Digestive disorders

IV./3.2.: X-ray

IV./3.2.1.: Direct radiographic signs of peptic ulcer

IV./3.2.1.1.: Lateral view

In lateral view a „ulcer-bay” exceeding the gastric contour can be seen, whose silhouettes are smooth (ulcer size might range between a quite small size and 4-5 cm). If smaller, it is similar to a collar-stud. „Hampton line” is a less X-ray absorbant straight line between the ulcer neck and the ulcer crater  indicating a mucosal thickening. On the peripherial part the ulcer itself is undercut via the circular protrusion of the edematously thickened mucosal ring located above. It can be specifically seen well if the signed spot is palpated by a distinctor during the X-ray examination.

The infundibulum of the benign e.g. peptic  ulcer is smooth and well defined in contrast to the malignant ulcer. The real depth of the ulcer is often not visible, the extra filling is not presented in the ulcer’s entire magnitude since blood or scran can fill out the bay on one hand, or, on the other hand, the traction of the muscular mucosal layer might constrict and largely occlude the bay infundibulum which can inhibit the contrast filling. The stomach can be also malformed: so called organic sand-glass stomach can developwhileas the shape of the lesser curvature might assimilate a snail.

IV./3.2.1.2.: Anteroposterior view

In anteroposterior view, flat contrast depot (so called tight spot ) and radial folds can be observed, ulcer crater and contours are flat. Halo defect can be also seen (with palpation) which is a circular radiolucent zone on the margin of the ulcer.

IV./3.2.2.: Indirect radiographic signs of peptic ulcer

Only the so called dynamic examination – barium swallow with fluoroscopy – can demonstrate that the peristaltic wave stops on the greater curvature in contrast to the ulcer located on the lesser curvature and „points” towards the contralateral sided ulcer with an finger-like constriction. The functional sandglass stomach caused by this finger-like spasm on the ulcer’s contralateral side belongs to the indirect signs. An additional indirect sign which might help the radiologist is the pressure pain provoked by palpation during the examination in the location corresponding to the ulcer. The pain can also emanate.

Hyperperistalsis is also an indirect sign. Hypersecretion can be already realized at the beginning of the examination which must be evaluated as an alarming sign if the examination was performed in appropriate time in morning hours, following several hours of fasting (carentia). If the examination is disturbed by the amount of hypersecretion, the attenuation of contrast material alters the opacity inadequate. In addition, if the contast material cannot adhere to the gastric wall therefore, peptic secretion (succus) must be drawn off by a nasogastric tube before the examination.

IV./3.2.3.: Penetrating ulcer

Most frequently the penetrating ulcer penetrates into the pancreas. Hereby the ulcer bay will be amended by an additional bay which is located in the adjacent organ affected by the penetration, and the two bays might be connected by a narrow canal. Triple stratification can be observed by the contrast filling study: the contrast is located below, above is the peptic secretion, and above that is an air cap. The canal between the two bays might be so narrow that the contrast media cannot be detected inside thus the penetrating part might appear independent.

IV./3.2.4.: Radiologic signs of malignant ulcer

Malignant ulcers might develop anywhere in the stomach, no preferated location is known in contrast to the peptic ulcer (see Magenstrasse). Fundal ulcers (to visualize them by gastroscopy is not easy) are usually malignant. In the lateral view of a classic radiograph, contour of a malignant ulcer is inside the gastric wall in contrast to one of the peptic ulcer which exceeds that. The ulceration inside the tumor, which protudes thus mimicing the folds, is not necessarily located in the middle but excentrically. Borders are not flat but irregular, eroded. If visualizable, the bottom of the ulcer is also irregular.

Ulceration rather extends far and wide than in depth, this ratio is inversed in case of the peptic ulcer (probably except the old-age giant ulcer). No Hampton line is present. Borders of the malignant ulcer are rather twisted and grossly eroded. The peristaltic motion does not pass along the contour, wall stiffening can be observed. It is often to see – rather to perceive – by radiograph that the ulceration is located in the center of a large mass. In anteroposterior view, the contrast filling is irregular and the contour of the ulceration is also irregular. The surrounding mucosal folds are irregular – in contrast to the peptic ulcer where they are starlike –, their end is clubbed and amputated at the rim of the ulcer. Double contrast study can visualize that the folds are fused, their surface is not flat but nodular, and the ulcer crater is irregular in anteroposterior view and not circular.

IV./3.2.5.: Radiographic examination of the operated stomach

IV./3.2.5.1.: Early postoperative examination

Questions to answer by an early postoperative examination:

• - Is the gastric exhaustion normal? Large amount of stagnating secretum is also visible on an unenhanced examination. In case of the dumping syndrome, contrast material empties rapidly.

• - Is there a suture insufficiency? If this question arises, the patient must drink only absorbing contrast material (iodinated, water soluble).

If stagnating secretum is in the stomach, which could attenuate the contrast material inordinately, it must be drawn off before the patient starts drinking the contrast agent. Exit of contrast material from the lumen must be checked. (Air streak in the early postoperative period is not informative, since air can be sticked even for a week after surgery.) Indirect signs: small interstine sentinel loops referring to a peritonitis. Inactive, limited diaphragmatic motion.

IV./3.2.5.2.: Late postoperative examination

Late postoperative examination usually aims to reveal a recurrence.

IV./3.2.5.3.: Radiograph of an operated stomach according to the surgery method

Long experience is needed to adjudge the abdominal status. We must be informed about the type of the performed surgery. If an atypic resection was performed, surgeon is recommended to draft – even draw – the anastomosis performed by himself/herself.

• - In case of Billroth I. resection, end-to-end, sometimes end-to-side anastomosis is performed between the gastric stump and the duodenum.

• - In case of Billroth II. resection, which is performed more frequently as Billroth I. resection, the gastric stump is anastomosed end-to-side with the jejunum loop pulled up retro- or antecolic, thus both afferent and efferent loops will be developed, whose identification has an important role.

• - Roux-type Y-gastroenterostomy or -jejunostomy.

Traditional contrast swallowing studies play an important role in the investigation of the operated stomach, because secure identification of certain afferent and efferent loops might be difficult by optical endoscopy. The task of the radiologist includes monitoring of gastric motion, identification of possible inflammatory signs and recurrence.