Single contrast barium meal of the stomach: The stomach is with reduced volume, with

distorted mucosal folds and rigid walls in the region of the body and the antrum. It is a typical
finding for diffuse type of gastric cancer or linitis plastica appearance.
Double-contrast barium meal of the stomach: After administration of effervescent agent, the
stomach is still with reduced volume and severe desmoplastic reaction of the wall. It has
identical finding as the image above.
ydro !T of the stomach: Severe infiltration of the stomach wall, the same is thic"ened, rigid
with reduced volume in the region of the body and the antrum. There is a fluid collection or
ascites around the liver and...

#S of the stomach: There is severe thic"ness of the wall of the stomach, with volume reduction
and impaired peristalsis, which gives impression for malignant process.

#S of the ovaries: There are two large tumor masses that belong to the ovaries, with ascites in
the peritoneum. Impression for metastases in the ovaries.

!T of the abdomen: There are two large tumor masses in the pelvis that originate from the
ovaries and there is a free fluid in the peritoneum. Impression for metastases into peritoneum
and ovaries.

Gastric carcinoma
Diagnosis
The diagnosis of gastric carcinoma is usually made by endoscopy or barium meal. "Early" gastric cancers
(EGC), i.e. those limited to mucosa +/ submucosa regardless of the presence of lymph node metastases) are
pre!alent in some communities, such as "apan, but are relati!ely uncommon in most #estern societies. They
can appear as Type $ (polypoid), Type $$ (superficial% Type $$a ele!ated% Type $$b flat% Type $$c depressed), or
Type $$$ (e&ca!ated). 'i&ed types occur. The surface of early polypoid lesions on (C)' is lobular or granular
and simulates the areae gastricae. (ifferentiation is re*uired from adenomas and hyperplastic polyps (see
belo+). Type , lesions are seen as flat mucosal ele!ations. #here a central depression is present (i.e.
superficial erosion) this is irregular in outline +ith an une!en surface. -olds radiating to+ards

Figure 29.
Diffuse infiltrative gastric carcinoma.
causing obstruction at the antrum.
the lesion may sho+ e!idence of infiltration such as nodularity, amputation or fusion. Type $$$ lesions
demonstrate deeper e&ca!ations.
.d!anced gastric cancers are more common than EGC in #estern societies. These in!ol!e the muscularis
propria or deeper layers. They may be classified on gross radiological appearances as polypoid, ulcerati!e
+ith raised margins (-igs. /0 b, /1, /2), a larger infiltrati!e and ulcerating type, and a diffuse infiltrati!e type
(often se en as a constricting tumour in the antrum) (-ig. /3). These correspond to )orrman types 45,
respecti!ely. 6initis plastica is a diffuse infiltration, predominantly submucosal, +hich is manifest on contrast
studies as a poorly distensible socalled "leather bottle"stomach. This not infre*uently may be o!erloo7ed
endoscopically and, to a lesser e&tent, radiographically. .d!anced ulcerati!e or raised cancers are often large
and ob!ious radiologically. .ll lesions need endoscopic biopsy for confirmation.
Staging
The need for staging of gastric carcinoma is less ob!ious than for oesophageal lesions. ,o+e!er, in
communities +here EGC is pre!alent, it is useful to help determine therapy and prognosis, particularly +here
nonsurgical endoscopic treatment is contemplated. #here ad!anced lesions are more pre!alent it could be
argued that surgery, +hether for attempted cure or palliation, is the treatment of choice and that preoperati!e
staging does not influence management. ,o+e!er, surgeons8 practices differ% if staging is re*uired then this is
best achie!ed by CT or E9: for local staging, and dynamic enhanced or helical CT (or con!entional 9:) for
distant metastases. E9: has been sho+n consistently superior to CT for local staging, but is of limited
a!ailability. CT !isualises the thic7ened gastric +all and its relationship to ad;acent structures, but is unable to
determine the depth of +all in!asion. CT can detect lymph node enlargement but is nonspecific, unable to
distinguish reacti!e from malignant nodes. The criterion for enlargement is usually ta7en as < 4= mm. :ince
metastases can also be present in nonenlarged nodes, CT is not !ery sensiti!e. #hen performed
optimallyCT, using either a dynamic se*uential techni*ue +ith bolus contrast enhancement or the ne+er spiral
(helical) techni*ues, is relati!ely accurate (probably in the region of 3=>) at sho+ing +hether the patient has
li!er metastases or nor, but is significantly less sensiti!e at demonstrating all lesions in an indi!idual patient.
'oss has suggested a CT staging scheme for gastric carcinoma (Table 0).
Table 5.CT Staging of gastric carcinoma (after Moss et al)
Stage I
$ntraluminal mass +ithout +all thic7ening (i.e. ? 4= mm thic7). @o metastases.
Stage Il
#all thic7ening < 4= mm +ithout tumour e&tension or metastases.
Stage III
Thic7ened +all +ith ad;acent organ in!ol!ement but no distant metastases.
Stage IV
(istant metastases +ith thic7ened +all.

The accuracy of E9: in T and @ staging of gastric carcinoma is similar to its accuracy in
oesophagealcarcinoma and significantly better than dynamic CT, being 2=3=> for T and 10> + for @ in most
series. Ance again, there is difficulty in distinguishing benign from malignant nodes although positi!e and
negati!e predicti!e !alues of21.0 > and 2/ > ha!e been achie!ed for nodal metastasis. E9: is highly
accurate in distinguishing EGC from ad!anced cancer. $n linitis plastica E9: demonstrates
a diffuse thic7ening of the submucosa and muscularis propria layers.

Figure 30.
Submucosal smooth muscle tumour of the gastric body
(seen in single contrast) exhibiting
central ulceration (arrowed). Note otherwise smooth
surface and right angled conjunction with gastric walls.
Other gastric tumours
Submucosal tumours
.lthough many cell types can gi!e rise to submucosal tumours in the stomach, the !ast ma;ority are smooth
muscle lesions leiomyomas, leiomyoblastomas and the malignant leiomyosarcomas. Badiology essentially
cannot distinguish these three lesions. 'ost smooth muscle tumours are fundal, rounded and often e&hibit
central ulceration (-ig. C=). The latter accounts for the fre*uent presentation of bleeding. :iDe is !ariable. .s
for all submucosal lesions they appear on (C)' as smooth surfaced +ith normal o!erlying mucosa. $n profile
the margins are at right angles or obtuse to the line of the gastric +all. 'uch of the bul7 of the tumour may be
e&ophytic to the stomach an "iceberg" phenomenon. E9: is useful for confirming the origin of
the tumourfrom muscularis propria and distinguishing bet+een a submucosal and an e&trinsic mass (-ig. C4).
-or larger lesions +here malignancy is suspected, E9: or CT are helpful in assessing infiltration of ad;acent
structures.
,aematogenous metastases from malignant melanoma, breast and lung carcinoma, phaeochromocytoma
and, in recent times, Eaposi sarcoma, may gi!e rise to small submucosal tumours. These are usually multiple
and ha!e a "bull8s eye" or target appearance due to central ulceration. )reast carcinoma may spread
submucosally li7e scirrhous carcinoma.

Figure 31.
EUS image of submucosal smooth muscle
gastric tumour(leiomyoblastoma), T. Lesion seen to arise
from muscularis propria layer of gastric wall (arrow).
!normal wall (see "ig.#)$ b!water fille% balloon
covering trans%ucer.
(&epro%uce% with permission of 'ustralasian
&a%iology).
Mucosal polyps
These occur in 4/> of (C)'s. They appear as rounded filling defects in the barium pool on the dependent
+all or a ringshado+ on the nondependent +all. They may be pedunculated or sessile. The ma;ority are
hyperplastic and possibly result from regeneration follo+ing gastritis. The minority are adenomas and are
important because of their malignant potential. $n addition, there is an increased ris7 of carcinoma in the same
stomach +hen adenomas are present. -eatures to help distinguish bet+een hyperplastic and adenomatous
gastric polyps are listed in Table F. ,o+e!er, if there is any doubt, endoscopy and biopsy are recommended.
Table 6. Gastric polyps
HYPERPLASTIC ADENOMATOUS
Frequency >90% !0% >
Size ! cm ! cm
Number multi"le single or few
Site fundus# body antrum
Other gastric polyps
.lthough occasionally gastric adenomas occur in -amilial .denomatous Golyposis (- .G), most gastric polyps
in this condition are hamartomas. ,amartomas are also seen in GeutD"egher syndrome.



Figure 32.
(astric lymphoma. 'n infiltrative polypoi% mass
involves the car%ia an% pro)imal stomach.
Gastric lymphoma
These constitute 4C > of all gastric malignancies. 'ost are of the non,odg7in8s lymphoma type, and
thelesion may be localised to the stomach +ith or +ithout regional nodes, or part of a generalised
in!ol!ement.Badiographic appearance on contrast studies is !ariable. $nfiltrati!e, nodular,
ulcerati!e, polypoid or mi&ed forms occur (-ig. C/). :ometimes the predominant sign is mar7edly thic7ened
folds. The site +ithin the stomach is !ariable. Af ten it is not possible to distinguish lymphoma from carcinoma.
-urther difficulties arise since mucosal biopsies are fre*uently negati!e, as much of the spread is submucosal.
(istinction is important since the prognosis is considerably more fa!ourable for lymphoma than for carcinoma.
:taging of gastriclymphoma is best performed by a combination of CT and E9:. CT (or transabdominal 9:)
+ill determine +hether there is in!ol!ement of regional nodes% CT +ill define the presence of more generalised
disease in other regions and +ill help assess gastric transmural infiltration. E9: is accurate at mapping out the
distribution of disease +ithin the stomach and the depth of intramural and transmural spread. :e!eral E9:
patterns of mural spread ha!e been described.
The post-operative stomach
$n the early postoperati!e period follo+ing gastric surgery, contrast studies are re*uired to test for
anastomotic lea7age (+hen +ater soluble contrast agents should be used) and for gastric emptying.
$n the late postoperati!e situation, modifications to the standard double contrast techni*ue are re*uired for
satisfactory !isualisation% if the anatomy is 7no+n then this +ill help determine those modifications.
,o+e!er,endoscopy is superior to radiology in assessing recurrent disease in a gastric remnant or at an
anastomosis. Badiology may still be re*uired to determine the anatomy, if this is uncertain, and to assess
gastric emptying.
Duodenal disease
Contrast e&amination of the duodenum is part of the (C)'. Good distended !ie+s are obtainable
usinghypotonic agents and it is no+ rarely necessary to perform hypotonic duodenography using a tube
techni*ue. Ather modalities, including 9:, CT, endoscopy and endoscopic retrograde
cholangiopancreatography ha!e largely surplanted duodenography in imaging periampullary and pancreatic
lesions.
The duodenum, e&tending from the pylorus to the duodeno;e;unal fle&ure, is appro&imately /0C= cm long and
di!ided into four parts. The first part (the "cap") is about 0 cm in length and e&tends posteriorly, superiorly and
to the right from the pylorus and is triangular in shape on barium studies. The pro&imal /C cm is
intraperitoneal% the rest of the duodenum is retroperitoneal. The second part e&tends from the superior
duodenal fle&ure, at the end of the first part, inferiorly to the inferior fle&ure. .t the ape& of the superior fle&ure
there is often a redundant mucosal fold +hich may be mista7en for a lesion on contrast studies. An the
posteromedial +all of the descending duodenum is the ma;or papilla +hich appears
on hypotonicduodenography as a rounded or o!al filling defect. The appearance is !ariable but there are
usually mucosal folds +hich ser!e as landmar7s, the most constant of +hich is a !ertical fold e&tending distally
from the papilla and a hooded fold co!ering the papilla itself (-ig. CC). The minor papilla is much less
fre*uently seen radiologically. The third part of the duodenum e&tends from the inferior fle&ure almost
Figure 33.
*ormal hypotonic %uo%enogram showing area of ma+or
papilla. ,oo%e% fol% (h) covering papilla (p), obli-ue
fol%s (f), pro)imal longitu%inal fol% (pl), %istal
longitu%inal fol% (%l) an% probable site of minor papilla
(a). The pattern of mucosal fol%s is -uite variable.
horiDontally and to the left across the midline. The fourth part begins +here the duodenum becomes more
!ertical and directed superiorly to+ards the duodeno;e;unal fle&ure. The duodenum terminates at the
suspensory ligament of TreitD. The normal mucosal pattern of the duodenal bulb on (C)' is smooth and
relati!ely featureless. . minority of patients e&hibit a fine recticular pattern or small punctate collections
ofbarium +hich are e!enly spaced and appear as triangular spiculations in profile. The latter must be
distinguished from erosions (+hich are irregularly spaced, less numerous and associated +ith oedema and
other signs of duodenitis) and barium precipitates (+hich are more dense and +ash off during the procedure).


Figure 34.
$runner%s gland hy"er"lasia&nodular erosi'e duodenitis
Note multi"le nodules in duodenal ca"# se'eral with
central erosion. "("ylorus.
Table 7. Duodenal "tumour-lie" filling defects
BLH Bruer!" Heter#t#$%& Cr#'!" N#(ular
gla(" ga"tr%&
(%"ea"e (u#(e%t%"
)u&#"a
Site )* +), )! -&. ), juxta"yloric 'ariable )! -&. ),
Si/e !., mm u" to ! cm small 'ariable 'ariable
Number uniform si/e occ. central
de"ression
angular thic0 folds
ulceration strictures
thic0 folds -&.
erosions
Duodenal nodular filling defects
. guide to differential diagnosis of nodular defects is gi!en in Table 1. )enign lymphoid hyperplasia ()6,) may
be a normal finding in a small number of indi!iduals or associated +ith immunoglobulin deficiency and )6,
else+here in the bo+el. )runner8s gland hyperplasia is most prominent in the duodenal bulb, decreasing
belo+ the papilla. :e!eral patterns ha!e been describedH focal hyperplasia consisting of solitary lesions or
small clusters% diffuse +ith innumerable small uniform nodules% multifocal% hyperplasia +ith e!idence
ofduodenitis% hyperplasia +ith erosi!e duodenitis (-ig. C5). There is also an association +ith hyperacidity
states and chronic renal failure. Crohn8s disease of the duodenum is usually associated +ith other signs
besides nodularity, including ulceration, thic7 folds and stricturing. There is of ten antral in!ol!ement, as +ell
as disease else+here in the G$ tract. ,eterotopic gastric mucosa is seen in about 0 > of barium meals and is
of doubtful pathological significance, although there is same e!idence that there is an

Figure 35.
Duo%enal ulceration. .ne mo%erate si/e% ulcer (arrowe%)
an% other possible small erosions are seen. There are
oe%ematous fol%s with linear collections ofbarium among
them, some ra%iating towar%s a central erosion. *ote the
tenting of the base of the %uo%enal cap %ue to fibrotic
scarring (open arrow).
Figure 36.
0ultiple %uo%enal erosions with ra%iating an% oe%ematous
fol%s an% %uo%enal cap %eformity. 1onsistent with
%uo%enal ulceration an% %uo%enitis. *ote the coarse areae
gastricae in the stomach antrum suggesting gastritis.
association +ith ,. pyloris infection.
!on-specific duodenitis
.lthough there is contro!ersy regarding the true nature of nonspecific duodenitis, and the natural history is
some+hat different than duodenal ulceration, it is probably part of the spectrum of peptic ulcer
disease.)arium studies are not especially accurate, but criteria for diagnosis include nodularity, thic7ened
folds (< 5 mm thic7), bulbar deformity and punctate collections of barium +ith halos of oedema, representing
erosions. There is a significant false negati!e rate and false positi!e rate for (C)'. -alse positi!es occur
particularly +hen the diagnosis is made on the presence of only one radiological sign. The pattern
of duodenitis may sometimes be predominantly nodular (-ig. C5). There is considerable o!erlap +ith )runner8s
gland hyperplasia% indeed the t+o often coe&ist and it is not clear +hether the nodules of duodenitis represent
inflammatory infiltrate or )runner8s glands.