presentation of this article abstract: Rakita D, McElligott SE,
Primakov D, Sideridis K, Davidoff S, Friedman B. Gastric Pathology Found
during Routine Abdominopelvic CT Imaging with Confirmatory Endoscopic
Correlation. Radiological Society of North America(RSNA) Annual Meeting
2006. Educational Exhibit.
Dr. Rakita and Dr. Yacobozzi are at Baystate Medical Center, Springfield, MA; Dr. Hines, Dr. Friedman, and Dr. Sideridis are at Long Island Jewish Medical Center, New Hyde Park, NY; and Dr. Davidoff is at Gastroenterology & Nutrition, PC, Forest Hills, NY.
experiencing upper gastrointestinal discomfort are routinely referred
for abdomino-pelvic computed tomography (CT) imaging.Although dedicated
gastric CT imaging utilizing gastric distention is very effective,1
routine examinations usually are not tailored for evaluation of the
stomach. Nevertheless, this modality can diagnose a large spectrum of
gastric pathology, including inflammatory, neoplastic, and structural
abnormalities. Most patients with gastric pathology are then referred
for upper endoscopy, which is used for additional characterization,
histologic confirmation, and sometimes therapy.
our institution, routine abdomino-pelvic CT scanning in the portal
venous phase is performed following administration of positive oral and
intravenous contrast. Most patients do not receive effervescent granules
for stomach distention. Scanning takes place on a 16- or64-channel
helical scanner at 5-mm collimation. Coronal reformatted images are
prevalence of gastric cancer peaks between 50 and 70 years of age. Risk
factors include familial adenomatous polyposis, chronic atrophic
gastritis, pernicious anemia, history of partial gastrectomy (after
15-20 years), and Ménétrier disease.2 Most gastric cancers
are adenocarcinomas of mucous cell origin. Signet-ring cell carcinomas
account for up to 15% of all gastric cancers and typically cause
scirrhous infiltration of the gastric wall (linitis plastica).1
CT appearance of gastric adenocarcinoma depends on the stage of the
lesion. Early cancers appear as focal enhancing mucosal thickening or as
polypoid lesions (Figure 1). Advanced cancers demonstrate various
degrees of gastric wall thickening and ulceration as well as extension
into perigastric fat and adjacent organs (Figure 2).1
gastric lymphoma is confined to the stomach and regional lymph nodes.
These are predominantly non-Hodgkin’s lymphomas of B-cell origin and are
more frequently found in the antrum.1,3 Secondary gastric
involvement by advanced diffuse lymphoma is also common. It is found in
10% of patients with non-Hodgkin’s lymphomas at diagnosis, and in up to
60% of those with advanced non-Hodgkin’s lymphomas.1,3 The
imaging appearances of gastric lymphoma includes focal or diffuse wall
thickening, occasionally ulcerated polypoid lesions, and the submucosal
nodular form (Figure 3).1,3
stromal tumors (GIST) represent a unique group of mesenchymal neoplasms
that are distinct from true smooth muscle and neural tumors. GIST is
the most common mesenchymal neoplasm of the gastrointestinal tract and
is most frequently found in the stomach, representing 2% of all gastric
tumors.4 The defining feature of these tumors is the
expression of c-KIT (CD117), a tyrosine kinase growth factor receptor.
The immunoreactivity for c-KIT distinguishes GISTs from true leiomyomas,
leiomyosarcomas, schwannomas, and neurofibromas. Additionally, it is
important in targeted treatment of GIST by Gleevec.4
GIST tumors, 10% to 30% are malignant. The risk of malignancy is
increased in tumors that are located outside the stomach, are greater
than 5 cm in diameter, and demonstrate extension into adjacent organs. A
characteristic CT imaging feature of gastric GISTis intraluminal and
extraluminal ex-tension (Figures 4, 5).4 Endoscopy in GIST patients with a small intraluminal component can be under-whelming (Figure 5).
lipomas are typically found in patients in their fifth or sixth decade
of life and 90% are submucosal in location. Hemorrhage, abdominal pain,
obstruction, and dyspepsia represent the most common symptoms associated
with gastric lipomas, although most by far are asymptomatic and
discovered incidentally.5 Lipomas closest to the pylorus can
cause obstructive symptoms, frequently by obstructing the pylorus or
prolapsing into the duodenum.5 Their CT appearance is that of a submucosal homogeneous mass of fatty attenuation (Figure 6).5
is a term covering a broad spectrum of entities that induce
inflammatory changes in the gastric mucosa. The common mechanism of
injury is an imbalance between the aggressive and the defensive factors
that maintain the integrity of the gastric mucosa. Acute gastritis can
be broken down into 2 categories: erosive (caused by NSAIDs, alcohol,
radiation, ischemia, stress) and nonerosive (generally caused by Helicobacter pylori). H. pylori
infection is also the most common cause of chronic, nonerosive
gastritis. Colonization of the mucosa by the bacterium leads to chronic
inflammation and loss of gastric glands responsible for the production
of acid, leading to an atrophic gastritis.6
common CT imaging findings of acute gastritis is nonspecific gastric
wall thickening. Vivid enhancement of the gastric rugae is commonly
noted (Figure 7). Shallow ulcerations and linear erosions of erosive
gastritis as well as mucosal nodularity have been on barium radiography
and are difficult to visualize on CT.6
ulcers are mucosal breaks of 3 mm or larger. They are common, occurring
in about 10% of adults in western countries. Gastric ulcers account for
about 1/3 of peptic ulcers, and duodenal ulcers account for the rest. H. pylori infection
and nonsteroidal anti-inflammatory drugs (NSAIDs) are the 2 main
factors in the pathogenesis of peptic ulcers. Other factors include
steroids, aspirin, smoking, alcohol or coffee consumption, stress,
delayed gastric emptying, and duodenogastric bile reflux.7
a routine CT, gastric ulcers are usually not visualized unless they are
penetrating or perforated. The ulcers can appear as mucosal defects and
luminal outpouchings, with varying degrees of surrounding wall
inflammation. Differentiating between benign and malignant ulcers on CT
imaging is not always easy; however, benign ulcers more commonly appear
as mucosal defects with smooth, flat borders (Figure8), and malignant
ulcers as elevated ulcerated masses (Figure 9),1,7 although there is imaging overlap.
Hyperplastic gastric polyposis
polyps are the most common benign epithelial tumor in the stomach,
constituting as many as 80% to 90% of all gastric polyps. They are
non-neoplastic proliferations of surface epithelium, presumably
resulting from excessive regenerative hyperplasia in areas of chronic
inflammation. Histologically, these lesions consist of hyperplastic
foveolar cells that form elongated, cystically dilated glandular
structures. Unlike adenomatous polyps, which consist of dysplastic cells
that may degenerate to form invasive adenocarcinoma, hyperplastic
polyps are composed of nondysplastic cells with virtually no malignant
Hyperplastic polyposis in the stomach is a
frequent finding in familial polyposis and Gardner’s syndrome. Long
term use of proton pump inhibitors has also been associated with
development of hyperplastic and fundic gland type polyps.8 These polyps are asymptomatic and do not need any treatment.8 (Figure 10).
varices, as well as esophageal varices, are typically induced by portal
hypertension, which is commonly a consequence of cirrhosis.
varices can also be seen in cases of isolated splenic vein thrombosis.
Gastric varices are classified according to their distribution and
whether associated esophageal varices are present. Most gastric varices
appear as a continuation of esophageal varices and extend 2 to 5 cm
below the gastroesophageal junction, along the lesser curvature of the
Submucosal, intramural, and perigastric
serpentine vascular structures are well demonstrated on CT (Figure 11),
best performed in the portal venous phase. Occasionally gastric varices
appear as polypoid masses on endoscopy (Figure 12), leading to biopsy.
volvulus is defined as an abnormal rotation of the stomach of more than
180°, creating a closed loop obstruction that can result in
incarceration and strangulation. There are 2 forms of gastric volvulus,
organoaxial and mesentericoaxial.10 Organoaxial volvulus is
the more common and is usually associated with diaphragmatic defects.
The stomach rotates around the axis, which connects the gastroesophageal
junction and the pylorus, with the greater curvature rotating from an
inferior to a superior position. Strangulation and necrosis are
common,reported in 5% to 28% of cases.10 (Figures 13 and 14).
less common form is the mesentericoaxial volvulus. The antrum rotates
anteriorly and superiorly, with the axis of rotation bisecting both the
lesser and greater curvatures. Rotation is usually incomplete and occurs
intermittently; vascular compromise is uncommon. This type occurs more
commonly in young children, is associated with ligamentous laxity, and
is not associated with diaphragmatic defects.10
experiencing upper gastrointestinal discomfort are routinely referred
for abdomino-pelvic CT imaging and endoscopy, which are complimentary in
evaluation of gastric pathology. Although dedicated CT imaging of a
distended stomach is very effective, routine abdomino-pelvic CT imaging
can diagnose a wide range of gastric pathology, including neoplastic,
inflammatory, and structural abnormalities. Correlative endoscopic
images were provided for most cases.
- Ba-Salamah A, Prokop M, Uffmann M, et al. Dedicated multidetector CT of the stomach: Spectrum of diseases. Radiographics. 2003;23:625-644.
- Oiso T. Incidence of stomach cancer and its relation to dietary habits and nutrition in Japan between 1900 and 1975. Cancer Res. 1975;35:3254-3258.
D, Lim HK, Lee SJ, et al. Gastric mucosa-associated lymphoid tissue
lymphoma: Helical CT findings and pathologic correlation. AJR Am J Roentgenol. 2002;178:1117-1122.
AD, Remotti H, Thompson W, et al. From the archives of the AFIP:
Gastrointestinal stromal tumors: Radiologic features with pathologic
correlation. Radiographics. 2003;23:283-304.
- Thomson WM, Kende AI, Levy AD. Imaging characteristics of gastric lipomas in 16 adult and pediatric patients. AJR Am J Roentgenol. 2003;181:981-85.
- Gelfand DW, Ott DJ, Chen MY. Radiologic evaluation of gastritis and duodenitis. AJR Am J Roentgenol. 1999;173(2): 357-361.
- Levine MS. Peptic ulcers. In: Gore RM, Levine MS, eds. Textbook of Gastrointestinal Radiology. 2nd ed. Philadelphia: WB Saunders, 2000:514-545.
U, Boyce HW, Coppola D. Proton pump inhibitor-associated gastric
polyps: A retrospective analysis of their frequency, and endoscopic,
histologic, and ultrastructural characteristics. Am J Clin Pathol. 1998;110(5):615-621.
- Afessa B, Kubilis P. Upper gastrointestinal bleeding in patients with cirrhosis: Clinical course and mortality prediction. Am J Gastroenterol. 2000;95:484-489.
- Milne LW, Hunter JJ, Anshus JS, Rosen P. Gastric volvulus: Two cases and a review of the literature. J Emerg Med. 1994; 12:299-306.