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

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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