Double-contrast upper gastrointestinal radiography: a pattern approach for diseases of the stomach

Pan-alimentary assessment of motility, luminal content, and structures: an MRI-based framework

BACKGROUND

Gastrointestinal symptoms originating from different segments overlap and complicate diagnosis and treatment. In this study, we aimed to develop and test a pan-alimentary framework for the evaluation of gastrointestinal (GI) motility and different static endpoints based on magnetic resonance imaging (MRI) without contrast agents or bowel preparation.

METHODS

Twenty healthy volunteers (55.6 ± 10.9 years, BMI 30.8 ± 9.2 kg/m2) underwent baseline and post-meal MRI scans at multiple time points. From the scans, the following were obtained: Gastric segmental volumes and motility, emptying half time (T50), small bowel volume and motility, colonic segmental volumes, and fecal water content. Questionnaires to assess GI symptoms were collected between and after MRI scans.

KEY RESULTS

We observed an increase in stomach and small bowel volume immediately after meal intake from baseline values (p<.001 for the stomach and p=.05 for the small bowel). The volume increase of the stomach primarily involved the fundus (p<.001) in the earliest phase of digestion with a T50 of 92.1 ± 35.3 min. The intake of the meal immediately elicited a motility increase in the small bowel (p<.001). No differences in colonic fecal water content between baseline and 105 min were observed.

CONCLUSION & INFERENCES

We developed a framework for a pan-alimentary assessment of GI endpoints and observed how different dynamic and static physiological endpoints responded to meal intake. All endpoints aligned with the current literature for individual gut segments, showing that a comprehensive model may unravel complex and incoherent gastrointestinal symptoms in patients.

Barium-induced toxic anterior segment syndrome

Toxic anterior segment syndrome (TASS) is a rapid-onset inflammation of the eye following uneventful ocular surgery. We report a case of TASS following Baerveldt glaucoma implant (BGI) surgery. Inductively coupled plasma-mass spectrometry (ICP-MS) identified barium in the eye and in the eluate from the bleb of the BGI. We attribute TASS in our patient to the dissolution of barium from the BGI and its entry into the eye, where it causes severe inflammation.

ACR Appropriateness Criteria® Epigastric Pain

Epigastric pain can have multiple etiologies including myocardial infarction, pancreatitis, acute aortic syndromes, gastroesophageal reflux disease, esophagitis, peptic ulcer disease, gastritis, duodenal ulcer disease, gastric cancer, and hiatal hernia. This document focuses on the scenarios in which epigastric pain is accompanied by symptoms such as heartburn, regurgitation, dysphagia, nausea, vomiting, and hematemesis, which raise suspicion for gastroesophageal reflux disease, esophagitis, peptic ulcer disease, gastritis, duodenal ulcer disease, gastric cancer, or hiatal hernia. Although endoscopy may be the test of choice for diagnosing these entities, patients may present with nonspecific or overlapping symptoms, necessitating the use of imaging prior to or instead of endoscopy. The utility of fluoroscopic imaging, CT, MRI, and FDG-PET for these indications are discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Clinicopathological features and prognosis of developed gastric cancer based on the diagnosis of mucosal atrophy and enlarged folds of stomach by double-contrast upper gastrointestinal barium X-ray radiography

BACKGROUND

Mucosal atrophy and enlarged folds of stomach by double-contrast upper gastrointestinal barium X-ray radiography (UGI-XR) are two major features of Helicobacter pylori-induced chronic gastritis. These were previously shown to be risk indicators of gastric cancer, but their predictability for clinicopathological characters of developed gastric cancer is unelucidated. In addition, evidence for decreasing the mortality of gastric cancer by appropriate follow-up of UGI screening is needed.

METHODS

The 5134 generally healthy UGI-XR examinees, who underwent follow-up UGI-XR or upper gastrointestinal endoscopy (UGI-ES) more than once, were prospectively observed for 10 years.

RESULTS

At the beginning of follow-up, 1515 (29.5%) had mucosal atrophy and 990 (19.5%) had enlarged folds. For the serum anti-H. pylori IgG, 1301 (25.3%) were positive, 177 (3.4%) were possibly positive, and 3656 (71.2%) were negative. During the 10-year observation period, gastric cancer developed in 15 subjects, among which 13 had mucosal atrophy and 10 had enlarged folds. These two features were expectedly useful indicators for gastric cancer incidence, but they showed no significant association with tumor stage or histological type of developed cancer. Only one of the 5134 subjects died of gastric cancer during 10 years, which was significantly lower than the predicted number of gastric cancer death (6.78 for 10 years) according to the mortality rate in Japan.

CONCLUSIONS

Neither mucosal atrophy nor enlarged folds of stomach showed a significant association with clinicopathological features of developed gastric tumors. Appropriate follow-up of cancer screening by UGI-XR or UGI-ES can reduce the risk of gastric cancer-related death.

Intra-mural distribution of the blood vessels in the stomach demonstrated by contrast medium injection: a cadaver study

PURPOSE

With advances in diagnostic imaging techniques of gastric cancer screening with X-ray fluoroscopy, it has been suggested that mucosal projections induced by the vessels distributed in the submucosal layer of the stomach may be mistaken for abnormal mucosal folds. In this study, we aimed to describe the distribution of blood vessels in the submucosal layer of the stomach to improve the diagnostic accuracy of screening of gastric cancer.

METHODS

Twenty-four stomachs from Japanese cadavers were used in this study. Uncolored or colored contrast agents were injected into arteries and/or veins for macroscopic analyses, X-ray imaging, and methyl salicylate clearing. In addition, histological analysis was performed to examine blood vessels distributed inside the stomach wall.

RESULTS

Following contrast agent injection, thick blood vessels were distributed perpendicular to both curvature sides, and branches parallel to both curvature sides flowed from these thick blood vessels, and a vascular network was formed throughout the stomach wall. This vascular network had intra-mural anastomoses connecting both curvature sides. Moreover, in histological analyses, blood vessels depicted by injection were mainly distributed in the submucosal layer.

CONCLUSION

This study strongly suggests that the mucosal projections induced by arteries and veins in the submucosal layer could be mistaken for abnormal mucosal folds. Therefore, a better understanding of the vascular distribution in the submucosal layer is important to improve diagnostic accuracy from imaging studies of the stomach. The information provided by this research may facilitate better accuracy in diagnosis and reduce the number of unnecessary invasive procedures.

Post-lung transplantation abdominopelvic complications: the role of multimodal imaging

Lung transplantation (LT) is an established method for treating end-stage lung disease. Although most of the post-lung transplant imaging surveillance is focused on chronic lung allograft rejection, abdominopelvic complications have been reported in 7-62% of patients. The reported wide range of post-LT abdominopelvic complications is thought to be secondary to lack of current standardized definitions. These complications encompass a heterogeneous group of disorders including upper and lower gastrointestinal (GI) disorders, inflammatory conditions of solid organs, lymphoproliferative disorders, and neoplasms; each with varying pathophysiology, timing, severity, and treatment. Clinical manifestations of these complications may overlap or be masked by immunosuppression; therefore, imaging plays a paramount role in the early management and treatment.

Novel contrast media based on the liquid metal gallium for in vivo digestive tract radiography: a feasibility study

The barium sulfate has been playing an important role as the contrast medium in gastrointestinal radiography and disease diagnosis. However, its application has been gradually reduced due to the limitation of its imaging effect and the progress of other imaging techniques. Here, the liquid metal gallium was proposed as an improved contrast agent, which was applied in the in vivo digestive tract radiography of the mice for the first time. Under the CT scanning, the gallium produced excellent contrast effect intuitively. According to the records of discharge time, the tissue sections of organs, the survival state and body weight, the liquid metal was proven to be capable and safe for gastrointestinal radiography. Further, the mixture of the gallium and the barium sulfate has been tested, which showed better performance in both contrast and detail. Therefore, with the characteristics of better imaging contrast effect and acceptable safety, the gallium and its mixture with the barium sulfate might be useful as potential candidates for digestive tract contrast agent in animal experiments, even possibly as alternative contrast agents for clinical use.

Isolated IgG4-related gastric disease presenting as diffuse gastric wall thickening with ulcer

An 81-year-old male presented with loss of appetite, early satiety and iron deficiency anaemia. A computed tomography (CT) scan of the abdomen and pelvis during initial work-up revealed diffuse gastric mural thickening associated with a large ulcer and adjacent gastro-hepatic lymphadenopathy. The CT appearances, together with the clinical features, were highly suspicious for an infiltrative type of gastric malignancy. Endoscopic biopsy however showed erosive inflammation, IgG4 plasmacytosis and fibrosis, raising the possibility of IgG4-related disease. A serologic assay for IgG showed normal IgG4 and elevated IgG2 serum levels. After appropriate steroid treatment, endoscopy and CT scan showed resolution of the ulcer and gastric wall thickening. This case shows yet another possible appearance of gastric involvement in IgG4-related disease on the current evolving spectrum of this disease presentation. Greater awareness and education of this disease would help in patient care, ensuring earlier diagnosis, prevention of severe organ damage and morbidity, as well as unnecessary surgery.

Risk factors for atrophic gastritis in the Japanese young and middle-aged: a study using double-contrast upper gastrointestinal barium X-ray radiography

PURPOSE

To identify risk factors for atrophic gastritis in Japanese young and middle-age subjects by double-contrast upper gastrointestinal barium X-ray radiography (UGI-XR).

MATERIALS AND METHODS

We included 351 consecutive Japanese subjects (158 males, 193 females; age 25-49 years, mean 44 years) seen between October 2014 and March 2016. All underwent serum Helicobacter pylori (Hp) antibody- and UGI-XR examinations. Two radiologists independently recorded their UGI-XR findings of atrophic gastritis (AG). Interobserver agreement was assessed by calculating the kappa (κ) coefficient. Univariate and multivariate analyses were performed to investigate the association between AG and the subjects' gender, smoking habit, alcohol intake, body mass index, and Hp infection.

RESULTS

AG was diagnosed in 85 subjects (24%) on UGI-XR images; interobserver agreement was good (κ = 0.745). By univariate analysis, the male gender and a high serum Hp titer (IgG ≥ 10 U/ml) were significantly association with AG (p < 0.05). Multivariate analysis revealed that a high serum Hp titer was the only independent, significant factor (p < 0.05). The odds ratio for a high serum Hp titer was 128 (95% CI, 54.8-498.4).

CONCLUSION

Our UGI-XR study indicated that Hp infection was significantly associated with AG in Japanese young and middle-aged subjects.

Imaging Manifestations of Peptic Ulcer Disease on Computed Tomography

Although the overall prevalence of peptic ulcer disease (PUD) has decreased in modern times, its actual incidence may be underestimated owing to the nonspecific clinical presentations patients' manifest. The potential lethal complications that can result from PUD include life-threatening abdominal hemorrhage and bowel perforation that result in significant morbidity and mortality. Computed tomography (CT) imaging historically lacks specificity in detecting PUD-related pathology in the stomach and proximal small bowel segments. Therefore, these are potential pitfalls in the radiologist's search pattern on abdominopelvic CT imaging. This article highlights imaging features of uncomplicated PUD on CT imaging in order to allow for early detection of this disease process on imaging and the prevention of potential high-grade complications by recommending esophagogastroduodenoscopy.

Gastric polyps diagnosed by double-contrast upper gastrointestinal barium X-ray radiography mostly arise from the Helicobacter pylori-negative stomach with low risk of gastric cancer in Japan

BACKGROUND

Double-contrast upper gastrointestinal barium X-ray radiography (UGI-XR) is a method broadly used for gastric cancer screening in Japan. Gastric polyp is one of the most frequent findings detected by UGI-XR, but how to handle it remains controversial.

METHODS

Gastric polyps of the 17,264 generally healthy subjects in Japan who underwent UGI-XR or upper gastrointestinal endoscopy (UGI-ES) in 2010 were analyzed.

RESULTS

Of the 6,433 UGI-XR examinees (3,405 men and 3,028 women, 47.4 ± 9.0 years old), gastric polyps were detected in 464 men (13.6 %) and 733 women (24.2 %) and were predominantly developed on the non-atrophic gastric mucosa (p < 0.0001). Multiple logistic regression analysis showed that the presence of gastric polyps has significant association with lower value of serum anti-Helicobacter pylori IgG titer, female gender, lighter smoking habit, older age, and normal range of body mass index (≥18.5 and <25), but not with drinking or serum pepsinogen I/II ratio. During the 3-year follow-up, gastric cancer occurred in 7 subjects (0.11 %), but none of them had gastric polyps at the beginning of the follow-up period. Of the 2,722 subjects with gastric polyps among the 10,831 UGI-ES examinees in the same period, 2,446 (89.9 %) had fundic, 267 (9.8 %) had hyperplastic, and 9 (0.3 %) had adenomatous/cancerous polyps.

CONCLUSIONS

Gastric polyps diagnosed by UGI-XR predominantly arise on the Helicobacter pylori-negative gastric mucosa with a low risk of gastric cancer in Japan. In the prospective observation, none of the UGI-XR examinees with gastric polyps developed gastric cancer for at least 3 years subsequently.

Computed tomography features of gastrointestinal linitis plastica: spectrum of findings in early and delayed phase imaging

PURPOSE

To analyze the features of gastrointestinal linitis plastica obtained by computed tomography (CT).

MATERIALS AND METHODS

We conducted a single-center, retrospective analysis of 45 cases of gastrointestinal tract linitis plastica collected over a 10-year period. "Linitis plastica" was defined based on histological characteristics. Primary and secondary linitis plastica were included. Two readers independently assessed the radiological findings (i.e., number of lesions, mass, wall thickening, and enhancement).

RESULTS

The patient cohort comprised 23 men and 22 women with an average age of 63.2 years. The main presenting signs and symptoms were impaired general health and ascites (22/45 patients, 48.8%). The stomach was the affected organ in 68.3% of the cases, while the rectum was affected in 11.7% of the cases. Primary linitis was found in 73.3% of the cases, and solitary lesions were found in 77.8% of the cases. The most common CT finding was wall thickening (91.7%) with a complete disappearance of folds and enhancement of the entire wall at 2 min. Four lesions (6.6%) were described as masses, and only one (1.7%) was described as a wall atrophy.

CONCLUSION

Linitis plastica can affect the entire digestive system. Its potentially secondary nature necessitates a systematic search for a primary tumor. An appropriate CT protocol is required to detect the specific radiological features of this fibrous cancer. CT can help confirm the diagnosis of linitis plastica, rule out differential diagnoses, and indicate the need for deep biopsies where possible.

Atrophic gastritis and enlarged gastric folds diagnosed by double-contrast upper gastrointestinal barium X-ray radiography are useful to predict future gastric cancer development based on the 3-year prospective observation

BACKGROUND

Double-contrast upper gastrointestinal barium X-ray radiography (UGI-XR) is the standard gastric cancer screening method in Japan. Atrophic gastritis and enlarged gastric folds are considered the two major features of Helicobacter pylori-induced chronic gastritis, but the clinical meaning of evaluating them by UGI-XR has not been elucidated.

METHODS

We analyzed healthy UGI-XR examinees without a history of gastrectomy, previous Helicobacter pylori eradication and usage of gastric acid suppressants.

RESULTS AND CONCLUSIONS

Of the 6433 subjects, 1936 (30.1 %) had atrophic gastritis and 1253 (19.5 %) had enlarged gastric folds. During the 3-year prospective observational follow-up, gastric cancer developed in seven subjects, six of whom (85.7 %) had atrophic gastritis with H. pylori infection and five of whom (71.4 %) had enlarged gastric folds with H. pylori infection. The Kaplan-Meier method with log-rank testing revealed that both UGI-XR-based atrophic gastritis (p = 0.0011) and enlarged gastric folds (p = 0.0003) are significant predictors for future gastric cancer incidence.

Comparative analysis of upper gastrointestinal endoscopy, double-contrast upper gastrointestinal barium X-ray radiography, and the titer of serum anti-Helicobacter pylori IgG focusing on the diagnosis of atrophic gastritis

BACKGROUND

Upper gastrointestinal endoscopy (UGI-ES) and double-contrast upper gastrointestinal barium X-ray radiography (UGI-XR) are two major image-based methods to diagnose atrophic gastritis, which is mostly induced by Helicobacter pylori infection. However, there have been few studies directly comparing them.

METHODS

Atrophic gastritis was evaluated using the data of 962 healthy subjects who underwent UGI-ES and UGI-XR within 1 year.

RESULTS AND CONCLUSION

Based on UGI-ES and UGI-XR, 602 subjects did not have atrophic gastritis and 254 subjects did have it. Considering UGI-ES-based atrophic gastritis as the standard, sensitivity and specificity of UGI-XR-based atrophic gastritis were 92.0 % (254/276) and 92.8 % (602/649), respectively. The seven-grade Kimura-Takemoto classification of UGI-ES-based atrophic gastritis showed a strong and significant association with the four-grade UGI-XR-based atrophic gastritis. Sensitivity and specificity of serum anti-Helicobacter pylori IgG to detect UGI-ES/UGI-XR-based atrophic gastritis were 89.4 % (227/254) and 99.8 % (601/602), indicating that atrophic gastritis can be overlooked according to serum anti-Helicobacter pylori IgG alone.

Clinicopathological features of primary gastric neuroendocrine neoplasms: A single-center analysis

OBJECTIVE

To assess the clinical characteristics, diagnosis and therapeutic modalities for gastric neuroendocrine neoplasms (GNENs) among the Chinese population in a single institution.

METHODS

A total of 57 patients with histologically confirmed GNENs, who were diagnosed between 1995 and 2015 at the Peking Union Medical College Hospital were retrospectively reviewed. The clinical, imaging and histopathologic characteristics as well as the treatments of GNENs were collected and analyzed.

RESULTS

Patients with GNENs mostly presented with non-specific symptoms. Gastric body was the most common site of involvement. The choice of imaging modality, such as endoscopy and computed tomography depended on the tumor subtype. Chromogranin A (CgA) and synaptophysin were indispensable immunohistochemical markers for diagnosis. Significant inter-group differences in the positivity rate of CD56 were observed among the three grades (G1, G2 and G3). Therapeutic modalities included endoscopic intervention, surgical resection and pharmacotherapy, which were largely guided by the tumor subtype and the presence or absence of distant metastasis or tumor recurrence.

CONCLUSIONS

Routine endoscopic examination is recommended for the early diagnosis of GNENs. Histopathological examination can make the definite diagnosis of GNENs and clarify the nature of gastric polyps. A multidisciplinary approach is important in the management of patients with GNENs.

Associated factors of atrophic gastritis diagnosed by double-contrast upper gastrointestinal barium X-ray radiography: a cross-sectional study analyzing 6,901 healthy subjects in Japan

Background

Double-contrast upper gastrointestinal barium X-ray radiography (UGI-XR) is one of the most widely conducted gastric cancer screening methods. It has been executed to find gastric cancer, but has not been usually executed to detect premalignant atrophic mucosa of stomach. To understand the meaning of UGI-XR-based atrophic gastritis, we analyzed its association with several causative factors including Helicobacter pylori (HP) infection.

Methods

We evaluated 6,901 healthy adults in Japan. UGI-XR-based atrophic gastritis was diagnosed based on the irregular shape of areae gastricae and its expansion in the stomach.

Results

Of the 6,433 subjects with no history of HP eradication and free from gastric acid suppressants, 1,936 were diagnosed as UGI-XR-based atrophic gastritis (mild: 234, moderate: 822, severe: 880). These were univariately associated with serum HP IgG and serum pepsinogen I/II ratio with statistical significance. The multiple logistic analysis calculating standardized coefficients (β) and odds ratio (OR) demonstrated that serum HP IgG (β = 1.499, OR = 4.48), current smoking (β = 0.526, OR = 1.69), age (β = 0.401, OR = 1.49), low serum pepsinogen I/II ratio (β = 0.339, OR = 1.40), and male gender (β = 0.306, OR = 1.36) showed significant positive association with UGI-XR-based atrophic gastritis whereas drinking and body mass index did not. Among the age/sex/smoking/drinking-matched 227 pairs derived from chronically HP-infected and successfully HP-eradicated subjects, UGI-XR-based atrophic gastritis was detected in 99.1% of the former but in only 59.5% of the latter subjects (p<0.0001). Contrastively, UGI-XR-based atrophic gastritis was detected in 13 of 14 HP-positive proton pump inhibitor users (92.9%) and 33 of 34 HP-positive histamine H₂-receptor antagonist users (97.1%), which are not significantly different from gastric acid suppressant-free subjects.

Conclusions

The presence of UGI-XR-based atrophic gastritis is positively associated with Helicobacter pylori infection, current smoking, age, decreased serum pepsinogen I/II ratio, and male gender. Eradication of Helicobacter pylori seems to superficially improve UGI-XR-based atrophic gastritis whereas intake of gastric acid suppressants does not.

Multimodality imaging evaluation of an uncommon entity: esophageal heterotopic pancreas

A 25-year-old male was referred to the Radiology Department with new onset of right upper quadrant and epigastric abdominal pain. He had no past medical or surgical history. Physical exam was unremarkable. The patient underwent computed tomography (CT), fluoroscopic upper gastrointestinal (GI) evaluation, endoscopic ultrasound (EUS), and positron emission tomography (PET) evaluation, revealing the presence of a heterogeneous esophageal mass. In light of imaging findings and clinical workup, the patient was ultimately referred for thorascopic surgery. Surgical findings and histology confirmed the diagnosis of esophageal heterotopic pancreas.