Gastroduodenal ulcers on CT: forgotten, but not gone

Development and validation of a CT algorithm for the identification of nonperforated duodenal bulb ulcer

PURPOSE

To assess the value of multiplanar computed tomography (CT) in the diagnosis of nonperforated duodenal bulb ulcer (NPDBU).

METHOD

We retrospectively analyzed data from 135 patients with NPDBU (ulcer group) and 150 patients with a normal duodenal bulb (control group) who underwent contrast-enhanced abdominal CT and were diagnosed via upper endoscopy from January 2018 to February 2022. The clinical and CT features were compared between the two groups. Independent prognostic factors for diagnosing NPDBU were determined using binary logistic regression analysis. An external validation cohort to determine the model's efficiency comprised 80 patients from another center.

RESULTS

Gastrointestinal bleeding was more frequent in patients with NPDBU than in those without (p < 0.001). No significant differences in age and sex were observed between the groups (all p > 0.05). The duodenal bulbar wall was significantly thicker in the ulcer group than in the control group, as determined using CT (p < 0.001). Irregular mucosal surface, layered enhancement, and blurred fat space around the duodenal bulb were more common in the ulcer group than in the control group (all p < 0.001). Binary logistic regression analysis revealed that gastrointestinal bleeding, wall thickness of ≥ 4.85 mm, irregular mucosal surface, and blurred peripheral fat space were the most significant variations associated with NPDBU, with an area under the curve (AUC) of 0.974. The external validation cohort had an AUC of 0.916.

CONCLUSIONS

Careful multiplanar CT interpretation suggests the underlying presence of NPDBU and allows timely endoscopic verification and appropriate treatment.

Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms

Gastrointestinal (GI) bleeding is a common potentially life-threatening medical condition frequently requiring multidisciplinary collaboration to reach the proper diagnosis and guide management. GI bleeding can be overt (eg, visible hemorrhage such as hematemesis, hematochezia, or melena) or occult (eg, positive fecal occult blood test or iron deficiency anemia). Upper GI bleeding, which originates proximal to the ligament of Treitz, is more common than lower GI bleeding, which arises distal to the ligament of Treitz. Small bowel bleeding accounts for 5-10% of GI bleeding cases commonly manifesting as obscure GI bleeding, where the source remains unknown after complete GI tract endoscopic and imaging evaluation. CT can aid in identifying the location and cause of bleeding and is an important complementary tool to endoscopy, nuclear medicine, and angiography in evaluating patients with GI bleeding. For radiologists, interpreting CT scans in patients with GI bleeding can be challenging owing to the large number of images and the diverse potential causes of bleeding. The purpose of this pictorial review by the Society of Abdominal Radiology GI Bleeding Disease-Focused Panel is to provide a practical resource for radiologists interpreting GI bleeding CT studies that reviews the proper GI bleeding terminology, the most common causes of GI bleeding, key patient history and risk factors, the optimal CT imaging technique, and guidelines for case interpretation and illustrates many common causes of GI bleeding. A CT reporting template is included to help generate radiology reports that can add value to patient care. An invited commentary by Al Hawary is available online. Online supplemental material is available for this article. ^©RSNA, 2021.

Causes of Melena and Effective Examination Strategies in Children

Background and Aim: Melena, or tarry black stool, is not a rare symptom encountered in pediatric clinical practice, and the bleeding source varies from the upper gastrointestinal tract to the small intestine. Endoscopy is effective in identifying bleeding, but it does not always identify the source of bleeding. Endoscopic examination in children is commonly challenging, and there are no detailed reports about the causes of melena in children. This observational study aimed to validate the cause of melena in children and to investigate more effective and less burdensome examination methods. Methods: We retrospectively reviewed the clinical records of 55 patients who underwent examination for melena. Results: In this research, 38 patients had underlying diseases such as malignancy and severe mental and physical disorders. The bleeding source was identified in 39 patients. The most common final diagnosis was duodenal ulcer (n = 22), and the other diagnoses were gastric ulcer, esophagitis, and esophageal varices. The upper gastrointestinal tract was the most common source of bleeding (n = 34). In five patients, the bleeding source was the small intestine. Vomiting, abnormal abdominal ultrasonography findings, and a hemoglobin level of ≤ 3 g/dL than the lower normal limit were significant factors indicating that the bleeding source can be found on esophagogastroduodenoscopy. Conclusions: The upper gastrointestinal tract was the most common bleeding source of melena in children. As in adults, esophagogastroduodenoscopy is the primary endoscopic method of choice. Furthermore, small bowel capsule endoscopy may be useful in identifying the bleeding source in children without upper gastrointestinal lesions.

Computed tomography findings of acute gastric peptic ulcer

PURPOSE

To report the computed tomography (CT) findings of acute peptic ulcer disease (PUD) and to evaluate the usefulness of contrast media for diagnosis.

METHODS

This retrospective study included 51 patients diagnosed with acute gastric peptic ulcer by endoscopy. Using a κ analysis, two radiologists independently reviewed contrast-enhanced emergency CTs performed within 24 h of endoscopy. Evaluation findings included low-attenuation wall thickening, focal wall thickening, focal luminal outpouching, perigastric fat stranding, ascites, adjacent lymphadenopathy, and high-density gastric contents. Of the 51 patients, 48 underwent both non-contrast-enhanced and contrast-enhanced CT, and two radiologists also evaluated the presence or absence of these findings on a non-contrast-enhanced CT. McNemar's test was used to evaluate the contrast media's usefulness.

RESULTS

Interobserver variability of perigastric fat stranding revealed substantial agreement between evaluators, and other findings had almost perfect agreement. High-density gastric contents were the most recognized findings (60%). Low-attenuation focal wall thickening and focal luminal outpouching were observed in relatively large numbers (~50%) of the cases on contrast-enhanced CT. The CT examinations using contrast media provided significantly higher detectability of low-attenuation wall thickening and focal luminal outpouching than CT examinations without using contrast media.

CONCLUSION

Acute PUD can be suspected in patients with nonspecific abdominal symptoms in whom emergency CT shows high-density gastric contents, focal low-attenuation wall thickening, and/or focal luminal outpouching. Our study showed that contrast media are useful for diagnosis.

Diagnostic Utility of Ultrasonography for Duodenal Ulcers in Pediatric Cases in Japan

Objective: To evaluate the diagnostic utility of wall hypertrophy of the duodenal bulb with a hyperechoic lumen, designated as the "HH sign," using ultrasound sonography (US) in pediatric duodenal ulcer (DU) patients. Study design: We performed a US for five pediatric subjects diagnosed with DU by upper gastroscopy to determine the presence of the potentially diagnostic HH sign. The sonographic images were analyzed before and after DU treatment. Computed tomography was performed in three cases and fecal occult blood test (FOBT) in all five cases. Results: Upper gastroscopy confirmed DU in all patients. While the HH sign was observed using US in four cases, with the DU located in the anterior bulb, the FOBT was positive in only one case. In these four cases, the HH sign diminished in response to treatment, as visualized by US. This was observed for both the initial as well as recurrent episodes. A mass-like region was observed in only one case, with the ulcer located in the proximity of the inferior duodenal wall. Conclusion: The HH sign is useful for the follow-up of DU, and US may be a suitable modality for the follow-up. We believe that this diagnostic marker can aid in following up a greater number of DU cases.

The characteristics of 83 giant peptic ulcers in Chinese children: Evaluation and follow-up

BACKGROUND/AIMS

Giant peptic ulcers (GPUs) are detrimental for all patients, especially for children. However, few reports have described GPUs in children. This study aims to evaluate the characteristics of GPUs in Chinese children and to identify risk factors.

PATIENTS AND METHODS

We retrospectively analyzed patients at the Children's Hospital of Fudan University from April 2014 to August 2017. Patients with GPUs (>2.0 cm) were included in the study, and the clinical data, pathological characteristics and presence of Helicobacter pylori (H. pylori) infection were analyzed to evaluate the outcomes.

RESULTS

A total of 19208 children underwent gastroscopic examinations, and 83 patients with GPUs were enrolled. The mean age of onset for GPU patients was 9.7 ± 3.2 years(range, 1-15). The main complaints were abdominal pain (92.7%), anemia (53%), retching (45.8%), hematochezia (21.7%) and hematemesis (16.9%). With respect to the types of GPU, 68 patients (81.9%) had duodenal ulcers, and 15 patients (18.1%) had gastric ulcers. Compared to the group <6 years of age, the group ≥6 years was more susceptible to GPU (P < 0.05). Among GPU patients, 71.1% of cases were H. pylori (*) (59/83), and 16.9% (14/83) of patients were H. pylori (-). Compared to the H. pylori (-) group, the H. pylori (*) group showed inflammatory activity, atrophy and lymphoid follicular formation in the gastric mucosa (P < 0.05).

CONCLUSIONS

This study suggests that GPUs are strongly associated with H. pylori infection in Chinese children. Duodenal ulcers are the main type of GPU in patients older than 6 years. Appropriate diagnosis, treatment and follow-up are necessary for children with GPUs.

Emphysematous pancreatitis associated with penetrating duodenal ulcer

In the “proton pump inhibitors era”, a penetrating peptic ulcer (PPU) represents an exceptional cause of abdominal pain, and was more frequently observed in the past where there was not an effective antacid treatment. Ulcer-induced pancreatitis is very rare, too, and manifests with persistent, intense pain radiating to the back. A mild to severe pancreatitis with peripancreatic fluid collection can be observed at imaging. However, only a few cases of association between PPU and emphysematous pancreatitis (EP) have been published in the literature. EP is a rare but potentially fatal form of acute necrotizing pancreatitis in which gas grows in and outside the pancreas, and typically involves the whole parenchyma in diabetic individuals.

Here we report an extremely rare case of a duodenal ulcer penetrating the pancreas and complicated with EP. Unlike the classic form of EP, which involves the whole parenchyma and has a poor prognosis, we found that the emphysematous involvement of the pancreas by PPU has a benign course if a conservative therapy is promptly established. Gas is confined to the site of penetration, usually the pancreatic head, and ulcers most often involve the duodenum.

Imaging Manifestations of Peptic Ulcer Disease on Computed Tomography

Although the overall prevalence of peptic ulcer disease (PUD) has decreased in modern times, its actual incidence may be underestimated owing to the nonspecific clinical presentations patients' manifest. The potential lethal complications that can result from PUD include life-threatening abdominal hemorrhage and bowel perforation that result in significant morbidity and mortality. Computed tomography (CT) imaging historically lacks specificity in detecting PUD-related pathology in the stomach and proximal small bowel segments. Therefore, these are potential pitfalls in the radiologist's search pattern on abdominopelvic CT imaging. This article highlights imaging features of uncomplicated PUD on CT imaging in order to allow for early detection of this disease process on imaging and the prevention of potential high-grade complications by recommending esophagogastroduodenoscopy.

Distinguishing gastric anisakiasis from non-anisakiasis using unenhanced computed tomography

PURPOSE

This study aimed to assess the diagnostic performance of unenhanced computed tomography (CT) for distinguishing gastric anisakiasis from non-anisakiasis gastric conditions and the reproducibility of CT findings.

METHODS

Fifty-six anisakiasis and 74 non-anisakiasis cases with gastric wall thickening on urgent observation using unenhanced CT were included. Using a κ analysis, two radiologists independently assessed the reproducibility of CT findings, including "circumferential gastric wall thickening," "gastric wall thickening extending more than two segments," "bulky and low-density gastric wall thickening," "increase in peri-gastric fat density," and "ascites." An anisakiasis diagnostic score (ADS) was developed for this study and was used to quantitatively evaluate the CT findings. An anisakiasis diagnostic prediction (ADP) with an appropriate cutoff value was used to further evaluate the ADS. Two radiologists reassessed the findings in consensus to determine the sensitivity, specificity, and accuracy of the CT findings, including the ADP and ADS area under the curve (AUC).

RESULTS

Considering reproducibility, a substantial agreement (0.6 < κ < 0.8) was achieved for all findings except "circumferential gastric wall thickening" (κ = 0.499), whereas for diagnostic performance, all findings except ascites were significantly more frequent among the anisakiasis cases. "Bulky and low-density gastric wall thickening" had the highest sensitivity (98%), whereas "gastric wall thickening extending more than two segments" had the highest specificity (80%). The ADP sensitivity, specificity, and accuracy were 91%, 84%, and 87%, respectively. The AUC was 0.902 (p < 0.05).

CONCLUSIONS

Unenhanced CT findings are useful for distinguishing anisakiasis from non-anisakiasis gastric conditions with sufficient reproducibility.

Non-perforated peptic ulcer disease: multidetector CT findings, complications, and differential diagnosis

Abstract

Despite availability of effective therapies, peptic ulcer disease (PUD) remains a major global disease, resulting from a combination of persistent Helicobacter pylori infection and widespread use of nonsteroidal anti-inflammatory drugs. Albeit endoscopy definitely represents the mainstay diagnostic technique, patients presenting to emergency departments with unexplained abdominal pain generally undergo multidetector CT as an initial investigation. Although superficial ulcers generally remain inconspicuous, careful multiplanar CT interpretation may allow to detect deep ulcers, secondary mural and extraluminal signs of peptic gastroduodenitis, thereby allowing timely endoscopic verification and appropriate treatment. This pictorial essay aims to provide radiologists with an increased familiarity with CT diagnosis of non-perforated PUD, with emphasis on differential diagnosis. Following an overview of current disease epidemiology and complications, it explains the appropriate CT acquisition and interpretation techniques, and reviews with several examples the cross-sectional findings of uncomplicated PUD. Afterwards, the CT features of PUD complications such as ulcer haemorrhage, gastric outlet obstruction, biliary and pancreatic fistulisation are presented.

Teaching points

• Gastric and duodenal peptic ulcers are increasingly caused by nonsteroidal anti-inflammatory drugs

• Multiplanar CT interpretation allows detecting deep ulcers and secondary signs of gastroduodenitis

• CT diagnosis of uncomplicated peptic disease relies on direct and indirect signs

• Currently the commonest complication, haemorrhage may be treated with transarterial embolisation

• Other uncommon complications include gastric outlet obstruction and biliopancreatic fistulisation

Evaluating Patients with Left Upper Quadrant Pain

Imaging plays a major role in the evaluation of patients who present to the emergency department with acute left upper quadrant (LUQ) pain. Multidetector computed tomography is currently the primary modality used for imaging these patients. The peritoneal reflections, subperitoneal compartment, and peritoneal spaces of the LUQ are key anatomic features in understanding the imaging appearance of acute diseases in this area. Diseases of the stomach, spleen, pancreas, and splenic flexure are encountered in patients with acute LUQ pain. Optimization of the imaging protocol is vital for accurate diagnosis and characterization of these diseases in the acute setting.

An Approach to Various Gastric Pathologies Using an "Image Appearance-Based Classification" on Computed Tomography

Although pathologies affecting stomach are commonly encountered in computed tomography imaging of the abdomen, they are frequently overlooked. Their etiologies are often diverse; however, most of them have certain well-documented imaging characteristics. Conventionally the stomach abnormalities were classified according to their etiopathogenesis. This article aims at providing the readers with an easy approach by categorizing abnormalities of stomach using a novel image appearance-based classification. An attempt to illustrate various gastric pathologies using this new classification by means of pictorial examples is made. Basic computed tomography imaging anatomy of the stomach and imaging techniques that need to be adapted are also emphasized in the outset of the discussion.

Detection of gastric cancer using transabdominal ultrasonography is associated with tumor diameter and depth of invasion

Gastric cancer is occasionally diagnosed using transabdominal ultrasonography (US) during screening or investigation of patients with abdominal symptoms. Therefore, the present study analyzed the association of the tumor diameter, pathological T (pT) staging and depth of invasion with the detection of gastric cancer using US. Patient records were analyzed retrospectively and 13 patients were enrolled, who underwent US screening prior to endoscopic mucosal resection, endoscopic submucosal dissection or surgery. In total, 5 patients were diagnosed with gastric cancer using US (positive detection group), while US was unable to detect the gastric cancer in 8 patients (negative detection group). The tumor diameter and depth of invasion were determined by pathologists. One-way analysis of variance or the χ2 test was performed. Wall thickness in gastric cancer cases ranged between 7 and 20 mm (mean, 12.2±5.9 mm), as measured using abdominal US. The hemoglobin level was significantly lower in the positive detection patients compared with the negative detection patients (P=0.0455). In addition, the diameters of the gastric wall in the negative and positive detection patients were 24.5±16.4 and 54.4±26.2 mm, respectively (P=0.0266). These results indicate that gastric cancer in the positive detection patients were at a more advanced-stage compared with that in the negative detection patients. Furthermore, gastric cancer with a stage over pT2 was diagnosed using abdominal US (P=0.0242), whereas stage pT1a gastric cancer was not detected by abdominal US. Gastric tumors invading deeper than the submucosa were diagnosed using US (P=0.0242). However, the gastric cancer cases limited to the mucosa remained undetected. In conclusion, the detection of gastric cancer correlated well with the tumor diameter, pT staging and depth of invasion.