Examination of the stomach and duodenum

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

Interrogation

Complaints. Abdominal pain caused by stomach pathology is usually localized in the epigastric region and can be either constant or paroxysmal. The most typical are paroxysmal pains associated with food intake, occurring shortly after eating after a certain period of time or passing after eating. Patients may complain of an undefined painful feeling of pressure or tension in the epigastric region associated with overfilling of the stomach and its bloating. Pains associated with stomach disease occur as a result of disturbances in the motor function of this organ (with spasm or stretching of the smooth muscle fibers of its wall).

Heartburn is a burning sensation in the esophagus caused by the reflux of stomach contents.

Nausea is an unpleasant sensation in the epigastric region. In diseases of the stomach, it is usually combined with pain.

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

Belching is a sudden release of a small portion of gastric contents into the oral cavity due to compression of the stomach between the diaphragm, abdominal wall and distended intestines or spasm of the pylorus.

Change in appetite - loss of appetite is common. Lack of appetite - anorexia - is a common symptom of stomach cancer.

History of the disease. The onset of the disease may be acute (gastritis after a dietary error) or gradual. Exacerbations and long periods of remission (in peptic ulcer disease) are often observed. Progression of the disease is typical for stomach cancer. It is always important to clarify the connection between the stomach disease and the use of medications, such as non-steroidal anti-inflammatory drugs.

Physical research methods

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

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

Deep sliding palpation only rarely allows one to feel the lesser and greater curvature and the pyloric sections of the stomach, and even more rarely - a stomach tumor. Percussion and auscultation of the stomach, as a rule, are of no significant importance.

Additional research methods

X-ray examination. First of all, it is necessary to prepare the patient for the examination. For this purpose, the evening before and in the morning of the examination, the patient's intestines are cleaned using enemas; laxatives are prescribed for persistent constipation. The examination is performed on an empty stomach, with the patient in an upright position. Barium sulfate is used as a contrast agent. The examination begins with determining the relief of the gastric mucosa, the folds of which have large variations and often change depending on the stage of the digestion process, sometimes becoming more prominent and distinct, sometimes flattening. If their course is interrupted, the presence of a pathological process in this place is assumed. It is important to study the contours of the stomach. A persistent protrusion of its shadow is designated as a niche, which serves as a typical sign of gastric ulcer. The absence of filling of a section of the stomach with a contrast mass is called a filling defect and is an important symptom of a neoplasm.

Gastroduodenoscopy. With the use of fiber optics, gastroduodenoscopy has been intensively developed and has become the most effective and quickly applied method. Simultaneous biopsy and morphological examination made this method the most effective diagnostic method. The main indication for gastroduodenoscopy is bleeding from the upper gastrointestinal tract and pain in the epigastrium. The great importance of this method also lies in the possibility of using local treatment in case of ongoing bleeding. The advantage of gastroscopy is the ability to detect superficial changes in the mucous membranes that are not detected radiologically. In the presence of a gastric ulcer detected during an X-ray examination, endoscopy is usually also required for visual and histological exclusion of an ulcerated tumor. At any suspicion of a gastric tumor, including in the presence of such symptoms as weight loss, anemia, an endoscopic examination is necessary.

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

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

Basal acid secretion is the total amount of hydrochloric acid secreted in the stomach over four 15-minute periods of time and is expressed in mmol/h. This indicator normally fluctuates between 0 and 12 mmol/h, with an average of 2-3 mmol/h.

Stimulated secretion of hydrochloric acid. The most powerful stimulators of gastric secretion are histamine and pentagastrin. Since the latter has fewer side effects, it is used more and more often nowadays. To determine basal acid secretion, pentagastrin or histamine is injected subcutaneously and gastric contents are collected over four 15-minute periods. As a result, the maximum secretion of acid is determined, which is the sum of the maximum successive secretion values for 15 minutes of gastric juice collection.

Basal and maximum acid secretion is higher in patients with ulcer localization in the duodenum, while with ulcer localization in the stomach, acid secretion in patients is lower than in healthy people. Benign gastric ulcer rarely occurs in patients with achlorhydria.

Serum gastrin test. Serum gastrin levels are determined using a radioimmune method and may be of diagnostic value in gastroduodenal diseases. Normal fasting values for this indicator are 100-200 ng/l. Increased gastrin levels over 600 ng/l (pronounced hypergastrinemia) are observed in Zollinger-Ellison syndrome and pernicious anemia.

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