Stomach and Duodenum Flashcards
provides excellent evaluation of stomach and duodenum and remains part of radiologic armamentarium
UGI
technique that entails using small amounts of barium to coat the mucosa without distending the bowel to demonstrate abnormalities such as varices
mucosal relief technique
essentially a hollow tube consisting of four concentric layers of tissue
GI tract
innermost layer of the GI tract exposed to the lumen is the
mucosa
GI mucosa consists of epithelium supported by loose connective tissue of the lamina propria and a thin band of smooth muscle called the
muscularis mucosae
layer of GI wall lining that contains the primary vascular and lymphatic channels, lymphoid follicles and autonomic nerve plexuses
submucosa
major muscular structure of the bowel wall is
muscularis propria
muscularis propria consist of
inner circular and outer longitudinal layers
outer covering of the bowel
serosa or adventitia
layer of GI tract that contains the lymphoid tissue
mucosa (epithelium and lamina propria), submucosa, and the mesenteric lymph nodes
major component of GI lymphoid tissue that plays a major role in host defense and is a site of significant disease
mucosa-associated lymphoid tissue (MALT)
refers to region of GEJ
cardia
portion of stomach above the level of GEJ
fundus
central 2/3 portions from cardia to incisura angularis
body of stomach
acute angle formed on the lesser curvature that marks the boundary between the body and antrum
incisura angularis
gastric cells which produce hydrochloric acid and chief cells, which produce pepsin precursors and located in the fundus and body
parietal cells
distal 1/3 of stomach and contains gastrin-producing cells but no acid-secreting cells
antrum
junction of the stomach with the duodenum and the pyloric canal
pylorus
pyramidal first portion of the duodenum
duodenal bulb or cap
duodenal bulb like the stomach is covered on call surfaces by
visceral peritoneum
remainder of the duodenum is located where
retroperitoneal and within the anterior pararenal compartment.
part of duodenum that is lateral to the head of pancreas
second or descending portion of duodenum
common bile duct and pancreatic duct pierce the medial aspect of the descending duodenum at the
ampulla of Vater
part of duodenum that passes to the left between the SMV and IVC and aorta
3rd or horizontal portion
part of duodenum that ascends on the left side of aorta to the level of L2 and ligament of Treitz, where it turns abruptly ventrally to form the duodenal-jejunal flexure
fourth or ascending portion
this term refers to the detailed pattern of gastric mucosa as demonstrated by double-contrast technique. it varies from a fine reticular pattern to a course nodular pattern
areae gastricae
refers to gastric mucosal folds that produce distinct radiolucent ridges when the stomach is partially distended
rugae
rugae are composed of
mucosa, lamina propria, muscular mucosae and portions of submucosa
rugal folds are most prominent in what part of stomach
fundus and proximal gastric body
rugal folds are usually absent in
antrum
lesser curvature of the stomach is attached to the liver by the
lesser omentum
attaches the greater curvature of stomach
greater omentum
an intraperitoneal space posterior to the stomach and anterior to the pancreas
lesser sac
normal gastric wall on ct when well distended in the antrum measures ___ and in the body ___
5-7 mm thick and 2-3 mm
wall of normal duodenum measures
less than 3 mm
major cause of chronic gastritis, duodenitis, benign gastric and duodenal ulcers, gastric adenocarcinoma and MALT lyphoma
H. Pylori
H.pylori will only infect what cell-type and is usually located where
gastric-like epithelium, gastric antrum
H.pylori survives in gastric acid by
using a powerful urease enzyme to break down urea into ammonia and bicarbonate, creating a more alkaline environment for itself
double contrast technique demonstrates ____ in 50% of patients with H.pylori infection
enlarged areae gastricae
diagnosis of H.pylori infection is made by
serology, urease breath tests and endoscopic biopsy
tx for H.pylori
combination of 2 or more drugs, including one or more antibiotics, H2 blockers to decrease acid secretion, and occasionally a bismuth compound
third most common GI malignancy, following colon and pancreatic CA
gastric carcinoma
most (95%) gastric carcinomas are of what cell type
adenocarcinoma
remaining 5% of gastric carcinomas are of what cell type
diffuse anaplastic (signet ring) carcinoma, squamous cell carcinoma or rare cell types
predisposing factors for gastric carcinoma
smoking, pernicious anemia, atrophic gastritis and gastrojejunostomy
cause of half of gastric adenocarcinoma
H.pylori
peak age and gender predilection of gastric adenocarcinoma
50-70 y.o with males predominating 2:1
4 common morphologic growth pattern of gastric carcinoma
polypoid, broad-based and papillary, ulcerative, infiltrating tumors
type of morphologic growth pattern of gastric carcinoma that present as filling defects within the gastric lumen
polypoid
type of morphologic growth pattern of gastric carcinoma that present as focal plaque-like lesions with central ulcer or diffusely infiltrating with poorly differentiated carcinomatous cells producing bizarre thickened folds and thickened rigid stomach wall, so-called scirrhous carcinomas
infiltrating
term that may be applied to describe the resulting stiff narrowed stomach
linitis plastica, water bottle stomach
lymphatic spread of gastric carcinoma
perigastric nodes along the lesser curvature, celiac axis, hepatoduodenal, retropancreatic, mesenteric, and para-aortic nodes
hematogeneous spread of gastric carcinoma
liver, adrenal glands, ovaries and rarely, bone and lung
intraperitoneal seeding of gastric carcinoma presents as
carcinomatosis or Krukenberg ovarian tumors
early gastric cancers appear on barium studies as
gastric polyps with risk of malignancy increased for lesions than 1 cm, superficial plaque-like lesions or nodular mucosa, shallow irregular ulcers with nodular adjacent mucosa
what GI organ is the most common site of involvement of primary GI lymphoma, accounting for approximately 50% of cases
stomach
risk factors for gastric lymphoma
chronic infection with H. Pylori, Epstein-Barr virus, Hepa B virus or campylobacter jejuni, celiac disease, atrophic gastritis and IBD
most of gastric lymphomas are of what cell type
B-cell type especially MALT type
4 morphologic patterns of gastric lymphoma
polypoid solitary mass, ulcerative mass, multiple submucosal nodules and diffuse infiltration
UGI findings in gastric lymphoma
polypoid lesions, irregular ulcers with nodular thickened folds, bulky tumors with large cavities, multiple submucosal nodules that commonly ulcerate and create a target or”bull’s eye” appearance, diffuse but pliable wall and fold thickening and rarely, linitis plastical appearance of diffuse, stiff narrowing
Multiplicity of gastric lesions favors what malignancy
MALT lymphoma
imaging features of gastric adenocarcinoma
focal wall thickening (> 1 cm), diffuse wall thickening (linitis plastica), large mass, ulcerated mass that is predominantly intraluminal, soft tissue stranding from mass into perigastric fat, adenopathy, peritoneal implants, distal metastasis
imaging features of gastric lymphoma
marked wall thickening (4-5 cm), circumferential wall thickening without luminal narrowing, homogeneous attenuation of tumor, multiple polyps with ulceration, extensive adenopathy, especially if below the renal hila, transpyloric tumor spreads to duodenum
imaging features of malignant GIST
large, heterogeneous exophytoc mass (> 5cm), extensive ulceration of the mass, prominent necrosis, hemorrhage, liquefaction, calcification within the tumor
imaging features of metastases to stomach
wall thickening, similar to primary carcinoma, focal intramural mass, ulcerated mural nodule, direct invasion of the stomach from adjacent tumor
most common mesenchymal tumor to arise from the GI tract. most, but not all tumors previously classified as leiomyomas, leiomyosarcomas and leiomyoblastomas are now classified as this entity
GISTs
approximately 60 to 70% of GISTs arise from
stomach
true or false: ture leiomyomas and leiomyosarcomas are very rare in the stomach
true
characteristic of GIST
long term growth to a large size
CT imaging characteristics of benign GIST
smaller (4 to 5 cm), homogeneous in density, show uniform diffuse enhancement
CT imaging features of malignant GIST
larger tumor (> 10 cm) with central zones of low density caused by hemorrhage and necrosis and show irregular patterns of enhancement
common primary tumors that metastasize in the stomach are
melanoma, breast and lung ca
breast cancer metastasis to stomach produce
linitis plastica
common symptom of Kaposi sarcoma in the stomach
bleeding
adenomatous polypoid masses that produce multiple frond-like projections. most are solitary and 3 to 9 cm in size although giant tumors may be as large as 15 cm. malignant potential is high and varies with size of lesion. barium trapped in clefts between fronds produces a characteristic soap bubble appearance. tumors are mobile and deform with compression
villous tumors
malignant potential is high in villous tumors, __% in 2-4 cm lesions and ___% for lesions > 4cm
50% and 80%
this sign is produced by the acute angle of attachment of the polyp to the mucosa
bowler hat sign
this sign consists of two concentric rings and is produced by visualizing a pedunculated polyp end on. Polyps are commonly multiple
mexican hat sign
accounts for 80% of gastric polyps
hyperplastic polyps
true or false: hyperplastic polyps are not neoplasms, but rather hyperplastic responses to mucosal injury, especially gastritis, have no malignant potential but are indicative of chronic gastritis
hyperplastic polyps
accounts for 15% of gastric polyps
adenomatous polyps
most adenomatous polyps are seen in what part of stomach
antrum
polyps that are larger than ___ cm and appears ____ should have biopsies taken of them because of risk of malignancy
larger than 1 cm, lobulated or pedunculated
polyps that occur in Peutz-Jeghers syndrome. they have no malignant potential
Hamartomatous polyps
true or false: gastric lipomas are submucal neoplasms composed of mature benign fatty tissue. UGI reveals a smooth, well-defined submucosal lesion that occasionally ulcerates
true
ectopic pancreas in the stomach is usually seen at what part
antrum
appearance of ectopic pancreas in the stomach
up to 5 cm in size, are covered by gastric mucosa, most are nipple- or cone-shaped with small central orifices
refers to an intraluminal gastric mass consisting of accumulated undigested material
bezoar
normal gastric folds are thicker and more undulated in what part of the stomach
proximal stomach and along the greater curvature
irregular, focal (<5 cm length), asymmetric bowel wall thickening suggests
malignancy
Regular, homogeneous, symmetric bowel wall thickening suggests a
benign process
diffuse bowel wall thickening (> 6 cm in length) is usually caused by a
benign, inflammatory, ischemic or infectious diseases
following IV contrast administration, bowel thickening that shows alternating densities of high or low attenuation (target appearance) indicates _____. the low-density layer is indicative of bowel wall edema
nearly always benign and secondary to inflammation or ischemia
perigastric fat stranding, disproportionately more severe than the degree of wall thickening suggests a
an inflammatory process
convenient label used to describe a wide variety of diseases affecting the gastric mucosa
gastritis
hallmarks of gastritis
thickened folds and superficial mucosal ulcerations (erosions)
defined as defects in the mucosa that do not penetrate beyond the muscularis mucosae
erosions
also called varioliform erosions, are complete erosions that appear as tiny central flecks of barium surrounded by a radiolucent halo of edema
aphthous ulcers
true or false: erosion heals without scarring
true
gastritis is commonly associated with
duodenitis
most common form of gastritis and is the most common cause of thickened gastric folds
H pylori gastritis
erosive gastritis is most often caused by
alcohol, aspirin and other NSAIDs or steroids
crohn gastritis characteristically involves the
gastric antrum and proximal duodenum
a chronic autoimmune disease that destroys the fundic mucosa but spares the antral mucosa
atrophic gastritis
destruction of parietal cells results in
decreased acid and intrinsic factor production that lead to vitamin B12 deficiency and pernicious anemia
UGI findings in this disease entity include decreased or absent folds in the fundus and body (“bald fundus”), narrowed, tube-shaped stomach (fundal diameter <8cm) and small (1 to 2 mm) or absent gastricae
atrophic gastritis
type of gastritis that is acute, often fatal bacterial infection of the stomach . alpha hemolytic streptococci are the most common cause, but a variety of other bacteria has also been identified
Phlegmonous gastritis
phlegmonous gastritis may arise as a complication of
septicemia, gastric surgery or gastric ulcers
in this type of gastritis, multiple abscesses are formed in the gastric wall, which is markedly thickened. rugae are swollen. barium may penetrate into abscess crypts in the gastric wall. peritonitis develops in 70% of cases. healing usually results in a severely contracted stomach
phlegmonous gastritis
form of phlegmonous gastritis caused by gas-producing organisms, usually E.coli, clostidium welchiii, or mixed infectious with S. aureus. most cases are caused by caustic ingestion, alcohol abuse, surgery, trauma or ischemia. multiple gas bubbles are apparent within the wall of stomach. gastric folds are thickened and edematous
emphysematous gastritis
rare type of gastritis characterized by diffuse infiltration of the wall of stomach and small bowel by eosinophilar and perihilar areaseos
eosinophilic gastroenteritis
in eosinophilic gastroenteritis, what part of the abdomen is narrowed with a nodular “cobblestone” mucosal pattern
antrum
also called giant hypertrophic gastritis is a rare condition characterized by excessive mucus production, giant rugal hypertrophy, hypoproteinemia and hypochlorhydria
Menetrier disease
UGI findings of menetrier disease include
markedly enlarged (> 10 mm in the fundus) and tortuous but pliable folds in the fundus and body, especially along the greater curvature, with sparing of the antrum, and hypersecretion but has diluted the barium and impaired mucosal coating. CT demonstrates nodular markedly thickened folds with smooth serosal surface and normal gastric wall thickness between folds
gastric varices are common in
fundus
isolated gastric varices occur with
splenic vein occlusion
what part of the stomach is the most common location for neoplasms
distal stomach
defined as full-thickness defect in the mucosa. it frequently extends to the deeper layers of the stomach, including the submucosa and muscularis propria.
ulcer
true or false: 95% of ulcerating gastric lesions are benign
true
diagnostic method of choice for gastric ulcers
gastroduodenal endoscopy
ulcers that are usually associated with increased production of acid
duodenal ulcers
ulcers that occur with normal or even decreased acid levels
gastric ulcers
this must be present for peptic ulceration to occur
hydrochloric acid
major complications of peptic ulcer disease are
bleeding, obstruction and perforation
hallmark of benign ulcers
mucosa is intact to the very edge of an undermining ulcer crater
reliable radiographic evidence of benign ulcer
complete and sustained healing
edematous ulcer collar with overhanging mucosal edge is a sign of benign or malignant ulcer?
benign
ulcer projecting beyond the expected lumen is a sign of benign or malignant ulcer?
benign
radiating folds extending into the crater is a sign of benign or malignant ulcer?
benign
depth of ulcer that is greater than width is a sign of benign or malignant ulcer?
benign
presence of hampton line, best demonstrated on spot films obtained with compression, is caused by an overhanging gastric mucosa in an undermined ulcer is a sign of benign or malignant ulcer?
benign
wall thickening usually involving both antrum and duodenum is a sign of benign or malignant ulcer?
benign
edema and edematous stranding extending into periantral and periduodenal fat or involving adjacent organs is a sign of benign or malignant ulcer?
benign
deep ulcers that may show focal discontinuity of mucosal enhancement and/or outpouching of the lumen is a sign of benign or malignant ulcer?
benign
true or false: the size, depth, and location of the ulcer and the contour of the ulcer base are of no diagnostic value in differentiating benign from malignant ulcers
true
differential diagnosis for benign ulcers include
H.pylori peptic disease, gastritis, hyperparathyroidism, radiotherapy and Zollinger-elison syndrome
irregular tumor mass or infiltration of the surrounding mucosa is a sign of benign or malignant ulcer?
malignant
ulcer within the lumen of the stomach and an ulcer eccentrically located within the tumor mound is a sign of benign or malignant ulcer?
malignant
shallow ulcer with width greater than its depth is a sign of benign or malignant ulcer?
malignant
an ulcer with nodular, rolled, irregular or shouldered edges is a sign of benign or malignant ulcer?
malignant
presence of carmen meniscus sign is a sign of benign or malignant ulcer?
malignant
sign that appears as a large flat-based ulcer with heaped-up edges that fold inward to trap a lens-shaped barium collection that is convex toward the lumen is called
carmen meniscus sign
differential diagnosis of malignant ulcer include
gastric adenocarcinoma, lymphoma, leiomyoma, leiomyosarcoma
equivocal ulcers may show these characteristics
coarse areae gastricae abutting the ulcer, nodular ulcer collar, mildly irregular folds extending into the ulcer edge
90% of tumors in the duodenal bulb are benign or malignant
benign
most tumors in this portion of the duodenum are malignant
4th portion
signs of malignant duodenal tumor include
central necrosis, ulceration or excavation, exophytic or intramural mass, evidence of tumor beyond the duodenum
duodenal adenocarcinoma are most common in the
periampullary region
this duodenal malignancy appears on CT and MR as an enhancing intramural or exophytic soft tissue mass with frequently bilobed “dumbbell” shape
duodenal adenocarcinoma
metastases to the duodenum may occur in what part of duodenum
wall or subserosa of the duodenum presenting with wall thickness
most common primary malignancies that metastasise to duodenum
breast, lung, GI
presents as polypoid lesion that may be pedunculated or sessile. this accounts for about half of the neoplasms in the duodenum
duodenal adenoma
these duodenal adenomas have a high incidence of malignant degeneration and a characteristic “cauliflower” appearance on double contrast UGI serires
villous adenomas
GISTs in duodenum are common in what part
second or third portion
second most common primary malignant tumor of duodenum
malignant GIST
presents as small (1 to 3 mm) polypoid nodules diffusely throughout the duodenum. it is associated with immunodeficiency states in some adults
lymphoid hyperplasia
true or false: there is no evidence that supports the concept that lymphoid hyperplasia is a precursor to lymphoma
true
this disease entity may prolapse through the pylorus during peristalsis and cause a lobulated mass at the base of the duodenal bulb. diagnosis is suggested by characteristic location and change in the configuration with peristalsis, which may be observed on UGI
gastric mucosal prolapse/heterotopic gastric mucosa
this lesion has the appearance of areae gastricae in the duodenal bulb, or as clusters of 1-3 mm plaques on the smooth duodenal bulb mucosa
gastric mucosal prolapse/heterotopic gastric mucosa
located in the submucosa of proximal 2/3 of duodenum and secrete an alkaline substance that buffers gastric acid
brunner gland hyperplasia/hamartoma
hyperplasia has size of
multiple and smaller than 5 mm
hamartomas has size of
> 5 mm
true or false: brunner gland hamartomas are benign and without cellular atypia
true
common cause of multiple nodules, often with a cobblestone appearance
diffuse nodular gland hyperplasia
usually presents as solitary nodule and is identical in appearance to other benign duodenal nodules
Brunner gland hamartoma
True or false: Brunner glands are located deep in the wall of duodenum that may be overlooked on endoscopy
true
ectopic pancreas in duodenum occurs in what part
proximal descending portion
most characteristic for ectopic pancreas in the duodenum
solitary mass with central dimple
valvulae conniventes is also known as
Kerckring folds
valvulae conniventes begin at what portion of duodenum
secondary to suboptimal inspiration
they are permanent circular folds of mucosa supported by a core of fibrovascular submucosa
valvulae conniventes
thickened valvulae conniventes measures
greater than 2-3 mm wide
refers to inflammation of duodenum without discrete ulcer formation
duodenitis
major cause of duodenitis
H.pylori
UGI findings in duodenitis include
thickening (>4 mm) of proximal duodenal folds, nodules or nodular folds (enlarged Brunner glands), deformity of duodenal bulb and erosions
Crohn disease of duodenum involve what portion
first and second portions
most commonly involved part of the duodenum in duodenal ulcers
duodenal bulb, anterior wall
en face appearance of ulcer crater
persistent collection of barium or air
appearance of ulcers in profile
project beyond the normal lumen
duodenal ulcer size are mostly
smaller than 1 cm diameter
caused by gastrin-secreting neuroendocrine tumor (gastrinoma)
Zollinger-Ellison syndrome
gastrinomas are found in the
pancreas, duodenum and extraintestinal sites (liver, lymph nodes, ovary)
multiple peptic ulcers in Zollinger-Ellison syndrome are most characteristic in what part of duodenum
postbulbar duodenum
duodenal diverticula are most commonly seen along the
inner aspect of descending duodenum
diverticula are differentiated from ulcers on a UGI series by demonstration of
mucosal folds entering the neck of diverticulum and change in appearance with peristalsis
these are duodenal diverticula that are caused by thin, incomplete, congenital diaphragm that is stretched by moving intraluminal contents to form a “windsock” configuration within the duodenum
intraluminal diverticula
most common congenital anomaly of pancreas
annular pancreas
portion of duodenum that is encircled and narrowed by annular pancreas
descending portion
congenital abnormality that occurs when the bilobed ventral component of pancreas fuses with the dorsal pancreas on both sides of duodenum
annular pancreas
annular pancreas is associated with high incidence of what abnormality in the duodenum
postbulbar peptic ulceration in adults
postbulbar duodenal ulcer is commonly associated with
narrowing of the lumen of second and third portions of duodenum
common cause of upper GI bleeding
duodenal ulcer
