt ulcer on the lesser curve of the ody of the stomch. Note the prominent tumour collr round the mrgin of the ulcer Fig. 2.5,. Ischemic gstric ulcer (itrogenic). Doule Contrst rium study () showing deep penetrting ulcer ffecting the greter curve of the ody of the stomch, mimicking mlignnt ulcer. Three months prior to this investigtion, the ptient hd undergone coelic xis plexus lockde with the injection of 96% lcohol prtly within the gstric wll. Endoscopy () demonstrtes the deep ulcer with well defined mrgins

16 8 J. W. A. J. Reeders, A. H. Freemn, nd E. Sl c d Fig. 2.6 d. Hypertrophic Gstritis. Doule Contrst rium study () demonstrting enlrged tortuous nodulr folds, lso shown t endoscopy (), endo-ultrsonogrphy (c) nd CT (d)

17 Rdiologicl Pthologicl Correltion 9 Fig. 2.7 c. Zollinger-Ellison Syndrome. Doule Contrst rium study () showing enlrged thickened tortuous folds in the ody of the stomch, lso well demonstrted t endoscopy (,c) c Fig. 2.8,. Gstric Polyps. Doule Contrst rium study () nd Endoscopy () demonstrting innumerle enign hyperplstic polyps in the ody nd ntrum of the stomch

18 10 J. W. A. J. Reeders, A. H. Freemn, nd E. Sl c d e Fig. 2.9 e. Leiomyosrcom of the stomch Doule Contrst rium study (A) shows lrge ulky mss, protruding into the lumen of the ody of the stomch, covered with norml mucos. Note the deep ulcertion t the cudl side of the tumour, commonly seen with lrger leiomyoms (GISTs) nd leiomyosrcoms. Endoscopy (,c) demonstrtes the upper nd lower orders of the well delineted mss, with the ulcer clerly seen with retroversion of the endoscope (). Endoscopic ultrsound (d) shows tht the mss does not penetrte through the musculris mucose of the stomch wll. Histopthology of the resection specimen (e) is tken through the level of the ulcer in the leiomyosrcom

19 Rdiologicl Pthologicl Correltion 11 c Fig c. Kposi s srcom of the stomch. Doule Contrst rium study () shows multiple well delineted smll ullous protrusions into the lumen of the ody nd ntrum of the stomch. Ultrsound () shows multiple protrusions into the wter-filled lumen. Endoscopy (c) demonstrtes purple coloured round shrply delineted lesions, on ckground of norml mucos, typicl of Kposi s srcom Fig. 2.11,. Metstsis to the stomch. Doule Contrst nd Single Contrst rium studies () demonstrte villous type tumour rising from the lesser curve spect of the ntrum, confirmed t endoscopy (). Biopsy reveled metstsis from rest cncer

20 12 J. W. A. J. Reeders, A. H. Freemn, nd E. Sl Fig. 2.12,. Erly Gstric Cncer. Doule Contrst rium study () shows flt ulcerted lesion on ckground of norml mucos. The folds re distorted nd truncted t the level of the flt lesion. Histopthology of the resection specimen () confirmed n erly gstric denocrcinom Fig. 2.13,. Erly Gstric Cncer. Doule Contrst rium study () shows slight distortion of norml mucosl folds on the posterior wll of the ntrum of the stomch. Endoscopy () demonstrtes the non-depressed lesion, with distortion of the norml gstric mucosl pttern. Histopthology confirmed erly gstric cncer

21 Rdiologicl Pthologicl Correltion 13 c Fig c. Linitis Plstic of the stomch. Doule Contrst rium study () shows mrked circumferentil nrrowing of the fundus nd proximl ody of the stomch. Ultrsound () nd CT (c) confirm extensive thickening of the gstric wll. Multiple iopsies confirmed the presence of linitis plstic Fig. 2.15,. Leiomyom of the stomch. Doule Contrst rium study () shows well delineted smooth mss rising from the lesser curve of the stomch. Endoscopic-ultrsound () demonstrtes mssive lesion which does not penetrte through the gstric wll. Biopsy reveled enign leiomyom

22 14 J. W. A. J. Reeders, A. H. Freemn, nd E. Sl c Fig c. Crohn s Disese of the stomch. Doule Contrst rium study () shows distortion of the norml gstric mucosl pttern with mrked nodulrity nd multiple phthous lesions. Note the irregulr sclloping ffecting the greter curve, due to ctive Crohn s Disese. Ultrsound () nd Endoscopic-ultrsound (c) show mrked trnsmurl thickening of the gstric wll. The musculris propri is intct

23 Rdiologicl Pthologicl Correltion 15 c d Fig e. Non Hodgkin Lymphom (NHL) of the stomch. Doule Contrst rium study () demonstrting thickened rditing gstric folds on the posterior wll of the ody of the stomch, with centrl ulcerted elevtion of mucos. Endoscopic-ultrsound () performed two weeks fter () confirms ulcerted nodulr elevtion of the gstric wll. Endoscopy (c) shows nodulr gstric mucosl elevtions with centrl ulcertions. At CT (d) mrked symmetric gstric wll thickening is present. Histopthologic resection specimen (e) confirms NHL e

24 16 J. W. A. J. Reeders, A. H. Freemn, nd E. Sl Fig. 2.18,. Benign Cyst of the stomch. Doule Contrst rium study () demonstrtes hlf-round protrusion into the gstric lumen which rises from the lesser curve spect of the stomch. Endoscopic-ultrsound () confirms its fluid nture, comptile with enign cyst, such s gstric retention cyst Fig. 2.19,. Borrmnn 4 Adenocrcinom of the stomch. Doule Contrst rium study () demonstrtes n irregulr constriction ffecting the ody of the stomch, due to n extensive mlignnt process. Endoscopy () confirms the ulcerted irregulr culiflower lesion which is oozing lood. Biopsy reveled n denocrcinom of the stomch

25 Rdiologicl Pthologicl Correltion 17 c d Fig d. Gstric Polyp. Doule Contrst rium study () demonstrtes lrge pedunculted polyp in the ntrum of the stomch. Endoscopy () nd Endoscopic-ultrsound (c) confirm the pedunculted polyp which ws confirmed s non ulcerted firoid polyp on histopthology (d)

26 18 J. W. A. J. Reeders, A. H. Freemn, nd E. Sl Fig. 2.21,. Metsttic Invsion of the stomch. Doule Contrst rium studies of the stomch nd colon (). This imge demonstrtes irregulrity of the greter curvture of the ody nd ntrum of the stomch, together with pinpoint tpered irregulr stenosis of the trnsverse colon. Note the irregulr trnsverse ridges, running perpendiculr to the colonic xis. Gstroscopy () demonstrtes n ulcerted nodulr surfce of the stomch. Dignosis: Adeno-crcinom of the colon with secondry metsttic ingrowth into the stomch Fig. 2.22,. Ectopic Pncres in the stomch. Doule Contrst rium study () shows smll nodule in the ntrum of the stomch (ottom left of imge). Endoscopy () demonstrtes the chrcteristic round umilicted lesion situted few centimeters proximl to the pylorus. Biopsy confirmed ectopic pncres (pncretic rest)

27 Rdiologicl Pthologicl Correltion 19 Fig. 2.23,. Antrl Mucosl Prolpse. Doule Contrst rium study () demonstrting prolpse of ntrl mucos through the pylorus. Note the typicl mushroom shped deformity t the se of the duodenl ul cused y this norml vrint. Endoscopy () shows the prolpsed folds Fig c. Duodenl gstric heterotopi. Doule Contrst rium study () shows multiple hexgonl mucosl islnds in the duodenum, clssiclly situted t the se of the duodenl ul. These re confirmed t endoscopy () nd prticulrly well seen fter stining with methylene-lue (c). Dignosis: Gstric heterotopi c