Methods of duodenal intubation

In adults, duodenal intubation produced rubber duodenal probe with metal olive. A more perfect is a double gastroduodenal probe: sucked through a tube duodenal contents, through the second - stomach, thereby preventing their mixing. Duodenal intubation is desirable to produce in a special laboratory or office, to avoid the occurrence of negative emotions.

Sounding contraindicated narrowing of the esophagus and oesophageal varices, bleeding tumors or ulcers of the stomach and duodenum, aortic aneurysm, decompensation of the heart and other serious conditions.

To eliminate the complications of probing patients must first be thoroughly examined and spend fluoroscopy. Patients, costive, It recommended a day before the study enema. Sounding spend the morning, through 12 h after a light carbohydrate meal. It should be explained to the patient the need for research, pointing out its importance and the harmlessness.

The methodology of the duodenal intubation

Handling sister should check the status of the probe and the absence of damage to sterilize it by boiling for 40 m. To eliminate the smell of rubber in boiling water add a few drops of menthol. Simultaneously sterilize two syringes, which are necessary for the introduction of stimuli (cholagogue substances) and if necessary suction duodenal contents. Bile substance, grelku, a set of test tubes to collect bile, tray of gastric juice is placed on the table to probe next to the couch.

The patient is in a seated position on an empty stomach with a small tilt your head forward administered warm boiled probe. This olive is laid to the root of the language and offer a relaxed deep breathing with your mouth closed, and at the height of the exhalation to do vigorous gulp. Oliva passes into the esophagus. In the future, offer the patient after each deep breath through your nose quietly making swallowing and swallowing probe.

In order to facilitate ingestion of the probe and reduce or prevent the gag reflex when passing through olive throat, must be submitted through a tube water, which the subject involuntarily swallows, while swallowing tube. To decrease the gag reflex during the passage of the probe through the esophagus to the patient suggest to drink water in small sips, and at this time the probe is advanced to the first mark, situated at a distance of 40-45 cm from olives. In marked gag reflex, you can lubricate the mouth of 2 % solution dikaina; sometimes, in the absence of diseases of the nasal part of the pharynx, You can enter the probe through the nose without olive. With the introduction of the probe to the mark 0.45-0.5 m (in children aged up to one year to the mark 0.3-0.35 m) the patient is placed on the right side on a soft cushion, and on the area of ​​the liver put a warm hot water bottle, a pillow under your head does not enclose. In this position, the patient swallows the probe slowly to the mark 0,65-0,7 m. At this time, due to peristalsis of the stomach probe passes through the pylorus and into the duodenum. This process continues from 30 to 60 m. The free end of the probe is lowered into one of the tubes tripod, located below the head of the patient.

While Olive is in the stomach, It follows turbid colorless stomach contents acid reaction. If you get an olive into the duodenum appears yellowish clear liquid with a pH above 7,0.

To verify the location of the olive can be carried out with a sample of air gavage or make fluoroscopy.

The sample with the introduction of air

Using a syringe, air is introduced through the probe. If the patient feels the pressure of the right of the umbilicus, manipulator and the obstacle by blowing notes - the probe is in the duodenum. When finding the probe in the stomach the patient feels the flow of air to the left of the navel and heard rumbling in the time of introduction of air, who freely enters the probe.

If the probe does not pass through the pylorus into the duodenum and remains twisted in the stomach, its partially (at 0.1-0.15 m) removed. Then administered by gavage 10-20 mL of warm 2% solution of sodium bicarbonate, and the patient again slowly swallows the probe to the previous index.

Duodenal contents, resulting free gavage, collected in a series of test tubes. It represents the bile to a greater or lesser impurity mucosal secretions duodenum and pancreas.

Further research may be carried out by the classical method or fractional duodenal intubation.

The classic method of duodenal intubation

When duodenal sounding classical method of getting three servings of bile.

A portion - Duodenal content, which falls in bile from the common bile duct, t. it is. a mixture of bile, secretion of pancreatic juice and duodenal mucosa. It is a clear, straw-yellow, and in stagnation of bile darker colored liquid alkaline reaction. Clouding may occur from its impurities gastric juice (in such cases a pH below 7,0). Detectable mucus and flakes examined microscopically, since they may indicate a pathology duodenum.

In the portion - Duodenal content, which includes the gallbladder bile. It is produced by the action of a reflex cholagogue substances as follows. After 15 20 minutes after receiving portions A bile administered by gavage in the form of heat to 30-50 ml 33 % magnesium sulfate solution, to cause a contraction of the gallbladder (reflex Meltzer-Lyon). Sometimes the introduction of a hypertonic solution of magnesium sulfate causes increased motility and sensation of pain (especially in patients, suffering from colitis). As stimuli can be applied bile secretion 10 % peptone solution, 10 % sorbitol solution, and other polyhydric alcohols, 40 % glucose, 10 % sodium chloride solution, and Olive oil, egg yolks, Bile mineral water, etc.. Immediately after the administration of choleretic agents probe tie and 5-8 minutes later, again collected duodenal contents. With a positive reflex by reducing the gallbladder for 25–35 minutes, a gallbladder bile, which normally brown or dark yellow, transparent, alkaline, viscous.

Dark brown or greenish brown observed in gallbladder bile stagnation in the gallbladder. When inflammation of the gallbladder gallbladder bile contains lumps of mucus, which on microscopic examination reveal the characteristic cytological picture. In severe inflammation concentration function of the gallbladder is broken, therefore allocated gallbladder bile has a light yellow color, not differing in color from the portion A bile. If cholelithiasis, violation of patency of the cystic duct due to stones or inflammatory edema gallbladder contraction do not arise and a second portion of the bile is not allocated (negative reflex).

Portions - Hepatic bile golden yellow, transparent. After receiving two of the three tubes bile sensing end. Previously administered by gavage water or a solution of glucose in the warm state, to avoid the feeling of bitterness in the mouth, and slowly remove the tube.

The resulting bile immediately investigate, since after 30 min may change its composition (cells are destroyed, Giardia). If necessary, bacteriological examination of the bile is collected in sterile tubes.

Where, when to get in portions fails, Some researchers recommend reintroduction of gall material. In the absence of positive cystic reflex stop sounding. Re-sensing appointed in a few days (no sooner than 24 no).

For sensing infants using a catheter Nelatona, older children - a plastic tube duodenal lumen diameter of 1-2 mm with olive size 4x15 mm. The study was conducted on an empty stomach (After 7-8 hours after feeding).

While holding the child in an upright position, determine the distance from the corner of the mouth to the ear lobe and then to the navel. Then introduced into the baby's mouth probe olive and gently pushing it up to the entrance to the stomach. After the child is placed on the right side, placing it on the platen, and continue to slowly introduce probe. After receiving portions A bile administered by gavage 2 ml 25 % warm magnesium sulfate solution. After 5-10 minutes after the administration of the stimulus a second crop of bile - in portions, having a golden brown. Then on the right side of the child placed a warm heating pad, Soon after that starts to separate the bile portions with, the color of which is considerably weaker, than previous servings.

Fractional multiple moment duodenal intubation

Fractional multiple moment duodenal intubation makes it possible to realistically assess the functional state of the biliary tract, gallbladder and thus determine the localization of the pathological process.

Preparing for sensing the same, as in classic sounding to give three servings.

After ingestion patients probe duodenal contents was collected in separate tubes every 5 m. Take into account the five-phase sensing.

The first phase - holedohovaya (the common bile duct). Usually right after receipt of a probe into the duodenum in a patient on an empty stomach bile flow is observed. Oliva probe mechanically irritate the sphincter of common bile duct, and 5-7 minutes begins to stand out light yellow transparent liquid without flakes, consisting of duodenal, bile and pancreatic secretion, coming from the common bile duct. This bile is collected for 10-15 min.

The second phase - the closing of the sphincter of liver-pancreas ampoule. Upon receipt of bile from the common bile duct is administered by gavage choleretic agent (33 % solution of magnesium sulfate, or 40 % xylitol or sorbitol solution). The probe is not tied. Entered choleretic substance irritates the nerve endings major duodenal papilla, with the result that there comes a spasm of the sphincter of the common bile duct, which normally lasts 4-6 minutes. Bile is not allocated. During this time, the duodenal mucosa formed cholecystokinin, which, influencing reflex and humoral, It relaxes the sphincter of common bile duct, causing a contraction of the gallbladder.

The third phase - getting bile portions A. It starts with the relaxation of the sphincter of the common bile duct, and ends with the appearance of cystic reflex and is characterized by the release of light- yellow bile from the common bile duct. The normal secretion of bile A portion continues 3-6 minutes (until the appearance of the gallbladder bile).

The duration of phase II and III in the amount of bile secretion, t. it is. the time interval between the stimulus and the appearance of cystic reflex, called the latent period, normally it is 7 12 m.

The fourth phase - getting bile servings, is characterized by the appearance of gallbladder bile, yellow-brown as a result of occurrence of cystic reflex.

In normal within 20-25 minutes for around 35-50 ml gallbladder bile.

The fifth phase - getting bile portions C light yellow color of the liver and intrahepatic bile ducts, which is released after the reduction of the gall bladder. Having two or three tubes of bile portions, which is sufficient for research, once introduced choleretic agent, to check, is fully contracted gall bladder. Normally, after the introduction of the stimulus implies hepatic bile.

The appearance of the patient during the probe complaints of pain, nausea and other diagnostic value, because normally they should not be.

With fractional duodenal intubation is possible to diagnose gallbladder dyskinesia, hepatic, pancreatic sphincter ampoule (Simple) and sphincter Lyutkensa.

Chromatic Sensing

Chromatic Sensing (test with methylene blue) It is used in cases, when the concentration function of the gallbladder and broken distinguish gallbladder bile in color and other characteristics of the bile common bile duct and liver impossible or difficult.

The study was conducted as follows:. In the evening, eve sensing, the patient takes 0,15 g of methylene blue into double gelatin or starch capsule, whereupon the liquid and does not use food for 14-15 hours, t. it is. to the end of the study. In the morning on an empty stomach is carried out fractional duodenal intubation, A bile collecting portions, IN, FROM.

Normally in portions colored blue, while other portions - pale yellow. This is, that the methylene blue in the liver becomes colorless and excreted in the bile. Getting into the gallbladder, methylene blue stain again oxidised and gallbladder bile in the blue-green color. This allows you to accurately determine the origin of bile, the volume of the gallbladder, while cystic reflex bladder emptying. A negative reflex cystic painted blue-green bile is not released. When the gallbladder dyskinesia violation concentration ability chromatographic sensing provides an opportunity to clarify its character.