Perforated ulcer x-ray. X-ray examination for gastric and duodenal ulcers. Erosive chronic gastritis on x-ray

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 everything radiographic symptoms ulcerative lesion stomach 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 ulcer “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 These changes require resorting 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 number 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 considered more characteristic feature 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 upper section stomach. Anatomical features This section of the stomach creates 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 it was diagnosed correct diagnosis). 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.

X-ray picture and methodology for studying ulcers antrum 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 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 a diagnosis is well known. peptic ulcer duodenum. 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 also helps pharmacological drugs. 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 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 filling occurs biliary tract contrast agent through the fistula 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 movement disorders 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, conversely, a slowdown: 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 through at a slower pace pace; sometimes only bulbostasis is visible. Extra-bulb “niches” in most cases exceed the usual size of bulbous ulcers, most often they are round, but can be cylindrical, prismatic, cone-shaped or irregular 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 descending part of the duodenum. The folds of the mucous membrane thicken and become inactive. Quite often there is a convergence of the folds of the mucosa to the “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.

Not detected. To determine it, you must perform special methods– tight filling or double contrasting.

At complete destruction air enters the abdominal cavity and forms a life-threatening condition. To prevent pathology, esophagogastroduodenoscopy (EGD) or gastrography is performed.

IN lately advantage in diagnosis perforated ulcer and stomach cancer, tube methods are preferred. They do not expose patients to radiation and are therefore safe.

We believe that tube gastroduodenoscopy for suspected ulcerative defects or cancer small intestine must be supplemented with X-ray contrast. To substantiate this opinion, we present in the article some interesting facts obtained when practical activities 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 execution requires urgent surgical intervention - gastric resection or suturing of the 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 serious condition patient will allow us to assume 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 clinical symptoms there may not be.

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:

Gas bubble in the upper abdominal cavity. It shifts when lying on the back to the subcostal region.
In the lateral position of the patient, the crescent-shaped lucency is located above the sternum.
An ulcer of unknown etiology is initially confirmed by the consumption of sparkling water. The resulting gas escapes through the hole and is re-detected on the x-ray.
To clearly contrast the ulcerative defect, you can use water-soluble contrast (gastrografin), but not barium. Contrast agent if the organ wall is perforated, it will exit 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, you can use it, 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:

When air is pumped with the Bobrov apparatus, a person’s pain increases.
De Quervain's syndrome - limited spasm and increased peristalsis of the stomach is observed with an ulcer on the lesser curvature.
The remainder of the contrast suspension in the organ cavity 6 hours after the examination due to increased accumulation 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 of 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 contrasting; 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 the presence of pathological tissue in the wall of the stomach, the doctor observes the wall of the organ during X-ray examination. 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 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.

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

Cancer of the body and upper part of the 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 shouldn't. Endophytic (growing inside 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)

The main role in recognizing gastritis is played by clinical examination 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. At the same time, when 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.

Simultaneously register functional disorders. 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.

Aspects of X-ray diagnosis of gastric cancer

A perforated ulcer is detected on x-ray after studying a plain radiograph 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 survey 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.

Causes, signs and treatment of duodenal ulcers

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 - up to 2 cm, large - 2-4 cm and giant - 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 granulation tissue, accumulations of mucus, 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 inner surface stomach or bulb. This accumulation is surrounded by a light structureless rim - an area of edema of the mucous membrane. With a chronic ulcer, the relief niche may be irregular in shape with uneven outlines. Sometimes there is a convergence (convergence) of the folds of the mucous membrane towards the ulcerative defect.

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.

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 different phases stomach contractions. 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. Thick fabrics 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 if available specific signs will allow specialists to detect cancer at an early stage and carry out radical treatment.

Indirect symptoms

“pointing finger” symptom;
hypersecretion;
increased tone;
accelerated deep peristalsis;
symptom of local hypermotility;
scar changes in the form of an hourglass;
deformation, elongation of the pylorus – with ulcers
gatekeeper.
reflux esophagitis, often combined with hiatal hernia;

“Pointing finger” symptom: local spasm of the greater curvature

Hypersecretion

Liquid on an empty stomach or
rapid accumulation
fluids during
research:
presence in the stomach
two levels: below –
barium suspension,
at the top are liquids.

Scar changes

a) hourglass type; b) according to the type of snail

Develops as a result of long-term
existing spasm of the greater curvature of the body
stomach and scar changes of oblique and
circular muscle bundles for small ulcers
curvature of the body of the stomach.
Two cavities connected asymmetrically
located isthmus.
The constriction is usually in the middle part of the stomach,
divides it into two approximately equal
half.
No significant motor impairment
functions. Even with narrow isthmuses
the contrast mass does not stay long in
upper part of the stomach.

hourglass

Asymmetrically positioned
isthmus in the middle third of the body
stomach;
Retraction predominantly
large curvature;
Small curvature somewhat
straightened;
In the area of the isthmus - ulcerative
niche and convergence of folds
mucous membrane;
No significant violation
motility and contrast delays
in the proximal part of the stomach.

Scar changes: cochlear-type deformation, or “purse-string stomach”

Scar changes: deformation by type
snails, or "purse-string stomach"
Develops with an ulcer of the lesser curvature of the gastric body and
cicatricial changes in the longitudinal muscle bundle.
Significant shortening of the lesser curvature of the body of the stomach;
The greater curvature is enlarged and hangs downwards;
Tightening of the antrum and WDP bulbs To
small curvature;
The pylorus is located high and close to the cardia;
Sagging sinus;
The stomach is hypotonic;
Motor function is often reduced;
Due to the bending of the stomach, a mechanical
obstruction of gastric emptying and contents
the latter is delayed for many hours and even days
(in the absence of vomiting, after 24 hours it is detected in the stomach
the remainder of the barium suspension).

Scar changes: cochlear-type deformation, or “purse-string stomach”

Scar changes: deformation by type
snails, or "purse-string stomach"
Significant shortening
small curvature of the body
stomach;
Sagging sinus;
Antral tightening
department and bulbs of the duodenum to
small curvature;
The stomach is hypotonic;
Motor
function is reduced;
Evacuation delay.

Symptom of local hypermotility

increased tone and
peristalsis,
passage acceleration
barium suspension.
Ulcer on the small
curvature;
Deep
peristaltic
wave in the antrum
section of the stomach.

Features of ulcers of various localizations

FEATURES OF VARIOUS ULCERS
LOCALIZATIONS

Most often - men 30-60 years old.
Frequency: 2-19%.
Features of the clinic:
◦ Pain in the epigastric region 15-20 minutes after
meals
◦ The pain is aching, bursting, pressing, squeezing
(resembles an angina attack)
◦ Irradiates to the heart area, behind the sternum, to the left arm,
under left shoulder blade
◦ Vomiting
◦ Heartburn
◦ Dysphagia (with malignancy)

Ulcers of the cardial part of the stomach

Features of Rn research
◦ Research in vertical and
horizontal position
◦ Optimal projections:
◦ Oblique, lateral
◦ On the stomach with a slight turn to the right side
(posterior left scapular).
◦ Difficulty: the impossibility of studying the terrain with
using dosed compression.

Cardiac ulcer of the stomach

Rn symptoms:
niche on the contour
◦ dimensions: 0.7-1.8 cm;
◦ the posterior wall is closer to the small
curvature;
◦ wide entrance;
◦ convergence of folds
mucous membrane;
◦ flat inflammatory shaft;
◦ quick release from
contrast agent.
niche on the relief

Ulcer of the cardial part of the stomach: differential. diagnosis:

Diverticulum
– narrow entrance;
– presence in the diverticulum
folds of the mucosa
shells;
– long delay
barium suspension.

Diverticulum of the cardia of the stomach

Ulcers of the cardial part of the stomach

Complications
◦ Often – bleeding, penetration,
malignancy.
◦ Diagnosis is difficult.

Frequency: 35-65%.
Clinic:
– Pain in the epigastrium, to the left of the midline,
after eating;
– Dependence of pain on the nature and quantity
food;
– Duration of pain: 1-1.5 hours.
– Heartburn, sour belching.
– Episodic vomiting at the height of pain.

a) Spasmodic contractions of the stomach,
deformation of the duodenal bulb by type
shamrock
b) Gastric hypotension,
straightened WDP bulb

Ulcer of the duodenal bulb: a niche on the relief

Diagnostic methods
Bleeding:
◦ Endoscopy
◦ Ultrasound
Perforation:
◦ Radiography
◦ CT
◦ Endoscopy (as
auxiliary method)
Penetration:
◦ Radiography
◦ Ultrasound
◦ CT
Stenosis:
◦ X-ray
study
◦ Ultrasound
◦ CT
Malignization:
◦ Endoscopy+biopsy
◦ X-ray
study
◦ Ultrasound
◦ CT

Ulcer perforation

Ulcer perforation: CT

Arrows indicate free gas in the abdominal cavity

Diffuse expansion
stomach;
Lower border of the stomach
located below
scallop line;
Large amount of liquid
on an empty stomach;
The barium suspension forms
horizontal level in
distended sinus;
Slowing down evacuation.

Patient 33 years old with long-term ulcerative
medical history (duodenal bulb ulcer)
Diffuse expansion
stomach;
Lower border of the stomach
located below
scallop line;
Large amount of liquid
on an empty stomach;
Variegated content due to
barium stirring
suspensions with liquid and food;
Slowing down evacuation.

Decompensated pyloric stenosis

Diffuse expansion
stomach;
Lower border of the stomach
located below
scallop line;
Large amount of liquid
in the stomach;
The barium suspension forms
horizontal level in
distended sinus;
Evacuation slowdown > 24
hours.

Stenosis of the duodenal bulb: CT

Diffuse
extension
stomach;
thickening of the walls
WDP bulbs with
cords in
surrounding
periduodenal
fiber (arrow).

Ulcer malignancy

Frequency: 2 - 10%.
Frequent localization: mediogastric ulcers (cardiac and
body ulcers), especially ulcers of the subcardial region and large
curvature.
When diagnosing, it is necessary to consider:
–
–
–
–
–
–
niche size,
dense wide edge shaft,
localization in the antrum and subcardial region,
long history of ulcers,
perigastric and cicatricial deformities of the stomach,
worsening of the clinical course of the disease.

Ulcer malignancy

1. with long-term observation
tumor development is detected
the location of a previously defined niche;
2. in a typical ulcer niche
signs of cancer appear.

uneven edges of the ulcer niche;
increase in niche size: ulcers with a diameter of 2-2.5 cm often
there are cancerous manifestations.
however, large ulcers are not necessarily
malignant (diameter approximately 4% of benign
ulcers larger than 4 cm);

Ulcer malignancy: radiological signs

asymmetry of a dense, tuberous shaft, especially on
the area facing the exit from the stomach;
breakage of the folds of the mucous membrane at the border with
inflammatory shaft;
rigidity of the areas of the stomach wall adjacent to the niche.
These signs are better identified in double conditions
contrasting with significant stretching
stomach gas.

Large ulcerative
depot;
wrong
elongated shape;
with uneven
contours;
asymmetric
inflammatory shaft.

Malignant ulcer of the prepyloric stomach

Decompensated pyloric stenosis

Diffuse expansion
stomach;
Large quantity
fasting fluids;
Variegated contents due to stirring
barium suspension with
liquid and food;
Slowing down evacuation.

Problems with the gastrointestinal tract arise due to disorders of the mucous membrane. Correct diagnosis of stomach ulcers is the basis for solving the problem. The disease is characterized by a burning sensation in the abdominal cavity. It should be understood that it is impossible to cure it, and the process becomes chronic. Treatment for stomach ulcers is indicated for every sick person, since the disease causes a lot of discomfort and painful symptoms. To identify an ulcer, a range of examinations are recommended, based on the results of which the patient is prescribed a set of measures to help avoid complications.

Information about stomach ulcers

The pathology is characterized by damage to the gastric mucosa. She has chronic course with periods of remission and exacerbations.

A tenth of the total population has stomach problems, most often affecting men in middle age or women after menopause. Peptic ulcers have the following symptoms: heartburn, vomiting, nausea and bloating. With such a disease, a person’s gastrointestinal tract functions are disrupted, severe discomfort when digesting food, especially spicy food. A sign of a complication is gastric bleeding, which, in the absence of timely assistance, ends in death.

The main causes of ulcers include:

poor nutrition;
stressful situations;
physiological characteristics and predisposition to this disease;
hormonal imbalances or changes (in women).

Diagnostic methods

To identify gastric ulcers, examinations are carried out in a complex to determine differential diagnosis. The following types of diagnostics are prescribed:

gastroscopy;
X-ray;
general blood test;
stool analysis for blood discharge;
electrogastroenterography;
biopsy.

X-ray and its importance in ulcers

Radiography is a procedure based on use x-rays to identify any defects in the mucous membrane. It allows you to assess the condition of the stomach. This examination helps to identify early stages diseases of the gastrointestinal tract, tumors and other defects. This procedure is indicated for everyone except pregnant women, patients with last stage ulcers, which may cause bleeding in the stomach, as well as children under 7 years of age. Before the examination, you should not eat for at least 6 hours. The accumulation of gases in the abdominal cavity on the eve of an x-ray is unacceptable, so you need to avoid carbonated drinks, acidic foods, juices, beans, and other things. For constipation, a therapeutic enema is done. The study itself is carried out in 3-6 projections for clarity of the picture.

Endoscopic diagnostics

Endoscopy refers to methods for studying organs into which an examination device can be inserted. Among such bodies we can highlight gastrointestinal tract, bronchi, vessels, gall bladder and others that contain a cavity. This diagnosis helps to identify in the early stages dangerous diseases, such as stomach ulcers, cancer, gastritis, etc. Modern devices make it possible to clearly identify the source of the disease, which will help to further adjust the treatment.

There are rigid and flexible devices for endoscopic examination fabrics, flexible ones are more often used, since with their help you can get into small cavities where large and clumsy tubes will not fit. Modern technologies allow patients who are afraid of swallowing tubes to use capsules with chambers, they are practical and painless.

Gastroscopy as the main diagnostic method

An examination method that shows the localization of pathology, its scale and depth. Helps take a biopsy for histological examination, detect the source of bleeding, remove pathogenic growths. The procedure is carried out with a fiberscope, which is a flexible optical instrument. The device is inserted into oral cavity, and then enters the area of the stomach and duodenum. The image from a small camera at the end of the device is displayed on a screen, and a gastroenterologist examines the patient. Complications during gastroscopy occur in 0.07% of cases, but they can lead to death due to bleeding in the stomach or anaphylactic shock. This examination is not suitable for patients who have:

mental disorders;
poor blood clotting;
myocardial infarction or stroke;
obvious symptoms of the last stage of the ulcer;
bronchial asthma.

Other types of examination

When the considered diagnostic methods are contraindicated, patients are referred for ultrasound and computed tomography. CT makes it possible to obtain a picture of the state of the gastrointestinal tract using small x-ray doses. As an addition, carry out ultrasound examination, it's harmless. There are external and endoscopic ultrasound. When externally, the abdominal cavity is examined ultrasonic sensor, the information is displayed on the monitor. In the second case, the examination is carried out by inserting a device into the esophagus.

To detect defects in the folds of the stomach, it is palpated. The doctor, with light pressure on the abdomen, palpates it to smooth out the gastric walls and get full information about his condition. This procedure requires caution, as the ulcer may begin to bleed due to physical impacts. When a tumor is detected, material is taken for a biopsy. To plan further tactics, you need to know the results of such indicators as:

pH-metry;
physical examination;
PCR method for detecting Helicobacter pylori;
blood test.

Based on the diagnostic results, the patient is individually prescribed complex treatment. It consists of drug therapy, diet and the fight against concomitant diseases such as gastritis. At acute symptoms The patient is indicated for surgery. Signs of gastrointestinal disease cannot be ignored; they can be fatal.