












































BANGLADESH JOURNAL OF MEDICAL SCIENCE


Bangladesh Journal of Medical Science Vol.10 No.3 Jul’11 

1. *Akanda Fazle Rabbi, Lecturer, Dhaka Medical College, Dhaka, Bangladesh. 
2. Robindra Nath Sarker, Assistant Professor, 
3. Ahmed Hossain, Professor and Head, 
Department of Radiology and Imaging, Dhaka Medical College and Hospital, Dhaka, Bangladesh. 
*Corresponds to: Dr. Akanda Fazle Rabbi, Department of Anatomy, Dhaka Medical College, Dhaka, Bangladesh. Email: 
rabbi.dmc44@yahoo.com. 

Original aricle 

Diagnostic value of transabdominal hydrosonography in gastric carcinoma 
 

Rabbi AF1, Sarker RN2, Hossain A3 
Abstract 

Aim: To evaluate the efficacy of transabdominal hydrosonography in the diagnosis of gastric carcinoma. 
Materials and Methods: Transabdominal hydrosonography of the stomach was carried out on fifty patients 
with clinical suspicion of gastric carcinoma. Endoscopic or peroperative biopsy was taken from 
pathological sites in all cases. The validity of transabdominal hydrosonography of the stomach was 
evaluated as compared to histopathological diagnoses. Results: The sensitivity, specificity, accuracy, 
positive predictive value and negative predictive value of transabdominal hydrosonography in the diagnosis 
of gastric carcinoma were 81.82%, 96.43%, 90.00%, 94.74% & 87.10% respectively. Conclusion: 
Transabdominal hydrosonography is a useful diagnostic modality for the diagnosis of gastric carcinoma. 
 
Key words: Gastric carcinoma, transabdominal hydrosonography. 

Introduction 

Gastric carcinoma is the fourth most common 
cancer worldwide with 930,000 cases diagnosed in 
2002.1 It is more common in men and in developing 
countries.2 Many Asian countries, including Korea, 
China, Taiwan, and Japan have very high rates of 
gastric carcinoma. Although it is a common 
malignant tumour in Bangladesh, no 
epidemiological study has yet been carried out to 
find out its prevalence. Incidence of gastric 
carcinoma is increasing day by day with high 
prevalence of Helicobacter pylori being an 
important contributing factor. 3   It is a disease with 
a high death rate (about 800,000 per year 
worldwide) making it the second most common 
cause of cancer-related deaths in the world. 4 The 
high mortality is mainly due to early metastasis 
before the diagnosis is made and recurrence of the 
disease after surgical resection. So, an accurate and 
early preoperative diagnosis as well as follow-up of 
the patients under treatment is necessary for proper 
management. 
 
Numerous imaging modalities have been used to 
diagnose gastric carcinoma. Computed tomography, 
magnetic resonance imaging, and positron emission 
tomography have all been used with varying 
degrees of success 5 .But these modalities are 
expensive and not widely available in Bangladesh 
and other developing countries. Endoscopy and 
upper gastrointestinal series with double-contrast 
study have significantly improved the diagnostic 
accuracy in gastric carcinoma but they cannot 

assess of the exogastric extension and distant 
metastases and therefore are unable to assess the 
surgical resectability preoperatively. Another useful 
modality is endoscopic ultrasonography which can 
detect tumour infiltration and metastasis 6 but is an 
invasive, relatively complex and expensive 
procedure and can not be performed successfully in 
some patients due to obstruction of gastric lumen 
caused by the tumour or intolerable discomfort of 
the patient during the examination. Moreover, 
follow-up of gastric carcinoma requires repeated 
examinations of the tumour. So a less invasive and 
cheaper method would be welcome. 
 
Transabdominal ultrasound performed after 
injection of a hypotonic agent and ingestion of 
water provides detailed evaluation of the stomach 
because water provides an acoustic window of 
transmission to the tissue defining the stomach and 
adjacent tissues or organs. This technique is 
referred to as transabdominal hydrosonography. In 
transabdominal hydrosonography, the normal wall 
of the water-filled stomach is seen as a 5-layer 
structure. 7 The wall thickness, echotexture and wall 
layering can suggest the diagnosis. Localized or 
circumferential wall thickening more than 5mm in 
the fundus and body or more than 8 mm in the 
antrum, hypoechoic mural mass or heterogeneous 
intraluminal mass with loss of wall layering, 
luminal narrowing, reduced peristalsis and breached 
serosa with features of exogastric extension or 
distant metastasis suggest a malignant lesion while 



AF Rabbi, RN Sarker, A Hossain 

171 

increased wall thickness with maintained wall 
stratification suggests a benign lesion. 8-14   
 
The efficacy transabdominal hydrosonography in 
the evaluation of the gastric carcinoma have been 
studied extensively. Different studies concluded 
that it is a reliable and accurate diagnostic and 
staging method of gastric carcinoma 8,12,15-18 having 
higher specificity than computed tomography19-21  
and is comparable to endoscopic ultrasonography in 
assessing depth of invasion of early gastric 
carcinoma.22 As ultrasound is often used as the first 
imaging modality in a large variety of abdominal 
complaints, clinically unsuspected gastric 
carcinoma may also be imaged first by it.23 
Moreover this method is also found to be ideal for 
follow-up of patients under treatment. So, authors 
recommended it as an initial technique for the 
diagnosis and follow-up of gastric carcinoma taking 
into accounts its non-invasiveness, wide-
availability, low-cost, easiness-to-use, and lack of 
radiation load.24 Some investigators, however, 
recommended further studies.25 
 
As no similar study was carried out before in 
Bangladesh and it was yet to be known whether this 
method can be equally useful in Bangladesh with 
our present knowledge, skill and available 
instruments, the aim of this study was to assess and 
validate the diagnostic value of transabdominal 
hydrosonography in gastric carcinoma. 
 
Materials and methods  

This cross-sectional study was carried on 50 
patients clinically suspected as gastric carcinoma 
(32 males 18 females, aged 31-80 years) admitted 
in the department of Surgery of Dhaka Medical 
College Hospital, Dhaka during the period of July 
2005 to December 2006. 50 of the 62 patients 
approached for this study agreed and cooperated 
fully yielding a response rate of 80.65%. The 
patients were subjected to transabdominal 
hydrosonography at the department of Radiology 
and Imaging, Dhaka Medical College Hospital, 
Dhaka.  Sonography was performed first by one 
investigator which was then confirmed by another 
investigator. The sonographic findings were noted. 
The extent of tumour infiltration and metastasis was 
assessed in all patients with suspected gastric 
malignancy. 41 patients subsequently underwent 
endoscopic examination and biopsy was taken from 
pathological or suspicious sites. In nine patients 
who underwent surgery without endoscopic 

examination operative findings were noted and 
excision biopsy was carried out from the 
pathological sites. Tissues of the biopsies were sent 
to a pathologist for histopathological diagnosis. 
Transabdominal hydrosonographic diagnoses and 
histopathological diagnoses were then compared. 
  
The diagnosis of gastric carcinoma was based on 
the following four criteria: 
 
i) Localized or circumscribed wall thickening (> 5 

mm in the fundus and body or > 8 mm in the 
antrum) or hypoechoic mural mass or 
heterogeneous intraluminal mass with /without 
breached serosa, exogastric extension and 
distant metastasis. 

ii) Loss of normal wall stratification  
iii) Luminal narrowing. 
iv) Absent or reduced peristalsis. 
 
Ultrasound examinations were performed using real 
time image units (Toshiba- 400, Siemens-G20, 
Logic-α200) with transducer frequency varied 
between 3.5- 7.5 MHz as required for proper 
visualization. Patients were examined in empty 
stomach after overnight fasting or after Ryle's tube 
aspiration in cases of gastric outlet obstruction. First 
20mg Hyoscine N butyl bromide (Butapan) was 
injected intravenously to achieve optimal distension 
and to suppress gastric peristalsis. Then patients 
were given 250 ml to a maximum of 1000 ml of 
water orally or through Ryle’s tube. 
Transabdominal ultrasonography was performed 3 
min after ingestion of water. Patients were 
examined usually in the supine position. For 
optimum visualization of lesions at different 
locations sitting position and left or right lateral 
decubitus position were also chosen if required. 
Scanning was done in longitudinal, transverse and 
left subcostal oblique planes. The appearance of 
each disorder on US scans was analyzed in terms of 
wall thickness, wall stratification and the 
echogenicity of the lesion. Wall thickness was 
measured by electronic caliper on the transverse 
view of the most thickened lesion. Liver, pancreas, 
gallbladder, aorta, spleen, diaphragm, duodenum 
were also examined for features of metastasis. 
Ascites and metastatic paraaortic lymph nodes were 
also looked for. Large (length 2cm or more), 
irregular, fusiform and inhomogenously hypoechic 
lymph nodes were considered as metastatic lymph 
nodes. Sonographic findings of metastasis were 
compared with the peroperative findings.  
 



Diagnostic value of transabdominal hydrosonography in gastric carcinoma 

172 

Data was analyzed with the SPSS (Statistical 
Package for the Social Sciences) version 11.5. 
Diagnostic value of transabdominal 
hydrosonography in gastric carcinoma was 
determined by its sensitivity, specificity, accuracy, 
positive and negative predictive values.  
 
Prior to commencement of this study, the research 
protocol was approved by the local ethical 
committee. 
 
Observations and results 

Of the total 50 patients, transabdominal 
hydrosonography diagnosed 19 as gastric 
carcinoma and 31 as normal or benign conditions. 
Histopathology of the biopsied tissues confirmed 22 
as gastric carcinoma and the rest 28 as normal or 
benign conditions. Among the 22 cases of gastric 
carcinoma, 19 cases (86.36%) were 
adenocarcinoma. Lymphoma, squamous cell 
carcinoma and Leiomyosarcoma comprised one 
case each. 18 cases diagnosed as gastric carcinoma 
by transabdominal hydrosonography were proved to 
be correct by histopathological findings but four 
cases of gastric carcinoma which escaped diagnosis 
by transabdominal hydrosonography or considered 
benign were subsequently diagnosed correctly by 
histopathology. One case suspected as gastric 
carcinoma by transabdominal hydrosonography was 
finally diagnosed as a benign condition by 
histopathology. 
 
Among the 18 cases of gastric carcinoma diagnosed 
correctly by transabdominal hydrosonography, the 
commonest site of involvement was the antrum – 10 
out of 18 cases (55.56%). Involvement was seen in 
the fundus in 3 (16.67%) cases, the body in 3 cases 
and diffuse involvement of the stomach was seen in 
2 cases. In one case, two sites of involvement was 
noted- one in the fundus and the other in the antrum 
.In all 18 cases (100%) wall layering was 
completely lost and wall thickness was increased 
ranging from 10mm to 34 mm with an average of 
23.5 mm. Luminal narrowing and reduced 

peristalsis was also seen in all cases. Heterogeneous 
intraluminal masses were seen in 15 out of 18 
(83.33%) and serosal breach was seen in 13 out of 
18 (72.22%) cases. Gastric carcinoma presented as 
hypoechoic mural mass in only 5 (27.78%) cases. 
(Table I).  
 
Table I: Ultrasonographic findings of gastric 
carcinoma (n=18) 

Characteristics No. Percentage 
Wall layering 
Preserved 
lost 

0 
18 

0% 
100% 

Wall thickness 
Normal 
Increased 

0 
18 

0% 
100% 

Lumen 
Normal 
Narrow 

0 
18 

0% 
100% 

Peristalsis 
Normal 
Reduced/Absent 

0 
18 

0% 
100% 

hypoechoic mural mass 
Present 
Absent 

5 
13 

27.78% 
72.22% 

Intraluminal mass 
Present 
Absent 

15 
3 

83.33% 
16.67% 

Serosa 
Intact 
Breached 

5 
13 

27.78% 
72.22% 

 
In this study, the sensitivity, specificity, accuracy, 
positive predictive value and negative predictive 
value of transabdominal hydrosonography for the 
diagnosis of gastric carcinoma were 81.82%, 
96.43%, 90.00%, 94.74% & 87.10% respectively. 
The validity parameters are shown in table II.  
 
Transabdominal hydrosonography demonstrated 
exogastric extension and distant metastasis in 13 
patients (Table III). Among them metastatic para-
aortic lymph nodes were seen in 5 patients and 
hepatic metastases was detected in 4 patients 
Ascites was seen in 8t patients. Sonography 
detected involvement of duodenum in 2 patients.

 
Table II: Validity of transabdominal hydrosonography as diagnostic modality for gastric carcinoma 

95% Confidence Interval Test  parameter Estimated  value 
Lower Limit Upper Limit 

Sensitivity 81.82 % 58.99% 94.01% 
Specificity 96.43% 79.76% 99.81% 
Accuracy 90.00% 77.41% 96.26% 
Positive predictive value 94.74% 71.89% 99.72% 
Negative predictive value 87.10% 69.23% 95.78% 

 



AF Rabbi, RN Sarker, A Hossain 

173 

Involvement of the gallbladder and hilum of the 
spleen seen at operation in 1 patient each was not 
seen preoperatively on sonography. 
 
Table III: Exogastric extent and distant spread of 
gastric carcinoma as detected by ultrasound (n=13) 

Exogastric extent and  
metastasis No. of patients 

Liver 04 
Para aortic lymph nodes 05 
Ascites 08 
Pancreas 04 
Duodenum 02 

 
Discussion  

Transabdominal hydrosonography is a simple and 
rapid technique in which water is introduced to 
substantially fill the stomach of a fasting patient by 
ingestion or intubation, preferably the former. To 
prevent rapid gastric emptying and allow 
examination while water is present in the stomach 
of an antispasmodic agent is injected which inhibits 
peristalsis. The upper abdomen is then scanned with 
conventional ultrasound diagnostic equipment to 
produce an image of the stomach and of the upper 
abdominal organs if required. Because of its 
sonolucency, water appears dark and makes 
possible the ultrasonographic visualization of the 
five distinct layers of the stomach wall: superficial 
mucosa, deep mucosa, submucosa, muscularis 
propria, and serosa as alternating hypoechoic and 
hyperechoic layers. The ultrasonic images may be 
used to detect extension of gastric carcinoma in the 
tissues or organs being visualized.  
 
Previous studies indicate that transabdominal 
ultrasonography can be used effectively in the 
diagnosis and staging gastric carcinoma.  Some 
researchers consider this method as a supportive 
and supplementary diagnostic procedure to 
endoscopy 8, but others as a reliable screening 
method for the diagnosis of gastric carcinoma 20 
which can be a routine diagnostic approach 17 and 
should rank with the initial methods used for 
diagnosing gastric carcinoma. 21 Yet some 
researchers think that it can be a diagnostic 
alternatives in selected patients who cannot be 
stressed by other methods 10 and it is possible to 
diagnose gastric carcinoma by it despite silent 
clinical symptoms.23 According to some, its use in 
initial evaluation of patients may allow earlier 
detection of gastric carcinoma.18 and it can be an 
alternative method in the follow-up of patients 
already diagnosed.16 

 
In this study, the sensitivity, specificity, accuracy, 
positive predictive value and negative predictive 
value of transabdominal hydrosonography for the 
diagnosis of gastric carcinoma were 81.82%, 
96.43%, 90.00%, 94.74% & 87.10% respectively. 
These findings are compared with those of one past 
study in table IV. 
 
Table IV: Validity parameters of present study 
compared with a previous study 

Validity  parameters Present study 
Tous & 
Busto 

Sensitivity 81.82% 77.8% 
Specificity 96.43% 99.1% 
Accuracy 90.00% - 
Positive predictive value 94.74% 94.9% 
Negative predictive value 87.10% 95.5% 

 
In both of the studies it is obvious that 
transabdominal hydrosonography has high validity 
parameters that make it useful as a diagnostic 
method of gastric carcinoma. 
 
In the present study increase in wall thickness, 
complete loss of wall stratification, luminal 
narrowing and reduced peristalsis was observed in 
all cases of gastric carcinoma. Heterogeneous 
intraluminal masses were seen in 15 out of 18 cases 
(83.33%). Gastric carcinoma presented as 
hypoechoic mural mass in only 5 (27.78%) cases. In 
rest of the cases, gastric wall showed hypoechoic 
intramural infiltration and thickening. Breach of 
serosa was seen in 13 out of 18 (72.22%) cases. In 
two cases of gastric carcinoma, diffuse 
circumferential wall thickening was seen- one was a 
case of scirrhous carcinoma, another gastric 
lymphoma. The sonographic features of gastric 
carcinoma found in this study are similar to that of 
the previous studies.8-10 Transabdominal 
hydrosonography demonstrated exogastric 
extension and distant metastasis of gastric 
carcinoma in 13 patients.   
 
In this study, 4 cases of gastric carcinoma could not 
be diagnosed by transabdominal hydrosonography 
which were subsequently diagnosed correctly by 
histopathology. In one case the tumour was too 
small to be detected by sonography and in three 
cases small tumours located at the fundus and 
gastro-esophageal junction could not be visualized 
by sonography. In our study, most of the cases of 
gastric carcinoma diagnosed correctly by 
hydrosonography were in advanced stage of the 



Diagnostic value of transabdominal hydrosonography in gastric carcinoma 

174 

disease with a relatively large tumour. It is obvious 
that transabdominal hydrosonography can miss 
detection of very small lesions and lesions at certain 
locations e.g. fundus and gastro-esophageal 
junction. 
 
Pancreas is a common organ invaded by gastric 
carcinoma. In this study, metastasis of the pancreas 
was identified in four patients by transabdominal 
hydrosonography. The above four cases of 
metastasis was confirmed at surgery. In addition 2 
patients having pancreatic metastasis undetected by 
transabdominal hydrosonography were detected at 
surgery. In one patient pancreas was invaded 
slightly. In the remaining one, the tail of pancreas 
was invaded which was not detected by sonography 
due to interference of bowel gas and ribs.  
 
Transabdominal hydrosonography failed to detect 
involvement of duodenum seen at operation in two 
patients. Correct diagnosis was made preoperatively 
in 2 of 4 patients with duodenum invasion by 
transabdominal hydrosonography. It is necessary to 
fill duodenum by water for the assessment of 
duodenum. Because tumour caused gastric lumen 
obstruction, duodenum was not filled adequately 
and not visualized clearly leading to misdiagnosis. 
Involvement of the gallbladder and hilum of the 
spleen seen at operation in one patient each was not 
seen preoperatively on sonography. Splenic hilum 
could not be observed completely with 
hydrosonography leading to the detection failure.  
 
In this study liver metastases were seen in four 
patients. Tumours invading liver located in anterior 
wall of stomach or lesser curvature and were close 
to the liver. The relationship between tumour and 
liver could be visualized clearly by using 
ultrasonographic beam through liver without 
interference of bowel gases. Ascites was seen in 
eight patients, only five of these patients had 
presented clinically. 
 
Para-aortic lymphadenopathy was identified at 
sonography in five patients. Very small lymph 
nodes were undetectable with transabdominal 
hydrosonography. In addition, bowel gas was 
unfavorable for detection of lymph nodes.  
 
Thus, though sonography misdiagnosed or 
underdiagnosed the presence and exogastric extent 
of gastric carcinoma in a few cases, it did provide 
accurate diagnosis and a rough estimate of its extent 
in the majority of the cases. The possible reasons 
for misdiagnosis or underdiagnosis were as follows: 

(1) the procedure did not practice adequately, 
because the investigators had limited experience of 
this procedure. (2)The transducers that were 
available and used in this study had frequencies up 
to 7.5MHz. So resolution more than this limit was 
not technically possible. Higher resolution is 
needed for optimal visualization of small lesions. 
(3)  Location of gastric carcinoma also affected the 
diagnosis. Transabdominal hydrosonography may 
fail to correctly diagnose carcinoma located in 
gastric fundus or cardia. Three cases of gastric 
carcinoma not diagnosed correctly by 
hydrosonography in this study were located in the 
above locations. (4) Location of the involved organs 
and size of the metastases also affects the diagnosis 
of exogastric extension. For example, it is difficult 
to clearly visualize the hilum of the spleen and the 
tail of the pancreas by transabdominal 
hydrosonography. Invasions of the tail of pancreas 
in one patient and hilum of the spleen in anther 
were not detected with transabdominal 
hydrosonography in this study. Very small 
metastases were also undetected by 
hydrosonography. Moreover, this study involved 
only a limited number of patients. A larger study 
population could have given more precise results 
regarding diagnostic validity of this method.  
 
Conclusion 

This study concluded that transabdominal 
hydrosonography is a useful diagnostic modality for 
the diagnosis of gastric carcinoma and to asses its 
exogastric invasion and validates the related 
previous study findings regarding its efficacy.  
 

 
Sonograph 1: US image of scirrhous carcinoma 
showing diffuse hypoechoic wall thickening with 
loss of stratification 



AF Rabbi, RN Sarker, A Hossain 

175 

 
Sonograph 2: Ultrasound showing gross 
hypoechoic wall thickening with luminal narrowing 
in the region of the antrum. Serosa appears intact-
carcinoma antrum 
 

 
Sonograph 3: Transverse scans of the fluid filled 
stomach showing hypoechoic circumferential wall 
thickening and loss of wall layers-gastric lymphoma 

 
Sonograph 4: Sonogram of the fluid filled stomach 
showing two heterogeneous intraluminal masses, 
one in the fundus and the other in the antrum with 
complete disruption of wall layering in the region of 
the masses with breach of serosa – carcinoma 
stomach 

 
Sonograph 5: Sonogram of the fluid filled stomach 
showing a heterogeneous intraluminal mass in the 
body with complete disruption of wall layering in the 
region of the mass– carcinoma stomach. Huge 
ascites is also seen 

______________ 



Diagnostic value of transabdominal hydrosonography in gastric carcinoma 

176 

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