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Anatomy of stomach DD of gastric masses

Barium Meal

Reticular pattern Area Gastricae Rugae

Rosette of folds in gastric cardia

2-3 layered structure Max thickness of stomach wall _4mm

5 layers of bowel wall Wall thickness of distended stomach _3 mm

Benign tumours

Malignant tumours

Miscellaneous causes

Hyperplastic

Polyps

-Local hyperplasia of glandular tissue


-Small , smooth , sessile ,multiple -Size < 1 cm -Fundus & body of stomach

-Arise from mucosa affected by chronic


atrophic gastritis.

Dependant part of stomach__filling defect Anterior wall polyp__ring Small, sessile,smooth polyps__always benign Polyp>1cm OR irregular surface__further workup needed

Majority dysplastic_may undergo malignant change -Tubular -Tubulovillous -Villous >1cm ,larger than hyperplastic Solitary with nodular surface Commonest site__Gastric antrum May pedunculate,prolapse in pylorus

Risk of malignant transformation relative to size Carcinoma may co-exist


1. 2.

Include
Stromal tumours Neurofibroma Lipoma Hemangioma Lymphangioma Glomus tumour Neural tumour Brunner gland hemartoma Duplication cyst Ectopic pancreatic rest

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Difficult to diagnose by endoscopy because overlying mucosa may be intact Large tumours tend to ulcerate
Smooth bulge into bowel lumen , margins forming a right angle/obtuse angle with normal bowel wall.

Complications :
Necrosis Ulceration Gastric outflow obstruction Intussusception Large abdominal mass

Barium Meal: -clearly defined margins -if central ulcer present__bulls eye/target appearance

CT: -well defined, homogenous mass -larger tumours__ulceration, necrosis -glomus tumour, pancreatic, carcinoid __ hypervascular -stromal, glomus tumour, hemangioma __calcifications

EUS diagnostic modality of choice -mass arising from mucularis propria or muscularis mucosa -smaller,echo-poor ,well-defined >3cm tumors surgically removed

Soft , may change shape with peristalsis or palpation May ulcerate , bleed , intussuscept Diagnosed by : -EUS__echogenic tumour Confirmed by: - CT

Capillary /cavernous type Solitary / multiple

-endoscopy for diagnosis -may complicate into: Phlebolith GI bleeding

Greater curve of antrum OR anteromedialy in 1st or 2nd part of duodenum Congenital failure of bowel recanalization Gastric duplication present in early childhood Filled with clear mucinous fluid

Small __ 1-3 cm Distal end of greater curve OR proximal duodenum Incidental finding If tissue well-diffrentiated,barium study may show a central niche or fill a short ductal system.

Complications : Pancreatitis Pseudocyst Adenocarcinoma CT variable appearance -homogenous , strongly enhancing tumours OR -avascular cystic lesions

Include : 1. Gastric carcinoma 2. Lymphoma 3. Malignant stromal tumours (GIST) 4. Kaposi sarcoma 5. Carcinoid tumour 6. Metastatic tumours

Risk factors: Atrophic gastritis intestinal metaplasia dysplasia neoplasia Pernicious anemia H. Pylori infection Partial gastrectomy Nitrates intake

Symptoms:

Anorexia Dyspepsia Weight loss Anemia

Mucosa and submucosa 90% 5 yr survival rate Diffrentiate benign ulcers from ulcerating malignancy __nodularity, clubbing, interrupted or fused mucosal folds

Muscularis propria invasion May be Polypoid Fungating Ulcerated Infiltrating (linitis plastica)

Stippled calcification in mucin producing Ca Ulcerated early Ca resembles benign ulcer (meniscus sign) Large tumours__obvious filling defects on barium studies

Most common mets in stomach from: Malignant melanoma Ca breast Kidney, lung, thyroid, testes

Bulls eye / target lesion

Mets from Ca breast

Pad sign. Ca head of pancreas

Most common site of GI lymphoma H.Pylori __MALT lymphoma Coeliac disease __T-cell lymphoma Middle aged men Doesnt cause obstruction commonly

Radiological appearance o Often identical to gastric Ca, benign ulcers, suspect lymphoma if: Giant cavitating lesions Pronounced gastric folds thickening

Multiple polypoid tumours(bulls eye)

CT
-Bulky homogenous tumour
-gastric wall thickness -perigastric fat plane preserved -transpyloric spread -splenomegally -multicentricity __CT used for staging

1% of gastric malignancies Fundus and body involved Middle age / elderly __ males > females Large tumours, might pedunculate Central necrosis and ulceration

CT

Exophytic growth Low density necrotic centre Dystrophic calcification Mets to peritoneal cavity, liver, lung ,bone

Tumour of blood vessels 1/3rd of homosexual male patients with AIDS Multifocal tumours throughout GIT

Diagnosed by

Endoscopy
-hemorhagic patches on gastric mucosa

Barium meal
- large polypoid tumors OR -submucosal nodule,later ulcerates_bulls eye lesion -linitis plastica

CT
-retroperitoneal LN enlargement -splenomegaly

Rare in stomach/duodenum Slow-growing__distal antrum,lesser curvature Submucosal nodules__may ulcerate/pedunculate Hypervascular__both pri. n liver mets ___assess in both arterial and venous phase on CT

Extrinsic compressions Gastric pseudotumours HPS Bezoar Peptic ulceration

Diagnosed by : Endoscopy Barium studies USG CT

Gastric fundal varices -filling defect on barium meal

Intragastric prolapse of sliding hiatus hernia -mucosal folds form the mass -disappears in recumbent position

Mass of ingested material Dragging sensation/ fullness 2 types: Trichobezoar -mass of matted hair -young girls , psychiatric patients Phytobezoars -vegetables/ fruit pith -unripe persimons, gastric surgery

Diagnosis: -Barium meal __filling defect __outlines the mass __may penetrate __mottled appearance

Rapunzels syndrome: -severe case of trichobezoar -extend into small bowel, even caecum

Plain radiograph of the abdomen showing multiple air fluid levels with dilated small intestinal loops and a sizable soft tissue density within the stomach

Congenital anomaly - Infantile - adult Stasis causes __ antral gastritis + ulceration Antrum tapers into >2cm long pyloric canal

To differentiate from annular Ca: Antral tapering Absence of mucosal destruction Intact mucosal folds passing through pyloric canal

In advanced cases, may cause gastric strictures