Transcript Document

Esophagus Disease
Achalasia
Achalasia
Achalasia is a primary esophageal motility disorder characterized by
failure of a hypertensive LES to relax and the absence of esophageal
peristalsis. These abnormalities cause a functional obstruction at the
gastroesophageal junction.
Pathophysiology:
• LES pressure and relaxation are regulated by excitatory (eg,
acetylcholine, substance P) and inhibitory (eg, nitric oxide, vasoactive
intestinal peptide) neurotransmitters.
• Persons with achalasia lack nonadrenergic, noncholinergic, inhibitory
ganglion cells, causing an imbalance in excitatory and inhibitory
neurotransmission.
• The result is a hypertensive, nonrelaxed esophageal sphincter.
Causes:
The cause of achalasia is unknown.
Achalasia
Frequency:
In the US: The incidence of achalasia is
approximately 1 per 100,000 people per
year.
In the GB: About 6.000 people are
affected
Age:
Achalasia typically occurs in adults aged
25 - 60 years. Fewer than 5% of cases
occur in children.
Achalasia
The specimen is the esophagus (27 cm), cardia, and a portion of stomach wall
(10 x 10 cm). The organs have been laid open to display the mucosal surfaces.
The esophagus is narrowed at the cardia to approximately 2 cm in circumference.
Above this constriction is dilated (maximum 10 cm).
There is patchy mucosal ulceration 7cm from the cardia.
The diagnosis is of achalasia of the oesophagus.
This is the very bottom of the
esophagus, and compared to normal
gastroesophageal junction, this is very
tightly shut - there is only a pinhole
opening. In patients with this condition,
there is difficulty in swallowing food
and it backs up into the esophagus.
This is example of a normal
gastroesophageal junction showing the
transition from the esophagus to the
stomach.
Symptoms of Achalasia
The most frequent presenting symptoms are difficulty swallowing
(dysphagia). It is insidious and intermittent in the beginning but tends to
become progressively worse. It is rare that it leads to an abrupt loss of ability
to eat or drink.
The symptoms are subtle in its onset and most describe "fullness".
• Over 90% of patients have regurgitation of undigested foods.
• Chest spasms or pains, resembling heart pain (angina), occur in 30-50% of
patients.
• Heartburn occurs in 25 to 45% of patients.
• Coughing and lung infections from food particles trapped in bronchial
tubes (aspiration of food) occur in 10% of patients. Some patients have
coughing at night from food aspirating into the trachea from food in the
esophagus. Elevating the head of the bed may often help these people.
• Hoarseness, drooling, and belching may also occur.
Because of these symptoms, the diagnosis may often be missed.
Most commonly, many are misdiagnosed as having gastroesophageal reflux
disease or GERD.
Symptoms of Achalasia
The patient's eating habits change by eating slower,
chewing longer, arching the back or raising their arms to
swallowing by gravity. At this point, the esophagus is only
a passive tube unable to contract.
Physical: Physical examination is noncontributory.
Lab Studies: Laboratory studies are noncontributory.
Achalasia
Imaging Studies:
Barium swallow:
• The esophagus appears
dilated, and contrast material
passes slowly into the
stomach as the LES opens
intermittently. The distal
esophagus is narrowed and
has been described as
resembling a bird's beak
• The test may show
esophageal dilatation
Achalasia
Other Tests:
Esophageal manometry findings include the following:
• Incomplete relaxation of the LES in response to swallowing
• High resting LES pressure
• Absent esophageal peristalsis
Prolonged esophageal pH monitoring is important for the following reasons:
• To rule out gastroesophageal reflux disease (GERD)
• To determine if abnormal reflux is being caused by treatment
Procedures:
An esophagogastroduodenoscopy (EGD) is performed to rule out cancer of the
gastroesophageal junction or fundus. If a tumor is suspected, an endoscopic
ultrasound is performed at the same time.
Achalasia
Achalasia
"bird-beak" at LES on esophagram
Achalasia
megaesophagus
Esophageal Diverticula
Esophageal Diverticula
1. Zenker's (pharyngeal, crycopharyngeal) diverticulum
is a posterior outpouching of the mucosa and submucosa
through the cricopharyngeal muscle. It probably results
from incoordination between pharyngeal propulsion and
cricopharyngeal relaxation.
2. Midesophageal (traditionally called traction)
diverticula are either caused by traction from mediastinal
inflammatory lesions or secondary to motor disorders.
3. Epiphrenic diverticulum, also probably of propulsive
origin, occurs just above the diaphragm and usually
accompanies an esophageal motor disturbance
(achalasia, diffuse esophageal spasm).
Zenker’s diverticula
A diverticulum is a pouch or sac that is created by herniation of a muscle
wall. Zenker’s diverticula are pouches that develop in the pharynx just
above the upper esophageal sphincter.
Zenker’s diverticula occur most often in northern European countries and
those whose heritage is northern European, including the US, Canada and
Australia. It is rare in Asia.
In the US: Fluoroscopic studies of the upper GI tract have shown that
the prevalence of Zenker diverticulum is 0.01-0.1%. They are present
in approximately 2% of patients with nonspecific dysphagia who are
referred for fluoroscopy.
Zenker’s diverticula
Surgical Picture of Zenker's Diverticulum
Zenker’s diverticula generally are
categorized as small, intermediate, or
large in size.
The excised diverticulum is opened and inspected
They extend into the left side of the neck
90% of the time due to a slight convex shape
of the esophagus to that side and the
presence of a potential space there.
Zenker’s diverticula
Killian's triangle is formed posteriorly
between the junction of the cricopharyngeus
muscle and the lower border of the inferior
constrictor muscle and is the site of origin of
Zenker's diverticulum.
Zenker’s diverticula
Upper esophageal sphincter area. Killian's
area is located between the inferior
pharyngeal muscle superiorly and the
cricopharyngeal muscle inferiorly.
Radiograph demonstrating a Zenker's
diverticulum. The barium filling the diverticular
pouch.
Zenker’s diverticula
Symptoms of Zenker’s Diverticulum:
The combination of the following symptoms is nearly pathognomonic for ZD:
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•
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•
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•
•
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Dysphagia
Regurgitation of undigested food hours after eating
Sensation of food sticking in the throat
Special maneuvers to dislodge food
Coughing after eating
Aspiration of organic material
Unexplained weight loss
Fetor ex ore
Borborygmi in the neck
Symptoms may last from months to years.
The most dangerous symptom is aspiration (30% of patients).
If the diverticula spread into a major vessel, obstruction of the esophagus or trachea
can occur. They can cause massive bleeding.
Very rarely, squamous cell carcinoma within diverticulum occur (< 0,5% of patients).
Zenker’s diverticula
Imaging Studies:
• The criterion standard of
confirmatory evaluations is the
barium swallow with
videofluoroscopy.
• This study provides information
about size, location, and
character of the mucosal lining
of the ZD.
• CT and MRI are not routinely
used to either confirm or exclude
Zenker’s diverticulum
Diagnostic Procedures:
• Flexible endoscopic evaluation of swallowing (FEES) provides information that
may suggest the presence of a ZD, but this test has not supplanted the barium swallow
in most surgeons' practices.
• Rigid or flexible esophagoscopy is essential before surgical management to assess
the nature of the mucosa of the ZD and to exclude the presence of SCC or carcinoma
in situ.
Zenker’s diverticula
• The fluoroscopic barium esophagram is the
primary tool for the diagnosis of Zenker
diverticulum.
• The diverticulum appears as an outpouching
arising from the midline of the posterior wall of
the distal pharynx near the pharyngoesophageal
junction.
• This is best identified during swallowing and is
best seen on the lateral view, on which the
diverticulum is typically noted at the C5-6 level.
• When the diverticulum is large enough to
protrude laterally, it protrudes to the left in 90%
of the cases.
www.radiology.vcu.edu
• After the contrast agent bolus passes the upper
esophagus, the diverticulum is typically seen
extending posterior to the cricopharyngeus
muscle, and contrast material that was trapped
within the diverticulum may be regurgitated back
into the hypopharynx.
Zenker’s diverticula
73-year-old man with remnant diverticulum
after endoscopic stapling diverticulotomy for
dysphagia.
Steep oblique view from preoperative
barium study shows 3-cm Zenker's
diverticulum (white arrow) above prominent
cricopharyngeus (black arrow).
Radiographic Findings and Complications After Surgical or Endoscopic
Repair of Zenker's Diverticulum in 16 Patients
Am. J. Roentgenol. Sydow et al. 177 (5): 1067.
Zenker’s diverticula
• A Valsalva maneuver
may be helpful in
visualizing the
diverticulum after
swallowing.
• Occasionally, a patient
may aspirate contrast
material from the
diverticulum.
• Pay attention to the
lumen of the diverticulum
because irregularities
or filling defects within
the diverticulum may
indicate the rare
complication of
squamous cell
carcinoma.
Diverticula of the
esophageal body
Diverticula of the esophageal body
Midesophageal (traction) diverticula:
caused by traction from mediastinal inflammatory lesions or
secondary to motor disorders
Epiphrenic (supradiaphragmatic) diverticula:
Diverticula that occur in the distal esophagus, in the lower 6-10 cm,
are termed epiphrenic diverticula.
Epiphrenic diverticulum, probably of propulsive origin usually
accompanies an esophageal motor disturbance (achalasia, diffuse
esophageal spasm).
Diverticula of the esophageal body
Traction diverticulum
Developmental diverticulum
Diverticula of the esophageal body
Midesophageal
diverticulum
Diverticula of the esophageal body
Midesophageal
and epiphrenic
diverticula
Diverticula of the esophageal body
Epiphrenic diverticulum
Roentgenogram of esophagus showing a typical pulsion
diverticulum of lower part. Such diverticula usually present on
the right in the lower 10 cm of thoracic portion of esophagus.
(From Payne WS, and Clagett OT: Pharyngeal and
esophageal diverticula. Curr Probl Surg April: 1-31, 1965.)
Esophagus with huge epiphrenic diverticulum occupying
approximately half of the right thorax. Note associated
sliding esophageal hiatal hernia. (From Payne WS :
Esophageal diverticula. In Shields TW (ed.), General
Thoracic Surgery Second Edition. Philadelphia: Lea &
Febiger, 1983, pp. 859-872).
Diverticula of the esophageal body
Epiphrenic diverticulum
Caustic Burns of the
Esophagus
Caustic Burns of the Esophagus
• Alkaline caustics and acids are the commonest chemicals implicated in
caustic burns.
• Burns from ingestion of such agents may include the oral, pharynx,
larynx, esophagus and stomach. Destruction of tissues or of these
organs may lead to complications, of which respiratory compromise,
esophageal and gastric perforation, septicemia, or even death might
occur.
• Patients with ulceration, blisters, even areas of extensive necrosis
always tended to develop esophageal strictures with inability to swallow
food.
• Repeated dilations to maintain an adequate lumen diameter are
performed in patients with chronic strictures.
A barium-swallow esophagogram is performed before the dilatations (i.e.,
first time in two weeks after ingestions) to evaluate the sites of lesions,
degree of the stenosis and motor function of the esophagus.
Caustic Burns of the Esophagus
Radiographic
findings:
•esophagus
tapered
throughout its
path
•area of
narrowing
•irregular
contours
•loss of the
mucosal
pattern
•reduced
peristalsis
•rigidity
Esophageal Varices
Esophageal Varices
Most esophageal varices are a result of portal
hypertension resulting from cirrhosis.
• The leading cause of cirrhosis in the Western world is alcoholic
liver disease, closely followed by viral hepatitis.
• Outside the Western world, the leading causes of cirrhosis are
hepatitis B and hepatitis C.
• The lifetime incidence of esophageal varices is approximately 50%
for all patients with cirrhosis.
• The annual risk of developing varices is 5-15%.
Esophageal Varices
Hemorrhage is a major
complication in patients with
esophageal varices, occurring in
approximately one third of
patients.
• The mortality rate for each bleeding
episode is approximately 30%.
• If underlying etiology remains untreated,
as many as 70% of patients who develop
hemorrhage die within 1 year of the
initial bleeding episode.
• Bleeding from esophageal varices
accounts for approximately 10% of
episodes of upper GI bleeding.
Diagnosing varices is critical to prevent the first episode
of hemorrhage.
Esophageal Varices
Esophageal Varices
Although endoscopy is the criterion
standard in diagnosing and grading
esophageal varices, the anatomy
outside of the esophageal mucosa
cannot be evaluated with this
technique.
Therefore, imaging modalities such
as barium swallow, CT, MRI, and
EUS are also performed for a more
complete evaluation.
Grossly, esophageal varices appear
as tortuous, dilated, blue veins
running along the long axis of the
esophagus.
Esophageal Varices
Imaging Studies
Barium study
Barium swallow examination is not a sensitive test, and it must be
performed carefully with close attention to the amount of barium used and
the degree of esophageal distension. Barium swallow images may help in
detecting only 50% of varices.
However, according to American Academy of Family Physicians, barium
swallow is the imaging modality of choice for demonstrating esophageal
varices.
Esophageal Varices
Barium study
may be of benefit if the patient has
a contraindication to endoscopy or
if endoscopy is not available.
The procedure should be
performed with the patient in the
supine or slight Trendelenburg
position.
These positions enhance gravitydependent flow and engorge the vessels.
The patient should be situated in
an oblique projection.
This positioning prevents overlap with the
spine and further enhances venous flow.
Barium swallow demonstrates multiple
serpiginous filling defects primarily involving the
lower one third of the esophagus
Esophageal Varices
Barium study
Esophageal varices appear as tortuous,
serpiginous, longitudinal filling defects
projecting into the lumen of the
esophagus.
These defects are seen best on relief
projections of the esophagus.
Esophageal Varices
CT scans
• CT scanning is an excellent method for detecting moderate-to-large
esophageal varices and for evaluating the entire portal venous system.
• CT is a minimally invasive imaging modality that involves the use of only
a peripheral intravenous line; therefore, it is a more attractive method
than angiography or endoscopy in the evaluation of the portal venous
system.
• CT scans also help in evaluating the liver, other (than left gastric vein and
the venous plexus of the esophagus) venous collaterals, details of other
surrounding anatomic structures, and the patency of the portal vein.
Esophageal Varices
CT findings
• On nonenhanced studies, esophageal varices may not be
depicted well.
• On contrast-enhanced images, esophageal varices appear
as homogeneously enhancing tubular or serpentine
structures projecting into the lumen of the esophagus.
Esophageal Varices
CT findings
post contrast axial
and coronal
reconstructed
images
esophageal varices
and splenomegaly
From: http://home.earthlink.net/~radiologist/tf/120604.htm
Esophageal Varices
CT findings
enhancing paraesophageal varices
splenomegay, dilated paraumbilical veins
Esophageal Varices
MRI
• MRI is an excellent noninvasive
method for imaging the portal venous
system and esophageal varices.
• MRI is becoming a more common
examination in pre-TIPS and
pretransplantation evaluations.
• The only major disadvantages of MRI
compared with CT are its limited
availability and cost
• Varices appear as flow voids on
conventional T1- and T2-weighted
images.
• Esophageal varices and other
portosystemic collaterals are
demonstrated as serpiginous
contrast-enhanced vessels in the
portal venous phase.
From: www.medical.philips.com
Maximum intensity projection MRI of the
portal venous system demonstrates
esophageal varices
Hiatal Hernia
Hiatal Hernia
A hiatal hernia occurs when a portion of the
stomach prolapses through the diaphragmatic
esophageal hiatus.
Hiatal hernias are more common in Western
countries. The frequency of hiatus hernia increases
with age, from 10% in patients younger than 40 years
to 70% in patients older than 70 years.
Most hiatal hernias are found incidentally and usually are discovered on
routine chest radiographs or CT scans performed for unrelated symptoms.
When symptomatic, patients may experience:
• heartburn
• dyspepsia
• epigastric pain
Gastroesophageal reflux disease is a common finding in patients with
hiatal hernia
Hiatal Hernia
Diaphragmatic hernias may be congenital or acquired.
Acquired hiatal hernias are divided further into nontraumatic and traumatic
hernias. The most common types of hernias are those acquired in a
nontraumatic fashion.
Hernias acquired in a nontraumatic fashion are divided into 2 types:
1. sliding hiatal hernia
2. paraesophageal hiatal hernia.
A mixed variety is possible.
Approximately 99% of hiatal hernias are sliding, and the
remaining 1% are paraesophageal.
Hiatal Hernia
1. Sliding hiatal hernia is the most
common type of hiatal hernia.
• It occurs when the
gastroesophageal junction, along
with a portion of the stomach,
migrates into the mediastinum
through the esophageal hiatus.
• The majority of patients with
demonstrated hiatal hernias are
asymptomatic.
From: http://www.gastrointestinalatlas.com/index.html
Hiatal Hernia
2. In paraesophageal hernia, also called rolling-type hiatal hernia, the
widened hiatus permits the fundus of the stomach to protrude into the
chest, anterior and lateral to the body of the esophagus; however, the
gastroesophageal junction remains below the diaphragm.
Paraesophageal hernias are potentially life threatening because of
the risk of volvulus and incarceration.
No clear correlation exists between the size of a hiatal hernia and the
severity of the symptoms. A very large hiatal hernia may be present with no
symptoms at all.
Hiatal Hernia
Hiatal Hernia - Imaging Studies
An upper GI barium series is the definitive method of diagnosing hiatal hernias.
Ampulla phrenica
Normal anatomy of gastroesophageal junction
esophagus
stomach
Epiphrenic esophageal dilatation
The lower esophageal sphincter (LES)
Hiatal Hernia - Imaging Studies
Upper GI barium series
• A single-contrast barium swallow performed with the patient in the prone position is
more likely to demonstrate a sliding hiatal hernia than an upright double-contrast
examination.
• The A-ring is an
indentation sometimes
seen on barium studies,
and it marks the upper
part of the LES. Just
below this is a slightly
dilated part of the
esophagus, forming the
vestibule.
• A second ring, the Bring, may be seen just
distal to the vestibule
Hiatal Hernia - Imaging Studies
Upper GI barium series
• A single-contrast barium swallow performed with the patient in the prone position is
more likely to demonstrate a sliding hiatal hernia than an upright double-contrast
examination.
A sliding hiatal hernia
The presence of a Bring more than 1-2 cm
above the
diaphragmatic
impression confirms
the diagnosis of a
sliding hiatal hernia
Symptomatic lower
esophageal mucosal
ring (B-ring) that cause
dysphagia is termed
Schatzki ring.
Hiatal Hernia - Imaging Studies
Upper GI barium series
• The hernia can often be recognized by the demonstration of mucosal gastric folds
within the hernia.
• On a dynamic study, the esophageal peristaltic wave ceases above the hiatus; thus,
the end of a peristaltic wave delineates the esophagogastric junction.
Hiatal Hernia - Imaging Studies
Upper GI barium series
Esophagogram
shows that a portion
of stomach lies above
the diaphragm.
Hiatal Hernia - Imaging Studies
Upper GI barium series
A paraesophageal hiatal hernia is
diagnosed by the position of the
gastroesophageal junction.
The cardia of the stomach esophagogastric junction usually
remains in the normal position
below the diaphragmatic hiatus,
and only the stomach herniates
into the thorax, adjacent to the
normally placed gastroesophageal
junction.
Esophagogram depicts elevated
gastric fundus extending through
the widened esophageal hiatus to
the thoracic cavity (arrows).
The intra-abdominal position of
the gastroesophageal junction
(open arrow) is normal.
Hiatal Hernia - Imaging Studies
Upper GI barium series
Paraesophageal
Hernia
Hiatal Hernia - Imaging Studies
Plain radiography
• Most hiatal hernias are found incidentally on routine chest radiographs.
• The hernia may be seen as a retrocardiac mass with or without an air-fluid level.
• The hernia usually is positioned to the left of the spine
Hiatal Hernia - Imaging Studies
Plain radiography
• The air-fluid level in the lateral projection
Hiatal Hernia - Imaging Studies
Plain radiography
• The two air-fluid levels; one in the stomach and the other in the esophagus
• Inhomogeneous cardiac density
• Retrocardiac density
Hiatal Hernia - Imaging Studies
CT Findings
• Hiatal hernias often are seen
incidentally on CT scans
obtained for other indications.
• A hiatal hernia appears as a
retrocardiac mass with or
without an air-fluid level. The
mass usually can be traced
into the esophageal hiatus on
sequential cuts.
• Herniation of omentum
through the esophageal hiatus
may result in an increase in
the fat surrounding the lower
esophagus.
Mediastinal window of enhanced CT
scan obtained at the level of the
suprahepatic inferior vena cava shows
that the thorax contains a portion of
stomach (arrows). The aorta is
displaced to the right
Sliding hiatal hernia
Hiatal Hernia - Imaging Studies
A totally intrathoracic stomach is not a true hiatal hernia because herniation
occurs through a defect in the central tendon of the diaphragm.
Hiatal Hernia - Imaging Studies
Diaphragmatic herniation is a rare complication of thoracic and abdominal surgery
The barium swallow radiograph
An incarcerated barium-filled stomach in
the chest
From: Interactive Cardiovascular and Thoracic Surgery 2:544-546(2003)
Lateral view of magnetic resonance imaging
A rupture of the diaphragm and intrathoracic
stomach show a rupture of the diaphragm.
Peptic Ulcer
Peptic Ulcer
• Peptic ulcers are mucosal breaks of 3 mm or larger.
• Gastric ulcers account for about one third of peptic ulcers, and duodenal
ulcers account for the rest.
• Because a small percentage (<5%) of gastric ulcers are due to ulcerated
gastric carcinomas, all gastric ulcers must be carefully assessed to
differentiate benign lesions from malignant lesions.
Helicobacter pylori infection and the
use of nonsteroidal anti-inflammatory
drugs (NSAIDs) are the 2 main factors
in the pathogenesis of peptic ulcers.
H. pylori infection occurs in 75% of
gastric ulcers and 90% of duodenal
ulcers.
This photo taken with a high
powered electron microscope
shows the tiny H. pylori bacteria
(pink) attacking the gastric cells
which line the inside of the
stomach. This is the "ulcer
bacteria" that was re-discovered by
Dr. Barry Marshall in Australia in
1982. Each year, over 7 million
Americans suffer from H. pylori
related disease
Gastric Ulcer
Gastric Ulcer
Frequency:
In the US: Approximately 15% of the US population has evidence of a peptic ulcer at some
time. Of these, about 5% are gastric ulcers, and the rest are duodenal ulcers. Overall, the
incidence of gastric ulcers has been decreasing over the past 3-4 decades.
In contrast to duodenal ulcers that occur in adults of all ages, gastric ulcers occur mainly in
adults older than 40 years.
•
•
•
•
About 1 in 10 Americans develop at least one ulcer during their lifetimes.
Ulcers affect about 5 million people each year.
More than 40,000 people a year have surgery because of persistent symptoms or problems from ulcers.
Each year about 6,000 people die of ulcer-related complications.
Internationally: The annual incidence of gastric ulcers varies from approximately 1 case per
1000 population in Japan to 2.7 cases per 1000 population in Scotland.
People with low socioeconomic status
are more likely to acquire H. pylori
infection. Infected individuals are 3
times more likely to develop gastric
ulcer compared to those unexposed
to the bacteria.
Stomach ulcer at endoscopy
Surgical specimen
Gastric Ulcer
Preferred Examination:
•
•
•
•
Begin the evaluation with history taking and physical examination.
Perform blood tests, including a full blood count and liver function tests.
Inspect the stool, and test it for the presence of occult blood.
Perform either fiberoptic endoscopy or a double-contrast barium study of
the upper GI tract.
• Endoscopy has become the diagnostic procedure of choice for
patients with suspected duodenal ulcer.
• Double-contrast examinations of the upper GI tract remain a useful
alternative to endoscopy but have a lower sensitivity especially in the
detection of small duodenal ulcers.
• Test for the presence of H. pylori infection. This is essential in all
patients with peptic ulcers.
Gastric Ulcer
Preferred Examination:
Endoscopy with biopsy has a sensitivity of 95%.
However, endoscopy is more invasive and costly
than a double-contrast study and multiple biopsy
samples are needed to avoid sampling errors.
Single-contrast barium studies have an overall sensitivity of 75%, but
double-contrast barium examinations have a sensitivity of as high as 95% in
the detection of gastric cancer. These results are comparable to those of
endoscopy, and double-contrast barium examination remains a useful
alternative to endoscopy.
Barium studies have a disadvantage in that biopsy specimens of the lesion
cannot be obtained to test for H. pylori infection or to evaluate for the
presence of malignancy.
Gastric Ulcer
Radiologic features
• Gastric ulcers are usually seen as
round or ovoid collections of
barium, but they can also be linear,
rod or star shaped. Linear ulcers are
often observed in the healing
stages.
• Ulcers smaller than 5 mm may not
be detected on barium studies.
• Ulcers may vary from 3 mm to more
than 5 cm in diameter. Giant ulcers
(>3 cm) have a greater risk of
complications such as bleeding and
perforation.
Gastric Ulcer
Radiologic features
• Most benign ulcers are
located in the lesser curvature
or posterior wall of the antrum
or body of the stomach.
• Only about 5% of benign
ulcers are located in the
anterior wall or greater
curvature.
Gastric Ulcer
Radiologic features
The smooth, round, or
oval ulcer crater
projects beyond the
contour of the adjacent
gastric wall.
Areae gastricae
adjacent to the ulcer
may be enlarged
because of edema.
Hampton lines, ulcer collars, and ulcer
mounds are classic features of benign
gastric ulcers, but they are observed in only
a minority of lesser-curve ulcers.
Gastric Ulcer
Radiologic features
Undermining of the mucosa in the base of the ulcer results in the appearance of a thin radiolucent line
called the Hampton line that divides the barium in the ulcer crater from that in the body of the stomach.
spot radiograph
Gastric Ulcer
Radiologic features
If the rim of mucosa becomes edematous, a wider radiolucent band or ulcer collar may
be observed.
Posterior-wall ulcer - an ulcer collar is seen
as a radiolucent halo surrounding the ulcer
Lesser-curve ulcer - spot radiograph
Gastric Ulcer
Radiologic features
Less commonly, the edema
and swelling around the ulcer
may produce an ulcer mound
with poorly defined outer
borders.
the ulcer (U)
gastric mucosa (M)
large arteries at the base of the ulcer (A).
Gastric Ulcer
Radiologic features
Retraction of the gastric wall adjacent to
lesser-curve ulcers may lead to the
formation of smooth, symmetric folds that
radiate from the ulcer crater
The gastric mucosal folds tend to radiate outwards
from the margin of the ulcer - this is the result of
the fibrosis which occurs in the base of a long
standing chronic ulcer.
radiating mucosal folds (arrows)
Gastric Ulcer
Radiologic features
A rare cause of peptic ulcers
is Zollinger-Ellison syndrome
(ie, gastrinoma).
The hallmark of ZollingerEllison syndrome is the
profound hypersecretion of
gastric acid.
Significant disruption of the
mucosal integrity often results
in multiple duodenal and
gastric ulcers.
Gastric Ulcer
Radiologic features
- healing and scarring
Ulcer healing is demonstrated as
a decrease in ulcer size and,
often, a change in shape from
round to linear at follow-up
studies.
Complete healing, or
disappearance of the ulcer, is
usually observed 8 weeks after
medical treatment
spot radiograph
Gastric Ulcer
Radiologic features
- healing and scarring
"Hourglass" stomach
Due to chronic peptic ulceration there is fibrosis and contracture of the
stomach leading to an hourglass shape as well as altered mobility.
„The hypothesis is proposed that hour-glass stomach is produced by gross
scarring around a severe benign chronic gastric ulcer under the influence of
prolonged exposure to aspirin.”
From: Med J Aust. 1976 Oct 30;2(18):674-6. Hour-glass stomach: an explanation. Floate DA, Duggan JM.
Gastric Ulcer
Appearances suggestive of a benign ulcer
• About 95% of gastric ulcers are benign.
• The double-contrast technique allows differentiation of benign and
malignant gastric ulcers in most cases.
The following features are associated with a benign ulcer:
• The ulcer projects beyond the healthy lumen on the profile view.
• The margin of the ulcer crater is sharply defined and smooth en face.
• Any filling defect that surrounds the ulcer, as a result of edema, is smooth
and symmetric and merges with the healthy mucosa.
• The mucosal folds radiate to the edge of the ulcer.
Benign ulcers that do not have these typical features are classed as
indeterminate, and endoscopy and biopsy are required, as they are for
ulcers that appear malignant.
Gastric Ulcer
Appearances suggestive of malignancy
The following features are associated with a malignant ulcer:
• The ulcer crater has an intraluminal location. Exceptions are ulcers in the
antrum or greater curvature, where benign ulcers are often drawn inward
because of muscle spasm in the adjacent stomach wall.
• The margins of the ulcer crater may be irregular and nodular.
• The ulcer crater is surrounded by an asymmetric mass that has an abrupt
outer border with the healthy mucosa.
• Clubbed mucosal folds terminate short of the ulcer crater.
• Ulcers in the fundus are rare, and almost all are malignant.
There are no malignant ulcers; there are ulcerating malignancies.
The radiologic differentiation between benign and malignant ulcers
may be difficult.
Gastric Ulcer
CAT Scan
CT has no part in
the primary
detection of
gastric ulcers.
It has a role in the
detection of
subphrenic and
other collections
that may occur
after a perforation
of a gastric ulcer
68-year-old man with perforated duodenal ulcer (solid arrow), severe
epigastric pain, and diffuse peritoneal signs. CT scan shows free air and
extravasated contrast material in periphepatic space (open arrow).
From: AJR 2000; 174:901-913 Helical CT in the Evaluation of the Acute Abdomen. Richard M. Gore et al.
Gastric Ulcer
CAT Scan
30-year-old man with suspected
pancreatitis. CT scan reveals
benign gastric ulcer in lesser
curvature (arrow).
From: AJR 2000; 174:901-913 Helical CT in the Evaluation of the Acute Abdomen. Richard M. Gore et al.
Duodenal Ulcer
Duodenal Ulcer
Duodenal ulcer is a common condition characterized by the presence of a
well-demarcated break in the mucosa that may extend into the muscularis
propria of the duodenum.
Frequency:
In the US: The prevalence of duodenal ulcer is estimated to be 6-15% in the general
population. Most individuals do not have clinically significant ulcer disease. The prevalence
is linked to the presence of H pylori.
Approximately 10% of young men have H pylori, and the proportion of people with the
infection increases steadily with age.
Approximately 10% of the US population has evidence of a duodenal ulcer at some time. Of
those infected with H pylori, the lifetime prevalence is approximately 20%.
More than 95% of duodenal ulcers are found in the first part of the
duodenum; most are less than 1 cm in diameter.
Duodenal Ulcer
Endoscopy
• Esophagogastroduodenoscopy (EGD) is the most
sensitive test available to detect duodenal ulcer. It
has a sensitivity greater than 95%.
• With EGD, the ulcer can be visualized, a biopsy
specimen can be obtained, and, if required, bleeding
ulcers can be treated directly.
• EGD is a more invasive test and requires
conscious sedation in many patients.
Imaging Studies
• Single-contrast barium radiography can detect 70-80% of duodenal ulcers.
• The sensitivity increases to greater than 90% when double contrast radiography is performed
and evaluated by an experienced radiologist.
Test for the presence of H. pylori infection. This is essential in all patients
with peptic ulcers.
Duodenal Ulcer
Radiologic features
1. small, round/ovoid/linear ulcer niche
A 1 cm irregular ulcer crater in the duodenal bulb on air
contrast spot films with patient in the right posterior
oblique position
The specimen includes the
distal part of the gastric
antrum, the pylorus and
proximal duodenum.
On the posterior wall of the
duodenum there is an ulcer
3 cm in greatest diameter.
Duodenal Ulcer
Radiologic features
1. small, round/ovoid/linear ulcer niche
This is a 76 y.o. man with nausea
and abdominal pain who
underwent a barium study shown
above.
The series reveals a small, ovoid
ulcer in the duodenal bulb
(retained barium in the ulcer
crater).
The majority of gastric and
duodenal ulcers are single.
Duodenal Ulcer
Radiologic features
2. "kissing ulcers":
ulcers opposite from
each other
When multiple ulcers are
found, Zollinger-Ellison
syndrome should be
suspected.
A spot film of the duodenum with
compression reveals two typical
crater-form ulcers and symmetric
folds that radiate from the ulcers
A spot film of the duodenum
without abdominal compression
shows no evidence of deformity
of the duodenal bulb
Multiple duodenal ulcers
Duodenal Ulcer
Radiologic features
3. "clover-leaf deformity„ of the duodenal bulb
Duodenal ulcers usually
occur in the posterior
wall of the bulb.
Because of its recurrent
course, the resulting
scarring will produce a
typical cloverleaf
deformity in response to
constriction around the
ulcer.
Duodenal Ulcer
Radiologic features
This study reveals a small
duodenal ulcer crater on the
inferior aspect of the bulb with
a moderately severe
cloverleaf deformity of the
bulb.
Marked deformity with a large
pseudodiverticulum at the top (the
duodenal lumen is toward the bottom)
Complications of Peptic
Ulcer
Complications of Peptic Ulcer
• Bleeding
• Gastric outlet obstruction
• Perforation occurs
• Penetration
Complications of Peptic Ulcer
Bleeding is slightly more
common in the duodenum than
the stomach
• Hemorrhage occurs in 20-30%
of ulcers
• A filling defect in the ulcer
crater may represent a blood
clot
Complications of Peptic Ulcer
Gastric outlet obstruction is less common than bleeding (5%)
• It is most common in duodenal ulcers, but it also occurs in antral
or pyloric-channel ulcers
• Benign ulcer disease at pylorus is a more likely to cause gastric
outlet obstruction than ca
Complications of Peptic Ulcer
Gastric outlet obstruction
Barium upper GI studies are
very helpful because they
can delineate the gastric
silhouette and demonstrate
the site of obstruction.
An enlarged stomach with a
narrowing of the pyloric
channel or first portion of the
duodenum helps
differentiate GOO from
gastroparesis.
Contrast study demonstrating a
grossly distended stomach with
absence of distal intestinal gas due
to outlet obstruction
Complications of Peptic Ulcer
Gastric outlet obstruction
Endoscopy, CT abdomen and barium study are suggestive of gastric
outlet obstruction
Complications of Peptic Ulcer
Perforation occurs in as many as 10% of patients with peptic ulcer disease
but is less common in gastric ulcers
• Most perforations arise from ulcers in the anterior aspect of the duodenal
cap and, less commonly, from the anterior aspect of the lesser curve of the
stomach
• Free air is not detected by x-ray in 25-35% of perforated duodenal ulcers
Penetration is the extension of the ulcer beyond the serosa in to adjacent
structures
• Pancreas is most common site (in two thirds of cases), but also biliary
tree, colon
• An abscess may form in the lesser sac and liver