Stomach and Duodenum Anatomy Figures

DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

• Fig. 19.1 Anatomy of the stomach.

• Fig. 19.2 Areae gastricae. Normal reticular
pattern to the mucosa produced by areae
gastricae.

• Fig. 19.3 Fine transverse mucosal folds. Prone
view. A = antrum; C = duodenal cap. Asterisks
mark the second and third parts of the
duodenum.

• Fig. 19.4 The gastric cardia viewed en face in
the left anterior oblique position. Lesser
curve folds run to the oesophageal orifice,
where a fold forms a hood (arrowheads) over
the cardia.

• Fig. 19.5 Endoscopic ultrasound showing a
metastasis (M) in the left lobe of liver.
(Courtesy of Dr Keith Harris.)

• Fig. 19.6 The normal duodenal cap seen by
double contrast. The mucosa has a velvety
appearance due to the presence of villi. (A)
Surface coating, almost homogeneous. (B) A
fine velvety reticular pattern is produced by
the villi.

• Fig. 19.7 The normal duodenal cap and loop.
Routine double-contrast barium meal. Supine
right anterior oblique view. The papilla of
Vater (white arrow) has a longitudinal
(arrowhead) and two oblique folds (black
arrows) extending below it.

• Fig. 19.8 Acute erosive gastritis. There are
numerous erosions in the stomach (arrows).
Each erosion consists of a small central
collection of barium surrounded by a
translucent ring (a small 'target' lesion).

• Fig. 19.9 Severe antral gastritis. Conical
narrowing of the antrum with multiple
thickened gastric folds.

• Fig. 19.10 Crohn's disease. Antral erosions and a tapered
stricture involving the first part of the duodenum. The
second part of the duodenum is dilated as a result of a
further stricture of the third part.

• Fig. 19.11 Menetrier's disease. Gross thickening
of the folds of the upper two-thirds of the
stomach. These patients often weep a protein-
rich exudate from the stomach wall, and this
excess of fluid in the stomach may impair barium
coating.

• Fig. 19.12 Benign gastric ulcer. (A) Mid lesser
curvature ulcer demonstrated in profile. The
ulcer crater is projecting outside the wall of the
stomach. (B) Diagram of benign ulcer with an
oedematous collar. Beneath the collar, a thin
lucent line may be seen across the mouth of the
ulcer (Hampton's line).

• Fig. 19.13 Giant benign gastric ulcers. (A) Lesser curve gastric ulcer projecting from the
posterior wall of the stomach (arrowheads) and penetrating into the pancreas. (B) Greater
curve ('sump ulcer'). This ulcer is typical of those occurring in patients who are taking tablets
which produce contact irritation and damage to the gastric mucosa (e.g. non-steroidal anti-
inflammatory drugs, steroids, potassium chloride).

• Fig. 19.14 Three characteristic types of gastric
ulcer; the shading represents barium. A = benign,
projecting, lesser curvature ulcer with collar
(broken lines); B = malignant, intraluminal ulcer
with irregular nodular tumour rim; C = non-
projecting benign greater curvature ulcer.

Fig. 19.15 (A) Benign gastric ulceration. Small posterior wall ulcer (asterisk)
demonstrated en face. Radiating mucosal folds extend to the edge of the crater. (B)
Healed benign gastric ulcer. Radiating folds from a central niche (arrow). In this
patient the niche persists despite endoscopic evidence that
ulcer has healed

• Fig. 19.16 Healing benign
gastric ulcer. Incisura and
'hour-glass‘ stomach. A
typical benign ulcer (arrow)
on the mid lesser curvature
of the stomach is associated
with a prominent incisura
which divides the stomach
into two.

• Fig. 19.17 Duodenal ulcer. Supine projection.
Barium collects in an ulcer on the dependent
(posterior) wall of the duodenal cap.

• Fig. 19.18 Anterior wall duodenal ulcer. (A)
Prone projection. The ulcer (arrow) is
dependent, and so fills with barium. (B)
Supine projection. The ulcer, which is now on
the non-dependent wall of the cap, is outlined
with a ring of barium (arrow).

• Fig. 19.19 Healing duodenal ulcer. The linear
shape of the posterior wall ulcer is indicated
(large arrow). Folds radiate to the ulcer (small
arrows).

• Fig. 19.20 Scarring of the duodenal cap resulting
from a chronic duodenal ulcer which has now
healed. The pouches produced by the scarring
resemble the shape of a cloverleaf.

• Fig. 19.21 Postbulbar
duodenal ulcer.
Characteristic
appearance with
ulcer crater (asterisk)
in the middle of a
stricture produced by
spasm and oedema.

• 19.22 Giant duodenal ulcer replacing the
duodenal cap

• Fig. 19.23 Pyloric canal ulcer (arrow).

• Fig. 19.24 Perforated
duodenal ulcer. An
unexpected, silent
perforation which explains
why barium has inadvertently
been used as the contrast
medium instead of
Gastrografin. Fortunately the
leak was localised to the right
subphrenic and subhepatic
space, otherwise a generalised
barium peritonitis would have
resulted. S = stomach; D =
duodenum; B = leaked barium.
folds; several small ulcers are
also present. (B) Multiple
erosions

• Fig. 19.25 Double pyloric canal. An antral
ulcer has fistulated through to the base of the
duodenal cap. Asterisk = antrum; C =
duodenal cap; straight arrow = pyloric canal;
curved arrow = fistula.

• Fig. 19.26 Duodenitis. Typical appearances in
the cap. (A) Thickened folds; several small
ulcers are also present. (B) Multiple erosions.

• Fig. 19.27 ' Cobblestone' caps (A) Duodenitis. Two l arge nodules
are seen which are due to erosions on a single mucosal fold.
(Courtesy of Dr J. Virjee.) (B) Hyperplasia of Brunner's glands. The
nodules are clearly defined, discrete and randomly distributed in
the duodenal cap and postbulbar region. (Courtesy of Dr A.
Schulman.) (C) Nodular lymphoid hyperplasia is characterised by
numerous small nodules all of the same size and evenly distributed.
(Courtesy of Dr J. Virjee.) (D) Heterotopic gastric mucosa. The
presence of gastric epithelium in the duodenal cap produces small
nodules of various sizes and shapes extending from the pylorus
toward the apex of the cap. (Courtesy of Dr J. Virjee.)

• Fig. 19.27 ' Cobblestone' caps (A) Duodenitis. Two l arge nodules are seen which
are due to erosions on a single mucosal fold. (Courtesy of Dr J. Virjee.) (B)
Hyperplasia of Brunner's glands. The nodules are clearly defined, discrete and
randomly distributed in the duodenal cap and postbulbar region. (Courtesy of Dr
A. Schulman.) (C) Nodular lymphoid hyperplasia is characterised by numerous
small nodules all of the same size and evenly distributed. (Courtesy of Dr J. Virjee.)
(D) Heterotopic gastric mucosa. The presence of gastric epithelium in the duodenal
cap produces small nodules of various sizes and shapes extending from the pylorus
toward the apex of the cap. (Courtesy of Dr J. Virjee.)

• Fig. 19.28 Gastric polyps. Multiple benign
hyperplastic polyps (arrows) evenly
distributed throughout the stomach.

• Fig. 19.29 Prolapsing giant hyperplastic polyp.
(A) The polyp (asterisk) has a stalk and is
seen as a filling defect arising from the
antrum. (B) The polyp has prolapsed into the
base of the duodenal cap. A = antrum, C=
duodenal cap.

• Fig. 19.30 Large villous tumour arising from
the medial wall of the duodenum (arrows)
close to the papilla (asterisk). Prone view. C =
duodenal cap.

• Fig. 19.31 (A) Benign gastric stromal tumour. The margins
of this submucosal tumour make an obtuse angle with the
adjacent normal mucosa. (B) Benign duodenal stromal
tumour. Submucosal tumour of the third part of the
duodenum. (Courtesy of Dr B. M. Carey.) (C) CT. Benign
duodenal stromal tumour arising from the medial wall of
the second part of the duodenum

• Fig. 19.31 (A) Benign gastric stromal tumour. The margins of this
submucosal tumour make an obtuse angle with the adjacent
normal mucosa. (B) Benign duodenal stromal tumour. Submucosal
tumour of the third part of the duodenum. (Courtesy of Dr B. M.
Carey.) (C) CT. Benign duodenal stromal tumour arising from the
medial wall of the second part of the duodenum

• Fig. 19.32 Benign tumour growth. The margin of
a mucosal tumour (A) forms a more acute angle
with the normal mucosa than that of a
submucosal tumour (B), which forms a right or
obtuse angle with the mucosa. When growth is
predominantly exophytic the tumour may drag on
the gastric wall to produce a niche (C).

• Fig. 19.33 Endoscopic ultrasound. Benign gastric
stromal tumour. Echo-poor mass arising from the
fourth hypoechoic layer, the muscularis propria.
At the margins, the tumour can be seen to merge
with the muscularis propria (arrows). Benign
gastric stromal tumours can also arise from the
second hypoechoic layer, the muscularis mucosa.
(Courtesy of Dr Keith Harris.)

• Fig. 19.34 Gastric lipoma. Echogenic well-
defined tumour arising from and expanding
the submucosal layer (black arrow).
Muscularis propria is displaced but intact
(smaller black arrows). (Courtesy of Dr Keith
Harris.)

• Fig. 19.36 Duodenal duplication cyst. (A) The cyst is
impressing on the medial aspect of presenting as a
large submucosal tumour arising the second part of the
duodenum (arrows) and did not communicate with the
duodenal lumen. from the medial wall of the second
part of the (B)Ultrasound shows fluid contents.
(Courtesy of Dr R. Fowler.) duodenum. (Courtesy of Dr
Keith Harris).

• Fig. 19.37 Ectopic pancreatic rest. These are generally found in the
distal antrum on the greater curve. The small diverticulum results
from barium entering the primitive ductal system (arrow). Supine fil
m. A = distal antrum; C = duodenal cap.

• Fig. 19.38 The Japanese Endoscopic Society
has classified early tumours into three types.
Type 1, protrude more than 5 mm above the
mucosal surface. Type 2, flat (2A), slightly
elevated (<5 mm (2B)), or slightly depressed
(2C). Type 3, ulcerating and penetrate the
muscularis mucosa.

• Fig. 19.39 Early gastric carcinoma. (A) Shallow
ulcerating tumour, type 2C (arrow). (B) Mixed
type (2B and C). An elevated tumour (between
arrowheads) is outline by barium. Two small
irregular ulcers are present (arrows).

• Fig. 19.40 Evaluating the folds around an ulcer. (A)
The folds around an early or advanced gastric cancer
may be thickened (A), clubbed (B), interrupted (C),
nodular (D) or fused (E). Folds do not reach the margin
of the ulcer, but this may be seen with benign ulcers if
there is a rim of oedema around the ulcer. (B)
Thickened, clubbed, interrupted, nodular and fused
folds around a malignant ulcer.

• Fig. 19.41 Advanced gastric carcinoma. (A) Fungating cancer arising from the greater
curve (arrows). (B) Malignant gastric ulcer. Single-contrast examination. The ulcer is
situated close to the lesser curvature and near the incisura. The arrows indicate the base
of the ulcer, which is in line with the lesser curvature,i.e. the crater is non-projecting.
Tumour at the margin of the crater appears translucent and nodular creating a pool of
barium, convex one side and concave the other (arrows) (meniscus sign). (C) Infiltrating
and ulcerating gastric carcinoma. The proximal half of the stomach is involved with
thickening of the wall, destruction of mucosa, and narrowing of the lumen (arrows).
Ulceration is present on the greater curve (long arrow). (D) Small stomach as a result of
diffuse submucosal infiltration (linitis plastica). Air has been injected down the
nasogastric tube to distend the stomach.

• Fig. 19.41 Advanced gastric carcinoma. (A) Fungating cancer arising from the
greater curve (arrows). (B) Malignant gastric ulcer. Single-contrast examination.
The ulcer is situated close to the lesser curvature and near the incisura. The arrows
indicate the base of the ulcer, which is in line with the lesser curvature,i.e. the
crater is non-projecting. Tumour at the margin of the crater appears translucent
and nodular creating a pool of barium, convex one side and concave the other
(arrows) (meniscus sign). (C) Infiltrating and ulcerating gastric carcinoma. The
proximal half of the stomach is involved with thickening of the wall, destruction of
mucosa, and narrowing of the lumen (arrows). Ulceration is present on the greater
curve (long arrow). (D) Small stomach as a result of diffuse submucosal infiltration
(linitis plastica). Air has been injected down the nasogastric tube to distend the
stomach.

• Fig. 19.42 Mucus-producing gastric
adenocarcinoma. Faint calcification can be
seen in the thickened wall of the antrum and
distal body of the stomach.

• Fig. 19.43 Carcinoma of distal antrum. The rolled
margins suggest the diagnosis. The differential
diagnosis includes hypertrophic pyloric stenosis but in
this condition the antrum tapers into the pyloric canal
and the mucosa within the canal can be seen to be
intact.

• Fig. 19.44 Endoscopic ultrasound showing the
five layers of the gastric wall and an enlarged,
rounded, hypoechoic, metastatic lymph node
(N). (Courtesy of Dr Keith Harris.)

Fig. 19.45 Gastric carcinoma. (A) Tumour stage T1.
The echogenic submucosal layer has not been
breached (black arrows) by the tumour (T). (B)
Tumour stage T3. Tumour (T) has breached
muscularis propria between points A and B. Intact
muscularis propria can be seen at the margins of
the tumour (black arrows).

• Fig. 19.46 Gastric carcinoma. The tumour is
enhancing and thickening the wall of the
antrum (arrows). The stomach is distended
with food debris as a result of gastric outlet
obstruction.

• Fig. 19.47 Linitis plastica. (A) Diffuse
thickening of the gastric wall demonstrated
by CT. (B) Endoscopic ultrasound showing a
narrowed gastric lumen and diffuse thickening
of all layers of the gastric wall by tumour
infiltration (between arrows).

• Fig. 19.48 (A) Gastric carcinoma constricting the body of the
stomach (arrows). Stomach distended with water. Prone scan shows
fat plane between tumour and pancreas, indicating that the
pancreas is not invaded. (B) Gastric carcinoma (asterisk) extending
beyond the serosa to encase the coeliac axis vessels. (Courtesy of
Prof. R. W. Whitehouse.) (C) Extension into the transverse
mesocolon (arrows) from a carcinoma of the antrum of the
stomach.

• Fig. 19.48 (A) Gastric carcinoma constricting the body of
the stomach (arrows). Stomach distended with water.
Prone scan shows fat plane between tumour and pancreas,
indicating that the pancreas is not invaded. (B) Gastric
carcinoma (asterisk) extending beyond the serosa to encase
the coeliac axis vessels. (Courtesy of Prof. R. W.
Whitehouse.) (C) Extension into the transverse mesocolon
(arrows) from a carcinoma of the antrum of the stomach.

• Fig. 19.49 Krukenberg tumours. Bilateral
partly cystic ovarian tumours and malignant
ascites. (Courtesy of Dr John Spencer.)

• Fig. 19.50 Gastric 'target' lesion. (A) An
ulcerating (large arrow) tumour in the fundus of
the stomach (small arrows). This appearance is
typical of an ulcerating submucosal metastasis
from malignant melanoma. (B) CT scan shows the
same tumour (arrow).

• Fig. 19.51 Metastasis to the antrum of the
stomach from carcinoma of the breast. The
tumour has spread submucosally. CT scan.
Lateral decubitus scan in an attempt to better
distend the gastric antrum.

• Fig. 19.52 Carcinoma of the pancreas. (A) Carcinoma of the head of the pancreas
invading the medial wall of the duodenal loop. Note the reversed-'3‘ sign of
Frostberg (arrowheads). A percutaneous transhepatic cholangiogram performed
with the barium study shows the common bile duct to be obstructed at its lower
end. (B) Pancreatic tumour producing an impression on and elevating the gastric
antrum (the pad sign). C = duodenal cap.

• Fig. 19.53 MALT lymphoma. Multifocal
tumour (arrows) thickening the gastric wall.

• Fig. 19.54 Gastric lymphoma. (A) CT scan. A bulky tumour (small arrows)
arising from the posterior wall of the stomach (large arrow). The tumour
extends posteriorly to involve the pancreas and splenic hilum. (B) Gross
thickening of folds in the fundus and body of this stomach infiltrated by
lymphoma. (C) An irregular stricture is present in the distal stomach, also
involving the duodenal cap. Adjacent nodal enlargement is producing an
impression on the inside of the duodenal loop.

• Fig. 19.55 Malignant gastric stromal tumour. (A)
CT. This predominantly exophytic tumour is
compressing the stomach (arrow). (B) Endoscopic
ultrasound. These tumours tend to be less well
defined and larger than their benign counterparts
and to have a heterogonous echotexture, often
with cystic spaces.

• Fig. 19.56 Duodenal carcinoid tumour. There
is an irregular, lobulated filling defect with
central ulceration (arrowheads) in the
duodenal cap. Stromal tumours, melanoma
metastasis, and duodenal ulcer with oedema
can also produce this appearance.

• Fig. 19.57 Sites of extrinsic gastric
compression.

• Fig. 19.58 Types of gastric volvulus. (A) Organoaxial. Rotation occurs
around an axis connecting the pyloris to the oesophagogastric junction. (B)
Organoaxial volvulus of an intrathoracic stomach. The greater curve is
folded upward and to the right (small white arrows). There is a giant
duodenal ulcer (arrow) which perforated 10 days later.

• Fig 19.58: (C) Mesenteroaxial. Rotation occurs
around an axis connecting the middle of the
greater curve to the middle of the lesser
curve. Generally this type of volvulus is partial
as a result of excess mobility of the antrum
and duodenum and so the stomach often
kinks and obstructs between the body and the
antrum.

• Fig. 19.59 Superior mesenteric artery syndrome
caused by carcinoma of the pancreas involving the
root of the mesentery. (A) Supine position.
Compression of third part of duodenum. (B) Prone
position. The compression persists and dilatation of the
proximal duodenum is accentuated. (Courtesy of Drs J.
R. Anderson, P. M. Earnshaw and G. M. Fraser, and the
editor of Clinical Radiology.)

• Fig. 19.60 Aortoduodenal fistula. Recent
haematemesis. The third part of the
duodenum (stars) is stretched over the aortic
aneurysm, which contains thrombus. A fistula
accounts for the gas in the aortic wall (arrow).

• Fig. 19.61 Gastric varices associated with (A)
portal hypertension, (B) splenic vein occlusion

• Fig. 19.62 Pseudotumours of the gastric fundus. (A) Gastric fundal
varices. Filling defects (arrows) resembling a bunch of enlarged
nodular mucosal folds. (Courtesy of Dr G. M. Fraser and the editor
of Clinical Radiology.) (B) Intragastric prolapse of a sliding hiatus
hernia. The mass (arrowheads) is composed of mucosal folds, and
vanishes when the hernia expands above the diaphragm in the
recumbent posture.

• Fig. 19.63 Gastric diverticulum arising from
the fundus of the stomach. Sometimes gastric
folds can be seen entering the diverticulum, or
areae gastricae can be seen within it.

• Fig. 19.64 An antral diaphragm (between the
arrows). The pyloric canal is seen end on
(asterisk

• Fig. 19.65 Duodenal diverticulum into which the
papilla is opening (D). Loss of continence has
resulted in reflux of barium into the common bile
duct (C).

• Fig. 19.66 Annular pancreas. The direction of
rotation of the ventral pancreatic bud which
joins the dorsal bud at the seventh week of
embryonic life and finally comes to lie on the left
side of the duodenum.

• Fig. 19.67 Annular pancreas. (A) Producing a
characteristic narrowing of the second part of
the duodenum (arrows). (B) CT shows the
gland encircling the duodenum (arrows).

• Fig. 19.68 (A) Pyloroplasty. A wide gastroduodenal
channel has been produced. (B) Gastroenterostomy.
(C) Normal postoperative barium examinations
following Billroth I partial gastrectomy.

• Fig. 19.68 (A) Pyloroplasty.
A wide gastroduodenal
channel has been
produced. (B)
Gastroenterostomy. (C)
Normal postoperative
barium examinations
following Billroth I partial
gastrectomy.

• Fig. 19.69 (A) Billroth I partial gastrectomy.
(B, C) Polya partial gastrectomy; antecolic and
postcolic anastomoses. (D) Anteperistaltic
anastomosis. (E) Postgastrectomy Roux-en-Y
reconstruction. (F) Vertical banded
gastroplasty.

• Fig. 19.70 Vertical banded gastroplasty. Breakdown of the top end
of the staple line (arrow) with barium directly entering the fundus
of the stomach. Site of banding marked with an asterisk.

• Fig. 19.71 Complications following gastric surgery. (A) Early postoperative
oedema at a gastroenterostomy site (arrows). (B) Retrograde jejunogastric
intussusception following gastrojejunostomy. The loops of jejunum within
the stomach (arrowheads) have a characteristic 'coiled spring' appearance.

• Fig. 19.72 Stomal
(marginal) ulcer
(asterisk) with
scarring following
Polya partial
gastrectomy.

• Fig. 19.73 Bezoar. There is a large filling
defect (arrowheads) within the stomach; this
proved to be a phytobezoar.

• Fig. 19.74 Percutaneously placed gastrostomy
catheter. Some oral barium had been given prior
to the procedure to outline the colon. NGT =
nasogastric tube; PGT = percutaneous
gastrostomy tube; S = stomach; TC = transverse
colon.

• Fig. 19.75 (A) Normal gastric emptying curves
showing approximately linear solid phase and
exponential liquid phase. (B) Normal variant of
gastric emptying pattern with lag period
before onset of solid phase emptying.

• Fig. 19.76 Selected frames from a dual phase
gastric study showing typical progression of
liquid (A) and solid phase (B) emptying over
60 min after ingestion of the meal.

• Fig. 19.77 (A, B) Typical gastric emptying
curves after vagotomy in two patients, both
showing rapid transit of liquid but delayed
solid phase emptying

• Fig. 19.79 (A, B) Delayed liquid and solid
phase gastric emptying in two patients with
gastroparesis.

Stomach and Duodenum Anatomy Figures

Stomach and Duodenum Anatomy Figures

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