Technique of endoscopy of the intestine

In the study of the duodenum, the most widely used are duodenoscopes with a lateral arrangement of optics, which are most convenient for examining such an anatomically complicated organ as the duodenum and performing operations on it. Duodenoscopy can also be performed with instruments with a faceted optics arrangement. The greatest advantages they have in examining patients who have undergone stomach resection by the method of Bilrot-II.

Duodenoscopy with the help of endoscopes with end optics begins with a view of the gatekeeper, which is produced by bending the distal end of the endoscope upward and pushing the device forward. The lower the tone of the stomach and the more it sags, the stronger you have to bend the end of the endoscope. If the endoscope is located at the gatekeeper, you can see the greater part of the anterior and upper walls of the bulb, and with an inconspicuous bend of the intestine, one can view even the region of the postbulbar sphincter of Kapandji.

Passing through the ring of the gatekeeper and changing the position of the distal end of the endoscope, you can examine the greater part of the walls of the bulb of the duodenum and bend it backward. In case of insufficient relaxation, the gatekeeper is spasmodically reduced, and effort is needed in carrying out the endoscope, which falls deep into the bulb cavity and reaches the anterior surface of the duodenal wall in the area of its upper bend. In this case, either the field of vision becomes red (the endoscope is close to the mucosa), or the villous pattern of the mucous membrane is clearly visible (the endoscope is in close proximity to it). Sometimes the endoscope reaches the terminal part of the upper horizontal branch of the duodenum and even the descending part. The rapid passage of the gatekeeper and the deep penetration of the endoscope into the gut may lead to intestinal injury and even perforation in the presence of an ulcer.

The bulb of the duodenum, after carrying out the endoscope for the gatekeeper, looks like a triangular prism whose apex corresponds to the upper duodenal curve. The front wall is located at 9, the rear wall at 3 o'clock. When examining the walls of the intestine it is necessary to evaluate their shape, tone, elasticity and extensibility when insufflation of air.

With further carrying out of the endoscope, it is necessary to rotate it around its own axis clockwise and bend the distal end posteriorly (to the back). The smooth surface of the bulb is replaced by a folded relief in the distal half of the upper horizontal branch of the duodenum, especially pronounced in the sphincter region. When the endoscope moves in the field of view, the outer wall of the descending part of the duodenum appears, into which it rests when moving forward.

For the introduction of an endoscope with end optics in the descending part, examination of the small and large papillae of the duodenum is necessary, moving the endoscope forward, rotate it counterclockwise and bend left and down.

When using endoscopes with side optics, the gatekeeper is seen from afar well and there is no need to change the position of the distal end. When the apparatus is located at the gatekeeper, only the upper part of the ring gets in the field of vision and for its complete revision it is necessary to bend the distal end of the endoscope downward. When the gatekeeper passes, the end of the endoscope reaches the top wall of the bulb and the view of its walls is due to rotational movements of the device around its own axis, forward and backward movements and bending of the distal end downwards. Fibroendoscope while it is in the bulb of the duodenum must be constantly fixed by hand, because the peristalsis pushes it in the direction of the pylorus. Guts accumulating in the lumen and interfering with examination bile and mucus aspirate through the endoscope.

The mucous membrane of the bulb is paler than in the region of the stomach, with small delicate longitudinal folds that freely spread out when the air is injected. The mucous membrane is velvety, has a cellular appearance, juicy, its color is light pink, it sometimes shows a small-looped vascular pattern. An important reference point is a high semilunar fold, located 3-6 cm from the gatekeeper, which does not disappear when the air is injected. It sort of delimits the bulb from the rest of the duodenum. This place is called the angle of the bulb. Some researchers believe that in the area of the angle of the bulb of the duodenum there is a physiological sphincter. However, complete closure of the intestinal wall in this place does not always take place, due to which there is a gap through which regurgitation of bile from the descending part of the duodenum occurs. In some cases with reflux from the distal part of the intestine a small amount of foamy bile is thrown into the ampulla.

When moving the endoscope to the descending part of the duodenum, you must first rotate it around the axis clockwise and bend downwards, and after reaching the upper corner and bending, on the contrary, rotate counter-clockwise. The cylindrical channel of the descending part of the duodenum is somewhat narrowed in the middle section, where the intestine is crossed by the mesentery of the transverse colon with the middle colonic artery located in it. The pulsation of this artery is transmitted through the wall of the intestine and can be seen with endoscopy. The mucous membrane of the descending part, like the terminal part of the bulb, forms well-defined circular folds (Kerkring folds). Closer to the lower bend, they become larger, and the lumen of the intestine widens. The color of the mucosa is pink with a yellowish tinge, which is due to the bile on its surface.

On the posterior internal wall of the descending part of the duodenum there is a longitudinal cushion formed by a common bile duct passing through its wall. This roller ends in the middle of the descending part with an elevation - a large papilla of the duodenum of different sizes (0.4-1 cm) and shape. Outwardly, it resembles a polyp on a broad base or resembles a cone or hemispherical formation. The color of the surface of the papilla is yellow-orange, unlike the surrounding light pink duodenal mucosa. In the center of the papilla there is an opening that opens the common bile duct and pancreatic duct. Sometimes one finds not one but two papillae (small papilla of the duodenum). It is good to consider the large papilla of the duodenum, especially the endoscope with end optics, not always, because in some cases a fold of the mucous membrane hangs over it. More convenient for the study of a large papilla duodenoscope with a lateral observation tube. But at the same time he concedes at a circular examination of the wall of the duodenum. To remove the OBD from the "profile" to the "facet" position, it is often necessary to transfer the patient to the position on the abdomen, and to put the end of the endoscope below the papilla, bending the distal end of the apparatus downwards and to the right.

Inspection of the lower horizontal and ascending branches of the duodenum and jejunum is performed with a gradual soft advance of the endoscope forward and a change in the position of the device by rotating it around its own axis and bending the distal end in a particular plane.

After the end of duodenoscopy, the patient needs to turn on his stomach and bry the air. If a biopsy was performed, 2 ml of 1% solution of vicasol should be injected intramuscularly to prevent bleeding from the damaged areas of the mucosa. Food intake is allowed 1,5-2 hours after the test.