Some technical aspects in the demonstration of gastric lesions

S o m e Technical Aspects in the D e m o n s t r a t i o n of Gastric Lesions

By Josv, t~xi l l^,~zta~, M.D. HE ACTUAL TECHNIQUES of fluoroscopic and radiographic examination of tile stomach have not changed,, drastically over the past 40 years; there has been only a slow reluctant yieltting of the classic compression and palpation maneuvers, largely a response to modern technical innovations. With the passage of time, emphasis has shifted from demonstrating morbid changes to recording physiologic alterations. Angiography has properly captured the attention and imagination of the younger men with a corresponding and perhaps unfortunate deemphasis of other gastrointestinal methodolog3.,. Approximately 50 per cent of clinical practice is in the gastrointestinal area and these studies require as high as 85 per cent of the radiologist's time. 1~ Campbell et al. have resorted to the use of the highly trained technologist or ]eldscller to free the radiologist for other essential tasks. This mq)ervised program of tluoroscopy and spot filming by the technologist, interpreted by the radiologist, has not compromised diagnostic accuracy. The radiologist reviews films while the patient is still in the department, and additional investigation is done by him if necessary. Mass surveys from the time of the photoflt, orographic methods to the modern cine, video tape, and 70-ram exposures suggest that numerous exposures without fluoroscopy, utilizing multiple positions with small and then larger amot, nt, of barium, may be as accllrato as the staml:trd method of fl~=~ucJscopy combined with fihning. 4. ,-.6.so. so..sa

T

EQUIPMENT

Image intensifiers with and without television display have largely replaced the old fluoroscopic units. Manual palpation and compression have yielded to gravity maneuvers, mueosal coating, and double contrast techniques. The bulkiness of the intensifier has fortunately made manual palpation difficult, particat]arlv with the patient erect. The heightened fluoroscopic image more than compensates for this lack, in adclition to affording greater radiation protection to the patient and radiologist, s7 It should be emphasized that leacled gloves give only partial protection to the examiner's hands, even when the central beam area is avoided. 7 The use of unprotected lmnd palpation is to be c~mdemned a,a (Fil~. 1). Prest.nt-dav radiologists who persist in direct manual palpation should further appreciate that the higher kV fluoroscol)ic levels of image intensifiers make the conventional 0.5 mm lead equivalent protection gr,~ssl.v inaclequate. Tl..re is no real

" 1os .

Xt.D.:

r,,ft,

School, Boston, Ma.,t~.; Clinical Associate irl Radiolog.y. Ma~.~aclnuwtt.~ General 11o~7~ttal, Boston, Mas.~.; Chief of BadiohJt:!l. Nr'u'ton Wc'th'sh'y IIowital, Nett:hm l,tDtv~'r Falt~, Mass. 02162. SE~IINAIL~, IN I{OENTt.ENOLO~,Y, VOi,. 6. ,~r 2 (.'Xl'ltlt.), 1971

2,&5

JOSEPH HANELIN

Fig. 1.-Manual palpation during fluoroscopy (even with leaded glove) should be avoided. (Courtesy of B. R. Kirklin, M.D.; aa reproduced with permission of Charles C Thomas, Publisher.) substitute for the dexterous human hand, but if the standard attached cone is inadequate, a wooden spoon or pneumatic paddle is recommended. Remote control fluoroscopic equipment, 4~ pioneered by Jutras 9~ who was also among the first to ultilize video tape, is no longer a curiosity. Only very recently have I had the opportunity to use such a unit. It affords a superb demonstration of the fluoroscopic image. Many of the reproduced films were made with this equipment. The television image is frequently superior to the films themselves because of the ability to control contrast, and very fine mucosal depiction is possible.

Fig. 2.-Gastrie ulcer. A. Right anterior oblique erect position with 1 ounce of barium. The crater is well shown (arrow). B. In the right anterior oblique prone position, the ulcer (arrow) is barely visible.

T E C H N I C A L ASPECTS OF GASTRIC I,ESIONS

237

The 3-phase 1000 mA generator with phototimer provides films with little motion. Any size film can be used and there are many options to film division. Spo t films are in actuality overhead exposures monitored by fluoroscopy. The image intensifier is situated below the tabletop, and the tube can be extended from 43 to 60 inches. The long focal film distance provides greater geo,netric sharpness. The tube can be angled to 40* from either side of center. All table and tabletop motions, as well as tube angulation, are controlled remotely. Even laminagraphy is possible by remote control. Dosage rates to the patient are comparable to those with the conventional underlaable tube and overhead intensifier setup. The video tape is excellent and further affords the leisure of close scrutiny without patient overdosage. It should be emphasized that radiation levels around the table are considerably higher than with the conventional image intensifier, and special protection is necessary if technical personnel are to remain in the room while the patient is exposed. Palpation is accomplished with a manual remote control compression device which, while requiring a bit of muscle, also gives the examiner appreciation of pressure employed, thus preventing injury to the patient. 2s The compression instrument is concentric with the central beam, making it impossible to determine ft, ndic pliability when compression is made several inch?s below it, unless a wide aperture is employed. There is obvious need for an eccentric cone arrangement as an optional ,node of palpation and a cylinder extension. 44 which permits compression in the left anterior oblique posture. We have been using two television monitors to allow all assisting personnel to participate in the visual experience. They can more easily anticipate requests and this is an excellent mode of teaching radiology residents. Relief from the physical burden of fluoroscopy allows the radiologist to devote almost his total attention to the television image. The patient who is uncooperative because of infirmity, deafness, langamge barrier, or obtundity continues to be a problem. This may be partially answered with a special rotating cradle. CONTRAST ~X.IEDIA

In my earlier years, mixtures of equal parts by volume of USP barium and water stirred together, gave a varied efficacy. Suspending agents were frequently utilized, but tile resultant mixture was largely tile technologist's prerogative. The initial swallows often showed inadequate opacification because tile barium, had settled out. The make of barium seemed less important than the met.hod of fluoroscopy. The dim fluoroscopic image prompted ad,ninistration of more concentrated barium, which often obscured small lesions. Reliance was preponderantly on palpation and compression for mucosal demonstration, s't Plain USP barium is no longer considered acceptable by many :mthorities. Colloidal barium suspensions have been n.commended since 1951.~ Variotls commercial preparations have been studied iu different concentrations and coating. Miller has written on this theme extensively, including the mixing of combinations in a search for the one formula that would improve mucosal

JOSEPH

""

.O

~

i-

"O

HANELIN

".r'ECItNICAL ASPECTS OF GASTRIC I.ESIONS

0,~9

Fig. 5.--Two gastric ulcers in a 45 year old woman. A. Right anterior oblique prone. B. Left posterior oblique supine showing double contrast.

different brands of varying density, fluidity, anti viscosity. 4v.47'~ The barium suspension should be carefully monitored in preparation and mixing for optimal reproducible results. Eitlwr a weight/v(~lttme or weight/weight formula can be used to express proportions. The constancy of tile mixed product can be checked with special hydrolneters. 't'~ Miller '~7'' and I-[odgcszsu have been properly disturbed by the failure of manufacturers to fully impart the formula of their barium preparations. The adjuvants present may have different physiologic effects, both on gastric and small bowel rnotility and pattern. The physiologic effects of various additives should be appreciated. 1~ High density barium sulfate with high fluidity leaves the stomach with great rapidity and traverses the small bowel rapidly, s Agglutination or flocculation is larg(,ly the res~It of mucin in the gastrointestinal tract, and this is less apt to occur when proper suspending agents are added to the barium sulfate. 4r'' Adhesion, thickness of film, suspension characteristics, viscosity, foaming stability, taste, and texture are all considerations in evaluating barium products. The possibility of bacterial contamination of barium preparations should be appreciated. 1 Unused n'tixed barium is best tliscarded to avoid bacterial growth. Tantalum powder, although successfully omployed to screen the traeheobronchial tree and esophagus, does not presently have application for gastric demonstration. ~s.~.s.as. 60 \Vater soluMe media, sucll as Urokon and C,astragrafin, I2''.~4A and the still experimontal newer polymeric preI)arationsa primarily obviate barium accumulation in the large bowel of the immediately preoperative, or extrcmc,ly infirm patient and l)rc~cluclc l)arium l)eritolleal soiling wher(, l)erforati~m is likely. Gastric outline and even mucosal detail are frequelltly extremely well shown vr Castrografin. However, as the medium progresses in the small 1)owel, dilution occurs bccaust~ of its hyl)ertonicit3'. This increased intestinal hyperosmolaritv mav ]mve serious a(lv(,rse afft,ct upon water I)alance and e]eetrt)-

~40

JOSEPH I~Jtl~ELIN

: ~'~if~"

'~-~

9

-2 i L ' , , .

Fig. 6.-Gastroesophageal reflux in a 66 year old woman. A. Reflux in left anterior

oblique prone position. B. Supine film with high kV exposure. Stretched thin rugae are visible with and witl~out double contrast. lytes, especially in children. If intestinal obstruction exists, the increased fluid content of the bowel may further compromise a grave situation. TECHNIQUE

As might be expected, methods of gastric examination vary and a good c~ise can be made for any of the standard sequences. 11 It is important to begin the examination with a small amount (30 to 45 cc) of relatively viscid barium. A thinner mixture can be used later for more complete gastric distension. The more viscid material will generally result in better coating of the mucous membrane. swallow permits better detection of lesser curvature ulcers, most commonly Using the e r e c t right anterior oblique posture (Fig. 2A) for the initial found along the magenstrasse. They may be difficult to show if the stomach is completely filled (Fig. 2B). Initial palpation with the remote control pressure device helps to coat tile tnucosa. The patient is rapidly placed in the recumbent position, turned to the left, and then face down in the prone and right anterior oblique postures. Rotating the patient while horizontal is essential to assure good mucosa] detail and the fundus can also be s}mwn witholtt barium obscuration (Figs. 3 and 4). ~,Vhile the patient is in the left posterior oblique position, the antrum and duodenum can also be visualized advantageously.

TECHNICAL ASPECTS OF GASTRIC LESIONS

24]

Fig. 7.-SmaU gastric carcinoma. A, Slight irregularity of superior aspect of prepylorus. Examiner suspected some rigidity but was unable to confirm this. B. Sizable constricting and ulcerating carcinoma of the antrum seen 25 years later.

Four or five ounces of a thinner barium mixture can then be employed to study the esophagus and look for a hiatus hernia. Double contrast films of the antrum and bulb can now be taken with the table horizontal or partially raised ss (Figs. 5 and 6). Gastroesophageal reflux may be important in explaining symptoms. Reliance has been principally placed upon the water test, 14 Having utilized this test frequently in recent years, it has become apparent to me that even though ingested barium is already greatly diluted, combining ,water with it provides considerable diagnostic information ,as to gastric outline and distensibility and may allow demonstration of masses if high enough kV is employed (Fig. 6). Various applicances, such as a paddle with inflatable balloon, pillow, and urethanc bolster are helpflll not only for compression but for showing hiatus

242

josF.Pri HANELIN

Fig. 8.-Gastric carcinoma not diagnosed for 10 months, in a 76 year old t~

A

man. A. The area of straightening,along the lesser curvature distal to the a n g l e was not appreciated. A double contrast study was not done. B. Sizable gastric carcinoma with small ulceration, easily seen 10 months later.

Fig. 9.-Sevcrc gastric dilatation. A. Seccmdarv Io scarred duodt.niml in a 73 ,.'ear ohlw(unan. B. After 2-1 hours of ilspiralion. 4 ounces of barium and 300 cc of air were injected through a nasogaslric tube. Note good rugal detail.

TECHNICAL ASPECTS OF GASTRIC LESIONS

~3

Fig. 10.-Gas pill Cl series. A. lmmediatel,r ~fter 2 ounces of barium with 20 gas pellets. Gas is just beginning to generate. B. Hiafias hernia demon~tration is aided by !zaseotts eructation during s;,vailowing. The ftmdus is distended. C. Right anterior oblique prone. Less than ,1 ounces barium. Excellent double contra~t ,~f fundus. Note duodenal ulcer deformity.

hernia in the prone position during swallowing. 44.8r Intraesophageal balloon tamponade has been employed to better demonstrate r variccs and might be an aid in delineating gastric varices. I~.49

Double Contrast Studies Detection of a small gastric carcinoma necessitates a technically good double contrast examination. 51.so This is emphasized by Japanese authorities whose great experience has been gained by the high incidence of stomach cancer in their countrT.3~ It is well to appreciate the frequent slow growth of these lesions (Figs. 7 and 8) and the ease with which they may be ov~:rlooked, even when 2 to 8 cm in size. Any hope for successful surgical control depends on early diagnosis. Fortunately, other methods have become available, includinR the fiber optic gastroscope, 10 .ttastrocamera.n.zT. .~l an~tio~zraphy,~ and isotope scanning after direct arterial inieetion. 0t

JOSEPIt HANELIN

Fig. l l . - U s e of Pro-Banthine and gas pills. A. Narrowed antrum. B. The ProBanthine has caused gastric aT~d duode,al atonv.. The short, fixed, tubular, prepyloric narrowing is disclosed with double co, trasl. The diag~osis of carcinoma has not yet been confirmed.

The gastric volume is quite elastic, from the resting state where it may contain as little as 2 or 8 ounces, to the full state where it will hold a quart or more, and in pathologic situations where it may contain 4 to 8 quarts (Fig.

9). Certainly using a mere ounce of barium would be incapable of covering the entire gastric mucosa, even in the empty state, were it not for the residual fluid which dilutes as well as helps spread the medium over the mucous na<'mbr~lne. The m~cc,~s membrane is covered with a thickness of n H~c'in varying from 0.5 to 2.5 ll,m. t,ar~c au~olmts of mucin as well as a large residual fluid volume are. deleterious to good barium coating even when a wellsuspended l~arium l~rc,par:ltio, ix ilsr Un~ler such circumstances, aspiration of the fluid content is a great aid. Some air is ahvays present within the stomach, and var3,jng additional amounts will be swallowed tluriu,,, drinking. Amplatz advises using a straw witll ~l pinllolt, l~,rfi~rati~,~ tf~ assure, mor~, air e,try. 3 I lmve fo~nd that even mort' air will h~. I~ikt.lJ iI~ if tt~r lar.t~e calilwr plastic tubing is perforated, jl The most obvious means of introdlleintz air is. of course, injection through an indwelling naso~astrie tulw. Many patients will not tolerate this procedure, so it cannot be ~1s~,r as a rot~tint, toe'/hod. It may, nonetheless, be necessary ~for e dia.tr,nosis. After aspiration of rcsidilal thlir instillation of 2 to 3 ounces of l)arimn, rolalin,~ II~t, paticnt to assure goc~d coating, th~'n introducing 200 to 500

TECIINICAL ASPECTS OF GAS'ITtlC LESIONS

2,45

Fig. 12.-Leiomyosarcoma. Importance of positioning. This 77 year old bedridden woman with upper GI bleeding and ascites shows transverse organoaxial gastric rotation with the antrum and bulb uppermost. A. The lesion (arrow) is difficult to see in the right mlterior oblique. B. An ulcerating doughnut lesion of the gastric body (arrow) is shown well in only the left lateral view.

cc of air (not to the point of distress) will give a beautiful demonstration. Often a Seidlitz powder or carbonated beverage is used for gas contrast; these are not totally satisfactory because the mucosal barium film is frequently washed away. Gas pills recently introduced from Japan, containing taltaric acid, sodium bicarbonate, and dil.iethyl p()lysiloxanc, have great potential 21 (Fig. 10). Although also manufacturcd in a granular form, we have used the small pellets, 20 to 40 per patient. Each pellet releases 13 c:c of CO-. The gas is generated on contact with water and is released colnpletely in 3 minutes. It may 1)e taken with the 1)arium preparation. Some experimentation with the gas tablets is worthwhile. We have given 1

246

JOSEPH HANELIN"

j

Fig. 13.-Gastric ulcer demonstrated in A by Schatzki maneuver in right posterior oblique semiupright position, s8 Supine, en face, view (B) shows severe, irregular thickening of radiating gastric folds suggesting a malignant base.

TECItNICAL ASPEC'FS OF GASTRIC LESIONS

247

ounce of plain barium first and then anothcr ounce of barium with the pellets. Pro-Banthine can be used in combination (Fig. 11), in which case it should be given first so that the gas will not dissipate before the anticholinergic effect is achieved.

Positioning Positioning includes upright, semiupright, prone, supine, and Trendelenburg, but utilization of prone and supine lateral decubitus projections as weU as right and left lateral decubitus views may provide additional information (Figs. 12 and 13 ). The gastric fundus has been a most difficult area to examine, s,'~s,45 Knowledge of the normal anatomy of the cardia and immediate vicinity is a prerequisite for proper appreciation of fundic abnormality. In a classic paper, Justras et al, have elllcidated the normal and abnormal morbid appearances 8~ (Figs. 4 and 14). Delineation of mucosal relief and double contrast are emphasized. Reading of this paper in the original is strongly recommended.

Diagnostic Pncunmperitoneum Diagmostic pneumoperitoneum has been discussed by a number of authors 46,~ although not often resorted to. Taylor et al. have combined gaseolis gastric distension, artificial pnellmol)eritonetmL and nn.~iogrnphy to visualize the gastric wall. 6a The thickness of the gastric wall is beautifully seen in a patient with spontaneous pneunmperi'mneum (Fig. 15). Combining intraperitoneal air with a barium double contrast study of the stomach may be particularly helpflll ill studying the fundus. Siipramesocolic opaq~m pcritoncography with water soluble contrast medium might complement diagnostic pneumoperitoneum for this purpose, s PIIAIaMACOLOCIC INFLUENCE UPON GASTRIC MOTILITY

Pharmacologic agents 2a,ar,s9 for radiologic examination have been used more widely abroad than in this country until recently when interest was stimulated by the efficacy of hypotonic duodenography. 1~ Propantheline bromide (Pro-Banthine), widely employed in peptic ulcer therapy and as an intestinal

Fig. 14.--Reticulum cell sarcoma of gastric fundus (arrow) shown with double contrast. A. Posteroanterior, prone. B. Right anterior oblique, prone. C. Left anterior oblique, prone.

~zt8

JOSEPII HANELIN

Fig. 15.--Gastric wall shown by spontaneous pneumoperitoneurn in a 67 year old manw Supine fihn[ The wall thickness is visible* by contras~ be- : tween the air in and outside the stomach. (Courtesy of Dr. Laurence L. Robbins, Massachusetts General Hospital.)

antispasmodic, is anticholinergic, blocking vagal impulses at the autonomic ganglia situated within the gastric and intestinal wall. It causes decreased intestinal tone but has side effects which include loss of bladder tone, pupillary dilatation, drying of salivary, gastric, and upper respiratory tract secretions, and tachycardia. The drug is contraindicated in glaucoma, cardiac disease, and prostatism. As eye accommodation may be disturbed, the patient should not be permitted to drive for about two hours after the procedure. It is customary that the bladder be emptied before being given the preparation. It is essential that the referring clinician be consulted before undertaking this study. Pro-Bathine is generally given intramt,sctdarly, the usual close being 30 rag, although up to 60 mg have been given by this route. Dosage may be tempered by body weight and by the actual pharmacologic effect obtained. Intravenous doses of 10 to 15 mg are recommended. Morphine in small amount (10 rag) may be effective as an antidote if tachvcardia becomes troublesome. WhilePro-Banthine has a marked effect on the duodenum, making this area particularly easy to examine, it also generally produces good inhibition of motor activity in the stomach and to varying degree in the remainder of the gasirointestinal tract. The esophagus will frequently show dramatic cessation of peristalsis and, while generally remaining flaccid, may develop prolonged contraction in its lower segment. By incll~c'in.t~ gastric (Iilatation anti flaccidity, certain areas of the stomach, the fundus anti the antrum, become particularly easy to study. A retrogastrie mass may be more easily appreciated in tJae SllI~itit' lateral view mad,' with tlle llorizoldal heam. In Figure 16, Pro-Banthine was employed to good advantage to emphasize a focal zone of rigidity in the body of the stomach. Relieving the antral spasm

TEC'IINICAL ASPECTS OF CAS'I'RIC LESIONS

~4~

.;,

.',

Fig. 16.-Effect of Pro-Banthine A. Polypoid thickening and rigidity in the horizontal portion of gastric body shown en face. B. Profile view with cephalad tube angulation. C. With Pro-Banthi;le and Seidlitz powder. The atonic stomach drapes over tlae area of thickening. Gastroscop), and biopsy disclosed severe hypertrophic gastritis. with Pro-Banthine in another patient permitted demonstration o f a large saddle ulcer and showed that this zone was not devoid of elasticity, favoring a be.nigh process (Fig. 17). The combination of Pro-Banthine, good mueosal coating, and subsequent administration of gas pills with additional barium provides a beautiful double contrast study in many patients (Fig. 11). It is well to appreciate the sustained effect of long term use of drugs of the belladonna alkaloid family since there ma~- be persistence of the gastric atony and dclaved emptying after these drugs have been withdrawn for a number of days. Autonomic nervous system invoh,ement in diabetes may cause similar severe gastric atony, dilatation, and delayed emptying. 28^,3~.ss Additional pharmacologic aids are inch~ded for completeness, 22.z3.~t~.~~ although I have not used them. Morphine and insulin act as cholinergic drugs, stimul;,ting ~,agal action; on that basis they may bc effective for producing transient hypermotility of the stomach. The ustml dose of morphine is 10 mg and of insl~lin 10 lmits of the regular variety. Morphine appears to have been the more effective.. NaJ.orphine or atropine can be used to counteract some of the symptoms of dizzY'tess, nm~sea, and vomiting which may develop from morphine use. Oral procaine, 100 cc of 1~ solution, has been administered by R6ka and Lajtha to produce pyloric canal relaxation and. promote gastric emptying; s4 gastric peristalsis is not affected. Neostigmine methylsulfate (Prostigmin), 0.5 mg for the average patient, has been effective in accelerating barium transit through the small bowel but has not been spt.cifically ~sec1 to promote gastric hypermotility. 9.~ Adrener~,ic drugs have not been used for altering gastric muscle tone because of other well known more dominant effects, a~ Isotopes have been l~tilized in an effort to show gastric lesions, the nuclide being injected into the celiac axis.61 lalI MAA ,,.,,ill frequently concentrate in a

Fig. 17.-Benign ulcer versus carcinoma. A. Marked narrowing and Hgidity in prepyloric portion of antrum. Carcinoma questioned. B. Reexamination 24 hours later with Pro-Banthine and gas pills shows a large saddle ulcer along the lesser curvature. C. Hypotonia of the duodenum is relatively greater than in the stomach. D. In right posterior oblique position, the notch at crater base suggests a benign ulcer. Confirmed by gastroscopy.

neoplasm. Tc 99"~ pertechnetate is known to accumulate in the gastric glands, and organ scanning as well as count rate recording may some day be of value in differentiating benign from malignant lesions, lr Thus far, gastric scan following intravenous injeetionof Tc ~ " has not been useful in the detection of gastric pathology.

TECIINICAI. ASPECTS OF GASTRIC LESIONS

~51

REFERENCES

1. Amberg, J. R., and Unger, J. D.: Contamination of barium sulfate suspension. Radiology 97:182, 1970. 2. Amory, H. I.: The gastric inlet jet. Amer. J. Roentgen. 101:450, 1987. 3. Amplatz, K.: A new and simple approach to air-contrast studies of the stomach and duodenum, Radiology 70:392, 1958. 4. Beranbaum, S. L., and Lignon, A. J.: Routine gastrointestinal series with a 70-ram. sequence camera. Radiology 83:337, 1964. 5. Betoulieres, P., Jaumes, F., Voisin, G., and Gilbert, J.: Supramesocolic opaque peritoneography. J. Radiol. Electrol. 42:611, 1961. 6. Bj6rk, L., Erikson, U., and Ingelman, B.: Polymeric contrast media for rocntgenologic examination of gastrointestinal tract: preliminary report. Invest. Radiol. 5:142, 1970. 7. Braasch, N. K., and Nickson, M. J.: A study of the hands of radiologists. Radiology 51:719, 1948. 8. Brown, C. R.: High-density bariumsulfate suspensions: an improved diagnostic medium. Radiology 81:839, 1963. 9. Brfinner, S., Rahbek, I., and Mosbech, J.: Roentgenologic and g;tstrocamera examinations in the difl'erential diagnosis of gastric ulcer. Amer. J. Roentgen. 104:598, 1908. 10. Bryk, D.. and Roska, J. C.: Upper gastrointestinal studies with acid and alkaline barium sulfate suspensions. Radiology 92:832, 1968. 11. Burhenne, II. J.: Technique of examination of the stomach and duodenum. In Margulis, A. R., and Burhenne, It. J. (Eds.): Alimentary Track Rocntgenology,.Vol. I. St. Louis, Mosby. 1967. p. 4~ 12. Campbell. J. A., Licberman. M., Miller, R. E., Dree~n, R. C., and Hoover, C.: Experience with technician performance of gastrointestinal examinations. Ratliololty 92: 65. 1909. 12A. Canada. W. J.: Use of Urokon (.~'lium-3-acetylamino-2.4.6.t riiodo|mnzoate ) in roentgen study of tht, gastrointestinal tract. Radiology ff1:867, 1955. 13. Conn, 11. O., Creenspan, R. II.. Ch,melt. A. R. .Mitch,'ll. j. li.. arm Bmdoflr. M.: Balloon tami~m;tdt, iu the radiological

diagnosis of esophageal varices. Gastroenterology 50:29, 1966. 14. Crummy, A. B.: The water test in the evaluation of ga.~troesoplaageal rellux: its correlation with pyrosis, Radiology 87:501, 1966. 15. Donner, M. W., Silbiger, M, L., Hookman, P., and Hendrix, T. R.: Acid-barium swallows in radiographic evaluation of clinical esophagitis. Radiology 87:220, 19613. 16. Edwards, T. L., Jr., and Muggta, A. L.: Examination of the gastric fundus with the fibergastroscope: report of a new technic. Amer. J. Dig. Dis, 10:93t3, 1965. 17. Eliscu, E. H., Potsatd, M. S., and Lo, H. It.: The uptake of pertechnetate by tho vagotomized rat stomach: a preliminary re, port. Radiology 94:699, 1970, 18. Esguerra, )t., and Segura, J.: Tantalum esophagography: a preliminary clinical evaluation. Radiology 97:181, 1970. 19. Ferrucci, J. R., Jr., and Benedict, K. T., Jr.: Anticholinergic aided study of the gastrointestinal tract. Radiol. Cltn. N. Amer. ( in press). 20. Friedenberg, M. J., MeAlister, W. 11,, and Margulis, A. R.: Roentgen study of the s.nail lmwcl in adults and children with ne.'~sti~n'nine. Amer. J. Roentgen. 88:893, 1962. 21. Gelfand, I'). W., and Ilachiya, J.: The double-contrast examination of the stomach using ga_';-productng granules and tablets. Radiology 93:1381, 1969. 22. Gimes. B.: Pharmakoradiologisch Izekliirtcr Fall eines w|ederholt operterten Magens. Fort~hr. C,eb. Roentgenslr. 84: 69,1, 1956. ~ Golden. 'R.: Stomach. In Robbin% L. I. (Ed.): Gohten's Dlagno~ic Roentgenol. ogy. Baltimore, Williams and Wilkins. 19~9, p. 5.1t31. 24. Gravelle, I. II., and Marsden. R. T. II.: Radiological assessment of hypolactasta in ul. ct'rative colitis. Brit. J. Radif}l. 42:,1116, 1909. 25. |layt, D. B., and Simon, D.: Remote control prone pressure spot filming. Amer. I. R~ntgen. 103:456, 1909. 28. lliguehi, T., Ru~elI, W. J., Nakala, 11., and Antoku, S.: Radio~4raphlc survey of the upper l~a~trolnte.~tinal trac:t: an evahzat:cDn, lladic~lo~zy .{t3:1!t31. l.~!}.

252

27. llillman, tl. S.: Gastrophotography. Med. J. Aust. 1:618, 1965. 28. Hinchcliffe, W. A., Zamel, N., Fishman, N. II., Dedo, tt. H., Greenspan, R. II., and Nadel, J. A.: Roentgenographic study of the human trachea with powdered t,~ntalum. Radiology 97:327, 1970. 28A. Hedges, F. J., Rundles, R. W., and llanelin, J.: Roentgenologic study of the small intestine. II. Dysfunction associated with ncurologic diseases. Radiology 49:659, 1947. 28B. Hedges, P. C.: Roentgen examination of the colon. JAMA 153:1417, 1953. 29. Jutras, A.: Teleroentgen diagnosis by means of video-tape recording. Amer. J'. Roentgen 8"2:1099, 1959. 30. Jutras, A.. Levrier, P., ~nd Longtin, M.: ~"tude radiologique de l'oesophage paradiapllragmatiqut, et du cardia, j. Radiol. Electrol. 30:373, 1949. 31. Kalorkerinos, J.: The Olympus GTF camera gastroscope and the Olympus CT5 Standard Gastro camera: the realm of the radioli~gist. Aust. Radiol. 10:39, 1966. 32. Kaye, J. J., and Stassa, G.: /vlimicry and deception in the diagnosis of tumors of the gastric cardia. Amer. J. Roentgen. 110: 295, 1970. 33. Kirklin, B. R.: The meniscus-complex in the roentgenologic diagnosis of ulcerqting carcinoma of the stomach. Amer. J. Roentgen. 47:571, 194 ~ 34. Kleeberg, j. j.: Estimation of gastric acidity by x-ray. Israel ]. Med. Sci. 4:149, 1968. 35. Kuru, M.: Atlas of Early Carcinoma of the Stomach. Tokyo, N~ikayama-Shoten Co., 1067. 36. Lasscr, E. C.: Dynamic Factors in Roentgen Diagnosis. Baltimore, Williams & Wilkins, 1967, p. 133. 37. Lumsden, K., and Tnzelove, S. C.: Intravenous Pro-Banthine in diagnostic radiology of the gastrointestinal tract with special refcrence to colonic disease. Brit. J. Radiol. 32:517, 1959. 38. ,Margulis. A. R.. and Mandelstam, P.: The usc of par,.ntcral neostiffmine in the ro,'ntgen study ,,f the small bowel, lladiolog.v 76:223, 1961. 39..Marshak, R. 1t.. and Maklansky, D.: Diabetic ~a~tropathy. Amer. J. Dig. Dis. 9: :!6t3. I964.

JOSEPH HANELIN

40. Marshall, T. R.: Television and magnetic tape for gastrointestinal examinations. Curr. Med. l.)igest 36:980, 1969. 41. /Vlartel, W., Scholtens, P. A., and Lim, L. W.: "Tubeless" hypotonic duodenography: technique, value and limitations. Amer. J. Roentgen. 107:119, 1969. 42. Matsuda, H., Takai, G., Inui, Y., and Ninomiya, K.: Studies on application of remote control x-ray television installation for examination of the stomach and duodenum. Amer. J. Roentgen. 100:711, 1967. 43. Mattsson, O.: A simple method of ensuring correct concentration of barium con. trast media. Acta Radiol. 39:561,'1953. 44. McNabb, A. M., Roger, J. D., and Newton, I. L.: An adjustable pressure,cone for gastric spot roentgenography. Amer. J. Roentgen. 63:411, 1950. 45. Melamed, M., Steinberg, L. H., and Pantone, A. M.: Infiltrating carcinoma of the stomach: roentgen demonstration of the thickened stomach wall. Radiology 70:404, 1958. 46. Meneghini, C., and de Mar ehi, R.: Pnc, lmoperitoneum in radiologic diagnosis of tumors in and near the cardia. Radiol. Clin. 22:97. 1953. 47. 31iller, R. E.: Barium sulfate as a contrast medium. In Ma)'gulis, A. R., and Burhcnne, II. J. (Ed~.-): Alimentary Tract Roentgenology, Vol. I. St. Louis, Mosby, 1967. p. :295. 47A. Miller, R. E.: Barium sulfate suspensions. Radiology 84:241, 1965. 48. Nadel. J. A., Wolfe, W. G., and Graf, P. D.: Powdered tantalum as a mcdium for bronchograplay in canine and human lungs. Invest. Radiol. 3:229, 1968. 49. N:tthan, M. It.: Diagnosis of esophageal wlrices by a new radiologic method: a preliminary report. Radiology 73:725, 1959. 50. Rabushka, S. E., Melamed, M., Melam~.d, J. L., and llorwitz, .\!.: Evaluation of a radiographic survey method of upper gastrointestinal examinations: a preliminary study comparing fluoroscopic and radiographic t~xaminations in 100 cases. Radiology 89: 39. 1967. 51. Ragaglini, C,,.: Study of gastric tumors by air insufflation of the stomach. Radiol. Clin. 20:82, 1951. 52. Rigler, L. G.: Roentgen examination

TECHNICAL ASPECTS OF GASTRIC LESIONS

of the stomach in symptomless persons. JAMA 137:1501, 1948. 53. Roach, J. F., Sloan, R. D., and Morgan, R. H.: The detection of gastric carcinoma by photofluorographic methods. Part I. Introduction. Amer. J. Roentgen. 61:183, 1949. 54. R6ka, G., and Lajtha, L. C.: Abolition of pyloric spasm by orally administered procaine solutions. Brit. Med. J. 1:1174, 1950. 55. Rundles, R. W.: Diabetic neuropathy: general review with report of 19.5 cases. Medicine 9.4:111, 1945. 50. Ruzicka, F. F., Jr., and Rigler, L. G.: Inflation of the stomach with double contrast: a'roentgen study. JAMA 145:690, 1951. 57. Schatzki, R.: "You still have to work for it." Analysis of the impact of screen intensification. Radiology 87:759, 1966. 58. Schatzki, R., and Gary, J. E.: Face-on demonstration of ulcers in the upper stomach in a dependent position. Amer. J. Roentgen. 79:772, 1968. 59. Schwartz, I. R., Lehman, E., and Seibel, J. M.: A simple method for improving visualization of the hypermotile stomach and duodenal bulb. Amer. J. Gastroent. 28: 518, 1957. 60. Seneque, J.: Etude pharmaco..dynamique de l'ipeca dans h radio-diagnostic des 16sions gastriques. Schweiz. Med. Wchnschr. 75:858, 1945. 61. Shibata, S., and Iwasaki, N.: Angiographic findings in diseases of the stomach. Amer. J. Roentgen. 110:39-2, 1970. 69. StSssel, H. U.: Clinical importance of use of ceratin drags, especially morphine in

radiologic examination of stomach and duodenum. Schweiz. Meal. Wchnschr. 83:6,57, 1953. 63. Taylor, D. A., Macken, K. L., Fiore, A. S., Colcher, H., Bac]mmn, A. L., and Seaman, W. B.: A new method for vitalizing the gastric wall. II. Further studies, Radiology 86:711, 1966. 64. Truelove, S. C., and Lurasden, K.: Diagnostic pneumoperitoneum. Brit. Meal. J. 2: 585, 1955. 64A. Vest, B., and Margulls, A. R.: The roentgen diagnosis of postoperative ileus. obstruction. Surg. Cynec. Obstet. I15:421, 1962. 65. Windholz, F., Kaplan, H. S., and Jones, H. H.: Preliminary studies of gastrointestinal tract with colloidal barium. Calif. Med. 74:155, 1951. 66. Wolf, B. S.: Use of a half-inch barium tablet to detect minimal esophageal stflctures. J. Mount Sinai Hosp. N.Y, 28:80, 1981. 67. Wolf, B. S., and Gugllelmo, J.: Method for ~oentgen demonstration of minimal hiatal h~rniation. J. Mount Sinai Hosp. N.Y. 23:738, ~50. 68. Zaino, C., Poppel, M. H., and Blazsik, C. F.: Boentgenologic study of abdominal segment of esophagus in presence of pneumperitoneum. Amer. J. Dig. Dis, 22:121. 1955. 69. Zamel, N., Austin, J. H. M., Graf, P. D., Dedo, H. H., Jones, M. D., and Nadel, J. A.: Powdered tantalum as a medium for human laryngography. Radiology 94:547, 1970.