Summary: Take that extra second to inspect the entire stomach and gastric pouch on CT and MRI, leverage DWI sequences, and correlate manometry with fluoroscopy to detangle complex dysmotility.
Hard to Digest: Upper GI motility disorders and subtle gastric lesions don’t fit into neat tracts. Misidentifying esophageal patterns, or overlooking the excluded stomach after bariatric surgery, too often cause diagnostic delays, persistent symptoms, as well as missed malignancies.
As Dr. Kristina Flicek directed during ARRS26, look beyond the narrows to differentiate primary disorders from secondary postoperative changes. And keep an eye out for the nuances of gastric pathology on cross-sectional CT and MRI:
- Achalasia: Characterized by aperistalsis of the distal two-thirds of the esophagus and failure of the lower esophageal sphincter (LES) to relax, you get that classic bird beak sign.
- Giving adequate contrast during a timed esophagram uses hydrostatic pressure to force open the LES, helping rule out a fixed obstruction or pseudoachalasia from GE junction adenocarcinoma.
- EGJOO: Impaired transit across the EGJ with elevated LES relaxation pressure on manometry, albeit normal esophageal body peristalsis on fluoro? That’s esophagogastric junction outflow obstruction.
- Stems from structural—strictures, hiatal hernias, epiphrenic diverticula, fundoplication wraps—or non-structural causes (e.g., chronic opioid use, which disrupts nitric oxide releasing neurons, leading to unopposed excitatory cholinergic input and spastic LES contraction).
- POSED: A secondary achalasia developing after Roux-en-Y gastric bypass or sleeve gastrectomy, post-obesity surgery esophageal dysfunction is driven by elevated pressure or decreased compliance of the proximal pouch.
- Fluoro demonstrates disruption of the primary stripping wave, proximal escape, and distal motor incoordination (manometry frequently confirms type II achalasia pattern).
More Roux-en-Y Complications:
- GJ Fistula: An abnormal tract communicating between the gastric pouch and the excluded remnant stomach, usually, patients present with weight regain or reduced satiety.
- Marginal Ulcers: Outpouchings or small air foci right at the gastrojejunal anastomosis caused by gastric acid irritating vulnerable jejunal mucosa that’s readily identifiable on fluoro and targeted cross-sectional CT.
Exclusions Apply! Pathology in the bypassed remnant stomach (including large bleeding masses or mucosal lesions) can be completely missed on standard upper endoscopy, if cross-sectional imaging is not performed.
- Persistent antral thickening should not be dismissed as benign simply because it appears static over consecutive months; signet cell adenocarcinoma can masquerade as stable wall thickening.
- DWI is crucial for highlighting wall restriction, effectively distinguishing true gastric adenocarcinoma from poor stomach distension.
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