AJR 2002; 178:1292-1293
© American Roentgen Ray Society
Gastroduodenal Mucosal Prolapse
Diagnosis Using Conventional Abdominal Radiographs
Yvonne W. Lui and
Emil J. Balthazar
New York University Medical Center New York, NY 10016
Gastroduodenal prolapse of antral mucosa is a well-recognized entity
commonly encountered on upper gastrointestinal examinations in both
symptomatic and asymptomatic individuals. Incidence of this entity among the
adult population has been reported as ranging from as low as 0.1-7.7%
[1,
2] to as high as 14%
[2]. Diagnosis on an upper
gastrointestinal study is based on the detection of a transitory concavity at
the base of the duodenal bulb or, in severe forms, on the presence of a large
duodenal filling defect extending through the pylorus.
During the last 10 years, we have noticed an unusual, complex mass in the
right upper quadrant on several abdominal radiographs obtained with the
patient in the supine position. Conventional radiographs show a round
soft-tissue mass surrounded by a well-circumscribed round or oval radiolucency
(Figs. 3 and
4A). Fluoroscopic left
posterior oblique spot images obtained in three patients showed the
soft-tissue mass at the base of the air-filled duodenal bulb, protruding into
its lumen (Fig. 4B). Upper
gastrointestinal examinations available for two of the patients were
consistent with marked gastroduodenal prolapse
(Fig. 4C). Reports of
nonspecific abdominal pain were elicited from two patients, and endoscopy
performed in one patient revealed mild antral gastritis.
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Fig. 3. —Asymptomatic 62-year-old woman. Complex soft-tissue mass
(arrows) in right upper quadrant was incidental finding seen on
conventional abdominal radiograph. Diagnosis of gastroduodenal prolapse was
confirmed by subsequent upper gastrointestinal examination.
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Fig. 4A. —48-year-old man with abdominal pain. Fluoroscopic supine spot
image shows round soft-tissue mass (open arrows) surrounded by
well-circumscribed oval radiolucency (solid arrows). Central punctate
high density probably represents residual contrast medium.
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Fig. 4B. —48-year-old man with abdominal pain. Fluoroscopic left
posterior oblique spot image shows mass (open arrow) at base of
duodenum (large solid arrows). Air is seen in antrum (small solid
arrows).
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Fig. 4C. —48-year-old man with abdominal pain. Spot image from upper
gastrointestinal examination confirms marked gastroduodenal prolapse
(arrow). Thickened folds (arrowheads) in distal stomach (S)
are consistent with endoscopically confirmed gastritis. D = duodenum.
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Severe gastroduodenal prolapse can occasionally result in the appearance of
a complex mass in the right upper quadrant that is visible on supine abdominal
radiographs. The finding appears mainly in patients with transverse stomachs
if the air-distended duodenal bulb (located above the hepatic fixture) is
viewed en face (Figs.
3 and
4A,4B,4C).
The central soft-tissue density and surrounding radiolucent halo represent
prolapsed gastric mucosa and air within the duodenum, respectively. In our
experience, this appearance is characteristic of marked gastroduodenal mucosal
prolapse. Less likely is the possibility of a prolapsed distal gastric mass or
a duodenal tumor. Obtaining fluoroscopic left posterior oblique spot images of
the suspected lesion or performing an upper gastrointestinal examination can
easily confirm the diagnosis (Figs.
4B and
4C).
Factors implicated in the development of this abnormality include redundant
antral folds, increased peristalsis, and antral gastritis. The clinical
implication of gastroduodenal mucosal prolapse is controversial. Feldman and
Myers [2] found that 46% of
symptomatic patients with prolapse also had associated gastritis. More
recently, hypertrophic antral-pyloric folds have been described as being
associated with gastritis. One radiographic series
[3] found that of 40 patients
with such hypertrophic folds, 15 (38%) had prolapse of an enlarged fold into
the duodenal bulb.
Because gastroduodenal prolapse is often seen in patients with nonspecific
symptoms but is also often associated with gastritis
[2,3,4],
detection of the prolapse on conventional radiographs may elucidate the
patient's clinical complaints. In addition, care should be taken to ensure
that gastroduodenal prolapse found incidentally is not misinterpreted as other
abnormalities.
References
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Scott WG. Radiographic diagnosis of prolapsed redundant gastric
mucosa into the duodenum, with remarks on the clinical significance and
treatment. Radiology
1946;46:547
-568
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Feldman M, Myers P. The roentgen diagnosis of prolapse of the
gastric mucosa into the duodenum. Gastroenterology
1952;20:90
-99[Medline]
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Arora R, Levine MS, Harvey RT, et al. Hypertrophied
antral—pyloric fold: reassessment of radiographic findings in 40
patients. Radiography
1999;213:347
-351
-
Glick SN, Cavanaugh B, Teplick SK. The hypertrophied
antral—pyloric fold. AJR
1985;145:547
-549[Abstract/Free Full Text]
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