Examination of the contents of the duodenum. Membrane potential, its origin

The human body is prone to various diseases. Ailments can affect any internal organ. The duodenum is no exception. The most well-known ailment of this part of the digestive system is peptic ulcer. For many people, it is associated with the stomach, but in fact it is not only associated with it. The duodenum is often involved in the pathological process. What is this ailment? What other diseases can affect the duodenum? Before looking for answers to these questions, it is worth considering the structure of the named section of the digestive system.

The structure of the duodenum

The human digestive system is complex. One of its components is the duodenum. It is considered the initial section in the small intestine. The duodenum originates from and ends with the duodeno-jejunal flexure, which passes into the next section of the small intestine (jejunum).

In the duodenum, several components are distinguished:

• the upper part, the length of which is from 5 to 6 cm;
• the descending part, which is 7-12 cm in length;
• the horizontal part, which is 6-8 cm long;
• ascending part, equal in length to 4-5 cm.

Functions of the duodenum

The duodenum performs several important functions:

1. The process begins here. Food coming from the stomach is brought here to an alkaline pH that does not irritate other parts of the intestine.
2. The duodenum regulates the production of bile and pancreatic enzymes depending on the chemical composition and acidity of the food coming from the stomach.
3. The initial one also performs an evacuation function. From it, the food gruel that came from the stomach is sent to other parts of the intestine.

Some diseases that may be associated with the duodenum 12

One of the diseases that occur in the duodenum is duodenitis. This term refers to inflammatory-dystrophic changes in the mucous membrane. They arise due to the impact on the body of harmful factors: food poisoning, toxic substances that cause poisoning when they enter the digestive system, spicy foods, alcoholic beverages, foreign bodies. With duodenitis, pain is felt in the epigastric region, nausea, vomiting, weakness, body temperature rises.

Diseases of the duodenum also include chronic duodenal obstruction. This is a process that leads to a violation of the passage through the duodenum, i.e., the motor and evacuation activity in this part of the digestive system is disturbed. The disease occurs for many different reasons (for example, the presence of tumors, congenital anomalies, etc.). The signs depend on the causes that caused chronic duodenal obstruction, on the stage of the disease and on how long the duodenum has been affected. Symptoms sick people note in themselves such as discomfort and heaviness in the epigastric region, heartburn, loss of appetite, constipation, murmur and transfusion in the intestines.

Treatment of duodenitis and chronic duodenal obstruction

Treatment of diseases should be prescribed by a doctor. In order for the duodenum to restore its functions during duodenitis, the following measures may be required:

• hunger for 1 or 2 days;
• gastric lavage;
• appointment of a special diet (No. 1, 1a, 1b);
• the appointment of astringents, enveloping, antacid, antispasmodic, anticholinergic, ganglioblocking agents, vitamins;
• in some cases, surgery and antibiotic therapy are required.

In chronic duodenal obstruction, the treatment of duodenal ulcer requires an individual approach. If the disease provoked a mechanical obstruction, then surgical intervention is performed. In other cases, prokinetics may be prescribed. These drugs have a stimulating effect on the muscles of the gastrointestinal tract, increase contractile activity, the tone of the stomach and duodenum, and make the evacuation of gastric contents faster.

What is meant by peptic ulcer?

Considering the ailments of the duodenum, special attention should be paid to peptic ulcer. This term refers to a serious disease that occurs in a chronic form with alternating periods of remission and exacerbation. The etiology of this disease is not well understood. It used to be thought that peptic ulcers were caused by substances such as pepsin and hydrochloric acid, which are produced in the digestive system. However, studies have shown that Helicobacter pylori microorganisms play an important role.

Statistics show that the prevalence is from 6 to 15%. It cannot be said that a representative of a particular sex is sick less often or more often. Men and women are equally susceptible to this disease.

Features of duodenal ulcers

Ulcers are lesions in the duodenum. They can be compared to erosion. However, these two types of damage have significant differences. Erosion affects only the mucous membrane that lines the duodenum. The ulcer penetrates into the submucosal and muscular layers.

Studies show that ulcers in most cases are in the upper part. They are localized near the pylorus of the stomach. The size of the damage varies. Most often there are ulcers in which this parameter does not exceed 1 cm. In some cases, large ulcers are found. Doctors in their practice met with damage to the duodenum, which in diameter reached 3-6 cm.

Clinical manifestations of peptic ulcer

In some people, the disease goes unnoticed, while in others, duodenal ulcer manifests itself with suspicious signs. The most commonly observed symptoms are:

• recurrent pain localized in the upper abdomen;
• digestive disorders;
• deterioration in a sick person's appetite and weight loss;
• tarry stool;
• bleeding that occurs due to the erosion of the walls of the blood vessel by the gastric juice;
• pain in the back (they occur due to the germination of an ulcer in the pancreas);
• intense pain in the abdomen (they are observed when the ulcer is perforated, the development of peritonitis).

Of these symptoms, pain is the most common. By its nature, it is different - sharp, burning, aching, indefinite, dull. Pain, as a rule, occurs on an empty stomach (in the morning after waking up). They can also appear after eating in about 1.5-3 hours. Unpleasant sensations are stopped by antacids, food and even a glass of milk or warm water. The fact is that foods and drinks, when ingested, partially neutralize the effects of hydrochloric acid. However, after a short period of time, the pain resumes again.

Diagnostic procedures for peptic ulcer

The diagnosis of "duodenal ulcer" cannot be made on the basis of only one symptom and an external examination of a sick person, because the above signs are characteristic of a wide list of diseases. Behind the listed symptoms, not only a duodenal ulcer can be hidden, but also cholelithiasis, pancreatitis, benign tumors, etc.

A suitable and reliable method for diagnosing peptic ulcer is fibrogastroduodenoscopy. During this study, a special instrument with a light source and a camera is inserted through the mouth into the stomach to examine the lining of the digestive system. The image is formed on the monitor. The doctor evaluates the stomach and duodenum. Diseases are diagnosed by noticeable pathological changes. If necessary, the specialist takes a sample of the mucous membrane for examination for the presence of microorganisms that provoke the occurrence of peptic ulcer.

Drug treatment of duodenal ulcer

A peptic ulcer can be treated with medication or surgery. In the first method, sick people are prescribed drugs that neutralize hydrochloric acid. They are called antacids. Medicines that help suppress the production of hydrochloric acid in the human body also help with illness. For example, omeprazole may be prescribed.

If during the diagnosis Helicobacter pylori microorganisms are detected, then it is possible to prescribe a three-component therapy. "Omeprazole" or "Ranitidine" are prescribed in combination with antibiotics ("Amoxicillin" and "Clarithromycin").

Surgery for peptic ulcer

When a duodenal ulcer is diagnosed too late, surgical treatment is prescribed. It is carried out under certain indications:

• with perforation of an ulcer or heavy bleeding;
• frequent exacerbations of the disease that occur despite ongoing drug treatment;
• narrowing of the outlet section of the stomach, which arose due to cicatricial deformity of the duodenum;
• chronic inflammation that is not amenable to ongoing drug therapy.

The essence of surgical treatment is to remove. During the operation, that part of the internal organ that is responsible for the secretion of gastrin in the body is excised. This substance stimulates the production of hydrochloric acid.

In conclusion, it is worth noting that if you experience suspicious symptoms characteristic of diseases of the duodenum, you should seek help from specialists in the clinic. Self-medication for ailments is inappropriate, because improper drug therapy, its absence or unnecessary folk remedies can cause serious harm to your body, worsen your well-being.

The main signs of duodenostasis during fluoroscopy are: a) retention of a contrast suspension in the duodenum; b) violation of normal pendulum and peristaltic contractions; c) expansion of the intestine.

In the light of the above data, it can be considered that the retention of a contrast suspension in the duodenum for more than 30 seconds, the presence of enhanced antiperistaltic movements, or complete adynamia are radiological signs of duodenal stasis. In some cases, these disorders are combined with marked ectasia and atony of the intestine.

There are partial and total duodenal stasis, each of which can be hypotonic or spastic type.

Despite the well-studied radiological signs of duodenal stasis, most authors draw attention to the common difficulties in making a diagnosis and identifying the true state of duodenal motility. So, according to N. N. Elansky, on the basis of an X-ray examination, an accurate diagnosis is detected in no more than 1/3 of all cases, even by specialists who have experience in diagnosing this disease. It is emphasized that the x-ray pattern of duodenal patency largely depends on the research methodology, the period of the disease, and also on the stage of duodenal stasis. The difficulty of detecting this disease also depends on the intermittent nature of the suffering.

The cause of duodenal stasis on the basis of x-ray data is also difficult to establish. Fournier and Guien, Mizray noted that with a functional form of duodenal stasis, antiperistaltic bowel movements will be less pronounced than with mechanical function. According to Daumerie and Keerle, out of 30 patients studied in 11 people, in whom the mechanical cause of duodenostasis was assumed to be a mechanical cause of duodenostasis during the operation, no mechanical obstacles were found during the operation.

Ducasse recommended the use of drug blockade of the sympathetic nerves to differentiate between the functional and organic form of duodenal stasis. With functional forms of duodenal stasis, according to his data, after the blockade, the obstruction is eliminated.

The most variable are x-ray data in the arteriomesenteric form of duodenostasis. According to most radiologists, the intermittent nature of obstruction is typical for the arteriomesenteric form of duodenostasis. Radiologically, it is possible to make a correct diagnosis only during an attack of the disease, and between attacks, changes in the motor-evacuation activity of the duodenum can not be established.

According to A. V. Efremov and K. D. Eristavi, in the case of chronic arteriomesenteric obstruction, X-ray examination in a vertical and horizontal position on the back clearly shows the place of compression of the lower horizontal part of the duodenum along the break of the contrast mass on the line of the spine. When laying the patient on the stomach or in the knee-elbow position, the contrast mass quickly fills the lower horizontal part of the intestine to the end and passes into the jejunum.

Evaluation of the motor function of the duodenum can be more reliably and documented using X-ray cinematography.

Licht studied 21 patients with duodenal dysmotility, sometimes accompanied by duodenal ectasia, using conventional x-ray and radiographic cinematography. He notes that in cases where, during a conventional X-ray examination, it was possible to assume the organic nature of intestinal motility disorders, this suspicion was excluded with X-ray cinematography. Based on the data obtained, the author comes to the conclusion that the X-ray cinematographic method of research is more accurate and reliable.

I. A. Shekhter and P. A. Rabukhina revealed some deviations from the duodenum in 42 people during a routine x-ray examination of 108 patients with various diseases of the digestive system. At the same time, in the study of the same patients, X-ray cinematography using an electronic optical transducer, changes in the motor function of the duodenum in the form of dyskinesia or duodenostasis phenomena were detected in 94 people.

We performed X-ray examination in 322 patients. At the same time, in 16 patients, along with the usual study, the study of duodenal motility was performed using an electron-optical converter and cinematography.

In 8 patients who were operated on for emergency indications, X-ray examination was not performed.

Existing ecstasy of the duodenum with stagnant contents in its lumen was not diagnosed in 14 patients during X-ray examination. This applied to 12 patients in whom duodenostasis was in the stage of compensation or subcompensation, or in which the study was carried out in the calm stage. Changes in the duodenum, characteristic of duodenostasis, were detected in these patients during surgery performed with various preoperative diagnoses. In 2 patients, the radiologist made a conclusion about the stenosis of the outlet section of the stomach. During the operation, it turned out that the stenosis was due to the annular pancreas and led to duodenal ecstasy.

Among 90 patients with peptic ulcer in combination with duodenostasis, who underwent X-ray examination, the correct diagnosis of such a combination was established only in 52. In one patient, a conclusion was made about the combination of a duodenal diverticulum with duodenostasis, and in another - a combination of a tumor with duodenostasis ( with an ulcer). We will give an observation of the correct conclusion of the radiologist about the combination of an ulcer with duodenal stasis.

Patient V., aged 19, has been suffering from peptic ulcer for many years. Recently there was vomiting with an admixture of bile after eating. Nutrition reduced, pale. The conclusion of the x-ray examination: duodenal ulcer; pronounced hypotonic duodenostasis with ectasia and prolonged barium stagnation in the intestinal lumen for an hour of observation.

The operation revealed a callous ulcer of the duodenum with penetration into the head of the pancreas and stenosis of the exit from the stomach. In the submesocal region, the duodenum is 8 cm wide, protrudes from under the mesentery of the transverse colon, is atonic, and there is congestive bile in its lumen. There are no mechanical obstacles in the way of bile. The stomach is ectatic. Performed resection of the stomach to turn off with additional duodenojejunostomy. A PVC tube was inserted through the nose into the duodenum.

The postoperative course is smooth.

In 12 patients, the conclusion was given only about duodenostasis, and the existing ulcer was not detected. In these patients, duodenostasis was of short duration, was not accompanied by intestinal ectasia, and was partial and hypotonic. Taking into account the clinical picture in some patients, an assumption was made about the ulcerative nature of the disease, for which conservative treatment was carried out. A second x-ray examination revealed a duodenal ulcer.

In 24 patients who had a combination of ulcers with duodenostasis, the latter was not detected by x-ray examination. The most explainable is the underestimation of the motor-evacuation activity of the duodenum in 12 patients with stenosis of the gastric outlet of the ulcerative nature. As a result of the existing stenosis, the assessment of the condition of the duodenum was difficult or impossible. In the rest of the patients, duodenostasis was in the stage of compensation, and the study was carried out during the period of remission, therefore, radiographic signs of existing stasis were not detected. Duodenal ecstasy has been identified during surgery for gastric or duodenal ulcers.

Among the patients suffering from cholecystitis (53 people), pancreatitis (47), chronic gastritis (33), an X-ray examination revealed duodenostasis, to varying degrees, in the vast majority. It was of a short duration and was of a partial, hypotonic type. It should be noted that in these patients, a violation of the motor-evacuation activity of the duodenum was detected in the stage of exacerbation of the main process. When the inflammatory changes caused by the underlying disease subsided (after appropriate conservative measures), the motor-evacuation activity of the duodenum was restored. Only among patients with a long history of suffering and frequent attacks was persistent duodenostasis with duodenal ectasia.

We present an observation of a patient in whom an x-ray examination revealed a persistent form of duodenostasis in chronic pancreatitis.

Patient C, aged 50, has been suffering from abdominal pain for many years. Over the past year, the attacks of pain have become more frequent. X-ray examination revealed hypotension of the stomach; the contrast suspension lingers for a long time in the lower horizontal part of the duodenum, which is significantly dilated and atonic.

During the operation, along with chronic pancreatitis, significant ectasia and atony of the duodenum with the presence of stagnant contents in its lumen were revealed, for which the corresponding operation was performed.

Among 28 patients with tumor lesions, of particular interest is the duodenal stasis revealed during X-ray examination in 3 people suffering from stomach cancer. This concerned two patients with localization of cancer in the cardial section of the stomach and one - in the pyloroanthral section. In these patients, during the primary X-ray examination, only the presence of hypotonic duodenostasis was stated. However, taking into account the clinical picture, it was suspected of a cancerous lesion of the stomach as the root cause of duodenostasis. In one patient, this was confirmed during a repeated and targeted study, and in 2 during surgery. V. S. Levit drew attention to the possibility of duodenostasis in cancer of the cardia. He considered it necessary to exclude cancer of the cardia in all cases of identified duodenostasis.

In 14 patients suffering from cancer of the stomach (2) and pancreas (12), X-ray examination gave a correct assessment of the existing pathology. In 4 people, as a result of stenosis of the exit from the stomach, the assessment of the state of the motor-evacuation activity of the duodenum was not given. Existing changes were identified during the operation, when examining the horseshoe of the duodenum.

In X-ray cinematography of 16 patients, in 12 data from the study of duodenal motility corresponded to the results of conventional X-ray examination.

In 4 patients, cinematographically with the use of an electron-optical transducer, variously expressed disturbances in the motility of the duodenum were revealed, which was not noticed during conventional fluoroscopy. In 2 patients, a mechanical cause of duodenal stasis was established.

Here is one observation of persistent duodenal stasis, filmed on video.

Patient K., aged 40, has been suffering from dyspeptic disorders and aching pains in the epigastric region for 5 years, sometimes vomiting of bile. Nutrition reduced, asthenic physique. An x-ray examination revealed total hypotonic duodenostasis with prolonged stagnation of a contrast suspension in the intestine. X-ray cinematography data: the loop of the duodenum is stretched throughout, atonic, its mucosa is changed, the folds are edematous. During the study, deep peristalsis and antiperistalsis are observed. In the future, peristaltic activity fades, and the contrast mass settles in the expanded lower horizontal part of the intestine, forming a horizontal fluid level. Part of the contrast mass enters the loops of the jejunum and ileum, the passage through which is not disturbed. There is no data for mechanical obstruction.

Conclusion: total hypotonic duodenostasis of non-mechanical nature with significant intestinal ectasia.

During the operation, it was found that the duodenum, 12 cm wide, was atonic, with stagnant contents in its lumen. The intestinal wall is thinned. The pyloric sphincter gapes, the width of the pylorus is 6 cm. The gallbladder is in adhesions, it is hardly emptied. The pancreas is hardened. There are no mechanical obstructions throughout the duodenum. A vinyl chloride probe is inserted into the lumen of the duodenum, which is brought out through the nose. Within 12 days, the duodenal contents were evacuated through the probe.

The postoperative course is smooth. Monitoring the patient's condition after 3 years. Periodically worried about belching, and sometimes pain in the epigastric region. An X-ray examination revealed a delayed function of the duodenojejunostomy.

In the vast majority of patients, duodenal stasis was of a hypotonic type, partial (189 people) and less often total (63). Only 18 people had spastic type duodenal stasis. This concerned patients with an organic disease of the pancreatoduodenal zone, studied in the period of exacerbation. Their duodenal stasis was of a functional nature and existed for a short time.

Summing up the results of X-ray examination of patients with various types of duodenal stasis, we can conclude that, despite the well-developed methodology for this study of the duodenum, the correct identification of the true state of its motor-evacuation function and the presence of anatomical measurements in it is not always easy. This largely depends on the research methodology, as well as on the period of the disease (exacerbation or calm), the stage of duodenal stasis (compensation or decompensation).

In the presence of symptoms of duodenostasis, some authors consider it important to confirm or exclude the arteriomesenteric cause of obstruction to examine the patient in the knee-elbow position. Goin and Wilk for the same purpose recommend that the study be performed in the "legs to the chest" position (which causes pressure on the lower abdomen).

In case of clinical suspicion of a violation of the motor-evacuation activity of the duodenum, during an X-ray examination, attention should be paid to: 1) the state of the tone of the stomach, the strength of its peristalsis and size, the function of the pyloric sphincter and the beginning of evacuation from the stomach into the duodenum; 2) on the state of the horseshoe of the duodenum (its tone, the strength of peristalsis and antiperistalsis, the size of the intestine, etc.).

When duodenal stasis is detected, one should not forcibly push the contrast suspension, but it is necessary to monitor how it moves independently. In this case, the study of the patient must be carried out not only in a vertical position, but also in various positions of a horizontal position (on the back and on the stomach). This is especially important for the differential diagnosis between the arteriomesenteric form of duodenal obstruction and its other variants.

In cases where there was a suspicion of the presence of duodenal stasis, but it was not detected during the initial study, it is rational to repeat x-ray and it is best to do this in the acute stage (attack). It must be borne in mind that in the initial stage of duodenostasis (stage of compensation) and in the period of remission, radiological signs of dysmotility may be absent or only increased peristalsis of the stomach and duodenum will be observed while maintaining the passage of a contrast suspension through it. In the stage of exacerbation of the process, signs of impaired motility of the duodenum are usually detected. Initially, this is manifested by more active peristalsis of the stomach and duodenum, in which the peristaltic wave reaches the duodenal angle (place of physiological obstruction), and enhanced antiperistalsis appears, sometimes with barium reflux into the duodenal bulb. A little earlier, the reserve capacity of the duodenum is depleted. With the continued impact of the pathological agent on its wall, its contractility weakens and the intestine begins to expand. On x-ray examination, this manifests itself in a more weakened peristalsis of the intestine and antiperistalsis, ectasia and accumulation of barium in its lower horizontal part. Over time, one can note the depletion of reserve capacity and the stomach. If at first its active peristalsis is observed with preserved tone and size, then in the future it also expands and the activity of its contractions weakens (the stage of sub- and decompensation).

In the initial stage, the pyloric sphincter is spasmodic, and in the stage of sub- and decompensation, it gapes. X-ray examination in such cases, there is a reflux of barium from the duodenum into the stomach. A picture of gastritis and duodenitis develops (swelling of the folds and their smoothness).

However, it should be noted that the reserve capacity of the stomach is much greater than that of the duodenum. Therefore, in x-ray examination, it is often possible to see that in the presence of persistent and pronounced atony and ectasia of the duodenum with prolonged stagnation of the contents of the stomach in it, the stomach can be little changed and its contractile ability is preserved. In such cases, due to the active contractile activity of the stomach, the passage of the contents through the duodenum is carried out. Only in the future, with the depletion of the reserve capacity of the stomach, does its ectasia develop.

In connection with the development of X-ray cinematography, it became possible to clarify to a higher degree the nature and nature of the motor-evacuation activity of the duodenum and to shoot the whole process on film. The study is performed using an electron-optical converter by transilluminating the patient in an upright position without the use of palpation and compression.

The study of the motor function of the duodenum and the afferent loop in patients who underwent resection of the stomach according to Billroth II presents certain difficulties. During an x-ray examination, the patient is given a barium suspension, and its passage through the gastroenteroanastomosis is studied. Sometimes even with such a study, the passage of a contrast agent into the afferent loop of the jejunum and even into the duodenum is observed. In cases where the barium suspension does not enter the afferent loop, the outlet loop can be blocked by introducing a probe with a rubber balloon at the end into it through the mouth and stomach. After getting into the outlet loop, this balloon is inflated, the patient is given a contrast suspension, and then it is possible to trace its gradual passage into the afferent loop and the duodenum.

Kajas to study the state of the duodenum in patients who underwent resection of the stomach according to Billroth II, performs an X-ray examination of the patient in the supine position. After taking barium, the patient gradually turns to the right side so that the barium passes into the afferent loop and duodenum. In addition, Kajas introduces the tube into the stomach and, by manipulating it, tries to insert it into the afferent loop. Thanks to this technique, he managed to get a good and satisfactory visibility of the afferent loop and duodenum in 74.5%.

To assess the functional activity of the duodenum and afferent loop in patients who underwent resection of the stomach according to Billroth II, we examined the patient both in a vertical and horizontal position and in various positions. With such a study, in many cases it is possible to direct the barium suspension into the afferent loop and the duodenum and trace its evacuation from there. In difficult cases, we introduced a probe with a balloon into the stomach and, when it passed into the outlet loop of the intestine, inflated it. After that, the patient was given a contrast suspension and sent it to the afferent loop.

Among 60 patients who underwent resection of the stomach or gastroenteroanastomosis with clinical signs of afferent loop syndrome in the past, in whom X-ray examination was performed, the diagnosis was confirmed in 49 patients. At the same time, in 26 of these 49 patients, it was radiologically established that the contrast suspension passed from the stomach not only into the outlet loop of the anastomosis, but also into the adductor, and in 16 - even into the duodenum and lingered there. In 7 patients, a “vicious circle” was observed, i.e., a contrast suspension from the outlet loop passed through the existing interintestinal fistula into the afferent loop and again entered the stomach stump or (in the presence of gastroenteroanastomosis) from the stomach passed into the duodenum and returned through the existing gastroenteroanastomosis into the stomach.

In 11 patients with a clinical picture of the afferent loop syndrome, X-ray examination revealed no pathology. Diagnosis of the disease in such cases was based on the history and clinical picture. During the operation undertaken in all these patients, the diagnosis was confirmed. The adductor loop and duodenum were dilated, edematous and contained congestive bile in their lumen.

Duodenography. Due to the fact that it is not always possible to get a correct idea of ​​the existing changes in the duodenum and its motor activity with a conventional x-ray examination, duodenography (without hypotension) has been used, which excludes the effect of contractions from the stomach and allows you to establish only the contractility of the duodenum. In this case, the response of the duodenum to the introduction of the probe in the form of some increase in its tone will not have a significant impact on the result of the study.

Pribram and Kleiber used duodenography in combination with the introduction of a contrast suspension and air. They believed that air should hold the contrast mass in the duodenum, blocking entry and exit from it. However, S. G. Moiseev and A. P. Ivanov, using this technique, came to the conclusion that it has no advantages over other research methods.

A. D. Slobozhankin et al. give a positive assessment of duodenography without hypotension for the study of patients with duodenal stasis.

Using this method, they studied the nature of duodenal peristalsis in patients, the rate of its evacuation and the duration of the retention of a contrast suspension in it. According to the data of duodenography, they were able to ascertain, in the presence of duodenostasis, pronounced disorders of the motor activity of the duodenum, which manifested themselves in the form of a different duration of delay of the contrast agent in the intestinal lumen.

To study a number of patients, we also used duodenography without hypotension. In this procedure, the attending physician must necessarily take part together with the radiologist. A probe with an olive is passed through the mouth into the initial section of the duodenum, and through it, using a funnel or Janet syringe, a liquid, well-mixed and warm suspension of barium in the amount of 20-30 ml is slowly, without any pressure, introduced into the intestinal lumen. Thanks to this method of introducing a contrast suspension, the possibility of an active increase in pressure in the duodenum is excluded. At this moment, the true dimensions of the duodenum are established and the time of the release of the suspension into the initial part of the jejunum is fixed. Subsequently, another 100 ml of a contrast agent is injected, after which the probe is removed and the tone of the duodenum, its peristalsis, size and nature of evacuation are monitored. All changes during the study are recorded on x-ray film.

Along with duodenography without hypotension, duodenography in a state of artificial hypotension has become much more widespread and is successfully used. With the help of this method, the condition of the mucous membrane of the duodenum, its folds is assessed, an organic disease of the duodenum is detected, differentiation is made between the organic and functional causes of patency disorders, and the condition of the major duodenal papilla and pancreas is assessed. With this method, with the help of pharmacological agents, the tone of the duodenum is reduced and an artificial stasis is created, after which 200 ml of a warm contrast suspension is introduced into the intestinal lumen through a probe, and the intestine is examined with tight filling. Then part of the contrast suspension is aspirated, and air is introduced into the duodenum to reveal the "pneumorelief" of its mucous membrane.

The study of the duodenum and conditions of artificial hypotension was first made by G. I. Varnovitsky and V. V. Vinogradov. And in 1961, P. I. Rybakova and M. M. Salman published their modification of this method, and in 1963 - L. I. Dobychina.

N. A. Rabukhina and M. M. Salman, in a monograph devoted to duodenography in a state of artificial hypotension, specifically assessed the value of this method for recognizing extra-bulbous constrictions, anomalies of the duodenum, as well as for diagnosing arteriomesenteric obstruction. According to their data, among 7 patients with duodenostasis, 3 patients with conventional X-ray examination did not reveal any pathology. The diagnosis was confirmed by duodenography. These authors draw attention to the fact that in patients with chronic arteriomesenteric obstruction, duodenography reveals an elongated intestine with an increased diameter; at the left edge of the spine, they saw a narrow band of enlightenment, up to 1 cm wide, with smooth outer borders. When filling the intestine through the probe, a long delay of the contrast agent was observed at the right border of the area of ​​enlightenment.

Sometimes the contrast agent passed through the intestine only in the position of the patient on the stomach. The degree of filling with a contrasting suspension of the intestine changed with a change in the position of the patient.

While agreeing with the conclusion about the usefulness of duodenography with artificial hypotension for assessing the state of the mucosa and for differential diagnosis of the nature of duodenal narrowing, it should still be noted that it is not always easy to identify the band of enlightenment in the intestine at the left edge of the spine (which the authors write about).

With the help of probe duodenography, we studied 52 patients with various types of impaired motor-evacuation activity of the duodenum. In 27 patients, duodenography was performed without the use of artificial hypotension, and in 25 patients - in a state of artificial hypotension.

Among 27 patients who underwent duodenography without artificial hypotension, duodenostasis detected during conventional fluoroscopy was confirmed in 17 patients.

At the same time, in some patients it was possible to establish that the duodenum is atonic, ectatic, its contractile ability is sharply weakened or not observed at all. The barium introduced into the intestine accumulated in its lower horizontal part, which sagged. For a long time there was no evacuation of barium from the duodenum.

This picture was most often observed in patients with a pronounced stage of duodenostasis (sub- and decompensation) and with congenital anomalies in the development of the duodenum (megaduodenum). Here are the data of duodenography of the patient K. Diagnosis: megaduodenum.

In 10 patients with the initial stage of duodenostasis, especially as a concomitant condition of another disease, with the introduction of barium into the lumen of the duodenum, duodenostasis was noted for various periods of time: from several minutes to 30-40 minutes of the study, after which the contrast suspension passed into the jejunum. In these patients, bowel tone was preserved.

In 10 patients, the duodenostasis revealed by roentgenoscopy was not confirmed by duodenography. After the introduction of barium, its rapid evacuation was noted. The bowel tone was preserved or the bowel was somewhat spasmodic. This most often concerned patients with the initial stage of development of duodenal motility disorders.

We performed duodenography in a state of artificial hypotension according to the method recommended by L. I. Dobychina. For this purpose, 30 minutes before the study, the patient is injected with 1 ml of a 0.1% solution of atropine, and using a probe, 15-20 ml of a 2% solution of novocaine is injected into the duodenum, and then after 15 minutes - a heated suspension of barium, after which it begins x-ray observation.

In the study of the duodenum in the state of its artificial hypotension in 25 patients, we were able to assess the state of its mucous membrane, as well as to identify the interest of the pancreas.

In 4 patients, using duodenography in a state of artificial hypotension, the alleged mechanical cause of duodenostasis was excluded, and in 3 patients it was confirmed that it was caused by a mechanical obstruction.

Our data indicate that the use of duodenography without artificial hypotension is effective for assessing the motor activity of the duodenum only in the pronounced stage of duodenostasis (the stage of sub- and decompensation), while in the initial stage, especially if the stasis is of reflex origin, based on the data duodenography without hypotension may not reveal any signs of dysmotility.

Duodenography in a state of artificial hypotension allows assessing the condition of the duodenal mucosa, its folds, as well as making a differential diagnosis between the mechanical and functional forms of duodenostasis. With duodenography in a state of artificial hypotension, it is possible to identify the interest of the pancreas.

According to statistics, about 5% of people annually seek help for peptic ulcer. In most patients, the clinic proceeds classically, but along with this, there are erased forms of gastric and duodenal ulcers.

Manifestation of pathology

Patients, as a rule, begin to sound the alarm when a severe pain syndrome appears. Depending on the location of the mucosal defect, pain can be early, hungry, nocturnal, late, and in some cases not at all associated with food intake. This is due to the direct action of chyme on the ulcer of the duodenum and stomach. The damaged mucosa is additionally irritated by the motility of the organs during the advancement of the food bolus.

Characteristics of the pain syndrome

Pain is described with different intensity and color. There may be cramping or constant discomfort from the epigastric zone of the abdomen. The feeling is described as something squeezing, stabbing, cutting, squeezing the epigastrium.

In the presence of an ulcer in the cardial part of the stomach, pain can radiate to the sternum, to the shoulder, to the left side of the chest, simulating angina pectoris. This localization of pathological changes is characterized by the development/intensification of symptoms no more than 30 minutes after saturation with food.

After 1-1.5 hours, signs of an ulcer of the stomach and duodenum appear, the symptoms may include vomiting at the peak of abdominal pain. The disease is accompanied by constipation. If a deep defect is located on the back wall of the stomach, pain can be given to the back and lower back. In such a situation, women are suspected of problems in the gynecological field.

Ulcerative lesions of the duodenum in isolation are not so common. At the same time, the pain symptoms of the pathology of the bulbar and postbulbar regions differ. Signs of a duodenal ulcer in the region of the bulb are somewhat erased, pain does not depend on meals, can be permanent, localized in the right side of the epigastrium, radiating to the umbilical region and chest on the right. Ulceration of the mucosa outside the bulb can be determined due to the appearance of more intense pain after a couple of hours after eating and disappearing only after 20 minutes from satisfying hunger.

Up to a quarter of all clinical cases, a combination of localization of deep defects is determined. In this regard, in 6-25% of patients it is possible to identify the polymorphism of the pathology and the absence of a specific rhythm of pain.

Additional signs of gastric and duodenal ulcers

Together with the pain syndrome, dyspeptic phenomena are of some importance:

• nausea;
• vomit;
• heartburn and belching;
• constipation.

How to test assumptions?

Diagnosis of gastric ulcer, bulbar and extrabulbar duodenal ulcers includes the collection of information about the prescription of the condition, heredity, examination by a specialist, instrumental and laboratory studies. The therapist or gastroenterologist, performing a manual examination of the abdomen, identifies areas of maximum pain, is determined with a preliminary diagnosis and further diagnostic search.

The main methods by which you can diagnose diseases of the duodenum and stomach include:

• endoscopy (FGDS);
• x-ray;

FGDS

Fibrogastroduodenoscopy is a technique that allows you to visually examine the mucous membrane of the digestive organs of the upper part of the abdominal cavity from the inside. This study is extremely important for diagnosis. Thanks to FGDS, the doctor can determine the length of the area covered with ulcers, take material for analysis for helicobacter pylori and biopsy. In addition, in the presence of bleeding, endoscopy can really be transferred to the category of medical manipulations (drug instillation, coagulation).

Important! Endoscopic diagnosis of gastric ulcers is strictly required for suspected malignant degeneration of cells. If malignancy is detected, the patient is examined and subsequently treated by an oncologist.
If it is impossible to conduct EGD, the patient is prescribed alternative diagnostic methods.

Beam methods

Fluoroscopy / radiography of the stomach and duodenum is performed using a contrast agent. With the help of x-rays, the following signs of this pathology are revealed:

• symptom of "niche" (due to filling the bottom of the ulcer with contrast);
• convergence of folds to the center of the defect;
• inflammatory shaft around the ulcer (due to tissue edema);
• increase in fluid volume;
• radiographic symptoms of pyloric stenosis, scarring;
• motor-evacuation dysfunction.

Diagnosis of stomach ulcers by ultrasound is not very informative. Allows you to evaluate mainly the thickness of the walls of the body, the presence of fluid levels, peristalsis. The duodenum is more difficult to explore in this way.

The advantage of ultrasound is the ability to make a conclusion regarding the state of the liver, the morphology of the bile ducts and pancreas, which can be initially affected or secondarily after the stomach and intestines. In such a case, along with manifestations of peptic ulcer, disorders of the glands of the digestive system are noted.

Thus, the diagnosis of gastric ulcer is primarily based on the endoscopic picture of the disease and clinical symptoms. Ultrasound can differentiate some conditions and is an auxiliary method. X-ray of the stomach and duodenum confirms the diagnosis in case of contraindications to FGDS.

Laboratory methods

If a peptic ulcer is suspected or detected, the patient is prescribed blood tests (clinical, biochemical and for antibodies), urine, feces. The presence of anemia indirectly confirms the fact of bleeding. A positive Gregersen test indicates the presence of a bleeding vessel in the gastrointestinal tract.

For a complete diagnosis, it is possible to use various tests for Helicobacter pylori. The most famous is the breath test. The patient is given to drink a special solution with carbamide. Then, using an indicator in the exhaled air, the concentration of substances metabolized by Hp is estimated.

Complicated course

The formation of the adhesive process and the malignancy of the ulcer are chronic. In such cases, the symptoms progress gradually and for a long time. Dyspeptic manifestations are aggravated.

Diagnosis of a duodenal ulcer should be carried out as soon as possible with the development of a clinic of an acute abdomen, massive bleeding, vomiting of clotted blood of the color of "coffee grounds", black stools. The patient is urgently taken to the surgical hospital, where immediate treatment is carried out.

Where is it located and what are its main functions?

1 Structure and functions of the body

The duodenum has 4 sections:

The upper horizontal section of the intestine is considered the initial and is a continuation of the pylorus. The upper section has a round shape, and therefore it is also called an onion. Its length is 5-6 cm. The descending section, whose length is 7-12 cm, is located near the lumbar spine. It is in this section that the ducts of the stomach and pancreas are removed. The length of the lower horizontal section is about 6-8 cm. It crosses the spine in the transverse direction and passes into the ascending section. The ascending part is 4-5 cm long. It is located on the left side of the spinal column.

The duodenum is located within the 2-3 lumbar vertebrae. Depending on the age and weight of the person, the location of the intestine may vary.

The duodenum performs secretory, motor and evacuation functions. The secretory function is to mix the chyme with digestive juices that enter the intestine from the gallbladder and pancreas. The motor function is responsible for the movement of the food gruel. The principle of the evacuation function is to evacuate the chyme to the subsequent sections of the intestine.

2 Causes of pathology

Inflammation of the intestine, as a rule, occurs against the background of gastrointestinal disorders. Causative factors include a viral infection, inflammation of the lining of the stomach or gallbladder, diarrhea, and low blood flow to the intestines.

Inflammation of the intestine is often caused by an infection with Helicobacter pylori. This bacterium is in the stomach and does not manifest itself in any way. Its presence in the body leads to increased production of gastric acid, which further irritates the duodenal mucosa. Left untreated, the bacterium can cause intestinal ulcers.

Diseases of the duodenum can develop against a background of severe stress or surgery. In some cases, non-steroidal anti-inflammatory drugs (NSAIDs), smoking, or excessive alcohol consumption may be the underlying cause.

Inflammation of the duodenum 12 can be caused by food poisoning, eating spicy or fatty foods, as well as a foreign object. It has been proven that some pathologies of the intestine can be hereditary. Pathogenic factors such as diabetes mellitus and cholelithiasis are capable of causing the development of duodenal disease.

Symptoms of duodenal disease have their own clinical picture and may differ from each other.

3 Peptic ulcer

A characteristic symptom of peptic ulcer is indigestion. The patient has frequent and loose stools. Often, patients have a complete intolerance to dairy products and fruits. If the patient has a sharp weight loss in the presence of increased appetite, then this may indicate that the duodenum is inflamed.

If ulcers have affected an organ such as the duodenum, symptoms of the disease may appear in a characteristic yellow coating on the tongue. This is due to spasms of the bile ducts, which lead to stagnation of bile. In the advanced stages of the disease, pain appears in the right side and the skin acquires a yellow tint.

With a duodenal ulcer, cicatricial changes in the stomach occur, which as a result leads to the evacuation of food. Congestion in the stomach leads to nausea and vomiting. Often, after vomiting, the general condition of the patient improves for a while.

Pain is a characteristic symptom of peptic ulcer disease. It can be aching or sharp, prolonged or paroxysmal. As a rule, the pain subsides after eating, which is why they are also called "hungry." This symptom occurs in 70-80% of patients. The pain is felt most often in the lumbar or thoracic region. In some cases, patients with duodenal ulcer may complain of pain in the collarbone.

4 Colon cancer and duodenitis

If a patient has been diagnosed with colon cancer, the symptoms of the disease may manifest as jaundice, fever, and itching. With first-degree cancer, there is pain. It occurs as a result of compression of the nerve fibers by the tumor or blockage of the bile duct. The pain syndrome is most often felt in the right hypochondrium, but in some cases the pain can spread to other organs.

One of the symptoms of the disease is itchy skin. It appears due to the high content of bilirubin in the blood and irritation of skin receptors with bile acids. Against the background of itching, the patient develops agitation and insomnia.

No less common disease of the duodenum is duodenitis. This ailment manifests itself in the form of distension of the stomach after eating, dull and constant pain, nausea, loss of appetite, vomiting. In patients with this diagnosis, palpation of the epigastric region is painful.

5 Proper nutrition

For any of the diseases of the duodenum, the patient is prescribed a diet. The diet in combination with complex treatment eliminates exacerbations and significantly improves the general condition of the patient. If the duodenum is inflamed, then, first of all, foods that can stimulate the production of gastric acid are excluded from the diet. Such foods include sour fruits, fatty broths, fresh vegetable and fruit juices, mushrooms, smoked, salted, fried and pickled foods, and spices. Sweet carbonated and alcoholic drinks are also prohibited.

The menu should contain easily digestible fats, such as vegetable oil, cream or margarine.

It is necessary to limit the intake of products that in any way irritate the mucous membrane. In order to avoid overloading the stomach and exacerbating the disease, it is not recommended to eat cold or hot dishes. Food should be at room temperature.

It is forbidden to eat foods that have mechanical irritation. These foods include raw vegetables and fruits, beans, peas, and whole grains. With inflammation of the duodenum, doctors recommend excluding mustard, vinegar, salt and other seasonings from the diet.

Meals should be frequent. You need to eat about 4-5 times a day. Between meals should be at least 3-4 hours. Preference should be given to dishes cooked in boiling water or steamed.

6 Treatment activities

Symptoms and treatment of duodenal pathologies are determined by the doctor after an appropriate examination. If the diagnosis confirmed peptic ulcer, then the patient is prescribed medication. To destroy the Helicobacter pylori bacteria, the patient is prescribed a course of antibiotics. These drugs include Erythromycin, Clarithromycin, Metronidazole and Ampiox.

To reduce the production of hydrochloric acid, doctors prescribe Omeprazole, De-Nol and Ranitidine.

These drugs also have a bactericidal effect. For severe pain, doctors prescribe antacids.

Surgical treatment of duodenal ulcer is quite rare. Indications for surgery are complications of the disease. In this case, during the operation, the surgeon can remove the affected area of ​​​​the intestine, this helps to reduce the production of secretion and the level of hydrochloric acid.

Treatment of patients with a diagnosis of duodenal cancer is carried out with the help of surgery. The type of operation is chosen depending on where the malignant tumor is located and at what stage of development the disease is. A small tumor is removed laparoscopically, that is, through minimal punctures in the abdominal wall. If the tumor is large, then it is removed by extensive surgery. In this case, the doctor removes the outlet section of the stomach and the omentum adjacent to it, part of the duodenum, gallbladder and head of the pancreas.

If a malignant tumor was diagnosed at a late stage, then this greatly complicates the operation. In this case, the surgeon removes not only the tumor, but also the affected lymph nodes and adjacent tissues.

In addition to surgical treatment, the patient is prescribed radiation and chemotherapy. Such treatment helps prevent relapses and prolongs the life of the patient.

Patients diagnosed with duodenitis are prescribed medication and physiotherapy. In acute or chronic duodenitis, doctors prescribe painkillers: Drotaverine, No-shpu and Papaverine. To reduce the level of acidity of gastric juice, antacid drugs are prescribed, such as Omeprazole or Almagel.

If duodenitis has developed against the background of helminthic invasion, then treatment is carried out with antibiotics. To normalize the work of the intestine, drugs are prescribed that enhance its peristalsis. These drugs include Maalox and Domperidone.

As an auxiliary treatment, physiotherapy is performed. Ultrasound, heating, paraffin applications and magnetotherapy are considered effective. Physiotherapeutic procedures allow you to normalize the blood supply and lymph flow of the abdominal organs, relieve pain.

How to check the intestines for diseases?

If various diseases are suspected, an examination of the intestine is required. It involves examining the mucous membrane and determining peristalsis. Distinguish between small and large intestine. Inspection of the initial sections is difficult. Instrumental diagnostic methods are supplemented by laboratory tests, palpation and questioning of a sick person.

Instrumental examination of the intestine

Intestinal examination is performed according to certain indications. Patients can be both adults and children. There are endoscopic and non-endoscopic techniques. In the first case, the mucous membrane is examined from the inside using a camera. This is the most informative way to identify various diseases. It is necessary to examine a person if he has the following symptoms:

• persistent or intermittent abdominal pain;
• violation of the stool by the type of constipation or diarrhea;
• vomiting of feces;
• bloating;
• the presence of blood or other pathological impurities in the feces.

The following studies are most often organized:

• fibroesophagogastroduodenoscopy;
• colonoscopy;
• sigmoidoscopy;
• anoscopy;
• irrigoscopy;
• computed or magnetic resonance imaging;
• capsule colonoscopy;
• radionuclide research;
• radiography.

Sometimes a laparoscopy is performed. Therapeutic and diagnostic procedure, in which the organs of the abdominal cavity are examined from the outside. During the examination of patients, the following diseases can be detected:

• benign and malignant tumors;
• ulcerative colitis;
• Crohn's disease;
• diverticula;
• polyps;
• duodenal ulcer;
• duodenitis;
• enterocolitis;
• proctitis;
• haemorrhoids;
• anal fissures;
• condylomatosis;
• paraproctitis.

Endoscopic examination of the duodenum

FEGDS allows you to check the condition of the duodenum. This is an endoscopic method for examining patients. It allows you to examine only the initial section of the small intestine. FEGDS is often performed for therapeutic purposes. During the study, you can stop the bleeding or remove the foreign body. There are planned and urgent FEGDS.

The benefits of this study are:

• rapidity;
• information content;
• good tolerance;
• safety;
• low invasiveness;
• painlessness;
• the possibility of implementation within the walls of the clinic;
• availability.

The disadvantages include discomfort during the introduction of the probe and discomfort during the withdrawal of anesthesia. FEGDS is performed if the following pathology is suspected:

Before FEGDS preparation is required. It includes not eating immediately before the procedure and following a diet for several days. Spicy foods, nuts, seeds, chocolate, coffee and alcoholic beverages should be excluded from the diet 2-3 days before the study. Dinner on the eve should be no later than 18 pm.

In the morning you can not eat breakfast and brush your teeth. It is necessary to examine the duodenum and stomach in the supine position on the left side with the knees pressed to the body. A thin tube with a camera is inserted through the patient's mouth. Local anesthesia is carried out. This ensures a painless procedure. During the examination, the person should not talk. Saliva should be swallowed only with the permission of a doctor. You can eat only 2 hours after the study.

Contraindications for FEGDS are:

• curvature of the spinal column;
• atherosclerosis;
• neoplasms of the mediastinum;
• a history of stroke;
• hemophilia;
• cirrhosis;
• myocardial infarction;
• narrowing of the lumen of the esophagus;
• bronchial asthma in the acute phase.

Relative limitations include severe hypertension, angina pectoris, lymphadenopathy, acute inflammation of the tonsils, mental disorders, inflammation of the pharynx and larynx.

Performing an intestinal colonoscopy

The main instrumental method for diagnosing diseases of the colon in women and men is colonoscopy. It is classic and capsule. In the first case, a fibrocolonoscope is used. This is a flexible tube that is inserted into the intestine through the anus.

The possibilities of colonoscopy are:

• extraction of foreign objects;
• restoration of intestinal patency;
• stop bleeding;
• biopsy;
• removal of tumors.

How you can prepare for this procedure, not everyone knows. The main goal is to cleanse the intestines. For this, enemas or special laxatives are used. In case of constipation, castor oil is additionally prescribed. An enema is performed when a bowel movement is delayed. To carry it out, you will need a mug of Esmarch and 1.5 liters of water.

Within 2-3 days you need to follow a slag-free diet. It is forbidden to eat fresh vegetables, fruits, herbs, smoked meats, pickles, marinades, rye bread, chocolate, peanuts, chips, seeds, milk and coffee. On the evening before the procedure, it is required to clean the intestines. Used drugs such as Lavacol, Endofalk and Fortrans.

Colonoscopy is performed under local anesthesia. The procedure is less pleasant than FEGDS. A probe with a camera at the end is inserted into the rectum. The doctor examines all parts of the large intestine, starting with the rectum. The expansion of the intestine occurs due to the injection of air. This study lasts minutes. The following complications are possible with an incorrectly performed colonoscopy:

If the general condition worsens after the procedure, you should visit a doctor. Normally, in a healthy person, the mucosa of the large intestine is pale pink. It is shiny, without ulcerative defects, protrusions and outgrowths, smooth with slight striation. The vascular pattern is uniform. Seals, pus, blood, fibrin deposits and necrotic masses are not determined. Absolute contraindications to colonoscopy are peritonitis, severe heart and respiratory failure, heart attack, severe ischemic stroke, and pregnancy.

X-ray examination of the intestine

Methods for examining the intestines include irrigoscopy. This is a type of radiography that uses a dye. This study allows you to determine the pathological changes in the mucosa. The bowel relief is assessed in detail. Contrasting is simple and double. In the first case, barium sulfate is used. In the second, air is additionally introduced.

The advantages of irrigoscopy are:

• safety;
• painlessness;
• availability;
• information content;

The condition of the colon (ascending, transverse and descending), sigmoid and rectum is assessed. It is recommended to inject contrast not through the mouth, but through the rectum using an enema. During the examination, the patient is on his side with his upper leg pressed to his stomach. A rectal tube is installed through which a barium solution is injected.

Then an overview photo is taken. After that, the examined person empties the intestines. Next, a second photo is taken. There are the following indications for irrigoscopy:

• suspicion of a tumor;
• blood in the stool;
• the presence of stool with pus;
• pain during bowel movements;
• bloating with stool retention;
• chronic constipation and diarrhea.

There are 3 main methods of preparation for the procedure:

• cleansing enemas;
• taking the drug Fortrans;
• carrying out hydrocolonotherapy.

A conclusion is drawn from the picture. Irritable bowel syndrome can be suspected if uneven folds-gaustras, areas of narrowing of the intestine in combination with incomplete excretion of contrast during defecation are detected. If during the examination an uneven diameter of the colon, a narrowing of the lumen against a background of spasm, and areas of asymmetric contraction are found, this indicates ulcerative colitis. Barium enema should not be performed in pregnant women, with intestinal perforation, diverticulitis, ulcers, and severe heart failure.

Conducting a capsule study

Modern methods of examining the intestines include capsule colonoscopy. Its difference is that nothing is introduced into the anus of the patient. It is enough to take one capsule, equipped with two chambers. The advantages of this study are:

• safety;
• simplicity;
• no need for anesthesia;
• no radiation exposure;
• minimally invasive;
• the possibility of examining the intestine without a cleansing enema.

The disadvantages include the inconvenience of processing the received data and the difficulty of swallowing. A picture of the intestine with a capsule is recorded on a special device that is worn on a belt. This study is of limited use. It is costly. A capsule examination is performed when it is impossible to carry out colonoscopy and barium enema.

Complications include a delay in the removal of the capsule. Some patients develop allergic reactions. The study is carried out on an outpatient basis. The person does not need to be in the hospital. After swallowing the capsule, you can go about your daily activities. Preparation includes the use of laxatives.

Examination with a sigmoidoscope

To examine the final sections of the intestine, sigmoidoscopy is often organized. The procedure is performed using a sigmoidoscope. It is a lighting device with a metal tube. The thickness of the latter is different. Using a sigmoidoscope, you can examine the mucosa of the sigmoid and rectum at a distance of up to 35 cm from the anus.

• pain in the anus during bowel movements and at rest;
• persistent constipation;
• unstable chair;
• bleeding from the rectum;
• the presence of mucus or pus in the feces;
• feeling of a foreign body.

The study is carried out in chronic hemorrhoids and inflammation of the colon. Sigmoidoscopy is contraindicated in acute anal fissure, narrowing of the intestine, massive bleeding, acute paraproctitis, peritonitis, heart and lung failure. The preparation is similar to that for a colonoscopy.

Immediately before the introduction of the tube of the sigmoidoscope into the anus, it is lubricated with petroleum jelly. The advancement of the device is carried out during attempts. To straighten the folds of the intestine, air is pumped. In the presence of a large amount of pus or blood, an electric pump can be used. If necessary, material is taken for histological analysis.

Other research methods

Magnetic resonance imaging is a modern method for diagnosing bowel diseases. It can be done with double contrast. The dye is administered intravenously and through the mouth. This method cannot replace a colonoscopy. He is supportive. The advantages of MRI are painlessness, information content and the absence of radiation exposure.

Layered pictures of the organ are taken. The doctor receives a three-dimensional image on the screen. Tomography is based on the use of magnetic fields. The latter are reflected from the nuclei of tissue hydrogen ions. Before an MRI, you need to clean the intestines and follow a diet for several days. The procedure takes about 40 minutes. Pictures are taken while the patient is holding his breath.

The patient is placed on the platform and the body is fixed with straps. The methods of examination of patients include anoscopy. With it, you can examine the final section of the intestinal tube. An anoscope is required. This is a device that consists of an obturator, a tube and a light handle.

Before anoscopy, a digital rectal examination is often required. This is done in order to assess the patency of the intestine. If necessary, an anesthetic ointment is used. Thus, if intestinal pathology is suspected, an instrumental study is mandatory. It is impossible to make a diagnosis on the basis of a survey, examination and palpation.

Diseases of the duodenum

Medicine knows several major pathologies of the duodenum 12. Symptoms of duodenal disease differ depending on the type of disease. More often a person is faced with ulcers, duodenitis and neoplasms in this organ. Diagnostic procedures practically do not differ, which cannot be said about treatment, which is based on the characteristics of the pathological condition of the digestive department.

Organ structure

The duodenum is part of the small intestine. It takes part in the absorption of nutrients, and also provides further transportation of food. In the duodenum, the final digestion of products occurs, since the secretion necessary for this occurs in it. It receives enzymes, bile and acids secreted by other organs (pancreas, liver). The duodenum is one of the smallest components of the small intestine (30 cm). Its name is due precisely to the length of 12 fingers. This is the part of the intestine that exits directly from the stomach. Between these organs is the food valve. The duodenum is localized in the retroperitoneal space and is divided into 4 parts:

The mucous membrane of the duodenum is covered with folds, villi. On the descending section there is a large papilla, which contains the bile duct and the pancreatic excretory duct. The submucosal layer contains blood vessels and nerves. The muscular layer of the organ is responsible for the motility and tone of the intestine. The serous ball is the protection of the body from external factors.

Possible diseases

Diseases of the duodenum are inflammatory processes in the mucous membranes of the organ, which affect its functioning and the digestive chain as a whole. Various diseases that affect the performance of the whole organism can provoke the development of inflammation. Every year, the average age of patients decreases, which is due to the rhythm of life, bad habits, food "on the go" and other factors. Mucosal atrophy, duodenal hormonal insufficiency, fistulas, bleeding are common complications of inflammatory processes in the duodenum in a neglected state.

Duodenitis duodenal ulcer

Duodenitis is a disease of the duodenum, which is localized in the transitional intestine. Inflammation can be secondary (associated with another disease) and primary. In this case, a spasm of the sphincter of Oddi and a thickening of the walls of the organ occur. Often occurs against the background of secretory insufficiency. A neglected disease can lead to atrophy of the mucosa of the organ. There are such signs of pathology, which depend on the neglect of the process and concomitant disease:

• pain in the epigastrium - just below the stomach of a blunt or acute character;
• nausea;
• gagging;
• spasms;
• burning in the esophagus;
• prostration;
• swelling of the mucosa of the organ;
• feeling of fullness in the region of the stomach after eating.

peptic ulcer

A duodenal ulcer is an inflammation that is accompanied by the appearance of ulcers on the mucous membranes of the organ. The pathology is chronic and often recurs. The endoscopic picture shows a thickening of the intestinal wall. The disease can spread to other parts of the gastrointestinal tract. If the disease is not treated, fistulas, mucosal atrophy and severe bleeding may appear, which is dangerous for the patient's life. In the absence of adequate medical care, complications can lead to a fatal outcome.

The most common cause of ulcers is Helicobacter pylori. This type of pathological microorganisms affects the mucous membranes of the digestive organs with toxins, the release of which occurs during their life. They enhance the secretion of enzymes in the body. Peptic ulcer disease is often secondary, and occurs as a consequence of gastritis, duodenitis. Other reasons:

• genetic propensity;
• stress and psycho-emotional problems;
• drinking and smoking;
• bad nutrition.

• sharp pain in the epigastric region, which shoots into the back, ribs;
• nausea and vomiting due to stagnation of food;
• pain on the right under the ribs due to stagnation of bile;
• blood impurities in vomit and feces (sometimes).

Erosion of the duodenum

Erosion is an inflammatory process on the surface of the mucous membrane of an organ that does not penetrate into the muscle layer, and is accompanied by the appearance of eroded areas. On ultrasound, a thickening of the wall of the organ is observed. Can provoke the disease:

• stress and psycho-emotional stress;
• smoking;
• helicobacteria;
• poor nutrition;
• medicines.

Erosion of the duodenum is accompanied by a number of symptoms.

Signs of the pathological process:

duodenostasis

Duodenostasis is also called dyskinesia - a disease that affects the motor function of the duodenum, which is why food gruel (chyme) cannot be evacuated from the small intestine, which causes prolonged stagnation of food. Dysfunction is accompanied by such symptoms:

• rash;
• itching of the skin;
• diarrhea;
• pain (pain in the abdomen);
• heartburn.

Neoplasms

Duodenal cancer is rarely diagnosed, usually in older people. Its development is preceded by dysplasia. There are 3 degrees of pathology. In stage 3 dysplasia, the development of cancer is rarely avoided. With dysplasia, the histological structure of the epithelial tissue of the organ is disturbed.

Symptoms are similar to other organ diseases:

• painful sensations, which are enhanced by palpation;
• lack of appetite up to disgust for food;
• prostration;
• sharp weight loss;
• obstructive jaundice due to impaired bile excretion.

Lymphofollicular hyperplasia is a submucosal lesion of the duodenum, which can spread to all digestive organs, peritoneal lymph nodes. It is also considered a precancerous condition. If lymphofollicular hyperplasia affects the intestinal tissues on a large scale, external signs appear. But if it is limited to a small area of ​​the duodenum, there may be no symptoms at all. With any tumor, a uniform thickening of the intestinal walls is visible.

Obstruction

Chronic obstruction of the organ develops for a variety of reasons. Among them:

• incorrect rotation of the intestine;
• inverted and mobile intestine;
• congenital malformations;
• vascular compression.

The entry of gallstones into the stomach is possible through a fistula between the organ and the duodenum or stomach. The stone migrates through the alimentary canal, gets stuck in the thin sections of the intestine. This type of obstruction is extremely rare. Before the onset of the pathology of the patient, the pain syndrome on the right under the ribs worries for a long time. Gallstone obstruction of the small intestine is usually diagnosed in females in old age.

Malformations

Abnormal development of the organ is rare. One of the pathological conditions is congenital stenosis, which is diagnosed in the first hours of a child's life (vomiting, regurgitation, lack of stool). Congenital anomalies include a diverticulum (protrusion of the wall). Lymphangiectasia belongs to this group of diseases. The cause of development is unilateral lymphedema. Lymphangiectasia can develop due to other malformations of the digestive tract, for example, against the background of Crohn's disease, ulcerative colitis.

Diagnosis of diseases of the duodenum

Diseases of the duodenum are diagnosed using the following methods:

• fibrogastroduodenoscopy;
• biopsy and biopath analysis;
• analysis for Helicobacter pylori;
• general blood analysis;
• occult blood test;

Principles of treatment and prevention

Methods of treatment are chosen by the doctor depending on the pathology. You can treat the duodenum 12:

• antibiotics;
• drugs that reduce the secretion of hydrochloric acid;
• antacids;
• painkillers.

Treatment with folk remedies consists in taking medicines from components that increase immunity, improve digestion, and have healing and antibacterial properties. Use honey, chamomile, propolis, marshmallow, dandelion roots, aloe. The patient is on a diet. You need to drink plenty of fluids. The required liquid is calculated by the formula - 30 ml per 1 kg of weight. You can eat cereals (without giving up semolina, buckwheat, barley porridge), eggs, lean meats and fish, bread and milk. It is forbidden to use mushrooms, canned food, marinades, sausages, buns. Such a diet is the best prevention of diseases of the duodenum.

How to determine a duodenal ulcer, diagnosis of peptic ulcer

Diagnosis of duodenal ulcer is a complex process. The first stage consists in a thorough examination of the patient's subjective symptoms:

• Pain. When does it start regarding food intake? What helps to calm her down? How often does it show up? Where does it give? Does it depend on seasonality?
• Dyspeptic disorders - a survey about the presence of a patient with disorders of the gastrointestinal tract, changes in appetite, heartburn, vomiting or nausea.

The doctor also examines the patient, including palpation of the abdominal cavity. In most cases, an experienced specialist, with a high probability, based on the data obtained, will be able to make an accurate preliminary diagnosis and prescribe studies that should be carried out in the future in order to develop treatment tactics.

However, with a duodenal ulcer, diagnosis cannot consist only of subjective data, since many diseases of the gastrointestinal tract are similar in their symptoms. For accurate differentiation of the disease, it is necessary to use additional methods of examination.

So, how to identify a duodenal ulcer? A patient with suspected PU is necessarily sent for examination:

1. instrumental;
2. histological;
3. biochemical, etc.

Of the instrumental ones themselves, radiography and endoscopy are essential. For a long time it was believed that X-rays can accurately diagnose duodenal ulcer, but after the widespread use of endoscopes, it turned out that the accuracy of this method ranges from 50-80%, while endoscopy can give the opposite result in 30% of cases.

However, even today, the X-ray diagnostic method has not lost its relevance, although it is significantly inferior in reliability to esophagogastroduodenoscopy. The fact is that with peptic ulcer, over time, a gross deformation of the duodenal bulb often occurs, which makes the use of the endoscope impossible.

To accurately determine the diagnosis of the duodenum, evaluate the following signs:

Morphological features include: an ulcerative niche on the relief or contour, a defect in the area of ​​ulceration, deformity of the duodenum, a “filling defect” of the intestine.

Functional signs include changes in peristalsis, changes in evacuation function, and regional spasm.

Accompanying signs: changes in the gallbladder, spasticity of the colon, duodenitis, gastritis.

To achieve the best result, the doctor should refer the patient to both an x-ray and an endoscopy, supplementing the obtained data with the results of cytology and histology.

Such a complex diagnosis allows to establish the presence of a peptic ulcer in a patient, but does not allow choosing the optimal treatment tactics. To complete the picture, it is necessary to determine the deviations of the motor-evacuation and secretory functions of the duodenum and stomach. Let's see how you can diagnose a duodenal ulcer?

The study of motor-evacuation function can be carried out using:

• Radiography. The advantage of the method is its physiology, the disadvantages are the indirectness of the data obtained;
• Electrogastrography. The advantage of this method is the ability to explore the motor activity of the intestine for a long time without a probe. The disadvantage is that it is not possible to conduct a local study;
• Phonography or recording of peristalsis noises is carried out from the surface of the body, thus without causing inconvenience to the patient. Disadvantages - the impossibility of localizing the recorded noise.
• Ballonography - evaluates the motor activity of the digestive organs based on pressure in the gastrointestinal tract. Allows you to assess the state of motor activity of the intestine. The disadvantage is that it is not physiological (the balloons used in the procedure irritate the intestinal wall, stimulating its motility).

Radiation and endoscopic studies form the basis of a comprehensive diagnosis of stomach diseases. Among the ray methods, the most important is radiological. The plan of X-ray examination depends on the data of the anamnesis and the clinical picture of the disease.

In conditions of emergency diagnosis, i.e. in acute conditions, the patient is x-rayed in the chest and abdominal cavities in vertical and horizontal positions. Artificial contrasting of the digestive canal is performed only for special indications.

Verification studies of the stomach during clinical examination are carried out on special X-ray diagnostic devices - gastrofluorographs - under the control of X-ray television transillumination. The study is carried out on an empty stomach. 20-30 minutes before it, the patient puts 2-3 tablets under the tongue

Rice. Sh.98. A series of gastrofluorograms of the stomach.

a-b - with the patient in the vertical position in the front and left lateral projections; c-d - in a horizontal position on the back and on the stomach.

ki aerona to relax the stomach. As a contrast agent, a specially prepared highly concentrated suspension of barium sulphate, and to stretch the stomach use granular gas-forming drug. X-ray filming is performed in several standard projections with the patient in the vertical and horizontal positions. The resulting images are called "gastrofluorograms"(Fig. Sh.98). Their size, unlike conventional radiographs, is small - 10x10 or 11x11 cm, the number is 8-12. If pathological changes are found on the pictures, then the patient is usually referred for fibrogastroscopy. Conducting screening mass x-ray studies is justified in those geographical areas where the incidence of gastric cancer is high.

Planned x-ray examination of the stomach and duodenum produced according to clinical indications on a universal x-ray machine that allows serial x-rays under the control of X-ray television transmission. Currently, two methods of contrasting the stomach are used: ingestion of a barium suspension or primary double contrasting - with a barium suspension and gas.

Rice. III. 99. Radiographs of normal stomach and duodenum.

a - with a small filling with a contrast mass: folds of the mucous membrane of the stomach and intestines are visible; b - with tight filling.

Rice. Sh.100. Target radiographs of the body of the stomach (double contrasting). A thin relief of the mucous membrane is displayed.

a - fine mesh (granular) relief (the so-called gastric fields); b - coarse nodular relief with atrophic gastritis.

When using the first method, the patient comes to the X-ray room on an empty stomach. After a small sip of a liquid aqueous suspension of barium sulfate, the radiologist evaluates the act of swallowing, the passage of the contrast mass through the esophagus, and the state of the esophageal-gastric junction. Then he distributes the contrast mass along the interstitial spaces of the stomach and makes a series of radiographs that fix the folded relief of the gastric mucosa (Fig. III.99). Next, the patient drinks 100-150 ml of a liquid aqueous suspension of barium sulfate, and the doctor examines the position, shape, size and shape of the stomach, its tone and peristalsis, the course of emptying, the condition of the pyloric canal and duodenum. Pictures are taken in different projections and at different positions of the patient's body.

If necessary, in addition to barium, the patient is given a gas-forming mixture to drink, as a result of which the stomach is stretched with gas and at the same time it becomes possible to obtain some additional diagnostic data. This approach is called "double gastric contrast".

For primary double contrast stomach a special barium suspension is used, the density of which is 4-5 times higher than the density of a conventional suspension. It is distinguished by uniformity, increased adhesion to the mucous membrane, and is resistant to flocculation, i.e. does not precipitate in the acidic contents of the stomach. Before the study, the patient is parenterally injected with metacin to relax the alimentary canal. Then, in a vertical position, the esophagus is examined after 2-3 sips of barium suspension. After taking 50-70 ml of a contrast agent, the patient is offered to drink a gas-forming powder. Further studies are carried out in a horizontal position (Fig. W.100). After several rotations around the longitudinal axis, during which a chemical gas formation reaction takes place and the stomach swells and its mucous membrane is coated with barium, serial radiography of the stomach and duodenum is performed in various projections, usually in two or three anterior (straight and oblique) and two- three rear (also straight and oblique). Fluoroscopy is performed mainly in order to select the best projections for radiography. Analysis of the results of the study is carried out on a series of radiographs.

4.2.1. Normal stomach and duodenum

Before taking the contrast mass, there is a small amount of air in the stomach. When the body is in a vertical position, the gas bubble is located in the region of the arch. The rest of the stomach is a roller with thick and maximally approximated walls.

The contrast mass swallowed by the patient, with the vertical position of the body, gradually passes from the esophagus to the stomach and descends from the cardiac opening into the body, sinus and antrum. Already after the first small sips of barium, folds of the gastric mucosa appear - a relief appears internal surface of the organ(see fig. Sh.99). This folded relief is unstable and reflects the physiological state of the stomach.

In the region of the arch, various variants of the course of the folds are observed; usually long and arcuately directed folds are combined here with transverse and oblique ones. In the body of the stomach, 3-4 longitudinal slightly sinuous folds are determined. Oblique and longitudinally extending folds predominate in the outlet part of the stomach. They converge to the pylorus, continue in its canal and in the duodenal bulb. However, starting from the upper inflection of the duodenum, the relief of the mucous membrane changes dramatically: transverse and oblique short folds appear. Only at the moment of passage of the peristaltic wave do they take a longitudinal direction.

As the stomach expands with air, the shape and thickness of the folds change and eventually they disappear. An image of a peculiar cellular pattern appears on the pictures - thin relief of the inner surface of the stomach(see Fig. III. 100). It is formed by oval and rounded elevations of 2-3 mm in size - areola, or gastric fields. Thin relief differs from folded relief in its constancy.

After receiving the entire contrast mass, the stomach in the vertical position of the body takes the form of a hook (see Fig. 111.99). It distinguishes main divisions: fornix, body, sinus, antrum and gatekeeper. The area around the foramen magnum is called cardiac part(in it allocate supra- and subcardiac departments). The place on the lesser curvature, where the body of the stomach passes into its outlet, is called corner of the stomach. A small part of the antrum in front of the pylorus - 2-3 cm long - is called prepyloric (prepyloric) department. The pylorus canal is visible only when barium passes through it.

In the duodenum, there are upper, descending and horizontal (lower) parts and three bends: upper, lower and duodenum-skinny. In the upper part of the intestine secrete ampoule or, in radiological terminology, bulb. There are two pockets in the bulb - medial and lateral. In the descending part of the intestine, an oval elevation can be detected - large papilla- the confluence of the common bile duct and the pancreatic duct (Wirsung duct). Sometimes the Wirsung duct flows into the intestine on its own. In such cases, radiographically it is sometimes possible to detect a second oval elevation - minor papilla duodenum.

Manifestations of the muscular activity of the stomach are its contractions and relaxation, which can be recorded in a series of images, as well as peristaltic waves following from the cardia to the pylorus with an interval of approximately 20 s. The total duration of the wave passage along this distance is about 20 s; 200 ml of an aqueous suspension of barium leaves the stomach within lVi-3 hours. Food stays in the stomach much longer.

More accurate data on the evacuation of contents from the stomach allows you to get dynamic scintigraphy. On an empty stomach, the patient is offered breakfast with a total weight of 500 g. Its standard composition: 10% semolina, tea with sugar, a piece of stale white bread. In this breakfast, "d1 Tc-colloid with an activity of 10-20 MBq is introduced. Scintigraphy begins immediately after the end of the meal (in a vertical position) and is repeated with a pre-selected

The gastric mucosa is capable of extracting and accumulating 99m Tc-pertechnetate from the blood. After its intravenous administration, scintigrams show "hot zone" corresponding to the location of the stomach. This property is used to identify areas ectopic gastric mucosa. Most often, its islands are found in the esophagus (the so-called Berret's esophagus) or in a diverticulum of the ileum (Meckel's diverticulum) located in its distal section. In the esophagus, this pathology can be complicated by inflammation and development peptic ulcer, and in Meckel's diverticulum diverticulitis and bleeding(these complications are more common in children of the first 2 years of life). To detect an ectopic mucosa, 10 MBq of "TC-pertechnetate" is injected into the patient's vein. When it is localized in a Meckel's diverticulum, on the scintigram, one can see a zone of radiopharmaceutical accumulation in the right iliac region.

4.2.2. Diseases of the stomach and duodenum

Indications for radiological examination of the stomach are very wide due to the high prevalence of "gastric" complaints (dyspepsia, abdominal pain, lack of appetite, etc.). X-ray examination is carried out with suspicion of peptic ulcer, tumor, in patients with achilia and anemia, as well as with gastric polyps, which for some reason have not been removed.

Chronic gastritis. In the recognition of gastritis, the main role is played by clinical examination patient in combination with endoscopy and gastrobiopsy. Only by histological examination of a piece of the gastric mucosa, it is possible to establish the shape and extent of the process and the depth of the lesion. However, with atrophic gastritis, radiological

In terms of efficiency and reliability, a logical study is equivalent to fibrogastroscopy and is second only to biopsy microscopy.

X-ray diagnostics is based on a set of radiological signs and their comparison with a set of clinical and laboratory data. A combined assessment of the thin and folded relief and function of the stomach is mandatory.

The leading value is the definition of the state of the areola. Normally, a finely meshed (granular) type of thin relief is observed. Areoles have a regular, mostly oval shape, clearly defined, limited by shallow narrow grooves, their diameter varies from 1 to 3 mm. Chronic gastritis is characterized by nodular and especially coarse nodular types of thin relief. With the nodular type, the areola is irregularly rounded, 3-5 mm in size, limited by narrow but deep grooves. The gross-nodular type is distinguished by large (over 5 mm) areolas of irregular polygonal shape. The furrows between them are widened and not always sharply differentiated (see Fig. III.100).

Changes in the folded relief are much less specific. Patients with chronic gastritis have thickening of the folds. On palpation, their shape changes slightly. The folds are straightened or, on the contrary, strongly twisted; small erosions and polyp-like formations can be detected on their crests. At the same time, functional disorders are recorded. During the period of exacerbation of the disease, the stomach contains liquid on an empty stomach, its tone is increased, peristalsis is deepened, an antral spasm may be observed. During remission, the tone of the stomach is lowered, peristalsis is weakened.

Peptic ulcer of the stomach and duodenum. Radiology plays an important role in recognizing an ulcer and its complications.

In an x-ray examination of patients with peptic ulcer of the stomach and duodenum, the radiologist faces three main tasks. The first is an assessment of the morphological state of the stomach and duodenum, first of all, the detection of an ulcerative defect and the determination of its position, shape, size, shape, and the state of the surrounding mucous membrane. Second task sound- included in the study of the function of the stomach and duodenum: detection of indirect signs of peptic ulcer, establishing the stage of the disease (exacerbation, remission) and evaluating the effectiveness of conservative therapy. The third task is to recognize the complications of peptic ulcer disease.

Morphological changes in peptic ulcer are caused both by the ulcer itself and by concomitant gastroduodenitis. Signs of gastritis are described above. A niche is considered a direct symptom of an ulcer. This term refers to the shadow of a contrasting mass that filled the ulcerative crater. The silhouette of the ulcer can be seen in profile (such a niche is called contour) or full face against the background of mucosal folds (in these cases they speak of a niche on the relief

fe, or relief niche). The contour niche is a semicircular or pointed protrusion on the contour of the shadow of the stomach or duodenal bulb (Fig. III. 102). The size of the niche generally reflects the size of the ulcer. Small niches are indistinguishable under fluoroscopy. To identify them, sighting radiographs of the stomach and bulb are necessary.

At double contrast stomach it is possible to recognize small superficial ulcerations - erosion. They are more often localized in the antral and prepyloric sections of the stomach and have the form of rounded or oval enlightenments with a dotted central accumulation of a contrasting mass (Fig. III. 103).

The ulcer can be small - up to 0.3 cm in diameter, medium in size - up to 2 cm, large - 2-4 cm and giant - more than 4 cm. The shape of the niche is round, oval, slit-like, linear, pointed, irregular. The contours of small ulcers are usually even and clear. The outlines of large ulcers become uneven due to the development of granulation tissue, accumulations of mucus, blood clots. At the base of the niche, small indentations are visible, corresponding to edema and infiltration of the mucous membrane at the edges of the ulcer.

The relief niche has the appearance of a persistent round or oval accumulation of a contrasting mass on the inner surface of the stomach or bulb. This accumulation is surrounded by a light structureless rim - a zone of edema of the mucous membrane (Fig. III. 104). In a chronic ulcer, the relief niche may be irregular in shape with uneven outlines. Sometimes there is a convergence (convergence) of the folds of the mucous membrane to the ulcer.

As a result of scarring of the ulcer at the level of the niche, straightening and some shortening of the contour of the stomach or bulb are revealed. Sometimes the cicatricial process reaches a significant degree, and then gross deformations of the corresponding part of the stomach or bulb are determined, which sometimes takes a bizarre shape. Scarring of an ulcer in the pyloric canal or at the base of the bulb can lead to pyloric stenosis or duodenal stenosis. Due to a violation of the evacuation of the contents of the stomach is stretched. In it on an empty stomach they find

Rice. Sh.104. Target radiographs of the duodenal bulb, a - relief niche (indicated by arrows); b - a niche (indicated by arrows) on the contour of the shadow of the bulb.

liquid contents and even leftover food. The passage of the contrast agent through the pyloric canal or stenotic bulb is sharply slowed down, sometimes for several hours.

There are a number of indirect x-ray symptoms of peptic ulcer disease. Each of them individually does not give grounds for establishing the diagnosis of an ulcer, but in the aggregate their value is almost equal to the identification of a direct symptom - a niche. In addition, the presence of indirect signs forces the radiologist to look for an ulcer with special attention, performing a series of sighting radiographs. A sign of a violation of the secretory function of the stomach is the presence of fluid in it on an empty stomach. This symptom is most indicative of an ulcer of the duodenal bulb. When the body is in a vertical position, the liquid forms a horizontal level against the background of a gas bubble in the stomach. An important indirect symptom is regional spasm. In the stomach and bulb, it usually occurs at the level of the ulcer, but on the opposite side. There, a retraction of the contour with even outlines is formed (see Fig. III. 102). In the stomach, it is shaped like the end of a finger, hence the name of this symptom - “pointing finger symptom”. With an ulcer of the bulb during the period of exacerbation, as a rule, a spasm of the pylorus is observed. Finally, with ulcers, a symptom of local hyperkinesia is noted, which is expressed in the accelerated advancement of the contrast agent in the ulcer zone. This symptom is explained by increased irritability and motor activity of the wall in the area of ​​ulceration. Another indirect symptom is associated with it - a symptom of point pain and local tension of the abdominal wall during palpation of the area corresponding to the location of the ulcer.

In the stage of exacerbation of peptic ulcer, an increase in the niche and an expansion of the inflammatory shaft surrounding it are observed. During the period of remission, there is a decrease in the niche up to its disappearance (after 2-6 weeks), the functions of the stomach and duodenum are normalized. It is important to emphasize that the disappearance of the niche does not mean a cure if symptoms of impaired function persist. Only the elimination of functional disorders guarantees a cure, or at least a long-term remission.

With peptic ulcer and chronic gastritis, duodenogastric reflux is often observed. To identify it, the patient is dynamic scintigraphy. For this purpose, he is intravenously injected with radiopharmaceutical "Tc-butyl-IDA" or a related compound with an activity of 100 MBq. After obtaining an image of the gallbladder on scintigrams (these drugs are excreted in the bile), the patient is given a fatty breakfast (for example, 50 g of butter). On subsequent scintigrams, it is possible to observe the emptying of the bladder from radioactive bile. With pyloric insufficiency, it appears in the stomach cavity, and with gastroesophageal reflux - even in the esophagus.

The ulcerative niche may vaguely resemble a diverticulum of the stomach - a kind of developmental anomaly in the form of a saccular protrusion of the wall of the digestive canal. In 3/4 cases, the diverticulum of the stomach is located on the back wall near the esophageal-gastric junction, i.e. near the cardiac opening (see Fig. 111.91). Unlike an ulcer, a diverticulum has a regular rounded shape, smooth arcuate contours.

ry, often well-formed neck. The folds of the mucous membrane around it are not changed, some of them enter the diverticulum through the neck. Diverticula are especially common in the descending and lower horizontal parts of the duodenum. Their radiological signs are the same, only with the development of diverticulitis, the contours of the protrusion become uneven, the mucous membrane around is edematous, palpation is painful.

An important role is played by radiation methods in the diagnosis of complications of peptic ulcer. First of all, this refers to the perforation of a stomach or duodenal ulcer. The main sign of perforation is the presence of free gas in the abdominal cavity (Fig. III. 105). The patient is examined in the position in which he was brought to the X-ray room. The gas that has penetrated into the abdominal cavity through the perforation hole occupies the highest sections in it. When the body is vertical, gas accumulates under the diaphragm, when positioned on the left side - in the right lateral canal, when positioned on the back - under the anterior abdominal wall. On radiographs, the gas causes a clearly visible enlightenment. When the position of the body changes, it moves in the abdominal cavity, which is why it is called free. Gas can also be detected by ultrasound

If acute ulcerative bleeding is suspected, they usually resort to emergency endoscopy. However, valuable data can be obtained from an X-ray examination, which is advisable to carry out if fibrogastroduodenoscopy is impossible or not indicated. After stopping the bleeding or even during the period of ongoing bleeding, fluoroscopy and radiography of the stomach and duodenum with barium sulfate can be performed, but with the patient in a horizontal position and without compression of the anterior abdominal wall.

As a result of scarring of the pyloric ulcer, stenosis of the gastric outlet may develop. According to x-ray data, the degree of its severity is determined (compensated, with b-compensated or decompensated).

Stomach cancer. Initially, the tumor is an island of cancerous tissue in the mucous membrane, but in the future, various ways of tumor growth are possible, which predetermine the radiological signs of small cancer (Fig. III. 106). If necrosis and ulceration of the tumor predominate, then its central part sinks in comparison with the surrounding mucous membrane - the so-called in-depth cancer (Fig. W.-Yu7). In this case, when double contrasting an irregularly shaped niche with uneven contours is determined, around which there are no areolas. The mucosal folds converge to ulceration, expanding slightly in front of the niche and losing their outlines here.

With another type of growth, the tumor spreads mainly to the sides along the mucous membrane and in the submucosal layer - a superficial, or flat-infiltrating, cancer that grows endophytically. It causes an area of ​​altered relief, in which there are no areolas, but at the same time, unlike in-depth cancer, there is no ulceration and there is no convergence of mucosal folds to the center of the tumor. Instead, randomly located thickenings are observed with lumps of contrasting mass unevenly scattered over them. The contour of the stomach becomes uneven, straightened. There is no peristalsis in the infiltrate area.

In most cases, the tumor grows in the form of a node or plaque, gradually protruding more and more into the cavity of the stomach - “towering” (exophytic) cancer. In the initial stage, the x-ray picture differs little from that of an endophytic tumor , but then a noticeable uneven deepening of the contour of the shadow of the stomach appears, which is not involved in peristalsis. Further, a marginal or central filling defect is formed, corresponding in shape to a tumor protruding into the lumen of the organ. With plaque-like cancer, it remains flat, with polypous (mushroom-shaped) cancer it has an irregular rounded shape with wavy outlines (Fig. 111.108).

It should be emphasized that in most cases, it is impossible to distinguish early cancer from peptic ulcer and polyp using radiation methods, and therefore endoscopic examination is required. However, X-ray examination is very important as a method of selecting patients for endoscopy.

With the further development of the tumor, various x-ray pictures are possible, which, perhaps, never copy one another. However, it is conditionally possible to distinguish several forms of such “advanced cancer”. A large exophytic tumor gives a large filling defect in the shadow of the stomach filled with a contrast mass. The contours of the defect are uneven, but quite clearly demarcated from the surrounding mucous membrane, the folds of which in the area of ​​the defect are destroyed, peristalsis is not traced.

Ryas. III. 106. Small stomach cancer (scheme).

a - initial tumor; b - picture with double contrasting; c - a picture with tight filling of the stomach. 1 - towering cancer; 2 - superficial cancer; 3 - in-depth cancer.

Rice. III. 107. Slightly deepened cancer with a small ulceration in the center (indicated by an arrow).

Rice. Sh.108. Target radiograph of the upper part of the stomach. A large cancerous tumor with a bumpy surface (indicated by arrows).

In a different "guise" appears infiltrative-ulcer venous cancer. With it, not so much a filling defect is expressed as destruction and infiltration of the mucous membrane. Instead of normal folds, the so-called malignant relief is determined: shapeless accumulations of barium between pillow-shaped and structureless areas. Of course, the contours of the shadow of the stomach in the affected area are uneven, and there is no peristalsis.

The radiographic picture of a saucer-shaped (more often similar) cancer is quite typical; tumors with raised edges and a decaying central part. On radiographs, a round or oval filling defect is determined, in the center of which a large niche stands out - an accumulation of barium in the form of a spot with uneven outlines (Fig. III. 109). A feature of saucer-shaped cancer is the relatively clear demarcation of the edges of the tumor from the surrounding mucosa.

Diffuse fibroplastic cancer leads to narrowing of the gastric lumen. In the affected area, it turns into a narrow, rigid tube with uneven contours (Fig. SLU). When the stomach is inflated with air, the deformed section does not expand. On the border of the narrowed part with unaffected sections, small ledges can be seen on the contours of the shadow of the stomach. The mucosal folds in the tumor area thicken, become immobile, and then disappear.

Ryas. III. 109. Cup-shaped (saucer-shaped) cancer of the stomach. In the antrum there is a rounded filling defect with an accumulation of a contrast agent in the ulceration (indicated by an arrow).

A tumor of the stomach can also be detected with computed tomography and ultrasound examination. On sonograms, areas of thickening of the stomach wall are distinguished, which makes it possible to clarify the volume of the tumor lesion. In addition, according to sonograms, it is possible to determine the prevalence of infiltrate in the surrounding tissues and detect tumor metastases in the lymph nodes of the abdominal cavity and retroperitoneal space, the liver and other organs of the abdominal cavity. Ultrasound signs of a tumor of the stomach and its germination into the wall of the stomach are especially clearly defined when endoscopic sonography stomach. At CT the wall of the stomach is also well visualized, which makes it possible to reveal its thickening and the presence of a tumor in it. However, the earliest forms of gastric cancer are difficult to detect on both sonography and CT. In these cases, the leading role is played by gastroscopy, supplemented by targeted multiple biopsy.

Benign tumors of the stomach. The X-ray picture depends on the type of tumor, the stage of its development and the nature of growth. Benign epithelial tumors (papillomas, adenomas, villous polyps) originate from the mucous membrane and protrude into the lumen of the stomach. Initially, an unstructured rounded area is found among the areolas, which can be seen only with double contrasting of the stomach. Then the local expansion of one of the folds is determined. It gradually increases, taking the form of a rounded or slightly oblong defect (Fig. SHLI). Mucosal folds bypass this defect and are not infiltrated.

Non-epithelial benign tumors (leiomyomas, fibromas, neurinomas, etc.) look completely different. They develop mainly in the submucosal or muscular layer and little protrude into the stomach cavity. The mucous membrane over the tumor is stretched, as a result of which the folds are flattened or moved apart. Peristalsis is usually preserved. The tumor can also cause a round or oval defect with even contours. Postoperative diseases of the stomach. X-ray examination necessary for the timely detection of early postoperative complications - pneumonia, pleurisy, atelectasis, ulcers in the abdominal cavity, including subdiaphragmatic abscesses. Gas-containing abscesses are relatively easy to recognize: in the pictures and with transillumination, it is possible to detect a cavity containing gas and liquid. If there is no gas, then a subdiaphragmatic abscess can be suspected by a number of indirect signs. It causes a high position and immobilization of the corresponding half of the diaphragm, its thickening, uneven outlines. There is a "sympathetic" effusion in the costophrenic sinus and foci of infiltration at the base of the lung. In the diagnosis of subdiaphragmatic ulcers successfully used sonography and computed tomography, since accumulations of pus are clearly visible in these studies. An inflammatory infiltrate in the abdominal cavity gives an echo-inhomogeneous image: there are no areas free of echo signals in it. An abscess is characterized by the presence of a zone devoid of such signals, but a denser rim appears around it - a display of an infiltrative shaft and a pyogenic membrane.

Rice. GO.Ul. Target radiograph of the outlet part of the stomach. Large pedunculated adenomatous polyp (indicated by an arrow).

Among the late postoperative complications, two syndromes should be mentioned: adductor loop syndrome and dumping syndrome. The first of them is radiologically manifested by the flow of a contrast mass from the stomach stump through the anastomosis into the afferent loop. The latter is expanded, the mucous membrane in it is edematous, its palpation is painful. Particularly indicative is the long retention of barium in the afferent loop. Dumping syndrome is characterized by a significant acceleration in the emptying of the stomach stump and the rapid spread of barium through the loops of the small intestine.

A peptic ulcer of the anastomosis may occur 1-2 years after surgery on the stomach. It causes a radiological symptom of a niche, and the ulcer is usually large and surrounded by an inflammatory shaft. Her palpation is painful. Due to the concomitant spasm, there is a disorder in the functions of the anastomosis with a delay in the contents in the stomach stump.

4*3. X-ray examination of the intestine

X-ray examination- the traditional way of studying the small and large intestines. The indications for it are numerous. In a medical emergency - this is a suspicion of intestinal non-

patency, perforation of the intestine, thromboembolism of the mesenteric vessels, gastrointestinal bleeding. In normal clinical practice, indications are abdominal pain, changes in the frequency and nature of the stool, unexplained anemia, the search for a hidden cancerous process, signs of gastrointestinal bleeding, the source of which is not found either in the esophagus or in the stomach.

On conventional radiographs, the outlines of intestinal loops are poorly distinguishable, only accumulations of gas and shadows of formed feces in the distal colon and in the rectum are visible. Concerning survey radiographs are used mainly in the diagnosis of acute intestinal obstruction(see below). The leading method of x-ray examination is artificial contrasting - the introduction of a contrast agent into the intestinal lumen.

Each section of the intestine is examined with a different degree of filling with a contrasting mass and with a different position of the patient's body. Small filling makes it possible to assess in detail the relief of the inner surface of the intestine, the folds of its mucous membrane. In combination with the inflation of the intestine with air, it provides a plastic picture of the walls and the inner surface of the intestine. Massive (tight) filling allows you to determine the position, shape, size, shape, displacement and function of the organ. In the course of the study, survey and sighting radiographs are combined. In recent years, computed tomography and ultrasound examination of the intestine have become increasingly important.

4.3.1. Normal small intestine

The most physiological way of artificial contrasting of the small intestine is oral contrasting, achieved by taking an aqueous suspension of barium sulfate inside. After passing through the stomach and duodenum, the contrast mass enters the jejunum and further into the ileum. After 10-15 minutes after taking barium, the shadow of the first loops of the jejunum is determined, and after 1-2 hours - the rest of the small intestine (Fig. IM 12).

The filling phases of the small intestine are recorded on radiographs. If it is necessary to accelerate the advancement of the contrast mass, then strongly chilled barium is used, which is taken in separate portions, or additionally ice-cold isotonic sodium chloride solution. The effect of accelerating the passage of barium is also observed under the influence of a subcutaneous injection of 0.5 mg of prostigmine or intramuscular injection of 20 mg of metoclopramide. The disadvantages of this technique for studying the small intestine are the long duration of the procedure and the relatively high radiation exposure.

All oral methods of artificial contrasting have a significant drawback: the filling of the intestine is uneven, fragmentary, its individual segments are not visible at all on radiographs. As a result, according to the results of oral contrasting, only an approximate idea of ​​the morphological state of the small intestine can be made.

The main method of x-ray examination of the small intestine is radiopaque enteroclysm.

In this study, for uniform tight filling of the small intestine, an elongated intestinal probe (or a special catheter) is inserted into the duodenum in a patient under conditions of artificial medical hypotension of the intestine. 600-800 ml of an aqueous suspension of barium sulfate is poured through the probe. Normally, within 10-15 minutes, the contrast mass fills the entire small intestine and begins to enter the blind (Fig. III. 113). This creates the possibility of studying the morphological features of the jejunum and ileum. To improve the visualization of the intestinal wall, after the barium suspension, air is dosed into the intestine through the catheter, i.e. perform double contrasting of the small intestine.

Loops of the jejunum are located mainly in the central parts of the abdominal cavity (see Fig. III. 112). They have the appearance of narrow ribbons 1.5-2 cm wide, the contours of the intestine are serrated, since narrow notches are evenly distributed on them - a reflection of circular (kerkringo-out) mucosal folds. The folds themselves stand out as delicate transversely and obliquely directed strips, the location and shape of which change with various movements of the intestinal loops. At the moment of passage of circular waves, the folds take on a longitudinal direction. In general, for the jejunum it is considered characteristic

Rice. Sh. 113. Through probe enterography. Loops of the small intestine are evenly filled with contrast medium through the probe.

called pinnate relief pattern of the inner surface. The loops of the ileum are found below, often in the pelvis. In the course of the ileum, the serration of the contours becomes smaller and eventually disappears. The caliber of the folds decreases from 2-3 mm in the small intestine to 1-2 mm in the ileum.

The last loop of the ileum flows into the caecum. At the point of entry is ileocecal valve (Bauhin's valve), its edges appear as semi-oval notches on the contour of the caecum. By observing the intestinal loops using fluoroscopy, one can see their various movements that promote the movement and mixing of the contents: tonic contractions and relaxation, peristalsis, rhythmic segmentation, pendulum movements. In the ileum, as a rule, its segmentation is noted.

The processes of absorption in the small intestine are studied using radionuclide methods. If you suspect pernicious anemia explore all

elimination of vitamin B 12 in the intestines. To do this, the patient takes two radiopharmaceuticals inside: Co-B | 2 and 57 Co-B 12 , one of which is associated with gastric intrinsic factor (IGF), which is secreted by the gastric mucosa. In its absence or deficiency, the absorption of vitamin B12 is impaired. Then the patient is injected parenterally with a large amount of unlabeled vitamin B, 2 - about 1000 mcg. The stable vitamin blocks the liver, and its radioactive counterparts are excreted in the urine. Having collected the urine released during the day and determining its radioactivity, it is possible to calculate the percentage of absorbed B i 2 . Normal excretion of this vitamin in the urine is 10-50% of the administered dose. As noted above, the patient takes two radiopharmaceuticals. Since the radiation of the two cobalt radionuclides differ in their characteristics, this makes it possible to find out what underlies the poor absorption of the vitamin - a lack of VHF or other causes (impaired absorption in the intestine, genetically altered transport of vitamin B i 2 by blood proteins, etc.).

Absorption of neutral fat and fatty acid in the small intestine assessed after the patient has ingested the labeled sh 1 trioleate-glycerol and oleic acid. Most often, this is resorted to in order to establish the cause of steatorrhea, i.e. increased fat content in feces. A decrease in the absorption of trioleate-glycerol indicates that steatorrhea is associated with insufficient secretion of lipase, a pancreatic enzyme. The absorption of oleic acid is not disturbed. In bowel diseases, the absorption of both trioleate-glycerol and oleic acid is impaired.

After taking these drugs, radiometry of the whole body of the patient is performed twice: first without a screen, and then with a lead screen over the stomach and intestines. Radiometry is repeated after 2 and 24 hours. The assimilation of trioleate-glycerol and oleic acid is judged by their content in tissues.

4.3.2. Normal colon and rectum

Conventional x-rays do not show a clear image of the colon and rectum. If you take pictures after the patient has taken an aqueous suspension of barium sulfate inside, then you can register the passage of the contrast mass through the digestive canal. From the terminal loop of the ileum, barium passes into the caecum and then sequentially moves to the rest of the colon. This method is the method "contrast breakfast"- used only to assess the motor function of the colon, but not to study its morphology. The fact is that the contrast content is distributed unevenly in the intestine, mixed with food waste, and the relief of the mucous membrane is not displayed at all.

The main radiation method for examining the colon and rectum is their retrograde filling with a contrast mass - irrigoscopy.

In this study, careful preparation of the patient is very important: a slag-free diet for 2-3 days, taking laxatives - one tablespoon of castor oil at lunch the day before, holding

Rice. III. 114. Radiographs of the colon.

a - after retrograde filling with a contrast agent: 1 - caecum, 2 - ascending colon, 3 - transverse colon, 4 - descending colon, 5 - sigmoid colon, 6 - straight; b - after bowel emptying: a folded relief of the intestinal mucosa is visible.

a series of cleansing enemas - the night before and early in the morning on the day of the study. Some radiologists prefer preparation with special tablets, such as contact laxants, which promote the rejection of stool from the intestinal mucosa, as well as the use of laxative suppositories and magnesium sulfate.

An aqueous barium suspension is injected through the anus using the Bobrov apparatus in the amount of 600-800 ml. Assess the position, shape, size, shape, mixing of all parts of the colon and rectum (Fig. III. 114). The patient is then asked to empty the colon. As a result, the bulk of the contrast suspension is removed from the intestine, and the barium plaque remains on the mucous membrane and outlines its folds (see Fig. III. 114).

After studying the relief of the mucous membrane, up to 1 liter of air is blown into the colon under the control of fluoroscopy. This makes it possible to assess the extensibility (elasticity) of the intestinal walls. In addition, against the background of stretched folds of the mucous membrane, the slightest irregularities are better distinguished, for example, granulations, polyps, small cancerous tumors. Such a technique is called double contrast colon.

In recent years, the method has gained popularity simultaneous double contrasting of the colon. In this study, a relatively small amount of contrast mass is first introduced into the intestine - about 200-300 ml, and then, under the control of transillumination, dosed and

Rice. III. 115. Radiograph III. 116. Sighting X-ray

caecum and ascending colon ma caecum. The contrast agent

(double contrast). filled the appendix.

air is gently blown in, thus pushing the previously introduced bolus of barium suspension proximally, up to the ileocecal valve, with an air column. Then a series of survey radiographs of the abdominal cavity organs is made in standard positions, supplementing them with separate images of the intestinal area of ​​interest (Fig. P1.115). A prerequisite for conducting a study using the method of primary double contrasting is a preliminary drug-induced hypotension of the intestine.

The large intestine occupies mainly the peripheral parts of the abdominal cavity. The caecum is located in the right iliac region. At its lower pole, the appendix is ​​often filled with a contrasting mass in the form of a narrow canal 6–10 cm long (Fig. IIIL16). The caecum without sharp boundaries passes into the ascending colon, which rises to the liver, forms a right bend and continues into the transverse colon. The latter goes to the left, forms a left bend, from which the descending colon runs along the left side wall of the abdominal cavity. In the left iliac region, it passes into the sigmoid colon, forming one or two bends. Its continuation is the rectum, which has two bends: the sacral, facing the bulge backwards, and the perineal, the bulge anteriorly.

The caecum has the largest diameter; in the distal direction, the diameter of the colon generally decreases, increasing again when passing into the rectum. The contours of the large intestine are wavy due to haustral constrictions, or haustr. During oral filling of the colon, haustra are distributed relatively evenly, have smooth rounded outlines. However, the distribution, depth and shape of the gaustra change in connection with the movements of the intestinal contents and the movements of the intestinal wall. With irrigo-shda, the haustration is less deep, and in some places it is invisible. On the inner surface of the intestine, the haustras correspond to the semilunar folds of the mucous membrane. In those departments where the contents linger longer, oblique and transverse folds predominate, and in those departments that serve to remove feces, narrow longitudinal folds are more often visible. Normally, the relief of the intestinal mucosa is variable.

4.3.3. Bowel disease

Recognition of bowel diseases is based on clinical, radiological, endoscopic and laboratory data. An increasing role in this complex is played by colonoscopy with biopsy, especially in the diagnosis of early stages of inflammatory and tumor processes.

Acute mechanical obstruction of the intestine. It is of great importance in its recognition x-ray study. Plain radiographs of the abdominal organs are made to the patient in a vertical position. Obstruction is indicated by swelling of the intestinal loops located above the site of blockage or compression of the intestine. In these loops, gas accumulations and horizontal liquid levels (the so-called bowls, or levels, Caoibera; rice. Sh.117). All bowel loops distal to the occlusion are in collapsed state and do not contain gas and liquid. It is this sign - the subsidence of the post-stenotic segment of the intestine - that makes it possible to distinguish mechanical intestinal obstruction from dynamic (in particular, from paresis of intestinal loops). In addition, with dynamic paralytic obstruction, peristalsis of intestinal loops is not observed. With fluoroscopy, it is not possible to notice the movement of the contents in the intestine and fluctuations in fluid levels. With mechanical obstruction, on the contrary, repeated pictures never copy those made earlier, the picture of the intestine changes all the time.

The presence of acute mechanical intestinal obstruction is established by two main features; swelling of the prestenotic part of the intestine and post-stenotic collapse.

These signs appear 1-2 hours after the onset of the disease, and after another 2 hours they usually become distinct.

It is important to distinguish between the obstruction of thin and thick to and sh to and. In the first case, the loops of the small intestine are swollen, and the large intestine is in a collapsed state. If it is not clear enough from the pictures, then you can

Rice. Sh.117. Plain radiograph of the abdomen. Acute mechanical obstruction of the small intestine. Intestinal loops are swollen with gas, they have numerous levels of fluid (indicated by arrows).

to produce retrograde filling of the colon with barium suspension. Swollen intestinal loops with small bowel obstruction occupy mainly the central parts of the abdominal cavity, and the caliber of each loop does not exceed 4-8 cm. Against the background of swollen loops, transverse striation is visible, due to expanded circular (kerkring) folds. Of course, there are no gaustral retractions on the contours of the small intestine, since they occur only in the large intestine.

With obstruction of the colon, there are huge swollen loops with high gas bubbles in them. The accumulation of fluid in the intestine is usually small. Gaustral retractions are outlined on the contours of the intestine, arched rough semilunar folds are also visible. By injecting a contrast suspension through the rectum, it is possible to clarify the location and nature of obstruction (for example, to detect a cancerous tumor that led to a narrowing of the intestine). We only point out that the absence of radiological signs does not exclude intestinal obstruction, since in some forms of strangulation obstruction, the interpretation of the x-ray picture can be difficult. In these cases, it is of great help sonography and CT scan. They make it possible to detect stretching of the prestenotic part of the intestine, a break in its image at the border with the collapsed poststenotic part, and a shadow of nodulation.

Diagnosis of acute intestinal ischemia and necrosis of the intestinal wall is especially difficult. When blocking the upper

mesenteric artery, there are accumulations of gas and fluid in the small intestine and in the right half of the large intestine, and the patency of the latter is not impaired. However radiography and sonography provide recognition of mesenteric infarction in only 25% of patients. At CT it is possible to diagnose a heart attack in more than 80% of patients on the basis of thickening of the intestinal wall in the area of ​​necrosis, the appearance of gas in the intestine, as well as in the portal vein. The most accurate method is angiography performed using spiral CT, magnetic resonance imaging, or catheterization of the superior mesenteric artery. The advantage of mesentericography is the possibility of subsequent directed transcatheter administration of vasodilators and fibrinolytics. Rational research tactics are presented in the diagram below.

With partial obstruction, re-examination after 2-3 hours is of great benefit. It is acceptable to introduce a small amount of water-soluble contrast agent through the mouth or nasojejunal probe (enterography). When inversion of the sigmoid colon to and sh-k and valuable data is obtained with an irri state copy. With adhesive obstruction, they resort to x-ray examination in different positions of the patient, registering areas of fixation of intestinal loops.

ACUTE INTESTINAL OBSTRUCTION

X-ray examination of the organs of the chest and abdominal cavities

X-ray contrast study (according to indications)

Sonography

No signs

obstruction

Sonography

The picture is unclear

obstruction

Delayed

X-ray

research or

sonography

No signs of obstruction

Angiography

CT or follow-up

Appendicitis. Clinical signs of acute appendicitis are known to every doctor. X-ray examination is a valuable way to confirm the diagnosis and is especially indicated for deviations from the typical course of the disease. The survey tactics is presented in the form of the following scheme.

sonography of the abdominal organs. Symptoms of acute appendicitis include expansion of the appendix, filling it with fluid, thickening of its wall (more than 6 mm), detection of stones in the appendix and its fixation, accumulation of fluid near the wall of the appendix and the caecum, hypo-echogenic image of the abscess, depression from the abscess on the intestinal wall , hyperemia of periappendicular tissues (with Doppler sonography).

The main radiological signs of acute appendicitis:
small accumulations of gas and fluid in the distal iliac
intestines and in the caecum as a manifestation of their paresis, thickening of the wall of the
sing the intestine due to its edema, thickening and rigidity of the mucosal folds
patches of this intestine, stones in the appendix, a small effusion in
abdominal cavity, swelling of the soft tissues of the abdominal wall, blurred outline
tania of the right lumbar muscle. Appendicular abscess
causes darkening in the right iliac region and depression on
wall of the caecum. Sometimes in the abscess and in the projection of the process is determined
There is a slight accumulation of gas. When the process is perforated, there may be chalk
bubbles of gas under the liver. sssssssssssss

CT is somewhat more effective than sonography and radiography in diagnosing acute appendicitis, making it possible to discuss with greater clarity the thickening of the appendix wall and appendicular abscess.

Ryas. Sh.118. Virtual endoscopy on a spiral computed tomograph. Spasmodic contractions of the descending and sigmoid colon in colitis.

In chronic appendicitis, appendix deformity, its fixation, fragmentation of its shadow in X-ray contrast examination or non-filling of the appendix with barium sulfate, the presence of stones in the appendix, the coincidence of the painful point with the shadow of the appendix are noted.

Intestinal dyskinesia. X-ray examination is a simple and affordable method for clarifying the nature of the movement of the contents through the loops of the small and large intestine and diagnosing various types of constipapia (constipation) (Fig. III.118).

Enterocolitis. In acute enterocolitis of various etiologies, similar symptoms are observed. Small bubbles of gas appear in the intestinal loops with short liquid levels. The promotion of the contrast agent is uneven, there are separate accumulations of it, between which constrictions are observed. The mucosal folds are thickened or not differentiated at all. For all chronic enterocolitis, accompanied by a syndrome of malabsorption (malabsorption), common symptoms are characteristic

signs: expansion of intestinal loops, accumulation of gas and liquid in them (hypersecretion), separation of the contrast mass into separate lumps (sedimentation and fragmentation of the contents). The passage of the contrast medium is slow. It is distributed unevenly over the inner surface of the intestine, small ulcerations can be seen.

Malabsorption. With it, the absorption of various components of food is disturbed. The most common diseases of the sprue group. Two of them - celiac disease and non-tropical sprue - are congenital, and tropical sprue - acquired. Regardless of the nature and type of malabeorbtion, the x-ray picture is more or less the same: the expansion of the loops of the small intestine is determined. They accumulate fluid and mucus. Because of this, the barium suspension becomes inhomogeneous, flocculates, divides into fragments, turns into flakes. The folds of the mucous membrane become flat and longitudinal. In a radionuclide study with trioleate-glycerol and oleic acid, malabsorption in the intestine is established.

Regional enteritis and graiulomatous colitis (Crohn's disease). With these diseases, any part of the alimentary canal can be affected.- from the esophagus to the rectum. However, the most commonly observed lesions are the distal jejunum and the proximal ileum (young and l e and t), the terminal ileum (terminal ileitis), and the proximal parts of the colon.