X-ray signs of gastric ulcer. Atony and hypotension of the stomach on x-ray. Benign stomach tumors on x-ray

An X-ray of the stomach is performed with contrast enhancement. For these purposes, a person takes half a glass of barium sulfate solution (the dosage varies depending on the purposes of the study). A provocative test is preliminarily carried out to exclude allergic reactions for this water-insoluble contrast.

If no skin rashes or other changes in the patient’s body are observed within 15 minutes, proceed to fluoroscopy. In case of allergies, the test is not performed.

To identify pathology in the stomach, there are certain pathological syndromes. When interpreting the radiographs, the radiologist describes them and forms an analytical conclusion based on a comparison of the detected pathological signs.

What can be determined on an x-ray of the stomach

A number of x-ray symptoms can be identified on an x-ray of the stomach:

1. Serpa.
2. Syringe.
3. Flows.
4. Filling defect.
5. Kloiber bowls.

When using the double contrast technique (barium and air), it is possible to assess the state of the relief of the mucous membrane of the esophagus and stomach. Normally, the wall of these organs consists of protrusions and concavities. In the esophagus they are directed longitudinally from top to bottom, and in the stomach they have a tortuous course. In the presence of inflammatory diseases, cancer, ulcerative defects, the grooves change direction, decrease or increase (with Ménétrier's disease).

On a conventional contrast radiograph, a change in the relief of the mucous membrane is not detected, since folds are not visible against the background of barium. Studying with air allows you to evenly distribute contrast particles in the grooves, which allows you to clearly trace their contours.

At pathological changes additional shadows (contrast accumulation) and highlights also appear.

An X-ray of the stomach is informative if you master gastrography tactics and use several examination methods simultaneously. Its quality significantly depends on the qualifications of the radiologist.

What does the “sickle” symptom on a gastrogram indicate?

The “sickle” symptom on the gastrogram appears when air accumulates in the upper part abdominal cavity. The cause of the pathology is a rupture of the intestinal wall with the release of free air during intestinal obstruction, ulcerative defects and necrotizing colitis (inflammation of the intestine with death of the epithelium).

Positioning the patient for abdominal radiography in lateral projection

How to identify the “sickle” symptom in an image:

• a strip of clearing under the right dome of the diaphragm with the patient in an upright position;
• clear upper contour of the liver;
• absence of additional shadows against the background of enlightenment

This symptom requires differential diagnosis with the introduction of the colon between the diaphragm and the liver (interpositio colli). This is quite easy to do. It is necessary to trace the presence or absence of folds formed by intestinal constrictions on an x-ray under the diaphragm.

Identifying a “sickle” in an image requires immediate surgical treatment to save a person's life. Otherwise, peritonitis (inflammation of the peritoneum) will develop and the person will die from painful shock.

X-ray symptom of “Kloiber cup”

“Kloiber cups” appear on the gastrogram in the presence of intestinal obstruction (mechanical or spastic). At the interface between the intestinal contents and air, darkening with a horizontal level can be traced, which are clearly visible on the x-ray.

How to identify “Kloiber cups” in an image:

• rounded clearing in the projection of the intestine;
• liquid level with a wider width gas bubble(in the large intestine);
• detection of “bowls” or “arches” (2 types of X-ray symptoms of intestinal obstruction).

When the amount of air content in the intestines changes, the cups can turn into arches and vice versa.

What does a “filling defect” mean on a stomach image?

“Filling defect” in the image of the stomach means partial disappearance of the anatomical contour of the organ wall due to growth pathological formation. Radiologists call this the “minus shadow plus tissue” symptom. The defect is formed due to the presence of additional tissue, which disrupts the normal x-ray anatomy of the organ structure.

How to detect a filling defect on a gastrogram:

• lack of physiological contour of the stomach wall;
• atypical relief of the mucous membrane;
• uneven, unclear, jagged contours.

By the location of the “filling defect” one can distinguish a benign tumor from a malignant one. With the central location of the “plus tissue” and a slight change in the relief of the folds of the stomach, one can assume the benign nature of the formation.

In malignant tumors, a “filling defect” can reveal a “niche” symptom when organ tissue is destroyed. A “niche” for cancer is different from an ulcerative defect. It is wide, but not deep. A series of gastrographs show an increase in the crater mainly in width.

What does the “niche” symptom show?

This symptom indicates destructive cancer or peptic ulcer. The ulcerative defect has a smooth, clear contour. Its width significantly exceeds the depth of the shadow. Sometimes radiologists describe this symptom as “a niche in a filling defect.” This description indicates that an infiltrative shaft has been formed around the ulcer, which leads to the appearance of “plus tissue” on the radiograph. It is not large in shape and shrinks over time.

A benign ulcer is localized on the lesser curvature of the stomach, and on the opposite side a spastic contraction of the greater curvature is detected.

How to detect cancer “niches” in an image (symptoms of “syringe” and “wraparound”):

• are localized in the stomach most often along the greater curvature;
• lead to deformation of the fundus or esophagus;
• symptom of “syringe” and “flow around” - concentric compression of the stomach by a tumor with a decrease in its size by x-ray.

How to identify an ulcer on a stomach image

The main radiological manifestation of an ulcer in the image is the “niche” symptom. It is a crater, the length of which is perpendicular to the wall of the organ.

With contrast gastrography, barium fills the “niche”, so it is clearly visible on the lateral image. On the anterior gastrogram the symptom can be traced in the form of an even round spot.

How to identify ulcers in a stomach image:

• oval and clear contours;
• swelling of the folds of the mucous membrane (“filling defect”);
• narrow and deep “niche”;
• infiltrative shaft due to inflammatory or sclerotic changes in the mucous membrane;
• the “pointing finger” symptom is an indentation on the opposite contour of the stomach due to muscle spasm.

How to detect early stage cancer on a stomach x-ray

The increasing number of patients with stomach cancer requires doctors to detect malignant tumors in the early stages. When tumors are detected gastrointestinal tract Contrast radiographic studies play a leading role.

How to detect early stage cancer:

1. Do not forget about studying the relief, since many tumors begin to grow in the submucosal layer.
2. The absence of organ folding on an x-ray may be a sign of a malignant neoplasm. To detect pathology, double contrast is necessary.
3. An increase in the distance between the diaphragm and the gas bubble can occur not only with the “sickle” symptom, but also with cancer of the subcardial part of the stomach.
4. Carefully examine the gas bubble of the stomach in the image. Its shape changes when the organ is bent, which is often found in tumors of the cardiac region.
5. An inflection (the “waterfall” symptom) often occurs with cancerous ulceration of the greater curvature.

To detect the above-described x-ray symptoms, it is important to conduct a polypositional examination of the patient and use different techniques for this. In the horizontal, vertical and lateral position of a person on the X-ray table, during fluoroscopy of the gastrointestinal tract it is necessary to take pictures. They will help identify additional signs of pathology that the doctor did not notice during X-ray examination.

For patients, we remind you that the effectiveness of diagnosing gastrointestinal pathology significantly depends on the quality of intestinal cleansing at the stage of preparation for the study. Follow the radiologist's recommendations carefully!

Perforated ulcer on plain radiograph the stomach is not detected. To determine it, you must perform special methods– tight filling or double contrasting.

When the wall is completely destroyed, air enters the abdominal cavity and forms a life-threatening condition. To prevent pathology, esophagogastroduodenoscopy (EGD) or gastrography is performed.

Recently, preference has been given to tube methods in the diagnosis of perforated ulcers and gastric cancer. They do not expose patients to radiation and are therefore safe.

We believe that probe gastroduodenoscopy in cases of suspected ulcerative defects or small intestinal cancer should be supplemented with X-ray contrast. To substantiate this opinion, we present in the article some interesting facts obtained during the practical activities of our radiologists.

X-ray in the diagnosis of perforated ulcers

A perforated ulcer is accompanied by the presence of air in the abdominal cavity. Its detection during radiography requires urgent surgical intervention– gastric resection or suturing of an ulcer.

Examination with a probe (FGDS) will allow you to see only the ulcerative defect of the mucous membrane, but it is difficult to determine its perforation in the distal part, since there is an accumulation of blood and infiltrative fluid at the site of damage. Only the patient's serious condition will suggest a perforation of the wall.

X-ray gastroscopy with barium during perforation is contraindicated, since this contrast is water-insoluble, therefore, when it enters the abdominal cavity, it does not resolve and provokes acute peritonitis (inflammation of the peritoneum).

How to identify a perforated ulcer on an x-ray

X-ray signs of gastric perforation are determined in the images by the sickle symptom - accumulation of air under the right dome of the diaphragm. Signs with a high degree of certainty indicate that a person has perforated intestinal erosion, although there may be no clinical symptoms.

Sight images of the duodenal bulb: a – relief niche; b – bulb on the outline

The quality of the X-ray examination is affected by the volume of air contents of the abdominal cavity. Small amounts of it may not be detected in a timely manner, which sends the doctor on the wrong trail.

Other bowel perforation syndromes:

1. Gas bubble in the upper abdominal cavity. It shifts when lying on the back to the subcostal region.
2. In the lateral position of the patient, the crescent-shaped lucency is located above the sternum.
3. Ulcer unknown etiology first confirmed by drinking sparkling water. The resulting gas escapes through the hole and is re-detected on the x-ray.
4. To clearly contrast an ulcerative defect, you can use a water-soluble contrast agent (gastrografin), but not barium. When the organ wall is perforated, the contrast agent will leak into the abdominal cavity. 20 ml of gastrografin is enough to diagnose the disease.

If the ulcer is not detected after using all the X-ray diagnostic methods described above, FGDS can be used, although it is problematic to insert the probe into the stomach against the background of spasmodic contractions. It is difficult to count on its information content, so we suggest studying indirect signs of perforation:

1. When air is pumped with Bobrov's apparatus, a person's pain increases.
2. De Quervain's syndrome - limited spasm and increased peristalsis of the stomach is observed with an ulcer on the lesser curvature.
3. The remainder of the contrast suspension in the organ cavity 6 hours after the examination due to increased accumulation of mucus.

Based on the above information, we can conclude that the ulcer is perforated when X-ray examination is found more often. For some reason, doctors consider esophagoduodenoscopy better for diagnosing this pathology, so they prescribe it more often than gastrography.

X-ray signs of a classic ulcer:

• niche for contrasting;
• filling defect in the presence of an infiltrative shaft;
• "pointing finger" on the side of the greater curvature due to spastic contraction muscle fibers;
• the passage of a peristaltic wave through the area of ​​damage.

How to detect stomach cancer using X-rays

Diagram of a small cancer: a – original tumor; b – with double contrast; c – with tight filling

The stomach ulcer in the picture is a niche with a narrow width and great depth. Cancer may appear radiographically as a filling defect or as a “plus shadow.”

The first sign that allows us to make an assumption that the patient has a malignant tumor is an additional shadow against the background of a gas bubble of the stomach when the formation grows exophytically (inward).

To confirm availability pathological tissue in the wall of the stomach, during transillumination, the doctor observes the wall of the organ. Cancer forms dense tissue through which the peristaltic wave does not pass.

When performing a probe gastroduodenoscopy, it is possible to detect cancer and take a tissue biopsy from the pathological node. Because of this property, FGDS for gastric cancer is considered a more preferable method than contrast gastrography. X-ray can only reveal cancer of the cardiac rosette, where there is no submucosal layer and changes during the growth of an endophytic tumor are clearly visible in the images.

With dosed compression, cardiac cancer is manifested by the following symptoms:

• unevenness of the contour during tight barium filling;
• “syringe” symptom - narrowing of the lumen of the stomach with concentric growth of the tumor;
• wall thickening with double contrast.

The above symptoms have different degrees severity: from an uneven contour of a few millimeters to 4 cm. These symptoms are detected most often, regardless of what kind of cancer a person has.

1. Filling defect (with a large exophytic formation).
2. Lack of peristalsis at the site of pathology.
3. Atypical relief with double contrast.

Body cancer and upper section stomach is better detected when the stomach is filled with air after the contrast has passed into the underlying parts of the gastrointestinal tract. Cancer leads to deformation of the contour with tight filling during endophytic growth of the formation. The exophytic growth of the neoplasm causes an accumulation defect on the radiograph.

The final result of the article should be considered the decision that ulcers and cancer are better detected when X-rays are combined with esophagogastroduodenoscopy. Reduce the role of gastric radiography with barium in identifying ulcerative defects and malignant tumors do not do it. Endophytic (growing into the wall) forms of cancer can be detected by radiography earlier than FGDS.

X-ray photo: small in-depth cancerous tumor with slight ulceration (indicated by arrow)

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Stomach ulcer

Modern representations about peptic ulcer disease with localization of the ulcer in the stomach are significantly deepened and clarified thanks to x-ray examination, which not only confirms clinical diagnosis stomach ulcers, but can provide comprehensive information about its location and size, secondary changes of a deforming nature, connections with neighboring organs etc. Finally, X-ray examination helps to recognize an ulcer, when clinically there is often no suspicion of its presence. Such “silent” ulcers are not so rare. However, modern X-ray diagnostics with its rich technical equipment does not yet make it possible to recognize gastric ulcers in all cases without exception. As for the reliability of the radiological diagnosis of gastric ulcer, it is very high and, according to surgical comparisons, reaches 95-97%.

X-ray signs of a gastric ulcer can be divided into two groups: 1) indirect, indirect signs characterizing functional disorders in the ulcer and 2) anatomical, direct signs, which include: ulcer niche, accompanying the ulcer reactive changes from the mucous membrane and scar deformities.

Indirect signs, which are indicators of functional disorders, are of little importance for establishing the diagnosis of gastric ulcer. Changes in tone, evacuation, secretion, as well as pain sensitivity are not pathognomonic for ulcers and occur in many diseases of the abdominal cavity.

Peristalsis in gastric ulcers is often increased, especially when the ulcer is localized at the pylorus or in the duodenal bulb. However, peristalsis often retains a “quiet” type and is even weakened, so it is not possible to evaluate the nature of peristalsis as one of the signs contributing to the diagnosis due to insufficient reliability. Peristalsis may weaken or even completely disappear at the very site of ulceration. This is especially clear on polygrams in which there is a lack of crossover of peristalsis due to infiltration and rigidity of the stomach wall. However, this must be treated with a critical assessment, since the same nature of peristalsis can also affect the so-called “minor forms” of stomach cancer.

Evacuation delays are common. But this is not the rule, and it is often necessary to note very rapid emptying of the stomach even with such ulcers that are detected on the basis of direct symptoms.

Especially important place Among the indirect signs of the ulcerative process is local spasm of the circular muscles of the stomach. This symptom manifests itself in the form of deep retraction along the greater curvature (De Quervain's symptom). Often, opposite such retraction, an ulcerative niche is observed along the lesser curvature.

Pain sensitivity is of great importance in determining an ulcer, but the value of this sign is weakened by the fact that very often patients either do not notice pain sensitivity at all, or the pain point is found outside the stomach, mostly in the solar plexus area.

To establish a diagnosis of gastric ulcer based on indirect symptoms, the entire symptom complex of functional disorders may be important.

Although not sufficiently diagnostically valuable, indirect signs become of great importance during repeated radiological observations in cases of ulcers established on the basis of anatomical changes. Taking into account functional abnormalities in the X-ray picture of a gastric ulcer makes it possible to correctly assess the dynamics of the disease under the influence of the therapy chosen for a given patient.

Direct signs. The main radiological symptom of a gastric ulcer is the so-called niche (Fig. 86). The niche corresponds to an anatomical disruption of the integrity of the stomach wall and usually has a crater-shaped shape. This is a barium depot at the site of a tissue defect. Thus, “minus tissue” is radiographically expressed as “plus shadows.” Superficial, flat ulcers that do not have a more or less deep bottom, the so-called “niches on the relief,” are especially difficult to recognize, since the anatomical disorders in them are expressed to a small extent.

Rice. 86. Stomach ulcer (x-ray). a - niche along the lesser curvature with convergence of the mucosa; b - niche along the lesser curvature with a shaft of edematous mucosa.

Diagnosis of an ulcerative niche is facilitated by the fact that it is accompanied by changes in the relief of the mucous membrane. At a niche you can often observe the convergence of folds, or their so-called convergence. A ring-shaped ridge forms around the ulcer, protruding above the surface of the mucosa. This cushion occurs due to infiltration of the mucous membrane, which contributes to the deepening of the ulcerative crater. Thus, the depth of the niche depends not only on the degree of destruction of the stomach wall, but also on the protrusion of the mucosal shaft above it. Therefore, the depth of the niche often does not correspond to the depth of the wall defect. The shaft itself surrounding the ulcer, called the “ulcer shaft,” is an expression of swelling of the mucous membrane and functional changes of a spastic nature on the part of the muscles of the submucosal layer. This shaft has an important diagnostic value and not only helps to identify the niche, but makes it possible to evaluate the evolution of the ulcerative process with repeated studies. Often there is a picture in which the reaction from the mucous membrane becomes pronounced. Then the swelling of the mucous membrane leads to the formation of a massive shaft that closes the entrance to the ulcerative defect - a crater, which makes it difficult to diagnose the ulcer during the initial examination. Only subsequently, as such a reactive process subsides, can a niche be clearly identified.

There are often cases when, with the appropriate clinical symptom complex and in the presence of pronounced changes in the mucous membrane in the form of significant swelling and deformation of the relief, the initial study fails to identify a niche. If the general condition of the patient improves or after decongestant preparation, the niche becomes clearly visible within a few days.

With an ulcer, there is also infiltration of the walls of the stomach, often reaching large sizes and sometimes even palpable under the screen in the form of some swelling.

Changes in the mucosa become important when they are localized in the antrum. It is here that we most often observe the appearance of a niche when the reactive edema of the mucous subsides. In some cases, a small niche detected during the initial study becomes larger with clinical improvement. This “paradoxical dynamics” of the niche (S.V. Reinberg, I.M. Yakhnich, G.A. Gusterin, B.M. Stern) is observed with a decrease in edema around the ulcer and indicates a favorable course of the process.

Great difficulties arise when identifying prepyloric and, especially, pyloric ulcers. However, now ulcers of this localization are detected quite often (Fig. 87). Ulcers along the greater curvature of the body of the stomach are most rarely recognized and difficult to differentiate, especially with severe symptoms of mucosal edema. But even here, the typical picture of changes in the relief of the mucous membrane in the form of convergence of folds provides significant assistance in the diagnosis of these ulcers. Often a large niche is separated from its “maternal” base, separated by a narrow isthmus, sometimes reaching a considerable length. This most often occurs with penetrating ulcers or covered perforations, but can also be caused by inflammatory infiltrative changes in the edges of the ulcer. A niche that has a spur-like shape or the shape of a sharp thorn is characteristic of an ulcer accompanied by pronounced perigastric changes.

Rice. 87. Stomach ulcer (x-ray).

The arrow indicates the gatekeeper's niche.

In some cases, such a sharply manifested infiltration can be observed around the ulcer that small filling defects are formed due to the contrast mass flowing around these protrusions of the stomach walls and folds of the mucosa. In this case, the niche takes on a scalloped appearance with uneven and sometimes unclear contours. Similar large niches with these changes are very suspicious for the presence of malignant transition, especially if they are located in the subcardial or antrum (Gutman, 1950; Massa, 1958). Patients with such niches require very careful clinical and radiological observation so that timely action can be taken. surgery.

X-ray examination, repeated during the treatment of patients, makes it possible to make a judgment about the effectiveness of the treatment used and about the reverse development of the ulcer based on changes in its main feature - the niche. Reduction in niche size as a result of proper treatment is common. It should be taken into account that such a decrease may depend not only on the direct influence therapeutic measures on the ulcer in general. Reducing the size of a niche may also be associated with an improvement in the functional background. Manifestations of “paradoxical dynamics” may also occur. Therefore, a decrease in the niche does not yet indicate a tendency to cure the ulcer.

In the process of monitoring the results of treatment and assessing its effectiveness, the study of changes in the relief of the mucous membrane becomes of great importance. If, during dynamic observation, a decrease in the accompanying edema is detected before a decrease in the size of the niche is detected, then in similar cases can be expected positive effect treatment.

• Stomach deformities due to ulcers

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X-ray signs of diseases of the stomach and duodenum

Indications for x-ray examination of the stomach are very wide due to the high prevalence of “gastric” complaints (dyspeptic symptoms, abdominal pain, lack of appetite, etc.). X-ray examination is carried out in cases of suspected peptic ulcer disease, tumor, in patients with achylia and anemia, as well as with gastric polyps that for some reason are not removed.

Chronic gastritis

In recognizing gastritis, the main role is given to the clinical examination of the patient in combination with endoscopy and gastrobiopsy. Only by histological examination of a piece of the gastric mucosa can the shape and extent of the process and the depth of the lesion be established. However, in atrophic gastritis, X-ray examination is equivalent in effectiveness and reliability to fibrogastroscopy and is second only to biopsy microscopy.

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

Determining the condition of the areolas is of key importance. Normally, a fine-mesh (granular) type of fine relief is observed. The areoles have a regular, predominantly oval shape, clearly defined, limited by shallow narrow grooves, their diameter varies from 1 to 3 mm. Chronic gastritis is characterized by nodular and especially coarse-nodular types of thin relief. With the nodular type, the areola is irregularly round in shape, measuring 3-5 mm, limited by narrow but deep grooves. The coarse nodular type is distinguished by large (over 5 mm) areolas of irregular polygonal shape. The furrows between them are widened and not always sharply differentiated.

Changes in folded relief are much less specific. In patients with chronic gastritis, thickening of the folds is noted. Upon palpation, their shape changes slightly. The folds are straightened or, conversely, strongly curved; small erosions and polyp-like formations can be detected on their ridges. At the same time, functional disorders are recorded. During the period of exacerbation of the disease, the stomach on an empty stomach contains fluid, its tone is increased, peristalsis is deepened, and spasm of the antrum may be observed. During the period of remission, the tone of the stomach is reduced, peristalsis is weakened.

Peptic ulcer of the stomach and duodenum

Radiology plays an important role in recognizing ulcers and their complications.

When performing an X-ray examination of patients with gastric and duodenal ulcers, the radiologist faces three main tasks. The first is an assessment of the morphological state of the stomach and duodenum, primarily the detection of an ulcerative defect and determination of its position, shape, size, outline, and the condition of the surrounding mucous membrane. The second task is to study the function of the stomach and duodenum: detecting indirect signs of peptic ulcer disease, establishing the stage of the disease (exacerbation, remission) and assessing the effectiveness of conservative therapy. The third task comes down to recognizing complications of peptic ulcer disease.

Morphological changes in peptic ulcer disease are caused by both the ulcer itself and concomitant gastroduodenitis. The signs of gastritis are described above. A direct symptom of an ulcer is considered to be a niche. This term refers to the shadow of a contrasting mass that fills the ulcerative crater. The silhouette of the ulcer can be seen in profile (such a niche is called a contour niche) or in full view against the background of the folds of the mucous membrane (in these cases we talk about a niche in relief, or a relief niche). The contour niche is a semicircular or pointed protrusion on the contour of the shadow of the stomach or duodenal bulb. The size of the niche generally reflects the size of the ulcer. Small niches are indistinguishable under fluoroscopy. To identify them, targeted radiographs of the stomach and bulb are necessary.

With double contrasting of the stomach, it is possible to recognize small superficial ulcerations - erosions. They are more often localized in the antral and prepyloric parts of the stomach and have the appearance of round or oval clearings with a pinpoint central accumulation of contrast mass.

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

The relief niche has a persistent round or oval accumulation of contrasting mass on the inner surface of the stomach or bulb. This accumulation is surrounded by a light structureless rim - an area of ​​edema of the mucous membrane. In a chronic ulcer, the prominent niche may be irregular shape with uneven outlines. Sometimes there is a convergence (convergence) of the folds of the mucous membrane towards the ulcerative defect.

As a result of scarring of the ulcer at the niche level, straightening and some shortening of the contour of the stomach or bulb are revealed. Sometimes the ruby ​​process reaches a significant degree, and then gross deformations of the corresponding part of the stomach or bulb are determined, which sometimes takes on a bizarre shape. Scarring of an ulcer in the pyloric canal or at the base of the bulb can lead to pyloric stenosis or duodenal stenosis. Due to impaired evacuation of contents, the stomach stretches. Contrast is detected in it on an empty stomach).

There are a number of indirect radiological symptoms of peptic ulcer disease. Each of them individually does not provide grounds for establishing a diagnosis of an ulcer, but taken together their value is almost equal to identifying a direct symptom - a niche. In addition, the presence of indirect signs forces the radiologist to special attention look for an ulcerative defect by performing a series of targeted radiographs. A sign of a violation of the secretory function of the stomach is the presence of fluid in it on an empty stomach. This symptom is most indicative of an ulcer of the duodenal bulb. When the body is in a vertical position, the liquid forms a horizontal level against the background of a gas bubble in the stomach. An important indirect symptom is regional spasm. In the stomach and bulb it usually occurs at the level of the ulcer, but on the opposite side. There a retraction of the contour with smooth outlines is formed. In the stomach, it is shaped like the end of a finger, hence the name of this sign - “pointing finger symptom.” With an ulcer of the bulb during the period of exacerbation, as a rule, a spasm of the pylorus is observed. Finally, with ulcers there is a symptom of local hyperkinesia, expressed in accelerated progression contrast agent in the ulcer area. This symptom is explained by increased irritability and physical activity walls in the area of ​​ulceration. Another indirect sign is associated with it - a symptom of point pain and local tension. abdominal wall when palpating the area corresponding to the location of the ulcer.

In the stage of exacerbation of peptic ulcer disease, an increase in the niche and expansion of the inflammatory shaft surrounding it are observed. During the period of remission, a decrease in the niche is observed until it disappears (after 2-6 weeks), the functions of the stomach and duodenum are normalized. It is important to emphasize that the disappearance of a niche does not mean a cure if symptoms of dysfunction remain. Elimination only functional disorders guarantees a cure or at least a long-term remission.

With peptic ulcers and chronic gastritis, it is often observed duodenogastric reflux. To identify it, the patient is dynamic scintigraphy. For this purpose, he is injected intravenously with the radiopharmaceutical 99mTc-butyl-IDA or a related compound with an activity of 100 MBq. After obtaining a scintigram image of the gallbladder (these drugs are excreted in the bile), the patient is given a fatty breakfast (for example, 50 g of butter). On subsequent scintigrams, it is possible to observe the emptying of the bladder from radioactive bile. With pyloric insufficiency, it appears in the stomach cavity, and with gastroesophageal reflux - even in the esophagus.

The ulcerative niche may vaguely resemble a gastric diverticulum - a peculiar developmental anomaly in the form of a saccular protrusion of the wall alimentary canal. In 3/4 of cases, the gastric diverticulum is located on the posterior wall near the esophagogastric junction, i.e. near the cardiac opening. Unlike an ulcer, a diverticulum has a regular rounded shape, smooth arched contours, and often a well-formed neck. The folds of the mucous membrane around it are not changed, some of them enter through the neck into the diverticulum. Diverticula are especially common in the descending and lower horizontal parts of the duodenum. Their X-ray signs are the same, only with the development of diverticulitis the contours of the protrusion become uneven, the mucous membrane around it becomes swollen, and palpation becomes painful.

Play an important role radiation methods in the diagnosis of complications of peptic ulcer disease. First of all, this applies to perforation of a stomach or duodenal ulcer. The main sign of perforation is the presence of free gas in the abdominal cavity. The patient is examined in the position in which he was brought to the X-ray room. Gas that has entered the abdominal cavity through a perforation occupies the most high departments. When the body is in an upright position, gas accumulates under the diaphragm, when positioned on the left side - in the right lateral canal, when positioned on the back - under the anterior abdominal wall. On X-ray photographs, the gas causes clearly visible clearing. When the position of the body changes, it moves in the abdominal cavity, which is why it is called free. Gas can also be detected by ultrasound.

Penetration of an ulcer into surrounding tissues and organs is indicated by two signs: the large size of the niche and its fixation. Penetrating ulcers often have three layers of content: gas, liquid and contrast agent.

If acute ulcer bleeding is suspected, emergency endoscopy is usually performed. However, valuable data can be obtained from an X-ray examination, which is advisable to carry out if fibrogastroduodenoscopy cannot be performed or is not indicated. After stopping the bleeding or even during the period of ongoing bleeding, fluoroscopy and radiography of the stomach and duodenum with barium sulfate can be performed, but horizontal position patient and without compression of the anterior abdominal wall.

As a result of scarring of the pyloric ulcer, gastric outlet stenosis may develop. Based on X-ray data, the degree of its severity is determined (compensated, subcompensated or decompensated).

Stomach cancer

Initially, the tumor is an island of cancerous tissue in the mucous membrane, but later it is possible different ways tumor growth, which determine the radiological signs of small cancer. If necrosis and ulceration of the tumor predominate, then its central part sinks in comparison with the surrounding mucous membrane - the so-called in-depth cancer. In this case, with double contrast, an irregularly shaped niche with uneven contours is determined, around which there are no areolas. The folds of the mucous membrane converge towards the ulceration, slightly expanding in front of the niche and losing their outlines here.

With another type of growth, the tumor spreads mainly laterally along the mucous membrane and in the submucosal layer - superficial, or flat-infiltrating cancer, growing endophytically. It causes an area of ​​altered relief in which there are no areolas, but unlike deep-seated cancer there is no ulceration and there is no convergence of the folds of the mucous membrane towards the center of the tumor. Instead, randomly located thickenings with lumps of contrasting mass unevenly scattered throughout them are observed. The contour of the stomach becomes uneven and straightened. There is no peristalsis in the area of ​​infiltration.

In most cases, the tumor grows in the form of a node or plaque, gradually protruding more and more into the stomach cavity - “rising” (exophytic) cancer. In the initial stage, the x-ray picture differs little from that of an endophytic tumor, but then a noticeable uneven deepening of the contour of the shadow of the stomach appears, which is not involved in peristalsis. Next, a marginal or central filling defect is formed, the shape corresponding to the tumor protruding into the lumen of the organ. With plaque-like cancer, it remains flat; with polypous (mushroom-shaped) cancer, it has an irregular round shape with wavy outlines.

It should be emphasized that in most cases, using radiation methods, it is impossible to distinguish early cancer from peptic ulcers and polyps, and therefore endoscopic examination is required. However, X-ray examination is very important as a method of selecting patients for endoscopy.

With further development of the tumor, various radiological pictures are possible, which, perhaps, never copy one another. However, it is conditionally possible to identify several forms of such “advanced cancer”. A large exophytic tumor produces a large filling defect in the shadow of the stomach filled with contrast mass. The contours of the defect are uneven, but quite clearly demarcated from the surrounding mucous membrane, the folds of which in the area of ​​the defect are destroyed, peristalsis is not traced.

Infiltrative ulcerative cancer appears in a different “guise”. With it, it is not so much the filling defect that is expressed as the destruction and infiltration of the mucous membrane. Instead of normal folds, the so-called malignant relief is determined: shapeless accumulations of barium between cushion-shaped and structureless areas. Of course, the contours of the stomach shadow in the affected area are uneven, and peristalsis is absent.

The X-ray picture of saucer-shaped (cup-shaped) cancer is quite typical, i.e. tumors with raised edges and a disintegrating central part. Radiographs reveal a round or oval filling defect, in the center of which there is a large niche - an accumulation of barium in the form of a spot with uneven outlines. A feature of saucer-shaped cancer is the relatively clear demarcation of the edges of the tumor from the surrounding mucous membrane.

Diffuse fibroplastic cancer leads to a narrowing of the gastric lumen. In the affected area, it turns into a narrow, rigid tube with uneven contours. When the stomach is inflated with air, the deformed section does not straighten out. At the border of the narrowed part with the unaffected parts, you can notice small ledges on the contours of the shadow of the stomach. The folds of the mucous membrane in the tumor area thicken, become immobile, and then disappear.

A stomach tumor can also be detected by computed tomography and ultrasound. Sonograms highlight areas of thickening of the stomach wall, which makes it possible to clarify the extent of the tumor lesion. In addition, sonograms can be used to determine the extent of infiltration into surrounding tissues and detect tumor metastases in the lymph nodes of the abdominal cavity and retroperitoneal space, liver and other abdominal organs. Especially clearly ultrasound signs stomach tumors and their growth into the stomach wall are determined by endoscopic sonography of the stomach. CT also clearly visualizes the wall of the stomach, which makes it possible to detect its thickening and the presence of a tumor in it. However, the earliest forms of stomach cancer are difficult to detect with both sonography and CT. In these cases, the leading role is played by gastroscopy, supplemented by targeted multiple biopsy.

Benign stomach tumors

The X-ray picture depends on the type of tumor, the stage of its development and the nature of its growth. Benign tumors of an epithelial nature (papillomas, adenomas, villous polyps) originate from the mucous membrane and protrude into the lumen of the stomach. Initially, a structureless rounded area is found among the areolas, which can only be seen with double contrast contrast of the stomach. Then the local expansion of one of the folds is determined. It gradually increases, taking the form of a round or slightly oblong defect. The folds of the mucous membrane bypass this defect and are not infiltrated.

The contours of the defect are smooth, sometimes wavy. The contrast mass is retained in small depressions on the surface of the tumor, creating a delicate cellular pattern. Peristalsis is not disturbed if malignant degeneration of the polyp has not occurred.

Non-epithelial benign tumors (leiomyomas, fibromas, neuromas, etc.) look completely different. They develop mainly in the submucosal or muscular layer and extend little into the gastric cavity. The mucous membrane over the tumor is stretched, as a result of which the folds are flattened or moved apart. Peristalsis is usually preserved. The tumor can also cause a round or oval defect with smooth contours.

Postoperative stomach diseases

X-ray examination is necessary for the timely detection of early postoperative complications- pneumonia, pleurisy, atelectasis, ulcers in the abdominal cavity, including subphrenic abscesses. Gas-containing abscesses are recognized relatively simply: on photographs and with x-ray examination, it is possible to detect a cavity containing gas and liquid. If there is no gas, then subphrenic abscess can be suspected based on a number of indirect signs. It causes a high position and immobilization of the corresponding half of the diaphragm, its thickening, and uneven outlines. A “sympathetic” effusion appears in the costophrenic sinus and foci of infiltration at the base of the lung. In the diagnosis of subdiaphragmatic ulcers, sonography and computed tomography are successfully used, since accumulations of pus are clearly visible in these studies. The inflammatory infiltrate in the abdominal cavity gives an echo-inhomogeneous image: there are no areas free from echo signals. An abscess is characterized by the presence of a zone devoid of such signals, but a denser rim appears around it - a display of the infiltrative shaft and the pyogenic membrane.

Among the late postoperative complications, two syndromes should be mentioned: afferent loop syndrome and dumping syndrome. The first of them is radiographically manifested by the flow of contrast mass from the gastric stump through the anastomosis into the afferent loop. The latter is dilated, the mucous membrane in it is swollen, its palpation is painful. Particularly indicative is the long retention of barium in the afferent loop. Dumping syndrome is characterized by a significant acceleration of emptying of the gastric stump and rapid spread of barium through the loops of the small intestine.

1-2 years after surgical intervention a peptic ulcer of the anastomosis may occur on the stomach. It causes a radiographic symptom of a niche, and the ulcer is usually large and surrounded by an inflammatory shaft. Its palpation is painful. Due to the concomitant spasm, there is a dysfunction of the anastomosis with retention of contents in the gastric stump.

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X-ray examination for gastric and duodenal ulcers

X-ray examination reveals a number of signs that have: important diagnostic value. Direct symptoms of an ulcer include a niche, an ulcer shaft, and convergence of mucosal folds (a star-shaped scar observed in cicatricial ulcers).

The main diagnostic value is the so-called “niche” symptom, which appears in the form of various sizes and shapes of an additional shadow to the silhouette of the stomach (plus a shadow or the so-called profile niche) or in the form of a more or less clear shadow spot (the so-called relief niche). The size of the “niche” may vary. The “niche” in the duodenum is usually much smaller in size than in the stomach.

The “niche” symptom is not determined in all patients with an ulcer, since the possibility of its detection depends on a number of conditions: the localization of the ulcer, its condition and size at the time of examination, changes in the mucosa in the area of ​​the ulcer, as well as on the technique, thoroughness and repeatability of x-ray research.

X-ray. Niche symptom. Deep (penetrating) ulcer of the lesser curvature of the stomach.

Even with a fairly large ulcer crater, if it is filled with food debris, mucus, and blood clots that prevent it from filling with barium, it is not possible to obtain “niche” symptoms. An ulcerative shaft, an atonic state of the walls of the stomach, which leads to stretching of the walls when contacted with a contrast mass, significant swelling of the folds and swelling of the mucous membrane can also prevent the identification of the “niche”. In such cases, the “niche” is discovered some time after the inflammatory process has subsided. With a sharp exacerbation of the process, accelerated emptying of the duodenal bulb is observed, which also makes it impossible to detect an ulcerative defect. To find a niche, special techniques should be used, such as blocking.

For some ulcer localizations, in particular, for highly located subcardial ulcers, as well as ulcers located in the pyloric part of the stomach, the “niche” symptom may not be detected if patients are examined only in an upright position. A subcardial ulcer can be detected if you carefully monitor the passage of each swallow of barium, slowing its progress with the help of a palpating hand with ballistic movements of the latter in order to distribute the contrasting mass between the folds of the mucosa; At the same time, the patient should be turned into oblique and profile positions. However, in some cases, diagnosis of ulcers of the specified localization is possible only with the patient in a horizontal position on the trochoscope.

X-ray. Niche symptom (profile niche) in the duodenal bulb.

In some cases, a pyloric ulcer can only be detected through careful palpation of each section of the stomach wall. Indirect or indirect symptoms include a group of signs associated with impaired motor function, which is manifested by hyperperistalsis (segmenting or lacing), changes in the tone of the stomach, the appearance of local circular spasms of its muscles, causing more or less pronounced retractions on the greater curvature, sometimes according to the localization of the ulcer on the lesser curvature (the so-called “pointing finger” symptom).

An indirect sign of a gastric ulcer is peristaltic immobility in a limited area of ​​the lesser curvature, identified using the so-called polygraphy. In patients with gastric ulcers, radiological examination can also reveal pylorospasm, impaired gastric emptying and other symptoms.

Violations of evacuation most often manifest themselves in its slowdown. In some patients, dissociation of motor skills is detected: in some cases, at the beginning of the study, a persistent spasm of the pylorus occurs with rapid partial evacuation after some time, in others, at the beginning of the study, evacuation is accelerated, and a delay is observed at the end of it.

In patients with duodenal ulcers, functional changes in the duodenum occur: rapid passage of contrast, sometimes in the form of a thin stream, the appearance of spasms and stasis in the duodenum, and sometimes deformation of the bulb.

X-ray. Relief niche in the antrum of the stomach.

These deformations should be distinguished from persistent deformations of the bulb, which are observed during scarring of the ulcer or the development of periduodenitis: the most common deformation is in the form of a butterfly or trefoil, less often - a tube-shaped bulb and a bulb with the formation of pocket-like protrusions.

In some patients, fluid in the stomach on an empty stomach or a pronounced intermediate layer is detected. An indirect symptom of a cardiac ulcer is a high position of the diaphragm on the left. Indirect symptoms can only have diagnostic value in conjunction with others clinical signs, especially during dynamic monitoring of patients. Their significance also lies in the fact that their presence forces the radiologist to more carefully look for direct symptoms.

Often in patients with peptic ulcer characteristic changes are observed in the terminal section ileum: long-term contrasting of the ileum over 15-18 cm (and sometimes more) with retention of barium in it for up to 12-32 hours, spasm of this section, which takes the form of a thin cord, unevenness of the intestinal lumen, spasm of the bowin's valve, antiperistalsis, etc.

When examining the large intestine, functional changes are observed in the form of spastic states of its individual segments, spastic haustration, hypotension and atony of the longitudinal muscles of the transverse colon.

Signs of a stomach ulcer: first symptoms

Herbs for stomach and duodenal ulcers

The importance of the x-ray method in identifying gastric ulcers is undeniable. The percentage of detection of ulcers in the stomach, according to various authors, ranges from 90 to 97. X-ray diagnosis of gastric ulcerations consists of establishing the presence of both the ulcer itself and complications of the ulcerative process. The radiologist should strive to identify not only organic lesions stomach, but also functional manifestations of the process.

X-ray symptoms of gastric ulcers are varied. It depends on the location of the ulcer and the stage of the ulcerative process. Thus, ulcers of the subcardial region and pyloric ulcers are manifested by both various changes in the shape of the stomach and the forms of the ulcer “niche”. Therefore, identifying ulcers various localizations requires the use of special methodological techniques each time. Nevertheless, all radiological symptoms of gastric ulcer can be divided into two main groups: direct and indirect, or indirect. The most pathognomonic and the only direct sign of an ulcer is, as is known, the “niche” described by Gaudek in 1909 - an ulcer crater filled with barium suspension. However, when the ulcer is localized on the anterior or posterior wall of the stomach or in the pyloric canal, the ulcer crater filled with barium suspension gives the picture of a “spot” or “depot” against the background of the relief of the gastric mucosa. It is not always possible, due to deformations of the stomach, especially in its subcardial section, to bring the ulcerative “niche” onto the contour of the stomach, even in a wide variety of patient positions. Therefore, in such cases, you need to look for an ulcerative “niche” in the form of a spot, not a protrusion.

The ulcerative “niche” has the shape of a cone, cylinder, or oval. Its dimensions range from a few millimeters to gigantic ones (6-8 cm). Naturally, the size of the ulcerative “niche” depends on its location, as well as on the complications accompanying the ulcerative process. Thus, a penetrating ulcerative “niche” can reach huge size depending on where the ulcer has penetrated, how large the inflammatory process is. Finally, the shape of the “niche” can change as the patient’s body position changes.

Large in diameter, but shallow ulcerative “niches” are localized along the lesser curvature of the body of the stomach and are accompanied by compaction and infiltration of the edges of the ulcerative crater proximal and distal to the “niche” itself. Because of this, rather large areas of the stomach wall may not peristalt, and there is a need to differentiate such a lesion from a stomach tumor. Pointed ulcers are more often found in the subcardial part of the stomach, and their shape and depth are similar to the accumulation of barium suspension, located between the folds of the gastric mucosa that are usually thickened here.

For differential diagnosis of these changes, it is necessary to resort to special methodological techniques, which will be discussed in the relevant sections.

The size of the ulcerative “niche” on radiographs does not always correspond to the true depth of the ulcerative crater on the resected organ, autopsy, and even during endoscopic examination, which is associated with swelling of the surrounding tissues, big amount mucus and food debris.

A characteristic radiological sign of penetration of an ulcer “niche” is its three-layer appearance on radiographs: a dense barium suspension in the lower part of the crater, a less intense part of the layer above it (a mixture of barium suspension and liquid) and, finally, a layer of air.

During control X-ray studies during treatment, a change and reduction in the ulcer “niche” serves as an indicator of its reverse development, i.e., scarring of the ulcer. So, cup-shaped or oval shape The “niche” changes to a cone-shaped form due to the filling of the bottom of the ulcer crater. Naturally, to compare the size of the ulcer “niche” it is necessary to take radiographs in strictly identical positions and on the same X-ray machine. It is very important in assessing the dynamics of the ulcerative process to study changes in the tissues surrounding the ulcerative niche: convergence of the folds of the mucous membrane to the “niche”, a decrease in swelling and hardening of the stomach wall and other indirect signs.

Indirect symptoms of stomach ulcers are varied. These include primarily functional changes. Thus, hypersecretion on an empty stomach, although it is considered a more characteristic sign of duodenal ulcers, with ulcers of the gastric outlet, especially with pyloric ulcers, is a constant symptom. Spasmodic contractions in various areas stomach problems can be permanent or temporary. The well-known “pointing finger” - retraction from the greater curvature of the stomach in ulcers of the lesser curvature of the gastric body - is a reflection of spasm of the circular muscle (Fig. 8). Such retractions occur in different parts of the stomach and can disappear when the ulcer scars. The direction of retraction can be horizontal or oblique, depending on the lesion of circular or oblique muscle fibers. Spasms of the circular sphincter separating the antrum or located in the pyloric region can be so prolonged that they delay evacuation from the stomach. As you heal, the spasms usually decrease and gradually disappear. Shortening of the lesser curvature and deformation of the stomach in the form of a cascade can also be caused by spastic contractions of the corresponding groups of muscle fibers. The study after the patient has taken Aeron is quite effective.

An indirect sign is a feeling of pain on palpation of the stomach. However, this symptom is not of particular value, since in the presence of an ulcerative “niche” it is not important, and in its absence it is unconvincing. The group of indirect signs also includes anatomical (organic) changes detected by the X-ray method that occur during a chronic ulcerative process (deformation of the stomach in the form of a “snail”, “ hourglass", gastric adhesions, cicatricial narrowing of the pylorus).

Let us consider the x-ray picture of gastric ulcerations depending on their location.

Ulcer of the upper stomach. The anatomical features of this part of the stomach create certain difficulties in X-ray diagnosis of ulcers. There is a need for special diagnostic techniques (additional portions of barium suspension, drug effects etc.), the use of which, according to our data, improves the X-ray diagnosis of ulcers in this department (in 68% of patients the correct diagnosis was made). The peculiarities of ulcerations of the upper stomach are their relatively small (up to 1.5 cm) size, which makes it difficult to identify against the background of the rough relief of the mucous membrane in the absence of an inflammatory shaft, which is excreted with great difficulty, and the convergence of folds of the mucosa to the site of the ulcer. As a rule, ulcers of the subcardial part of the stomach are accompanied by its deformation in the form of a cascade, sometimes very persistent and pronounced (Fig. 9).

Gastric body ulcer. A direct radiological sign of an ulcer of the body of the stomach along the lesser curvature is a “niche” (with a tight filling of the stomach with barium suspension). The “niche” can have a pointed, cylindrical or round shape (Fig. 10-12), its contour is often smooth, except in cases where mucus accumulates in the ulcer crater and granulations grow. With cicatricial deformation of the body of the stomach, it is not always possible to see the ulcerative “niche”. The barium suspension accumulating in the ulcer crater appears in the form of a barium “spot” on the relief of the gastric mucosa. The diameter of this accumulation of contrast agent will correspond to the width of the entrance to the ulcer “niche”. The depth of the ulcerative “niche” itself cannot be determined. Important indirect signs of ulceration on the lesser curvature of the body of the stomach are its deformation and shortening. It can be caused by both spasm of longitudinal muscle fibers along the lesser curvature and scars. In such cases, the study is carried out according to the method described above using antispasmodics (atropine, aeron). It is important to correctly place the patient in a supine position and remain in this position for a long time.

The X-ray picture and technique for examining ulcers of the antrum of the stomach are similar to those described above.

Pyloric ulcer. Detection of an ulcerative defect in the pyloric canal in many cases is very difficult. This is due to several reasons. First of all, what is important is the intense and long-lasting spasm of the powerful muscles of the pylorus, characteristic of ulcers, which often occurs, which, in combination with the often observed rapid passage of barium suspension through the pyloric canal, prevents the filling of the ulcer crater with a contrast agent. In addition, ulcerative “niches” in the pyloric canal are small in size and are often accompanied by a pronounced inflammatory process and deformation. Hypersecretion, delay gastric juice and food debris also make it difficult to identify the ulcer “niche”. In most cases, it appears on the contour in the form of a shallow, pointed depot of barium suspension, surrounded by a small inflammatory shaft, which passes to the main bulbs. This can create a picture of an “inverted three” (Fig. 13). On the relief, the ulcerative “niche” is defined as a flat oval or round-shaped depot of barium suspension located in the center of the pyloric canal. There are awl-shaped “niches”, usually invisible during fluoroscopy and revealed only on targeted radiographs (small, pinhead-sized “niches” located on the shadow of the narrowed pyloric canal).

A scarring ulcer of the pyloric canal often appears as a star-shaped contrasting spot with radiating folds of the mucous membrane. In addition to the convergence of the folds of the mucosa to the ulcerative “niche,” sometimes there is one, significantly thickened fold of the mucosa of the pyloric canal, extending into the bulb.

Indirect signs of an ulcerative “niche” of the pyloric canal are various deformations of it: elongation due to infiltration or sclerosis of adjacent areas of the antrum or bulb, asymmetrical location of the pyloric canal in relation to the antrum of the stomach and bulb, curvature of the pyloric canal, sometimes knee-shaped, or expansion and narrowing his; In some patients, the pyloric canal has uneven jagged contours. A combination of these deformations is often observed. A sharp, sometimes prolonged (up to several hours) spasm of the pylorus often accompanies ulcers of this part of the stomach; the lumen of the canal narrows and is only partially filled in small portions contrast agent, which further complicates the identification of the ulcer “niche” and complicates diagnosis.

Duodenal ulcer. The importance of x-ray examination in establishing the diagnosis of duodenal ulcer is well known. However, identifying ulcers, especially acute ones, not accompanied by deformation against the background of a sharp increase in the tone of the muscle wall of the bulb, with an abundance of mucus in the lumen, presents certain difficulties, especially when the “niche” is located on the posterior or anterior wall of the bulb. No less difficulties arise, as is known, when recognizing ulcers in a deformed bulb: cicatricial deformities often simulate ulcerative “niches” or, conversely, hide an inconspicuous inflammatory shaft; a slight reaction of the surrounding mucous membrane complicates diagnosis.

There are three types of symptoms that clarify the radiological diagnosis: direct - morphological, indirect - functional and signs accompanying the ulcer. Direct signs: a “niche” on the contour or relief, a defect in the “niche” area, cicatricial retraction on the wall opposite the ulcer, convergence of the folds of the mucous membrane towards the “niche”; deformation of a scarring organ - periduodenitis (Fig. 14 and 15). Functional signs: hypersecretion, regional spasm, local hypermobility, changes in evacuation function (delay, acceleration), peristalsis (stenotic, deep, aperistaltic zone) and tone. Accompanying signs: changes in the relief of the mucous membrane (serration along the greater curvature, thickening and tortuosity of the folds of the mucous membrane of the duodenal bulb, local pain, manifestations of duodenitis, etc.).

It should be noted that when examining patients with duodenal ulcers, the listed symptoms are detected in various combinations. In addition to them, it is important to characterize the relief of the mucosa, as well as the use of various techniques to establish a diagnosis, in particular in different positions, etc. Ulcerative “niches” are often located on the posterior wall, on the medial, less often on the anterior and lateral; there are “niches” at the base of the bulb (by some authors they are regarded as pylorobulbar ulcers and ulcers located at the apex of the bulb).

Among the existing methods of X-ray examination of the duodenum, there are no methods that can be used to accurately diagnose bulb ulcers. The most effective research technique is in double contrast conditions. This can be achieved by examining the patient in a horizontal position, turning first on the right side (tight filling of the bulb), then on the back and on the left side. In this position, the air in the stomach moves into the pyloric canal and bulb, and a pneumorelief is formed. However, with severe hypertonicity, in hypersthenics, when the bulb is located high and posteriorly, and immediately behind the pyloric canal, with overlapping spasms or gross deformities, it is not always possible to tightly fill the bulb with a contrast agent or stretch it. In such patients, it is necessary to take radiographs in lateral projections; Research with pharmacological drugs also helps. Most often for these purposes we use Aeron (2 tablets under the tongue). 20-25 minutes after dissolving the tablets, the patient is given another portion of barium suspension and the study is repeated according to the described method. As a rule, in 90% of cases, ulcerative “niches” are detected at a distance of 3-4 cm from the pyloric canal, in 10% - in other parts of the bulb.

As in the stomach, ulcers can be found on the walls of the bulb or on the relief (relief “niche” or “spot”); in this case, most of the ulcers are located near the lesser curvature of the bulb. When the folds of the mucous membrane swell due to the inflammatory reaction, a shaft is created around the ulcerative crater, which increases the demonstrativeness of the “niche.” With pneumorelief, in most cases it is possible to identify a “spot” of barium suspension with folds of the mucous membrane converging to this place. Obviously, duodenal ulcer can be equally often detected on the anterior and posterior walls of the bulb. It is clear that the ulcer back wall the bulb will be visible when turning left, and the front wall will be on the opposite side from the rear wall of the bulb. Ulcers on the anterior wall may seem to move away from it and go out onto the contour, but if the ulcer penetrates into the adjacent tissues, in particular the greater or lesser omentum, then “departure” from the wall of the bulb does not occur. In some cases, when the ulcer penetrates into bile ducts, it is not possible to identify the ulcerative “niche” and filling occurs biliary tract contrast agent through fistulous tract(Fig. 16).

Using another method - dosed compression - we were able to diagnose an ulcer that looked like a spot to which the folds of the mucous membrane converged; after the compression was removed, this picture disappeared (Fig. 17).

It is difficult to exaggerate the importance of the x-ray method in identifying extra-bulb ulcerations. Most often, such ulcers are found in the upper flexure of the duodenum (up to 67%) and the upper third of the descending part of the duodenum (up to 25%), i.e., according to S. A. Reinberg and M. M. Salman, in the most “ critical zone." In addition to the “niche” symptom, this type of ulceration reveals a narrowing of the intestinal lumen at the site of the lesion, deformation, thickening of the folds of the mucous membrane, as well as motor disturbances of the duodenum in the form of either increased peristalsis, when the barium suspension quickly moves along the bulb and the descending part of the intestine, or , on the contrary, slowing down: in this case, the bulb or even the entire descending part of the intestine, its upper and lower bends expand and, accordingly, the contrast agent passes at a slower pace; sometimes only bulbostasis is visible. Extra-bulb “niches” in most cases exceed the usual size of onion ulcers; they are often round, but can be cylindrical, prismatic, cone-shaped or irregular in shape. Extra-bulb ulcers, most often located on the inner or posterior wall of the duodenum, can be brought to the contour; the visible narrowing of the intestinal lumen at the site of the lesion is either the result of a reflex local spasm or is formed by scar tissue. More often, such a narrowing is asymmetrical and is expressed in retraction of the wall opposite the ulcerative “niche”, reminiscent of the “pointing finger” symptom. As a rule, first it is possible to identify this asymmetric narrowing of the intestine, and then the ulcerative “niche” (Fig. 18). Deformation of the folds of the mucous membrane in most cases is observed not only in the area of ​​the ulcer niche, but also proximal and distal to it, in the bulb and the descending part of the duodenum. The folds of the mucous membrane thicken and become inactive. Quite often there is a convergence of mucosal folds towards a “niche”, which can persist even after the appearance of a scar at the site of the ulcer. Stenoses caused by extrabulb ulcers are usually detected in the superior flexure and in the upper half of the descending part of the duodenum; the contours of the narrowing are clear, uneven, the length of the narrowing is 1 - 1.5 cm. Deformation of the duodenal bulb is caused by unstable spastic contractions or scars (Fig. 19). Sometimes there is a gaping of the pylorus. It should be noted that the deformation of the bulb depends on the localization of the ulcerative “niche”: the closer to the initial segment of the intestine the “niche” is located, the more often the deformation is observed.

Extrabulb ulcers must be differentiated from duodenal diverticula. The presence of a neck at the diverticulum with folds of the mucous membrane extending into it helps in correct diagnosis. Differentiation with adhesive process is more difficult. Periduodenitis in most cases is manifested not only by a cone-shaped protrusion of the intestinal wall, but also some serration of the contour is revealed over a greater or lesser extent of the duodenal wall; in addition, during the adhesive process there are no organic and functional signs inherent in an ulcer. If a tumor of the major duodenal papilla or invasion of the duodenal wall by a pancreatic tumor is suspected, relaxation duodenography with a probe is necessary.

The most reliable radiological symptom of an ulcer(direct sign) is an ulcerative niche, which is visible in the form of a protrusion of the contour of the stomach in a tangential position. When transilluminated en face, the niche is revealed in the form of a persistent contrasting spot.

Approximately in 85% ulcer niches located on the lesser curvature of the stomach. The remaining 15% are ulcers of the greater curvature (localization in the horizontal part is especially suspicious for cancer), ulcers of the posterior wall (especially in older people, the leading clinical symptom is back pain), and ulcers in the pyloric area. The niche symptom can also be observed with stomach cancer.

To indirect signs of an ulcer relate:
a) spastic retraction on the opposite wall of the stomach. This retraction, designated as a symptom of the index finger, is not certainly indicative of an ulcer, since it can also be observed with adhesions of various origins. When the ulcer heals, an hourglass picture may appear due to cicatricial wrinkling of the lesser curvature and spastic retraction of the greater;
b) studying the relief of the gastric mucosa sometimes reveals folds of the mucosa concentrically leading to the ulcer;
c) further, weakening of peristalsis may be observed in the area of ​​the ulcer. This sign, therefore, cannot be considered as pathognomonic for gastric cancer;
d) with a chronic ulcer of the lesser curvature, retraction of the lesser curvature and the resulting displacement of the pylorus to the left are noted.

Limits of X-ray diagnostics: some ulcers are not detected by X-ray examination; Especially often fresh, bleeding ulcers are not detected. Cardiac ulcers are also difficult to recognize in most cases.

The leading radiological sign of cancer is a filling defect. It is an expression of expansively growing tumors of the so-called polyposis carcinoma or cauliflower-shaped carcinoma. Usually the filling defect has irregular boundaries. To make a diagnosis, consistency of the x-ray pattern during serial examinations is necessary. The relief of the mucous membrane in the area of ​​the filling defect is disturbed. However, a filling defect in a pronounced form is revealed only in late stages diseases with an unfavorable prognosis for surgical treatment.

For early cancer detection One should also take into account such more difficult to interpret symptoms as rigidity of the stomach wall (due to its infiltration) and various forms of the niche (ulcerated cancers). The question of what is preferable for early cancer detection is still being debated: tracing the relief of the mucous membrane or studying the tight filling of the stomach. Optimal results can be obtained using both methods.

To others X-ray signs of cancer relate:
a) absence of a continuous peristaltic wave and
b) changes in the relief of the mucous membrane.

These signs are especially typical for cancer with infiltrating growth, scirra, which more often eludes radiological detection than expansive growing tumors. With scirra there is usually no filling defect. The shape of the stomach may also remain almost unchanged. For the most part, there are only slightly pronounced, but persistent irregularities in the contour of the stomach. Extremely rarely, persistent rigidity of the stomach wall can be caused by gastritis.

In identifying meaning various forms niches The merits of the French radiology school (Gutman) are especially great. According to Gutman, the following radiological signs are highly suspicious for cancer: submerged niche, plateau-shaped niche, meniscus-shaped niche. It goes without saying that even with these forms of niche, it is not single images that are decisive, but the constancy of the x-ray picture during serial examinations.

Especially differential diagnosis is difficult between callous ulcer and the so-called cancer with annular ridge. There are the following differential diagnostic criteria: in case of cancer, the crater of the ulcer protrudes only slightly above the edge of the stomach and the cancerous ridge is more clearly demarcated compared to the ulcer, and the folds of the mucous membrane break off suddenly (Henning). With a callous ulcer, on the contrary, the niche is usually found outside the contour of the stomach; the folds of the mucosa are not so sharply demarcated and can converge towards the ulcerative ridge.

Ulcer size cannot be used for differential diagnosis. Especially during the war and post-war years, ulcers with a strikingly large crater have been described - wartime ulcers, which are morphologically very similar to saucer crayfish. Crucial for the diagnosis (Henning) is the condition of the gastric wall around the ulcer, as well as changes in the relief of the mucosa.

Even if these criteria are taken into account the diagnosis often remains unreliable; this can only be eliminated by control tests X-ray examinations at short intervals (2-3 weeks). After appropriate treatment, a benign ulcer shows clear signs of reverse development, while with cancer no significant changes are observed.

A perforated gastric ulcer on an X-ray with barium is detected by specific signs, but before gastrography, fibrogastroduodenoscopy is recommended, and to determine cancer, X-rays, CT, MRI, PET / CT are needed

X-ray of the stomach: ulcer (perforated) and cancer - specific signs

Ulcers (perforated, ordinary) and stomach cancer are the main diseases for which X-rays with barium are prescribed. Contrasting allows you to clearly trace the structure, function, and shape of an organ. In both nosological forms, a filling defect is observed, in which specific niches are visible on the radiograph.

Perforated gastric ulcer - X-ray diagnosis

A perforated ulcer is a destruction of the wall of an organ, in which free gas escapes into the abdominal cavity. The condition is life-threatening, as it causes dangerous disease– peritonitis (inflammation of the peritoneum). At perforated ulcer It is impossible to contrast the stomach with barium, since barium penetrates through the free opening. The contrast is water-insoluble, so it does not dissolve when it enters the abdominal cavity. Barium provokes severe irritation internal organs. Symptoms of the condition are severe pain in the abdominal area.

A perforated ulcer on an x-ray can be seen as a strip of clearing under the right dome of the diaphragm, shaped like a sickle. To exclude a threat to the life of the patient due to pathology, it is necessary to perform fibrogastroduodenoscopy (FGDS) before gastrography. Using a probe, the condition of the inner walls of the mucous membranes is monitored. With a perforated ulcer, a gaping defect with a peripheral red shaft is noted. An ulcer during fibrogastroscopy is characterized by deep erosion. When perforated, a gaping defect with particles of fibrous fibers is visible.

Cancer erosion is characterized by a large width with a shallow lesion depth. Such niches are clearly visible when contrasting the stomach with barium. X-ray is one of the best methods detection of pathology.

X-ray to detect a perforated ulcer

A perforated ulcer is detected on x-ray after studying a plain x-ray of the abdominal cavity. The detection of a crescent-shaped clearing under the right dome of the diaphragm is due to more standing tall of this dome when compared with the left-sided analogue.

If FGDS does not detect a perforated defect and there is no “sickle” on the plain X-ray, a contrast X-ray of the stomach can be performed. Gastroscopy is performed under the control of an X-ray television screen. When performing the procedure, the doctor has the opportunity to monitor the condition of the stomach during the passage of contrast and stretching of the walls with gas.

The ability to dynamically track barium progress allows for assessment of peristalsis. Muscle contractions the walls of the stomach allow differential diagnosis between cancer and ulcer. A wave of contraction passes through the site of the ulcer. On the opposite side, a spastic protrusion appears, which is clearly visible in the picture.

The peristaltic wave does not pass through the cancerous niche, which makes it possible to determine the nature of the ulcerative defect at the stage of gastroscopy.

Basic x-ray signs of gastric perforation:

The gas bubble is located in the projection of the abdominal cavity, shifts to the hypochondrium in the supine position;
On the side, the crescent-shaped lucency shifts to the center;
For high-quality contrasting of the defect, a double technique is used. The patient first swallows a few drops of barium and then drinks an effervescent gas that relaxes the stomach wall.

If it is not possible to detect an ulcer during gastrography, fibrogastroduodenoscopy (FGDS) is necessary. It should be taken into account that during spasmodic contractions it is difficult to advance the probe. The patient experiences vomiting reflex, nausea, chest pain. If an x-ray is taken in such a situation, specific signs of an ulcer can be observed:

De Quervain syndrome - gastric peristalsis is increased along the lesser curvature with the formation of limited spasm;
If you try to take a gas-forming drug in excess, the pain syndrome increases due to stretching of the mucous membrane;
During a spasm, the remainder of the contrast agent suspension is removed from the stomach after a few hours, although normally the contents are evacuated after 45 minutes. The accumulation of mucus reduces the quality of contrast, so good preparation is recommended before the study.

Fibrogastroduodenoscopy is a more preferable method than gastrography when diagnosing an ulcerative defect. The method does not lead to radiation exposure to humans. Gastrography and X-ray diagnostics have different tasks, but for screening examinations, FGDS is recommended.

X-ray criteria for stomach cancer

It is better to diagnose stomach cancer when the stomach is tightly filled with barium. When the cavity is filled with contrast, the mucous membranes are straightened, so the defect is filled well and is clearly visible in the image.

When interpreting serial radiographs obtained after gastrography, the radiologist must pay attention to the different phases of gastric contraction. It is advisable to record the state of the organ during the passage of a peristaltic wave.

There is a visual difference between an X-ray defect in cancer and an ulcer. Filling defect at cancerous tumor can be traced as an additional formation against the background of a gas bubble (exophytic cancer). Sometimes the sign is detected on a plain X-ray of the abdominal cavity.

Cancer forms not only a niche, but also thick walls through which the peristaltic wave does not pass. Dense tissues lead to deformation of the greater curvature of the stomach, which is visualized by tight filling.

During gastroscopy, specialists do not have the opportunity to perform a biopsy, but competent decoding in the presence of specific signs will allow specialists to diagnose cancer on early stage, carry out radical treatment.

When performing gastrography, it is important to follow the dosed compression technique, in which, using a special tube of the gastrograph apparatus, pressure is applied to the area where the stomach is located. The technique allows you to straighten the mucous membrane for a thorough study of the relief. Along with double contrast, dosed compression allows you to visualize specific symptoms:

Thickening of the wall at the location of the formation;
Narrowing of the organ lumen during concentric growth (symptom of “syringe”);
Uneven contour of the defect with tight filling.

With an ulcer, the defect is about 4 cm wide. If the “filling defect” is visible against the background of an altered relief, the diagnosis of cancer is beyond doubt.

A tumor in the upper part of the stomach is clearly visible when the organ is filled with air. When cancer is localized in the area of ​​the pylorus or duodenal bulb, there is difficulty in passing the contrast agent into the underlying parts of the intestine.

Difficulties in X-ray diagnosis of stomach cancer arise with creeping cancer in the initial stages, when the tumor grows inside the wall. A competent radiologist can identify pathology based on indirect signs, conduct additional examination, or prescribe PET/CT.

Aspects of X-ray diagnosis of gastric cancer

Practical results of X-ray diagnostics of stomach cancer show that in 25% of cases gastrography does not detect malignancy if available. Previous lesions of the mucous membrane are not always examined by a radiologist during an X-ray television examination or when reading images. Not every specialist uses double contrast, limiting himself only to tight filling. Such facts add up to negative statistics.

When determining indirect signs of cancer, computed tomography is recommended. The specificity and sensitivity of the method makes it possible to detect a tumor at an early stage. The accuracy of the examination is 36-69%.

Lymph node involvement is detected by computed tomography (CT) in 70% of cases. Modern spiral multi-slice tomographs allow three-dimensional spatial reconstruction of the image. Virtual gastroscopy for cancer is important for choosing surgical planning tactics.

Using CT, you can determine the depth of cancer invasion into the organ wall. Damage to the lymph nodes affects the nature of treatment.

It is rational to carry out magnetic resonance imaging in late stages of a cancer tumor to determine distant metastases. The specificity and sensitivity of the method, according to various studies, ranges from 85 to 100% when studying cancerous lesions of lymph nodes. Preliminary results make it possible to clarify the localization of the process in different parts of the gastrointestinal tract. Changes in the magnitude of the MR signal when studying the nature of infiltration of the mucous membrane are less specific. To study education, it is rational to use computed tomography.

PET/CT (positron emission tomography) has sufficient sensitivity, since the method is based on the absorption of specific substances labeled with short-lived radionuclides with affinity for the gastric wall.

Statistics indicate that since the creation of the method, the study has been able to identify only 26% of patients with early stomach cancer. Based on these facts, it should be assumed that PET/CT in detecting gastric cancer does not have the required degree of reliability in detecting early cancers. It is rational to use examination in the verification of lymphatic disseminated processes and tumors of lymphatic origin.

Thus, the X-ray method for detecting tumors of the gastrointestinal tract has not lost its relevance. It is rational to combine an X-ray of the stomach with fibrogastroduodenoscopy. The combined method makes it possible to identify intramural formations with exophytic distribution.

In European countries, all existing radiation methods should be used to diagnose gastric cancer. A competent combination of gastrography, FGDS, computed tomography and magnetic resonance imaging makes it possible to identify gastric tumors at an early stage.

X-ray of an ulcer of the antrum of the stomach

X-ray – endophytic cancer of the body of the stomach