GIT Stomach

Stomach

By: Dr. Abdullah Nouh

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EDiR Notes
• Incisura angularis lies between body & antrum of stomach.
• NOTE - 5th layer in stomach, duodenum & rectum is serosa.
• Magenstrasse is normal longitudinal mucosal folds adjacent to lesser curvature of stomach on barium.
• Atrophic gastritis is associated with pernicious anemia & shows featureless tubular stomach, loss of parietal cells
leading to achlorhydria.
• Erosive gastritis is characterized by aphthoid ulcer in antrum & body of stomach that show central erosions
collecting barium with mucosal mounds representing surrounding halo or lucencies.
• Eosinophilic gastritis affects the stomach antrum & proximal small bowel.
• Menetrier’s disease is characterized by hypertrophy of gastric folds affecting greater curvature & upper part of
stomach with sparing of antrum. There is hypoproteinaemia, ankle edema & hypochlorhydria.
• Thickened mucosal folds of stomach alter their position & size in Menetrier’s disease.
• Stomach distention is preserved in Menetrier’s disease.
• Barium shows impaired mucosal coating due to hypersecretion in Menetrier’s disease.
• Lymphoma involves any part of the stomach body & antrum.
• Gastric lymphoma shows preservation of perigastric fat planes (not seen in other tumors).
• GIST presents as an extraluminal mass with heterogeneously enhancing margins & necrotic centre. Lymph nodes
are not normally seen. PET uptake is seen.
• Stomach GIST are seen above 50 yrs of age. They are heterogeneously enhancing exophytic mass with central
necrosis.
• GIST shows “KIT” - a tyrosine kinase growth factor receptor.
• Gastric carcinoma involving body & antrum is more likely to cause direct invasion of left lobe of liver
(gastric lymphoma does not cause this).
• Gastric carcinoma involving posterior wall tends to involve pancreas first (body & tail)
• Multiple small gastric ulcers & duodenal ulcers with a well-defined hypoechoic enhancing lesion in pancreatic
head in s/o gastrinoma causing Zollinger Ellison syndrome.
• Bull’s eye lesion in stomach is either carcinoma, GIST, melanoma metastasis & NF.
• Nodal staging of gastric cancer
▪ N1 = 1-6 nodes
▪ N2 = 7-15 nodes regional nodes
▪ N3 = >15 nodes
• Non regional nodes such as para-aortic & retropancreatic nodes are considered M1.
• Gastric banding is connected by tubing to a port anterior to rectus sheath. Band is perpendicular to GE junction &
best assessed on AP x-ray view
• Gastric banding is an inflatable band across the proximal stomach, forming a small fundal, neo-stomach or pouch.
• Complication of gastric banding:
▪ Acute concentric pouch dilatation due to band over-inflation. It requires prompt decompression of the
obstructed stroma.
▪ Chronic concentric pouch dilatation withwidely patient stoma. It requires nutritional advice.
▪ Eccentric pouch dilatation due to band slippage. It requires complete decompression & surgical
replacement of band.
Benign ulcer Malignant
Projected outside the gastric contour • Not extend beyond the confine of gastric wall
Round • Irregular
Collar of edematous mucosa
• Gastric folds do not extend to ulcer edge
Gastric folds extending to the edge of ulcer crater
• Symmetrical mound with smooth radiating mucosal folds are findings of benign ulcer. Scar retraction can be seen.
• Peptic strictures are associated with hiatus hernia & show small mucosal ulcers.
• Peptic strictures cause incomplete fixed transverse folds with step ladder appearance due to trapping of barium
between the fold.
• Bezoars are composed of poorly digested vegetable matter showing mottled appearance on barium. They are seen
mostly in patient with previous gastric surgery due to diminished gastric emptying. They are mobile filling defects
& may cause ball valve mechanism of obstruction.
• Borchardt triad: sudden epigastric pain, intractable retching & inability to pass a NGT. It is seen in gastric
volvulus. There is markedly distended stomach & left upper quadrant is extending into the chest.

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Succeeding
1- Regarding laparoscopic adjustable gastric banding:
A. On scout films, the band should be parallel to the Gastro Oesophageal Junction (GOJ)
B. When patient ingests contrast, position of band best assessed on lateral decubitus projection
C. Is connected by tubing to a port anterior to the rectus sheath
D. With band slippage, the pouch is narrowed
E. Perforation rates are typically 1-2%

C
Band should be perpendicular to GOJ on scout film. Position is best assessed straight AP or slightly RPO. Band
slipping leads to eccentric pouch dilation. Perforation typically < 0.5%

2- Which of the following favours gastric lymphoma rather than other gastric malignancies?
A. Preservation of the fat plane around the stomach
B. Luminal narrowing
C. Involvement of the proximal half of the stomach
D. Heterogenous gastric wall thickening
E. A single site of disease within the stomach

A
Preservation of the fat plane around the stomach, diffuse and homogenous wall thickening, multifocal disease
within the stomach, nodal disease either side of the mesenteric vessels, nodal disease extending below the level of
the renal veins and a propensity for the distal half of the stomach are all features of gastric lymphoma.

3- Which of the following is the most correct statement with regards to Gastrointestinal Stromal tumor (GIST) of
the stomach?
A. Most patients present below the age of 50
B. GISTS of the stomach have a more aggressive histology when compared with GISTS from other sites
C. Mural calcification is a common feature
D. Larger lesions tend to be more homogenous in enhancement
E. Central fluid attenuation/necrosis is common

E
Stomach GISTs tend to present in patients over 50. CT usually shows a well-defined heterogeneously enhancing,
round, exophytic mass, commonly with central necrosis. Mural calcification is recognised but not common.
Stomach GISTs tend to be less aggressive histologically than GISTs at other sites.

Get Through
1. A 64-year-old man undergoes a barium meal examination for upper abdominal pain. A 10 mm ulcer is
demonstrated at the gastric antrum. Which radiological feature would favour a diagnosis of malignant rather than
benign gastric ulcer?
A. round ulcer shape
B. ulcer crater confined within the gastric contour
C. gastric folds identified up to the edge of the ulcer crater
D. associated duodenal ulcer disease
E. uniform mucosal collar around a centrally located ulcer

The answer is: B

Many distinguishing features of gastric ulceration have been proposed in an attempt to classify gastric ulcers as
benign or malignant, but there is significant overlap between the two categories. One reliable sign of a benign ulcer
is the projection of the ulcer outside the gastric contour in profile, due to excavation into the mucosal wall. In
contrast, a malignant ulcer occurring within a tumour mass does not usually extend beyond the confines of the
gastric wall. Other features indicative of benignity include around, centrally located ulcer with a uniform collar of
edematous mucosa, gastric folds extending to the edge of the ulcer crater and associated duodenal ulcer disease.

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2. A 65-year-old woman, with a history of previous partial gastrectomy 10 years earlier, presents with upper
abdominal pain and early satiety. She undergoes a double-contrast barium meal, which demonstrates a 4 cm
intraluminal, mottled filling defect in the gastric remnant with no fixed attachment to the gastric wall. What is the
most likely diagnosis?
A. suture granuloma
B. trichobezoar
C. phytobezoar
D. gastric carcinoma
E. villous adenoma

The answer is: C

Bezoars are masses of accumulated ingested material forming in the stomach or intestines. Phytobezoars are the
commonest type, composed of poorly digested fibre and vegetable matter. They are seen particularly in patients
with previous gastric surgery, probably due to diminished gastric emptying. Patients may be asymptomatic or
present with early satiety or symptoms of gastritis, as phytobezoars are irritant. Occasionally, they may obstruct the
stomach with a ball–valve mechanism. They are seen as relatively mobile filling defects, the interstices of which
are filled with barium. Trichobezoars are composed of hair, and are usually larger, and found in younger patients,
particularly those with a psychiatric history. Gastric carcinoma, villous adenoma and suture granuloma are all
causes of gastric filling defects but have a constant relationship to the gastric wall.

3. A 54-year-old man with known metastatic malignant melanoma presents with epigastric pain and hematemesis.
What is the most likely finding in the stomach on double-contrast barium meal?
A. multiple submucosal nodules with central ulceration
B. solitary ulcerated mass in the gastric antrum
C. linitis plastica
D. solitary, well-defined, pedunculated filling defect
E. thickened tortuous gastric folds

The answer is: A

GI tract metastases are seen in 4–8% of patients with malignant melanoma. The small intestine is most commonly
affected, followed by the colon and stomach. Typical features are of multiple submucosal nodules, with a target
appearance due to central ulceration. This appearance is particularly seen with malignant melanoma metastases but
may also be seen with gastric metastases from breast, lung and renal cell carcinoma. Other common appearances of
gastric metastases include linitis plastica in 20%, most typically from breast cancer, and a solitary mass in 50%.

4. A 66-year-old woman with a known large para-oesophageal hiatus hernia presents with sudden onset of severe
epigastric pain and vigorous retching without production of vomitus. Passage of a nasogastric tube is unsuccessful.
Plain abdominal radiograph demonstrates a markedly distended stomach in the left upper quadrant extending into
the chest. What is the most likely diagnosis?
A. pyloric stenosis
B. ‘cup-and-spill’ stomach
C. acute gastric volvulus
D. acute gastric dilatation
E. paraduodenal hernia

The answer is: C

Acute gastric volvulus is abnormal rotation of one part of the stomach around another part, which may be classified
as organoaxial, mesenteroaxial or combination type, depending on the axis of rotation. Predisposing factors include
ligamentous laxity, hiatus hernia and diaphragmatic eventration. The classic presentation is with the Borchardt
triad of sudden severe epigastric pain, intractable retching with no vomitus produced, and inability to pass a
nasogastric tube into the stomach. Other plain film findings include unexpected location of the gastric bubble and
air–fluid levels in the mediastinum or upper abdomen, but definitive diagnosis is by barium meal. The condition is
a surgical emergency, as it may result in gastric ischaemia or perforation. Acute gastric dilatation and pyloric
stenosis may result in gastric distension on plain film, but would not present with intractable retching or difficulty
with nasogastric tube passage. A ‘cup-and-spill’ stomach is an anatomical variant on barium meal, which may
simulate an organoaxial volvulus. A paraduodenal hernia usually presents acutely as small bowel obstruction.

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5. A 48-year-old man presents with epigastric pain, weight loss and peripheral oedema. Blood tests demonstrate
hypoalbuminaemia. At barium meal the stomach is well distended, but there is poor mucosal coating. Markedly
enlarged and tortuous gastric rugae are seen in the fundus and body of the stomach, with sparing of the antrum.
What is the most likely diagnosis?
A. lymphoma
B. Ménétrièr's disease
C. gastric carcinoma
D. Zollinger–Ellison syndrome
E. eosinophilic gastroenteritis

The answer is: B

Ménétrièr's disease is characterized by mucosal hypertrophy of the fundus and body of the stomach, with excessive
mucus secretion and a protein-losing enteropathy. There may be associated gastric ulceration. Barium meal shows
impaired mucosal coating due to hypersecretion and marked gastric fold thickening, though the stomach distends
normally. The stomach is the commonest site for gastrointestinal lymphoma, which maybe polypoid, ulcerating or
infiltrative. The infiltrative form may cause pronounced thickening of gastric folds, with preserved stomach
distensibility, but hypersecretion isn’t a feature. Infiltrating gastric carcinoma may also cause thickened gastric
folds, but associated desmoplastic reaction results in a rigid, poorly distensible stomach. Zollinger–Ellison
syndrome results in hypersecretion of gastric acid, which impairs mucosal coating of barium, and is associated with
ulceration and enlargement of rugal folds, buthypoproteinaemia is not a feature. Eosinophilic gastroenteritis may
cause enlarged gastric folds and be associated with protein-losing enteropathy if the small bowel is involved.
However, the antrum is most commonly involved.

6. On a barium meal examination, the incisura angularis marks the border between which structures?
A. lesser and greater curvatures of the stomach
B. antrum and pylorus of the stomach
C. fundus and body of the stomach
D. body and antrum of the stomach
E. oesophagus and the stomach

The answer is: D

The stomach is divided into the fundus, body, antrum and pylorus. The fundus is that part of the stomach extending
superiorly and to the left of the cardiac orifice. The body extends from the cardiac orifice to the incisura angularis,
which is a constant notch at the lower end of the lesser curvature marking the border between the body and the
antrum of the stomach. The antrum extends from the incisura angularis to the proximal pylorus.

7. A 41-year-old woman with morbid obesity presents with a plateau in weight loss 12 weeks after laparoscopic
gastric banding. She undergoes a contrast swallow, which demonstrates concentric dilatation of the neostomach
with a widely patent stoma. What is the most appropriate management?
A. no action necessary
B. nutritional advice
C. prompt decompression of the stoma by the radiologist
D. fluoroscopically guided band inflation
E. surgical replacement of the gastric band

The answer is: B

Laparoscopic gastric banding involves laparoscopic placement of an inflatable gastric band across the proximal
stomach, forming a small fundal neostomach or pouch. The band is connected to a subcutaneous port that can be
accessed percutaneously to allow inflation or deflation of the band and adjustment of stomal width and degree of
hold-up. The commonest postoperative complication is dilatation of the pouch. Three main types are described. (1)
Acute concentric pouch dilatation is due to band overinflation, and is seen as a prestenotic dilatation proximal to an
obstructed stoma. It presents as acute dysphagia and requires prompt decompression of the stoma. (2) Chronic
concentric pouch dilatation with a widely patent stoma is seen in patients who continue to overfill their neostomach
after surgery. Nutritional advice is required. (3) Eccentric pouch dilatation occurs due to slippage of the band, and
requires complete decompression and surgical replacement of the band. A plateau in weight loss may also be due
to loss of effect of band tightening. At fluoroscopy, fluid may be injected to tighten the band to achieve an optimal
stomal width of 3–4 cm

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8. A 69-year-old man undergoes staging of gastric carcinoma diagnosed at upper gastrointestinal endoscopy. CT of
the abdomen demonstrates focal gastric wall thickening with extension into the perigastric fat, but no invasion of
adjacent structures. Five local lymph nodes measuring 10–12 mm in short axis diameter are identified. There is no
distant metastatic disease. What is the TNM staging of the tumour?
A. T2 N0 M0
B. T2 N1 M0
C. T2 N2 M0
D. T3 N1 M0
E. T3 N2 M0

The answer is: D

T3 tumours penetrate the subserosa but do not invade adjacent structures. On CT, this may be appreciated as
blurring of the tumour margin or wide reticular strands radiating from the tumour edge. Nodal staging depends on
the number of regional nodes visible, with nodes larger than 8cm being regarded as pathological. The presence of
1–6 regional nodes results in a stage of N1, with 7–15 nodes and >15 nodes representing nodal stages of N2 and
N3 respectively. Non-regional nodes such as para-aortic and retropancreatic nodes are considered M1 disease.

9. A 65-year-old man presents with early satiety and bloating, and undergoes barium meal. This demonstrates a
smoothly marginated, 15 cm mass in the body of the stomach, making an obtuse angle with the gastric wall. CT
demonstrates peripheral enhancement of the mass with central areas of low attenuation and extragastric extension
into the lesser sac. There is no associated lymphadenopathy. What is the most likely diagnosis?
A. gastrointestinal stromal tumour
B. gastric carcinoma
C. gastric lymphoma
D. adenomatous polyp
E. gastric carcinoid

The answer is: A

Gastrointestinal stromal tumours are the commonest mesenchymal tumours of the gastrointestinal tract. They are
characterized by expression of KIT, a tyrosine kinase growth factor receptor, which distinguishes them from
leiomyomas and leiomyosarcomas. They occur most commonly in the stomach, and have the classic appearance of
a submucosal mass on barium meal, forming an obtuse angle with the gastric wall in profile. Focal areas of
ulceration are seen in 60%. On CT, the tumours measure up to 30 cm and are often predominantly extragastric.
Typical features are of peripheral enhancement, with central low attenuation representing necrosis, haemorrhage
and cyst formation. Lymphadenopathy is not a feature. Gastric carcinoma and lymphoma rarely demonstrate
exophytic growth and commonly have associated lymphadenopathy. Adenomatous polyps are mucosal lesions.
Gastric carcinoid is usually seen in the antrum and characteristically shows associated ulceration.

Barret1
4.Emphysematous gastritis is most commonly associated with which of the following organisms?
(a) S.pnemoniae
(b) C.difficile
(c) S.milleri
(d) E.coli
(e) S.aureus

4(d)
Clostridium welchii is another common cause of this unusual condition. S.pneumoniae, S. aureus (and E.coli) may
cause non-emphysematous gastritis. S.milleri is a cause of liver abscesses and C. difficile colitis

14.A patient with a metastasis from a GIST tumour undergoes a contrast-enhanced CT study before and after
chemotherapy. On the initial study, the lesion measures 5 cm in diameter and has a density of 100 HU. At follow
up, the lesion measures 6 cm and has a density of 80 HU. How should you classify the response to chemotherapy?
(a) Complete response
(b) Partial response
(c) Mixed response
(d) Stable disease
(e) Progressive disease

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14 (b)
metastatic GIST tumours are treated with monoclonal antibody agents. These typically reduce the blood supply and
metabolism of the tumours with little change in tumour size and as such, the RECIST criteria are of little value.
The Choi criteria differ from RECIST in that to obtain a PR, one needs a 10% reduction in size or a 15% reduction
in density. Progressive disease requires 1 tumour growth a 15% reduction in lesion density, a lesion or a or
growing nodule of enhancing tumour within an existing lesion. There is no mixed response category.

21.Which of the following is not a recognised cause of gastric fold thickening?

(a) Adult hypertrophic pyloric stenosis
(b) lymphoma
(c) Gastritis
(d) Menetrier's disease
(e) Zollinger-Ellison syndrome

21 (a)
This has similar appearances to infantile hypertrophic pyloric stenosis but may be associated with ulceration.
Differentiation from malignancy in the antrum may also be difficult.

32.Where do gastrointestinal stromal tumours (GIST) most commonly arise?

(a) Esophagus
(b) Stomach
(c) Small intestine
(d) Colon
(e) Appendix

32 (b)
Approximately 60% arise in the stomach, 30% in the small bowel, 7% in the ano-rectal region and the remainder in
the oesophagus and colon .
20.Which of the conditions does not predispose patients to gastric volvulus?
(a) Hiatus hernia
(b) Phrenic nerve palsy
(c) Previous sigmoid volvulus
(d) Diaphragmatic eventration
(e) Splenic abnormalities

20(c)
Other predisposing factors include gastric distension and traumatic diaphragmatic hernia. It is more commonly
seen in the elderly and presents with acute upper Gl obstruction and wrenching without producing vomitus. It is
important to assess the patient for signs of ischaemia on cross-sectional imaging as this is a surgical emergency.
31.Which of the following is not a recognised complication of partial gastrectomy?
(a) Bezoar
(b) Gastric carcinoma
(c) Fistula formation
(d) Gastric lymphoma
(e) Marginal ulceration

31 (d)
Partial gastrectomy was previously a common operation for the treatment of peptic ulcer disease, often in
association with a vagotomy.
43.A 56-year-old has undergone previous surgery is referred to nuclear medicine for a gastric emptying study. The
patient ingests radio-labelled fruit juice, bread and scrambled egg. The gastric emptying curves demonstrate the
liquid phase to have a T1/2 of 10 minutes and the solid phase to have a T1/2 of 20 minutes. How would you interpret
these findings?
(a) Normal gastric emptying
(b) Dumping syndrome
(c) Gastric stasis
(d) Previous vagotomy
(e) Gastric outlet obstruction

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43 (b)
The T1/2 for both of these phases is abnormally low indicating rapid transit of liquid and solid components;
dumping syndrome may be seen following gastric surgery. Normal rates of emptying are T 1/2<30 minutes for
liquids, and 30-120 minutes for solid food. Vagotomy leads to rapid gastric emptying and delayed solid emptying.
Gastric stasis will result in delayed transit of solid and liquid components.

53.A 46-year-old man presents vomiting, epigastric pain, ankle swelling, poor appetite, and weight loss. OGD
shows marked enlargement of the proximal rugal folds and ulceration. A subsequent barium examination shows
dilution of barium in the stomach and thickening of folds the small intestine. What is the most likely diagnosis?
(a) Carney syndrome
(b) Helicobacter pylori infection
(c) Ménétrier's disease
(d) Pernicious anemia
(e) VIPoma

53 (c)
Ménétrier's disease (giant hypertrophic gastritis) results in marked thickening of the gastric mucosal folds, typically
in the proximal half of the stomach. The gastric mucosa secretes copious mucus (dilution of barium), which results
in a protein-losing enteropathy (leading to SB fold thickening). It is ass achlorhydria which can lead to ulceration
55.Which of the following conditions is not associated Helicobacter pylori colonisation?
(a) Oesophageal cancer
(b) Gastric ulcer
(c) Gastric carcinoma
(d) MALT Lymphoma
(e) Duodenal ulcer

55 (a)
Esophageal carcinoma rates have been increasing as H. pylori colonisation rates have fallen. A protective effect
against some conditions has been postulated but this is highly controversial.
73.A patient undergoing an endoscopic US examination is found to have a lesion within the muscularis propria
layer of the stomach wall. What is the most likely diagnosis?
(a) Adenocarcinoma
(b) Lipoma
(c) Gastro-intestinal stromal tumour
(d) Peritoneal metastasis
(e) Varices

73 (c)
GIST, leiomyoma and leiomyosarcoma arise in this level. Adenocarcinoma arises within the mucosa. Lipoma
within the submucosa. Metastases are seen at the serosal surface. Varices may be in the submucosa or extrinsic to
the stomach.
CURRIE
26. A 50-year-old male is admitted with epigastric pain, diarrhoea and vomiting. Ascites is present clinically.
Serum albumin is low and the patient is anaemic. Colonoscopy is normal but the patient is intolerant of upper
gastro-intestinal endoscopy. Barium meal reveals a normal antrum but elsewhere there are diffusely thickened and
enlarged gastric folds despite good gastric distension. Which one of the following is the most likely diagnosis?
a. Gastric lymphoma
b. Menetrier’s disease
c. Gastric adenocarcinoma
d. Acute gastritis
e. Linitis plastic

26. b. Menetrier’s disease

Menetrier’s disease is a condition characterized by gastric mucosal hypertrophy and protein-losing enteropathy. It
is often associated with anaemia. The changes are most marked along the greater curve and the antrum is spared in
approximately 50% of cases. Gastric lymphoma typically involves the antrum. With gastric adenocarcinoma and
linitis plastica, stomach distension is not typically preserved.

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Grainger & Allison
QUESTION 4
A 72-year-old man presents to his GP with increasing dyspepsia and weight loss. He has not experienced any other
GI symptoms and physical examination is unremarkable. A barium meal is performed with the administration of
intravenous Buscopan. The oesophagus is normal in appearance but a ‘bull's eye’ lesion is noted in the gastric
mucosa. Which one of the following is not a recognized cause of this appearance?
A Gastric carcinoma
B Gastrointestinal stromal tumour (GIST)
C Magenstrasse
D Melanoma metastases
E Neurofibromatosis

ANSWER: C
Magenstrasse refers to the normal longitudinal mucosal folds seen adjacent to the lesser curve of the stomach
during a barium meal. The ‘bull's eye’ appearance seen during a barium meal is due to a central ulcer in an elevated
area of submucosa. A GIST may well have this appearance and neurofibromatosis an cause single or multiple
target lesions. Melanoma is the commonest cause of submucosal gastric metastases.
QUESTION 18
A 68-year-old man presents to his GP with a 1-month history of epigastric pain, vomiting and mild weight loss.
Examination is unremarkable and the patient is referred for an upper gastrointestinal endoscopy. This demonstrates
mild gastritis with biopsies positive for Helicobacter pylori and he is commenced on eradication therapy. Three
months later, the symptoms have persisted and the patient has lost 5 kg in weight. A double contrast barium meal is
performed and reveals a shallow ulcer on the lesser curve of the stomach. Which additional finding would make
the ulcer more likely to be benign than malignant?
A Hampton's line is present.
B Nodular mucosal folds stop at the edge of the lesion.
C The ulcer does not extend beyond the gastric wall.
D The ulcer has an irregular margin.
E The ulcer measures 40 mm in size.

ANSWER: A
Hampton’s line refers to a lucent line crossing the ulcer base: its presence is highly suggestive of a benign ulcer.
QUESTION 33
A 48-year-old man presents to his GP with epigastric pain, diarrhoea and weight loss over a period of 6 months.
Laboratory investigations reveal a reduced serum albumin, and a contrast-enhanced CT of the abdomen
demonstrates diffuse thickening of the gastric mucosa. A double contrast barium meal examination is performed
and shows markedly thickened mucosal folds in the gastric body with sparing of the gastric antrum. The mucosal
folds alter in size and position during the examination. What is the most likely diagnosis?
A Eosinophilic gastritis
B Gastric lymphoma
C Infiltrative gastric adenocarcinoma (Linitis Plastica)
D Menetrier's disease
E Organoaxial gastric volvulus

ANSWER: D
Menetrier’s disease characteristically produces thickened hyperplastic mucosa (sparing the gastric antrum) but the
stomach remains pliable.
QUESTION 36
A 49-year-old man develops weight loss, upper abdominal pain and three episodes of vomiting fresh red blood.
Subsequent upper gastrointestinal endoscopy reveals a distal gastric adenocarcinoma. The patient undergoes a
surgical procedure to resect the tumour, but develops increasing epigastric pain and fever 4 days later. An upper GI
contrast study is performed. Which one of the following statements is true regarding this examination?
A A partial distal gastrectomy with gastrojejunostomy (Billroth II procedure) involves an end-to-end anastomosis.
B Control images prior to contrast administration are not indicated in this
C If a water-soluble contrast examination appears normal, barium can be used as it has a higher sensitivity in
identifying anastomotic leaks.
D The oesophago-gastric junction is the most common site for perforation and contrast leaks.
E Thickening of the mucosa at the surgical anastomosis with delayed gastric emptying is most likely due to
residual gastric tumour.
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ANSWER: C
Anastomotic leakage is one of the most serious complications following gastric surgery and may occur in the acute
or chronic phase. In a contrast study, water-soluble contrast should be used initially, but if no leak is detected then
barium can be used as it is more sensitive for the detection of subtle postoperative leaks (outweighing the risk of
barium spilling into the peritoneal cavity). The most common site for leakage is at surgical anastomoses and suture
lines; therefore, control images are invaluable to note the location of these sites and look for extraluminal gas.
Oxford
1. A 63-year-old man is day 7 post-operative following a Billroth II partial gastrectomy for a gastric
carcinoma. The initial post-operative phase was uncomplicated, but the patient has begun complaining of
increasing abdominal pain. Inflammatory markers have increased with white cell count (WCC), rising from
12 to 42, and CRP increased from 8 to 56. A CT scan carried out with oral and intravenous contrast
demonstrates no evidence of contrast leakage into the peritoneum. A skiff of free air is noted in the
abdomen. A fluid collection is noted in the right subhepatic space, which extends toward the peripancreatic
area. What is the most likely diagnosis?
A. Leakage from the gastroduodenal anastomosis site.
B. Leakage from the duodenal stump.
C. Post-operative pancreatitis.
D. Tumour recurrence.
E. Pseudocyst formation following post-operative pancreatitis.

1. B. Leakage from the duodenal stump.

There is no gastro-duodenal anastomosis in a Billroth II procedure. The amylase is not sufficiently elevated for
pancreatitis in most cases and there is no described abnormality in the pancreas. It is too early for pseudocyst
formation and tumour recurrence.
6. A patient presents to an outpatient barium meal list with a history ofepigastric discomfort and weight loss
of 8 kg over 6 months. The bariummeal reveals an ulcer on the greater curve of the stomach, near the
pylorus. This ulcer has a surrounding mound. It is demonstrated to project slightly beyond the lumen of the
stomach. There is a thin line noted which crossesthe base of the ulcer and a degree of retraction of the
greater curve aroundthe ulcer. What type of ulcer is this likely to be?
A. Benign due to the line noted crossing the base of the ulcer.
B. Benign due to the ulcer projecting beyond the lumen of the stomach.
C. Benign due to the surrounding mound.
D. Malignant due to the finding of scar retraction of the greater curve.
E. Malignant due to being found on the greater curve.

6. A. Benign due to the line noted crossing the base of the ulcer.
This line—Hampton’s line—represents undermining of the mucosa by the more vulnerablesubmucosa. It is not
commonly seen, but is taken to be virtually diagnostic of a benign ulcer whenpresent. Projection beyond the lumen
and a symmetrical mound are features of a benign ulceralong with smooth radiating mucosal folds. Scar retraction
can be seen with benign ulcers. Bothbenign and malignant ulcers are more commonly seen on the lesser curve
13. A patient is undergoing a barium meal. What is the best position to place the patient in to see an en face
view of the lesser curve?
A. Left lateral.
B. Left anterior oblique (LAO).
C. Supine.
D. Right anterior oblique (RAO).
E. Right lateral.

13. B. LAO.
The right lateral position is not routinely used. The RAO shows the body and antrum of the stomach. Supine
positioning shows the greater curve and the antrum of the stomach. Left lateral position shows the fundus of the
stomach.

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MasterPass1
A staging CT was performed on a 49-year-old gentleman with a histologically proven adenocarcinoma of the
fundus of his stomach. The CT showed invasion of the adjacent contiguous structures but no invasion of adjacent
organs, the diaphragm or the abdominal wall. Multiple prominent local nodes were evident and a 1.3-cm (short
axis) lymph node was seen in the left para-aortic region. No distant metastases were visible. What is staging?
a T4b N2 MO
b T4a N3 MO
c T3 N3 MO
d T3 N3 M1
e T4a N2 MO
Answer B: T4a N3 MO
A patient had recently been diagnosed with gastric carcinoma that had been staged locally as T2 disease. To what
extend has the tumour penetrated through the wall?
a Penetrated thorough the serosa
b Invading adjacent organs
c Limited to the submucosa
d Limited to the serosa
e Limited to the mucosa
Answer D: Limited to the serosa.
An 80-year-old male underwent a barium meal to investigate epigastric pain and early satiety. There was a narrow,
tubular stomach with a lack of rugal folds in the proximal stomach and a smooth greater curve. What is diagnosis?
a Zollinger-Ellison syndrome
b Linitis Plastica
C Atrophic gastritis
d Menetrier's disease
e Corrosive gastritis

Answer C: Atrophic gastritis

The incidence of atrophic gastritis increases with age and symptoms may include epigastric pain and early satiety.
Radiological features are a narrow tubular stomach and a reduction in the normal gastric folds.
A middle-aged man underwent a barium meal which showed an abnormality of the gastric wall with mural
thickening, irregularity, reduced distensibility and absent peristalsis. What is the most likely underlying diagnosis?
a Amyloid
b Pancreatic carcinoma
c Radiation therapy
d Scirrhous cancer
e Syphilis

Answer D: Scirrhous cancer

The listed radiological features are typical of Linitis Plastica (leather bottle stomach) of which scirrhous cancer is
the most common cause. Other causes include: other tumours (lymphoma, metastases, pancreatic carcinoma),
inflammation (erosive gastritis, radiation therapy), infiltrative disease (sarcoid, amyloid, intramural haematoma)
and infection (TB, syphilis).
MASTERPASS 2
13 An 88-year-old lady presented with a tender distended abdomen. A dilated viscus was visible in the left upper
quadrant on plain radiography with a long fluid level. There was leftward and upward displacement with a raised
left hemidiaphragm and little gas elsewhere in the abdomen. What is the most likely diagnosis?
a Air swallowing
b Caecal volvulus
c Gastric outlet obstruction
d Gastric volvulus
e Paralytic ileus
13 Answer D: Gastric volvulus
Gastric volvulus, although rare, is more common in the elderly population. It may result from twisting in the
longitudinal, transverse or mesenteric axis. The dilated stomach usually contains a long fluid level and is displaced
upwards and to the left, causing a raised left hemidiaphragm.
11
GIT Stomach
15 A gastric ulcer was visible during a barium meal. What feature would favour a benign aetiology over
malignancy?
a Irregular contour
b Hampton's line
c Shallow ulcer
d No protrusion beyond stomach
e Asymmetrical mass

15 Answer B: Hampton's line

16 A patient was diagnosis with Menetrier's disease on histology. What radiological appearance would support this
diagnosis?
a Absence of gastric folds in the proximal stomach
b Thickened folds in the proximal stomach
C Multiple gastric ulcers
d Rigid stomach wall
e Aphthoid ulcers

16 Answer B: Thickened folds in the proximal stomach

This is hypertrophic gastritis and may present with epigastric pain, achlorydia, and protein loss. There are
thickened gastric folds mainly in the proximal stomach and greater curve. Unlike in a malignant process the
stomach wall does not become rigid, but endoscopy and biopsy are usually necessary for diagnosis.

17 A patient underwent a barium meal which demonstrated multiple filling defects. Upper GI endoscopy confirmed
multiple gastric polyps, which were biopsied. What is the histology most likely to show?
a Adenomatous polyps
b Hamartomatous polyps
c Hyperplastic polyps
d Leiomyomas
e Metastases

17 Answer C: Hyperplastic polyps

Hyperplastic polyps occur mainly in the body and fundus of the stomach but also randomly throughout the
stomach. They measure under 1 cm in size, but rarely be 3-10 cm. This type makes up 80-90% of gastric polyps.
18 A 50-year-old publican with a history of back pain developed retrosternal pain and melaena. He visited his
doctor and, following a negative urea breath test, was referred for a barium meal. This showed linear streaks and
dots of barium within the gastric mucosa, preferentially affecting the gastric antrum. What is the most diagnosis?
a Crohn's disease
b Gastric varices
C Gastric carcinoma
d Emphysematous gastritis
e Erosive gastritis

18 Answer E: Erosive gastritis

Erosive (haemorrhagic) gastritis is associated with peptic disease, infection and Crohn's disease. Non-steroidal
anti-inflammatory drugs are a common underlying cause, which may have been used to treat his back pain.
Contrast studies may show complete or incomplete erosions. Complete erosions show a spot of barium surrounded
by a radiolucent ring of oedema (target lesion). Incomplete erosions show dots and linear streaks of barium without
associated oedema.

12
GIT Stomach
19 A 30-year-old man with no previous medical or surgical history presented to the Emergency Department with
severe epigastric pain. He was retching but was unable to vomit. Plain radiographs demonstrated a large hiatus
hernia and grossly distended stomach and an abdominal CT revealed features of a gastric volvulus associated with
the hiatus hernia. What feature would suggest an organoaxial volvulus?
a Diaphragmatic rupture
b Evidence of gastric ischaemia
c Gas in the stomach wall
d Greater curvature located cranially
e The fundus positioned caudal to the antrum

19Answer D: Greater curvature located cranially

Masterpass3
14 A 37-year-old male presented with gastric outlet obstruction. He had a history of epigastric pain related to food
and an abdominal CT showed a dilated stomach with irregular inflammatory narrowing in the distal stomach. What
is the most likely cause?
a Antral carcinoma
b Crohn's disease
c Peptic ulcer disease
d Sarcoidosis
e Syphilis

14 Answer C: Peptic ulcer disease

In gastric outlet obstruction caused by inflammatory narrowing 60-65 % is caused by peptic ulcer disease. This is
particularly likely in a patient with a history of symptoms probably related to peptic ulcer disease.
15 A 55-year-old male presented with severe symptoms of reflux. A barium study showed thickened gastric rugae,
duodenal and jejunal folds and multiple peptic ulcers. His serum gastrin level was elevated. What is the most likely
diagnosis?
a Barrett's oesophagus
b Oesophageal Crohn's disease
c Zollinger-Ellison syndrome
d Pancreatitis
e Helicobacter pylori infection

15 Answer C: Zollinger-Ellison syndrome

Zollinger-Ellison syndrome is secondary to a functional pancreatic islet cell tumour producing gastrin. It causes
gastric hypersecretion, which leads to multiple ulcers and a diffuse inflammatory response accounting for the
thickened folds.
16 A patient presented three months after a gastrojejunostomy with left to right anastomosis with epigastric
fullness relieved by bilious vomiting, and B 12 deficiency. CT demonstrated a fluid dense mass adjacent to the
head of the pancreas with a further similar mass near the tail of the pancreas. What diagnosis are these findings
most suggestive of?
a Anastomotic leak
b Blind loop syndrome
C Incorrect anastomosis
d Anastomotic dehiscence
e Gastric volvulus

13
GIT Stomach
16 Answer B: Blind loop syndrome
This occurs following a Billroth II procedure when the afferent loop intermittently partially obstructs and
overdistends. Typical features on a contrast examination would be preferential emptying of the stomach into the
proximal loop, stasis and regurgitation.

17 A 50-year-old landscape gardener presented with abdominal pain and was assessed with a CT scan on which
gastric mucosal irregularity was noted. His pain settled with conservative management and he was followed up
with a barium meal as an outpatient, which showed multiple target ('bull's-eye') lesions in the stomach.
a Pancreatic `rest'
b Gastric Crohn's disease
C Gastric carcinoma
d Neurofibroma
e Submucosal metastases

17 Answer E: Submucosal metastases

The commonest cause of `bull's-eye' lesions in the stomach is submucosal metastases and of these the commonest
primary tumour is malignant melanoma. Other causes of gastric `bull's-eye' lesions include: leiomyoma, pancreatic
rest and neurofibroma.

18 A patient was noted to have an abnormal appearance of the stomach wall on abdominal CT. A barium meal was
subsequently performed and a diagnosis of ectopic pancreatic tissue (pancreatic rest) was considered. What finding
would be most typical of this diagnosis?
a Dots and linear streaks of barium
b Featureless gastric mucosa
c Multiple aphthous ulcers
d Polypoid fundal mass
e Submucosal umbilicated mass

18 Answer E: Submucosal umbilicated mass

Pancreatic rests (ectopic pancreas) typically occur in the greater curvature, pylorus, duodenal bulb or proximal
jejunum. They manifest as submucosal nodules between 1 and 5 cm in size. Central umbilication is often present,
representing the orifice of the filiform duct.

19 Following an episode of haematemesis a 48-year-old man visited his doctor. He admitted several months of
dyspeptic symptoms, some weight loss and said he had been drinking up to a bottle of spirit daily. He was referred
for an endoscopy, which he was not able to tolerate. Consequently, a barium meal was performed which showed a
large ulcer within an oedematous mound on the greater curvature. What further feature would suggest a malignant
ulcer?
a Carman's (meniscus) sign
b Central location of ulcer within mound
C Extension of mucosal folds to crater edge
d Hampton's line
e Thin mucosal folds

19 Answer A: Carman's (meniscus) sign

Radiological signs of a malignant ulcer include: thick irregular mucosal folds, projection of ulcer within luminal
surface, Carman's (meniscus) sign, eccentric location of ulcer in tumour mound, a thick nodular irregular collar and
limited gastric distensibility and peristalsis.
Gupta
18.A 48-year-old woman presents with history of upper abdominal pain, weight loss and bilateral ankle oedema.
CT abdomen shows thickened gastric wall with prominent mucosal folds affecting the upper part of the stomach
and greater curvature, while the antrum, pylorus and rest of the bowel appear normal.
The most likely diagnosis is?
(a) Crohn’s disease
(b) Gastric carcinoma
(c) Lymphoma
(d) Ménétrier’s disease
(e) Eosinophilic gastritis

14
GIT Stomach
(d) Ménétrier’s disease
This is characterised by hypertrophy of gastric folds affecting the greater curvature while usually sparing the
antrum, hypoproteinemia (causing ankle oedema) and hypochlorhydria.
Lymphoma involves any part of stomach and antrum. Eosinophilic gastritis often affects the antrum and the
proximal small bowel. Crohn’s disease shows multiple aphthous ulcers and commonly affects antrum and pylorus.
It usually affects the terminal ileum as well.
27. A 65-year-old woman presents with non-specifc abdominal discomfort. Contrast-enhanced abdominal shows a
homogenous, extraluminal mass with heterogeneous enhancement and a low attenuation centre arising from the
greater curvature of stomach. No lymphadenopathy is seen. A subsequent PET scan shows markedly increased
glucose uptake by the lesion. What is the most likely diagnosis?
(a) Carcinoma of the stomach
(b) Gastrointestinal stromal tumour
(c) Lymphoma
(d) Carcinoid
(e) Metastases

27. (b) Gastrointestinal stromal tumour

This is the likely diagnosis given the CT appearances. It presents as predominantly extraluminal masses with
heterogeneously enhancing margins and a necrotic centre. Lymph node enlargement is not a feature. Carcinomas
show more vigorous local infltration. Metastases from bowel are usually multiple and often present with a history
of known primary malignancy. Lymphomas cause circumferential thickening with homogenous enhancement and
lymph nodes. Carcinoids are mainly seen around terminal ileum and produce a desmoplastic reaction

EDiR
15. Following statements regarding lymphoma of the gastrointestinal tract are correct:
(a) There is an increased risk associated with ulcerative colitis.
(b) The stomach is the most common site of involvement by non-Hodgkin’s lymphoma.
(c) In the colon the rectum is most commonly involved.
(d) Diffuse involvement of the whole stomach is seen in 10-15%.
(e) Presents with thickened valvulae conniventes in the small bowel.

Answers:
(a) Not correct
(b) Correct
(c) Not correct
(d) Not correct
(e) Correct

Explanation:
Lymphoma of the gastrointestinal tract has an increased risk association with Crohn’s disease, coeliac disease,
AIDS and SLE. Diffuse involvement of the stomach is seen in 50% of the cases. Caecum is most commonly
involved in colon
17. Regarding gastrointestinal stromal tumours (GIST):
(a) The most significant criteria for predicting malignant potential is tumour size.
(b) It is a cause of haematemesis.
(c) The commonest location is the sigmoid.
(d) There is an association with neurofibromatosis Type 1
(e) Contrast enhancement is invariably uniform.

Answers:
(a) Correct
(b) Not correct
(c) Not correct
(d) Correct
(e) Not correct

15
GIT Stomach
Explanation:
Gastrointestinal stromal tumour does not cause hematemesis since they are mostly exophytic.
It is commonly located at stomach. There is heterogenous enhancement with significant hemorrhage and necrosis.

15. Following statements regarding lymphoma of the gastrointestinal tract are correct:
(a) There is an increased risk associated with ulcerative colitis.
(b) The stomach is the most common site of involvement by non-Hodgkin’s lymphoma.
(c) In the colon the rectum is most commonly involved.
(d) Diffuse involvement of the whole stomach is seen in 10-15%.
(e) Presents with thickened valvulae conniventes in the small bowel.

Answers:
(a) Not correct
(b) Correct
(c) Not correct
(d) Not correct
(e) Correct
Explanation:
Lymphoma of the gastrointestinal tract has an increased risk association with Crohn’s disease, coeliac disease,
AIDS and SLE. Diffuse involvement of the stomach is seen in 50% of the cases. Caecum is most commonly
involved in colon

33. Which of the following are correct regarding mucosal associated lymphoid tissue (MALT) lymphoma of
the gastrointestinal tract?
(a) Perforation of the stomach is a recognised feature of gastric MALT lymphoma.
(b) MALT lymphoma is widely disseminated at the time of diagnosis is most patients.
(c) The most common site within the stomach is the antrum.
(d) Ulceration is a common feature on barium study.
(e) The normal stomach does not contain lymphoid follicles.

Answers:
(a) Correct
(b) Not correct
(c) Correct
(d) Not correct
(e) Correct

Explanation:
MALT lymphoma shows very less dissemination and generally has a better prognosis than non-Hodgkin’s
lymphoma. The most common pattern on barium study is infiltrative, either focal or diffuse. Ulcerative lesions,
especially in stomach are rare.

16