Menetrier’s disease (giant hypertrophic gastritis) is an uncommon disorder of unknown cause that is charac¬terized by massive enlargement of rugal folds due to hyperplasia of the gastric glands. There is usually hy posecretion of acid and excessive secretion of gastric mucus. Loss of protein into the lumen of the stomach may result in hypoproteinemia and edema. The thick-ened gastric rugae become contorted and folded on each other in a convolutional pattern suggestive of the gyri and sulci of the brain. Enlarged rugal folds are particu¬larly prominent along the greater curvature. Although the disorder is classically described as a lesion of the fundus and body, involvement of the entire stomach can occur. The disease can be diffuse or localized, and the transition between normal and pathologic folds is usually abrupt.
Radiographically, affected rugal folds are thick, tor¬tuous, and angular with no uniformity in pattern or di¬rection. When seen on end, the folds may closely simulate polypoid filling defects. Lines of barium can be seen perpendicular to the stomach because of spicules of contrast material trapped by apposed giant rugal folds.
Menetrier’s disease must be differentiated from a malignant process, especially lymphoma. If the thickened rugal folds predominantly involve the fundus and spare the lesser curvature, if there is no ulceration or true rigidity, or if excess mucus can be demonstrated, Menetrier’s disease is the probable diagnosis. If the enlarged rugal folds predominantly involve the distal portion of the stomach and the lesser curvature, or if there’ is some loss of pliability of the gastric wall, lymphoma is more likely.
Gastric Mucosal Prolapse
Redundant mucosa of the gastric antrum can prolapse through the pylorus under the influence of active peristalsis, resulting in single or tabulated filling defects at the base of the duodenal bulb. Mucosal folds in the prepyloric area of the stomach can usually be traced through the pylorus to the base of the bulb, where they become continuous with the characteristic mushroom-, umbrella-, or cauliflower-shaped prolapsed mass. Under fluoroscopy, mucosal prolapse can be detected as a gastric peristaltic wave passes through the antrum. As the wave relaxes, the mucosal folds tend to return into the antrum, and the defect in the base of the bulb diminishes or completely disappears. Some degree of mucosal prolapse is frequently observed during gastrointestinal examinations. Antral prolapse is generally considered to be asymptomatic, though associated ulceration and bleeding have occasionally been reported.
Gastric volvulus is an uncommon acquired twist of the stomach upon itself that can lead to gastric outlet obstruction. It usually occurs in conjunction with a large paraesophageal hernia or eventration of the diaphragm that permits part or all of the stomach to assume an intrathoracic position. Organoaxial volvulus refers to rotation of the stomach upward along its long axis (a line connecting the cardia with the pylorus). In this condition, the antrum moves from an inferior to a superior position. In the mesenteroaxial type of gastric volvulus, the stomach rotates from right to left or left to right around the long axis of the gastrohepatic omentum (a line connecting the middle of the lesser curvature with the middle of the greater curvature).
Gastric volvulus can be asymptomatic if there is no outlet obstruction or vascular compromise. Acute volvulus associated with interference of the blood supply is a surgical emergency with a high mortality rate.
The radiographic signs of gastric volvulus are characteristic. They include a double air-fluid level on upright films, inversion of the stomach with the greater curvature above the level of the lesser curvature, positioning of the cardia and pylorus at the same level, and downward pointing of the pylorus and duodenum.
Foreign Bodies and Bezoars
Small blunt foreign bodies such as coins, marbles, or even closed safety pins usually pass through the stomach and bowel without difficulty. Elongated, sharp objects such as needles, toothpicks, or open safety pins may hold up at some point and cause obstruction, ulceration, bleeding, abscess, or peritonitis. Metallic foreign bodiesappear opaque on plain abdominal radiographs. Non-metallic foreign bodies appear as lucent filling defects within the barium-filled stomach.
A bezoar is an intragastric mass composed of accumulated ingested material. Phytobezoars, which are composed of undigested vegetable material, have classically been associated with the eating of unripe persimmons. This fruit contains substances that coagulate on contact with gastric acid to produce a sticky gelatinous material, which then traps seeds, skin, and other foodstuffs. Trichobezoars (hairballs) occur predominantly in females, especially those with schizophrenia or other mental disorders. Bezoars in the gastric remnant are a common complication following partial gastric resection with Billroth I or II anastomoses. The chief constituent of postgastrectomy bezoars is the fibrous, pithy component of fruits and vegetables, the consumption of which should be reduced as much as possible in postgastrectomy patients.
Symptoms of gastric bezoars result from the mechanical presence of the foreign body. They include cramplike epigastric pain and a sense of dragging, fullness, lump, or heaviness in the upper abdomen. The incidence of associated peptic ulcers is high, especially with the more abrasive phytobezoars. When bezoars are large, symptoms of pyloric obstruction can clinically simulate symptoms of a gastric carcinoma. Occasionally, bezoars can lodge in the jejunum or ileum and cause small bowel obstruction.
Plain abdominal radiograpl often show a bezoar as a soft tissue mass floating in the stomach at the air-fluid interface. On barium studies, contrast material coating the mass and infiltrating into the interstices results in a characteristic mottled or streaked appearance. The filling defect may oc sionally be completely smooth, simulating an enor.uous gas bubble that is freely movable within the stomach.
In atrophic gastritis, severe mucosal atrophy may cause thinning and a relative absence of mucosal folds, with the fundus or the entire stomach having a bald appearance. This is a nonspecific radiographic pattern that can be related to such factors as age, malnutrition, medication, and complications of alcoholism; it also occurs in patients with pernicious anemia. Although atrophic gastritis itself does not produce symptoms, the condition is associated with an increased incidence of gastric malignancy. Conversely, in the elderly an atrophic stomach may be hypotonic and show limited distensibility, simulating scirrhous carcinoma.
Eosinophilic gastritis causes thickening of the muscular layer of the wall of the stomach due to edema and a diffuse infiltrate of predominantly mature eosinophils. It primarily involves the antrum and produces irregular narrowing and rigidity (linitis plastica pattern) that may simulate an infiltrating carcinoma. The disease is characterized by peripheral eosinophilia and the development of gastrointestinal symptoms and signs following the ingestion of specific foods. Although eosinophilic gastritis can simulate a more aggressive process, it is essentially a benign condition that is self-limited and often completely returns to normal after steroid therapy.
The ingestion of corrosive agents results in a severe form of acute gastritis characterized by intense mucosal edema and inflammation. RadiographicaIly, thickened gastric folds are associated with mucosal ulcerations, atony, and rigidity. A fixed, open pylorus is usually seen, probably due to extensive damage to the muscular layer. The presence of gas in the wall of the stomach after the ingestion of corrosive agents is an ominous sign that may precede the development of free gastric perforation.
Corrosive gastritis predominantly involves the antrum, though the entire stomach may be involved. Ingested acids generally produce more severe gastric damage than ingested alkalies, in contrast to the effects of acids and alkalies on the esophagus.
The acute inflammatory reaction of corrosive gastritis heals by fibrosis and scarring, which results in stricturing of the antrum within several weeks of the initial injury. In patients who have rigidity and narrowing of the stomach without a history of corrosive ingestion, the clinical symptoms of weight loss and early satiety, combined with the radiographic pattern of narrowing of the stomach (linitis plastica), can be impossible to distinguish from gastric malignancy.stomach cancer · esophagus surgeries · Bariatric surgery ·