Rarely Performed

Fasting for atleast 6 hours prior to examination

Stomach distended with gas producing agent

Intravenous injection of short acting smooth muscle relaxant is often given

Patient drinks about 200ml of barium

The duodenal cap or bulb arises just below the short pyloric canal and duodenal forms a loop around head of pancreas to reach duodenojejunal flexure

Normal Barium Meal

Normal stomach and duodenum on double-contrast barium meal. On this supine view, barium collects in the fundus of the stomach. The body and the antrum of the stomach together with the duodenal cap and loop are coated with barium and distended with gas. Note how the fourth part of the duodenum and duodenojejunal flexure are superimposed on the body of the stomach

Diverticula arising beyond the first part of duodenum are a common finding and are usually without clinical significance

Contrast radiography (barium or Gastrografin meal) is used for

• Failed gastroscopy.
• Assessment of duodenal strictures which cannot be characterized. or navigated on endoscopy.
• Assessment of functional patency/gastric emptying following.

gastroenterostomy or anti-obesity surgery

• To confirm or rule out anastomotic leak following gastric surgery (a water-soluble contrast agent is used rather than

barium).

CT of the stomach and duodenum

• Must not eat for 6 hours prior to CT to ensure the stomach remains empty
• The patient is given about 100ml of tap water to drink as well as a smooth muscle relaxant in order to distend the stomach and duodenum
• If the stomach is not distended during the scan any thickening of gastric wall could be misinterpreted as being a mass

CT of normal stomach. The stomach has been distended by oral water contrast and the use of an intravenous smooth muscle relaxant

CT of the stomach and duodenum

Stage the extraluminal extent of any disease notably carcinoma discovered at endoscopy

Further evaluation as if suspicion of external mass compressing the stomach

Upper GI endoscopy

It enables the mucosa of stomach and duodenum to be directly inspected and biopsied

Diagnostic and followups 1-4

Biopsies for Coeliac disease and confirmation

Therapeautics including injections removal stenting and feeding tube

Gastric pathologies that will be discussed

Gastric cancer Gastric lymphoma

• Gastric ulcers may be benign or malignant.
• whereas duodenal ulcers are almost invariably benign.
• Ulcers are identified as projections of barium beyond the mucosal profile.

parameter	Benign gastric ulcer	Malignant gastric ulcer
Projection	Ulcer project beyond the gastric contour (extraluminal)	does not protrude beyond the gastric contour (endoluminal)
crater	smooth rounded and deep ulcer crater	irregular and shallow ulcer crater
Mound shape and location	smooth ulcer mound centrally located within edema	nodular and angular ulcer mound eccentrically located within tumor
Mucosal folds	Smooth thin gastric folds that reach the margin of the ulcer	nodular thick gastric folds that do not reach the ulcer margin
collar	Hampton’s line	Carman meniscus sign

In profile, the ulcer (arrow) projects from the lesser curve of the stomach.

En face the ulcer (arrow) is seen as a rounded collection of barium.

Benign and malignant gastric ulcers

Malignant and benign gastric ulcer

Malignant GU of the distal lesser curvature biconvex meniscus sign with a nodular ulcer mound

Gastric cancer

At barium examination: gastric carcinoma typically produces an irregular filling defect (yellow arrows)with alteration of the normal mucosal pattern

There are a number of large filling defects in the antrum and body of stomach.

Gastric carcinoma in CT scan

CT is main imaging Modality for preoperative staging

CT is required for full evaluation

Direct infiltration of surrounding tissues may be assessed

The presence of enlarged lymph nodes and liver metastases can be recorded for tumor staging and determining best treatment

Gastric cancer CT

focal ulcer (yellow arrow)is seen arising in the antrum arising within focal wall thickening (white arrow)     ——Gastric ca

there is diffuse thickening of the wall of the stomach(blue arrows) .Several lymph nodes (white arrow) and a liver metastasis(white arrow head)—- Metastatic gastric ca

Other Investigations

• Endoscopic ultrasound may be used in some cases for local staging of early gastric cancer.

FDG-PET and FDG-PET/CT do not have a clear role in the primary staging of gastric cancer due to the normal uptake of FDG by the gastric mucosa

Gastric lymphoma

Diffused thickening of wall of gastric antrum (yellow arrows)

Lymphoadenopathy surrounds the inferior vena cava (white arrows)

Gastrointestinal stromal cell tumors

Arise from wall of stomach resulting in smooth round submucosal filing defect which may ulcerates as tumor enlarges

usually benign and well differentiated

several different subtypes such as leiomyoma type neural type

non differentiated type

may occur in GI tract but 60-70 percent occur in stomach

Gastrointestinal stromal tumor (GIST). There is a smooth ovoid mass arising from the anterior wall of the stomach

Neuroendocrine tumours of the stomach and duodenum

Duodenal gastrinoma. The duodenum(D) has been distended using a smooth muscle relaxant and oral water. The tiny gastrinoma (yellow arrow)is seen as a brightly enhancing lesion in the wall of the duodenum on the arterial phase of enhancement. A is aorta

Gastric Polyps

Single or Multiple

Sessile or have a stalk

It is often impossible to distinguish benign from polyp even with high quality radiographs

Gastroscopy with biopsy or operative removal is invariably carried out on all suscepted polyps

Causes of gastric outlet obstruction

Malignant Benign

Pyloric stenosis in infants

In infants the commonest form of gastric obstruction

Ultrasound has superseeded the gastric meal obstruction

Ultrasound shows thickened elongated pyloric canal

Pyloric stenosis. Ultrasound scan in a neonate showing a thickened elongated pyloric canal

A hiatus hernia is herniation of stomach into mediastinum through esophageal hiatus into diaphragm

It is a common finding

Sliding

• commoner type
• the gastro-oesophageal junction and a portion of the stomach are situated above the diaphragm.
• The cardiac sphincter is usually

incompetent. so reflux from the stomach to the esophagus occurs readily

Rolling

• Less common
• the fundus of the stomach herniates through the diaphragm, but the oesophagogastric junction often remains competent below the diaphragm.

SLIDING ROLLING

TYPES

SLIDING HIATUS HERNIA

Hiatus Hernia

Fundus of stomach extending into posterior