(Radiology. 1999;212:861-865.)
© RSNA, 1999
Tumorous Gastric Varices: Radiographic Findings in 10 Patients1
Laura R. Carucci, MD,
Marc S. Levine, MD,
Stephen E. Rubesin, MD and
Igor Laufer, MD
1 From the Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104. Received November 24, 1998; revision requested December 30; revision received January 25, 1999; accepted March 3. Address reprint requests to M.S.L.
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Abstract
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PURPOSE: To determine the appearance of tumorous gastric varices on double-contrast barium studies and whether these varices have characteristic radiographic features.
MATERIALS AND METHODS: Review of radiology files revealed 86 patients with gastric varices diagnosed during double-contrast upper gastrointestinal tract examinations. Of these 86 patients, 12 (14%) had a conglomerate mass of varices, or tumorous varices. Five of the 12 patients had proved gastric varices and five were presumed to have varices on the basis of additional diagnostic test results, clinical follow-up findings, or both. Radiographs from these 10 patients were reviewed retrospectively to determine the size, location, and morphologic features of these lesions.
RESULTS: Tumorous varices had a mean size of 6.8 cm (range, 3–11 cm). They involved the posteromedial border of the gastric fundus in eight patients, the central cardiac region in one, and the anterolateral-inferior fundal border in one. Viewed in profile, the varices appeared as smooth submucosal masses with undulating contours and discrete borders. Viewed en face, the varices manifested as a conglomerate of thickened, tortuous folds that faded peripherally into the adjacent mucosa.
CONCLUSION: Tumorous gastric varices manifest as remarkably similar findings on double-contrast barium studies, usually appearing en face as a conglomerate of thickened, lobulated folds and in profile as smooth, undulating, submucosal masses on the posteromedial border of the gastric fundus. It is important to be aware of the characteristic features of tumorous gastric varices on double-contrast studies so that they are not mistaken for neoplastic lesions in the stomach.
Index terms: Stomach, neoplasms, 72.30 • Stomach, varices, 72.75
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Introduction
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When varices occur in the stomach, they classically appear on barium studies as multiple rounded, submucosal nodules that have been likened to the appearance of a bunch of grapes in the gastric fundus (1). Occasionally, however, a conglomerate mass of varices, or tumorous varices, may manifest as a large, polypoid, fundal mass that can be mistaken radiographically for a neoplastic lesion (1–11). Although most of these have been anecdotal case reports, many authors believe that it is difficult or impossible to differentiate tumorous varices from a polypoid carcinoma, lymphoma, or gastrointestinal stromal tumor (leiomyosarcoma) on barium studies (3,4,6,8). We have encountered a number of patients with a conglomerate mass of fundal varices during double-contrast upper gastrointestinal tract examinations. This investigation was therefore undertaken to determine the appearance of tumorous gastric varices on double-contrast barium studies in a series of patients with this finding and to determine whether these varices have characteristic radiographic features.
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MATERIALS AND METHODS
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A review of computerized radiology files at our university hospital revealed 54 patients with gastric varices that were diagnosed at double-contrast upper gastrointestinal tract examinations (patients swallowed a barium sulfate solution [E-Z–HD; E-Z–Em, Westbury, NY; 120 mL]) during a 10-year period between 1988 and 1998. A review of radiology files at our affiliate, the Veterans Affairs Medical Center of Philadelphia, revealed another 32 patients with gastric varices that were diagnosed during a 5-year period between 1993 and 1998. Of these 86 patients with radiographically diagnosed gastric varices, 74 (86%) had typical findings of varices on double-contrast studies with multiple rounded, submucosal nodules or serpentine folds in the gastric fundus. The remaining 12 patients (14%) had a conglomerate mass of varices, or tumorous varices, that manifested as a polypoid fundal mass rather than as multiple submucosal nodules or serpentine folds. In a subsequent review of medical, radiology, and endoscopy records, five of these 12 patients were proved to have gastric varices and five were presumed to have varices on the basis of clinical, radiologic, and/or endoscopic follow-up data (Table). The remaining two patients did not have adequate follow-up. Our study group comprised the 10 patients proved or presumed to have gastric varices.
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Summary of Predisposing Clinical Conditions, Status of Esophageal Varices, and Other Diagnostic Tests in 10 Patients with Tumorous Varices
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All 10 patients had preexistent conditions known to predispose them to the development of gastric varices (see Results). Eight patients had findings of additional diagnostic testing that supported or confirmed the diagnosis of gastric varices, including endoscopy in five patients, abdominal computed tomography (CT) in four, abdominal ultrasonography (US) in four, and angiography in three (see Results). Although two patients did not undergo additional diagnostic testing, one had known portal hypertension and the other had chronic pancreatitis and pseudocyst formation with presumed splenic vein obstruction.
The images from double-contrast upper gastrointestinal tract examinations of these 10 patients with tumorous gastric varices were reviewed retrospectively by two gastrointestinal radiologists (M.S.L., I.L.) together to determine the size, location, and morphologic features of the varices.
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RESULTS
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Clinical Findings
The mean age of these 10 patients was 54.9 years (age range, 22–73 years). Nine were men, and one was a woman. All 10 patients had clinically documented conditions known to predispose them to the development of gastric varices, including hepatitis in five patients, portal hypertension in two, cirrhosis in three, liver failure in two, and pancreatitis in one (Table). Five patients presented with symptoms of acute upper gastrointestinal bleeding (hematemesis or melena).
Radiographic Findings
The conglomerate masses of gastric varices in these 10 patients had a mean size of 6.8 cm (range, 3–11 cm). The varices involved the posteromedial border of the gastric fundus in eight patients (six varices extended superiorly to the fundal apex and two extended inferiorly to the lower fundus), the central cardiac region in one, and the anterolateral-inferior border of the fundus in one. Thus, 80% of patients had varices that involved the posteromedial border of the gastric fundus and usually extended to the fundal apex. When viewed in profile, these tumorous varices appeared as smooth submucosal masses with an undulating contour and discrete borders (Figs 1a, 2a, 3a). When viewed en face, the varices were manifest as a conglomerate of thickened, tortuous folds that faded peripherally into the adjacent mucosa (Figs 1b, 2b, 3b). These tumorous varices therefore had a characteristic appearance both en face and in profile on double-contrast studies.
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Figure 1a. Tumorous gastric varices in a 67-year-old man with alcoholic cirrhosis. (a) Lateral double-contrast barium radiograph shows a smooth, undulating, submucosal mass (arrows) in profile on the posteromedial border of the gastric fundus. (b) Oblique radiograph shows a conglomerate of thickened, lobulated folds (arrows) that fade peripherally into adjacent mucosa. These findings are characteristic of tumorous varices. (c) Contrast-enhanced axial CT scan shows a lobulated mass (arrows) on posteromedial border of the fundus that enhances to the same degree as the great vessels. These findings are typical of gastric varices on CT scans.
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Figure 1b. Tumorous gastric varices in a 67-year-old man with alcoholic cirrhosis. (a) Lateral double-contrast barium radiograph shows a smooth, undulating, submucosal mass (arrows) in profile on the posteromedial border of the gastric fundus. (b) Oblique radiograph shows a conglomerate of thickened, lobulated folds (arrows) that fade peripherally into adjacent mucosa. These findings are characteristic of tumorous varices. (c) Contrast-enhanced axial CT scan shows a lobulated mass (arrows) on posteromedial border of the fundus that enhances to the same degree as the great vessels. These findings are typical of gastric varices on CT scans.
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Figure 1c. Tumorous gastric varices in a 67-year-old man with alcoholic cirrhosis. (a) Lateral double-contrast barium radiograph shows a smooth, undulating, submucosal mass (arrows) in profile on the posteromedial border of the gastric fundus. (b) Oblique radiograph shows a conglomerate of thickened, lobulated folds (arrows) that fade peripherally into adjacent mucosa. These findings are characteristic of tumorous varices. (c) Contrast-enhanced axial CT scan shows a lobulated mass (arrows) on posteromedial border of the fundus that enhances to the same degree as the great vessels. These findings are typical of gastric varices on CT scans.
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Figure 2a. Tumorous gastric varices in a 39-year-old man with cirrhosis. (a) Lateral double-contrast barium radiograph shows a smooth submucosal mass (arrows) in profile on the posteromedial border of the fundus. (b) Oblique radiograph shows markedly thickened, lobulated folds (arrows) in fundus that fade peripherally into adjacent mucosa.
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Figure 2b. Tumorous gastric varices in a 39-year-old man with cirrhosis. (a) Lateral double-contrast barium radiograph shows a smooth submucosal mass (arrows) in profile on the posteromedial border of the fundus. (b) Oblique radiograph shows markedly thickened, lobulated folds (arrows) in fundus that fade peripherally into adjacent mucosa.
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Figure 3a. Tumorous gastric varices in a 57-year-old man with portal hypertension. (a) Lateral double-contrast barium radiograph shows a smooth, flat, undulating submucosal mass (arrows) in profile on the posteromedial border of the gastric fundus. This patient had the largest mass of fundal varices encountered in our series. (b) Oblique radiograph shows a conglomerate of thickened, lobulated folds (arrows) that fade peripherally into adjacent mucosa.
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Figure 3b. Tumorous gastric varices in a 57-year-old man with portal hypertension. (a) Lateral double-contrast barium radiograph shows a smooth, flat, undulating submucosal mass (arrows) in profile on the posteromedial border of the gastric fundus. This patient had the largest mass of fundal varices encountered in our series. (b) Oblique radiograph shows a conglomerate of thickened, lobulated folds (arrows) that fade peripherally into adjacent mucosa.
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In five (50%) of the 10 patients with tumorous varices, barium studies also revealed serpentine longitudinal folds in the lower third or half of the thoracic esophagus that were compatible with esophageal varices.
Other Diagnostic Tests
Endoscopic results confirmed the presence of tumorous varices in three of the five patients who underwent endoscopy (Table). In the remaining two patients, gastric varices were not seen at endoscopy. In two patients, CT scans revealed typical findings of gastric varices, with lobulated fundal masses that enhanced to the same degree as the great vessels after intravenous contrast material administration (Fig 1c). In two other patients, nonenhanced CT scans revealed cirrhosis and portal hypertension. Abdominal US revealed cirrhosis in two patients, cirrhosis and ascites in one, and splenomegaly in one. Finally, angiographic results confirmed the presence of gastric varices in all three patients who underwent this procedure.
In summary, the presence of gastric varices was proved with endoscopy, CT, angiography, or all three methods in five patients. The remaining five patients were presumed to have gastric varices because of a history of end-stage liver disease or cirrhosis, or both in four (with findings of cirrhosis at US in three) and a history of recurrent pancreatitis in one.
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DISUSSION
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Conglomerate masses of gastric varices, or tumorous varices, have traditionally been considered a rare finding of radiologic or endoscopic examinations. In our series, however, tumorous varices were found to represent 14% of all gastric varices diagnosed on double-contrast barium studies. In a previous series, tumorous varices represented nearly 10% of all gastric varices diagnosed at endoscopy (12). These conglomerate masses of gastric varices therefore appear to be more common findings on barium studies or at endoscopy than has generally been recognized.
It is important to be aware of the clinical implications of tumorous varices, as they are more likely to bleed than other forms of gastric varices (13,14). In our study, 50% of patients with tumorous varices presented with symptoms of acute upper gastrointestinal tract bleeding. In previous studies, signs of bleeding have been found at endoscopy in approximately 35% of patients with tumorous varices versus in only 6%–7% of all patients with gastric varices (13,14). These individuals must therefore be followed up closely because of their greater risk of gastrointestinal tract bleeding than patients with smaller, more typical gastric varices.
The overall reported sensitivity of endoscopy in the detection of gastric varices has ranged from 40% to 80% (10,12,15). Conglomerate masses of varices may be even more difficult to detect at endoscopy than most gastric varices. In one series (10), the lesions were misdiagnosed at endoscopy in two of three patients with tumorous varices diagnosed on double-contrast studies.
Unlike esophageal varices, which typically have a bluish hue at endoscopy because of their superficial location beneath the esophageal mucosa, gastric varices tend to have a subserosal location, so a bluish hue may not be present (8,16). Also, gastric varices are often obscured by overlying gastric rugae (14). As a result, tumorous varices may be mistaken at endoscopy for other submucosal masses or a conglomerate of thickened folds. In fact, several deaths have been reported as a result of catastrophic bleeding due to endoscopic biopsy or attempted surgical resection of unrecognized varices (3,17). It is therefore important to be aware of the limitations of endoscopy in diagnosing tumorous varices and of the potential danger of obtaining endoscopic biopsy specimens in these patients.
Although most gastric varices are associated with typical findings on barium studies, tumorous varices have been mistaken on radiographs for polypoid carcinomas, gastrointestinal stromal tumors, or other neoplastic lesions (1–11). Some authors (3,4,6,8) have used terms such as "mimicry" and "deception" to emphasize this difficulty in differentiating conglomerate masses of fundal varices from true neoplasms. In these previously reported cases, it is important to recognize that most of the patients had single-contrast barium studies on which the varices appeared as nondescript masses in the gastric fundus.
In our study, however, tumorous varices had a characteristic location and appearance on double-contrast studies. The varices were typically located on the posteromedial border of the gastric fundus at or near the fundal apex. Moreover, the varices had remarkably similar radiographic findings, appearing in profile as smooth submucosal masses with an undulating contour and discrete borders and en face as a conglomerate of thickened, tortuous folds that faded peripherally into the adjacent mucosa (Figs 1 –3). In 50% of patients, the diagnosis was supported on barium studies by the presence of associated varices in the esophagus. Our experience therefore suggests that, on double-contrast studies, tumorous gastric varices have characteristic features that enable their differentiation from true neoplasms in most patients.
When tumorous gastric varices are suspected on barium studies, other diagnostic imaging, including contrast material-enhanced CT and angiography, may be required to confirm the presence of varices (18). Recently, endoscopic US has also been advocated as a useful technique for the diagnosis of gastric varices (19–21). In fact, some authors believe that endoscopic US is superior to endoscopy for detecting these lesions (20,21).
The lack of definitive confirmation of the diagnosis of varices represents a limitation of our study, as the presence of tumorous gastric varices was proved with endoscopy, CT, and/or angiography in five of 10 patients. Although the remaining five patients did not have documented varices, four had end-stage liver disease and/or cirrhosis and one had recurrent pancreatitis. These five patients were therefore presumed to have gastric varices on the basis of the clinical data.
Despite the classic teaching that patients with isolated gastric varices have splenic vein obstruction rather than portal hypertension, it has previously been shown that these individuals are more likely to have portal hypertension as the pathophysiologic basis for the varices, even in the absence of esophageal varices (11). In our series, all five patients with isolated gastric varices on barium studies had liver disease and/or portal hypertension as the cause of the varices. Although this is a small number of patients, our findings suggest that tumorous varices in the stomach (without esophageal varices) are more likely to be caused by portal hypertension than by splenic vein obstruction.
In conclusion, a conglomerate mass of gastric varices was found in 14% of all patients with radiographically diagnosed gastric varices, so tumorous varices are more common lesions than has generally been recognized. Tumorous varices manifest as remarkably similar findings on double-contrast barium studies, usually appearing en face as a conglomerate of thickened, lobulated folds and in profile as smooth, undulating, submucosal masses on the posteromedial border of the gastric fundus. It is important to be aware of the characteristic features of tumorous gastric varices on double-contrast studies so that they are not mistaken for neoplastic lesions in the stomach.
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Footnotes
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Author contributions: Guarantor of integrity of entire study, M.S.L.; study concepts, M.S.L.; study design, M.S.L., L.R.C.; definition of intellectual content, M.S.L., L.R.C., S.E.R., I.L.; literature research, L.R.C.; clinical studies, M.S.L., S.E.R., I.L.; data acquisition, L.R.C.; data analysis, L.R.C., M.S.L.; manuscript preparation, L.R.C., M.S.L.; manuscript editing, M.S.L., S.E.R., I.L. manuscript review, S.E.R., I.L.
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S. E. Rubesin, M. S. Levine, and I. Laufer
Double-Contrast Upper Gastrointestinal Radiography: A Pattern Approach for Diseases of the Stomach
Radiology,
January 1, 2008;
246(1):
33 - 48.
[Abstract]
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Abstract
Introduction
