2011 Stomach Talk for Barrie RVH

7/28/2019 2011 Stomach Talk for Barrie RVH

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Stomach: The Forgotten Organ:Stomach: The Forgotten Organ:

A Pictorial Tour of Gastric Abnormalities with A Pictorial Tour of Gastric Abnormalities with

on Crosson Cross--section Imagingsection Imaging

Ania Kielar,Ania Kielar, Vineeta SethiVineeta Sethi, Vivek Virm, Vivek Virm


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Introduction

CT allows evaluation of the gastric lumen, gas

adjacent structures.

Familiarity with imaging findings helps to estab

diagnosis and guide effective and timely mana


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Outline of presentation and corresponding examp

Classification Examples

Malignant neoplasms Carcinoma, Lymphoma, GIST, Carcinoid, Metastases

Benign neoplasms Leiomyoma, Neural tumor, Lipoma, Polyp, Inflammatory Ppancreatic rest

Benign wall thickening Caustic ingestion, Retching, Hypertrophic pyloric stenosis

Inflammatory Peptic ulcer, Crohns, GVHD, Bouveret syndrome

Infectious Gastric abscess

Vascular Infarction, Herniation with ischemia, Varices

Congenital Duplication cyst

Trauma Nasogastric tube trauma

Foreign bodies Cocaine packets, Bezoar, Gastric pacemaker

Miscellaneous Gastric diverticulum


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General NoticeGeneral Notice

There will be a quiz at the end!!!!There will be a quiz at the end!!!!


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Imaging of the stomaImaging of the stoma

Not usually thought about but canNot usually thought about but can

Positive or negative oral contrastPositive or negative oral contrast

IV contrastIV contrast

Axial/Coronal reconstructionsAxial/Coronal reconstructions


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Gastric CarcinomaGastric Carcinoma

CT appearance of Gastric carcinoma - Focal wall thickening with or wit

- Polypoidal mass

- Diffuse infiltration - > (name?

Gastric wall thickness > 1cm & focal, eccentric or enhancing wall thicke

CT can differentiate T2 (limited to serosa) and T3 lesions (transmural e

sensitivity and specificity ( 90 and 95%).

Polypoidalal mass along lesser curvature. Smooth outer gastric wall and

absence of perigastric stranding = T2 gastric carcinoma.

Markedly enhancing wall thick

gastric outlet obstruction. Irreg

along the medial margin signi

1 2


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CarcinomaCarcinoma

Metastases - Lymph nodes ( suspicious features = > 6mm, round shape,

enhancement missing fatty hilum )

- Peritoneal spread including ovarian metastases (Krukenbe

- Hematogenous metastases (most common liver)

Unusual CT features Calcification (rare, seen in mucinous adenocarcino

a b

72-year-old female with signet ring cell gastric carcinoma. Diffusely thickened and enhancing gastric wall cons

In the pelvis there are bilateral complex solid-cystic masses consistent with ovarian metastases = Krukenbe


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CarcinomaCarcinoma

Site: Antrum 30%, Body- 30%, Fundus & cardia- 30%, Diffuse- 10%

Schirrous carcinoma / Linitis plastica

- Frequently involves distal half of stomach

- Frequently under-staged

- Typically caused by signet ring cell carcinomas

- Peritoneal spread is more common

Diffuse thickening and enhancement of the gastric wall in the distal stomach with obliteration of the

distention in the affected region. This is classical of Linitis plastica and on pathology was a T3 signe

a b


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Gastric LymphomaGastric Lymphoma

1-5 % of gastric malignant tumors of the stomach; Most common extra-n

B-cell type Non-Hodgkins lymphoma or Low grade mucosa-associated ly

CT features

- Segmental or diffuse gastric wall thickening.

- Less commonly, a localised polypoidal lesion with or without ul

Diffuse large B-cell gastric lymphoma with peritoneal lymphomatosis in a 62-year-old man with epig

concentric, homogenous thickening of the gastric wall with maintained perigastric fat planes. Diffus

extensive mesenteric and retroperioneal lymphadenopathy.

a b


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CT Characteristics of gastric wall thickening in lymphoma:

- > 1cm (Average 2.9 5 cm) but significantly less in MALT lymphom- Diffuse infiltration in > 50 % of cases, can be segmental (antrum mo

- Homogenous wall thickening with less pronounced enhancement.

- Outer wall is smooth with maintained perigastric fat planes.

Low grade gastric lymphoma in a 45-year-old man presenting with loss of appetite and dyspepsia. B

lymphoma, a relatively indolent form of lymphoma.

a b


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Trans-pyloric spread more common than carcinoma (30%). Stomach remains pliable and gastric outlet obstruction is uncommon.

Perforation and fistulization are known complications, especially after c

Bulky adenopathy below level of renal hilum favours lymphoma over ca

A. Diffuse large B-cell gastric lymphoma infiltrating the spleen.

B. Follow-up coronal CT post 4 cycles of chemotherapy shows localised perforation of the stomac

surgery and underwent splenectomy and partial gastrectomy .

a b


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Gastroinstestinal Stromal Tumor (GIST)Gastroinstestinal Stromal Tumor (GIST)

Most common mesenchymal tumor of the GI tract with 60-70% affecting

2-3 % of all gastric tumors.

CT predictors of malignancy: >5cm, heterogeneous enhancement, ulcer

a

b

c

d

54-year-old male presenting with GI bleeding and epigastric pain.


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GISTGIST1 2

CT features of GIST:

- Large (3 - 10 cm). Predominant exophytic component with small intralu

- Hypervascular.

- Often heterogeneous because of necrosis, hemorrhage or cystic dege

- Mucosal ulceration or fistula (15 - 50%)- presence of air or oral contras

- Calcification may be present.

62-year-old male with malignant GIST. Biopsy of GIST is

contraindicated due to risk of peritoneal seeding.

Malignant GIST in a 55-year-old male. S

mass of the lesser curvature extending in

There is necrosis within it and a speck of

though unusual in GIST, is more common


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GISTGIST

a b

Does not involve gastric wall concentrically: bowel obstruction is rare.

Usually displaces rather than invades adjacent organs.

50% of patients with GIST present with metastasis.

- most common = liver (hematogenous spread) and peritoneum.

- lymph nodal metastases are rare and suggest alternate diagnosis.

Surgically proven gastro-gastric intussusception with malignant gastric GIST as the lead point.There is a homogenously enhancing mass as the lead point. Pathology revealed a malignant GIS

intussusception is extremely rare and has been reported in polyps or of a gastric remnant throug

Ulusan S, Koc Z, Kayaselcuk F. Gastrointestinal stromal tumours: CT fin


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CarcinoidCarcinoida b c

ed

Rare tumors (0.3 % of all gastric tumors), 3% of GI carcinoids are seen in stomach.

Gastric

carcinoid

Frequency Association Carcinoidsyndrome

CT fea

Type I 80%

Chronic atrophic gastritis and

pernicious anemiaHypergastrinemia+

Usually Body > Fundus.

CT features:

- Solid, round or ovoid submucosal masses usually < 5 cm.

- Outer margin smooth with preserved fat planes.

- Inner margin may be irregular due to ulceration.

- Variable enhancement; calcification may be present occasionally.

Liomyoma of the stomach in a 38-year-old female with GI bleeding. CT shows a smooth submucosal mascomponent and mild enhancement. Tiny hyperdense foci represent oral contrast within the mass due to u


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Neurogenic tumorNeurogenic tumor

TumorTumora b

0.2% of all gastric tumors and 4% of all benign gastric neoplasms.

CT features:

- Well-demarcated, homogeneous, solid, ovoid or multi-lobulated masses.

- May have exogastric component.

- Uncommonly ulceration, calcification or cystic change may occur; variable

Carneys Triad- Gastric neural tumor, extra-adrenal paraganglioma and pulm

2).

Gastric mass in a 29-year-old male with epigastric pain. There is predominantly exophytic submucosal mas

stomach with a speck of calcification in it. There is mild homogenous enhancement after contrast enhancem

and calcification are not common in gastric neural tumorus.

Park SO, Han JK, Kirn TK et al. Unusual gastric tumours: radiologie pathologic correlatio


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LipomaLipoma

a b

2-3 % of gastric benign tumors and 5% of all GI lipomas.

Antrum is the most common site.

CT features:

- Solitary, submucosal, well-demarcated lesion with homogenous fat atte

- Occasionally linear strands of soft tissue at base or mild adjacent gastr

Complications with large lesions- Ulceration with hemorrhage, intussus

Gastric lipoma incidentally detected in a 36-year-old female. There is a well defined submucosal endogastrof the stomach. There is minimal adjacent gastric wall thickening .

Ferrozzi F, Tognini G, Bova D, et al. Lipomatous tumours of the stomach: CT findings and differential diagnosis. J C


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PolypsPolyps

a b

Non-neoplastic gastric polyps include hyperplastic and hamartomatous

Hyperplastic polyps constitute 80-90% of all polyps while hamartomato

in syndromes such as Peutz-Jeghers, Juvenile Polyposis and Cronkhite

CT findings:

- Multiple smooth, sessile, clustered round or oval lesions 5-10 mm in siz

- Rarely can be large and lobulated.

Gastric and small bowel hamartomatous polyps in a 16-year-old with Peurtz-Jeghers syndrome. A

sessile, homogenously enhancing polyps in the body of the stomach. In the pelvis there is a small

a polyp as the lead point.


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PolypsPolyps

a b

Adenomatous polyps have malignant potential & harbor carcinomatous

Larger than hyperplastic polyps, usually >2cm.

Usually solitary and occur adjacent to the antrum; sessile or pedunculat

Can be multiple especially when associated with syndromes like Famili

Turcot syndrome and Gardners syndrome.

Adenomatous gastric polyps in a 28-year-old male with Familial Polyposis Coli. CT reveals innumer

polyps measuring 1-4 cm distributed diffusely in the stomach. Lower down, there are multiple simila

many of these to harbor malignant foci.

Merino S, Saiz A, Moreno MJ et al. CT evaluation of gastric wa


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Inflammatory Myofibroblastic TumorInflammatory Myofibroblastic Tumora b

Synonyms: Inflammatory pseudotumor and myofibroblastic tumor.

In the abdomen: most commonly in terminal ileum and greater curvat

Predominance in females and preschool age children.

CT appearance:

- Hypodense to isodense on unenhanced scans with variable to no en

- May have aggressive features including ulceration and exogastric ex

- Calcification has been reported.

Myofibroblastic tumor in a 14-year-old female with epigastric pain. There is a well -defined, hypod

body of the stomach with an exogastric component. Pathology revealed it to be myofibroblastic t


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Ectopic pancreatic restEctopic pancreatic rest

a b c

Heterotopic pancreas is rare; most commonly found in the stomach.

Usually located along greater curvature in the prepyloric region.

CT findings:

- 1-3 cm, well-defined oval, submucosal. Indistinguishable from other subm

- Small cystic areas could represent dilated anomalous duct.

MRI diagnostic as heterotopic pancreas follows signal and enhancement

Ectopic pancreatic rest in a 35-year-old male presenting with GI bleeding. The lesion is following

pancreas on all sequences. A few small cystic areas were confirmed to be an anomalous dilated d


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Benign Wall ThickenBenign Wall Thicken


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BAdult Hypertrophic Pyloric StenosisAdult Hypertrophic Pyloric Stenosis

a b

Hypertrophic pyloric stenosis is a rare cause of gastric outlet obstruction

1 ary or 2 ary to scarring of gastric / duodenal ulcer, post-op adhesions, c

CT findings:

- Smooth circumferential pyloric wall thickening.

- Elongation and narrow pylorus with intact smooth border analogous to a

sign

-

Adult hypertrophic pyloric stenosis 2ndary to scarring of a gastric ulcer in a 54-year-old male. CT re

wall thickening of antro-pyloric region with narrowing a of pylorus. Coronal CT confirms narrowing o


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OmeprazoleOmeprazole--induced & Reflux surgeryinduced & Reflux surgery

12

Proton pump inhibitor induced (PPI)wall thickening:

Chronic use of PPIs can lead to gastric parietal cell hypertrophy and hyp

CT: Areas of fold thickening mimicking other causes of hypertrophic gast

Reflux surgery-induced wall thickening and pseudomass:

Surgery for GE reflux can lead to wall thickening / pseudomass at GE jun

Turning patient prone / decubitus may result in decreased prominence of th

Parietal cell hyperplasia in a 52-year-old man on long term

omeprazole tx CT shows gastric mucosa hypertrophy.

Pseudomass at the GE junction pos

contrast CT reveals a mass like-lesi(arrowheads). Endoscopy confirmed

Merino S, Saiz A, Moreno MJ et al. CT evaluation of gastric w


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Inflammatory causeInflammatory cause


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GraftGraft--versusversus--Host disease (GVHD)Host disease (GVHD)

GVHD occurs when immunocompetent graft reacts against immune- in

can be seen with bone marrow or other solid organ transplantation.

CT findings of gastric GVHD:

- Hyperemic granulation tissue surrounded by lower-attenuation outer gas

- Fold thickening; Mesenteric stranding.

- Intraluminal hemorrhage due to severe mucosal damage.

- Complications like gastric necrosis and perforation can occur.

Acute gastrointestinal G

20 days after autologous

There is low attenuation

intense mucosal enhanc

sign. There is adjacent

ascites.

Biopsy showed epithelia

dilatation of glands lined

crypt abscesses and franclassical for GVHD.


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Peptic UlcerPeptic Ulcer

1 2

90 % along lesser curvature or posterior wall of antrum or body.

CT features: Gastric wall thickening, demonstration of ulcer crater.

CT is excellent for detection of peptic ulcer complications; Not optimal fo

uncomplicated peptic ulcers (as most are superficial).

Strong enhancement, marked peri-ulcer wall thickening, loss of normal w

gastric fat plane infiltration and presence of lymphadenopathy favor malign

Perforated gastric ulcer. CT reveals large gastric ulcer along the

lesser curvature with localised extravasation of contrast. There is

adjacent gastric wall thickening.

Perforated gastric ulcers. Axial Contra

perforation of a gastric ulcer into the le

ulcer is seen which has perforated into

Jacobs JM, Hill MC, Steinberg WM. Peptic ulcer disease: CT


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Peptic UlcerPeptic Ulcer

1 2

Complications- Perforation, penetration, hemorrhage and obstruction.

Perforation:

- Anteriorly located ulcers or along curvatures.

- CT: Pneumoperitoneum or loculated collection, contrast extravasation, d

Penetration:

- Posterior located ulcers,

- CT: Ulcer crater, wall thickening, adjacent inflammatory changes.

Perforated gastric ulcer in the antrum with ulcer crater perforatingalong the anterior wall. There is adjacent gastric wall thickening

and pneumoperitoneum.

Gastric ulcer penetrating into splen

There is irregularity of splenic artery

of pyo-pneumoperitoneum & mass


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CrohnCrohns Diseases Disease

a b

Gastrocolic fistula in a 45-year-old male with Crohns disease presenting with diarrhea and fe

demostrates a communication between the stomach and the colon.

Gastrocolic fistulas may occur in Crohns, TB, complicated peptic ulcer d

colon cancer, gastric lymphoma, pancreatitis etc.

Isolated gastric involvement in Crohns is rare (incidence of 0.2-2 %).

CT findings in gastric Crohns disease:

-Narrowing and wall thickening of the distal stomach, especially the antru

-Scarring may cross the pylorus to involve the duodenal bulb creating a tu


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Bouveret SyndromeBouveret Syndrome

a b

Gastric outlet obstruction produced by gallstone impacted in distal stomach

duodenum.

Imaging features:

- Pneumobilia.

- Obstructing gallstone in the duodenum or distal stomach.

- Gastric and duodenal distension.

Bouveret syndrome in a 65-year-old woman presenting with vomiting and epigastric pain. CT of the

air within the gall bladder. A gall bladder calculus is seen within the stomach. Caudal sections re

duodenum .


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Infectious CausesInfectious Causes


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Gastric abscessGastric abscess1 2

Rare condition representing a localized form of supurative gastritis.

Predispositions: alcoholism, immunosuppression, diabetes, HIV, old age

CT findings:

- Localized mural thickening within stomach wall or focal mass with hetero

- Fluid and air may be seen within the mass. Adjacent inflammatory strand

65-year-old AIDS patient with intramural gastric and liver abscess. CT

reveals heterogeneously enhancing masses in the wall of the stomach

and liver . Biopsy revealed abscess in both the liver and stomach with

gram negative organisms.

Perforated peptic ulcer with m

abscesses. CT reveals multi

abscesses in the gastric and

greater curvature of the stom


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Vascular CausesVascular Causes


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Gastric infarctionGastric infarction1 2

Gastric infarction is rare because of stomachs abundant blood supply.

Etiologies: arterial thrombosis, herniation /volvulus, caustic ingestion, therapeutic e

Emphysematous gastritis- severe phlegmonous gastritis characterized by ga

CT features:

- Wall thickening with non-enhancing wall.

- Intramural gas and perforation may be present.

- Associated findings may include other visceral infarctions and portal venous

Acute gastric and small bowel infarction in a 62-year -old woman with

heart failure and atrial fibrillation. CT reveals thickened non-enhancinggastric wall with pneumatosis . The small bowel is fluid distended and

dilated with non-enhancing walls with extensive pneumatosis .

Emphysematous gastritis in a 33-y

abuse. CT shows intramural gas wvenous gas. Common causes of e

corrosive ingestion, trauma or gast


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Herniation with gastric ischemiaHerniation with gastric ischemia

1a 1b

2b2a

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s

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da

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Gastric VaricesGastric Varices

a b

Dilated peripheral branches of short gastric and left gastric veins associ

obstruction or portal hypertension. Isolated gastric varices are due to sple

CT findings:

- Well-defined clusters of rounded and tubular structures with vascular en

- Seen most commonly in posterior and postero-medial wall of fundus and

Gastric varices in a 45-year-old male with alcoholic cirrhosis and portal hypertension. CT demonstrate multip

and proximal body along the posteromedial wall. Associated varices between medial wall of stomach and li

signifying increased blood flow through the coronary venous plexus. The liver is cirrhotic with splenomegaly

There has been a prior TIPS stent placement for portal hypertension.

Carucci LR, Levine MS,Rubesin SE, Laufer l. Tumourous gastric varices: radiographie findings in


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Congenital CauseCongenital Cause


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Duplication cystDuplication cyst

a b

Gastric duplication cyst is the least common of the enteric duplications.

7% of GI tract duplications.

Usually asymptomatic, but occasionally present with vomiting and abdom

Most commonly seen in infants.

Gastric duplication cyst in a 21-year-old female presenting with epigastric pain. CT reveals a hyper

medial wall of the fundus with an air speck within it suggesting focal communication with the stoma

mucosa within the cystic lesion. The age of presentation, location and communication with the stom

duplication.


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Duplication cystDuplication cyst

a b

Most common site is the greater curvature.

CT findings:

- Non-communicating, spherical or ovoid cysts close to the greater curvat

- May show peripheral enhancement or marginal calcification.

Surgically proven gastro-gastric intussusception with duplication cyst as the lead point in a 32-ye

severe vomiting and epigastric pain. CT reveals intussusception of the lesser curvature into the s

point. The patient underwent surgery which confirmed true gastro-gastric intussusception with a d


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Gastric diverticulumGastric diverticulum

a b c

Gastric diverticula are uncommon and usually asymptomatic (Compared to duo

Posterior wall of the gastric cardia are the most common site.

Often single, varying in size from 1 - 3 cm. Occasionally can be multiple

Gastric cardia diverticula may simulate a left adrenal mass.

Air-fluid level, retained contrast, communication with stomach and wall e

differentiating it from other masses.

Gastric diverticulum in an asymptomatic 54-year-old female. CT reveals a well-defined cystic lesion

simulating an adrenal mass. It shows retained oral contrast within it . Sections caudally show the legastric cardia With an air speck within it. The diverticulum is in proximity to the cardia and the fluid


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Iatrogenic/TraumaticIatrogenic/Traumatic


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Nasogastric (NG) Tube TraumaNasogastric (NG) Tube Trauma

a b

Penetrating injuries may cause gastric perforation. Blunt injuries rarely c

trauma (0.02 - 1.7%).

Site of perforations: Anterior wall > greater curvature > lesser curvature >

Predisposing factors for NG tube trauma: Altered mental status, tracheal

neck osteophytes, pre-existing gastric abnormalities, mal-positioned tube i

Gastric perforation due to NG tube trauma in a patient with altered mental status. CT reveals the N

wall with extensive pneumoperitoneum. There is air tracking from the site of perforation into the pe

trauma very rarely causes gastric perforation.


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Cocaine packetsCocaine packets

a b

GI tract & vagina have been used as vehicles for smuggling narcotics (B

Narcotics are wrapped in latex gloves, condoms, plastic bags, balloons,

Life threatening intoxication may follow leaking or rupture of these packe

CT findings:

- Single or multiple homogenous well demarcated ovoid or cylindrical fore

- Surrounded by a thin radiolucent halo due to air trapped between the mu

24-year-old female with seizures and cardiac arrest due to cocaine toxicity from rupture of cocaine p

reveals a well-defined cylindrical hyperdense foreign body with a radiolucent halo. Lower down there

in the cecum. The patient underwent a gastrotomy and cecotomy for removal of these cocaine pack


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BezoarBezoar

a b

Trichobezoar in a 20-year-old female presenting with epigastric pain and vomiting with history of tric

There is distension of the lumen of the stomach with multiple intermixed gas bubbles giving it a mo

underwent endoscopic suction for removal of the bezoar.

Bezoar: A conglomerate mass of food or foreign matter in the GI tract.

Predispositions: Gastroparesis, gastric bypass surgery, high fibre diet.

Trichobezoar: Matted hair seen in young women with trichophagia.

Phytobezoar: Poorly digested fruit (oranges or persimmons) and vegeta

CT findings: Well-defined oval intraluminal mass with air bubbles retaine


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ForeForeGastric PacemakerGastric Pacemaker

58-year-old male with Crohns disease having gastroparesis and intractable abdominal pain. The

generator and leads implanted into the serosa of the stomach.

Gastric pacemakers are used for gastroparesis refractory to medical the

Consists of a subcutaneous electric generator with two bipolar leads imp

laproscopically into the serosa of the stomach.

Generates high frequency stimuli that enhance motility and facilitate em

Potential complications: gastric perforation, lead migration, infection, se

a b


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Time for mental gymnaTime for mental gymna


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QuizQuiz

Can adults get Hypertrophic PyloCan adults get Hypertrophic Pylo

Stenosis?Stenosis?

What is Bouveret Syndrome?What is Bouveret Syndrome?

What part of the stomach is mostWhat part of the stomach is most

commonly affected by Crohncommonly affected by Crohns diss dis

What is the name for a ball of haiWhat is the name for a ball of hai

stomach?stomach?

What is linitis plastica and what aWhat is linitis plastica and what a

causes?causes?


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2011 Stomach Talk for Barrie RVH