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Perspective

Radiologic Evaluation of Gastritis and Duodenitis

David W. Gelfand1, David J. Ott, Michael V. M. Chen

C astritis
the
and
most
duodenitis
common
are among
upper gas- greatly
Diagnosis of H. pylon
simplified. Initially,
infection
the organism
has become
could
tis caused
than gastritis
by alcohol
caused
tends to be more
by NSAIDS but tends
diffuse
to
trointestinal abnormalities, being be detected only on biopsy samples taken at en- be most common distally [9].
several times more common than gastric ulcer doscopy. However, the urea breath test and sev-
or duodenal ulcer, respectively. The purpose of eral office- and laboratory-based serum tests
this perspective is to increase awareness of the have made the diagnosis of infection rapid and Radiologic Findings in Gastritis
possibilities for radiologic diagnosis of these inexpensive. Appropriate symptoms, an H. py- The literature regarding radiologic findings
two entities.
In this presentation, the discussion ion serum or breath test with positive findings, in patients with gastritis describes at least four
is limited to the acute or subacute gastritis and and signs of gastritis or duodenitis on an upper useful radiologic signs of this disease: thick
duodenitis most likely to cause a patient to see gastrointestinal series or endoscopy are a rea- folds, inflammatory nodules, erosions, and
a physician. We do not attempt to present a sonable basis for treatment. coarse areae gastricae. Any of these signs may
pathologic classification ofgastritis or duoden- NSAIDs are a recognized cause of gastritis be present in gastritis regardless of etiology.
itis, and we discuss these diseases on the basis and duodenitis, as well as of gastric and Thick folds can be defined as gastric folds
of the most likely causes and generally ac- duodenal ulcers [6-9]. The most commonly greater than 5 mm in caliber as measured on
cepted radiologic signs. used NSAIDs are aspirin, ibuprofen, and radiographs obtained with the stomach moder-
naproxen; these drugs are capable of causing ately distended [ 10, 1 1 ] (Fig. I ). The folds may
gastritis, duodenitis, and ulcers when taken be located in a limited region of the stomach or
Causes of Gastritis persistently or in quantity. In our experience, throughout the stomach. Although thick folds
Three etiologic agents are responsible for the most severe cases of gastritis, duodenitis, can be seen in gastritis of any cause, when
most cases of acute and subacute gastritis in and ulcer disease due to NSAIDs are caused present in a symptomatic patient they are most
which a specific cause can be identified. These by the more potent antiinflammatory agents, often associated with H. pylon infection.
agents are Helicobacterpylori, nonsteroidal an- particularly naproxen and indomethacin. Be- Inflammatory nodules are a second sign of
tiinflammatory drugs (NSAIDs), and alcohol. cause of the effects of gravity and because acute or subacute gastritis [12, 13] (Fig. 2).
H. pylon is the most frequent cause of gas- NSAIDs act as direct irritants on the gastric However, their origin is uncertain. Some nod-
tritis in the adult population throughout the mucosa, gastritis and gastric ulcers caused by ules may represent edema surrounding em-
world [ 1-5]. The infection may involve the en- these agents are often seen distally and on or sions that are too shallow to trap barium and
tire stomach or any region of the stomach. In- near the greater curvature [9]. that therefore are not recognized radiologically
fection is infrequent in children and young Alcohol is also a direct gastric irritant and is as erosions. Others may represent erosions that
adults, but it becomes increasingly common in a third cause of gastritis.
important Potent al- have epithelialized but that still have the asso-
middle-aged and elderly persons. The organ- coholic drinks such as whiskey, vodka, or gin ciated edema.
ism is transmitted as a fecal contaminant, and are more likely to cause alcoholic gastritis than Compared with benign neoplastic polyps,
in countries without effective water treatment, are beverages with a lower alcoholic content most inflammatory nodules caused by gastritis
infection with H. pylon is almost universal. such as beer or wine. The distribution of gastri- are smaller and do not project as sharply into

Received August 1, 1997; accepted after revision January 25, 1999.

‘All authors: Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157. Address correspondence D. W. Gelfand.

AJR 1999;173:357-361 0361-803X/99/1732-357 © American Roentgen Ray Society

AJR:173, August 1999 357

 Gelfand et al.
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Fig. 1.-Helicobacterpylorigastritis
in 63-year-old man.
A and B, Radiographs of gastric
body (A) and antrum (B) show thick-
ened mucosal folds (arrows).

Fig. 2.-Gastritiscaused by nonsteroidal antiinflammatory drugs in 58-year-old woman. Fig. 3.-Helicobacterpylorigastrttis in 79-year-old man. Double-contrast radiograph of
Compression radiograph of stomach reveals multiple nodules (arrowheads) and thick- stomach shows enlarged, prominent areae gastricae in gastric body.
ened mucosal folds in antrum.

the lumen. These nodules are usually less than gastritis and may be associated with absence the case of NSAID-associated gastritis, the em-
1 .0 cm in diameter and are most commonly of the mucous layer that normally protects the sions may be linear or serpiginous and may be
seen in the distal stomach. The edges are less gastric mucosa; loss of the mucosal layer al- seen on or near the greater curvature [19]. In
well defined than those of benign neoplastic lows barium suspension to more completely most instances, gastric erosions are accompa-
polyps and tend to taper onto the adjacent mu- fill the intervening grooves. Enlargement of nied by an underlying mound or halo of edema
cosa. Inflammatory nodules lined up on the the areae gastricae may reflect inflammatory [14]. A double-contrast examination is usually
folds of the gastric antrum is a characteristic swelling and may also be associated with gas- required to best reveal gastric erosions.
appearance of gastritis. tric hypersecretion. Reliable demonstration of Two additional radiologic signs of gastritis
Enlarged areae gastricae is a sign of gastri- enlarged areae gastricae requires a double- that have been described are less reliable indica-
tis that is not strongly associated with a spe- contrast examination using high-density bar- tors of gastritis: antral narrowing and crenation
cific cause [ I 1, 141 (Fig. 3). The areae gastricae, ium suspension. of the distal lesser curvature [13]. The former
when visible, are usually 1-3 mm in size. En- Gastric erosions are the most specific sign of may also result from scarring due to healing of
larged, coarse, irregular, or abnormally prom- gasiritis [15-18] (Figs. 4 and 5) and are associ- an antral ulcer; the latter accordionlike irregular-
inent areae gastricae are often associated with ated with all three of the causes mentioned. In ity is difficult to describe or quantify.

358 AJR:173, August 1999

 Gastritis and Duodenitis
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Fig. 4.-Nonspecific gastritis in 72-year-old woman. Compression radiograph shows Fig. 5.-Nonspecific gastritis in 52-year-old woman. Double-contrast radiograph of an-
multiple nodules; some have shallow barium collections in their centers (arrowheads), trum shows two erosions (arrowheads).
indicating erosions.

Fig. 6.-Duodenal radiograph shows thickened and nodular mucosal folds of proximal Fig. 1.-Nonspecific duodenitis in 52-year-old man. Radiograph shows that thickened
duodenum. (Reprinted with permission from [21]) mucosal folds are present in posthulbar region.

Causes of Duodenitis may be an additional factor. AlthOUgh present in and erosions. Deformity of the duodenal bulb
Inflammation ofthe dUOdenal mucosa unasso- only a small number of patients with duodenitis also may be seen in duodenitis [20, 21].
ciated with ulcer is several times as frequent as [20], gastric hypersecretion may cause fold thick- Thickened folds in duodenitis can be defined
duodenal ulcer. The causes ofduodenitis parallel citing in the proximal duodenum that mimics as folds thicker than 4 mm as seen on overhead
those of gastritis, although the relationship of H duodenitis radiologically. radiographs of the duodenum (Figs. 6 and 7).
p_ with duodenitis is more problematic than Because the folds vary in thickness with disten-
its established association with gastaitis. Never- tion, radiographic measurements should be
theless, it seems likely that many cases of Radiologic Findings in Duodenitis taken with the bulb and proximal duodenum
duodenitis are associated with H pylo,i infection. The radiologic findings in duodenitis are moderately distended. Thickened folds and
NSAIDS and ingestion ofhard liquor likewise are similar to those in gastritis. Findings include other radiologic signs of duodenitis are almost
significant causes [20]. Gastric hypersecretion thickening of folds, nodules or nodular folds, always found proximal to the ampulla of Vater.

AJR:173, August 1999 359

 Gelfand et al.
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Fig. 8.-Nonspecific duodenitis. Double-contrast radiograph shows multiple nodules Fig. 9.-Compression radiograph shows multiple small collections of barium suspen-
on duodenal bulb and one erosion (arrow). sion in openings of Brunner’s glands (arrows). No erosions were seen on endoscopy.

commonly, the bulbar deformity in duodenitis is

caused by large inflammatory nodules protrud-
ing into the lumen of the bulb that prevent the
bulb from assuming its normal spade-shaped
contour (Fig. 10).

Accuracy of Radiologic Diagnosis

A question frequently asked is, How often
can gastritis and duodenitis be diagnosed ra-
diologically? The answer is, sometimes. Stud-
ies indicate that radiologic signs of gastritis
and duodenitis are present and retrospectively
detectable in approximately 70% of patients
in whom gastritis and duodenitis are detected
endoscopically [ 1 1, 2 1, 22]. However, sensi-
Fig. 10-Radiograph shows duodenal bulb deformed due to presence of large inflammatory nodules. (Reprinted with tivity for the prospective radiologic diagnosis
permission from [21])
of symptomatic gastritis or duodenitis is prob-
ably closer to 50%. As with the diagnosis of
Nodules and nodular folds are the second tients [21] (Fig. 8). When clearly seen, erosions esophagitis, moderate and severe cases are
most common radiologic finding in duodenitis are the most specific sign of duodenitis. How- most likely to show detectable radiologic
(Figs. 6 and 8). The presence of radiographi- ever, one must be cautious in making the diag- signs, and the radiologic diagnosis is most
cally visible nodules may be related to two fac- nosis of duodenal erosions because the likely to be certain in these cases. Diagnoses
tors. First, many of the nodules seen in the openings of the Brunner’s glands can trap small based on marginal or borderline findings may
proximal duodenum in patients with duodenitis amounts of barium suspension and mimic the be false-positive.
represent enlarged Brunner’s glands. A second appearance of erosions (Fig. 9). Differentiation An important factor affecting accuracy is
form of nodule is similar to the inflammatory between erosions and barium-filled openings of that the radiologic examination of the stomach
nodule seen in gastritis and is endoscopically Brunner’s glands is possible: Seldom are more in particular must be meticulous. On single-
visible as a localized erythematous mucosal than a few mucosal erosions present in duodeni- contrast examinations, graded compression or
swelling. As with thickened folds, the nodules tis, whereas the openings of Brunner’s glands mucosal relief radiographs (or both) of the dis-
and nodular folds of duodenitis are seen almost are numerous and diffuse. tal half of the stomach must be obtained to
exclusively in the duodenal bulb and loop Deformity of the duodenal bulb is also seen show the rugal folds and intervening mucosa.
proximal to the ampulla of Vater. in duodenitis. However, the deformity is usually Overhead views of the barium-filled stomach
Erosions are also present in duodenitis but not that of the typical cloverleaf bulb caused by taken during single-contrast studies reveal
are radiologically seen in a small number of pa- scarring from the healing ofa peptic ulcer. More few cases of gastritis. Double-contrast exam-

360 AJR:173, August 1999

 Gastritis and Duodenitis

inations must have good mucosal coating tion to resolution.AJR 1997;168:l4l5-l420 14. Keto P, Suoranta H, Tarpila S. Areae gastricae and
and be without substantial overlap of the 6. Chapman BL Duggan JM. Aspiiin and uncompli- gastritis in double-contrast barium meal. Fortschr
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stomach by barium suspension in the proxi-
7. Silvoso GR, Ivey KJ, Butt JH, et al. Incidence of 15. Henning N, Sctiatzki R. Gastrophotographisches
mal small bowel.
gastric lesions in patients with rheumatic disease on und ROntgenologisches Bild der Gastritis ulcerosa.
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must keep in mind that gastritis and duodenitis 517-520 16. Tragardh B, Wehlin L Ohashi K. Radiologic ap-
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AJR:173, August 1999 361