Duodenal sounding of the gallbladder

Until recently, it was very common to study the biliary tract with duodenal probing, which is the introduction of a probe into the duodenum to obtain its contents. 

[1], [2], [3], [4]

Indications for the procedure

This study is used in the diagnosis of diseases of the gallbladder and biliary tract, duodenum. However, at present, this method is used less often due to the extensive use of endoscopy and ultrasound. The contents of the duodenum is a mixture of bile, secretions of the pancreas and duodenum with a small amount of gastric juice.

Multimoment fractional duodenal sounding makes it possible to get bile from the common bile duct, gallbladder and intrahepatic bile ducts with subsequent biochemical and microscopic examination of it. In addition, this method gives an idea of the functional state of the gallbladder and bile ducts.

[5], [6], [7], [8]

Preparation

Before inserting the probe, a pharyngeal smear should be taken for bacteriological examination, then the patient should rinse the oral cavity with a disinfectant solution to reduce the possibility of drifting microflora from the oral cavity into bile portions. The duodenal probe is injected into the 12-colon early in the morning on an empty stomach. It is more preferable to use the two-channel probe of NA Skuya for separate extraction of gastric and duodenal contents. One channel of the probe is located in the stomach, the other in the duodenum. Gastric juice should be continuously removed by a syringe or vacuum unit, as when gastric acid enters the 12-colon, the bile becomes cloudy. In addition, hydrochloric acid stimulates pancreatic secretion and bile secretion through the release of secretin secretion and cholecystokinin-pancreosimin.

In the absence of a dual-channel probe, a single-channel duodenal probe should be used.

[9], [10], [11]

The device for carrying out the procedure

The investigation is best done with a two-channel probe, which has a metal olive with holes at the end. The probe is marked with 3 marks: at a distance of 45 cm (distance from the incisors to the subcardial part of the stomach), 80 cm (distance to the large duodenal papilla).

Fractional duodenal sounding (PDD) has the following advantages over conventional duodenal sounding:

• allows you to get a clearer idea of the functional state of the gallbladder and biliary tract;
• allows to diagnose the type of dyskinesia of the gallbladder.

Technique of the duodenal sounding

Collection of bile of duodenal contents is carried out in numbered test tubes every 5 minutes.

There are 5 phases of fractional duodenal sounding.

• 1 - choledochus phase - begins after the olive probe is located in the duodenum (angle of the descending and lower horizontal part). During this period, the sphincter of Oddi is in a relaxed state and a portion of clear light yellow bile is allocated from the common bile duct (d. Choledochus) as a result of irritation of the duodenal ulcer of the olive probe.

The time during which bile is secreted and its volume are taken into account.

1 phase reflects basal secretion of bile (outside digestion) and partially functional state of the sphincter of Oddi.

Normally, 15-20 ml of bile is released within 10-15 minutes (according to some data - within 20-40 minutes).

After the end of the bile secretion into the 12 duodenum through the duodenal probe slowly, within 5-7 minutes, a warm 33 ° solution of magnesium sulfate-30 ml or 5% -50 ml heated to 37 ° C is introduced.

In response to the introduction of the stimulus, the sphincter of Oddy reflexively closes and is closed during the entire second phase of probing.

• 2 phase - the closed sphincter of Oddi (the phase of the latent period of bile secretion) - reflects the time from the administration of the cholecystokinetic solution to the appearance of a secretion of the gall. At this time, bile is not excreted. This phase characterizes the cholestatic pressure in the biliary tract, the readiness of the gallbladder to emptying and its tone.

Normally, the closed sphincter phase of Oddi lasts 3-6 minutes.

If the bile appeared before 3 minutes, this indicates a hypotension of the sphincter of Oddi. The increase in the time of the closed sphincter of Oddi is greater than 6 minutes indicating an increase in its tone or a mechanical obstruction to the outflow of bile. To resolve the issue of the nature of the changes, 10 ml of warm (warmed to 37 ° C) 1% solution of novocaine can be introduced through the probe. The appearance of a light yellow bile after this testifies to the spasm of the sphincter of Oddi (novocaine relieves spasm). If after injection of novocaine bile is not released within 15 minutes, the patient can give under the tongue 1/2 of the nitroglycerin tablets and, in the absence of the effect, re-enter through the probe into the 12-colon of the cholekinetic agent (20 ml of vegetable oil or 50 ml of 40% glucose solution, xylitol). If bile does not appear and after this, the position of the probe in the duodenum should be checked radiographically, and if the probe is positioned correctly, stenosis in the region d can be assumed. Choledochus.

• 3 phase - A-bile (the phase of the cystic duct) - begins with the opening of the sphincter of Oddi and the appearance of light bile A before the release of dark concentrated bile of the gallbladder.

Normally, this period lasts 3-6 minutes, during which 3-5 ml of light bile is released from the vesicle and common bile duct.

This phase reflects the state of these ducts. Increasing the time of 3 phases more than 7 minutes indicates an increase in the tone of the sphincter of Lutkens (it is located at the junction of the cervix of the gallbladder in the cystic duct) or hypotension of the gallbladder.

About the hypotension of the gallbladder can only speak after comparing the data of III and IV stages.

Bile 1, 2 and 3 phases constitute the classical portion of A normal (non-fractional) duodenal sounding.

• 4 phase - the gallbladder (gall bladder, the phase of B-bile) - characterizes the relaxation of the sphincter of Lutkens and the emptying of the gallbladder.

The 4th phase begins with the discovery of the sphincter of Lutkens and the appearance of dark olive concentrated bile and ends at the moment of stopping the secretion of this bile.

Isolation of the gall bladder at first is very intense (4 ml per 1 minute), then gradually decreases.

Normally, the time for emptying the gallbladder is 20-30 minutes, during this time, an average of 30-60 ml of dark olive gallbladder is released (in chromatic probing, the bile is colored blue-green).

Intermittent excretion of cystic bile indicates the dissyncism of the sphincters of Lutkens and Oddi. The lengthening of the time for the release of cystic bile (more than 30 minutes) and an increase in the amount of more than 60-85 ml indicates a hypotension of the gallbladder. If the duration of 4 phases is less than 20 minutes and less than 30 ml of bile is released, this indicates hypertonic dyskinesia of the gallbladder.

• 5 phase - the phase of hepatic bile-C - occurs after the end of the allocation of B-bile. 5 phase begins from the moment of allocation of a golden bile (hepatic). This phase characterizes the exocrine function of the liver. The first 15 minutes of liver bile is secreted intensively (1 ml or more in 1 minute), then its release becomes monotonic (0.5-1 ml per 1 minute). Significant excretion of hepatic bile in phase 5, especially in the first 5-10 minutes (> 7.5 ml / 5 min) indicates the activity of the sphincter Mirizzi, which is located in the distal part of the hepatic duct and prevents the retrograde movement of bile with a contraction of the gallbladder.

Bile-C is advisable to collect for 1 hour or more, studying the dynamics of its secretion, and try to get the residual vesicle bile without repeated administration of the gallbladder stimulus.

The repeated contraction of the gallbladder normally occurs 2-3 hours after the introduction of the stimulus. Unfortunately, in practice duodenal sounding is completed 10-15 minutes after the appearance of hepatic bile.

• Many suggest to allocate 6 phase - a phase of a residual cystic bile. As indicated above, 2-3 hours after the introduction of the stimulus, a repeated contraction of the gallbladder occurs.

Normally the duration of the 6th phase is 5-12 minutes, during this time 10-15 ml of dark olive gallbladder is secreted.

Some researchers suggest not to wait 2-3 hours, and soon after receiving the hepatic bile (after 15-20 minutes) to introduce an irritant to be sure of complete emptying of the gallbladder. The receipt of additional amounts of vesicle (residual) bile in this time interval indicates an incomplete emptying of the gallbladder with its first contraction and, consequently, its hypotension.

Normal performance

For a more detailed study of the function of the sphincter apparatus of the bile ducts, it is advisable to study biliary excretion graphically, while the volume of bile obtained is expressed in ml, at the time of bile secretion - in min.

Propose to determine a number of indicators of biliary excretion:

• the rate of excretion of bile from the bladder (reflects the efficiency of the ejection of bile by the bladder) is calculated by the formula:

H = Y / T, where H is the rate of bile excretion from the bladder; V - volume of cystic bile (B-portion) in ml; T - time of bile secretion in min. Normally, the rate of bile secretion is about 2.5 ml / min;

• the index of evacuation - the index of the motor function of the gallbladder - is determined by the formula:

IE = H / Vostat * 100%. IE-evacuation index; H is the rate of excretion of bile from the bladder; Vostat - residual volume of cystic bile in ml. Normally, the evacuation index is about 30%;

• the effective release of bile by the liver is determined by the formula:

VEV = V portion B from bile for 1 hour in ml / 60 min, where EVP is an effective release of hepatic bile. Normally, the EWL is about 1-1.5 ml / min;

• the index of secretory liver pressure is calculated by the formula:

Index of secretory liver pressure = EVL / H * 100%, where EVL is an effective release of hepatic bile; H is the rate of excretion of hepatic bile from the bladder (effective ejection of bile by the bladder). Normally, the secretory pressure index of the liver is approximately 59-60%.

Fractional duodenal sounding can be made chromatic. For this, on the eve of duodenal sounding at 2100 2 hours after the last meal, the patient takes inward 0.2 g of methylene blue in a gelatin capsule. The next morning at 9.00 (i.e., 12 hours after dye ingestion), fractional sounding is carried out. Methylene blue, sucked in the intestines, with blood flow enters the liver and is restored in it, turns into a colorless leuco compound. Then, after getting into the gallbladder, the discolored methylene blue oxidizes, turns into a chromogen and stains the bladder bile in a blue-green color. This allows you to confidently distinguish between gall bladder and other phases of bile that retain the usual color.

The bile obtained by duodenal probing is examined biochemically, microscopically, bacterioscopically, its physical properties and sensitivity to antibiotics are determined.

To investigate bile it is necessary immediately after its reception, as contained in it bile acids quickly destroy uniform elements. To deliver bile to the laboratory should be in a warm form (tubes with bile are placed in a jar with warm water), so that it is easier to detect lamblias with microscopy (in cold bile they lose their motor activity).

Changes in the indices of duodenal sounding (portion "B"), characteristic of chronic cholecystitis

1. The presence of a large number of leukocytes, especially the detection of their accumulations. Finally, the question of the diagnostic value of the detection of leukocytes of bile, as a sign of the inflammatory process, has not been resolved. In any portion of the duodenal contents, leukocytes can get from the mucous membrane of the oral cavity, stomach, duodenum. Often, leukocytes are taken by leukocytoids - cells of the cylindrical epithelium of the duodenum, transformed under the influence of magnesium sulfate into large round cells resembling leukocytes. In addition, it should be borne in mind that leukocytes are quickly digested by bile, which of course reduces their diagnostic significance.

In connection with this, it is now believed that the detection of leukocytes in portion B is a sign of the inflammatory process only if the following conditions exist:

• if the number of leukocytes is really large. To identify leukocytes, the Romanovsky-Giemsa coloration should be used, as well as a cytochemical study of the content in peroxidase cells. Leukocytes give a positive response to myeloperoxidase, leukocytoids - no;
• if clusters of leukocytes and cells of the cylindrical epithelium are found in flaky mucus (mucus protects leukocytes from the digestive action of bile);
• if the detection of leukocytes in bile is accompanied by other clinical and laboratory signs of chronic cholecystitis.

Detection of leukocytoid is not given a diagnostic value. To detect leukocytes and other cells in the bile, you should view at least 15-20 preparations before the microscope.

2. Identification of a visual examination of bile expressed by its turbidity, flakes and mucus. In a healthy person, all portions of bile are transparent and do not contain pathological impurities.
3. Detection of a large number of cells in the bile of the cylindrical epithelium. It is known that three types of cylindrical epithelium can be found in bile: fine epithelium of intrahepatic bile ducts - with cholangitis (in "C" portion); elongated epithelium of the common bile duct with its inflammation (portion "A"); wide epithelium of the gallbladder with cholecystitis.

Chronic cholecystitis is characterized by the detection of a large number of cells of the cylindrical epithelium in the gall bladder in a large number of cells. Cells of the cylindrical epithelium are found not only in the form of separate cells, but also in the form of clusters (strata) of 25-35 cells.

4. Decreased pH of the gallbladder. The bile bile has a pH of 6.5-7.5. In inflammatory diseases of the bile-excreting system, the reaction becomes acidic. According to the researchers at an exacerbation of chronic cholecystitis the pH of the gall bladder can be 4.0-5.5.
5. The appearance of crystals of cholesterol and calcium bilirubinate. Chronic cholecystitis is characterized by the appearance of crystals of cholesterol and calcium bilirubinate. The detection of a large number of them indicates the destabilization of the colloidal structure of bile (discrinia). With the appearance of conglomerates of these crystals and mucus, we can speak about the lithogenic properties of bile, the formation of microliths, and the peculiar transformation of cholecystitis to calcale calcite. Along with microlites, sand is often found - small, recognizable only under a microscope, grains of various sizes and colors (colorless, refracting light, brown), which are located in the flakes of mucus.
6. Reduction of the relative density of the gall bladder. Normally, the relative density of the gall bladder is 0.016-1.035 kg / l. With a pronounced exacerbation of chronic cholecystitis, the relative density of the gall bladder decreases as a result of the dilution of its inflammatory exudate.
7. Change in the biochemical composition of bile. Bile is a complex colloidal solution containing cholesterol, bilirubin, phospholipids, bile acids and their salts, minerals, proteins, mucoid substances, enzymes.

When the chronic cholecystitis worsens , the biochemical composition of bile changes:

• the amount of mucin substances reacting with the DPA reagent is increased, which significantly increases the activity of the DPA reaction;
• increases in 2-3 times the content of bile glycoproteins (hexosamines, sialic acids, fucoses);
• the content of bile acids decreases;
• decreases the cholate-cholesterol ratio (the ratio of bile acids in bile to the level of cholesterol in it);
• the content of the lipoprotein (lipid) complex decreases.

Lipoprotein macromolecular complex formed in the liver complex compound, which includes the main components of bile: bile acids, phospholipids, cholesterol, bilirubin, protein, grouped around the lipoprotein nuclei with the formation of a macromolecular complex. The lipoprotein complex provides colloidal stability of bile and its intake from the liver into the intestine. Bile phospholipids form micelles with cholesterol, and bile acids stabilize them and transfer cholesterol into a soluble form;

• the content of fibrinogen and the products of its metabolism in the cystic bile increases sharply;
• proteinocholia is observed - increased secretion of whey proteins (mainly albumins) in bile, while reducing the secretion of immunoglobulin A.

8. Increase in the content of gall bladder peroxide lipids.

An increase in the number of lipid peroxides in bile is a consequence of the rapid activation of free radical lipid oxidation. The level of lipid peroxides clearly correlates with the severity of the inflammatory process in the gallbladder.

9. Bacteriological study of bile. The purpose of bacteriological study of bile is the detection of bacterial flora and the determination of its sensitivity to antibacterial agents. The study is of diagnostic significance if the number of bacteria exceeds 100,000 in 1 ml of bile.

[12], [13], [14]