Laboratory methods for diagnosing ulcers. Radiological signs of stomach ulcers

The date: 19.07.2019

Indications for X-ray studies of the stomach are very wide due to the great prevalence of "gastric" complaints (dyspeptic phenomena, abdominal pain, no appetite, etc.). X-ray study It is carried out with suspicion of peptic disease, a tumor, in patients with Achilia and anemia, as well as with stomach polyps, which for some reason are not deleted.

Chronic gastritis

In the recognition of gastritis, the main role is removed by the clinical examination of the patient in combination with endoscopy and gastrobiopsy. Only by histological examination, a piece of the stomach mucosa can be established the form and prevalence of the process and the depth of the lesion. At the same time, with atrophically gastritis, X-ray research on the efficiency and reliability of equally fibrogastroscopy and is inferior only by biopsy microscopy.

X-ray diagnostics is based on the aggregate of x-ray signs and their comparison with the complex of clinical and laboratory data. Committed combined assessment of the fine and folded relief and the functions of the stomach.

The leading value is the definition of the status of Areol. Normally, the finest relief type (granular) is observed. Areolas have the right, mostly oval shape, clearly outlined, are limited to shallow narrow grooves, the diameter varies from 1 to 3 mm. For chronic gastritis, it is typical and especially coarse-edible types of fine relief. With an oil type, an irregular rounded form of a size of 3-5 mm are limited to narrow, but deep-grooves. Mlowerodular type is characterized by large (over 5 mm) aroles incorrect polygonal form. The furrows between them are expanded and not always sharply differentiated.

Changes in folded relief are much less specific. In patients with chronic gastritis, the folds are marked. When palpation, the shape of them varies slightly. The folds are straightened or, on the contrary, strongly agolates, small erosions and polypoid formations can be detected on their ridges. Simultaneously register functional disorders. During the exacerbation of the disease in the stomach, an empty stomach contains liquid, the tone of it is increased, the peristalistic is deepened, the spasm of the anthral department can be observed. During remission, the tone of the stomach is lowered, the peristalsis is weakened.

Gastric ulcer and duodenal ulcer

Radiology plays an important role in recognizing ulcers and its complications.

With a radiographic study of patients with ulcer of the stomach and duodenal gut In front of the radiologist there are three main tasks. The first is an assessment of the morphological state of the stomach and duodenum, primarily the detection of the ulcer defect and the definition of its position, forms, the values, the outlines, the state of the surrounding mucous membrane. The second task is to study the functions of the stomach and duodenal: detection of indirect signs of peptic disease, the establishment of the stage of the disease (exacerbation, remission) and evaluation of efficiency conservative therapy. The third task is reduced to recognizing complications of ulcerative disease.

Morphological changes for ulcerative disease are due to both the ulcer itself and the concomitant gastroduodenitis. Gastritis signs are described above. A direct symptom of ulcers is a niche. This term denotes the shadow of the contrasting mass that filling the ulcerative crater. Silhouette of ulcers can be visible to the profile (such a niche is called contour) or anfas on the background of the folds of the mucous membrane (in these cases they say about the niche on the relief, or relief niche). The contour niche is a semicircular or pointed ledge on the stainless shadow circuit or a duodenal bulb. The magnitude of the niche in general reflects the size of the ulcers. Small niches are indistinguishable with radioscopy. To identify them, targeted radiographs of the stomach and bulbs are necessary.

With double contrasting the stomach, it is possible to recognize small surface ulcerations - erosion. They are often localized in the ANT-rally and prebillar sections of the stomach and have a type of round or oval enlightenment with a point central accumulation of contrasting mass.

A ulcer can be a small - diameter up to 0.3 cm, medium sized - up to 2 cm, large - 2-4 cm and giant - more than 4 cm. The shape of the niche is rounded, oval, slightly, linear, oval, incorrect. The contours of small ulcers are usually smooth and clear. The outlines of large ulcers become uneven due to the development of granulation tissue, mucus clusters, blood clots. At the base of the niche, small excavations are visible, corresponding to the edema and infiltration of the mucous membrane at the edges of the ulcers.

Relief niche has a durable rounded or oval accumulation of contrast masses on internal surface Stomach or bulbs. This cluster is surrounded by a light unstructured rim - the zone of edema of the mucous membrane. In chronic ulcers, the embossed niche can be incorrect form with uneven outlines. Sometimes there is an alignment (convergence) of the folds of the mucous membrane to the ulcerative defect.

As a result of the scarring of ulcers at the niche level, straightening and some shortening of the contour of the stomach or bulbs are revealed. Sometimes the ruby \u200b\u200bprocess reaches a significant extent, and then the coarse deformations of the corresponding part of the stomach or bulb are determined, which sometimes takes the bizarre form. The scarring of ulcers in the canal of the gatekeeper or at the base of the bulb can lead to stenosis a gatekeeper A or duodenal stenosis. Due to the disorder of the evacuation of the contents of the stomach stretches. On an empty stomach detect contrast).

There are a number of indirect radiological symptomasted disease. Each of them separately does not provide grounds for establishing the diagnosis of ulcers, but in the aggregate their value is almost equal to the identification of a direct symptom - niche. In addition, the presence of indirect signs causes a radiologist with a special attention to seek a peptic defect, performing a series of targeted radiographs. A sign of the violation of the secretory function of the stomach is the presence of fluid fluid in it. This symptom is the most indicative for the duodenal bulbs ulcers. With a vertical position of the body, the liquid forms a horizontal level on the background of the gas bubble in the stomach. An important indirect symptom is regional spasm. In the stomach and bulb, it usually occurs at the ulcer level, but on the opposite side. A contour with smooth outlines is formed there. In the stomach, it resembles the end of the finger in shape, hence the name of this feature is the "symptom of the fiction finger". With the bulbs in the period of exacerbation, as a rule, the spasm of the gatekeeper is observed. Finally, with ulcers, the symptom of local hyperkinesia is marked, expressed in the accelerated advancement of the contrast agent in the ulcer zone. This symptom is explained by increased irritability and motor activity Walls in the area of \u200b\u200bulceration. It is connected with another indirect sign - a symptom of point pain and local abdominal wall tension at palpation of a region corresponding to the location of the ulcer.

In the aggravation stage of ulcerative disease, there is an increase in the niche and expanding the surrounding inflammatory shaft. During the remission, there is a decrease in the niche until 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 cure if the symptoms of the function of the function are preserved. Only elimination functional disorders It guarantees a cure or at least a long-lasting remission.

With peptic ulcer and chronic gastritis It is often observed duodenogastral reflux. To identify it, the patient is carried out dynamic scintigraphy. To this end, it is administered intravenously introduced RFP 99MTS-Butyl-Ida or a conjunctional compound of an activity of 100 MBK. After receiving an image of the gallbladder on scintigrams (these drugs are highlighted with bile), a fat breakfast gives a patient (for example, 50 g butter). On subsequent scintigrams, the emptying of the bubble from radioactive bile can be observed. With insufficiency of the gatekeeper, it appears in the cavity of the stomach, and with the gastroesophageal reflux - even in the esophagus.

A peptic niche can remotely resemble the diverticulus of the stomach - a peculiar anomaly of development in the form of a bag-shaped protrusion of the wall of the digestive channel. In 3/4 cases, the diverticulus of the stomach is located on back wall Near the esophageal and gastric transition, i.e. Near the cardiac hole. Unlike ulcers, the diverticulus has the correct rounded shape, smooth arcuate contours, often a well-formed neck. The folds of the mucous membrane around it are not changed, some of them come through the neck in the diverticulus. Especially often there are diverticulus in the downstairs and lower horizontal parts of the duodenum. X-ray signs are the same, only when developing the diverticulitis of the contour of the protusion becomes uneven, the mucous membrane around - swelling, palpation is painful.

The radial methods in the diagnosis of complications of peptic ulcer are played important role. First of all, this refers to the argenration of the stomach or duodenal ulcers. The main feature of the spinning is the presence of free gas in abdominal cavity. The patient will examine in the position in which it is brought to the X-ray office. The gas that penetrates the abdominal cavity through the perforation hole occupies the highest departments. With a vertical position of the body, the gas accumulates under the diaphragm, when it is on the left side - in the right side channel, when the back is on the back - under the front abdominal wall. On radiographs, gas determines clearly visible enlightenment. When changing the position of the body, it moves in the abdominal cavity, why it is called free. Gas can also be detected at ultrasound exam.

The penetration of ulcers into the surrounding tissues and organs indicate two signs: large sizes of niche and its fixation. In penetrating ulcers, there are often three-layer contents: gas, liquid and contrast agent.

In suspected acute ulcerative bleeding, they usually resort to emergency endoscopy. However, the valuable data can be obtained at a x-ray study that it is advisable to carry out if the fibrogastodenoscopy cannot be performed or it is not shown. After stopping bleeding or even in the period of continuing bleeding, it is possible to carry out x-ray and radiography of the stomach and duodenum with barium sulfate, but with a horizontal position of the patient and without compression of the anterior abdominal wall.

As a result of the scarring of the ulcers of the gatekeeper, stenosis of the weekend of the stomach can develop. According to radiological data, it is determined by the degree of its severity (compensated, subcompensated or decompensated).

Stomach cancer

Initially, the tumor is an island of cancer fabric in a mucous membrane, but in the future various ways of tumor growth are possible, which predetermine the radiographic signs of small cancer. If necrosis and tumor ulceration prevail, then its central part plays compared to the surrounding mucous membrane - the so-called deepened cancer. In this case, with double contrast, a niche of an irregular shape with uneven contours is determined, around which there are no Area. The folds of the mucous membrane converge to ulceration, slightly expanding in front of the niche and losing their outlines here.

With a different type of growth, the tumor is distributed mainly on the side of the mucous membrane and in the sublifted layer - surface, or flat-coinflowing, cancer, growing endophoe. It causes a plot of an altered relief in which there are no Area, but, unlike in-depth cancer, there is no ulceration and there is no convergence of the folds of the mucous membrane to the center of the tumor. Instead, randomly arranged thickening with unevenly scattered lumps of contrast masses are observed. The contour of the stomach becomes uneven, straightened. Peristalistic in the field of infiltrate is absent.

In most cases, the tumor grows in the form of a node or plaques, gradually increasingly going into the cavity of the stomach, - "towering" (exofic) cancer. IN initial stage The radiological picture differs little from such an endophyte tumor, but then a noticeable uneven recess of the outline outline of the stomach shadow, not participating in the peristaltics appears. Next, the regional or central defect of the filling is formed, in the form of an appropriate tumor serving in the enumeration of the organ. With a plaque-shaped cancer, it remains flat, with a polypotic (mushroom) cancer, has an improperly rounded shape with wavy outlines.

It should be emphasized that in most cases it is impossible to distinguish with radiation methods. early cancer from peptic ulcers and polypa, and therefore endoscopic research is required. However, X-ray study is very important as a method of selection of patients for endoscopy.

With the further development of the tumor, various radiographic patterns are possible, which, perhaps, never copy one other. However, it is conditionally possible to publish several forms of such "developed cancer". A large exofite tumor gives a major defect filling in the shade of a contrasting stomach filled. The contours of the defect are uneven, but quite clearly excluded from the surrounding mucous membrane, the folds of which in the defect area are destroyed, the peristalistic is not traced.

In another "Oblitsa" appears infiltrative and ulcerative cancer. With it, not so much defect filling, how much the destruction and infiltration of the mucous membrane is expressed. Instead of normal folds, the so-called malignant relief is determined: the shapeless accumulations of the barium between the patterned and structured areas. Of course, the contours of the shadow of the stomach in the area of \u200b\u200bthe lesion are uneven, and the peristalistic is absent.

Pretty typical X-ray pattern of a cross-shaped (cupid) cancer, i.e. Tumors with raised edges and a decaying central part. On radiographs, a rounded or oval defect of the filling is determined, in the center of which a large niche is distinguished - the accumulation of barium in the form of a spot with uneven outlines. A feature of the crumpled cancer is the relatively clear degradation of the tumor edges from the surrounding mucous membrane.

Diffuse fibroplastic cancer leads to narrowing the lumen of the stomach. In the field of damage, it turns into a narrow rigid tube with uneven contours. When inflating the stomach with air, the deformed department does not frame. At the border of the narrowed part with unaffected departments, you can see small ledges on the contours of the stomach shadow. The folds of the mucous membrane in the tumor zone are thicken, become fixed, and then disappear.

The tumor of the stomach can also be detected in computed tomography and ultrasound examination. At the sonograms, areas of thickening of the stomach wall are distinguished, which allows you to clarify the volume of tumor lesion. In addition, by sleepograms, you can determine the prevalence of infiltration into the surrounding tissues and detect tumor metastasis in lymph nodes Abdominal cavity and retroperitoneal space, liver and other abdominal organs. Especially clearly ultrasound signs of the tumor of the stomach and its germination into the wall of the stomach are determined at endoscopic gastric sonography. With CT, the wall of the stomach is also well visualized, which allows you to reveal her thickening and the presence of tumors in it. However, the earliest forms of gastric cancer both with sonography and CT to find it difficult to discover. In these cases, gastroscopy plays a leading role, supplemented by aiming multiple biopsy.

Benign stomach tumors

The radiographic picture depends on the type of tumor, the stage of its development and the nature of growth. Benign tumors of epithelial nature (papillomas, adenoma, naval polyps) come from the mucous membrane and go into the lumen of the stomach. Initially, an unstructured rounded area is found among the Area, which can only be seen when the stomach is double-contrast. Then the local expansion of one of the folds is determined. It gradually increases, taking the form of a rounded or slightly oblong defect. The folds of the mucous membrane bypass this defect and not infiltrated.

The contours of the defect are smooth, sometimes wavy. A contrasting mass is delayed in small recesses on the surface of the tumor, creating a gentle cellular pattern. The peristalistic is not disturbed if the malignant rebirth of the polyp has occurred.

Quite differently look ne imitress benign tumors (Leiomiomes, fibromes, neuromy and D.R.). They are developing mainly in the sublimatist or muscular layer And little go to the cavity of the stomach. The mucous membrane over the tumor is stretched, as a result of which the folds are flattened or spread. Peristaltics is usually saved. The tumor can also determine the rounded or oval defect with smooth circuits.

Postoperative diseases of the stomach

X-ray study is necessary for the timely detection of early postoperative complications - pneumonia, pleurisites, atelectasis, jets in the abdominal cavity, including subadiaphragmal abscesses. The gas-containing abscesses are relatively simply recognized: in the pictures and when translucent, it is possible to detect the cavity containing gas and liquid. If there is no gas, then subiaphragmal abscess can be suspected for a number of indirect signs. It causes a high position and immobilization of the corresponding half of the diaphragm, its thickening, irregularity of the outlines. The "sympathetic" effy in the rib-diaphragmal sine and the foci of infiltration at the base of the lungs appear. In the diagnosis of subadiaphraggmal uluses, sonography and computed tomography are successfully used, since the accumulations of the pus are clearly identified under these studies. The inflammatory infiltration in the abdominal cavity gives an echoneal image: there are no sections free from echo signals. The abscess is characterized by the presence of a zone devoid of such signals, but more dense bezel is evaporated around it - the mapping of the infiltrative shaft and the pyrogen shell.

Among the late postoperative complications it is necessary to mention two syndrome: leading loop syndrome and dumping syndrome. The first of them is radiologically manifested by the flow of contrast mass from the stomach culture through the anastomosis into the leading loop. The latter is expanded, the mucous membrane in it is feathering, palpation of its painful. Especially indicative of long barium delay in the leading loop. For dumping syndrome, a significant acceleration of the emptying of the stomach culture and the rapid spread of the barium on the loop of the small intestine are characterized.

1-2 years after operational intervention On the stomach may occur peptic ulcer Anastomoz. It causes an X-ray symptom of a niche, and the ulcer is usually large and surrounded by an inflammatory shaft. Palpation of her painful. Due to the concomitant spasm, an anastomosis function disorder is observed with the delay in the content of the stomach.

Ulcery disease is a clinical and anatomical concept. This is a chronic disease with a polycyclic flow, characterized by the formation of ulcers in those areas of the mucous membrane, which are smaller in greater degrees are washed by active gastric juice. The peptic disease is a common chronic, cyclically flowing, recurrent disease, based on complex etiological and pathogenetic mechanisms for the formation of ulcers in the gastroduodenal zone

X-ray semiotics of predicable state. In the parapillar zone, it is characterized by several options, among which the "irritated stomach" can be observed. At the same time, in the stomach of an empty stomach there is a significant amount of hypersecreator liquid and mucus, which in most patients increases during the study process. Barium suspension first sinks in a liquid, settled on lumps of mucus in the form of flakes, the folds of the mucous membrane at that moment are not visible, and only after evacuation of a significant amount of content under the action of palpation, the barium suspension is mixed with it, after which it becomes possible to study the relief of the mucous membrane. It is usually represented by large, convulsions, often transversely located the folds of the mucous membrane. In a number of patients, the arrival of the first sips of the barium suspension in the stomach leads its contents, the barium suspension in the form of large lumps also makes random movements - the contents of the stomach "Burlit". The tone of the stomach is somewhat reduced, the peristalsis is sluggish, the stomach is moderately stretched. Very often the initial short-term spasm of the gatekeeper arises, after which the tone of the stomach increases, deep peristalistic appears and begins accelerated evacuation Barium suspension from the stomach in the duodenum (for 15-20 minutes of the stomach is almost completely freed from the barium). The bulb is irritated, contains a lot of mucus, very quickly frees from a contrast agent, in view of which its true form cannot be determined, the folds of the mucous membrane are also not visible. At the same time, duodenogastral reflux is usually expressed: after the barya suspension is received in the downward duodenal department, it is often receded in the stomach. Niche in the saworoduodenal zone is not detected. Diskinetic disorders are also noted in the proximal loops of the small intestine. A number of patients are determined by cardia. The radiographic picture of the "irritated stomach" is rarely observed, usually in patients with a short history and pronounced clinical picture peptic disease. X-ray semiotics of ulcerative disease For many decades of the formation of x-ray diagnostics of ulcerative disease, various groups of radiological symptoms were proposed. Most authors allocated direct and indirect symptoms.

The direct X-ray symptom of peptic ulcer is a niche on the contour of the Barium spot on the relief. The frequency of identification of the latter depends on many reasons: the localization and size of ulceration, deformation, organ, the presence of liquid in the stomach, filling the ulcerative deepening of mucus, blood clot, the qualifications of the X-ray rhygenic, etc. In the methodological properly correct, this symptom has been detected in the clinic in 89-93 % of cases. Modern properly carried out x-ray study allows you to identify ulcers with a size: 2-3 mm. Ulceal niche can have different shape: rounded, oval, sliding, linear, pointed, incorrect, etc. Some authors believe that the shape of a peptic niche depends on its size. The rounded and the conical shape of the ulcer niche occurs mainly at relatively small ulcers. As the disease progressing and increasing the size of the ulceration, the shab shape becomes incorrect. It is believed that fresh ulcers have a pointed form and smooth outlines, and old-rounded-shaped ulcers, however, it is possible that a pointed form is associated with not enough tight filling of the niche. The shape of the peptic niche depends on the position of the patient with a radiographic study. It has been established that the shape of the peptic niche changes in the treatment process. According to endoscopic studies, sharp ulcers in patients with peptic ulcer disease are more often oval, under the scarring stage - linear or divided into smaller fragments on the background of focal hyperemia of the mucous membrane ("pepper with salt" in Japanese authors). Summarizing the given data should be emphasized that the form of a peptic niche is not an objective criterion for assessing the nature and timing of ulcers. It should be noted that standard X-ray study under conditions of radiothelision (radioscopy and radiography, natural pneumography) and double contrast when identifying ulcers give the same results. The contours of the peptic niche can be even clear and uneven fuzzy. According to P.V. Vlasova and I.D. Blippechevsky (1982), even contours are characteristic of relatively small ulcers. With an increase in the sizes of the ulcers, the contours are increasingly becoming uneven due to the development of granulation tissue, protruding in the lumen of the ulcerative crater of the naked vessel, blood clot, food residues and mucus. However, in the process of scarring and small ulcers in some cases, the irregularity of contours appears. As a result of the confluence of ordinary (up to 20 mm), large ulcers with uneven contours are formed. These evidence suggests that with differential diagnosis of ulcers with malignant ulcers, the state of the contours of ulcers should be considered only along with other symptoms and the clinical picture. Features of x-ray diagnostics depending on the localization of ulcers with ulcerative disease.

Ulcers localized in the upper (cardiac) stomach department. The difficulties arising from the x-ray study of the upper stomach department due to the features of its anatomical location, consequently, when revealed, the majority of the authors emphasize. The study is carried out necessarily in vertical and horizontal positions, while preference should be given to lateral and oblique projections, as well as horizontal position on the stomach with a small turn to the right side and double contrast.

The main symptom is a niche on the contour or niche in the form of the residual stain of the barium suspension on the relief. The niche on the contour should be differentiated from the diverticula, which is often localized in the upper part. The entrance to the diverticulus is narrow, the folds of the mucous membrane are determined in it, in its lumen for a long time Barium suspension is delayed. The entrance to the niche is wide, it is quickly freed from the contrast agent, often the folds of the mucous membrane are often converted to the niche, its shaft is expressed in the circumference, a spastic retracting from a large curvature is noted. Cardial ulcers are often complicated by bleeding, penetration, malignation. X-ray examination in bleeding and interpretation of the data obtained is often significantly difficult. The pathognomonic symptom of penetration is a three-layer niche, but the niche is not always detected.

Ulcers of small curvature of the body of the stomach. On the peculiarities of the x-ray picture of the ulcers of this localization, attention was drawn to the consideration of direct and indirect symptoms of the stomach peptic disease.

The ulcers of the prebyroche of the stomach and the pyloric canal. With a x-ray study, a direct symptom, as with other localizations of ulcers, is a niche symptom, however, a niche in the form of a residual barium suspension spots on the relief is greater importance. Niche on the contour is determined in those rarely cases when the ulcer is located strictly in a small curvature of the stomach. The true sizes of the ulcer of the prebillard department can only be determined when examining the patient in a horizontal position. Due to the frequent location of ulcers on the walls of the stomach frequent symptom is the shaft, often rounded shape. The symptom of niche in many cases accompany the convergence of folds, which is almost often common in erosive-ulcerative cancer. Permanent satellites of ulcers are hypermotility and regional spasm, anthral gastritis (in a number of sick erosive), duodenogastral and gastrointestinal reflux (hernia ecoming hole, Reflux-Ezophagitis), dual ten-vectors and a cushion dyskinesia, in a number of patients with a long-term course of ulcerative disease develops enteritis. Over the years in the diagnosis of peptic ulcer great importance attached to scar modifications. For the most part, they are typical and depend on the localization of ulcers and engage in the scar process of muscle beams. In this regard, there is a deformation in the form of an hourglass, which develops due to a long existing spasm of the large curvature of the body of the stomach and the scar change of oblique and circular muscle beams with a small curvature of the gastric body. At the same time, deformation develops in the form of two cavities connected by the asymmetrically located ister. Such changes may be observed in the infiltrative form of cancer, while the deformation is symmetric. Ulitko-shaped deformation, or "brisk stomach", also develops with a small curvature of the bodies of the gastric and scar changes in the longitudinal muscular beam. At the same time, the shortening of the small curvature of the body of the gastric is shortened, the cursed angle is noted, pulling up the antral dust and the bulbs of the duodenum to a small curvature, sinus saving. In these patients, in the absence of vomiting after 24 hours, the residue of the barium suspension is detected in the stomach. Such deformation is much less common in infiltrative stomach cancer, in which stenosis of the gatekeeper is observed, the delay in the barium suspension in the stomach within 24 hours and vomiting. At the same time, the anthraral department of the stomach and duodenum is usually located. The deformations are more likely to develop in the anthral department, with a small curvature ulcery, Gudek deformation can be observed - the ulit-shaped curvature of the anthral department. At the same time, the sconping retraction is also localized on great curvature, the axis curvature and the twisting of the anthral department occurs. However, it should be noted that in the conditions of modern anti-sized therapy, the deformations described above began to meet more and less. According to L. M. Torchnaya et al. (1982), the deformation of the stomach is more often expressed in significant shortening, as if strongerness of small curvature. The authors allocate five options for the post-point scar: the first - the contour of the stomach is uneven, the convergence of the folds of the mucous membrane to this area; The second - the contour of the stomach is uneven, small rounded filling defects near an uneven circuit, convergence of the folds of the mucous membrane to it; The third is a small niche with the convergence of the folds of the mucous membrane; The fourth is a small niche without convergence to it the folds of the mucous membrane; The fifth - the contour of the stomach is even, the convergence of the folds of the mucous membrane to the place of the ex-ulcer.

Indirect functional symptoms. The X-ray-functional features include the classic de Kerven syndrome - local spasm, hypersecretion, local hypermotility, changes in the peristaltic, evacuation and tone of the stomach. The dependence of the severity of these symptoms from the localization of ulcers is established: they are less pronounced or even absent when damaged to the body of the stomach and, on the contrary, the most clearly manifested in the ulcers of the pyloric department and the bulbs, as well as the process of exacerbation of the process. The most constant of the functional symptoms consider hypersecration, regional spasm but large curvature and symptom of local hypermotility.

De Kervena syndrome, as is well known, manifests itself with a spastic increase in the great curvature of the gastric body at the location of ulcers in a small curvature. Popping is unstable, can occur and disappear in the process of research, when using antispasmodic agents. In practical diagnosis, this symptom is more common in the ulcers of the yases of the stomach N is of great importance due to the difficulty of identifying the ulcers of this localization. A significant amount of fluid in the stomach of an empty stomach is a constant symptom of peptic ulcer and manifestation of concomitant gastritis. It is well known an increase in hypersecretion in the process of x-ray research.

The symptom of local hypermotility, or an increased reduction in the accelerated emptying of the department affected by an ulcer, is described in the ulcers of the bulb of the duodenum. This symptom is expressed in the ulcers of the appral ventricular and the bulbs of the duodenum, to the greatest extent to the aggravation phase of ulcerative disease.

Most reliable x-ray symptom of ulcers (Direct sign) is a peptic niche, which is visible in the form of a stomach contour with a tangential position. When enchanting en Face, niche is detected in the form of a persistent contrasting stain.

About 85% ulcerative niches Located on the small curvature of the stomach. The remaining 15% is the ulcers of large curvature (localization in the horizontal part is particularly suspicious on cancer), the rear wall ulcers (especially in the elderly leading clinical symptom - Pain in the back), ulcers in the field of gatekeeper. The symptom of the niche can also be observed with a stomach cancer.

To indirect signs of ulcers relate:
a) spastic retracting on the opposite wall of the stomach. This is the retractor designated as a symptom. indicative finger, not definitely evidence for ulcers, as it can also be observed in adhesive processes various origin. In the healing of ulcers, a picture of an hour-albums of mulk curvature and spastic retracting large curvature may occur.
b) the study of the relief of the gastric mucosa sometimes detects concentrically reaching the mashedral of the mucous membrane;
b) Next, in the area of \u200b\u200bulcers, the peristaltics can be easily observed. This feature, therefore, cannot be considered as pathognonic for cancer of the stomach;
d) With a chronic ulcer of a small curvature, a retraction of small curvature is noted and caused by the displacement of the gatekeeper to the left.

Radiological diagnostic limits: Some ulcers are not detected at x-ray; Especially often not detected fresh, bleeding ulcers. It is also difficult to recognize in most cases of the cordial department ulcers.

Leading radiographic sign of cancer is a fill defect. It is an expression of expansively growing tumors of the so-called polypotic cancer or cancer in the form of cauliflower. Usually, the defect of the filling has the wrong borders. For the diagnosis, the constancy of the X-ray picture under serial studies is necessary. The relief of mucosa in the field of filling defect is disturbed. However, the defect of filling in a pronounced form is detected only in the later stages of the disease with an unfavorable forecast regarding operational treatment.

For early cancer recognition It is also necessary to take into account such more difficult to interpret the symptoms as the rigidity of the stomach wall (due to its infiltration) and various forms of the niche (ulcerated cancers). Until now, the question is still discussed that it is preferable for early cancer recognition - tracking of the relief of the mucosa or a study when tight filling the stomach. Optimal results can be obtained using both methods.

To others radiographic signs of cancer relate:
a) the absence of a continuous peristaltic wave and
b) the relief changes of the mucous membrane.

These signs are especially typical of cancer With infiltrating growth, skirr, which often eludes radiological detection than expansively growing tumors. When the filling defect skir, it usually does not happen. The shape of the stomach can also be almost unchanged. Mostly there are only few pronounced, but the resistant irregularity of the contour of the stomach. Extremely rarely resistant rigidity of the stomach wall may be caused by gastritis.

In identifying value various forms of niche Especially great merit of French x-ray school (Gutman). According to Gutman, the following radiological signs are highly suspicious on cancer: immersed niche, niche in the form of a plateau, niche in the form of a meniscus. It goes without saying that, with these forms of the niche, not single pictures are crucial, but the constancy of the X-ray picture under serial studies.

Special differential diagnosis is difficult Between the kallese ulcer and the so-called cancer with a ring roller. There are the following differential diagnostic criteria: when cancer crater, ulcers only slightly performs above the edge of the stomach and the cancer roller compared to the ulcer more clearly degraded, and the folds of the mucosa are broken suddenly (Henning). With a cellular ulcer, on the contrary, niche is usually detected outside the stomach contour; The folds of the mucosa are not so dramatically excreted and can be converged to the ulcement roller.

Sizes of ulcers Cannot be used for differential diagnosis. Especially in the military and postwar years, ulcers have been described with a strikingly large crater - military time ulcers, which are morphologically very similar to sorting cancer. The crucial value for the diagnosis has (Henning) the state of the gastric wall in the circumference of ulcers, as well as changes in the relief of the mucous membrane.

Even when taking into account these criteria The diagnosis often remains unreliable, this can be eliminated only by control radiological studies after short intervals (2-3 weeks). After appropriate treatment, a benign ulcer at the same time detects distinct signs of reverse development, while the cancer of significant changes is not noted.

The importance of the X-ray method in establishing gastric ulcers Independent. The percentage of the detection of ulcers in the stomach, according to different authors, ranges from 90 to 97. X-ray diagnostics of the ulcerations of the stomach is made up of the establishment of the presence of both the ulcers itself and the complications of the ulcer process. The radiologist should strive to identify not only organic lesions of the stomach, but also functional manifestations of the process.

Radiosimptomatics of the ulcer of the stomach is diverse. It depends on the localization of the ulcers and the stage of the ulcer process. Thus, the ulcers of the subcardial department and the gatekeeper ulcers are manifested by both various changes in the shape of the stomach and the forms of ulcerative "niche". Therefore, the identification of ulcers various localization Requires special methodological techniques each time. Nevertheless, all X-ray symptoms ulcerative lesion The stomach can be divided into two main groups: direct and indirect, or indirect. The most pathognomonic and only direct sign of ulcers is, as is known, described by Gaudex in 1909, "Niche" - a peptic crater filled with a barial suspension. However, when localizing ulcers on the front or rear wall of the stomach or in the pyloric canal, the ulcerative crater filled with the barium suspension gives a picture of "spots" or "depot" against the background of the relief of the stomach mucosa. It is not always possible due to the deformations of the stomach, it is especially true of the subcardial department, to bring the ulcerative "niche" to the contour of the stomach, even with the most different provisions of the patient. Therefore, in such cases, it is necessary to look for a peptic "niche" in the form of a span, and not a protrusion.

The ulceal "niche" has the form of a cone, cylinder, oval. Its sizes range from several millimeters to gigantic (6-8 cm). Naturally, the dimensions of the ulcerative "niche" depend on its location, as well as on the complications associated with an ulcer process. Thus, the penetrating ulcer "niche" can reach huge sizes, depending on where the penetration of ulcers occurred, as far as the inflammatory process. Finally, the form "Niche" can change when the patient's body change changes.

Large in diameter, but shallow ulcerative "niches" are localized in a small curvature of the body of the gastric and are accompanied by a seal and infiltration of the edges of the ulcerative crater, proximal than the idioser than the "niche" itself. Because of this, quite large sections of the stomach wall may not be peristalistic, and there is a need to differentiate such a lesion with the tumor of the stomach. Pointed ulcers are often found in the sub-cardial stomach department, the shape and depth of them are similar to the accumulation of the barium suspension, located between the stomach mucosa usually thickened here.

For differential diagnosis of these changes, you have to resort to a special methodical techniqueswhich will be stated in the relevant sections.

The size of the ulcerative "niche" on radiographs does not, always correspond to the true depth of the ulcerative crater on the resected body, opening, and even with an endoscopic study, which is associated with the edema of the surrounding tissues, big amount mucus and food residues.

A characteristic X-ray sign of penetration of a penetrate "niche" is its three-layerness on radiographs: dense barium suspension at the bottom of the crater, a less intense part of the layer above it (a mixture of barium suspension and liquid) and, finally, the air layer.

With control x-ray studies in the process of treatment, the change and decrease in the ulcerative "niche" serves as an indicator of its reverse development, that is, the scarring of ulcers. Thus, a cup-like or oval form "Niche" changes to conesoid due to filling the bottom of the ulcerative crater. Naturally, in order to compare the sizes of the peptic "niche", it is necessary to produce radiographs in strictly the same positions and on the same X-ray machine. It is very important in assessing the dynamics of the ulcer process. Studying changes in the tissues surrounding peptic niches: convergence of the folds of the mucous membrane to "niche", a decrease in edema and sealing the walls of the stomach and other indirect signs.

Indirect symptoms of stomach ulcers are diverse. These include primarily functional changes. Thus, the hypersection of an empty stomach, although it is considered a more characteristic sign of the duodenal ulcers, with ulcers of the outlet of the stomach, especially with the gatekeeper ulcers, is a constant sympathetic. Spastic abbreviations in various stomach sites can be permanent or temporary. The well-known "pointing finger" is the increase from the side of the large curvature of the stomach in the ulcers of the small curvature of the gastric body - is the display of the circular muscle spasm (Fig. 8). Such retracts occur in different stomach departments and can disappear when scarring ulcers. The direction of retracting can be horizontal or oblique depending on the damage to circular or space-based muscle fibers. The spasms of circular rings separating the anthral department or in the field of gatekeeper can be so long that they delay the evacuation from the stomach. As spasms are recovered, as a rule, decrease and gradually disappear. The shortening of small curvature, the deformation of the stomach in the form of a cascade can also be due to spastic abbreviations of the respective groups of muscle fibers. It is quite effective at the same time a study after administration by the AERON patient.

An indirect feature is the feeling of pain in palpation of the stomach. However, this symptom does not represent much value, since in the presence of a ulcerative "niche" it is not important, and in the absence of it is unconvincing. The group of indirect signs includes and detected by the radiological method - analytical (organic) changes arising in the chronic ulcerative process (deformation of the stomach in the form of a "snail", "hourglass", stomach fusion, scar suspense of the gatekeeper).

Consider x-ray picture Stomach ulcerations depending on their localization.

Ulcer upper Department Stomach. Anatomical features This stomach department creates certain difficulties in X-ray diagnostics of ulcers. There is a need for special diagnostic techniques (additional portions of the barium suspension, drug exposure, etc.), the use of which, according to our data, improves X-ray diagnostics of the ulcers of this department (68% of patients were given the correct diagnosis). The features of the ulcerations of the upper stomach supply are relatively small (up to 1.5 cm) sizes, which makes it difficult to identify against the background of the coarse relief of the mucous membrane in the absence of an inflammatory shaft, highlighted with great difficulty, and convergence of folds of the mucosa to the site of ulcers. As a rule, the ulcers of the subcarordial stomach department are accompanied by its deformation in the form of a cascade, sometimes very persistent and expressed (Fig. 9).

Body ulcer stomach. The direct X-ray sign of the ulcer of the body of the gastric in a small curvature is "niche" (when tight filling the stomach of the barya weighing). "Niche" may have a pointed, cylindrical or rounded form (Fig. 10-12), the contour is more likely to be even, except in cases where the mucus accumulates in the ulcerative crater, granulation growth. With the scar deformation of the body of the stomach, it is not always possible to see the ulcerative "niche". Barium suspension accumulating in the ulcerative crater is represented in the form of a barium "spot" on the relief of the mucous membrane of the stomach. The diameter of this accumulation of the contrast agent will correspond to the width of the entrance to the ulcerative "niche". The depth of the most ulcer "niche" cannot be determined. Important indirect signs of ulceration at the small curvature of the body of the stomach are its deformation and shortening. It may be due to both the spasm of longitudinal muscle fibers along the small curvature, and the scars. In such cases, the study is carried out according to the method described above with the use of spasmolitics (atropine, aeon). The correct laying of the patient to the back position with the stay in such a posture for a long time is important.

The X-ray picture and the method of studying the ulcers of the anthral gastric department are similar to those described above.

Pylorial canal ulcer. The identification of the ulcerative defect in the pyloric canal in many cases is of great difficulty. This is due to several reasons. First of all, it matters characteristic of the ulcers, quite often the intensive and long-term spasm of the powerful muscles of the gatekeeper, which, in combination with the often observed rapid passage of the barium suspension through the pyloric channel, prevents the filling of the ulcerative crater with a contrasting agent. In addition, ulcerative "niches" in the pylorical canal have small sizes and are often accompanied by a pronounced inflammatory process, deformation. Hypersection, delay gastric juice And food residues also make it difficult to identify the peptic "niche". In most cases, it acts on the contour in the form of a shallow pointed depot of the barium suspension, surrounded by a small inflammatory shaft, which goes to the main bulbs. This can create a picture of the "inverted triple" (Fig. 13). On the relief, the ulcerative "niche" is defined as a flat oval or round shape of the depot of the barium suspension located in the center of the pyloric canal. The cylinder "niches" are found, as a rule, invisible during radioscopy and detectable only on targeted radiographs (small, with a niche pin head, located on the shadow of a narrowed pyloric canal).

The scarring ulcer of the pyloric canal often looks like a star contrast spot with radiant diverging folds of the mucous membrane. In addition to the convergence of folds of the mucous membrane to the ulcerative "niche", sometimes there is one, a significantly thickened fold of the mucous membrane of the pyloric canal, passing into the bulb.

The indirect signs of the peptic "niche" of the pyloric channel are various deformations of it: elongation due to infiltration or sclerosis of the adjacent sections of the anthral department or bulbs, the asymmetric location of the pyloric canal relative to the antral part of the stomach and the bulb, the curvature of the pylorial canal, sometimes the knee-like, or expansion and narrowing his; In some patients, the pylorial canal has uneven biased contours. Often there is a combination of these deformations. A sharp, sometimes long-term (up to several hours) spasm of the gatekeeper often accompanies the ulcers of this stomach department; The absentee channel is narrowed, is filled with only partially in small portions of the contrast agent, which further complicates the identification of the ulcerative "niche" and makes it difficult to diagnose.

Duodenal ulcer. It is well known to the value of x-ray research in establishing a diagnosis of duodenal ulcer disease. However, the detection of ulcers, especially sharp, not accompanied by deformation against the background of a sharp increase in tone muscular wall The bulbs, with the abundance of mucus in the lumen, represent certain difficulties, especially when the "niche" is located on the back or the front wall of the bulbs. No less difficulty arise, as is well known, when recognizing an ulcers in a deformed bulb: scar deformations often simulate ulcerative "niches" or, on the contrary, hide a small-facilitating inflammatory shaft, a minor reaction of the surrounding mucous membrane makes it difficult to diagnose.

Three types of symptoms specify the X-ray diagnosis are known: direct - morphological, indirect - functional and accompanying signs. Direct signs: "Niche" on the contour or relief, a defect in the field "Niche", the patching of a scars on the opposite of the walls of the wall, the convergence of the folds of the mucous membrane to the "niche"; The deformation of the scarceing organ is perideodenitis (Fig. 14 and 15). Functional signs: hypersecretion, regional spasm, local hypermobility, change of evacuator function (delay, acceleration), peristaltics (stenotic, deep ,peristic zone) and tone. Accompanying signs: a change in the relief of the mucous membrane (cog in a large curvature, thickening and sinkness of the folds of the mucous membrane of the duodenum, local pain, manifestation of duodenitis, etc.).

It should be noted that when examining patients with duodenal ulcers, the listed symptoms are detected in various combinations. In addition to them, the characteristic of the relief of the mucous membrane is important, as well as the use of various methods for establishing a diagnosis, in particular in various positions, etc. The ulceal "niches" are more often located on the back wall, on the medial, less often on the front and lateral; There are "niches" at the base of the bulbs (by some authors they are regarded as pylorobulbar ulcers and ulcers located at the top of the bulbs).

Among the existing methods of x-ray examination of the duodenum there are no such, with the help of which it would be possible to unmistakably diagnose bulbs ulcers. The most effective research method is in double contrast. It can be achieved in the study of the patient in a horizontal position with a turn at first to the right side (tight filling of the bulb), then on the back and on the left side. In this position in the stomach, the air moves to the pyloric canal and the bulb, the pneummatore is formed. However, with a sharp hypertonus, the hyperstoles, when the bulb is located high and the stop, and immediately behind the pyloric canal, with the enjoying spasms or coarse deformations, it is not always possible to tightly fill the bulb with a contrasting agent or stretch it. In such patients, it is necessary to remove radiographs in lateral projections; The study with pharmacological preparations also helps. Most often for these purposes, we use Aeron (2 tablets under the tongue). After 20-25 minutes, after dissolving the tablets, the patient is given another portion of the barium suspension and the study is repeated according to the described method. As a rule, in 90% of cases, ulcerative "niches" are detected at a distance of 3-4 cm from the pyloric canal, 10% in other bulbous departments.

As in the stomach, ulcers can be found on the walls of the bulbs or on the relief (embossed "niche" or "spot"); At the same time, most of the ulcers are located near the small curvature of the bulbs. When raging the folds of the mucous membrane, due to the inflammatory response, the shaft is created around the ulcerative crater, which increases the demonstration of the "niche". In most cases, the pneummatore can be identified by the "spot" of the barium suspension with the folds of the mucous membrane converging towards this place. Obviously duodenal ulcer The same can often be detected on the front and rear walls of the bulbs. It is clear that the rear wall of the bulbs will be visible when turning left, and the front wall - on the opposite side of the back wall of the bulbs. Ulcers on the front wall can be how to move away from it and go out on the contour, but if the ulcer penetrates the adjacent fabrics, in particular a large or small gland, then "death" from the bulb wall does not occur. In some cases, with penetration of ulcers in bile moves, to identify the ulcerative "niche" is not possible and filling bile paths contrasting material through a fistula (Fig. 16).

With the help of another method - dosed compression - we managed to diagnose an ulcer having a look of a spot to which the folds of the mucous membrane were converged; After removal of compression, this picture disappeared (Fig. 17).

It is difficult to exaggerate the value of the x-ray method in identifying non-volunteered ulcerations. Most often, such ulcers are found in the upper bending of the duodenum (up to 67%) and the upper third of the downward part of the duodenum (up to 25%), i.e., according to S. A. Rainberg and M. M. Salman, in the most " critical zone" In addition to the symptom of "Nici", while the type of ulcerations are detected by the narrowing of the intestine of the intestine at the place of lesion, deformation, thickening of the folds of the mucous membrane, as well as the motor disorders of the duodenum in the form of either the enhancement of the peristaltics, when the barium suspension is quickly moving around the bulbs and downstairs, or , on the contrary, slowing down: while the bulb or even the entire descending part of the intestine, the upper and lower bending is expanding and, respectively, the contrast agent is in a slower pace; Sometimes only bulbostasis is visible. Outlukovic "Niche" in most cases exceed the usual dimensions of bulbous yazv, more often they are rounded, but there may be a cylindrical, prismatic, cone-shaped or incorrect form. Outlukovichny ulcers, located more often on the inner or rear wall of the duodenum, can be displayed on the contour; At the same time, the narrowing of the intestinal lumen in place of the defeat is either the result of a reflex local spasm or formed by a scar cloth. It is more often such a narrowing asymmetrically and is expressed in retracting the walls opposite from the peptic "niche" resembling the symptom of the "pointing finger". As a rule, it is first possible to identify this asymmetric narrowing of the intestine, and then an already peptic "niche" (Fig. 18). The deformation of the folds of the mucous membrane in most cases is observed not only in the region of the ulcerative niche, but also proximal and distal than it, in the bulb and the descending part of the duodenum. The folds of the mucosa are thicken, become low-loving. Quite often there is a convergence of folds of mucosa to "niche", which can be maintained and after the appearance of the scar at the site of ulcers. Stenoses due to non-volukovic ulcers are usually detected in the upper bending and in the upper half of the descending part of the duodenum; The contours of the narrowing are clear, uneven, the length of the narrowing of 1 - 1.5 cm. The deformation of the duodenum of the bulbs is determined by unstable spastic abbreviations or scars (Fig. 19). Sometimes the gaping of the gatekeeper is observed. It should be noted that the deformation of the bulb depends on the localization of the ulcerative "niche": the closer to the initial segment of the intestine, "Niche" is located, the more often the deformation is observed.

Outlukovical ulcers need to be differentiated with digestive digests. The presence of a cervical from the diverticulus with the folds passing into it, the mucous membrane helps proper diagnosis. Harder differentiation with the adhesive process. In most cases, perideoodenitis is manifested not only by conesoid protrusion of the intestinal wall, some contour cog is also detected on a larger or smaller over the wall of the duodenum; In addition, adhesive process There are no organic and functional signs inherent in an ulcer. If the tumor is suspected of a large duodenal papilla, or germination of the duodenal wall of the pancreas tumor is needed relaxation duodenography with a probe.

The ulcer of the stomach and duodenal intestine due to the generality of the pathogenesis of morphological and clinical manifestations Considered as a single disease - a peptic disease.

X-ray study plays an extremely large role in recognizing ulcerative disease. Recognition of ulcerative disease is based on direct radiographic signs of ulcers and on indirect.

Direct radiographic signs of peptic ulcer.

The main direct sign of ulcers is "niche". Niche is a limited protrusion on the silhouette of the stomach filled with contrast substance. Niche appears as a result of the fact that the ulcerative defect of the stomach wall is filled with a contrast agent. Niche represents something added, additional to the wall of the stomach, an additional shadow, + shadow.

In the event that the niche is located on the front or rear wall, it can be expressed in the form of a spot on the relief of the mucous membrane - "Niche on the relief". Around the niche is expressed by the regional inflammatory shaft due to the edema of the mucous. The dimensions of the niche are different depending on the degree of destruction of the wall and from the value of the inflammatory shaft. The inflammatory shaft can lengthen a niche, and sometimes it can be expressed so dramatically that it closes the entrance to the niche. Niche can be filled with food, blood clot, mucus. Therefore, in some cases, the niche is not detected x-ray.

In chronic recurrent or rally ulcers, the recycling of the relief of the mucosa in the form of convergence of folds to the niche is often detected. Such a restructuring is caused by scar by reference. Convergence of folds and inflammatory shaft are also direct signs of ulcers.

Niche in size can be small, medium and large. A niche of acute ulcers with a recent disease, determined during the first study, usually sizes 0.5 x 0.8 cm. Small niches with a pea size are more often in the bulb of the duodenum.

The most common niches of the average value of 0.5 - 0.8 x 1.0 - 1.2 cm.

Ulcerative niche large sizes, the diameter and depth of which are equal to several centimeters, is usually observed in exhausted people, with a large prescription of the disease with a sharply pronounced clinical picture. Such niches are usually found with penetrating ulcers.

Penetrical niche - This is a deep niche, penetrating outside the wall of the stomach into some other organ. Such a niche is often three-layer - barium, liquid, air, or two-layer - barium and air. The presence of air bubble in Niche always talks about penetration. A peptic niche usually has smooth walls. The irregularity of the walls speaks or about bleeding or, on the reincarnation of ulcers in cancer.

Indirect signs of peptic ulcer.

Indirect signs of peptic disease are mainly functional changes. These include:

1. Increasing the tone of the stomach, which is expressed in slow stomach deployment.

2. Strengthened peristalistic - the presence of deep waves, sometimes peristaltic waves are rejected by the stomach into separate segments.

3. Hypersecretion - the presence of fluid in the stomach of an empty stomach.

4. Evacuation delay - caused by the spasm of the gatekeeper under the ulcer of the pyloric stomach. But sometimes, with stomach ulcers, a faster evacuation can be celebrated.

5. Paints in a certain area of \u200b\u200bthe stomach shadow in combination with other indirect signs, which often indicate the presence of ulcers.

Stomach cancer.

In the domestic literature in the description of the X-ray selection of all known forms of cancers of the stomach, the values \u200b\u200bof the works of such authors like Yu.N. Sokolova, A.I. Ruderman (1947); Yu.N.Sokolova and P.V. Vlasova (1968) and others.

Currently, the classification of the pathological forms of developed gastric cancer (Sokolova Yu. N., 1965)

1. Exofite cancer

a. Knotted:

i. In the form of cauliflower

iI. Polypovoid

iII. Mushroom

b. Cache-like:

i. With preserved shaft

iI. With a destroyed shaft

c. Blash-shaped:

i. Without ulceration

iI. With ulceration