19DAVID SUTTON

DAVID SUTTON PICTURES

DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL

• Fig. 19.1 Anatomy of the stomach.

• Fig. 19.2 Areae gastricae. Normal reticular pattern to the mucosa produced by areae gastricae.

• Fig. 19.3 Fine transverse mucosal folds. Prone view. A = antrum; C = duodenal cap. Asterisks mark the second and third parts of the duodenum.

• Fig. 19.4 The gastric cardia viewed en face in the left anterior oblique position. Lesser curve folds run to the oesophageal orifice, where a fold forms a hood (arrowheads) over the cardia.

• Fig. 19.5 Endoscopic ultrasound showing a metastasis (M) in the left lobe of liver. (Courtesy of Dr Keith Harris.)

• Fig. 19.6 The normal duodenal cap seen by double contrast. The mucosa has a velvety appearance due to the presence of villi. (A) Surface coating, almost homogeneous. (B) A fine velvety reticular pattern is produced by the villi.

• Fig. 19.7 The normal duodenal cap and loop. Routine double-contrast barium meal. Supine right anterior oblique view. The papilla of Vater (white arrow) has a longitudinal (arrowhead) and two oblique folds (black arrows) extending below it.

• Fig. 19.8 Acute erosive gastritis. There are numerous erosions in the stomach (arrows). Each erosion consists of a small central collection of barium surrounded by a translucent ring (a small 'target' lesion).

• Fig. 19.9 Severe antral gastritis. Conical narrowing of the antrum with multiple thickened gastric folds.

• Fig. 19.10 Crohn's disease. Antral erosions and a tapered stricture involving the first part of the duodenum. The second part of the duodenum is dilated as a result of a further stricture of the third part.

• Fig. 19.11 Menetrier's disease. Gross thickening of the folds of the upper two-thirds of the stomach. These patients often weep a protein-rich exudate from the stomach wall, and this excess of fluid in the stomach may impair barium coating.

• Fig. 19.12 Benign gastric ulcer. (A) Mid lesser curvature ulcer demonstrated in profile. The ulcer crater is projecting outside the wall of the stomach. (B) Diagram of benign ulcer with an oedematous collar. Beneath the collar, a thin lucent line may be seen across the mouth of the ulcer (Hampton's line).

• Fig. 19.13 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. non-steroidal anti-inflammatory drugs, steroids, potassium chloride).

• Fig. 19.14 Three characteristic types of gastric ulcer; the shading represents barium. A = benign, projecting, lesser curvature ulcer with collar (broken lines); B = malignant, intraluminal ulcer with irregular nodular tumour rim; C = non-projecting benign greater curvature ulcer.

Fig. 19.15 (A) Benign gastric ulceration. Small posterior wall ulcer (asterisk) demonstrated en face. 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

ulcer has healed

• Fig. 19.16 Healing benign gastric ulcer. Incisura and 'hour-glass‘ stomach. A typical benign ulcer (arrow) on the mid lesser curvature of the stomach is associated with a prominent incisura which divides the stomach into two.

• Fig. 19.17 Duodenal ulcer. Supine projection. Barium collects in an ulcer on the dependent (posterior) wall of the duodenal cap.

• Fig. 19.18 Anterior wall duodenal ulcer. (A) Prone projection. The ulcer (arrow) is dependent, and so fills with barium. (B) Supine projection. The ulcer, which is now on the non-dependent wall of the cap, is outlined with a ring of barium (arrow).

• Fig. 19.19 Healing duodenal ulcer. The linear shape of the posterior wall ulcer is indicated (large arrow). Folds radiate to the ulcer (small arrows).

• Fig. 19.20 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.

• Fig. 19.21 Postbulbar duodenal ulcer. Characteristic appearance with ulcer crater (asterisk) in the middle of a stricture produced by spasm and oedema.

• 19.22 Giant duodenal ulcer replacing the duodenal cap

• Fig. 19.23 Pyloric canal ulcer (arrow).

• Fig. 19.24 Perforated duodenal ulcer. An unexpected, silent perforation which explains why barium has inadvertently been used as the contrast medium instead of Gastrografin. Fortunately the leak was localised to the right subphrenic and subhepatic space, otherwise a generalised barium peritonitis would have resulted. S = stomach; D = duodenum; B = leaked barium. folds; several small ulcers are also present. (B) Multiple erosions

• Fig. 19.25 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.

• Fig. 19.26 Duodenitis. Typical appearances in the cap. (A) Thickened folds; several small ulcers are also present. (B) Multiple erosions.

• Fig. 19.27 ' Cobblestone' caps (A) Duodenitis. Two l arge nodules are seen which are due to erosions on a single mucosal fold. (Courtesy of Dr J. Virjee.) (B) Hyperplasia of Brunner's glands. The nodules are clearly defined, discrete and randomly distributed in the duodenal cap and postbulbar region. (Courtesy of Dr A. Schulman.) (C) Nodular lymphoid hyperplasia is characterised by numerous small nodules all of the same size and evenly distributed. (Courtesy of Dr J. Virjee.) (D) Heterotopic gastric mucosa. The presence of gastric epithelium in the duodenal cap produces small nodules of various sizes and shapes extending from the pylorus toward the apex of the cap. (Courtesy of Dr J. Virjee.)

• Fig. 19.27 ' Cobblestone' caps (A) Duodenitis. Two l arge nodules are seen which are due to erosions on a single mucosal fold. (Courtesy of Dr J. Virjee.) (B) Hyperplasia of Brunner's glands. The nodules are clearly defined, discrete and randomly distributed in the duodenal cap and postbulbar region. (Courtesy of Dr A. Schulman.) (C) Nodular lymphoid hyperplasia is characterised by numerous small nodules all of the same size and evenly distributed. (Courtesy of Dr J. Virjee.) (D) Heterotopic gastric mucosa. The presence of gastric epithelium in the duodenal cap produces small nodules of various sizes and shapes extending from the pylorus toward the apex of the cap. (Courtesy of Dr J. Virjee.)

• Fig. 19.28 Gastric polyps. Multiple benign hyperplastic polyps (arrows) evenly distributed throughout the stomach.

• Fig. 19.29 Prolapsing giant hyperplastic polyp. (A) The polyp (asterisk) has a stalk and is seen as a filling defect arising from the antrum. (B) The polyp has prolapsed into the base of the duodenal cap. A = antrum, C= duodenal cap.

• Fig. 19.30 Large villous tumour arising from the medial wall of the duodenum (arrows) close to the papilla (asterisk). Prone view. C = duodenal cap.

• Fig. 19.31 (A) Benign gastric stromal tumour. The margins of this submucosal tumour make an obtuse angle with the adjacent normal mucosa. (B) Benign duodenal stromal tumour. Submucosal tumour of the third part of the duodenum. (Courtesy of Dr B. M. Carey.) (C) CT. Benign duodenal stromal tumour arising from the medial wall of the second part of the duodenum

• Fig. 19.31 (A) Benign gastric stromal tumour. The margins of this submucosal tumour make an obtuse angle with the adjacent normal mucosa. (B) Benign duodenal stromal tumour. Submucosal tumour of the third part of the duodenum. (Courtesy of Dr B. M. Carey.) (C) CT. Benign duodenal stromal tumour arising from the medial wall of the second part of the duodenum

• Fig. 19.32 Benign tumour growth. The margin of a mucosal tumour (A) forms a more acute angle with the normal mucosa than that of a submucosal tumour (B), which forms a right or obtuse angle with the mucosa. When growth is predominantly exophytic the tumour may drag on the gastric wall to produce a niche (C).

• Fig. 19.33 Endoscopic ultrasound. Benign gastric stromal tumour. Echo-poor mass arising from the fourth hypoechoic layer, the muscularis propria. At the margins, the tumour can be seen to merge with the muscularis propria (arrows). Benign gastric stromal tumours can also arise from the second hypoechoic layer, the muscularis mucosa. (Courtesy of Dr Keith Harris.)

• Fig. 19.34 Gastric lipoma. Echogenic well-defined tumour arising from and expanding the submucosal layer (black arrow). Muscularis propria is displaced but intact (smaller black arrows). (Courtesy of Dr Keith Harris.)

• Fig. 19.36 Duodenal duplication cyst. (A) The cyst is impressing on the medial aspect of presenting as a large submucosal tumour arising the second part of the duodenum (arrows) and did not communicate with the duodenal lumen. from the medial wall of the second part of the (B)Ultrasound shows fluid contents. (Courtesy of Dr R. Fowler.) duodenum. (Courtesy of Dr Keith Harris).

• Fig. 19.37 Ectopic pancreatic rest. These are generally found in the distal antrum on the greater curve. The small diverticulum results from barium entering the primitive ductal system (arrow). Supine fil m. A = distal antrum; C = duodenal cap.

• Fig. 19.38 The Japanese Endoscopic Society has classified early tumours into three types. Type 1, protrude more than 5 mm above the mucosal surface. Type 2, flat (2A), slightly elevated (<5 mm (2B)), or slightly depressed (2C). Type 3, ulcerating and penetrate the muscularis mucosa.

• Fig. 19.39 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).

• Fig. 19.40 Evaluating the 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 oedema around the ulcer. (B) Thickened, clubbed, interrupted, nodular and fused folds around a malignant ulcer.

• Fig. 19.41 Advanced gastric carcinoma. (A) Fungating cancer arising from the greater curve (arrows). (B) Malignant gastric ulcer. Single-contrast examination. The ulcer is situated close to the lesser curvature and near the incisura. The arrows indicate the base of the ulcer, which is in line with the lesser curvature,i.e. the crater is non-projecting. Tumour at the margin of the crater appears translucent and nodular creating a pool of barium, convex one side and concave the other (arrows) (meniscus sign). (C) Infiltrating and ulcerating gastric carcinoma. The proximal half of the stomach is involved with thickening of the wall, destruction of mucosa, and narrowing of the lumen (arrows). Ulceration is present on the greater curve (long arrow). (D) Small stomach as a result of diffuse submucosal infiltration (linitis plastica). Air has been injected down the nasogastric tube to distend the stomach.

• Fig. 19.41 Advanced gastric carcinoma. (A) Fungating cancer arising from the greater curve (arrows). (B) Malignant gastric ulcer. Single-contrast examination. The ulcer is situated close to the lesser curvature and near the incisura. The arrows indicate the base of the ulcer, which is in line with the lesser curvature,i.e. the crater is non-projecting. Tumour at the margin of the crater appears translucent and nodular creating a pool of barium, convex one side and concave the other (arrows) (meniscus sign). (C) Infiltrating and ulcerating gastric carcinoma. The proximal half of the stomach is involved with thickening of the wall, destruction of mucosa, and narrowing of the lumen (arrows). Ulceration is present on the greater curve (long arrow). (D) Small stomach as a result of diffuse submucosal infiltration (linitis plastica). Air has been injected down the nasogastric tube to distend the stomach.

• Fig. 19.42 Mucus-producing gastric adenocarcinoma. Faint calcification can be seen in the thickened wall of the antrum and distal body of the stomach.

• Fig. 19.43 Carcinoma of distal antrum. The rolled margins suggest the diagnosis. The differential diagnosis includes hypertrophic pyloric stenosis but in this condition the antrum tapers into the pyloric canal and the mucosa within the canal can be seen to be intact.

• Fig. 19.44 Endoscopic ultrasound showing the five layers of the gastric wall and an enlarged, rounded, hypoechoic, metastatic lymph node (N). (Courtesy of Dr Keith Harris.)

Fig. 19.45 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).

• Fig. 19.46 Gastric carcinoma. The tumour is enhancing and thickening the wall of the antrum (arrows). The stomach is distended with food debris as a result of gastric outlet obstruction.

• Fig. 19.47 Linitis plastica. (A) Diffuse thickening of the gastric wall demonstrated by CT. (B) Endoscopic ultrasound showing a narrowed gastric lumen and diffuse thickening of all layers of the gastric wall by tumour infiltration (between arrows).

• Fig. 19.48 (A) Gastric carcinoma constricting the body of the stomach (arrows). Stomach distended with water. Prone scan shows fat plane between tumour and pancreas, indicating that the pancreas is not invaded. (B) Gastric carcinoma (asterisk) extending beyond the serosa to encase the coeliac axis vessels. (Courtesy of Prof. R. W. Whitehouse.) (C) Extension into the transverse mesocolon (arrows) from a carcinoma of the antrum of the stomach.

• Fig. 19.48 (A) Gastric carcinoma constricting the body of the stomach (arrows). Stomach distended with water. Prone scan shows fat plane between tumour and pancreas, indicating that the pancreas is not invaded. (B) Gastric carcinoma (asterisk) extending beyond the serosa to encase the coeliac axis vessels. (Courtesy of Prof. R. W. Whitehouse.) (C) Extension into the transverse mesocolon (arrows) from a carcinoma of the antrum of the stomach.

• Fig. 19.49 Krukenberg tumours. Bilateral partly cystic ovarian tumours and malignant ascites. (Courtesy of Dr John Spencer.)

• Fig. 19.50 Gastric 'target' lesion. (A) An ulcerating (large arrow) tumour in the fundus of the stomach (small arrows). This appearance is typical of an ulcerating submucosal metastasis from malignant melanoma. (B) CT scan shows the same tumour (arrow).

• Fig. 19.51 Metastasis to the antrum of the stomach from carcinoma of the breast. The tumour has spread submucosally. CT scan. Lateral decubitus scan in an attempt to better distend the gastric antrum.

• Fig. 19.52 Carcinoma of the pancreas. (A) Carcinoma of the head of the pancreas invading the medial wall of the duodenal loop. Note the reversed-'3‘ sign of Frostberg (arrowheads). A percutaneous transhepatic cholangiogram performed with the barium study shows the common bile duct to be obstructed at its lower end. (B) Pancreatic tumour producing an impression on and elevating the gastric antrum (the pad sign). C = duodenal cap.

• Fig. 19.53 MALT lymphoma. Multifocal tumour (arrows) thickening the gastric wall.

• Fig. 19.54 Gastric lymphoma. (A) CT scan. A bulky tumour (small arrows) arising from the posterior wall of the stomach (large arrow). The tumour extends posteriorly to involve the pancreas and splenic hilum. (B) Gross thickening of folds in the fundus and body of this stomach infiltrated by lymphoma. (C) An irregular stricture is present in the distal stomach, also involving the duodenal cap. Adjacent nodal enlargement is producing an impression on the inside of the duodenal loop.

• Fig. 19.54 Gastric lymphoma. (A) CT scan. A bulky tumour (small arrows) arising from the posterior wall of the stomach (large arrow). The tumour extends posteriorly to involve the pancreas and splenic hilum. (B) Gross thickening of folds in the fundus and body of this stomach infiltrated by lymphoma. (C) An irregular stricture is present in the distal stomach, also involving the duodenal cap. Adjacent nodal enlargement is producing an impression on the inside of the duodenal loop.

• Fig. 19.55 Malignant gastric stromal tumour. (A) CT. This predominantly exophytic tumour is compressing the stomach (arrow). (B) Endoscopic ultrasound. These tumours tend to be less well defined and larger than their benign counterparts and to have a heterogonous echotexture, often with cystic spaces.

• Fig. 19.56 Duodenal carcinoid tumour. There is an irregular, lobulated filling defect with central ulceration (arrowheads) in the duodenal cap. Stromal tumours, melanoma metastasis, and duodenal ulcer with oedema can also produce this appearance.

• Fig. 19.57 Sites of extrinsic gastric compression.

• Fig. 19.58 Types of gastric volvulus. (A) Organoaxial. Rotation occurs around an axis connecting the pyloris to the oesophagogastric junction. (B) Organoaxial volvulus of an intrathoracic stomach. The greater curve is folded upward and to the right (small white arrows). There is a giant duodenal ulcer (arrow) which perforated 10 days later.

• Fig 19.58: (C) Mesenteroaxial. Rotation occurs around an axis connecting the middle of the greater curve to the middle of the lesser curve. Generally this type of volvulus is partial as a result of excess mobility of the antrum and duodenum and so the stomach often kinks and obstructs between the body and the antrum.

• Fig. 19.59 Superior mesenteric artery syndrome caused by carcinoma of the pancreas involving the root of the mesentery. (A) Supine position. Compression of third part of duodenum. (B) Prone position. The compression persists and dilatation of the proximal duodenum is accentuated. (Courtesy of Drs J. R. Anderson, P. M. Earnshaw and G. M. Fraser, and the editor of Clinical Radiology.)

• Fig. 19.60 Aortoduodenal fistula. Recent haematemesis. The third part of the duodenum (stars) is stretched over the aortic aneurysm, which contains thrombus. A fistula accounts for the gas in the aortic wall (arrow).

• Fig. 19.61 Gastric varices associated with (A) portal hypertension, (B) splenic vein occlusion

• Fig. 19.62 Pseudotumours of the gastric fundus. (A) Gastric fundal varices. Filling defects (arrows) resembling a bunch of enlarged nodular mucosal folds. (Courtesy of Dr G. M. Fraser and the editor of Clinical Radiology.) (B) Intragastric prolapse of a sliding hiatus hernia. The mass (arrowheads) is composed of mucosal folds, and vanishes when the hernia expands above the diaphragm in the recumbent posture.

• Fig. 19.63 Gastric diverticulum arising from the fundus of the stomach. Sometimes gastric folds can be seen entering the diverticulum, or areae gastricae can be seen within it.

• Fig. 19.64 An antral diaphragm (between the arrows). The pyloric canal is seen end on (asterisk

• Fig. 19.65 Duodenal diverticulum into which the papilla is opening (D). Loss of continence has resulted in reflux of barium into the common bile duct (C).

• Fig. 19.66 Annular pancreas. The direction of rotation of the ventral pancreatic bud which joins the dorsal bud at the seventh week of embryonic life and finally comes to lie on the left side of the duodenum.

• Fig. 19.67 Annular pancreas. (A) Producing a characteristic narrowing of the second part of the duodenum (arrows). (B) CT shows the gland encircling the duodenum (arrows).

• Fig. 19.68 (A) Pyloroplasty. A wide gastroduodenal channel has been produced. (B) Gastroenterostomy. (C) Normal postoperative barium examinations following Billroth I partial gastrectomy.

• Fig. 19.68 (A) Pyloroplasty. A wide gastroduodenal channel has been produced. (B) Gastroenterostomy. (C) Normal postoperative barium examinations following Billroth I partial gastrectomy.

• Fig. 19.69 (A) Billroth I partial gastrectomy. (B, C) Polya partial gastrectomy; antecolic and postcolic anastomoses. (D) Anteperistaltic anastomosis. (E) Postgastrectomy Roux-en-Y reconstruction. (F) Vertical banded gastroplasty.

• Fig. 19.69 (A) Billroth I partial gastrectomy. (B, C) Polya partial gastrectomy; antecolic and postcolic anastomoses. (D) Anteperistaltic anastomosis. (E) Postgastrectomy Roux-en-Y reconstruction. (F) Vertical banded gastroplasty.

• Fig. 19.69 (A) Billroth I partial gastrectomy. (B, C) Polya partial gastrectomy; antecolic and postcolic anastomoses. (D) Anteperistaltic anastomosis. (E) Postgastrectomy Roux-en-Y reconstruction. (F) Vertical banded gastroplasty.

• Fig. 19.70 Vertical banded gastroplasty. Breakdown of the top end of the staple line (arrow) with barium directly entering the fundus of the stomach. Site of banding marked with an asterisk.

• Fig. 19.71 Complications following gastric surgery. (A) Early postoperative oedema at a gastroenterostomy site (arrows). (B) Retrograde jejunogastric intussusception following gastrojejunostomy. The loops of jejunum within the stomach (arrowheads) have a characteristic 'coiled spring' appearance.

• Fig. 19.72 Stomal (marginal) ulcer (asterisk) with scarring following Polya partial gastrectomy.

• Fig. 19.73 Bezoar. There is a large filling defect (arrowheads) within the stomach; this proved to be a phytobezoar.

• Fig. 19.74 Percutaneously placed gastrostomy catheter. Some oral barium had been given prior to the procedure to outline the colon. NGT = nasogastric tube; PGT = percutaneous gastrostomy tube; S = stomach; TC = transverse colon.

• Fig. 19.75 (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.

• Fig. 19.76 Selected frames from a dual phase gastric study showing typical progression of liquid (A) and solid phase (B) emptying over 60 min after ingestion of the meal.

• Fig. 19.77 (A, B) Typical gastric emptying curves after vagotomy in two patients, both showing rapid transit of liquid but delayed solid phase emptying

• Fig. 19.79 (A, B) Delayed liquid and solid phase gastric emptying in two patients with gastroparesis.