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1 All authors: Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104.
Received November 3, 2000;
accepted after revision January 4, 2001.
Address correspondence to M. S. Levine.
Abstract
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MATERIALS AND METHODS. A total of 141 double-contrast upper gastrointestinal tract examinations with normal findings were reviewed for the presence or absence of areae gastricae on double-contrast images of the stomach. All images were evaluated by two radiologists who were blinded to the age of the patients. The data were then analyzed to determine if the frequency of visualization of areae gastricae on double-contrast studies was significantly related to the age of patients.
RESULTS. The frequency of visualization of areae gastricae increased
significantly with increasing age (p = 0.008). The youngest age group
(20-29 years old) exhibited areae gastricae in only four (19%) of 21 cases,
whereas the oldest age group (
70 years old) exhibited areae gastricae in
19 (76%) of 25 cases. On average, the rate of visualization of areae gastricae
on double-contrast studies increased by 9% per decade.
CONCLUSION. Our data show that the frequency of visualization of areae gastricae on double-contrast upper gastrointestinal tract examinations increases significantly with increasing patient age. It is important for radiologists to be aware of the effect of aging on the delineation of areae gastricae on double-contrast studies.
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To elucidate age-related trends in visualization of areae gastricae on double-contrast examinations, one of the authors selected a random sample of 145 adult patients who underwent this procedure during our study period. The sample was stratified by age, creating a data set that included a comparable number of patients from each decade of life starting at 20 years. For the purposes of this study, we included only examinations of the stomach and duodenum with normal findings or examinations with findings of gastroesophageal reflux, hiatal hernias, or prominent areae gastricae.
The digital images from these 145 double-contrast examinations were reviewed in random order by two experienced gastrointestinal radiologists who were blinded to the age of the patients. In all cases, a decision was made by reviewer consensus about the presence or absence of areae gastricae seen covering at least 25% of the mucosal surface of the stomach, a criterion used previously by others for delineation of areae gastricae on double-contrast studies [1]. When areae gastricae were visualized, their size and location were also recorded. Four patients were found to have suboptimal double-contrast studies because of inadequate mucosal coating, and these studies were excluded from our analysis.
The final data set consisted of 141 patients, ranging from 21 to 88 years old; the mean age was 51 years (SD, 17.7 years). Fifty-five patients (39%) were men, and 86 (61%) were women. Of the 141 patients, 21 (15%) were 20-29 years old, 23 (16%) were 30-39 years old, 24 (17%) were 40-49 years old, 25 (18%) were 50-59 years old, 23 (16%) were 60-69 years old, and 25 (18%) were 70 years old or older.
The data were analyzed with the chi-square test and logistic regression.
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70 years old)
exhibited areae gastricae in 19 (76%) of 25 cases. Representative examples are
shown in Figures 1 and
2. When visualization of areae
gastricae was plotted as a function of age (grouped by decades), a calculated
linear fit (with regression analysis) showed that the rate of visualization of
areae gastricae increased by 9% per decade
(Fig. 3).
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When areae gastricae were present, they were visualized in the antrum alone in six patients (8%), in the body alone in 16 (22%), in the fundus alone in two (3%), in the antrum and body in 13 (18%), in the antrum and fundus in two (3%), in the body and fundus in seven (10%), and in the antrum, body, and fundus in 26 (36%). The average diameters of the areae gastricae were 1-2 mm in 41 patients (87%) and 3-4 mm in six patients (13%) in the antrum; 1-2 mm in 41 patients (66%) and 3-4 mm in 21 patients (34%) in the body; and 1-2 mm in 22 patients (59%) and 3-4 mm in 15 patients (41%) in the fundus. The areae gastricae, therefore, tended to be larger in the more proximal stomach. However, a statistical analysis of the distribution or size of areae gastricae in relation to age could not be performed because the sample sizes were too small to stratify the patients by age.
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Although the density and viscosity of the barium suspension, the thickness
of the gastric mucus layer, and even pathophysiologic conditions such as
peptic ulcers have all been implicated as factors affecting visualization of
areae gastricae on double-contrast studies, we are not aware of any published
data about the effect of age on our ability to visualize these structures. In
our study, however, the frequency of visualization of areae gastricae on
double-contrast studies increased significantly with the increasing age of
patients (p = 0.008) (Figs.
1 and
2). On average, the rate of
visualization of areae gastricae increased by 9% per decade
(Fig. 3). The greatest
differences were detected in the extremes of our study population; the
youngest age group (20-29 years old) exhibited areae gastricae in only 19% of
cases, whereas the oldest age group ( 70 years old) exhibited areae
gastricae in 76% of cases.
The explanation for this age-related variation in the frequency of visualization of areae gastricae on double-contrast barium studies is uncertain. However, the number of mucus-secreting cells in the stomach has been shown to decrease with age [8]. Mucolytic agents have also been shown to improve visualization of the gastric mucosa on endoscopy [9]. A thinner mucus layer in the stomach related to aging, therefore, could lead to improved visualization of areae gastricae on double-contrast studies by allowing better barium filling of this reticular network.
Greater visualization of areae gastricae on double-contrast studies in older patients may also be related to infection by H. pylori because the prevalence of H. pylori gastritis is known to increase with age. More than 50% of asymptomatic Americans older than 60 years are infected by this organism [10]. It, therefore, is possible that H. pylori gastritis affects the composition or thickness of the gastric mucus layer, so more barium can enter the reticular network of grooves that the areae gastricae comprises. In fact, several investigators have shown that the urease activity of H. pylori damages the gel structure of mucus in the stomach [11] and that H. pylori contains various proteases that enzymatically degrade this mucus layer [12, 13]. In a recent study, it was also found that the effect of H. pylori on this mucus gel structure is age related; greater thinning of the mucus layer was observed in patients with advancing age with findings positive for H. pylori [14]. Thus, the higher prevalence of H. pylori in older patients may contribute to improved visualization of areae gastricae on double-contrast studies in these individuals. Nevertheless, we believe that visualization of areae gastricae per se is not abnormal unless the areae gastricae are enlarged or are associated with other radiographic signs of gastritis. In any case, further investigation is needed to better elucidate the relationship between H. pylori gastritis, thinning of the gastric mucus layer, and delineation of areae gastricae on double-contrast radiographs.
In the past, it has been shown that areae gastricae can be visualized on double-contrast studies in slightly more than two thirds of all patients [1]. However, our findings indicate that areae gastricae are less likely to be visualized in younger patients even in the absence of gastric disease. The age of the patient, therefore, should be considered when delineation of areae gastricae is used as a criterion for assessing the quality of mucosal coating in the stomach on double-contrast studies.
In conclusion, our data show that the frequency of visualization of areae gastricae on double-contrast upper gastrointestinal tract examinations increases significantly with increasing patient age. This observation may be related to a higher prevalence of H. pylori gastritis and thinning of the gastric mucus layer that occurs with aging. Whatever the explanation, it is important for radiologists to be aware of the effect of aging on the delineation of areae gastricae on double-contrast studies.
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