How I Do I t

Marc S. Levine, MD Stephen E. Rubesin, MD Hans Herlinger, MD

Igor Laufer, MD

Double-Contrast Upper Gastrointestinal

Examination: Technique and Interpretation1

T HE development of routine double-

contrast techniques for examining
the upper gastrointestinal (GI) tract has
mine-blocking agents has also changed
the clinical approach to patients with
dyspepsia or ulcer symptoms, since
a biphasic study in which both double-
contrast and single-contrast views of
the esophagus, stomach, and duode-
dramatically improved our ability to di- many of these patients are now treated num are obtained. In the double-con-
agnose a variety of inflammatory and empirically without further diagnostic trast portion of the study, a series of
neoplastic diseases in the esophagus, evaluation. However, another major maneuvers is required to achieve ade-
stomach, and duodenum. Despite in- factor in the declining number of fluo- quate gaseous distention of the lumen
creasing acceptance of this technique, roscopic examinations is the increasing while a thin layer of high-density bari-
many radiologists still use convention- use of endoscopy as the initial screen- um is spread on the mucosa. The dou-
al single-contrast radiography as the ing study in these patients. This trend ble-contrast examination is facilitated
primary modality for examining the has been spurred by a number of cor- by the routine use of hypotonic agents.
upper GI tract. In a recent survey, more relative radiologic-endoscopic studies Subsequently, the double-contrast
than 50% of the responding radiolo- from the gastroenterology literature in study should be supplemented by
gists at major academic institutions in- which endoscopy was found to be a prone or upright single-contrast views
dicated that they did not perform dou- more accurate diagnostic examination of the esophagus, stomach, and duode-
ble-contrast upper GI studies on a rou- (4-6). However, these studies tended to num obtained with low-density barium
tine basis (1). In many cases, double- be biased in favor of endoscopy, be- and varying degrees of compression.
contrast techniques are avoided cause the primary authors were usually The basic elements of the double-con-
because of lack of experience or train- endoscopists. It also remains unclear trast examination, including mucosal
ing in the technical aspects of perform- whether the ability of endoscopy to de- coating, gaseous di'stention, hypotonia,
ing or interpreting these studies. pict radiographicaily missed leiions in fluoroscopic maneuvers, and a step-by-
The issue of single- versus double- the upper GI tract has any significant step approach to the routine examina-
contrast technique has recently been effect on the management o r eventual tion, are discussed separately in the fol-
overshadowed by another, more omi- outcome of the conditions in these pa- lowing sections.
nous development in the practice of GI tients.
radiology. Data indicate that there has While fiberoptic endoscopy has been
been a gradual but steady decline in recognized as a highly accurate tech- Mucosal Coating
the total number of upper GI fluoro- nique for examining the upper GI tract, Adequate mucosal coating is
scopic examinations p;rformed during it is also an invasive technique with a achieved in the upper GI tract by flow-
the past decade (2,3). This trend can be small but measurable risk of gastric ing a high-density barium suspension
attributed partly to the increased use of perforation or other complications. over the mucosa. Because mucosal coat-
cross-sectional imaging modalities, Furthermore, it is an expensive tech- ing depends on the physical and chem-
such as computed tomography or ultra- nique, costing three to four times more ical properties of the barium suspen-
sound, to evaluate GI problems. The in the United States than double-con- sion, the choice of barium directly af-
greater availability of effective hista- trast upper GI examinations. Because fects the quality of the examination. In
barium studies are safer and less expen- general, the best results are obtained
sive than endoscopy, radiologic evalua- with high-density (ie, 200% wt/vol), in-
Index terms: Duodenum, abnormalities, 73.2 tion of the upper GI tract remains a via- termediate-viscosity barium, such as
Duodenum, neoplasms, 73.3 Duodenum, ra- ble alternative as long as its radiologic E-Z-HD (E-Z-EM, Westbury, NY) or HD
diography, 73.123 Esophagus, abnormalities, accuracy approaches that of endoscopy 85 (Lafayette Pharmacal, Lafayette,
71.2 Esophagus, neoplasms, 71.3 Esophagus, for clinically significant disease. We be-
radiography, 71.123 Radiology and radiolo- Ind). Adequate mucosal coating is usu-
lieve that a carefully performed dou- ally present when a thin, uniform
gists, How 1 Do I t Stomach, abnormalities,
ble-contrast upper GI study provides white line is observed with fluoroscopy
72.2 Stomach, neoplasms, 72.3 Stomach, ra-
diography, 72.123
the best opportunity for radiology to be along the contour of the stomach. The
competitive with endoscopy as a diag- quality of mucosal coating may also be
Radiology 1988; 168:593-602 nostic modality. A detailed description judged on the basis of whether an areae
of the technical aspects of performing gastricae pattern is visible in the stom-
and interpreting these examinations is ach. With standard barium suspen-
I From the Department of Radiology, Hospi-
therefore presented. sions, however, areae gastricae can be
tal of the University of Pennsylvania, 3400 detected in only about 70% of patients
Spruce St, Philadelph~a,PA 19104. Received (7). Since visualization of these struc-
March 22, 1988; accepted and revision request- TECHNIQUE
ed April 22; revision received May 13. Address tures depends on multiple factors, in-
reprint requests to M.S.L. The routine double-contrast upper cluding the amount and viscosity of
RSNA, 1988 GI examination should be performed as mucus in the stomach, failure to dem-
onstrate an areae gastricae pattern does achieved. If esophageal disease is be- duces effective but transient hypotonia
not necessarily indicate that mucosal lieved to be present, a soft rubber cath- of the esophagus, stomach, and duode-
coating is inadequate. eter may be inserted into the esopha- num. Because this agent relaxes the py-
Food or fluid in the stomach may gus and a tube esophagogram obtained lorus, excellent double-contrast views
also interfere with the quality of muco- by insufflating air through the catheter of the duodenum can also be obtained.
sal coating. Patients are therefore in- as the patient swallows high-density While Buscopan is a popular hypotonic
structed to fast overnight before under- barium (9).Similarly, gas may be intro- agent in Europe, it is not available in
going a double-contrast examination, duced via a tube in the stomach or duo- the United States.
in order to minimize the amount of flu- denum when gaseous distention of
id or secretions in the stomach. Patients these structures is inadequate on rou-
should also be discouraged from smok- tine double-contrast studies in patients Maneuvers
ing on the day of the examination, as who are believed to have disease.
cigarette smoke increases gastric secre- For performance of the double-con-
tions and impairs mucosal coating (8). trast examination, a standard set of ma-
Nevertheless, some patients with gas- neuvers is required to achieve adequate
Hypotonia mucosal coating and gaseous disten-
tric outlet obstruction, gastroparesis, or
hypersecretory states may have so Glucagon is an effective hypotonic tion. The examination must be per-
much residual fluid or debris in the agent for double-contrast examinations formed quickly, since overlapping
stomach that adequate mucosal coating of the upper GI tract. A standard dose loops of barium-filled small bowel may
cannot be achieved despite these pre- of 0.1 mg administered intravenously impair visualization of the stomach and
cautions. In such cases, a nasogastric produces adequate gastric hypotonia in duodenum. The major purpose of fluo-
tube may be used to aspirate fluid from most patients within 45 seconds of the roscopy is to determine the volume of
the stomach before the examination. injection (10). With the use of glucagon barium and gas, to assess mucosal coat-
to decrease gastric peristalsis, it is pos- ing, and to insure accurate positioning
sible to obtain better double-contrast and timing of spot radiographs. Be-
views of the antrum and body of the cause the quality of mucosal coating
Gaseous Distention tends to deteriorate rapidly during the
stomach in a relaxed, hypotonic state.
Gaseous distention is required to ef- Because glucagon also tends to delay fluoroscopic examination, repeated
face normal folds, in order to visualize gastric emptying, double-contrast turning of the patient is required to
the overlying mucosa. If adequate dis- views of the stomach can be obtained manipulate the barium pool and obtain
tention is achieved, the surface features in most patients before it is obscured a fresh mucosal coating before each ex-
of the mucosa can be assessed both en by overlapping loops of barium-filled posure.
face and in profile. If distention is in- duodenum or small bowel. At the same While it is important to develop a
adequate, however, prominent folds time, delayed filling of the duodenum standard routine for performance of
may obscure mucosal lesions, and bari- may be an undesirable side effect of the examination, additional maneuvers
um trapped between the folds can glucagon, prolonging the examination and/or spot radiographs may be re-
mimic ulceration. By contrast, overdis- in some patients. Otherwise glucagon quired if an abnormality is suspected at
tention may impair mucosal coating or has virtually no side effects, except for fluoroscopy. When the double-contrast
may obliterate abnormal folds or vari- the remote possibility of a hypersensi- portion of the study has been complet-
ces. As a result, spot radiographs tivity reaction. The only contraindica- ed, prone and upright single-contrast
should be obtained at varying degrees tions to the use of glucagon are pheo- views should be obtained with com-
of distention during the fluoroscopic chromocytoma, insulinoma, and brittle, pression to supplement the double-
examination. insulin-dependent diabetes. contrast examination. Because careful
The simplest method for introducing In the evaluation of known gastric fluoroscopic positioning of the patient
gas into the stomach and duodenum is lesions (ie, healing of gastric ulcers), is required, the double-contrast study
to have the patient swallow efferves- larger doses of glucagon (usually 1.0 consists only of fluoroscopic spot radio-
cent tablets, granules, or powder that mg) may be given intravenously to graphs without routine overhead radio-
rapidly release 300-400 mL of carbon achieve greater levels of gastric hypo- graphs.
dioxide on contact with fluid in the tonia for a detailed double-contrast ex-
stomach. Occasionally, however, bub- amination. Similarly, a hyyotonic duo-
The Routine Examination
ble formation may occur in the esopha- denogram may be obtained in patients
gus or stomach as an undesirable arti- who are believed to have duodenal dis- 1. A standard dose of 0.1 mg of gluca-
fact. Thus, most effervescent agents ease, by administering 1.0 mg of gluca- gon diluted to 0.25 mL with sterile wa-
used for double-contrast examinations gon to induce duodenal hypotonia af- ter is given intravenously.
contain simethicone, an antifoaming ter barium has entered the duodenum. 2. 'The patient swallows one packet of
agent, to minimize this problem. While glucagon is a useful hypotonic effervescent granules or "fizzies" (ie,
While the stomach and duodenum agent for the stomach and duodenum, E-Z Gas; E-Z-EM) followed by 10 mL of
are readily distended by effervescent it has no effect on esophageal peristal- water.
agents, the patient must gulp a high- sis and will not produce better double- 3. The patient gulps a cup of high-
density barium suspension as quickly contrast views of the esophagus. How- density barium (120 mL) as quickly as
as possible to achieve adequate gaseous ever, it has been shown that glucagon possible. The two best barium suspen-
distention of the esophagus. With rapid relaxes the lower esophageal sphincter sions for this purpose are E-Z-HD (E-Z-
swallowing, the peristaltic sequence is ( 1 1) and therefore increases the fre- EM) and HD 85 (Lafayette Pharmacal).
interrupted, and the esophagus be- quency of spontaneous gastroesopha- 4. One three-on-one or two two-on-
comes hypotonic. As the patient gulps geal reflux (12). Anticholinergic drugs, one upright spot radiographs are ob-
the high-density barium, swallowed air such as propantheline bromide (Pro- tained in rapid sequence to demon-
also distends the esophagus, contribut- Banthine; Searle, San Juan, Puerto strate the entire length of the esopha-
ing further to the double-contrast ef- Rico), may be given to paralyze the gus in a left posterior oblique (LPO)
fect. However, some elderly or debili- esophagus, but these drugs are rarely projection (Fig la). (All radiographic
tated patients may only be able to take used because of their marly side effects. projections are indicated with respect
small sips of barium, so that adequate Another anticholinergic drug, Busco- to the tabletop.)
esophageal distention cannot always be pan (nyoscine N-butyl bromide), pro- 5. The table is brought to the hori-

594 Radiology September 1988

zontal position with the patient's back turns before obtaining a radiograph. and body of the stomach is obtained in
to the tabletop. While some barium may spill into the the LPO position.
6. The patient turns to the right duodenum during this maneuver, 360' 8. The patient turns into a right later-
through a 360" circle back to the supine rotation of the patient provides optimal al position for a double-contrast view
position. If mucosal coating is ade- coating of all mucosal surfaces of the of the gastric cardia and fundus (Fig
quate, a frontal spot radiograph of the stomach by the high-density barium. Ic). This view also permits visualiza-
stomach is obtained for a double-con- (If the patient cannot be rotated 360" tion of the retrogastric area.
trast view of the gastric antrum and because of age, debilitation, or other 9. "Uphill" flow technique is per-
body (Fig lb), since barium pools in the reasons, a gentle rocking maneuver can formed by turning the patient onto the
fundus in the supine position. If muco- be performed to achieve adequate mu- back and then slowly into an LPO posi-
sal coating is inadequate, the patient cosal coating in most cases.) - tion. This maneuver causes the barium
may be rotated one or more additional 7. A spot radiograph of the antrum pool to flow gradually from the antrum
toward the body and fundus of the
stomach. While the flow of barium is
carefully monitored with fluoroscopy,
four-on-one spot radiographs of the
upper and lower body and antrum of
the stomach are obtained. These radio-
graphs are deliberately taken while the
posterior wall of the body and antrum
are covered by a thin layer of barium,
to delineate shallow depressed or pro-
truded lesions (13).
10. With the table in a semiupright
position, the patient is turned into a
right posterior oblique (RPO) position
f& a double-contrast view of the upper
body and lesser curvature of the stom-
ach. "Downhill" flow technique may
also be performed by observing the
stomach with fluoroscopy as the pa-
tient is slowly turned to the RPO posi-
tion. This maneuver causes the barium
pool to flow from the fundus along the
lesser curvature and vosterior wall into
the body and antrum: better delineat-
ing lesions high on the lesser curvature
of the stomach. Additional four-on-one

II Figure 1. Normal double-contrast upper GI

examination. (a) Upright LPO view of
esophagus. (b)Supine view of stomach.
(c) Right lateral view of cardia and fundus.
1 (d) Semiupright LPO view of duodenum.

Volume 168 Number 3 Radiology 595

Figures 2,3. (2) Flow artifact in esophagus. (a) Residual layer of high-density barium obscures mucosal detail in esophagus. (b) Repeat dou-
ble-contrast view obtained moments later shows reflux esophagitis in distal esophagus, with mucosal nodularity and inflammatory esopha-
gogastric polyp (arrow) not visible on earlier image. (3) Value of prone esophagogram for distal esophagus. (a) Double-contrast radiograph
shows no definite abnormality,although distal esophagus is not optimally distended. (b) Prone esophagogram from same examination
shows hiatal hernia and adjacent peptic stricture (arrow) not visible on double-contrast image.

spot radiographs may be obtained dur- exposed during continuous drinking, each radiograph are summarized in Ta-
ing this maneuver. to permit optimal distention of the dis- ble 1. With some experience, the fluo-
11. By this time, barium usually has tal esophagus and gastroesophageal roscopist should be able to complete
emptied into the duodenum. The pa- junction. the study in 2-4 minutes of fluoroscopy
tient is turned into an LPO position for 14. With the patient in a prone or time and about 10 minutes of room
four-on-one double-contrast spot radio- RAO position, four-on-one spot radio- time. When a lesion is suspected at flu-
graphs of the duodenal bulb and de- graphs of the gastric antrum and duo- oroscopy, the double-contrast examina-
scending duodenum (Fig Id). If the denal bulb are obtained with varying tion should be tailored to demonstrate
bulb is inadequately distended with degrees of compression using an inflat- the lesion both en face and in profile.
gas or obscured by barium, the table able balloon or other prone compres- In many cases, flow technique and
may need to be elevated to a fully up- sion device positioned beneath the pa- prone or upright compression views
right position. This maneuver causes tient's abdomen. These views are im- may also be needed to better delineate
barium to pool in the antrum or de- portant for showing depressed or a suspected abnormality. Ultimately,
scending duodenum and air to rise into protruded lesions on the anterior wall each radiologist must develop his or
the duodenal bulb, which tends to as- of the stomach or duodenum. her own routine for performing the ex-
sume a vertical configuration, so that 15. The patient is turned onto the left amination. While individual maneu-
adequate double-contrast views of the side and then onto the back, so that vers or filming sequences may vary,
bulb usually can be obtained. barium pools in the fundus. The gastro- the end result should be a high-quality
12. An upright LPO spot radiograph esophageal junction is then monitored double-contrast examination.
of the stomach is obtained for an addi- with fluoroscopy as the patient turns
tional double-contrast view of the fun- slowly to the right, in order to demon-
dus. strate spontaneous gastroesophageal re-
Problems and Pitfalls
13. The table is lowered to the hori- flux. A straight-leg raising maneuver or Esop/lngus.-Technical factors related
zontal position, and the patient drinks Valsalva maneuver can also be per- to the amount of barium and gas in the
a low-density barium suspension in a formed to elicit reflux. esophagus may greatly affect the quali-
prone RAO position. To assess esopha- 16. The patient is returned to the ty of the double-contrast examination.
geal peristalsis, the patient is instructed right lateral position, and the table is Because double-contrast radiographs of
to take single swallows of barium, so fully elevated for four-on-one upright the esophagus are obtained with the
that the entire peristaltic sequence can spot radiographs of the barium-filled patient in an upright position, pooling
be evaluated with fluoroscopy. A single stomach and duodenum with varying of barium in the distal portion of the
three-on-one or two two-on-one spot degrees of compression. esophagus may obscure mucosal detail
radiographs of the esophagus are then The filming sequence and purpose of in this region. As barium enters the

596 Radiology September 1988

 (Fig 3) (17,18).
Stomach.-The proper volume of bar-
ium and gas are required for optimal
double-contrast views of the stomach.
A 120-mL cup of high-density barium
is usually adequate for this purpose.
Occasionally, however, barium may
empty rapidly from the stomach de-
s ~ i t intravenous
e administration of
glucagon. In such cases, additional bar-
ium may be given to the patient in a re-
cumbent LPO position to obtain better
mucosal coating. Similarly, if the pa-
tient belches during the examination,
a. 6. an additional packet of effervescent
Figure 4. Value of combined double-contrast technique and prone compression for anteri- agent may be required to produce ade-
or wall lesions in stomach. (a) Supine double-contrast view shows ring shadow (arrow) in quate gaseous distention. Conversely,
antrum. (b)Prone compression view demonstrates filling of anterior wall ulcer (arrow). the patient may be asked to belch if the
stomach is overdistended with gas,
since overdistention may efface abnor-
mal folds associated with ulcers or ul-
cer scars. Even when the proper
amounts of barium and gas a;e present,
retained fluid or debris in the stomach
may impair mucosal coating, so that ad-
ditional turning of the patient is re-
quired to wash the mucosal surface and
achieve adequate coating.
In patients who are relatively unre-
sponsive to glucagon, rapid emptying
of barium into the duodenum may
cause portions of the stomach to be ob-
scured by overlapping loops of barium-
filled duodenum o r small bowel. This
overlap may particularly impair visual-
ization of the distal antrum. If it is a
frequent problem, the first part of the
double-contrast study may be modified
so that the table is returned to the hori-
zontal position with the patient facing
stomach, a residual layer of high-densi- obtained when the routine double-con- the table immediately after swallowing
ty barium in the esophagus may also trast examination is inconclusive (9). the high-density barium suspension.
obscure the mucosa (Fig 2a). When this While mucosal disease is best evalu- The patient then may be turned from
"flow artifact" is observed at fluorosco- ated with double-contrast technique, the prone position onto the left side
py, however, repeat views obtained abnormalities of the longitudinal folds and back in order to obtain unobscured
moments later should better delineate are better seen on mucosal relief views double-contrast views of the distal an-
mucosal lesions as the volume of resid- of the collapsed or partially collapsed trum before barium spills into the duo-
ual high-density barium on the mucosa esophagus. For example, esophageal denum. The usual routine then may be
decreases (Fig 2b) (14). At the same varices may be effaced or even obliter- followed for the rest of the examina-
time, esophageal peristalsis causes the ated by esophageal distention, so that tion.
esophagus to collapse almost immedi- mucosal relief views should be ob- In other patients who are unusually
ately after passage of the barium bolus tained with the patient in the recum- sensitive to glucagon, gastric hypotonia
into the stomach. The fluoroscopist bent position whenever varices are sus- may significantly delay spillage of bari-
therefore must time the exposures to pected on the basis of clinical findings. um into the duodenum, prolonging the
capture the esophagus during a rela- Various types of esophagitis may also examination. When this problem is en-
tively brief period of optimal disten- be recognized due to the presence of countered, the patient may be asked to
tion and coating. With some experi- thickened, irregular longitudinal folds wait outside the examinihg room for 10
ence, it is possible to obtain satisfactory in the collapsed esophagus. or 15 minutes until the glucagon effect
double-contrast views of the esophagus When a ring or stricture is suspected has subsided. Since another study can
in about 75445% of patients (15,16). in the distal portion of the esophagus, be performed while the patient is wait-
When esophageal disease is believed particular emphasis should be placed ing, the fluoroscopy schedule need not
to be present, the cup of high-density on prone single-contrast views of the be delayed by a glucagon-sensitive per-
barium may be split into two portions esophagus during continuous drinking son.
for a more detailed double-contrast ex- of a low-density barium suspension, to Most lesions on the anterior wall of
amination. By having the patient drink produce optimal distention of the distal the stomach will be shown by the com-
half of the barium during the usual esophagus and gastroesophageal junc- bination of supine double-contrast and
LPO projection and half during an RPO tion. Both Schatzki rings and peptic prone compression radiographs. For ex-
projection, protruded or depressed le- strictures that are not visible on dou- ample, a shallow ulcer on the anterior
sions in the esophagus may be evaluat- ble-contrast radiographs may be detect- wall may appear as a "ring shadow" on
ed both en face and in profile. Alterna- ed when the esophagus is maximally double-contrast views (Fig 4a), but
tively, a tube esophagogram may be distended by means of this technique prone compression views of the an-

Volume 168 Number 3 Radiology 597

trum should demonstrate filling of a
discrete ulcer niche (Fig 4b). When
such lesions are not clearly shown by
these routine maneuvers, however, a
double-contrast study of the anterior
wall can be performed (19). In such
cases, the patient is placed in a prone
LAO Trendelenberg position. This ma-
neuver causes the barium to pool in the
fundus of the stomach with only a thin
residual layer of barium on the anterior
wall, so that double-contrast views of
this region can be obtained.
In patients who have undergone par-
tial gastrectomy (ie, Billroth I1 opera-
tion), the altered anatomy of the stom-
ach requires modification of the rou-
tine double-contrast study. The patient
initially should be given a larger intra-
venous dose of glucagon (ie, 1.0 mg
rather than 0.1 mg) to prevent rapid Figure 5. Normal double-contrast appear- I
spillage of barium through the gas- a&e of postoperative stomach (ie, after Bill-
troenterostomy into the proximal small roth I1 operation).
bowel. At the same time, a smaller dose
of effervescent agent (ie, half of a pack-
et of "fizzies") is sufficient to achieve sient phenomenon due to contraction
adequate gaseous distention of the gas- of the longitudinally oriented muscu-
tric remnant. Also, the patient should laris mucosae (Fig 6) (22). However, the
not gulp a full cup of high-density bar- normal longitudinal folds are usually
ium, since a large volume of barium in effaced or obliterated by gaseous dis-
the gastric remnant may obscure muco- tention of the esophagus.
- - While the
sal detail in this region. Instead, several presence of mucosal nodularity usually
swallows of barium in a semiupright Figures 6,7. (6) Transverse folds in esoph-
indicates an inflammatory or neoplastic agus due to contraction of longitudinally
position should permit adequate muco- process, the mucosa occasionally may oriented muscularis mucosae. ( 7 ) Glycogenic
sal coating of the anastomosis and gas- have a nodular appearance in some acanthosis with discrete plaques and nod-
tric remnant (Fig 5). The reader is re- middle-aged or elderly individuals ules in midesophagus. Candida esophagitis
ferred to other articles for a more de- with glycogenic acanthosis, a benign could produce a similar appearance.
tailed discussion of double-contrast degenerative condition in which there
techniques for examining the postoper- is accumulation of glycogen within the
ative stomach (20,21). squamous epithelial lining of the served in the duodenum both en face
Duodenum.-Once the duodenum has esophagus (Fig 7) (23,24). and in profile due to trapping of bari-
filled with high-density barium, ade- Stomach.-While the appearance of um in normal mucosal pits (Fig 8b)
quate double-contrast views of the duo- the rugae in the stomach is important (27). This finding is important because
denal bulb and descending duodenum on conventional barium studies, these it can be mistaken radiographically for
can usually be obtained by placing the folds are effaced or obliterated by gas- erosive duodenitis.
patient in a recumbent, semiupright, or eous distention on double-contras~ex-
upright LPO position to distend the aminations. Instead, emphasis is placed
bulb with gas. When the duodenal bulb Depressed Lesions
on radiologic evaluation of the gastric
is located in a posterior position, the mucosa. With adequate mucosal coat- Esophagus.-Double-contrast radiog-
patient may be turned into a left lateral ing, the normal areae gastricae are usu- raphy is particularly valuable for the
or even a prone LAO position to ally most prominent in the antrum and detection of shallow ulcers and ero-
achieve adequate gaseous distention of body of the stomach. Enlargement or sions due to various types of esophagi-
the bulb. If, despite these maneuvers, distortion of the areae gastricae may be tis. In most cases, the underlying cause
satisfactory double-contrast views of related to the presence of superficial can be suggested on the basis of the ra-
the duodenum cannot be obtained, the gastritis, hypersecretory states, intesti- diographic findings and clinical histo-
fluoroscopist should proceed to the sin- nal metaplasia, or, rarely, early gastric ry. In patients with reflux esophagitis,
gle-contrast portion of the study rather cancer (25,26). However, further inves- superficial ulceration in the distal por-
than prolong the double-contrast exam- tigation is required to understand bet- tion of the esophagus may manifest on
ination, since it is almost always possi- ter the significance of these variations radiographs as multiple tiny collections
ble to obtain adequate prone or upright in the surface pattern of the stomach. of barium on the esophageal mucosa
compression views of the bulb. Duodenum.-The duodenal bulb usu- (Fig 9a) (28). Although some patients
ally has a smooth, featureless appear- may have a more diffuse erosive esoph-
ance on double-contrast radiographs. agitis involving the distal one-third or
INTERPRETATION two-thirds of the thoracic esophagus,
Occasionally, however, a lacy, reticular
mucosal pattern may be observed in there is almost always a continuous
Normal Appearances the duodenum as a normal variation area of mucosal disease extending prox-
Esopllagus.-The esophageal mucosa (Fig 8a) (27). This appearance results imally from the gastroesophageal junc-
normally has a smooth, featureless en from trapping of barium in intersecting tion. Thus, the presence of superficial
face appearance on double-contrast ra- grooves between tiny villous structures ulceration in the midesophagus with
diographs. Occasionally, delicate trans- on the mucosa. In other patients, punc- distal esophageal sparing should indi-
verse folds may be observed as a tran- tate collections of barium may be ob- cate some other cause for the patient's

598 Radiology September 1988

 esophagitis.
Superficial ulcers predominantly in-
volving the midesophagus are usually
caused by herpes or drug-induced esoph-
agitis. In the early stages of herpes eso-
phagitis, double-contrast radiographs
may reveal discrete, superficial ulcers
clustered together or widely separated
by normal intervening mucosa (Fig 9b)
(29,30). The ulcers are often surround-
ed by a radiolucent halo of edematous
mucosa. Similarly, drug-induced eso-
phagitis may manifest as one or more
discrete areas of superficial ulceration
in the mid or, less commonly, distal
esophagus, so that differentiation from
herpes esophagitis may not be possible
on the basis of the radiologic findings
(Fig 9c) (31,32). However, a temporal
relationship between ingestion of the
offending medication (usually tetracy-
cline or doxycycline) and the onset of
esophagitis khould indicate the correct
diagnosis.
Stomach.-Gastric erosions may be
classified radiographically as complete
or incomplete erosions. Most patients
have complete or "varioliform" ero-
a. b. sions in which a punctate or slitlike
Figure 8. Normal variations of duodenal mucosa. (a) Delicate reticular pattern in duodenal barium is surrounded by a
bulb. (b) Tiny collections of barium in normal mucosal pits. Erosive duodenitis could pro- radiolucent halo of edematous mucosa
duce a similar appearance. (Fig 10a)(33). Varioliform erosions are
most commonly found in the antrum of
the stomach a& are often aligned on
rugae. While no etiologic significance
is generally attributed to the shape or
location of these gastric erosions, aspi-
rin and other nonsteroidal antiinflam-
matory drugs may produce linear or
serpiginous erosions that tend to be
clustered in the body of the stomach,
on or near the greater curvature (Fig
lob) (34). Because these lesions have a
distinctive appearance on double-con-
trast studies, a specific cause for the pa-
tient's gastritis can be suggested on the
basis of the radiographic findings.
Double-contrast radiography is a
valuable technique for diagnosing gas-
tric ulcers and for differentiating be-
nign from malignant lesions (35,36).
The majority of ulcers detected on dou-
ble-contrast studies are less than 1 cm
in size (36). While some benign ulcers
are round and symmetric (Fig 1 la), oth-
ers may have a rod-shaped or linear ap-
pearaice. Enlarged areae gastricae are
often observed surrounding the ulcer,
due to edema and inflammation of the
adjacent mucosa (Fig 12a) (36).Subse-
quent ulcer healing may manifest not
only as a decrease in the size of the ul-
cer but as a change in its shape (Fig
12b).In most cases, ulcer healing pro-
duces a radiographically visible ulcer
scar with a central pit or depression, ra-
Figure 9. Esophageal ulcers. (a) Reflux esophagitis with superficial ulceration in distal diating folds, and/or retraction of the
esophagus. (b) Herpes esophagitis with several shallow ulcers (arrows) separated by normal
intervening mucosa. (Reprinted, with permission, from reference 29.) (c) Drug-induced adjacent gastric wall (36,37). While a re-
esophagitis with discrete ulcers (arrows) in midesophagus. Although herpes 'sophagitis sidual depression could be mistaken for
could produce identical findings (cf Fig 9h), this particular patient was receiving orally ad- an active ulcer crater, the central por-
ministered tetracycline. tion of a reepithelialized scar some-

Volume 168 Number 3 Radiology 599

 b.
Figure 10. Erosive gastritis. (a) Typical varioliiform erosions in gastric antrum. (b) Linear and serpiginous erosions in body of stomach (pre-
dominantly near greater curvature) due to rece'nt ingestion of indomethacin.

times can be differentiated from an ac-

tive ulcer by the presence of normal
areae gastricae within the scar (Fig 1l b )
(36).
Duodnlum.-Erosive duodenitis is di-
agnosed less frequently than erosive
gastritis on double-contrast studies be-
cause of the difficulty in differentiating
duodenal erosions from normal muco-
sal pits (27). However, erosive duodeni-
tis can be diagnosed when double-con-
trast radiographs reveal one or more
varioliform erosions in the proximal
duodenum (Fig 13).
Unlike gastric ulcers, which occur
primarily on the posterior wall of the
stomach, as many as 50% of duodenal
ulcers are located on the anterior wall
(38). Since most double-contrast radio-
graphs are obtained with the patient in
a supine or supine oblique position, the a. b.
anterior wall of the duodenum is not Figure 11. Benign gastric ulcer and ulcer scar in different patients. (a) Round, symmetric
optimally coated with barium, so that ulcer on posterior wall of stomach with smooth folds radiating to edge of ulcer crater.
anterior wall ulcers may be missed on (b) Reepithelialized ulcer scar with radiating folds and normal areae gastricae (arrow) in
the double-contrast portion of the central portion of scar.
study. For this reason, double-contrast
views of the duodenum should be sup-
plemented by prone compression
views obtained with a low-density bari- with intervening segments of normal slightly lobulated contour (Fig 15a)
um suspension to demonstrate ulcers mucosa (Fig 14) (39). Because the le- (40). Other early cancers may be super-
on the anterior wall (38). In other pa- sions have well-defined borders, they ficial s p readin g lesions, causing local-
tients with anterior wall ulcers, a "ring may be etched in white by a thin layer ized nodularity or granularity of the
shadow" may be detected on double- of barium trapped between the edge of mucosa (Fig 15b) (40). When a suspi-
contrast radiographs due to a thin coat- the plaque and the adjacent mucosa. cious lesion is detected on double-con-
ing of barium on the rim of a nonde- Glycogenic acanthosis may also pro- trast radiographs, endoscopy and biop-
pendent ulcer. In such cases, the ulcer duce plaquelike lesions indistinguish- sy should be performed for a definitive
can almost always be filled with bari- able from those of Candida esophagitis diagnosis.
um and diagnosed definitively on (Fig 7) (23,24). However, most patients Stomnch.-Early gastric cancers may
prone or upright compression views of with glycogenic acanthosis are asymp- be elevated, flat, or depressed lesions.
the duodenum. Thus, biphasic tech- tomatic, so that these conditions usual- The Japanese have developed an ele-
nique is particularly important in the ly can be differentiated on the basis of gant system for classifying these can-
evaluation of this area. clinical findings. cers based c n the predominant mor-
Early esophageal cancers classically phologic features of the lesion (41). Ele-
appear on radiographs as small pro- vated lesions may be plaquelike or
Protruded Lesions truded lesions less than 3.5 cm in diam- polypoid and occasionally may occupy
Esophng~ts.-CnirdidR esophagitis usu- eter (40). They may be plaquelike le- a considerable burface area of the stom-
ally manifests on double-contrast ra- sions (often with central ulceration) or ach without invading beyond the sub-
diographs as discrete plaquelike lesions flat, sessile polyps with a smooth or mucosa. ~ n f o r t u n a t ~most
l ~ , patients

600 Radiology September 1988

a. b. Figure 13. Erosive duodenitis with varioli-
Figure 12. Benign gastric ulcer with healing. (Reprinted, with permission, from reference form erosions (arrows) in proximal duode-
36.) (a)Posterior wall ulcer (arrow) in upper body of stomach. Note enlarged, nodular areae num.
gastricae adjacent to ulcer due to surrounding edema and inflammation. (b)Considerable ul-
cer healing is seen 3 months later, with residual linear ulcer (arrow). Note return of normal
areae gastricae in this region. (718 and 10.16 indicate dates of image acquisition.)

lated lymphoid hyperplasia of the duo-

denum may be observed in patients
who have no underlying disease.

14. 151. 15b. References

Figures 14,15. (14)C ~ l r d i d nesophagitis with discrete plaquelike lesions in the esophagus. 1. Ominsky SH, Margulis AR. Radiographic
Note linear configuration of plaques. (15)Early esophageal cancer. (a) Small sessile polyp examination of the upper gastrointestinal
(arrow) in midesophagus. (Courtesy of Seth N. Glick, MD, Philadelphia.) (b)Localized area tract: a survey of current techniques. Radi-
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2. Gelfand DW, Ott DJ. Declining volume
of gastrointestinal fluoroscopies: a survey
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noma already have advanced lesions at angulated or polygonal 1-5-mm filling 3. Gelfand DW. Ott DJ. Chen YM. Decreas-
the time of clinical presentation, so that defects that tend to be clustered near ing numbers of gastrointestinal studies:
report of data from 69 radiologic practices.
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as a relatively frequent finding on dou- hyperplasia of the duodenum and prospective comparison of upper gastroin-
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Volume 168 Number 3 Radiology 601

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602 Radiology September 1988