Stomach

Question 1

What types of cell(s) are in the cardia of the stomach and what do they secrete?

Answer 1

Mucous cells = mucus and pepsinogen II

Question 2

What types of cell(s) are in the fundus of the stomach and what do they secrete?

Answer 2

1) Parietal cells = hydrochloric acid
2) Chief cells = pepsinogen (which is responsible for protein breakdown)

Question 3

What types of cell(s) are in the antrum of the stomach and what do they secrete?

Answer 3

1) G-cells = gastrin
2) Mucous cells = mucus

Question 4

Which part(s) of the duodenum is/are intraperitoneal?

Answer 4

Only the 1st (superior) part.

Question 5

The horizontal part of the duodenum crosses midline at what lumbar level?

Answer 5

L3

Question 6

The descending part of the duodunum travels down the right side of which lumbar levels?

Answer 6

L1-3

Question 7

Duodenaljejunal flexure supported by what structure?

Answer 7

Suspensory muscle of Treitz

Question 8

Purpose of single contrast study for the stomach?

Answer 8

Assesses:

1) Thickness of the gastric folds (rugae)
2) Evaluation of gastric emptying
3) Large luminal defects can be detected

Question 9

Purpose of double study contrast for the stomach?

Answer 9

Visualize mucosal surface

Question 10

Tubeless hypotonic duodenography

Answer 10

Causes temporary paralysis (I.V. or I.M.)

Assess mucosal fold pattern in possible diagnosis of carcinoma of the distal common bile duct, ampulla of Vater, or pancreas

Question 11

Types of congenital anomalies

Answer 11

1) Failure of tubulation (atresia)
2) Dextroposition
3) Duplication and diverticula
4) Congenital rests
5) Microgastria
6) Congenital hypertrophic pyloric stenosis
7) Annular pancreas

Question 12

Duodenal atresia

Answer 12

1) Is COMPLETE obliteration of the intestinal lumen at the level of the duodenum
2) Distal to the Ampulla of Vater (in 75% of patients)
3) Discovered quickly after birth => A higher incidence of atresia is seen in Down’s Syndrome newborns
4) Vomiting (usually containing bile) begins a few hours after birth or after the first feeding
5) Incompetence of the sphincter of Oddi can permit gas into the biliary tract and into the portal venous system

MOST COMMON CAUSE OF OBSTRUCTION IN THE DUODENUM

Question 13

Duodenal atresia (radiographic finidngs)

Answer 13

DOUBLE BUBBLE SIGN = upright film - two gas bubbles; one in stomach and one in duodenum proximal to obstruction

Question 14

Causes of radiographic DOUBLE BUBBLE SIGN

Answer 14

1) Duodenal atresia
2) Malrotation of small bowel
3) Volvulus of the small bowel

Question 15

Pyloric atresia

Answer 15

1) Rare condition (1/1,000,000 newborns)
2) Congenital membranous obstruction of the gastric outlet, with vomiting of gastric contents only (no bile)

Question 16

Pyloric atresia (radiographic findings)

Answer 16

Single gastric bubble with no gas pattern distally on plain film

Question 17

Congenital Duodenal Diaphragm (Duodenal Web)

Answer 17

1) Web-like projections of the mucous membrane that occlude the lumen of the duodenum to varying degrees
2) Occurs in the second part of the duodenum near the ampulla of Vater
3) Radiographically => Thin radiolucent line extending across lumen (often proximal duodenal dilatation)

• Duodenal obstruction INCOMPLETE, small amounts of gas are scattered through the more distal portions of the bowel
• Rarely, the thin diaphragm balloons out distally (WIND SOCK), producing a rounded barium-filled comma-shaped sac (INTRALUMINAL DIVERTICULUM)

Question 18

Duplication of the Stomach

Answer 18

1) Rarest in the GI tract (7%)
2) Along the greater curvature - rarely communicates with the lumen of the stomach
3) Usually closed, therefore forming a cystic sac comprised of stomach tissue (can mimic an intramural tumor)
4) Open duplications are rare

5) S&S: Often asymptomatic but can present with abdominal pain and vomitting

(Image: large submucosal mass with mass effect extending in to the lumen of the greater curvature of the stomach.)

Question 19

Duplications of the Duodenum

Answer 19

1) Rare
2) Closed cystic mass; variable size in duodenal wall (1st or 2nd part)
3) The coats of the cyst reproduce the coats of the duodenum or other GI structures so the cystic lining may be gastric, colonic, or duodenal
4) Cyst may be submucosal, intramural, or subserosal
5) Can fill w/ fluid & obstruct the lumen (mimics intramural mass) OR may change shape (mimic a lipoma) –> given its location, may also cause biliary obstruction and pancreatitis

Two radiographic appearances:

a) M/C is a sharply defined intramural defect, usually located in the CONCAVITY of the first and second portions of the duodenum
b) Well-defined oval filling defect

Question 20

Diverticulum of the Stomach (Anatomical presentation)

Answer 20

1) Very rare; when present, usually found in the posterior wall of the fundus close to the cardia (below the gastroesophageal junction)
2) Is a filling defect
3) Thought to be acquired and not congenital
4) Very rare cases - a tumor may form in a gastric diverticulum
5) Bleeding from an ulcerated diverticulum is rare

Question 21

Diverticulum of the Stomach (Radiographic Findings)

Answer 21

a) Luminal outpouching with a broad neck
b) Normal mucosal pattern may be seen within the pouch
c) Location: 75% near GE junction; 25% on greater curvature of the stomach at the gastric antrum
d) Defect changes size and shape during imaging

Question 22

Diverticulum of the Duodenum (Anatomical features)

Answer 22

1) The most common site is the inner side of the descending duodenum close to the ampulla of Vater
2) Are acquired lesions consisting of a sac of mucosal and submucosal layers herniated through a muscular defect
3) Typically smooth, rounded shape – often multiple and generally change configuration during the course of the study
4) Can vary greatly in size from 1cm up to 8-10cm and as large as 20cm in diameter
5) Rarely, can cause BLIND LOOP syndrome

Question 23

Heterotrophic or Aberrant Pancrease?

Answer 23

1) Nodules of pancreatic tissue found in the wall of the first and second portions of the duodenum
2) 1cm or greater – can cause filling defect, which will appear as a small intramural tumor
3) The pancreatic nodule may demonstrate a small pit or niche (at the site of a miniature excretory duct) that may show retained barium

Question 24

MICROGASTRIA

Answer 24

(a) Small, vertically oriented, midline stomach = RARE
(b) No structural differentiation into the fundus, body, and antrum
(c) Usually is associated with other congenital anomalies –> incompatible with life
(d) GERD and esophageal dilatation are often present

Question 25

Hypertrophic Pyloric Stenosis (S & Sx INFANTILE)

Answer 25

idiopathic hypertrophy and hyperplasia of circular muscle fibers of the pylorus with proximal extension into the gastric antrum 1) congenital 2) Seen in males 4:1 3) Persistent, projectile, non-bilious vomiting seen in a 3-5 week old infant 4) At times the hypertrophied pyloric muscle (olive-shaped) can be palpated

Question 26

Hypertrophic Pyloric Stenosis Radiographic Signs (INFANTILE)

Answer 26

_Radiographically_: i. Dx depends on seeing an elongated pyloric canal (\> 14mm in longitudinal view) ii. Thick muscle bulging (\> 4mm) into the base of the duodenal bulb iii. A delay in gastric emptying is not enough for dx (this can occur normally) iv. Exaggerated peristaltic waves _Roentgen signs:_ i. Stomach may be enlarged ii. Deep peristaltic waves may occur intermittently which only forces a small amount of barium through the narrow pylorus iii. The pylorus is 1-2cm in length iv. A **THIN STRING OF BARIUM** is seen v. A **DOUBLE TRACK** sign may be seen, which is a result of a central mucosal fold in the pylorus, which allows barium to move along either side of it vi. A contracted antrum can mimic a double track sign vii. A concave duodenal bulb may be seen. This appearance is due to the thickened pyloric muscle bulging into it known as the **UMBRELLA** or **MUSHROOM** appearance, or **SHOULDERING** **DOBLE TRACK SIGN**

Question 27

Hypertrophic Pyloric Stenosis Clinical Features (ADULT)

Answer 27

a) The infantile type persisting into adulthood (or delayed in appearance) b) Antral gastritis c) Chronic central ulcers (collection of pooled contrast) causing chronic pylorospasm d) Circumferential antral carcinoma

Question 28

Hypertrophic Pyloric Stenosis Radiographic Signs (ADULT)

Answer 28

i. Similar to the infantile type, but is easier to demonstrate ii. The pyloric canal may measure 3-4cm in length iii. Mucosal folds can be seen at times

Question 29

Adult Hypertrophic Pyloric Stenosis vs. Annular Antrum Carcinoma

Answer 29

_Pyloric hypertrophy_ will demonstrate: i. Mucosal folds ii. Concavity at the base of the duodenal bulb iii. Slight changes in the contour of the narrowed prepyloric area seen on serial x-ray iv. A smooth change from normal to abnormal gastric wall, demarcated by a transverse fold v. Incisura of the greater curvature of the elongated canal vi. Regular symmetric shape and contour vii. Deep peristalsis without much gastric dilatation viii. Presence of a benign ulcer is usually near the incisura ix. Absence of a palpable mass

Question 30

Annular Pancreas

Answer 30

1) Rare 2) Fusion of the ventral bud and dorsal bud of the pancreas --\> completely surrounds the duodenum 3) Produces a partial duodenal obstruction - usually found distal to the duodenal bulb 4) Associated with anomalies such as malrotation, duodenal diaphragm, and peritoneal bands _Radiographically_: a) Similar to duodenal stenosis b) Smooth annular constriction upper portion of the descending duodenum c) Eccentric narrowing of the lumen, proximal small bowel obstruction --- proximal duodenum will be dilated _DDx_: a) Malignant primary tumor of duodenal b) Duodenal ulcer c) Child: Congenital peritoneal bands/veins

Question 31

Congenital Peritoneal Bands or Veins AKA?

Answer 31

Ladd's Bands

Question 32

Congenital Bands overview?

Answer 32

1) Cholecystoduodenocolic bands or membranes -- may cause obstruction of the duodenum in the infant 2) Usually they don’t cause obstruction and can be seen in adults 3) In adult life, allow the duodenum to twist on itself resulting in volvulus and obstruction 4) These bands are asymptomatic until the volvulus (twisting of the duodenum) occurs 5) Obstruction can be caused when congenital bands occur in association with faulty rotation of the gut in its final stage of development 6) Symptomatic bands alone are rare in the adult _DDx_: a) Duodenal ulcer

Question 33

Helicobacter and GD ulcers?

Answer 33

70% of peptic ulcer disease and 95% of duodenal ulcers

Question 34

H. pylori and carcinoma and MALT?

Answer 34

Patients infected with H. pylori have a six times risk of developing gastric carcinoma and a 90% association with mucosal-associated lymphoid tissue (MALT)

Question 35

Causes of infectious gastritis?

Answer 35

tuberculosis, histoplasmosis, and syphilis

Question 36

Ulcers are best identified on what study?

Answer 36

double-contrast studies

Question 37

Locations of gastric ulcers?

Answer 37

common on the posterior wall of the stomach and least common on the fundus

Question 38

Ulcers secondary to nonsteroidal anti-inflammatory drugs and alcohol are often seen where?

Answer 38

On the greater curvature of the antrum, possibly owing to the direct toxic effects.

Question 39

Signs of gastric ulcers on double-contrast studies?

Answer 39

Pooling of barium within the ulcer crater (on the dependent wall). A thin radiolucent line is often seen separating the barium in the lumen from that in the crater and is referred to as Hampton's line. If the ulcer is on the nondependent wall, the barium coats the “rim,” causing a ring-like effect.

Question 40

Signs of ulcer benignity on double contrast?

Answer 40

Folds radiating from the ulcer that are smooth and symmetric with normal areae gastricae. Classically, benign ulcers are seen on the lesser curvature. Giant ulcers (\>3 cm) are virtually almost always benign.

Question 41

Duodenitis Radiographic Sign?

Answer 41

Thickening of duodenal folds \>5mm (most sensitive but least specific)

Question 42

Pathological presentation of gastritis

Answer 42

1. **Rugal Enlargement** -- best predictor of H. pylori infection 2. **Erosions** 3. **Ulcers** -- penetrate deeper into mucosa and have greater diameter than erosions

Question 43

Overview of gastric benign ulcers (not including imaging findings)

Answer 43

1. _Location_: Antrum, pyloric canal, lesser curvature or posterior wall 2. Benign ulcers found on greater curvature after ingestion of drugs 3. Peristalsis will be interrupted at the site of the ulcer (b/c most ulcers involve the muscularis layer of the stomach) 4. Pyloric ulcers S&S: a) Atypical epigastric pain b) Nausea and vomiting c) Weight loss d) Intermittent obstruction is probably the cause 5. Can be any size,

Question 44

Radiographic appearance of gastric benign ulcers

Answer 44

a) Conical/button shaped projection beyond normal margin of gastric lumen b) Smooth, round, oval c) Extension of smooth ulcer folds to the margin _Roentgen Signs_ 1. **Hampton's line** -- thin, sharply demarcated lucent line through base of ulcer 2. **Ulcer collar** -- larger lucent region separating ulcer from gastric lumen due to mucosal edema 3. **Ulcer mound** -- even larger lucent region due to extensive mucosal edema - ulcer within the mound should be central, smooth, symmetrically convex around ulcer and join the gastric wall at an obtuse angle 4. **Incisura** may be seen on opposite side 5. **Gastroduodenal fistula** -- caused by peptic ulcer (connects the lesser curvature (distal antrum) with duodenal bulb) --\> **DOUBLE CHANNEL** pyloris may be seen

Question 45

Cuases of benign ulcers

Answer 45

1. Peptic ulcer disease 2. Gastritis 3. Granulomatous disease 4. Benign tumors 5. Radiation-induced ulcer --\> greater than 5000rad 6. MALT lymphoma --\> rugal fold enlargement

Question 46

Causes of malignant tumors

Answer 46

1. Carcinoma --\> 90-95% 2. Lymphoma 3. Leiomyosarcoma 4. Metastasis 5. Carcinoid tumor 6. Marginal ulceration

Question 47

Bulbar ulcers overview

Answer 47

1. _Location_: lesser curvature on posterior wall 2. Can be very large, called "giant ulcer" - - can be as big as the bulb and replace it 3. _Deformities_: - - **COLLAR BUTTON**: apex of bulb is constricted leaving rounded projections at base near pylorus - - **CLOVER LEAF**: variation of the collar button

Question 48

Post-Bulbar ulcers overview

Answer 48

1. Location: inner side at junction of bulb and descend duodenum 2. Get crater niche & incisura (incisura becomes fixed & permanent as result of scar tissue) 3. Gastric ulcers can develop concomitantly 4. Complication: - - Bleeding - - Obstruction: MOST COMMON cause of pyloric obstruction - peristalsis may be increased in frequency & depth - gastric retention may present in partial or complete obstruction 5. Perforation: - - MOST COMMON cause of spontaneous pneumoperitoneum - - perforates into lesser omental sac - - air shows as gas bubbles in posterior abdominal wall (retroperitonum -- seen along the psoas sheaths) - - adynamic ileus can result in 5-6hrs after perforation - - free fluid evidenced by blurring of inferior edge of right lobe of liver - - sinus tract can result from a walled-off perforation - - plain upright films show free air under the diaphragm 6. Cause of obstruction, pancreatitis, GI bleeding and atypical abdominal pain

Question 49

Ulcer scarring overview

Answer 49

1. Erosions heal with no scar but medium to large ulcers may heal with considerable deformity 2. In the stomach, the folds radiate toward a central point, which is indicative of a healed ulcer 3. Doudenal craters occur in mid-bulb just beyond pyloric canal and they leave a characteristic **CLOVERLEAF** or **BUTTERFLY** deformity 4. Scarring of pylorus and duodenum may become severe to cause partial or complete gastric obstruction

Question 50

Zolinger-Ellinson Syndrome overview (Non-Imaging)

Answer 50

a) Fulminating peptic ulcer usually found in duodenal bulb, can be seen in other areas (eg. distal duodenum or proximal jejunum) b) Hypersecretion of hydrochloric acid by stomach c) Non-beta islet cell tumors of the pancreas. At times these tumors may be ectopic d) Half these tumors are malignant e) Upon partial gastric resection - recurrence of ulcer is usually seen f) Some cases, pancreatic tumor is part of the syndrome, with multiple tumors in other endocrine glands, such as the parathyroid, thyroid, pituitary and adrenal glands g) Severe diarrhea is a symptom h) Occurs in middle aged patients i) The large amounts of gastric secretion by the tumor causes hyperchlorydia and the resulting symptomatology j) Failure of the ulcer to heal post therapy after partial gastrectomy occurs with stomach and jejunal ulcers k) This syndrome should be considered when thickened duodenal folds are seen associated with enlarged gastric rugae and ulcerations in atypical positions Zollinger-ellison syndrome distinguished from other diseases with increased serum gastrin by seeing increased levels of gastrin even after secretin injections

Question 51

Zolinger-Ellinson Syndrome Imaging Findings

Answer 51

_Barium_ a) Enlarged rugal folds b) Hypersecretion -- increased gastrin levels after overnight fasting c) Peptic ulcers (esp in unusual locations) d) Thickened folds in proximal small bowel e) Dilation of descending duodenum _CT_ a) Gastric and duodenal wall thickening and hypersecretion b) Primary tumor in pancreas (or nearby organs) may be seen c) evidence of metastases may also be seen

Question 52

Bezoars overview

Answer 52

1) Mass composed of accumulated ingested material 2) **Phytobezoars**: composed of undigested vegetable material (a) Most common: *PERSIMMONS* (a fruit that contains substances that coagulate on contact with gastric acid and trap seeds, skin and other foodstuff) 3) **Trichobezoars** (a) Ingested hair (b) Most common: *FEMALES WITH SCHIZOPHRENIA OR MENAL INSTABILITY* (c) May fill the entire stomach 4) **Tricophytobezoar** (a) Combination of both hair and vegetable matter 5) Other substances to form bezoars in the stomach include glue, tar, paraffin, shellac, asphalt, bismuth carbonate, magnesium carbonate, laundry starch, and wood fibers 6) _S&S_: (a) Cramping, epigastric pain (b) Sense of dragging, fullness, lump or heaviness in upper abdomen (c) Incidence of associated peptic ulcers is high with more abrasive phytobezoars 7) When bezoars are large they may cause PYLORIC OBSTRUCTION (a) _Plain film_: soft tissue mass floating on an air/fluid level in stomach (b) _Barium study_: contrast coating results in mottled or streaked appearance i. Can also present as a smooth gas bubble (filling defect) ii. Can distinguish from neoplasms because they are freely movable with the patient's position 8) Bezoars can also form in gastric remnants (a) Postgastrectomy (b) Constituents of fruits and vegetables (c) Occurs because after vagotomy, HCl secretion is reduced or eliminated and normal gastric digestion does not occur predisposing to formation of bezoars (d) These bezoars vary in size, consistency and number (e) Postgastrectomy patients should avoid citrus fruits or mince them before ingestion

Question 53

Crohn's disease in Stomach and Duodenum overview (non-radiographic findings)

Answer 53

(a) Combined gastroduodenal involvment occurs in 2-20% of patients with Crohn’s disease elsewhere in the GI tract (b) Crohn’s disease is rare to occur isolated only to the stomach or duodenum (c) TYPICALLY SEEN ELSEWHERE (d) Upper GI involvement as the initial presentation is rare (e) The findings very similar to those seen in small bowel and colon, except for the formation of fistulas i. Results in smooth, tubular antrum -- poorly distensible and exhibits sluggish peristalsis ii. Narrowed antrum flares out into normal gastric body and fundus --\> **RAM's HORN** (f) Recovery of the granulomas from the stomach is rare (g) There is a tendency toward pyloro-antral and duodenal involvement at the same time 1) The blending of the antrum, pylorus, and duodenal bulb into a single tubular or funnel shaped structure is suggestive of Crohn’s disease 2) Can then produce clinical and radiographic signs of gastric outlet obstruction i. Develops in up to 2/3 of patients with Crohn's involvement of the stomach 3) Can cause narrowing and partial obstruction of the duodenum --\> tends to be more fusiform and concentric

Question 54

Crohn's disease radiographic findings

Answer 54

1) **Aphthous ulcers:** early sign (are indistinguishable radiographically from superficial gastric erosions 2) Nodules, thickened gastric/duodenal folds, linear and transverse ulcers, and strictures can be seen mimicking both peptic ulcer disease and neoplasms such as lymphoma 3) In the duodenum may see spiculated ulcers and linear ulcers 4) CHARACTERISTIC: **RAM HORN sign** a) The narrowed antrum flares out into a normal gastric body and fundus b) This appearance can closely simulate the radiographic appearance in a patient who has undergone a Billroth-1 type of gastroduodenostomy 5) **COBBLESTONE** appearance of antral folds with fissures and ulceration 6) Gas in the biliary tree and experience pancreaticobiliary reflux. a) In Crohn’s disease, reflux is postulated to occur either by fistula formation or through a damaged ampulla of Vater

Question 55

Celiac disease of Stomach and Duodenum Overview

Answer 55

(a) Radiographic findings -- begin in the duodenum and extend into the jejunum (b) **Dilation** -- *most reliable finding*; it may be so severe it can be called megaduodenum (c) At times the mucosal folds are enlarged (d) Early diagnosis in the small bowel by biopsy = may be no abnormal radiographic findings

Question 56

Menetrier's Disease Overview

Answer 56

aka **GIANT HYPERTROPHIC GASTRITIS** (a) Uncommon disorder (b) Can mimic carcinoma (c) CHARACTERIZED BY: **MASSIVE ENLARGEMENT RUGAL FOLDS** → hypertrophy/hyperplasia of the gastric glands 1. Massive localized thickening of the rugal folds is seen 2. At times the thickened folds can resemble a mass of polyps (d) Usually hyposecretion of acid and excessive secretion of gastric mucus, which can be associated with **PROTEIN LOSS** into the lumen of the stomach 1. PROTEIN LOSS due to altered mucosal permeability 2. Considerable loss of protein → leads to hypoproteinemia and intestinal edema 3. Excess mucus secretion is common and may add to the mottled appearance of the lesion (e) Involvement of the fundus and body is classic (especially greater curvature), but can involve the entire stomach (f) Can be diffuse or localized (g) In another type the mucosa is stretched over the mass making the surface very smooth (h) Eosinophilia and anemia are often present (i) May have an increased incidence of **ADENOCARCINOMA**

Question 57

Thickened Gastric Folds DDx

Answer 57

* *_H. pylori gastritis_** - Usually in antrum - Commonest manifestation * *_Zollinger-Ellison Syndrome_** - Hypersecretion and ulcerations in stomach & duodenum - Dilated duodenum - Thickened folds in s. bowel as well - Enhancing pancreatic mass * *_Crohn's disease_** - Stomach is uncommon location - Aphthous ulcers and fold thickening * *_Varices_** - Portal hypertension - Esophageal varices - Usually in cardia & fundus * *_Menetrier disease_** - May have hypresecretion - Usually in cardia & fundus - Diagnosis of exclusion * *_Lymphoma_** - Variable size - Enlarged folds disorganized, nodular & irregular * *_Idiopathic_** - No clinical disorder - Can be masked/erased with distention of the gastric fundus * *_Eosinophilic gastritis_** - Thickened folds in stomach and s.bowel & history of allergy

Question 58

Gastric Varices Overview

Answer 58

(a) Similar to varices in the esophagus, however may be isolated to the stomach in cases of splenic vein thrombosis/obstruction 1) With obstruction, splenic drainage is shunted through short gastric veins to the portal veins, causing them to dilate a) Splenic vein thrombosis: most commonly caused by pancreatitis, pancreatic pseudocyst, or pancreatic carcinoma 2) Although isolated gastric varices occur in 75-85% of patients w/ splenic vein obstruction, portal hypertension is much more common that its likely to account for most patients who have this finding (b) Caused by cirrhosis of the liver (same as esophageal varices) (c) _X-ray findings_ 1) Usually ONLY IN FUNDUS 2) Appear as multiple smooth, lobulated filling defects projecting between curvilinear, crescent collections of barium 3) Best seen by barium or air-contrast techniques 4) Long tortuous filling defects in the wall of the fundus a) Demonstrates considerable changeablity in size and shape i. This helps to differentiate them from other processes

Question 59

Duodenal Varices Radiographic Findings

Answer 59

1) Collateral flow in a dilated superior pancreaticoduodenal vein causes vertical compression defects on the duodenal bulb about 1cm distal to the pylorus 2) Small varices produce a diffuse polypoid mucosal pattern in the duodenum similar in appearance to inflammatory fold thickening 3) Large dilated submucosal veins can project into the lumen, causing serpiginous filling defects, similar to the typical appearance of esophageal varices 4) An isolated duodenal varix occasionally presents as a discrete filling defect on the medial aspect of the descending duodenum **The varices are seen in the prone position (with contrast) and disappear in the upright position.**