A New Technic in the Study of the Mucosal Pattern in the Cardiac Area of the Stomach

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In the chronological development of methods for the roentgen examination of the stomach, the older procedures consisted in the demonstration of filling defects, produced by large lesions, in an opaque medium. Later, more refined technics made it possible to outline the mucosal pattern with a thin layer of barium, under controlled compression, thus revealing involvement at an earlier stage. The different regions of the stomach, however, have not benefited equally from this improved technic. Whereas in the body of the stomach, the antrum, and pylorus, the mucosal folds are demonstrated with great clarity, in the region of the cardia dependence is still placed on the older procedures, which reveal only the more advanced lesions. The most important obstacle in the way of study of the mucosal relief in the cardiac portion of the stomach is its anatomical position, hidden behind the thoracic cage, where it is inaccessible to compression. In addition, since this part of the stomach forms a cavity of considerable size, it is impossible to secure an even distribution of the barium in a thin layer. Instead, it collects in an opaque mass, obscuring all details. The Trendelenburg position, formerly considered basic for examination of this zone, only serves to exaggerate these drawbacks. Actually this position is useful only in the visualization of lesions on the margins of the gastric chamber and is quite useless in the diagnosis of disease involving the anterior or posterior surfaces and in the cardia. We have found it possible to study the cardiac portion of the stomach with the aid of procedures which bring about deflation of the gas bubble so that the walls approach each other and the cavity becomes similar to the remainder of the stomach. The barium then flows through this space in a thin layer, permitting observation of the mucosal folds. Our first studies were done with pneumoperitoneum, which we frequently use when the surgeon wishes to find out if a carcinoma in the area of the cardia has extended beyond the stomach and has become adherent to the adjacent organs. We make use of this procedure, also, in the differential diagnosis of shadows sometimes appearing in the clearness of the air bubble which actually represent organs in the neighborhood of the stomach. Apart from these uses, which have been known for years, we have resorted to pneumoperitoneum to collapse the gastric chamber with the object of visualizing the mucosal relief. In many cases we have been able to push out the gas in the bubble completely, reducing the fundus to a spindle-shaped segment very much like the esophagus (Fig. 1). By this means, the course of the folds which have a normal structure can be followed quite clearly. In other cases air in the area of the cardia has remained in place in spite of the injection of large quantities of gas into the peritoneum.