Diagnostic Tests

 Esophagogastroduodenoscopy Patients with one or more of the alarm

symptoms listed in Table 26-5 should undergo expeditious upper endoscopy.
Esophagogastroduodenoscopy (EGD) is a safe and accurate outpatient procedure
performed under conscious sedation.38 Smaller flexible scopes with excellent optics and a
working channel are easily passed transnasally in the unsedated patient. Following an 8-
hour fast, the flexible scope is advanced under direct vision into the esophagus, stomach,
and duodenum. The fundus and GE junction are inspected by retroflexing the scope. To
rule out cancer with a high degree of accuracy, all patients with gastric ulcer diagnosed
on upper GI series or found at EGD should have multiple biopsy specimens of the base
and rim of the lesion. Brush cytology also should be considered. Gastritis should be
biopsied both for histologic examination and for a tissue urease test to rule out the
presence of H. pylori. If Helicobacter infection is detected, it should probably be treated
because of the etiologic association with peptic ulcers, mucosa-associated lymphoid
tissue (MALT), and gastric cancer. The most serious complications of EGD are
perforation(which is rare, but can occur anywhere from the cervical esophagus to the
duodenum), aspiration, and respiratory depression from excessive sedation. Although
EGD is a more sensitive test than double-contrast upper GI series, these modalities should
be considered complementary rather than mutually exclusive.
 Radiologic Tests. Plain abdominal X-rays may be helpful in the diagnosis of gastric
perforation (pneumoperitoneum) or delayed gastric emptying (large air-fluid level).
Double-contrast upper GI series may be better than EGD at elucidating gastric diverticula,
fistula, tortuosity, stricture location, and size of hiatal hernia. Although there are
radiologic characteristics of ulcers that suggest the presence or absence of malignancy,
gastric ulcers always require adequate biopsy.
 Computed Tomographic Scanning and Magnetic Resonance
Imaging. Usually, significant gastric disease can be diagnosed without these
sophisticated imaging studies. However, one or the other should be part of the routine
staging work-up for most patients with a malignant gastric tumor. Magnetic resonance
imaging (MRI) may prove clinically useful as a quantitative test for gastric emptying, and
may even hold some promise for the analysis of myoelectric derangements in patients
with gastroparesis. Virtual gastroscopy using multi detector CT scan or MRI is not yet
widely used but these techniques may prove useful for screening and staging of gastric
disease.39–41(Fig. 26-21)Arteriography may be helpful in the occasional poor-riskpatient
with exsanguinating gastric hemorrhage, or in the patientwith occult gastric bleeding.
 Endoscopic Ultrasound. Endoscopic ultrasound (EUS) is useful in the evaluation
and management of some gastric lesions.42–44 Local staging of gastric adenocarcinoma
with EUS is quite accurate, and this modality can be used to plan therapy. At some
centers, patients with transmural and/or node positive adenocarcinoma of the stomach
are considered for preoperative (neoadjuvant) chemoradiation therapy. EUS is the best
way to clinically stage these patients locoregionally. Suspicious nodes can be sampled
with EUS-guided endoscopic needle biopsy. Malignant tumors that are confined to the
mucosa on EUS may be amenable to endoscopic mucosal resection (EMR). EUS also can
be used to assess tumor response to chemotherapy. Submucosal masses are commonly
discovered during routine EGD. Large submucosal masses should be resected because of
the risk of malignancy, but observation may be appropriate for some small submucosal
masses (e.g., lipoma or small GIST). There are endoscopic characteristics of benign and
malignant mesenchymal tumors, and thus, EUS can provide reassurance, but no
guarantee, that small lesions under observation are probably benign. Submucosal varices
also can be assessed by EUS.
 Gastric Secretory Analysis. Analysis of gastric acid output requires gastric
intubation, and it is performed infrequently nowadays. This test may be useful in the
evaluation of patients with hypergastrinemia, including the Zollinger-Ellison syndrome
(ZES), patients with refractory ulcer or GERD, and patients with recurrent ulcer after
 operation. Historically, gastric analysis was performed most commonly to test for the
adequacy of vagotomy in postoperative patients with recurrent or persistent ulcer. Now
this can be done by assessing peripheral pancreatic polypeptide levels in response to
sham feeding.45 A 50% increase in pancreatic polypeptide within 30 minutes of sham
feeding suggests vagal integrity. Normal basal acid output (BAO) is greater than 5 mEq/h.
MAO is the average of the two final stimulated 15-minute periods and is usually 10 to 15
mEq/h. Peak acid output is defined as the highest of the four stimulated periods. Patients
with a gastrinoma commonly have a high BAO, often above 30 mEq/h, but consistently
above 15 mEq/h unless there has been previous vagotomy or gastric resection. In
patients with gastrinoma, the ratio of BAO to MAO exceeds 0.6. Normal acid output in the
patient prescribed acid-suppressive medication usually means that the patient is
noncompliant. To assess acid-secretory capacity in the absence of medication effect, H2
blockers and PPIs should be withheld before gastric analysis.
 Scintigraphy. The standard scintigraphic evaluation of gastric emptying involves the
ingestion of a test meal with one or two isotopes, and scanning the patient under a
gamma camera. A curve for liquid and solid emptying is plotted, and the half-time
calculated. Normal standards exist for each facility. Duodenogastric reflux can be
quantitated by the IV administration of hepatobiliary iminodiacetic acid (HIDA scan),
which is concentrated and excreted by the liver into the duodenum. Software allows a
semiquantitative assessment of how much of the isotope refluxes into the stomach.
Positron emission tomography (PET) scan or CT/PET scan may be useful in staging certain
patients with gastric malignancy.
 Tests for Helicobacter pylori. A variety of tests can help the clinician to
determine whether the patient has active H. pylori infection.46 The predictive value
(positive and negative) of any of these tests when used as a screening tool depends on
the prevalence of H. pylori infection in the screened population. A positive test is quite
accurate in predicting H. pylori infection, but a negative test is characteristically
unreliable. Thus, in the appropriate clinical setting, treatment for H. pylori should be
initiated on the basis of a positive test, but not necessarily withheld if the test is negative.
Because of the association between H. pylori infection and gastric lymphoma and
carcinoma, many clinicians recommend treating Helicobacter infection when the
diagnosis is made. A positive serologic test is presumptive evidence of active infection if
the patient has never been treated for H. pylori. Histologic examination of an antral
mucosal biopsy using special stains is the gold standard test. Other sensitive tests include
commercially available rapid urease tests, which assay for the presence of urease in
mucosal biopsy specimens (strong presumptive evidence of infection). Urease is an
omnipresent enzyme in H. pylori strains that colonize the gastric mucosa. The labeled
carbon-13 urea breath test has become the standard test to confirm eradication of H.
pylori following appropriate treatment.47 In this test, the patient ingests urea labeled with
nonradioactive 13 C. The labeled urea is acted upon by the urease present in the H. pylori
and converted into ammonia and carbon dioxide. The radiolabeled carbon dioxide is
excreted from the lungs and can be detected in the expired air (Fig. 26-22). It also can be
detected in a blood sample. The fecal antigen test also is quite sensitive and specific for
active H. pylori infection and may prove more practical in confirming a cure.
 Antroduodenal Motility Testing and Electrogastrography.
Antroduodenal motility testing and electrogastrography (EGG) are performed in
specialized centers and may be useful in the evaluation of the patient with anomalous
epigastric symptoms. EGG consists of the transcutaneous recording of gastric myoelectric
activity. Antroduodenal motility testing is done with a tube placed transnasally or
transorally into the distal duodenum. There are pressure-recording sensors extending
from the stomach to the distal duodenum. The combination of these two tests together
with scintigraphy provides a thorough assessment of gastric motility.

INVESTIGATION OF THE
STOMACH AND DUODENUM
Flexible endoscopy
Flexible endoscopy is the ‘gold standard’ investigation of the
uwere fibreoptic (Hirschowitz), but now most use a solid-state
camera mounted at the instrument’s tip (Figures 63.5 and
63.6). Other members of the endoscopy team see the image
and this is useful when taking biopsies or performing interventional
techniques, and it also facilitates teaching and training.pper gastrointestinal tract. The
original flexible endoscopes

Flexible endoscopy is more sensitive than conventional

radiology in the assessment of the majority of gastroduodenal
conditions. This is particularly the case for peptic ulceration,
gastritis and duodenitis. In upper gastrointestinal bleeding,
endoscopy is far superior to any other investigation and offers
the possibility of endoscopic therapy. In most circumstances
it is the only investigation required.
Fibreoptic endoscopy is generally a safe investigation, but
it is important that all personnel undertaking these procedures
are adequately trained. Careless and rough handling of
the endoscope during intubation of a patient may result in
perforations of the pharynx and oesophagus. Any other part
of the upper gastrointestinal tract may also be perforated. An
inadequately performed endoscopy is also dangerous as a serious
condition may be overlooked. This is particularly the case
in respect of early and curable gastric cancer, the appearances
of which may often be extremely subtle and may be missed
by inexperienced endoscopists. A more experienced endoscopist
will have a higher index of suspicion for any mucosal
abnormalities and will take more biopsies. Spraying the
mucosa with dye endoscopically may allow better discrimination
between normal and abnormal mucosa, so allowing a
small cancer to be more easily seen. In the future, advances in
technology may allow ‘optical biopsy’ to determine the nature
of mucosal abnormalities in real time.
Upper gastrointestinal endoscopy can be performed without
sedation, but when sedation is required incremental doses
of a benzodiazepine are usually administered. Sedation is of
particular concern in the case of gastrointestinal bleeding
as it may have a more profound effect on the patient’s cardiovascular
stability. It has now become the standard to use
pulse oximetry to monitor patients during upper gastrointestinal
endoscopy, and nasal oxygen is often also administered.
Buscopan is useful to abolish duodenal motility for examinations
of the second and third parts of the duodenum. Examinations
of this type are best carried out using a side-viewing
endoscope such as is used for endoscopic retrograde cholangiopancreatography
(ERCP).
Some patients are relatively resistant to sedation with
benzodiazepines, particularly those who are accustomed to
drinking alcohol. Increasing the dose of benzodiazepines
in these patients may not result in any useful sedation, but
merely make the patient more restless and confused. Such
patients are sometimes better endoscoped fully awake using a
local anaesthetic throat spray and a narrow-gauge endoscope.
Whatever the circumstances, it is important that resuscitation
facilities are available including agents that reverse the
effects of benzodiazepines, such as flumazenil.
The technology associated with upper gastrointestinal
endoscopy is continuing to advance. Instruments which allow
both endoscopy and endoluminal ultrasound to be performed
simultaneously (see later) are used routinely. Bleeding from
the stomach and duodenum can be treated with a number of
haemostatic measures. These include injection with various
substances, diathermy, heater probes, lasers and clips. These
approaches appear to be useful in the treatment of bleeding
ulcers, although there are few good controlled trials in this
area. There is no good evidence that such interventional
procedures at the moment work in patients who are bleeding
from very large vessels, such as the gastroduodenal artery or
splenic artery, although technology may overcome this problem
in the future.
Contrast radiology
Upper gastrointestinal radiology is not used as much as in
previous years, as endoscopy is a more sensitive investigation
for most gastric problems. Computed tomography (CT) imaging
with oral contrast has also replaced contrast radiology in
many of the areas where anatomical information is sought,
eg large hiatus hernias of the rolling type and chronic gastric
volvulus. In these conditions it may be difficult for the endoscopist
to determine exactly the anatomy or, indeed, negotiate
the deformity to see the distal stomach.
Ultrasonography
Standard ultrasound imaging can be used to investigate the
stomach, but used conventionally it is less sensitive than other
modalities. In contrast, endoluminal ultrasound and laparoscopic
ultrasound are probably the most sensitive techniques
available in the preoperative local staging of gastric cancer. In
endoluminal ultrasound, the transducer is usually attached to
the distal tip of the instrument. However, devices have been
developed which may be passed down the biopsy channel,
albeit with poorer image quality. Five layers (Figure 63.7)
of the gastric wall may be identified on endoluminal ultrasound
and the depth of invasion of a tumour can be assessed
with exquisite accuracy (90% accuracy for the ‘T’ component
of the staging). Enlarged lymph nodes can also be identified
and the technique’s accuracy in this situation is about 80%.

Finally, it may be possible to identify liver metastases not

seen on axial imaging. Laparoscopic ultrasound is also a very
sensitive imaging modality to a large measure because of the
laparoscopy itself (see below). It is one of the most sensitive
methods of detecting liver metastases from gastric cancer.
An additional use of ultrasound is in the assessment of
gastric emptying. Swallowed contrast is utilised, which is
designed to be easily seen using an ultrasound transducer. The
emptying of this contrast is then followed directly. The accuracy
of the technique is similar to that of radioisotope gastric
emptying studies (see below).
CT scanning and magnetic
resonance imaging
The resolution of CT scanners is continuing to improve, and
multislice CT is of increasing value in the investigation of the
stomach, especially gastric malignancies (Figure 63.8). The
presence of gastric wall thickening associated with a carcinoma
of any reasonable size can be easily detected by CT, but
the investigation lacks sensitivity in detecting smaller lesions.
It is much less accurate in ‘T’ staging than endoluminal ultrasound.
Lymph node enlargement can be detected and, based
on the size and shape of the nodes, it is possible to be reasonably
accurate in detecting nodal involvement with tumour.
However, as with all imaging techniques, it is limited. Microscopic
tumour deposits in lymph nodes cannot be detected
when the node is not enlarged and, in contrast, lymph nodes
may undergo reactive enlargement but not contain tumour.
These problems apply to all imaging techniques.
The detection of small liver metastases is improving,
although in general terms metastases from gastric cancer are
less easy to detect using CT than those, for instance, from
colorectal cancer. This is because metastases from gastric cancer
may be of the same density as liver and may not handle
the intravenous contrast any differently. At present, magnetic
resonance imaging (MRI) scanning does not offer any specific
advantage in assessing the stomach, although it has a higher
sensitivity for the detection of gastric cancer liver metastases
than conventional CT imaging.
CT/positron emission tomography
Positron emission tomography (PET) is a functional imaging
technique which relies on the uptake of a tracer in most cases
by metabolically active tumour tissue. Fluorodeoxyglucose
(FDG) is the most commonly used tracer. This tracer has a
short half-life hence manufacture and use have to be carefully
coordinated. To be of value, anatomical and functional
information need to be linked, hence PET/CT is now used
universally. It is increasingly being used in the preoperative
staging of gastro-oesophageal cancer as it will demonstrate
occult spread which renders the patient surgically incurable
in up to 10% of patients who would otherwise have undergone
major resections (Figure 63.9). PET/CT may also be
used to determine the response to neoadjuvant chemotherapy
in oesophagogastric malignancies although this is the subject
of ongoing studies.
Laparoscopy
This technique is routine in the assessment of patients with
gastric cancer. Its particular value is in the detection of peritoneal
disease, which is difficult by any other technique, unless
the patient has ascites or bulky intraperitoneal deposits. Its
main limitation is in the evaluation of posterior extension but
other techniques are available to evaluate posterior invasion,
especially CT and endoluminal ultrasound. Usually laparoscopy
is combined with peritoneal cytology unless laparotomy
follows immediately.
Gastric emptying studies
These are useful in the study of gastric dysmotility problems,
particularly those that follow gastric surgery. The principle
of the examination is that radioisotope-labelled liquid and
solid meals are ingested by the patient and the emptying of
the stomach is followed on a gamma camera. This allows the

proportion of activity in the remaining stomach to be assessed

numerically, and it is possible to follow liquid and solid gastric
emptying independently (Figure 63.10).
Angiography
Angiography is used most commonly in the investigation of
upper gastrointestinal bleeding that is not identified using
endoscopy. Therapeutic embolisation may also be of value
in the treatment of bleeding in patients in whom surgery is
difficult or inadvisable. In expert centres embolisation now
replaces surgery in the majority of cases.