Duodenal ulcer

Duodenal ulcer is located mainly in the bulb. In this part radiographically and postmortem determine from 95 to 99% of all ulcers duodenal ulcer (Mama). Most ulcers is located closer to the gatekeeper, and the frequency decreases as you approach the top of the knee intestine. In rare cases, the plague is found below the top of the knee.
When duodenal ulcer, and gastric ulcer, also there are direct (anatomic) and indirect (functional) signs.
The main and the most evidence-based, and therefore the most valuable in the sense of reliability of x-ray characteristic of duodenal ulcer is the niche that represents the reflection of the ulcer walls of the duodenum (Fig. 101).

Fig. 101. Ulcer duodenal ulcer (x-ray). NIS (arrow).

Other types of direct x-ray symptoms of duodenal ulcers submitted by scar deformations or inflammatory nature.
Localization niches are determined on the front and rear, large or small curvature. Most often radiographically niche is located on the back near the lesser curvature and the gatekeeper. There are also multiple ulcers. Sometimes ulcers oppose one another. Such ulcers strengthened the name "kissing", although it is more correct to call them "opposition".
Niches are presented in the form of oval or round accumulation of contrast agent and are available for the identification in size from 2 mm and above. The outlines of niches cutting. Sometimes in the development of scar processes from the ulcer or around her form niches can change the contours of her often gear. Often niche bulbs is accompanied by the presence of ulcerative shaft, like that of stomach ulcers.
Very typical for NIS bulbs are retraction around it. Here, as in the niches of the stomach are important regional spastic retraction and swelling of the mucous membrane in the form of circular roller or indrawing from the opposite side.
Sometimes when anthrax cannot find a niche, but it is so cutting changes in the mucous bulbs related nabukalu folds that it formed a strong filling defects caused by phenomena of edema or duodenitis.
The consequences of duodenal ulcers impact in terms of different strains, which is manifested mainly in the reduction of the bulb, because of the impact scar processes, giving the impression bulbs are the most diverse forms. For example, you can find the onion in the form of "trefoil", formed as a result of varying degrees of constricting walls scars. The most common deformation, in which deformation of one of the walls of the bulb or manifested in the form of persistent retraction because of scar retraction, having the form of interception, creating a picture of persistent "hourglass". When expressed more processes scarring, with longitudinal direction is observed shortening of the bulbs and the whole upper part of the duodenum, which is accompanied by the shift of the whole Department. This may be offset and gall bladder, which as a result of inflammatory changes, moving with onions, involved in adhesive scar process. Cicatricial changes that have circular direction, lead to the formation of irregular shape of the bulb.
Between circular scars may remain the wall of the intestine, not surrounded by them. In such cases there is a stretch of healthy tissues, resulting get diverticulosis protrusion, which are usually located on the lateral path bulbs. They are able to shrink, which differs significantly from the niche. In the process of scanning or serial images can be observed variability of their shape and size. According to some authors (C. A. Fanarjyan, 1961, 1964)that diverticula ulcers can result spastic narrowing at the level of ulcers. Deformation associated with such diverticulosis the protrusions bulbs, typical of ulcers, and, as in other circumstances, as such, they are not found, may be attributed to direct signs of duodenal ulcers and without detectable niches. Unlike true diverticula duodenum they are located within bulbs, often closer to the ground, limited mobility and do not have legs. Located on the lateral path bulbs, such diverticulectomy protrusion accompanied by retraction of the medial circuit, resulting in a pronounced asymmetry of the bulb. Niche in such cases is located either in the centre or on diverticulitis pocket.
Recognition ulcers bulbs in conditions of deformation contributes developed Century A. Fanarjyan position is included in the literature under the name of "the pattern of fanarjyan". This pattern is based on the fact that between the location of the defect bulbs, ulcerative pocket and localization of duodenal ulcers there is a definite relationship: 1) in case of a defect, localized on lateral path bulbs, there is a plague of the front wall of her; 2) in case of a defect of the bulb, located on the medial circuit - sore back wall of the duodenum; 3) in case of a defect of the bulb, located on its lateral and medial circuit, has a double-ulcer - front and back of the bulb; 4) in the pockets of the bulb, localized on its lateral path - sore back of the bulb; 5) in the pockets of the bulb, located on the medial circuit, - the plague of the front wall of the duodenal bulb; 6) in the pockets of the bulb, developed up and down on its lateral and medial circuit, there is a double duodenal ulcer - on the front and the back of the bulb.

The formation of these pockets and variety of paintings deformations and binding bulbs facilitate changes, which are combined under the common name of peridotite. Thanks to peridotite onion can have a strong deformation of various shapes, buying sometimes bizarre butterflies, hammer, the shape of teeth, character, etc.
Significant impact scar processes and in the form of gatekeeper. The latter often bends shifted and shortened. In contrast to these changes at an ulcer pyloric there eccentric position of the porter toward the bulb, while there eccentricity goes in the direction of the antrum.
Cicatrices on the basis of peridotite in most cases lead to a narrowing of the duodenum. Puckering up to a large extent and cause a sharp decrease of the bulb, and then she turns to a small tank with the wrong shape. Deformation changes accompany the plague more than half of all radiographically of recognized cases when there is a niche.
Changing the shape of the bulb arise on the grounds of processes outside the duodenum. So, for example, peri-cholecystitis may make any of the above forms of peridotite, but almost always there is a right-wing bias of the bulb. Deformation of the duodenum occur not only on the basis of pericholecystic, but due to pressure on the bulb enlarged gallbladder when it is stretching that can cause the impression from the top or from the outer edge of the bulb. Such compression phenomenon can cause liver enlargement, gases in hepatic the loop of the colon, cancer of the abdomen, etc., is very important deformation on the basis of increasing the pancreatic head that often happens when cancer.
Detailed x-ray study of the duodenum allowed in recent times to identify ulcers, those located outside of the bulb. In Russian literature the first and detailed description of such ulcers, named postularse, presents S. A. Reinberg with employees. Details of these ulcers are available in the monograph by M. F. Wyrzykowski (1963). Postularse sores very difficult for x-ray detection. Especially when such ulcers difficult to see the convergence of folds, because the plague is developing in the area of cross carrinhovp folds, then this is well expressed variability associated with rapid motor function of the duodenum. Leading to postlarni of the ulcer is the symptom of a niche that is beyond the outline of the colon and has a rounded shape. The size of the niche can vary greatly, however, S. A. Reinberg indicates that for postlarni ulcers characteristic is a high value niche than the ulcer bulb (Fig. 102).

Fig. 102. Postbalance duodenal ulcer (arrow). Radiograph.

Postlarni ulcers accompany the phenomenon of peridotite, accompanied by a narrowing of the high level location
ulcers. Often when postlarni ulcers detects changes to the side of the stomach and bulbs, mainly functional.
How and when gastric ulcer, duodenal ulcer are characteristic of indirect or functional symptoms.
When duodenal ulcer meet functional changes as the bulbs, and on the part of the stomach.
The tone of the stomach is often elevated. Sometimes there spastic changes from the greater curvature. In many cases there is increased peristalsis on both curvature, and peristalsis is sometimes with deep categorizes banners.
Violations evaquatorna stomach ulcers, duodenal ulcers occur in the two extreme directions. The primary evacuation of the stomach comes quickly, with the big delay. May be a significant delay evacuation in General and normal emptying. Often spastic phenomena from the pylorus with conventional term evacuation. Even the variety of manifestations of functional disorders deprives of their value as of the symptoms of duodenal ulcers.
Infringements of impellent functions of the bulbs can also manifest itself in two forms. It's either slow emptying of the bulb, or the accelerated passage of the contrast agent through it. With a long filling in it there is a remnant, and after emptying of the stomach. Sometimes it is still only visible contrast spot. Such disorders can be caused by Rubtsove changes wall, the spikes in the upper knee, cicatrices when pericholecystic, accompanying the plague. Residual stain may be due pockets, resulting from peridotite, and the ulcer niche.
The state of the muscles of the bulbs in the sense of its tone may change when the plague, and is often pronounced hypotension, resulting in the bulb long barium, and it becomes large. But not less often very rapid expulsion of mass under the influence of enhanced tone bulbs.
Pain sensitivity in the field bulbs acquires meaning only if it is clearly localized. In such cases, requires particularly careful inspection to identify anatomical substrate causing her pain. Note that in this field sensitivity to palpation may depend on the suffering of the gallbladder.