GASTROSCOPY (Greek gaster a stomach + skopeo to consider, investigate) — a method of a research of an inner surface stomach by means of the device — the gastroscope entered through a mouth and a gullet into a stomach.
The first attempts to examine a stomach were made by A. Kussmaul in 1868, but the founder of a method is considered to be I. Mikulich (1881) who by means of the special device (like the cystoscope) the first examined an inner surface of a stomach. Depending on a design of gastroscopes all history of development of G. can be divided into three periods. The first period (1881 — 1932) — use of rigid unbending lens gastroscopes, the second (1932 — 1958) — use of semi-flexible devices which distal part of a tube could be bent that considerably expanded possibilities of a method; the third period (after 1958) — implementation of flexible gastroscopes with a fiber optics. About a wedge, use of the gastroscope with a fiber optics (gastrofibroskop) the first were told by Girshovitts (V. of I. Hirschowitz); he showed gastroduodenoskop with this optics on the congress of gastroenterologists in Washington in 1958. Use of gastrofibroskop simplified a research of patients, it became safe, the «blind» zones characteristic at use of lens devices practically ceased to exist, there was a possibility of detailed survey of all surface of a stomach, his stump, anastomozirovanny loops of guts, and also researches of a stomach by means of a biopsy, tsitol. a method and photography of the studied objects.
In the fiber gastroscope illumination of a gastric cavity and obtaining the image of a surface of his mucous membrane happens to the help of the special light guide consisting of a large amount of fibers from special glass. Each fiber is covered with the material having low index of refraction that provides total internal reflection of a beam of light and prevents its dispersion. The arrangement of end faces of fibers on an entrance of the light guide precisely corresponds to their arrangement at the exit, it prevents distortion of the image. The coefficient of passing of light in the light guide is 2,5 times higher, than in lens devices, and does not decrease at bends. The light source both for survey, and for film photography is located in the transformer, about the Crimea gastrofibroskop connects the special light guide.
The fiber gastroscope (fig.) consists: 1) from a head of the device where are an eyepiece, control levers of the distal end of the device, button of management of giving in a stomach and suctions from it of air, liquid, entrances to channels with valves, on the Crimea it is possible to enter various tools into a stomach (kelectomes, catheters, tiny special scissors, needles, brushes, loops for a polypectomy and removal of foreign bodys, electrodes for coagulation etc.); 2) the working part of the gastroscope entered into a stomach, edge represents a flexible tube to dia. 8 — 12 mm, 860 — 1200 mm long, and connecting light guide. The design of the distal end of a working part of the gastroscope is various and depends on an arrangement of optics (side or axial — face). The distal end of the gastroscope can be bent in two perpendicular planes: in front back at an angle to 200 °, from left to right to 120 °. Near a watch window the channel of air delivery and liquid and other channel open, in Krom the manipulator allowing to change a form and the direction of the tools entered for a biopsy is located. Inflation of air and suction of liquids from a stomach is carried out automatically. The high svetoprovodnost of the device provides good visibility in the range from 10 to 100 mm.
Devices universal (ezofagogastrofibroskopa, gastroduodenofibroskopa, ezofagogastroduodenofibroskopa) and target (ezofagofibroskopa, gastrofibroskopa) appointments which differ on length, diameter, character of an arrangement of optics on the distal end of the device and to some other features are designed. There are gastrofibroskopa for a research of a stomach for children.
These gastroscopes released in various countries (the USSR, Japan, the USA, Germany, etc.), differ from each other in the fact that various light sources, types of coverings, special tools, prefixes etc. are used. The majority them is supplied with a photoprefix for color photography. The natural color rendition of photographic materials allows to record documentary in photos and slides the revealed pathology that facilitates studying it in dynamics.
For the educational purposes the special prefix attached to an eyepiece is created, edges allows to observe a gastroscopic picture at the same time to two researchers. Also the prefix allowing to transfer an endoscopic picture to the color television screen and to record with the videorecorder is designed. These devices provide significant increase in the image, simultaneous sighting by a large number of medics and repeated reproduction of the conducted endoscopic research.
Gastrofibroskopa at sharp bending and a prelum can be easily damaged since fiber glasses break, and in sight of the endoscope there are black points that worsens visibility. For the prevention of deformation fiber devices store in vertically hover. The covering of a gastrofibroskop does not take out high temperature and collapses during the processing by alcohols. Gastroscopes disinfect after each research soap solution and solutions of Rivanolum or Furacilin. Careful attitude to the device, observance of rules of processing and storage provide durability of the device.
G. is carried out in all cases when it is necessary to establish or specify the diagnosis of any primary disease of a stomach (gastritis, a peptic ulcer, tumors, burns and their complications), to define the nature of the changes in a stomach caused by diseases of the next bodies (a liver, a pancreas, a gall bladder), to reveal foreign bodys, etc.
Researches with the help gastro-fiberscopes are shown for definition of prevalence of a malignant new growth, the choice of specific himiopreparat and control of efficiency of their use; for differential diagnosis of malignant and high-quality ulcerations, polyps and polipovidny cancer, tumors and tumorous gastritises, organic strictures of the gatekeeper etc. The great value was gained by a gastrofibroskopiya in the emergency surgery for diagnosis of a bleeding point in upper parts of a digestive tract, at suspicion on existence of the covered perforation of an ulcer, for differential diagnosis of acute diseases of a stomach with diseases of the next bodies.
Special training of the patient for a research is not required: planned G. carry out in the morning on an empty stomach, emergency — at any time. In 15 — 20 min. prior to a research under skin enter 1 ml of 2% of solution of Promedolum and 0,5 — 1 ml of 0,1% of solution of atropine. Usually apply local anesthesia of a mucous membrane of an oral cavity and throat (grease 3% with solution of Dicainum or the patient rinses a mouth of 0,25% solution, spray in an oral cavity from a spray 3% solution of Dicainum with 2 — 3 drops of 0,1% of solution of adrenaline).
the Patient is stacked on the left side on the operating table with rising head and foot the ends. At the emergency G. the research is begun at the lifted foot end of a table that contents of a stomach (blood, slime, food masses) are glazed to the fundal area and did not prevent survey of the most part of a stomach.
Carrying out a gastrofibroskop through cardial department of a gullet and stomach is felt on overcoming easy resistance. Force air in a gastric cavity that provides good visibility of a mucous membrane of a stomach, and start systematic and detailed survey of all its departments. Rotating gastrofibroskop around an axis and slowly carrying out it in the caudal direction, consistently examine all walls from the cardia to the gatekeeper; repeatedly examine the same departments at removal of the device. It is reasonable to perform inspection in the following sequence: small curvature with adjoining to it front and back walls, big curvature, a bottom with the cardia adjoining to it, a body and antral department of a stomach.
Usually combine with gastrotsitol. research and gastrobiopsiya. Material for gastrotsitol. researches receive by means of the special probe brush. The brush on a slide plate applies a smear, tsitol. the structure to-rogo is studied under a microscope. Gastrobiopsiya is carried out by means of special nippers cups. The design of the fiberscope allows to receive material for gistol, researches from any department of a stomach (tsvetn, the tab., fig. 11).
Gastrofibroskopiya allowed to implement in a wedge, practice new fiziol. methods of a research of a stomach: record of electric potentials from various departments of a mucous membrane — an endogastrografiya and definition of secretory zones of a mucous membrane of a stomach — chromogastroscopy.
Gastrofibroskopa made possible removal of polyps without laparotomy (V. M. Buyanov, 1970).
Failures at introduction of a gastrofibroskop are generally caused by insufficient anesthesia of a mucous membrane of a throat when it is impossible to overcome a spazmirovanny entrance to a gullet. Detailed survey of all mucosal surface of a cover of a stomach does not work well only in cases when more than a half of volume of a stomach is occupied with liquid. Change of provision of the head or foot end of a table, sick by a pripodnimaniye, also does not help with these cases. Therefore it is necessary to empty a stomach by sounding and washing by a cold water.
Picture of a normality of a stomach
Normal, at small insufflation of air in a stomach, a skladchatost of a mucous membrane it is more expressed on small and big its krivizna, on front and back body walls of a stomach (tsvetn. fig. 1). In the direction to a bottom and antral department the quantity of folds decreases, they become low. Folds of a mucous membrane of antral department gentle, various form (tsvetn. fig. 2). In process of forcing of air the gastric cavity increases, folds finish and almost disappear on front and back walls and small curvature. Are steadiest against inflating of a fold of big curvature. The relief of the gatekeeper is changeable that depends on motor function of a stomach. The gatekeeper is presented in the form of the socket formed by short valikoobrazny folds. The opening of the gatekeeper at a peristaltics and considerable inflating of a stomach reaches 1,5 cm in dia.
Features of a gastroscopic picture of a stump of a stomach are caused anatomic morfol, and the functional changes of a stomach arising after its resection: a small cavity of a stump, the expressed inflammatory infiltration and rigidity of walls, deformation of a distal part of a stump, constant receipt, various at different types and volumes of a resection, in a stomach of foamy duodenal contents, bystry evacuation of air from a stump. In a stump of a stomach the peristatic hyperemia of a mucous membrane, coarsening of folds, occasionally ulcerations is, as a rule, observed. After economical resections according to Billroth-I changes are found generally in the field of an anastomosis (tsvetn, the tab., fig. 12). The phenomena of an inflammation are more expressed at a resection of a stomach on the Steward of the household — to Finsterer: in the area of an anastomosis the mucous membrane of a stomach hangs over a mucous membrane of a gut, anastomozirovanny with it. At sufficient experience it is possible to perform inspection of all bringing loop and a stump of a duodenum.
Features of a gastroscopic picture at gastric bleeding
Availability of liquid blood and clots in a gleam of a stomach complicates survey and identification of a bleeding point. The quantity and a condition of blood are in a gleam of a stomach depending on intensity of bleeding, the term which passed from its beginning, the nature of bleeding (arterial, venous), its localizations, etc. In a stomach it is possible to see scarlet blood, liquid like a coffee thick, big clots in a gleam and small — on walls. Depending on intensity and duration of bleeding outward of a mucous membrane changes. At considerable blood loss the mucous membrane of a stomach becomes pale, opaque, the inflammatory phenomena around a bleeding point decrease or disappear.
Gastroscopic picture of diseases of a stomach
The pathological processes which are localized in a mucous membrane do not represent difficulties for diagnosis. At G. injuries of a mucous membrane — erosion, hemorrhages, anguishes, polyps easily come to light (tsvetn, the tab., fig. 8 and 9 and tsvetn. fig. 5), different types of gastritis (atrophic, hypertrophic, superficial, hemorrhagic), ulcerations and tumoral changes. Diagnosis patol, the processes which are localized in submucosal and muscular layers of a stomach (a lipoma, a leiomyoma, cancer etc.) is more difficult as it is based on indirect symptoms (protrusion of a mucous membrane, change of its relief, lack of a vermicular movement, a neraspravleniye of walls of a stomach at hyper insufflation of air, etc.).
On an endoscopic picture distinguish the following forms of gastritises: superficial, hemorrhagic, atrophic, hypertrophic and erosive.
Superficial gastritis is characterized by hypostasis (tsvetn, the tab., fig. 1), infiltration and a focal hyperemia of a mucous membrane, existence of a large amount of slime. Drain, intramukoidny hemorrhages are quite often observed punctulate, sometimes. More often the phenomena of superficial gastritis come to light in limited departments of a stomach (a body, antral department), but also total defeat is possible.
Plentiful hemorrhages in a mucous membrane and its diffusion bleeding speak about hemorrhagic gastritis (tsvetn, the tab., fig. 6).
At atrophic gastritis the mucous membrane of a stomach pale, grayish, is thinned, clearly illuminate blood vessels, its folds are maleficiated or are absent (tsvetn. fig. 3). The focal mucosal atrophy can be observed, at the same time sites of an atrophy are located more deeply than sites of a normal mucous membrane and seem as if sunk down.
At hypertrophic gastritis the mucous membrane has thick gyrose folds, quite often skintight to each other. Furrows between folds deep (tsvetn, the tab., fig. 7 and tsvetn. fig. 6). The mucous membrane pleated uneven, knotty, on certain sites has an appearance of warts, polyps. The specified changes meet is total also in limited sites (antral department, a body of a stomach).
At erosive gastritis small surface erosions of a mucous membrane (tsvetn. fig. 4) have the rounded, polygonal or star-shaped shape. The bottom of defect (tsvetn, the tab., fig. 3) more often pure, bright pink, is sometimes covered with a white-yellow plaque of fibrin or a clot. Erosion are quite often multiple, around them the phenomena of superficial gastritis can be observed. The most frequent localization — piloro-antral department of a stomach (see. Gastritis ).
Acute ulcers of a mucous membrane of a stomach can be flat and deep. Flat acute ulcers on gastroscopic signs are identical to erosion, but have a little big sizes, rounded shape and underlined edges (tsvetn, the tab., fig. 4); their bottom is pruinose, color to-rogo depends on prescription of developing of an ulcer (from white to dark brown). The mucous membrane around an ulcer is edematous, hyperemic, on it small erosion are possible. The deep acute ulcer has an appearance of cone-shaped defect of the Mucous membrane to dia. 1 — 4 cm. A little raised edges of an ulcer are well-marked, the bottom is covered with a brown plaque or a clot.
Chronic ulcers in a stage of an aggravation have an appearance of a crater with high steep edges and the dome-shaped bottom covered with a grayish-yellow plaque. The bright red edematous edge of an ulcer gradually passes into a surrounding mucous membrane (tsvetn, the tab., fig. 5). In a stage of subsiding of process the extent of defect decreases, just as swelled, infiltration and a hyperemia of surrounding fabrics; the bottom of an ulcer is cleared, there are visible folds of a mucous membrane, adjacent to defect. In a stage of scarring on site of an ulcer the bright red scar of various form (linear, star-shaped, semi-lunar, etc.) involved or towering over a mucosal surface of a cover is defined (tsvetn, the tab., rice 2). It is long not healing ulcers become kallezny. They are distinguished by the high rigid subdug edges, an uneven bottom with a necrotic plaque, is hilly an infiltrirovanny surrounding mucous membrane. Differential diagnosis of such ulcers with a malignant ulcer is extremely difficult. The main role in differential diagnosis belongs to a biopsy and tsitol. to a research (see. Peptic ulcer).
Cancer. On a gastroscopic picture allocate 4 types of a carcinoma of the stomach.
1. Polipovidny cancer — the formation of semi-spherical shape eminating in a gleam of a stomach with a chicken skin and the wide basis. Quite often on its top necroses and ulcerations come to light.
2. Not infiltrative cancer ulcer — a deep ulcer with the rough hilly edges towering over a surrounding mucous membrane of dark red color, with sites of black color, sharply contrasting with an adjacent pale mucous membrane. The bottom of an ulcer uneven, hilly, is covered with a dirty-white plaque.
3. An infiltrative cancer ulcer — the subsequent stage of development of not infiltrative cancer ulcer; externally it differs from it a little. The ulcer of usually considerable sizes, has the saucer-shaped form; transition of tumoral fabric to a surrounding mucous membrane is unsharply expressed or is absent. The mucous membrane around an ulcer is hilly, pale yellow coloring, with multiple hemorrhages (tsvetn, the tab., fig. 10). Narrowing of a gleam of a stomach owing to deformation of its walls is possible.
4. Diffusion cancer. The tumor grows endofitno in mucous, submucosal and muscular layers therefore its endoscopic diagnosis is complicated. The mucous membrane has no usual relief, a fold of uneven thickness, eminate a little. In a zone of defeat a mucous membrane of gray color that makes an impression of a «lifeless» relief. In later stages it is possible to find the superficial ulcerations reminding an acute ulcer. During the inflating of a stomach air rigidity of walls clearly comes to light, the peristaltics in this place quite often is absent (see. Stomach , tumors).
Contraindications to G. are diseases of a gullet (cicatricial and tumoral narrowings, diverticulites) and bodies (a retrosternal craw, an aortic aneurysm, a tumor of a mediastinum, a considerable rachiocampsis) surrounding it, and also the expressed cardiovascular and pulmonary insufficiency of various etiology.
Complications at G. are rare. However cases of perforation of a gullet and stomach, retrograde penetration of the distal end of the gastroscope into a gullet and its infringement are described that demanded the emergency laparotomy; cases of bleedings after a gastrobiopsiya, etc.
Bibliography: Savelyev V. S., Brawlers V. M. and Balalykin A. S. Diagnostic value of endoscopy of an upper part of a digestive tract, Vestn, hir., t. 109, No. 11, page 71, 1972; Silayev of Yu. S. Gastrobiopsiya in diagnosis of cancer and precancerous diseases of a stomach, Kiev, 1970; L. K Falcons. Special diagnostic methods of diseases of a stomach, in book: Sovr, methods of a research in gastroenterol., under red) V. of X. Vasilenko, page 103, M., 1971; about N e> the Atlas of endoscopy of a stomach and duodenum, M., 1975, bibliogr.; V. I. pods of ides of river of Ezofagogastro-skopiya at gastrointestinal bleedings, Surgery, JsTs 8, page 78, 1968; Tsepelev Yu. A. and Gorokhov L. I. Endoscopic devices for gastroenterology, M., 1976; Blackwood W. D. a. Silvis S. E. Gastroscopic electrosurgery, Gastroenterology, v. 62, p. 883, 1972; Endoskopie und Biopsie in der Gast-roenterologie, Technik und Indikation, hrsg. V. P. Fruhmorgen u. M. Classen, B., 1974; Kawai K., Murakami K. Misaki F. Endoscopical observation oi the gastric ulcer, Endoscopy, v. 1, p. 97, 1969; K r e n t z K. Synopsis der Magen-krankheiten, Klinik, Gastroskopie und R6n-tgenbefund, Stuttgart, 1974.
V. M. Buyanov; Yu. A. Tsepelev (tekhn.).