Imaging Pearls ❯ Stomach ❯ Inflammatory Disease
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- “Acute phlegmonous gastritis (PG) is a rare clinical disease mainly characterized by severe bacterial invasion of the gastric wall. Clinical manifestations of acute PG lack specificity, and patients often present with abdominal pain, nausea, vomiting, fever, and signs of infection. Early diagnosis is difficult, but this disease develops quickly and often with stomach wall necrosis and peritonitis. Acute PG has an extremely high mortality rate because diagnosis is often delayed or overlooked.Before the advent of antibiotics, its mortality rate reached as high as 92%; with antibiotics, the mortality rate dropped to 48%. However, immediate surgical intervention is needed to improve prognosis when antibiotic treatment is ineffective.”
“Diagnosis and treatment of acute phlegmonous gastritis: A case report.”
Yang, Hongxin et al.
Medicine vol. 97,18 (2018): e0629. - “At present, acute PG's cause is not entirely clear presumably due to fester bacterium invading the stomach. Hemolytic streptococcus is reportedly found in approximately 70% of cases, followed by Staphylococcus aureus, Pneumococcus, and Enterococcus. Bacterial invasion of the gastric wall can be caused by gastric ulcer, chronic gastritis, and the like, with the pathogenic bacteria of the pharynx directly infringing into the damaged mucosa; respiratory tract infection or other infection, with the pathogenic bacteria entering the gastric wall through blood flow; the pathogenic bacteria entering the gastric wall through the lymphatic system in the case of cholecystitis and peritonitis.”
“Diagnosis and treatment of acute phlegmonous gastritis: A case report.”
Yang, Hongxin et al.
Medicine vol. 97,18 (2018): e0629. - "Abdominal CT typically reveals the following characteristic findings of PG: thickening of the gastric wall, low-intensity areas within the gastric wall (indicative of an abscess), and gas accumulation. The patient's clinical manifestation included abdominal pain, epigastric peritonitis, and the feature of CT.”
“Diagnosis and treatment of acute phlegmonous gastritis: A case report.”
Yang, Hongxin et al.
Medicine vol. 97,18 (2018): e0629. - "Acute PG lacks specific clinical performance, and abdominal CT is helpful for both early diagnosis and detecting complications. Once acute PG is detected, antibiotic treatment is important, but if this treatment fails, surgery should be performed immediately to improve the prognosis. At present, given the use of antibiotics, the incidence rate is extremely low. However, once the disease occurs, it rapidly progresses and has an extremely high fatality rate. Thus, it requires serious attention by clinicians..”
“Diagnosis and treatment of acute phlegmonous gastritis: A case report.”
Yang, Hongxin et al.
Medicine vol. 97,18 (2018): e0629. - “CT is also useful in diagnosis of phlegmonous gastritis. Previously reported CT findings of acute phlegmonous gastritis include diffuse gastric wall thickening with circumferential intramural low attenuation surrounded by a peripheral enhancing rim. Air bubbles were seen within the thickened gastric wall and probably caused by gas-forming bacteria. Previously reported endoscopic findings of phlegmonous gastritis also include suppurative mucosa, hyperemic edematous folds, and multiple ulcers with purulent exudate.”
Acute phlegmonous gastritis
Chi-Hung Chen et al.
Advances in Digestive Medicine (2017) 4, 32–34
- “The term intraperitoneal focal fat infarction (IFFI) includes various self-limiting clinical conditions that are caused by focal fatty tissue necrosis. Most of the cases of IFFI concern torsion or infarction of the greater omentum or the epiploic appendages. However,although rarely, perigastric ligaments can also undergo torsion also leading to fat infarction. IFFI clinically may mimic other pathologies, such as acute appendicitis or diverticulitis, making their clinical diagnosis a challenge. Ultrasound (US) and computed tomography (CT) have a high sensitivity and specificity for the diagnosis of IFFI excluding other pathologies, and in most cases, the clinical evolution is spontaneously favorable, thus helping to reduce the need for unnecessary surgical intervention.”
Intraperitoneal focal fat infarction: the great mimicker in the acute setting
Eleni Lazaridou et al.
Emerg Radiol 2021 Feb;28(1):201-207 - "Intraperitoneal focal fat infarction may rarely involve the perigastric ligaments which include the gastrohepatic, gastrosplenic, splenorenal, hepatoduodenal, gastrocolic, and falciform ligament. These ligaments extend out from the stomach covering the blood vessels, lymph vessels, lymph nodes, nerves, and the surrounding fat and also provide anatomic contiguity between the liver, pancreas, spleen, stomach, and transverse colon. In particular, the inferior part of the falciform ligament is formed by the umbilical vein involution and contains the falciform artery and paraumbilical veins. The fatty appendages of the aforementioned ligaments can twist spontaneously, causing vascular compromise, resulting in inflammation or ischemia.”
Intraperitoneal focal fat infarction: the great mimicker in the acute setting
Eleni Lazaridou et al.
Emerg Radiol 2021 Feb;28(1):201-207 - “PA has a predilection for women (male vs female 1:3) and usually affects patients between 15 and 84 years old. Clinical presentation includes sudden onset of epigastric pain which may be accompanied by low-grade fever. Other gastrointestinal symptoms are typically absent. Due to the non-specific symptoms, PA may mimic more frequent gastroduodenal or pancreatic diseases.Torsion of the fatty appendage of the perigastric and falciform ligaments can be seen on US as a hyperechoic, non-compressible heterogeneous mass in the site of maximal pain . On CT, torsion of the fatty appendage of the falciform ligament appears as an oval, well-defined, heterogeneous area with fat density, associated with surrounding inflammatory changes in the adjacent fat planes . Post-contrast CT does not seem to offer extra information.”
Intraperitoneal focal fat infarction: the great mimicker in the acute setting
Eleni Lazaridou et al.
Emerg Radiol 2021 Feb;28(1):201-207 - “Perigastric appendagitis can present with an acute abdomen, which is safely managed conservatively if diagnosed correctly. Radiologists should be aware of the entity to avoid unnecessary intervention, and recognize the CT findings of ovoid fat inflammation in the distribution of the perigastric ligaments.”
Perigastric appendagitis: CT and clinical features in eight patients.
Justaniah AI et al.
Clin Radiol. 2014 Dec;69(12):e531-7
- “Gastric ulcers are common and often result from H. pylori infection or medications, especially NSAIDs. Superficial ulcers are not typically well visualized on MDCT; however, deep or penetrative ulcers may be appreciated. Secondary inflammation can result in adjacent wall thickening or other soft tissue change. Extraluminal gas or pneumoperitoneum may be present in cases of perforation. A prior study found specificities of 93%, 71%, and 43% for focal, eccentric, and enhancing gastric wall thickening with corresponding sensitivities of 8%, 75%, and 88% when assessing for malignant or potentially malignant lesions, thus the presence of enhancing, eccentric, focal gastric wall thickening of greater than 1 cm raises concern for underlying neoplasm and warrants endoscopy. Complications from gastric ulcers can be assessed with MDCT including perforation or fistula formation; however, these are unusual sequelae of a common condition.”
Nonmalignant gastric causes of acute abdominal pain on MDCT: a pictorial review
Christopher I. Fung , Elliot K. Fishman
Abdom Radiol (2017) 42:101–108 - “Upper gastrointestinal bleeding accounts for approximately 0.1% of hospitalizations in the USA each year, with a mortality rate of 10%. Common causes of gastric hemorrhage include ulcers, varices, Mallory– Weiss tears, vascular lesions, and neoplasms. Clinical presentation varies depending on the degree of blood loss, ranging from asymptomatic with less than 100 mL/day to systemic shock if greater than 15% of the circulating blood volume is lost. Contrast-enhanced MDCT may allow direct visualization of the bleeding site via high-attenuating contrast extravasation. In the absence of contrast, high-attenuating debris within the stomach fundus can suggest ongoing or prior hemorrhage, particularly in hospitalized patients without recent ingestion with unexplained anemia or abdominal pain. Attenuation of blood products within the lumen measures 30–45 HU if unclotted and 45–70 HU if clotted.”
Nonmalignant gastric causes of acute abdominal pain on MDCT: a pictorial review
Christopher I. Fung , Elliot K. Fishman
Abdom Radiol (2017) 42:101–108 - “Abdominal pain is a common complaint in the emergency department and clinical services are increasingly reliant on accurate imaging to aid in diagnosis and management. The stomach may result in acute abdominal pain via a breadth of pathology. Rapid recognition and high clinical suspicion, in combination with appropriate image acquisition, may dramatically alter patient management and serve to improve patient care. Due to the difficulty in adequately visualizing the stomach, cursory assessment is commonplace. Radiologists must actively and carefully evaluate the stomach on MDCT to allow early recognition of often subtle pathology.”
Nonmalignant gastric causes of acute abdominal pain on MDCT: a pictorial review
Christopher I. Fung , Elliot K. Fishman
Abdom Radiol (2017) 42:101–108 - “The photorealistic images of cinematic rendering may enable improved visualization of surface detail and the mucosal surface. This ability may also help identify subtle lesions and may further characterize neoplastic and nonneoplastic pathologic findings.”
Cinematic Rendering of a Perforated Benign Gastric Ulcer
HannahS.Recht,MD • ElliotK.Fishman,MD
Radiology 2021 (in press) 
- “Watermelon stomach (WMS), or gastric antral vascular ectasia, is an uncommon but clinically important cause of chronic occult or overt gastrointestinal (GI) blood loss. Patients typically present with symptomatic anemia and hemoccult positive stools. Although the diagnosis is based primarily on the typical endoscopic appearance, the lesion may be overlooked on initial evaluation or interpreted as "gastritis." Gastric biopsy may be helpful in confirming the diagnosis by showing vascular ectasia, typically without inflammation. WMS is idiopathic but is often associated with autoimmune diseases or cirrhosis of the liver. The majority of patients with classic WMS are elderly and female.”
- “Gastric antral vascular ectasia (GAVE) is a rare entity with unique endoscopic appearance described as "watermelon stomach." It has been associated with systemic sclerosis but the pathophysiological changes leading to GAVE have not been explained and still remain uncertain.”
Gastric Antral Vascular Ectasia in Systemic Sclerosis: Current Concepts.
Parrado RH et al.
Int J Rheumatol. 2015;2015:762546. - “Gastric antral vascular ectasia, or “watermelon stomach,” is a rare cause of chronic gastrointestinal bleeding, characterized endoscopically by a distinctive appearance of prominent red vascular folds traversing the gastric antrum and radiating to the pyloric sphincter; this appearance has been likened to the stripes on a watermelon rind.”
Gastric antral vascular ectasia ("watermelon stomach"): radiologic findings.
Urban BA, Jones B, Fishman EK, Kern SE, Ravich WJ.
Radiology. 1991 Feb;178(2):517-8. - “Gastric antral vascular ectasia primarily affects women (9:1 female-to-male ratio) aged 56-76 years, and is associated with liver cirrhosis (37%) and achlorhydria (35%). The usual symptoms are iron-deficiency anemia and melena due to chronic gastrointestinal bleeding from the dilated, superficial, and easily traumatized vessels. Antrectomy is curative, but endoscopic treatment with heat probes or lasers has shown promise.”
Gastric antral vascular ectasia ("watermelon stomach"): radiologic findings.
Urban BA, Jones B, Fishman EK, Kern SE, Ravich WJ.
Radiology. 1991 Feb;178(2):517-8. - “In our patient, the findings of prominent mucosal folds extending from the pyloric channel on upper gastrointestinal series and the thickened antral wall on CT scans correlate well with the known pathologic appearance of gastric antral vascular ectasia. Histologically, antral thickening results from a combination of foveolar and fibromuscular hyperplasia. Grossly, the antral fold prominence appears to result from bunching of the mucosa in the thickened, hypercontractile antrum.”
Gastric antral vascular ectasia ("watermelon stomach"): radiologic findings.
Urban BA, Jones B, Fishman EK, Kern SE, Ravich WJ.
Radiology. 1991 Feb;178(2):517-8.
- Purpose: To report the computed tomography (CT) findings of acute peptic ulcer disease (PUD) and to evaluate the usefulness of contrast media for diagnosis.
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 pro- vided 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.
Computed tomography findings of acute gastric peptic ulcer
Kanako Oyanagi , Takeshi Higuchi , Norihiko Yoshimura
Clinical Imaging 71 (2021) 77–82 - “The major complications of acute PUD are perforation and bleeding. Intraperitoneal free air is a major sign of perforation. Intravenous contrast media extravasation into the stomach is a sign of active bleeding. High-density gastric contents, with a suspicion of blood clots, can also indicate recent bleeding and are generally found close to the bleeding site. Although many reports have described CT findings of complicated PUD, the CT findings of uncomplicated PUD have not been well documented.”
Computed tomography findings of acute gastric peptic ulcer
Kanako Oyanagi , Takeshi Higuchi , Norihiko Yoshimura
Clinical Imaging 71 (2021) 77–82 - "The most recognized sign of PUD on a CT scan was high-density gastric contents. Of course, this finding was the result of not only bleeding, but also surgical material, foreign bodies, medications, etc. However, high-density gastric contents were suspected of intra- luminal bleeding in our study because bleeding was confirmed on endoscopy in up to 93% subjects with high-density gastric contents. In the emergency department, if CT findings in patients with acute abdomen reveal high-density gastric contents, acute PUD should be suspected since it is the most common cause of gastrointestinal bleeding.”
Computed tomography findings of acute gastric peptic ulcer
Kanako Oyanagi , Takeshi Higuchi , Norihiko Yoshimura
Clinical Imaging 71 (2021) 77–82 - "Focal luminal outpouching is a direct CT finding of PUD and corresponds to the ulcer crater, for which a defective mucosa occurs endo- scopically. Focal luminal outpouching was observed in 50% of patients undergoing contrast-enhanced CT and in 23% of patients undergoing non–contrast-enhanced CT. These proportions were higher than in previous reports. We speculated that the findings were easier to detect by limiting the subjects of our study to those in the acute phase.”
Computed tomography findings of acute gastric peptic ulcer
Kanako Oyanagi , Takeshi Higuchi , Norihiko Yoshimura
Clinical Imaging 71 (2021) 77–82 - "In conclusion, we found that the most important CT findings of acute-phase gastric ulcer are high-density gastric contents, focal luminal out- pouching, and focal low-attenuation wall thickening. When emergency department patients with nonspecific abdominal symptoms present with these CT findings, acute PUD can be suspected, which is helpful for determining subsequent examinations and appropriate treatment.”
Computed tomography findings of acute gastric peptic ulcer
Kanako Oyanagi , Takeshi Higuchi , Norihiko Yoshimura
Clinical Imaging 71 (2021) 77–82
- “Although the mucosal detail of CT is relatively poor compared with barium fluoroscopy or endoscopy, CT can be used with the appropriate imaging protocols to identify inflammatory conditions of the stomach ranging from gastritis to peptic ulcer disease. In addition, CT can readily demonstrate the various complications of gastric disease, including perforation, obstruction, and hemorrhage, which may direct further clinical, endoscopic, or surgical management.”
CT of Gastric Emergencies. Guniganti P et al. Radiographics. 2015 Nov-Dec;35(7):1909-2 - “Inadequate gastric distention limits diagnostic evaluation of the stomach and poses a potential pitfall, as it may create a false appearance of thickening or, conversely, may obscure true disease. When evaluating abnormal gastric wall thicken- ing in a nondistended stomach, supplementary findings can be helpful in identifying disease.”
CT of Gastric Emergencies. Guniganti P et al. Radiographics. 2015 Nov-Dec;35(7):1909-2
- Drug-induced gastropathy is most commonly caused by nonsteroidal anti-inflammatory medications (NSAIDs), as these are one of the most frequently prescribed classes of medications worldwide.The mechanism of injury is related to reduced prostaglandin synthesis. Prostaglandins play an important role in gastric epithelial defense by stimulating mucus and bicarbonate secretion and suppressing gastric acid secretion, thus helping to maintain epithelial cell reconstitution and mucosal blood flow . Most traditional NSAIDs inhibit the cyclooxygenase (COX) enzyme involved in prostaglandin synthesis.
Imaging of Drug-induced Complications in the Gastrointestinal System McGettigan MJ et al. RadioGraphics 2016; 36:71–87 - “Chemotherapy may cause gastric mucosal ulceration, hemorrhage, and perforation.This is particularly the case with cytotoxic agents that tar- get rapidly dividing cells, such as those in the gasrointestinal tract. In some cases of primary gastric or mesenteric metastases, the tumor provides structural stability to the gastrointestinal tract. When targeted with chemotherapy, tumor necrosis.”
Imaging of Drug-induced Complications in the Gastrointestinal System McGettigan MJ et al. RadioGraphics 2016; 36:71–87
- Giant Gastric Folds: Differential Diagnosis
- Menetrier disease
- Acute gastric mucosal lesions ( hypertrophic gastritis, eosinophilic gastritis, chronic gastritis)
- Gastric lymphoma
- Scirrhous carcinoma
- Zollinger Ellison syndrome
- Sarcoidosis "MDCT may be a reliable means of noninvasive diagnosis in the care of patients with endoscopically detected giant gastric folds and may be useful for differentiating benigh from malignant disease."
MDCT of Giant Gastric Folds: Differential Diagnosis
Chen CY et al.
AJR 2010; 195:1124-1130- Crohn’s Disease: Complications
- Bleeding
- Obstruction
- Strictures
- Abscesses
- Fistulae formation