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DOI: http://dx.doi.org/10.20534/ESR-17-5.6-19-22
Diomidova Valentina Nikolaevna, I. N. Ulianov Chuvash State University, Cheboksary, Russia E-mail: diomidovavn@rambler.ru Fazilov Akram Akmalovich, Doctor of medical science, professor Academician of the academy of Medical and Technical science of Russian Federation Head of department ultrasound diagnostics Tashkent institute for postgraduate medical education
Tashkent, Uzbekistan E-mail: fazilovuz@gmail.com Sayfiyeva Suraye Hasanovna, Department of ultrasound diagnostics Tashkent institute for postgraduate medical education
Tashkent, Uzbekistan E-mail: fazilovuz@gmail.com
OPPORTUNITIES OF MULTIPARAMETRICAL ULTRASONIC STUDY OF GASTRODUODENAL ULCERS
Abstract: A diagnostic layer-by-layer image of the stomach and duodenum (empty and with their cavities filled with water) obtained by ultrasonography allowed not only to assess the functional activity (motor, contractile, evacuative etc.), but to identify the presence of organic changes in the given hollow organs walls as well. A diagnostic image of the stomach in healthy people with presentation of quantitative characteristics of walls was reflected earlier. Results of complex research of 117 patients with stomach ulcer and DU were analyzed. Implementation of the offered technology of multi-parametric layer-by-layer ultrasound examination of the stomach and duodenum, including examination with tight cavities filling with water, allows to detect in time significant signs of gastric and duodenal ulcers and to recommend application of the method as early as possible at the onset of gastroduodenal ulceration in patients.
Keywords: ulcer, stomach, duodenum, ultrasound investigation, multi-parametric study.
Introduction. Almost all methods of X-ray diagnosis can successfully be used to obtain medical imaging — a structural-functional stomach and duodenum image (like any other human organ) in order to collect necessary information about the status of a healthy or a pathologically changed organ being examined [1]. At this, the main sources for obtaining medical or diagnostic imaging ofabdominal organs, including when studying the stomach and duodenum, are X-ray, magnetic-resonance, ultrasound methods, allowing in most cases to get important diagnostic information, which is complementary to endoscopic studies results [1-5].
Despite the fact that ultrasound examination method in the algorithm of other methods of gastro duodenal zone (GD) examination is a relatively young trend, improving existing and developing of new diagnostic techniques enhanced opportunities of the method [6]. Many publications contain data confirming high accuracy and informative value ofultrasonic diagnostic technologies in identification ofprecancerous conditions, inflammatory, neoplastic and other various gastric and duodenal pathologies [7-9]. There are works on successful use of ultrasound diagnostics for pyloric and duodenal pathologies [10; 11]. It is also noted that ultrasound examination method ofhollow digestive organs due to simplicity of its use and absence of invasive intervention is positively perceived by
patients, while it gives the opportunity to obtain information on in-traparietal changes and is a reliable monitoring means in gastric ulcer (sensitivity: 89% — 85%, specificity, accuracy — 86%) [12]. Currently, though sufficient experience in ultrasonic diagnostics of gastroduodenal pathology [6-11] is gained, the binding protocol of ultrasound abdominal examination does not include gastric and duodenal studies as mandatory.
Study purpose: determining diagnostic opportunities and informative value of multi-parametric transabdominal ultrasound examination in gastroduodenal ulcers.
Material and methods. The work is performed on the basis of data analysis obtained by gastric ultrasound examination of 117 patients with gastric ulcer (GU, n=45) and duodenal ulcer (DU, n=72) included into treatment group of the study, those who applied to the Budget Institution "Municipal Clinical Hospital № 1" of Public Health Ministry of the Chuvash Republic (Cheboksary, Chuvash Republic) and Kashkadarynsky regional medical diagnostic centre (Karshi, the Republic of Uzbekistan). Joint study was performed on the basis of cooperation agreement between Federal State Budget Educational Institution of Higher Education «I. N. Ulianov Chuvash State University» and Tashkent Physicians'
Continuing Education Institute. The age range of the patients was 17-68 years old (mean age was 40.7 ± 11.5 years). Among them, there were most men — 57.9%, and 42.1% women. In the control group 100 healthy individuals without any gastroduodenal pathology were examined. Among healthy persons examined there was an equal number of men and women (average age 42.8 ± 12.3 years).
The plan of patients' integrated examination included ultrasound, endoscopic, X-ray, MRI studies of the stomach and the duodenum, histomorphological studies of endoscopic biopsy and postoperative materials. All the patients had ultrasound examination of abdominal organs and kidneys performed. Ultrasound examination was performed using Aixplorer scanners (Supersonic Imagine, France) and Ascuvix V10 and Ascuvix V20 (Medison, South Korea) in different modes, 2D-3D ultrasound imaging using curved transducers, mini-curved transducers, sector and linear types of transducers at 3.5 to 7.5 Mhz. Magnetic-resonance tomography study was conducted in pulse sequence T1 WI, T2 WI, T1 and T2 Fsat, T2 STIR, with slice thickness up to 2.5 mm in axial, sagittal and coronary planes (EXCEL ART Vantage Atlas, 1.5 TSL «Toshiba», Japan) at tight filling of gastric and duodenal cavities with water at room temperature.
An improved technique of transabdominal gastric ultrasound examination and normal diagnostic image of the stomach were described in detail earlier [7; 9; 14].
The technique of multi-planar ultrasound of the duodenum was the following. Duodenal examination started after a thorough visual inspection of all gastric sections both under fasting condition and after filling the cavity with fluid [11; 14].
Results and discussion.
In most cases, normal diagnostic duodenal image received was better in duodenal bulb, which was determined to be more distally, more to the right and posteriorly of the pyloric gastric part (inferiorly and posteriorly in relation to right lobes of the liver, cervical and proximal parts of the gall bladder body and above the pancreatic head). At this, pyloric gastric part and duodenal bulb when their cavities were filled tightly with fluid gave a visual ultrasound image of semiorbicular interconnected liquid structures in the form of «Sandglass», and when scanning along the long axis — in the form of liquid structures located in different planar sections relative to each other depending on the beam and scan plane direction (fig. 1.2).
a)
Figure 1.
b)
Fig. 1 (a, 6). Ultrasound image of pyloric part of the stomach and duodenal bulb in the norm in different scanning planes: a — without tight cavities filling with water, the patient is lying on his
back, the sensor is in epigastric area, 6 — the same in mesogastic area with filling with water.
Diagnostic ultrasound image of descending duodenal part in the norm when the cavity was filled with fluid was visualized a little more medially, lower and anteriorly of the medial contour and right reni-portal structures (when studying in fasting condition in the norm it was practically impossible to differentiate it echographically from surrounding). It should be noted that when studying the given duodenal part, the patient was given an additional portion ofliquid (the amount depended on the time of initial fluid evacuation from the stomach cavity, in the average — 160±35,0 ml). The remaining duodenal parts due to rapid fluid evacuation from them were not investigated.
Figure 2 (a, 6). Ultrasound image of gastric and duodenal parts in the norm at their examination with their cavities filling depending on the patient's position: a — the patient is in right lateral decubitus; 6 — half-turn posteriorly.
The peripheral part of duodenal structures (the wall) had a significantly lower echogenicity and a layered structure in the form of a thin rim with smooth contours of uniform thickness, covering the
central echogenic (when studying in fasting condition) or unecho-genic (in the presence of liquid in the cavity) zone. Duodenal wall thickness normally averaged 4.9 ± 0.2 mm (p<0,001, when compared with treatment group), wall thickness of the bulb and thickness of postbulbar part did not significantly differ. The diameter of the bulb when filling the duodenum tight with water according to ultrasonography made 29.6 ± 2.7 mm. Echo-layers of duodenal bulb wall were identical to echo-layers of gastric wall [7; 9; 14].
When examining patients both under fasting condition and with filling the stomach and the duodenum with fluid in most cases (93.2%) in ulcerative defect localization in the wall of the stomach and duodenum the symptom of «hyperechogenicity» in the wall of the affected organ was found (DU — 68 cases (94,4%) GU — 41 cases (91,1%,) as a significant (p < 0,001) sign of ulcer which was characterized by the presence of local amplification in echogenicity in ulcerative fossa area, whose width size matched the size ulcerative fossa (fig. 3).
a)
b)
Figure 3.
Figure 3 (a, 6). Ultrasound image of ulcer in the posterior wall of pyloric gastric part (a — antero-posterior image: 6 — profile image): local increased echogenicity in ulcerative fossa zone, hyper-echogenic inner contour of ulcer edges and bottom are limited by hy-poechogenic peri-ulcerative infiltration. An equal ratio of ulcerative fossa diameter to peri-ulcerative infiltration thickness is determined.
Gastroduodenal ulcers may be a manifestation of not only ulcers, it is necessary to be aware of symptomatic (secondary) ulcers that occur, for example, after extensive surgeries and injuries or acute vascular and other diseases of internal organs [15].
Both primary and secondary benign ulcerations ofthe stomach and the duodenum at multi-parametric ultrasound examination were characterized by breach of integrity and contours smoothness in the first two echolayers of their cavities, breach of the thickness of individual echolayers and the wall in general, breach of echolayers differentiation in the affected part. In all cases of stomach ulcer and duodenal ulcer the bottom, edges of ulcerative fossa were limited by peri-ulcerative infiltration, at this the wall thickness in GU (without complications) made 12.2 ± 2.6 mm and in DU — 11.3 ± 3.1 mm (when compared with the control group p < 0.001). Visual image of peri-ulcerative hypo-echogenic infiltration in acute benign ulcer with no complication was characterized by roughly an equal ratio
of ulcerative fossa diameter to peri-ulcerative infiltration thickness (from ulcerative fossa edge to peripheral edge of peri-ulcerative infiltration). Combination of more than one stomach ulcer and a duodenal ulcer or an ulcer and erosions identified at transabdominal ultrasound examination was 5.1% (6 observations).
In cases where frequent exacerbations of ulcers were observed and ulcerative anamnesis was longer, the «syndrome of ulcer bottom exit outside the wall outer contour» was determined (14.5% of observations, of them in GU — 11.1%, in GU — 3.4%), in which the outer contour of peri-ulcerative infiltration stood out for the fifth external echolayer on the border with the unmodified wall. At this the visual ulcer image was characterized by decreasing in ulcer bottom thickness (GU — 1.8 ± 0.2 mm; DU — 2.4 ± 0.2 mm; p < 0.001), by increasing ofulcerative fossa depth (11.1 ± 0.4 mm in GU; 10.5 ± 0.1 mm in DU; p < 0.05). The given complex allowed to suspect the presence of ulcer penetration into nearby structures (mainly into the pancreas). In cases where the wall body in the field ofulcer bottom was thinner than 2 mm, there was a threat ofulcer perforation (1.7%).
Disturbance of differentiation in stomach wall layers in projection of peri-ulcerative infiltration depended on the thickness and length ofperi-ulcerative infiltration. The smaller the ulcer depth and the peri-ulcerative infiltration thickness in a benign ulcer were, the
safer the third, the fourth, the fifth echolayers in the field of ulcer bottom were determined.
Table 1. - Informative value of multi-parametric transabdominal ultrasound gastric and duodenal examination in gastroduodenal ulcers (n = 117)
Indices Number of cases
Total number of patients examined
Among them: 117
- True-positive result 95
- True-negative result 11
- False-positive result 2
- False-negative result 2
Sensitivity 97,9%
Specificity 84,6%
Accuracy 96,4%
In studies of Z. A. Lemeshko et al. it is noted that in the presence of perforated GU and DU ultrasound examination marks thickening of hypoechogenic organ wall with discontinuous outer contour in
the field of perforation orifice, which is filled with highly-echogenic content and is located in the zone of thickening that does not contradict our findings. The results of the ultrasound stomach and duodenal examinations were significant (p < 0.001) at their verification by MRI data, endoscopic, X-ray, histomorphological studies that served as the basis for statistical calculation of sensitivity, specificity and accuracy of the method in the diagnosis of gastroduodenal ulcers (table).
The results of our work on informative value of ultrasound gastric and duodenal examination method in GU and DU find their confirmation in other researchers. There are publications on informative value of ultrasound examination in gastroduodenal pathology, according to S. A. Sedykh et al., in definition of gastric cancer transition to the duodenum specificity of the method made 100%, its accuracy — 94.9% with sensitivity of 97.3% [8]. According to other researchers, ultrasound examination sensitivity in detecting gastric and duodenal ulcers reaches 84%, its specificity — 92% and accuracy — 89%, in identifying gastric and duodenal leiomyomas — sensitivity makes 96.3%, specificity 98.4% and accuracy 97.8%.
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