CHRONIC HYPERTROPIIIC ANTRUM GASTRITIS JULIAN ARENDT, M.D. CHICAGO, ILL. FROMTHEDEPARTMENTOFROENTGENOLOGY,MOUNTSINAI HOSPITAL, CHICAGO,ILLINOIS. ANTRUM GASTRITIS iS of the greatest clinical significance when one con- siders it as an ever-present differential diagnostic possibility. It has many clinical features in common with ulcer of the antral region. It has frequently dleceiving similarity with a malignalncy of the same region, roentgenologically and clinically. The purpose of our study is to evaluate clinical and roentgenologic find- ings, to see how much reliance can be placed on them, and which cases should be sent to the gastroscopist as a last resort before surgery. WNe shall try to avoid, however, a shortcoming frequently found in the presenta- tion of the subject-the presentation of the gastroscope rather than of gas- tritis. The instrument's value is not in doubt; but, as cystitis and nephritis can be diagnosed without the cystoscope, we should find the means of making the diagnosis of gastritis with simple, clinical methods. The history is usually regarded as unreliable, but then it is an art to take a stomach history which is analytical and more than an indefinite report of sensations; yet, as experienced clinicians know, a good history with roentgeno- grams make a stomach diagnosis. In hypertrophic antrum gastritis the patient has no pain in general, but chooses "discomfort after eating, fullness, burning sensation" as terms of description. Yet, taking a sip of ice water or hot tea frequently elicits real pain, not localized but spread over the entire stomach. At certain stages of the disease the stomach wall becomes tender to careful palpation or slight percussion. Antrum gastritis is frequently asso- ciated with cramp-like, painful sensations. Even before seeing his physician, the patient learns to avoid meat and prefers milk and a light diet. There is no seasonal let-up; the discomfort is usually persistent throughout the day and night for weeks and months. Only occasionally have we observed a case with severe clinical symptoms-weight loss, nausea, and vomiting. Bleeding. however, has often been noted. Hemorrhage leading to death has b)een observed. Benedict, in a recent publication, reports the incidence of hemorrhage as I9.7 per cent (43 to 2I3 cases). Peritonitis has occurred. The next step in the examination should be aspiration of the stomach contents. This should not be an Ewald meal, but a fractionated aspiration after a cup of tea and a slice of buttered toast has been given. Such examina- tion will show in chronic hiypertrophic antrum gastritis a considerable incidence of hyperchlorhydria, definitely more frequent than in pangastritis. While such findings are helpful in the differential diagnosis of carcinoma, subacidity and anacidity are occasionally found, either due to increased mutcous secretion or to the insufficienicy of the secreting glands in later stages 235 JULIAN ARENDT AAnnualgsuosft.Sur1g9et4r5 A B C FIG. i.-A. Longitudinal. B. Transverse and oblique musculature of the stomach, ac- cording to Forssell. C. Mucosal folds of normal stomach under prevalence of longitudinal muscle contraction. 236 Volu%e 122 HYPERTROPHIC ANTRUM GASTRITIS Nuimber 2 of the inflammation. In our opinion this does not greatly detract from the considerable value of the aspiration test, as other signs of inflammation might be found in the extract-increased white cells, red cells, and mticous secretion. The next step in our examination is the roentgenologic examination of the stomach. The roentgenologist should have on hand all the clinical data thus far obtained. There are various distinctive signs of chronic hypertrophic antrum gastritis evident in roentgenograms. Some of them might well be FIG. 2.-Case i: Severe hypertrophic antrum gastritis in a girl i8 years of age. Targe filling defects. Note borderfold not disrupted. accessible for direct inspection, others are bevond the reach and limitation of the optical instrument. The term "antrum gastritis" needs justification; in fact, the entire classification of gastritis demands a review. It should not be based solely on gastroscopic findings, but should have either an anatomic or physiologic basis. The classification of gastritis, according to Schindler, has great prac- tical merits, but is not the only one possible. He differentiates: (i) Super- ficial gastritis; (2) atrophic gastritis; (3) hypertrophic gastritis; and (4) gastritis of the postoperative stomach. Such a classification shows gaps and incongruities; it suggests, for example, the question as to whether there is not a form of gastritis which, in contrast to a superficial gastritis, is one of the deeper layers; forms of interstitial gastritis; and stages of development of 237 JULIAN ARENDT Annals of Surgery August, 1945 the disease not accessible to direct inspection, at least not to. a single examination. Such cystic and nodular forms of gastritis have been described by pathologists as gastritis cystica superficialis and cystica profunda (Lubarsch). The question is important to the roentgenologist not as a contest between specialties, but as it might account for certain discrepancies between roentgen- ograms and negative gastroscopic findings. FIG. 3.--Case I: Spot-film: Wall infiltration. Round filling defect. Antral narrowiiig. Not all types of gastritis are exogenous (coming from the surface), such as is the case in alcoholic gastritis; otherwise, the considerable divergence between the advocates of the ulcer theory due to gastritis and those due to peptic-corrosive influence of the stomach secretion, would not be such a fundamental one. More frequently it is an elimination gastritis (Bourget) (coming fromthe depthaftervarious infections). Gastritis has been observed accompanying influenza, cholecystitis, and even common colds; uremic gastritis is another type which comes from the depth to the surface. Thus, the pathologist might choose a different principle of differentiation: 238 Volume 122 HYPERTROPHIC ANTRUM GASTRITIS Number 2-) FIG. 4.-Case I: Same case one week later. Progressive involvement. FIG. 5.-Case I: Six months later peristalsis restored, only slight mucosal irregularity left. 239 JJULIAN ARENDT Annals of Surgery A,ugust, I:)45 (I) Topographic, whether diffuse or localized; (2) according to the type of inflammation; and (3) he might prefer, as would the clinician, to differentiate between gastritis of different etiology or propagation-endogenous and exogenous. The term "antrum gastritis" could mean just such a topographic des- FIG. 6.-Case 2: Pylorus hypertrophy (Ross Golden) and Kirklin's signi: invagination of bulbar base present in hypertrophic antrum gastritis. ignation, but as the term is not unanimously accepted, it requires clarifica- tion. As to the occurrence of gastritis limited to the antrum, veterinary medicine offers some interesting facts. Two authors, Bongart and Tantz, examined the stomach of I,500 calves, and found at the age of four to five weeks an erosive gastritis in the second part of their stomach. When the calves were I2 to I4 weeks old, the authors found such erosive gastritis in 98 per cent; when they grew up and were one to one and one-half years old, no ulcers were found, but there were many star-shaped scars limited to the antral region. The microscopic examination proved them to be subacute or 240 Volume 122 HYPERTROPHIC ANTRUM GASTRITIS Number 2 chronic gastritis. The ulcers occur at the timiie when the calves are weaned, with transition from milk to raw fodder and the beginning of rmnlination. This illustrates well that in addition to the chemical changes a mechanical factor plays an important r6le in the antral localization of gastritis. Experi- mentally induced gastritis in dogs is usually localized in the antrum. In man we have frequently observed, roentgenologically, a pathologic involvement strictly limited to the antrum, and the anatomy of the antral region explains such localization. The antral systole creates considerable FIG. 7.-Case 2: Spot-film showing invagination of bulbar base. pressure within the antral chamber. A spherical pressure chamber is created between the closed pylorus and the plica angularis; this contraction being soon arrested by spasm, and later on followed by muscular hypertrophy. It is pointed out by Ross Golden that antrum gastritis is frequently accompanied by disturbance in motility, antral spasm, and prepyloric narrow- ing, and he quotes Serck Hanssen, who found gastritis "invariably present with hypertrophy of the pyloric muscle." Thus, we have a roentgenologic sign helpful in the diagnosis of chronic hypertrophic gastritis: Visible pylorus hypertrophy or antral spasm in adults. A second sign is a change in the mucosal pattern. The significance of the mucosal pattern for the recognition of early malignancy and ulcers cannot 241 JULIAN ARENDT Ainnals of SurgerS August, 1943 be too highly eniphasized. How much value does it have in the diagnosis of gastritis, in general, and of antrum gastritis, in particular? The mucosal pattern of the stomach is neither something invariably frozen, like our skin lines, nor as variable as ocean waves. G6sta Forssell, in his great work on the autoplasty of the mucosal pattern, has demonstrated and analyzed the great variation of the mucosal folds of the working stomach. In contrast to the working stomach, the fasting and empty stomach has a characteristic initial pattern. The region of the lesser curvature shows the system of the longitudinal folds, the fornix and the greater curvature, mainlh. FJG. 8.-Case 3: Nodular hypertrophic gastritis. Confirnied by gastroscopy as three shallow nodulai- protrusionis. the system of the elliptic curved folds. In the region of the lower angle there is a quite characteristic, inverted Y-shapedl fold-the plica angularis. Towards the antrum the folds are usually arranged in the pressure axis of the antrum. Several adjacent folds have usually the samle direction. Upon the initial pattern is superimposed the workinlg pattern, depeniding on functional re- quirements, hydrodynamiiics, and nervoous iml)ulses. After emptying, the stomach returns to its initial pattern. How much this mucosal pattern conformis to the structure of the mucosal system is evident by comparison of the schematic drawing (according to Forssell) and a normal, regular roentgenogram taken of the fasting stomach (Fig. i). The constancy of the mucosal pattern of the empty stomach makes it possible for the roentgenologist to attach significance to any change in struc- 242 Volume 122 HYPERTROPHIC ANTRUM GASTRITIS -Nuiber 2 .ture and direction of these folds, provided a proper and exacting technic is used. Only upon the changes in the inherent, basic design, and not upon the various autoplastic movements can roentgenologic diagnosis rely. In spite of certain variations the basic design in the antrum is sufficiently clear to recognize any major break and deviation. Roentgenology was able to demonstrate the convergence of mucosal folds around a duodenal ulcer, tFe torus form of the folds around a gastro-enterostomy, and even the Ascaris FIG. p.-Case 3: Spot-film showing cobblestone appearance with preserved architecture. worm in the duodenum. It should be relied upon to find a coiisiderable swelling, stiffness, and deformity of the miucosal folds. This is not in contrast to Forssell's doctrine of the autoplastic, as he states that the anatomic structure at each side facilitates the formation of the pattern characteristic of that side. Any break of the continuity of one or several folds; granular appearance of the mucosal folds; irregular translucencies; and abrupt changes in direction if found in an empty stomach are suggestive of pathology. The differential diagnosis between antrum carcinoma and chronic hypertrophic gastritis, is, admittedly, difficult; but frequently, as our examples demonstrate, the diffi- culties are not insurmountable. 243 JULIAN ARENDT Aninials of Surgery Au4u5t, 19445 The characteristic, grape-like appearance of polypi in the antrum gives the same roentgenologic and gastroscopic picture, whether they are of an inflammatory or neoplastic character. The small, wart-like elevation, niot so rarely found in the antrum, and the single, elevated growth, flat or lobu- lated, are either the end-product of chronic hypertrophic gastritis or true adenoma, fibroadenoma, papilloma, or adenopapilloma. Only histologic study may decide it. FIG. io.-Case 4: Muscular hypertrophy of antrum with cellular infiltration. Antrum gastritis, not carcinoma. Spriggs, in his exhaustive, well illustrated study of polypi, found that many of the cases diagnosed as polvpi were, in fact, such of polypoid gas- tritis. Among his i9 cases of polypoid gastritis were seven in which the polypi developed after gastro-enterostomv or accomiipanied peptic ulcer. Brunn and Pearl found polypi in 85 per cent of their cases localized in the antrum, and in 35 per cent they were exclusively in the prepyloric region. These wart-like elevations are, however, sometimes spread throughout the stomach and arise from an atrophic mucosa. (See Fig. I7.) The roentgeno- logic appearance in the antrum is that of a cobble stone street on a rainy day: the rivulets of barium passing around the cups. The malignancy has usually 244