(医学影像学)中英文对照学生翻译版

团队的力量 Strength of our team！

湘雅医院2008级五年制临床医学、麻醉医学及口腔七年制18组同学合作完成本文的翻译

Double-Contrast Upper Gastrointestinal Radiography: A Pattern Approach for Diseases of the Stomach

Abstract

The double-contrast upper gastrointestinal series is a valuable diagnostic test for evaluating structural and functional abnormalities of the stomach. This article will review the normal radiographic anatomy of the stomach. The principles of analyzing double-contrast images will be discussed. A pattern approach for the diagnosis of gastric abnormalities will also be presented, focusing on abnormal mucosal patterns, depressed lesions, protruded lesions, thickened folds, and gastric narrowing.

This article presents a pattern approach for the diagnosis of diseases of the stomach at double-contrast upper gastrointestinal radiography. After describing the normal appearance of the stomach on double-contrast barium studies and the principles of

double-contrast image interpretation, we will consider abnormal surface patterns of the mucosa, depressed lesions (erosions and ulcers), protruded lesions (polyps, submucosal masses, and other tumors), thickened folds, and gastric narrowing. 上消化道双重对比造影：一种用于胃部疾病诊断的成像方法

摘要

上消化道双重对比造影系列是用于评估胃部结构性和功能性病变的一种极有价值的诊断方法。本文将回顾胃部正常解剖的影像学表现，探讨双重对比造影图像分析的原则。文中还介绍了一种胃部病变的诊断方法，该法侧重于观察异常的黏膜形状，凹陷性的病变、突出性的病变、增厚的黏膜皱襞和消化道的狭窄。

本文阐述了一种通过上消化道双重对比造影诊断胃部疾病的方法。在描述双重对比造影中胃的正常表现和双重对比造影图像分析原则后，我们将关注胃粘膜表面的异常形态，凹陷性的病变（糜烂和溃疡）、突出性的病变（息肉、黏膜下的块状物和其他肿块）、增厚的黏膜皱襞和消化道狭窄。

NORMAL STOMACH Gastric Configuration and Rugal Folds

The normal stomach is a J-shaped pouch that lies in the left upper quadrant (Fig 1). The stomach has a fixed

configuration created by the greater length of the longitudinal muscle layer on its greater curvature. The lesser curvature of the stomach is suspended from the retroperitoneum by the

hepatogastric ligament, a portion of the lesser omentum. The gastrosplenic ligament and gastrocolic ligament (ie, the proximal portion of the greater omentum) are attached to the greater curvature of the stomach. The gastric cardia is attached to the diaphragm by the surrounding phrenoesophageal membrane.

Figure 1: Normal stomach. Double-contrast spot

image of stomach with patient supine

shows distal gastric body (B) and

antrum (A). Greater curvature (white

arrows) and lesser curvature (black

arrows) are coated by barium. Rugal

fold on posterior wall of gastric body is

depicted as tubular, slightly undulating,

radiolucent filling defect (black

arrowheads) in shallow barium pool.

Dense barium pool outlines contour

(white arrowheads) of gastric fundus

正常胃 胃的外形与皱襞

正常的胃位于左上腹，形似J 型嚢袋（图1），

胃固定的形态是由胃大弯上较长的纵向肌层形成的。胃小弯通过小网膜的一部分--肝胃韧

带悬挂在腹膜后腔内。胃脾韧带和胃结肠韧带（即大网膜近端）连于胃大弯上。胃贲门通过其周围的隔食管膜连于隔上。

图1：

正常胃：病人取仰卧位进行双重对比造影可以

显示远端的胃体（B）和胃窦（A）。胃大弯（白

色箭头所示）和胃小弯（黑色箭头所示）均覆

盖有一层钡剂。射线透过钡池较浅的胃体部，

能显示出胃体后壁的粘膜皱襞，呈管状、细小

的波浪形的充盈缺损。胃底部（F）钡池稠密，

勾勒出胃底的轮廓（白色小箭头所示）。胃底

的粘膜表面和皱襞被稠密的钡池掩盖而不易

看见，胃窦部无皱襞。

(F). Mucosal surface and folds in fundus are obscured by barium pool, and antrum is devoid of rugal folds.

cardiac “rosette” (Fig 2) (1,2). The gastric fundus is defined as the

portion of the stomach craniad to the

gastric cardia. The gastric body is

defined as the portion of the stomach

extending from the gastric cardia to the

smooth bend in the mid lesser curvature

known as the incisura angularis. The

gastric antrum is defined as the portion

of the stomach extending from the

incisura angularis to the pylorus (a

structure created by a muscle sphincter

shaped like a figure eight).

Figure 2:

Double-contrast spot image of gastric

fundus with patient in right-side-down

position shows normal gastric cardia

with smooth folds radiating to central

point (white arrow) at closed

gastroesophageal junction, also known

as cardiac rosette. Long, straight fold

(arrowheads) extends inferiorly from

cardia along lesser curvature. Black

arrows denote normal extrinsic

impression by adjacent spleen.

Rugal folds are most prominent in the gastric fundus and body, whereas the gastric antrum is often devoid of folds (Fig 1). Gastric rugae are changeable

贲门“玫瑰花形”（图2）（1,2） 胃底是指胃贲门入口水平线以上的部分。胃小

弯中断转弯处称为角切迹，胃自贲门至角切迹

的部分称为胃体。胃窦指从角切迹至胃幽门

（一个由括约肌组成的“8”字形结构）的部

分。

图2

在病人的仰卧水平右侧位胃底的双对比

造影点片上，可观察到正常的胃贲门有很多光

滑的皱襞，这些皱襞呈放射性的指向（大白箭

头）中间胃食管连接部即贲门瓣的位置。小白

箭头指的是直接从贲门延伸到胃小弯的纵行

皱襞，黑箭头则为邻近的脾压迫胃所产生的压

迹。

胃皱襞大部分突起于胃底和胃体，胃窦通常是没有皱襞的（图1）。胃皱襞由粘膜层和粘膜下层组成（3,4），这些皱襞在胃小弯部比较直，在胃大弯部则呈波浪形。胃皱襞的厚

structures composed of mucosa and submucosa (3,4). The rugal folds are relatively straight on the lesser curvature of the stomach but larger and more

undulating on the greater curvature. The thickness of the rugal folds varies with the degree of gastric distention (5).

Areae Gastricae

The mucosal surface of the stomach

consists of flat polygonal-shaped tufts of

mucosa, known as areae gastricae,

separated by narrow grooves (6,7). The

areae gastricae are recognized on

double-contrast studies as a reticular

network of barium-coated white lines

when barium fills the grooves between

these mucosal tufts (Fig 3). Individual

mucosal tufts of areae gastricae

normally have a diameter of 2–3 mm in

the gastric antrum and of 3–5 mm in the

gastric body and fundus (Fig 3) (6,8).

Areae gastricae are detected on

double-contrast studies in nearly 70% of

patients and are observed with greater

frequency in the elderly (8,9).

Figure 3:

Double-contrast spot image of stomach with patient in left posterior oblique position shows normal areae gastricae pattern in antrum as 2–3-mm polygonally shaped radiolucent tufts of mucosa outlined by barium in grooves. 度随胃膨胀的程度而变化（5）。

胃区 胃黏膜表面由扁平多边形黏膜丛构成，称

为胃区，它被狭窄的凹槽分隔（6,7）。在双

对比造影研究中，钡剂填充在黏膜丛的凹槽

中，胃区为由钡剂覆盖的白色线条交错构成的

复杂网状结构（图3）。机体胃区黏膜丛直径

在胃窦部一般为2至3厘米，在胃体和胃底部

为3至5厘米（图3）（6，8）。在近70%的

病人中，胃区能通过双对比相研究观察到，而

对于老年人，能被观察到的概率则更大（8,9）。

图3

在病人左后斜位胃的双对比造影点片上可观察到胃窦部正常的胃区图像，即长为2至3厘米，多边形、射线可穿透的黏膜丛，由钡剂显示其轮廓。胃体尾部的胃小区比胃窦部稍微大些。

Areae gastricae are slightly larger in distal gastric body than in antrum.

Comparison of Histologic Anatomy with Macroscopic Anatomy

A basic understanding of the histologic anatomy of the stomach is helpful for understanding peptic ulcer disease, as well as other gastric abnormalities (5,10). The stomach contains several types of mucosa: cardiac-type mucosa, body/fundic-type mucosa, and

antral/pyloric-type mucosa. Gastric foveolae (or pits) are conical depressions in the mucosal surface that communicate with gastric glands (4,10). The glands are long, straight, and tightly packed structures. The foveolae in all parts of the stomach are lined by surface foveolar mucous cells. The cardiac-type mucosa comprises a short (1 cm in length) segment of the gastric mucosa adjacent to the gastroesophageal junction (4). The distinguishing feature of the body-type mucosa is the presence of parietal and chief cells in the glands. The parietal cells produce hydrochloric acid and intrinsic factor, and the chief cells produce proteolytic enzymes. No parietal or chief cells are found in antral-type mucosa. The surface foveolar mucous cells line both antral pits and glands.

Body-type mucosa lines the anatomic gastric fundus and the gastric body and extends into the gastric antrum along the greater curvature (4). Antral-type mucosa lines the antrum along the lesser curvature from the pylorus to the incisura angularis, but only lines a small amount of antrum along the greater 组织学与宏观解剖学的比较

对胃组织学结构有一个基本的学习有助于我们更好的理解消化性溃疡及其它胃功能紊乱性疾病（5，10）。胃包括几种不同类型的黏膜：贲门型黏膜、胃体/胃底型黏膜，以及幽门/胃窦型黏膜。胃黏膜表面有些圆锥形的凹陷，叫做胃小凹（胃小点），它与胃腺相沟通（4,10）。腺体形直体长，且为严密包裹的结构。在胃的各个部分，胃小凹均由表层小凹黏膜细胞连接而成。贲门型黏膜由一个邻近胃食管连接部只有1厘米长的胃黏膜小段构成（4）。胃体型黏膜最明显的特征是其胃腺中有壁细胞和主细胞。壁细胞分泌盐酸和内因子，主细胞分泌蛋白水解酶。胃窦型黏膜中无壁细胞和主细胞。胃窦胃小凹和胃腺由胃小凹黏膜细胞相连。

胃体型黏膜移行贯穿于解剖学上的胃底和胃体，并沿着胃大弯延伸至胃窦部。胃窦型黏膜则沿着胃小弯从幽门到角切迹移行贯穿于整个胃窦部，但在胃大弯处只移行一小部分。所以，组织学上分型把胃分为体型及窦型黏膜，和解剖学上及放射学上把胃分为底部、体部、窦部是没有相关性的。

curvature. Thus, the histologic division of the stomach into body- and

antral-type mucosa does not correlate with the anatomic and radiologic division of the stomach into fundus, body, and antrum (5).

The transition zone between body- and antral-type mucosa is a line that extends from the incisura angularis to the distal greater curvature. The transition zone migrates proximally with age, extending progressively higher on the lesser curvature. Peptic ulcers frequently develop on the lesser curvature at the transition zone (Fig 4).

Figure 4:

Double-contrast spot image of stomach with patient in supine position shows benign lesser curvature gastric ulcer (U) as smooth, ovoid collection of barium extending outside expected luminal contour of gastric body. Smooth folds are seen radiating to edge of ulcer crater.

PRINCIPLES OF IMAGE ANALYSIS

Appearance of the Stomach The radiologist first examines the overall position, shape, and size of the

胃体部和胃窦部黏膜之间的过渡区是从角切迹到胃大弯最低端的一条连线。这个过渡区随着年龄变化而迁移，随着年龄的增加逐渐向上移行。过渡区的胃小弯侧也是消化性溃疡的好发部位（图4）。

图4：

患者仰卧位时胃的双重对比造影片显示了良性胃小弯侧溃疡（如图U 示）呈边缘光滑、卵圆形被钡剂充填的钡斑，并呈局限性向胃轮廓外突出。溃疡周围黏膜皱襞光滑，并从四周向火山口状溃疡边缘集中，呈放射状。

图像分析原则

胃的形态

放射科工作人员首先检查胃的整体位置，形状和大小）.胃底紧邻左膈肌，贲门的中线处紧邻左膈肌侧脚）.胃像一个凸向右边的圆括弧跨越

stomach. The gastric fundus abuts the left hemidiaphragm. The cardia has a midline location, abutting the crus of the left hemidiaphragm. The stomach curves to the right across the midline, with the distal gastric antrum and duodenum extending to the right of the spine. There is considerable variation in the size of the stomach, depending on the amount of barium and effervescent agent administered.

Luminal Contour

In the barium pool, the contour is demarcated by a smooth edge of barium (Fig 1). With air contrast, the luminal contour appears as a smooth, continuous barium-coated white line (Fig 1) (11).

Barium Pool

The pool of high-density barium is the tool the radiologist uses to scrub and coat the mucosal surface (12–15). Some lesions are best shown in the barium pool, whereas others are obscured by even a small pool of high-density barium. Protruded lesions on the dependent wall usually appear as radiolucent filling defects in the barium pool (Fig 5) (16), whereas protruded lesions on the nondependent wall appear as barium-coated “ring shadows” due to barium coating the edge of these lesions (Fig 5). When filled with barium, depressed lesions appear as barium collections on the dependent wall (Fig 4). When barium spills out of depressed lesions on the dependent wall, they may appear as ring shadows.中线连接胃窦和十二指肠延伸到脊柱右侧.考虑到钡剂和泡沫作用剂的用量，胃的大小发生了极大的变动。

管腔轮廓

在钡造影池中，胃的各部分结构的界线是根据钡剂覆盖所造成的平滑的边缘而显示出来的。在与空气影像的对比之下，气钡界线表现出来的是平滑的、连续性的钡剂涂抹出来的一道白线。

钡池

版本1：高密度钡池是放射学家用来区分胃肠道粘膜表面形态的有效工具.部分粘膜损伤可以在钡造影池中很好的显示出来，而其他正常组织会被小剂量的钡所掩盖.移动度较好的胃肠道壁上严重的粘膜损伤在钡餐造影中常常表现为透光性强的未被钡剂填充的点状阴影，而移动度不强的胃肠道壁上的凸起性的粘膜病变则表现为不被钡剂覆盖的环状阴影，损伤边缘的界线以钡剂覆盖的范围界定.粘膜的凹陷性损伤时，钡剂会填充于损伤部位，表现为钡剂聚集影.当填充于损伤部位的钡剂溢出时，亦将呈现出环状阴影.

版本2：高密度的钡池是影像检查中的一种工具，影像学家用它来灌注并显示黏膜的表面 一些损伤可以被钡池清晰的显示，然而对于其他一些损伤，微量的钡剂也会把它们掩盖。腔壁本身的膨出性损伤在钡池中通常显示为射线可穿透的灌注不足的影像。而非腔壁本身膨出的损伤显示为钡剂“印戒征”，因为钡剂覆盖了这些损伤的边缘。当充盈了钡剂，凹陷性损伤表现为腔壁钡剂的聚集。当钡剂散出了凹陷性损伤的的腔壁，有时也可表现为印戒征。

Figure 5:

Double-contrast spot image of gastric body with patient in supine right posterior oblique position shows multiple hyperplastic polyps on dependent, or posterior, wall as small (< 1 cm in size), round or ovoid, finely lobulated radiolucent filling defects in barium pool (arrows). In contrast, polyps on nondependent, or anterior, wall are coated by barium and appear as white lines (arrowheads). Barium is seen to fill interstices between lobules of some polyps.

En Face Mucosal Detail

When viewed en face, the mucosal surface either has a smooth appearance (Fig 1) or is manifested as a reticular network of barium-filled grooves between the areae gastricae (Fig 3). Disruption of the normal areae gastricae pattern or the smooth mucosal surface of the stomach by barium-coated lines is abnormal (Fig 5).

PATTERN APPROACH FOR DOUBLE-CONTRAST DIAGNOSIS Abnormal Mucosal Patterns Striations.—Thin, barium-coated striations perpendicular to the 图5

为病人仰卧右后斜位的胃体部双重对比造影，位于胃后壁的多发性增生性息肉的图像呈钡池内小的（直径<1cm）、圆形或卵圆形的细碎分叶状充盈缺损（如有尾箭头所示）。与之形成对比的是，位于前壁的息肉由于表面覆盖了钡剂而显示出白色的线条（如无尾箭头所示），并且钡剂渗入到了部分息肉的小叶间隙里。

黏膜的正面情况

从正面看，胃黏膜表面平整（见图1），也可见胃区中由充满钡剂的凹槽交织成的网状结构（见图3）。胃区正常黏膜纹理的中断，也即覆盖于平整胃粘膜的钡剂的轮廓的中断，表示该处有病变（见图5）。

双重对比造影的诊断思路

异常的黏膜纹理

条纹.—即很细的、覆盖有钡剂的、与胃窦的长轴垂直的条纹，也叫胃的“细纹”。当胃窦部

longitudinal axis of the gastric antrum, also known as gastric “striae,” are sometimes seen as a transient finding when the antrum is slightly collapsed (Fig 6) (17). These striae are a sign of chronic antral gastritis (16).

Figure 6:

Double-contrast spot image of antrum

with patient in supine position shows

gastric striae as transient finding due to

barium filling delicate transverse

grooves between thin radiolucent folds

traversing circumference of slightly

collapsed gastric antrum.

Conspicuous or enlarged areae

gastricae.—Visualization of the areae

gastricae in the stomach depends on the

thickness of barium in the grooves

between the mucosal tufts in relation to

the thickness of barium overlying the

tufts (8,9). Thus, an increase in the

height of the mucosal tufts or thinning

of the mucous gel layer in the stomach

may cause the areae gastricae to become

more visible or conspicuous. When

viewed in profile, barium in the grooves

between areae gastricae may be

manifested as tiny spikelike

outpouchings, producing subtle

spiculation of the luminal contour that

should not be mistaken for erosions. In

addition, the areae gastricae may be

只是轻度受损时，这些条纹也只是短暂出现（见图6）。这些条纹提示了慢性胃窦炎的可能性。 图6 为病人仰卧位胃窦部的双重对比造影，由于胃

窦部轻度损伤，其周围薄的、放射透过性好的

皱襞之间的横沟内只有少量钡剂填充，因而条

纹只是短暂出现。

胃区明显或增大.—胃区的影像学特点取决于

胃区内褶皱间沟的钡剂厚度，同时和覆盖于褶

皱上的钡剂厚度相关。因此，粘膜褶皱的高度

增加或者胃内粘膜凝胶层变薄会导致胃区变

得更明显可见。侧位片时，沟内的钡剂可能会

形成小芒刺样突起，产生围绕空腔的细小的小

穗样结构，需要和胃壁缺损区分。此外，如果

粘膜褶皱增大，即在胃窦部超过正常值

2-3mm，在胃底部和胃体部超过3-5mm,胃区

可能会增。于此相反，在胃萎缩和溶血性贫血

的患者中，可以发现缩小的甚至消失的胃区。

enlarged by conditions that increase the size of the mucosal tufts beyond their normal diameter of 2–3 mm in the antrum and of 3–5 mm in the body and fundus. Enlarged areae gastricae have been reported in about 50% of patients with Helicobacter pylori gastritis (Fig 7) (18). In contrast, small or even absent areae gastricae have been reported in patients with severe atrophic gastritis and pernicious anemia (19).

Figure 7:

Double-contrast spot image of stomach with patient in supine position shows

enlarged areae gastricae in patient with H pylori gastritis. Areae gastricae in

antrum (white arrow) are larger than

those in distal gastric body (black

arrow).

H pylori is a curved or spiral-shaped,

gram-negative bacillus (20–22) that

infects the stomach in more than 50% of

Americans over 50 years of age and in

nearly 100% of Japanese adults (23,24).

H pylori most frequently involves the

gastric antrum (25). H pylori gastritis

can be documented in almost all patients

with duodenal ulcers and in about 80%

of patients with gastric ulcers (26). The

mechanism by which H pylori causes

ulceration is not fully understood. H

pylori gastritis is also a major causative

factor in the development of both gastric

carcinoma (27,28) and gastric

图7： 胃部仰卧位双对比造影

如图显示幽门螺旋杆菌胃炎患者的胃小区扩大，

胃窦（白箭头）处胃小区大于胃体末端（黑色箭头）处胃小区。

幽门螺旋杆菌是一种弯曲或螺旋形的革兰阴

性杆菌（20-22）。在美国超过50岁的人群中

有50%有过胃部感染史，而近100％的日本成

年人有过胃部感染史（23,24）。幽门螺旋杆菌

最常影响胃窦部（25）。几乎所有的十二指肠

溃疡患者和约80%胃溃疡患者都有幽门螺旋

杆菌胃炎的患病记录（26）。现在我们对于幽

门螺杆菌引起溃疡的机制尚无充分的了解。幽

门螺旋杆菌胃炎也是胃癌（27,28）和胃淋巴

瘤（29,30）发展的主要致病因素。

lymphoma (29,30).

Uniform nodules.—Innumerable small (1–2 mm in size), round, uniform

nodules disrupting the normal polygonal areae gastricae pattern are usually caused by lymphoid hyperplasia of the stomach resulting from chronic H pylori gastritis (Fig 8) (31–33). At birth, no lymphoid tissue is present in the stomach. When H pylori infects the stomach, the organism colonizes the mucous layer and attaches to the membranes of the surface epithelial cells, resulting in the development of chronic gastritis (22). Repeated infections may eventually lead to

lymphocytic infiltration of the stomach, followed by the formation of lymphoid aggregates and even true lymphoid follicles (34). Thus, when lymphoid hyperplasia is detected on

double-contrast barium studies, these patients are almost always found to have chronic H pylori gastritis (33).

Figure 8:

Double-contrast spot image of gastric antrum with patient in left posterior oblique position shows lymphoid hyperplasia with innumerable round, uniform, 1–2-mm nodules carpeting mucosa and replacing normal polygonal areae gastricae pattern. This patient had

均匀小结节——无数较小（1-2毫米大小）、圆

且均匀的结节打乱正常的多边形胃小区形式。通常是由于慢性幽门螺旋杆菌胃炎造成胃淋巴组织增生（图8）（31-33）而引起。人刚出生时，胃内并没有淋巴组织。当胃幽门螺旋杆菌感染时，菌体定殖于粘膜层并附着在表面上皮细胞的细胞膜上，进而发展成慢性胃炎（22）。幽门螺旋杆菌的反复感染最终可导致淋巴细胞浸润胃，进而形成淋巴聚集体甚至真淋巴滤泡（34）。因此，当使用双对比钡造影检测淋巴增生患者时，几乎总能发现其患有慢性幽门螺旋杆菌胃炎（33）。

图8：

患者左后斜位的胃窦部双对比造影可以看到如下改变：被覆有粘膜和替代了胃区正常组织机构的淋巴组织增生，它们数目比较多，呈圆形，形状规则，直径为1-2mm，结节样增生。这位病人患有慢性幽门螺杆菌胃炎。

chronic H pylori gastritis.

Nonuniform nodules.—Irregular nodules disrupting the smooth mucosal surface or the polygonal areae gastricae pattern of the stomach may be caused by

inflammation, metaplasia (alteration of one form of epithelium to another), or malignant tumor. The nodules are

nonuniform in size and shape and have a patchy or diffuse distribution, involving a focal or large surface area of the

stomach on barium studies. Nonuniform mucosal nodularity is a worrisome radiographic finding for gastric mucosa-associated lymphoid tissue (MALT) lymphoma (Fig 9) or, rarely, superficial spreading carcinoma (Fig 10) (35).

Figure 9:

Double-contrast spot image of gastric

body with patient in right posterior

oblique position shows nonuniform

nodules disrupting normal surface

pattern. Nodules (arrows) appear as

round or lobulated, confluent

protrusions varying from 3–6-mm in

size. Endoscopic biopsy specimens

revealed low-grade, B-cell, gastric

MALT lymphoma in patient with

chronic H pylori gastritis.

不规则的结节——不规则的结节破坏了原本

光滑的粘膜表面或者胃的胃区多边形的模式，可能由炎症、化生（一种形式的上皮向另一种转变）或者是恶性肿瘤引起。结节的大小和形状上都是不规则的，在钡剂造影的图像上可以看到在胃粘膜表面呈局灶性或大面积的散在不均匀片状或弥漫样分布。若发现不均匀的粘膜结节在影像学上基本上可以诊断为胃黏膜相关淋巴组织型的淋巴瘤，或者更为少见的表层分布性胃癌。

图9：

患者右后斜位的胃体双侧对比造影显示正常

光滑表面被大小不均匀的结节所中断，结节

（箭头所示）表现为大小为3~6毫米圆形或分

叶状融合突起，在慢性胃幽门螺旋杆菌性胃炎

患者的标本内镜组织活检中显示为低级胃黏

膜相关淋巴组织B 细胞淋巴瘤。

Figure 10:

Double-contrast spot image of gastric fundus with patient in semiupright position shows superficial gastric carcinoma as focal area of slightly elevated, irregular radiolucent nodules (arrows) in shallow barium pool. Clubbed, irregular folds (arrowheads) are seen radiating toward central area of mucosal nodularity.

Gastric lymphomas usually arise from preexisting MALT in the stomach associated with chronic H pylori gastritis. A lymphoid response to chronic infection by H pylori has been postulated as the precursor milieu for the development of low-grade B-cell gastric MALT lymphomas (36). These tumors are sometimes recognized on double-contrast studies by the presence of innumerable poorly defined, confluent mucosal nodules of varying size (Fig 9) (35). In such cases, endoscopic biopsy specimens are required to rule out gastric MALT lymphoma.

Because of mass screening of the adult population in Japan, early gastric cancers (EGCs) constitute as many as 25%–46% of all gastric cancers detected in that country (37,38). In contrast,

图10：

双重对比病人仰卧/侧卧位置时胃底的斑点图像，用轻微隆起的聚焦区、浅钡池内的不规则透明结节（箭头）表示浅表胃癌。锤形的，不规则的皱褶（箭头方向）呈放射状指向粘膜结节的中心。

胃淋巴瘤通常来源于本存在胃中的粘膜相关淋巴组织，与慢性幽门杆菌胃炎有关。对幽门杆菌引成的慢性感染的免疫反应已被认为是形成低分化B淋巴细胞胃粘膜相关淋巴组织淋巴瘤的先决因素。这类肿瘤有时在双重造影检查中被识别，显示出无数轮廓不清的不同大小融合粘膜小结。在这种情况下，内镜活检标本需要排除胃粘膜相关淋巴组织淋巴瘤的可能。

根据对日本成年人的大量筛查发现，早期胃癌在该国所有检测到的胃癌中占到多达25%～46%（37,38）。相反的，早期胃癌在西方国家所有检测到的胃癌中只构成一个小得多的百分比，因为内窥镜检查和钡剂造影检查

EGCs constitute a much smaller percentage of gastric cancers detected in the West, because endoscopy and barium studies are performed predominantly in symptomatic patients who already have advanced lesions (39–41). In the Japanese classification system for EGC, polypoid EGCs that protrude more than 5 mm into the lumen are type I lesions; flat EGCs that appear as plaques, nodules, or tiny ulcers are type IIa (elevated), IIb (flat), or IIc (depressed) lesions (Fig 10); and ulcerated EGCs that are more than 5 mm in depth are type III lesions (42). Depressed Lesions

Erosions.—An erosion is a focal area of mucosal necrosis confined to the epithelium or lamina propria without extending through the muscularis mucosae into the submucosa (5). In contrast, a true ulcer niche or crater extends through the muscularis mucosae into the deeper layers of the gastric wall (4). The actual histologic depth of an ulcer cannot be determined on barium studies. Instead, the radiographic size and depth are used to distinguish an erosion from an ulcer. When viewed in profile, a depressed lesion greater than several millimeters in depth is arbitrarily called an ulcer.

Erosions are manifested on

double-contrast studies as tiny, 1–2 mm in depth collections of barium, usually in the gastric antrum. Erosions may be punctate, round, linear, or stellate in configuration and are often surrounded by radiolucent halos of edematous mucosa (Fig 11) (43). Erosions are 对那些有严重病变的症状性患者有主要作用（39-41)。在日本的早期胃癌分类系统中，突出进入管腔超过5mm的隆起型早期胃癌为I 型病变；表现为斑块，结节，或者小溃疡的表浅型早期胃癌是IIa（起型)，IIb（平坦型），或者IIc（凹陷型）病变（图像10）；超过5mm 深的溃疡型早期胃癌称作III型病变。

凹陷性病变

糜烂——一处糜烂是指一块仅限于上皮或固有层而不通过粘膜基层向粘膜下层延伸的粘膜坏死区域。与其相比，一处真正的溃疡壁或火山口样溃疡是通过粘膜基层扩展到胃壁更深层的。胃镜不能确定一处溃疡的实际组织深度。但是，糜烂和溃疡可以用影像检查的大小和深度鉴别。我们硬性规定，从侧面看时，一个大于若干毫米的凹陷性病变为溃疡。

侵蚀主要表现为双对比研究，就像通常在胃窦部得极微小的1-2mm深处的钡聚集。侵蚀在构造布局上可以是点状，圆形，线形或者星状，而且经常被粘膜水肿的透亮晕包围着（图11）.侵蚀经常被发现存在于扩大的扇形胃窦部得最高点，特别是当病人缓慢的从一边转向另一边时，所以一小部分钡流过胃的相关界面。如果侵蚀是被水肿的透亮晕所包围那么

frequently seen to reside on the crests of enlarged scalloped antral folds (44), particularly when the patient is slowly turned from side to side, so a shallow pool of barium flows over the dependent surface of the stomach (45). Erosions are defined as complete or varioliform if surrounded by a radiolucent halo of edema and as incomplete if there is no surrounding edematous mound. Incomplete erosions are much less

common, appearing as punctate or linear collections of barium that may be difficult to differentiate from barium trapped between areae gastricae or alongside rugal folds.

Figure 11:

Double-contrast spot image of distal gastric antrum with patient in left posterior oblique position shows

NSAID-induced erosive antral gastritis. Multiple varioliform erosions are seen as punctate (small white arrow) and linear (large white arrow) collections of barium surrounded by radiolucent mounds of edema (black arrows). This patient was taking aspirin.

Aspirin and other nonsteroidal

anti-inflammatory drugs (NSAIDs) are

by far the most common cause of gastric 他就被定义为完整的或者天花样的，如果没有包绕水肿样的堆积就是不完整的。不完整的侵蚀很少见，呈现出点状或者线形的钡聚集，这可能很难与困陷在胃区或者褶皱折痕处的钡相区分。

图11:

病人左后斜位的胃窦末梢双重对比影像显示非甾体抗炎药诱导的糜烂性窦性胃炎。大量天花样糜烂在钡剂显影下呈现为点状（小白箭头所示）或线状影（大白箭头所示），其周围为射线可透的大片水肿区（黑箭头所示）该病人当时在服用阿司匹林。

到目前为止阿司匹林和非甾体抗炎药是

胃部糜烂的最主要诱因（46）

。服用非甾体抗

erosions (46). NSAID exposure causes breakdown of the mucosal barrier and mucosal hypoxia, resulting in focal areas of epithelial necrosis with hemorrhage, edema, and vascular dilatation in the lamina propria (47). Because often there is relatively little inflammatory response, the term NSAID gastropathy rather than NSAID gastritis is favored by some authors (10,48). NSAID-induced erosive gastritis is typically manifested as multiple varioliform erosions in the antrum or antrum and body of the stomach (18). Less frequently, these patients may have incomplete erosions that appear as linear or serpiginous barium collections (Fig 12), many of which are located on or near the greater curvature of the gastric body secondary to the effect of gravity (49).

Figure 12:

Double-contrast spot image of gastric

antrum with patient in left posterior oblique position shows NSAID-induced linear and serpiginous erosions (arrows). This patient was taking aspirin. Surgical clips in right upper quadrant are from prior cholecystectomy.

Other causes of gastric erosions include alcohol, viral infections, Crohn disease,

炎药会引起粘膜屏障的崩解和粘膜缺氧，导致伴有出血、水肿的上皮坏死中心区域和固有层的血管扩张（47）。

因为相对而言较少出现炎症反应的情况很常见，一些学者更青睐于使用非甾体类抗炎药诱导的胃病而不是非甾体类抗炎药诱导的胃炎来命名（10,48）。

非甾体类抗炎药诱导的糜烂性胃炎已被证实为在胃窦或胃窦和胃体出现的天花样糜烂（18）。至少，这些病人可能会出现不完全的糜烂，呈现为线性或匐行性的钡剂显影区（图像12），又受重力的影响，多数位于胃大弯及其附近（49）。

图12：

病人左后斜位的胃窦双重对比影像显示非甾体类抗炎药诱导的线性和匐行性糜烂（箭头所示）。该病人当时在服用阿司匹林。位于右上角的外科夹是早前胆囊切除术留下的。

胃部糜烂的诱因还包括酒精、病毒性感染、克

hemorrhagic gastropathy, and iatrogenic trauma (4,50–55). Surprisingly, erosions

are infrequently seen in patients with H pylori gastritis (18).

Ulcers.—An ulcer is a focal area of mucosal disruption that penetrates

through the muscularis mucosae into the deeper layers of the gastric wall. When viewed en face, most benign gastric ulcers on the dependent wall are

manifested on double-contrast studies as a smooth round or ovoid collection of barium filling the ulcer crater (Fig 13). Some shallow ulcers on the dependent wall and ulcers on the nondependent wall may be manifested as a circular or hemispheric ring due to barium coating the rim of the unfilled ulcer crater (Fig 14) (56). Most ulcers are round or ovoid, but some may have a linear, serpentine, rectangular, flame-shaped, or

rod-shaped configuration (56–58).

Figure 13:

Double-contrast spot image of gastric body with patient in left posterior

oblique position shows gastric ulcer (U) as smooth, ovoid collection of barium on posterior wall. Smooth, straight folds radiate directly to edge of ulcer crater. These are typical findings of a benign

罗恩病、出血性胃病和医源性精神创伤（4,50-55）

。让人意外的是，糜烂很少出现在幽门螺旋菌性胃炎病人身上（18）。

溃疡——溃疡是穿透粘膜肌层直到胃壁更深

层的粘膜破损中心区。

从表面上看，大部分位于内壁的良性胃溃疡通过双重对比研究证实为充填溃疡破口的光滑圆形或卵圆形钡剂显影区（图像13）。 一些位于内壁的浅表溃疡和位于外壁的溃疡因为钡剂修饰了未被填充的溃疡破口缘可呈现出环形或半圆环影（图像14）（56）。大部分溃疡是圆形或卵形，但是一些可表现为线形、波浪形、矩形、焰状、杆状（56-58）。

图13：

病人左后斜位的胃体双重对比影像显示胃溃疡为在后壁的光滑、卵形钡剂影。光滑而直的皱襞呈放射状直接指向溃疡破口边缘。这些都是良性胃溃疡的典型表现。

gastric ulcer.

Figure 14:

Double-contrast spot image of gastric body with patient in supine position shows incompletely filled ulcer on dependent, or posterior, wall as hemispheric ring shadow with two crescent-shaped barium-coated lines (arrows) coating various portions of inferior rim of ulcer. Smooth, straight folds radiate almost to edge of ulcer crater. The findings are characteristic of a benign gastric ulcer with retraction of adjacent gastric wall.

When viewed in profile, benign gastric ulcers may be recognized by a focal barium collection or barium-coated line extending outside the expected luminal contour (Fig 4) (11,59–61). Some ulcers have a smooth radiolucent rim of variable thickness directly adjacent to the ulcer crater, representing a collar of edema and inflammation, whereas others have a thin radiolucent line (also known as a Hampton line) traversing the base of the crater due to undermining of the submucosa (59). The presence of a Hampton line is diagnostic of a benign gastric ulcer. Chronic inflammation and scarring may cause retraction of the adjacent gastric wall with the 图14

患者取仰卧位，其胃体的双重对比影像显示溃疡凹陷，溃疡边缘的不同部分的胃皱襞也涂上了两条新月形的线状钡影。胃皱襞沿溃疡周边呈光滑，直行的放射状排列。这是良性胃溃疡伴周围胃壁萎缩的特征性表现。

从剖面上看，良性胃溃疡的影像学观察可能是局灶性的钡堆积或者是钡涂层线延伸超过了等高线(Fig 4) (11,59–61) 。一些胃溃疡有射线可透的不同厚度的直接比邻火山口溃疡的边缘,代表这一带水肿或发生炎症，然而其他的由于粘膜下层的破坏有较细的射线可透的线（亦称汉普顿线）穿过火山口(59)。汉普顿线的存在对良性胃溃疡具有诊断意义。慢性炎症和瘢痕化可能引起邻近胃壁的萎缩伴随着在火山口溃疡边缘呈光滑，折叠的发展(Figs 13, 14)。

development of smooth, straight folds that radiate directly to the edge of the ulcer crater (Figs 13, 14).

Although giant gastric ulcers are at greater risk for bleeding and perforation (62), the size of the ulcer crater is not a useful criterion for differentiating benign and malignant gastric ulcers. Most benign gastric ulcers are located on the lesser curvature or posterior wall of the stomach at or near the transition zone between body- and antral-type mucosa (Fig 4). Some benign ulcers may be located on the greater curvature (almost all of these greater curvature ulcers are caused by the use of aspirin or other NSAIDs) (14,63) or within hiatal hernias, where the stomach traverses the diaphragm (64). Thus, ulcer location also is not a useful criterion for differentiating benign and malignant gastric ulcers. Radiologists therefore should ignore the size and location of ulcers when assessing the risk of malignancy; instead, they should focus on the morphologic features of these lesions.

In general, malignant gastric ulcers produce radiographic findings diametrically opposed to those of benign ulcers. With malignant ulcers, the ulcer crater represents a focal area of necrosis and excavation within a malignant tumor, usually gastric carcinoma or lymphoma. The surface of the ulcer and of the surrounding mucosa is therefore composed of nodules, irregular elevations, or irregular depressions of varying size within the tumor (Fig 15) (42). The folds adjoining a malignant ulcer may have a coarse, lobulated,

虽然巨大的胃溃疡并发出血和穿孔的危险性更大，但是溃疡喷口的大小并不是区分良、恶性胃溃疡[1]的有效标准[2]。良性胃溃疡大多位于胃体-胃窦粘膜移行区的或其附近的胃小弯侧或胃后壁。一些良性胃溃疡可位于大弯侧（这些大弯侧的溃疡几乎都是由服用阿司匹林或其他非甾体类抗炎药物引起的）或胃横穿膈肌的食管裂孔疝内。因此，溃疡的部位也不是一个区分良、恶性胃溃疡的有效标准。

[3]所以放射科医师在评估恶性胃溃疡的可能性时应忽略溃疡的大小和部位，而应该关注这些损伤的形态学特点[4]。

译者注：

[1]良性胃溃疡即胃溃疡，恶性胃溃疡即溃疡型胃癌。

[2]中晚期胃癌的直径常大于2cm，但早期胃癌较小，与胃溃疡相近。

[3]恶性胃溃疡也好发于胃窦部小弯侧。

[4]如X线鉴别诊断应从龛影的形状、位置、周围和口部以及邻近胃壁的柔软性和蠕动等情况作综合分析。

一般来说恶性胃溃疡在影像学表现上与良性胃溃疡完全相反。恶性胃溃疡，溃疡周边有一个局部坏死和恶性肿瘤凹陷区域，常常是胃癌或淋巴瘤。溃疡表面和粘膜周边是由瘤根，肿瘤内部的不规则的突起或者不规则的大小不一凹陷组成。恶性溃疡周边的皱襞由于被恶性肿瘤浸润而呈粗大，分叶状，锤状或铅笔状。

clubbed, or penciled shape due to infiltration of the folds by the tumor (Fig 10) (42).

Figure 15:

Double-contrast spot image of gastric body with patient in supine position shows malignant gastric ulcer due to lymphoma. Large lobules of tumor (arrows) surround irregular central ulcer (U) filled with barium, although barium pool is too dense to clearly delineate margins of ulcer.

Radiologists can often differentiate

benign and malignant gastric ulcers on

the basis of the radiographic findings

(Fig 16). If an ulcer has a smooth

surface with smooth, straight folds

radiating to the ulcer margin and no

surrounding mass effect or mucosal

nodularity (Figs 4, 13, 14), it fulfills the

radiographic criteria for a benign gastric

ulcer. About two-thirds of all gastric

ulcers diagnosed on double-contrast

barium studies have an unequivocally

benign radiographic appearance;

virtually all of these unequivocally

benign ulcers are ultimately proved to

be benign (56,65).

图15 仰卧位病人胃体的双对比实时图像显示了淋巴瘤所致的恶性胃溃疡。尽管钡区过于浓厚以至于无法清晰显示出溃疡的边缘，但是仍可见箭头所指的肿瘤大叶包裹着不规则的填充着钡的中央溃疡（U）

放射科医生通常能够借助影像学检查区分

良性和恶性胃溃疡（图16）。如果溃疡表面光

滑、有笔直的放射状粘膜皱襞直至溃疡边缘，

无占位效应或粘膜结节（图4,13,14），则其满

足良性肿瘤的X 线标准。用双重对比钡餐造影

技术诊断的胃溃疡约有三分之二有明确的良

性X 线表现，几乎这些溃疡都被证实是良性的

（56,65）。