CHẨN ĐOÁN X QUANG DẠ DÀY VÀ TÁ TRÀNG.

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  • Hiện nay, nội soi hài hòa có sinh thiết với phổ biến ưu thế hơn, nhưng chụp lưu thông dạ dày-tá tràng vẫn giữ nguyên giá trị trong việc chẩn đoán 1 số tổn thương bệnh lý vùng này. Nó vẫn siêu hữu ích để xác định vị trí cũng như mức độ lan rộng tại chỗ của ổ loét hoặc ung độc dạ dày, để chẩn đoán và tiên đoán các thoát vị hoành, để kiểm tra tình trạng hẹp bao tử tá tràng.

1. KỸ THUẬT X QUANG

1.1. Chuẩn bị bệnh nhân:

thăm khám được tiến hành vào buổi sáng mang bệnh nhân nhịn đói, không uống, không hút thuốc từ khi ngủ dậy. Bệnh nhân không được uống các chất cản quang quẻ ít ra 3 ngày trước lúc chụp.

1.2. Kỹ thuật

1.2.1. Kỹ thuật cổ điển:

dưới sự kiểm tra của chiếu X quang (tốt nhất là chiếu có tăng sáng truyền hình) bệnh nhân uống một ngụm sau đó một cốc (80–100ml) dịch treo barite. Các loại phim được chụp theo các kiểu tư thế khác nhau.

1.2.2. Kỹ thuật đối quang kép:

kỹ thuật này tinh tường hơn, chỉ vận dụng được cho các bệnh nhân với hợp tác rẻ và vận động dễ dàng trên bàn khám. Hai đổi quang đãng được sử dụng: đổi quang quẻ âm tính (hơi) và đối quang quẻ dương tính (baryte).

Sau khi uống một lượng nhỏ dịch treo baryte tất nhiên chế phẩm chống bọt khí, dạ dày được làm cho phồng lên bởi tương đối được bơm qua ống thông hoặc được tạo ra bằng những chất sinh hơi. Người bệnh tự xoay người cho dịch treo baryte trải đều trên bề mặt dạ dày và những tấm phim được chụp ở các thì khác nhau. Phương pháp này cho phép phát hiện được những thương tổn nhỏ khu trú ở niêm mạc, đặc trưng là những thương tổn ở mặt dạ dày.


Ngày nay, ngoài chụp dạ dày mang cản quang, rất âm, đặc biệt là cực kỳ âm nội soi và chụp cắt lớp vi tính cũng sở hữu thể được chỉ định trong 1 số bệnh lý dạ dày, tá tràng, nhất là bệnh lý khối u.

2. GIẢI PHẪU X QUANG BÌNH THƯỜNG

2.1. Giải phẫu và hình thái

Trên những phim chụp bao tử cũng được phân chia thành các vùng như trên giải phẫu thường và được mô tả, tuỳ theo trương lực của dạ dày, theo tạng người cao thấp, béo hay gầy mà dạ dày sở hữu thể mang những hình thái thay đổi .

2.2. Niêm mạc

Mặt trong của bao tử và tá tràng được phủ bởi niêm mạc mang độ dày khác nhau tạo bắt buộc những nếp nằm song song mang nhau và mang đường bờ.

2.3. Liên quan của dạ dày

Dạ dày thúc đẩy có những tạng của tầng trên ổ bụng. Sự phì đại hoặc u của những cơ quan này có thể tạo buộc phải các ấn lõm hoặc đè đẩy vào dạ dày.

Hình 1. Các kiểu, tu thế chụp dạ dày và hành tá tràng theo kỹ thuật cổ điển.
1. Phim lớp mỏng để nhìn thấy niêm mạc; 2. Phim đầy thuốc thẳng, 3. Chụp dáng chếch trước phải có ép để khám bệnh góc bờ cong nhỏ; 4. Phim ép vào hành tá tràng; 5. Phim hàng loạt lấy hang vị và hành tá tràng; 6. Phim nằm ngửa toàn bộ để thăm khám mặt sau 7. Phim nằm sấp lấy toàn bộ dạ dày.
Hình 2. Giải phẫu dạ dày trên ảnh phim thẳng và ảnh phim nghiêng.
1. Thực quản bụng, 2.Tâm vị, 3. Góc His, 4.Phình vị hay của túi hơi dạ dày, 5.Bờ cong lớn, 6. Bờ cong nhỏ, 7. Phần đứng hay thân dạ dày, 8. Phần ngang hay hang vị, 9. Ống môn vị, 10. Hành tá tràng, 11. Gối trên, 12. Đoạn 2 tá tràng, 13. Gối dưới, 14. Đoạn 3 tả tràng, 15. Đoạn 4 tả tràng, 16. Góc tá—hỗng tràng hay góc Treitz, 17. Quai hỗng tràng đầu tiên, 18. Sản phình vị lớn, 19. Mặt sau, 20. Mặt trước, 21. Cơ hoành.

Hình 3. Các hình thái của dạ dày.
a. Dạ dày nằm ngang; b. Dạ dày thẳng đứng; c. Dạ dày hình thác.

Hình 4. Niêm mạc dạ dày và hành tá tràng không có gì bất ổn.
a. Niêm mạc dạ dày; b. Hành tả và tả tràng; c. Niêm mạc đây hành tá tràng

Hình 5. Niêm mạc dạ dày và hành tá tràng không có gì bất ổn
. a. Niêm mạc dạ dày; b. Hành tả và tả tràng; c. Niêm mạc đây hành tá tràng.

Hình 6. Liên quan đến giải phẫu của dạ dày và hành tá tràng
. 1. Gan, 2. Túi mật, 3.Lách, 4. Tụy, 5, Góc đại tràng (phải và trái)

3. TRIỆU CHỨNG ĐIỆN QUANG

3.1. Hình ổ loét

Là 1 vết cản quang quẻ được tạo nên bởi baryte chui vào trong vùng mất đơn vị của thành bao tử và được tồn tại thường xuyên và không thay đổi hình dáng trên những phim chụp. Ổ loét dễ dàng thấy được ví như nằm ở bờ dạ dày; ví như ở mặt, nó chỉ được thấy trên các phim chụp nghiêng hoặc phim chụp niêm mạc hoặc chụp đối quang đãng kép. Hình dạng, kích tấc của ổ thay đổi tuỳ theo ổ loét nằm trên thành dạ dày thông thường hay thành bị xâm nhiễm và sùi.

Hình7
. Ổ loét dạ dày. a. Ổ loét lành tinh; b. Ổ loét ác tính (loét thấu kính).

3.1.1. Hình ảnh ổ loét trên thành bình thường.

Thường là ổ loét lành tính. Nhìn nghiêng, ổ loét mang hình tam giác đáy tròn, bờ đều, nhô lên khỏi bờ bao tử bình thường. Tại vùng tiếp giáp giữa ổ loét và thành thường nhật với chỗ lõm nhẹ vào lòng bao tử gọi là thành ổ loét.

Ổ loét mặt biểu hiện như 1 vết cản quang tròn được bao quanh bởi vòng sáng đều đặn, những nếp niêm mạc tụ hợp sát thành ổ loét và không bị biến dạng.

3.1.2. Hình ảnh ổ loét bị thâm nhiễm.

Hay còn gọi là ổ loét trừ. Ổ loét này mang hình tam giác hoặc hình phẳng nông nằm trên 1 đoạn bờ dạ dày sụt nhẹ vào trong lòng so với đường bờ bình thường. Nó thể hiện ổ loét nông trên vùng thành bao tử bị xâm nhiễm hay viêm dày lên.

Ố loét trên thành bị sùi: ổ loét nằm sụt và đục khoét sâu vào lòng phổ biến so với bờ cong dạ dày. Nó phân bí quyết sở hữu lòng dạ dày và các nếp niêm mạc bởi một băng sáng rộng, ko đều tạo phải gờ ổ loét, bên cạnh gờ này nếp niêm mạc tập hợp dày lên và phình to, ổ loét này thường là ác tính.

3.2. Hình khuyết.

-Hình khuyết tròn hoặc bầu dục, đường bờ đều và có thể thay đổi hình dáng thường gặp trong các loại u dạ dày lành tính.

– Hình khuyết bờ bị nham nhở và cứng thường là biểu hiện của bệnh ung thư thể sùi.

3.3. Hình cứng

Biểu hiện sự đứng yên ổn của một phần hoặc hầu hết thành dạ dày khi sóng nhu động lan tới. Nếu thương tổn lan rộng thì hầu hết bao tử như đông cứng lại. Nếu hình cứng ngắn, sóng nhu động giới hạn lại tại vùng này và đoạn cứng được nâng lên như “tấm ván trên mặt sóng”. Đoạn cứng có thể cong hoặc thẳng và giả dụ nằm ở góc bờ cong nhỏ làm cho cho góc này mở rộng.

3.4. Thay đổi các nếp niêm mạc

Độ dày của những nếp niêm mạc sở hữu thể đổi thay tuỳ theo độ căng của dạ dày. Sự thành sẹo hay LÀ tiến triển xơ hoá của ổ loét gây co kéo niêm mạc dạ dày. Viêm bao tử thể phì đại những nếp niêm mạc phình to, thô trái lại viêm teo niêm mạc thì những nếp niêm mạc bị xoá khiến cho bề mặt bao tử nhẵn, đồng đều. Nhưng các hình ảnh này không có giá trị chẩn đoán vì thường ko ưa thích sở hữu kết quả nội soi sinh thiết.

4. MỘT SỐ BỆNH LÝ DẠ DÀY – TÁ TRÀNG HAY GẶP

4.1. Loét dạ dày:

tất cả các vùng của dạ dày đều có thể bị loét, nhưng vị trí hay gặp nhất là bờ cong nhỏ, sau đó đến ống môn vị, sàn phình vị, các mặt của hang vị dạ dày và bờ cong lớn.

4.1.1, Loét bờ cong nhỏ:

là những ổ loét ở bờ cong nhỏ giải phẫu trừ đoạn sát tâm vị và tiền môn vị, Dấu hiệu X quang quẻ trực tiếp là hình ổ loét, gồm: Loét nông: ổ loét chỉ nằm ở lớp niêm mạc nên hình lồi siêu bé như gai hoa hồng.

– Loét trong thành: ổ loét đã ăn sâu vào lớp cơ sở hữu hình đáy tròn hoặc vuông.

Hình 9. Loét dạ dày.
a. Hình ảnh đại thể: 1. Thanh mạc, 2. Lớp cơ, 3. Tổ chức đệm, 4. Lớp cơ niêm, 5. Lớp dưới niêm mạc, 6. Lớp niêm mạc; b. Sơ đồ giải phẫu: hội tụ niêm mạc và ngấn lõm bờ cong lớn; c. Hình điện quang của ổ loét: 1. ổ loét, 2. Cổ, 3. Viền phủ nề, 4. Baryte trong lòng dạ dày.

4.1.2. Loét các vị trí khác của dạ dày:

dù vị trí nào khi bị loét cũng có các dấu hiệu như loét bờ cong nhỏ.

Tuy nhiên, tuỳ theo đặc điểm hình thái từng vị trí mà có những dấu hiệu khác:

– Loét tiền môn vị: là ổ loét nằm sát môn vị, thường ổ loét nhỏ, chân lõm sâu; đồng thời vùng này thường với đa dạng hình giả do sóng nhu động, do nếp niêm mạc nằm ngang… tạo bắt buộc những hình giống ổ loét.

Do đó , chẩn đoán loét tiền môn vị nhiều khi gặp rất nhiều khó khăn.

– Loét môn vị: ổ loét với thể nằm ở ống môn vị hoặc lệch về phía bao tử hoặc về phía hành tá tràng. Ngoài ổ loét, ống môn vị mang thể bị lệch hướng hoặc gập góc.

– Loét phình vị to thường gặp vùng dưới tâm vị và vùng sàn, ổ loét thường thấy trên phim chụp nghiêng hoặc dưới dạng vết treo thuốc.

– Loét mặt: loét mặt sau hay gặp hơn loét mặt trước, thường chỉ thấy trên phim chụp niêm mạc, chụp đối quang đãng kép hoặc phim nghiêng.

– Loét bờ cong lớn: ổ loét thường lớn và nằm trên một vùng khuyết do bờ cong lớn lõm xuống.

Hình10. Các dạng ổ loét dạ dày.
1–9, Loét bờ cong nhỏ: 1. Loét nông; 2–5. Loét trong thành (vật treo thuốc ở ổ loét); 6–7. Ổ loét thủng bit: 6. Hình ngốn tay đeo bao tay; 7. Ổ loét Haudeck; 8 và 9. Bờ cong nhỏ của dạ dày co rút che lấp ổ loét; 10. Loét ổng môn vị; 11. Loét tiền môn vị 2 và 13. Loét phía mặt sau chụp thẳng và chụp ảnh nghiêng: 14. Loét bờ cong lớn.

4.2. Loét hành tá tràng

Hình ảnh thay đổi tuỳ theo quá trình tiến triển của ổ loét:

– Giai đoạn phù nề: hành tá tràng không biến dạng, ổ loét được bao loanh quanh bởi 1 viên sáng do phù năn nỉ và niêm mạc tụ hợp về chân ổ loét. Giai đoạn này thường thấy được trên phim với thuốc mang ép.

hình chiếc đồng hồ cát, hình 2 túi 1 túi giãn lớn và 1 túi bị teo nhỏ.

– Giai đoạn u xơ teo: hành tá tràng thì bị teo nhỏ, chỉ còn lại những hình ảnh của ổ loét. Giai đoạn này thường kèm theo bị hẹp môn vị

– Giai đoạn phù nề: hành tá tràng không biến dạng, ổ loét được bao vòng vèo quéo bởi 1 viên sáng do phù nài nỉ nỉ và niêm mạc giao hội về chân ổ loét. Giai đoạn này thường thấy được trên phim có thuốc có ép.

– Giai đoạn xơ phù: hành tá tràng biến dạng do quá trình xơ hoá co kéo, mang đa dạng kiểu biến dạng như hình hai cánh, ba cánh,

Hình 11. Loét hành tá tràng.
1. Loét non; 2, 3, 4. Loét biến dạng hành tá tràng; 5. Loét hành tá tràng teo nhỏ (xơ chai).

4.3. Loét sau hành tá tràng

Thường thấy hình ảnh ổ loét có phần tá tràng trước và sau bị teo nhỏ (chủ yếu do phù nề) tạo buộc phải hình ảnh “hạt ngọc xâu chỉ”.

Hình 12. Loét sau hành tá tràng,
1. Sau hành tá tràng, 2. Gối trên, 3. Loét D2.

4.4. Ung thư dạ dày

Hình 13. Ung thư dạ dày.
1 và 2. Hình cứng khu trú (thể thăm nhiễm), 3. Ung thư thể chai teo, 4. Ung thư thể loét, 5. Ung thư phỉnh vị, 6. Ung thư phần đứng, 7. Ung thư hang vị, B.Hẹp môn vị, 9. Viêm loét ác tính ở góc bờ cong nhỏ, 10. Ung thư ở góc bờ cong nhỏ (góc mở rộng ra ngoài ).

4.4.1. Ung thư giai đoạn đầu

hay còn gọi là ung độc nông, thương tổn chỉ khu trú ở lớp niêm mạc chưa ăn sâu vào lớp cơ. Hình điện quang quẻ được chia làm ba thể:

– Thể thâm nhiễm: sở hữu thể thể hiện bằng các hình cứng sau:

+ 1 đoạn cứng nằm ở trên bờ cong.

+ Hình đục khoét là biểu hiện của 1 vùng cứng sụt rẻ vào trong lòng da day.

+ Hình phễu hay hình nón tương ứng có thương tổn tiêm nhiễm vòng quanh vùng tiền môn vị.

Nếu ung thư khu trú ở môn vị làm cho môn vị hẹp kéo dài và gập góc

Chẩn đoán phân biệt: thể này buộc phải phân biệt có viêm xơ hang vị, hình cứng do seo loét cũ.

– Thể loét: thường ổ loét nông và rộng, sở hữu thể có những hình sau:

+ Loét hình khay hay hình đĩa: ổ loét rộng, nông, đáy với thể phẳng hoặc cong.

+ Loét thấu kính; ổ loét rộng, nông, có hình thấu kính, không lỗi lên khỏi bờ cong mà nằm trong hình khuyết. Nó diễn tả của ổ loét ở cả mặt trước và mặt sau, vắt ngang qua bờ cong nhỏ.

+ Loét với chân đục khoét: mang thể là loét lành tính hoặc ác tính. Ổ loét ác tính mang chân đục khoét sâu, ổ loét nằm sụt hẳn xuống, dừng giữa vùng lành và tổn thương là 1 góc đột ngột.

+ Ngoài ra một số ổ loét sau cũng sở hữu thể có khả năng ác tính: ổ loét sở hữu đáy không đều; loét nằm trong hình khuyết; loét nằm trên một đoạn cứng hoặc ngay dưới ổ loét bờ cong có 1 đoạn cứng lún.

— Thể sùi: thể hiện bằng hình khuyết bờ ko đều, cứng.

4.4.2. Ung thư giai đoạn muộn

Chẩn đoán hơi dễ, các dấu hiệu của quá trình sớm rõ hơn, với khi cả ba thể kết hợp với nhau.

– Ung thư phình vị to thường là thể u sùi tạo phải hình mờ trong túi hơi bao tử (hình “núi mặt trăng”).

– Ung thư hang vị làm cho hang vị hẹp, cứng với hình lõi tạo hay hình đường hầm.

– Ung thư phần đứng chia bao tử thành hai túi, ở giữa thắt hẹp nham nhở.

– Thể chai teo: thường là gặp ở người bệnh trẻ. Toàn bộ bao tử xơ cứng lan toả, teo nhỏ. Thể này tiến triển vô cùng nhanh.

4.5. Dạ dày đã mổ

4.5.1. Các loại phẫu thuật

Hình14. Dạ dày đã mổ.
1.Nổi vị tràng, 2. Tạo hình môn vị, 3. Cắt 2/3 phần của dạ dày và nối Pean, 4. Noi Finsterer, 5. Noi polya, 6. Loét quai di

Phẫu thuật bảo tồn mang mục đích khiến giảm acid bao tử bằng bí quyết cắt dây thần kinh X kết hợp mang nối dạ dày ruột hoặc tạo hình môn vị.

– Cắt 2/3 dạ dày nổi dạ dày…tá tràng (kiểu Péan), nối dạ dày–hỗng tràng (kiểu Polya hoặc Finsterer).

4.5.2. Biến chứng

4.5.2. Biến chứng
– Ngay sau mổ: rò mồm nối, phát hiện bằng chụp bao tử tá tràng mang thuốc cản quang đãng tan trong nước. – Muộn: viêm mồm nổi; loét miệng nối hoặc loét quai tới.

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