Diffrential diagnosis of gastric masses and narrowing

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Diffrential diagnosis of gastric masses and narrowing

  1. 1.  Anatomy of stomach  DD of gastric masses
  2. 2.  Barium Meal
  3. 3.  Reticular pattern Area Gastricae  Rugae  Rosette of folds in gastric cardia
  4. 4.  2-3 layered structure  Max thickness of stomach wall _4mm
  5. 5.  5 layers of bowel wall  Wall thickness of distended stomach _3 mm
  6. 6.  Benign tumours  Malignant tumours  Miscellaneous causes
  7. 7.  Hyperplastic Polyps -Local hyperplasia of glandular tissue -Small , smooth , sessile ,multiple -Size < 1 cm -Fundus & body of stomach -Arise from mucosa affected by chronic atrophic gastritis.
  8. 8.  Dependant part of stomach__filling defect  Anterior wall polyp__ring  Small, sessile,smooth polyps__always benign  Polyp>1cm OR irregular surface__further workup needed
  9. 9.  Majority dysplastic_may undergo malignant change  -Tubular -Tubulovillous -Villous  >1cm ,larger than hyperplastic  Solitary with nodular surface  Commonest site__Gastric antrum  May pedunculate,prolapse in pylorus
  10. 10.  Risk of malignant transformation relative to size  Carcinoma may co-exist
  11. 11.  Include 1. Stromal tumours 2. Neurofibroma 3. Lipoma 4. Hemangioma 5. Lymphangioma 6. Glomus tumour 7. Neural tumour 8. Brunner gland hemartoma 9. Duplication cyst 10. Ectopic pancreatic rest
  12. 12.  Difficult to diagnose by endoscopy because overlying mucosa may be intact  Large tumours tend to ulcerate  Smooth bulge into bowel lumen , margins forming a right angle/obtuse angle with normal bowel wall.
  13. 13.  Complications :  Necrosis  Ulceration  Gastric outflow obstruction  Intussusception  Large abdominal mass
  14. 14.  Barium Meal: -clearly defined margins -if central ulcer present__bull’s eye/target appearance
  15. 15.  CT: -well defined, homogenous mass -larger tumours__ulceration, necrosis -glomus tumour, pancreatic, carcinoid __ hypervascular -stromal, glomus tumour, hemangioma __calcifications
  16. 16.  EUS – diagnostic modality of choice -mass arising from mucularis propria or muscularis mucosa -smaller,echo-poor ,well-defined  >3cm tumors surgically removed
  17. 17.  Soft , may change shape with peristalsis or palpation  May ulcerate , bleed , intussuscept  Diagnosed by : -EUS__echogenic tumour  Confirmed by: - CT
  18. 18.  Capillary /cavernous type  Solitary / multiple -endoscopy for diagnosis -may complicate into:  Phlebolith  GI bleeding
  19. 19.  Greater curve of antrum OR anteromedialy in 1st or 2nd part of duodenum  Congenital failure of bowel recanalization  Gastric duplication present in early childhood  Filled with clear mucinous fluid
  20. 20.  Small __ 1-3 cm  Distal end of greater curve OR proximal duodenum  Incidental finding  If tissue well-diffrentiated,barium study may show a central niche or fill a short ductal system.
  21. 21.  Complications : • Pancreatitis • Pseudocyst • Adenocarcinoma  CT – variable appearance -homogenous , strongly enhancing tumours OR -avascular cystic lesions
  22. 22.  Include : 1. Gastric carcinoma 2. Lymphoma 3. Malignant stromal tumours (GIST) 4. Kaposi sarcoma 5. Carcinoid tumour 6. Metastatic tumours
  23. 23.  Risk factors: • Atrophic gastritis intestinal metaplasia dysplasia neoplasia • Pernicious anemia • H. Pylori infection • Partial gastrectomy • Nitrates intake
  24. 24.  Symptoms: • Anorexia • Dyspepsia • Weight loss • Anemia
  25. 25.  Mucosa and submucosa  90% 5 yr survival rate  Diffrentiate benign ulcers from ulcerating malignancy __nodularity, clubbing, interrupted or fused mucosal folds
  26. 26.  Muscularis propria invasion  May be • Polypoid • Fungating • Ulcerated • Infiltrating (linitis plastica)
  27. 27.  Stippled calcification in mucin producing Ca  Ulcerated early Ca resembles benign ulcer (meniscus sign)  Large tumours__obvious filling defects on barium studies
  28. 28.  Most common mets in stomach from: • Malignant melanoma • Ca breast • Kidney, lung, thyroid, testes
  29. 29.  Bull’s eye / target lesion
  30. 30. Padsign.CaheadofpancreasMetsfromCabreast
  31. 31.  Most common site of GI lymphoma  H.Pylori __MALT lymphoma  Coeliac disease __T-cell lymphoma  Middle aged men  Doesn’t cause obstruction commonly
  32. 32.  Radiological appearance o Often identical to gastric Ca, benign ulcers, suspect lymphoma if: • Giant cavitating lesions • Pronounced gastric folds thickening • Multiple polypoid tumours(bull’s eye)
  33. 33. CT -Bulky homogenous tumour -gastric wall thickness -perigastric fat plane preserved -transpyloric spread -splenomegally -multicentricity __CT used for staging
  34. 34.  1% of gastric malignancies  Fundus and body involved  Middle age / elderly __ males > females  Large tumours, might pedunculate  Central necrosis and ulceration
  35. 35.  CT  Exophytic growth  Low density necrotic centre  Dystrophic calcification  Mets to peritoneal cavity, liver, lung ,bone
  36. 36.  Tumour of blood vessels  1/3rd of homosexual male patients with AIDS  Multifocal tumours throughout GIT
  37. 37. Diagnosed by  Endoscopy -hemorhagic patches on gastric mucosa  Barium meal - large polypoid tumors OR -submucosal nodule,later ulcerates_bull’s eye lesion -linitis plastica  CT -retroperitoneal LN enlargement -splenomegaly
  38. 38.  Rare in stomach/duodenum  Slow-growing__distal antrum,lesser curvature  Submucosal nodules__may ulcerate/pedunculate  Hypervascular__both pri. n liver mets ___assess in both arterial and venous phase on CT
  39. 39.  Extrinsic compressions  Gastric pseudotumours  HPS  Bezoar  Peptic ulceration
  40. 40.  Diagnosed by :  Endoscopy  Barium studies  USG  CT
  41. 41.  Gastric fundal varices -filling defect on barium meal  Intragastric prolapse of sliding hiatus hernia -mucosal folds form the mass -disappears in recumbent position
  42. 42.  Mass of ingested material  Dragging sensation/ fullness  2 types:  Trichobezoar -mass of matted hair -young girls , psychiatric patients  Phytobezoars -vegetables/ fruit pith -unripe persimons, gastric surgery
  43. 43.  Diagnosis: -Barium meal __filling defect __outlines the mass __may penetrate __mottled appearance
  44. 44.  Rapunzel’s syndrome: -severe case of trichobezoar -extend into small bowel, even caecum  Plain radiograph of the abdomen showing multiple air fluid levels with dilated small intestinal loops and a sizable soft tissue density within the stomach
  45. 45.  Congenital anomaly - Infantile - adult  Stasis causes __ antral gastritis + ulceration  Antrum tapers into >2cm long pyloric canal
  46. 46.  To differentiate from annular Ca:  Antral tapering  Absence of mucosal destruction  Intact mucosal folds passing through pyloric canal
  47. 47.  In advanced cases, may cause gastric strictures

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