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Thứ Bảy, 30 tháng 8, 2014

GASTRIC ULTRASOUND: ANTRAL GASTRITIS and H.pylori



Sonography can be used effectively to evaluate the   stomach and duodenum. 16,17 A mucosal thickness greater than 4 mm in the gastric antrum may suggest the presence of gastritis. Marked transmural gastric wall thickening is typical of gastritis, with documented resolution after appropriate therapy. Loss of the normal multilaminar gut signature at the posterior wall of the gastric antrum is another useful sonographic characteristic of inflammation.
The mucosa often seems to be hyperenhancing adjacent to the hypoattenuation of edematous submucosa. 

Antral gastritis displays a spectrum of findings on double-contrast upper gastrointestinal tract examinations, including thickened rugal folds, erosions, mucosal nodularity, and antral striae.4,16,18. Wall thickening that is focal, eccentric, and enhancing can resemble a malignant tumor, and further steps must be taken with this possibility kept in mind.
Our study is unique and original, since we suggest that antral wall and mucosal layer thicknesses as well as the mucosal layer-to-antral wall thickness ratio may be predictive parameters for detection of antral gastritis and H pylori infection on sonography. Cutoff values have not yet been established, and further controlled studies are necessary for validation and standardization of these parameters.
Inflammation and structural changes in the gastric mucosa seem to be more prominent in the presence of H pylori. Therefore, careful investigation for detection of H pylori and effective treatment for its eradication should be mainstays of the management strategy.
This study recommends that sonography of the gastric antrum can be beneficial for patients with presumed antral gastritis. If thickening of the antral walls and mucosal layers is detected, antral gastritis and H pylori infection must be kept in mind, and further diagnostic and therapeutic steps should be taken accordingly. 13 Even though the sonographic appearance of antral thickening can rarely be found in healthy individuals, this characteristic appearance should strongly suggest gastric disease, necessitating an upper gastrointestinal series. 4
There are several noninvasive methods for evaluating the severity of inflammation in the stomach and the presence or absence of H pylori infection, such as a serum pepsinogen test, including pepsinogen I/II, pepsinogen II, and immunoglobulin G antibody for H pylori. In this study, we found that sonography of the stomach may be quite useful for noninvasive evaluation of the antrum. Radiologists should be aware of the usefulness of these specific criteria in the evaluation of gastric wall thickening on sonography to better differentiate gastritis or a normal stomach from malignant or potentially malignant lesions that warrant further diagnostic evaluation.
Our study had several limitations. Since we only measured the gastrointestinal wall in white participants in Gumushane, Turkey, the reference values may not be transferrable to populations with other diets or ethnicities.
In addition, gastrointestinal wall thickness differs with the ages, heights, weights, sexes, and smoking habits of patients. Some history details and factors that may influence the outcome may not haven been completely documented. Another limitation of our study was the lack of absolute proof of antral gastritis in all cases, as no perfect reference standard exists for this diagnosis. Furthermore, the wall thickness in vivo can be influenced by muscular contraction, especially in the gastric antrum. The correlation between the wall thickness evaluated by sonography and the real thickness of the stomach as determined by macroscopic features (or histologic sections) of resected stomach may well be different. However, a single 20-mg dose of butylscopolamine was administered via an intramuscular route before the sonographic examinations in all patients in our study. In addition, the degree of atrophic change (or degree of inflammatory cell infiltration) that may influence the degree of wall thickness in H pylori–positive patients was not considered in this study. Due to these restrictions, associations should be interpreted with caution. Further prospective and controlled studies with larger patient populations are warranted for making more accurate interpretations of the sonographic findings of antral gastritis and H pylori infection of the stomach. In terms of methods, we have used fasting guidelines and intramuscular administration of a pharmacologic agent.
Since most patients present with generalized abdominal symptoms, and routine use of this protocol would be impractical in most busy ultrasound practices, a fluid-filled antrum can be alternatively used for measuring the wall layers.

The main limitation of this study was the relatively small number of patients. Furthermore, the format of expressing average measurement data for the 3 groups may not allow for determination of threshold values and true-positive and -negative rates. Because of these restrictions, associations should be interpreted with caution. However, this article raises awareness of sonographic clues and will lead to further studies of this method.


In conclusion, our results suggest that antral gastritis caused by H pylori infection is associated with characteristic features such as thickening of the antral walls and mucosal layers on sonography. Thus, these clues may be useful for diagnosis of gastritis cases that require further investigation and may avoid at least some unnecessary interventions and measures.

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