Method for diagnosing destructive ulcerating complications in duodenum ulcer cases

FIELD: medicine.

SUBSTANCE: method involves detecting duodenum wall integrity disorders in performing endoscopic examination of duodenal ulcer after removing necrotic detritus from ulcer bottom. Available wall defect is subjected to endoscopic probing with catheter introducing water-soluble radiopaque solution through the probe and followed with fistulographic examination. The radiopaque solution being observed outside of duodenum, duodenal fistula or perforated ulcer are diagnosed.

EFFECT: high reliability of early stage diagnosis.

3 dwg

 

The present invention relates to medicine, namely to gastroenterology, endoscopy, radiology and surgery. The problem of diagnostics and treatment of peptic ulcer of the duodenum (YAB KDP) remains in recent years one of the most acute. Despite the progress made in the study of etiology and pathogenesis, review of medical algorithms, it retains its relevance. Thus, according to the Ministry of health of Russia for the period 1999-2001, the number of scheduled operations at YAB WPC decreased in 2 times. While the number of emergency operations associated with urgent complications of this disease, for the same period increased by 2-3 times, the operative mortality rate has increased by 20-25%. [Nmin, Wtihin et al. Treatment of peptic ulcer disease: the views of the physician and surgeon. The "round table". // Russian journal of gastroenterology, Hepatology, Coloproctology. - 2001 - No. 2. - P.9-16].

This situation is due to insufficient position of medical diagnosticians and surgeons in timely detection and treatment of these patients, because the risk of surgical intervention increases significantly when it is in the later stages of the development of complications of duodenal ulcer [Resolution all-Russian conference of surgeons, Saratov, 2003].

High diagnostic value of endoscopic who Yoda in the study YAB KDP has made it a priority for this pathology. The main requirement to the study of the gastroduodenal area these patients is increased attention to duodenal ulcer - substrate life-threatening destructive complications YAB duodenum. The advent of endoscopic video system broadband, next generation equipment allows to perform a broad range of instrumental manipulation in the area of pathological changes in the gastrointestinal tract, including in the field of duodenal ulcers. This strengthening method improves the quality of research in early detection of complications YAB duodenum. Application to patients with duodenal ulcer x-ray endoscopic diagnostic complex increases the informativeness of these methods in the study of the gastroduodenal region.

There is a method of x-ray fistulografii [Ludlinderhof, Lbowman. Methods x-ray examinations of organs and systems of man. - Publishing House "Medicine". - 1976. - S]. Fistulography is applied in the presence of abdominal wall fistulous openings. Its objectives: to determine the source of the fistula, to clarify the position, size, branching fistulous course, to detect possible foreign body (bullet injuries and postoperative fistula). To fistulografii necessarily produce an overview radiograph of the abdomen in the nternet and lateral projections, and, if necessary, additional images. These radiographs often shed light on the origin of the fistula (of subdiaphragmatic or other intraperitoneal ulcer, one of the organs of the abdominal cavity, retroperitoneal space). It is advisable to introduce into the fistulous channel contrast mass through the catheter. As water-soluble roentgenocontrast use 50% solution "Hipac". Due to the complexity of the relationship of the fistula and abdominal organs, it is especially important to combine radiography - fluoroscopy and radiography. Remove the clip (a sticker) and let the contrast agent is not necessary until analyzed received fistulogram. In many cases, it is necessary to conduct additional research - artificial contrast study of the stomach, intestines, urography, to determine the ratio between the fistula, abscess and neighbouring authorities.

This method offers a diagnosis only those fistulous formations that appear on the anterior abdominal wall, fistulas, communicating with the KDP - internal fistulas, in this study remain inaccessible to the review.

A significant drawback of this method is that it does not reveal the internal fistula resulting from acute or chronic inflammatory reactions between the bodies of the gastroduodenal and HepB is Mobiliare areas.

As the closest analogue is adopted a method of endoscopic prediction of bleeding from ulcers of the stomach and duodenum, described in 1974 J.A.N Forrest et al. [Vincotto, Tchubinsky, Ari. Endoscopic treatment of bleeding from the upper gastrointestinal tract. (Tutorial). Russian medical Academy of postgraduate education. M, - 2000. - 24 S.]. Scientists have described and systematized pathological changes in the area of the bottom of the ulcer is diagnosed endoscopically in patients with peptic ulcer disease. Assessed the presence of stigma active, held or likely bleeding in the bottom of the ulcer in the form of a pulsating jet or stream, visible vessel, thrombus or black spots in the bottom of the investigated ulcers. Thus, in accordance with the proposed classification is performed endoscopic visualization of the bottom of the ulcer and the prediction of the risk of complications YAB bleeding.

Classification of ulcer bleeding by Forrest:

Type I is active bleeding:

Ia - pulsating stream

Ib - flow

Type II - signs of recent bleeding:

IIa - visible vessel

IIb - fixed thrombus-clot

IIc - flat black spot (black bottom ulcers)

Type III ulcers with a clean (white) bottom

Currently, this classification has been recognized worldwide as a basis for the distribution tactics of conducting the patient with peptic ulcer disease, complicated by bleeding [ibid, Vinsonneau et al., 2000]. When you clean the bottom of ulcer type sores - Forrest III) the likelihood of recurrence is less than 5%, when the type Forrest IIc - 10%. The highest risk of recurrent bleeding - up to 40% of patients with visible in the bottom of the ulcer necroticism vessel - type Forrest IIa or type Forrest IIb. However, many gastroenterologists note that the type of ulcers Forrest III (ulcer with a clean white bottom)observed in patients after an episode of gastrointestinal bleeding is the most unpredictable. It is assumed that a thick layer of detritus can hide stigma bleeding (vessel, thrombus, black spot) in the bottom of the ulcer.

The disadvantage of this method is:

1) passive endoscopic visualization of the bottom of the ulcer can lead to erroneous prediction of re-bleeding - destructive complications of peptic ulcer disease;

2) in the present method is not the focus of all possible and important pathological changes of the bottom of the ulcer of the duodenum. The diagnostic potential of endoscopic method in the study ulcer-destructive complications YAB WPC used in full.

Task:

improving the diagnostic accuracy of endoscopic method in the detection of hidden complications of peptic ulcer of the duodenum.

The technical result of the proposed method is the use of endosco the systematic manipulation in the area duodenal ulcer, allowing in combination with x-ray method to diagnose more accurately ulcerative-destructive complications YAB duodenum. In addition, the application of the method allows to expose the pathological zone duodenal ulcers, concealment, which distorts the results of the study. Execution of radiographic contrast defect found in the duodenal wall allows to differentiate complications of duodenal ulcer is perforated ulcers from duodenal fistula.

The method provides:

- determination of optimal timing of surgical treatment YAB duodenum complicated by perforation of the ulcer or the formation of duodenal fistula;

- improving clinical and economic effectiveness of treatment YAB duodenum, by eliminating unsuccessful conservative treatment and determine the indications for surgical treatment by endoscopic criteria;

acceleration of functional recovery of the upper gastrointestinal tract in the postoperative period by timely identification of indications for surgical treatment.

The essential novelty of the proposed method is the endoscopic examination of the bottom of the ulcer by prior removal of necrotic debris and revealing the hidden violating the integrity of the walls of the duodenum. Filling patologica the zone through which the catheter is water-soluble radiopaque solution and execution prepositional by fistulography can detect and differentiate such complications YAB KDP, as the perforation duodenal ulcer and duodenal fistula.

The method is tested on 129 patients within 3 years (2002-2005). All patients were referred to the clinic of the FGI "RZQHG University" in a planned manner. The method is as follows. Patients with YAB KDP esophagogastroduodenoscopy performed using videoconferencing system with digital image quality firm Olympus Evis Exera CV-160 GIF TYPE × P160 (Japan) in the Cabinet, equipped relentlessing install - Baccara with electro-optical Converter of the firm "Apelet" (France).

40 minutes before the study, patients perform sedation in the composition of the Sol. Athropini 0,1% - 1 ml, Sol. Sibazoni 2% 2 ml. Pay special attention to the study of the proximal DICK. Subject to the discovery of duodenal ulcers (figure 1-a; 2-a; 3-a) endoscopically remove necrotic detritus from the bottom of the ulcer by leaching through the catheter aseptic aqueous solution (0.9% NaCl, furatsilina 1:3000 and others) and/or scarification fixed fragments of detritus biopsy forceps (Fig 2-b; 3-b). In case of detection in the bottom of ulcer disorders of the integrity of the duodenum (figure 1-b; 2-b; 3-b) carry out endoscopic intubation of the defect catheter (figure 1-b; 2-d; 3-b), followed by the introduction through the catheter with water-soluble radiopaque solution "omnipak", "Ultravi is -370", and others) and perform prepositional fistulografii. Provided x-ray determination of unidirectional fill the contrast of adjacent organ (1-g) or destructive cavity (2-d) state the complication YAB KDP education duodenal fistula, while the multidirectional flow of contrast into the peritoneal cavity determine the perforation ulcers (3-in).

Example 1. Patient D., 49 years old, was admitted to the surgical Department of the FGI "RZQHG University" 9.10.03, with a diagnosis of peptic ulcer disease duodenal ulcer, constantly relapsing course. Upon receipt of a complaint on a constant aching pain in the epigastrium and right hypochondrium, worse in the evening, calmed down after taking antisecretory drugs, heartburn, nausea, bitter taste in the mouth. Ulcer history 10 years, exacerbation were seasonal. Took various antisecretory agents. In 2000, after determining the cytological method in gastrobioptates HP-contamination, high contamination, the patient was assigned several schemes antihelicobacter therapy, in accordance with the provisions of the 2nd Maastricht conference 2000 as a result was achieved full erradicate HP-bacteria. In spite of this the last 2-3 years the patient had noted a deterioration of General health with the changing nature of the pain syndrome, proyavlyayuschego is his constant presence, the average intensity and a more extensive localization (in the epigastrium and right hypochondrium). On this occasion, the patient was forced to take a daily antisecretory drugs (omez - 40 mg/day). Endoscopic examination of the bulb of the duodenum revealed in its middle third on the back of ulcerative defect (Fig 1-a). After laundering necrotic detritus in the bottom of the ulcer was detected violation of the integrity of the duodenal wall (figure 1-b). Endoscopic intubation of the defect catheter and subsequent fistulography (figure 1-C) 10 ml of the solution "omnipak" revealed the message of the duodenum with an expanded and deformed choledochal. After administration of 20 ml of the solution "omnipak" radiographically determined contrasting the common bile, gallbladder and hepatic ducts (figure 1-g). Based on the results of clinical and diagnostic examination the patient was recommended to perform routinely organ-preserving surgical treatment is radical duodenoplasty.

14.10.03. According to intraoperative studies of KDP in the middle - third of the bulb of the duodenum on the back of the semicircle revealed duodenal ulcer, fixed robovie spikes from serosa of the duodenum to choledocho. The proximal half of the duodenum expanded to 35 mm. Identified commissural fixation with external compression of Obodo the Noah and the small intestine. Completed bridge duodenoplasty with the formation choledocho-duodenal fistula on the back of the duodenum, supplemented by the removal of the duodenum from under the root of the mesentery by the method developed in the clinic Veenapani [Vignobles et al. The complicated forms of peptic ulcer of the duodenum. A guide for physicians, surgeons gastroenterologists. Russian center of functional surgical gastroenterology health Ministry. - Krasnodar, 2002. - 655 S.]. The patient locally excised sore back wall of the duodenum in healthy tissues, adhesive bands and granulation tissue forming the wall of the fistula in choledocho created choledocho-duodenal fistula on the back of the duodenum. Defect of the duodenum was restored by shifting two of the lateral and anterior duodenal wall. External compression of the small intestine was removed by removal of the adhesive fixation and mobilization duodenojejunal transition of the gastrointestinal tract. The postoperative period was uneventful. On the 3rd day removed the nasogastric tube. On the 5th day are allowed to eat. Discharged from hospital on the 10th day. The patient is examined after 2 months. Had no complaints, dieted (table No. 1 by Pevsner). Endoscopy of the proximal duodenum: the gatekeeper rounded functioning properly. The bulb of the duodenum is shortened in the longitudinal dimension, her question is no barrel-shaped with a diameter of up to 3.5 cm, mucosa with mild diffuse hyperemia. Postbulbar departments without signs of pathology. 6 months after surgery, the patient felt well, antisecretory drugs is not accepted, quit Smoking, currently adheres to the recommended diet, works in the specialty.

Example 2. Patient S., 46 years old, was admitted to the surgical Department of the FGI "RZQHG University" 14.04.03, with a diagnosis of peptic ulcer disease duodenal ulcer, constantly relapsing course. Upon receipt complained of constant pain in the epigastrium and right hypochondrium weak and medium intensity, heartburn, belching air. Ulcer history 15 years. Exacerbations were seasonal. Took various schemes antiulcer therapy with varying degrees of success. The last 3 months, the patient noted the ineffectiveness of conservative anti-ulcer treatment, manifested by deterioration of General health and permanent nature of the pain syndrome. Endoscopic examination of the duodenum was found in postbulbar Department of the ulcer (figure 2-a). After removal of necrotic detritus from the bottom of the ulcer (figure 2-b) was detected violation of the integrity of the duodenal wall (figure 2). Endoscopic intubation of the defect catheter (figure 2-d) and the subsequent water-soluble contrast fistulography showed unidirectional shall ispolnenie fistulous destructive cavity (figure 2-d).

The patient was performed routinely bridges radical duodenoplasty. The patient locally excised sore back wall of the duodenum in healthy tissues, extrauterine commissural fibers and granulation tissue forming the wall of the fistula and destructive cavity. The postoperative period was uneventful. On the 3rd day removed the nasogastric tube, on the 5th day are allowed to eat. Discharged from hospital on the 10th day. The patient is examined after 2 months. Had no complaints, complied with the recommended diet. Endoscopy of the proximal duodenum: the pylorus is closed, the bulb of the duodenum is shortened in the longitudinal size of its lumen had a cylindrical shape and a diameter up to 4 cm, slimy pink. Postbulbar departments without signs of pathology. 6 months after surgery, the patient felt well, antisecretory drugs is not accepted, started to work in the specialty.

Example 3. Patient A., 68 years. Did 23.04.2004, with complaints of persistent epigastric pain, radiating to the left hypochondrium, heartburn, vomiting, bringing relief.

Suffered from peptic ulcer of the duodenum about 13 years. Noted seasonal exacerbations (spring, autumn) with an average duration of about 10-14 days. Has taken various schemes antiulcer treatment in inpatient and outpatient is again order by place of residence, with a follow fibrogastroduodenoscopy study. The present deterioration of health came within 5 days of emergency admission to the surgical Department RZQHG, manifested severe pain in the epigastric region, intractable analgesics and antagonists, proton pump.

Endoscopic examination of the duodenum revealed on the front wall of the middle third of the bulb duodenum ulcer (figure 3-a: A; b: (A) polygonal shapes with high sides and bottom covered with necrotic debris. Endoscopic examination of the bottom of the ulcer with the removal of detritus by laundering with 0.9% NaCl and scarification biopsy forceps revealed the violation of the integrity of the duodenal wall (figure 3-b: B).

Performing a sensing catheter pathological region, followed by the introduction of water-soluble contrast medium and holding prepositional fistulografii showed multidirectional flow of contrast into the peritoneal cavity (Fig 3-C). The obtained diagnostic data suggest a complication flow YAB duodenum the patient perforated duodenal ulcer. The patient was performed emergency radical duodenoplasty method Vieodrive (1995).

Intraoperative study revealed in all departments of the abdomen moderate quantity the STV fibrinous-purulent discharge. The right half of the greater omentum, lesser omentum, hepatoduodenal ligament, infiltrated, with fibrin, involved in the subhepatic space, which is determined by a moderate amount of duodenal contents. The gall bladder is deformed, a solid elastic consistence, wall infiltrated and swollen. The gastric antrum and expanded in size, wall thickened, infiltrated. In the duodenal bulb ulcer has front wall, closer to the greater curvature with perforating a hole in the bottom to 0.5 see the edges of the ulcer swollen. WPC due to widespread ulcerative-destructive process that has become complicated, shifted inwards and downwards towards the retroperitoneal tissue. Thin, thick intestines and other parenchymatous organs without features.

The complex of preventive manipulations aimed at the prevention of acute pancreatitis, including the introduction enzymeinhibitor solutions on the basis of a 0.25% solution of novocaine in retroduodenal space, parapancreatic fiber and periduodenal. According to the clinic technique the edges of the ulcer of the duodenum is consistently excised to a healthy, well krovosnabjaemah tissues. Through the window in a small gland and during the manual control of the gastrocolic ligament pancreas dissected the back wall of the duodenum. When Beeman the social study clearly reveals the preservation of biostructure gatekeeper. Large duodenal papilla is located 1.5 cm from duodenotomy holes. Clearly defines the difference between the diameter of the matched ends of the duodenum. After applying bonding orienting seams-taped imposed first map, and then closing the seams. Formed anastomosis.

The nasogastric tube torrigiano and fixed. In the subhepatic space and pelvis installed Winternitz drainage tube. Layered seams on the wound. In the subcutaneous tissue is installed drain pipe with however. Aseptic bandage.

The postoperative period was uneventful. On the 5th day removed the nasogastric tube, allowed to eat. Drainage tube removed within 8-12 days. Discharged from the hospital on the 15th day, with the recommendations of the receiving antisecretory drug (lanzap from 60 to 30 mg/day) on the proposed scheme within 2 months.

The patient is examined after 2 months. Had no complaints. When the control endoscopy of the duodenum was observed shape recovery gatekeeper with some slow contractile function. Proximal division of the duodenum is shortened in the longitudinal size of its lumen is cylindrical, with a diameter of 4 cm, the mucosa with mild diffuse hyperemia. At follow-up at 1 year after surgery, the functional indicators with the situation of the gastroduodenal junction normalized.

Method for the diagnosis of latent destructive complications of peptic ulcer of the duodenum, including endoscopic examination of the bottom of duodenal ulcers, characterized in that after removal of necrotic detritus from the bottom of the ulcer, if the integrity of the walls of the duodenum, perform endoscopic intubation catheter detected defect wall with the probe through a water-soluble radiopaque solution and then fistulography, when the contrast beyond the duodenum determine the presence of duodenal fistula or perforation of an ulcer.



 

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2 cl, 2 dwg, 2 ex

FIELD: medicine.

SUBSTANCE: method involves producing X-ray picture with step attenuator being applied, building graduation curve matching optical density of X-ray picture and specific calcium hydroxyapatite content in volume in g/cm2. The step attenuator is manufactured from copper alloy.

EFFECT: high accuracy of estimation.

8 dwg

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