Indications

Peptic ulcer disease (gastric and duodenal)
Gastric outlet obstruction
Gastric carcinoma / linitis plastica
Post-surgical evaluation (anastomosis, leak, obstruction)
Upper GI bleeding evaluation (when endoscopy unavailable or inconclusive)
Suspected perforation (water-soluble contrast protocol)
Hiatal hernia characterization
Motility disorders

Normal Anatomy and Landmarks

Structure	Normal Finding
Gastric cardia	Smooth, symmetric folds converging at GEJ
Fundus	Air-filled on upright; dependent on supine
Body	Rugal folds — smooth, parallel, <1 cm in width; effaced on distension
Antrum	Smooth, narrowing toward pylorus; peristaltic activity visible
Pylorus	Opens to 1 cm or more; closes symmetrically
Duodenal bulb (D1)	Triangular; featureless mucosa; smooth walls; no folds
D2 (descending duodenum)	Valvulae conniventes (Kerckring folds); pancreatic head impression on medial wall
D3 and D4	Transverse and ascending segments; normal folds; retroperitoneal course

Key Findings — Gastric

Gastric Ulcer — Benign vs. Malignant Features

Feature	Benign	Malignant
Projection	Projects beyond gastric wall	Does not project beyond wall (intraluminal)
Ulcer collar	Present — smooth, symmetric edematous rim	Absent or irregular
Hampton's line	Thin radiolucent line at ulcer neck = benign	Not present
Radiating folds	Thin, symmetric, reach ulcer edge	Thick, irregular, fused — stop short of ulcer
Ulcer shape	Round or oval, smooth	Irregular, nodular
Location	Lesser curvature (most common); antrum	Greater curvature, antrum, cardia — higher malignancy risk

Greater curvature and cardia ulcers carry higher malignancy risk. Any gastric ulcer on fluoroscopy requires endoscopy with biopsy for definitive tissue diagnosis — fluoroscopy cannot exclude malignancy. Report features favoring benign vs. malignant morphology, but recommend endoscopy.

Other Gastric Findings

Finding	Features
Linitis plastica	Diffuse submucosal infiltration (scirrhous carcinoma); rigid, non-distensible "leather bottle" stomach; absent peristalsis; no rugal folds; narrow lumen
Gastric polyp	Sessile or pedunculated filling defect; hyperplastic polyps most common (smooth, small); adenomatous polyps larger, higher malignancy risk
Gastric outlet obstruction	Markedly dilated stomach; food residue; poor or absent gastric emptying; pyloric narrowing on fluoroscopy
Hypertrophic gastritis (Ménétrier's)	Giant rugal folds (>1 cm) in fundus and body; spares antrum; associated protein loss

Key Findings — Duodenal

Finding	Features
Duodenal ulcer	Niche in the duodenal bulb; "cloverleaf" deformity of bulb from repeated ulceration/scarring; anterior ulcers may only be visible on one projection
Duodenal web	Thin intraluminal web in the duodenal bulb or D2; complete obstruction in neonates (windsock deformity)
Annular pancreas	Extrinsic narrowing at D2; "double bubble" sign if complete; eccentric or concentric narrowing
SMA syndrome	Extrinsic compression of D3 between SMA and aorta; obstruction resolves in left lateral decubitus or prone position (diagnostic maneuver)

Reporting Checklist

Esophagus: morphology, peristalsis, GEJ, hiatal hernia
Stomach: distensibility, rugal folds, peristalsis, mucosal pattern
Gastric ulcer: location, size, benign vs. malignant features; recommend endoscopy
Masses: location, size, morphology (sessile/pedunculated, smooth/irregular)
Duodenal bulb: morphology, ulcer, deformity
D2/D3: extrinsic compression, filling defect, mucosal pattern
Gastric emptying: qualitative assessment
Post-surgical: anastomosis caliber, leak, obstruction (if applicable)

Common Pitfalls

Pitfall	How to Avoid
Missing anterior wall ulcers	Anterior wall ulcers fill with barium only in supine or prone positions — profile views missed on upright study; always obtain multiple positions
Missing subtle linitis plastica	Insufficient distension of the stomach mimics linitis plastica; maximize CO2 and barium volume; true linitis plastica persists despite adequate distension
Duodenal bulb scarring vs. active ulcer	Scarred/deformed bulb from old disease vs. active ulcer niche — active ulcer = barium collection persisting after compression; scarring = fixed deformity without niche
SMA syndrome missed	D3 extrinsic compression only visible when stomach is full and patient upright — always check in left lateral decubitus if D3 obstruction suspected
Confusion of gastric folds with mass	Rugal folds efface with distension; true mass does not — ensure adequate stomach distension before reporting filling defects

Step-by-step fluoroscopy technique and systematic search patterns available in RadCall Pro.

Upper GI Series — Interpretation and Findings