Additional methods for examining the organs of the gastrointestinal tract. Examination of the gastrointestinal tract: research methods, X-ray examination

The appointment of examinations of the gastrointestinal tract is based on the symptoms presented by the patient, and in order to control and prevent diagnosed chronic diseases of the gastrointestinal tract. Indications for diagnostic procedures can be: difficult and painful digestion (dyspepsia), regular nausea, vomiting, heartburn, stomach pain, suspicion of oncopathology.

To date, the most accurate examination of the gastrointestinal tract is fibrogastroduodenoscopy. During FGDS, the gastroenterologist has the opportunity to assess in detail the condition of the mucous membrane of the stomach and duodenum, and to make the only correct diagnosis. The difficulty of the examination is the inability of some patients to swallow the flexible hose equipped with a video camera.

Many people ignore the procedure precisely because of the uncomfortable sensations. Therefore, it will be useful to find out how to check the stomach without gastroscopy in order to diagnose one or another pathology in a timely manner. In addition to the autonomic bias towards EGD, there are a number of contraindications to its conduct: a history of hemostasis (blood clotting) disorders, bronchial asthma, and emetic hyperreflex.

In such cases, other methods of examination of the stomach are prescribed. Diagnosis of diseases and abnormalities in the work of the stomach is carried out in three main areas: physical complex of measures, laboratory examination of patient analyzes, examination by means of medical diagnostic equipment, alternative endoscopy.

Simple diagnostics

Simple diagnostic methods are mandatory when a patient complains of an acute abdomen, nausea and other symptoms of gastric diseases.

Physical examination

Physical activities are carried out at a doctor's appointment, the results depend on the qualifications of the medical specialist. The complex includes:

• study of the anamnesis, assessment of symptoms according to the patient's words;
• visual examination of mucous membranes;
• feeling painful areas of the body (palpation);
• palpation in a specific position of the body (percussion).

Based on the results obtained during such an examination, it is extremely difficult to diagnose the disease. The doctor may suspect the presence of pathology, but deeper research methods are needed to confirm it.

Microscopic laboratory diagnostics

Laboratory methods consist in taking tests from the patient for further study and evaluation of the results. Most often, the following physical and chemical studies are assigned:

• general urine analysis;
• coprogram (feces analysis);
• clinical blood test. The number of all types of blood cells (erythrocytes, leukocytes, platelets) is counted, the level of hemoglobin is determined;
• gastropanel. This blood test is aimed at studying the state of the gastric mucosa. According to its results, it is established: the presence of antibodies to Helicobacter pylori bacteria, the level of pepsinogen proteins produced, the level of the polypeptide hormone - gastrin, which regulates the acidic environment in the stomach;
• blood biochemistry. Quantitative indicators of bilirubin, liver enzymes, cholesterol and other blood cells are established.

Blood sampling for clinical analysis is carried out from the finger

Analyzes help to identify inflammatory processes and other disorders of the functioning of organs and systems. If the results differ significantly from the standard indicators, the patient is assigned an instrumental or hardware examination.

Applying hardware techniques

Examination of the stomach without gastroscopy is carried out with the participation of special medical devices. They record the state of the mucous membrane, density, size and other parameters of the organ, and transmit information that is subject to subsequent decoding by a specialist.

• X-ray examination (using contrast);
• CT and MRI (computed and magnetic resonance imaging);
• EGG (electrogastrography) and EGEG (electrogastroenterography);
• Ultrasound (ultrasound examination).

With a gastric examination by hardware, all manipulations are performed without direct intervention in the body, without damaging the external tissues of the body (non-invasively). The procedures do not cause painful sensations in the patient.

The significant disadvantages of the method include low information content in the initial period of the disease, exposure to X-rays, which is unsafe for health, and side effects from taking a barium solution.

X-ray with contrast

The method is based on the use of X-rays. To improve visualization of the stomach, the patient drinks a barium solution before the examination. This substance plays the role of contrast, under the influence of which soft tissues acquire the ability to absorb X-rays. Barium darkens the organs of the digestive system in the picture, which makes it possible to detect possible pathologies.

X-rays help in identifying the following changes:

• incorrect arrangement of organs (displacement);
• the state of the lumen of the esophagus and stomach (enlargement or narrowing);
• non-compliance of bodies with regulatory sizes;
• hypo- or hypertonicity of the muscles of the organs;
• a niche in the filling defect (most often, this is a symptom of a peptic ulcer).

CT scan

In fact, this is the same X-ray, only modified, with advanced diagnostic capabilities. The examination is carried out after pre-filling the stomach with liquid for a clearer view.

In addition, an iodine-based contrast agent is injected intravenously to isolate blood vessels on a tomogram. CT, as a rule, is used when there is a suspicion of tumor processes of oncological etiology. The method allows you to find out not only whether a patient has stomach cancer and its stage, but also the degree of involvement of adjacent organs in the oncological process.

The imperfection of diagnosis consists in the exposure of the patient to X-rays, possible allergic reactions to contrast, as well as the inability of CT to complete and detailed study of the digestive tract, since its hollow tissues are difficult to diagnose with CT. The procedure is not performed for women during the perinatal period.

MRI tomography

The prerogative aspects of MRI are the use of magnetic waves that are safe for the patient, the ability to determine the initial stage of gastric cancer. In addition, this diagnosis is prescribed for suspected ulcers, intestinal obstruction and gastritis, to assess the adjacent lymphatic system, to detect foreign objects in the gastrointestinal tract. The disadvantages include contraindications:

• body weight 130+;
• the presence of metal medical items in the body (vascular clips, pacemaker, Ilizarov apparatus, inner ear implant prostheses);
• rather high cost and inaccessibility for peripheral hospitals.

Examination of the gastrointestinal tract on a magnetic resonance imager is more often performed with contrast

EGG and EGEG

Using these methods, the stomach and intestines are assessed during the period of peristaltic contractions. A special device reads the pulses of electrical signals that come from the organs when they contract during the digestion of food. It is practically not used as an independent research. Applied only as an auxiliary diagnosis. The disadvantages are the long time period of the procedure (about three hours) and the inability of the electrical device to establish other diseases of the gastrointestinal tract.

Ultrasound

Ultrasound diagnostics of the stomach is most often carried out as part of a comprehensive examination of the abdominal organs. However, unlike the indicators of other organs (liver, pancreas, gallbladder, kidneys), it is not possible to fully examine the stomach. There is no full picture of the organ.

In this regard, the list of diagnosed diseases is limited:

• abnormal change in the size of the organ, edema of the walls;
• purulent inflammation and the presence of fluid in the stomach;
• limited accumulation of blood in case of damage to an organ with rupture of blood vessels (hematomas);
• narrowing (stenosis) of the lumen;
• tumor formations;
• bulging of the walls (diverticulosis) of the esophagus;
• intestinal obstruction.

Ultrasound examination of the abdominal organs is desirable to be carried out annually

The main disadvantage of all hardware diagnostic procedures is that a medical specialist examines only external changes in the stomach and adjacent organs. At the same time, it is impossible to determine the acidity of the stomach, to take tissue for further laboratory analysis (biopsy).

Supplement to hardware diagnostics

An additional method is Acidotest (taking a combined medicinal product to establish approximate indicators of the pH of the gastric environment). The first dose of the medication is taken after the bladder has been emptied. After 60 minutes, the patient takes a urinalysis and takes a second dose. An hour and a half later, urine is taken again.

Do not eat for eight hours before testing. According to the analysis of urine, the presence of a dye in it is revealed. This allows you to roughly determine the acidity of the stomach without gastroscopy. The acidotest does not give 100% effectiveness, but only indirectly indicates a low (increased) level of acidity.

Alternative endoscopy

Capsular endoscopy is the closest to FGDS in terms of information content. The examination is carried out without swallowing the probe, and at the same time reveals a number of pathologies that are inaccessible to hardware procedures:

• chronic ulcerative and erosive lesions;
• gastritis, gastroduodenitis, reflux;
• neoplasms of any etiology;
• helminth invasions;
• inflammatory processes in the small intestine (enteritis);
• the cause of systematic digestive upset;
• Crohn's disease.

The diagnostic method is carried out by introducing a capsule with a scanty video camera into the patient's body. There is no need for an instrumental introduction. The weight of the micro-device does not exceed six grams, the shell is made of polymer. This makes it easy to swallow the capsule with plenty of water. These video cameras are transmitted to a device mounted on the patient's waist, the readings from which the doctor removes in 8-10 hours. At the same time, the rhythm of a person's usual life does not change.

Gastric endoscopic capsule

Removal of the capsule occurs naturally during bowel emptying. The significant disadvantages of the technique include: the inability to conduct a biopsy, the extremely high cost of the examination. All methods of diagnostics of the gastrointestinal tract provide for the preliminary preparation of the body. First of all, it concerns nutrition correction.

The diet should be lightened a few days before the examination. Hardware procedures are possible only on an empty stomach. The stomach can be checked using any method that is convenient and not contraindicated for the patient. However, the palm tree in terms of information content, and therefore the maximum accuracy of the diagnosis, remains with EGD.

According to medical statistics, 95% of the world's inhabitants need regular monitoring. Of these, more than half (from 53% to 60%) are firsthand familiar with chronic and acute forms (inflammatory changes in the gastric mucosa), and about 7-14% suffer.

Symptoms of gastric pathology

The following manifestations may indicate problems in this area:

• pain in the stomach, a feeling of fullness, heaviness after eating;
• pain in the sternum, in the epigastric region;
• difficulty swallowing food;
• feeling of a foreign body in the esophagus;
• belching with a sour taste;
• heartburn;
• nausea, vomiting of undigested food;
• vomiting mixed with blood;
• increased gas formation;
• black feces, bleeding during bowel movements;
• attacks of "wolf" hunger / lack of appetite.

Of course, a serious indication for a gastroenterological examination is the previously identified pathologies of the digestive system:

• inflammatory processes;
• oncological diseases, etc.

Diagnosis of stomach diseases

Diagnosis of stomach diseases is a whole complex of studies, including physical, instrumental, laboratory methods.

Diagnostics begins with a survey and examination of the patient. Further, based on the collected data, the doctor prescribes the necessary research.

Instrumental diagnosis of stomach diseases involves the use of such informative methods as:

• CT scan;

The complex of laboratory methods for diagnosing stomach diseases, as a rule, includes:

• general blood analysis;
• blood chemistry;
• general analysis of urine, feces;
• gastropanel;
• PH-metry;
• analysis for tumor markers;
• breath test for.

General blood analysis ... This study is indispensable for assessing health in general. When diagnosing diseases of the gastrointestinal tract by changes in indicators (ESR, erythrocytes, leukocytes, lymphocytes, hemoglobin, eosinophils, etc.), one can state the presence of inflammatory processes, various infections, bleeding, and neoplasms.

Blood chemistry ... The study helps to identify abnormalities in the functions of the gastrointestinal tract, to suspect an acute infection, bleeding or growth of a neoplasm in the subject.

General urine analysis ... According to characteristics such as color, transparency, specific gravity, acidity, etc., as well as the presence of inclusions (glucose, blood or mucous inclusions, protein, etc.), one can judge the development of an inflammatory or infectious process, neoplasms.

General analysis of feces ... The study is indispensable in diagnosing bleeding, digestive dysfunction.

Tumor markers ... To detect malignant tumors of the gastrointestinal tract, specific markers are used (CEA, CA-19-9, CA-242, CA-72-4, M2-PK).

PH-metry ... This method allows you to obtain data on the level of acidity in the stomach using flexible probes equipped with special measuring electrodes, which are inserted into the stomach cavity through the nose or through the mouth.

It is carried out in cases when the doctor needs this indicator to make a diagnosis, to monitor the patient's condition after gastric resection, as well as to assess the effectiveness of drugs designed to lower or increase the acidity of gastric juice.

PH-metry is carried out in a medical institution, under the constant supervision of a doctor.

Gastropanel ... A special set of blood tests to help assess the functional and anatomical state of the gastric mucosa.

The gastroenterological panel includes the most important indicators for the diagnosis of gastric pathologies:

• antibodies to Helicobacter pylori (these antibodies are detected in patients suffering from gastritis, duodenitis, peptic ulcer disease);
• gastrin 17 (a hormone that affects the regenerative function of the stomach);
• pepsinogens I and II (the level of these proteins indicates the state of the mucous membrane of the body of the stomach and the organ as a whole).

How to prepare for tests

Urine, feces tests ... The biomaterial is collected in a special sterile container (purchased at a pharmacy). The day before, it is not recommended to drink multivitamins and consume foods that can change the color of the biomaterial, as well as laxative and diuretic drugs.

Urine is collected in the morning, after careful hygiene of the external genital organs. It is necessary to drain the first dose of urine into the toilet, and collect the middle portion (100-150 ml) in a container.

Feces are collected in the morning or no later than 8 hours before the analysis.

Gastropanel ... A week before the study, you should stop taking drugs that can affect the secretion of the stomach. For a day, exclude the use of funds that neutralize hydrochloric acid. On the morning of the analysis, do not drink, eat, or smoke.

The study consists of donating blood from a vein in two steps: immediately upon arrival at the treatment room and 20 minutes after taking a special cocktail designed to stimulate the hormone gastrin 17.

Blood tests (general, biochemical) ... Blood for research is donated in the morning on an empty stomach. On the eve of the analysis, you should avoid stress, refrain from eating heavy food, alcohol. On the morning of the analysis, you must not eat or smoke. The use of pure water is allowed.

PH-metry. The probe is installed in the morning on an empty stomach. At least 12 hours should have passed since the last meal, and you can drink water no later than four hours before the procedure. Be sure to warn the doctor about the medications you are taking before the planned study; they may have to be canceled several hours (and some drugs - several days) before the procedure.

Subjective examination of the patient

Subjective examination patients with diseases of the digestive system includes such traditional sections as:

Passport part,

Patient complaints

History (anamnesis) of the present disease,

History (anamnesis) of the patient's life.

Patient complaints

The complaints of patients with diseases of the gastrointestinal tract (GIT) are very diverse and depend on which part of the digestive tract is involved in the pathological process.

To complaints characteristic of diseases of the esophagus, include dysphagia, pain along the esophagus (single phagia), heartburn, esophageal vomiting, and esophageal bleeding.

Dysphages I am- this is the difficulty or inability to completely swallow the food taken. Distinguish oropharyngeal (oropharyngeal) and esophageal (esophageal) dysphagia.

Oropharyngeal dysphagia occurs at the very first swallowing movements and is often combined with the ingress of food into the nasal cavity, larynx. In this case, the patient develops a cough. It happens with some diseases of the oral cavity, larynx, or more often with damage to the nervous system.

Esophageal dysphagia occurs, as a rule, after several swallowing acts and is accompanied by unpleasant sensations along the esophagus. This type of dysphagia occurs in esophageal cancer, scarring after a burn of the esophagus with alkalis or acids, and ulcers of the esophagus. In addition, dysphagia can also be observed when the esophagus is compressed by an aortic aneurysm or a mediastinal tumor. Unlike dysphagia caused by organic diseases, functional dysphagia is also distinguished due to esophageal spasm, esophageal dyskinesia, achalasia of the cardia (impaired relaxation of the cardiac sphincter). It is possible to distinguish these two forms from each other on the basis of careful questioning of the patient and instrumental research methods.

At organic dysphagia difficulty in swallowing food through the esophagus is usually permanent. With the progression of the disease, which caused the phenomenon of dysphagia, there is a gradual increase in it up to a complete retention of not only solid, but also liquid food.

For functional dysphagia Difficulty swallowing liquid food, water, is characteristic, while solid food passes freely. Often, functional dysphagia is of a fickle nature, appears in any stressful situations. However, it should be remembered that the diagnosis of functional dysphagia is eligible only after a thorough instrumental examination and exclusion of all organic causes of the disease.

Dysphagia can be combined with painful sensations along the esophagus(odonophagy ). This happens with burns of the esophageal mucosa, inflammation of the esophagus (esophagitis), tumors of the esophagus and mediastinum.

With a sharp narrowing of the esophagus usually appears esophageal vomiting ... It differs from the stomach in that the vomit is alkaline and contains unchanged pieces of food. In addition, vomiting is not preceded by nausea and dysphagia is necessarily observed in the patient.

An admixture of blood to vomit is observed during the decay of a tumor, an ulcer of the esophagus. Excessive bleeding can occur due to rupture of varicose veins of the esophagus. This happens with cirrhosis of the liver.

Heartburn (pyrosis). Heartburn is a strong burning sensation in the esophagus, which the patient feels behind the breastbone. The main cause of heartburn should be considered the throwing of stomach contents into the esophagus ( gastroesophageal reflux ). Somewhat more often, heartburn occurs with increased acidity of gastric juice, but it can also be with low acidity. It is also caused by insufficiency of the cardiac sphincter. As a result of this, the gastric contents, when the body bends and in the horizontal position of the patient, enters the esophagus. The acid contained in the gastric juice irritates the esophageal mucosa and causes a burning sensation.

For diseases of the stomach the main complaints are pain in the epigastric region, a burning sensation in the epigastrium, nausea, vomiting, and impaired appetite.

In the presence of pain it is necessary to clarify the exact localization of it, the irradiation, to find out the nature and conditions under which it occurs (to find a connection with the time of eating, the nature of the food). By the time of the onset of pain, they are conventionally divided into "early pains" - arising immediately after eating or 10-30 minutes after eating and late pains - 1-2 hours after eating. In addition, there may be "hunger pains" - pains on an empty stomach. It is also important to establish where the pain subsides. So, for example, in diseases of the stomach, accompanied by increased acidity of gastric contents, the pain soothes after eating, artificially induced vomiting, taking a solution of soda.

Belching – it is the sudden onset of ingestion of stomach contents into the mouth. Belching is air ( eructatio ) or food ( regurgitatio ). Belching with air can be in people with habitual swallowing of air ( aerophagia ). It should be noted that swallowing air while eating and drinking is a normal physiological process. This air is released during periodic relaxation of the lower esophageal sphincter. Therefore, belching can be considered a disorder when it begins to cause anxiety to the patient. This excessive belching can occur with gastroesophageal reflux disease. In addition, sometimes belching with air can also be with intensified fermentation processes in the stomach with the formation of gases.

Rumination syndrome Is a condition characterized by repeated, spontaneous regurgitation of recently eaten food into the mouth, followed by repeated chewing and swallowing or spitting out. It is important to note that regurgitation is not caused by nausea; the regurgitation contents contain detectable food with a pleasant taste. The process stops when the regurgitant contents become acidic.

Nausea (nausea). It often precedes vomiting, but it can be without it. This is a reflex act associated with irritation of the vagus nerve. The mechanism of nausea is not fully understood. Nausea manifests itself as a kind of hard-to-define unpleasant feeling of pressure in the epigastric region, an unpleasant sensation of an impending need for vomiting. It can be combined with general weakness, dizziness, severe salivation (salivation). It occurs frequently and without any connection with stomach ailments. For example, nausea occurs with toxicosis of pregnant women, renal failure, and cerebrovascular accident.

Vomit (vomitus) is a common complaint. It can occur in various diseases of the stomach (acute and chronic gastritis, gastric ulcer and duodenal ulcer, pyloric stenosis, stomach cancer). However, it can also occur with other diseases that are not related to the disease of the stomach itself. Distinguish:

1) Vomiting of nervous (central) origin

(brain tumors, meningitis, traumatic brain injury, increased intracranial pressure, etc.).

2) Vomiting of visceral origin (peripheral, reflex). It is observed in gastric ulcer and duodenal ulcer, acute cholecystitis, cholelithiasis.

3) Hematogenous-toxic vomiting. It is observed with uremia, various intoxications and poisoning.

In many cases, various causes are involved in the mechanism of vomiting. When vomiting in a patient, it is necessary to clarify the nature of the vomit, whether vomiting brings relief or not.

When questioning, you need to pay attention to the state appetite at the patient. With a reduced acid-forming function of the stomach, appetite is often reduced, while in diseases of the stomach, accompanied by an increase in the acidity of the gastric juice, it is usually increased. Complete lack of appetite (anorexia ) and especially aversion to meat products is characteristic of stomach cancer. Along with loss of appetite, these patients complain of weight loss.

Currently, in foreign gastroenterological practice, the term is very widely used gastric dyspepsia .

Under gastric dyspepsia syndrome they understand the symptom complex, which includes pain in the epigastric region, epigastric burning, a feeling of fullness in the epigastric region after eating, and rapid satiety. In the old Russian literature, a slightly different meaning was put into this concept. During a clinical examination of a patient, the doctor can conditionally distinguish two fundamentally different types of gastric dyspepsia:

- organic - it is based on diseases such as stomach ulcer, chronic gastritis, stomach cancer, etc.;

- functional dyspepsia - symptoms related to the gastroduodenal region, in the absence of any organic, systemic or metabolic diseases that could explain these manifestations (Rimsky III Consensus, 2005).

Currently, the following types are distinguished functional dyspepsia:

1.Dyspeptic symptoms caused by food intake (postprandial dyspeptic symptoms), which include quick satiety and a feeling of fullness in the epigastrium after eating. These symptoms should be noted at least several times a week.

2. Epigastric pain syndrome ... This is pain or burning, localized in the epigastrium, of at least moderate intensity with a frequency of at least once a week. It is important to note that there is no generalized pain or pain localized in other parts of the abdomen or chest. No improvement after stool or passing gas. Pain usually appears or, conversely, decreases after eating, but it can also occur on an empty stomach.

With intestinal diseases the main complaints are pain along the intestines, bloating (flatulence ), diarrhea, constipation and sometimes intestinal bleeding.

Pain in the intestines can be caused by a sharp spasm of the intestinal muscles, for example, in acute inflammatory processes in the small and large intestine. They can also be caused by a sharp stretching of the intestine as a result of intestinal obstruction or the presence of a large amount of gas in it.

It is important to find out the localization of pain. Their appearance in the left ileal region occurs in diseases of the sigmoid colon, in the right - in diseases of the cecum, appendicitis. Pain in the middle of the abdomen is characteristic of diseases of the small intestines. Pain during the act of defecation is observed with a disease of the rectum (hemorrhoids, fissures of the anus, cancer of the rectum or sigmoid colon) and is accompanied by the release of scarlet blood. If intestinal bleeding occurs from the upper intestines, which is more common with duodenal ulcer disease, the stools acquire a dark tarry color ( mel a ena ).

Constipation characterized by a low frequency of bowel movements (three or less times a week), its low productivity, the presence of a compacted non-plastic stool, the need for additional efforts to empty the intestines.

Diarrhea (diarrhea) is characterized by an increased frequency of stools per day (more than twice), the presence of loose or loose stools. (For more on stool disturbances, see below.)

History of the present disease

When collecting anamnesis in patients with diseases of the digestive system, it is necessary to ask them about how the disease began and what symptoms it manifested itself. Further, find out in detail whether the patient sought medical help, what examination and treatment was carried out, and his state of health after treatment. It is necessary to find out the nature of the course of the disease, the presence of exacerbations in its course, outpatient or inpatient treatment. It is necessary to find out in great detail the time, the nature (symptoms) of the last deterioration of the patient's condition.

Patient's life story

Irregular nutrition, systematic intake of spicy, very hot food, frequent consumption of alcohol and smoking are of great importance in the development of a number of diseases of the stomach and intestines. It is important to identify occupational hazards (frequent stress, contact with toxic substances at work, for example, ingestion of metal dust). So, for example, frequent stress, smoking can serve as factors contributing to the formation of peptic ulcer disease with a hereditary predisposition to this disease. Therefore, the analysis of the patient's heredity is very important, since it is well known that many diseases of the gastrointestinal tract have a genetic predisposition. However, in the implementation of this genetic defect, the above-mentioned unfavorable environmental factors play a certain role.

It should also be noted that long-term intake of certain medicinal substances can cause not only indigestion, but also contribute to the development of a number of gastrointestinal diseases. We are talking about non-steroidal anti-inflammatory drugs, antibiotics and other drugs.

In general, they can be divided into the study of the structure, functions of the gastrointestinal tract, the identification of infections.

Structural exploration: visualization

Standard radiography

Standard X-ray of the abdominal organs shows the distribution of gas in the small and large intestine, it is used in the diagnosis of intestinal obstruction or paralytic ileus, when dilated intestinal loops and (when viewed in a standing position) fluid level are revealed. You can see the contours of the parenchymal organs, such as the liver, spleen and kidneys (visualization of calcifications and stones in these organs is possible), pancreas, blood vessels, lymph nodes. Abdominal x-rays are not helpful in diagnosing gastrointestinal bleeding. On a chest X-ray, you can see the diaphragm, and on images taken in a standing position, you can find free gas under the diaphragm when a hollow organ is perforated. It is also possible that a pulmonary pathology such as pleural effusion is accidentally detected.

Contrast studies

Barium sulfate, which is used in contrast studies, is non-reactive, envelops the mucous membrane well and provides the necessary contrasting of the structures of interest. However, it can thicken and stop proximal to the site of obstruction. Water-soluble X-ray contrast is used to contrast the intestine before abdominal CT and if perforation is suspected, but it absorbs X-rays to a lesser extent and is also irritating in the case of aspiration. Studies with contrast are carried out under fluoroscopic control, which makes it possible to assess the movement of organs and correct the position of the patient. The double-contrast technique using gas inflating the barium-coated inner walls of hollow organs improves visualization of the mucosa.

Barium tests are used to detect filling defects. A distinction is made between intraluminal (eg, food or feces), intramural (eg, carcinoma), or extra-wall (eg, lymph nodes) filling defects. Strictures, erosion, ulcers, and organ motility disorders can also be detected.

X-ray studies with contrast in the diagnosis of diseases of the gastrointestinal tract

	Taking barium inside	Barium breakfast	Barium suspension passage	Barium enema
Indications	Dysphagia Chest pain Possible motor disorders	Dyspepsia Epigastric pain Possible perforation (non-ionic contrast)	Diarrhea and abdominal pain of small bowel origin Possible obstruction due to strictures	Abdominal discomfort Rectal bleeding
Primary use	Strictures Hiatal hernia Gastroesophageal reflux and motor disorders such as achalasia	Gastric or duodenal ulcers Stomach cancer Pyloric obstruction Disorders of gastric emptying	Malabsorption Crohn's disease	Neoplasia Diverticulosis Strictures such as ischemic Megacolon
Restrictions	Risk of aspiration Poor mucosal detail Inability to take a biopsy	Low sensitivity in detecting early cancer Failure to take a biopsy or detect Helicobacter pylori	Time consuming method Exposure to radiation	Difficulty in frail elderly or patients with incontinence Inconvenient The need to perform a sigmoidoscopy to assess the condition of the rectum Possibility of skipping polyps< 1 см Менее пригодно при воспалительных заболеваниях кишечника

Ultrasound examination, computed and magnetic resonance imaging

The use of these methods in the diagnosis of diseases of the abdominal organs has become widespread. They are non-invasive and provide a detailed view of the contents of the abdominal cavity.

Ultrasound scanning, computed tomography and magnetic resonance imaging in gastroenterology

Study	Ultrasonic	CT scan	MPT
Basic indications	Masses in the abdomen, such as cysts, tumors, abscesses Organ enlargement Expansion of the biliary tract Gallstones Controlled fine needle aspiration biopsy from the lesion	Assessment of pancreatic diseases Location of liver tumors Assessment of vascularization of lesions	Assessment of the stage of liver tumors Pelvic / Perianal Diseases Swish for Crohn's disease
disadvantages	Low sensitivity for small lesions Little informative about the function Depends on the researcher Gases and the thickness of the subject's fat layer can obscure the picture.	Costly research High dose of radiation Possible underestimation of some tumors, such as gastroesophageal	The role in the diagnosis of gastrointestinal diseases has not been definitively established. Limited availability Time consuming research Claustrophobia (in some patients) Contraindicated in the presence of metal prostheses, cardiac pacemakers

Endoscopy

Video endoscopy has replaced endoscopic examination using fiberoptic endoscopes. The image is displayed on a color monitor. Endoscopes are equipped with handpiece controls and suction channels for air and water. Additional instruments are passed through the endoscope to perform diagnostic and therapeutic procedures.

Upper gastrointestinal endoscopy

Indications

• Dyspepsia in patients over 55 years of age or with anxiety symptoms
• Atypical chest pain
• Dysphagia
• Vomit
• Weight loss
• Acute or chronic gastrointestinal bleeding
• Suspicious Barium Breakfast Study Results
• Biopsy of the duodenal mucosa to identify the causes of malabsorption

Contraindications

• Severe shock
• Recent myocardial infarction, unstable angina, cardiac arrhythmia
• Severe respiratory illness
• Atlas subluxation
• Possible perforation of internal organs
• These are relative contraindications: it is possible to perform an endoscopic examination by an experienced specialist

Complications

• Aspiration pneumonia
• Perforation
• Bleeding
• Infective endocarditis

Endoscopy in the elderly

• Tolerability: Endoscopic procedures are generally well tolerated by individuals, even in very old age Adverse effects of sedation: Elderly persons are more sensitive to sedation; respiratory depression, hypotension and increased recovery time are more common.
• Bowel preparation for colonoscopy can be difficult in emaciated, immobilized people. Preparations containing sodium phosphate can cause dehydration or hypotension. Antiperistaltic agents: hyoscine butyl bromide is contraindicated in glaucoma, and it can also cause tachyarrhythmias. If it is necessary to use an antiperistaltic substance, the drug of choice is glucagon.

Fibroesophagogastroduodenoscopy

The study is carried out under intravenous benzodiazepine premedication to a state of mild sedation or using only a local anesthetic sprayed onto the mucous membrane of the patient's pharynx (the procedure is carried out on an empty stomach for at least 4 hours). When the patient lies on his left side, the entire esophagus, stomach and the first 2 parts of the duodenum can be seen.

Enteroscopy and capsule endoscopy

Using a long endoscope (enteroscope), most of the small intestine can be visualized. Enteroscopy is of particular importance in assessing obstruction, recurrent gastrointestinal bleeding. Capsule endoscopes contain a light source and lenses. After swallowing, the endoscope transfers the picture from the small intestine to the data recording device. Then, to localize the detected deviations, the images are processed using software. Capsule endoscopy is used when upper gastrointestinal bleeding, a tumor, or ulcer of the small intestine is suspected.

Sigmoscopy and colonoscopy

Sigmoscopy can be performed on an outpatient basis using a 20 cm rigid plastic sigmoidoscope or in the endoscopy unit using a 60 cm flexible colonoscope after bowel preparation. When sigmoidoscopy is combined with rectoscopy, hemorrhoids, ulcerative colitis, and distal colorectal neoplasia can be detected. After a complete bowel cleansing, the entire colon and often the terminal ileum can be examined using a longer colonoscope.

Colonoscopy

Indications

• Suspected inflammatory bowel disease
• Chronic diarrhea
• Abdominal discomfort
• Rectal bleeding or anemia
• Evaluation of abnormalities identified in the study with "barium enema"
• Colorectal cancer screening
• Colorectal adenoma monitoring
• Therapeutic procedures
• Colonoscopy is not suitable for determining the cause of constipation

Contraindications

• Severe acute ulcerative colitis
• Same as for upper gastrointestinal endoscopy

Complications

• Cardiac and respiratory depression due to sedation
• Perforation
• Bleeding
• Infective endocarditis (in patients with a history of endocarditis or with an artificial heart valve, prophylactic antibiotics are indicated)

ERCP

ERCP allows visualization of the ampulla of Vater and obtaining X-ray images of the bile duct system and pancreas. Diagnostic ERCP has largely been replaced by magnetic resonance cholangiopancreatography (MRCP), which provides comparable images of the bile duct system and the pancreas. MRCP complements CT and endoscopic ultrasound in assessing obstructive jaundice, identifying the cause of gallbladder pain and suspected pancreatic disease. Then ERCP is used to treat a number of diseases of the biliary tract and pancreas, identified by these non-invasive methods. ERCP includes removal of common bile duct stones, stenting of biliary strictures, and treatment of ruptured pancreatic ducts. Performing therapeutic ERCP is associated with technical difficulties and a significant risk of pancreatitis (3-5%), bleeding (4% after sphincterotomy) and perforation (1%).

Histological examination

Biopsy material obtained by endoscopy or percutaneous biopsy can provide important information.

Indications for biopsy and cytological examination

• Suspected malignancy
• Assessment of abnormalities in the structure of the mucous membrane
• Diagnosis of infections (eg, Candida, H. pylori, Giardia lamblia)
• Determination of enzyme composition (e.g. disaccharidases)
• Analysis of genetic mutations (eg, oncogenes, tumor suppressor genes)

Infection tests

Bacteriological examination

Identification of bacterial cultures in feces is necessary to determine the causes of diarrhea, especially acute or bloody, as well as to identify pathogenic microorganisms.

Serological examination

Antibody detection is of limited value in the diagnosis of gastrointestinal infection caused by microorganisms such as H. pylori, some Salmonella species and Entamoeba histolytica.

Urease test

Non-invasive breath tests for H. pylori infection and suspected small bowel bacterial overgrowth are discussed below.

Functional studies

Several functional tests are used to investigate various aspects of intestinal activity (digestion, absorption), inflammation and epithelial permeability.

Functional tests in the study of the gastrointestinal tract

Process	Test	Principle	Comments (1)
Suction
Fats	14 C-triplets - new test	Measurement of 14 CO 2 concentration in exhaled air after consuming C-labeled fat	Fast and non-invasive, but not quantitative
	3-day fecal test	Quantification of the fat content in feces when the patient consumes fat 100 g / day Normal<20 ммоль/сут	Non-invasive, but slow and unpleasant for all research method
Lactose	Lactulose hydrogen breath test	Measurement of expired H 2 after consuming 50 g of lactose. Undigested sugar is metabolized by bacteria in the colon during hypolactosemia, and hydrogen is determined in the exhaled air	Non-invasive and accurate. May provoke pain and diarrhea in subjects
Bile acids	75 SeHCAT test	Determination of the amount of isotope retained in the body for 7 days after ingestion of 75 Se-labeled homocholitaurin (> 15% norm,<5% - патология)	Accurate and specific method, but requires 2 visits to the doctor, radioactive. The results can be interpreted in two ways. 7α-hydroxycholestenone test is also sensitive and specific
Exocrine pancreatic function
	Pancreolauril test	Pancreatic esterases bind fluorescent dilaurate after ingestion. Fluorescein is absorbed in the intestines and measured in urine	Accurate and does not require duodenal intubation. Takes 2 days. Needs accurate urine collection
	Fecal chymotrypsin or elastase	Immunoassay of pancreatic enzymes in stool	Simple, fast and no urine collection required. Does not detect mild forms of the disease
Inflammation / mucosal permeability
	51 Cr-EDTA	Determination of the concentration of the label in the urine after ingestion. With increased permeability of the mucous membrane, a greater amount is absorbed	Relatively non-invasive and accurate, but radioactive. Limited availability
	Tests with sugars (lactulose, rhamnose)	In the non-inflamed small intestine, mono-, but not disaccharides, are absorbed. Urinary excretion of ingested 2 sugars is estimated as a ratio (normal<0,04)	A non-invasive test that determines the integrity of the mucous membrane of the small intestine (for example, in colitis, Crohn's disease). Needs accurate urine collection
	Calprotectin	A nonspecific protein secreted by neutrophils in the colon in response to inflammation or neoplasia	Useful Screening Test for Colon Disease

If malabsorption is suspected, it is necessary to conduct blood tests [with counting blood cells, erythrocyte sedimentation rate (ESR), determining the concentration of folates, vitamin B 12, iron, albumin, calcium and phosphates], determine the state of the gastrointestinal mucosa in biopsy material obtained during endoscopy ...

Peristalsis of the gastrointestinal tract

There are a number of different X-ray, manometric and radioisotope tests for the study of intestinal motility, but most of them are very limited in clinical practice.

Peristalsis of the esophagus

A study carried out after thoroughly swallowing a suspension of barium sulfate can provide information on the peristalsis of the esophagus. In difficult cases, video fluoroscopy may be helpful. Esophageal manometry, usually in combination with a 24-hour pH measurement, is useful in the diagnosis of gastroesophageal reflux, cardiac achalasia, and noncardiac chest pain.

Emptying the stomach

Delayed gastric emptying (gastroparesis) causes persistent nausea, vomiting, bloating, or early satiety. Endoscopy and barium sulfate results are usually within normal limits. The rates for the emptying of solids are highly variable, but approximately 50% of the contents leave the stomach in 90 minutes (T1 / 2). Calculation of the amount of radioisotope remaining in the stomach after ingestion of food containing solid and liquid labeled components can reveal pathology.

Passage through the small intestine

This parameter is much more difficult to quantify and is rarely required in clinical practice. The study of the passage of barium sulfate can give an approximate idea of ​​the functional state of the intestine when determining the time required to achieve contrasting of the terminal ileum (normally 90 minutes or less). Orocecal transit can be assessed using a lactulose-hydrogen breath test. Lactulose is a disaccharide that normally enters the colon unchanged; here, the breakdown of lactulose by bacteria in the colon leads to the release of hydrogen. The time at which hydrogen appears in exhaled air is a measure of orocecal transit.

Colon and rectal peristalsis

Direct radiography of the abdominal organs, performed on the 5th day after ingestion of inert plastic pills of various shapes, in the first 3 days from the start of the test, gives an idea of ​​the duration of the complete intestinal transit. The test is used to identify the causes of chronic constipation, as the location of any of the retained pills can be seen; it helps to differentiate cases of delayed transit from the presence of an obstacle to the movement of feces. The mechanism of defecation and the functional state of the anorectal region can be assessed using anorectal manometry, electrophysiological tests and proctography.

Radioisotope tests

Many different radioisotope tests are used. Some give information about the structure, for example, the localization of the Meckel diverticulum, or the activity of the inflammatory process in the intestine. In other tests, radioisotopes are used to obtain information about functional status, such as the degree of bowel movement or the ability to reabsorb bile acids. There are tests for infection, they are based on the ability of bacteria to hydrolyze radioactively labeled substances with subsequent determination of the isotope in the exhaled air (for example, the respiratory urease test for H. pylori).

Radioisotope tests commonly used in gastroenterology

Test	Isotope	Basic indications and principle of the test
Study of gastric emptying		Used to assess gastric emptying, especially if gastroparesis is suspected
Urease breath test	13 C- or 14 C-urea	Used for non-invasive diagnosis of N. pylori infection. The bacterial enzyme urease breaks down urea into CO 2 and ammonia, which is detected in the exhaled air
Diverticulum scan	99m Tc-pertechnate	Diagnostics of the Meckel diverticulum in cases of latent gastrointestinal bleeding. The isotope is administered intravenously and determined in the ectopic parietal mucosa inside the diverticulum
Radionuclide study for labeled erythrocytes	51 Cr-labeled erythrocytes	Diagnosis of latent and recurrent gastrointestinal bleeding. Determine the labeled erythrocytes released from the bleeding vessel into the intestine
Radionuclide study for labeled leukocytes	111 In- or 99m Tc-HMPAO-labeled leukocytes	Reveal the accumulation of leukocytes in the area of ​​the abscess and the length of the inflammatory bowel disease. The patient's leukocytes are labeled in vitro, returned to the bloodstream, after which the leukocytes migrate to the sites of inflammation or infection
Radionuclide test for somatostatin receptors	111 In-DTPA-DPhe-octreotide	The labeled somatostatin analog binds to specific receptors located on the cell surface of pancreatic neuroendocrine tumors

Patient complaints:

1. Impairment of appetite (increase, decrease, absence - anorexia),

2. Perversion of taste (addiction to inedible substances, aversion to certain foods).

3. Belching (air, odorless or odorless gas, food, sour, bitter).

4. Heartburn (frequency, intensity).

5. Nausea.

6. Vomiting (in the morning on an empty stomach, after eating, brings relief or no effect).

7. Pain in the abdomen (localization, intensity, character, localization, connection with food intake, stool discharge, gas, frequency, irradiation).

8. Flatulence.

9. Diarrhea (character, color, odor, presence of mucus, blood, pus).

10. Constipation (duration, shape, color of stool).

11. Skin itching.

12. Decrease in body weight.

Disease history:

1. The onset of the disease, the probable causes of its occurrence.

2. Development (frequency of exacerbations, variability of symptoms).

3. Treatment carried out (frequency of hospitalizations, duration, effectiveness, drugs used - constantly, periodically).

Life story:

1. Postponed diseases (presence of viral hepatitis, jaundice).

2. The nature of the diet (irregular, dry food, monotonous, coarse food, abuse of hot spices).

3. Heredity (the presence of peptic ulcer disease, cholelithiasis in blood relatives).

4. Bad habits.

5. Family and living conditions

6. Allergies (food, medicinal, household, the presence of allergic diseases).

7. Long-term intake of hormones, non-steroidal anti-inflammatory drugs, anti-tuberculosis drugs.

Physical examination:

1. Examination: yellowness of the sclera, skin, traces of scratching, decreased turgor of the skin and tissues, vascular "stars", edema on the legs; changes in the tongue (plaque, papillary atrophy, dryness, discoloration), oral mucosa, teeth; examination of the abdomen (participation in the act of breathing, shape, size, symmetry of both halves, the presence of hernial protrusions, expansion of the venous network).

2. Palpation (tension, local soreness (in the gallbladder, navel, sigmoid colon, epigastric region) or throughout the abdomen, the liver is enlarged, painful, not palpable, the spleen is palpable, not palpable, the symptoms of Kera, Shchetkin-Blumberg) ...

3. Percussion (Ortner's symptom).

Laboratory research methods:

1. Clinical analysis of blood, urine.

2. Biochemical blood test: protein and its fractions, prothrombin, fibrinogen, bilirubin, cholesterol, alkaline phosphatase, transaminase, amylase, lipase, trypsin inhibitor.

3. Analysis of urine for diastasis, bile pigments.

4. Analysis of feces (macro- and microscopic examination, bacteriological, for occult blood, for helminth eggs).

5. Serological blood tests.

6. Duodenal intubation.

7. Fractional study of gastric juice.

Instrumental research methods:

1. Stomach and duodenum: fluoroscopy, gastroduodenoscopy.

2. Intestines: irrigiscopia, sigmoidoscopy, colonoscopy.

3. Liver, biliary tract and pancreas6 Ultrasound, cholecystography, computed tomography, scanning, liver puncture biopsy, laparoscopy.

Stage II. Identifying patient problems.

With diseases of the digestive system, the most frequent problems of patients (real or real) are:

• impaired appetite;

· Abdominal pain of various localization (specify);

· nausea;

Belching;

Heartburn;

Bloating

Itching, etc.

In addition to the present, already existing problems of the patient, it is necessary to identify potential problems, that is, complications that a patient may experience with insufficient care and treatment, an unfavorable development of the disease. In diseases of the stomach and duodenum, these can be:

Ø transition of an acute disease into a chronic one;

Ø perforation of the ulcer;

Ø penetration of the ulcer;

Ø gastrointestinal bleeding;

Ø development of pyloric stenosis;

Ø development of stomach cancer, etc.

With bowel diseases, problems are possible:

Ø intestinal bleeding;

Ø development of intestinal cancer:

Ø dysbiosis;

Ø hypovitaminosis.

For diseases of the liver, biliary tract and pancreas:

Ø development of liver failure;

Ø development of liver cancer;

Ø development of diabetes mellitus;

Ø development of hepatic colic, etc.

In addition to physiological problems, the patient may have psychological problems, for example:

Lack of knowledge about your disease;

Feeling of false shame on special bowel examinations;

Lack of knowledge of the principles of medical nutrition in case of a disease;

Lack of understanding of the need to quit bad habits;

Lack of understanding of the need for systematic treatment and visits to a doctor, etc. .

After identifying the problems, the nurse establishes nursing diagnosis, for example:

Increased gas formation (flatulence) due to intestinal digestion disorders;

Pain in the epigastric region after eating due to the formation of a stomach ulcer;

Loss of appetite due to liver disease;

Heartburn due to chronic inflammation of the stomach lining;

Itching caused by liver failure;

Diarrhea due to inflammatory disease of the small intestine, etc.

Stage III. Nursing care and care planning.

The nurse sets priorities, sets short-term and long-term goals, makes nursing choices (independent, interdependent and dependent), develops a care plan and determines the expected result.

Independent nursing interventions for diseases of the digestive system may include:

Control of blood pressure, pulse, body weight, daily urine output and stool;

Skin and mucous membrane care;

Timely change of bed and underwear;

Control over the transfer of food to the patient;

Creation of a comfortable position in bed;

Teaching the patient and his family members to determine blood pressure, pulse rate, provide first aid in case of emergency;

Conversations about the correct intake of medications, diet, exclusion of bad habits;

Feeding in bed;

Provision of care items;

Providing emergency care for an attack of hepatic colic, gastric bleeding.

Interdependent nursing interventions:

Heating pad, ice bladder supply;

Preparation of the patient and collection of biological material for laboratory types of research;

Preparing the patient and accompanying him to instrumental types of research;

Helping a doctor with an abdominal puncture.

Dependent nursing interventions:

Timely and correct administration of medications prescribed by a doctor.

Stage IV. Implementation of a nursing intervention plan.

When implementing the nursing intervention plan, it is necessary to coordinate the actions of the nurse with the actions of other health workers, the patient and his relatives according to their plans and capabilities. The nurse is the coordinator.

Stage V. Evaluation of the effectiveness of nursing interventions.

Efficiency assessment is carried out:

Ø by the patient (the patient's response to nursing intervention);

Ø nurse (goal achievement);

Ø by regulatory authorities (the correctness of the nursing diagnosis, the definition of goals and the preparation of a plan for nursing interventions, the compliance of the performed manipulations with the standards of nursing care).

Evaluating the effectiveness of the results allows:

§Determine the quality of care;

§ to identify the patient's response to nursing intervention;

§ find new problems of the patient, identify the need for additional help.