Barium studies

Radiologic and/or endoscopic procedures are usually required to objectively document the presence of ulcers. Barium studies have a high sensitivity and are considered first-line tests to radiographically document an ulcer. However, the cost and complexity of all of these tests has led to the promotion of an early empiric treatment strategy for patients at low risk for PUD-related sequelae (e.g., malignancy). An empiric treatment strategy is appropriate for patients less than 50 years of age who have mild or intermittent epigastric symptoms and no evidence of PUD-related systemic symptoms or complications. 

Endoscopic approaches are typically used and may include colonoscopy, proctosigmoidoscopy, or possibly upper GI endoscopy in patients with suspected CD. Endoscopy is useful for determining the disease distribution, pattern and depth of inflammation, and to obtain mucosal biopsy specimens. Supplemental information from imaging procedures, such as computed tomography (CT), abdominal x-ray, abdominal ultrasound, or intestinal barium studies may provide evidence of complications such as obstruction, abscess, perforation, or colonic dilation.3... 

W.L. Janower, Hypersensitivity reactions after barium studies of the upper and lower gastrointestinal tract. Radiology 161 139-140, 1986. 

Smith HJ, Jones K, Hunter TB. What happens to patients after upper and lower gastrointestinal tract barium studies Invest Radiol 1988 23(ll) 822-6. 

Complications Strictures String sign on barium studies Obstruction Abscesses Fistulas Sinus tracts Toxic megacolon... 

Barium studies Polypoid mass Apple core lesion... 

On barium studies, the contour of the stomach typically will appear smooth in newborns and young infants, while in older children the normal gastric rugal folds will be visible as seen in adults. 

H. pylori infection is well known as the causative agent of antral gastritis and peptic ulcer disease (see Sect. 3.4.2). On barium studies, the most frequent finding will be (markedly) thickened gastric folds, or even thickened and lobulated gastric folds can be seen. 

On barium studies a strikingly nodular pattern in the gastric antrum can be seen with relative sparing ofthe body and fundus (lEELEetal. 1979) (Fig. 3.15). Hummer-Ehret et al. (1998) reported that eosinophilic gastroenteritis could mimic hypertrophic pyloric stenosis on US. 

A barium study (Fig. 3.16) will demonstrate narrowing of the antropyloric region (occurring in up to 16% of patients) (Griscom et al. 1974) secondary to chronic inflammation and fibrosis, which can eventually lead to gastric outlet obstruction. In some cases, the proximal duodenum will also be involved. Ultrasound will also reveal a thickening of the antropyloric wall, simulating HPS. Most patients, however, will be older than the typical HPS patient. 

Barium studies will reveal serpentine filling defects, which are compressible, typically in the fundus and along the lesser curvature or less commonly in the antrum of the stomach or proximal duodenum. US and CT can directly demonstrate the different collaterals. 

If the ectopic pancreatic tissue is localized in the stomach or duodenum it may be detected on a barium study as a small broad-based submucosal mass with central umbilication. This central umbili-cation corresponds to remnants of pancreatic ducts. The bull s eye appearance represents barium accumulation inside these remnants (Gazelle et al. 1998). 

Findings on plain film and contrast (barium) studies are similar to celiac disease. 

Both CT and MRI have proven to be valuable adjuncts to barium studies and endoscopy in the evaluation of gastric, esophageal and small bowel diseases because of their ability to delineate the primary pathologic condition and demonstrate how far the disease has extended to adjacent or distant organs. 

Although not the examination of choice, volumetric CT might show esophageal diverticula, with images comparable to conventional barium studies. 

Fig. 3.7a, b. An 8-year-old patient with recurrent signs of obstruction 4 weeks after stent placement for pyloric stenosis, a A barium study shows obstruction of the outflow at the distal end of the stent due to abutting of the stent end to the wall of the descending duodenum, b There is good flow of barium after placement of a second stent coaxially... 

A 48-year-old woman developed a fever and pain in the right lower quadrant of the abdomen 8 hours after a barium study that was performed through an ileostomy stoma [19 ]. Her temperature was 38.5°C and there was tenderness and rebound tenderness over McBurney s point. The white cell count was raised. A supine plain abdominal X-ray showed retained barium in the cecum and appendix, which was confirmed by a Cr scan, which also showed mild swelling of the appendiceal walk The appendix was resected. It was red and edematous and there was barium in the lumen. 

Fig. 2.1a,b. Erosive Gastritis. Double Contrast barium study (a) showing multiple erosions in the body and antrum of the stomach. Note the typical round lucencies with a central pit of barium. Endoscopy (b) confirms the small bulbous elevations with central ulcerations... 

Fig. 2.3a,b. Benign gastric ulcer. Double Contrast barium study (a) shows a small benign ulcer niche on the greater curve of the body of the stomach, with folds radiating to the ulcer crater. Endoscopy (b) confirmed a benign ulcer... 

Fig. 2.6a-d. Hypertrophic Gastritis. Double Contrast barium study (a) demonstrating enlarged tortuous nodular folds, also shown at endoscopy (b), endo-ultrasonography (c) and CT (d)... 

Fig. 2.9a-e. Leiomyosarcoma of the stomach Double Contrast barium study (A) shows a large bulky mass, protruding into the lumen of the body of the stomach, covered with normal mucosa. Note the deep ulceration at the caudal side of the tumour, commonly seen with larger leiomyomas (GlSTs) and leiomyosarcomas. Endoscopy (b,c) demonstrates the upper and lower borders of the well delineated mass, with the ulcer clearly seen with retroversion of the endoscope (b). Endoscopic ultrasound (d) shows that the mass does not penetrate through the muscularis mucosae of the stomach wall. Histopathol-ogy of the resection specimen (e) is taken through the level of the ulcer in the leiomyosarcoma... 

Fig. 2.10a-c. Kaposi s sarcoma of the stomach. Double Contrast barium study (a) shows multiple well delineated small bullous protrusions into the lumen ofthe body and antrum of the stomach. Ultrasound (b) shows multiple protrusions into the water-filled lumen. Endoscopy (c) demonstrates purple coloured round sharply delineated lesions, on a background of normal mucosa, typical of Kaposi s sarcoma... 

Fig. 2.11a,b. Metastasis to the stomach. Double Contrast and Single Contrast barium studies (a) demonstrate a villous type tumour arising from the lesser curve aspect of the antrum, confirmed at endoscopy (b). Biopsy revealed a metastasis from breast cancer... 

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