FATEROV of PACIFIERS [papilla duodeni major (PNA); by name it is mute. anatomist Fater (A. Vater, 1684 — 1751); synonym: a big duodenal nipple, a big nipple of a duodenum, papilla Vateri] — vozvyshe-
Fig. Makropreparat of a part of a duodenum (the gleam of a gut is opened):
I \the descending part of a duodenum, II — a horizontal part of a duodenum; 1 — santorinets of pacifiers (small); 2 — fater of pacifiers (a big nipple of a duodenum); 3 — the probe entered into the general bilious canal.
walls of a duodenum, ny on an inner surface, corresponding to the place of falling of the general bilious channel and pancreat duct into a duodenum.
For the first time this education was described by Fater in 1720. Width F. the page apprx.
4 mm, height is up to 7 mm; most often it is located approximately on the middle of the descending part of a duodenum (see). Its origin is connected with passing in this site of a wall of a gut of the general bilious channel (ductus choledoehus) and pancreat duct, or virzungov of a channel (ductus pancrea-ticus, s. ductus wirsungi). The general bilious channel raises her mucous membrane in the form of a longitudinal fold, at the basis the cut also is formed by F. page (fig). Most often in the area F. the page the general bilious channel extends, forming a pechenochnopodzheludochny ampoule (ampulla hepatopancreatica), in to-ruyu the pancreat duct falls (see), and both channels open on F. page one general opening. There are also other options of falling of these channels into a duodenum (see. Bilious channels). In a circle of a hepatopancreatic ampoule, in the thickness of F. pages are available ring slanting and longitudinal muscle bundles, to-rye intertwine among themselves and form a sphincter of a hepatopancreatic ampoule, or Oddi's sphincter (sphincter ampullae liepatopancreaticae, s. sphincter Od-di) functioning irrespective of muscles of a duodenum. The general bilious channel and a pancreat duct at the place of their merge have independent sphincters (sphincter ductus choledo-chi, sphincter ductus pancreatici).
Blood supply F. the page is carried out by ventral and dorsal branches of pozadiduodenalny arteries (aa. retrod uodenales). Venous outflow of blood happens on front and back pankreatoduodenalny veins (vv. pancreaticoduo-denales) falling into an upper mesenteric vein (v. mesenterica sup.). Limf, vessels are connected with limf, and are reported by vessels of terminal department of the general bilious channel, a duodenum and a head of a pancreas with limf, nodes of a root of a mesentery of a colon. In an innervation F. pages participate a vagus nerve and sympathetic fibers of a celiac texture (plexus celiacus).
Faterov to a nipple, in particular a sphincter of a hepatopancreatic ampoule, and also sphincters of the general bilious channel and a pancreat duct possesses the main role in regulation of intake of bile (see) and juice of a pancreas in a duodenum and prevention of a duodenobiliarny and duodenopankreatichesky reflux (see). At relaxation of the specified sphincters bile and juice of a pancreas come to a duodenum, at reduction — receipt them in a gut stops, and bile goes through a vesical channel to a gall bladder (see). In the mechanism of moving of bile to a duodenum play a role also secretory pressure of a liver (see), motility of a gall bladder, a tone of walls of bilious channels, a peristaltics of a duodenum, etc.
To methods of a research F. pages belong: duodenal a zondirova
ny (see), a duodenografiya (cm, Duode-nog a raffia relaxation), a duode-noskopiya (see), an endoscopic retrograde pankreatokholangiogra-fiya (see Pankreatokholangiog a raffia retrograde), a holangiografiya (see), an intravenous holegrafiya (see), a ho-ledokhomanometriya, a holedokhoskopiya (see), ultrasonic examination of bilious channels and a pancreas (see. Ultrasonic diagnosis), a computer tomography (see the Tomography computer).
Diseases F. pages are clinically shown by a syndrome of a stenosis (see the Stricture). According to V. V. Vinogradov (1962), stenosis F. by page it was observed approximately at 26% of patients, the Crimea operation on bilious channels concerning iyeopu-cholic diseases was performed.
Reasons of a stenosis F. pages are various. In some cases stenoses F. pages
happen inborn character. Nek-ry researchers point to a possibility of a stenosis F. the page caused by functional disturbances like dyskinesia (see) at to-rykh the long spasm of a sphincter of a hepatopancreatic ampoule alternating with its atony is observed. These disturbances are usually combined with similar disturbances of bilious channels and a gall bladder and can be observed also at diseases of a stomach (see), a pancreas, a duodenum. Most often stenosis F. the page arises at cholelithiasis (see) owing to frequent passing of sand and small concrements, and also at a duodenitis (see), a cholangitis (see), pancreatitis (see), the inflammation resulting at these diseases F. page — acute or hron. papillitis.
Morphologically in an initial stage of a stenosis F. the page is observed hypostasis and leukocytic infiltration of its walls. Later find atrophic or hypertrophic process in a mucous membrane of a hepatopancreatic ampoule quite often with a hyperplasia of the ferruterous device and formation of adenomatous growths.
In the muscular device of a sphincter of an ampoule connecting fabric develops, there occur the sclerous and cicatricial changes leading to narrowing F. page. Sometimes these changes extend to output departments of the general bilious channel p a channel - a pancreas.
Wedge, picture of a stenosis F. the page develops of symptoms of bilious hypertensia, and in the most hard cases — a holangioyetaz and mechanical jaundice (see), and these phenomena are temporary often, and jaundice happens remittiruyu-Russian cabbage soup. Pains in right hypochondrium are noted at the vast majority of patients. Approximately at 30 — 40% of patients a stenosis F. the page is followed by a picture of the recurrent pancreatitis connected with the developments of stagnation in a pancreas caused by blockade of pancreatic channels. Expressiveness a wedge, manifestations depends on degree of a stenosis F. the page, to-ry can be compensated, subkompensiro-bathing and dekompensirovanny.
Diagnosis of a stenosis F. for page it is difficult since the main its wedge, symptoms are not specific; they are observed also at cholelithiasis, a cholangitis, a duodenitis, pancreatitis and other diseases, with to-rymi a stenosis F. the page is often combined. Diagnosis of a stenosis F. the page can be sometimes specified at the multimoment nomas duodenal sounding, an intravenous holegrafiya, a duodeno-skopiya by means of a fiber optics. Most effectively for diagnosis of a stenosis F. page a research of the general bilious channel during operation (sounding, a holangio-manometriya, a holangiografiya, a holedokhoskopiya).
Treatment of functional stenoses F. page conservative (spasmolytic and antihistamines, cholagogue means, at indications — antibiotics and streptocides). Treatment of organic strictures F. page operational. At the isolated stenosis F. page and lack of the inflammatory phenomena in it and a wall of a duodenum make operations on F. page — bougieurage, a transduodenal papillotomiya (a section of a mucous membrane F. page), transduodenal papillosfinkterotomiya (section of a mucous membrane F. page and a sphincter of a hepatopancreatic ampoule) and to a papillosfinkteroplastik (sewing together after a papillosfink-terotomiya of edges of a dissect mucous membrane of a duodenum and a hepatopancreatic ampoule); less traumatic method of an endoscopic papillosfinkterotomiya — a section of a sphincter the special tool — papillotomy, entered via the biopsy channel of the endoscope gained distribution (see Endoscopy). At distribution of the stenosing cicatricial and sclerous changes on the general bilious canal, existence of the stenosing pancreatitis (blocking current of bile at its passing in the field of a head of a pancreas) and the inflammatory phenomena in a wall F. page and a duodenum, make a choledochotomy (see), a choledochostomy (see) or impose a bypass zhelcheotvodyashchy anastomosis (see Choledochoduodenostomy, the X oletsistoentero-stomiya).
In nek-ry cases both the papillosfinkterotomiya and supraduodenalny choledochoduodenostomy is shown. E.g., at a combination of a stenosis F. the page with the stenosing pancreatitis a bypass holedokhoduodeno-anastomosis eliminates impassability of the general bilious channel, and the papillosfinkterotomiya recovers passability of a pancreat duct.
The forecast at the isolated stenosis F. page in cases of recovery of outflow of bile favorable. At a combination of a stenosis F. the page with other diseases the forecast depends on the nature of these diseases and the applied operations.
To new growths F. pages belong the benign and malignant (cancer) tumors arising in a mucous membrane of the duodenum covering F. page, hepatopancreatic ampoule and mouth of the general bilious channel or pancreat duct.
Benign tumors F. pages meet quite seldom. More often it is papillomas (see Papilloma, a papillomatosis) or adenomas (see Adenoma), to-rye carry out a pechenochnopodzheludochny ampoule and prolabi-rut in a gleam of a duodenum. The sizes of tumors make in the diameter from several millimeters to 3 — 4 cm. Most often tumors consist of mature epithelial cells and have a ferruterous structure; quite often in them the expressed phenomena of an inflammation are observed.
The main wedge, displays of benign tumors F. pages are connected with its obturation (pains in right hypochondrium, the alternating jaundice, symptoms of recurrent pancreatitis). Sometimes in duodenal contents blood is found. The most effective diagnostic method is visual survey F. page at a fibroduodeno-skopiya, in time a cut it is possible to make a biopsy of a tumor (see the Biopsy). Treatment of benign tumors F. page operational (papillectomy). The forecast during timely removal of a new growth favorable. The malignancy of a tumor is in some cases possible.
Cancer F. the page (see Cancer), according to different researchers, occurs approximately at 5 — 10% of patients with malignant new growths of gepatobiliarny and pankreatoduodenalny zones.
Macroscopically cancer tumor F. the page has an appearance of a solitary node, a polyp or an ulcer. The solitary node causes a prolapse F. the page and a gaping of its mouth, through a cut are visible the bleeding tumoral masses. Polypostural forms remind a cauliflower. A cancer ulcer of usually irregular shape with the dense subdug edges, the bleeding bottom and purulent imposings. Sometimes the tumor infiltrirut the next fabrics, extending to a duodenum, the general bilious channel and a pancreas. Microscopically most often the adenocarcinoma with a picture of solid or mucous cancer is found. For cancer F. page rather slow growth is characteristic, however impassability F pages develops already at the beginning of a disease. Innidiation happens in regional limf, nodes, later — in the remote bodies.
The disease arises usually on average and advanced age, a thicket at men. Sometimes at the beginning of a disease at patients the pains reminding bilious colic, weakness, a febricula, fervescence are noted. However more often an early symptom of a disease is jaundice, edges quite often has constant character, then the dispeptic phenomena (anorexia, nausea, feeling of weight in an anticardium), weakness, weight loss join; sometimes, owing to the accompanying cholangitis, body temperature increases. At a wedge, inspection of the patient increase in a liver is defined and the increased painless gall bladder (a symptom of Kur-vuazye) is palpated. Data laboratory a wedge, researches (blood, urine, a calla, etc.) confirm existence of mechanical jaundice; in duodenal contents blood and atipichesky cancer cells can be found.
Diagnosis of cancer F. pages put on the basis of data a wedge, inspections of the patient and the results received by means of tool methods of a research (see above). Essential help is given by X-ray inspection of a duodenum and bilious channels. The most effective diagnostic method of cancer F. the page is a fibroduodenoskopiya, at a cut it is possible to see directly changes in F. page and to make a biopsy of a tumor.
Cancer therapy F. page only operational. At limited tumors make to a traisduodenalnra excision F. page (papillectomy). In cases of germination by a tumor of a wall of a duodenum or its distribution on a pancreat duct and the general bilious channel make a pankreatoduodenalny resection (removal of a head of a pancreas and duodenum) or a total pancreatoduodenectomy (see). At impossibility Uda lendya a tumor or existence of the remote metastasises impose a bypass zhelcheotvodyashchy anastomosis.
The forecast at cancer F. the page depends on timeliness of carrying out and the nature of radical operation. According to many surgeons, radical cancer operation F. page it is possible at 50 — 70% of patients; quite often it yields the encouraging results.
Bibliography: And r and p about in U. A. and d river. Big duodenal
nipple and pancreas operations, Tashkent, 1978; The Ball of l y to and A. S's N., To r-nilov Yu. M. and P e in I to and V. I N. An endoscopic sphincterotomy of an ampoule of a faterov of a nipple at mechanical jaundice, Owls. medical, No. 11, page 45, 1979; In ii of N of au grads of V. V. Diseases of a faterov of a nipple, M., 1962, bibliogr.; r and sh to e-in and the p E. V. Klinika, diagnosis and surgical treatment of a stenosis of a faterov of a nipple, Klin, hir., No. 7, page 12, 1965; N of ides e r l e B. and d river. Surgery of bilious ways, the lane from Czeches., Prague, 1982; With and - in e l e in V. S., V. M. Brawlers and B and l and l y to and A. S's N. Endoscopy of abdominal organs, M., 1977;
Shkrob O. S., Shovel Yu. M. and Safronov V. V. The diagnostic value of special methods of a research at mechanical jaundice, Surgery, No. 9, page 48, 1973; Fodisch H. J. Feingewebliche Studien zur Orthologie und. Pathologie der Papilla Vateri, Stuttgart, 1972; Mattig H. Papilla Vateri, Lpz., 1977; The papilla vateri and its diseases, ed. by M. Classen a. o., Baden-Baden a. o.,
1979. D.F. Blagovidov, A.S. Yakovlev.