Diagnosis of peptic ulcer disease

The diagnosis is based on medical history, presence of typical pain, x-ray studies of secretory and motor function of the stomach, gastroscopy. The reaction of the occult blood in feces in the presence of other symptoms of peptic Ulcer disease is known value judgments about the activity of ulcers.


Fig. 2. Stomach ulcer (radiograph): 1 - ulcer niche on the path curvature (arrow); 2 - shaft around the niches in the form of light bezel at the mouth sores (indicated by arrows).
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<a href=X-ray diagnosis of peptic ulcer disease is based on a characteristic morphological changes and functional disorders. To morphological features include niche (Fig. 2), shaft around her and convergence (convergence) folds. NIS is formed as a result of filling barium recesses in the wall of the stomach or duodenum. Relatively easy to detect ulcers duodenal bulb, and the lesser curvature of the stomach. Harder identified valikuline duodenal ulcer, ulcer pyloric canal, ulceration of the upper part of the stomach and the greater curvature of the stomach. Find often in exacerbation of ulcer disease shaft around niches displays swelling of the tissues surrounding the ulcer. Convergence folds of mucous membrane indicates the restructuring of its relief.
Functional symptoms of peptic ulcer disease, detectable by x-ray, are hypersecretion, increased tone of the stomach and increased peristalsis. The process of ulcer cicatrization can lead to the change of the form of the stomach (lithography, hourglass) and duodenal ulcer (trefoil, hammer and others). Gastroscopy (see) gives an idea of the form, size, depth, and the exact location of the ulcer. Using a gastroscopy, you can evaluate the effectiveness of therapeutic measures and set anatomical recovery or improvement of ulcers. Using gastroscopy found that the disappearance of a niche does not always mean the disappearance of ulcers, so as to reduce inflammation and spastic phenomena reduced shaft, contributing to the formation of a niche, but ulcerative defect when it may be. Using gastroscopy't detect hidden (or dumb) and flat ulcers that are not detected x-ray study, and ulcers subjected malignancy (malignant). In doubtful cases, to address the issue of malignization is of great importance endoscopy, biopsy, i.e. the final diagnosis can be established only on the basis of histological data.
Complications may develop slowly (adhesions, the narrowing of the pyloric, penetration) or occur suddenly (perforation, massive bleeding).
Symptoms of perforation of the ulcer is very typical. Patients complain of severe pain that occurs suddenly, as by a blow from a knife ("dagger of pain in podlojecna area, and immediately applicable to the entire upper half of the abdomen. Pain paralyzed patient, forcing him to avoid changes in body position. Belly doskoobraznye flattened, sometimes even slightly involved, is not involved in breathing. When superficial palpation is determined symptom muscle protection, expressed, as a rule, in all departments of the abdominal wall. Very clear symptom Shchetkina - Blomberg - the emergence of a sharp pain in the abdomen after a quick sudden loss of pressure with the thumb on the front wall of the abdomen. Percutere almost always detected reduction and the absence of hepatic stupidity that speaks about presence of free gas in the abdominal cavity (under the diaphragm). Notes pale, haggard face, cold sweat, bradycardia, soon replaced by a significant increased heart rate. Nausea and vomiting usually not the case. Need urgent hospitalization.
In the gastro-intestinal bleeding need urgent hospitalization. Before arrival of the doctor, take measures to stop the bleeding: full peace with strict bed regime, cold on the stomach, the use of means increasing the clotting of blood - chloride calcium 10 ml of 10% solution intravenously, menadione 3 ml of 1% solution intramuscularly, transfusion hemostatic of donations 100-150 ml (under medical supervision).
When life-threatening ongoing bleeding (reduction in blood pressure, inefficiency of conservative funds, the decline of hemoglobin, tarry stools, re bloody vomiting) shows emergency surgery.
Forecast ulcers set individually, depending on age, sex of the patient, the localization of ulcers, peculiarities of clinical course (relapse), presence of complications related diseases, as well as consumer and professional conditions.
Death at a stomach ulcer is possible only in case of complications: bleeding, perforation.

Diagnosis of uncomplicated form of peptic ulcer set based on history, the presence of pain, x-ray examinations and studies of gastric secretion (when using physiological stimuli).
Gastroscopy allows you to set the ulcerative defect, not detected by x-ray.
Obtained using endoscopy researches data about the healing of the ulcer is more accurate than x-ray, since the disappearance of a niche does not always mean the disappearance of ulcers. Starting rebirth ulcers in cancer also revealed endoscopy (see Gastrostomy).
The secretory activity of the stomach increases in the digestive and mezhpischevaritelny period in duodenal ulcer.
Stomach ulcers, this ratio remains within the normal figures or decreases.
The reaction of the occult blood in feces in the presence of other symptoms is of great value judgments about the activity of ulcers.
Differential diagnosis. Of crucial importance in differential diagnosis between ulcers and chronic gastritis (see) have a gastroscopy and gastrobiopsy.
Extremely complex and requires all modern methods of research (in the aggregate) differential diagnosis between ulcer and malignant neoplasms (primary ulcerative form of cancer, ulcerated carcinoma and the so-called cancer of ulcers) (see Gastric tumors).
The big place in the differential diagnosis of ulcerative diseases are diseases of the biliary tract.
Especially great difficulties arise in the differentiation of these diseases in women.
Note that peptic ulcer disease in women of childbearing age is less common than in men, and lesions of the biliary tract often.
Distinctive signs of cholecystitis are: the absence of periodicity and circadian rhythm pain, shorter periods of exacerbation compared with peptic ulcer disease; localization of pain in the right hypochondrium with radiating to the right and upward; local tenderness at the point of the gallbladder, the existence of positive menicus-symptom; exacerbation of pain after intake of fatty foods, exercise, bumpy ride; in the study of duodenal content - inflammatory elements. When calculous cholecystitis pain may be accompanied by fever, jaundice.
Known value is the position of the patient during an attack of pain - induced ulcers and restless, seeking to find a more advantageous position in hepatic colic. Great value for diagnosis have roentgenologic examination of the bile ducts (see Cholecystography, Cholangiography).
Ulcers disease duodenal ulcers often complicated cholecystitis. Ulcers disease should be differentiated with chronic pancreatitis. Pain in chronic pancreatitis are uncertain, sometimes herpes nature, are located to the left of the median line in the upper abdomen. You may find the left menicus-symptom. Sometimes pain in the ulcers are localized in the right lower quadrant of the abdomen. In this case, it should be differentiated from chronic appendicitis, which pains are paroxysmal character, iradionet in the right foot, accompanied by fever, leukocytosis, missing the frequency and seasonality of pain.
Ulcers disease should be differentiated with different diseases of the bowel (colitis, megakolon, dyskinesia, carcinoma of the proximal colon, ileocecal tuberculosis), which serverelement by cause of gastric dyspepsia. Laboratory, rectoromanoscopy, angiography (vessels of the abdominal cavity) and x-ray data specify the diagnosis.
Hernia white line of the abdomen and diaphragmatic hernia sometimes cause dyspepsia and pains that depend on food intake and often simulating peptic ulcer disease. Hernia white line of the abdomen find palpation and percussion belly-up occurs a sharp pain in the midline of the abdomen in a limited area). Diaphragmatic hernia detect when a special x-ray examination (lying down).
The so-called irritated stomach occurs predominantly in young age. Clinical manifestations it is similar with duodenal ulcer: secretory rates sharply increased, but there are diarrhoea disorders; painful, recurring heartburn. Unreasonably diagnosed with chronic hyperacid gastritis, while, apparently, this state is the functional stage of peptic ulcer. Pain in highly located ulcers body of the stomach are often mistaken for stenocardiceskie. It is necessary to consider the relationship of these pains with eating, their rhythmic nature and adverse electrocardiographic data at rest and after food load. K. Shirokova.
X-ray diagnosis of gastric ulcer and duodenal ulcer is based on identifying characteristic morphological and functional changes.
To roentgenomorphological signs include niche (Fig. 1,1), shaft around niches (Fig. 1,2) and convergence folds (Fig. 2). The niche symptom is a direct mapping of ulcers, and therefore has the greatest diagnostic value. Identifying niches largely depends on the sizes, forms and localization ulcers. It is difficult to be diagnosed flat, shallow ulcers. Deep ulcer small diameter also sometimes not detected due to the fact that the entry can be closed swollen surrounding tissues. Relatively easy to detect ulcers duodenal bulb, and the lesser curvature of the stomach (most frequent localization). Harder identified ulcers antrum and valikuline of duodenal ulcers and it is especially difficult subcardial sores and ulcers greater curvature of the stomach. In normal conditions due to skew the arrangement of the folds in these departments often is expressed Jaggy, against which it is difficult to diagnose ulcerative niche.
Depending on the localization of ulcers and posture of the patient niche is either the path or the terrain. The plague of the body of the stomach, usually easily able to outline, in contrast ulcers front and rear walls of the antrum.
Niche on the relief is found in the form of a contrast spots correct round form with quite distinct outlines, with a diameter of about 5 to 10 mm, sometimes more.
Niche on the path usually looks pointed ledge with smooth outlines. By increasing the dimensions of the ulcer bottom it becomes a blunt, rounded (Fig. the 1.1). If the bottom niches uneven, there is reason to suspect covered perforation. The roughness of the bottom of the ulcer may also determine the protrusion in ulcer crater naked vessel that on profile image ulcers looks as small filling defect in the niche.

Fig. 1. Peptic ulcer: 1 - ulcer niche on the path curvature (arrow); 2 - shaft around the niches in the form of light bezel at the mouth ulcers.

Ulcerative niche, usually surrounded by a more or less pronounced shaft, morphological substrate which are swelling of the tissues surrounding the ulcer, retraction of the mucous membranes due to the reduction of muscles of a stomach [Berg (N. N. Berg), Forssell (G. Forssell)] and the development of connective tissue. In direct projection shaft looks bright rim around the niches, external fuzzy outlines of which, gradually turning to the relief of the surrounding mucosa. If you are able to withdraw niche on the path, the result is a profile image of the shaft. While on either side of niches identified symmetric filling defects. Exploring the suspension of barium not very thick consistency and using hard radiation (100-125 kV), you can get an image of the shaft to the full width of the isthmus ulcers. In this case, the shaft looks like a bright rim at the mouth sores (Fig. 1, 2), the width of which varies depending on the degree of swelling of the edges of the ulcer and severity of sclerotic process. In this wide bright rim sometimes seen another more subtle stripes - the so-called line of HAMPTON, which is considered the display of the decrease of the mucosa. The appearance of lines of HAMPTON during treatment regarded as favorable prognostic indicator pointing to reduce inflammatory infiltration and edema of surrounding tissues.
The reorganization of the relief ulcers is not limited convergence folds. For peptic ulcer disease characterized by rough topography of the mucous membrane of the stomach, sometimes with a thickening folds around the stomach. Often folds are directed obliquely and cross forming on the greater curvature rough aliasing. In the basis of elevation changes of the mucous membrane ulcers are a variety of processes. It is necessary to consider spastic reduction of different layers of the muscles of the stomach. A significant role in changing terrain plays associated gastritis and functional-morphological reconstruction of the mucosa.

Fig. 2. Ulcer duodenal ulcer (arrow). Medial path bulbs smoothed. Clearly visible convergence folds to the niche.


Functional symptoms of peptic ulcer disease, detectable by x-ray, are hypersecretion, violations tone and peristalsis, spastic deformation, the reorganization of the relief I other
Hypersecretory liquid in the stomach can be detected even during the review x-ray of the abdomen. In the study with barium observed sedimentation. Being mixed with mucus, contrast weight becomes inhomogeneous. The amount of fluid increases rapidly in the research process. In a tight filling gastric hypersecretory liquid looks as a semi-transparent strip between the gas bubble and suspension of barium.
The tone stomach ulcers often increases peristalsis is increasing. The periods of vigorous motor skills become longer, pause peace was short. In the area of the ulcer weakened peristaltic waves [, A. Zedgenidze, Frenkel (A. Frankel)]. For ulcers antrum of the stomach and duodenum fastest porozhdaemom affected Department.
To identify ulcers are of great importance spastic and scar deformations of the affected organ. These deformations in most cases is so typical that allow the utter to speak of peptic ulcer in present or past (Yu. N. Sokolov and others).
Very typical for stomach ulcer symptom de quervain's - spastic the reduction circular muscles when anthrax curvature. At the greater curvature is formed indrawing, which is in the form of "pointing finger" is directed toward the sores. Long-existing spasm leads to the development of scar connective tissue, resulting in the stomach hourglass shape (Fig. 3). Another option deformation of the stomach is the shortening of the curvature. The progressive development of sclerosis ultimately leads to the formation of ULITKA - or kislorodnogo stomach (Fig. 4). When the gatekeeper is pulled to the cardia and sinus sags down. Deformation of the stomach may be limited to antral a Department or tapering, reminding picture with rigid antral gastritis or lithopane twisted.

Fig. 3. Deformation of the stomach in the shape of an hourglass.
Fig. 4. Widebody stomach. Small curvature shortened. The porter together with the onion is pulled up and left.
Fig. 5. A schematic representation of the stages of deformation duodenal ulcers (Akerlund). Ulcer small curvature (arrow). Consistent development of shortening the lesser curvature, retraction greater curvature and diverticulitisdog expansion of the outer pocket.

Very diverse ulcer strain of the duodenal bulb. Onion becomes irregular shape due to an inflammatory swelling, persistent spastic contractions and scarring. The main regularities of deformation of the bulb (Fig. 5) were represented by Akerlund (A. Akerlund), later supplemented Century A. Fanarjyan. In General onion deformed by the same laws as the stomach. The localization of ulcers near the lesser curvature arise shortening the last and smoothness medial pocket. You receive a filling defect greater curvature caused believed to spasm or scarring. Outside pocket, as a rule, diverticulosis stretched. Depending on localization of the ulcer and the inflammatory, antispasmodic and Scar phenomena onion takes the form of a hammer, trefoil, etc.
When complications of ulcer disease x-ray picture is enriched by a number of additional symptoms. In case of penetration of NIS penetrates far beyond the outline of the stomach and can be a three-layer: the lower layer - barium, medium - liquid, top - gas. For perforation is characterized by the presence of gas in the abdominal cavity under the right diaphragm cupola. Shed abroad in the abdominal cavity stomach contents and reactive effusion are revealed in the form of multiple small Crescent of shadows and wider horizontal levels between hyped gas intestinal loops.
Stenoses privratnika stomach ulcer, as a rule, has an organic scar character. Only rarely the cause of spinal stenosis is a spasm privratnika. The pyloric stenosis leads to more or less long delay evacuation. Even when fully compensated stenosis, gastric emptying slowed down. Often contrast weight delayed in the stomach for several days. When plain x-rays in epigastria determined by extensive shadow increased stomach filled with a large number of fluids, mucus and food. The gas bubble stomach looks like a narrow strip above the wide horizontal fluid level. The pyloric stenosis first is accompanied by increased peristalsis, and further - the change of rhythm motor skills. The periods of physical activity be a short pause peace - longer.
Great value has x-ray diagnostics malignities ulcers. Ulcers in different locations have different tendency to malignancy. So, for example, duodenal ulcer is practically not malignities. Ulcers of different parts of the stomach also have unequal cancer potency. Unfavourable in this respect ulcers greater curvature, antral and cardiac departments. Rarely malignities ulcers small curvature, the body of the stomach, even rarer ulcer pyloric (C. A. Reinberg, Yu. N. Sokolov). Characteristic radiological signs of malignization sores typically considered increasing the size and shape change niches, the irregularity of its outlines, uneven depth, the prevalence of cross-section niches above the depth, the appearance of uneven hilly shaft around niches, the absence of the isthmus, the disappearance line of HAMPTON, change the topography of the mucous membrane around the ulcer (the appearance of a clear rigidity, irregular thickening folds places full smoothness of relief, breakage folds).