Table Of ContentI
Contents
MEDICAL RADIOLOGY
Diagnostic Imaging
Editors:
A. L. Baert, Leuven
M. Knauth, Göttingen
K. Sartor, Heidelberg
III
Contents
A. H. Freeman · E. Sala
(Eds.)
Radiology of the
Stomach
and Duodenum
With Contributions by
K. Balan · A. Ba-Ssalamah · N. R. Carroll · C. Cousins · M. Dux · T. Fork · A. H. Freeman
K. M. Harris · H.-U. Laasch · D. Martin · M. Memarsadeghi · P. Pokieser · M. Prokop
J. W. A. J. Reeders · E. Sala · T.C. See · P. J. Shorvon · M. Uffmann · R. Zissin
Foreword by
A. L. Baert
With 322 Figures in 588 Separate Illustrations, 129 in Color and 9 Tables
123
IV
Contents
Alan H. Freeman, MB, BS, FRCR
Consultant Radiologist
Department of Radiology
Addenbrooke’s Hospital
Box 219, Hills Road
Cambridge, CB2 2QQ
UK
Evis Sala, MD, PhD
University Lecturer/Honorary Consultant Radiologist
University Department of Radiology
Addenbrooke’s Hospital
Box 219, Hills Road
Cambridge CB2 2QQ
UK
Medical Radiology · Diagnostic Imaging and Radiation Oncology
Series Editors:
A. L. Baert · L. W. Brady · H.-P. Heilmann · M. Knauth · M. Molls · C. Nieder · K. Sartor
Continuation of Handbuch der medizinischen Radiologie
Encyclopedia of Medical Radiology
Library of Congress Control Number: 2003064923
ISBN 978-3-540-42462-8 Springer Berlin Heidelberg New York
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V
Contents
To my wife
Jackie
for all her patience
during the preparation of this book
Alan H. Freeman
To my son
Pier
and my husband
Gezim
Evis Sala
VII
Contents
Foreword
Notwithstanding the major contributions of endoscopy in the diagnosis and manage-
ment of disorders of the stomach and the duodenum, radiology still has an important
role in specifi c disease settings.
This volume provides up to date information on multimodality imaging of this ana-
tomic section of the upper gastrointestinal tract within the framework of a multidisci-
plinary approach.
The editors, A.H. Freeman and E. Sala, judiciously selected the topics and were very
successful in engaging the help of several other internationally recognised experts
in gastrointestinal radiological imaging. The book comprehensively covers all main
areas of interest, is superbly illustrated and the references include the most important
recent publications in the fi eld.
I am confi dent that this outstanding volume will fi nd a great interest from general as
well as specialised gastrointestinal radiologists but also from gastroenterologists and
abdominal surgeons, who want to update their knowledge and abilities on the actual
value of radiological imaging for patients with stomach or duodenal disorders. I hope
that it will meet the same success as the previous volumes in our series.
Leuven Albert L. Baert
IX
Contents
Preface
Following Roentgen’s discovery of X-rays, early experimenters quickly realised that this
new technology held promise for investigating the hitherto unknown area of the gas-
trointestinal tract. Only 1 year after the publication of Roentgen’s paper, W. Becher fed
lead subacetate to a guinea pig and thus performed probably the fi rst contrast study of
a living stomach. Studies on humans soon followed, with Roux and Balthazard report-
ing their fi ndings using bismuth subnitrate as a contrast agent in 1897. Herman Rieder
in 1904 was the fi rst to standardise the gastric examination, using as a contrast agent
a mixture of 40 g of bismuth subnitrate mixed with gruel – henceforth known as the
“Rieder meal”. However, it was realised that bismuth subnitrate had toxic side effects
so investigators had to search for another form of contrast agent. They soon realised
that barium sulphate, a naturally occurring mineral, possessed the ideal parameters
of inertness, non-absorption from the gastrointestinal tract and excellent X-ray dif-
fraction properties, which made it a perfect contrast agent for opacifying the upper
GI tract. Its potential use had been suggested by Walter Cannon but it was Bachem
and Gunter in 1910 that fi rst described the use of barium sulphate in the stomach, and
thus was borne the barium meal. Modifi cations occurred over the years, particularly
with the introduction of double contrast, in an attempt to provide better delineation
of the mucosal surface. Although the principle of double contrast in the colon had
been fi rst advocated by Fischer in 1923, its use in the stomach was slow to catch on in
the Western world. The major stimulus for double contrast studies came from Japan
in the 1960s, when a population screening programme was started to detect early gas-
tric cancer – a condition with a very high prevalence in Japan. Hikoo Shirakabe, in
particular, popularised the technique which requires the adherence of a thin fi lm of
high density barium sulphate to the gastric mucosa whilst the stomach is infl ated with
gas – usually CO . Improvements in barium preparations, including the addition of
2
numerous gums and anti-fl occulating agents, meant that by the late 1970s excellent
mucosal detail could be demonstrated of the entire stomach and duodenum. And then
along came fl exible endoscopy, with its ability not only to see all the mucosa in glori-
ous technicolour, but also to take biopsies of any suspicious or doubtful lesion. Here
was a simple outpatient procedure requiring minimal sedation and within a decade
the barium meal virtually died. However, conventional examination of the upper GI
tract is still performed, although now the indications are different – often for function
as well as morphological detail. New indications, such as studying the stomach after
surgery for morbid obesity, have come into vogue and are likely to increase with the
obesity epidemic in the Western world. It should also be remembered that endoscopy
X
Preface
is not infallible – a point addressed in Chapter 4 – and that there are still occa-
sions when a patient cannot or will not tolerate an endoscopy.
Whilst demand for conventional radiology of the stomach has substantially
dropped, aided by the discovery of Helicobacter pylori and its relationship to
peptic ulcer disease, new technology has introduced a host of indications for
radiological imaging of the stomach and duodenum. This particularly applies
to CT with the subsequent development of multidetector CT (MDCT). Early CT
rapidly proved its worth in staging gastric carcinoma, particularly in the sphere
of distant spread to nodes and the liver. Delineation of the wall of the stomach,
however, proved diffi cult both because of duration of scan time as well as lack
of fi ne detail. These problems have been largely overcome with MDCT, which
can now offer exquisite detail of the gastric wall acquired in the space of a few
seconds. Very fi ne detail of the distinction between the mucosa and submucosa
can still only be achieved by the use of endoscopic US as is outlined in Chap. 8.
It is interesting to speculate as to whether or not CT will eventually have this
capability or will MRI possibly supersede both, aided by its real time capabili-
ties. The latter clearly takes the radiologist into the role of functional studies, a
sphere up to now dominated by Nuclear Medicine examinations. Radiological
intervention in the stomach and duodenum is also growing in importance and
whilst it is helpful to have endoscopic expertise, this is not essential, as is shown
in Chapter 11.
Finally, it goes without saying that accurate interpretation of radiological
images (however they are acquired) requires a full knowledge of pathological
processes and the way that they affect the organ. The principle of radiologic/
pathologic correlation is now well established, but it is always helpful to remind
ourselves of the macroscopic changes and how they come about from different
disease processes. This we have attempted to do in Chaptre 2.
In conclusion, we would like to thank Prof. A. Baert for entrusting us with
the preparation of this project in the Medical Radiology series, and our par-
ticular thanks go to all our authors for contributing to this volume. We hope
that it will provide useful and informative reading for any radiologist with an
interest in the stomach and duodenum. Finally we wish to thank Ms Ursula
Davis, Mr Kurt Teichmann and all the production team at Springer, whose tre-
mendous help and expertise brought the project to fruition.
Cambridge Alan H. Freeman
Evis Sala
XI
Contents
Contents
1 Introduction and Clinical Overview
Alan H. Freeman. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Radiological–P athological Correlation
Jacques W. A. J. Reeders, Alan H. Freeman, and Evis Sala. . . . . . . . . . . . . 5
3 Endoscopy of the Upper Gastrointestinal Tract
Thomas Fork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4 Problems and Pitfalls of Gastrointestinal Endoscopy.
Is There Still a Role for Barium Meal?
Philip John Shorvon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
5 Conventional Radiology of the Stomach and Duodenum
Evis Sala and Alan H. Freeman . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
6.1 CT of the Stomach
Teik C. See, Nicholas R. Carroll, and Alan H. Freeman. . . . . . . . . . . . . . 111
6.2 Multislice CT of the Stomach
Ahmed Ba-Ssalamah, Martin Uffmann, Peter Pokieser, and
Mathias Prokop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
7 Magnetic Resonance Imaging of the Stomach
Markus Dux. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
8 Endoscopic Ultrasound of the Stomach
Keith M. Harris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
9 CT of the Duodenum
Rivka Zissin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
10 Radionuclide Imaging of the Stomach
Kottekkattu Balan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
11 Radiological Intervention in the Stomach and Duodenum
Derrick F. Martin and Hans-Ulrich Laasch . . . . . . . . . . . . . . . . . . . . 185
12 The Acute Stomach and Duodenum
Evis Sala and Alan H. Freeman. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
13 The Postoperative Stomach and Duodenum
Peter Pokieser, Ahmed Ba-Ssalamah, and Mazda Memarsadeghi. . . . . . . 231
14 Angiography of the Stomach and Duodenum
Claire Cousins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
1
Introduction and Clinical Overview
1
Introduction and Clinical Overview
Alan H. Freeman
CONTENTS fail then the patient is likely to consult his family
doctor. Here, a brief history is essential, if only to rule
1.1 Which Patients Should Undergo out ominous symptoms as indicated above. Physical
Endoscopy? 2 examination is largely unrewarding, unless there are
1.2 Is There Ever a Role for the Upper
obvious signs such as a gastric mass, lymphadenopa-
Gastrointestinal Series (Barium Meal)? 3
thy, etc. Again in the first instance treatment is likely
References 4
Additional Reading 4 to be symptomatic; for example, if GORD is sus-
pected then simple measures such as the avoidance
of large meals late at night, elevating the head of the
Diseases of the stomach and duodenum are bed and weight reduction are indicated. If symptoms
immensely common, accounting for 4% of family persist, then consideration has to be given to the
doctor visits per year. The generic title “indigestion” prescription of a proton pump inhibitor (PPI). This
encompasses a collection of symptoms including is usually administered first thing in the morning
heartburn, nausea, bloating, belching and some- over a 4- to 8-week trial period. Failure to respond
times vomiting. All of these may arise from disor- to this regime is common, probably in the order of
ders of the lower oesophagus, stomach or duode- a quarter of the patients, and therefore the dose has
num. In addition, disorders of the biliary tree may to be increased. Usually this is doubled so the medi-
also cause such symptoms, resulting in diagnostic cation is taken before breakfast and before dinner.
and treatment dilemmas Alternatively a trial of another manufacturer’s PPI is
In many instances there may not be an under- often advocated and it has to be noted that there are
lying physical abnormality, so-called functional different genetic responses to the various PPIs. It is
dyspepsia which is probably related to motor dis- also worth remembering that there are other causes
turbances of the stomach and duodenum (Hammer of oesophagitis apart from GORD. Medications such
and Talley 2000). In particular, this may be related as doxycycline, tetracycline, aledronate, potassium
to personal habits such as smoking, eating too much chloride, non steroidal anti-inflammatory agents
and too quickly or drinking too much alcohol. (NSAIDs) and quinidine are all well recognised
When organic causes are present, they most com- causes of oesophagitis. If the patient remains symp-
monly relate to gastro-oesophageal reflux disease tomatic after these manoeuvres, and a confounding
(GORD), gastritis and duodenitis, as well as frank drug history has been excluded, then it is time to con-
ulceration. Occasionally, ominous symptoms such as sider endoscopy (see below) and probably ph testing.
loss of appetite, increased satiety and loss of weight Endoscopy is also necessary to exclude rarer causes
suggest a more sinister cause such as a carcinoma. of oesophagitis such as eosinophilic oesophagitis in
Understandably, most patients are aware of an which the oesophageal wall becomes infiltrated with
association between indigestion and excess gastric eosinophils; usually without a peripheral eosino-
acid and are therefore likely to self medicate – as wit- philia. This condition typically responds to steroids.
ness the large number of proprietary antacids avail- Diseases of the stomach and duodenum account
able across pharmacy counters. If simple measures for about 50% of cases of dyspepsia, in the form of
gastritis, duodenitis and duodenal ulcer. Most of
these conditions are linked to infection with Heli-
A. H. Freeman, MB, BS, FRCR
cobacter pylori (HP); for example it is shown to be
Consultant Radiologist, Department of Radiology,
present in 95% of cases of duodenal ulcer. Therefore,
Addenbrooke’s Hospital, Box 219, Hills Road, Cambridge,
CB2 2QQ, UK the goal here is the detection and eradication of this
