This document discusses the radiological anatomy and pathologies of the stomach. It begins with an overview of examination techniques including endoscopy, barium meal, CT, and endoscopic ultrasound. It then describes the anatomy of the stomach and surrounding structures. The main pathologies discussed are gastritis, peptic ulcer disease, neoplasms, and congenital anomalies. For inflammatory conditions like gastritis and peptic ulcers, the document outlines imaging findings and distinguishing features of different types. It similarly discusses imaging features that help differentiate benign from malignant ulcers.

1. STOMACH : RADIOLOGICAL ANATOMY AND
PATHOLOGIES
DR. SARASWATI SHAH
JUNIOR RESIDENT II
M.L .B MEDICAL COLLEGE JHANSI
RADIODIAGNOSIS DEPARTMENT

2. EXAMINATION
•ENDOSCOPY :Now first line investigation for imaging of esophagus, stomach ,duodenum and
colon. Biopsy can be taken.
•DOUBLE CONTRAST BARIUM
•CT
•ENDOSCOPIC USG
•MRI

3. DOUBLE CONTRAST BARIUM MEAL
1. Prerequisites:
• fast for 6 hr.
• Abstain from smoking.
• Ask for previous H/O of gastric Sx.
2.Technique:
• Buscopan (20 mg i.v) or glucagon (0.1-0.2 mg i.v).
• swallows Effervescent agent (
approx.4ooml co2).
• quickly swallow 120 ml high density barium (250
%w/v) on RAO erect position.
• Rolling pt. side by side and film of stomach are taken.
• Contrast has entered to Duo. ,turn RAO ,DC film are
taken.
• Prone swallow with diluted barium (125 % w/v ) to
distend the lower esophagus.
• Finally on standing position SC film obtained of
compressible part of stomach and duodenum .

4. Barium meal on post surgical UGI tract.
• Barium will quickly flood the
jejunum in case of partial
gastrectomy .
• To avoid early flooding Examination
sequence should be modified.
• Examine should start with prone
swallow using high density
barium .
• When barium reaches the
duodenum or
gastroenterostomy ,turn supine
for DC film of these.
• Then take DC film of oesophagus
and stomach.

5. CT
• For optimal demonstration of
the gastric wall , when enhanced
with I.V contrast and distended
with water.
• gastric mucosa and most gastric
tumors are vascular, with peak
attenuation in the arterial
phase.
Main indication
• Staging of gastric tumor
• Monitor the effect of
chemotherapy.

7. ENDOSCOPIC USG
• 7.5 and 12 MHz.
• a water-filled balloon can be
used as a coupling agent to clear
visualization of all layers.

9. ANATOMY OF STOMACH
• 1. CARDIA :area surrounding the GEJ.
• 2. FUNDUS : portion of the stomach
lying above a horizontal line drawn from
the GEJ to the greater curvature.
• 3. BODY : between the fundus and a
point on the lesser curve. designated as
the incisura angularis. abundant acid-
secreting parietal cells.
• 4. ANTRUM : b/w gastric body and
pylorus. parietal cells as well as G cells,
which make gastrin, and D cells, which
make somatostatin.
• 5. PYLORUS : transition point from the
antrum to duodenum.Fig. 1. Anatomy of the stomach

10. ON BARIUM MEAL
• Rugal folds : most
prominent in the gastric
fundus and body, whereas
gastric antrum is often
devoid of folds.
• Areae gastricae :The
mucosal surface of
stomach consist of flat
polygonal shaped(2-4mm)
tuft of mucosa ,known as
areae gastricae.
Abnormal areae gastricae
Rugal fold ,
radiolucent filling
defect
(black arrowheads)

11. ON CT
• two- or three-layered structure
1. inner layer : mucosal layer,
enhances markedly.
2. intermediate layer : low
attenuation , the submucosal layer.
3. outer layer : slightly higher
attenuation , muscular-serosal layer.
• normal gastric wall is 2 to 5 mm
thick (in air-filled stomach, 3or 5mm
is upper limit of normal), with 10
mm being the upper limit for
normal.
Normal gastric wall of the stomach (S) with layered
appearance

12. On Endoscopic USG
• 1= an echogenic layer representing
superficial mucosa.
• 2= a hypoechoic layer representing
the deeper mucosa ,
• 3= an echogenic layer comprising
the submucosa,
• 4= a hypoechoic layer, the
muscularis propria.
• 5= echogenic Layer ,serosa
E= echoendoscope,b= water-filled balloon and
associated ring-artefacts.

13. PERIGASTRIC LIGAMENT
• peri gastric ligaments contain major
vessels and lymph nodes that are
important pathways for lymphatic
metastasis and direct extension of
gastric pathology.
• Gastro-hepatic Ligament : the left
gastric artery and coronary vein and
lymph nodes.
• Gastrosplenic And Gastrocolic
Ligaments : gastroepiploic vessels and
lymph nodes that drain the greater
curvature.

14. VESSELS AND NODES
• ARTERIAL SUPPLY :celiac axis, hepatic
artery, and splenic artery.
• LYMPHATIC DRAINAGE
1. Cardia and most of the lesser curvature
into left gastric nodes
2. Pylorus and the distal lesser curvature
into right gastric and hepatic nodes
3. Proximal portion of the greater
curvature into pancreaticosplenic nodes in
the splenic hilum
4. Distal portion of the greater curvature
into right gastroepiploic nodes in the
greater omentum and the pyloric nodes at
the head of the pancreas

15. Lymph nodes station : by the Japanese Research Society for Gastric Cancer
1-6=N1 ,7-15= N2 ,>15= N3.

16. • INFLAMMATORY AND ULCERATIVE
DISEASES:
I. GASTRITIS
II. PEPTIC ULCER
• NEOPLASM
I. BENIGN :MUCOSAL AND
SUBMUCOSAL
II. MALIGNANT : EARLY AND
ADVANCED
CONGENITAL DISEASES:
I. DIVERTICULA
II. ECTOPIC PANCREATIC REST
III. ANTRAL DIAPHRAGM
• MISCELLANEOUS:
I. EXTRINSIC MASSES
II. VARICES
III. VOLVULUS
• POST OP. STOMACH

17. 1.GASTRITIS :
ACUTE EROSIVE GASTRITIS
CHRONIC GASTRITIS
OTHER TYPES OF GASTRITIS
2.PEPTIC ULCER :
GASTRIC ULCER
DUODENAL ULCER

18. GASTRITIS
TYPES
•ACUTE EROSIVE GASTRITIS
•CHRONIC GASTRITIS

19. SYMPTOMS
• No symptoms
• Abdominal upset
• Indigestion
• Abdominal bloating
• Nausea and vomiting
• Pernicious anaemia
CAUSES
1. prolonged use of asprin and other NSAIDS
2. Excessive alcohol consumption
3. Traumatic injury and burns
4. Bile reflux
5.Direct mucosal trauma i.e from endoscopy
6. Crohns disease
7.Severe viral and fungal infections
ACUTE EROSIVE GASTRITIS

20. EROSIVE GASTRITIS
• Most frequently found in antrum
• Seen only up to 20% good quality
DC barium meals.
IMAGING FINDINGS:
• Mucosal erosions are seen as small
pools of barium en face.
• Erosion surrounded by a
translucent halo of edema.
if the halo is absent they are referred
to as` incomplete erosions’.
Barium pool surrounded by a
translucent ring (target lesion)
small bulbous elevations with central ulcerations

21. CHRONIC GASTRITIS :H.PYLORI ASSOCIATED
• Histological diagnosis
• Characterise by replacement of
normal epithelial cell by mucus
secreting cells.
• The no. of these cells may be
increased ,producing thicker mucosa
,the end stage is mucosal thinning and
atrophy.
• CAUSES
1.stress
2. H. Pylori
3.chronic bile reflux
4.Autoimmune disorders
• Subdivided into on the basis of location
1.antral predominant
2.Pangastritis
2.Corpus predominant

22. • 1.ANTRAL PREDOMINANT GASTRITIS:
• Associated with duodenal ulcer;
• thicken Folds of the upper two-thirds of
the stomach (K/A hypertrophic gastritis).
3. PANGASTRITIS :
• Antral and corpus mucosa
• Inflammation progress to atrophy and
intestinal metaplasia and dysplasia.
• Pt. with H.pylori gastritis may develop
MALT type gastric lymphoma.
2. CORPUS PREDOMINANT
GASTRITIS:
• Body and fundus .
• Genetic tendency to develop
autoimmune disease due to
circulating parietal cell antibodies.
• Associated with Hashimoto’s
disease, Addison's disease and
diabetes mellitus.

23. CHRONIC
GASTRITIS
Hypertrophic Gastritis.
Enlarged tortuous nodular
fold
Atrophic gastritis. Featureless
narrowed stomach..
HYPERTROPHIC

24. CAUSES OF THICK GASTRIC FOLDS
Antrum
• Lymphoma, carcinoma
• Crohn's disease ,tuberculosis
• Amyloidosis, sarcoidosis
• Caustic ingestion, radiotherapy,
• 5-flurouracil
• Eosinophilic gastroenteropathy
• Watermelon stomach: Antral venous
ectasia causing chronic blood loss. Some times
seen in portal hypertension.
Fundus and body
• Lymphoma, carcinoma
• Hypertrophic gastritis
• Menetrier's disease
• Zollinger-Ellison syndrome

25. OTHER TYPES OF GASTRITIS
Crohns disease .antral erosion and
tapered stricture involving the first
part of duodenum. second part of
duodenum is dilated as a result of
further stricture of third part.
.
• REACTIVE: bile and pancreatic reflux, OH and
NSIDS
• LYMPHOCYTIC :Atypical response of H .Pylori
• EOSINOPHILIC :50% pt. having peripheral
eosinophilia and allergic history. Protein
losing enteropathy or malabsorption.
• CROHNS DISEASE: duodenum mc than
stomach. Aphthous erosion ,deep ulcer, skip
lesions and scarring.
• AMYLOIDOSIS :thick wall rigid stomach with
diminised or absent peristalsis simulating
lintis plastica.
• GRANULOMATOUS :Crohn’s disease
tuberculosis, sarcoidosis, syphilis, and fungal
infections. both ulcerative and hypertrophic.

26. DIFFERENT STAGES OF CROHN’S DISEASE:
A. Aphthous ulcers.
B. Interlacing ulcers involving first and second part of
the duodenum producing a cobblestone appearance(fissures and ulcers
separating island of mucosa).
C. stenotic phase with narrowing of the gastric pylorus
A B C
D
B

27. (a) distortion of the normal gastric
mucosal pattern with marked nodularity and multiple
aphthous lesions. irregular scalloping affecting the
greater curve, due to active Crohn’s Disease.
(b,c) marked transmural thickening of the gastric wall.
The muscularis propria is intact

28. MENETRIES DISEASE
• males over the age of 40.
• pronounced hypertrophy of the
glands of the body and fundus
of the stomach, leads to
excessive mucus secretion.
• A protein-losing enteropathy
• may contain ulcers
• The excessive gastric mucus makes it
difficult to coat the stomach when
performing a barium meal.
• The stomach distends normally but
there is gastric fold thickening .
Gross thickening of the folds .
THICKENED GASTRIC FOLDS
THICK RUGAL FOLD

29. CORROSIVE GASTRITIS
• Alkaline caustic agents produce
liquefaction necrosis. This
characteristic of an alkali enhances
its penetration into tissues,
resulting in complete damage of
the upper GI tract and adj.
structures .
• concentrated acids produce a
coagulative necrosis with a
protective eschar that develops
rapidly and may limit penetration
to deeper muscle layer.
• However, CT is useful in
evaluating structures beyond the
first site of injury, thus avoiding
the risk of instrumental
perforation associated with
endoscopy.
nearly complete loss of posterior wall of the stomach

30. PEPTIC ULCERATION
DUODENAL ULCER GASTRIC ULCER
1. more common. 1. less common
2.At any age. 2. After age of 40 yr.
3. symptom: intermittent epigastrial pain
before meal or after several hours of
meal.
symptom: intermittent epigastrial pain
shortly after meal.

31. GASTRIC ULCER
BENIGN
•Along lesser curve and adj. Part of
post.wall
• Giant ulcer (>3cm):on dependent
part of greater curature with use of
aspirin and NSAIDS.
MALIGNANT •Upper part of grater curvature

32. BENIGN ULCER
• Barium collection within ulcer crater in
two patters 1. IN PROFILE
2.EN FACE
IN Profile
• the classical feature of benign ulcer is the
sign of penetration i.e the ulcer crater
projects through the wall of the stomach.
• Hamptons line: a thin lucent line across
the mouth of ulcer representing intact
mucosa.
• Ulcer collar: smooth thick lucent band at
neck of ulcer in profile view representing
thicker rim of edematous gastric wall.(a) in profile ulcer . ulcer
crater projecting outside the
wall.
(b) diag.of benign ulcer with
oedematous collar beneath
the collar Hamptons line.

33. 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. NSAIDS drugs, steroids, potassium chloride).
A
B

34. En face :
It demonstrated as a collection of
barium.
• an ulcer on the dependent wall of
the stomach fills with barium
• ulcer on the non-dependent wall is
seen as a ring ( ring shadow).
• The thickened smooth folds
radiating directly from the edge of
a benign ulcer.
The areae gastricae pattern may be
coarse and prominent at the margin
of ulcers, possibly as a consequence
of oedema(A) posterior wall ulcer (asterisk) With 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 the ulcer has
healed.

35. Thin regular radiating folds are converging
to the ulcer
ulcer crater is outlined by a ‘ring’
shadow with surr. Lucent edema..
deep ulceration with
thickening of the
surrounding
margin.
u
L-LIPOMA
Edematous outer layer (arrows
L

36. MALIGNANT GASTRIC ULCER
• ulcer at the apex of a protruding tumor
mass will lie within the outline of the
stomach.
• an Irregular ulcer crater with nodular and
amputated radiating mucosal folds
indicating infiltration.
• Malignant lesser curve ulcers: a double-
contrast barium meal study shows a malignant
lesser curve ulcer. Note the nodular margin and
amputated radiating mucosal folds.

37. • Carman meniscus” sign :
which represents the ulcer
crater with an associated
elevated border.
b “Carman meniscus” sign (arrow) with malignant lesser
curve ulcer

38. MALIGNANT ULCER FEATURES
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
edema around the ulcer.
Clubbed and fused Thick, clubbed, interrupted, nodular
and fused folds around a malig. ulcer

40. FINDINGS BENIGN GASTRIC ULCER MALIGNANT GASTRIC
ULCER
HUMPTONS LINE PRESENT ABSENT
EXTENDS BEYOND GASTRIC
WALL
YES NO
FOLDS SMOOTH,EVEN IRREGULAR,NODULAR,MAY
FUSE
ASSO.MASS ABSENT PRESENT
CARMAN MENISCUS ABSENT PRESENT
ULCER SHAPE ROUND ,OVAL,LINEAR IRREGULAR
HEALING HEALS COMPLETELY RARELY HEALS

42. • Barium evaluation to assess healing :after
an interval of 8 weeks of medical
treatment .
• Healing of mucosa may be complete or
with scarring.
• In pronounced scarring ,gastric deformity
may seen and can lead to an hour glass
configuration to stomach.
HEALED GASTRIC ULCER
niche persists
despite endoscopic
evidence that the
ulcer has healed.

43. DUODENAL ULCER
• Majority of DU occurs within cap.
• Involve anterior and posterior Wall with
equal frequency.
• An ulcer on the depend wall fills with
barium and shows radiating folds which
stop short of the margin if there is a rim of
edema.
• An ulcer on the non-dependent wall is
etched by barium and appears as a ring
• It can be difficult to coat the anterior wall
of the duodenum and prone or erect
compression views of the duodenal cap
should therefore be obtained.

44. • Spasm and scarring may draw in
the margins of the duodenal cap,
distorting its shape and often
producing a characteristic
cloverleaf appearance .
• The ulcer niche may persist,
reduce in size, become linear or a
depression.
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

45. • usually on the medial wall of the
duodenal loop above the papilla.
• often associated with edema and
pronounced spasm .
• Scarring produce permanent
stricture
GIANT ULCER OF D.CAP
• A giant ulcer may replace the whole
of the duodenal cap, and, when
smooth margined, such ulcers may
be mistaken for a normal cap.
• However, the giant ulcer will
maintain its shape during a barium
Study , whereas the normal cap,
(also Outpouchings or
pseudodiverticula) can at times be
seen to contract with peristalsis.
ulcer crater (asterisk) in the middle of a stricture
produced by spasm and edema. POST BULBAR DUODENAL ULCER

46. PERFORATED PEPTIC ULCER
• ulcer of Anterior wall of stomach or
duodenum perforate into peritoneal
cavity.
• ulcer of Posterior wall of stomach
perforate into lesser sac or penetrate
into retroperitoneum and pancreas.
• The most frequent cause of perforation is
anterior wall of duodenal ulcer.
• Gastrograffine can be used to pt. with
perforation and right decubitus position
best demonstrate leakage from
duodenum and lesser curve gastric ulcer.
Perforated duodenal ulcer. An unexpected, silent perforation
,the leak was localised to the right subphrenic and
subhepatic space. S = stomach,D=duodenum,b= leaked
barium.

47. • An antral ulcer may fistulate to
duodenal cap to give the appearance of
a double pyloric canal.
• Rarely DU may fistulate into CBD,
causing cholangitis and air in biliary
tree.
• 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.

48. ZOLLINGER ELLISON SYNDROME
• severe form of peptic ulcer
disease.
• Gastrin secreting tumor
(gastrinoma) causing excess
acid production.
• tumor can develop from
Non beta cell islet tumor of
pancreas ,endocrine sell
tumor of duodenum or
gastric mucosa. c.)
Symptoms
• Abdominal pain and diarrhoea with
severe peptic ulceration of stomach
and small bowel usually not
responding to treatment.
• Single or multiple
• 50 % of multiple
• 50 % malignant
• 50 % have metastasize to liver by
the time of diagnosis.

49. • 25 % pt. with gastrinoma have
multiple tumors as part of MEN
type 1.
• MEN 1 have tumors in pancreas
,pituitary and parathyroid gland.
enlarged thickened tortuous
folds in the body of the
stomach
marked gastric distention and fluid excess with
prominent and thickened mucosal folds (astrick)
with small mass i.e gastrinoma

50. NEOPLASM
I. BENIGN
II. MALIGNANT

51. BENIGN GASTRIC TUMORS
• May be mucosal or submucosal.
• mucosal tumour (A) :forms acute
angle with the normal mucosa.
• submucosal tumour (B)
( intraluminal): forms a right or
obtuse angle with the normal
mucosa.
• Submucosal tumor
( extraluminal) : the tumors may
drag on the gastric wall to produce
a niche (C).
Benign tumor growth.

52. MUCOSAL POLYP
HYPERPLASTIC POLYP
• local hyperplasia of the glandular
tissue.
• small, smooth surfaced and
sessile.
• <1cm size.
• often multiple
• fundus and body of the stomach .
ON BARIUM :
• A polyp on the dependent wall is
seen as a filling defect within the
barium pool.
PROLAPSING GIANT HYPERPLASIA
POLYP(ASTERIK),A(ANTRUM),C(CAP).

53. • on the anterior wall a polyp is
outlined by a thin rim of
barium.
• endoscopy only required, if the
polyp's surface is irregular or
the polyp measures more than
a centimeter
).

54. ADENOMATOUS MUCOSAL
POLYP
• Two type: tubulo-villous (majority) and
villous.
• Nodular surface, pedunculated
• Solitary
• Usually at antrum
• >1cm in size (should be removed).
• risk of malignant changes in 50% polyps
larger than 2cm.
• when viewed en face, a droplet of barium
hanging from the apex of the polyp may
simulate ulceration.

55. BENIGN SUBMUCOSAL TUMOR :generally solitary
SOLITARY BST DDS
• Stromal tumor
• Neurofibroma
• Lipoma
• Haemangioma :capillary or cavernous type.
Cavernous type occasionally contain phlebolith.
• Lymphangioma
• Glomus tumor
• Neural tumor
• Brunner's gland hematoma
• Duplication cyst
• Ectopic pancreatic rest
DDs OF MULTIPLE
SUBMUCOSAL TUMOURS
•metastases
• lymphoma
• Kaposi's sarcoma
Submucosal tumours are rare
in the duodenum

56. BENIGN STROMAL TUMOR
• Endoscopic ultrasound shows a mass arising from
the muscularis propria or muscularis mucosa
• benign tumors tending to be smaller (<I0 cm)
homogenous , echo poor and better defined .
Echo-poor mass arising from the fourth
hypoechoic layer, the muscularis propria. At the
margins, the tumor can be seen to merge with
the muscularis propria (arrows).
A calcified mass (M) (arrow) is seen at the gastric high body

57. GASTRIC LIPOMA
• Echogenic well-defined tumor
arising from and expanding the
submucosal layer (black arrow).
Muscularis propria is displaced but
intact (smaller black arrows).
fatty mass in the antrum

58. MALIGNANT TUMORS
PREDISPOSING FACTORS
• Atrophic gastritis
• A past infection with H. pylori
• Polyps may undergo malignant
Changes.
• Patients with pernicious anemia have
an ant parietal cell antibody which
produces atrophic gastritis
• Partial gastrectomy ( Billroth II),ca
occurs close to the gastrojejunal
anastomosis due to bile rellux.
• Intake of nitrates, get converts into
nitrosamine in stomach.
( vitamin C prevent the formation of
nitrosamines).
SYMPTOMS : asymptomatic until
advanced case.
loss of appetite, dyspepsia, weight
loss and anaemia. Ulcerating tumours
may haemorrhage, dysphagia,
vomiting

59. EARLY CARCINOMA
• confined to mucosa and submucosa,
irrespective of whether or not regional
lymph nodes are involved.
• These tumors have a 90% 5 year survival.
Japanese Endoscopic Society has classified
early tumors into three types
• Type l are elevated tumors protruding more
than 5 mm above the mucosal surface.
• Type 2 are either flat(2a), slightly elevated
(<5 mm ) (2b), or slightly depressed but do
not extend through the muscularis
mucosa(2c) .
• Type 3 are ulcerating tumors which
penetrate the muscularis mucosa.

60. 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).
2c
2B
2C

61. 1. A, no definite
pathologic lesion at
gastric angle
(arrow). B, Focal wall
thickening with
subtle enhancement
of inner layer
(arrow) . IIa.
1. 1.
2.(A) mild
enhancement of
thickened gastric
wall (astrck). Scan
shows good
enhancement in the
equilibrium phase
(astrick) (B).
Early gastric cancer
2
.
2.

62. ADANCED GASTRIC CARCINOMA
• only 10% 5 year survival
• Invasion of muscularis propria
• Carcinoma may protrude in to
lumen and be polypoidal ,or
fungating, or may ulcerate or
infiltrate
• When infiltration becomes extensive it
makes the stomach wall rigid, with loss
of peristalsis, and the gastric lumen
narrows called `leather bottle' or 'linitis
plastica' appearance.
• In such cases the mucosa is nodular,
and the fold pattern is lost or deformed
.

63. (A) Fungating cancer at greater curve (arrows)
(B) non-projecting ulcer crater with meniscus sign.
(C) Infiltrating and ulcerating gastric carcinoma. Thickened wall,
destruction of mucosa, and narrowing of the lumen (arrows) in
upper half . Ulceration on the greater curve (long arrow).
(D) Small stomach due to diffuse submucosal infiltration .

64. 1.A, eccentric gastric mass (arrows) with extensive metastatic lymphadenopathy (N).
B, FDG PET : extent of gastric tumor, without discrimination of metastatic lymph node
from primary tumor
2.Advanced gastric
adenocarcinoma with
peritoneal seeding. A,
suspicious peritoneal
seeding nodule at
rectovesical pouch
(arrows).
B, strong hot uptake at
FDG PET indicating
definite malignant
seeding nodule
1.
2.
N

65. Diseases narrowing the lumen of stomach.
Entire stomach
• Gastric cancer
• Metastatic breast cancer
• Hodgkin's disease
• Kaposi's sarcoma
Antrum
• Amyloidosis, sarcoidosis
• Crohn's disease, tuberculosis,
syphilis
• Caustic ingestion, radiotherapy
• Eosinophilic gastroenteropathy
• CMV gastritis
Other diseases narrowing
the lumen of the stomach

66. (B) Endoscopic ultrasound showing a narrowed
gastric lumen and diffuse thickening of all layers of
the gastric wall by tumour infiltration (between
arrows).
(A) Diffuse thickening of the gastric
wall demonstrated by CT
LINTIS PLASTICA

67. Scirrhous adenocarcinoma of the stomach. gastric wall thickening with
a markedly enhanced submucosal layer and a poorly enhanced thin rim
of mucosal layer. Ascites also seen
SCIRRHOUS CARCINOMA
• Less common variety
• Spread in submucosa.
• CT: diffuse circumferential
thickening of gastric wall with
mean range 1-3 cm.
• Preservation of thin rim of
hypoattenuating Mucosal lining
intramural calcification may be
seen

68. • mucin producing adenocarcinomas
may shows stippled calcification.
• On CT : wall thickness and
calcification with poor contrast
enhancement
Mucinous adenocarcinoma

69. A. concentric gastric wall thickening (M) involving the
antrum of the stomach.
B. portal vein thrombus (P) and a metastatic lesion (asterisk)
in the caudate lobe .
Hepatoid adenocarcinoma
• originating from the gastric mucosa
• tends to invade portal or hepatic veins
and to metastasize to the liver;
• the prognosis is poor .
• produces a large amount of serum
AFP.
M
P

70. TUMOR STAGING
CT :
• distant metastasis
• to monitor effect of chemotherapy
EUS :
• depth of cancer invasion
• relative movement and fixity between
ca and adjacent organ
• to assess Local lymphadenopathy
LAPROSCOPY :
• Used to assess peritoneal
disease
• Sampling of lymph nodes

71. DAVID SUTTON
7TH EDITION
,PAGE NO. 593

72. T stages of gastric cancer
enlarged, rounded,
hypoechoic,
metastatic L.N
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)

73. Lymphatic spread
Considered Malignant nodal
deposits :
• Gastro hepatic ligament and
porta hepatis nodes: 8 mm
• coeliac axis to renal arteries
:10mm
• renal arteries to aortic
bifurcation: 12 mm.
• High attenuation (>100 HU)
lymph nodes also more likely
to be malignant, even if small.
• Regional nodal spread :
accompanied left gastric,
splenic, coeliac , common
hepatic arteries.
• Enlarged retro pancreatic and
para-aortic lymph nodes are
classified as distant
metastases, and
contraindication of surgery.
Normal size –may malignant
Larger size - reactive

74. Peritoneal spread
• Fluid collection
• Mesenteric Soft tissue thickening and stranding
• Omental cacking
Krukenberg tumor : u/l or b/l
• predominantly cystic component
(Primary ovarian ca are rarely multicystic)
Hematogenous spread
• Primarily liver Haematogenous metastases from
gastric carcinoma (b/c of venous drainage of the
stomach is via the portal vein)
• may involve Lung ,adrenal, kidney and brain.
• Fundal adenocarcinoma involving oesophagus
• Antral tumor involves duodenum.
Krukenberg tumours. Bilateral partly cystic ovarian
tumours and malignant ascites.

75. METASTATIC DISEASE
• Malignant melanoma :bulls eye
or target type lesion due to
ulceration of submucosal
deposits.
• Breast ca : spread submucosally
but does not reduced volume as
same as in primary ca.
• Enlarged nodes around the
coeliac axis may denervate the
stomach to cause gastric
dilatation.
• Extrinsic infiltration of the
stomach by an adjacent tumor
produces nodularity, speculation
and, finally, ulceration of the
mucosa.

76. • Squamous ca of the esophagus
may spread via the lymphatics to
the fundus of stomach.
• Carcinoma of the head of the
pancreas may infiltrate greater
curve of the antrum of the stomach
• Tumours of the tail of the pancreas
invade the fundus and upper
posterior wall of the body of the
stomach via splenorenal-
gastrosplenic ligaments.
• Tumors of the transverse colon
may spread by the gastrocolic
ligament to involve the greater
curve of the antrum and body of
the stomach.
•
Gastric 'target' lesion
ulcerating submucosal metastasis from malignant melanoma

77. 1.recurrence at the
anastomotic site following
subtotal gastrectomy.
2.Tumor recurrence at
the surgical plication.
prominent surgical
plication (arrowheads).
3.recurrence at incisional wound
after gastric ca sx.
With ascites and peritoneal
thickening due to peritoneal
carcinomatosis.
M
1
2
3
RECURRENCE

78. LYMPHOMA
• Commonest site for G.I
lymphoma.
• late middle-aged with male
predisposition.
• H. pylori gastritis is associated
with the development of MALT
in lamina propria, which leads to
MALT lymphoma (low grade B-
cell type).
• Two type :low and high grade b.
cell lymphoma.
• ACCORDING TO Megibow’s group,
gastric wall involvement divided
into three patterns:
1. Diffuse infiltration involving more
than 50% of the length of the
stomach: extensive submucosal
infiltration lintis plastica.
2. Segmental infiltration.
3. localized polypoid form :if ulcerate
can give bulls eye appearance.
Radiologically :polypoidal ,ulcerative
,infiltrative similar to ca.

79. • most commonly circumferential
Wall thickening , with thickness
greater than 4 cm. outlet
obstruction is rare.
• submucosal spread of the
tumor within the normally
enhanced mucosal layer and
spares the muscular coats until
late in its course( diff. from ca) .
• usually show poor and
homogeneous contrast
enhancement (diff. from ca).
• Sometimes shows
heterogeneous enhancement
due to necrosis and
hemorrhage.
Gastric wall is markedly thickened
(M) with predominant involvement
of the submucosa. The mucosal
layer is well preserved.
tumor extends posteriorly
involve the pancreas and
splenic hilum

80. LYMPHOMA GASTRIC CA
WALL THICKENING VERY THICK ,MEAN=4 cm LESS THICK ,MEAN=1.8 cm
PERIGASTRIC FAT PLANES USUALLY PRESERVED MAY BE OBLITERATED
REGIONAL LYMPHADENOPATHY COMMON COMMON
EXTENT OF ADENOPATHY MAY EXTEND BELOW LEVEL
LARGE AND BULKY NODES
DOES NOT EXTEND BELOW
RENAL VEIN
LESS BULKY
EXTENT MAY INVOLVE DUODENUM DOES NOT COMMONLY INVOLVE
DUODENUM
LYMPHOMA VS GASTRIC CA

81. , T2-weighted MRI shows a mass (M) with
intermediate signal intensity.
Mass along lesser curva.
Poor contrast enha. On
early arterial phase
isointensity to that of the liver in the delayed phase (D).
GASTRIC LYMPHOMA
:segmental

82. CT STAGING OF LYMPHOMA
• Stage 1 Tumor confined to bowel
wall
• Stage 2 Limited to regional nodes
• Stage 3 Widespread nodal
disease (above and below
diaphragm)
• Stage 4 Disseminated to bone
marrow, liver, spleen and other
organs
Peritoneal lymphomatosis. omental cake (arrows) and diffuse
mesenteric infiltration.
• Advanced cases of lymphoma (peritoneal
lymphomatosis )can show diffuse peritoneal
involvement with ascites, omental
infiltration, and peritoneal implants,
mimicking carcinomatosis

83. MALIGNANT STROMAL TUMOR
• 1% of gastric malignancy
• Middle or elderly male pt.
• often large intramural tumor's
that protrude into the stomach
and have a tendency to central
necrosis and ulceration
• can grow exophytically and May
invade the diaphragm, pancreas
or colon
• Dystrophic calcification may be
observed.
• An association with functional extra
adrenal paraganglioma and
pulmonary chondromas (Carney's
syndrome)
• metastasize to the peritoneal cavity,
and hematogenous spread is to liver
( vascular), lung and bone.
Lymphatic spread is rare.

84. 1. Huge exophytic
mass arising
from the gastric
body , with
central
necrosis. intact
overlying
mucosal layer
enhancement
(arrow).
macroscopic specimen
1.well-defined filling
defect in the
proximal stomach
with central ulcer,
2.Infected malignant GIST . a large
heterogeneous mass (arrows) with
central cavitation and gas
collection
1.
2.
3.1
.
1.
3.Heterogenous exophytic

85. CARCINOID TUMOR
• Distal antrum and lesser curve
of the stomach
• It produces a submucosal
nodule which can ulcerate or
become pedunculated.
• do not produce 5-
hydroxytryptamine not
produce carcinoid syndrome.
• Both the primary tumor and the
liver metastases are typically
hyper vascular.
• Hypergastrinemia predisposes
to the formation of multiple
benign gastric carcinoids
(polyp) , so ass. with chronic
atrophic gastritis or Zollinger-
Ellison syndrome .
.
an irregular, lobulated filling defect with central
ulceration (arrowheads) in the duodenal cap.
duodenal carcinoid (a) a bulky
rounded mass, protruding into the
lumen of the duodenum.

86. KAPOSI SARCOMA
• Tumor of blood vessels
• Homosexual male patients
infected with AIDS
• multifocal
• Early diagnosis by endoscopy :
hemorrhagic patches
• large polypoid masses, or
submucosal nodules which later
ulcerate to produce `bull's eye'
lesions.
• Linitis plastica
• Retroperitoneal lymphnodes,
splenomegaly
Diffuse nodularity of the duodenum

87. CONGENITAL DISEASES
1.DIVERTICULA
2.ECTOPIC PANCREAS
3.ANTRAL DIAPHRAGM
4.HYPERTROPHIC PYLORIC
STENOSIS

88. GASTRIC DIVERTICULA
• most frequently arising from the
posterior wall of the fundus of the
stomach , but rarely may be prepyloric
in location.
• smooth outline and change shape
during the course of a barium study
• the lining mucosa show areae
gastricae pattern.
Gastric diverticulum arising from the fundus of
the stomach.

89. ECTOPIC PANCREATIC REST
• located at Submucosa
• Usually at antrum ,on posterior wall
along greater curvature side.
• Other site ,duodenum or jeujenum
• On barium: umblication ,which
represent filling of rudimentary
pancreatic duct.
• CT: When nodule exceed >2cm
,appears as mural nodule.
• may be complicated by pancreatitis,
pseudocyst formation or
adenocarcinoma.The small diverticulum results from barium entering the primitive ductal
system (arrow). Supine film. A = distal antrum; C = duodenal cap.

90. Ectopic Pancreas in the stomach.
• A small nodule in the antrum of
the stomach (bottom left of image).
• Endoscopy (b) characteristic round umbilicated lesion situated a
few centimeters proximal to the pylorus.

91. ANTRAL DIAPHRAGM
• Thin diaphragm with a small
central opening that involves the
antrum.
• presentation: asymptomatic or
cause GOO.
• Congenital, but can present
clinically at adult life.
Antral diap. (bw arrow).pyloric canal
(asterisk)

92. HYPERTROPHIC PYLORIC STENOSIS
• An infantile and adult form
of this congenital
abnormality of the pyloric
musculature.
• The adult form is probably a
milder version of the
infantile from.
• The gastric antrum tapers
into an elongated pyloric
canal (>2 cm), which bulges
into the base of the
duodenal cap.

93. Barium
• "double track" sign when thin tracks of barium are
compressed between thickened pyloric mucosa.
• A "shoulder" sign when barium collects in the dilated
prepyloric antrum.
• String sign :passing of barium streak through pyloric
canal.
• Diamond sign : niche in mid of pyloric canal with apex
inferiorly sec. to mucosal bulging b/w 2 separated
hypertrophic muscle bundles on G.C side .
• P. Teat sign : outpouching along lesser curvature due
to disruption of antral peristalsis.
• Caterpillar sign : gastric hyperperistaltic waves
• Mushroom sign : indentation of base of bulb.
USG :
• single Muscle width: > or equal to 3mm
• Pyloric canal length :> or equal to 15 mm
• no peristalsis through pylorus
Target sign on cross section
Cervix sign on longitudinal scan

94. MISCELLANEOUS
I. EXTRINSIC MASSES
II. VARICES
III. VOLVULUS

95. EXTRINSIC MASSES
• Any intra-abdominal mass, if large
enough, may impress on or
displace the stomach.
• Lesions of the head of the
pancreas may displace the gastric
antrum and produce a smooth
impression on the greater curve
(the PAD SIGN).
Pancreatic tumor producing an impression on and elevating the
gastric antrum (the pad sign). C = duodenal cap.

96. GASTRIC VOLVULUS
• Due to Laxity of the gastro
hepatic, gastrocolic and
gastrolienal ligaments.
• Primary volvulus
• Secondary volvulus
• Primary: due to cong. Absence
of supporting lig. Without
diaphragmatic hernia.
• Secondary: lig. Stretch as the
stomach ascends to enter a
diag. hernia or eventration. MC
THREE TYPES
1.organoaxial
2.mesenteroaxial
3.combined
half-Fourier acquisition single-
shot turbo-spin echo (HASTE)
MRI.

97. • ORGANOAXIAL VOLVULUS:
Stomach rotates around an axis that runs
between the relatively fixed duodenum
and esophagogastric junction.
The greater curve rotates forwards and
upwards (less often backwards and
upwards)
• Acute volvulus : sx emergency.

98. MESENTEROAXIAL VOLVULUS
• Rotation around an axis that runs between
the midpoints of the greater and lesser
curves . less common.
• The duodenum rotates anteriorly (less
often posteriorly) from right to left so that
the posterior surface of the stomach lies
anteriorly and the greater curve remain at
bottom.
• The characteristic appearance is an
‘upside-down stomach’ with the distal
antrum and pylorus assuming a position
cranial to the fundus and proximal
stomach.
• This type of volvulus is often associated
with traumatic diaphragmatic ruptures.

99. B) Organoaxial volvulus of an intrathoracic
stomach. The greater curve is folded upward and
to the right (small white arrows).
Mesentero-axial volvulus
O.A

100. CUP and SPILL stomach
• Normal variant that simulate organo
axial volvulus.
• Biloculation of stomach .
upper loculus formed by out pouching
of the fundus backward and downward
.lower loculus is narrow ,tubular portion
formed by body of stomach: giving
appearance of cup and spill or
champagne cup deformity.
• The distinction is made by asking the
patient to swallow barium while
standing in a lateral position. The
dependent part of the fundus fills and
forms the `cup', which is situated
posteriorly. The barium then spills
from this part of the fundus and
cascades down the posterior gastric
wall.

101. GASTRIC VARICES
• Dilatation of the venous plexus, which
normally communicates with the
esophageal venous plexus and drains into
left gastric and short gastric veins.
• posteromedial border of fundus is most
common site.
• with esophageal varices in patients with
portal hypertension .
• without esophageal varices, when splenic
vein is occluded, as may result from
pancreatitis or pancreatic carcinoma.
• gastric varices occurs in subserosal location
(esophageal varices in submucosal)
Gastric varices associated with (A) portal hypertension, (B) splenic vein occlusion

102. ON BARIUM
:multiple
serpiginous
filling defect.
CT :
enhancing
tubular
structures.

103. POSTOPERATIVE STOMACH CASE
• Marginal ulcer : Usually distal to
gastrojejunal anastomosis. Can be multiple
• Afferent loop syndrome: Dilated
duodenum. May not fill at UGI. CT helpful
for directly visualizing
• Blown duodenal stump : Fluid or abscess
adjacent to proximal duodenum or
subhepatic space
• Jejunogastric intussusception: Filling
defect in postoperative stomach. Valvulae
confirm enteric nature
• Gastric remnant bezoar : Filling defect in
postoperative stomach. No wall
attachment
• Post gastrectomy carcinoma : Filling
defect, luminal irregularity, or shrinkage of
gastric pouch
• Bile reflux gastritis: Usually associated
with Billroth I or II gastroenterostomy.
Thickened folds, filling defect
• Gastric bypass complications
• Anastomotic leak :Usually at
gastrojejunostomy. Extraluminal
collection. Early complication
• Staple line dehiscence :Contrast
material fils bypassed gastric segment
• Internal hernia :Clustered loops.
Displaced suture line
• Obstruction: Dilated jejunal loop to
jejunojejunostomy

104. REFERENCE
• TEXT BOOK OF RADIOLOGY AND IMAGING ,DAVID SUTTON ,7TH EDITION
• CT AND MRI OF WHOLE BODY ,JOHN R. HAAGA. 6TH EDITION.
• DIAGNOSTIC RADIOLOGY ,GRAINGER AND ALLISONS,6TH EDITION
• RADIOLOGY OF STOMACH AND DUODENUM , SPRINGER.
• DIAGNOSTIC USG ,RUMACK,5TH EDITION.
• MAYO CLINIC G.I REVIEW ,C.DANIEL JOHNSON,2ND EDITION.

105. RADIONUCLIDE IMAGING OF GASTRIC MOTALITY
TECHNIQUE
• Ingestion of a test meal including
10-20 radio-opaque markers.
TEST MEAL INCLUDES
liquid phase :400ml in fruit juice
labelled with "'In-DTPA
solid phase : two slices of bread and
a helping of scrambled egg labelled
with 9smTc-colloid.
• A single abdominal film 60 min
later, or sequential films at 1-4 h,
can then he obtained to check the
progress of the opaque markers
along the GIT .
INDICATIONS
• Patients with persistent nausea, vomiting,
bloating or suspected dumping syndromes
after gastric surgery.
• Patients with symptoms suggestive of outflow
obstruction but normal endoscopy.
• Patients with suspected non-obstructive gastric
stasis, e.g. autonomic neuropathy in diabetes,
chronic renal failure, thyroid disorders, etc.
• Patients with severe or resistant reflex
oesophagitis.
• Patients with biliary gastritis.

106. • Result analyzed by producing time
activity curve for both solid and liquid.
• Four basic patterns may be observed:
1.Normal. Liquid phase t1/2h is less
than 30 min (typically 10-20 min); solid
phase t'/2 is greater than 30 min but at
least 25% of the meal leaves the
stomach by 60 min.
(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.

107. 2.vagotomy pattern: Solid
phase emptying is delayed,
liquid phase is normal or
rapid .
3.Dumping pattern. Both
liquid and solid phases arc
abnormally rapid, with solid
phase t'/2 less than 30 min .
4. Gastric stasis. Both liquid
and solid phases are
delayed
B) after vagotomy :rapid
transit of liquid ,delayed
solid phase emptying.
Gastric stasis Dumping pattern

108. Factor affecting
rate of gastric
emptying

109. THANKS