X-ray of the stomach and duodenum: two-phase and classic. Diseases of the duodenum: symptoms, therapy, diagnostic methods

> X-ray (x-ray) of the stomach and duodenum

This information cannot be used for self-treatment!
Be sure to consult with a specialist!

This type of radiography is an X-ray examination of the upper parts of the digestive tract (stomach, duodenum), carried out with the use of contrast. The method allows you to identify a serious pathology, provided that the pathological focus falls into the field of view of the device. If abnormalities are found on radiographs, an endoscopic examination with the possibility of taking a biopsy is necessary.

In what cases is an x-ray of the stomach and duodenum prescribed?

The study is prescribed by general practitioners, gastroenterologists and surgeons in case of suspected peptic ulcer or volumetric neoplasm of the stomach or duodenum. On the basis of radiography, it is also possible to diagnose a hernia of the esophageal opening of the diaphragm, narrowing of the outlet section of the stomach (stenosis), deformity of the duodenum in its bulbous part. This study is carried out if patients complain of belching, heartburn, nausea and vomiting immediately after eating or after some time. They may experience pain in the upper abdomen, usually associated with hunger. When saturated, the pain goes away. Exacerbations of the disease often have an autumn-spring seasonality.
Where can I get an X-ray of the stomach and duodenum?

The study is available and widely used in outpatient and inpatient health care facilities: hospitals, hospitals, consultative diagnostic centers. X-ray imaging requires appropriate equipment and competent, qualified specialists.

How to prepare for an x-ray of the stomach and duodenum?

You should come to the study on an empty stomach. Your doctor will tell you if you need to stop taking medications that stimulate the digestive tube or relieve spasm. For several days before the procedure, you should not drink alcohol or smoke. With excessive gas formation, dairy products, fresh bread, pastries, legumes, cabbage should be excluded from the diet.

How is an x-ray of the stomach and duodenum performed?

First, the laboratory assistant performs a survey radiography of the abdominal organs in a direct projection in a standing position. This allows you to identify acute surgical pathology: rupture of a hollow organ, bleeding, acute intestinal obstruction. Then the patient is given a glass of barium suspension to drink. The consistency of the mixture resembles sour cream and has a characteristic aftertaste of lime. Usually, lemon pop is added to the mixture, which allows the contrast to be distributed throughout the entire volume of the stomach. After that, the X-ray laboratory assistant conducts a series of X-ray images in various projections (direct, lateral, oblique). The position of the patient's body changes during the study: standing, lying and with the foot end of the table raised. After the end of the procedure, drinking plenty of water is shown - this will help to quickly remove barium from the body.

When is radiography contraindicated?

Due to the significant radiation exposure, the study should not be performed on pregnant women and young children. With perforation of the intestine or acute obstruction, taking barium suspension can aggravate the situation.

How is the conclusion interpreted?

Normally, on radiography of the stomach, its walls look smooth and even, without filling defects and pathological outgrowths. The suspension of barium partially settles on the folds of the mucous membrane, contouring them. If a neoplasm or flattening of the relief of the mucosa in the form of a platform without folds is detected, the doctor concludes that there is a pathological process in the stomach or an adjacent organ. Endoscopy helps to establish the structure of the process in detail.

The contrast agent should freely enter the duodenum. With stenosis of the outlet, barium lingers in the stomach for a long time. The normal duodenum is covered on the inside with mucosal folds arranged in a circle. Filling defects, deformations, pathological outgrowths are symptoms of intestinal pathology.

The radiologist reflects all the changes revealed in the pictures in the conclusion, with which you should come to the doctor who sent you for this examination.

According to statistics, about 5% of people annually seek help for peptic ulcer. In most patients, the clinic proceeds classically, but along with this, there are erased forms of gastric and duodenal ulcers.

Manifestation of pathology

Patients, as a rule, begin to sound the alarm when a severe pain syndrome appears. Depending on the location of the mucosal defect, pain can be early, hungry, nocturnal, late, and in some cases not at all associated with food intake. This is due to the direct action of chyme on the ulcer of the duodenum and stomach. The damaged mucosa is additionally irritated by the motility of the organs during the advancement of the food bolus.

Characteristics of the pain syndrome

Pain is described with different intensity and color. There may be cramping or constant discomfort from the epigastric zone of the abdomen. The feeling is described as something squeezing, stabbing, cutting, squeezing the epigastrium.

In the presence of an ulcer in the cardial part of the stomach, pain can radiate to the sternum, to the shoulder, to the left side of the chest, simulating angina pectoris. This localization of pathological changes is characterized by the development/intensification of symptoms no more than 30 minutes after saturation with food.

After 1-1.5 hours, signs of an ulcer of the stomach and duodenum appear, the symptoms may include vomiting at the peak of abdominal pain. The disease is accompanied by constipation. If a deep defect is located on the back wall of the stomach, pain can be given to the back and lower back. In such a situation, women are suspected of problems in the gynecological field.

Ulcerative lesions of the duodenum in isolation are not so common. At the same time, the pain symptoms of the pathology of the bulbar and postbulbar regions differ. Signs of a duodenal ulcer in the region of the bulb are somewhat erased, pain does not depend on meals, can be permanent, localized in the right side of the epigastrium, radiating to the umbilical region and chest on the right. Ulceration of the mucosa outside the bulb can be determined due to the appearance of more intense pain after a couple of hours after eating and disappearing only after 20 minutes from satisfying hunger.

Up to a quarter of all clinical cases, a combination of localization of deep defects is determined. In this regard, in 6-25% of patients it is possible to identify the polymorphism of the pathology and the absence of a specific rhythm of pain.

Additional signs of gastric and duodenal ulcers

Together with the pain syndrome, dyspeptic phenomena are of some importance:

• nausea;
• vomit;
• heartburn and belching;
• constipation.

How to test assumptions?

Diagnosis of gastric ulcer, bulbar and extrabulbar duodenal ulcers includes the collection of information about the prescription of the condition, heredity, examination by a specialist, instrumental and laboratory studies. The therapist or gastroenterologist, performing a manual examination of the abdomen, identifies areas of maximum pain, is determined with a preliminary diagnosis and further diagnostic search.

The main methods by which you can diagnose diseases of the duodenum and stomach include:

• endoscopy (FGDS);
• x-ray;

FGDS

Fibrogastroduodenoscopy is a technique that allows you to visually examine the mucous membrane of the digestive organs of the upper part of the abdominal cavity from the inside. This study is extremely important for diagnosis. Thanks to FGDS, the doctor can determine the length of the area covered with ulcers, take material for analysis for helicobacter pylori and biopsy. In addition, in the presence of bleeding, endoscopy can really be transferred to the category of medical manipulations (drug instillation, coagulation).

Important! Endoscopic diagnosis of gastric ulcers is strictly required for suspected malignant degeneration of cells. If malignancy is detected, the patient is examined and subsequently treated by an oncologist.
If it is impossible to conduct EGD, the patient is prescribed alternative diagnostic methods.

Beam methods

Fluoroscopy / radiography of the stomach and duodenum is performed using a contrast agent. With the help of x-rays, the following signs of this pathology are revealed:

• symptom of "niche" (due to filling the bottom of the ulcer with contrast);
• convergence of folds to the center of the defect;
• inflammatory shaft around the ulcer (due to tissue edema);
• increase in fluid volume;
• radiographic symptoms of pyloric stenosis, scarring;
• motor-evacuation dysfunction.

Diagnosis of stomach ulcers by ultrasound is not very informative. Allows you to evaluate mainly the thickness of the walls of the body, the presence of fluid levels, peristalsis. The duodenum is more difficult to explore in this way.

The advantage of ultrasound is the ability to make a conclusion regarding the state of the liver, the morphology of the bile ducts and pancreas, which can be initially affected or secondarily after the stomach and intestines. In such a case, along with manifestations of peptic ulcer, disorders of the glands of the digestive system are noted.

Thus, the diagnosis of gastric ulcer is primarily based on the endoscopic picture of the disease and clinical symptoms. Ultrasound can differentiate some conditions and is an auxiliary method. X-ray of the stomach and duodenum confirms the diagnosis in case of contraindications to FGDS.

Laboratory methods

If a peptic ulcer is suspected or detected, the patient is prescribed blood tests (clinical, biochemical and for antibodies), urine, feces. The presence of anemia indirectly confirms the fact of bleeding. A positive Gregersen test indicates the presence of a bleeding vessel in the gastrointestinal tract.

For a complete diagnosis, it is possible to use various tests for Helicobacter pylori. The most famous is the breath test. The patient is given to drink a special solution with carbamide. Then, using an indicator in the exhaled air, the concentration of substances metabolized by Hp is estimated.

Complicated course

The formation of the adhesive process and the malignancy of the ulcer are chronic. In such cases, the symptoms progress gradually and for a long time. Dyspeptic manifestations are aggravated.

Diagnosis of a duodenal ulcer should be carried out as soon as possible with the development of a clinic of an acute abdomen, massive bleeding, vomiting of clotted blood of the color of "coffee grounds", black stools. The patient is urgently taken to the surgical hospital, where immediate treatment is carried out.

The intestine is an organ of the digestive system that performs very important functions in the human body, but today intestinal pathologies are very common. Conducting preventive examinations of the intestine in order to prevent the development of various diseases comes to the fore. In this article, we will talk about what methods of examining the intestines medicine offers, and discuss the advantages and disadvantages of each of the methods.

What is the intestine for?

The intestine is an organ that is located in the abdominal cavity and is involved in the process of digestion. It absorbs nutrients, which later enter the bloodstream. Undigested substances are excreted from the body along with intestinal gases.

It reaches four meters in a person. It is inhabited by a huge number of bacteria that provide the processes of digestion, so it is very important that the microflora of the body is in constant balance. Otherwise, the body will fail, which will lead to the development of various pathologies. Intestinal dysfunction can be manifested by a variety of symptoms, among which the most obvious are rumbling in the abdomen, flatulence, pain, diarrhea, stool retention, chronic constipation, etc.

The structure of the intestine

The anatomical structure of the organ is represented by two segments:

• small intestine,
• colon.

The small intestine is located between the stomach and the large intestine. It is where the process of digestion takes place. This section of the intestine is divided into the following components:

• duodenum,
• jejunum,
• ileum.

The small intestine got its name due to the fact that, in comparison with the anatomical structure of the large intestine, it has less thick and durable walls. In addition, the cross-sectional diameter of its departments is much smaller.

The large intestine is the lower part of the digestive tract where water is absorbed and feces are formed. Its length is approximately 1.5-2 m.

The large intestine is represented by segments:

• and appendix,
• colon, which includes the ascending colon, transverse colon, descending colon, and sigmoid colon,
• with a wide part and a terminal tapering part.

I must say that the methods of examining the intestines are very similar for both the small intestine and the large intestine, although there are nuances.

Relevance of bowel examination

Today, intestinal pathologies are very common. Unfortunately, there are often serious diseases - oncological neoplasms. About 1 million new cases of colorectal cancer are diagnosed every year worldwide. Half of the patients diagnosed with this disease die. Oncology of the intestine occupies a leading position among all malignant tumors. Therefore, it becomes relevant to conduct preventive examinations of the intestine in order to prevent the development of diseases.

Modern ones make it possible to detect various intestinal pathologies in the early stages and begin immediate treatment, which increases the patient's chances for a speedy recovery or at least maintaining his quality of life at a good level. More in demand is the diagnosis of diseases of the colon, because serious disorders occur in these parts of the intestine. Medicine offers patients a whole range of methods for diagnosing this organ, including:

• capsule examination,
• colonoscopy,
• endoscopy,
• MRI diagnostics,
• irrigoscopy.

Intestinal examination with video capsule

Among all the available diagnostic methods, this method is considered the most painless and at the same time quite informative. The essence of the study is that the patient swallows a capsule equipped with a video camera. Once in the human body, the “device” travels through all parts of the gastrointestinal tract, taking a photo every two seconds. The data from the chip is processed by a special program, and based on the results, medical conclusions are drawn.

It is necessary to prepare for the procedure in advance. On the eve of the manipulation, food intake is prohibited, the study is performed on an empty stomach. A device is attached to the human body, which will record the results of the study. The diagnostic procedure takes about eight hours, during which the patient leads a normal life - goes about his business without disturbing the daily rhythm. After the examination, the capsule dissolves and is excreted from the body in a natural way.

The most modern methods of examining the intestines today are represented by the use of video capsules, although this method has its drawbacks. Such manipulation is very expensive. The fact is that "smart" capsules cost about 1 thousand USD. That is, and only two countries offer them today - Japan and Israel, leaders in the market for such services. The CIS countries do not yet have their own production of diagnostic chips.

Intestinal endoscopy

An endoscope is an optical device that is used in medicine to examine hollow human organs, such as the esophagus, stomach, and intestines. In most cases, it is injected through the natural opening of the body, less often through surgical incisions.

Endoscopic methods for examining the intestine are prescribed for suspected presence of polyps or tumor formations in the intestine. Before the procedure, the patient should carefully prepare the body - cleanse the intestines. Today, this measure is easily performed through special medications. The doctor introduces an ultrasonic sensor into the intestine, which allows you to examine in detail the mucous membrane and the condition of the walls of the organ under study. In order to clarify the results during the procedure, biological material may be taken for additional laboratory tests.

Endoscopic ultrasound of the large intestine is performed in most cases, with the exception of moments when the patient has diseases of the heart and blood vessels or lungs. This is directly related to the need to take special drugs. However, the expediency of conducting such a study is decided individually in each case.

Colonoscopy

Colonoscopy is a research method based on the use of a special device - a fibrocolonoscope - a plastic tourniquet with an optical system. Such a study is recommended for preventive purposes to be performed every five years for people over forty years of age and for those whose heredity is aggravated by oncological pathologies of the intestine.

Before the procedure, it is necessary to cleanse the intestines with the help of medications. Usually a colonoscopy lasts no more than 30-40 minutes, but it is a rather unpleasant procedure. The patient may experience discomfort due to the fact that the intestines are filled with air, and the person has a feeling of bloating. Methods for examining the intestine with a fibrocolonoscope also allow the sampling of biomaterial for histological analysis. In addition to diagnostic functions, colonoscopy allows you to remove polyps or benign formations of small sizes. Using this technique, adhesions in the intestine can also be detected. The results of the study are ready, as a rule, immediately after the manipulation.

Irrigoscopy

The method of irrigoscopy is a method of examining the intestines using x-rays. Before the procedure, the patient must carefully prepare the body - cleanse the intestines, while eating is not allowed. Immediately before the study, a liquid is introduced into the body, which contains a radiopaque preparation - barium sulfate. The essence of the study is as follows. Once in the gastrointestinal tract, the solution fills all areas of the intestine and allows you to evaluate the contours and degree of intestinal lumen in the pictures. The procedure can be supplemented by another manipulation. After the contrast agent is removed from the body, air is injected into the intestine - this provides an additional opportunity to examine in detail the contours of the organ sections.

This technique makes it possible to diagnose fistulas, birth defects, ulcers, scars, but is considered insufficiently informative. The procedure is considered conditionally safe, since during the study the body is exposed to radiation exposure.

MRI bowel examination

Another way to diagnose bowel diseases is magnetic resonance imaging, which is based on the use of a magnetic field in the study. This procedure is painless and is considered safe, as it does not carry a radiation load on the body. On the eve it is necessary to clean the intestines, and immediately before the manipulation - to introduce a contrast agent into the body. The study itself takes no more than ten minutes and allows you to identify serious disorders in the intestines, up to malignant tumors.

I must say that the diagnosis should be carried out in a complex manner, therefore, methods of clinical examination of the intestine are added to the above manipulations. To detect dysbacteriosis, a stool sample is taken, in addition, rectal and bacteriological studies can be carried out. Blood is taken from the patient - as a rule, both biochemical and clinical analysis of the material is performed. Modern diagnostic methods, however, will not replace digital

Examination of the small intestine: methods

As noted earlier, most often serious pathologies affect the sections of the large intestine, however, diseases of the small intestine also occur. Diagnosis, as a rule, begins with a study of the duodenum, located between the stomach and large intestine. For these purposes, fibroscopy or endoscopy is prescribed, in addition they can resort to irrigoscopy or radiography. A few days before the manipulation, the patient is advised to adhere to a certain diet.

With the help of endoscopy, you can not only diagnose the intestines, but also remove polyps, stop bleeding, and install a probe for food intake. The most modern method for diagnosing diseases of the small intestine is double-balloon enteroscopy, which is performed under general anesthesia. This procedure is considered quite severe and is performed only in a hospital setting. Enteroscopy is prescribed for bleeding in the small intestine, with its obstruction.

Thus, capsule examination, endoscopy, colonoscopy, barium enema and MRI are the basic methods by which the diagnosis and examination of the intestine is carried out. I must say that in general, pathological conditions of the organ are diagnosed more often in women, but this is only due to the fact that the beautiful half of humanity carefully monitors their health and consciously undergoes a medical examination for preventive purposes. There is also an opinion that such diseases are inherent in people with prosperity, because they are more able to afford refined food.

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 significant.

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, or 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.

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Chapter VIII
Examination of the duodenum
A. Possibilities and methods of examination
Access to the duodenum is rather difficult, since it is located deep and covered by the parietal peritoneum, which in this area is partially fixed to the pancreas and the posterior wall of the abdominal cavity. The descending branch (D2), the inferior horizontal branch (D3) and the ascending branch (D4) are crossed transversely by the base of the mesentery of the colon and in the sagittal plane by the mesentery of the small intestine.
It should also be emphasized that usually the examination of the duodenum during surgery is incomplete, limited only to the area above the mesentery of the colon, more accessible during conventional interventions (stomach, liver, biliary tract).
The subpyloric part (D1), surrounded by the peritoneum, is the only one that can be viewed from all sides without special techniques. In other cases, only the ventral semicircle of the wall can be seen and felt.
This difficulty is joined by the shape variants that change the size and ratio of different segments, and the different confluence of the mesentery of the transverse colon or the mesentery of the small intestine, which changes, depending on the case, access to different segments. Before proceeding to surgical treatment, these options should be carefully considered, guided by the anatomical location and adapted to each individual case.
To examine segment D1 and part of segment D2, located above the mesentery of the colon, it is necessary to move cranially the liver (after dissection of possible adhesions between the duodenum and gallbladder) and caudally the colon with the mesentery of the transverse colon. As for segment D2, located under the mesentery of the colon, as well as D3 and D4, to examine them, it is necessary to shift the omentum, colon and mesentery of the colon cranially, moving the initial part of the jejunum with the mesentery to the left or right.
If it is necessary to examine the dorsal (retroperitoneal) wall of the duodenum, additional abduction techniques are needed.
For D2, as well as for the terminal part of the choledochus or the dorsal surface of the pancreatic head, the classic abduction of the duodenum and pancreas (Kocher-Jourdan) is used, which consists in dissecting the parietal peritoneum in the dihedral angle, which is formed when it passes to the ventral branch of D2. Then, with the help of a dissecting tupfer or a finger, the horizontal and descending branches of the duodenum are mobilized.
In practice, mobilization can be small and extended. As Fruchaud (1960) points out, the usual mobilization of the duodenum and pancreas, which is limited to the dissection of the peritoneum along the outer edge of the segment D2, located above the mesentery of the colon, gives little visibility of this part and the terminal section of the common bile duct. In essence, this technique is reduced to the preparation of the preduodenal part, which is a continuation of the ligament of Treitz, and the dissection of the retroperitoneal space, which only lengthens the ligament of Treitz (Fig. 5a).

Rice. 5. Duodeno-pancreatic mobilization.
a - simple dissection of the peritoneum along the outer edge D2 - low mobilization; b - dissection of the parietal peritoneum in the right hypochondrium, retraction of the ascending and transverse colon down and medially allow to expose the entire segment D2 - the anterior surface of the common bile duct - extended mobilization (according to Fruchaud).
To completely expose the dorsal part of D2 and the lower part of the common bile duct, it is necessary to continue the incision of the peritoneum and dissect the duodeno-colonic ligaments (Fig. 5,6). The degree of mobilization of the pancreatoduodenal zone must be established depending on the conditions and characteristics of the given case, especially since this technique is not always distinguished by the simplicity and good quality that the authors of works on anatomy attribute to it. This technique is especially difficult in the adhesive process and a significant number of newly formed vessels.
To examine D3, it is necessary to increase the mobilization of the duodenum and pancreas to the midline, to the level of the bend connecting it with D2, supplementing it in certain anatomical variants with an incision of the adjacent parietal peritoneum or the caudal leaf of the mesentery of the colon. As for the segment, it can be brought to the midline after an incision in the left sheet of the base of the mesentery and dissection of the ligament of Trade at the junction of it with the intestinal wall. Under these conditions, D4 can even be moved posterior and to the right of the mesenteric vessel trunk. All these techniques must be used carefully so as not to damage neighboring vessels (superior mesenteric vein and artery, inferior mesenteric vein, first arch of the jejunum).
To expose D3 and D4 widely without risk of vessel injury, Catell recommends retraction of the ascending colon in the plane of Toldt's fascia, to the left of the superior mesenteric artery.

Consistent application, depending on the case, of these techniques allows you to examine the entire circumference of the duodenum and, through the wall, its cavity, with the exception of the area adjacent to the pancreas. In this way it is possible to recognize the nipple - a key landmark in biliary and pancreatic surgery - by palpation through the outer wall after retraction of the duodenum - pancreas. It gives the impression of a "grain of lead", usually located in the middle part of the medial wall of D2.
Under normal conditions, the recognition of the Vater nipple by external palpation is difficult, since it can be covered with folds of the mucous membrane, and its location is very different. Usually the nipple is within D2, in the zone starting at a distance of 2 cm from the upper knee and ending at a distance of 1 cm from the lower knee; in some cases it may be on D1 or D3 (Fig. 6). Given these differences, and the fact that retractile sclerosis can deform landmarks under pathological conditions, intraoperative cholangiography remains the correct way to locate the nipple (without duodenotomy).

Rice. 6. Operational cholangiography. Low confluence of the common bile duct into the duodenum.

Internal examination of the duodenal lumen can be performed under extraordinary conditions without duodenotomy, and also only partially. In this sense, we recall that by diagnostic gastrotomy or after dissection of the duodenum during gastrectomy, it is possible to visually examine the proximal part of the duodenal cavity, pushing back the walls with small valves using the optical apparatus Th. Firica or by palpation (insertion of a finger into the pylorus). In the same way, we make biopsies to recognize some tumors that are not detected by external palpation, sometimes we extract foreign bodies with tweezers. Usually, we systematically conduct a digital examination of the Vater nipple through the incision of the duodenum during the cold duct.
Apart from such exceptional cases, we resort to diagnostic duodenotomy, which can be done in any segment, but more often due to the need to examine the papilla, we choose the second part of the duodenum.
The first stage consists in retracting the duodenum - the pancreas, which facilitates both the examination itself and the suturing of the incision. For the same purpose, the mesentery of the colon should be separated whenever it empties higher into D2. The incision is made on the ventral side of D2 - it can be in the longitudinal direction (McBurney) or in the transverse direction (Kocher). In the first case, there is the advantage that the incision can be continued if necessary (low localization of the nipple); The disadvantage of such an incision is the possibility of developing stenosis. Both incisions are acceptable provided the correct technique is used. Given that it is usually possible to locate the nipple before duodenotomy, we use a transverse incision that spares the vessels.
After establishing the location of the papilla, the incision is oriented towards it. The incisions are small. To avoid further breaks in the wall, the edges of the incision must be strengthened with a seam. The duodenotomy wound can be sutured with a single- or double-row interrupted suture. Under these conditions, ninety-six diagnostic duodenotomies were performed, in two cases, their complications were fistulas, which closed spontaneously. In both cases, exploratory duodenotomy was followed by complex sphincterotomy.
Except in the case when we are guided by a guide probe inserted through the choledochus, the papilla must be carefully looked for among the contiguous mucosal folds that cover it and which should be straightened. To recognize the papilla, you can use various landmarks or techniques: palpation (a node like a "grain of lead"), cholangiography during surgery, compression of the gallbladder, possibly in combination with the introduction of a solution of methylene blue into its cavity. The papilla resembles a cone-shaped elevation covered cranially by a transverse fold of mucosa and caudally by a longitudinal fold of mucosa (the frenulum). At the end of the papilla, a pinhole can be seen opening into the ampulla, into which the common bile duct and the Wirsungian duct usually empty.
Through the opening of the nipple, we can insert a stylet or a thin plastic tube into the Wirsungian duct or into the common bile duct in order to examine these ducts, make cholangiography and, accordingly, Wirsungography. Experience has shown that the probe penetrates into the Wirsungian duct more easily than into the choledochus, the catheterization of which is much more difficult without sphincterotomy. This is due to the direction of both ducts (the Wirsungian duct is located caudally and runs in the transverse direction).
The small caruncle (the confluence of the santorini duct) has the form of a point, barely noticeable formation, the opening in which is located 2-3 cm ventral and cranial of the papilla of Vater. Finding this caruncle is very difficult.
If we do not find the nipple after careful examination, we must either assume an abnormal location or one of the morphological variants (absence of the ampulla, separate confluence of the common bile and Wirsungian ducts at the apex of the caruncle; confluence of the Wirsungian duct into the terminal segment of the common bile duct, etc.). The best ways to detect the nipple in such cases are cholangiography performed during surgery, or the introduction of a catheter into the choledochus (after choledochectomy).