Internal med sem 6 lect 1

Questioning and examination ofQuestioning and examination of
patientspatients
withwith
gastrointestinal tract disordersgastrointestinal tract disorders
Propedeutic of internal
medicine
PhD, assistant Zozuliak N.V.

Analysis of publications in recent years clearly
shows that the incidence of the digestive system
diseases increases, especially in developed
countries. These trends are due to several
reasons. First and foremost is the impact of such
pathogenic factors such as chronic stress,
allergy , the impact of negative factors,
environmental factors (health and safety
characteristics of water, air , eating canned food),
and the resultant change in the body's immune
properties of modern man. It was found that
chronic gastritis wasdiagnosed in 50 % of the
adult population, duodenitis in 70-90 % of
patients with gastroenterological diseases.

Аnathomy of the GITAnatomical features of the
digestive tract

Topographic anathomy of the abdomenAnatomical
landmarks stomach

Horizontal topograhic lines
l. costarum – connects the
lower edges of costal arches
l. spinarum – connects the
front upper iliac bones
еpigastrium
mesogastrium
hypogastrium

Parts of the anterior abdominal wall
(by M.D. Strazhesko)
regio iliaca
dex.
regio
epi-
gastrica
regio
hypochondrica
dex.
regio
paraum
bilicalis
regio
abdominalis
dex.
regio
supra-
pubica
regio
hypochondrica
sin.
regio
abdominalis
sin.
regio iliaca
sin.

 Pain
 syndrome of gastric dyspepsia (disorders of
appetite, bad taste in the mouth, bad breath,
belching, nausea, heartburn, vomiting)
 syndrome of intestinal dyspepsia (disorders of stool
- diarrhea or constipation, bloating, rumbling,
increased gas emission (meteorism), tenesmus)
 complaints related to liver disfunction (jaundice,
skin itching, etc.)
 hemorrhagic syndrome
Complains during digestive tract disorders

Features of the pain:
 location, in spread pain - location of maximum pain
sensation
 Irradiation
 Character (burning, squeezing, knife-like)
 Duration
 provocation of the pain (food intake, changes in diet,
hunger, some body position, weight lifting, jumping in after
bumpy ride) and after how many minutes?
 determine whether there is or not a growing pain in a
certain body position, what relieves the pain, describe other
symptoms that precede the pain, occur during or after the
pain (nausea, vomiting, flatulence, defecation)

Topography of the abdominal organs lesions
• stomach (large curvature)
• spleen
• tail of the pancreas
• splenic angle of the colon
• the upper pole of the left
kidney
right hepatic lobe
• gallbladder
• hepatic angle of the colon
transverse
• the upper pole of the right
kidney
liver (left lobe and small
part of the right lobe)
• stomach (body and pylorus)
• upper half of duodenum
• Pancreas
• aorta
descending colon
• part of the small intestine loops
• lower pole of the left kidney
• ascending colon
• small intestine
• lover pole of the left kidney
sigmoid colon
• loops of small intestine
• left ureter
• Left Ovary
* appendix
• iliac intestine
• cecum
* The right ureter
• The right ovary
lower horizontal part of the
duodenum
• transverse colon
• cecum and ileum
• right kidney (medial part)
• aorta
8
loops of small intestine
• bladder (upper half)
• part of the sigmoid colon
• uterus
7 9
6
32
5 4
1

Esophagus (acute inflammatory lesions of the
mucous membrane, heartburns)
located along the course of the esophagus or
behind the breastbone
irradiation to the shoulder, lower jaw,
interscapular region
closely associated with the food intake
increases or decreases during swallowing
PAIN

Stomach: main reasons of the pain
occurence
 spasm
 strain
 disturbances in the motor function
 transition of the inflammation to the peritoneum
PAIN

 Spastic contraction of the muscles of the stomach →
periodic pain
 Irritation of the nerves of the stomach → permanent pain
 Increased tone of the n. vagus - ↑ acidity of the stomach
juice. The pain occurs in different time period: early (30-
40 min), late (1.5-2 h), night pain. Improvement after
vomiting - release of acidic content.
 Seasonality of pain - the occurence or exacerbation at
autumn or spring.
 Connection with food intake: Increased pain after taking
spicy, salty food
 Stomach pain irradiats to the back, shoulder, lower
interscapular area, left hypochondrium.
Pain in the stomach

Stomach:
Character of pain (feeling of tension,
overflow, heaviness, swelling, drilling,
burning)
- Pulling pain - as a result of stretching.
- Paroxysmal (colic) - spasm of the
pylorus.
- During ulcer perforation is observed a
sharp pain (occurs suddenly, piercing the
belly, “knife-like")
Pain

Stomach: More higher ulcer location is
characterized by lesser time interval of pain
occurrence after food intake
 Ulcer of cardiac part of stomach and small curvature –
pain occurs after 15-20 min;
 Ulcer of the big curvature – pain occurs after 30-45 min;
 Ulcer of the antrum – after 1-1,5 hours;
 Ulcer of duodenum - 2 hours after food, often – in the
night.
Pain

Intestinal Pain differs from the stomach:
 is independent from eating time
 There is connection with the act of defecation (increases before and
during defecation, decreasing after defecation)
Character
 Spastic pain - spasm - short-term
 Distensional pain - stretching – long-term
Location
 right iliac area - appendicitis, an inflammation of the cecum
(typhlitis)
 left iliac area - sigmoiditis, intestinal obstruction
 around the navel - enteritis.
 in the perineum - diseases of the rectum.
 irradiation depends on the part of the intestine
Pain

Pancreas
 Head - the pain is localized in the epigastric region from the right
 Body - in the epigastric region from the left
 Tail - left upper quadrant
 The whole pancreas - encircling pain, upper abdominal pain
Features of the pain
 intense, most pronounced in hemorrhagic pancreatitis, pancreatic
edema
 irradiating to the left half of the body - left upper quadrant, shoulder,
arm, waist
 due to stretching of the capsule, increased pressure in the duct,
irritation of the parietal peritoneum that covers the pancreas
Pain

Печінка, жовчовивідні шляхи
– ураження / розтягнення Гліссонової капсули
– запалення жовчного міхура і жовчних протоків, а
також при їх розтягненні та спазмі
Патологічні процеси паренхіми можуть не давати
больових відчуттів
 локалізується в правому підребер’ї, пов'язаний з вживанням їжі
(жирної чи смаженої) та глибоким диханням.
 особливо гострий біль при спазмі м’язів жовчного міхура,
проток чи закупорці їх каменем (жовчна або печінкова коліка).
 характер болю: колючий, ріжучий.
 іррадіює в ділянку правого плеча, праву лопатку, праву
половину шиї
БІЛЬ
Liver, Gallbladder
– Damage of the Glissons capsule
– Inflammation of the gallbladder and bile ducts, and
during them distension or spasm
N.B! Pathological processes in parenchyma do not cause
pain sensations
Features:
 Is localized in right hypochondrium, is connected with food intake в
(fat or fried food) and deep breathing.
 Especially acute pain occurs in case of gallbladder or it's ducts
spasm or stone formation (liver colic).
 Character of pain: piercing, knife-like.
 Irradiates to the right shoulder, right part of the neck
Pain

disorders of the swallowing act : can not to swallow or it
is paintfull
 disturbed promotion of the food in the pharynx and
along the esophagus
 discomfort feelings, associated with delayed food in the
pharynx and esophagus
Often patients should drink water after taking food.
Reasons:
functional restriction - dysphagia occurs periodically
organic - increases gradually and progresses
Paradoxical dysphagia – patient can eat solid food, and
cannot - liquid food
Dysphagia

Burning sensation of the
patients behind a sternum, in
epigastric area.
Occurs due to the irritation of
the esophagus by an acid
stomach juice due to the
reflux.
Heartburn (pyrosis)

discharge of air from the mouth, which was accumulated in the
stomach (eructatio) or air with food (regurgitatio);
caused by contraction of the muscles of the stomach and
simultaneous relaxation of the lower esophageal sphincter
The smell of rancid oil (due to oil and lactic acid ) due to the
development of fermentation processes
regurgitation with the smell of rotten eggs - gastritis with
secretory failure;
Rotten, putrid belching before food intake - pyloric stenosis ;
 regurgitation with unbearable odor occurs in a case of fistula
formation between the stomach and colon ;
Acidic regurgitation is observed in increased acid formation in
stomach 
Bitter taste may be associated with throwing bile into the stomach
(duodeno-gastral reflux).
Belch (відрижка)

shows involvement in the pathological
process of the phrenic nerve
Reflector hyper function (n. vagus )
Salivatory glands due to the esophageal
receptors irritation
Hiccup
Hypersalivation

reflex associated with n.vagus irritation
- Shows an unpleasant feeling of pressure in the
epigastric region, general weakness, increased
salivation and sweating, dizziness, decreased blood
pressure, pale skin
- Often precedes vomiting, but can occur without it
- - Nausea often observed in diseases of the biliary tract
- Nausea can be caused by toxic drugs, toxins produced
in the body in uremia, diabetes, burns
- - Reflex nausea may occur during stimulation of the
tongue, throat, pharynx, trachea, vomiting center in the
brain
Nausea

complex reflex due to excitation of the vomiting center,
during which occures release of stomach contents
through the esophagus, throat, mouth, sometimes
nasal cavity
Reasons of the vomiting
central
haematogenic-toxic
visceral or reflectory
Vomiting which is not connected with the stomach
diseases:
- is not associated with food intake
- is not preceded by nausea
- is repeated and do not brings relief
Reasons: medicines, infectious diseases, pregnancy,
brain tumor
Vomiting, (emesis)

 morning vomiting with a lot of mucus and saliva -
chronic gastritis
 a few minutes after eating - narrowing of the esophagus,
ulcer of the stomach cardia
 2-3 hours. after eating - chronic gastritis, peptic ulcer
disease, gastric atony of muscles
 stagnant vomiting, in vomit mass there is a residues of
1-2 days ago food – pylorus stenosis
 a small amount of vomiting - stomach neurosis.
Acid vomiting mass - hypersecretion
putrid smell - the disintegration of the tumor
ammonia smell - uremic gastritis, renal failure
Alcohol odor - acute alcohol poisoning
fecal vomiting - during intestinal obstruction
Vomiting (emesis)

Impurities in the vomiting mass, mucus (gastritis), bile
(reflux from the duodenum to the stomach), pus
(abscess), blood, worms.
Blood in vomiting mass
- Bloody vomiting (haematemesis, "coffee grounds") due
to the formation of chloride hematin, which has a brown
color and is formed by the interaction of hemoglobin with
HCl
- With hypo- and anacid blood is not changed in vomiting
mass
- Vomiting by the not changed blood due to the
esophageal bleeding in a case of portal hypertension
(cirrhosis)
- An admixture of blood can be in the case of ingestion in
cases of bleeding from the gums, nose
Vomiting (emesis)

Порушення апетиту
 anorexia – loss of appetite due to decreased excitability
of food center
 loss of appetite can be selective - aversion to meat
dishes - during gastric secretory function reducing
 forced refusal of food: citofobia - refusal to eat food
because of fear of pain (pancreatitis)
 increased appetite bulimia (bulimia means: bus - buffalo,
limos - hunger)
 distortion of appetite, passion to chalk, graphite, coal –
at anemia, pregnancy, hysteria . This condition is called
pica or parorexia
Apetite disorders

desire to defecate, accompanied by sharp
pain and spasms in the rectum, whicjh are
completed by incomplete release of
intestinal contents or without defecation.
During tenesmus occurs spastic contraction
of the smooth muscle of the colon (rectum
and sigmoid).
Tnesmus (teino - strain, stretch; tenesmus -
unsuccessful desire to defecate; colica rectalis)

Meteorism is a medical condition in which excess
gas accumulates in the gastrointestinal tract and
causes abdominal distension
The digestive tract always contains a large amount of air and gases:
an average amount is 900 cm3, under certain conditions, this
number increases
Flatulence occurs in a case of:
- enhanced gas production in the intestine in the use of products
that contain high amounts of fiber and starch (beans, cabbage,
potatoes, black bread)
- excessive swallowing air (aerophagia)
- violating of the gas emission from intestine (atony, ileus)
- digestive disorders in the intestine due to insufficient enzyme
production, violation of the intestinal microflora (dysbiosis)
- hysteria (psychogenic flatulence).

it is sounds in the stomach, they can be heard at a
distance from the patient that occur during the
passage of gas through relatively narrowed
intestine.
Diagnostic value of grumbling is that it points on a
combination of flatulence with difficulty of fecal
passage through the intestines - spastic character.
Intestinal growl (borborigmus)

- the presence of bright red blood in the stool -
ulcerative colitis, intestinal tumors, fissures,
hemorrhoids (bleading from the lower part of
intestines)
- Black stool - melena - bleeding from the
stomach, upper parts of intestine
- The allocation of a large number of bright red
blood - bleeding below the left colon flexure
Intestinal bleading

is rapid (more than 2 times per day) bowel movement with
the release of liquid or soft excrements.
Diarrhea is a symptom of many diseases of internal organs:
- intestinal infections (dysentery, cholera)
- inflammatory bowel disease (enteritis, colitis)
- other diseases of the digestive system (chronic
pancreatitis, hepatitis and liver cirrhosis, disease of the
biliary ways)
worms,
- poisoning by salts or heavy metals (mercury, lead and
others.)
- endogenous intoxication (chronic renal failure)
- endocrine diseases (hyperthyroidism, insufficiency of
adrenal glands)
- vitamins insufficienty,
- food allergies.
Diarrhea (diarrhoea)

The mechanism of diarrhea occurrence is complex and
includes several pathogenetic parts:
- increasing osmolarity of intestinal content (for
example, during taking laxatives)
- increased secretion of water and electrolytes by
epithelial cells of the small intestine (in case of cholera)
- disturbance of digestion and absorption in the
intestine (especially after extensive resection of the
small intestine)
- disorders of motor function of the intestine with the
acceleration passage of intestinal contents
- inflammatory changes of the intestinal mucosa

There are such types of diarrhea
- enteric
- colitical
Enteral diarrhea have next features:
- lower frequency (not more than 4-5 times a day)
- a significant volume of stool
- is a manifestation of maldigestione syndrome (impaired digestion
in the wall and cavity) and malabsorption (malabsorption) that
occurs in various diseases of internal organs
Colical type of diarrhea is characterized by :
- greater frequency (10 times or more per day)
- the release of a small amount of feces (often mixed with mucus
and blood)
- usually accompanied by cramping abdominal pain and tenesmus

In a case of violating of the splitting and absorption of proteins occurs
liquid stool dark color with alkaline reaction (due to the formation of
ammonia) containing particles of undigested food with disgusting
putrid smell, muscle fibers (creatorrhea) and connective tissue -
putrefactive dyspepsia. In addition to intestinal methane also are
formed hydrogen sulfide, indole, skatole and other products.
In a case of violating of the splitting and absorption of
carbohydrates in combination with the activation of gut
fermentation appear frothy mushy stool with acidic reaction,
containing a significant amount of starch grains (amylorrhea) and
iodinophilic microflora - fermentation dyspepsia. Stool is light
yellow, defecation is not more than 5-6 times a day. Pain arise long
before a bowel movement, are dull and not very intense,
accompanied by rumbling. Flatulence is marked with a large amount
of gas.
In a case of violating of the splitting and absorption of fats occurs
their active excretion in the feces (steatorrhea) - fatty dyspepsia.
Patients complain of bloating, rumbling, frequent liquid stools. Stool
is usually light, with neutral or alkaline reaction.

slowing of the intestinal emptying more than 2 days (in severe cases
5-7days). The water content in the stool decreases, it becomes
harder, looks like "Sheep feces."
Constipation can be caused by various reasons:
- alimentary - deficient fiber, liquid content in diet; fasting
- so-called "conventional" constipation are associated with the
weakening of the fefecation reflex
- in a case of sedentary lifestyle, prolonged supine position, with
the weakening of the abdominal muscles
- neural – occurs in a case of spastic colon (or hyperkinetic or
spastic constipation) or reducing of its motility (hypokinetic or
atonic constipation)
- proctogenic constipation - patients suffering from hemorrhoids
- when taking certain medications (antacids)
- endocrine diseases (myxedema)
- constipation associated with organic diseases of the intestine,
abnormal development (dolichosygma, megacolon), tumors of
colon, diverticuls, intestinal obstruction due to adhesive process
of the intestines (after surgery)
Obstipation (obstipatio)

Through history should be taking by common scheme, it
is necessary to clarify:
- how disease began (acute, gradually);
- the sequence in which complains appeared;
- connection with food intake, the act of defecation;
- tolerance of certain food products;
- how patient nutrition affect the condition of the
patient;
- check the medical records – data of ultrasound
(presence of stones in the gall bladder), previous
endoscopic, radiologic studies;
- Previous use of drugs (prolonged use of antibiotics
can cause diarrhea and bloating, NSAIDs cause
erosive lesions of the digestive tract, hormonal
contraceptives cause biliary dyskinesia)
- the nature of the treatment, its effectiveness.
case history

Doctor have to find out :
 regime and the nature of food intake
 use of a large number of fatty meat in combination with alcohol -
the risk of acute pancreatitis ;
 stress - important in the development of peptic ulcer ;
 Smoking - promotes diseases of stomach and duodenum ;
 hereditary factor ( cholelithiasis , peptic ulcer, hereditary
disease - congenital benign hyperbilirubinemia );
 pay attention to surgery on abdominal organs, previous
diseases, helminths;
 contact with patients with jaundice in the last month or a history
of parenteral interventions over the last six months ;
 Occupation of the patient can also help in establishing the
diagnosis : the drivers are prone to diseases of the stomach and
duodenum, is due to irregular eating and stressful nature of the
work;
 Professional intoxication ( lead, arsenic, mercury, gasoline
vapors);
 use of chemical and herbal poisons ( alcohol substitutes,
mushrooms).
Anamnesis of the life

- pale skin indicates cancer, anemia (after
bleeding, iron malabsorption or insufficient
production of hematopoietic factors by gastric
glands)
- signs of itching
- jaundice (icterus)
General view of the patient
Skin and mucous membrane

Patients with gallbladder disease often
have cholesterol deposits on the
eyelids (xanthelasma)
and skin (xanthoma).
At the review can also be noted the presence of:
-Telangiectasia
- spider navi
- Hyperaemia of the tenar (palmar erythema or "liver palms“)
-in men can be observed, gynecomastia (breast enlargement)
These are all symptoms associated with hyperestrogenemia.
Skin and mucous membrane
gynecomastia
Telangiectasia

Is performed in a vertical and horizontal position of the
patient
Doctor should pay attention to:
condition of skin
development of subcutaneous veins
state of the navel
the shape of the abdomen
symmetry
size, presence and character of the rash on the skin
the presence of postoperative scars
visible pulsations
Examination of the abdomen

Gastric dyspepsia: nausea, vomiting, heartburn, regurgitation,
distortion appetite.
Intestinal dyspepsia, flatulence, disorders stool (diarrhea,
constipation).
Liver and biliary tract diseases are characterized by fatty
indigestion (or soap) depends on fat digestion disorders. One of
its causes is the rapid transition of food through the small
intestine, lack of lipolytic pancreatic function, and violation of the
flow of bile into the intestine.
Syndrome fermentation dyspepsia - indigestion in the colon. In
the analysis, mushy stool, yellow color, with acidic reaction, a
small amount of soaps and fatty acids; planty of starch, digested
fiber and iodinophillic flora
Syndrome putrefactive dyspepsia - indigestion in the colon. In
the fecal analysis, mushy stool with alkaline reaction and
putrefactive smell; increased amount of fiber; increased
ammonia content
Main syndromes

Malabsorption syndrome - clinical
syndrome caused by malabsorption
through the mucous membrane of the
small intestine of one or more nutrients.
Maldigestion syndrome - clinical
syndrome caused by indigestion of food
particles required for absorption, which
leads to malabsorption in the intestines
through the intestinal wall
Main syndromes

jaundice syndrome
Hemorrhagic syndrome: bleeding gums, nosebleeds,
skin hemorrhages.
Cholestatic syndrome: persistent have itching, jaundice,
skin pigmentation, ksantelazms.
Intrahepatic cholestasis - lesions of hepatocytes.
Extrahepatic cholestasis, compression or inflammation
of the liver ducts from inside by stone or from outside
(tumor of the pancreas).
Hypersplenism syndrome, liver enlargement, anemia.
Portal hypertension – caput medusae
Main syndromes

INSTRUMENTAL METHODS OF
gastrointestinal tract and kidneys
investigation

 X-ray examination of the stomach
 Plain radiograph of the abdomen
 Іrrigoscopy
 Computer tomography
Gastric probing
PH metry
Duodenal probing
INSTRUMENTAL METHODS OF THE GASTROINTESTINAL TRACT ARE
divided into:
Endoscopic:
Esophagogastroduodenoscopy
Sigmoidoscopy
Fibrokolonoscopy
X- ray:
Probe methods:
Sonographic:
Ultrasound of the abdomen

Fibroezophagogastroduodenoscopy
a review of the mucous
membrane of the
esophagus, stomach and
duodenum using an
endoscope, which is
administered to the patient
after anesthesia of the
pharynx

 Research of the mucosa
membraine
 Determination of pH
 Biopsy → morphological
study (diagnosis of the forms
of chronic gastritis, gastric
cancer)
 Possibility of introducing
drugs
 Opportunity to stop the
bleeding in the stomach or
duodenum
Fibroezophagogastroduodenoscopy
OBJECTIVE:

- Fibrogastroduodenoscopy is performed at the morning on an empty
stomach, emergency - at any time
- - At first anestesia of the throat and esophagus is performed by 3% solution
of dicaine
- -The patient is placed on the left side
- -Inserted into the mouth and injected sterile mouthpiece probe
- Before examining the patient for 2 hours should not eat, drink, smoke, and
- if biopsy was performed, patient can not eat that day a hot meal
Prepare patient for examination

Rectoromanoscopy (RRS)
With rectoromanoscop can be
examined the colon mucosa
to a depth of 30-35 cm from
the anus.
Method of the endoscopic examination of the
rectum and distal sigmoid, investigation of their
inner surface with rectoromanoskop introduced
through the anus.

Indications:
- pain in the anus
- discharge of blood, mucus or
pus
- violation of stool (constipation,
diarrhea)
- suspected cancer of rectum or
sigmoid
Contraindications:
No absolute contraindications.
Relative contraindications are:
- cardiac decompensation
- severe general condition
- narrowing of the rectum
- acute inflammation of the anus
- stenosing tumor of the anal canal

Preparing to RRS
An important condition for RSS is a thorough
colon cleanse from the content.
At the evening before investigation diet is
prescribed - just tea is allowed .
Investigation is performed on an empty
stomach.
- In the evening and 2 hours before
investigation cleaning enemas are used.

Normal mucous membrane
РЕКТОРОМАНОСКОПІЯ (RRS)
RRS зазвичай виконується в колінно-ліктьовому положенні пацієнта.
При виражених болях в області заднього проходу RRS проводять під
місцевою або загальною анестезією.
У анальний канал вводять ректоскоп і поступово просувають його
вперед при подачі повітря для розправлення просвіту кишки.
Після видалення обтуратора ректоскопа під контролем зору його
проводять вгору до сигмоподібної кишки.
При RRS можна провести біопсію для гістологічного дослідження.
 Показання до біопсії є: наявність поліпів, пухлини, виразок,
інфільтратів.

Colonoscopy





Method of endoscopic investigation of colon
Colonoscopy is the most informative method of early diagnosis of
benign and malignant tumors of the colon, ulcerative colitis,
Crohn's disease allows to inspect 80-90% of the colon.
It is possible also to perform various therapeutic manipulation -
removal of benign tumors, stop the bleeding, extracting of the
foreign bodies, recanalisation of bowel stenosis
Показання:
підозра на пухлину
запальні захворюваннях
товстої кишки (особливо
неспецифічний виразковий
коліт, хвороба Крона)
кишкові кровотечі
кишкова непрохідність
наявність сторонніх тіл
Протипоказання:
гострі інфекційні хвороби
перитоніт
пізні стадії серцевої та
легеневої недостатності
виражені порушення
згортання крові
важкі форми виразкового та
ішемічного коліту

The success of the research depends on correct preparation for the
procedure.
At the evening before research should be performed two cleansing
enemas
In the morning before study should be done the same two enemas
3-4 days before investigation should be prescribed a diet, excluding
from the diet fresh fruits and vegetables, brown bread, cabbage in any
form
Colonoscopy
Preparation

Colonoscopy
Normal mucous
membrane

X-ray investigation of stomach
Indications:
- Dysphagia
- Complaints: heartburn, belching, loss of appetite,
abdominal pain, nausea, vomiting
- stomach ulcers or tumors
- weight loss
- The presence of seals abdominal palpation
- ascites
- anemia of unknown ethiology
- the presence of occult blood in the stool
makes it possible to investigate the shape, size, position, mobility of
stomach, ulcer, localization of tumors, relief of the stomach, damage or
lack of folds, a symptom of "niche" (ulcers), "filling defect" in a case of
tumors.

X-ray of stomach
Pefformed on an empty stomach
2 - 3 daysbefore investigation
should be removed from the
patient's diet foods that cause
flatulence (beans, cabbage,
potatoes, black bread)
Dinner before the test should be
light, not later than 20:00.
Immediately before the test
patient drink 200 ml of a mixture of
barium
Preparing
Normal

Irrigoscopy
X-ray examination of rectum and colon, allows to determine the
localization of the pathological process, the presence of diverticuls
and evaluate the functional capacity of the intestine.
Indications:
bloating
diarrhea
constipation
blood in the stool
weight loss
Preparing – cleaning enema, diet

рН-metry
The method of gastric secretion determination
The clinical significance of pH metery: it is the
best diagnostic method of functional disorders,
acid-dependent diseases, in the digestive tract
diseases, allowing in all cases, especially when
combined pathologies develop an adequate
treatment strategy and monitor the progress of
treatment

рН
Stomach
body
рН
Antral part
hyperacidity < 1,6 < 2,1
Normoacidity 1,6-2,3 2,1-3,0
Hypoacidity > 2,3 > 5,9-6,0
рН-metry

Duodenal probingDuodenal probing
Research of duodenal content that is performed to
investigate the bile to detect lesions of the biliary
tract and gall bladder

The patient is siting with opened mouth
The probe is introduced that olive was at the root of the tongue,
and we offer the patient to swallow
When the probe, according to the marks, must be in the stomach,
its position shoud be checked by aspirating of gastric content by
syringe: muddy liquid with acid reaction. The liquid may be yellow
in the case of throwing to the stomach contents of the duodenum,
but the reaction should be acidic
When the probe is in the stomach, the patient is placed on the
right side that olive was mooved to pylorus
Then the patient continues to swallow slowly probe till mark 70
cm, then expect the olive passage in the duodenum, which is due
to 1-1,5 hours.
If the olive is in the duodenum, the tube starts flowing with
yellow liquid with alkaline reaction

Phase duration volume characteristic portion
І Choledochus 10-15 min. 15-20 ml
Light yellow
duodenal content
“А”
ІІ
Closed Oddi’s
sphincter
2-3 min. - - -
ІІІ
Bile excretion from
bile duct
3-6 min. 3-5 ml Light yellow bile
ІV
Bile excretion from
gallbladder
20-30 min.
30-50 ml Dark brown bile “В”
V
Bile excretion from
liver duct
20-30 min.
10-30 ml Light yellow bile “С”

Ultrasound
Review subject:
Liver, spleen
Portal, spleen and splenic vein
gallbladder
pancreas
retroperitoneal lymph nodes
kidneys
Ultrasound is performed on an empty stomach. For the patient with
increased gas production is recommended for 2-3 days before the
test use a diet, excluding from the diet raw vegetables, foods rich in
fiber, milk, black bread, beans, sweets. It is advisable to take during
this time enzymes and enterosorbents.
Preparing

Excretory urography - one of the leading X-ray techniques to
study the morphology and function of the kidneys and urinary tract.
It is based on the physiological ability of the kidneys to capture from
the blood iodinated organic compounds, excreting them with urine
and contrast porous system of the kidneys, ureters and bladder.
Contrast is introduced
i.v.

Ascending (retrograde) pyelography - a method
that helps to clarify the status of renal pelvis
system
Investigation is carried out on an empty stomach, after cleaning the
bowel. In aseptic conditions, using a special cystoscope at first
examine the bladder wall, than through the ureter in the renal pelvis
is introduced the X-ray catheter. Than in the bowl slowly is injected
8-10 ml of 20-30% solution of sterile contrast agent.

Internal med sem 6 lect 1

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Internal med sem 6 lect 1