Stomach ulcer x-ray. X-ray diagnosis of peptic ulcer of the stomach and duodenum. Greater curvature ulcer

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 the formation of a dangerous disease - peritonitis (inflammation of the peritoneum). In case of a 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 of 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 for detecting 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 the higher position 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 of the stomach wall allow differential diagnosis between cancer and ulcers. 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 a gag reflex, nausea, and 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. A filling defect in a 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 interpretation in the presence of specific signs will allow specialists to identify cancer at an early stage and 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 a malignant neoplasm if it is present. 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

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 of the stomach, but also the 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 of various locations 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 ulcer “niche” can reach enormous sizes, depending on where the ulcer has penetrated and 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, a large amount of 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. Thus, the cup-like or oval shape of the “niche” changes to a cone-shaped one due to the filling of the bottom of the ulcerative 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 parts of the stomach 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”, fusion of the stomach, 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, medication, etc.), the use of which, according to our data, improves the X-ray diagnosis of ulcers in this section (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 methodology 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, retention of 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 filled only partially with small portions of the contrast agent, which further complicates the identification of the ulcerative “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 revealed 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, a duodenal ulcer can equally often be detected on the anterior and posterior walls of the bulb. It is clear that the ulcer of the posterior wall of the bulb will be visible when turning to the left, and the ulcer of the anterior wall will be visible on the opposite side from the posterior 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 the bile ducts, it is not possible to identify the ulcerative “niche” and the bile ducts are filled with a contrast agent through the 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 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 jaggedness of the contour is detected 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.

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Clinical examination

The information that can be collected during a patient interview has varying diagnostic value. Based on this, all patients can be divided into several groups. IN first includes patients who have suffered from peptic ulcer in the past and this diagnosis was previously confirmed x-ray or endoscopically. In such cases, diagnosis is not very difficult. Second group consist of individuals who have not previously been examined, but with careful questioning, typical manifestations of peptic ulcer disease can be identified (sour belching, pain soon after eating or on an empty stomach, night pain, regular consumption of baking soda, periodic tarry stools, etc.). TO third group include persons who, due to an uncritical attitude towards existing manifestations of the disease, deny any history of gastric disease. As A. Mondor wrote, many of the patients have a “dyspeptic past,” but it seems to them that the catastrophe that has happened to them at the moment has no connection with any long-standing minor digestive disorders and therefore they answer negatively to the doctor’s question about the presence of the disease in past. And finally fourth group- patients in whom the most careful questioning fails to identify any gastrointestinal disorders in the past. In approximately 10% of cases, perforation occurs against the background of complete well-being without previous symptoms of peptic ulcer disease.

Immediately before perforation of the ulcer, prodromal symptoms often occur, expressed in increased pain in the epigastric region, chills, low-grade fever, nausea, and occasionally vomiting. Some surgeons assess these signs as a state of impending perforation. Unfortunately, such a conclusion is made only in hindsight, in retrospect.

For diagnosis, the characteristic posture of the patient, his appearance, and especially the detection of pronounced muscle tension, determined by superficial palpation, are important. When assessing this symptom, it is necessary to take into account the time that has passed since the perforation, since with the development and progression of peritonitis, the pronounced tension of the abdominal wall is replaced by a gradually increasing bloating, which largely masks the protective tension of the muscles. In addition, if the perforation occurs in a patient with flabby muscles and obesity, muscle tension can be difficult to detect. In such cases, it is possible to identify rigidity and constant tonic tension of the muscles of the anterior abdominal wall with the help of careful methodical palpation (you should try not to cause severe pain to the patient), during which the tension intensifies.

Free gas in the abdominal cavity can be detected by percussion of the liver area in approximately 60% of cases of perforation of gastroduodenal ulcers. The absence of hepatic dullness is crucial in cases where the area of ​​tympanitis found above the liver moves when the patient changes position and when turning from the back to the left side.

Laboratory diagnostics

Instrumental methods

The gas bolus is located in the highest parts of the abdominal cavity. When the patient is positioned on his back, the highest point of his position is the upper part of the anterior abdominal wall. As the patient turns on his side, it moves to the corresponding subcostal region - to the place of attachment of the diaphragm and to the side wall of the abdomen, and in a vertical position, the gas occupies the highest position under the domes of the diaphragm (Fig. 51-2).

Rice. 51-2. A “crescent” of gas (indicated by an arrow) under the dome of the diaphragm (survey radiograph).

Adhesions in the abdominal cavity distort the patterns outlined above, and the accumulation of gas can be localized in an atypical location.

Radiographic differential diagnosis between pneumoperitoneum and interposition of the pneumatized colon, located between the liver and the diaphragm, is based on the fact that the strip of free gas localized in the abdominal cavity moves depending on the position of the patient, and the part of the colon swollen with gases usually does not change its position.

In unclear cases, patients are offered to drink intensely carbonated water (“fizzy mixture”): the released gas escapes through a perforated hole and can easily be detected during a repeated x-ray examination. For the same purpose, you can use any water-soluble contrast agent (20-40 ml). Its extension beyond the contours of the stomach and duodenum is an absolute sign of perforation of the ulcer.

Ultrasound may be useful in diagnostically difficult situations. It is not easy to detect free gas in the abdominal cavity, but it is usually possible to detect encysted fluid accumulation or exudate in the free abdominal cavity. In addition, ultrasound helps in differential diagnosis; it can help detect signs of cholecystitis or pancreatitis, exudative pleurisy.

Laparoscopy serves as a decisive diagnostic method, which is used in cases where it is not possible to recognize a covered or atypically occurring perforated gastroduodenal ulcer, and the diagnosis of peritonitis cannot be excluded.

Diagnostic protocol in a surgical hospital

• In the emergency department, a doctor should examine a patient with a suspected perforated ulcer first.
• Body thermometry is carried out, the necessary laboratory tests are performed (blood type, Rh factor, blood plasma glucose, etc.), and the number of leukocytes in the blood is determined.
• In all cases, an ECG is recorded to exclude the abdominal form of myocardial infarction.
• A plain radiography of the abdominal cavity is performed to detect free gas. If the patient's condition allows, studies are carried out in a vertical position; if not, in a lateral position.
• In addition to patients with a confirmed diagnosis of perforated gastroduodenal ulcer, patients with questionable clinical symptoms are hospitalized in the surgical department.
• In the surgical department, the diagnosis of a perforated ulcer must be finally confirmed or rejected. Laparoscopy can be used for this. If it is impossible to perform it or if there are indisputable signs of peritonitis, the cause of which is unclear, they resort to diagnostic mid-median laparotomy.

Differential diagnosis

Perforation of a malignant tumor of the stomach- a fairly rare complication of the cancer process. The age of patients is usually over 50 years. The course of the disease has many similarities with perforation of a gastroduodenal ulcer. Although the onset is not as violent as with an ulcer, it is characterized by the rapid development of diffuse purulent peritonitis. A history may reveal weight loss, loss of appetite, and weakness that occurred in the last few months before admission to the surgical hospital.

During an objective examination, the assumption of perforation of the tumor is confirmed by palpation (detection of a dense tuberous formation in the epigastric region). Otherwise, the clinical manifestations are the same as with a perforated ulcer. Laparoscopy reveals a tumor with perforation and entry of stomach contents into the abdominal cavity, and metastases can also be seen in the liver and other organs.

The clinical differences between acute cholecystitis, hepatic colic, acute pancreatitis, acute appendicitis and renal colic from perforated ulcers of the stomach and duodenum are well known; it is most difficult to exclude rarer diseases.

Stomach phlegmon. The disease is difficult to differentiate from a perforated ulcer. Phlegmon is characterized by sudden pain in the epigastric region radiating to the back, nausea, and rarely vomiting. There is a history of dyspeptic disorders. The patient is restless and takes a forced position on his back. The tongue is coated and dry. The abdomen is retracted, participates in breathing to a limited extent, and is tense in the epigastric region. Hepatic dullness is preserved; dullness in sloping areas of the abdomen is possible. Peristalsis is heard. Characterized by a rapid pulse, increased body temperature and high leukocytosis.

During fibrogastroscopy, pronounced inflammation of the gastric mucosa is found throughout. A control radiography of the abdominal cavity, performed after an endoscopic examination, confirms the absence of free gas in the abdominal cavity.

Acute disturbance of mesenteric circulation manifests itself as suddenly occurring severe abdominal pain without a specific localization. It is necessary to take into account the presence of atrial fibrillation, dyspeptic complaints and anamnestic information regarding previous embolism and currently existing chronic occlusions in the systemic circulatory system. The patient is restless, tosses about in bed, and collapse is possible. Characterized by the rapid development of intoxication with an unclear clinical picture from the abdominal cavity. Vomiting is rare, more often - loose stool mixed with blood. The abdomen is swollen, soft, and there are no peristaltic sounds from the very beginning of the disease. The pulse is frequent, often arrhythmic. There is no increase in body temperature. The number of leukocytes in the blood is sharply increased. In case of intestinal infarction, peritoneal symptoms occur.

The final diagnosis in the early stages of the onset of the disease, that is, at the stage of intestinal ischemia, is carried out using laparoscopy and X-ray contrast aortomesentericography.

Retroperitoneal rupture of abdominal aortic aneurysm begins suddenly with severe pain in the upper abdominal cavity. As a rule, this disease occurs in elderly people with severe cardiovascular pathology. From the anamnesis it is often possible to obtain information about the presence of an aortic aneurysm in a patient. An objective examination reveals a painful, immobile, pulsating tumor-like formation in the abdominal cavity, over which a rough systolic murmur can be heard. The abdomen is not swollen in the first hours of the disease; muscle tension often occurs due to blood entering the abdominal cavity. The pulse may be rapid, blood pressure may be decreased, and body temperature may be normal or decreased. The pulsation of the iliac and femoral arteries is sharply weakened, the lower extremities are cold. Patients quickly develop anuria and renal failure. Most patients show signs of acute anemia.
Therapeutic diseases can also simulate a perforated ulcer.

Myocardial infarction. In the case of its gastralgic form, a sudden onset of acute pain in the epigastric region with irradiation to the heart and interscapular region is possible. Elderly people who have previously had angina attacks are more likely to get sick. Palpation can reveal pain and tension of the abdominal wall in the epigastric region. Hepatic dullness is preserved, peristaltic sounds are normal. The electrocardiogram reveals fresh focal disturbances of the coronary circulation.

Pneumonia and pleurisy sometimes they begin acutely with pain in the upper abdomen without a specific localization. The anterior abdominal wall may be moderately tense in the epigastric region. Hepatic dullness is preserved. Clinical and radiological studies confirm the presence of pneumonia and the absence of pneumoperitoneum.

Surgeons must remember that accurate differential diagnosis is possible only in the first hours after perforation of a gastroduodenal ulcer. During the period of purulent peritonitis, the picture of perforation smoothes out and becomes similar to the clinical picture of inflammation of the peritoneum of any other origin. Emergency midline laparotomy finally determines its cause.

A.I. Kirienko, A.A. Matyushenko

Modern ideas about peptic ulcer disease with localization of the ulcer in the stomach have been significantly deepened and clarified thanks to x-ray examination, which not only confirms the clinical diagnosis of gastric ulcer, but can provide comprehensive information about its location and size, secondary changes of a deforming nature, connections with neighboring organs, etc. 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: ulcerative niche, reactive changes in the mucous membrane accompanying the ulcer and cicatricial 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.

A particularly important place among the indirect signs of the ulcerative process is occupied by 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 emergence of a niche during the decline of the jet
swelling of the mucous membrane. 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. Such large niches with these changes are very suspicious for the presence of a 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 surgical treatment can be undertaken in a timely manner.

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 effect of therapeutic measures on the ulcer as a whole. 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 such cases a positive effect of treatment can be expected.

Peptic ulcer is a clinical and anatomical concept. It's chronic

a disease with a polycyclic course, characterized by the formation of ulcers

in those areas of the mucous membrane that are to a greater or lesser extent

washed with active gastric juice. Peptic ulcer disease is common

chronic, cyclical, relapsing disease, based

which underlie complex etiological and pathogenetic mechanisms

formation of ulcers in the gastroduodenal zone

X-ray semiotics of pre-ulcerative condition. IN

in the parapyloric zone it is characterized by several variants, including

which may cause an “irritable stomach.” At the same time in the stomach

on an empty stomach there is a significant amount of hypersecretory fluid and mucus,

which in most patients increases during the study.

The barium suspension first sinks in the liquid, settling on lumps of mucus in the form

flakes, the folds of the mucous membrane are not visible at this moment, and only after

evacuation of a significant amount of contents under the influence of palpation

barium suspension is mixed with it, after which it becomes possible to study

relief of the mucous membrane. It is usually presented in large, convoluted, often

transversely located folds of the mucous membrane. In a number of patients

the entry of the first sips of barium suspension into the stomach sets in motion

its contents, barium suspension in the form of large lumps, also

erratic movements - the contents of the stomach “boil.” Stomach tone

slightly reduced, peristalsis is sluggish, the stomach is moderately distended.

Very often there is an initial short-term spasm of the pylorus,

after which the tone of the stomach increases, deep peristalsis appears and

accelerated evacuation of barium suspension from the stomach into

duodenum (within 15-20 minutes the stomach is almost completely

freed from barium). The bulb is irritated, contains a lot of mucus, very

quickly freed from the contrast agent, causing its true form

cannot be determined, the folds of the mucous membrane are also not visible. Wherein

Duodenogastric reflux is usually pronounced: after receiving barium

suspension into the descending duodenum, it often returns

is thrown into the stomach. A niche in the pyloroduodenal zone is not detected.

Dyskinetic disorders are also noted in the proximal lemniscus

intestines. In a number of patients, cardia insufficiency is determined.

The X-ray picture of an “irritable stomach” is rarely observed,

usually in patients with a short history and severe clinical picture

peptic ulcer disease.X-ray semiotics of peptic ulcer disease Over many decades

development of X-ray diagnostics of peptic ulcer, various

groupings of radiological symptoms. Most authors highlighted

direct and indirect symptoms.

A direct radiological symptom of peptic ulcer disease is a niche on

contour or barium stain on the relief. The frequency of detection of the latter depends on

many reasons: localization and size of ulceration, deformation, organ,

the presence of fluid in the stomach, filling the ulcerative cavity with mucus,

blood clot, radiologist qualifications, etc. If methodically correct

performing an X-ray examination in the clinic, this symptom

detected in 89-93% of cases. Modern done right

X-ray examination allows to detect ulcers measuring 2-3 mm.

The ulcer niche can have different shapes: round, oval, slit-like,

linear, pointed, irregular, etc. Some authors believe that

the shape of the ulcer niche depends on its size. Round and conical shape

ulcer niche occurs mainly with relatively small ulcers.

As the disease progresses and the size of the ulceration increases

the shape of the ulcer becomes irregular. There is an opinion that fresh ulcers

have a pointed shape and smooth contours, and old ulcers are rounded

shape, however, it is possible that the pointed shape is associated with insufficient

tightly filling the niche. The shape of the ulcer niche also depends on the position

of the patient during an x-ray examination. It has been established that the form

The ulcer niche changes during treatment. According to

endoscopic studies, acute ulcers in patients with peptic ulcer

often oval, in the scarring stage - linear or divided into more

small fragments against the background of focal hyperemia of the mucous membrane (“pepper with

emphasize that the shape of the ulcer niche is not an objective criterion

assessing the nature and timing of ulcer development. It should be noted that

standard x-ray examination under x-ray television conditions

(fluoroscopy and radiography, natural pneumography) and double

contrast when identifying ulcers give the same results. Outlines

ulcer niches can be smooth, clear and uneven, unclear. According to

P.V. Vlasov and I.D. Blipchevsky (1982), smooth contours are characteristic of

relatively small ulcers. As the size of the ulcers increases, the contours become more frequent

become uneven due to the development of granulation tissue protruding into

lumen of an ulcerative crater of an exposed vessel, a blood clot, food debris

and mucus. However, in the process of scarring and small ulcers in some cases

uneven contours appear. As a result of the merger of ordinary (up to size

20 mm) ulcers form large ulcers with uneven contours. Given

data indicate that in the differential diagnosis of ulcers with

malignant ulcerations, the state of the ulcer contours must be taken into account

only along with other symptoms and clinical picture.

Features of X-ray diagnostics depending on the location of ulcers in

peptic ulcer disease.

Ulcers localized in the upper (cardiac) part of the stomach.

Difficulties arising during X-ray examination of the upper

part of the stomach due to the peculiarities of its anatomical location, and

therefore, when identifying poverty, most authors emphasize.

The study must be carried out in vertical and horizontal

positions, with preference given to lateral and oblique

projections, as well as horizontal position on the stomach with a slight

turning on the right side and double contrasting.

The main symptom is a niche on the contour or a niche in the form

residual stain of barium suspension on the relief. The niche on the contour should

differentiate from a diverticulum, which is often localized in the upper

department The entrance to the diverticulum is narrow; folds of the mucous membrane are defined in it

shell, a barium suspension is retained in its lumen for a long time.

The entrance to the niche is wide, it is quickly cleared of the contrast agent,

often folds of the mucous membrane converge towards the niche, around it

the shaft is pronounced, spastic retraction is noted on the side of the greater curvature.

Cardiac ulcers are often complicated by bleeding, penetration,

malignancy. X-ray examination in conditions of bleeding and

interpretation of the obtained data is often significantly difficult.

The pathognomonic symptom of penetration is a three-layer niche, but the niche

is not always detected.

Ulcers of the lesser curvature of the body of the stomach.

The features of the X-ray picture of ulcers in this localization were

attention is paid when considering direct and indirect symptoms of ulcerative

stomach diseases.

Ulcers of the prepyloric stomach and pyloric canal.

With X-ray examination, a direct symptom, as with other

localizations of the ulcer, is a symptom of a niche, however, for this localization

The niche in the form of a residual spot of barium suspension on

relief. A niche on the contour is determined in those rarer cases when

the ulcer is located strictly along the lesser curvature of the stomach. True size of ulcers

prepyloric region can only be determined by examining the patient in

horizontal position. Due to the frequent location of the ulcer on the walls

A common symptom of the stomach is a shaft, often round in shape. Symptom

niche in many cases is accompanied by convergence of folds, which is almost

also often found in erosive-ulcerative cancers. Constant companions

ulcers are hypermotility and regional spasm, antral gastritis (in

some patients erosive), duodenogastric and gastroesophageal

reflux (hiatal hernia, reflux esophagitis), dyskinesia

duodenum and jejunum, in a number of patients with long-term

peptic ulcer enteritis develops.For many years in diagnostics

In peptic ulcer disease, great importance was attached to cicatricial changes in the organ. IN

for the most part they are typical and depend on the location of the ulcer and involvement in

cicatricial process of muscle bundles. In this regard, deformation is distinguished in

hourglass shape, which develops as a result of long-term

spasm of the greater curvature of the body of the stomach and cicatricial changes in oblique and

circular muscle bundles for ulcers of the lesser curvature of the gastric body. Wherein

deformation develops in the form of two cavities connected asymmetrically

located isthmus. Similar changes can be observed when

infiltrative form of cancer, while the deformation is symmetrical.

A snail-shaped deformity, or “purse-string stomach”, also develops

with an ulcer of the lesser curvature of the body of the stomach and cicatricial changes in the longitudinal

muscle bundle. In this case, the lesser curvature of the body is shortened

stomach, an extended angle, tightening of the antrum and

duodenal bulbs to the lesser curvature, sagging sinus. U

in these patients, in the absence of vomiting, after 24 hours a residue is detected in the stomach

barium suspension. Such deformation develops much less frequently when

infiltrative gastric cancer, in which pyloric stenosis is observed,

retention of barium suspension in the stomach for 24 hours and vomiting. Wherein

The antrum of the stomach and duodenum are located normally.

Deformities often develop in the antrum, with small ulcers

curvature may be observed Gaudek deformation - cochlear

curvature of the antrum. In this case, scar retraction is localized

also at greater curvature, axis bending and twisting occurs

antrum. However, it should be noted that in modern conditions

antiulcer therapy, the deformities described above began to occur all

less often. According to L.M. Portnoy et al. (1982), gastric deformation is more common

is expressed in significant shortening, as if tension of the lesser curvature.

the stomach is uneven, convergence of folds of the mucous membrane to this area;

second - the contour of the stomach is uneven, small round filling defects nearby

uneven contour, convergence of folds of the mucous membrane towards it; third -

a small niche with convergence of folds of the mucous membrane; fourth

- a small niche without convergence of folds of the mucous membrane; fifth -

the contour of the stomach is smooth, the folds of the mucous membrane converge to the place

former ulcer.

Indirect functional symptoms. To X-ray functional signs

include classic de Quervain syndrome - local spasm, hypersecretion,

local hypermotility, changes in peristalsis, evacuation and tone

stomach. The dependence of the severity of these symptoms on localization has been established

ulcers: they are less pronounced or even absent when the body of the stomach is affected and,

on the contrary, they are most clearly manifested in ulcers of the pyloric region and

bulbs, as well as in the acute phase of the process. The most constant of

functional symptoms include hypersecretion, regional spasm but

greater curvature and a symptom of local hypermotility.

De Quervain's syndrome is known to manifest itself as spastic retraction

greater curvature of the body of the stomach when the ulcer is located on the lesser curvature.

This retraction is unstable, it can appear and disappear during the study,

when using antispasmodic drugs. In practical diagnostics

this symptom is more common with ulcers of the gastric outlet and has

great importance due to the difficulty of identifying ulcers in this localization.

A significant amount of fluid in the stomach on an empty stomach - constant

a symptom of peptic ulcer and manifestation of concomitant gastritis. Fine

known increase in hypersecretion during X-ray

research.

Symptom of local hypermotility, or increased contractility and

accelerated emptying of the area affected by the ulcer, described in ulcers

duodenal bulbs. This symptom is expressed in ulcers

aptral part of the stomach and duodenal bulb, in

to the greatest extent in the phase of exacerbation of peptic ulcer disease.