Elliot K. Fishman M.D.
Johns Hopkins Hospital

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“Gastritis can be secondary to many etiologies including infection, systemic illness such as trauma or burns, and autoimmune disease. Peptic ulcer disease is most commonly caused by Helicobacter Pylori infection and chronic NSAID use . The most common sites for ulcer formation are the gastric antrum/pylorus and proximal duodenum. The resultant edema and fibrosis around the ulcer site can cause narrowing and eventual obstruction of the gastric outlet. Prior to the widespread use of H2 blockers and proton pump inhibitors, peptic ulcer disease was the most common cause of gastric outlet obstruction, however in the era of H2 blockers, outlet obstruction now predicts malignancy. While endoscopy is the modality of choice for diagnosing gastritis, CT is often performed first particularly in the setting of acute abdominal pain.”
Imaging of acute gastric emergencies: a case-based review 
Jetty S et al.
Clinical Imaging 72 (2021) 97–113

“On CT, gastritis will appear as wall thickening with alternating hyper- and hypoattenuation representing mucosal enhancement and submucosal edema. The presence of mucosal enhancement (hyperemia) on CT suggests gastritis as the cause of gastric wall thickening. An uncommon form of gastritis is emphysematous gastritis. It is usually caused by gas-forming Escherichia coli. Initially obtained AXR may show mottled gas outlining the gastric wall. CT can confirm the diagnosis. Mottled gas can also be a sign of gastric pneumatosis from ischemia.”
Imaging of acute gastric emergencies: a case-based review 
Jetty S et al.
Clinical Imaging 72 (2021) 97–113

“On imaging, it can be difficult to distinguish benign peptic ulcer disease from malignant causes of gastric outlet obstruction and biopsy is required for confirmation. Peptic ulcers can perforate and should be recognized on imaging.”
Imaging of acute gastric emergencies: a case-based review 
Jetty S et al.
Clinical Imaging 72 (2021) 97–113

”Fistulae can form between the stomach and adjacent viscera. In patients with chronic cholecystitis or long-standing cholelithiasis gradual erosion can develop between the inflamed gallbladder wall and stomach or first part of duodenum. The Gallstone can extend into the bowel and cause gallstone ileus, a relatively rare cause of a mechanical small bowel obstruction. CT with contrast is the imaging modality of choice. The gallstone becomes impacted in the ileocolic valve and results in pneumobillia, ectopic gallstone and proximal small bowel dilatation. A rarer form of gallstone ileus can occur where the stone is impacted in the pylorus or the duodenum and is called Bouveret syndrome. Morbidity is high and has been reported as high as 33%.” 
Imaging of acute gastric emergencies: a case-based review 
Jetty S et al.
Clinical Imaging 72 (2021) 97–113

”Primary gastric cancer (GC) is a common cause of cancer related death worldwide and can initially present as a gastric ulcer. The characteristic CT finding in GC is disruption of the multilayered pattern of the gastric wall enhancement with thickening, variable enhancement and ulceration. Malignancy is the most common cause of gastric outlet obstruction. Malignant obstruction is an advanced disease presentation that occurs in up to 20% of patients with primary pancreatic, gastric, or duodenal carcinomas. It can be intrinsic or extrinsic. Extrinsic obstruction is almost always due to compression of the gastric outlet from tumor growth in surrounding organs. It is most commonly seen with primary tumors of the pancreas and duodenum.”
Imaging of acute gastric emergencies: a case-based review 
Jetty S et al.
Clinical Imaging 72 (2021) 97–113

“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 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