PURPOSE: To retrospectively compare the diagnostic accuracy for detecting primary gastric cancer on positron emission tomography/computed tomography (PET/CT) and hydro-stomach CT (S-CT) and determine whether the combination of the two techniques improves diagnostic performance. MATERIALS AND METHODS: A total of 253 patients with pathologically proven primary gastric cancer underwent PET/CT and S-CT for the preoperative evaluation. Two radiologists independently reviewed the three sets (PET/CT set, S-CT set, and the combined set) of PET/CT and S-CT in a random order. They graded the likelihood for the presence of primary gastric cancer based on a 4-point scale. The diagnostic accuracy of the PET/CT set, the S-CT set, and the combined set were determined by the area under the alternative-free receiver operating characteristic curve, and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS: Diagnostic accuracy, sensitivity, and NPV for detecting all gastric cancers and early gastric cancers (EGCs) were significantly higher with the combined set than those with the PET/CT and S-CT sets. Specificity and PPV were significantly higher with the PET/CT set than those with the combined and S-CT set for detecting all gastric cancers and EGCs. CONCLUSION: The combination of PET/CT and S-CT is more accurate than S-CT alone, particularly for detecting EGCs.