X-ray signs of bowel disease

The recognition of bowel diseases is based on clinical, radiological, endoscopic and laboratory data. A growing role in this complex is played by a colonoscopy with biopsy, especially in the diagnosis of early stages of inflammatory and tumor processes.

Acute mechanical obstruction of the intestine. In its recognition, radiology is of great importance. The patient in an upright position produces an overview of the chest radiographs of the abdominal organs. The obstruction is indicated by the swelling of the intestinal loops located above the site of obstruction or compression of the intestine. In these loops, gas accumulations and horizontal liquid levels are determined (the so-called bowls, or levels, of Clauber). All loops of the intestine distal to the occlusion site are in a collapsed state and do not contain gas and liquid. It is this symptom - the collapse of the poststenotic segment of the intestine - that makes it possible to distinguish between mechanical obstruction of the intestine and the dynamic (in particular, from the paresis of the intestinal loops). In addition, with dynamic paralytic obstruction there is no peristalsis of intestinal loops. When fluoroscopy can not detect the movement of contents in the gut and fluctuations in fluid levels. With mechanical obstruction, on the contrary, repeated pictures never copy previously made, the picture of the intestine changes all the time.

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

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

It is important to distinguish between the obstruction of the small and large intestine. In the first case, the loops of the small intestine are swollen, and the thick is in a collapsed state. If this is not clear enough from the pictures, then you can retrograde filling the colon with a barium suspension. Swollen intestinal loops with intestinal obstruction mainly occupy the central parts of the abdominal cavity, the caliber of each loop not exceeding 4-8 cm. Against the background of swollen loops, the transverse striation is visible due to the expanded circular (kerkring) folds. Of course, there are no Gaustral tendons on the contours of the small intestine, since they are only in the large intestine.

If the colon is obstructed, huge swollen loops with high gas bubbles in them are observed. The accumulation of fluid in the gut is usually small. On the contours of the intestine, there are haustral retractions, and also arcuate coarse semilunar folds. By introducing a contrasting suspension through the rectum, you can specify the place and nature of obstruction (for example, to detect a cancer that led to the narrowing of the intestine). We only indicate that the absence of radiographic signs does not exclude intestinal obstruction, since in some forms of strangulation obstruction the interpretation of the radiographic pattern may be difficult. In these cases, sonography and computed tomography are of great help. They allow to reveal the stretching of the pre-intestinal part of the intestine, the breakage of its image on the border with the post-stenotic asleep, the shadow of the knot formation.

Especially difficult is the diagnosis of acute bowel ischemia and necrosis of the intestinal wall. When the upper mesenteric artery occludes, gas and liquid accumulations in the small intestine and in the right half of the colon are noted, and the patency of the latter is not disturbed. However, radiography and sonography provide recognition of mesenteric infarction in only 25% of patients. At CT, it is possible to diagnose a heart attack in more than 80% of patients on the basis of thickening of the intestinal wall in the necrosis zone, the appearance of gas in the gut, and also in the portal vein. The most accurate method is angiography performed with spiral CT, magnetic resonance imaging or catheterization of the superior mesenteric artery. The advantage of mesentericography is the possibility of subsequent directed transcatheter injection of vasodilators and fibrinolytics. The rational tactics of the study are presented below in the diagram.

With partial obstruction, re-examination after 2-3 hours is of great benefit. It is permissible to administer a small amount of water-soluble contrast medium through the mouth or naso-natural probe (enterography). When turning a sigmoid colon, valuable data are obtained with an irrigoscopy. With adhesive obstruction resort to X-ray examination in different positions of the patient, registering the sites of fixation of intestinal loops.

Appendicitis. Clinical signs of acute appendicitis are known to every doctor. X-ray examination serves as a valuable way to confirm the diagnosis and is especially indicated if you deviate from a typical course of the disease. The survey tactics are presented as the following scheme.

As can be seen in the diagram, it is advisable to start the radiation study with sonography of the abdominal cavity organs. Symptoms of acute appendicitis include enlargement of the appendix, filling it with a liquid, thickening of its wall (more than 6 mm), revealing stones in the appendage and fixing it, accumulation of fluid at the appendix wall and cecum, hypoechoic abscess image, abscess on the intestinal wall, hyperemia perianpendicular tissues (with dopplerography).

The main radiographic signs of acute appendicitis: small accumulations of gas and liquid in the distal part of the ileum and in the caecum as a manifestation of their paresis, thickening of the cecal wall due to its edema, thickening and rigidity of the folds of the mucous membrane of this gut, 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. The appendicular abscess causes a darkening in the right ileal region and an impression on the cecal wall. Sometimes a small accumulation of gas is detected in the abscess and the projection of the shoot. When the process is perforated, there may be small bubbles of gas under the liver.

CT is somewhat more effective than sonography and radiography in the diagnosis of acute appendicitis, allowing you to detect with great clarity the thickening of the wall of the appendix and the appendicular abscess.

With chronic appendicitis, note the deformity of the process, its fixation, fragmentation of its shadow during radiopaque examination, or failure to complete the process with barium sulfate, the presence of stones in the appendage, the coincidence of the pain point with the eye of the appendage.

Dyskinesin of the intestine. X-ray examination is a simple and accessible method of clarifying the nature of the content flow through the loops of the small and large intestine and diagnosing various variants of constipation (constipation).

Enterocolitis. With acute enterocolitis of different etiology, there are similar symptoms. Small bubbles of gas with short liquid levels appear in the intestinal loops. The progress of the contrast medium is uneven, there are separate clusters of it, between which there are constrictions. The folds of the mucosa are thickened or not at all differentiated. For all chronic enterocolitis, accompanied by a syndrome of malabsorption, characteristic features are common: the expansion of the intestinal loops, the accumulation of gas and liquid in them (hypersecretion), the separation of the contrast mass into separate lumps (sedimentation and fragmentation of the contents). Passage of contrast medium is slowed down. It is distributed unevenly over the inner surface of the intestine, small ulceration can be seen.

Malabsorption. With it, the absorption of various constituents of food is impaired. The most common are the diseases of the sprue group. Two of them - celiac disease and non-tropical sprue - belong to the congenital, and tropical sprue - to the acquired. Regardless of the nature and type of malabsorption, the X-ray picture is more or less the same: the expansion of the small intestine loops is determined. They accumulate liquid and mucus. Barium suspension because of this becomes non-uniform, flocculates, is divided into fragments, turns into flakes. The folds of the mucosa become flat and longitudinal. In a radionuclide study with trioleate-glycerin and oleic acid, a violation of absorption in the intestine is established.

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

With these diseases, any part of the digestive canal can be affected - from the esophagus to the rectum. However, the most common lesions are the distal part of the jejunum and the proximal part of the iliac (ileoileitis), terminal iliac (terminal ileitis), proximal parts of the large intestine.

In the course of the disease, two stages are distinguished. In the first stage, thickening, rectification and even disappearance of the folds of the mucosa and superficial ulceration are noted. The contours of the intestine become uneven, jagged. Then, instead of the usual picture of the folds, there are multiple round enlightenments caused by the islets of the inflamed mucosa. Among them, strip-like shadows of barium, deposited in transverse cracks and slit-like ulcers, can be distinguished. In the area of lesions, intestinal loops are straightened, narrowed. In the second stage there is a significant narrowing of the intestinal loops with the formation of scarring of 1-2 to 20-25 cm in length. In the pictures, the stenotic portion may look like a narrow uneven canal (symptom of the cord). Unlike the syndrome of impaired absorption, there is no diffuse expansion of the intestinal loops, hypersecretion and fragmentation of the contrast medium, and the granular character 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 the radial control.

Tuberculosis of the intestine. The ileocecal angle is most often affected, but already in the study of the small intestine, there is a thickening of the folds of the mucous membrane, small accumulations of gas and liquid, slow progress of contrast mass. In the region of the lesion, the intestinal contours are uneven, the folds of the mucous membrane are replaced by infiltration sites, sometimes with ulceration, and there is no gaustration. It is curious that the contrast mass in the infiltration zone is not delayed, but quickly moves further (a symptom of local hyperkinesia). Later, the intestinal loop wrinkles with a decrease in its lumen and restriction of dislocation due to adhesions.

Nonspecific ulcerative colitis. With mild forms, there is a thickening of the folds of the mucous membrane, point accumulations of barium and small dentition of the gut contours as a result of the formation of erosions and small ulcers. Heavy forms are characterized by constriction and stiffness of the affected parts of the colon. They are slightly stretched, do not expand with retrograde insertion of contrast mass. Gausstration disappears, the contours of the intestine are made small-serrated. Instead of folds of the mucous membrane, granulations and accumulations of barium in ulceration appear. Primarily affects the distal half of the large intestine and rectum, which in this disease is sharply narrowed.

Bowel cancer. Cancer occurs in the form of a small thickening of the mucosa, a plaque or a poly-like flat formation. On the radiographs, the marginal or central defect of filling in the shadow of the contrast mass is determined. The folds of the mucosa in the area of the defect are infiltrated or absent, the peristalsis is interrupted. As a result of necrosis of the tumor tissue in the defect, a barium depot of irregular shape may appear - a display of ulcerated cancer. As the tumor grows further, two variants of the radiographic pattern are observed. In the first case, a tuberous formation appears, which penetrates into the lumen of the intestine (exophytic type of growth). 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 department turns into a rigid tube with uneven outlines (endophytic type of growth). Sonography, CT and MRI allow us to clarify the degree of invasion of the intestinal wall and adjacent structures. In particular, endorectal sonography is valuable in cancer of the rectum. Computer tomograms make it possible to assess the state of the lymph nodes in the abdominal cavity.

Benign tumors. About 95% of benign neoplasms of the intestine are epithelial tumors - polyps. They are single and multiple. The most common adenomatous polyps. They are small, usually not larger than 1-2 cm, overgrowth of glandular tissue, often have a stem (stem). In the X-ray study, these polyps cause filling defects in the shade of the intestine, and with double contrasting, additional rounded shadows with smooth and smooth edges.

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

Sharp abdomen.

The causes of the syndrome of an acute abdomen are diverse. To establish an urgent and accurate diagnosis, anamnestic information, the results of clinical examination and laboratory tests are important. To radiation study resorted to the need to clarify the diagnosis. As a rule, it begins with the radiography of the chest cavity, since the syndrome of the acute abdomen can be a consequence of the irradiation of pain in the lungs and pleura (acute pneumonia, spontaneous pneumothorax, diaphragmatic pleurisy).

Then perform radiography of the abdominal cavity in order to recognize perforated pneumoperitoneum, intestinal obstruction, kidney and gallstones, calcifications in the pancreas, acute curvature of the stomach, infringement of the hernia, etc. However, depending on the organization of admission of patients in the medical institution and the alleged nature of the disease, the procedure for the examination can be changed. At the first stage, ultrasound can be performed, which in a number of cases will allow further to be limited to radiography of the thoracic cavity organs.

The role of sonography is particularly great in the detection of small accumulations of gas and fluid in the abdominal cavity, as well as in the diagnosis of appendicitis, pancreatitis, cholecystitis, acute gynecological diseases, and kidney damage. When there is doubt about the results of sonography, CT is shown. Its advantage over sonography is that the gas accumulation in the intestine does not interfere with diagnosis.