X-ray examination of the organs surrounding the pancreas. Relaxation duodenography

Duodenostasis is the development of duodenal obstruction of a physical or mechanical nature. Early diagnosis gives positive result treatment. Advanced forms lead to the need for surgical intervention. Adults are susceptible to the disease young(20–40 years), most often women.

The disease is characterized by painful sensations V different departments gastrointestinal tract, nausea, vomiting. Stagnation in the intestines leads to intoxication of the body, which is expressed fatigue, irritation, weight loss.

Main causes of duodenostasis

Nutrients necessary for human life come from food. The duodenum (duodenum) takes part in the process of digesting food, from where everything useful enters the blood. This section of the intestine is always in an active state (to a greater or lesser extent). If for some reason the food lump lingers in the duodenum, duodenostasis develops.

The disease is classified as follows:

1. Primary – the pathology is not associated with other problems, it arose on its own.
2. Secondary is the cause of others internal changes and pathological conditions that led to stagnation in the duodenum.

The causes of duodenostasis are varied. They can be divided into several groups:

Functional disorders

Associated with changes in work the following systems body:

• problems with nervous function;
• disruption of endocrine functioning;
• disruption of the digestive system.

Internal diseases

The occurrence of certain diseases leads to inconsistent management of the work of the duodenum. These include:

• inflammation of the gallbladder;
• stomach ulcer;
• inflammation in the pancreas;
• duodenal ulcer;
• duodenitis;
• gastritis.

Mechanical obstacles

The passage of food through the duodenum is hampered by obstacles, as a result of which duodenostasis develops. They are divided:

• external - the duodenum is compressed by various formations in abdominal cavity;
• internal - the lumen of the duodenum is clogged from the inside.

External obstacles include:

• tumors formed in the intestine itself or in organs located nearby;
• connective formations resulting from adhesive disease;
• compression of the mesentery by vessels with their atypical location;
• consequences of surgery;
• bend of the duodenum;
• abnormal development of the duodenum during pregnancy.

Internal obstacles:

• stones that have entered the initial part of the duodenum due to cholelithiasis;
• worms rolled up into balls.

Development of the disease

There are three stages of the disease:

1. Compensation - the contractile functions of the intestine change for a short period of time. Uncoordinated spasm and relaxation of individual areas occurs, as a result, intestinal motility is disrupted, and a backflow of contents into the duodenal bulb occurs.
2. Subcompensation – changes become permanent. This process involves the valve device and Bottom part stomach. The gatekeeper does not cope with the functions (remains open, although this should not be the case), which causes duodenogastric reflux(part of the food mass is thrown back into the stomach).
3. Decompensation - peristalsis of the duodenum is constantly impaired, the lower section is dilated. The bile ducts and pancreas become inflamed. The return of intestinal contents to the stomach leads to inflammation of its mucosa. The circle closes.

A disease of the digestive system contributes to the development of duodenostasis, an increase in its manifestations leads to a worsening of the condition and the appearance of other pathologies.

Characteristic symptoms

From initial signs It takes several weeks for the disease to reach the stage of decompensation. In rare cases, patients live with untreated pathology for many years. But the more time the duodenum is in an altered state, the more difficult it is subsequently to treat the pathology.

Characteristic symptoms of duodenostasis:

• dyspeptic symptoms are associated with changes in the functioning of the digestive system;
• intoxication – deterioration of health due to poisoning of the body.

Dyspeptic signs

Symptoms:

• stomach ache;
• nausea;
• vomiting manifestations;
• regurgitation;
• discomfort due to gas accumulation.

Description of the nature of the pain:

• appear after eating (half an hour or a little more);
• manifest themselves in attacks, spasms, when they temporarily stop, the person notices relief;
• are felt in the hypochondrium with right side, in the pit of the stomach;
• at the first stage the pain stops after vomiting attacks, later this does not happen.

Description of the nature of nausea:

• has a constant exhausting manifestation, especially in the third stage;
• V initial period weakens after vomiting, when the situation worsens this no longer happens;
• reduces appetite, the patient loses weight.

Description of the nature of vomiting:

• eating food provokes a gag reflex;
• at the beginning of the illness it becomes easier; during the period of decompensation, pain and nausea after vomiting do not go away;
• vomit mixed with bile.

Regurgitation is a lighter version of vomiting. In the future, as the pathology progresses, the first symptom will certainly develop into the second.

Intoxication signs

Symptoms of body poisoning are associated with the fact that food debris remains in the duodenum for longer than expected, fermentation occurs, and toxic products enter the blood. This is expressed as follows:

• fatigue sets in quickly during light work;
• the patient becomes irritated or falls into an apathetic state;
• aversion to food and exhaustion occur.

If treatment is not started on time, intoxication leads to damage to the heart, kidneys, and ultimately death.

Diagnostic methods used

Specific patient complaints indicating symptoms do not allow a quick and accurate diagnosis. Most gastrointestinal diseases have similar symptoms. When determining the disease, consultations with a gastroenterologist, surgeon, and endoscopist are required.

Apply following methods diagnostics:

1. Esophagogastroduodenoscopy can reveal a gaping valve device, the return of duodenal contents to the stomach, dilatation of the intestine and its inability to contractile function.
2. Endoscopic biopsy reveals dystrophic changes in the intestine, leading to aggravation of the situation.
3. Barium passage X-ray identifies the area of ​​the intestine through which the movement of contents is difficult. A delay of more than 40 seconds is considered a deviation from the norm.
4. Relaxation duodenography: with the help of anticholinergics, the duodenum is brought into a hypotonic state and its capabilities are tested using drunk barium.
5. Antroduodenal manometry confirms decreased activity and expansion of the duodenum.
6. Duodenal sounding reveals the degree stagnation in the gut.
7. The study of the contents of the duodenum determines the degree of intoxication of the body.
8. Ultrasound examination reveals the presence mechanical reasons pathology.
9. Mesentericography allows you to detect tumors, vascular abnormalities, adhesions, and stones. This is necessary to determine treatment tactics.

To compile a general picture of the disease, laboratory methods are used:

• According to a blood test, the pathology is confirmed by an increase in ESR and leukocytosis;
• urine analysis reveals the level of poisoning in the body and kidney damage by changes in red blood cell counts, specific gravity urine.

Differential diagnosis allows you to separate the following diseases from duodenostasis:

• gastritis in acute form and acute chronic stage;
• acute and aggravated chronic duodenitis;
• stomach ulcer;
• duodenal ulcer;
• adhesions in the abdominal cavity.

Treatment of duodenostasis

Treatment of this pathology begins with the use of conservative methods regardless of the stage at which the disease was diagnosed. In case of decompensation, such an approach prepares the patient for surgical intervention(improves intestinal condition, removes substances that contribute to poisoning of the body).

Drugs

At drug therapy prescribe:

• prokinetics - drugs that change intestinal motility (Itomed, Motilium, Domidon);
• antispasmodics for relief pain syndrome for chronic duodenal obstruction (“Drotaverine”, “No-shpa”);
• drugs to reduce acidity (Maalox) and to reduce secretions of hydrochloric acid(“Ranitidine”);
• vitamins to support a depleted body.

Except medicines, appoint:

1. Diet - eat small portions at least 5 times a day. Food should be nutritious, fortified, but with a minimum amount of fiber.
2. Therapeutic gymnastics - feasible physical exercise strengthen muscles, which has a positive effect on intestinal health.
3. Self-massage of the abdomen enhances the contraction of the intestinal walls and the movement of chyme through the duodenum.
4. Intestinal lavage relieves poisoning of the body and improves contractile function. Using a probe that has two channels, 300–350 ml of mineral water is introduced into the duodenum and simultaneously removed.

Folk remedies

Facilities traditional medicine Use only with the permission of the attending physician. Use herbs that have these properties.

The duodenum is one of the organs accessible to x-ray examination, therefore many diseases of this organ can be detected during a routine x-ray contrast examination.

What does this research reveal?

Since the topographic-anatomical relationship of the duodenum with the biliary system (biliary tract) is particularly close, using this procedure it is also possible to identify pathologies developing in the structures:

• big duodenal papilla;
• pancreas;
• terminal section of the common bile duct;
• gallbladder.

However, during the traditional x-ray examination Gastrointestinal tract using barium suspension, the area of ​​the major duodenal papilla, containing the final sections of the pancreatic and common bile ducts opening into it, does not fall into the field of view of the specialist performing the procedure.

This type of study also does not reveal changes in the duodenum caused by pressure on its walls exerted from the outside, gallbladder or an enlarged head of the pancreas.

The above-mentioned difficulties that make it difficult to study individual characteristics duodenum, are explained by the too rapid passage of a radiopaque substance through it.

A real breakthrough in radiology in 1955 was made by the Argentine surgeon Liotta, who proposed combining the supply (through a probe) of a barium suspension into the duodenum with simultaneous hypotension of this organ, caused by the administration of anticholinergic (the so-called substances that interfere with the conduction of nerve impulses) drugs.

This procedure is called an X-ray examination of the duodenum under conditions of artificial hypotension (relaxation) or hypotonic (relaxation) duodenography.

With the help of relaxation duodenography, radiologists can:

• Check availability tumor process in the structures of the papilla of Vater and the head of the pancreas, thereby confirming the mechanical etiology of the developed jaundice.
• Diagnose the presence of bilioduodenal.
• To draw a conclusion about the work of bilioduodenal anastomoses formed in patients who underwent surgery for biliary tract. Thanks to discovery pathological processes, occurring in the tissues and lumen of the hepatobile duct, doctors are able to establish the causes of relapses of suffering.
• Reveal chronic pancreatitis.

Indications

The relaxation duodenography procedure is used if:

• clinical suspicion of any disease of the duodenum;
• anemia ( pathological condition, characterized by a significant decrease in the number of red blood cells and the level of hemoglobin in the blood) of unknown etiology;
• pathologies of the pancreas, liver and diaphragm;
• disorders of the motor-evacuation function of the gastrointestinal tract;
• suspicions of (occurring in infiltrative form) that arose during endoscopic examination;
• from the gastrointestinal tract, reflected in the anamnesis;
• jaundice of unknown origin;
• suspicions about .

Duodenography also allows for dynamic monitoring of patients suffering from organic diseases duodenum.

Contraindications

The procedure is absolutely contraindicated:

• patients in serious condition;
• at gastrointestinal bleeding, which opened shortly before the scheduled study;
• in the presence of severe vomiting.

Preparation

When consulting the patient on the eve of the scheduled procedure, the attending physician must explain to him:

1. Purpose of the study.
2. Where and by whom it will be held.
3. The sequence and essence of the upcoming medical manipulations. The patient must be aware that during the study, a radiopaque substance (barium sulfate solution) and a certain amount of air will be introduced into his body through a special catheter.
4. That the introduction of air into the lumen of the intestine under study may be accompanied by the occurrence of painful sensations. In this case, to relieve pain, the patient will have to breathe slowly and deeply through the mouth, since such breathing will promote maximum relaxation of the muscles of the anterior abdominal wall.
5. Probability of occurrence side effects caused by the administration of an anticholinergic drug or glucagon. Exposure to an anticholinergic drug may cause severe thirst, dry mouth, temporary visual impairment, tachycardia and urinary retention. Glucagon can cause nausea, vomiting, flushing (redness) of the face and skin rash(like urticaria).
6. Necessity:

• the presence of any acquaintances or relatives who, after the end of the procedure, could accompany the patient home;
• refrain from eating any food during the night hours preceding the scheduled study (a light dinner should take place before 19:00);
• bowel movements before the procedure;
• complete abstinence from drinking liquids, food and smoking on the day of the study (otherwise the procedure will give biased results).

Before undergoing duodenography, the patient may be prescribed a preliminary examination, including:

• careful collection of medical history (information about any operations ever undergone is of particular value);
• consultation with specialized specialists (primarily oncologist and gastroenterologist);
• performing esophagogastroduodenoscopy;
• taking tests: blood (general, biochemical and tumor markers) and urine (general).

How is duodenography performed?

Before performing the procedure, the patient will be asked to remove metal hair clips and hairpins from his hair, dentures from his mouth, and remove jewelry, glasses and clothing with decorative metal elements.

The duodenography procedure can be carried out in two versions: with and without the use of a duodenal probe. The first version of the study is carried out as follows:

• Having sat the patient down and monitoring the actions using the X-ray machine monitor, a thin probe with a metal olive at the end is inserted into his stomach through one of the nasal passages (in some clinics they prefer not to use an olive, believing that without it it is easier for the probe to pass through the pylorus).
• With the patient lying on his back and continuing to act under the control of the translucent screen, the probe is advanced into the vertical (descending) branch of the duodenum.
• To relax the intestine under study, anticholinergic drugs are used to help reduce its motor activity: the patient is injected intravenously with 1-2 ml of a 0.1% atropine solution or intramuscularly with 3-5 ml of a 0.1% solution of metacin (the dosage is calculated taking into account body weight).
• Twenty minutes later, the mucous membranes of the duodenum are irrigated with a 2% solution of novocaine (10-15 ml is required).
• After ten minutes, the patient is placed on the X-ray table and, using a Janet syringe under slight pressure, using a probe, a liquid barium suspension (250-300 ml) at room temperature is injected into the duodenum. The introduction of a suspension helps to achieve tight and uniform filling of the intestine under study along its entire length, which persists for a long time.
• During the study, the patient is placed on his back, stomach, left and right side, taking a series of radiographs. The film used, which has parameters of 24x30 cm, allows you to capture not only the examined intestine, but also the organs located next to it.
• After examining the condition of the walls of the duodenum, air is blown through the duodenal tube (300-350 cm 3). Thanks to this manipulation, the contrast mass moves into the lumen of the jejunum, and the radiologist takes another series of radiographic images that help to get an idea of ​​the pneumorelief of the organ under study, which helps identify existing pathological changes in the structures of the intestinal walls.
• After completing the study, carefully remove the probe. Relaxation of the duodenum, artificially created with the help of novocaine and metacin, persists for thirty to forty minutes, after which its motor function is restored in full.

To prevent the possibility of unwanted side effects, the radiologist is obliged to monitor the condition of his patient during the examination.

If anticholinergic drugs were used to relax the test bowel, medical staff must ensure that the patient urinates during the first hours after the procedure.

Outpatients who come to the clinic without an accompanying person should, if possible, spend at least two hours in emergency room: until their vision is fully restored.

A patient who has undergone duodenography receives a recommendation to drink as much fluid as possible (of course, provided there are no contraindications), which will help accelerate the removal of barium from the body. Some patients will require laxatives after duodenography.

Before the patient leaves the X-ray room, the doctor must warn him about the likelihood of developing flatulence and belching air, as well as the inevitable release of discolored feces, the consistency of which will resemble lime for 24-72 hours.

The patient is advised to pay attention to the consistency and color of his stool. If after this period its character does not change (this indicates that barium continues to remain in the intestines), the patient must definitely inform his doctor about this.

Duodenal hypotension can be created without the use of a probe: it is enough to take one or two Aeron tablets and place them under the tongue.

In some cases, aeron may be added to water solution barium sulfate. It has been established that sufficient atony of the duodenum occurs within fifteen to twenty minutes after taking the above drug.

The probeless version of duodenography, of course, is much easier to tolerate by patients, but the relaxation of the examined intestine, achieved with the help of a probe, is more stable and consistent.

In addition, it allows you to regulate the rate of introduction of the radiopaque substance and its volume, as well as the possibility of pumping air into the intestinal lumen, which gives greater expressiveness to the X-ray picture.

Decoding norms and deviations

The normal indicator on the resulting radiograph is considered to be:

• V-shaped or U-shaped shape of the intestine under study, due to the action of anticholinergic drugs that contribute to the temporary shutdown of its motor activity;
• uniformity and smoothness of the mucous membranes of the hypotonic duodenum, the walls of which were stretched due to the introduction of air and barium sulfate solution;
• the presence of jagged outlines of folds of the mucous membrane, located circularly;
• the smoothness of the contours of the intestinal walls surrounding the head of the pancreas, which has no signs of pathological changes;
• increase in the diameter of the duodenum to 50-60 mm;
• the presence of uniform transverse keyboard striations formed by clearing of the folds of the mucous membrane.

The major duodenal papilla is detected in only 30% of patients.

Deviations from the norm on an x-ray may include:

• Irregular outlines of the walls of the examined intestine, distorted by the presence of nodules and protrusions. This radiological sign may indicate the presence of chronic pancreatitis, a tumor of the head of the pancreas or the hepatopancreatic ampulla.
• A number of signs indicating the likelihood of pancreatic diseases:
  • unfolding of the intestinal loop;
  • the presence of depressions on the medial contour of the descending part of the intestine being examined;
  • double-circuitry of the intestinal walls (referred to as the “backstage symptom”);
  • specific deformation of internal contours (the so-called “inverted Frostberg triple” symptom);
  • the presence of pancreatic and bile reflux;
  • an increase in the shadow of the major duodenal papilla, due to the presence of edema or tumor.

To be sure preliminary diagnosis it is necessary to carry out a number of additional diagnostic procedures And laboratory research, For example:

• endoscopic retrograde cholangiopancreatography (ERCP);
• computed tomography (CT) or ultrasound examination(ultrasound) of the pancreas;
• an analysis aimed at determining amylase activity in urine and blood serum.

Precautionary measures

Several decades of practical use have proven that the relaxation duodenography procedure does not cause complications, and precautions may be required due to the presence of certain diseases.

• The administration of anticholinergic (cholinolytic) drugs is contraindicated in patients with glaucoma and severe diseases of the heart muscle.
• The use of glucagon is absolutely contraindicated in patients with insufficiently compensated diabetes mellitus, and in relation to patients suffering from type I diabetes mellitus, it should be used with great caution.
• The relaxation duodenography procedure is absolutely contraindicated for stenoses of the upper gastrointestinal tract, provoked either by a large and voluminous neoplasm, or by the presence of an ulcer.

The relaxation duodenography procedure can provoke the development of gastroesophageal reflux in elderly patients and in patients suffering from severe pathologies.

If you ignore the ban on eating food several hours before the scheduled procedure, the results of the study may be unreliable.

To clarify the nature of the narrowing of the duodenum (functional or mechanical), 1.0 ml of a 0.1% solution of atropine sulfate or 4 ml of a 0.1% solution of metacin was injected under the skin 30 minutes before the study.

This reduced the possibility of errors in the interpretation of the results.

At the first stage of the study, fluoroscopy of organs was performed chest. At the same time, the height of the domes of the diaphragm was assessed, the subdiaphragmatic spaces were examined, and a survey fluoroscopy of the abdominal organs was performed. Attention was paid to the presence of fluid levels in the intestinal loops and free fluid in the stomach on an empty stomach.

If a patient’s esophagogastroduodenoscopy did not reveal signs of stenosis of the gastric outlet, then we considered an increase in its size and the presence of fluid and a large amount of bile in the lumen on an empty stomach as one of the signs of a mechanical obstruction in the duodenum. If there was a lot of fluid in the stomach, then before taking the contrast suspension it was probed and the fluid was evacuated.

Then, under the control of an electron-optical converter, the patient ingested 50-100 ml of barium suspension, while the passage of the contrast through the esophagus and its entry into the stomach was observed, and a change in the pattern of the mucous membrane was noted. After which, the patient drank 300 ml of a liquid suspension of barium sulfate.

The study was carried out in the direct and lateral planes. Often for better visualization various departments We used polypositional fluoroscopy of the duodenum, which was supplemented with survey and targeted radiography. If necessary, dosed compression was performed on the anterior abdominal wall.

To study the postbulbar section of the duodenum and the place of its transition to the jejunum, the patient was turned into the right oblique position, since in the direct projection these sections are often covered by the shadow of the contrasted stomach.

If necessary, to examine the area of ​​the duodeno-jejunal junction, moderate compression was used on the anterior abdominal wall, while the stomach was shifted upward.

To study the relief of the mucous membrane, a loofah was placed on the duodenum.

During the study, we consistently paid attention to: the presence of gastroesophageal reflux, studied the pattern of the gastric mucosa, the elasticity of its walls, especially in the antrum, the time of onset and type of evacuation of the contrast agent from it, the presence
duodenogastric reflux, size, shape, pattern of the mucous membrane, degree of expansion of the lumen of the duodenum, changes in the timing of the start of contrast evacuation into the small intestine.

Normally, the diameter of the duodenum was 1-2 cm. Even under relaxation conditions, the barium suspension entered the duodenal bulb in portions and quickly passed through all its sections into the first loop of the jejunum. At the same time, a small amount of contrast agent remained in the lumen of the duodenum between the folds of the mucous membrane, giving it a feathery pattern. The evacuation of contrast into the small intestine normally begins at 30 seconds.

The change in the tone of the pylorus was expressed in a violation of its closure function, which led to the reflux of duodenal contents into antrum stomach.

Changes in the plastic tone of the duodenum were observed in three types: hypertonic, hypotonic and atonic.

X-ray signs of changes in the tone of the duodenum according to hypertensive type there was increased peristalsis with frequent antiperistaltic waves, while the intestinal diameter was normal (up to 2 cm).

The hypotonic type was characterized by slow passage of barium suspension through all parts of the duodenum, expansion of its lumen from 2 to 3 cm and slower evacuation of contrast into the jejunum.

With atony, the lumen of the duodenum was expanded by more than 5 cm, reaching in some cases 6-10 cm in diameter. Peristalsis was characterized by a small amplitude of rare and irregular contractions of the duodenal wall.

Inflammation and degenerative changes in the muscle layer and nerve plexuses of the duodenal wall observed with mechanical CDN led to changes in the pattern of the mucous membrane. At the same time, in areas of compression

folds of the mucous membrane took longitudinal direction or the pattern of the mucous membrane was completely absent. The folds of the duodenal mucosa looked swollen and dilated.

Greek graphō write, depict; lat. relaxatio relaxation, reduction)

X-ray contrast examination of the duodenum under conditions of artificial hypotension. Used to diagnose diseases of the duodenum and adjacent organs (head of the pancreas, terminal department common bile duct). The study is carried out on an empty stomach. The subject under fluoroscopy control top part a probe is inserted into the duodenum. Then (to reduce muscle tone) one of the anticholinergic drugs is administered (1-2 ml 0.1% atropine solution in 1-10 ml 10% calcium gluconate solution intravenously, 3-6 ml 0.1% metacin solution or 1-2 ml% aprofen solution subcutaneously or intramuscularly). After 10-15 min the patient is laid down and the duodenum is filled through a probe with a warm suspension of barium sulfate (50 G barium sulfate at 150 ml water). Pictures are taken in direct and oblique projections ( rice .). Then the probe is inflated and the images are repeated under double contrast conditions.

Relaxation duodenography can also be performed using a probeless method during a routine X-ray examination of the gastrointestinal tract. To do this, after examining the esophagus and stomach, the subject is administered an anticholinergic drug and allowed to swallow an additional portion (150-200 ml) barium suspension.

Complications with D. r. not noted. May be observed adverse reactions associated with the administration of anticholinergic drugs (dry mouth, impaired accommodation), which go away on their own after 30-60 min. The use of atropine and aprofen is not indicated for patients with coronary circulation disorders or glaucoma.

X-ray of the duodenum in conditions of its artificial hypotension: for cancer of the papilla of Vater; the arrow indicates the tuberous contrast in the descending part of the intestine">

Rice. b). X-ray of the duodenum in conditions of its artificial hypotension: for cancer of the papilla of Vater; The arrow indicates a tuberous contrast defect in the descending part of the intestine.

1. Small medical encyclopedia. - M.: Medical encyclopedia. 1991-96 2. First health care. - M.: Great Russian Encyclopedia. 1994 3. encyclopedic Dictionary medical terms. - M.: Soviet encyclopedia. - 1982-1984.

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