Perspective

Radiologic Evaluation of Gastritis and Duodenitis

V. M. Chen

David W. Gelfand1,

David J. Ott, Michael

C
several times or duodenal this perspective

astritis

and most

duodenitis

are among upper gastric gasbeing ulcer of

of the

Diagnosis greatly be detected

of H. pylon Initially, only on biopsy

infection samples

has become could at entaken

tis caused

by alcohol caused

tends to be more by NSAIDS [9].

diffuse to

the

common than

simplified.

the organism

than gastritis

but tends

trointestinal more ulcer, for

abnormalities,

be most common

distally

common respectively.

The purpose
awareness

doscopy. However, the urea breath eral office- and laboratory-based have made the diagnosis inexpensive. Appropriate ion serum or breath and signs of gastritis gastrointestinal series of infection symptoms,

test and sevserum tests rapid and an H. pyRadiologic Findings in Gastritis radiologic findings describes at least four of this disease: thick
nodules, erosions, and

is to increase

possibilities
two

radiologic

diagnosis

of these

The literature

regarding

In this presentation, the discussion is limited to the acute or subacute gastritis and duodenitis most likely to cause a patient to see a physician. pathologic We do not attempt classification ofgastritis to present or duodena

entities.

test with positive findings, or duodenitis on an upper or endoscopy

cause

in patients with gastritis useful radiologic signs folds, inflammatory in gastritis folds coarse areae gastricae.

are a reaof gastritis

sonable basis for treatment. NSAIDs are a recognized and duodenitis, as well [6-9]. The are aspirin, drugs
and

Any of these regardless in caliber

signs

may folds on may or folds when

be present Thick
greater

of etiology. as gastric as measured I ). The folds

of the stomach

itis, and we discuss of the most likely cepted radiologic

these diseases on the basis causes and generally acsigns.

as of

gastric

and

can be defined

duodenal ulcers used NSAIDs naproxen;

gastritis,

most commonly ibuprofen, and of causing

when taken

than 5 mm obtained
[

radiographs
ately

with the stomach

region

moder-

these
duodenitis,

are capable
ulcers

distended

10, 1 1 ] (Fig.

be located throughout
can

in a limited

Causes Three
most

of Gastritis etiologic
of acute

persistently agents
are responsible

or in quantity. severe
disease due

In our experience, duodenitis,

are caused

the stomach. in gastritis

Although of any

thick cause,

for

the most
and ulcer

cases of gastritis,
to NSAIDs

be seen

cases

which

a specific

and subacute gastritis in cause can be identified. These nonsteroidal anand alcohol.
cause of gas-

by the more

potent

antiinflammatory

agents,

agents are Helicobacterpylori, tiinflammatory drugs (NSAIDs),

H. pylon is the most frequent

particularly
cause NSAIDs mucosa,
near

naproxen of the effects act as direct

gastritis and

and indomethacin. Beof gravity and because

irritants gastric

present in a symptomatic patient they are most often associated with H. pylon infection. Inflammatory nodules are a second sign of acute ules or subacute their may represent gastritis origin edema shallow [12, 13] (Fig. Some barium 2). nodemand However, is uncertain. to trap

on the gastric ulcers distally caused and irritant by on or and is

tritis world

in the
[

adult

population may
children

throughout involve
and

the the enInin

young

surrounding radiologically

1-5].

The infection or any region

in

these agents the greater Alcohol

a third

are often curvature

seen
[9].

sions that are too that therefore

as erosions.

tire stomach

of the stomach. common The

are not recognized

fection is infrequent adults, but it becomes middle-aged and

is also a direct

gastric

increasingly persons.

elderly

organ-

ism is transmitted as a fecal in countries without effective infection with H. pylon

contaminant, and water treatment,

universal.

cause of gastritis. Potent alcoholic drinks such as whiskey, vodka, or gin are more likely to cause alcoholic gastritis than are beverages with a lower alcoholic content
important

have ciated most

Others epithelialized edema.

with

may represent erosions that but that still have the assobenign neoplastic

Compared

inflammatory

nodules

caused

polyps, by gastritis into

is almost

such as beer

or wine.

The distribution

of gastri-

are smaller

and do not project

as sharply

Received August 1, 1997; accepted

All authors: Department AJR 1999;173:357-361

after revision January

25, 1999. Medical Center Blvd., Winston-Salem, NC 27157. Address correspondence D. W. Gelfand.

of Radiology, Wake Forest University School of Medicine, American Roentgen Ray Society

0361-803X/99/1732-357

AJR:173,

August

1999

357

Gelfand

et al.

Fig. 1.-Helicobacterpylorigastritis in 63-year-old man. A and B, Radiographs of gastric

body (A) and antrum (B) show thickened mucosal folds (arrows).

caused by nonsteroidal antiinflammatory drugs in 58-year-old woman. radiograph of stomach reveals multiple nodules (arrowheads) and thickened mucosal folds in antrum. Fig. 2.-Gastritis

Fig. 3.-Helicobacterpylorigastrttis
stomach shows enlarged, prominent

in 79-year-old man. Double-contrast

areae gastricae in gastric body.

radiograph of

Compression

the lumen. These nodules 1 .0 cm in diameter and

seen

are usually less than are most commonly The onto

edges are less

gastritis

and

may be associated

with

absence

the case of NSAID-associated sions seen

most nied

gastritis, curvature

the em[19]. In

in the distal defined

stomach.

of the mucous layer that normally protects the gastric mucosa; loss of the mucosal layer allows barium suspension to more completely fill the intervening grooves. Enlargement of the areae gastricae may reflect inflammatory swelling
tric

may

be linear

or serpiginous
erosions

and may be are accompa-

on or near
instances,

the greater
gastric

well polyps

than those

of benign

neoplastic mu-

and tend to taper

the adjacent

cosa. Inflammatory folds of the gastric

appearance

nodules lined up on the antrum is a characteristic gastricae is a sign of gastriwith a spe-

by an underlying [14]. A double-contrast

mound or halo of edema examination is usually gastric erosions. signs of gastritis

indica-

and may areae

examination

also be associated Reliable gastricae using requires

with

gasof bar-

required Two

to best reveal additional

of gastritis. areae
[

hypersecretion.

demonstration a doublehigh-density specific

radiologic antral from narrowing

Enlarged tis that is not cific cause when larged, inent visible, coarse, areae

enlarged
contrast ium

that have been described tors of gastritis: of the distal may also result
ity is difficult

are less reliable

strongly

associated

and crenation The former of

I 1, 141 (Fig. 3). The areae gastricae, are usually irregular, gastricae 1-3 mm in size. or abnormally associated Enwith prom-

suspension.
Gastric

lesser curvature scarring

[13].

erosions all three

are the most of the causes

sign of In

due to healing irregular-

gasiritis

[15-18] (Figs. 4 and

5) and are associ-

an antral ulcer; the latter accordionlike

to describe or quantify.

are often

ated with

mentioned.

358

AJR:173,

August

1999

Gastritis

and

Duodenitis

Fig. 4.-Nonspecific gastritis in 72-year-old woman. Compression radiograph shows multiple nodules; some have shallow barium collections in their centers (arrowheads),
indicating erosions.

Fig. 5.-Nonspecific

gastritis in 52-year-old woman. Double-contrast

radiograph of an-

trum shows two erosions (arrowheads).

Fig. 6.-Duodenal
duodenum.

(Reprinted

radiograph shows thickened and nodular mucosal folds of proximal with permission from [21])

Fig. 1.-Nonspecific duodenitis in 52-year-old man. Radiograph shows that thickened mucosal folds are present in posthulbar region.

Causes ciated those p_ theless,

duodenitis

of Duodenitis ofthe dUOdenal times

the

may be an additional mucosa unassoas

of H

factor.

AlthOUgh with

present duodenitis

in

Inflammation with ulcer

only a small citing

number

of patients duodenum

and erosions. Deformity of the duodenal also may be seen in duodenitis [20, 21].

bulb

is several

as frequent

[20], gastric hypersecretion in the proximal radiologically. duodenitis

may cause

fold thickthat mimics

duodenal ulcer. The causes ofduodenitis of gastritis, although

with duodenitis relationship

parallel than Nevercases infection.

are

Thickened folds in duodenitis can be defined as folds thicker than 4 mm as seen on overhead radiographs
Because

of the duodenum
vary

(Figs.

6 and should duodenum folds

7). be and

is more with
that with

problematic gastaitis. many H pylo,i

the folds radiographic with

in thickness and proximal Thickened of duodenitis to the ampulla

with disten-

its established

association likely

tion, Radiologic The similar thickening Findings in Duodenitis in duodenitis are Findings include or nodular folds, taken radiologic to those findings in gastritis. nodules

measurements

it seems

of

the bulb distended. signs proximal

are associated

moderately always found

NSAIDS
significant

and ingestion ofhard liquor likewise causes [20]. Gastric hypersecretion

other radiologic

are almost of Vater. 359

of folds,

AJR:173, August 1999

Gelfand

et al.

Fig. 8.-Nonspecific duodenitis. Double-contrast on duodenal bulb and one erosion (arrow).

radiograph

shows

multiple

nodules

Fig. 9.-Compression

radiograph shows multiple small collections of barium suspension in openings of Brunners glands (arrows). No erosions were seen on endoscopy.

commonly,

the bulbar

deformity

in duodenitis nodules protrudthat prevent

spade-shaped

is the

caused by large inflammatory ing into the lumen bulb from contour (Fig. assuming 10). of the bulb
its normal

Accuracy A question can gastritis diologically? ies indicate

of Radiologic frequently

Diagnosis asked is, How often

and duodenitis be diagnosed raThe answer is, sometimes. Studthat radiologic signs
70%

of gastritis
of patients

and duodenitis are present detectable in approximately

in whom gastritis
[

and retrospectively are detected However, sensidiagnosis is probof are cases radiologic

and

duodenitis

endoscopically Fig. 10-Radiograph shows duodenal bulb deformed due to presence of large inflammatory nodules. (Reprinted with permission from [21]) tivity ably Nodules and nodular folds are the second tients [21] (Fig.
8). When clearly seen,

1 1, 2 1, 22].

for the prospective gastritis to 50%. moderate to show closer likely

radiologic or duodenitis and severe

of symptomatic esophagitis, most

As with

the diagnosis

erosions

most common radiologic finding in duodenitis (Figs. 6 and 8). The presence of radiographically
tors.

are the most specific sign of duodenitis. However, one must be cautious in making the diagnosis of

detectable

visible
First,

nodules
many of

may be related
the nodules

to two facseen in the

duodenal of the Brunners of barium

erosions glands suspension

because can trap and mimic

the small the of

signs, and the radiologic diagnosis is most likely to be certain in these cases. Diagnoses based on marginal or borderline findings may be false-positive. An important that the radiologic
in particular must

openings amounts
appearance

proximal

duodenum

in patients

with duodenitis

represent enlarged Brunners glands. A second form of nodule is similar to the inflammatory nodule visible swelling. exclusively proximal Erosions in gastritis as a localized
seen

between

of erosions (Fig. 9). Differentiation erosions and barium-filled openings

factor affecting accuracy is examination of the stomach

be meticulous. On single-

and is endoscopically erythematous mucosal folds, bulb the nodules and loop but
of pa-

Brunners glands is possible: Seldom are more than a few mucosal erosions present in duodeni-

contrast mucosal tal half show taken

examinations, relief the rugal views during radiographs

folds

graded must

compression be obtained
mucosa.

or to

As with

thickened duodenal present

tis, whereas are numerous Deformity in duodenitis.

the openings and diffuse. of the duodenal However, the healing

of Brunners bulb

glands

(or both)

of the dis-

and nodular folds of duodenitis in the are also to the ampulla of Vater.

are seen almost

of the stomach

is also seen is usually ulcer. More

and intervening studies

the deformity cloverleaf ofa peptic

Overhead few cases

of the barium-filled single-contrast Double-contrast

stomach reveal exam-

in duodenitis
number

not that of the typical scarring

from

bulb caused by

are radiologically

seen in a small

of gastritis.

360

AJR:173, August 1999

Gastritis

and

Duodenitis 1997;168:l4l5-l420 JM. Aspiiin and uncompli1969:10:443-450

inations and
mal

must

have

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mucosal overlap

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To achieve must
The

reasonable

accuracy,

therapy.
G, Nelson

keep
radiologic

in mind

that gastritis

and duodenitis as ulcer disease. two entities

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