The Duodenal sounding
The

Duodenal sounding

Duodenal sounding is the acquisition of duodenal contents with a probe. The duodenal probe (fig.) Is a soft, thin rubber tube 140-150 cm long, at the end of which is attached a metal olive, equipped with numerous apertures. On the probe there are three marks: the first - at a distance of 45 cm from the olive tree (the distance from the incisors to the cardiac part of the stomach), the second - 70 cm (from the incisors to the pylorus), the third - 80 cm [from the incisors to the large teat of the duodenum )]. Before insertion, the probe should be boiled and moist.

Probing is performed on an empty stomach. Sitting patient put the olive on the root of the tongue and offer to swallow it, while recommending a deep breathing. After the first mark is at the level of the incisors, the researcher is placed on the right side on the edge of the bed or bench. Collapsed in the form of a roller cushion is placed under the waist, so that the stomach was higher than the head and legs. This position facilitates the further passage of the probe through the pylorus into the duodenum. Near the bed on a low stand (below the bed) is placed a tripod with clean dry tubes for collecting duodenal contents. Lying on the right side, the patient continues to swallow the probe, and it should be done very slowly, gradually, since otherwise the probe can curl up in the stomach. If the olive is moving right, then by the time the second mark is at the level of the incisors, the olive should be at the gatekeeper. One of the next openings of the gatekeeper allows the olive to pass into the duodenum. This usually occurs 45-60 minutes later, in rare cases after 15-20 minutes. After making sure that the olive has passed into the duodenum, they suggest that the patient swallow the probe to the last mark. The location of the olive is determined by the nature of the liquid flowing out of the probe: the duodenal contents are completely transparent, have a golden color, a stiff consistency and an alkaline reaction (when this liquid is applied to the blue litmus paper it does not turn red, but the red litmus paper turns blue); the gastric contents give a haze and have an acid reaction (blue litmus paper when a drop of content is applied to it blushes). The most reliable is the method of checking the location of the olive by fluoroscopy .

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If the duodenal contents can not be learned for a long time, it must be assumed that the probe wrapped in the stomach. In such cases, the probe is pulled to the first mark and again offered to swallow it slowly. If, in the future, the olive does not penetrate the duodenum, we must assume a spasm or stenosis of the pylorus. To remove the spasm, inject 1 ml of a 0.1% solution of atropine. If the spasm is caused by high acidity of the gastric juice, 2% sodium hydrogen carbonate solution (1 teaspoon per 1 cup) is injected through the 1 / 4-1 / 5 probe. In cases of organic obstruction of the gatekeeper, penetration of the probe into the duodenum is impossible. If within 3 hours the olive does not pass into the duodenum despite all the above measures, the probe should be removed and reintroduced after 1-2 days.


Portions of bile A, B and C. On the left in the corner is the scheme of the bile ducts, from which the corresponding portions of bile are extracted

The resulting duodenal contents consist of bile, intestinal and pancreatic juice . It is usually called portion A. To obtain the contents of the gallbladder, lift the free end of the probe with a syringe without a piston above the duodenum level, pour through it 50 ml of a 25% solution of magnesium sulfate, heated to t ° 37 °. After 5-10 minutes. a dark brown or olive thick liquid, portion B, begins to emerge. The appearance of portion B is due to reflex contraction of the gallbladder with simultaneous relaxation of the sphincter of Oddy as a result of contact of magnesium sulfate with the mucous membrane of the duodenum, the so-called bubble reflex. Instead of magnesium sulfate, you can apply 100 ml of olive or sunflower oil heated to t ° 37 °, 30 ml of a 10% solution of peptone, 1-2 ml of pituitrin subcutaneously. After 15-20 min., And sometimes earlier, the excretion of bile, which makes part B, ceases, and a transparent golden-yellow liquid - portion C, originating from the intrahepatic bile ducts - begins to appear (Fig. 29). After receiving it, the probe is removed.

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The results of duodenal sounding are of great diagnostic importance. If a patient has jaundice, portion A is colorless, this indicates a mechanical character of jaundice. Absence of portion B is observed in pathological processes in the gallbladder, accompanied by a violation of the concentration and contractile function (cholelithiasis, chronic cholecystitis, pericholecystitis, occlusion of the bladder duct with stone). In some cases, the bile portion B is somewhat darker than portion A, but does not have a normal dark brown color. This indicates a decrease in the absorption capacity of the mucous membrane of the gallbladder (with chronic cholecystitis). Dyskinesia of the gallbladder is characterized by the inconstancy of the "bubble reflex" or its production after repeated administration of the stimulus, as well as the release of a very dark, almost black bile, often in large quantities. In the study of duodenal contents, its physical properties (color, transparency, consistency) are determined. Normally, all 3 portions are transparent. The consistency is viscous, especially in portion B. The specific gravity of the contents in portions A and C usually ranges from 1.008 to 1.012, in portion B from 1.026 to 1.032. The normal amount of portion B is 50-60 ml. If it is more than 100 ml, it is necessary to suspect the stretching of the gallbladder as a result of prolonged stagnation of bile. The admixture of a large number of leukocytes and mucus causes the appearance of turbidity. The chemical study (determination in the content of bilirubin, urobilin , bile acids, cholesterol ) has no practical value.

The most important is the microscopic examination, which, when the three portions are separately obtained, allows the localization of the painful process to be determined. Normally, the microscopic picture of the sediment is almost the same for all portions of the duodenal contents. The sediment consists of single leukocytes, a scant amount of epithelial cells, individual crystals of cholesterol and crystals of sodium oxalate. When inflammatory processes in the sediment can be found a large number of white blood cells and a lot of mucus in the form of long crimped filaments. A large number of white blood cells, sometimes colored with bile (bile gall infection), and mucus in portion B indicates an inflammatory process in the gallbladder, in portion C - in the intrahepatic bile ducts ( cholangitis ); a large number of crystals of cholesterol in portion B - the presence of stones in the gallbladder. Important is the detection in the duodenal contents of parasites - lamblia. In size they are somewhat larger than leukocytes and are easily recognized by the lively movements. To detect them, it is necessary to examine the sediment immediately after obtaining the duodenal contents and preheat the tube with the contents in warm water. In addition, in duodenal contents, eggs of the cat (Siberian) fluke or liver fluke can be found. For bacteriological examination, the bile is taken into a sterile test tube without touching its edges, and after burning the edges, the tubes are closed with a fired stopper. In diseases of the biliary tract, the most frequently secreted E. coli, staphylococcus , streptococcus , enterococcus , typhoid bacillus. Duodenal sounding is one of the methods for treating diseases of the gallbladder and biliary tract (see Cholecystitis , Gallstone disease ).

A duodenal probe is used to administer antibiotics for inflammation of the biliary tract and medicines for the purpose of de-worming. Duodenal sounding is contraindicated in acute cholecystitis, exacerbation of chronic cholecystitis and cholelithiasis, with high temperature and leukocytosis, with varicose veins of the esophagus and stomach, patients with coronary insufficiency.