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Gastrointestinal Imaging |
1 From the Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104. Received December 23, 1998; revision requested March 9, 1999; revision received March 29; accepted June 9. Address reprint requests to M.S.L. (e-mail: levine@oasis.rad.upenn .edu).
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Abstract |
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MATERIALS AND METHODS: A search of radiologic files resulted in recovery of records of 1,796 patients with findings of antral gastritis on double-contrast upper gastrointestinal studies. According to radiologic reports, 40 patients had a hypertrophied antral-pyloric fold. The radiographs were reviewed retrospectively to determine the size, location, and morphologic features of the folds. Clinical, radiologic, and/or endoscopic follow-up data were obtained in 22 patients.
RESULTS: All but two patients were symptomatic, and all but one responded to medical treatment. The hypertrophied antral-pyloric fold was located on the lesser curvature of the distal antrum in all patients and extended to the pylorus in 25 (62%) and into the base of the duodenal bulb in 15 (38%). The fold appeared as a smooth or slightly lobulated submucosal mass in 37 (92%) patients and as a plaquelike lesion in three (8%). Other radiographic findings of antral gastritis were present in 26 (65%) patients. In nine patients who underwent endoscopy, endoscopic and/or histologic findings of antral gastritis were present in five, but none had evidence of tumor.
CONCLUSION: A hypertrophied antral-pyloric fold may be a sign of antral gastritis that is associated with characteristic radiographic findings. Endoscopy and biopsy may not be warranted when lesions with features typical of a hypertrophied antral-pyloric fold are seen on double-contrast barium studies.
Index terms: Gastritis, 72.202, 72.291 • Helicobacter infection, 72.291 • Stomach, abnormalities, 72.91 • Stomach, inflammation, 72.202
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Introduction |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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In the series by Glick et al (1), however, the finding of a hypertrophied antral-pyloric fold was made on the basis of a limited number of cases. Since that time, we have repeatedly encountered a hypertrophied antral-pyloric fold on double-contrast upper gastrointestinal studies obtained at our hospital. To our knowledge, however, no further descriptions of this finding have been published in the radiology literature. The purpose of our investigation was, therefore, to reassess the radiographic findings and clinical relevance of these folds.
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MATERIALS AND METHODS |
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Thirty-two of the patients were women, and eight were men. The average age was 51 years (range, 25–81 years). All 40 patients underwent double-contrast upper gastrointestinal examinations performed as biphasic studies by using the technique described previously by Levine et al (2). All examinations were performed by residents in training or by fellows or attending physicians in gastrointestinal radiology, and all were originally interpreted by the attending radiologists (M.S.L., I.L., S.E.R.). The spot radiographs were reviewed retrospectively by one of the authors (M.S.L.) to determine the size, location, and morphologic features of the hypertrophied antral-pyloric folds. The images were also evaluated for other findings of antral gastritis, including thickened or scalloped folds, erosions, nodules, and enlarged areae gastricae (3,4). In 36 cases, both double-contrast views and prone single-contrast views obtained with graded compression were available for review. In the remaining four cases, prone views of the antrum either had not been obtained or were missing.
Subsequent review of computer radiologic files for these 40 patients with a hypertrophied antral-pyloric fold revealed that six (15%) patients had undergone serial double-contrast upper gastrointestinal examinations, including a total of two examinations in four patients and three examinations in two. The average interval between these radiologic examinations was 5.3 years (range, 1.5–10.0 years). These studies also were reviewed retrospectively by one of the authors (M.S.L.) to determine whether the folds had changed in size or appearance over time.
The clinical findings at presentation that prompted performance of the barium studies were obtained from the clinical request slips for all 40 patients. As part of this retrospective study, additional clinical data were obtained from medical records in 18 (45%) patients. The average clinical follow-up in these 18 patients was 19.2 months (range, 3 weeks to 5.6 years). Nine (22%) patients underwent subsequent endoscopy, with an average interval of 2.8 months (range, 16 days to 8 months) between endoscopic and radiologic examinations, excluding one patient who underwent endoscopy 6 years after the barium study. Endoscopic biopsy specimens were obtained in five of these nine patients. Both the endoscopic and pathologic reports were reviewed retrospectively. In all, 22 (55%) of 40 patients with a hypertrophied antral-pyloric fold underwent one or more forms of clinical, radiologic, or endoscopic follow-up.
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RESULTS |
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Of 14 patients treated with antisecretory agents (histamine blocking agents or proton pump inhibitors), antibiotics, or both, nine had complete resolution of symptoms, and five had varying degrees of symptomatic improvement. In one patient in whom symptoms improved, recurrent symptoms developed 1 month after completion of therapy. More important, none of the 18 patients with adequate follow-up developed any clinical signs or symptoms (eg, anorexia, weight loss, early satiety, palpable epigastric mass, lymphadenopathy, ascites, hepatomegaly) of gastric neoplasms during an average follow-up of more than 1.5 years.
Radiographic Findings
A hypertrophied antral-pyloric fold was detected on double-contrast upper gastrointestinal studies in 40 (2.2%) of 1,796 patients with antral gastritis diagnosed on the basis of radiographic findings (Figs 1–4). The average length of the folds was 2.4 cm (range, 1–5 cm). The hypertrophied fold was located on the lesser curvature of the distal antrum in all 40 patients. The hypertrophied fold appeared as a submucosal mass in 37 (92%) patients (Figs 1, 2, 4) and as a flat, plaquelike lesion in three (8%) patients (Fig 3).
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Twenty-six (65%) of 40 patients had other radiographic findings of antral gastritis, including thickened, scalloped folds in 16 patients (Figs 1a, 1b, 2); thickened, scalloped folds and antral erosions in five; thickened, transverse folds in two; thickened, scalloped folds and enlarged areae gastricae in two; and nodular mucosa and enlarged areae gastricae in one. When the hypertrophied antral-pyloric folds with a submucosal or plaque-like appearance were considered separately, other findings of antral gastritis were present in 25 (68%) of 37 patients with a submucosal lesion and in one (33%) of three patients with a plaquelike lesion.
Six patients underwent subsequent double-contrast examination, the results of which showed no change in the size or appearance of the hypertrophied antral-pyloric fold during an average follow-up of more than 5 years. Two of these patients also underwent a barium study 1.4 years and 7.2 years before the development of the hypertrophied fold. In both patients, the previous studies revealed no radiographic findings of antral gastritis.
Endoscopic and Pathologic Findings
Endoscopy was performed in eight patients in whom the hypertrophied antral-pyloric fold had a submucosal appearance and in one in whom the fold had a plaquelike appearance. Of these nine patients, five had findings of antral gastritis; the findings included thickened, edematous folds and edema, erythema, friability, or nodularity of the mucosa. Two patients with antral gastritis also had tiny (<5-mm-diameter) ulcers in the antrum. In three of these five patients, endoscopic biopsy specimens revealed chronic inflammatory changes in the antrum without evidence of tumor. In the remaining two patients (including the patient with a plaquelike lesion seen on the double-contrast barium study), endoscopic biopsy specimens revealed normal antral mucosa. In four of the five patients with antral gastritis, thiazine staining for Helicobacter pylori was performed, with positive stains observed in three. In four patients with a normal-appearing antrum at endoscopy, biopsy specimens were obtained in one, and this specimen showed normal antral mucosa without evidence of H pylori at thiazine staining.
In the five patients with findings of antral gastritis at endoscopy, the average interval between radiologic and endoscopic examinations was 1.2 months (range, 16 days to 2.3 months), excluding one patient who underwent endoscopy 6 years after the barium study. As a result, some of the hypertrophied antral-pyloric folds could have undergone healing in the interval between the radiologic and endoscopic examinations. In the four patients with a normal-appearing antrum at endoscopy, the average interval between radiologic and endoscopic examinations was 3.7 months (range, 25 days to 8 months). The longer duration between examinations in the latter group may have allowed healing of antral gastritis to occur, which would perhaps account for the discrepancy between radiologic and endoscopic findings.
More important, in none of the nine patients who underwent endoscopy were endoscopic or histologic findings of carcinoma or other neoplastic lesions in the stomach observed. Although the endoscopic reports did not specifically include mention of the hypertrophied antral-pyloric fold seen at the barium study, there was no reason to do so because the preceding radiologic reports described these folds as benign lesions associated with antral gastritis.
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DISCUSSION |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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In more than 90% of the patients in our study, the hypertrophied antral-pyloric fold appeared as a smooth or slightly lobulated submucosal mass that was located on the lesser curvature of the distal antrum and that extended to the pylorus (Figs 2–4) or across the pylorus into the medial fornix of the base of the duodenal bulb (Fig 1). In the series of Glick et al (1), all of the folds extended into the base of the duodenal bulb, and three (23%) of 13 were located on the greater curvature of the distal antrum. In contrast, the hypertrophied antral-pyloric fold in all the patients in our series was located on the lesser curvature, and, in nearly two-thirds of the patients, the fold terminated at the pylorus without crossing into the duodenal bulb. This discrepancy may be partly related to selection bias. In any case, the folds in our series manifested with strikingly similar radiographic findings. Furthermore, in more than 70% of patients, the fold was visible on double-contrast views but not on prone single-contrast views obtained with graded compression. It is possible that the folds were easier to demonstrate with gaseous distention or that they extended further on the posterior wall than on the anterior wall. Whatever the explanation, the double-contrast study appears to be the best radiographic technique for demonstration of these lesions.
The most important consideration in the differential diagnosis of a hypertrophied antral-pyloric fold is a polypoid or plaquelike antral carcinoma. However, the average duration of symptoms in our series was 10 months at the time the barium study was performed; this would be an unusually long interval in patients with gastric carcinoma, which tends to be associated with a shorter duration of symptoms. Also, two-thirds of the patients in our series had thickened, scalloped folds or other radiographic findings of antral gastritis (Figs 1a, 1b, 2). Finally, the contour of the majority of polypoid or plaquelike carcinomas has been found to be more lobulated or irregular than that of a hypertrophied fold and is not associated with a smooth, contiguous component that extends to the pylorus or crosses into the base of the duodenal bulb. Our experience, therefore, suggests that a hypertrophied antral-pyloric fold can usually be differentiated from an antral carcinoma on the basis of the clinical and radiographic findings, without the need for endoscopy.
Nevertheless, three (8%) patients in our study with hypertrophied antral-pyloric fold had atypical radiographic findings, with the fold appearing as a flat, plaquelike lesion (Fig 3) rather than as a submucosal mass. In this small subset of patients, endoscopy and biopsy probably should be performed to rule out a plaquelike carcinoma arising on the lesser curvature of the distal antrum.
When a hypertrophied antral-pyloric fold appears as a submucosal mass, the possibility of a gastrointestinal stromal tumor (leiomyoma), ectopic pancreatic rest, or other mesenchymal tumor might also be considered in the differential diagnosis of this lesion, particularly if it does not extend across the pylorus into the base of the duodenal bulb. Although a leiomyoma arising on the lesser curvature of the distal antrum could produce similar radiographic findings, none of the patients in our series with endoscopic follow-up showed evidence of a leiomyoma or other mesenchymal tumor in the antrum. When ectopic pancreatic rests occur in the antrum, they almost always are located on the greater curvature within 1–6 cm from the pylorus (5,6), whereas a hypertrophied antral-pyloric fold is usually located on the lesser curvature. In the final analysis, a gastrointestinal stromal tumor coincidentally arising on the lesser curvature of the distal antrum could mimic the appearance of a hypertrophied fold, but such a tumor would most likely represent a benign leiomyoma, and the implications of overlooking a small submucosal lesion in the antrum are much less serious than those of overlooking a carcinoma or other malignant tumor in the stomach.
It is important to recognize the limitations of our study. Because this was a retrospective review, selection bias was unavoidable; hypertrophied antral-pyloric folds that produced atypical findings on double-contrast studies might have been misinterpreted as other lesions and, thus, would not have been included in our series. As a result, this study was skewed toward finding hypertrophied antral-pyloric folds that had a more typical radiographic appearance. Our study was also limited by the fact that endoscopic or pathologic correlation was obtained in only nine (22%) patients. However, the majority of patients (55%) in our series had undergone one or more forms of clinical, radiologic, or endoscopic follow-up, and none of these patients had evidence of gastric neoplasms.
Glick et al (1) proposed that the hypertrophied antral-pyloric fold is a sign of chronic antral gastritis. On occasion, a healing chain of antral erosions is known to lead to the development of an enlarged, polypoid fold, probably because of scarring and fibrosis on the crest of the fold (7). In much the same way, the hypertrophied antral-pyloric fold could serve as a marker of chronic antral gastritis because of granulation tissue that forms on the lesser curvature of the distal antrum. In fact, the absence of other associated radiographic findings of antral gastritis in one-third of our patients and the persistence of these folds on serial double-contrast studies suggests that the hypertrophied fold is not always a sign of active gastritis but can sometimes occur as a sequela of prior inflammation.
The relationship between the hypertrophied antral-pyloric fold and H pylori gastritis remains uncertain. H pylori gastritis is known to be associated with thickened antral folds (8) but not, to our knowledge, with a single hypertrophied fold on the lesser curvature. Only four patients in our series were examined for H pylori (with positive results in three); so, our sample size was too small to draw any definite conclusions. Further investigation is, therefore, needed to elucidate the relationship between a hypertrophied antral-pyloric fold and H pylori gastritis.
In conclusion, the hypertrophied antral-pyloric fold appears to be a sign of antral gastritis that is associated with characteristic radiographic findings. It usually appears as a smooth or slightly lobulated submucosal mass on the lesser curvature of the distal antrum and extends into the pylorus or base of the duodenal bulb. Our experience suggests that endoscopy and biopsy are not warranted when a lesion with the typical features of a hypertrophied antral-pyloric fold is encountered on a double-contrast barium study.
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Footnotes |
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References |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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This article has been cited by other articles:
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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] [Full Text] [PDF]
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 T. Luna and P.-A. Sinn Sonographic Appearance of an Antral Mass in an Infant Journal of Diagnostic Medical Sonography, March 1, 2007; 23(2): 101 - 105. [PDF]
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 S Dheer, M S Levine, R O Redfern, D C Metz, S E Rubesin, and I Laufer Radiographically diagnosed antral gastritis: findings in patients with and without Helicobacter pylori infection Br. J. Radiol., October 1, 2002; 75(898): 805 - 811. [Abstract] [Full Text] [PDF]
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