REKTOROMANOSKOPIYA

From Big Medical Encyclopedia

REKTOROMANOSKOPIYA (Latin rectum a rectum + sigma romanum a sigmoid gut + Greek skopeo to observe, investigate; synonym: proktosigmoidoskopiya, rektosigmoidoskopiya) — method of an endoscopic research of an inner surface of a direct and distal part of a sigmoid gut.

Development of a method P. became possible thanks to works of the fr. surgeon A. J. Desormeaux, to-ry in 1865 designed the endoscope allowing to examine a rectum. Significant progress of R. was made after the invention by Layter (J. Leiter, 1879), M. Nittsa (1879) and Kelly (N. of A. Kelly, 1895) devices, in to-rykh an electric light source was located in the distal end of the tool.

R.'s development in Russia is connected with a name of S. P. Fedorov, in 1897 for the first time in our country published the article «Rektoskopiya» and offered the original device for this purpose.

Indications and Contraindications

Indications: complaints to locks, ponosa; allocations from a rectum of slime, pus, blood; pains in lower parts of a stomach and rectum; suspicion on existence of inflammatory process or a new growth of a large intestine; assessment of results of treatment of nek-ry diseases direct and sigmoid (sigmoid colonic, T.) guts; production of a number of manipulations and operations (capture of scraping and biopsy, removal of polyps, foreign bodys, etc.). R. which is carried out with the preventive purpose gains ground.

Contraindications: sharply expressed acute inflammatory diseases of a wall of a rectum and surrounding fabrics; low located stenosing tumors of a rectum, hl. obr. proctal channel; corrosive and thermal burns in an acute stage, a condition of a decompensation at cardiovascular pathology, psychoses.

The equipment

Rektoromanoskopiya is made by means of special endoscopic devices — rektoromanoskop (rektoskop). Modern rektoskop includes a set of hollow tubes of various diameter and length, obturators to them and nek-ry other tools (e.g., a telescopic magnifying glass or an optical tube). Lighting is, as a rule, carried out from the desktop lighter by means of the fiber-optical lighting cable or a fiber light guide located in a tube on all its length or sometimes only in its proximal part. Also rektoskopa with lighting from the tiny filament lamp strengthened in a tube on its distal end are applied. Among them rektoskopa of the Krasnogvardeets Leningrad Production Association (LPA) were widely adopted (model 185 intended for adults and model 170 — for children).

Since 1973 LPO «Red Guard» releases the rektoskopa with fiber light guides developed in All-Union scientific research institute of medical instrument making including two models of rektoskop for adults — Re-VS-3 (big set) and Re-VS-3-1 (small set) and two models of children's rektoskop — Re-VS-5 (big set) and Re-VS-5-1 (small set). Rektoskopa are supplied by lighters for the equipment with fiber light guides, napr, the OS-100 type.

Fig. 1. Rektoskop with a fiber light guide of Re-VS-3: 1 — a tube; 2 — an eyepiece; 3 — a fiber light guide; 4 — a light source.

In each tube the fiber glass light guide is laid. Rektoskopichesky tubes 11, 20, 25 and 30 cm long, to dia are included in the package of the device Re-VS-3 (fig. 1). 15, 20 mm, and also proktoskop and anoskop. Rektoskop of Re-VS-5 is completed with tubes 15, 20, 25 and 20 cm long, to dia. respectively 10, 15, 20 and 20 mm. All components and nodes of rektoskop are unified. To each tube there is an obturator. The nozzle, a protective cover, a body a magnifying glass, the handle for deduction of tubes, vatoderzhatel of collet type, a rubber bulb and a set of kelectomes — gear and spoon-shaped are included in the package. For photographing through rektoskopa the device consisting of an optical tube for a photocopy and a photoprefix to endoscopes is issued.

Fig. 2. Rektomikroskop RMS-1: 1 — a light source for survey; 2 — a light source for photographing; 3 — a tube; 4 — the docking device for connection of the camera; 5 — the camera; 6 — a fiber light guide.

Kind of a rektoskop is rektomikroskop (fig. 2), serving for an intravital research of a rectum and adjacent sites of a sigmoid gut in the contact way at big increase (to 220 X) for the purpose of diagnosis of early forms of diseases.

Makes also flexible endoscopes for a research of direct and sigmoid guts of LPO «Red Guard» — sigmoidokolonoskopa (see. Kolonoskopiya ).

Training of the patient

Training of the patient for R. depends on the nature of a disease, the purposes and problems of inspection. For detection of tumors and hron. diseases during the performance of various manipulations and operations careful cleaning of a large intestine of contents is necessary. For this purpose the patient before a research appoint a low-slag diet (the day before a breakfast and a lunch without bread, to a dinner — sweet tea). The research is conducted on an empty stomach. On the eve of survey put cleaning enema (see). In the morning in day of a research the enema is repeated not later than 1,5 — 2 hours that there took place the irritating impact of an enema on a mucous membrane of a large intestine.

When long preparation for R. is impossible, use of special microclysters — mikrolaks, a micro-klist, aerosol microclyster is recommended. At acute inflammatory diseases (dysentery, an acute stage of nonspecific ulcer colitis) R.'s carrying out is possible after the next defecation without pre-treatment. Special preparation is not recommended and at the raised bleeding of a mucous membrane of a rectum.

A technique of a research

the Most widespread provisions of the patient at R. are kolennoloktevy, also knee and humeral is applied. At the same time there is a shift of abdominal organs towards a diaphragm, the small pelvis is exempted from loops of a small bowel, are as much as possible straightened fiziol. bends of distal department of a large intestine. It creates favorable conditions for advance of an unbending metal tube and allows to examine better a mucous membrane of a large intestine at all length of a tube of the device. When similar situation for the patient is intolerable (the expressed weakness, an asthma, raised by the ABP) or it is impossible (damage of joints, lack of an extremity), it is possible to use situation on the left side with the raised basin and the hips pressed to a stomach.

Fig. 3. The diagrammatic representation of stages of introduction of a rektoskop at a rektoromanoskopiya in genucubital position of the patient: and — the beginning of introduction; — the subsequent introduction with simultaneous lowering of a tube from top to bottom according to a bend of a rectum; in — lifting of a tube up; — establishment of a tube parallel to an axis of a trunk after passing of a rectum; shooters specified the direction of movement of a tube of a rektoskop.

In the beginning the doctor shall examine attentively proctal area and area of a crotch, and then to make a manual research of a rectum (see. Rectal research ) for an exception of such situations when R. can be dangerous or impracticable (the low stenosing tumors, a stricture, acute cracks). Rubles will see off usually without anesthesia though greasing of the proctal channel anestezinovy or ksilokainovy ointment is possible. The tube of a rektoskop greased with vaseline and closed by the obturator is entered via the proctal channel into a rectum (fig. 3, a). After introduction of the device on depth of 4 — 5 cm the obturator is deleted, and the tube is closed an eyepiece or a magnifying glass. Further carrying out a rektoskop is carried out surely under control of sight. Advance of the tool shall be smooth, without rough efforts, the direction of the movement of the device is defined by an arrangement of a gleam of a gut (fig. 3, in, d). Introduction of a rektoskop to a sigmoid gut demands big care. As a rule, the entrance is located asymmetrically, walls of a gut are in the fallen-down state, blocking a gleam, to-ry behind folds of a mucous membrane it is not always easy to define. It is necessary to give to the tool various provisions, moving apart and straightening serially these folds.

At the same time big help is given by easy blowing of air. The movements of the tool and administration of air shall not hurt investigated. It is necessary to avoid an emphasis of a tube of a rektoskop in a wall of a gut, and especially its pressing to a sacrum and a pubic joint. If small movement of the distal end of the device and administration of air not only cause pain, but also do not allow to define a gleam, the research shall be stopped. The similar situation can be caused by the fixed excesses of a sigmoid gut, at to-rykh rough manipulations can lead to perforation. After the tube of a rektoskop is entered at all length, he is slowly brought outside. At this moment make repeated survey of a mucous membrane. Before extraction of the device it is necessary to remove excesses of the entered air from a rectum. It is reached removal of an eyepiece. In nek-ry cases (e.g., at big tumors or a rectostenosis) the device manages to be entered only on 15 — 17 cm, i.e. the research is limited to a rektoskopiya.

A normal endoscopic picture

In to a rectum (see) there is a number of cross folds, lower of to-rykh (coccygeal) is located at distance of 5 — 7 cm from the outer edge of the proctal channel. Above it on 2 — 3 cm the lower sacral fold crossing with coccygeal at an acute angle is visible. 2 — 3 cm above the upper sacral fold, usually smaller size is located. At distance of 13 — 14 cm from anus (see) there is a terminal fold defining transition to a distal part sigmoid gut (see). A mucous membrane of a rectum wet, brilliant, pink color (see tsvetn. the tab. to St. Rectum , fig. 4), in nizhneampulyarny department are sometimes visible submucosal vessels, circular folds are absent. In a sigmoid gut the mucous membrane forms a set of the semi-lunar folds which are easily straightened by the movement of the device or administration of air. Gleam of a sigmoid gut considerably already, than gleam of a rectum, mucous membrane more juicy, dark pink color.

An endoscopic picture at main types of pathology. Nonspecific ulcer colitis — changes of a mucous membrane from small hypostasis with a hyperemia and lack of the vascular drawing before formation of the ulcers covered with a fibrinopurulent plaque.

A disease Krone of a large intestine — rigidity of a wall of a rectum and formation of multiple longitudinal cracks of a mucous membrane are characteristic, on a cut usually there are fibrinoznognoyny imposings. Multiple cracks and hypostasis of a mucous membrane create the characteristic endoscopic picture which is quite often compared to «cobblestone road».

Polyps of a large intestine — tumorous educations with a smooth or fleecy surface on the narrow basis — a leg (see tsvetn. the tab. to St. Rectum , fig. 7) or wide basis. These educations can be single or multiple.

Colon cancer. On an endoscopic picture distinguish two main forms of cancer — exophytic and endophytic. The exophytic form presents itself education in the form of a node, a polyp or a fleecy tumor with the growths on the periphery reminding a cauliflower (see tsvetn. the tab. to St. Rectum , fig. 6). Endophytic forms have an appearance of the crateriform ulcer with infiltration of all thickness of a wall of a gut. The bottom of an ulcer is usually covered with fibrin or gray necrotic masses.

See also tsvetn. the tab. to St. Proctitis .

Complications

At observance of indications and technology of performance of R. is rather safe method of inspection. Rough manipulations, excessive inflating of a gut can lead to perforation of its wall. At nek-ry diseases, such, e.g., as hemangiomas, large fleecy tumors, bleedings (are possible see. Gastrointestinal bleeding ). This complication can arise also during the performance of a biopsy or removal of polyps. The stop of bleeding is made by means of electrothermic coagulation of the bleeding site. At perforation the immediate surgery is necessary, character a cut depends on localization of the perforative opening and term which passed from the moment of perforation.

Rektoromanoskopiya at children

is applied by Rektoromanoskopiya at children usually as addition to a manual rectal research. Indications to it: release of blood through an anal orifice, locks, an unstable chair, suspicion on polyps, ulcers, a tumor, injuries of a mucous membrane, portal hypertensia. The river is made for identification of varicose veins in places of an anastomosis upper pryamokishechny (hemorrhoidal), average and lower pryamokishechny veins, in need of overseeing by dynamics patol. process, the course of recovery of a mucous membrane of a large intestine at nonspecific ulcer colitis, acute and hron. dysentery. The same contraindications, as at adults.

Fig. 4. Position of the child and doctor during the carrying out a rektoromanoskopiya. Knees of the child are tightened to a stomach (the direction of pulling up is specified by an arrow).

The night before the child is given an enema cleansing and do not give a dinner. In the morning in 1,5 — 2 hours prior to a research give an enema again, and in 20 — 30 min. enter a colonic tube. Success of a research in many respects depends on quiet behavior of the child at the time of the procedure. In advance explain to the child the purpose and need of a research, warn about possible subjective feelings. In the course of the research the attention of the child is distracted a conversation or a toy. Usually R. carry out without anesthesia and only at small and uneasy children, and also in cases of performance of surgical manipulation there is a need for a short-term anesthesia. At children of younger age it is more preferable to conduct a research in situation on spin (fig. 4), at children of advanced age (10 — 14 years) — in genucubital situation or on the left side.

Fig. 5. The diagrammatic representation of stages of introduction of a rektoskop at a rektoromanoskopiya at the child lying on spin: and — the beginning of introduction; — the subsequent introduction with simultaneous lifting of a tube up according to a bend of a rectum; in — lowering of a tube; — establishment of a tube parallel to an axis of a trunk after passing of a rectum; shooters specified the direction of movement of a tube of a rektoskop.

Introduction of a rektoskopichesky tube and survey of a mucous membrane carry out step by step (fig. 5). Depth, on to-ruyu is possible to enter a tube of a rektoskop, depends on age of the child and version of the provision of a pelvic piece of a sigmoid gut. On average 15 — 20 cm of intestines are available to survey, however use of devices with a fiber optics allows to expand considerably these borders up to survey of all large intestine (see. Kolonoskopiya ).

See also Endoscopy .



Bibliography: Aminev A. M. Guide to a proctology, t. 1, page 141, Kuibyshev, 1965; Lenyushkin A. I. Proctology of children's age, page 53, M., 1976; L at to about m with to and y G. I. and Berezov Yu. E. Endoskopicheskaya of the technician in surgery, M., 1967; Fedorov of S. P. Rektoskopiya, Surgery, t. 1, No. 6, page 516, 1897; Tsepelev Yu. A. and Gorokhov L. I. Endoscopic devices for gastroenterology, page 47, M., 1976; Chulkov of P. S. Rektoromano-skopiya, L., 1952; Endoscopy at diseases of a straight line and colon, the Atlas, under the editorship of V. D. Fedorov, M., 1978; I am LF e in V. G. Rektoromanoskopiya, Sofia, 1959 (on bolg. language); Bensaude R. Rectoscopie, Sigmoi'doscopie, P., 1956; Eisenberg S. W. Proctosigmoidoscopy, J. int. Coll. Surg., y. 36, p. 243, 1961; Freeman G. C. Twenty-five hundred proctoscopic examinations, Amer. Surg., v. 26, p. 431, 1960.


G. I. Vorobyov; A. I. Lenyushkin (it is put. hir.), Yu. A. Tsepelev (tekhn.).

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