DOI:10.2214/AJR.05.1117
AJR 2006; 187:S480-S482
© American Roentgen Ray Society
AJR Teaching File: Persistent Epigastric Pain
R. Mark Shideler1,
Kevin P. Banks2 and
Ernesto Torres2
1 Third Medical Group, 24800 Hospital Dr., Elmendorf Air Force Base, AK
99506-3700.
2 Department of Radiology, Brooke Army Medical Center, MCHE-DR, 3851 Roger
Brooke Dr., Fort Sam Houston, TX 78234.
Received June 28, 2005;
accepted after revision January 23, 2006.
The opinions and assertions contained herein are the private views of the
authors and are not to be construed as official or as representing the views
of the Department of the Army, the Department of the Air Force, or the
Department of Defense.
Address correspondence to K. P. Banks
(Kevin.Banks{at}amedd.army.mil).
Keywords: abdominal imaging • barium studies • gastrointestinal radiology • lymphoma • stomach
Clinical History
A 41-year-old woman presented with epigastric pain elicited by food intake
and relieved with antacids. A trial of medical therapy with proton pump
inhibitors failed to alleviate symptoms, and a double-contrast upper
gastrointestinal evaluation was requested to evaluate for possible peptic
ulcer disease.
Radiologic Description
Fluoroscopic imaging from an upper gastrointestinal barium series
(Fig. 1A) shows a
moderate-sized, relatively smooth filling defect along the lesser curvature of
the stomach. There is also a large irregular marginated mass involving the
greater curvature. The adjacent rugal folds are distorted. The findings are
seen to persist with repositioning (Fig.
1B). Peristalsis in these regions is markedly abnormal (seen
during real-time imaging). CT of the abdomen with oral contrast material
(Fig. 1C) reveals a 6-cm
circumferential mass involving the distal stomach. The mass infiltrates the
wall and has both intraluminal and extraluminal extensions. The lesion has a
lobulated or nodular margin and enhances heterogeneously. The gastric fold
pattern is distorted.
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Fig. 1A —41-year-old woman with epigastric pain on food intake that is
relieved with antacids. Fluoroscopic image from upper gastrointestinal barium
series shows moderate-sized, relatively smooth filling defect
(arrows) along lesser curvature of stomach. Note also large irregular
marginated mass (arrowheads) involving greater curvature. Adjacent
rugal folds are distorted.
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Fig. 1B —41-year-old woman with epigastric pain on food intake that is
relieved with antacids. Fluoroscopic findings of irregular mass
(arrows) persist with repositioning. Peristalsis in these regions is
markedly abnormal (seen during real-time imaging).
|
|
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Fig. 1C —41-year-old woman with epigastric pain on food intake that is
relieved with antacids. CT scan of abdomen after administration of oral
contrast agent reveals 6-cm circumferential mass involving distal stomach.
Mass infiltrates wall and has both intraluminal and extraluminal extensions.
Lesion has lobulated or nodular margin and enhances heterogeneously. Gastric
fold pattern is distorted.
|
|
Delayed images obtained with the patient in the prone position
(Fig. 1D) show a similar
appearance and persistence of the marked wall thickening.
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Fig. 1D —41-year-old woman with epigastric pain on food intake that is
relieved with antacids. Delayed CT image obtained with patient in prone
position shows similar appearance and persistence of marked wall
thickening.
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|
Differential Diagnosis for an Aggressive Gastric Mass
The differential diagnosis for this patient is adenocarcinoma, primary
gastric lymphoma, leiomyosarcoma, carcinoid, Kaposi sarcoma, and metastatic
disease.
Diagnosis
The diagnosis is primary gastric lymphoma (high-grade B-cell gastric
lymphoma).
Commentary
Gastric tumors share many characteristics, making a definitive diagnosis
challenging. When upper gastrointestinal barium studies are performed with
strict attention to proper technique (Figs.
1A and
1B), they can have excellent
diagnostic yield but certainly cannot assess extragastric extent
[1,
2]. Therefore, the role of CT
in assessing gastric tumors may be fundamental for evaluating the local extent
and nodal involvement of disease, especially in locally advanced malignant
disease. Distention of the stomach, however, is essential for accurate
dedicated CT interpretation. Conventional positive contrast agents are well
tolerated and generally produce effective distention but are less appropriate
than low-attenuation contrast agents for advanced CT gastric applications such
as 3D imaging and CT angiography.
The differential diagnosis for gastric tumors is broad and includes both
benign and malignant entities (see preceding list). Patients with gastric
tumors present clinically with epigastric pain, gastroesophageal reflux
disease (GERD), hematemesis, melena, anorexia, nausea, or obstruction.
Patients with carcinoid tumors may present with pernicious anemia (type I),
multiple endocrine neoplasia (type 1) (MEN-1) or Zollinger-Ellison syndrome
(type II), or carcinoid syndrome (type III)
[3]. Bilroth II operations
increase the risk of adenocarcinoma
[4]. Kaposi sarcoma should be
considered in HIV-positive patients.
Gastric lymphomas are usually focal homogeneous tumors originating in the
distal two thirds of the stomach or antrum and arising from the sites of
mucosa-associated lymphoid tissue (MALT). There is commonly gastric wall
thickening in excess of 1 cm and more than 50% infiltration of the gastric
wall, but often without significant distortion of the gastric rugae.
Circumferential involvement of most of the stomach may be seen, as well as
lymphadenopathy on either side of the mesenteric vessels. The presence of
lymphadenopathy can be used to differentiate lymphoma from malignant
gastrointestinal stromal tumors (GISTs)
[4,
5], although, as this case
points out, lymphomas can also present as heterogeneous masses and may distort
the rugal folds, highlighting the fact that gastric neoplasms are sometimes
difficult to diagnose radiographically.
Gastric adenocarcinomas represent 95% of malignant stomach tumors and most
often appear as a heterogeneous mass with focal wall thickening, diffuse
infiltration and possible ulceration, loss of rugal folds, abnormal
perigastric fat, exophytic disease, possible metastasis, and involvement of
the peritoneal ligaments
[4].
An interesting but rare group of tumors, GISTs are of mesenchymal origin
and include both malignant and benign neoplasms such as leiomyomas,
leiomyoblastomas, leiomyosarcomas, schwannomas, neurofibromas, carcinoids, and
fibrous tumors. Malignant GISTs may present as large heterogeneous masses with
an enhancing rim, central necrosis, liquefaction, ulceration, and/or
calcification. There is usually no associated lymphadenopathy, in contrast
with lymphoma [4,
5].
A multinodular pattern may be suggestive of type II carcinoid lesions. Type
III lesions are distinguished as solitary lesions with ulceration and may
present with carcinoid syndrome if the liver is involved
[3,
4].
Metastatic tumors of the stomach are rare and most commonly present as
multiple submucosal tumors with calcifications, although solitary metastases
may be indistinguishable from primary gastric tumors
[4].
Glomus and other vascular tumors are seen as smooth submucosal tumors that
enhance with contrast material
[6].
This case accentuates the difficulty in identifying specific gastric tumors
on imaging. CT, particularly with adequate gastric distention, may be helpful
when attempting to categorize and characterize gastric lesions and for
evaluating the extent of disease. The lesion in this instance typifies the
classic features of gastric lymphoma: a distal stomach mass showing
circumferential involvement and severe wall thickening with concurrent
adenopathy. Even with such characteristic findings, imaging patterns are not
pathognomonic, and patients almost always need to be referred for endoscopic
or surgical evaluation for a definitive diagnosis.
Objective
The educational objective of this article is to describe the imaging
features in a case of primary gastric lymphoma.
Conclusion
With detailed knowledge of the radiologic and clinical differences among
neoplasms afflicting the stomach, analysis of these tumors can provide a
focused and accurate differential diagnosis that may aid clinicians in the
management of these individuals.
References
- Park MS, Ha HK, Choi BS, et al. Scirrhous gastric carcinoma:
endoscopy versus upper gastrointestinal radiography.
Radiology 2004;231
: 421-426[Abstract/Free Full Text]
- Low VH. Diagnosis of gastric carcinoma: sensitivity of
double-contrast barium studies. AJR 1994;162
: 329-334[Abstract/Free Full Text]
- Aaron JB, Johnson CD, Stephens DH, et al. Carcinoid tumors of the
stomach: a clinical and radiographic study. AJR2001; 176:947
-951[Abstract/Free Full Text]
- Ba-Ssalamah A, Prokop M, Uffmann M, et al. Dedicated multidetector
CT of the stomach: spectrum of diseases. RadioGraphics2003; 23:625
-644[Abstract/Free Full Text]
- Kim HC, Lee JM, Choi SH, et al. Imaging of gastrointestinal stromal
tumors. J Comput Assist Tomogr 2004;28
: 596-604[CrossRef][Medline]
- Park SH, Han JK, Kim TK, et al. Unusual gastric tumors:
radiologic-pathologic correlation. RadioGraphics1999; 19:1435
-1446[Abstract/Free Full Text]
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Clinical History
Radiologic Description
