Methods for the study of the stomach and duodenum. Duodenum: location, structure and functions

Diseases of the stomach and duodenum are the main and widespread diseases of the digestive system. Of the diseases of the stomach, functional disorders of the stomach (FRG), acute and chronic gastritis - inflammation of the gastric mucosa, peptic ulcer of the stomach or duodenum - ulceration of the gastric mucosa, chronic duodenitis, polyps and gastric cancer are most often detected. The clinical manifestations of these diseases are diverse, reflect their pathogenetic essence - digestive disorders - and are described as a syndrome of dyspepsia, including various symptoms (pain, heartburn, feeling of stomach expansion, nausea, vomiting, etc.). Detailed clinical and laboratory studies allow to identify the pathological processes that caused the symptoms characteristic of this particular disease.

Instrumental diagnostics

Esophagogastroduodenoscopy (EGDS)

It is carried out for the purpose of diagnosing diseases of the stomach and duodenum. Modern flexible fibrous endoscopes have direct, oblique and lateral vision, which allows for constant visual control and perform various manipulations: pinch and brush biopsy, removal of foreign bodies, polyp coagulation, etc.

EGDS is performed after a detailed explanation to the patient of the nature of the manipulation. At the beginning of the procedure, local anesthesia of the pharynx with lidocaine is performed. The tip of the endoscope is brought to the upper edge of the crico-pharyngeal sphincter, the patient is asked to swallow and the endoscope is moved forward, introducing a small amount of air, under visual control, into the esophagus and stomach. The body and antrum of the stomach are examined in detail. To examine the cardiac region, the bottom and the greater curvature, turn the head of the endoscope with the simultaneous introduction of air. Then the device is carried out to the pyloric section and the upper and middle parts of the duodenum are examined. Special fibrous endoscopes can be used to examine the major papilla (vater) of the duodenum, to contrast the pancreatic duct and/or bile duct. Detected pathological formations are photographed or filmed on videotape. A biopsy or brush biopsy is taken from suspicious areas.

The risk of serious complications of endoscopy (bleeding, infection with viral hepatitis and HIV, gastric perforation, etc.) in the hands of experienced specialists is 1:800, and death is 1:5000. The risk is increased in emergency investigations and in elderly patients. Contraindications for gastroduodenoscopy are grade III hypertension, severe, high-risk, unstable angina pectoris, aortic aneurysm, decompensated heart disease, and cor pulmonale.

X-ray examination

Carry out after appropriate preparation of the patient. On the eve of the study, in the evening, the intestines are cleansed with an enema, in the morning, on the day of the study, the enema is given a second time. X-ray examination is carried out on an empty stomach, using an aqueous suspension of barium. During the study, the relief of the mucous membrane and the contours of the stomach, its peristalsis and emptying, the presence of pathological formations (niches, tumors, pyloric stenosis) are determined. Currently, the role of X-ray examination of the stomach and duodenum is decreasing. In urgent situations in women who can become pregnant, EGDS is performed.

Electrogastrography (EGG)

Electrogastrography is a method of selective recording of stomach biocurrents. EGG is recorded using an electrogastrograph in the frequency range of 0.03-0.07 Hz. Biocurrents are recorded from the surface of the abdominal wall in the projection of the stomach. On the EEG in healthy people, teeth are visible, the amplitude of which is 0.1-0.4 mV, the rhythm is correct, the frequency is 3 oscillations per minute. In pathology, the amplitude of the EEG waves mainly changes (from 0.02 to 1 mV).

Laboratory diagnostics

Fractional sensing

Fractional sounding is carried out to determine gastric secretion. Explore submaximal and maximum secretion by stimulating it. To determine submaximal secretion, a histamine test is used (histamine dihydrochloride is injected under the skin at a dose of 0.008 mg/kg of body weight), to determine maximum secretion, pentagastrin is injected under the skin at a dose of 6 mg/kg of body weight.

Immediately after the introduction of the probe, all the contents of the stomach are pumped out for 5-7 minutes (the portion is not subject to examination). Then within an hour with a 15-minute interval receive 4 servings (basal secret); after the introduction of histamine or pentagastrin under the skin, 4 portions of gastric juice are extracted with an interval of 15 minutes (stimulated secretion). In each serving, the volume of gastric juice, total acidity, free and bound HCl are determined. The main standards for indicators of gastric secretion are presented in the table below.

Debit-hour determines the function of the stomach and is calculated by the formula: D \u003d V * P / 1000, where V is the volume of gastric secretion in ml, P is the concentration of total acidity or free HCl in mg%. Trial breakfasts (meat broth according to Zimnitsky, cabbage decoction according to Leporsky, 5% ethyl alcohol solution according to Erlich, etc.) are not currently used due to the instability of the results obtained. Intragastric pH-metry is carried out with a probe with two sensors, which allow registering acid formation in the body of the stomach and obtaining data on the alkaline reserve in the pyloric region.

Acid formation in the body of the stomach on an empty stomach is classified by the following values:
pH 0.9-1.5 - hyperacidity;
pH 1.6-2.0 - normacidity;
pH 2.1-5.0 - hypacidity;
pH over 6 - achlorhydria.

In the pyloric part of the stomach, pH is usually recorded above 2.5. A decompensated acidic stomach is characterized by a pH in the body of the stomach of 0.6-1.5 and a pH in the pyloric section of 0.9-2.5. With high acid formation, secretion irritants are not used, with acid formation of medium and low intensity or achlorhydria, stimulation with histamine or pentagastrin is performed. After stimulation, pH values ​​are recorded for 30-60 minutes until they stabilize.

The pH values ​​of the stomach after stimulation are estimated as follows:
pH 0.9-1.2 - hyperacidity;
pH 1.2-2.0 - normacidity;
pH 2.0-3.0 - moderate hypacidity;
pH 3.0-5.0 - pronounced hypacidity;
pH over 6 - true achlorhydria.

Based on the analysis of changes in the secretory and motor-evacuation function of the stomach, two types are distinguished: hypersthenic, hypo- and asthenic.

• The hypersthenic type is characterized by a combination of hypersecretion of gastric juice, gastric hypermotility, increased gastric tone, and periodic muscle spasms of the cardiac and pyloric sphincters.
• The hypo- and asthenic type is characterized by a combination of hyposecretion (achlorhydria) of gastric juice with a decrease in tone and hypomotility of the stomach.

Diagnosis of Helicobacter pylori infection

Diagnosis of Helicobacter pylori infection (Helicobacter pylori) is made using invasive and non-invasive tests.

Invasive tests

It is carried out on biopsy specimens obtained using fibroesophagogastroduodenoscopy, and includes bacteriological, morphological and biochemical research methods.

1. bacteriological method. The biopsy is homogenized, inoculated into a nutrient medium supplemented with starch, blood or charcoal, grown under microaerophilic conditions at a temperature of 37 °C, and the grown bacteria are identified. An accurate diagnosis is established with the growth of several colonies of Helicobacter pylori.
2. Morphological methods:
   1. cytological method. Smears - prints of biopsy specimens of the gastric mucosa are stained according to Romanovsky-Giemsa and Gram.
   2. histological method. Biopsies are fixed in formalin and then embedded in paraffin. Sections are stained with hematoxylin-eosin according to Romanovsky-Giemsa or impregnated with silver according to Wartin-Stari. The number of microbial bodies in the field of view is counted. The degree of contamination of the mucous membrane is evaluated according to the following criteria:
      - weak - up to 20 microbial bodies in the field of view;
      - medium - up to 40 microbial bodies in the field of view;
      - high more than 40 microbial bodies in the field of view.

Non-invasive tests

Includes a Helicobacter pylori antibody test and a breath test.

1. Detection of antibodies to Helicobacter pylori. Antibodies to Helicobacter pylori are detected using enzyme-linked immunosorbent assay (ELISA test).
2. Breath test. The patient ingests a solution containing 13 C or 14 C labeled urea, which is cleaved by the urease enzyme secreted by Helicobacter pylori. Exhaled air contains CO 2 labeled with a carbon isotope (13 C or 14 C), the content of which is determined using a scintillary counter or mass spectroscopy. Normally, the content of the isotope 13 C or 14 C does not exceed 1% of the total amount of CO 2 in the exhaled air. With Helicobacter pylori infection, the amount of isotope C increases dramatically.

Examination of patients with diseases of the gastroduodenal region begins with questioning. Most often, these patients complain of pain in the epigastric region, nausea, belching, vomiting, change in appetite. However, these complaints are quite common in the pathology of other organs and therefore are of little specificity. The data of the physical examination of patients (examination, palpation of the abdomen) are usually uninformative. In this regard, additional research methods, primarily gastroduodenoscopy and X-ray examination, are of decisive importance in the diagnosis of diseases.

questioning

Complaints. pain in the abdomen, caused by the pathology of the stomach, are usually localized in the epigastric region and can be both permanent and paroxysmal. The most characteristic are paroxysmal pains associated with eating, which occur shortly after eating after a certain period of time or disappear after eating. Patients may complain of a vague painful feeling of pressure or tension in the epigastric region associated with gastric overflow and bloating. Pain associated with a disease of the stomach occurs as a result of violations of the motor function of this organ (with spasm or stretching of the smooth muscle fibers of its wall).

Heartburn- a burning sensation in the esophagus, due to the reflux of gastric contents.

Nausea - discomfort in the epigastric region. In diseases of the stomach, it is usually combined with pain.

Vomit- paroxysmal ejection of the contents of the stomach into the esophagus and further into the oral cavity as a result of contractions of the abdominal press, movements of the respiratory muscles with a closed pylorus, often combined with nausea, abdominal pain. In patients with gastric disease, pain usually subsides after vomiting.

Belching- sudden release into the oral cavity of a small portion of gastric contents due to squeezing of the stomach between the diaphragm, abdominal wall and swollen intestines or pyloric spasm.

Change in appetite- its decline is widespread. Lack of appetite - anorexia is a common symptom of stomach cancer.

Disease history. The onset of the disease can be acute (gastritis after an error in the diet) and gradual. Exacerbations and long periods of remission (with peptic ulcer) are often observed. The progression of the disease is characteristic of gastric cancer. It is always important to clarify the relationship of stomach disease with medications, such as non-steroidal anti-inflammatory drugs.

Physical research methods

A general examination of the patient reveals weight loss (up to fco cachexia), pallor of the skin associated with anemia, and a white-coated tongue.

Superficial palpation of the abdomen often reveals pain in the epigastric region and slight tension in the abdominal muscles, usually associated with peptic ulcer or gastritis.

Deep sliding palpation only occasionally allows you to feel the small and large curvature and pyloric parts of the stomach, and even less often - a tumor of the stomach. Percussion and auscultation of the stomach, as a rule, are not essential.

Additional research methods

X-ray examination. First of all, it is necessary to prepare the patient for the study. To this end, the night before and in the morning on the day of the study, his intestines are cleansed with enemas, with persistent constipation, laxatives are prescribed. The study is performed on an empty stomach, in the upright position of the patient. Barium sulphate is used as a contrast. The study begins with determining the relief of the gastric mucosa, the folds of which have great variations and often change depending on the stage of the digestion process, becoming either more prominent and distinct, then flattening. If their course is interrupted, the presence of a pathological process in this place is assumed. It is important to study the contours of the stomach. The persistent protrusion of its shadow is designated as a niche, which is a typical symptom of gastric ulcer. Lack of filling of the stomach area with a contrast mass is called a filling defect and is an important symptom of a neoplasm.

Gastroduodenoscopy. With the use of fiber optics, gastroduodenoscopy has been intensively developed and has become the most effective and rapidly applied method. Simultaneous biopsy and morphological examination made this method the most effective diagnostic method. The main indication for gastroduodenoscopy is upper gastrointestinal bleeding and epigastric pain. The great importance of this method lies also in the possibility of applying local treatment with ongoing bleeding. The advantage of gastroscopy is the ability to detect superficial changes in the mucous membranes that are not detected radiographically. In the presence of a stomach ulcer found on x-ray, endoscopy is also usually required to visually and histologically rule out an ulcerated tumor. For any suspicion of a tumor of the stomach, including the presence of symptoms such as weight loss, anemia, an endoscopic examination is necessary.

Biopsy of the gastric mucosa and cytological examination. This method is used to exclude or confirm the presence of a tumor. In this case, tissue for research is taken in several (preferably 6-8) places, the accuracy of the diagnosis in this case reaches 80-90%. It should be noted that both false positive and false negative results are possible.

Examination of gastric juice. The study is carried out using a thin probe, the introduction of which requires the active assistance of the subject. A portion of gastric contents is obtained on an empty stomach and then every 15 minutes after the introduction of the stimulus. The acidity of gastric contents can be determined by titrating it with 0.1 mmol/l NaOH solution in the presence of dimethylaminoazobenzene and phenolphthalein (or phenol red) indicators to pH 7.0 while neutralizing the acidic contents with alkali.

Basal acid secretion is the total amount of hydrochloric acid secreted in the stomach over four 15-minute time intervals and expressed in mmol/h. This indicator ranges normally from 0 to 12 mmol / h, on average 2-3 mmol / h.

Study of stimulated secretion of hydrochloric acid. The strongest irritants of gastric secretion are histamine and pentagastrin. Since the latter has fewer side effects, it is now being used more and more. To determine basal acid secretion, pentagastrin or histamine is injected subcutaneously and gastric contents are collected over four 15-minute periods. As a result, the maximum secretion of acid is determined, which is the sum of the maximum consecutive values ​​of secretion for 15 minutes of collection of gastric juice.

Basal and maximum acid secretion is higher in patients with localization of the ulcer in the duodenum, with the location of the ulcer in the stomach, acid secretion in patients is less than in healthy ones. Benign gastric ulcers rarely occur in patients with achlorhydria.

The study of gastrin in blood serum. The determination of the content of gastrin in the serum is carried out by the radioimmune method and may be of diagnostic value in diseases of the gastroduodenal zone. The normal values ​​​​of this indicator on an empty stomach are 100-200 ng / l. An increase in the content of gastrin over 600 ng/l (severe hypergastrinemia) is observed in Zollinger-Ellison syndrome and pernicious anemia.

The duodenum is easily accessible to x-ray examination, and the recognition of its diseases occupies a prominent place in x-ray diagnostics.

The shape of the duodenum most often approaches a horseshoe (Fig. 94), but varies depending on the constitution and position of the body, varying widely, acquiring either the shape of a ring, or bending, or forming a loop-shaped figure of the run. The position and shape of the duodenal bulb also vary depending on the constitutional features (Fig. 95).

Rice. 94. Normal run of the duodenum (X-ray).

Rice. 95. Normal duodenal bulb (X-ray).

The shape of the bulb may change in different phases of the study, depending on the contractile activity of the muscles. According to the course of the curvature of the stomach in the bulb, a large and a small curvature are distinguished. The size of the bulb varies depending on the tone. It can be small with normal tone and enlarged with reduced tone, while sometimes acquiring large sizes.

When examining the duodenum in a state of artificial hypotension, it is possible to see the nipple of Vater, which forms a double depression on the inner contour, resembling the Latin letter W (Fig. 96). Under pathological conditions of Vater, the nipple is deformed, enlarged, and in case of tumors it creates a filling defect along the inner contour of the duodenum.

Rice. 96. Normal duodenum in a state of artificial hypotension (X-ray).

The arrow indicates the papilla of Vater.

The tone of the bulb can be judged by the nature of its emptying. If the bulb is emptied quickly, even before reaching its tight filling, then this indicates an increase in tone. Slow emptying, accompanied by a significant residue, may indicate a decrease in tone.

Often there is a so-called duodenoptosis. In this case, in addition to the low location, the duodenum is elongated and expanded. In such cases, expansion and bulbs are noted. Duodenoptosis occurs together with general splanchnoptosis or in the presence of the mesentery of the duodenum.

The relief of the mucous membrane of the bulb and the rest of the run of the duodenum has a different appearance. In the region of the bulb, longitudinal folds predominate, repeating the relief of the mucosa of the gastric outlet. The folds of the bulb are clearly visible either at the time of its contraction or during compression. Starting from the upper knee of the duodenum, there are already typical Kerckring folds, which have a transverse arrangement and form a pinnate relief pattern, similar to how it occurs in the small intestine.

Examination of the operated stomach

Contrast breakfast - research in progress fluoroscopy and radiography. In the course of the study, the type of operation performed, the shape and size of the stomach stump, the size and function of the gastrointestinal anastomosis, the features of the passage of the contrast agent through the anastomosis and the jejunum (abductor loop), the presence or absence of peptic ulcer are determined.

ulcers, signs of periprocess, recurrence of the oncological process, as well as the duration of the delay of the contrast agent in the afferent loop, etc.

Examination of the duodenum

X-ray examination of the duodenum can be performed sequentially as the contrast suspension advances during the study of the esophagus and stomach - duodenography without a probe, or targeted administration of a contrast agent using a duodenal probe - probe duodenography. Also used relaxation duodenography.

Duodenography without a probe. A detailed examination of the bulb and other parts of the duodenum is performed at the moment when they are well filled with a contrast agent. Sometimes it is beneficial to interrupt the study of the stomach and take pictures of the bulb. It is most convenient to study the bulb in oblique projections, when its front and back walls are displayed on the contour.

When examining the duodenum, it is also necessary to study the state of the relief of the mucous membrane and take pictures with its "tight" filling. Relaxation duodenography is often used. By the shape of the duodenum, one can judge the presence of indirect symptoms of pancreatic damage.

This method is used more often as the main method for diagnosing pathological changes in the duodenum.

Indications: ulcers, diverticula, neoplasms of the duodenum, volumetric processes of the pancreas.

Probe duodenography. With the help of this method, the details of already detected changes in the duodenum are more often clarified.

Indications: the same as with duodenography without a probe.

Contraindications: intestinal bleeding, perforation, acute intestinal obstruction, general serious condition of the patient.

contrast agent:

Methodology: A duodenal probe is introduced into the vertical branch of the duodenum under screen control in a patient prepared for examination of the gastrointestinal tract. Then later

200-300 ml of a liquid contrast suspension at room temperature is introduced through the probe for tight filling, and duodenal images are taken in frontal and oblique projections. Further, for double contrasting and studying the relief of the mucosa, 200-300 ml of air is introduced and images are taken in the same way.

Relaxation duodenography with aeron (without probe and probe) - a study of the duodenum against the background of the action of neurotropic drugs that cause a decrease in intestinal tone. The use of aeron in duodenography was first proposed by Professor B.M. Sosina in 1969.

Indications and contraindications: the same as with probe duodenography.

contrast agent - aqueous suspension of barium sulfate.

Methodology: the patient, depending on age and weight, is prescribed 1-3 tablets of aeron under the tongue. After resorption of the tablets, a routine examination of the esophagus, stomach and duodenum is carried out.

After 20-30 minutes, under the action of aeron, relaxation and expansion (hypotension) of all hollow organs is observed - the pyloric canal opens wide and a barium suspension freely fills the lumen of the duodenum.

First, the intestine is examined in the vertical position of the patient - they study the shape, size, position, mobility of the intestine, and the relief of the mucous membrane.

To obtain a pneumorelief, the patient is transferred to a horizontal position and laid on his left side, while the air from the stomach enters the duodenum and is evenly distributed in it.

For a more tight filling of the duodenum with a contrast agent, the patient is given another glass of barium suspension to drink and laid on the right side for 2-3 minutes, after which a series of radiographs is performed. Hypotension lasts about 30 minutes. By-effects at application of Aeron it is not noted.

Anatomy of the duodenum

The duodenum (duodenum, fig. 415) occupies a somewhat isolated place in the small intestine, due to its anatomical and physiological features.

1 - upper part of the intestine;

2 - descending part;

3 - horizontal part;

4 - ascending part;

5 - the beginning of the jejunum;

6 - pancreatic duct.

The duodenum, with the exception of its upper part adjacent to the pylorus, is located retroperitoneally. It has a length of about 20 cm (9-30 cm) and a width of 1.5-5 cm.

Bulb of the duodenum mobile, the rest is fixed to the back wall of the abdomen.

WPC form closer to the horseshoe, there are several complex bends.

top bend short, lies to the right of the spine at the level of the II thoracic or I lumbar vertebra, has a horizontal or upward direction.

Descending part also lies to the right of the spine, looks like a loop.

Lower horizontal part of the duodenum located approximately at the level of the III lumbar vertebra, crosses the spine and to the left of it at the level of the II lumbar vertebra passes into the jejunum.

The wall of the duodenum consists of 3 shells in the upper part -

1. serous,
2. muscular,
3. mucous,

1. muscular and
2. mucous.

The mucous membrane of the duodenum has 2 layers -

1. epithelial and
2. muscular.

On the inner surface of the mucosa there are many villi up to 0.5 mm high, rich in capillary network and lymphatic vessels. Above the villi in the own layer of the mucosa are crypts - tubular depressions lined with epithelium. The muscular layer of the mucous membrane consists of several thin muscle fibers.

submucosa It is a loose connective tissue, in the thickness of which the duodenal (Brunner's) glands are located.

In the descending section of the duodenum there is Vater papilla, 11-21 mm high, 5-10 mm wide. At its top, the common bile and pancreatic ducts open (about 70% in the form of a single duct). The end part of the common bile duct in the wall of the duodenum is covered by the sphincter of Oddi.

The duodenum lies in close proximity to a number of important organs:

• adjacent to the stomach
• and the upper, descending, horizontal part touches the head of the pancreas,
• ascending part - the body of the pancreas.
• The duodenum is located near the right lobe of the liver,
• aorta,
• right adrenal gland
• inferior vena cava.

The duodenum is located to the left and back of the gallbladder, the anterior or anterior-lower edge of the bulb is in contact with the body of the gallbladder.

Lymphatic system of the duodenum

The lymphatic system of the duodenum is well developed, the vessels flow into the lymph nodes located in front of and behind the head of the pancreas, in the mesentery on the border with the pyloric part of the stomach, partially the lymph flow goes to the hepatic node, to the blood nodes of the mesentery.

Physiology of the duodenum

The duodenum anatomically and functionally is a continuation of the stomach, it takes food from the stomach, it mixes the juices of the duodenal, pancreas and bile, as well as the absorption of some digestive products.

The main physiological role of bile is carried out in the duodenum- "to replace gastric digestion with intestinal, destroying the effect of pepsin, as an agent dangerous for pancreatic enzymes, and extremely favoring pancreatic juice enzymes, especially fat" (IP Pavlov, 1951).

Activation occurs in the duodenum protein, fat and starch enzymes. Here, bile is emulsified and food masses are processed with pancreatic juice, hydrolytic breakdown of nutrients occurs, that is, digestion in the proper sense.

The duodenum plays a significant role as a receptor zone, which has a great influence on the processes of food transport, the secretory function of the pancreas. The hormones secreted by it (enterogastron, secretin, cholecystokinin, pancreozymin, villikinin, enterokinin) actively influence the activity of the stomach, pancreas, liver, and intestines.

Inspection of the duodenum

When examining the area of ​​the duodenum in a healthy person, no abnormalities are detected, the abdominal wall is actively involved in the act of breathing, the level of its surface is similar to the level of the symmetrical region on the left. The skin color does not differ from the skin color of other areas of the abdomen. The thickness of the subcutaneous fat layer is normal.

Pathology of duodenum(duodenitis, ulcer, tumor) are often accompanied by a decrease in the patient's nutrition, pallor of the skin during bleeding and perforation of the ulcer, hyperpigmentation of the skin of the duodenal region.

When an ulcer perforates- non-participation of the abdomen in the act of breathing, board-shaped abdomen. In persons who underwent duodenal surgery, a scar is visible from the xiphoid process to the umbilicus. With stenosis of the duodenum, as with stenosis of the pylorus, there will be noticeable bulging of the epigastrium mainly on the left, periodic waves of peristalsis of the overflowing stomach from the left hypochondrium down to the navel, fading a few seconds after the onset. In this situation, other parts of the abdomen usually look sunken.

Palpation of the duodenum

Palpation (Fig. 416). Close proximity to other organs, its deep occurrence does not allow with full confidence to attribute the identified palpation findings only to this organ.

A. Scheme of the topography of the DP K
B. The position of the doctor's hand during palpation, the hand is flat on the stomach on the right at the outer edge of the rectus muscles, the position of the fingertips is 1-2 cm below the costal arch or the edge of the liver

Given the physiological variants of the structure and position of the duodenum, palpation begins from the lower edge of the liver at the lateral edge of the right rectus abdominis muscle. 4 fingers of the right hand are placed 1-2 cm below the edge of the liver.

Having shifted the skin up, gradually on exhalation, the fingers sink into depth. Upon reaching the back wall, on the next exhalation of the subject, the fingers make a sliding movement down by 2-4 cm. Palpation must be repeated, descending from the initial level of the study by 3-4 cm.

Thus, the initial, descending and partially lower horizontal part of the duodenum will be palpated. In a healthy person, the duodenum is not palpable. Palpation is painless.

Pain on palpation of the duodenum observed with its inflammation, erosive and ulcerative process, with periduodenitis. Palpation of a dense band as thick as the little finger indicates a pronounced spasm of the duodenum, which is possible with peptic ulcer. The presence of a site of compaction suggests periduodenitis, a tumor.