An ulcer associated with nodularity of the adjacent mucosa, mass effect, or coarse, lobulated, or irregular radiating folds or oral contrast projecting into the mass (either inside or outside expected luminal contour) is concerning for gastric malignancy, requiring an endoscopic evaluation for a definite diagnosis [17]. Fluoroscopic examinations hold a special role in diagnosing scirrhous gastric carcinoma. Scirrhous gastric carcinomas may manifest as diffuse, long-segment, or even short-segment narrowing of a portion of the stomach. Endoscopy and biopsy have a poor sensitivity in diagnosing this entity, and a fluoroscopic examination may be essential in its diagnosis. Tumor cells invading the gastric wall result in a desmoplastic reaction that narrows the gastric lumen, making the wall rigid and nondistensible at fluoroscopy, with obliteration of gastric peristalsis [17]. MRI Abdomen Although patients with gastric cancer may exhibit nodular or irregular wall thickening or enhancement, lymphadenopathy, or distant metastases on MRI, there is no relevant literature to support the use of MRI in the prospective diagnosis of gastric cancer. MRI Abdomen with MRCP There is no relevant literature to support the use of MRCP sequences in the prospective diagnosis of gastric cancer. Variant 3: Epigastric pain with clinical suspicion for hiatal hernia. Initial imaging. In a patient with epigastric pain/discomfort and reflux symptoms, a hiatal hernia may be suspected. Hiatal hernias are reported to affect 10% to 50% of the population, with sliding hernias accounting for more than 85% of hiatal hernias and paraesophageal hernias accounting for up to 5% of all operated hiatal hernias [20]. In a relatively healthy patient with only a sliding hiatal hernia and reflux symptoms, dietary modification and a short treatment course of proton pump inhibitor may be curative with no additional testing necessary [21].
Epigastric Pain. An ulcer associated with nodularity of the adjacent mucosa, mass effect, or coarse, lobulated, or irregular radiating folds or oral contrast projecting into the mass (either inside or outside expected luminal contour) is concerning for gastric malignancy, requiring an endoscopic evaluation for a definite diagnosis [17]. Fluoroscopic examinations hold a special role in diagnosing scirrhous gastric carcinoma. Scirrhous gastric carcinomas may manifest as diffuse, long-segment, or even short-segment narrowing of a portion of the stomach. Endoscopy and biopsy have a poor sensitivity in diagnosing this entity, and a fluoroscopic examination may be essential in its diagnosis. Tumor cells invading the gastric wall result in a desmoplastic reaction that narrows the gastric lumen, making the wall rigid and nondistensible at fluoroscopy, with obliteration of gastric peristalsis [17]. MRI Abdomen Although patients with gastric cancer may exhibit nodular or irregular wall thickening or enhancement, lymphadenopathy, or distant metastases on MRI, there is no relevant literature to support the use of MRI in the prospective diagnosis of gastric cancer. MRI Abdomen with MRCP There is no relevant literature to support the use of MRCP sequences in the prospective diagnosis of gastric cancer. Variant 3: Epigastric pain with clinical suspicion for hiatal hernia. Initial imaging. In a patient with epigastric pain/discomfort and reflux symptoms, a hiatal hernia may be suspected. Hiatal hernias are reported to affect 10% to 50% of the population, with sliding hernias accounting for more than 85% of hiatal hernias and paraesophageal hernias accounting for up to 5% of all operated hiatal hernias [20]. In a relatively healthy patient with only a sliding hiatal hernia and reflux symptoms, dietary modification and a short treatment course of proton pump inhibitor may be curative with no additional testing necessary [21].