Diffrential Diagnosis of Gastric Masses and Narrowing
Transcript of Diffrential Diagnosis of Gastric Masses and Narrowing
DIFFRENTIAL DIAGNOSIS OF GASTRIC MASSES AND NARROWING
LAYOUT… Anatomy of stomach DD of gastric masses
Anatomy of Stomach
Radiographic Anatomy Barium Meal
Reticular pattern Area Gastricae
Rugae
Rosette of folds in gastric cardia
CT 2-3 layered
structure
Max thickness of stomach wall _4mm
EUS 5 layers of
bowel wall Wall thickness of
distended stomach _3 mm
Differential Diagnosis Of Gastric Masses
Benign tumours
Malignant tumours
Miscellaneous causes
Benign Mucosal Tumours Hyperplastic Polyps -Local hyperplasia of glandular tissue -Small , smooth , sessile ,multiple -Size < 1 cm -Fundus & body of stomach -Arise from mucosa affected by chronic
atrophic gastritis.
Radiographic Appearance
Dependant part of stomach__filling defect
Anterior wall polyp__ring
Small, sessile,smooth polyps__always benign
Polyp>1cm OR irregular surface__further workup needed
Adenomatous polyps Majority dysplastic_may undergo
malignant change -Tubular -Tubulovillous -Villous >1cm ,larger than hyperplastic Solitary with nodular surface Commonest site__Gastric antrum May pedunculate,prolapse in pylorus
Risk of malignant transformation relative to size
Carcinoma may co-exist
BENIGN SUBMUCOSAL TUMORS
Include 1. Stromal tumours2. Neurofibroma 3. Lipoma4. Hemangioma5. Lymphangioma6. Glomus tumour7. Neural tumour8. Brunner gland hemartoma9. Duplication cyst10. Ectopic pancreatic rest
Difficult to diagnose by endoscopy because overlying mucosa may be intact
Large tumours tend to ulcerate
Smooth bulge into bowel lumen , margins forming a right angle/obtuse angle with normal bowel wall.
Complications : Necrosis Ulceration Gastric outflow obstruction Intussusception Large abdominal mass
Radiographic Findings Barium Meal: -clearly defined margins -if central ulcer present__bull’s
eye/target appearance
CT: -well defined, homogenous mass -larger tumours__ulceration, necrosis -glomus tumour, pancreatic, carcinoid
__ hypervascular -stromal, glomus tumour, hemangioma __calcifications
Benign stromal tumours
EUS – diagnostic modality of choice -mass arising from mucularis propria or
muscularis mucosa -smaller,echo-poor ,well-defined >3cm tumors surgically removed
Lipomas
Soft , may change shape with peristalsis or palpation
May ulcerate , bleed , intussuscept Diagnosed by : -EUS__echogenic tumour Confirmed by: - CT
Hemangioma
Capillary /cavernous type Solitary / multiple
-endoscopy for diagnosis -may complicate into: Phlebolith GI bleeding
Duplication cysts
Greater curve of antrum OR anteromedialy in 1st or 2nd part of
duodenum Congenital failure of bowel
recanalization Gastric duplication present in early
childhood Filled with clear mucinous fluid
Ectopic pancreatic rest
Small __ 1-3 cm Distal end of greater curve OR proximal
duodenum Incidental finding If tissue well-diffrentiated,barium study
may show a central niche or fill a short ductal system.
Complications :• Pancreatitis• Pseudocyst• Adenocarcinoma CT – variable appearance -homogenous , strongly enhancing
tumours OR -avascular cystic lesions
MALIGNANT TUMOURS Include :1. Gastric carcinoma2. Lymphoma3. Malignant stromal tumours (GIST)4. Kaposi sarcoma5. Carcinoid tumour6. Metastatic tumours
Gastric Carcinoma Risk factors:• Atrophic gastritis intestinal
metaplasia dysplasia neoplasia • Pernicious anemia• H. Pylori infection• Partial gastrectomy• Nitrates intake
Symptoms:• Anorexia • Dyspepsia• Weight loss• Anemia
Early Carcinoma Mucosa and submucosa 90% 5 yr survival rate Diffrentiate benign ulcers from
ulcerating malignancy __nodularity, clubbing, interrupted or fused mucosal folds
Advanced Carcinoma Muscularis propria invasion May be• Polypoid • Fungating• Ulcerated• Infiltrating (linitis plastica)
Stippled calcification in mucin producing Ca
Ulcerated early Ca resembles benign ulcer (meniscus sign)
Large tumours__obvious filling defects on barium studies
Linitis Plastica
Metastatic Carcinoma Most common mets in stomach from:• Malignant melanoma• Ca breast• Kidney, lung, thyroid, testes
Malignant melanoma
Bull’s eye / target lesion
Pad sign. Ca head of pancreas
Mets from
Ca breast
Lymphoma Most common site of GI lymphoma H.Pylori __MALT lymphoma Coeliac disease __T-cell lymphoma Middle aged men Doesn’t cause obstruction commonly
Radiological appearanceo Often identical to gastric Ca, benign
ulcers, suspect lymphoma if:• Giant cavitating lesions• Pronounced gastric folds thickening
• Multiple polypoid tumours(bull’s eye)
CT-Bulky homogenous
tumour-gastric wall thickness -perigastric fat plane
preserved-transpyloric spread-splenomegally-multicentricity__CT used for staging
Malignant stromal tumors_GIST
1% of gastric malignancies Fundus and body involved Middle age / elderly __ males > females Large tumours, might pedunculate Central necrosis and ulceration
CT Exophytic growth Low density
necrotic centre Dystrophic
calcification Mets to peritoneal
cavity, liver, lung ,bone
Kaposi Sarcoma
Tumour of blood vessels 1/3rd of homosexual male patients with
AIDS Multifocal tumours throughout GIT
Diagnosed by Endoscopy -hemorhagic patches on gastric mucosa Barium meal - large polypoid tumors OR -submucosal nodule,later
ulcerates_bull’s eye lesion -linitis plastica CT -retroperitoneal LN enlargement -splenomegaly
Carcinoid Tumour
Rare in stomach/duodenum Slow-growing__distal antrum,lesser
curvature Submucosal nodules__may
ulcerate/pedunculate Hypervascular__both pri. n liver mets ___assess in both arterial and venous
phase on CT
Miscellaneous Causes of Gastric narrowing
Extrinsic compressions Gastric pseudotumours HPS Bezoar Peptic ulceration
Extrinsic Gastric Compressions
Diagnosed by : Endoscopy Barium studies USG CT
Gastric Pseudotumours Gastric fundal varices -filling defect on
barium meal
Intragastric prolapse of sliding hiatus hernia
-mucosal folds form the mass
-disappears in recumbent position
Bezoar Mass of ingested material Dragging sensation/ fullness 2 types: Trichobezoar -mass of matted hair -young girls , psychiatric patients Phytobezoars -vegetables/ fruit pith -unripe persimons, gastric surgery
Diagnosis: -Barium meal __filling defect __outlines the mass __may penetrate __mottled appearance
Rapunzel’s syndrome:
-severe case of trichobezoar
-extend into small bowel, even caecum
Plain radiograph of the abdomen showing multiple air fluid levels with dilated small intestinal loops and a sizable soft tissue density within the stomach
Hypertrophic Pyloric Stenosis
Congenital anomaly - Infantile - adult Stasis causes __ antral gastritis +
ulceration Antrum tapers into >2cm long pyloric
canal
To differentiate from annular Ca:
Antral tapering Absence of mucosal
destruction Intact mucosal
folds passing through pyloric canal
Gastric Ulcers In advanced cases, may cause gastric
strictures