X-ray signs of bowel disease

Recognition of bowel diseases is based on clinical, radiological, endoscopic and laboratory data. Colonoscopy with biopsy plays an increasingly important role in this complex, especially in the diagnosis of early stages of inflammatory and tumor processes.

Acute mechanical intestinal obstruction. Radiographic examination is of great importance in its recognition. The patient is in an upright position and undergoes general radiographs of the abdominal organs. Obstruction is indicated by swelling of the intestinal loops located above the site of obstruction or compression of the intestine. Gas accumulations and horizontal fluid levels (the so-called Kloiber cups or levels) are determined in these loops. All intestinal loops distal to the site of obstruction are in a collapsed state and do not contain gas or fluid. It is this sign - collapse of the poststenotic segment of the intestine - that allows us to distinguish mechanical intestinal obstruction from dynamic (in particular, from paresis of the intestinal loops). In addition, with dynamic paralytic obstruction, peristalsis of the intestinal loops is not observed. Fluoroscopy does not reveal the movement of contents in the intestine and fluctuations in fluid levels. With mechanical obstruction, on the contrary, repeated images never copy those taken earlier, the picture of the intestine is constantly changing.

The presence of acute mechanical intestinal obstruction is established by two main signs: swelling of the prestenotic part of the intestine and collapse of the poststenotic part.

These symptoms appear 1-2 hours after the onset of the disease, and usually become distinct after another 2 hours.

It is important to differentiate between small and large intestine obstruction. In the first case, the small intestinal loops are distended, while the large intestine is in a collapsed state. If this is not clear enough from the images, then retrograde filling of the large intestine with a barium suspension can be performed. The distended intestinal loops in small intestinal obstruction occupy mainly the central sections of the abdominal cavity, and the caliber of each loop does not exceed 4 - 8 cm. Against the background of the distended loops, transverse striation is visible, caused by the spread circular (Kerckring) folds. Naturally, there are no haustra retractions on the contours of the small intestine, since they occur only in the large intestine.

In case of colon obstruction, huge distended loops with high gas bubbles in them are observed. Fluid accumulation in the intestine is usually small. Haustral retractions are outlined on the intestinal contours, and arcuate coarse semilunar folds are also visible. By introducing a contrast suspension through the rectum, it is possible to specify the location and nature of the obstruction (for example, to detect a cancerous tumor that has led to intestinal narrowing). We will only point out that the absence of radiographic signs does not exclude intestinal obstruction, since in some forms of strangulation obstruction, interpretation of the radiographic picture can be difficult. In these cases, sonography and computed tomography are of great help. They allow us to detect stretching of the prestenotic section of the intestine, a break in its image at the border with the collapsed poststenotic section, and a shadow of nodule formation.

Diagnosis of acute intestinal ischemia and intestinal wall necrosis is especially difficult. When the superior mesenteric artery is blocked, gas and fluid accumulate in the small intestine and in the right half of the colon, while the patency of the latter is not impaired. However, radiography and sonography provide recognition of mesenteric infarction in only 25% of patients. CT can diagnose infarction in more than 80% of patients based on thickening of the intestinal wall in the necrosis zone, the appearance of gas in the intestine, and in the portal vein. The most accurate method is angiography, performed using spiral CT, magnetic resonance imaging, or catheterization of the superior mesenteric artery. The advantage of mesentericography is the possibility of subsequent targeted transcatheter administration of vasodilators and fibrinolytics. Rational research tactics are presented in the diagram below.

In case of partial obstruction, a repeat examination after 2-3 hours is of great benefit. It is permissible to introduce a small amount of water-soluble contrast agent through the mouth or a nasojejunal probe (enterography). In case of volvulus of the sigmoid colon, valuable data are obtained by irrigoscopy. In case of adhesive obstruction, X-ray examination is used in different positions of the patient, recording the areas of fixation of intestinal loops.

Appendicitis. The clinical signs of acute appendicitis are known to every doctor. X-ray examination serves as a valuable method of confirming the diagnosis and is especially indicated in case of deviation from the typical course of the disease. The examination tactics are presented in the form of the following diagram.

As can be seen from the diagram, it is advisable to begin the radiological examination with sonography of the abdominal organs. Symptoms of acute appendicitis include expansion of the appendix, filling it with fluid, thickening of its wall (more than 6 mm), detection of stones in the appendix and its fixation, accumulation of fluid at the wall of the appendix and the cecum, hypoechoic image of the abscess, indentation from the abscess on the intestinal wall, hyperemia of the periappendicular tissues (with Dopplerography).

The main radiographic signs of acute appendicitis are: small accumulations of gas and fluid in the distal ileum and in the cecum as a manifestation of their paresis, thickening of the wall of the cecum due to its edema, thickening and rigidity of the folds of the mucous membrane of this intestine, stones in the appendix, small effusion in the abdominal cavity, edema of the soft tissues of the abdominal wall, blurred outlines of the right lumbar muscle. An appendicular abscess causes darkening in the right iliac region and an indentation on the wall of the cecum. Sometimes a small accumulation of gas is determined in the abscess and in the projection of the appendix. When the appendix is perforated, there may be small gas bubbles under the liver.

CT is somewhat more effective than sonography and radiography in diagnosing acute appendicitis, allowing for greater clarity in detecting thickening of the appendix wall and appendicular abscess.

In chronic appendicitis, deformation of the appendix, its fixation, fragmentation of its shadow during X-ray contrast examination or failure to fill the appendix with barium sulfate, the presence of stones in the appendix, and the coincidence of the pain point with the shadow of the appendix are noted.

Intestinal dyskinesin. X-ray examination is a simple and accessible method for specifying the nature of the movement of contents through the loops of the small and large intestine and diagnosing various types of constipation.

Enterocolitis. Similar symptoms are observed in acute enterocolitis of various etiologies. Small gas bubbles with short liquid levels appear in the intestinal loops. The movement of the contrast agent is uneven, with separate accumulations of it observed, with constrictions between them. The folds of the mucous membrane are thickened or not differentiated at all. All chronic enterocolitis accompanied by malabsorption syndrome are characterized by common signs: dilation of the intestinal loops, accumulation of gas and liquid in them (hypersecretion), separation of the contrast mass into separate lumps (sedimentation and fragmentation of the contents). The passage of the contrast agent is slow. It is distributed unevenly over the inner surface of the intestine, small ulcers may be visible.

Malabsorption. It is a disorder of absorption of various components of food. The most common diseases are those of the sprue group. Two of them - celiac disease and non-tropical sprue - are congenital, and tropical sprue is acquired. Regardless of the nature and type of malabsorption, the X-ray picture is more or less the same: dilation of the loops of the small intestine is determined. Liquid and mucus accumulate in them. Because of this, the barium suspension becomes heterogeneous, flocculates, divides into fragments, and turns into flakes. The folds of the mucous membrane become flat and longitudinal. A radionuclide study with trioleate-glycerol and oleic acid establishes a violation of absorption in the intestine.

Regional enteritis and granulomatous colitis (Crohn's disease).

In these diseases, any part of the digestive tract can be affected - from the esophagus to the rectum. However, the most common lesions are those of the distal jejunum and proximal ileum (jejunoileitis), terminal ileum (terminal ileitis), and proximal colon.

The disease progresses in two stages. In the first stage, thickening, straightening, and even disappearance of the folds of the mucous membrane and superficial ulcerations are observed. The contours of the intestine become uneven and jagged. Then, instead of the usual picture of folds, multiple rounded enlightenments are found, caused by islands of inflamed mucous membrane. Among them, strip-like shadows of barium deposited in transverse cracks and slit-like ulcers may stand out. In the affected area, the intestinal loops are straightened and narrowed. In the second stage, significant narrowing of the intestinal loops with the formation of cicatricial constrictions from 1-2 to 20-25 cm long is observed. In the images, the stenotic area may look like a narrow uneven channel (the "cord" symptom). Unlike the syndrome of impaired absorption, diffuse expansion of the intestinal loops, hypersecretion and fragmentation of the contrast agent is not observed, the granular nature of the relief of the inner surface of the intestine is clearly expressed. One of the complications of Crohn's disease is abscesses, the drainage of which is carried out under radiation control.

Tuberculosis of the intestine. The ileocecal angle is most often affected, but examination of the small intestine already reveals thickening of the mucous membrane folds, small accumulations of gas and fluid, and slow movement of the contrast mass. In the affected area, the intestinal contours are uneven, the mucous membrane folds are replaced by infiltration areas, sometimes with ulcerations, and there is no haustration. It is curious that the contrast mass does not linger in the infiltration zone, but quickly moves on (a symptom of local hyperkinesia). Subsequently, the intestinal loop shrinks with a decrease in its lumen and limited mobility due to adhesions.

Non-specific ulcerative colitis. Mild forms are characterized by thickening of the mucosal folds, point accumulations of barium, and fine serration of the intestinal contours as a result of the formation of erosions and small ulcers. Severe forms are characterized by narrowing and rigidity of the affected sections of the colon. They stretch little and do not expand with retrograde administration of a contrast mass. Haustration disappears, the intestinal contours become finely serrated. Instead of folds of the mucosa, granulations and accumulations of barium in ulcers appear. The distal half of the colon and the rectum are predominantly affected, which are sharply narrowed in this disease.

Colon cancer. Cancer appears as a small thickening of the mucous membrane, a plaque, or a polyp-like flat formation. Radiographs show a marginal or central filling defect in the shadow of a contrast mass. The folds of the mucous membrane in the defect area are infiltrated or absent, peristalsis is interrupted. As a result of tumor tissue necrosis, an irregularly shaped barium depot may appear in the defect - a reflection of ulcerated cancer. As the tumor grows further, two types of radiographic images are mainly observed. In the first case, a tuberous formation protruding into the intestinal lumen (exophytic growth type) is revealed. The filling defect has an irregular shape and uneven contours. The folds of the mucous membrane are destroyed. In the second case, the tumor infiltrates the intestinal wall, leading to its gradual narrowing. The affected section turns into a rigid tube with uneven contours (endophytic growth type). Sonography, CT, and MRI help to clarify the degree of invasion of the intestinal wall and adjacent structures. In particular, endorectal sonography is valuable in rectal cancer. CT scans make it possible to assess the condition of the lymph nodes in the abdominal cavity.

Benign tumors. About 95% of benign neoplasms of the intestine are epithelial tumors - polyps. They can be single or multiple. The most common are adenomatous polyps. They are small, usually no more than 1-2 cm in size, growths of glandular tissue, often have a stalk (stem). In X-ray examination, these polyps cause filling defects in the intestinal shadow, and with double contrast - additional rounded shadows with even and smooth edges.

Villous polyps look somewhat different on X-ray. The filling defect or additional shadow with double contrast has uneven outlines, the tumor surface is covered with barium unevenly: it flows between the convolutions, into the grooves. However, the intestinal wall retains elasticity. Villous tumors, in contrast to adenomatous polyps, often become malignant. Malignant degeneration is indicated by such signs as the presence of a persistent depot of barium suspension in the ulceration, rigidity and retraction of the intestinal wall at the location of the polyp, its rapid growth. The results of colonoscopy with biopsy are of decisive importance.

Acute abdomen.

The causes of acute abdomen syndrome are varied. For establishing an urgent and accurate diagnosis, anamnestic information, clinical examination results and laboratory tests are important. X-ray examination is used when it is necessary to clarify the diagnosis. As a rule, it begins with chest X-ray, since acute abdomen syndrome can be a consequence of pain irradiation due to lung and pleural damage (acute pneumonia, spontaneous pneumothorax, supradiaphragmatic pleurisy).

Then, an X-ray of the abdominal organs is performed to identify perforated pneumoperitoneum, intestinal obstruction, kidney and gallstones, calcifications in the pancreas, acute gastric volvulus, strangulated hernia, etc. However, depending on the organization of patient admission in a medical institution and the suspected nature of the disease, the examination procedure may be changed. At the first stage, an ultrasound examination may be performed, which in some cases will allow us to limit ourselves to X-ray of the chest organs in the future.

The role of sonography is especially great in detecting small accumulations of gas and fluid in the abdominal cavity, as well as in diagnosing appendicitis, pancreatitis, cholecystitis, acute gynecological diseases, and kidney damage. If there are doubts about the results of sonography, CT is indicated. Its advantage over sonography is that gas accumulations in the intestine do not interfere with diagnostics.