Diagnosis of Partial Gastric Diverticula
1
Diagnostic Radiology
Jurgen Treichel, M.D., Eckard Gerstenberg, M.D., Gerhard Palme, M.D., and Tilman Klemm, M.D. Five partial (intramural) gastric diverticula were observed in about 10,000 routine examinations of the stomach and confirmed by endoscopy or operation. All diverticula were located on the greater curvature of the antrum. A round or oval pouch with a small neck and typical changes in shape and size represent the diagnostic radiographic features of partial diverticulum. Complete filling of the diverticulum by administration of a spasmolytic and the use of the double-contrast method proved to be important for the correct diagnosis. INDEX TERM:
Stomach, diverticula
Radiology 119:13-18, April 1976
of a so-called partial diverticulum has been presented by Samuel (18), who defined it as a projection of the mucosa into the muscular coat of the stomach without abnormality of the serosa. The conventional classification divides such diverticula into (a) a true type containing all of the usual layers of the gastric wall and (b) a false type with loss of the muscularis propria. Partial or intramural diverticula cannot be correctly classified by these meansthey represent a third group in which the bottom of the diverticulum is covered by all layers of the gastric wall but the serosa does not participate in the extrusion (Fig. 1). To our knowledge, only four other partial diverticula have been reported; pronounced changes in shape and size during x-ray studies have been described as their typical diagnostic features (7, 15). In his 1951 review of world literature, Palmer (12) found 412 cases of gastric diverticula; 267 of them were discovered during life, the incidence in routine x-ray series of the gastrointestinal tract being 0.043 %. The most frequent location is the posterior wall about 2 cm below the esophago-gastric junction (1,3,5,8, 13, 19,21,23); the radiological features of these diverticula are well known. Diverticula arising in other parts of the stomach (in "unusual positions") are very rare (12); those which appear as pronounced extrusions at the greater curvature of the corpus ventriculi (4, 14) are not difficult to diagnose, but small diverticula in the antrum may be confused with ulcers (7, 11, 15-18, 21), for which treatment is then needlessly given. We present 5 cases of incomplete diverticula of the antrum found in 4 patients among about 10,000 routine examinations of the upper gastrointestinal tract in the past 4 years. Clinical findings, treatment, and radiological and endoscopic diagnoses are summarized in TABLE I.
A
DESCRIPTION
A
B
c
fi&,DA
Fig. 1. Schematic drawing of true (A), false (B) and partial (C) diverticula. M = mucosa; 8M = submucosa; PM = muscularis propria; S = serosa.
METHOD
When a diverticulum was suspected, a series of spot films were taken in order to demonstrate the changing appearance of the lesion. Spot films were taken of different body positions and filling states of the stomach and under compression in the upright position. In 3 cases we repeated the examination after injection of a spasmolytic (Buscopan), expecting better filling of the pouch in the hypotonic muscular coat; at the same time a double-contrast study (9, 22) was performed in order to observe the diverticulum and the surrounding area
1 From the Department of Radiology, Division of Internal Medicine, Klinikum Steglitz der Freie Universitat Berlin, Berlin, Germany. Revised edition accepted for publication in December 1975. elk
13
JURGEN TREICHEL AND OTHERS
14
Table I:
Summary of 4 Cases of Partial Diverticulum
Age (years)
Sex
27
M
Epigastric pain
II
63
F
Abdominal pain, weight loss
III
31
M
IV
24
F
Intermittent abdominal pain, epigastric burning Abdominal pain
Case
Clinical Findings
Table II:
Case
II III
IV
April 1976
Location
X-Ray Diagnosis
Endoscopy
Associated Diseases
Partia I d iverticulum Partial diverticulum
Moving orifice Orifice not visible
2 partial diverticula
2 slit-like orifices
Partial diverticulum
Moving orifice
Atrophic gastritis (biopsy) Benign ulcer, chronic polyarthritis Ben ign gastric ulcer duodenal ulcer Appendicitis(?)
Treatment Medical Operation (Billroth I) Operation (pyloroplasty, vagotomy) Medical
X-Ray Features of 5 Partial Diverticula Largest Diameter of Filled Diverticulum (mm)
Prepyloric greater curvature Prepyloric greater curvature Prepyloric greater curvature (2 diverticula) Prepyloric greater curvature
without interference from peristalsis and overlapping in a well-distended stomach. All patients underwent radiological follow-up studies and endoscopic examination. Two patients have been operated on for associated disease of the stomach. The clinical findings in all cases were reviewed. RESULTS
Radiographic Findings: All diverticula in this series were discovered by radiographic examination. In all cases (1 case with 2 diverticula) the diverticulum was located in the antrum on the greater curvature within 1-4 cm of the pylorus (TABLE II; Figs. 2, 3, 5, and 6). The diverticula measured 4-10 mm in diameter. The barium-filled diverticula were round or oval and showed a smooth outline. All diverticula changed in size and shape during the x-ray examination. The variable filling of the pouches could be observed without compression and was largely independent of the position of the patient. Study of the diverticula using several spot films revealed typical changes of the pouch in all cases (Figs. 2-6). The filled diverticulum was round or oval, with decreased filling in the bottom of the flattened pouch [in one case (Fig. 2) the diverticulum presented a rather irregular outline in this phase]. Finally, the diverticula exhibited a nearly linear or "collar-stud" shape extending parallel to the longitudinal axis of the antrum. The neck, too, became thinner as the diverticulum emptied. In the 3 patients who were re-examined after injection of a spasmolytic, better filling of the diverticula in the hypotonic stomach was evident (Figs. 2, 3, and 6).
A double contour, seen as a very small filling defect around the ostium of the diverticulum (suggesting slight
Shape of Filled Diverticulum
Neck
Change in Size and Shape
Oval
+
+
8
Round
+
+
a) 5 b) 4 5
Round Oval Oval
+ + +
+ + +
10
elevation of the mucosa) was found in 3 instances (Figs. 2, 3, and 6). This finding proved to be inconstant on spot films. In all patients examined by our doublecontrast method, the mucosal surface surrounding the diverticulum was clearly visualized (Figs. 2 and 6); hence, other pathological changes could be ruled out. We did not observe mucosal folds radiating to the diverticulum in any of our patients. Correct radiographic diagnosis of the partial diverticulum was made in all cases. As expected, follow-up studies showed the unchanged features of the diverticula. Endoscopy: In all of our patients, the x-ray examination was followed by endoscopy. Two diverticula (CASES I and IV) showed a small round or oval ostium closing and opening during observation; a moving concentric elevation around the orifice covered by normal mucosa corresponded exactly to the radiographic findings (Figs. 2 and 6). In the case where two diverticula were found by radiography (CASE III), the first endoscopic examination failed to reveal these lesions; however, a second gastroscopic study revealed the two stomata of the diverticula, which presented as small slitlike openings surrounded by normal mucosa (Fig. 5). In CASE II the stoma of the diverticulum was not visible during endoscopy because it was located near the prepyloric region, which was narrowed by a large ulcer scar (Fig. 3). Operation: Two of our patients (CASES II and III) were operated on for associated disease. The patient with two diverticula of the antrum was operated on for recurrent ulcers of the stomach and duodenum; he underwent vagotomy with pyloroplasty. Exploration of the outer surface of the stomach revealed a normal smooth serosa in the area of the diverticula, proving that the lesions were contained entirely within the gastric wall.
Vol. 119
15
DIAGNOSIS OF PARTIAL GASTRIC DIVERTICULA
Diagnostic Radiology
Fig. 2. CASE I. A. Smooth, oval shape of the barium-filled diverticulum on the greater curvature of the prepyloric antrum. Slight elevation of the surrounding mucosa. Double-contrast examination after injection of a spasmolytic . . B. With decreased filling, the diverticulum changes in shape and size and the contour becomes irregular. C. Nearly linear shape of the contracted divertlculum extending parallel to the long axis of the antrum. D. Endoscopic photograph shows the oval orifice (small arrow) of the diverticulum and slight elevation of the normal surrounding mucosa. Large arrow = Pylorus. (Courtesy Dr. U. Ziegler, Klinikum Steglitz, Freie Universltat. Berlin)
The other patient (CASE II) had to undergo surgery for stenosis of the antrum. The surgical specimen showed the partly everted diverticulum covered by normal mucosa with a small stoma at its center (Fig. 3); the serosal coat revealed no abnormality at that site. Unfortunately, a thorough microscopic examination of this diverticulum was not performed. Clinical Findings: All of our patients had symptoms assignable to the gastrointestinal tract (TABLE I), but the associated disease was probably the cause of these symptoms.
DISCUSSION
To our knowledge only 5 cases of partial gastric diverticula have been reported since 1955 (7, 15, 18). The 5 partial diverticula we found in about 10,000 radiographic examinations of the stomach give a relatively high incidence of 0.05 %, which is in agreement with the overall incidence of gastric diverticula as quoted by Palmer (12). This suggests that a large proportion of these small diverticula of the antrum either are not detected by x-ray examination or are misdiagnosed as
16
JORGEN TREICHEL AND OTHERS
April 1976
Fig. 3. CASE II. Partial diverticulum on the greater curvature of the antrum. Benign stenosis of the prepyloric region. Three typical phases of the emptying diverticulum are demonstrated. A. Round barium-filled pouch. B. Smaller, more oval shadow of the pouch. The neck has disappeared. C. Linear or "collar-stud" shape of the diverticulum. D. Surgical specimen showing the everted diverticulum.
III
II
Fig. 4. Schematic drawing of the three typical phases of change of the partial diverticulum. I round irregular shape of the shape and smooth contour. II linear or incompletely contracted diverticulum. III "collar-stud" shape.
=
=
=
penetrating ulcers. It may, therefore, be assumed that with better knowledge of the typical appearance of a partial diverticulum and a suitable examination technique, the frequency of this diagnosis would increase. Flachs et al. (7) stressed the importance of spot films in showing the pliability and varying degrees of distension of the partial diverticulum. Rabushka et al. (15) de-
scribed the change of size and shape of the bariumfilled pouch with the position of the patient, peristalsis, and extrinsic pressure; they noted flattening of the dome of the diverticulum. Our observations confirm the diagnostic criteria established by these authors and complement them by the description of typical changes of the partial diverticulum (Fig. 4), l.e., a continuous diminution of a round or oval pouch to a "collar-stud" or linear shape-findings which enabled us to differentiate the diverticulum from a penetrating ulcer. The fact that we did not observe radiating mucosal folds in any of our patients gives another important diagnostic clue, because this sign is rather frequent in penetrating benign ulcers. Some authors have emphasized the difficulty in differentiating uncommon gastric diverticula from ulcerating tumors or aberrant pancreas (2, 7, 20). This problem may arise when a diverticulum with a slight elevation around the ostium is seen en face (Fig. 6) as a
Vol. 119
17
DIAGNOSIS OF PARTIAL GASTRIC DIVERTICULA
Diagnostic Radiology
round filling defect with a central depot, but all partial diverticula reported so far, including our 4 cases, were situated on the greater curvature; thus the typical pouch could be demonstrated in profile. For the same reason, these lesions are easier to detect by radiography than by endoscopy. The occurrence of pancreatic tissue in diverticula near the pylorus seems to be relatively frequent (6, 8, 12) and was considered by Nauwerck (10) to prove the origin of these diverticula as a developmental defect. The question of whether or not a small nest of pancreatic tissue is present in the wall of a partial diverticulum can only be answered by histological examination. CONCLUSIONS
Partial gastric diverticula are considered to be extremely rare. Their relatively high incidence in our experience suggests that they might be overlooked or misdiagnosed as penetrating ulcers. This diagnostic error can be avoided by an appropriate radiographic examination, including the use of a spasmolytic and the double-contrast method. The typical location of the partial diverticulum seems to be the greater curvature of the antrum. The shape of the partial diverticulum and its change during the x-ray examination are diagnostic features.
Klinik fur Radiologie u. Nuklearmedizin Klinikum Steglitz der Freie Universitat Berlin 1 Berlin 45, Hindenburgdamm 30 Germany
REFERENCES 1. Barsony T, Koppenstein E: Spitzendivertikel des Magenfundus. Fortschr Geb Roentgenstr Nuklearmed 46:414-422, Oct
1932 2. Bothen NF, Eklof 0: Diverticula and duplications (enterogenous cysts) of the stomach and duodenum. Am J Roentgenol 96: 375-381, Feb 1966 3. Bralow SP, Spellberg MA: Diverticula of the stomach; report of 26 cases. Gastroenterology 11:59-82, Jul 1948 4. Dodd GD, Sheft D: Diverticulum of the greater curvature of the stomach: A roentgenologic curiosity. Am J Roentgenol 107: 102-104, Sep 1969 5. Eells RW, Simril WA: Gastric diverticula; report of 31 cases. Am J Roentgenol 68:8-14, Jul 1952 6. Falconer AW: A case of congenital diverticulum of the stomach and duodenum in a physiological hour glass stomach. Lancet 1:1296, May 1907 7. Flachs K, Steiman HH, Matsumoto PJH: Partial gastric diverticula. Am J Roentgenol 94:339-342, Jun 1965 8. Frik W: Anomalien und Lageveranderungen des Magens einschliesslich Divertikel. [In] Diethelm L, Olsson 0, Strnad F, et aI., Eds: Handbuch der medizinischen Radiologie. Berlin, Springer, 1969, Vol II, Part 1, pp 309-344 9. Hietzeberg H, Treichel J: Intensivierte Rontgendiagnostik des Magnes mittles Doppelkontrast. Fortschr Geb Rontgenstr Nuklearrned 116:529-533, Apr 1972 10. Nauwerck C: Zur Kenntnis der Divertikel des Magens. Dtsch Med Wochenschr 46: 119-121, Jan 1920 11. Niemeyer T: Diverticule de la grande courbure de I'antre prepylorlque de I'estomac. J Radiol Electrol 31:5-6, 282, 1950
Fig. 5. CASE III. Two intramural diverticula of the greater curvature of the antrum. A. Barium-filled stomach in the right anterior oblique position, showing a round pouch with a small neck and a second collar-stud-shaped diverticulum near the pylorus. B. Double-contrast image showing change in the size and form of the two diverticula. Note the ulcer scar near the greater curvature (arrow). C. Gastroscopic photograph demonstrates the orifices of Ulcer scar. the two diverticula (small arrows). Large arrow
=
12. Palmer ED: Collective review; gastric diverticula. Int Abst Surg 92:417-428, May 1951 13. Palmer ED: Gastric diverticula, with special reference to subjective manifestations. Gastroenterology 35:406-408, Oct 1958 Magendivertikel seltener Lokalisation. 14. Pudwitz KR: Fortschr Geb Roentgenstr Nuklearmed 95:714, Nov 1961
18
JURGEN TREICHEL AND OTHERS
April 1976
Fig. 6. CASE IV. Partial diverticulum on the greater curvature of the antrum. A. Filled diverticulum. B. "Collar-stud" shape of the contracted pouch. C. Diverticulum seen en face on a double-contrast radiograph. Around the ostium of the diverticulum is a smoothcontoured ring-like fold which disappeared when the stomach was further distended by air inflation. D. Gastrocamera picture of the diverticulum, showing the orifice and concentric elevation of the surrounding mucosa.
15. Rabushka SE, Melamed M, Melamed JL: Unusual gastric diverticula; report of two cases. Radiology 90: 1006-1 008, May 1968 16. Riemann H: Anomalien des Magens. Radiologe 7:27-29, Jan 1967 17. Rivers AB, Stevens GA, Kirklin BR: Diverticula of the stomach. Surg Gynecol Obstet 60: 106-113, Jan 1935 18. Samuel E: Gastric diverticula. Br J Radiol 28:574-578, Oct 1955 19. Sommer AW, Goodrich WA Jr: Gastric diverticula. JAMA 153:1424-1428, 19 Dec 1953
20. Stone DD, Riddervold HO, Keats TE: An unusual case of aberrant pancreas in the stomach. Am J Roentgenol 113: 125-128, Sep 1971 21. Teske HJ von: Das Magendivertikel. Klinik und Technik der rontgenologischen Darstellung. Munch Med Wochenschr 107: 1525-1529, Aug 1965 22. Treichel J, Oeser H: Die Doppelkontrastmethode: optirnale Technik der rontqenoloqischen Magenuntersuchung. Dtsch Med Wochenschr 100:2226-2229, Oct 1975 23. Willard JH: Diverticula of the stomach. [In) Bockus HL Ed: Gastroenterology, 2d Ed, 1963, Vol 1, pp 893-898
1
Diagnostic Radiology
Jurgen Treichel, M.D., Eckard Gerstenberg, M.D., Gerhard Palme, M.D., and Tilman Klemm, M.D. Five partial (intramural) gastric diverticula were observed in about 10,000 routine examinations of the stomach and confirmed by endoscopy or operation. All diverticula were located on the greater curvature of the antrum. A round or oval pouch with a small neck and typical changes in shape and size represent the diagnostic radiographic features of partial diverticulum. Complete filling of the diverticulum by administration of a spasmolytic and the use of the double-contrast method proved to be important for the correct diagnosis. INDEX TERM:
Stomach, diverticula
Radiology 119:13-18, April 1976
of a so-called partial diverticulum has been presented by Samuel (18), who defined it as a projection of the mucosa into the muscular coat of the stomach without abnormality of the serosa. The conventional classification divides such diverticula into (a) a true type containing all of the usual layers of the gastric wall and (b) a false type with loss of the muscularis propria. Partial or intramural diverticula cannot be correctly classified by these meansthey represent a third group in which the bottom of the diverticulum is covered by all layers of the gastric wall but the serosa does not participate in the extrusion (Fig. 1). To our knowledge, only four other partial diverticula have been reported; pronounced changes in shape and size during x-ray studies have been described as their typical diagnostic features (7, 15). In his 1951 review of world literature, Palmer (12) found 412 cases of gastric diverticula; 267 of them were discovered during life, the incidence in routine x-ray series of the gastrointestinal tract being 0.043 %. The most frequent location is the posterior wall about 2 cm below the esophago-gastric junction (1,3,5,8, 13, 19,21,23); the radiological features of these diverticula are well known. Diverticula arising in other parts of the stomach (in "unusual positions") are very rare (12); those which appear as pronounced extrusions at the greater curvature of the corpus ventriculi (4, 14) are not difficult to diagnose, but small diverticula in the antrum may be confused with ulcers (7, 11, 15-18, 21), for which treatment is then needlessly given. We present 5 cases of incomplete diverticula of the antrum found in 4 patients among about 10,000 routine examinations of the upper gastrointestinal tract in the past 4 years. Clinical findings, treatment, and radiological and endoscopic diagnoses are summarized in TABLE I.
A
DESCRIPTION
A
B
c
fi&,DA
Fig. 1. Schematic drawing of true (A), false (B) and partial (C) diverticula. M = mucosa; 8M = submucosa; PM = muscularis propria; S = serosa.
METHOD
When a diverticulum was suspected, a series of spot films were taken in order to demonstrate the changing appearance of the lesion. Spot films were taken of different body positions and filling states of the stomach and under compression in the upright position. In 3 cases we repeated the examination after injection of a spasmolytic (Buscopan), expecting better filling of the pouch in the hypotonic muscular coat; at the same time a double-contrast study (9, 22) was performed in order to observe the diverticulum and the surrounding area
1 From the Department of Radiology, Division of Internal Medicine, Klinikum Steglitz der Freie Universitat Berlin, Berlin, Germany. Revised edition accepted for publication in December 1975. elk
13
JURGEN TREICHEL AND OTHERS
14
Table I:
Summary of 4 Cases of Partial Diverticulum
Age (years)
Sex
27
M
Epigastric pain
II
63
F
Abdominal pain, weight loss
III
31
M
IV
24
F
Intermittent abdominal pain, epigastric burning Abdominal pain
Case
Clinical Findings
Table II:
Case
II III
IV
April 1976
Location
X-Ray Diagnosis
Endoscopy
Associated Diseases
Partia I d iverticulum Partial diverticulum
Moving orifice Orifice not visible
2 partial diverticula
2 slit-like orifices
Partial diverticulum
Moving orifice
Atrophic gastritis (biopsy) Benign ulcer, chronic polyarthritis Ben ign gastric ulcer duodenal ulcer Appendicitis(?)
Treatment Medical Operation (Billroth I) Operation (pyloroplasty, vagotomy) Medical
X-Ray Features of 5 Partial Diverticula Largest Diameter of Filled Diverticulum (mm)
Prepyloric greater curvature Prepyloric greater curvature Prepyloric greater curvature (2 diverticula) Prepyloric greater curvature
without interference from peristalsis and overlapping in a well-distended stomach. All patients underwent radiological follow-up studies and endoscopic examination. Two patients have been operated on for associated disease of the stomach. The clinical findings in all cases were reviewed. RESULTS
Radiographic Findings: All diverticula in this series were discovered by radiographic examination. In all cases (1 case with 2 diverticula) the diverticulum was located in the antrum on the greater curvature within 1-4 cm of the pylorus (TABLE II; Figs. 2, 3, 5, and 6). The diverticula measured 4-10 mm in diameter. The barium-filled diverticula were round or oval and showed a smooth outline. All diverticula changed in size and shape during the x-ray examination. The variable filling of the pouches could be observed without compression and was largely independent of the position of the patient. Study of the diverticula using several spot films revealed typical changes of the pouch in all cases (Figs. 2-6). The filled diverticulum was round or oval, with decreased filling in the bottom of the flattened pouch [in one case (Fig. 2) the diverticulum presented a rather irregular outline in this phase]. Finally, the diverticula exhibited a nearly linear or "collar-stud" shape extending parallel to the longitudinal axis of the antrum. The neck, too, became thinner as the diverticulum emptied. In the 3 patients who were re-examined after injection of a spasmolytic, better filling of the diverticula in the hypotonic stomach was evident (Figs. 2, 3, and 6).
A double contour, seen as a very small filling defect around the ostium of the diverticulum (suggesting slight
Shape of Filled Diverticulum
Neck
Change in Size and Shape
Oval
+
+
8
Round
+
+
a) 5 b) 4 5
Round Oval Oval
+ + +
+ + +
10
elevation of the mucosa) was found in 3 instances (Figs. 2, 3, and 6). This finding proved to be inconstant on spot films. In all patients examined by our doublecontrast method, the mucosal surface surrounding the diverticulum was clearly visualized (Figs. 2 and 6); hence, other pathological changes could be ruled out. We did not observe mucosal folds radiating to the diverticulum in any of our patients. Correct radiographic diagnosis of the partial diverticulum was made in all cases. As expected, follow-up studies showed the unchanged features of the diverticula. Endoscopy: In all of our patients, the x-ray examination was followed by endoscopy. Two diverticula (CASES I and IV) showed a small round or oval ostium closing and opening during observation; a moving concentric elevation around the orifice covered by normal mucosa corresponded exactly to the radiographic findings (Figs. 2 and 6). In the case where two diverticula were found by radiography (CASE III), the first endoscopic examination failed to reveal these lesions; however, a second gastroscopic study revealed the two stomata of the diverticula, which presented as small slitlike openings surrounded by normal mucosa (Fig. 5). In CASE II the stoma of the diverticulum was not visible during endoscopy because it was located near the prepyloric region, which was narrowed by a large ulcer scar (Fig. 3). Operation: Two of our patients (CASES II and III) were operated on for associated disease. The patient with two diverticula of the antrum was operated on for recurrent ulcers of the stomach and duodenum; he underwent vagotomy with pyloroplasty. Exploration of the outer surface of the stomach revealed a normal smooth serosa in the area of the diverticula, proving that the lesions were contained entirely within the gastric wall.
Vol. 119
15
DIAGNOSIS OF PARTIAL GASTRIC DIVERTICULA
Diagnostic Radiology
Fig. 2. CASE I. A. Smooth, oval shape of the barium-filled diverticulum on the greater curvature of the prepyloric antrum. Slight elevation of the surrounding mucosa. Double-contrast examination after injection of a spasmolytic . . B. With decreased filling, the diverticulum changes in shape and size and the contour becomes irregular. C. Nearly linear shape of the contracted divertlculum extending parallel to the long axis of the antrum. D. Endoscopic photograph shows the oval orifice (small arrow) of the diverticulum and slight elevation of the normal surrounding mucosa. Large arrow = Pylorus. (Courtesy Dr. U. Ziegler, Klinikum Steglitz, Freie Universltat. Berlin)
The other patient (CASE II) had to undergo surgery for stenosis of the antrum. The surgical specimen showed the partly everted diverticulum covered by normal mucosa with a small stoma at its center (Fig. 3); the serosal coat revealed no abnormality at that site. Unfortunately, a thorough microscopic examination of this diverticulum was not performed. Clinical Findings: All of our patients had symptoms assignable to the gastrointestinal tract (TABLE I), but the associated disease was probably the cause of these symptoms.
DISCUSSION
To our knowledge only 5 cases of partial gastric diverticula have been reported since 1955 (7, 15, 18). The 5 partial diverticula we found in about 10,000 radiographic examinations of the stomach give a relatively high incidence of 0.05 %, which is in agreement with the overall incidence of gastric diverticula as quoted by Palmer (12). This suggests that a large proportion of these small diverticula of the antrum either are not detected by x-ray examination or are misdiagnosed as
16
JORGEN TREICHEL AND OTHERS
April 1976
Fig. 3. CASE II. Partial diverticulum on the greater curvature of the antrum. Benign stenosis of the prepyloric region. Three typical phases of the emptying diverticulum are demonstrated. A. Round barium-filled pouch. B. Smaller, more oval shadow of the pouch. The neck has disappeared. C. Linear or "collar-stud" shape of the diverticulum. D. Surgical specimen showing the everted diverticulum.
III
II
Fig. 4. Schematic drawing of the three typical phases of change of the partial diverticulum. I round irregular shape of the shape and smooth contour. II linear or incompletely contracted diverticulum. III "collar-stud" shape.
=
=
=
penetrating ulcers. It may, therefore, be assumed that with better knowledge of the typical appearance of a partial diverticulum and a suitable examination technique, the frequency of this diagnosis would increase. Flachs et al. (7) stressed the importance of spot films in showing the pliability and varying degrees of distension of the partial diverticulum. Rabushka et al. (15) de-
scribed the change of size and shape of the bariumfilled pouch with the position of the patient, peristalsis, and extrinsic pressure; they noted flattening of the dome of the diverticulum. Our observations confirm the diagnostic criteria established by these authors and complement them by the description of typical changes of the partial diverticulum (Fig. 4), l.e., a continuous diminution of a round or oval pouch to a "collar-stud" or linear shape-findings which enabled us to differentiate the diverticulum from a penetrating ulcer. The fact that we did not observe radiating mucosal folds in any of our patients gives another important diagnostic clue, because this sign is rather frequent in penetrating benign ulcers. Some authors have emphasized the difficulty in differentiating uncommon gastric diverticula from ulcerating tumors or aberrant pancreas (2, 7, 20). This problem may arise when a diverticulum with a slight elevation around the ostium is seen en face (Fig. 6) as a
Vol. 119
17
DIAGNOSIS OF PARTIAL GASTRIC DIVERTICULA
Diagnostic Radiology
round filling defect with a central depot, but all partial diverticula reported so far, including our 4 cases, were situated on the greater curvature; thus the typical pouch could be demonstrated in profile. For the same reason, these lesions are easier to detect by radiography than by endoscopy. The occurrence of pancreatic tissue in diverticula near the pylorus seems to be relatively frequent (6, 8, 12) and was considered by Nauwerck (10) to prove the origin of these diverticula as a developmental defect. The question of whether or not a small nest of pancreatic tissue is present in the wall of a partial diverticulum can only be answered by histological examination. CONCLUSIONS
Partial gastric diverticula are considered to be extremely rare. Their relatively high incidence in our experience suggests that they might be overlooked or misdiagnosed as penetrating ulcers. This diagnostic error can be avoided by an appropriate radiographic examination, including the use of a spasmolytic and the double-contrast method. The typical location of the partial diverticulum seems to be the greater curvature of the antrum. The shape of the partial diverticulum and its change during the x-ray examination are diagnostic features.
Klinik fur Radiologie u. Nuklearmedizin Klinikum Steglitz der Freie Universitat Berlin 1 Berlin 45, Hindenburgdamm 30 Germany
REFERENCES 1. Barsony T, Koppenstein E: Spitzendivertikel des Magenfundus. Fortschr Geb Roentgenstr Nuklearmed 46:414-422, Oct
1932 2. Bothen NF, Eklof 0: Diverticula and duplications (enterogenous cysts) of the stomach and duodenum. Am J Roentgenol 96: 375-381, Feb 1966 3. Bralow SP, Spellberg MA: Diverticula of the stomach; report of 26 cases. Gastroenterology 11:59-82, Jul 1948 4. Dodd GD, Sheft D: Diverticulum of the greater curvature of the stomach: A roentgenologic curiosity. Am J Roentgenol 107: 102-104, Sep 1969 5. Eells RW, Simril WA: Gastric diverticula; report of 31 cases. Am J Roentgenol 68:8-14, Jul 1952 6. Falconer AW: A case of congenital diverticulum of the stomach and duodenum in a physiological hour glass stomach. Lancet 1:1296, May 1907 7. Flachs K, Steiman HH, Matsumoto PJH: Partial gastric diverticula. Am J Roentgenol 94:339-342, Jun 1965 8. Frik W: Anomalien und Lageveranderungen des Magens einschliesslich Divertikel. [In] Diethelm L, Olsson 0, Strnad F, et aI., Eds: Handbuch der medizinischen Radiologie. Berlin, Springer, 1969, Vol II, Part 1, pp 309-344 9. Hietzeberg H, Treichel J: Intensivierte Rontgendiagnostik des Magnes mittles Doppelkontrast. Fortschr Geb Rontgenstr Nuklearrned 116:529-533, Apr 1972 10. Nauwerck C: Zur Kenntnis der Divertikel des Magens. Dtsch Med Wochenschr 46: 119-121, Jan 1920 11. Niemeyer T: Diverticule de la grande courbure de I'antre prepylorlque de I'estomac. J Radiol Electrol 31:5-6, 282, 1950
Fig. 5. CASE III. Two intramural diverticula of the greater curvature of the antrum. A. Barium-filled stomach in the right anterior oblique position, showing a round pouch with a small neck and a second collar-stud-shaped diverticulum near the pylorus. B. Double-contrast image showing change in the size and form of the two diverticula. Note the ulcer scar near the greater curvature (arrow). C. Gastroscopic photograph demonstrates the orifices of Ulcer scar. the two diverticula (small arrows). Large arrow
=
12. Palmer ED: Collective review; gastric diverticula. Int Abst Surg 92:417-428, May 1951 13. Palmer ED: Gastric diverticula, with special reference to subjective manifestations. Gastroenterology 35:406-408, Oct 1958 Magendivertikel seltener Lokalisation. 14. Pudwitz KR: Fortschr Geb Roentgenstr Nuklearmed 95:714, Nov 1961
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Fig. 6. CASE IV. Partial diverticulum on the greater curvature of the antrum. A. Filled diverticulum. B. "Collar-stud" shape of the contracted pouch. C. Diverticulum seen en face on a double-contrast radiograph. Around the ostium of the diverticulum is a smoothcontoured ring-like fold which disappeared when the stomach was further distended by air inflation. D. Gastrocamera picture of the diverticulum, showing the orifice and concentric elevation of the surrounding mucosa.
15. Rabushka SE, Melamed M, Melamed JL: Unusual gastric diverticula; report of two cases. Radiology 90: 1006-1 008, May 1968 16. Riemann H: Anomalien des Magens. Radiologe 7:27-29, Jan 1967 17. Rivers AB, Stevens GA, Kirklin BR: Diverticula of the stomach. Surg Gynecol Obstet 60: 106-113, Jan 1935 18. Samuel E: Gastric diverticula. Br J Radiol 28:574-578, Oct 1955 19. Sommer AW, Goodrich WA Jr: Gastric diverticula. JAMA 153:1424-1428, 19 Dec 1953
20. Stone DD, Riddervold HO, Keats TE: An unusual case of aberrant pancreas in the stomach. Am J Roentgenol 113: 125-128, Sep 1971 21. Teske HJ von: Das Magendivertikel. Klinik und Technik der rontgenologischen Darstellung. Munch Med Wochenschr 107: 1525-1529, Aug 1965 22. Treichel J, Oeser H: Die Doppelkontrastmethode: optirnale Technik der rontqenoloqischen Magenuntersuchung. Dtsch Med Wochenschr 100:2226-2229, Oct 1975 23. Willard JH: Diverticula of the stomach. [In) Bockus HL Ed: Gastroenterology, 2d Ed, 1963, Vol 1, pp 893-898
