X-ray signs of diseases of the stomach and duodenum

Indications for x-rays of the study of the stomach are very wide due to the high prevalence of "gastric" complaints (dyspeptic phenomena, abdominal pain, lack of appetite, etc.). X-ray examination is carried out with suspicion of peptic ulcer, tumor, in patients with achilles and anemia, as well as with polyps of the stomach, which for some reason are not removed.

Chronic gastritis

In the recognition of gastritis the main role is assigned to the clinical examination of the patient in combination with endoscopy and gastrobiopsy. Only by histological examination of a piece of the gastric mucosa can the form and prevalence of the process and the depth of the lesion be established. However, with atrophic gastritis, an X-ray examination of efficacy and reliability is equivalent to fibrogastroscopy and second only to microscopy of the biopsy specimen.

X-ray diagnostics is based on a combination of radiographic signs and their comparison with a set of clinical and laboratory data. A combined assessment of the fine and folded relief and function of the stomach is mandatory.

The determination of the state of areoles is of paramount importance. Normally, there is a fine-grained (granular) type of fine relief. Areoles have a regular, mostly oval shape, are clearly delineated, limited by shallow narrow grooves, their diameter varies from 1 to 3 mm. Chronic gastritis is characterized by nodular and especially coarse-nodular types of delicate relief. In the nodular type, the areola of an irregular, rounded form, 3 to 5 mm in size, is confined to narrow but deep grooves. The coarse-nodular type is distinguished by large (more than 5 mm) areoles of irregular polygonal shape. The furrows between them are enlarged and not always sharply differentiated.

Changes in the folded relief are much less specific. In patients with chronic gastritis, condensation of the folds is noted. When palpated, their shape changes insignificantly. The folds are straightened or, on the contrary, strongly crimped, small erosions and poly-like formations can appear on their crests. At the same time, functional disorders are recorded. During the exacerbation of the disease in the stomach on an empty stomach contains fluid, the tone is increased, the peristalsis is deepened, spasm of the antrum can be observed. During the period of remission, the tone of the stomach is lowered, the peristalsis is weakened.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Stomach ulcer and duodenal ulcer

Radiography plays an important role in the recognition of ulcers and its complications.

When X-ray examination of patients with peptic ulcer of the stomach and duodenum before the radiologist, there are three main tasks. The first is the evaluation of the morphological state of the stomach and duodenum, primarily the detection of a ulcerative defect and the determination of its position, shape, size, shape, and the state of the surrounding mucosa. The second task is to study the function of the stomach and duodenum: the detection of indirect signs of peptic ulcer, the establishment of the stage of the disease (exacerbation, remission) and evaluation of the effectiveness of conservative therapy. The third task is to recognize the complications of peptic ulcer.

Morphological changes in peptic ulcer are caused both by the ulcer itself and by the accompanying gastroduodenitis. Symptoms of gastritis are described above. A direct symptom of an ulcer is a niche. This term denotes the shadow of the contrast mass that filled the ulcer crater. Silhouette of the ulcer can be seen in the profile (such a niche is called a contour line) or full face in the background of the folds of the mucous membrane (in these cases they speak of a niche on the relief, or a relief niche). The contour niche is a semicircular or pointed end on the contour of the shadow of the stomach or the bulb of the duodenum. The size of the niche in general reflects the size of the ulcer. Small niches are indistinguishable in fluoroscopy. For their detection, targeted radiographs of the stomach and bulbs are needed.

With double contrasting of the stomach, it is possible to recognize small superficial ulceration - erosion. They are more often localized in the anterior and prepyloric areas of the stomach and have the form of rounded or oval enlightenments with a pointlike central cluster of contrast mass.

The ulcer can be small - up to 0.3 cm in diameter, medium in size - up to 2 cm, large - 2-4 cm and giant - more than 4 cm. The shape of the niche can be round, oval, slit, linear, pointed, irregular. The contours of small ulcers are usually even and clear. The outlines of large ulcers become uneven due to the development of granulation tissue, congestion of mucus, blood clots. At the base of the niche, there are small indentations corresponding to edema and infiltration of the mucous membrane at the edges of the ulcer.

The relief niche has a fork of a stable round or oval congestion of contrasting mass on the inner surface of the stomach or bulb. This cluster is surrounded by a light structureless rim - the zone of edema of the mucous membrane. With a chronic ulcer, the relief niche may be irregular in shape with uneven outlines. Sometimes there is a convergence (convergence) of the folds of the mucous membrane to a ulcerative defect.

As a result of cicatrization of the ulcer at the level of the niche, rectification and some shortening of the contour of the stomach or bulb are revealed. Sometimes the ruby process reaches a considerable degree, and then the gross deformations of the corresponding part of the stomach or bulb are determined, which sometimes takes on a bizarre shape. Scarring of the ulcer in the canal or at the base of the bulb can lead to stenosis of the pyloric or duodenal stenosis. Due to the violation of the evacuation of the contents of the stomach is stretched. In it, an empty stomach is found contrasting).

There are a number of indirect radiographic symptomatic diseases. Each of them separately does not give grounds for establishing the diagnosis of an ulcer, but in aggregate their significance is almost equal to the detection of a direct symptom - a niche. In addition, the presence of indirect signs causes the roentgenologist to look for a ulcerative defect with special attention, performing a series of targeted radiographs. An indication of impaired secretory function of the stomach is the presence in it of fluid on an empty stomach. This symptom is most indicative for ulcers of the bulb of the duodenum. With the vertical position of the body, the liquid forms a horizontal level against the backdrop of the gas bubble in the stomach. An important indirect symptom is a regional spasm. In the stomach and onion, it usually occurs at the level of the ulcer, but on the opposite side. There, the contour is drawn in with even outlines. In the stomach it resembles in shape the tip of the finger, hence the name of this symptom - "the symptom of the pointing finger". With the ulcer of the bulb in the period of exacerbation, as a rule, there is a spasm of the pylorus. Finally, with ulcers, there is a symptom of local hyperkinesia, expressed in the accelerated movement of the contrast agent in the area of the ulcer. This symptom is explained by increased irritability and motor activity of the wall in the area of ulceration. Another indirect symptom is associated with it - a symptom of ache and abdominal local tension in the palpation of the area corresponding to the location of the ulcer.

In the stage of exacerbation of peptic ulcer there is an increase in the niche and expansion of the surrounding inflammatory shaft. During the period of remission, the niche is reduced down to its disappearance (after 2-6 weeks), the functions of the stomach and duodenum are normalized. It is important to emphasize that the disappearance of a niche does not mean a cure if symptoms of a function violation persist. Only the elimination of functional disorders guarantees a cure or at least a prolonged remission.

With peptic ulcer and chronic gastritis, duodenogastric reflux is often observed. To detect it, the patient is subjected to dynamic scintigraphy. To this end, it is intravenously injected with RFP 99mTc-butyl-IDA or a related compound with an activity of 100 MBq. After receiving on the scintigram images of the gallbladder (these drugs stand out with bile) the patient is given a fat breakfast (for example, 50 g of butter). On subsequent scintigraphs it is possible to observe the emptying of the bladder from the radioactive bile. When the pylorus is inadequate, it appears in the cavity of the stomach, and in gastroesophageal reflux - even in the esophagus.

Ulcer niche may remotely resemble the diverticulum of the stomach - a kind of anomaly of development in the form of saccular protrusion of the wall of the digestive canal. In 3/4 cases, the diverticulum of the stomach is located on the posterior wall near the esophageal-gastric junction, i.e. Near the cardial opening. In contrast to ulcers, the diverticulum has a regular rounded shape, smooth arched contours, often well-formed neck. The folds of the mucosa around it are not changed, some of them enter through the cervix into the diverticulum. Especially often there are diverticula in the descending and inferior horizontal parts of the duodenum. X-ray signs are the same, only with the development of diverticulitis contours of protrusion become uneven, the mucous membrane around - edematic, palpation - painful.

Radiation methods play an important role in the diagnosis of complications of peptic ulcer. First of all, this refers to the perforation of a stomach or duodenal ulcer. The main sign of perforation is the presence of free gas in the abdominal cavity. The patient is examined in the position in which he was brought to the X-ray room. The gas penetrating into the abdominal cavity through the perforation hole occupies the highest parts in it. With the vertical position of the body, the gas accumulates under the diaphragm, with the position on the left side - in the right lateral channel, with the position on the back - under the anterior abdominal wall. On the X-ray patterns, the gas causes a clearly visible bleaching. When you change the position of the body, it moves in the abdominal cavity, why it is called free. Gas can also be detected by ultrasound.

The penetration of ulcers into the surrounding tissues and organs indicates two signs: the large dimensions of the niche and its fixation. In penetrating ulcers, there is often a three-layered content: gas, liquid and contrast medium.

If suspicion of acute ulcer bleeding is usually resorted to urgent endoscopy. However, valuable data can be obtained by X-ray examination, which is expedient if a fibrogastroduodenoscopy is not performed or it is not shown. After stopping bleeding, or even during a period of continuing bleeding, it is possible to perform fluoroscopy and radiographs of the stomach and duodenum with barium sulfate, but with the horizontal position of the patient and without compression of the anterior abdominal wall.

As a result of cicatrization of the pylorus ulcer, stenosis of the outlet stomach may develop. According to roentgenological data determine the degree of its severity (compensated, subcompensated or decompensated).

Stomach cancer

Initially, the tumor is an islet of cancerous tissue in the mucosa, but in the future, different ways of tumor growth, which predetermine the radiographic signs of small cancer, are possible. If necrosis and ulceration of the tumor prevail, then its central part falls in comparison with the surrounding mucosa - the so-called advanced cancer. In this case, when double contrasting, a niche of irregular shape with uneven contours is defined around which there are no areolas. The folds of the mucous membrane converge to ulceration, slightly widening in front of the niche and losing its outlines here.

In another type of growth, the tumor extends predominantly in the sides along the mucosa and in the submucosa - a superficial, or flat-infiltrating, cancer that grows endophytically. It determines the site of the altered relief, in which there are no areoles, but in this case, unlike the deepened cancer, there is no ulceration and there is no convergence of the folds of the mucosa to the center of the tumor. Instead, irregularly distributed thickenings with irregularly scattered clumps of contrast mass are observed. The contour of the stomach becomes uneven, straightened. Peristalsis in the infiltration region is absent.

In most cases, the tumor grows in the form of a knot or plaque, gradually more and more going into the cavity of the stomach - "exalted" (exophytic) cancer. In the initial stage, the radiographic picture differs little from that of the endophytic tumor, but then there is a noticeable uneven deepening of the contour of the shadow of the stomach that does not participate in peristalsis. Further, an edge or central filling defect is formed, in a form corresponding to the tumor that protrudes into the lumen of the organ. With plaque-like cancer, it remains flat, with polypous (mushroom) cancer has an irregular rounded shape with wavy outlines.

It should be emphasized that in most cases, using radiotherapy, it is impossible to distinguish early cancer from peptic ulcer and polyp, which requires endoscopy. However, X-ray examination is very important as a method of selecting patients for endoscopy.

With the further development of the tumor, various X-ray pictures are possible, which, perhaps, never copy one another. However, it is possible to exaggerate several forms of such a "developed cancer". A large exophytic tumor gives a large defect of filling in the shade filled with a contrasting mass of the stomach. The contours of the defect are uneven, but quite clearly delineated from the surrounding mucous membrane, whose folds in the defect area are destroyed, the peristalsis is not traced.

In another "guise" appears infiltrative-ulcerous cancer. When it is expressed not so much the defect of filling as the destruction and infiltration of the mucous membrane. Instead of normal folds, the so-called malignant relief is defined: the formless accumulations of barium between the pillow-like and non-structural regions. Of course, the contours of the shadow of the stomach in the lesion are uneven, and the peristalsis is absent.

Quite typical is the radiographic picture of saucer-like (cup-like) cancer, i.e. Tumors with raised edges and a disintegrating central part. On radiographs a round or oval filling defect is defined, in the center of which a large niche is formed - a cluster of barium in the form of a spot with uneven outlines. A feature of saucer-like cancer is the relatively clear delimitation of the edges of the tumor from the surrounding mucous membrane.

Diffuse fibroplastic cancer leads to a narrowing of the lumen of the stomach. In the area of damage, it turns into a narrow rigid tube with uneven contours. When the stomach is blown with air, the deformed department does not straighten out. On the boundary of the narrowed part with unshagged sections, you can see small ledges on the contours of the shade of the stomach. The folds of the mucosa in the area of the tumor thicken, become immobile, and then disappear.

A gastric tumor can also be detected with computed tomography and ultrasound. On sonograms, areas of thickening of the stomach wall are distinguished, which makes it possible to specify the volume of tumor lesion. In addition, according to sonograms, it is possible to determine the prevalence of infiltrate in surrounding tissues and to detect tumor metastases in the lymph nodes of the abdominal cavity and retroperitoneal space, the liver and other organs of the abdominal cavity. Especially clear ultrasound signs of a tumor of the stomach and its germination in the wall of the stomach are determined by endoscopic sonography of the stomach. When CT is also well visualized the wall of the stomach, which allows us to identify its thickening and the presence of a tumor in it. However, the earliest forms of stomach cancer in both sonography and CT are difficult to detect. In these cases, a leading role is played by gastroscopy, supplemented by multiple multiple biopsy.

[11], [12], [13],

Benign tumors of the stomach

X-ray picture depends on the type of tumor, the stage of its development and the nature of growth. Benign tumors of epithelial nature (papillomas, adenomas, villous polyps) come from the mucous membrane and go into the lumen of the stomach. Initially, among the areolas, an unstructured, rounded portion is found, which can be seen only when the stomach is double-contrasted. Then determine the local extension of one of the folds. It gradually increases, taking the form of a rounded or slightly oblong defect. The folds of the mucous membrane bypass this defect and are not infiltrated.

The contours of the defect are even, sometimes wavy. Contrast mass is retained in small depressions on the surface of the tumor, creating a delicate cellular pattern. Peristalsis is not violated if there is no malignant degeneration of the polyp.

Quite differently look non-epithelial benign tumors (leiomyomas, fibromas, neurinomas, etc.). They develop mainly in the submucosal or muscular layer and penetrate into the cavity of the stomach. The mucous membrane above the tumor is stretched, so that the folds are flattened or spread apart. Peristalsis is usually preserved. A tumor can also cause a rounded or oval defect with even contours.

[14], [15]

Postoperative diseases of the stomach

X-ray examination is necessary for timely detection of early postoperative complications - pneumonia, pleurisy, atelectasis, abscesses in the abdominal cavity, including subdiaphragmatic abscesses. Gas-containing abscesses are comparatively easy to recognize: in the pictures and during the examination it is possible to detect a cavity containing gas and liquid. If there is no gas, a subdiaphragmatic abscess can be suspected for a number of indirect symptoms. It causes a high position and immobilization of the corresponding half of the diaphragm, its thickening, uneven outlines. There is a "sympathetic" effusion in the costal-diaphragmatic sinus and foci of infiltration in the base of the lung. In the diagnosis of subdiaphragmatic abscesses, sonography and computed tomography are successfully used, since pus accumulations clearly appear in these studies. Inflammatory infiltrate in the abdominal cavity gives an echo-inhomogeneous image: there are no areas that are free from echoes. Abscess is characterized by the presence of a zone devoid of such signals, but around it a denser rim appears - a mapping of the infiltrative shaft and the pyogenic shell.

Among the late postoperative complications, it is necessary to mention two syndromes: the syndrome of the resulting loop and the dumping syndrome. The first of these is radiologically manifested by the inflow of a contrast mass from the stump of the stomach through the anastomosis into the leading loop. The latter is enlarged, the mucous membrane in it is edematous, its palpation is painful. Especially indicative is the prolonged retention of barium in the leading loop. Dumping syndrome is characterized by a significant acceleration of emptying the stump of the stomach and rapid spread of barium through the loops of the small intestine.

In 1-2 years after surgical intervention on the stomach can occur peptic ulcer anastomosis. It determines the x-ray symptom of a niche, with the ulcer usually large and surrounded by an inflammatory shaft. Her palpation is painful. Because of the concomitant spasm, there is a breakdown in the functions of anastomosis with a delay in the contents in the stomach stump.