DUODENUM [duodenum (PNA, BNA); intestinum duodenum (JNA)] — the initial department of a small bowel beginning directly from a stomach.
- 1 The comparative anatomy
- 2 Embryology
- 3 Anatomy
- 4 Histology
- 5 Physiology
- 6 Pathological anatomy
- 7 Methods of a research
- 8 Pathology
- 9 Operations
- 10 Clinicodiagnostic characteristic of some diseases and injuries of a duodenum
The comparative anatomy
Initial department of a gut at fishes, amphibians and reptiles does not differ from other intestines. To. stands apart at birds and mammals. At primacies it has no mesentery.
D. to. at the person forms on the 5th week of an antenatal life from front department of an average gut. By this period the gut increases in length, is dugoobrazno bent kpered, being located in the sagittal plane on dorsal and ventral mesenteries. In it distinguish upper horizontal (descending) and lower horizontal (ascending) parts. An upper horizontal part goes in the direction from a backbone to a front abdominal wall. The lower horizontal part goes kzad. From a jejunum of D. to. it is separated by an excess, and from a stomach a cross fold. On the 6th week of an antenatal life along with turn of a stomach around the vertical axis to the right the gut also deviates to the right, lays down on a back wall of an abdominal cavity and grows together with it. A mesentery of a colon, covering the bottom of D. to., grows together with its front surface. Thus the gut is located zabryushinno. The rest of a mesentery forms a hepatoduodenal sheaf (lig. hepatoduodenale). In the second half of pre-natal development D.'s loop to. gets a form of not closed ring and keeps it till the birth of the child. The epithelium of a gut forms on the 5th week of pre-natal development from an entoderm, a mucous membrane, a submucosa and fibers — on 7 — 8th week from a mesenchyma, and a crypt — on 10 — 11th week. Duodenal glands appear on 20 — 24th week, a muscular plate of a mucous membrane only to 24 — 28th week. The inner circular muscular layer is formed to 7 — 8th week, and outside longitudinal to 8 — the 9th. The serous cover forms on the 5th week of development.
the Form D. to. depends on features of embryonic development, type of a structure of a thorax, age, degree of fatness etc. At newborns it usually has the ring-shaped form; at adults — U-shaped, V-shaped, With-shaped, folded or wrong. The adult has its length — 27 — 30 cm, capacity is 150 — 250 cm 3 .
To. it is subdivided into 4 parts (fig. 1):
1. An upper part — a bulb (pars sup., s. — bulbus) — the shortest, 3 — 4 cm long and with a diameter up to 4 cm, begins from a stomach, goes on the right surface of a backbone to the right and back; has rounded shape; nearly 3/4 of its circles are covered with a peritoneum.
2. The descending part (pars descendes) 9 — 12 cm long, to dia. 4 — 5 cm, begin from an upper bend of a gut (flexura duodeni sup.). Dugoobrazno or almost vertically goes down and comes to an end at the lower bend of D. to. (flexura duodeni inf.). To. it is covered with a peritoneum only on the small site. In D.'s gleam to. the general bilious and pancreatic channels open, forming a big (fater) nipple (papilla duodeni major) on a mucous membrane. Above it the small nipple (papilla duodeni minor) can be located. On it the additional pancreat duct (ductus pancreaticus accessorius) opens. Outflow of bile and pancreatic juice is regulated by a muscular press — the sphincter of a hepatopancreatic ampoule (Oddi) (m. sphincter ampullae hepatopancreaticae) put in a big nipple. The sphincter is formed by bunches of the circular, slanting and longitudinal muscle fibers intertwining among themselves and functions irrespective of activity of muscles of a gut.
3. A horizontal part (lower) D. to. — pars horizontalis (inferior) — from 1 to 9 cm long, is located below a mesentery of a cross colon, partially behind a root of a mesentery of a small bowel.
4. The ascending part (pars ascendens) — from 6 to 13 cm long. In the conjunction with a jejunum there is a clear excess — flexura duodenojejunalis.
Topography. To. is located zabryushinno at the I—IV level of lumbar vertebrae. At change of horizontal position on vertical it is displaced on 3 — 4 and to the right on 1,5 — 2 cm from top to bottom. In front of it the stomach, the right hepatic lobe and a mesentery of a cross colon covers; it podkovoobrazno surrounds a head of a pancreas. To upper part D. to. from above the square hepatic lobe, in front — a gall bladder, behind — a portal vein, a gastroduodenal artery and the general bilious channel, from below and snutr — a head of a pancreas prilezhit. To the descending part of a gut in front prilezhat the right hepatic lobe and a mesentery of a cross colon, behind — a right kidney and the lower vena cava, outside — the ascending colon and its right bend, snutr — a head of a pancreas and partially general bilious channel. To the horizontal and ascending parts from above prilezhat a head and a body of a pancreas, in front — the mesentery of a cross colon, a loop lean, a root of a mesentery of a small bowel, behind are located a big lumbar muscle, the lower vena cava, a ventral aorta and the left renal artery. The root of a mesentery of a small bowel crosses D. to. in the place of transition of its horizontal part to ascending. To a pancreas the gut is connected by unstriated muscles, output channels of gland and the general blood vessels, and to a liver a hepatoduodenal sheaf (lig. hepatoduodenale).
D.'s blood supply to. it is carried out from top and bottom pankreatoduodenalny arteries (aa. pancreatoduodenales sup. et inf.) — branches of gastroduodenal (. gastroduodenalis) and upper mesenteric artery (. mesenterica sup.). Vessels, anastomosing among themselves, form front and back arches. Arterial blood supply of an upper part of a gut is much poorer, than other departments. Besides, in it it is not enough as well the anastomosing intramural vessels. In a muscular coat thin arterial branches lie parallel to circular and longitudinal muscular layers, forming network with rectangular loops. In a serous cover they are located in the form of the rare krupnopetlisty network going diversely.
In a submucosa of an artery form textures. In a mucous membrane they break up to smaller vessels which surround crypts and get into fibers. Each fiber is plentifully supplied with an arterial blood. Arterial branches anastomose among themselves at tops of fibers.
Venous vessels are formed at tops of fibers. A venous blood comes to basal network, and then in a submucosal veniplex and flows through lobbies and back venous arches in a portal vein or its branches.
In D. to. there are two networks limf, capillaries. One begins in the center of fibers and consists of the central lacteal sine. At the basis of fibers sine share on 2 — 3 limf, a capillary which, anastomosing among themselves, form small network under crypts. The network is reported with larger network of a submucosa. Under duodenal glands capillaries join in limf, vessels, on the Crimea the lymph comes to ekstraorganny vessels and limf. nodes. This department limf, beds takes away the fats which are soaked up by fibers. The second network is presented by thin capillaries of muscular, intermuscular and serous layers. These capillaries connect with limf, vessels, on the Crimea the lymph comes to ekstraorganny vessels and limf. nodes.
From upper part D. to. outflow of a lymph goes towards portal fissures and towards a large intestine and a head of a pancreas. From all other parts preferential to the center of a horseshoe and partially to a root of a mesentery of a small bowel.
Innervation. A source are vagus nerves (nn. vagi), celiac (plexus celiacus), upper mesenteric (plexus mesentericus sup.), hepatic (plexus hepaticus), top and bottom gastric (plexus gastrici sup. et inf.) and zheludochnodvenadtsatiperstny (plexus gastroduodenalis) of a texture.
Numerous nervous branches get into all layers of a wall of a gut, and nerve terminations contact to a ferruterous epithelium, smooth muscle cells and elements of intramural textures. An intramural part of a nervous system is formed by three textures: the most superficial and the least developed — subserosal (plexus subserosus), the most developed — intermuscular (plexus myentericus — auerbakhovo), supporting numerous groups of nervous cells. Bunches of amyelenic fibers which part innervates muscular layers depart from it, and a part passes in a submucosa where forms a submucous plexus (plexus submucosus — meyssnerovo). The fibers departing from this texture go to a mucous membrane, braid crypts and get into fibers.
D.'s Wall to. consists of serous (tunica serosa), muscular (tunica muscularis) and mucous (tunica mucosa) of covers and a submucosa (tela submucosa), the muscular plate (lamina muscularis mucosae) separated from a mucous membrane. A mucous membrane in the field of upper part D. to. throughout 3 — 5 cm has no folds, distalny rare low, preferential longitudinal folds appear; in other departments — circular folds (plicae circulares). Their height increases as approaching a jejunum. In the splice of a gut with a head of a pancreas of a fold low, and at a big nipple one of them lies longwise (plica longitudinalis duodeni), and near flexura duodenojejunalis they go in the slanting direction.
On an inner surface of D. to. there are intestinal fibers (villi intestinales) 200 — 700 microns high. On 1 mm 2 from 10 to 40 fibers are located that considerably increases the area of a mucous membrane (tsvetn. fig. 1). By means of a stereo - and a submicroscopy it is established that in upper part D. to. fibers are wide, in distal parts — leaflike and finger-shaped (fig. 2). In basal department of a mucous membrane intestinal glands (glandulae intestinales) are located. Relation of number of crypts to number of fibers 4: 1 (L. B. Berlin, V. M. Uspensky, 1970). Fibers are covered with a high prismatic epithelium with a clear border (epithelocytus intestinalis cum limbo striato) from microvillis (microvilli) which increase an absorbtivny surface of a cell by 14 — 39 times [Brown, 1962]. The border (fig. 3) contains neutral mucopolysaccharides, in it high activity of an alkaline phosphatase, aminopeptidase and disaccharidases is noted. a border the thin strip of glycokalexum containing acid mucopolysaccharides comes to light. Cytoplasm of enterocytes with a border contains RNA; here activity of oxidation-reduction enzymes, acid phosphatase and nonspecific esterase is expressed. Kernels of enterocytes are located at a basal membrane, at tops of fibers they are a little shifted in the apical direction. The epithelium with a border alternates scyphoid enterocytes, or cells (enterocytus caliciformis) which secret contains acid and neutral mucopolysaccharides. Crypts are covered by beskayemchaty (enterocytus alimbatus) and enterocytes with a border (RNA in them more, than in an epithelium of fibers, meet small granules of neutral mucopolysaccharides), an undifferentiated epithelium, scyphoid enterocytes and enterocytes with acidophilic granules (enterocytus cum granulis acidophilis). Meet also argentaffin (argentaffinocytus intestinalis) and argyrophil cells; among them by methods of an immunomorphology and a submicroscopy reveal the E-cells containing serotin With - cells — gastrin, EG cells — enteroglyukagon, S-cells — secretin. Find figures of a mitosis in a middle part of crypts.
Own plate (lamina propria) of a mucous membrane moderately of an infiltrirovan lymphoid and plasmocytes, limf, follicles quite often meet.
In a submucosa from distal department of the gatekeeper to a big nipple mucous duodenal (brunnerova) glands (glandulae duodenales) are located. Sometimes at elderly people they occur in peloric department of a stomach, and at young people in a jejunum. In an upper part of a gut of gland are observed also in a mucous membrane. Trailer departments of the duodenal glands having a complex alveolar and tubular structure are formed by the large secretory cells containing neutral mucopolysaccharides. Sometimes as a part of duodenal glands find apical and granular and covering cells.
Output channels of duodenal glands open at the basis or on sidewalls of crypts. An epithelium of channels low - or high-prismatic, cytoplasm supports him the merging granules of neutral mucopolysaccharides.
Fibers and crypts of a mucous membrane of the basis of a big nipple of D. to. are covered with the same epithelium, as well as the mucous membrane surrounding a nipple. At top and in a gleam of a nipple an epithelium high prismatic with basally the located kernels and light slaboeozinofilny cytoplasm. The brush border does not come to light. Almost all nadjyaderny zone contains the secret giving bright CHIC reaction (See. CHIC reaction ) and Besta who is painted a carmine. Under kernels large granules of a glycogen come to light. Acid mucopolysaccharides are found in apical department of some cells. Thus, a structure and gistokhy, features of an epithelium allow to consider it mucoid, similar covering the surface of a stomach and the general bilious channel. On separate fibers in the field of top of a big nipple D, to. the epithelium of both types meets. Besides, it is possible to find groups of the cells having structural and cyto-chemical properties of both an intestinal, and mucoid epithelium of a nipple (fig. 4). Scyphoid cells of a big nipple lie continuous fields, but do not alternate enterocytes with a border, as in a mucous membrane. The secret supports them less acid mucopolysaccharides, the form quite often approaches cricoid.
A muscular coat of D. to. is continuation of a muscular coat of a stomach. It is formed by bunches of the smooth muscle cells located in two layers. Outside (thinner) layer make longitudinal (stratum longitudinale), internal (thicker) — circular (stratum circulare) yarns. Layers and bunches of muscles are divided by layers of friable connecting fabric. It is less of them in upper part D. to. (in a bulb) and more at D.'s transition to. to lean.
The serous cover consists of fibrous connecting fabric and contains a large amount of elastic fibers. It is covered with a layer of flat mesothelial cells. Between serous and muscular covers the layer of friable connecting fabric — a subserosal layer is located. This layer is almost not visible in the field of a bulb, however it is well developed in places of transition of a serous cover of a gut to sheaves or a parietal peritoneum, and also from top to bottom from a mesentery of a colon to a root of a mesentery of a small bowel.
See also Intestines .
D. to. in a complex with a pancreas, a liver and its zhelchevydelyayushchy device takes the central place in implementation of secretory, motor and evakuatorny function of a digestive tract. The gastric contents which came to D. to., continues to be exposed to further mechanical and chemical processing here. In a cavity of a gut stream juice pancreas (see) and bile (see), the changing pH of the gastric chyme arriving here and providing together with intestinal juice D. to. further hydrolysis of feedstuffs proteolytic, amylolytic and lipolytic enzymes. The person has pH in D. to. fluctuates within 4,0 — 8,0.
Juice of a pancreas is a source of hydrolases (see. Hydrolases ), providing a proteopepsis, fats and carbohydrates. One enzymes (amylase, a lipase and nucleases) cosecrete in an active state, and others (proteases — trypsin, chemo - trypsin and a phospholipase And) — in the form of zymogens. 70% of total quantity of proteins of pancreatic juice make proteolytic enzymes (see. Peptide-hydrolase ).
Trypsin activates zymogens of almost all pancreatic enzymes — trypsinogen, chymotrypsinogens A, B, C, pro-carboxypeptidases A and B, pro-elastase and zymogen of a phospholipase And. Activation of trypsinogen, unlike other proteolytic enzymes, can be carried out autocatalytically under action as trypsin, and the enterokinase which is contained in juice D. to. The factors causing release of enterokinase and it solubilization (see), trypsin, chymotrypsin y bilious to - you are. Kallikrein is also formed in a pancreas in an inactive form in the form of pro-kallikrein. It is activated as it is spontaneous, and in the presence of trypsin, hydrolyzing proteinaceous substrates — derivatives of arginine in alkaline condition. Carbohydrates are split by pancreatic amylase to glucose and a maltose.
The lipolytic enzymes synthesized by a pancreas are the lipase and A. Lipaz's phospholipase coming from a pancreas to D. to., affects the emulsified fats and it is also capable to split water-insoluble triglycerides to monoglycerides and fat to - t. Phospholipase And. cosecretes in an inactive form and it is activated in D. to. trypsin. Ribonuclease and a deoxyribonuclease of a pancreas split nucleinic to - you to nucleotides.
The secret of hepatocytes — bile — is allocated in D.'s gleam to. also facilitates process of emulsification of fats and stabilization of already formed emulsion. Bile acids (see) promote splitting of fats, activating the pancreatic and intestinal lipases operating on the emulsified fats. Bile directly participates in processes of digestion at the expense of own enzymes (amylase, proteases). It plays an important role in the course of absorption fat to - t, carotene, vitamins D, E, K, amino acids, cholesterol and salts of calcium. Bile raises a tone and strengthens a peristaltics of a gut. At the same time in bile there is a lipoproteidny connection for transfer of lipids from a liver in a gut. Bile, besides, has bacteriostatic action on an indestinal flora and participates in pristenochny digestion.
D.'s secret to. it is developed by scyphoid cells of intestinal crypts and duodenal glands. Gistokhim, researches showed that process of formation of intestinal enzymes begins in crypts, and proceeds and comes to an end on a surface of fibers, i.e. all mucous membrane of D. to. is the ferruterous device. D.'s secretion to. it consists of two processes — departments of a liquid, and then dense part of intestinal juice. Dense part consists of the epithelial cells which are torn away from a mucous membrane being in a condition of disintegration, leukocytes and slime (a secret of scyphoid cells). A dense part contains 60 — 70% of total quantity of intestinal enzymes. A mucous membrane of D. to. produces kinazinogen, activating enterokinase; allocates secretin (see), secretomotor a pancreas and braking secretory activity of a stomach, cholecystokinin, pancreozymin which exert the impact on fermentovydelitelny function of a pancreas, zhelcheobrazovatelny function of a liver and a zhelchevydeleniye, villikinin (see), strengthening the movement of fibers of a mucous membrane of the gut, and enterogastrin (see), stimulating secretion of a gastric juice in a third, so-called intestinal) a phase of gastric secretion. Besides, in a gut, according to some authors, the hormones participating in regulation of the general metabolism are emitted.
A secretory deyateyalnost of D. to. it is regulated by nervous and humoral mechanisms. The irritation of the wandering and mesenteric nerves strengthens secretion of brunnerovy glands. Cholinomimetics (acetylcholine, Pilocarpinum, etc.) and the substances blocking acetyl cholinesterase (physostigmine) strengthen secretion, and cholinolytics (atropine) and sympathomimetics (adrenaline, noradrenaline, etc.) it is braked. Besides, assume that in a mucous membrane of D. to. there is a special hormone — duokrinin which stimulates secretion of brunnerovy glands. Apparently, the stimulating impact on secretion is exerted by secretin and a glucagon. In a mucous membrane of a gut is also available enterokinin, strengthening secretion and saccharose activity intestinal and, in particular, duodenal juice.
Adrenocorticotropic hormone and adrenal hormones participate in regulation and stimulation of secretory activity of a gut. Apparently, adrenal hormones promote fuller implementation of the specific nervous impulses regulating intensity of development and a ratio of various enzymes.
To. tonic, peristaltic, pendulum contractions and rhythmic segmentation are inherent. The main role in advance of a chyme belongs to peristaltic waves (see. Peristaltics ). A considerable part of peristaltic waves begins in D. to. at the time of transition of contents of a stomach to it or to several seconds earlier, than the peristaltic wave of a stomach will reach peloric department. The important role in hashing and advance of a chyme is played also rhythmic segmentation (the gut is divided cross banners into small segments) and pendulum (up — down, forward — back, to the right — to the left) by the movements which are carried out due to reductions of longitudinal and circular layers of muscles. At the same time rhythmic segmentation mixes contents in the site of a gut, and the pendulum movements which develop further into peristaltic advance chyme (see).
To., as well as to all went. - kish. to a path, periodic activity — natural change of the periods of work and rest is inherent. Healthy people have a period of work of D. to. averages 64,2 min. and comes to an end with a phase of rhythmic activity with number of reductions 10 — 12 in 1 min. and lasting 5 — 10 min.; it is always followed by the dormant period equal of 23,8 min.
Character and dynamics of motor activity of D. to. in the course of digestion depends on physical. and chemical properties of food. Reception of bread and meat in pieces causes two-phase change of motor activity of a gut. In the first phase strong reductions during 1 — 2 hour against the background of the raised tone of a gut which then weaken are observed; in the second phase — wavy strengthening and easing of motility. The weakened motor activity of a gut continues before the end of process of intestinal digestion. Total speed of advance of contents of a gut in the first phase is 1,5 — 2 times more, than in the second. After reception of the crushed food (mincemeat, the crushed bread) the first phase is less long. Greasy food causes multiphase motility of a gut. During 2,5 — 3 hours there is a change of the periods of strengthening and weakening of reductions and a tone of a gut. Duration of the first period is 3 — 8 min., and the second 4 — 7 min. Then reductions and a tone become more uniform. Regulation of motor activity of D. to. it is carried out by myogenetic, nervous and humoral mechanisms.
In the field of falling of the general bilious channel into D. to. the «sensor» of a rhythm providing the correct alternation of reductions of duodenal and thin guts is found. Activity of the sensor of a rhythm depends on the level of a metabolism and temperature. Frequency of reductions of a gut decreases at systematic loss of bile and at hypo - and a hyper thyroidism. Reflex arcs of intramural regulatory mechanisms become isolated at the level of intermuscular and subserosal textures. Exert impact on these mechanisms as serotonin, a histamine, intestinal substance, substance P and angiotensin, and irritation of sympathetic and parasympathetic nerves. Motor activity of a gut is slowed down by adrenaline, noradrenaline and at irritation of sympathetic nerves. Acetylcholine in high doses causes two-phase reaction: the excitement which is replaced by braking. Serotonin, substance P, gastrin, angiotensin, bradikinin, cholecystokinin, prostaglandins, and also irritation of parasympathetic nerves stimulate reductions of a gut.
See also Digestion .
Dystrophy. To. can be surprised at primary and secondary amyloidosis (see). Sites of amyloid find in walls of blood vessels of a mucous membrane and a submucosa, between connective tissue fibers, and also in a muscular coat. About fatty dystrophy of D. to. it is difficult to judge since lipids can be in a mucous membrane in connection with their absorption.
A. I. Abrikosov (1956) established that at poisonings floridziny, starvation, after removal of a pancreas sharp obesity of an epithelium of crypts is observed; at the same time fatty inclusions in an epithelium of fibers (unlike digestive obesity) are absent. Fat in an epithelium and in own plate meets also in the centers of an inflammation. Small-drop obesity of muscle fibers is described at tuberculosis, alcoholism, peritonitis, and also at elderly people.
Necroses of a mucous membrane of D. to., leading to formation of erosion and acute ulcers (see), can arise under the influence of the gastric juice having the high digesting ability at insufficient neutralization by its contents by D. to., at the disturbances of blood circulation caused by acute impassability, edges, in particular, it can be caused by a prelum aortic aneurysms, a hepatic or splenic artery. A rupture of the stratified aortic aneurysm in a back wall of D. to. leads to formation of an intramural hematoma, and then to a necrosis of all layers and profuse intestinal bleeding. As the reasons of intramural hematomas serve also stupid injury of a stomach and hemorrhagic diathesis.
Disturbances of a lymphokinesis develop at periduodenites, defeat regional limf, nodes.
D.'s inflammation to. happens acute and chronic to hemorrhage. Hypostasis, staza are characteristic of an acute inflammation infiltration by neutrophilic leukocytes. At hron, an inflammation limfoplazmotsitarny infiltration, a picture of a disregeneration and atrophy prevail. In the centers of an inflammation it is possible to find inclusions of fat in an epithelium and in own plate.
D.'s tuberculosis to. meets seldom. As a rule, he is secondary. Infection happens as gematogenno, and during the swallowing a phlegm; also retrograde defeat of D. is possible to. at tuberculosis limf, nodes of an abdominal cavity. Initial tubercular changes arise in follicles and a submucosa in the form of epitelioidnokletochny hillocks. At dominance of exudative processes the caseous necrosis is noted. Caseose leads disintegration of hillocks and sites to formation of ulcers with the subdug edges. Ulcer infiltrate at tuberculosis unlike usual hron, D.'s ulcers to. its melkobugristy passes into not changed departments, a surface. Ulcers, extending, can connect among themselves, forming circular ulcerations, characteristic of tuberculosis. At their healing there is a stenosis which can result in impassability.
At lymphogranulomatosis (see) in a mucous membrane and a submucosa polymorphocellular infiltration with Berezovsky's cells — Shternberg is observed. Further there comes the necrosis, an ulceration, perforation is possible, and during the healing of ulcers — narrowing of a gleam of a gut.
D.'s defeats are described to. at actinomycosis (see). In an initial stage it is possible to find in a reinforced submucosa granulyatsionny fabric with druse of an actinomyce. These sites quickly are exposed to suppuration and an ulceration, in a circle connecting fabric expands.
Sometimes in D. to. the isolated inflammatory process with the granulematozny reaction characteristic of a disease Krone develops (see. Krone disease ), in these cases of D. to. usually is surprised together with a stomach. The wall of a gut is thickened, at gistol, a research the expressed lymphoid and cellular infiltration and granulomas with colossal cells like Langkhans's cells is observed.
Inflammatory and atrophic changes of a mucous membrane (fig. 5 and tsvetn. fig. 6) are described at hron, hepatitises and pancreatitis (see), cholecystitises (see), postcholecystectomy syndrome (see), duodenostaza.
Considerably the expressed mucosal atrophy of D. to. with sharp shortening of fibers it is noted at patients tropical and not tropical a spra; at the same time activity of an alkaline phosphatase and leucineaminopeptidase is lowered. Electronic microscopic examination reveals shortening, expansion and deformation of microvillis.
To. can be surprised at an intestinal lipodystrophy. Fibers in these cases are shortened, expanded. In own plate accumulations of lipids, the macrophages containing neutral mucopolysaccharides and having high activity of acid phosphatase histochemical come to light. At a submicroscopy find so-called batsilloformny little bodies in macrophages.
At the patients who transferred a resection of a stomach according to Billroth of II with switching off D. to., the mucosal atrophy develops, the content of acid mucopolysaccharides in scyphoid cells decreases.
Parasitic diseases. On autopsy in D. to. find many parasites (lyambliya, trematodes, cestodes, nematodes, etc.), however morfol, D.'s changes to. are studied only at some invasions.
At lambliasis (see) inflammatory infiltration of a mucous membrane of D. develops to., thickening and dystrophic changes of enterocytes, shortening and depression of microvillis, reduction of quantity of scyphoid cells. Mitotic activity of an epithelium increases that leads to emergence on fibers incompleteness of the differentiated epithelium. Changes of a mucous membrane connect with direct damage by lyambliya of an epithelium, the parasite is attached to Krom by the prisasyvatelny disks. The research by means of a transmission and raster submicroscopy revealed destruction of glycokalexum of microvillis.
Ankylostomas (see. Ankilostomidoza ) are attached to a mucous membrane of D. to., sticking into it the teeth, and some make cuts its cutting plates and get deep into. It leads to emergence of ulcerations which diameter can reach 2 cm. In sites of an attachment of parasites the mucous membrane is hyperemic, covered with slime, plentifully an infiltrirovana plasmocytes and neutrophils, fibers and crypts are shortened, growth of intersticial connecting fabric, a thickening of a mucous membrane and a submucosa is observed. Accession of consecutive infection is quite often noted.
At strongyloidosis (see) puberal females are implemented into a mucous membrane, often strike crypts, follicles, causing superficial ulcerations. In crypts of a female lay eggs, and larvae which developed from them penetrate surrounding fabric and conduct to the expressed inflammation of a mucous membrane.
Kompensatorno - adaptive processes. At patients with hypersecretion salt to - you (D.'s ulcer to. — tsvetn. fig. 2 — 5 — Zollinger's syndrome — Ellisona) is observed shortening of fibers, plentiful limfoplazmotsitarny infiltration of own plate of a mucous membrane, a hyperplasia of duodenal glands. Almost constantly enterocytes of fibers on certain sites are replaced with a muciparous epithelium. This epithelium has no ischerchenny border, a microvilli its short and rare, an apical part of cytoplasm contains neutral mucopolysaccharides, in subnuclear departments the glycogen comes to light, the lamellar complex, activity okislitelno is well developed - recovery enzymes very low, alkaline phosphatase and leucineaminopeptidase do not come to light. In giperplazirovanny scyphoid cells the content of the acid sulphated mucopolysaccharides sharply increases. It can be considered as expression of process of adaptation.
Postmortem changes. During the first hours after death there come the autolysis and desquamation of an epithelium of fibers. After death as a result of asphyxia the so-called distribution leukocytosis imitating inflammatory infiltration often develops. The epithelium of crypts, remains longer, it is possible to see it and in a day.
Methods of a research
Great value in the correct diagnosis of diseases D, to. play the anamnesis, and also data obtained at survey and a palpation. The nature of pains, time of their emergence, localization and irradiation allow to assume even before survey peptic ulcer (see). Change of a shape of a stomach, uniform or its asymmetric swelling are observed at various pathology. The palpation of epigastric area, more precisely than the site of a stomach higher and is more right than a navel, allows to reveal exact localization of pains and their irradiation. At percussion it is possible to establish area of the increased skin sensitivity that quite often takes place at a peptic ulcer. However the exact diagnosis is established only during the use of sounding (see. Duodenal sounding ), rentgenol. or other special methods of a research.
Rentgenol, D.'s studying to. begin with the moment of hit of the first portion of baric weight from a stomach to the peloric canal and a bulb. To investigate a bulb and all loop of D. to. follows in direct, slanting (I and II) and side provisions of the patient.
In direct situation a bulb and post-bulbar site D. to. are represented a little shortened since they lie not in the frontal plane. Other parts D. to. are visible well. In the first slanting projection all upper part, an upper bend and the descending part D. to. are visible without projective distortions.
When the bulb is located horizontally behind a stomach, the patient should be turned almost in the right side situation, and also a left shoulder-blade to the screen. At the same time the image of a bulb, all upper part and upper bend of D. to. it is almost deprived of projective distortions. The left side situation investigated in most cases allows to examine front and back walls of a bulb and an upper bend of a gut. Then to the patient allow to drink the rest of a baric suspension and watch, applying Polyposition research (see), behind transition of a suspension from a stomach in a bulb, its filling and advance according to all D. to. In horizontal position advance of baric weight according to D. to. it is considerably slowed down, and the stomach is displaced up that creates good conditions for survey of a gut.
It is reasonable to begin a research on a trokhoskopa in the first slanting position of the patient that gives the chance to examine small and big bulbs of curvature, and also an internal relief and an outside wall of all departments of D. to. In the same situation it is necessary to try to obtain receiving a pneumorelief of a gut. For this purpose in most cases the patient should be turned almost completely on the left side, then air from a stomach passes into D. to. On the course of a research make a palpation and a compression, and also survey and aim roentgenograms in the conditions of optimum visibility.
When at such careful research it is not possible with persuasiveness to prove or exclude existence of an ulcer in sharply deformed bulb or to reveal other changes in D. to., it is reasonable to carry out a relaxation duodenografiya for what intravenously enter 1 ml of 0,1% of solution of atropine; in 8 — 10 min. after its introduction the spasm is removed, the tone and motility of a gut decrease. It allows to examine the gut which extended, filled with a baric suspension. Approximately the same action causes reception under language 2 — 3 tablets of Aeronum (see. Duodenografiya relaxation ).
For specification of nature of defeat of a gut, and also make a biopsy of a mucous membrane for studying of its contractility and apply endoradio sounding (see) and duodenografiya. The biopsy of a mucous membrane is made most often by means of the special biopsionny probe (an aspiration biopsy) or during a duodenofibroskopiya (a biopsy aim).
The probe represents a rubber tube 140 cm long and to dia. 5 mm. On its distal end there is a biopsionny head with a side opening to dia. 2 mm. In a head the cylindrical knife is located. On the proximal end there is a vacuum epiploon connected by means of a tee to the mercury vacuum manometer and a Janet's syringe.
The probe under control of the x-ray screen is entered into D. to. After excision the piece of a mucous membrane is sucked in in a biopsy head and taken. Then it is investigated with use gistol, and gistokhy, techniques.
After a biopsy to the patient do not allow to eat food within 1 hour and give inside 1 table. l. 0,06% of solution of silver nitrate.
Endoradiozondirovaniye — the method allowing to study by means of the tiny transmitter strengthened on the duodenal probe motor evakuatornuyu function D. to., its pH, temperature and intra intestinal pressure.
The probe is entered into D. to., signals are accepted by the flexible antenna which is built in in a special silk belt which is imposed on area of a projection of a gut (fig. 6). All radio signals are fixed on the special recorder.
Duodenografiya — graphic registration of function of a gut. Write down pH of the environment, the intra intestinal pressure, frequency and amplitude of reductions. Researches are conducted on an empty stomach, during digestion, against the background of action pharmakol, drugs.
This method gives the chance to quantitatively characterize motor function of a gut, data on acidulation in dynamics, about a ratio of reductions of a gut and intra intestinal pressure, about its alkalizing ability on an empty stomach and at receipt of a chyme from a stomach, about the speed of a passage and evacuation of a chyme in a small intestine.
Malformations of D. to. meet more often than defects of other departments of intestines. Mark out defects of an arrangement and fixing, narrowing or total absence of a gleam (stenoses and atresias), abenteric stenoses, doubling of a gut and an accessory stomach, gamartoma, inborn diverticulums (see).
Defects clinically are most often shown at early children's age by high intestinal impassability. At the same time terms of emergence of the first sign of impassability — vomiting (its volume, frequency, contents, coloring) — and character of a chair have essential value.
For D.'s atresia to. plentiful vomiting in the first days after the birth is characteristic. Vomiting has congestive character, color of emetic masses green or brown. The chair is absent. The stomach is blown up in epigastric area. At rentgenol, a research the gastrectasia and lack of a passage of contrast in a small bowel are observed. Treatment only operational: imposing of an anastomosis between D. to. and small bowel.
Partitions in D. to. (intra intestinal membranes) meet extremely seldom. The wedge, a picture depends on absence or existence of defects in membranes and their sizes. So, in the absence of defects — clinic of an atresia. At small defects vomiting and vomiting by congestive food with impurity of slime and bile, locks, exhaustion and dystrophy are observed. Radiological the gastrectasia and the raised D.'s peristaltics are noted to., sometimes — an antiperistalsis. Treatment also only operational — a duodenotomy and excision.
Acute development of symptoms of impassability of D. to. it is observed also at torsion of «an average gut», Ladd's syndrome (incomplete turn of intestines). Wedge, manifestations arise to 4 more often — to the 5th days of life. Existence of a mekonialny chair in the first days of life, vomiting, vomiting is characteristic. The condition of the patient progressively worsens. In certain cases the disease has recurrent character. The diagnosis is established only as a result rentgenol. researches in the presence of «two levels» and two gas bubbles, an arrangement of a caecum under a liver at diagnostic administration of air in a large intestine. Treatment operational — a raspravleniye of torsion, excision embryonal tyazhy and release of a gut.
In the absence of turn of intestines the descending part does not turn on the left, and falls directly down. At the same time there is no flexura duodenojejunalis and D. to. imperceptibly passes into lean. Clinically defect is not shown and is an accidental find. In the presence of D.'s mesentery to. becomes mobile (duodenum mobile) and can form bends and loops unusual for it. Patients are disturbed by the pains in an anticardium irradiating in a back quickly disappearing in a prone position. If the mesentery is located at the descending part D. to., jaundice due to disturbance of outflow of bile can be observed. Most often and excessively mobile it is extended upper, is more rare — descending or both of these parts of a gut. In the first case X-ray inspection allows to find the mobile loop of upper part D. sagging down to. (fig. 7). During the lengthening of the descending department of a gut the additional bend is located, as a rule, medialny its top and bottom bends. In most cases in the extended sites some is defined staz a contrast agent. The relaxation duodenografiya with the probe allows to specify the diagnosis. Operational treatment — D.'s fixing to. to a back parietal peritoneum — it is shown only in hard cases.
Megaduodenum and megabulbus result from absence or an underdevelopment of ganglionic cells of own neuroplexes in certain sites D. to. Quite often this anomaly is combined with an inborn esophagectasia or a bladder. Sharp exhaustion of the child, a spasm are characteristic of a disease a cholemesis, plentiful since the first months of life, after each feeding. At survey protrusion of an upper right half of a stomach is noted. At a palpation in this zone morbidity and splash are defined; radiological — a delay of contrast in expanded D. to. or bulb. In the presence of a megaduodenum imposing of an anastomosis between D. is shown to. and small intestine.
At D.'s doubling to. (the additional tube to dia, from 1 to 4 cm and 15 — 20 cm long, edges has the general wall about the main D. to.) perhaps asymptomatic course of a disease. Vomiting, vomiting, pains in a stomach * are sometimes observed At rentgenol, a research — a uniform strip of an enlightenment against the background of D.'s narrowing to. or two parallel strips of an enlightenment on site D. to. Treatment only operational — imposing of an anastomosis between D. to. and additional gut.
An accessory stomach happens single and multiple. They can be located in all layers of a wall of D. to. A wedge, manifestations depend on the sizes and their localization. Perhaps long asymptomatic current, and also development of various complications (perforation, bleeding, acute or hron, intestinal impassability). Sometimes patients complain of pains and feeling of weight in epigastric area, attacks of nausea and vomiting. Radiological against the background of a relief of a mucous membrane there is a uniform strip of an enlightenment, a nek-swarm narrowing of a gleam and a smoothness of ridge edge of a gut; the peristaltics is weakened here. The cysts which are hanging down on a leg give a picture of a tumor. Treatment at impassability only operational — a tsistoyeyunostomiya at large cysts or a resection of small cysts.
D.'s diverticulums to. — the sacculate protrusions of a wall which are reported with a gleam — meet in 1,2 — 3% of all rentgenol, researches. Diameter of their from 0,5 to 3 — 4 cm. The majority of diverticulums is located in the descending part of a wall of D. to., turned to a pancreas. Usually come to light at adults, but conditions of their development are connected with inborn defects of a structure of a wall. Distinguish true and false diverticulums. The wall of true consists of all layers of a gut, in false there is no own muscular coat * True traction diverticulums usually arise after periduodenites, cholecystitises and have the wide basis and the cone-shaped form. False, or pulsion, diverticulums meet more often true. They are formed as a result of protrusion of a wall of a gut in places of an inborn underdevelopment of a muscular coat, have rounded shape, a neck their narrow. Due to the lack of muscles emptying is complicated. Diverticulums often clinically are not shown and are an accidental find at rentgenol, a research; can sometimes cause a feeling of pressure and weight, nausea or pain which arise in 2 — 3 hours after food. The prelum of the general bilious channel or a pancreat duct with jaundice, a cholangitis or pancreatitis is in rare instances possible. At a usual rentgenol, a research to reveal D.'s diverticulum to. not always it is possible since reductions of muscles of a gut, the squeezing already narrow entrances, the slime which is contained in its gleam and the remains of food, spasms in a neck at an entrance in a diverticulum and also Hypostasis of folds in won of a diverticulum can interfere with penetration of a contrast agent into his cavity-. Besides, bystry passing of baric weight according to D. to. and in some cases the small sizes of diverticulums complicates their diagnosis. Therefore negative data single rentgenol, a research completely do not exclude existence of diverticulums of D. to.
Radiological diverticulums (fig. 8) come to light in the form of additional cavities of various sizes and the form (a body of a diverticulum) filled with a baric suspension and connected with a gleam of a gut isthmuses (a neck of a diverticulum). At a careful research in a neck and in the diverticulum it is possible to reveal folds of a mucous membrane which pass from a gleam of a gut, being continuation of folds of D. to. To judge at rentgenol, a research the nature of a diverticulum (true or false), as a rule, it is not possible.
In most cases the wedge, manifestations are caused by complications of diverticulums from which the most frequent is the diverticulitis arising usually because of stagnation of food masses and liquid in a cavity of a diverticulum; the cavity of a diverticulum and the already his neck is more, the it is more than conditions for stagnation of food masses.
Diverticulites can be complicated by an ulceration therefore perforation and bleeding are possible. Quite often after a diverticulitis the diverticulitis, and also a duodenitis which can become complicated develop a feather cholecystitis (see), pancreatitis (see), gepatokholetsistity and periduodenitis (see).
Rentgenol, signs of a diverticulitis are a long delay of baric weight in a diverticulum, the bulked-up, edematous, deformed and rigid folds in a neck and a cavity of a diverticulum, a spasm of his neck, existence in a diverticulum of a large amount of liquid and slime, a trekhsloynost (baric weight below, over it liquid and gas). Confirm also sharply accelerated evacuation from a diverticulum of a contrast agent existence of a diverticulitis and the strengthened frequent reductions of its walls. Irregular shape of a body of a diverticulum with existence of points on contours indicates a peridiverticulitis. Sometimes at a diverticulitis even before giving a contrast agent in a diverticulum the gas bubble and a fluid level are defined.
To differentiate D.'s diverticulum to. it is necessary with the extra bulbous ulcer which is especially penetrating with the ulcerated cancer of a big nipple or cancer of a head of a pancreas burgeoning in D. to., in rare instances — with bilious fistula between a diverticulum and a gall bladder. Distinctiveness of diverticulums is existence of the folds of a mucous membrane passing from a gleam of a gut through a neck into a body of a diverticulum. In favor of a diverticulum also accurate smooth contours of its protrusion testify. Treatment conservative: fractional food (4 — 5 times a day) with an exception of rough food, at pains — rest and heat on a stomach; at aggravations — washing and sanitation of a cavity of a diverticulum through fibroduodenoskop. At increase of pains recommend operational treatment.
The greatest distribution was gained by operation of excision of a diverticulum with the subsequent sewing up of a wall of D. to. two-row seam. The abdominal cavity is opened, a verkhnesredinny or upper right-hand transrectal or pararectal section. As diverticulums are located on a back wall of D. more often to., will mobilize D. in the beginning to. and head of a pancreas. Cutting a back leaf of a peritoneum, find a diverticulum. Then it is careful not to injure the general bilious channel and a pancreat duct, otseparovyvat y allocate a diverticulum to a neck inclusive. This stage is applied also at other modifications of operations for a diverticulum (fig. 9, 1). If a neck narrow, it is stitched and tied up, at the wide basis the neck is cut, the wall of a gut is sewn up with the subsequent submersible seams on D.'s wall to. in transverse direction. For reliable sealing it is reasonable to enter the probe into D. to. through a nose for the subsequent active aspiration in the first (3 — 4) days after operation (see. Aspiration drainage ). At this time the patient through a mouth is not fed. For prevention of pancreatitis appoint Trasylolum, Contrykal, etc.
At localization of a diverticulum in a big duodenal nipple, the expressed inflammatory and infiltrative process which extended to D. to. and surrounding fabrics, and also during the thinning and flabbiness of a wall of D. to. make invagination of the mobilized diverticulum together with a neck in D. will cry to. with the subsequent imposing of submersible seams. For the purpose of prevention of a relative stenozirovaniye of a gleam of a gut carry out a duodenotomy on the party of a gut opposite to a neck of a diverticulum. A leg of the invaginated diverticulum from D.'s cavity to. stitch, hardly tie up (fig. 9, 2). The wall after a duodenotomy is sewn up with a two-row seam in transverse direction; also the dublikatura of a wall of a gut in the invaginated neck of a diverticulum is created. Only in some cases, when there are extensive commissural and inflammatory and infiltrative processes, above-mentioned operative measures are difficult feasible and there can be a question of the operation directed to switching off of a cavity of a diverticulum for receipt of food masses. Gastroenterostomy (see) in combination with switching off of the gatekeeper it is not recommended in connection with big danger of formation of round ulcers. The resection of pyloric department of a stomach is shown (see. Peptic ulcer, surgical treatment ) with switching off of a stump of D. to. At patients with high acidity it is reasonable to combine this operation with the selection vagisection (see). The absolute indication to operational treatment of diverticulums of D. to. the phenomena are peritonitis (see), testimonial or about development of phlegmonous process in a wall of a diverticulum, or about its perforation. The postoperative lethality fluctuates from 1 to 8%; the greatest lethality is observed at perforation and the progressing peritonitis.
Hron, arteriomesenteric impassability (or a compression) is the reason of nearly a half of all duodenal staz of the organic nature. The inborn short mesentery and additional branches of an upper mesenteric artery can be the reasons of a prelum. Regarding cases, despite existence of anatomic premises, for emergence of a prelum of a gut the accessory factors causing a tension of a mesentery (weight loss, the expressed lordosis, a visceroptosis) matter.
Patients are disturbed feeling of weight in an anticardium, pain, sometimes abdominal distention. Pains develop in 2 — 4 hours after food and several hours and even proceed days, decreasing after an eructation and vomiting. Sometimes pains abate in forced position of the patient (genucubital, on one side etc.).
At X-ray inspection in vertical position expansion D. is most often noted to. before its transition to the left from a backbone. In this site the shadow of a gut is as if cut off (fig. 10), passing of small portions of baric weight to distal parts of a gut after the strengthened reductions of its expanded departments is visible. The remains of baric weight in a stomach and D. to. over narrowing it is possible to find through 24 and even the 48th hour. At rentgenol, a research in horizontal position of the patient on the right side and on a stomach, and especially in genucubital situation the tension of a mesentery decreases and passing of baric weight through the squeezed site improves. At the same time it is possible to see not changed folds of a mucous membrane and contours in the site of a prelum of a gut. Duodenografiya with the probe allows to distinguish most precisely a zone and character of a compression (rice, 11).
Inborn outside banners of D. to. are formed owing to insufficiently full obliteration of a ventral mesentery and represent the fibrous tyazh crossing and squeezing a gut at various levels. Usually these tyazh are attached to the next bodies — a liver, a gall bladder, a peritoneum, a large intestine. Most often D.'s gleam to. it is squeezed in an upper half of the descending part by the sheaf going from a gall bladder to a hepatic bend of a large intestine. Wedge, a picture it is similar to an atresia. At a usual rentgenol. a research only disturbance of passability of a contrast agent to a greater or lesser extent comes to light (depending on degree of a prelum). The zone of narrowing of a gut, its character and extent are found or in the conditions of its artificial hypotonia (pharmakol. drugs), or — even more precisely — at a duodenografiya with the probe (fig. 12). The narrowed sites in length seldom exceed 0,6 — 1 cm. They can be at various levels of a gut. Proximal departments are usually extended and expanded, can even form additional bends. Contour of impression accurate, smooth. Treatment operational — excision of banners.
Foreign bodys most often are late in the descending D.'s piece to. at bends upon transition to a horizontal part. The wedge, a picture depends on character, the size and duration of stay in D. to. there is no foreign body, In early terms usually any subjective feelings since not only the small, but also rather large and even sharp objects enveloped by food masses safely pass intestines and leave in the natural way. At damage of a wall of D. to. the feeling of weight which is replaced by morbidity in epigastric area, the right hypochondrium and areas of a navel arises foreign bodys, and also during the fixing of foreign bodys. Are sometimes possible gastrointestinal bleedings (see). At D.'s inflammation to. pains accept constant character and quite often are followed by disturbances of motor function — from easy secondary duodenostaz to the relative alternating impassability with tendency to progressing. Sometimes results from perforation of a gut peritonitis (see). Foreign bodys come to light only at rentgenol, a research taking into account data of the anamnesis. The increasing value in diagnosis of foreign bodys is gained by a duodenofibroskopiya. This method gives the chance in considerable number of cases to delete foreign bodys.
At hit of foreign bodys for clarification of their advance on went to intestines. - kish. to a path the wedge, and rentgenol, overseeing by patients is carried out. The food containing a cellulose, and mucous porridges is appointed. At such treatment foreign bodys, as a rule, leave in the natural way. Serve as the indication to operational treatment fixing of foreign bodys in D. to. or their stay in intestines more than 3 days. Strengthening of abdominal pains, and also the expressed disturbances of motor function (relative intestinal impassability) serve as the indication to operational treatment. The absolute indication to urgent operation — emergence of the peritoneal phenomena.
Operational treatment — a laparotomy with the subsequent audit of D. to. After identification of its foreign body through D.'s wall to. fix two fingers and then delete through a small section. At sewing up of small cuts use a two-row purse-string seam. The long section of a wall of a gut is taken in by a two-row seam in transverse direction. Foreign bodys of the small sizes, and also needles, pins, it is rational to nail to delete through a small section of a wall of a gut. Previously this site is sheathed by a purse-string seam which drags on after removal of a foreign body. At perforation and decubituses sewing up of these sites with the subsequent peritonization separate serous and muscular submersible seams in transverse direction is made. The forecast at operational treatment, as a rule, favorable.
the Damages which are especially isolated meet seldom that is explained by a deep arrangement of D. to. in an abdominal cavity. D.'s damages to. are more often observed in combination with injuries of other abdominal organs. They are subdivided on opened and closed. The closed damages, as a rule, are observed at a stupid injury. Suffer the descending D.'s branch more often to. with the lower bend (44%) and lower horizontal (35,3%).
Clinically distinguish two types of damages of D. to. — intraperitoneal and retroperitoneal. At intraperitoneal along with disturbance of a wall of a gut the integrity of a back leaf of a parietal peritoneum is broken owing to what gastroduodenal contents stream in a free abdominal cavity. It is followed by the phenomena of peritonitis (see. Peritonitis ). The peritoneal phenomena generalizutsya quickly. At retroperitoneal damages, is more often observable at cut and chipped wounds, the integrity only of an extra peritoneal part of a wall of D. is quite often broken to. At the same time duodenal contents and food masses flow only into retroduodenal cellulose, leading to development of diffusion phlegmon of retroperitoneal cellulose and peritonitis. Due to the integrity of a back leaf of a peritoneum symptoms of peritonitis are originally expressed to a lesser extent, later is considerable. To early terms patients complain of the pains in the right lumbar area amplifying at a palpation and pressure (a false symptom of Pasternatsky); pains quite often irradiate to the right inguinal area, a leg («psoas-symptom») and are combined with rigidity and even pastosity of lumbar area. Damage finally can be revealed only at rentgenol, a research. At intraperitoneal damages free gas in an abdominal cavity (a symptom of a spontaneous pneumoperitoneum) is defined, at retroperitoneal — infiltration of retroduodenal and retroperitoneal cellulose and its emphysema.
In all cases operational treatment — a verkhnesredinny laparotomy is shown. At intraperitoneal damages of D. to. definition of localization and the nature of damage does not present any difficulties. At retroperitoneal damages chances of not recognition of damages of a back wall of a gut. Therefore especially careful studying of a condition of retroperitoneal cellulose is necessary. For its audit and survey of a back (extra peritoneal) wall of D. to. it is necessary to cut on an outside semi-circle of a duodenal horseshoe a back leaf of a peritoneum after preliminary introduction of the fencing-off napkins, to mobilize a back wall of a gut then the defect which is available in it easily comes to light. At small defect in D.'s wall to. it needs to be taken in after preliminary economical avivement: stitches are put in transverse direction usually to two floors. At extensive complete cross separations of D. to. after excision of the hurt edges of a wound D.'s continuity to. the end in the end or on type a side sideways is recovered after preliminary sewing up and peritonization of the ends of a gut in the place of its former gap more often by a circular seam. For the subsequent systematic loading of D. to. and fight against possible paresis introduction to a gut through a nose of the thin duodenal probe is recommended. Via the probe during the first 4 — 5 days make active aspiration. Retroperitoneal cellulose is drained and rykhlo tamponed with removal of a drainage and tampon through an additional section behind or sideways (extra peritoneal the Operational wound of an abdominal wall is sewn up. The drainage is used also for irrigations of retroperitoneal cellulose by solutions of antibiotics. The gastroenterostomy applied earlier is not recommended since it does not unload a gut from bile and pancreatic juice and does not eliminate a duodenostaz. This operation can be applied only when during the mending of defect or imposing of an anastomosis the gleam of a gut is considerably narrowed.
At massive bruises and crushes of a wall of a gut when there is a big danger of emergence of insolvency of seams, apply two-row or three-row seams. At the same time carry out drainage.
The forecast at D.'s damage to. not always favorable. The postoperative lethality fluctuates depending on terms of performance of an operative measure.
Duodenostaza — the most often found type of functional motive disturbances (diskinezy) D. to., a cut different types of coordinate movements are normal inherent (disharmony of movements, weakening of one and strengthening of others, disturbance of their rhythm, change of a tone in the absence of the mechanical reasons). More often such motive frustration are result of a neurometastasis ad nervos owing to a peptic ulcer of a stomach and D. to., pancreatitis, and also patol, changes in bilious ways and gall bladder. It is explained by extremely close anatomic and functional linkage of bodies of gepatopankreatoduodenalny system and a stomach.
To diskineziya, besides, can bring endocrine and nervous diseases, hypovitaminosis, pathological processes into c. N of page, injury of a skull, Opisthorchosis and other parasitic diseases of bilious ways, influence pharmakol. drugs, and also stomach operation. Duodenostaz can be early and only display of tumors of D. to. In some cases the reason of functional motive disturbances of D. to., and in particular duodenostaz, it is not possible to establish even at the most careful research of the patient. Such dyskinesia can call essential.
D.'s dyskinesia to. can proceed latentno, but can be followed by various disturbances of digestion. The earliest manifestations of a duodenostaz — feeling of weight and periodic dull aches in epigastric area and in right hypochondrium, appearing soon after food, an eructation, nausea, times vomiting and the vomiting giving relief. In the period of an exacerbation of pains swelling in an upper part of a stomach can periodically be observed. These phenomena are more often observed at the progressing process.
The greatest value in the correct diagnosis has rentgenol. research. Passing of baric weight on D.'s bulb is normal to. occurs during 6 — 10 sec., and on D.'s loop to. for 5 — 15 sec.
These terms vary over a wide range. A delay of contrast weight in any of sites D. to. for the term of St. 35 — 40 sec. is manifestation of a staz. Very bystry (for 1 — 2 sec.) advance of a contrast agent according to D. to. shall be considered as a hyperkinesia.
D.'s dyskinesia to. it is the most reasonable to group as follows: partial duodenostaza; total duodenostaza; a combination of a staz to accelerated promotion of a contrast agent according to D. to.; hyperkinesias. Bulbostaz is more often observed at patients with stomach ulcer or D.'s bulbs to., at cholecystitis, a holetsistopankreatita; bulbostaz in a combination with stazy in other parts D. to. — at an extra bulbous ulcer, cholecystitis and a holetsistopankreatita; partial duodenostaz without bulbostaz — at pancreatitis.
Total duodenostaz meets seldom. It is result of a post-bulbar (extra bulbous) ulcer, nervous diseases, influence pharmakol, drugs, defeats of c. N of page. From complications of diskineziya a duodenitis is most frequent, D.'s ulcerations meet much less often to. and bleedings.
Treatment of staz: at early stages conservative — a diet (reduction on the volume of portions, well crushed, wiped food, generally vegetables), vitamin therapy to lay down. gymnastics; at longer staz and the phenomena of the accompanying duodenitis — washings of a gut via the duodenal probe; at aggravations — a bed rest, heat on a stomach, emptying and washings of a gut. In the absence of effect of conservative therapy and at progressing D.'s ectasia to. operational treatment is shown. The main method of operational treatment is the duodenojejunostomy in various modifications. At staza in an upper half of D. to. or in a bulb it is recommended duodenojejunostomy (see) with crossing of a jejunum below flexura duodenojejunalis and anastamosing of a distal piece its end sideways or a side sideways with a bulb or the descending part D. to. and with recovery of a continuity of a small bowel an U-shaped anastomosis — the end of a proximal piece sideways distal. At D.'s prelum to. ring-shaped pancreatic gland showed crossing of a pancreatic ring on a front wall of D. to. with release and relative mobilization of this its site.
The duodenitis in most cases is not an independent disease, and accompanies damages of a stomach and the bodies surrounding a gut. Most often a duodenitis meets hron. A wedge, their manifestations in most cases differ in nothing from a peptic ulcer (see). The general discomfort, small temperature, a dispeptic syndrome, pain and feeling of weight in epigastric area, falling of blood pressure are sometimes noted. The duodenitis can be the cause of acute and occult bleeding. Sometimes jaundice or a syndrome of a stenozirovaniye of a gut are the first symptoms of a disease. Radiological hron, the duodenitis sometimes is followed by swelling, coarsening of folds of a mucous membrane of antral department of a stomach (see. Gastritis ).
The bulb at a duodenitis can be reduced in sizes, and passing of a contrast agent on it is sharply accelerated, contours of a bulb indistinct. Are noted a hyperperistalsis, longer, than normal, a delay of a contrast agent in D. to. and nek-swarm expansion of its gleam. Many deformations of a bulb are caused by an inflammation of her mucous membrane, on a cut polypiform swellings are found. Less often alternation of zones of sharp puffiness decides on sites of baric depots, suspicious on an ulceration. Folds of a mucous membrane because of hypostasis can disappear, and in some sites there is a picture of a pseudosclerosis which is expressed in narrowing of a gleam of D. to. The uniform thickening of a mucous membrane meets a smoothness of folds. All these changes can be combined. Contours of a bulb and the descending part D. to. are sometimes jagged, and the gut in the place of defeat is represented rigid.
The authentic diagnosis hron, a duodenitis can be established at the accounting of all a wedge, data, repeated rentgenol, the research allowing to find permanent changes of a mucous membrane of a gut (fig. 13), and in the presence gistol, confirmations (biopsy). Treatment conservative. The forecast of a disease favorable also depends first of all on the correct medical tactics.
D.'s tuberculosis to. occurs in 3 — 4% of cases of tuberculosis of intestines, generally at men up to 30 years, it is more often observed at primary pulmonary tuberculosis, tuberculosis of an ileocecal corner, retroperitoneal limf, nodes and quite often is display of the hematogenous disseminated tuberculosis. Distinguish two main forms of process — proliferative and destructive and four phases of a current — nodular, infiltrative, ulcer and cirrhotic.
Initial tubercular changes arise in follicles and a submucosa in the form of epithelioid and cellular hillocks. At dominance of exudative processes the caseous necrosis is noted. Caseose leads disintegration of hillocks and sites to formation of ulcers with the subdug edges. Ulcers, extending, can connect among themselves, forming circular ulcerations, characteristic of tuberculosis. At their healing there is a stenosis which can result in impassability. The disease begins almost asymptomatically or is followed by insignificant subjective feelings: weakness, perspiration, nausea. Through a nek-swarm time there are expressed wedges, manifestations. At a destructive form symptoms are observed round ulcer (see): night pains, pains on an empty stomach or in 1,5 — 2 hours after food in epigastric area, heartburn, locks. At proliferative — symptoms of a duodenitis, a periduodenitis: continuous dull ache in epigastric area regardless of meal. Pains amplify at the sharp movement. The disease is followed by a loss of appetite, gradual weight loss, increase of the weakness, steady subfebrile condition accelerated by ROE. Positive reaction of the Tuberculine test is quite often observed, and find mycobacteria of tuberculosis in rinsing waters of a stomach. At rentgenol, a research are found destruction of folds of a mucous membrane of D. to., thickening of its wall. The gleam of a gut can be narrowed on various extent; contours its uneven, places rigid, gear. Motive function of a gut is broken. Treatment of uncomplicated tuberculosis of D. to. conservative: diet, antacids, cholinolytics and specific antitubercular therapy. Indications to operational treatment are inefficiency of conservative therapy and development of complications. The forecast depends on time of diagnosis and to lay down. tactics.
The actinomycosis meets seldom. Actinomycetes get to an organism together with food and, without being late, pass through a stomach and D. to. D. is more often to. is surprised as a result of transition of specific inflammatory process to a wall of a gut from the next bodies and fabrics (from a large intestine or retroperitoneal cellulose). D.'s actinomycosis to. begins with implementation of actinomycetes in a wall, a peritoneum, retroperitoneal cellulose and an abdominal wall. Further there are condensed small knots which then are softened and often break up in connection with the joining consecutive infection that leads to formation of fistulas with purulent separated with impurity of kroshkovidny masses, and also to education and duodenal fistulas. At considerable distribution of process in D.'s wall to. and especially in the fabrics surrounding it in connection with deformation, a prelum and narrowing of a gleam of a gut motor disturbances which always progress are possible and are shown by intestinal impassability of various degree. Diagnosis of an actinomycosis of D. to. it is difficult only at early stages of a disease. At formation of fistulas and existence in their separated actinomycetes to make the diagnosis much more simply. Implementation in practice of a duodenofibroskopiya (see. Duodenoskopiya ) allows timely, at early stages of a disease to diagnose this rare localization of an actinomycosis.
Treatment is complex, the basis it is made by an immunotherapy. Antibacterial drugs, excitants, operational treatment can be in addition used (see. Actinomycosis, treatment ).
divide Fistulas on internal and outside.
Internal fistulas — messages of a cavity of D. to. with a cavity of the next body, most often with a gall bladder or the general bilious channel usually in its retroduodenal part (holetsistoduodenalny or holedokhoduodenalny fistulas — see. Bilious fistulas ). Much less often fistulas between D. meet to. and thick (usually cross colonic), D. to. and small bowel. Formation of internal duodenal fistulas between an echinococcal cavity and a cyst of a pancreas, and also between well delimited abscesses subphrenic, under hepatic and retroperitoneal spaces is possible. Fistulas result patol, defeats of a wall of D. to. with its subsequent distribution on a wall of other body or on the contrary.
At variety of the reasons leading to development of internal fistulas of D. to., their wedge, a picture and a current are also diverse. At the time of formation of internal fistula the exacerbation of pains in verkhnepravy department of a stomach — in right hypochondrium and lumbar area is always observed. At the same time in the relevant departments of an abdominal wall there is a muscular protection of various degree, the expressed phenomena of irritation of a peritoneum can sometimes be observed. At disturbance of a commissural barrier in the place of burrowing and at infiltration of intestinal contents in a free abdominal cavity generalization of peritonitis is noted. More often pains and the local inflammatory phenomena gradually abate to the following aggravation. The wedge, a picture depends on an aggravation, the nature of fistula and body, about the Crimea D. to. it is reported. So, at messages between D. to. and biliary tract gradually develop the phenomenon ascending cholangitis (see) with periodic rises in temperature, an oznobama, the alternating jaundice and a leukocytosis; at messages with a large intestine come to light and gradually the phenomena accrue colitis (see) with the exhausting ponosa, in fecal masses considerable impurity of undigested food is observed.
Existence of fistula can be revealed at the combined rentgenol, a research of a stomach, D. to. and bilious courses. At suspicion of fistula with a large intestine additional is necessary irrigoskopiya (see). The great value is gained by a duodenofibroskopiya and a kolofibroskopiya.
Treatment of the created internal duodenal fistulas, as a rule, operational. The exception is made holetsisto-also by holedokhoduodenalny fistulas with insignificant throwing of contents of D. to. in the biliary tract which is not followed a wedge, manifestations. As a rule, such fistulas come to light accidentally at a roentgenoscopic research of a stomach. However at emergence of pains, periodic rises in temperature and especially alternating jaundice it is necessary to raise a question of operational treatment which comes down to dissociation of the bodies connected among themselves by the fistular course and to sewing up of defect in an intestinal wall in transverse direction. At fistulas with a gall bladder it is shown cholecystectomia (see). If internal duodenal fistula was formed as a result of disintegration and an ulceration of a tumor in the absence of metastasises, are shown circular or wedge-shaped excision of a wall of D. to. and a resection or full removal of other hollow body involved in process. At impossibility of performance of radical operation imposing of the bypass or switching-off a zone of fistula anastomosis is shown.
Outside fistulas — the message of a cavity of D. to. directly through an abdominal wall with the environment. Such fistulas are formed at wounds and injuries of an abdominal cavity, and also during the carrying out various operations. In a stage of development and formation outside fistulas are always followed by considerable loss of bile, pancreatic enzymes, duodenal contents with impurity of food masses that leads to quickly progressing disturbances of water and electrolytic balance, acid-base equilibrium, hypoproteinemia, anemization and exhaustion. Contents of a gut through an opening of fistula stream on the surface of skin, causing heavy and persistent dermatitis. On character separated easily to reveal the place of defeat. At the narrow long fistular course and a small outside opening there is a danger of emergence of phlegmonous and necrotic process with formation of purulent zatek. Outside fistulas are followed by oznoba, rise in temperature, a leukocytosis. For definition of fistula, the extent of defect in a wall of a gut, and also for identification of zatek and additional cavities use fistulografiya (see).
Treatment of fistulas generally operational. Through a wall in D.'s cavity to. enter a thin drainage tube. It is fixed together with an epiploon to a wall of a gut. Other end is removed outside for assignment of duodenal contents. For the first 5 — 8 days continuous active aspiration from D. is reasonable to. The same action is directed to prevention and treatment of heavy dermatitis and maceration of skin in circles of fistula. At phlegmonous and necrotic process of retroperitoneal cellulose its broad opening and a tamponade with drainage of all zatek is shown. Attempts of sewing up of defect of a wall of D. to. in the presence of necrotic fabrics and edematous infiltration of the wall, as a rule, do not yield a positive take. Locally apply to prevention of maceration of skin various powders (a kaolin, gypsum, talc) and ointments (Lassar's paste, 5% metiluratsilovy ointment, etc.). At the progressing maceration irrigation of sites of an ulceration of 1% by solution milk to - you is shown. At the progressing exhaustion imposing of an eyunostoma is shown (see. Enterostomy ). The patient with outside fistulas of D. to. injections of solutions of electrolytes, plasmas, proteinaceous drugs, vitamins and blood are shown.
For decrease in secretion of a pancreas appoint atropine, Trasylolum, Contrykal, etc. At correct to lay down. to tactics fistula heals at 60% of patients. Only in rare instances at well created fistula and in the absence of the reactive inflammatory phenomena there can be a question of change of fistula in a loop of a jejunum (a hypodermic fistuloenterostomy according to Smirnov).
Tumours meet rather seldom, and malignant are observed more often than high-quality. So, according to clinic of Mayo (USA), on 6044 tumors of D. to., established preferential on autopsies, 44 were high-quality, and 6000 — malignant.
From benign tumors meet a polyp (see. Polyp, polyposes ), papilloma, leiomyoma, lipoma, adenoma, hemangioma, neurofibroma.
The majority of malignant tumors of D. to. (cancer, sarcoma) proceeds from a mucous membrane of the mouth or an ampoule of a big nipple or from a head of a pancreas. Primary malignant tumors proceeding directly from D.'s wall to., are observed extremely seldom. But as patients ask for the surgical help when process takes already all wall and D.'s gleam to. and clinical displays of primary and secondary tumors are identical, all tumors of this zone are considered together as tumors of a pankreatoduodenalny zone. The most frequent localization (75%) of primary tumors — the descending part D. to. (area of a big nipple); on a share of upper part D. to. 10 — 15% and horizontal (lower) — 10 — 15% are necessary.
Clinical displays of tumors of D. to. depend on speed and the nature of their growth, localization and possible involvement in process of adjacent bodies and fabrics. Owing to this fact benign tumors usually long time proceed asymptomatically and, only when the tumor reaches the considerable sizes and narrows a gleam of a gut or squeezes a terminal piece of a bile-excreting channel, secondary disturbances from D. begin to develop to. or biliary tract. At the rapid infiltrative growth of malignant tumors characteristic disturbances develop early and quickly progress. In clinic of benign and malignant tumors signs of the duodenostaz passing in duodenostenoz prevail. Patients complain of constant feeling of weight in an anticardium and in right hypochondrium, on the pains amplifying after food, nausea, vomiting, and later and vomiting.
At localization of a tumor in the field of a big nipple often first and only display of a disease is incremental bezbolevy jaundice. With increase of jaundice also painless, increased, intense gall bladder of an elastic consistence (Courvoisier's symptom) begins to be palpated clearly. Jaundice quickly accrues though in some cases at disintegration and an ulceration of a tumor can accept the alternating character. This sign is more often observed at cancer defeats of a big nipple of D. to., as well as at its papillomas. It is necessary to pay attention at diagnosis in case of the late address of the patient to it. Jaundice is followed by loss of appetite, the general weakness, gradually developing anemization, a skin itch, rise in temperature from oznoba and pouring sweats (it, apparently, is connected with the joining cholangitis). Are possible went. - kish. bleedings.
The exact diagnosis can be made only after rentgenol, researches and fibrogastroduodenoskopiya with tsitol, a research of prints and biopsy material from the respective sites of the affected mucous membrane.
At benign tumors radiological in D. to. single or multiple defects of filling of a rounded or semi-oval shape come to light.
Malignant tumors radiological are characterized by D.'s narrowing to. with rigidity of a wall of a gut on a bigger or smaller extent, uneven corroded contours and destruction of folds of a mucous membrane in the place of defeat. In addition to infiltration, the ulceration can be observed, and then these changes should be differentiated with an extra bulbous ulcer.
Treatment of benign tumors of D. to. and pankreatoduodenalny zone operational. At papillomas and early stages of cancer of a big nipple excision of tumors with the subsequent implantation of the crossed general bilious and pancreatic channels in D. is shown to. At distribution of blastomatous process on D.'s wall to. and a head of a pancreas the wide pankreatoduodenalny resection is shown (see. Pancreas, operations ) and various options of a pancreatoduodenectomy. The postoperative lethality at these operations fluctuates ranging from 30 to 60%. At inoperable tumors are shown cholecystogastrostomy (see), cholecystoduodenostomy (see), holetsistoenterostomiya (see) or holedokho-, gepatikoyeyunoanastomoza. At a stenozirovaniye of a gleam of D. to. apply gastroenterostomy (see) or duodenojejunostomy (see). The direct postoperative lethality at palliative operations, despite their smaller volume and relative technical simplicity, high also fluctuates from 25 to 45% that is connected first of all with weight of a condition of patients.
To. is an object of surgical intervention most often concerning an ulcer (see. Peptic ulcer ). At this pathology the resection of a stomach, vagisection in combination with various operations, gastroenteroanastomoses most were widely adopted. Besides, widely apply a duodenotomy, a papillotomiya and a sphincterotomy).
At the choice of a method of operation the main attention is paid to the general condition of the patient, anatomo-morfol. features of ulcer process and nature of gastric secretion. All interventions on D. to. are usually made under the general anesthesia. For access to D. to. use median laparotomy (see).
Duodenotomy — opening of a gleam of D. to. — is, in essence, only one of stages numerous, enough various operations undertaken for survey of a cavity of a gut and its mucous membrane and elimination patol. processes, is more often in a zone of a big nipple of D. to. and retroduodenal piece of the general bilious channel. A number of surgeons makes a duodenotomy in transverse direction — on the front wall covered with a peritoneum. At the same time circular muscle fibers of a muscular layer are not crossed and therefore at sewing up of a gut in transverse direction narrowing of its gleam is not observed. Others prefer a longitudinal duodenotomy, believing that this method allows, unlike cross, to sharply expand the field of intervention. It is necessary to take in a slit in transverse direction for prevention of narrowing of a gleam of a gut.
Papillectomy - excision of a big nipple — is made at benign tumors (more often papillomas), and also at early stages of cancer defeats of area of a nipple. After palpatorny definition of defeat of a big nipple over it on a front wall of D. to. the duodenotomy is made. On a back wall on a circle of a nipple it is opened and the mucous membrane, so not to break an integrity of a back wall of a gut otseparovyvatsya partially. The nipple is taken a handle and carefully removed through a duodenotomichesky opening with careful separating of walls of the general bilious and pancreatic channels (within healthy fabrics it is carried out easily). Further the allocated channels are crossed and hemmed to a mucous membrane of D. to. instead of the excised and remote big nipple (fig. 14).
Papillotomiya — a section of the mouth of a big nipple of D. to. It is applied preferential to removal of the stones restrained in it. At this intervention longwise cut only a mucous membrane in the mouth of a nipple. After that the stone easily is removed, and edges of a dissect mucous membrane are hemmed by two seams to a wall of the channel cut in the mouth (see. Cholelithiasis, surgical treatment ).
Sphincterotomy — section of a sphincter of Oddi. Operation is directed to a section of a muscular part of a sphincter; apply at the expressed cicatricial changes, a sclerosis of a muscle (a sclerosing papillitis) and especially at a combination of these changes to infringement of concrements. After D.'s opening to. klinovidno excise the site of a nipple in the form of a triangle with the basis at its mouth. After a section hem a mucous membrane of D. to. to a mucous membrane of a channel (in the place of a section or excision of a triangle — fig. 15). Operation a sphincterotomy judging by the long-term results, has serious consequences — the ascending angiocholites of various degrees as a result of, apparently, throwing of duodenal contents in biliary tract therefore at a vklineniya of a stone apply transduodenal suprapapillar choledochoduodenostomy (see).
Clinicodiagnostic characteristic of some diseases and injuries of a duodenum
Anatomy, embryology and physiology — Aganezov S.A. Variations of pancreaticoduodenal vessels, Surgery, No. 12, page 73, 1970; Berlin L. B. iuspensky B. M. Histologic and some histochemical features of a mucous membrane of a duodenum at healthy people, Arkh. annate., gistol, and embriol., t. 59, No. 10, page 64, 1970; Galperin Yu. M. and Rogatsky G. G. Relationship of motor and evakuatorny functions of intestines, M., 1971, bibliogr.; Kravchenko V. K. Intraparietal lymphatic system of a duodenum of the person, Arkh. annate., gistol, and embriol., t. 59, No. 12, page 18, 1970, bibliogr.; Kurtsin I. T. Mechanioreceptors of a stomach and operation of the digestive device, M. — L., 1952, bibliogr.; it, Hormones of the alimentary system, M., 1962, bibliogr.; F. P. marquises. Venous system of a digestive tract of the person, Kuibyshev, 1959; Mel-man E. P. Functional morphology of an innervation of digestive organs, page 105, M., 1970; Mosolov V. V. Proteolytic enzymes, M., 1971, bibliogr.; Motor function of digestive tract, under the editorship of P. G. Bogach, Kiev, 1965, bibliogr.; Serdyukov A. S. One of essential conditions of transition of food of a stomach to guts, yew., SPb., 1899; Ugolev A. M. Membrane digestion, L., 1972, bibliogr.; Physiology of digestion, under the editorship of A. V. Solovyov, L., 1974, bibliogr.; Surgical anatomy of a stomach, under the editorship of A. N. Maxi-menkova, page 248, L., 1972; Sh l y and G. K N. Enzymes of intestines are normal also of pathology, L., 1967, bibliogr.; Electric activity of unstriated muscles and motor function of a digestive tract, under the editorship of P. G. Bogach, page 32, Kiev, 1970; Biomembranes, ed. by D. H. Smyth, v. 4A, 4B 5, N. Y., 1974; F o d i s with h H. Feingeweb-liche Studien zur Orthologie und Patho-logie der Papilla Vateri, Stuttgart, 1972, Bibliogr.; Patten B. M. Carlson B. M. Foundations of embryology, N. Y., 1974; Piaseski C. Studies of the submucosal vessels of the stomach and duodenum in man and dog, J. Anat., v. 105, p. 194, 1969.
Pathology — Atlas of pathological histology of a mucous membrane of a stomach and duodenum, sost. L. B. Berlin, etc., L., 1975; Berezov E. L. Surgery of a stomach and duodenum, Gorky, 1950, bibliogr.; Diseases of digestive organs, under the editorship of Ts. G. Masevich and S. M. Rys-s, L., 1975, bibliogr.; Efremov A. V. and K. D Eristavi. Diseases of a duodenum, M., 1969, bibliogr.; Earth A. G. Diverticulums of digestive tract, L., 1970, bibliogr.; Littmann I. Belly surgery, the lane with it., Budapest, 1970; M and l x and with I V. A N. Duodenal stump, Yerevan, 1968; Mirzayeva. P. Duodenalny staz, L., 1976, bibliogr.; Nelyubovich Ya. Acute diseases of abdominal organs, the lane with polsk., M., 1961; Smirnov A. V., P about p e of m - with to and y O. of B. and F r and d D. I. Surgical treatment of diseases of a pancreas and periampulyarny area, L., 1972, bibliogr.; L. K falcons. Atlas of endoscopy of a stomach and duodenum, M., 1975, bibliogr.; Shalimov A. A. Diseases of a pancreas and their surgical treatment, M., 1970, bibliogr.; Shalimov A. A. and Semi-sir V. N. Atlas of operations on a gullet, stomach and duodenum, M., 1975; Shalimov A. A. and Saenko of V. F. Hirurgiya of a stomach and duodenum, Kiev, 1972, bibliogr.; With h e 1 i R. Duodenitis and duodenal ulcer, Digestion, v. 1, p. 175, 1968; Koelsch K. A. Das Duodenum nach Cholezystektomie, Dtsch. Z. Verdau. - u. Stoffwechselkr., Bd 28, S. 283, 1968; Maingot R. Abdominal operations, L., 1961; Mors on B. C. a. Dawson I. M. P. Gastrointestinal pathology, Oxford, 1974.
A.S. Belousov, A. P. Zlatkina; L. I. Aruin (An., gist., stalemate. An., malformations), T. V. Krasovskaya (it is put. hir.), B. S. Rozanov (PMC., hir.), M. M. Salman (rents.), Yu. N. Samko (physical.); authors of the table A.S. Belousov, A. R. Zlatkina, T. L. Kozhevnikova.