CLINICAL TRENDS AND TOPICS

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1 GASTROENTEROLOGY 68: , by The Williams & Wilkins Co. Vol. 68, No.2 Printed in U.S.A. CLINICAL TRENDS AND TOPICS DEMONSTRATION OF SUPERFICIAL GASTRIC EROSIONS BY DOUBLE CONTRAST RADIOGRAPHY IGOR LAUFER, M.D., F.R.C.P.( C}, JOHN HAMILTON, M.B., B.S., M.R.C.P., F.R.C.P.(C), AND J. E. MULLENS, M.D., F.R.C.S.(C) Departments of lladiology, Medicine, and Surgery, McMaster University Medical Centre, Hamilton, Canada Superficial gastric erosions were found in 30 of 267 patients undergoing esophagogastroduodenoscopy. In 13 of these patients, and in 7 others not submitted to endoscopy, superficial gastric erosions were demonstrated radiologically by the double contrast technique. These may appear as flat, linear streaks, as dots of barium, or as target-like lesions with a central fleck of barium surrounded by a radiolucent halo. In 1 patient, a ring-shaped density was demonstrated due to a small blood clot adherent to a gastric erosion. Although patients presenting with acute hemorrhagic gastritis should still be examined first by endoscopy, double contrast radiography has been of value in patients presenting after the cessation of bleeding and in patients with vague digestive complaints. Because of.our experience with the diagnosis of superficial gastric erosions, which have not been demonstrated by standard methods, and because of the Japanese experience with diagnosis of superficial gastric carcinoma, it is recommended that this technique be applied more widely to facilitate the detection of early and small lesions in the stomach. Superficial gastric erosions (SGE) are defined as defects in the epithelium of the stomach which do not penetrate beyond the muscularis mucosae. With the increasing application of flexible fiberoptic endoscopy, these lesions are being recognized frequently, and they are one of the commonest sources of upper gastrointestinal hemorrhage. 1-4 Causative factors include stress, ethanol, analgesics, and antiinflammatory agents such as acetylsalicylic acid, phenylubutazone, indomethacin, and steroids. However, in some patients, there are no known predisposing factors. It has generally been considered that these Received July 22,1974. Accepted August 20,1974. Address requests for reprints to: Dr. Igor Laufer, Department of Radiology, McMaster University Medical Centre, Hamilton, Ontario, Canada L8S 4J lesions are not demonstrable radiologically because they are very small and very shallow. Indeed, with the standard barium meal technique, there are very few and isolated instances in which SGE have been demonstrated. s - 10 At the McMaster University Medical Centre, we have been using a double contrast technique for routine examination of the stomach. This is a modification of the technique devised in Japan for the detection of early, superficial carcinoma of the stomach This method allows for visualization of minute mucosal detail and is well suited for the demonstration of SGE. We have reviewed our experience with the radiological and endoscopic diagnosis of superficial gastric erosions to show the value of double contrast radiography in the diagnosis of these small lesions.

2 388 CLINICAL TRENDS AND TOPICS Vol. 68, No.2 Methods Double contrast radiography of the stomach. The principle requirements are (a) good coating of the mucosa with a thin layer of barium, and (b) gaseous distention. The patient swallows 20 small effervescent pellets (Unik Zoru distributed by Unik Medical Labs, Montreal, Quebec) which release 200 to 300 cc of CO 2 in the stomach. This product is available in Canada but has not been approved by the FDA for use in the United States. Gaseous distention of the stomach may also be achieved by sipping barium through a perforated straw or by nasogastric intubation. Other effervescent agents may be used provided that they liberate sufficient CO 2 with a very small volume of water and that they do not interfere with mucosal coating. The patient then drinks 100 cc of a dense barium suspension (approximately 100% w/v) and is rotated through several revolutions to coat the mucosal surface with a thin layer of barium. The various preparations of barium sulfate differ in their viscosity at high concentrations and in their coating properties. We have used many different brands of barium in these double contrast studies, but have found that Barosperse (Mallinckrodt Pharmaceuticals, St. Louis, Mo.) and Baritop (Sakai Chemical Industry Co., Osaka, Japan) produce consistently superior mucosal coating. Fluoroscopic spot films of the stomach and duodenum are obtained to show each area filled with barium and with air contrast. In a normal double contrast study, the mucosal folds in the distal half of the stomach can be effaced completely. The mucosal surface may be smooth or may have a finely reticular appearance corresponding to the "areae gastricae." " Discrete flecks of barium are not seen in the normal stomach unless there has been flocculation of the barium suspension. This is easily recognized by the patchy nature of the mucosal coating. In patients with gastric retention or hypersecretion, adequate mucosal coating can usually be obtained by giving a larger volume of barium and by rotating the patient through a larger number of revolutions to wash the mucosal surface with barium. Gastroscopy. Gastroscopy was performed in the standard fashion during the course of endoscopic examination of the esophagus, stomach, and duodenum with the ACMI model F07089P panendoscope. Local anesthesia was obtained with 4% xylocaine gargle and premedication consisted of atropine, 0.6 mg, and Valium, 5 to 30 mg, intravenously. Photographs and biopsies were obtained as necessary. Results Endoscopic examinations were carried out on 267 patients during the past year. SGE were reported in 30 patients. In 12 patients, there were coexisting peptic ulcers of the stomach or duodenum, while in the remainder, the SGE were isolated abnormalities. Predisposing factors were found in 14 patients, as outlined in table 1. Four patients had presented with gastrointestinal bleeding, while the remainder complained of dyspepsia or epigastric pain often indistinguishable from peptic ulcer pain. Twenty-five of these patients were examined by the double contrast method, usually within 5 days of the endoscopic examination. The SGE were demonstrated radiologically in 13 of these patients. In 8 patients, this was a prospective radiological diagnosis made before endoscopy. In 2 patients, the lesions were recognized only on retrospective analysis of the radiographs, and 3 patients were not examined by the double contrast technique until after the SGE had been diagnosed by endoscopy. It is of interest that at least 17 of the 30 patients with endoscopically proven SGE had previous standard barium studies, and in none were the SGE demonstrated. In every case with a radiological diagnosis of SGE and subsequent endoscopy, the presence of these lesions was confirmed. Thus, there have been no false-positive radiological diagnoses of SGE. In addition to the 13 patients discussed above, we have demonstrated the typical radiological ap- TABLE 1. Predisposing causes for gastric erosions Factor ASA" Ethanol Gastric surgery Nongastric surgery Prednisone Crohn's disease None. Total a ASA, acetylsalicylic acid. No. b Biopsy-proved Crohn's disease of the stomach

February 1975 CLINICAL TRENDS AND TOPICS 389 pearance of SGE in 7 patients in whom endoscopy has not been performed.

erosion is a central epithelial defect surrounded by a mound of FIG. 2. Two shallow ulcers along the lesser curvature (black arrows).

A, close-up view of the antrum showing several superficial erosions with surrounding radiolucent halo.

3 February 1975 CLINICAL TRENDS AND TOPICS 389 pearance of SGE in 7 patients in whom endoscopy has not been performed. Correlation of Radiographic and Endoscopic Appearance of Erosions The appearance of erosions on double contrast study closely parallels their endoscopic appearance: The "complete"15 or "varioloform"6 erosion is a central epithelial defect surrounded by a mound of FIG. 2. Two shallow ulcers along the lesser curvature (black arrows). There are also two linear streaks of barium which were constant and reproducible (white arrows), corresponding to linear erosions seen at endoscopy. FIG. 1. A, close-up view of the antrum showing several superficial erosions with surrounding radiolucent halo. E, corresponding endoscopic photograph showing multiple erosions surrounded by a mound of edematous gastric mucosa. edematous mucosa. Radiographically, this is seen as a tiny fleck of barium representing the erosion and a radiolucent halo representing the edematous mound producing a "target" lesion (fig. 1). These are usually multiple, but occasionally a solitary erosion may be seen. The radiological study usually underestimates the number of erosions because of the difficulty in performing a double contrast study of the anterior wall of the stomach. "Incomplete" erosions 15 are flat epithelial defects without surrounding reaction. On double contrast study, these may coat with barium and present as reproducible streaks or dots of barium (fig. 2). In 1 patient, we were able to demonstrate a small circular collection of barium outlining a 3-mm blood clot adhering to an acetylsalicylic acid-induced erosion (fig. 3).. Biopsies of the SGE were generally not helpful and showed only nonspecific chronic inflammatory reaction.

For orientation, pylorus is outlined with black arrows. B, endoscopic photograph showing the small blood clot (large arrow). The pylorus is outlined by small arrows.

4 390 CLINICAL TRENDS AND TOPICS Vol. 68, No.2 FIG. 3. A, close-up view of gastric antrum showing a 2- to 3-mm circular density due to barium surrounding a blood clot (white arrow) adherent to an acetylsalicylic acid-induced erosion. For orientation, pylorus is outlined with black arrows. B, endoscopic photograph showing the small blood clot (large arrow). The pylorus is outlined by small arrows. Discussion Although double contrast radiography of the stomach was developed in Japan specifically for the detection of superficial carcinoma of the stomach, we have found it to be a sensitive technique for the detection of superficial ulcerating lesions in the stomach, including SGE. We have demonstrated these lesions in 20 patients during the past year. This is 'in striking contrast to our previous experience with the standard barium study whereby we had never been able to demonstrate these lesions. Success in the demonstration of erosive lesions requires optimal gastric distention, mucosal coating, and radiographic technique. Occasionally, compression studies without double contrast may demonstrate SGE. 9 We were unable to demonstrate these lesions by double contrast radiography in 12 of25 of the patients known to have SGE, even though the double contrast study was sometimes done on the same day as the endoscopic examination. Incomplete erosions are much more difficult to demonstrate and require optimal gastric distention and mucosal coating. The varioloform type of SGE is easier to demonstrate because of the surrounding mound of reaction. With additional refinements in this technique, it should be possible to demonstrate both types of lesions more regularly. Approximately 10 to 20% of patients with gastric erosions present with gastrointestinal hemorrhage. 7 Ideally, these patients should undergo panendoscopy as the primary diagnostic procedure. In such patients, good double contrast studies are difficult to perform because blood in the stomach precludes good mucosal coating. In patients who present after the cessation of bleeding, double contrast radiography may demonstrate the erosions or the adherent blood clot. In the absence of gastrointestinal bleeding and associated ulcers or tumors, most patients in whom SGE are found have nonspecific epigastric pain or dyspepsia. The relationship of these lesions to the patient's symptoms is unclear,3, 4, 7, 15 but, as our techniques improve and we are able to detect the presence and healing of these lesions without submitting patients to the discomfort of endoscopy, it should be possible to clarify these relationships. The demonstration of minute lesions, such as SGE, illustrates the sensitivity of double contrast radiography and suggests that it will be valuable for the detection of small and early lesions in the stomach which have escaped detection by the standard technique. Our modification of the Japanese method of double contrast radiography is easy to perform, requiring no special preparation of the patient and no added discomfort. The time required is approximately the same as that for a careful standard examination. The study can be performed with standard X-ray fluoroscopic equipment, but requires great attention to technical detail to ensure high

5 February 1975 CLINICAL TRENDS AND TOPICS 391 quality spot films which are necessary for detection of small lesions. Therefore, we think that this type of examination should be applied more widely and that this will eventually become the standard technique for radiological examination of the upper gastrointestinal tract. REFERENCES 1. Ivey KJ: Acute haemorrhagic gastritis: modern concepts based on pathogenesis. Gut 12: , Desmond AM, Reynolds KW: Erosive gastritis: its diagnosis, management, and surgical treat ment. Br J Surg 59:5-13, Dagradi AE, Lee ER, Bosco DL, et al: The clinical spectrum of hemorrhagic erosive gastritis. Am J Gastroenterol 60:30-46, Palmer ED: Upper Gastrointestinal Hemorrhage. Springfield, Ill, CC Thomas, 1970, p Cummack DH: Gastro-intestinal X-ray Diagnosis: A Descriptive Atlas. Edinburgh, E & S Livingstone Ltd, 1969, P Yamagata S, Ishikawa M: Endoscopic camera correlation, chap 55. In Alimentary Tract Roentgenology. Edited by AR Margulis, HJ Burhenne. St. Louis, CV Mosby, 1973, p Roesch W, Ottenjann R: Gastric erosions. Endoscopy 2:93-98, Abel W: Die roentgen diagnose der gastritis erosiva. Fortschr Geb Roentgenstr Nuklearmed 80:39-50, Frik W: Stomach in Roentgen Diagnosis, vol 5. Edited by HR Schinz, WE Brensch, W Frommholds, et al. New York, Grune & Stratton, 1967, p Henning N, Schatzki R: Gastrophotographisches und rontgenologisches bild der gastritis ulcerosa. Fortschr Geb Roentgenstr Huklearmed 48: , Shirakabe H: Double contrast studies of the stomach. Stuttgart, Georg Thieme Verlag, Shirakabe H, Ichikawa H, Kumakura K, et al: Atlas of X-ray Diagnosis of Early Gastric Cancer. Tokyo, Igaku Shoin, Prolla JC, Kobayashi S, Kirsner JB: Gastric cancer: some recent improvements in diagnosis based upon the Japanese experience. Arch Intern Med 124: , Kreel L, Herlinger H, Granville J: Technique of the double contrast barium meal with examples of correlation with endoscopy. Clin Radiol 24: , Demling L, Ottenjann R, Elster K: E n d o s ~ o p and Biopsy of the Esophagus and Stomach. Philadelphia, WB Saunders, 1972, p 86-88

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