FLUOROSCOPIC IMAGING ANATOMY AND PATHOLOGY OF STOMACH AND DUODENUM This document outlines the anatomy of the stomach and duodenum as seen on barium imaging studies. It describes the normal appearance and divisions of the stomach. Common pathologies are discussed, including gastric cancers, lymphomas, ulcers and polyps. Early gastric cancers appear as polyps or shallow ulcers while advanced cancers cause thickening or narrowing. Lymphomas manifest as thickened folds, masses or ulcers. Polyps are categorized as hyperplastic, adenomatous or villous. H. pylori infection is a common cause of thickened gastric folds and erosions. The

1. FLUOROSCOPIC IMAGING ANATOMY
AND PATHOLOGY OF STOMACH AND
DUODENUM
By-Dr. Abduljelil (RR-II)
NOV ,8, 2019 GC

2. OUTLINE
• BARIUM MEAL
• STOMACH ANATOMY
• PATTERN APPROACH TO STOMACH PATHOLOGY
• DUODENUM ANATOMY
• PATTERN APPROACH TO DUODENAL PATHOLOGY
• REFERENCES

3. BARIUM MEAL
• Replaced by endoscopy
• Primary radiological investigation
Single contrast
• For demonstration of gross anatomy/pathology
• Barium 100 -150ml , 250% wt/vol
• Will emphasize :-
ü barium filling,
ü compression and
ü mucosal relief

4. Double contrast
• method of choice to demonstrate mucosal pattern
• Antipersitalytic agent : buscopan/glucagon
• Effervescent ( gas producing agent)
• Barium 100 -150ml , 250% wt/vol
• Principles
- distension
- mucosal coating
- proper projection

5. Typical film Series for DC study
Position Demonstrates
Supine RPO Antrum and greater curve
Supine Antrum and body
Supine LPO Lesser curve
Supine Left Lateral Fundus
Prone Duodenal loop
Prone, RAO,Supine ,LPO
Erect RAO, LAO
Duodenal Cap series
Erect Fundus

6. STOMACH ANATOMY
• Shape and size
• Arbitrarily divided into
five segments: the
1.Cardia,
2.Fundus,
3.Body,
4.Antrum, and
5.Pylorus.

7. Gastric Cardia
• Characterized by three or
four smooth folds that
radiate to a central point at
the GEJ =cardiac “rosette”

8. Normal Areae Gastricae
• polygonally shaped radiolucent
tufts of mucosa outlined by
barium in grooves (reticular
network)
• Have a diameter of 2–3 mm in
the gastric antrum and of 3–5
mm in the gastric body and
fundus
• The hallmark of normal is the
regularity of the pattern in all
areas in which it is visualized

9. Normal Gastric rugal folds
• Are changeable structures
composed of mucosa and
portions of the submucosa
• Produce distinct radiolucent
ridges when the stomach is
partially distended
• Measuring 3–5 mm
• Are most prominent in the
fundus and proximal gastric
body and are usually absent in
the antrum
• Are thicker in the proximal
stomach, have a smooth
contour in profile, and taper
distally .

10. PATTERN APPROACH TO
STOMACH PATHOLOGY
• Gastric Filling Defects
• Thickened Gastric Folds
• Gastric Ulcers

11. Gastric Filling Defects
• Gastric carcinoma
• Lymphoma
• GI stromal tumors (GISTs)
• Gastric Polyps
• Villous tumors
• Ectopic pancreatic rests
• Metastasis
• Kaposi sarcoma
• Lipomas
• Bezoar/Foreign Body
• Extrinsic Impression

12. anterior or posterior wall in barium
study??

13. Gastric carcinoma
• Most common primary gastric tumour
• Third most common GI malignancy
• Most (95%) are adenocarcinomas
• Peak age is from 50 to 70 years, with males
predominating 2:1.
• Mortality is high with a 5-year survival rate of 10% to
20%

14. Early gastric carcinoma
• Limited to the mucosa and submucosa with or without
associated lymphadenopathy
• Are curable lesions, with 5-year survival rates as high as
90 to 95%.
• Appear on barium studies as:-
(1) gastric polyps with risk of malignancy increased for
lesions larger than 1 cm (type I),
(2) superficial plaque-like lesions or nodular mucosa (type II),
and
(3) shallow, irregular ulcers with nodular adjacent mucosa
and associated amputation of radiating folds (type III)

15. Japanese Endoscopic
Society classification

16. Early gastric carcinoma cont...

17. Advanced gastric carcinoma
• Large, irregular masses that may or may not be
ulcerated
• Appear as :-
ü polypoid,
ü ulcerative, or
ü infltrating lesions

18. Polypoid carcinomas
• Are lobulated or fungating masses that protrude into
the lumen

19. Ulcerated carcinomas
• Are those in which the bulk of the tumor mass has
been replaced by ulceration
Prone compression view

20. Infiltrating carcinomas (5%–15%)
• Usually arises near the pylorus and extends upwards
• Are manifested by irregular narrowing with nodularity
and spiculation of the mucosa
• Some may have polypoid or ulcerated components.
• In advanced cases, these lesions may cause gastric
outlet obstruction

21. Scirrhous Carcinoma
• classically manifested by
irregular narrowing and
rigidity of the stomach,
producing a linitis plastica
(“leather bottle”)
appearance
DDX :
Ø Lymphoma
Ø Metastases from breast
carcinoma

22. Gastric Lymphoma
• Accounts for 3%–5% of all gastric malignancies and 50% of
all GI lymphomas
• Most (80%) gastric lymphoma is non-Hodgkin, B-cell type
• MALT lymphoma accounts for the majority of primary
gastric lymphomas (50%–72%)
• 5-year survival rate of 62% to 90%.
• No anatomic predilection but when the antrum is involved
duodenum is often affected

23. Primary Gastric Lymphoma
• No typical radiographic appearance.
• May demonstrate:-
Ø An infiltrative appearance with thickened broad tortuous
mucosal folds,
Ø A circumscribed mass growing inside or outside the lumen , or
Ø Large irregular ulcers
• Multiplicity of lesions favors MALT lymphoma as the
diagnosis.
u Rounded, often confluent nodules of varying size
DDX: gastritis
leukaemic infiltration

24. DC study shows confuent, varying sized nodules in the gastric
body caused by a low-grade B-cell MALT lymphoma

25. Advanced Gastric Lymphoma
• Have an average diameter of 10 cm or more at the time
of diagnosis
• Demonstrates four morphologic patterns:-
1. Diffuse infiltration,
Ø linitis plastica appearance is much less common with
lymphoma than with adenocarcinoma
2. Ulcerative mass,
3. Polypoid solitary mass, and
4. Multiple submucosal nodules

26. A. Diffusely thickened,
irregular folds = because of
lymphomatous infltration of the
gastric wall.
B. linitis plastica, manifested by
focal narrowing of the gastric
body with nodularity and
sacculation of the adjacent
greater curvature.
C. Several discrete ulcers
(arrows) and thickened,
lobulated folds
D.Two separate polypoid
masses
E.Two centrally ulcerated
submucosal masses, or bull’s-
eye lesions

27. Gastric Lymphoma v/s Carcinoma on
fluoroscopic study
• Preservation of flexibility of gastric wall
» absence of associated fibrosis
• Infrequent luminal narrowing
• Stomach wall thickening is more significant and
homogeneous
• May involve duodenum

28. GI stromal tumours (GISTs)
• submucosal mesenchymal tumour
• second most common type of polypoid lesion in the
stomach after hyperplastic polyps
• Constitute about 90% of mesenchymal tumors and 40%
of all benign tumors in the stomach and duodenum
• Include most lesions previously designated leiomyoma,
leiomyoblastoma and leiomyosarcoma.
• ~ 70 % of GISTs occur in the stomach and most
(70–90%) are benign

29. GISTs Double contrast barium meal cont....
• Typicaly round, endophytic submucosal mass with smooth
mucosal surface with borders forming right or slightly obtuse
angles to the adjacent mucosa
– normal area gastrica pattern
• Ulceration becomes more common as the lesions grow to >2
cm in size
– ‘target’ or ‘bulls-eye’ lesion
• DDX : Kaposi sarcoma , metastasis , carcinoid tumor
• 15% grow predominantly outside the stomach (exogastric)
• < 5 % of cases –both growth pattern (‘dumbbell’)
• Malignancy should be strongly considered if the mass is
> 5 cm

30. A) large benign GIST (arrows) in
the fundus with a central area of
ulceration, producing a bull’s-
eye lesion
benign GI stromal tumor (arrowheads)
demonstrates the characteristic findings of
a submucosal mass on an upper GI series

31. Gastric Polyps
• Most common benign gastric tumours
• Broadly divided into:-
Non-neoplastic polyps
ü Hyperplastic, hamartomatous, and retention polyps
Neoplastic polyps
ü Adenomatous and villous polyps

32. Hyperplastic polyps
• Account for 80% of gastric polyps
• NOT considered to have malignant potential but are
indicative of chronic gastritis
• Round, smooth sessile lesions.
• Usually multiple and of uniform size (< 1.5 cm).
• Most common in the fundus and body of the stomach.

33. Fig:- Multiple hyperplastic polyps
hanging droplets of barium

34. Adenomatous polyps
• Account for 15% of gastric polyps
• Are true neoplasms with malignant potential
• Most are solitary, located in the antrum, and are larger
than 2 cm in diameter
• Polyps that are larger than 1 cm, lobulated, or
pedunculated should have biopsied
• Coexist with gastric carcinoma in 35% of cases
• Malignancy is detected in 50% of adenomas larger
than 2 cm

35. On DC barium meal cont..
• May be sessile or pedunculated, and they tend to be
more lobulated than hyperplastic polyps
• Smooth circular outline, with the stalk seen en face
overlying the head of the polyp= “Mexican hat sign”
• Adenomatous polyps are rarely ulcerated

36. Villous Tumors
• Polypoid masses, ranging from 2 to 9 cm in size
• Carry a very high risk for malignancy.
• In the stomach, malignant changes are found in 50% of
lesions 2 to 4 cm in size and in 80% of lesions larger
than 4 cm
• Lesions often have a reticular or soap bubble
appearance with serrated, feathery margins

37. Fig:- A giant villous tumor with
characteristic soap bubble
appearance
ücaused by trapping of
barium in multiple clefts
between the frondlike
projections of the tumor
DDX: bezoar=moves with
changes in the position

38. Ectopic pancreatic rests
• About 80% are located in the stomach, duodenum, or
proximal jejunum
• Smooth, broad-based submucosal masses with central
umbilication or dimple= orifice of a primitive ductal system
– Ddx;benign GISTs
• Almost always occur as solitary lesions (1 to 3 cm)
• Greater curvature of the distal antrum within 1 to 6 cm from
the pylorus

39. FIG:-discrete submucosal mass (arrows) on the greater curvature of
the distal antrum

40. Thickened Gastric Folds
• Gastritis
ü H.pylori gastritis
ü Erosive gastritis
ü Crohn gastritis
ü Atrophic gastritis
ü Phlegmonous gastritis
ü Emphysematous gastritis
ü Eosinophilic gastroenteritis
ü Ménétrier disease
• Varices
• Neoplasm

41. H.pylori gastritis
• Most common cause of thickened folds(>5mm) in the
gastric antrum or body
• +/-Enlarged areae gastricae (≥3 mm)
• Lymphoid hyperplasia is a potential marker for H. pylori
gastritis
u Innumerable tiny (1-3 mm), round, frequently
umbilicated nodules
• Erosions
• Others - antral narrowing, inflammatory polyps

42. Fig:-Thickened folds in the body of the stomach and enlarged areae
gastricae in the proximal antrum

43. Figure :- H. pylori gastritis with lymphoid hyperplasia. in A,many of
the nodules have central umbilications

44. Erosive gastritis
• Most often caused by alcohol, aspirin and other NSAID,
or steroids
• Erosions (aphthous ulcers)
• Thickened, nodular folds in the antrum;
• Limited distensibility of the antrum; and
• Wall stiffness and limited peristalsis.

47. GASTRIC VARICES
• Most common in the fundus
and usually accompany
esophageal varices.
• Isolated gastric varices should
raise the possibility of splenic
vein obstruction
• Thickened, tortuous folds or as
round submucosal flling
defects resembling a bunch of
grapes

48. Gastric Ulcers
• Benign Ulcers
• Malignant ulcers
• Equivocal ulcers

49. Gastric Ulcers
• Frequently extends to the deeper layers of the stomach,
including the submucosa and muscularis propria
• ~ 95% are benign
• H. pylori (70 %)
• NSAIDs
• Alcohol abus
• Most prevalent in the posterior wall distal stomach and along
the lesser curvature.
• NSAID- and alcohol-related ulcers = greater curvature of the
antrum
u direct toxic effect of the ingested material
• Ulcers are multiple in ~20% of patients

50. Benign Versus Malignant Ulcers

51. caused by a thin line of mucosa overhanging the ulcer's crater

53. Carmen Meniscus Sign:-barium collection is convex toward the
gastric lumen

54. DUODENUM ANATOMY
l Retroperitoneal and within the anterior
pararenal compartment except duodenal
bulb.
l Based on anatomic orientation
First portion
• Duodenal bulb, or cap, is the pyramidal
first portion.
• Lies at the level of L1 and runs superiorly
and posteriorly from the pylorus.
• Best seen in the RAO position.
• Gallbladder frequently makes a
prominent impression .

55. DUODENUM ANATOMY cont...
Second or descending portion
• There is often a posteromedial
filling defect with an inferior
longitudinal fold i,e ampulla
• Valvulae conniventes begin in D2
and become signifcantly more
prominent in D4.
• Folds greater than 2 to 3 mm wide
are usually considered thickened

56. Third or horizontal portion
• Can be indented by the SMA/SMV
and aorta
Fourth or the ascending portion
• Ascends on the left side of the aorta
to the level of L-2 and the ligament of
Treitz, where it turns abruptly
ventrally to form the duodenal–jejunal
flexure
DUODENUM ANATOMY cont...

57. PATTERN APPROACH TO
DUODENAL PATHOLOGY
• Duodenal Filling Defects
• Thickened Duodenal Folds
• Duodenal Ulcers and Diverticuli
• Duodenal Narrowing

58. Duodenal Filling Defects
• Duodenal adenocarcinoma
• GISTs
• Duodenal polyps
• Brunner Gland Hyperplasia/Hamartoma
• Lymphoma
• Lipoma
• Lymphoid hyperplasia
• Gastric Mucosal Prolapse/Heterotopic Gastric Mucosa
• Metastases
• Ectopic pancreas
• Extrinsic mass

59. General Rule
• Duodenal bulb, 90% of tumors are benign.
• Second and third portions of the duodenum, tumors are
50% benign and 50% malignant.
• Fourth portion of the duodenum, most tumors are
malignant
• Signs of malignancy include :
(1) central necrosis,
(2) ulceration or excavation

60. Duodenal carcinoma
• <1.5% of all GI neoplasms
• Usually appear as :-
1.Polypoid,
2.Ulcerated, or
3.Annular lesions at or, more
commonly, distal to the
ampulla of Vater

61. GISTs of the duodenum
• Malignant GISTs are the second
most common primary malignant
tumor of the duodenum
• Most commonly in D2 or D3
• Present as an intramural,
endoluminal, or exophytic mass
• Ulceration is common.
FIG;- Benign GISTs

62. Duodenal polyps
• Half of the neoplasms of the
duodenum
• Most duodenal polyps are
adenomatous
• usually appear as solitary
smooth, sessile lesions (<2 cm )
in the D1 or D2
A) Ring shadow (curved arrow) and
bowler hat (straight arrow)
B) Several adenomatous polyps
(arrows)

63. Brunner Gland Hyperplasia /Hamartoma
• Brunner glands are located in the proximal two-thirds
• Diffuse nodular gland hyperplasia is a common cause of multiple filling
defects, often with a cobblestone appearance
• Brunner gland hamartoma usually presents as a solitary filling defect
(>5mm)
• All lesions are benign

64. Thickened Duodenal Folds
• Duodenitis
• Crohn disease
• Pancreatitis and cholecystitis
• Normal Variant
• Parasites
• Lymphoma
• Intramural hemorrhage

65. Duodenitis
l Cause
Ø Findings:-
(1) Thickening (>4 mm) of the proximal duodenal folds,
(2) Nodules or nodular folds (enlarged Brunner glands),
(3) Deformity of the duodenal bulb, and
(4) Erosions without discrete ulcer formation

66. Crohn disease of the duodenum
• Usually involves the first and second portions
• Almost always associated with contiguous involvement of the
stomach.
• Manifest by thickened folds, aphthous ulcers, erosions, and
single or multiple strictures
DDX Peptic duodenitis

67. Duodenal Ulcers and Diverticuli
• Duodenal ulcers
• Duodenal diverticula
• Zollinger–Ellison syndrome
• Flexural pseudotumors
• Intraluminal diverticula

68. Duodenal ulcers
• H. pylori infection in 95% of cases
• Most (95%) are in the duodenal bulb, with the anterior wall being most often involved
(~50%)
• postbulbar ulcers are usually located along the medial aspect of D2 above the
ampulla of Vater
• Peptic duodenal ulcer is not a premalignant condition
barium collection (arrow) in the duodenal bulb.
A well-defined ulcer collar (arrowheads) formed
by mounds of edema is present

69. Duodenal diverticula
• Are common (5% ) and usually incidental
findings.
• Most common along the inner aspect of the
D2
• Differentiated from ulcers by the
demonstration of mucosal folds entering
the neck of the diverticulum and change in
appearance with peristalsis

70. Duodenal Narrowing
• Annular pancreas
• Duodenal adenocarcinoma
• Pancreatic carcinoma
• Lymphoma

71. Annular pancreas
• The most common congenital
anomaly of the pancreas
• Eccentric or concentric narrowing of
D2
• CT confirms the diagnosis

72. REFERENCES
• William E. Brant.Clyde A. Helms Fundamentals of diagnostic
radiology 4th ed ,published 2012
• Richard M. Gore.Marc S. Levine Textbook of Gastrointestinal
Radiology 4th ed ,published 2015
• Stephen E. Rubesin, MD Marc S. Levine, MD Igor Laufer, MD
REVIEW FOR RESIDENTS: Double-Contrast Upper
Gastrointestinal Radiography @ RSNA, 2008
• A. H. Freeman · E. Sala (Eds.) Radiology of the Stomach and
Duodenum published 2008
• Practical fluoroscopy of GI & GU Tracts First ,published 2012
• Applied Radiologic anatomy 1st ed and 2nd ed

73. Thank you