X-ray signs of diseases of the stomach and duodenum

Indications for X-ray examination of the stomach are very broad due to the high prevalence of "stomach" complaints (dyspeptic symptoms, abdominal pain, loss of appetite, etc.). X-ray examination is performed if there is a suspicion of peptic ulcer, tumor, in patients with achylia and anemia, as well as with gastric polyps that for some reason have not been removed.

Chronic gastritis

In recognizing gastritis, the main role is given to clinical examination of the patient in combination with endoscopy and gastrobiopsy. Only by histological examination of a piece of gastric mucosa can the form and prevalence of the process and the depth of the lesion be determined. At the same time, in case of atrophic gastritis, X-ray examination is equivalent in efficiency and reliability to fibrogastroscopy and is second only to biopsy microscopy.

X-ray diagnostics is based on a set of X-ray signs and their comparison with a complex of clinical and laboratory data. A combined assessment of the thin and folded relief and function of the stomach is mandatory.

Of primary importance is the determination of the condition of the areolae. Normally, a fine-mesh (granular) type of fine relief is observed. The areolae have a regular, predominantly oval shape, are clearly defined, and are limited by shallow narrow grooves; their diameter varies from 1 to 3 mm. Nodular and especially coarse-nodular types of fine relief are characteristic of chronic gastritis. In the nodular type, the areolae are irregularly rounded, 3-5 mm in size, and are limited by narrow but deep grooves. The coarse-nodular type is characterized by large (over 5 mm) areolae of irregular polygonal shape. The grooves between them are widened and not always sharply differentiated.

Changes in the folded relief are much less specific. In patients with chronic gastritis, folds are compacted. Their shape changes slightly upon palpation. The folds are straightened or, conversely, strongly twisted, small erosions and polyp-like formations may be detected on their ridges. Functional disorders are recorded at the same time. During an exacerbation of the disease, the stomach contains liquid on an empty stomach, its tone is increased, peristalsis is deepened, and spasm of the antral section may be observed. During remission, the tone of the stomach is decreased, peristalsis is weakened.

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ], [ 6 ], [ 7 ], [ 8 ], [ 9 ], [ 10 ]

Peptic ulcer of the stomach and duodenum

Radiography plays an important role in recognizing the ulcer and its complications.

When performing an X-ray examination of patients with gastric ulcer and duodenal ulcer, the radiologist faces three main tasks. The first is to assess the morphological state of the stomach and duodenum, primarily to detect the ulcer defect and determine its position, shape, size, outline, and the state of the surrounding mucous membrane. The second task is to examine the function of the stomach and duodenum: to detect indirect signs of ulcer disease, to establish the stage of the disease (exacerbation, remission), and to assess the effectiveness of conservative therapy. The third task is to recognize complications of ulcer disease.

Morphological changes in peptic ulcer disease are caused by both the ulcer itself and the accompanying gastroduodenitis. The signs of gastritis are described above. A niche is considered a direct symptom of an ulcer. This term refers to the shadow of a contrasting mass that has filled the ulcer crater. The ulcer silhouette can be seen in profile (such a niche is called a contour niche) or full face against the background of folds of the mucous membrane (in these cases, they speak of a niche on the relief, or a relief niche). A contour niche is a semicircular or pointed protrusion on the contour of the shadow of the stomach or duodenal bulb. The size of the niche generally reflects the size of the ulcer. Small niches are indistinguishable by fluoroscopy. To detect them, targeted radiographs of the stomach and bulb are necessary.

With double contrasting of the stomach, it is possible to recognize small superficial ulcerations - erosions. They are most often localized in the antral and prepyloric sections of the stomach and have the appearance of round or oval enlightenments with a point central accumulation of contrast mass.

The ulcer may be small - up to 0.3 cm in diameter, medium-sized - up to 2 cm, large - 2-4 cm and giant - more than 4 cm. The shape of the niche can be round, oval, slit-like, linear, pointed, irregular. The contours of small ulcers are usually smooth and clear. The outlines of large ulcers become uneven due to the development of granulation tissue, mucus accumulations, blood clots. At the base of the niche, small notches are visible, corresponding to edema and infiltration of the mucous membrane at the edges of the ulcer.

A relief niche has the appearance of a persistent round or oval accumulation of contrast mass on the inner surface of the stomach or bulb. This accumulation is surrounded by a light structureless rim - a zone of mucosal edema. In chronic ulcers, the relief niche may be irregular in shape with uneven outlines. Sometimes convergence of the folds of the mucosa to the ulcer defect is noted.

As a result of ulcer scarring at the niche level, a straightening and some shortening of the stomach or bulb contour is revealed. Sometimes the rubi process reaches a significant degree, and then gross deformations of the corresponding part of the stomach or bulb are determined, which sometimes takes a bizarre shape. Ulcer scarring in the pyloric canal or at the base of the bulb can lead to pyloric stenosis or duodenal stenosis. Due to the disruption of the evacuation of the contents, the stomach is stretched. Contrast is detected in it on an empty stomach).

There are a number of indirect radiographic symptoms of peptic ulcer disease. Each of them separately does not provide grounds for establishing a diagnosis of ulcer, but in combination their significance is almost equal to the identification of a direct symptom - a niche. In addition, the presence of indirect signs makes the radiologist look for an ulcer defect with special attention, performing a series of targeted radiographs. A sign of impaired secretory function of the stomach is the presence of fluid in it on an empty stomach. This symptom is most indicative of an ulcer of the duodenal bulb. In an upright position of the body, the fluid forms a horizontal level against the background of a gas bubble in the stomach. An important indirect symptom is regional spasm. In the stomach and bulb, it usually occurs at the level of the ulcer, but on the opposite side. There, a retraction of the contour with smooth outlines is formed. In the stomach, it resembles the end of a finger in shape, hence the name of this sign - "the symptom of the pointing finger". With an ulcer of the bulb during an exacerbation, as a rule, a spasm of the pylorus is observed. Finally, with ulcers, a symptom of local hyperkinesia is observed, expressed in the accelerated movement of the contrast agent in the ulcer zone. This symptom is explained by increased irritability and motor activity of the wall in the ulceration area. Another indirect sign is associated with it - a symptom of point pain and local tension of the abdominal wall during palpation of the area corresponding to the location of the ulcer.

During the acute stage of peptic ulcer disease, an increase in the niche and expansion of the inflammatory shaft surrounding it are observed. During the remission period, a decrease in the niche is observed up to its disappearance (after 2-6 weeks), the functions of the stomach and duodenum are normalized. It is important to emphasize that the disappearance of the niche does not mean a cure if the symptoms of dysfunction persist. Only the elimination of functional disorders guarantees a cure or at least a long-term remission.

In peptic ulcer disease and chronic gastritis, duodenogastric reflux is often observed. To detect it, the patient undergoes dynamic scintigraphy. For this purpose, he is given intravenous administration of the radiopharmaceutical 99mTc-butyl-IDA or a related compound with an activity of 100 MBq. After obtaining an image of the gallbladder on scintigrams (these drugs are excreted with bile), the patient is given a fatty breakfast (for example, 50 g of butter). On subsequent scintigrams, it is possible to observe the emptying of the bladder from radioactive bile. In case of pyloric insufficiency, it appears in the stomach cavity, and in case of gastroesophageal reflux - even in the esophagus.

A gastric diverticulum, a peculiar developmental anomaly in the form of a saccular protrusion of the wall of the digestive tract, may vaguely resemble an ulcer niche. In 3/4 of cases, a gastric diverticulum is located on the posterior wall near the esophagogastric junction, i.e. near the cardiac opening. Unlike an ulcer, a diverticulum has a regular rounded shape, smooth arcuate contours, and often a well-formed neck. The folds of the mucous membrane around it are not changed, some of them enter the diverticulum through the neck. Diverticula are especially common in the descending and lower horizontal parts of the duodenum. Their radiographic signs are the same, only with the development of diverticulitis, the contours of the protrusion become uneven, the mucous membrane around it is edematous, and palpation is painful.

Radiation methods play an important role in diagnosing complications of peptic ulcer disease. This primarily concerns perforation of gastric or duodenal ulcers. The main sign of perforation is the presence of free gas in the abdominal cavity. The patient is examined in the position in which he was brought to the X-ray room. The gas that has penetrated into the abdominal cavity through the perforation occupies the highest sections. When the body is in an upright position, the gas accumulates under the diaphragm, when lying on the left side - in the right lateral canal, when lying on the back - under the anterior abdominal wall. On X-rays, the gas causes a clearly visible enlightenment. When the body position changes, it moves in the abdominal cavity, which is why it is called free. Gas can also be detected by ultrasound examination.

Two signs indicate ulcer penetration into surrounding tissues and organs: large niche size and its fixation. Penetrating ulcers often contain three-layered contents: gas, liquid, and contrast agent.

If acute ulcer bleeding is suspected, emergency endoscopy is usually used. However, valuable data can be obtained from X-ray examination, which is advisable if fibrogastroduodenoscopy is impossible or not indicated. After bleeding has stopped or even during the period of ongoing bleeding, X-ray and X-ray of the stomach and duodenum with barium sulfate can be performed, but with the patient in a horizontal position and without compression of the anterior abdominal wall.

As a result of the pyloric ulcer scarring, stenosis of the outlet of the stomach may develop. The degree of its severity (compensated, subcompensated or decompensated) is determined by X-ray data.

Stomach cancer

Initially, the tumor is an island of cancerous tissue in the mucous membrane, but later on various paths of tumor growth are possible, which predetermine the radiographic signs of small cancer. If necrosis and ulceration of the tumor predominate, then its central part sinks in comparison with the surrounding mucous membrane - the so-called deepened cancer. In this case, double contrasting reveals a niche of irregular shape with uneven contours, around which there are no areolas. The folds of the mucous membrane converge to the ulceration, slightly expanding in front of the niche and losing their outlines here.

With another type of growth, the tumor spreads mainly to the sides along the mucous membrane and into the submucous layer - superficial, or flat-infiltrating, cancer, growing endophytically. It causes an area of altered relief in which areolae are absent, but at the same time, unlike deep cancer, there is no ulceration and no convergence of the folds of the mucous membrane to the center of the tumor is noted. Instead, there are randomly located thickenings with lumps of contrast mass unevenly scattered over them. The contour of the stomach becomes uneven, straightened. Peristalsis in the area of the infiltrate is absent.

In most cases, the tumor grows as a node or plaque, gradually protruding further into the stomach cavity - "elevated" (exophytic) cancer. At the initial stage, the X-ray picture differs little from that of an endophytic tumor, but then a noticeable uneven deepening of the contour of the stomach shadow appears, not participating in peristalsis. Then a marginal or central filling defect is formed, corresponding in shape to the tumor protruding into the lumen of the organ. In plaque-like cancer, it remains flat, in polypous (mushroom-like) cancer it has an irregular round shape with wavy outlines.

It should be emphasized that in most cases, it is impossible to differentiate early cancer from peptic ulcer and polyp using radiological methods, which is why endoscopic examination is required. However, radiological examination is very important as a method for selecting patients for endoscopy.

With further development of the tumor, various radiographic images are possible, which, perhaps, never copy each other. However, it is possible to conditionally distinguish several forms of such "developed cancer". A large exophytic tumor produces a large filling defect in the shadow of the stomach filled with a contrast mass. The contours of the defect are uneven, but are quite clearly delimited from the surrounding mucous membrane, the folds of which in the area of the defect are destroyed, peristalsis is not observed.

Infiltrative-ulcerative cancer appears in a different "guise". It is not so much a filling defect that is expressed, but rather destruction and infiltration of the mucous membrane. Instead of normal folds, the so-called malignant relief is determined: shapeless accumulations of barium between cushion-shaped and structureless areas. Of course, the contours of the stomach shadow in the affected area are uneven, and peristalsis is absent.

A fairly typical radiographic picture of saucer-shaped (cup-shaped) cancer, i.e. a tumor with raised edges and a disintegrating central part. Radiographs show a round or oval filling defect, in the center of which a large niche stands out - an accumulation of barium in the form of a spot with uneven outlines. A feature of saucer-shaped cancer is the relatively clear demarcation of the tumor edges from the surrounding mucous membrane.

Diffuse fibroplastic cancer leads to narrowing of the lumen of the stomach. In the affected area, it turns into a narrow rigid tube with uneven contours. When the stomach is inflated with air, the deformed section does not straighten out. At the border of the narrowed part with the unaffected sections, small ledges can be seen on the contours of the shadow of the stomach. The folds of the mucous membrane in the tumor area thicken, become immobile, and then disappear.

A stomach tumor can also be detected by computed tomography and ultrasound. Sonograms highlight areas of thickening of the stomach wall, which allows to specify the volume of tumor damage. In addition, sonograms can determine the spread of infiltrate into surrounding tissues and detect tumor metastases in the lymph nodes of the abdominal cavity and retroperitoneal space, liver and other abdominal organs. Ultrasound signs of a stomach tumor and its invasion into the stomach wall are especially clearly determined by endoscopic sonography of the stomach. CT also visualizes the stomach wall well, which allows to detect its thickening and the presence of a tumor in it. However, the earliest forms of stomach cancer are difficult to detect both by sonography and CT. In these cases, gastroscopy plays a leading role, supplemented by targeted multiple biopsy.

[ 11 ], [ 12 ], [ 13 ]

Benign tumors of the stomach

The radiographic picture depends on the type of tumor, its stage of development and growth pattern. Benign tumors of epithelial nature (papillomas, adenomas, villous polyps) originate from the mucous membrane and protrude into the lumen of the stomach. At first, an unstructured rounded area is found among the areolas, which can only be seen with double contrast of the stomach. Then, a local expansion of one of the folds is determined. It gradually increases, taking the form of a round or slightly elongated defect. The folds of the mucous membrane bypass this defect and are not infiltrated.

The contours of the defect are smooth, sometimes wavy. The contrast mass is retained in small depressions on the surface of the tumor, creating a delicate cellular pattern. Peristalsis is not disturbed unless malignant degeneration of the polyp has occurred.

Non-epithelial benign tumors (leiomyomas, fibromas, neurinomas, etc.) look completely different. They develop mainly in the submucosal or muscular layer and do not protrude much into the stomach cavity. The mucous membrane above the tumor is stretched, as a result of which the folds are flattened or moved apart. Peristalsis is usually preserved. The tumor can also cause a round or oval defect with smooth contours.

[ 14 ], [ 15 ]

Postoperative gastric diseases

X-ray examination is necessary for timely detection of early postoperative complications - pneumonia, pleurisy, atelectasis, abscesses in the abdominal cavity, including subdiaphragmatic abscesses. Gas-containing abscesses are relatively easy to recognize: images and transillumination can reveal a cavity containing gas and liquid. If there is no gas, then a subdiaphragmatic abscess can be suspected by a number of indirect signs. It causes a high position and immobilization of the corresponding half of the diaphragm, its thickening, unevenness of outlines. "Sympathetic" effusion in the costophrenic sinus and foci of infiltration at the base of the lung appear. Sonography and computed tomography are successfully used in the diagnosis of subdiaphragmatic abscesses, since accumulations of pus are clearly outlined in these studies. An inflammatory infiltrate in the abdominal cavity produces an echo-heterogeneous image: there are no areas free of echo signals. An abscess is characterized by the presence of a zone devoid of such signals, but a denser rim appears around it - a display of the infiltrative shaft and pyogenic membrane.

Among the late postoperative complications, two syndromes should be mentioned: afferent loop syndrome and dumping syndrome. The first of them is radiologically manifested by the entry of a contrast mass from the gastric stump through anastomosis into the afferent loop. The latter is dilated, the mucous membrane in it is edematous, and its palpation is painful. A long-term retention of barium in the afferent loop is especially indicative. Dumping syndrome is characterized by a significant acceleration of emptying of the gastric stump and rapid spread of barium along the loops of the small intestine.

A peptic ulcer of the anastomosis may develop 1-2 years after surgery on the stomach. It causes the radiographic symptom of a niche, and the ulcer is usually large and surrounded by an inflammatory ridge. Its palpation is painful. Due to the accompanying spasm, a disorder of the anastomosis functions is observed with retention of the contents in the gastric stump.