Stomach: The Forgotten Organ: A Pictorial Tour of Gastric Abnormalities with Emphasis on Cross-section Imaging Ania Kielar, Vineeta

Sethi, Vivek Virmani,

Introduction
CT allows evaluation of the gastric lumen, gastric wall and adjacent structures. Familiarity with imaging findings helps to establish correct diagnosis and guide effective and timely management.

Outline of presentation and corresponding examples

Classification Malignant neoplasms Benign neoplasms
Examples Carcinoma, Lymphoma, GIST, Carcinoid, Metastases Leiomyoma, Neural tumor, Lipoma, Polyp, Inflammatory Pseudotumor, Ectopic pancreatic rest

Benign wall thickening Caustic ingestion, Retching, Hypertrophic pyloric stenosis, Omeprazole, Reflux surgery Inflammatory Infectious Vascular Congenital Trauma Foreign bodies Miscellaneous
Peptic ulcer, Crohns, GVHD, Bouveret syndrome Gastric abscess Infarction, Herniation with ischemia, Varices Duplication cyst Nasogastric tube trauma Cocaine packets, Bezoar, Gastric pacemaker Gastric diverticulum

General Notice
There will be a quiz at the end!!!!

Imaging of the stomach

Not usually thought about but can be done Positive or negative oral contrast IV contrast Axial/Coronal reconstructions

Gastric Carcinoma
1 2

Malignant neoplasms

Polypoidalal mass along lesser curvature. Smooth outer gastric wall and absence of perigastric stranding = T2 gastric carcinoma.

Markedly enhancing wall thickening in the antrum with resultant gastric outlet obstruction. Irregular border with blurred fat plane along the medial margin signifying T3 carcinoma.

CT appearance of Gastric carcinoma - Focal wall thickening with or without ulceration,

- Polypoidal mass - Diffuse infiltration - > (name?) Gastric wall thickness > 1cm & focal, eccentric or enhancing wall thickening are most specific. CT can differentiate T2 (limited to serosa) and T3 lesions (transmural extension) with high sensitivity and specificity ( 90 and 95%).

Carcinoma
a b

Malignant neoplasms

72-year-old female with signet ring cell gastric carcinoma. Diffusely thickened and enhancing gastric wall consistent with linitis plastica. In the pelvis there are bilateral complex solid-cystic masses consistent with ovarian metastases = Krukenberg tumors.

Metastases - Lymph nodes ( suspicious features = > 6mm, round shape, heterogenous enhancement missing fatty hilum ) - Peritoneal spread including ovarian metastases (Krukenberg tumor) - Hematogenous metastases (most common liver) Unusual CT features Calcification (rare, seen in mucinous adenocarcinoma)

Carcinoma
a b

Malignant neoplasms

Diffuse thickening and enhancement of the gastric wall in the distal stomach with obliteration of the gastric folds and decreased distention in the affected region. This is classical of Linitis plastica and on pathology was a T3 signet ring cell carcinoma.

Site: Antrum 30%, Body- 30%, Fundus & cardia- 30%, Diffuse- 10% Schirrous carcinoma / Linitis plastica - Frequently involves distal half of stomach - Frequently under-staged - Typically caused by signet ring cell carcinomas - Peritoneal spread is more common

Gastric Lymphoma
a b

Malignant neoplasms

Diffuse large B-cell gastric lymphoma with peritoneal lymphomatosis in a 62-year-old man with epigastric pain and anemia.. Diffuse, concentric, homogenous thickening of the gastric wall with maintained perigastric fat planes. Diffuse infiltration of the omentum extensive mesenteric and retroperioneal lymphadenopathy.

1-5 % of gastric malignant tumors of the stomach; Most common extra-nodal lymphoma. B-cell type Non-Hodgkins lymphoma or Low grade mucosa-associated lymphoid tissue (MALT). CT features - Segmental or diffuse gastric wall thickening. - Less commonly, a localised polypoidal lesion with or without ulceration.

Gastric Lymphoma
a b

Malignant neoplasms

Low grade gastric lymphoma in a 45-year-old man presenting with loss of appetite and dyspepsia. Biopsy revealed MALT lymphoma, a relatively indolent form of lymphoma.

CT Characteristics of gastric wall thickening in lymphoma: - > 1cm (Average 2.9 5 cm) but significantly less in MALT lymphoma (<1.3 cm). - Diffuse infiltration in > 50 % of cases, can be segmental (antrum most common). - Homogenous wall thickening with less pronounced enhancement. - Outer wall is smooth with maintained perigastric fat planes.

Gastric Lymphoma
a b

Malignant neoplasms

A. Diffuse large B-cell gastric lymphoma infiltrating the spleen. B. Follow-up coronal CT post 4 cycles of chemotherapy shows localised perforation of the stomach . Patient was referred for surgery and underwent splenectomy and partial gastrectomy .

Trans-pyloric spread more common than carcinoma (30%). Stomach remains pliable and gastric outlet obstruction is uncommon. Perforation and fistulization are known complications, especially after chemotherapy. Bulky adenopathy below level of renal hilum favours lymphoma over carcinoma.

Gastroinstestinal Stromal Tumor (GIST)

a c

Malignant neoplasms

54-year-old male presenting with GI bleeding and epigastric pain.

Most common mesenchymal tumor of the GI tract with 60-70% affecting the stomach. 2-3 % of all gastric tumors. CT predictors of malignancy: >5cm, heterogeneous enhancement, ulcer, necrosis, metastases.

GIST
1 2

Malignant neoplasms

62-year-old male with malignant GIST. Biopsy of GIST is contraindicated due to risk of peritoneal seeding.

Malignant GIST in a 55-year-old male. Smooth heterogenous exogastric mass of the lesser curvature extending into the gastrohepatic ligament. There is necrosis within it and a speck of calcification . Calcification, though unusual in GIST, is more common than carcinoma or lymphoma.

CT features of GIST: - Large (3 - 10 cm). Predominant exophytic component with small intraluminal component. - Hypervascular. - Often heterogeneous because of necrosis, hemorrhage or cystic degeneration. - Mucosal ulceration or fistula (15 - 50%)- presence of air or oral contrast material within mass. - Calcification may be present.

GIST
a b

Malignant neoplasms

Surgically proven gastro-gastric intussusception with malignant gastric GIST as the lead point. There is a homogenously enhancing mass as the lead point. Pathology revealed a malignant GIST. True gastro-gastric intussusception is extremely rare and has been reported in polyps or of a gastric remnant through a gastrojejunal anastomosis.

Does not involve gastric wall concentrically: bowel obstruction is rare. Usually displaces rather than invades adjacent organs. 50% of patients with GIST present with metastasis. - most common = liver (hematogenous spread) and peritoneum. - lymph nodal metastases are rare and suggest alternate diagnosis.
Ulusan S, Koc Z, Kayaselcuk F. Gastrointestinal stromal tumours: CT findings Br J Radiol 2008; 81: 618 - 623

Carcinoid
a b c

Malignant neoplasms

Type III gastric carcinoid in a 39-year-old male with carcinoid syndrome. There is a solitary homogenous exogastric mass arising from the lesser curvature with multiple calcific foci .

Rare tumors (0.3 % of all gastric tumors), 3% of GI carcinoids are seen in stomach. Gastric carcinoid Type I Type II Type III Frequency Association
Chronic atrophic gastritis and pernicious anemia Hypergastrinemia+ Zollinger-Ellison syndrome and MEN I. Hypergastrinemia + Sporadic, Hypergastrinemia Carcinoid syndrome

CT features
Usually < 1cm, multicentric, mucosal or submucosal masses

Metastases Usually benign Lymphnodal metastases

Hematogenous

80% 5-10% 10-15%

Small masses + gastric wall thickening Large solitary hypervascular mass with exogastric component

metastases

Metastases to Stomach
1 2

Malignant neoplasms

Metastases to the stomach in a 45-year-old male with history of treated superficial spreading melanoma of the back.

58-year-old woman with gastric linitis plastica from metastatic lobular carcinoma of breast. CT shows diffusely thickened and enhancing gastric wall There were also multiple lung and hepatic metastases .

Rare (0.2% of gastric tumors); majority hematogenous from melanoma, breast, lung & ovarian cancers.

CT features: - Smooth submucosal mass +/- ulceration. - Hematogenous dissemination of infiltrating lobular breast carcinoma can cause metastatic gastric linitis plastica with diffuse thickening and enhancement of the gastric wall on CT.
Green LK. Hematogenous metastases to the stomach. A review of 67 cases. Cancer 1990; 65: 1596-1600

Benign tumors

Leiomyoma
a b

Benign neoplasms

Liomyoma of the stomach in a 38-year-old female with GI bleeding. CT shows a smooth submucosal mass with a small exogastric component and mild enhancement. Tiny hyperdense foci represent oral contrast within the mass due to ulceration.

Most common benign tumors of the stomach (2.5 % of all gastric tumors). Antrum > Body > Fundus. CT features: - Solid, round or ovoid submucosal masses usually < 5 cm. - Outer margin smooth with preserved fat planes. - Inner margin may be irregular due to ulceration. - Variable enhancement; calcification may be present occasionally.

Neurogenic tumor Tumor a

Benign neoplasms

Gastric mass in a 29-year-old male with epigastric pain. There is predominantly exophytic submucosal mass arising from the fundus of the stomach with a speck of calcification in it. There is mild homogenous enhancement after contrast enhancement. Large exogastric component and calcification are not common in gastric neural tumorus.

0.2% of all gastric tumors and 4% of all benign gastric neoplasms. CT features: - Well-demarcated, homogeneous, solid, ovoid or multi-lobulated masses. - May have exogastric component. - Uncommonly ulceration, calcification or cystic change may occur; variable enhancement. Carneys Triad- Gastric neural tumor, extra-adrenal paraganglioma and pulmonary chondroma (any
2).
Park SO, Han JK, Kirn TK et al. Unusual gastric tumours: radiologie pathologic correlation. RadioGraphics 1999; 19: 1435 -1446

Lipoma
a b

Benign neoplasms

Gastric lipoma incidentally detected in a 36-year-old female. There is a well defined submucosal endogastric fat density mass in the fundus of the stomach. There is minimal adjacent gastric wall thickening .

2-3 % of gastric benign tumors and 5% of all GI lipomas. Antrum is the most common site. CT features: - Solitary, submucosal, well-demarcated lesion with homogenous fat attenuation. - Occasionally linear strands of soft tissue at base or mild adjacent gastric wall thickening. Complications with large lesions- Ulceration with hemorrhage, intussusception & obstruction.
Ferrozzi F, Tognini G, Bova D, et al. Lipomatous tumours of the stomach: CT findings and differential diagnosis. J Comput Assist Tomogr 2000 ; 24: 854 -858

Polyps
a b

Benign neoplasms

Gastric and small bowel hamartomatous polyps in a 16-year-old with Peurtz-Jeghers syndrome. Axial CT reveals multiple, sessile, homogenously enhancing polyps in the body of the stomach. In the pelvis there is a small bowel ntussusception with a polyp as the lead point.

Non-neoplastic gastric polyps include hyperplastic and hamartomatous polyps. Hyperplastic polyps constitute 80-90% of all polyps while hamartomatous polyps are seen in syndromes such as Peutz-Jeghers, Juvenile Polyposis and Cronkhite-Canada. CT findings: - Multiple smooth, sessile, clustered round or oval lesions 5-10 mm in size in fundus or body. - Rarely can be large and lobulated.

Polyps
a b

Benign neoplasms

Adenomatous gastric polyps in a 28-year-old male with Familial Polyposis Coli. CT reveals innumerable sessile and pedunculated polyps measuring 1-4 cm distributed diffusely in the stomach. Lower down, there are multiple similar polyps. Biopsy confirmed many of these to harbor malignant foci.

Adenomatous polyps have malignant potential & harbor carcinomatous foci in 40% of cases. Larger than hyperplastic polyps, usually >2cm. Usually solitary and occur adjacent to the antrum; sessile or pedunculated. Can be multiple especially when associated with syndromes like Familial polyposis coli, Turcot syndrome and Gardners syndrome.
Merino S, Saiz A, Moreno MJ et al. CT evaluation of gastric wall pathology. BJR 1999; 72: 1124-1131

Inflammatory Myofibroblastic Tumor

a b

Benign neoplasms

Myofibroblastic tumor in a 14-year-old female with epigastric pain. There is a well -defined, hypodense mass arising from the body of the stomach with an exogastric component. Pathology revealed it to be myofibroblastic tumor.

Synonyms: Inflammatory pseudotumor and myofibroblastic tumor. In the abdomen: most commonly in terminal ileum and greater curvature of stomach. Predominance in females and preschool age children. CT appearance: - Hypodense to isodense on unenhanced scans with variable to no enhancement. - May have aggressive features including ulceration and exogastric extension. - Calcification has been reported.

Ectopic pancreatic rest

a b c

Benign neoplasms

Ectopic pancreatic rest in a 35-year-old male presenting with GI bleeding. The lesion is following the signal intensity of the pancreas on all sequences. A few small cystic areas were confirmed to be an anomalous dilated duct on pathology.

Heterotopic pancreas is rare; most commonly found in the stomach. Usually located along greater curvature in the prepyloric region. CT findings: - 1-3 cm, well-defined oval, submucosal. Indistinguishable from other submucosal lesions. - Small cystic areas could represent dilated anomalous duct. MRI diagnostic as heterotopic pancreas follows signal and enhancement patterns of pancreas.

Benign Wall Thickening

Adult Hypertrophic Pyloric Stenosis

a b

Benign Wall Thickening

Adult hypertrophic pyloric stenosis 2ndary to scarring of a gastric ulcer in a 54-year-old male. CT reveals circumferential smooth wall thickening of antro-pyloric region with narrowing a of pylorus. Coronal CT confirms narrowing of the pylorus = cervix sign.

Hypertrophic pyloric stenosis is a rare cause of gastric outlet obstruction in adults. 1 ary or 2 ary to scarring of gastric / duodenal ulcer, post-op adhesions, carcinoma etc. CT findings: - Smooth circumferential pyloric wall thickening. - Elongation and narrow pylorus with intact smooth border analogous to a doughnut - "cervix sign - Gastric distention due to gastric outlet obstruction

Omeprazole-induced & Reflux surgery

1 2

Benign Wall thickening

Parietal cell hyperplasia in a 52-year-old man on long term omeprazole tx CT shows gastric mucosa hypertrophy.

Pseudomass at the GE junction post Nissen fundoplication. Noncontrast CT reveals a mass like-lesion at the GE junction (arrowheads). Endoscopy confirmed this to be a pseudomass.

Proton pump inhibitor induced (PPI)wall thickening: Chronic use of PPIs can lead to gastric parietal cell hypertrophy and hyperplasia. CT: Areas of fold thickening mimicking other causes of hypertrophic gastritis like ZE syndrome. Reflux surgery-induced wall thickening and pseudomass: Surgery for GE reflux can lead to wall thickening / pseudomass at GE junction. Turning patient prone / decubitus may result in decreased prominence of these lesions on imaging.
Merino S, Saiz A, Moreno MJ et al. CT evaluation of gastric wall pathology. BJR 1999; 72: 1124-1131

Inflammatory causes

Graft-versus-Host disease (GVHD)

Inflammatory

Acute gastrointestinal GVHD in a 42-year-old female, 20 days after autologous bone marrow transplant.. There is low attenuation gastric wall thickening with intense mucosal enhancement, giving rise to the Halo sign. There is adjacent inflammatory stranding and ascites. Biopsy showed epithelial cell apoptosis and cystic dilatation of glands lined by regenerative epithelium, crypt abscesses and frank epithelial destruction, classical for GVHD.

GVHD occurs when immunocompetent graft reacts against immune- incompetent host and can be seen with bone marrow or other solid organ transplantation. CT findings of gastric GVHD: - Hyperemic granulation tissue surrounded by lower-attenuation outer gastric wall - Halo sign. - Fold thickening; Mesenteric stranding. - Intraluminal hemorrhage due to severe mucosal damage. - Complications like gastric necrosis and perforation can occur.

Peptic Ulcer
1 2

Inflammatory

Perforated gastric ulcer. CT reveals large gastric ulcer along the lesser curvature with localised extravasation of contrast. There is adjacent gastric wall thickening.

Perforated gastric ulcers. Axial Contrast CT reveals a localised perforation of a gastric ulcer into the lesser sac. Anteriorly another gastric ulcer is seen which has perforated into the peritoneal cavity.

90 % along lesser curvature or posterior wall of antrum or body. CT features: Gastric wall thickening, demonstration of ulcer crater. CT is excellent for detection of peptic ulcer complications; Not optimal for detection of uncomplicated peptic ulcers (as most are superficial). Strong enhancement, marked peri-ulcer wall thickening, loss of normal wall stratification, perigastric fat plane infiltration and presence of lymphadenopathy favor malignant ulcer.
Jacobs JM, Hill MC, Steinberg WM. Peptic ulcer disease: CT evaluation. Radiology 1991; 178:745748.

Peptic Ulcer
1 2

Inflammatory

Perforated gastric ulcer in the antrum with ulcer crater perforating along the anterior wall. There is adjacent gastric wall thickening and pneumoperitoneum.

Gastric ulcer penetrating into splenic artery with massive GI bleed. There is irregularity of splenic artery with air speck: this is an example of pyo-pneumoperitoneum & massive hemorrhage in the stomach.

Complications- Perforation, penetration, hemorrhage and obstruction. Perforation: - Anteriorly located ulcers or along curvatures. - CT: Pneumoperitoneum or loculated collection, contrast extravasation, discontinuity of wall. Penetration: - Posterior located ulcers, - CT: Ulcer crater, wall thickening, adjacent inflammatory changes.

Crohns Disease
a b

Inflammatory

Gastrocolic fistula in a 45-year-old male with Crohns disease presenting with diarrhea and feculent vomiting. CT demostrates a communication between the stomach and the colon.

Gastrocolic fistulas may occur in Crohns, TB, complicated peptic ulcer disease, gastric and colon cancer, gastric lymphoma, pancreatitis etc. Isolated gastric involvement in Crohns is rare (incidence of 0.2-2 %). CT findings in gastric Crohns disease: -Narrowing and wall thickening of the distal stomach, especially the antrum (Rams horn sign). -Scarring may cross the pylorus to involve the duodenal bulb creating a tubular appearance.

Bouveret Syndrome
a b

Inflammatory

Bouveret syndrome in a 65-year-old woman presenting with vomiting and epigastric pain. CT of the upper abdomen demonstrates air within the gall bladder. A gall bladder calculus is seen within the stomach. Caudal sections reveal a gallstone impacted in the duodenum .

Gastric outlet obstruction produced by gallstone impacted in distal stomach or proximal

duodenum.

Imaging features: - Pneumobilia. - Obstructing gallstone in the duodenum or distal stomach. - Gastric and duodenal distension.

Infectious Causes

Gastric abscess
1 2

Infectious

65-year-old AIDS patient with intramural gastric and liver abscess. CT reveals heterogeneously enhancing masses in the wall of the stomach and liver . Biopsy revealed abscess in both the liver and stomach with gram negative organisms.

Perforated peptic ulcer with multiple gastric and perigastric abscesses. CT reveals multiple peripherally enhancing abscesses in the gastric and perigastric location along the greater curvature of the stomach.

Rare condition representing a localized form of supurative gastritis. Predispositions: alcoholism, immunosuppression, diabetes, HIV, old age, foreign body. CT findings: - Localized mural thickening within stomach wall or focal mass with heterogeneous enhancement. - Fluid and air may be seen within the mass. Adjacent inflammatory stranding may be present.

Vascular Causes

Gastric infarction
1 2

Vascular

Acute gastric and small bowel infarction in a 62-year -old woman with heart failure and atrial fibrillation. CT reveals thickened non-enhancing gastric wall with pneumatosis . The small bowel is fluid distended and dilated with non-enhancing walls with extensive pneumatosis .

Emphysematous gastritis in a 33-year-old man with a history of ethanol abuse. CT shows intramural gas within the wall of the stomach with portal venous gas. Common causes of emphysematous gastritis include corrosive ingestion, trauma or gastric infarction.

Gastric infarction is rare because of stomachs abundant blood supply. Etiologies: arterial thrombosis, herniation /volvulus, caustic ingestion, therapeutic embolizations, post-op.

Emphysematous gastritis- severe phlegmonous gastritis characterized by gas in the stomach wall. CT features: - Wall thickening with non-enhancing wall. - Intramural gas and perforation may be present. - Associated findings may include other visceral infarctions and portal venous gas.

Herniation with gastric ischemia

1a 1b

Vascular
Perforation and ischemia of the stomach contained in an epigastric hernia. The distal stomach is seen within the hernia sac and is focally dilated. There is free fluid and air within the peritoneal cavity. Caudal sections reveal gastric perforation.

2a

2b

Mesenteroaxial volvulus with gastric outlet obstruction and ischemia in 35-year-old male with a large Bochdalek hernia. CT shows a grossly distended intra-thoracic stomach with poorly enhancing wall. Bowel is also seen within the hernia sac. Intrao-peratively there was a large Bochdalek diaphragmatic defect. There was also mesenteroaxial volvulus and gastric infarction.

Gastric Varices
a b

Vascular

Gastric varices in a 45-year-old male with alcoholic cirrhosis and portal hypertension. CT demonstrate multiple gastric varices in the fundus and proximal body along the posteromedial wall. Associated varices between medial wall of stomach and liver are almost always present signifying increased blood flow through the coronary venous plexus. The liver is cirrhotic with splenomegaly and multiple fluid collections. There has been a prior TIPS stent placement for portal hypertension.

Dilated peripheral branches of short gastric and left gastric veins associated with splanchic obstruction or portal hypertension. Isolated gastric varices are due to splenic vein occlusion. CT findings: - Well-defined clusters of rounded and tubular structures with vascular enhancement. - Seen most commonly in posterior and postero-medial wall of fundus and proximal body.
Carucci LR, Levine MS,Rubesin SE, Laufer l. Tumourous gastric varices: radiographie findings in 10 patients. Radiology 1999; 212:861 -865

Congenital Causes

Duplication cyst
a b

Congenital

Gastric duplication cyst in a 21-year-old female presenting with epigastric pain. CT reveals a hyperdense cystic lesion along the medial wall of the fundus with an air speck within it suggesting focal communication with the stomach. Pathology confirmed gastric mucosa within the cystic lesion. The age of presentation, location and communication with the stomach are all unusual for a gastric duplication.

Gastric duplication cyst is the least common of the enteric duplications. 7% of GI tract duplications. Usually asymptomatic, but occasionally present with vomiting and abdominal pain. Most commonly seen in infants.

Duplication cyst
a b

Congenital

Surgically proven gastro-gastric intussusception with duplication cyst as the lead point in a 32-year-old male presenting with severe vomiting and epigastric pain. CT reveals intussusception of the lesser curvature into the stomach. A cyst was the lead point. The patient underwent surgery which confirmed true gastro-gastric intussusception with a duplication cyst as the lead point.

Most common site is the greater curvature. CT findings: - Non-communicating, spherical or ovoid cysts close to the greater curvature. - May show peripheral enhancement or marginal calcification.

Gastric diverticulum
a b c

Miscellaneous

Gastric diverticulum in an asymptomatic 54-year-old female. CT reveals a well-defined cystic lesion in the left suprarenal location simulating an adrenal mass. It shows retained oral contrast within it . Sections caudally show the lesion is in close proximity to the gastric cardia With an air speck within it. The diverticulum is in proximity to the cardia and the fluid within the lesion .

Gastric diverticula are uncommon and usually asymptomatic (Compared to duodenal diverticulae). Posterior wall of the gastric cardia are the most common site. Often single, varying in size from 1 - 3 cm. Occasionally can be multiple and large. Gastric cardia diverticula may simulate a left adrenal mass. Air-fluid level, retained contrast, communication with stomach and wall enhancement help in differentiating it from other masses.

Iatrogenic/Traumatic/FB

Nasogastric (NG) Tube Trauma

a b

Trauma

Gastric perforation due to NG tube trauma in a patient with altered mental status. CT reveals the NG tube perforating the gastric wall with extensive pneumoperitoneum. There is air tracking from the site of perforation into the peritoneal cavity. Iatrogenice trauma very rarely causes gastric perforation.

Penetrating injuries may cause gastric perforation. Blunt injuries rarely cause isolated gastric trauma (0.02 - 1.7%). Site of perforations: Anterior wall > greater curvature > lesser curvature > posterior wall. Predisposing factors for NG tube trauma: Altered mental status, tracheal intubation, cervical neck osteophytes, pre-existing gastric abnormalities, mal-positioned tube in fundus.

Cocaine packets
a b

Foreign bodies

24-year-old female with seizures and cardiac arrest due to cocaine toxicity from rupture of cocaine packets she had swallowed. CT reveals a well-defined cylindrical hyperdense foreign body with a radiolucent halo. Lower down there is another similar foreign body in the cecum. The patient underwent a gastrotomy and cecotomy for removal of these cocaine packets due to risk of rupture.

GI tract & vagina have been used as vehicles for smuggling narcotics (Body packer syndrome). Narcotics are wrapped in latex gloves, condoms, plastic bags, balloons, etc. Life threatening intoxication may follow leaking or rupture of these packets. CT findings: - Single or multiple homogenous well demarcated ovoid or cylindrical foreign bodies. - Surrounded by a thin radiolucent halo due to air trapped between the multiple layers of
packing.

Bezoar
a b

Foreign bodies

Trichobezoar in a 20-year-old female presenting with epigastric pain and vomiting with history of trichophagia (swallowing hair). There is distension of the lumen of the stomach with multiple intermixed gas bubbles giving it a mottled appearance. The patient underwent endoscopic suction for removal of the bezoar.

Bezoar: A conglomerate mass of food or foreign matter in the GI tract. Predispositions: Gastroparesis, gastric bypass surgery, high fibre diet. Trichobezoar: Matted hair seen in young women with trichophagia. Phytobezoar: Poorly digested fruit (oranges or persimmons) and vegetable fibers. CT findings: Well-defined oval intraluminal mass with air bubbles retained within the interstices.

Gastric Pacemaker
a b

Foreign bodies - Iatrogenic

58-year-old male with Crohns disease having gastroparesis and intractable abdominal pain. There is a subcutaneous electric generator and leads implanted into the serosa of the stomach.

Gastric pacemakers are used for gastroparesis refractory to medical therapy. Consists of a subcutaneous electric generator with two bipolar leads implanted laproscopically into the serosa of the stomach. Generates high frequency stimuli that enhance motility and facilitate emptying. Potential complications: gastric perforation, lead migration, infection, seroma formation.

Time for mental gymnastics

Quiz
Can adults get Hypertrophic Pyloric Stenosis? What is Bouveret Syndrome? What part of the stomach is most commonly affected by Crohns disease? What is the name for a ball of hair in your stomach? What is linitis plastica and what are some causes?