An unpleasant odor and morning bitterness in the mouth, a coating on the tongue, pressing pain and a feeling of heaviness in the upper abdomen - all these symptoms may indicate diseases of the biliary tract. There are many methods for diagnosing pathology of the digestive tract, however, to make an accurate diagnosis it is necessary to conduct a laboratory analysis of bile and study the function of the gallbladder. For this, the classic method of duodenal intubation is used.

What is the research?

Duodenal intubation (from “duodenum” - duodenum) is a method for assessing the functional state of the bile ducts and gallbladder by inserting a probe (thin flexible tube) into the lumen of the duodenum.

Bile synthesis takes place in the liver, then, if there is no need for digestion at the moment, it enters the gallbladder. When there is fatty food in the stomach, the breakdown of which requires bile acids, the bladder contracts and bile, passing through the bile duct, enters the duodenum.

The study involves taking several portions of samples that reflect the state of various components of the biliary system.

To carry out sounding it is necessary:

• Probe (tube diameter 3-5 mm, length - 1.5 meters), at the end of which there is an olive.
• Syringe with a volume of 10 or 20 ml.
• Test tubes for individual portions of bile.

The duration of the procedure with the collection of 3 portions of bile is 1.5-2 hours. Then a laboratory analysis of the isolated samples is carried out to determine the presence of infectious agents, salts, and cholesterol crystals.

Varieties of the method

There are various methods for collecting bile from the gallbladder:

• Blind probing (tubage). The method involves the administration of choleretic agents and emptying of the gallbladder. It is carried out in the presence of symptoms of bile stagnation and the risk of stones, confirmed by ultrasound (ultrasound).
• Fractional duodenal intubation is a classic method of collecting 3 portions of bile at certain intervals using an inserted probe.
• Chromatic sensing. A subtype of the previous method with special staining of gallbladder bile. 12 hours before the study, the patient takes a contrast agent (methylene blue), which, during the study, colors a portion of bile from the bladder. This addition allows you to accurately determine the amount and diagnose the presence of an obstruction to the exit of gallbladder bile.

In addition, depending on the purpose of the study, diagnostic and therapeutic probing is distinguished. The latter is used to reduce the symptoms of bile stagnation.

Indications for use

Duodenal intubation is prescribed to patients, mainly of a gastroenterological profile. The study is recommended for the following conditions:

• Acute and chronic cholecystitis (in remission).
• Cholangitis (inflammation of the bile ducts).
• Infectious diseases: opisthorchiasis, giardiasis.
• Gallstone disease. Isolation of a calculus from the lumen of the biliary tract is the only reliable sign of the disease.
• Biliary tract dysfunction.

Important! Carrying out a study in the presence of gallstones is accompanied by a risk of complications. Therefore, the doctor must compare the likelihood of undesirable consequences and the diagnostic (or therapeutic) value of the procedure

Probing is also carried out for persons with symptoms of liver disease and impaired outflow of bile: jaundice, bitterness in the mouth, heaviness in the right hypochondrium. Stagnation can be caused by a tumor of the pancreas, stenosis (narrowing) of the openings of the bile ducts and many other pathologies.

Contraindications for duodenal intubation

The procedure involves stimulation of bile secretion and contractile activity of the biliary tract. Therefore, there are a number of conditions in which research is prohibited or undesirable:

• Acute cholecystitis.
• Exacerbation of chronic cholecystitis.
• Ultrasound confirmed presence of gallstones. After stimulation, the stone can come out and block the bile ducts, causing an acute condition - hepatic colic.
• Varicose veins of the esophagus. Passing a probe through the esophagus can damage the walls of blood vessels and cause bleeding.
• Pregnancy and breastfeeding period. The drugs used for the procedure can significantly reduce blood pressure, which impairs the blood circulation of the fetus and passes into breast milk.

In each individual case, the doctor himself assesses the risks and feasibility of conducting the study.

How to prepare for research

5-7 days before the procedure, it is necessary to stop taking choleretic drugs (Allohol, Holagol, Liv-52).

In order to obtain objective results, it is recommended not to take antispasmodics, antispasmodics (No-spa, Papaverine) and antibiotics.

2 days before the test, you should not eat foods that contribute to increased gas formation (cabbage, potatoes, flour and confectionery products, legumes). The evening before the study, the last meal should be no later than 7 o’clock.

How is duodenal intubation performed?

The procedure is carried out in the morning on an empty stomach in the treatment room of the hospital. The research takes place in several stages:

• The patient is in an upright position, and the doctor measures the required length of the probe. It is equal to the distance from the corner of the mouth to the navel. The insertion of the probe begins with the placement of the olive at the root of the tongue, then during the patient’s swallowing movements, the tube is gradually lowered to the first mark. The probe is in the stomach.
• To facilitate the passage of the probe into the duodenum, the patient lies on his right side, placing a heating pad under it. The stomach is leveled and the tube can pass through the pylorus. This is the part of the stomach that connects it to the duodenum.
• As the tube passes into the intestine, a light golden transparent liquid begins to be released through the lumen of the probe. This is portion A - a mixture of bile, pancreatic secretion and intestinal juice. The total volume should be up to 40 ml. The isolated material is sent to the first test tube.
• After this, a drug is injected into the intestine to stimulate the secretion of bile (magnesium sulfate, xylitol, sorbitol), the probe is clamped for 10 minutes.
• After 10 minutes, a dark green cloudy liquid is collected through a probe into a test tube - cystic bile, portion B. Its release lasts about 30 minutes. Total volume 60 ml.
• After 25-30 minutes, a bright yellow liquid begins to be released from the probe - liver bile, portion C. For laboratory analysis, 15-20 ml is taken.

Important! Swallowing the probe is carried out together with swallowing saliva, which prevents it from entering the respiratory tract.
You need to swallow slowly, otherwise in the initial stages the probe may curl up in the stomach, and the procedure will need to be repeated

After collecting the third portion of bile, the probe is gradually removed. To prevent discomfort, it is necessary to rinse your mouth with water or glucose solution.

You can eat 30 minutes after the test, but on this day you must exclude fatty and fried foods from your diet.

Advantage of the method

Duodenal intubation, drainage of the common bile duct (common bile duct) and ultrasound examination are used to collect bile and examine the condition of the biliary tract.

Comparative characteristics of these methods are presented in the table:

Criterion	Duodenal sounding	Common bile duct drainage	Ultrasound examination
Methodology	Insertion of a thin tube into the cavity of the duodenum with collection of bile	Open surgery with access to the bile ducts and insertion of a drainage tube into their lumen	Study of the passage and reflection of ultrasonic waves through body structures
Invasiveness	Minimally invasive method	Surgical intervention	Non-invasive procedure
Necessity of anesthesia	Local anesthesia according to indications	General anesthesia	No need
Laboratory diagnosis of bile composition	Ongoing. 3 bile samples from different parts of the biliary tract	Only fresh liver bile is collected	Not carried out
Duration of the procedure		1.5-2.5 hours

Analyzing the above data, the best option for laboratory analysis of bile with minimal interference in the functioning of the body is duodenal intubation.

Possible complications after duodenal intubation

Inserting a probe and using magnesium sulfate during the procedure can lead to the development of undesirable consequences:

• Significant salivation.
• Bleeding caused by damage to the organ by the probe during rapid swallowing.
• Nausea and vomiting. For people who cannot suppress the feeling of nausea, it is recommended that the back of the throat be anesthetized with a spray before the procedure.
• Diarrhea. Magnesium sulfate is considered a strong carrier, so people with unstable digestion are recommended to use other drugs.
• Dizziness and collapse due to the decrease in pressure caused by the action of magnesia.

Doctor's advice. To avoid unpleasant consequences such as loss of consciousness, after the procedure you need to lie down for a few minutes and then slowly get up

How to decipher the research results

The results obtained are assessed using laboratory diagnostics of the composition of bile and measuring the time intervals in which a certain portion of bile is released.

The standard methodology includes studies of 5 phases of bile excretion.

• The first (choledochus). Normally it lasts 10-15 minutes, during which up to 40 ml of light yellow transparent bile is secreted. The presence of blood in this portion may indicate duodenal cancer.
• The second (closed sphincter of Oddi is a muscle that regulates the flow of bile from the bile duct into the duodenum). No bile is released within 4-6 minutes. If this pause lengthens, you should think about inhibiting bile production.
• Third (open sphincter of Oddi). Up to 6 ml of golden-colored bile is released from the common bile duct within 3-6 minutes (portion A). Prolongation of this phase or the appearance of pain indicates the presence of stones in the duct.
• Fourth. Portion B is released, up to 60 ml of thick, dark green bile. Duration up to 30 minutes. The release of a larger amount of fluid (up to 120 ml) indicates cholecystotomy (increased tone of the gallbladder).
• Fifth. Phase of excretion of portion C (hepatic) 15 ml of bright yellow bile in 10-15 minutes. If the bile is pale yellow, a non-inflammatory liver disorder should be suspected.

The table shows the studied indicators of laboratory analysis of individual portions of bile and their indicators in normal conditions and in pathologies

		Cholecystitis	Giardiasis
	The color is golden yellow. Transparency is complete. There is no protein. Epithelium 1-2 in the field of view. Leukocytes 1-2 in the field of view. No salt crystals	Variant of the norm	The color is greenish. Transparency is incomplete. Epithelium 2-4 in the field of view. Leukocytes 1-2 in the field of view. There is a small amount of mucus. No salt crystals
	The color is dark green. Transparency is complete. Protein up to 4.5 g/l. Epithelium is absent 2-3 leukocytes per field of view. There is no mucus. Single salt crystals	The color is dark green. Protein is more than 5 g/l. Epithelium 2-3 in the field of view. More than 10 leukocytes per field of view. Significant amount of mucus	Color greenish Transparency - cloudy liquid. Epithelium - 1-2 in the field of view. Significant amount of mucus
	The color is light yellow. Transparency is complete. Protein up to 2.5 g/l. There is no epithelium. 2-3 leukocytes per field of view. There is no mucus. No salt crystals	Variant of the norm	The color is golden yellow. Transparency is complete. Epithelium 1-2 in the field of view. Leukocytes 10-12 per field of view. There is a small amount of mucus. Giardia is detected

Carrying out this study requires thorough knowledge and experience of the doctor. However, the results obtained during duodenal intubation can significantly affect the treatment tactics of the disease.

The video below shows the probing procedure and a description of the results obtained.

Thank you

The site provides reference information for informational purposes only. Diagnosis and treatment of diseases must be carried out under the supervision of a specialist. All drugs have contraindications. Consultation with a specialist is required!

Duodenal sounding is an instrumental examination method used to diagnostics diseases and assessment of the state of the biliary system, based on the analysis of selected portions of bile from the duodenum, where it enters from the biliary tract. The selected bile is subjected to cytological, biochemical, and bacteriological analyses, on the basis of which it is possible to identify disorders of bile formation, bile excretion and motility of the biliary system (for example, a type of gallbladder dyskinesia, cholestasis, etc.). In addition, duodenal intubation is used not only for diagnostic purposes, but also for suction of bile in case of congestion in the biliary system.

General information about duodenal intubation

Names of the method of duodenal intubation

Today there are two main types of duodenal intubation - these are classic three-phase And factional. To designate the three-phase classic version, no other names are usually used.

But the method of fractional duodenal intubation can now be fully called in the scientific literature and official medical documentation "fractional duodenal intubation", "portion duodenal intubation", "staged duodenal intubation", "multi-stage duodenal intubation". All these names are used to refer to the same examination method - fractional duodenal intubation.

You should know that there are no fundamental differences between the two types of duodenal intubation (fractional and three-phase) since they are performed in the same way from the patient’s point of view. It’s just that in fractional sounding, the stage, which was single in classical three-phase sounding, was divided into three stages, resulting in not a three-phase, but a five-phase method.

Duodenal intubation of the gallbladder and duodenal intubation of bile

The names "duodenal intubation of the gallbladder" and "duodenal intubation of bile" are misnomers for conventional duodenal intubation. In these incorrect names, a clarification has been introduced that the probing concerns the gallbladder or bile, which is incorrect, since during the procedure, three portions of bile are taken from the duodenum - from the common bile duct, from the gallbladder and from the hepatic ducts. After collection, all three portions of bile are sent for analysis. Accordingly, duodenal intubation involves taking different portions of bile, including from the gallbladder, so the above-described incorrect clarifications are completely unnecessary.

Thus, it is obvious that the terms “duodenal intubation of the gallbladder” and “duodenal intubation of bile” should be understood as ordinary duodenal intubation.

What does duodenal intubation show and why is it done?

The study of bile obtained during probing makes it possible to obtain highly accurate information for diseases of the gallbladder and bile ducts, as well as to judge the nature of the work of the bile ducts of the liver, the presence of an inflammatory process and microbes in the bile ducts. Probing, in addition, allows you to evaluate the concentration and contractile function of the gallbladder, that is, to understand how well the organ thickens hepatic bile, mixes it and throws it into the duodenum when a bolus of food enters it.

Duodenal intubation also makes it possible to assess the condition of the Lütkens and Oddi sphincters, which are a kind of sphincter that blocks the exit from the gallbladder and the exit from the common bile duct into the duodenum. Thus, the Lütkens sphincter is located in the neck of the gallbladder, and closes the exit of bile from it into the bile duct. Thanks to the Lutkens sphincter, the gallbladder remains a closed “bag” in which bile coming from the liver accumulates, concentrates and mixes well. Normally, when a bolus of food enters the duodenum, this, through various feedback mechanisms, leads to the opening of the Lutkens sphincter and contraction of the gallbladder, due to which bile enters the bile duct.

The sphincter of Oddi is located at the junction of the bile duct into the duodenum and, in turn, closes the bile duct. Normally, the sphincter of Oddi opens when bile from the bladder appears in the bile duct, passes it into the duodenum and closes again.

Good, correct and coordinated work of the sphincters of Oddi and Lutkens is extremely important for the normal functioning of the biliary system and digestion. With their excessive tension or, on the contrary, relaxation, as well as mismatch, various bile secretion disorders appear. For example, if the sphincters contract excessively, they do not open in a timely manner, which leads to stagnation of bile and digestive disorders due to its lack in the intestine. And when the sphincters relax, bile flows freely from the bladder into the intestine, irritating it, provoking reflux and inflammation.

Considering all of the above, it is obvious that duodenal intubation is indicated if a person has diseases of the liver, gall bladder or biliary tract. In other words, probing is carried out when it is necessary to assess the condition of the biliary system.

Types of duodenal intubation

Currently, depending on the characteristics of dividing duodenal intubation into stages (phases, stages), there are three main types of this study:

• Classic three-phase duodenal intubation;
• Fractional duodenal intubation;
• Chromatic staged duodenal sounding.

Let's look at a brief description of each type of duodenal intubation. We will present the specifics of conducting and interpreting the results of each type of sounding separately in the appropriate sections.

Classic three-phase sensing

The method received this name due to the fact that duodenal intubation is divided into three stages, in each of which portions of bile are selected, designated by the letters A, B and C (Figure 1). In this case, portion A corresponds to bile released at the initial moments of probing from the large bile ducts that connect the gallbladder to the duodenum. Portion B corresponds to the bile released from the gallbladder at the second stage of probing, which begins with the introduction of a choleretic drug (usually 33% magnesium) and continues until the bile completely flows out of the bladder. Finally, portion C corresponds to bile flowing from the intrahepatic bile ducts at the third stage of probing.

Classic three-phase sounding allows you to assess the condition and functional activity of the biliary tract, identify pathological processes in them, and clarify the diagnosis. Therefore, such probing is indicated for use in diseases of the liver, gallbladder and biliary tract.

Figure 1– Three portions of bile A, B and C, collected during classical three-phase intubation.

Fractional duodenal intubation

Fractional duodenal intubation is a modification of conventional three-phase intubation. The modification consists in the fact that the first stage, at which a portion of bile A is released, is divided into three stages, the duration of which is recorded separately. Thus, fractional duodenal sounding consists of five stages, the first three of which correspond to the first phase of three-phase sounding, and the second and third stages completely coincide with those of three-phase sounding (Figure 2).

Accordingly, during fractional duodenal intubation, three portions of bile are also obtained, designated by the letters A, B and C. These portions are obtained from the same parts of the biliary system as during three-phase intubation. And they are analyzed in the same way in the laboratory, determining physicochemical properties, biochemical content of substances and performing sediment microscopy.

The only difference between fractional duodenal intubation and classical three-phase intubation is that the stage of collecting bile from portion A is divided into three separate stages, the time duration of which is also recorded separately.

The purpose and indications for use for fractional duodenal intubation are exactly the same as for classical three-phase intubation. That is, the method is used to assess the state of the bile-forming and biliary system in diseases of the liver, gallbladder and biliary tract.

Figure 2– Stages of fractional duodenal intubation.

Chromatic staged duodenal sounding

It is a modification of fractional duodenal intubation with preliminary administration of a special dye. That is, 14 hours before the start of the fractional duodenal intubation procedure, the patient is given methylene blue at a dose of 0.15 g, which is a dye. Afterwards, the standard method of fractional duodenal intubation is carried out.

The dye enters the systemic bloodstream, from there it enters the liver, and begins to be released from it along with the secreted bile, coloring the latter in shades of blue and violet. The rate of excretion and the amount of methylene blue found in the bile of portions A, B and C make it possible to evaluate the concentration and contractile functions of the gallbladder, that is, to determine whether the bladder fully concentrates and mixes bile, and how actively it pushes it into the bile duct.

Instead of methylene blue, bromosulfophthalein can be used as a dye, which is administered intravenously during fractional duodenal intubation. In this case, the time after which the dye appears in the bile is measured. Normally, the dye appears within 25 minutes after its administration. If it is detected in the bile more than 25 minutes after intravenous administration, then this indicates impaired patency of the bile ducts.

Three portions of bile A, B and C obtained during probing are subjected to routine laboratory analysis with assessment of physical properties, sediment microscopy and biochemical determination of concentrations of various substances.

In addition to laboratory analysis of portions of bile, during chromatic stage probing, a graph of bile excretion is necessarily constructed, on which the time of each of the five phases is plotted along the X axis (abscissa), and the volume released in each phase of bile is plotted along the Y axis (ordinate). In addition, a simple formula calculates the rate of bile secretion at each of the five stages based on knowledge of its duration and the volume of bile received. A graphical image in combination with the calculated rate of bile excretion allows us to evaluate in detail the work of the sphincters of the entire biliary tract.

After all, the speed of bile movement at the first stage of fractional duodenal intubation depends on the condition and coordinated work of the sphincters of Oddi and Mirizzi. At the fourth stage, the rate of bile secretion depends on the contractility of the gallbladder and the state of the Lutkens sphincter. At the fifth stage, the rate of bile secretion depends on the secretory pressure of the liver. Thus, knowing the rate of bile secretion, measured during chromatic stage probing, it is possible to evaluate the work of the sphincters, the contractile activity of the gallbladder, and the secretory pressure of the liver. As a result, this makes it possible to determine the patency of the biliary tract, clarifying at the level of which area there is an obstacle and what causes it.

For example, if the rate of bile secretion is lower than normal at the first stage, then this indicates a mismatch in the work of the sphincters of Oddi and Mirizzi, or an overstrain of these sphincters, etc. If the rate of bile excretion is below normal at the fourth stage, then this indicates insufficient contractile activity of the gallbladder, that is, dyskinesia.

What do you get from duodenal intubation?

With duodenal intubation of any modification (three-phase, fractional, chromatic stage), portions of the contents of the duodenum are obtained, which includes the following juices:

• Bile, which is secreted into the duodenum through the common bile duct (choledochus);
• Pancreatic secretion, which is secreted into the duodenum through the Wirsung duct;
• Intestinal juice produced by the mucous membrane of the duodenum;
• Gastric contents entering the duodenum through the pylorus.

All of the above juices appear in portions of liquid taken during duodenal intubation. Most of each portion consists of bile, and therefore it is simplistically believed that during duodenal intubation, three different portions of bile are obtained, released from different organs of the biliary tract. The first portion of bile is secreted from the common bile duct, the second portion from the gallbladder, and the third from the liver.

What is a portion in duodenal intubation?

Duodenal sounding of any modification (classical three-phase, fractional, chromatic stage) is divided into stages or phases. During these stages, portions of bile are obtained, which flows from the probe into the prepared container. Accordingly, a portion in duodenal intubation is considered to be the volume of bile obtained during one stage of the study.

How is duodenal intubation done?

Below we will consider the rules for preparing and carrying out various modifications of duodenal intubation. Moreover, first of all, we will indicate the conditions and diseases in which this study is contraindicated.

Contraindications to duodenal intubation

Duodenal sounding in any modification (classical three-phase, fractional or chromatic stage) is contraindicated for use if a person has the following diseases and conditions at the time of examination:

• Acute cholecystitis;
• Exacerbation of chronic cholecystitis or cholelithiasis, occurring with an increase in body temperature;
• Exacerbation of gastric or duodenal ulcers, especially with bleeding ulcers;
• Cicatricial narrowing or diverticula of the esophagus;
• Varicose veins of the esophagus;
• Esophageal ulcers;
• Malignant neoplasms of the stomach or esophagus;
• Recent stomach surgery;
• Bleeding from the stomach;
• Choking or shortness of breath due to pulmonary or cardiac diseases (for example, bronchial asthma, respiratory failure, etc.);
• Myocardial infarction suffered less than one month ago;
• Uncontrolled severe bleeding disorder (eg hemophilia, von Willebrand disease, etc.);
• Mental disorders due to which the patient does not follow the instructions of medical personnel;
• Acute infectious diseases (open form of tuberculosis, viral hepatitis, acute respiratory infections, tonsillitis, etc.);
• Any diseases of the oral cavity, nose and pharynx for which it is impossible to insert a probe.

Preparation for duodenal intubation. Diet and before duodenal intubation

Preparation for the procedure of duodenal intubation of any modification (classical three-phase, fractional or chromatic stage) begins several days before it is carried out.

Firstly, during the week before the upcoming duodenal intubation, blind tubes of the biliary system should not be performed.

Secondly, at least 2 to 3 days before the scheduled date of duodenal intubation, any medications and herbs that affect the condition of the biliary system should be discontinued. The following medications and herbs should be discontinued:

• Choleretic drugs (Allohol, Holosas, Cholenzym, Holagol, Liv-52, Flamin, Cyqualon, etc.).
• Antispasmodic drugs (Papaverine, No-shpa, Bishpan, Tifen, Duspatalin, Belloid, Bellalgin, etc.).
• Laxatives with a choleretic effect (Carlsbad salt, Barbara’s salt, magnesium sulfate, xylitol, sorbitol, etc.).
• Digestive aids (Pancreatin, Mezim, Festal, Abomin, Panzinorm, Penzital, Creon, etc.).
• Agents that enhance gastric secretion (natural gastric juice, Acedin-pepsin, Pepsidil, Plantaglucid, etc.).
• Herbs with a choleretic effect (roots, bark, fruits of barberry, flowers of immortelle, cornflower, tansy, columns of corn, fruits of rowan, rose hips, juniper, leaves of the trifoliate, lingonberry, centaury herb, wormwood, burdock root, chicory, caraway seeds, hop cones, birch buds, cranberry juice).
• Herbs with antispasmodic effects (mallow grass, rhizomes, butterbur leaves, fennel fruits, cumin, coriander, anise, immortelle flowers and fruits, peppermint leaves, barberry and angelica roots).
• Herbs that reduce the secretory activity of the stomach (juice of potato tubers, plantain leaves, peppermint, gravilat rhizome, linden flowers, fennel fruits, drop cap herb).
• Herbs that enhance the secretory activity of the stomach (horseradish rhizome, wormwood, centaury, sorrel, gentian root, dandelion, angelica, chicory, watch leaves, cornflower, immortelle flowers, caraway seeds, mustard, coriander fruits, hop cones).

Thirdly, for at least 2 - 3 days before duodenal intubation, you should follow a diet, which consists of limiting the consumption of foods that strongly stimulate bile formation and bile excretion. Thus, you should limit the consumption of fatty and fried vegetable oils (sunflower, olive, etc.) as salad dressings, strong meat and fish broths, eggs and egg dishes, legumes (peas, beans, lentils, etc.) , sour cream, cream, spices, coffee, strong tea, sweets, carbonated drinks, alcoholic drinks, fresh vegetables, fruits and berries. It is recommended to compose a diet before duodenal intubation from soups with weak broths, porridges with water, low-fat cottage cheese, boiled meat and low-fat fish, steamed cutlets or soufflé, boiled vegetables, steamed fruits, and dried white bread.

On the day before duodenal intubation, you should have dinner at 18.00 and take 2 tablets of No-shpa. If you cannot have dinner before 6:00 pm, you should do so no later than 8:00 pm. After dinner, you can drink unsweetened tea, plain water with the addition of a small amount of honey.

On the morning of the day of duodenal intubation, you should not eat, drink (even unsweetened tea), smoke or chew gum! In the morning you should just brush your teeth, rinse your mouth with water and wait for the probing to begin, without trying to have breakfast or drink tea.

What is necessary for duodenal intubation?

List of items required for sounding

To perform duodenal intubation, the nurse prepares the following items in advance:

• Sterile probe with an olive at the end;
• Sterile syringe with a capacity of 20 ml;
• Soft rollers;
• Warm heating pad;
• Towel;
• Tray;
• 50 ml of 25% or 33% heated solution of magnesia (or other choleretic agent, for example, 40 ml of warm olive oil, 30 - 40 ml of 10% sodium chloride solution, 30 - 50 ml of 10% glucose solution );
• A stand with test tubes or other containers for collecting portions of bile;
• Set of linen;
• A glass of boiled water or a slightly pink solution of potassium permanganate, or a lightly salted solution, or a 2% soda solution;
• Aerosol for pain relief;
• Patch.

The probe is inserted into the duodenum, and it is through it that bile is taken. An anesthetic aerosol is used before inserting a probe in order to eliminate pain, gagging and, thereby, facilitate the penetration of the tube into the pharynx. A syringe is necessary for administering choleretic agents. The patient's neck and chest are covered with a towel so that he does not get dirty, and a set of clean linen is laid on the couch. Soft cushions are placed under the pelvis, and a heating pad is placed under the right side to facilitate the release of bile. The tray is used to collect saliva and vomit. Choleretic drugs are needed to stimulate the contraction of the gallbladder and the collection of a gallbladder portion of bile. The released bile is collected in test tubes. The patch is used to secure the free end of the probe to the patient's cheek so that it does not accidentally come out of the duodenum. Boiled water or a solution of potassium permanganate is needed to rinse the mouth after probing is completed.

Probe for duodenal intubation

To perform any modification of duodenal sounding (classical three-phase, fractional or chromatic stage), a special probe is used, which is a rubber tube 1.5 m long with marks applied to it and a metal tip (olive). Markers are necessary to determine the depth of penetration of the probe into the digestive tract, and the olive is intended to collect the contents of the duodenum. The olive itself is equipped with numerous holes through which bile flows into it. Such a probe is inserted into the digestive tract before it penetrates the duodenum, where it is left until the end of the duodenal intubation procedure.

Performing duodenal intubation in the classical three-phase technique

The patient goes into the treatment room, where a nurse performs duodenal intubation.

Before the manipulation begins, a towel is placed on the patient’s chest and neck so that it does not get dirty, and they are asked to remove dentures, if any. The patient is given a tray to collect saliva and vomit.

Next, the patient is seated on a chair and asked to slightly tilt his head forward. Moisten the end of the sterile probe with water and ask the patient to open his mouth, after which an anesthetic aerosol or gel is applied to the pharyngeal mucosa. Then the metal shaft of the probe is placed on the root of the tongue and the gag reflex is checked by touching the uvula and the back wall of the pharynx.

After this, the patient is asked to swallow, and at this moment the probe is advanced into the esophagus. After the first advancement of the probe, the patient is asked to breathe deeply through his nose in order, firstly, to stop the gag reflex, and secondly, to make sure that the probe has entered the esophagus. If after the first advancement of the probe a person begins to cough, then it should be pulled out, since the tube has entered the respiratory tract.

Then, with each swallowing movement, the probe is slowly moved inward to the fourth mark + another 10–15 cm. After this, a syringe is attached to the end of the probe, and the piston is pulled toward you to obtain liquid. If a cloudy liquid appears in the syringe, then the probe is in the stomach.

After this, using swallowing movements, the patient moves the probe inward to the seventh mark. If a person is able, it is best to do this by slowly walking around the treatment room.

When the probe is swallowed to the seventh mark, the patient is placed on the couch on the right side, with a cushion placed under the pelvis and a warm heating pad under the right hypochondrium. In this position, the patient should continue inserting the probe with swallowing movements until the ninth mark.

When the patient swallows the probe to the ninth mark, his olive is in the duodenum, and the collection of portions of bile can begin.

If bile does not flow after inserting the probe into the duodenum, then you will have to stand up, squat, or while lying on the bed, constantly pull your bent legs towards your stomach, or inflate your stomach and contract the abdominal press to try to push the liquid out of yourself.

To collect bile, the free end of the probe is lowered into a test tube or jar placed below the level of the couch. As soon as light yellow bile begins to flow from the probe, the nurse records the time and labels the container with the letter A. Then the bile is allowed to flow freely until it runs out. The time of completion of bile secretion is recorded, and the first phase of probing is considered completed, during which bile is collected from the common bile duct, designated by the letter A. Normally, 15–40 ml of bile is released during the first phase, and it lasts 20–30 minutes.

After this, they proceed to the second phase of probing - collecting bile from the gallbladder, which is designated by the letter B. To do this, a choleretic agent is injected through the probe with a sterile syringe - 30 - 50 ml of a warm 25 - 33% solution of magnesium sulfate, or 40 ml of warm olive oil , or 30 - 40 ml of 10% sodium chloride solution, or 30 - 50 ml of 10% glucose solution. After administration of the choleretic agent, a clamp is applied to the free end of the probe for 5 to 10 minutes. Then the clamp is removed, the free end of the probe is lowered into a container for collecting gallbladder bile, labeled with the letter B, and the time is noted. Thick dark olive bile begins to flow into the container. It is collected until bright yellow bile comes out of the tube. At this moment, the time is recorded, and the free end of the probe is transferred to a container labeled with the letter C to collect hepatic bile. That is, the second phase of probing, which consists in collecting gallbladder bile, ends when not dark, but bright yellow liver bile begins to flow from the probe. Normally, the second phase lasts 20–30 minutes, during which 50–60 ml of bile is released from the gallbladder.

After the start of the third phase, when bright yellow bile appears, it is collected within 15 minutes. During this time, 25–30 ml of liver bile normally flows.

When the last portion of bile C is collected, probing is considered complete. The patient is placed in a sitting position, and the probe is slowly and carefully pulled out. The patient is given a glass of water or antiseptic to rinse the mouth.

After this, the nurse measures the blood pressure, as it may decrease due to the use of magnesium. If the pressure is low, then drugs are administered that will increase it. Then you should return to the room and lie down for 30 - 60 minutes. After this you can have breakfast.

Technique of fractional duodenal intubation

Fractional duodenal intubation is also performed in the treatment room. In this case, the technique for inserting the probe is exactly the same as when performing classical three-phase probing. That is, the patient sits on a chair, tilts his head slightly down, picks up a tray for saliva and vomit, the nurse covers his neck and chest with a towel, smears the back wall of the throat with anesthetic gel or aerosol, after which he asks to make a swallowing movement, and during it execution advances the probe into the esophagus. When the tube is advanced into the esophagus, the nurse asks you to breathe deeply through your nose to eliminate the gag reflex and ensure that the tube does not enter your airway.

After this, the nurse asks you to make swallowing movements, and while performing them, slowly moves the probe deeper to the 45 cm mark (or the fourth place + 10 - 15 cm). Having reached this depth, the nurse pumps out the contents, which should be a cloudy liquid, from the probe with a syringe. This pumping of fluid is necessary to make sure that the tube is in the stomach.

Next, the patient is placed on the couch on his right side with his legs bent at the knees and hips, and a heating pad is placed in the right hypochondrium, and he is asked to move the probe deeper to the ninth mark with swallowing movements. At this point, the probe is considered inserted and begins collecting bile into different tubes, which must be labeled with the letters A, B and C. Bile is collected in one tube for five minutes, then for the next five minutes in the second tube, etc. Be sure to record the volume of released bile during each five-minute interval.

If bile does not flow after inserting the probe, then you will need to squat, or pull your bent legs towards your stomach, or inflate your stomach and forcefully try to push the air out of it.

The process of bile secretion consists of five successive phases.

First phase (stage I). It is called the stage of basal bile secretion or the choledochus phase, when in response to irritation of the duodenal wall by the metal olive probe, the release of light yellow transparent bile from the common bile duct (choledochus) begins. The duration of this stage is 20–40 minutes, during which 15–40 ml of bile is released.

The rate of bile secretion at the first stage is characterized by secretory pressure outside the liver and the state of the sphincter of Oddi.

When the secretion of bile at the first stage ends, a choleretic drug is slowly introduced through the probe with a syringe over 7 minutes (30 - 50 ml of a warm 25 - 33% solution of magnesium sulfate, or 40 ml of warm olive oil, or 30 - 40 ml of 10% th solution of table salt, or 30 - 50 ml of 10% glucose solution), after which a clamp is applied to the free end of the probe for three minutes. Then the clamp is removed, and usually after this a few milliliters of the injected choleretic drug are released.

Second phase (stage II). Called the latent period of bile secretion or the closed sphincter of Oddi phase. Characterizes cholestatic pressure in the biliary tract, as well as the readiness of the gallbladder for emptying and its tone.

It begins after removing the clamp from the end of the probe after the administration of a choleretic agent. At this stage, no bile is secreted. Its duration is 3 – 6 minutes. The second phase ends when bile begins to flow from the tube. Accordingly, with the beginning of bile secretion, the third phase begins.

Third phase (stage III). The stage of the Lütkens sphincter and common bile duct or the phase of bile secretion of portion A is called. The phase lasts 2–5 minutes, during which 3–5 ml of light brown bile is released from the common bile duct (common bile duct) at a rate of 1–2 ml/min. When dark olive-colored bile appears, this indicates the completion of the third phase and the beginning of the fourth.

The first three phases make up portion A of the classic three-phase duodenal intubation.

Fourth phase (IV stage). Called the gallbladder stage or cystic phase of bile secretion. It begins with the appearance of dark olive bile, which is called portion B. The duration of this phase is 20–40 minutes, during which 30–70 ml of gallbladder bile is secreted at a rate of 2–4 ml/min. The fourth phase characterizes the duration of emptying of the gallbladder and the volume of bile deposited in the bladder. The fourth phase ends and the fifth begins at the same time with the appearance of bright yellow bile.

Fifth phase (V stage). Called the liver exocrine stage or hepatic phase. Characterizes the bile-forming function of the liver. Normally, within 15–20 minutes, 15–30 ml of bright yellow or golden bile, called portion C, is secreted at a rate of 1 ml/min. Usually, after collecting hepatic bile for 15–20 minutes, duodenal intubation is completed. But if the probe is left in the duodenum, hepatic bile will continue to be secreted at a rate of approximately 0.5 ml/min due to the fact that the liver will constantly produce it.

After completing the probing, the nurse carefully and slowly removes the probe from the duodenum and measures blood pressure, which can be greatly reduced due to the action of magnesia. If the pressure has dropped significantly, then the necessary drugs are administered to increase it. After this, you need to go to the room and lie down for 30–60 minutes, after which you need to eat a diet breakfast.

Chromatic staged sensing algorithm

The algorithm for conducting staged chromatic sounding is exactly the same as fractional duodenal sounding. There is only one difference between them - 14 hours before probing, the patient is given a dye to drink - methylene blue at a dose of 0.15 g in a gelatin capsule. All other phases of chromatic stage sounding and the rules for collecting bile are exactly the same as for fractional sounding.

Is it painful to do duodenal intubation?

The procedure of duodenal intubation itself is not painful, but unpleasant, since inserting the probe into the duodenum causes a gag reflex due to irritation of the posterior wall of the pharynx. In addition, the very situation of finding a foreign body in the esophagus, stomach and duodenum is very unpleasant. The introduction of a choleretic drug into the tube also causes discomfort, but the process of releasing bile itself does not cause discomfort.

However, according to the testimony of many patients who have undergone duodenal intubation multiple times, pain often occurs after manipulation. At the same time, everything inside the body hurts for several days, but gradually the pain subsides and everything returns to normal.

After duodenal intubation

After completing duodenal intubation, you need to abstain from drinking and eating for two hours, after which you can have breakfast. Porridge with water or dried white bread, as well as a glass of unsweetened tea with a few spoons of honey are good for this. Throughout the day after the manipulation, you should follow the same diet as during the period of preparation for duodenal intubation. The next day after probing, you can lead your usual lifestyle and eat whatever you want.

Within 1–2 days after duodenal intubation, there may be loosening of the stool due to the action of magnesia. When the drug stops working, your bowel movements will return to normal.

Duodenal sounding is a diagnostic procedure aimed at studying the condition, as well as the contents. The described method makes it possible to accurately determine the composition and concentration of bile and digestive (that is, gastric, intestinal and pancreatic) juices circulating in the gastrointestinal tract.

Duodenal intubation - examination of the biliary tract.

Duodenal intubation is considered one of the advanced research methods, indispensable in the diagnosis of diseases of the bile ducts.

In other words, if inflammatory processes begin in the pancreas, liver or organs communicating with them, the composition of the secretions produced by the digestive system will change. And duodenal sounding will help detect and record such changes.

On what basis are such examinations prescribed? An indication for referring a patient for duodenal intubation may be the manifestation of such alarming symptoms as:

• copious sputum production;
• pain in the hypochondrium (usually on the right);
• nausea and vomiting syndrome;
• increased concentration of urine.

Progress of the procedure

Duodenal intubation is necessary for a complete diagnosis of gastrointestinal diseases.

As for the methodology for performing duodenal intubation, today doctors mainly use the fractional method.

What does this mean in practice? The essence of the fractional sounding method is to gradually extract the contents of the duodenum, carried out in several approaches (usually five) with intervals of 5-10 minutes between them.

This method allows not only to graphically record the amount of biomaterial obtained, but also to track changes in its composition over time.

Thanks to this feature, a specialist can reliably determine the level of bile acid secretion in the body, which is simply necessary for a full diagnosis of many.

Actually, this is the only advantageous difference between fractional probing and similar procedures performed by three-phase and classical methods.

It is also worth noting that the biological material obtained as a result of the described research can then be used in laboratory tests. Thus, portions of bile extracted from the patient’s body can be studied under a microscope in order to identify one or another bacteriological activity.

At the same time, the most useful information on this matter can be obtained from the “average” portion of biomaterial. And this is natural, because such a secret is obtained directly from.

Preparing for probing

Drugs that stimulate digestion should not be taken before probing.

As with any similar diagnostic procedure, the patient is prepared for duodenal intubation - carefully and in advance. What rules must the examinee adhere to in order for the examination to go as planned?

First of all, the patient should strictly adhere to all the recommendations given to him by the doctor who issued the referral for sounding. However, there are some general rules for preparing for the procedure. Let's list them:

• Duodenal intubation is carried out strictly on an empty stomach, therefore, after waking up and until the procedure itself, the subject is prohibited from taking any food.
• Preparation for the study should begin the day before. So, a few days before the scheduled procedure, the patient will have to temporarily give up any “heavy” foods, as well as any food that causes increased pain. In particular, any “milk”, potatoes, as well as bread made from dark varieties of flour will be strictly prohibited for the examinee.
• About a week before the procedure, the subject will have to completely stop using any choleretic drugs (allochol, barbara salt, holagol, barberine, flamin, cyclone, xylitol, magnesium sulfate, etc.).
• Similar bans will be imposed on some other drugs. These include laxatives and vasodilators, as well as agents that have a targeted antispastic effect. Any medications that stimulate digestion, for example, “” and “” also fall into the category of prohibited drugs.
• On the eve of the procedure, the patient is prescribed a special drug - atropine. This product is used in the form of a 0.1% solution. The patient can take the prescribed dose of 8 drops either orally, dissolving the drug in warm water, or in the form of a subcutaneous injection.

How is research done using a probe?

The probing procedure can take from an hour to an hour and a half.

Before starting the diagnostic procedure itself, the doctor asks the patient to take a standing position and measures the distance from the oral cavity to the navel of the subject.

A specialist will need this information to correctly calculate the length of the probe to use. After this, the patient is seated on the couch, given a special tray, and the examination begins directly.

The main difficulty of probing is that the patient will have to “swallow” the probe on his own. If the patient does this incorrectly, he will provoke the strongest. How can this be avoided? In this regard, experts give several clear recommendations:

1. The internal organs of the subject should not be “squeezed”. That is why before the procedure he should wear the loosest and most comfortable clothes possible.
2. During the examination itself, it is recommended to loosen the belt on your trousers and unbutton the top buttons on your blouse or shirt.
3. During the procedure itself, the patient should try to breathe through the nose and as deeply as possible, tightly fixing the probe with his lips.
4. While “absorbing” the probe, the patient should try to simultaneously swallow the saliva that has accumulated in the mouth. However, this must be done very slowly, as otherwise you may choke and provoke a gag reflex. Moreover, if the probe is quickly swallowed, there is a risk that the hose will simply curl up in the subject’s stomach.

The patient should follow all the above recommendations until the research device reaches him. You can judge that this happened by the marks on the probe itself. Or - by blowing air through the hose (usually this is done using a syringe). If during such manipulations in the chest area the patient hears gurgling and bubbling, then everything is going as planned.

As soon as the tube reaches the stomach, its introduction is temporarily suspended. The patient himself is placed on his side (strictly on the right). For comfort, a pillow is placed under the buttocks of the subject.

To facilitate further advancement of the probe, a warm heating pad may be placed under the patient's right side. This will allow the patient's stomach to move slightly upward. After all the described manipulations have been completed, the insertion of the probe continues.

The entire research procedure usually takes from an hour to an hour and a half. The bile collected during probing is poured into one container to make it easier to measure its exact amount.

In any case, as soon as the specialist receives a sufficient amount of bile for analysis, the procedure is stopped and the probe is removed from the patient’s body.

About “normal” indicators of bile secretion

Duodenal sounding does not give a 100% correct result.

In digestive bile obtained through duodenal intubation, the level of enzymes necessary for the normal functioning of the gastrointestinal tract organs can vary greatly.

How normal it is can be judged only by tracking the change in this indicator over time. As mentioned above, this can only be done with the help of fractional sounding, which is popular today.

At the same time, during the analysis process, specialists will focus on the indicators obtained during stimulation of secretion (that is, the “average” portion of bile will be subjected to especially careful examination).

Duodenal intubation (insertion of a probe into the duodenum to obtain its contents) plays an important role in the diagnosis of various gastroenterological diseases, primarily the gallbladder and biliary tract, pancreas, and duodenum. Duodenal intubation is also used for therapeutic purposes (for example, to pump out bile with reduced motor function of the gallbladder).

The study is carried out using a special duodenal probe with a diameter of 4-5 mm and a length of up to 1.5 m, which has a metal olive with holes at the end. There are three marks on the probe: at a distance of 45 cm (distance from the incisors to the subcardial part of the stomach), 70 cm (distance to the outlet part of the stomach), 80 cm (distance to the major duodenal papilla).

The procedure is carried out in the morning on an empty stomach (Fig. 26). A duodenal tube is inserted into the patient in a sitting position using active swallowing movements. As soon as the probe reaches 45 cm and enters the stomach (which is checked by suctioning acidic gastric contents through the probe), the patient is placed on the right side with a cushion or rolled blanket. In this position, he continues to slowly swallow the probe (up to a distance of approximately 75 cm), which after a certain time (usually 40 minutes - 1 hour) passes through the pylorus and ends up in the lumen of the duodenum. An attempt to swallow the probe more quickly leads to it collapsing.

Rice. 26. Technique of duodenal intubation.

occurs in the stomach, as a result of which the study is lengthened.

The outer end of the probe is lowered into one of the test tubes, the stand with which is installed below the level of the bed on which the patient lies. The correct position of the probe is judged by the appearance of yellow contents in the test tube, which have the main reaction. You can also check the position of the probe by introducing air into it through a syringe: if the probe is in the duodenum, then the introduction of air is not accompanied by any sounds, but if the probe still remains in the stomach, then when air is introduced, a characteristic bubbling sound is noted.

The most accurate way to check the position of the probe is x-ray control. If the position of the probe is incorrect, the radiologist will always give precise instructions in which direction and how much it needs to be moved.

With duodenal intubation, it is usually possible to obtain three portions of duodenal contents. The first portion (portion A), normally transparent and golden yellow in color, is a mixture of bile, pancreatic secretions and intestinal juice. If there is an admixture of gastric juice, the first portion becomes cloudy.

After receiving portion A, one of the gallbladder stimulants is administered through a probe: 25-40 ml of 33% or 40-50 ml of 25% magnesium sulfate solution, 30-40 ml of 40% glucose solution, 15-20 ml of warm vegetable oil. Sometimes hormonal cholagogues (pituitrin, cholecystokinin) are used parenterally. 10-15 minutes after the introduction of the stimulant, the second portion (portion B) begins to flow through the probe - gallbladder bile of brown or olive color, and in case of stagnation of bile - dark green color. If the concentration function of the gallbladder is weak, it is not always possible to distinguish portions A and B by color. In such cases,

It is convenient to use chromatic duodenal sounding: after taking 0.15 g of methylene blue in a gelatin capsule on the eve of the study, the resulting cystic bile turns blue. In some diseases, such as blockage of the bile duct by a stone, it is not possible to receive portion B.

After the release of gallbladder bile (on average 30-60 ml), lighter liver bile (portion C) begins to flow through the tube.

The nature and rate of bile secretion can be clarified using the so-called minute probing, when the duodenal tube is moved to the next tube every 5 minutes.

Microscopic examination of the obtained portions of duodenal contents allows us to identify signs of inflammation in the gallbladder and biliary tract (leukocytes, epithelial cells), detect various bacteria and protozoa (for example, Giardia), determine violations of the colloidal state of bile (a large number of cholesterol crystals), etc.

Enemas

An enema (from the Greek klysma - washing) is the procedure for introducing various liquids through the rectum for diagnostic or therapeutic purposes.

Diagnostic enema used, for example, to recognize intestinal obstruction. For X-ray examination of the colon (irrigoscopy), the so-called contrast enema, containing a suspension of radiopaque contrast agent. For therapeutic purposes, cleansing, siphon and medicinal enemas are used.

Cleansing enemas, designed to liquefy and remove the contents of the lower parts of the colon, are used for persistent constipation, to remove toxic substances in case of poisoning, before operations and childbirth, X-ray examinations of the digestive tract and endoscopic examinations of the colon, before using medicinal enemas.

They contraindicated for acute inflammatory and erosive-ulcerative lesions of the colon mucosa, some acute surgical diseases of the abdominal organs (acute appendicitis, acute peritonitis), gastrointestinal bleeding, disintegrating tumors of the colon, in the first days after operations on the abdominal organs, severe cardiovascular failure.

The liver and gallbladder perform many functions in the human body, including direct participation in digestion processes through the production of special enzymes, the synthesis and accumulation of bile. Any disturbances in these organs, their structure, structure or work, immediately affect a person’s well-being, manifesting itself in various symptoms such as heartburn, bowel disorders, weight loss, and pain. In some cases, pathological processes in the liver or gall bladder cause the development of dangerous diseases - liver cirrhosis, cholelithiasis, inflammation of the biliary tract. That is why, if alarming symptoms appear in the abdominal area, you should not delay going to the doctor. In this case, one of the procedures that the doctor will prescribe to examine the condition of the internal organs may be duodenal intubation.

What is duodenal intubation and why is it prescribed?

Duodenal intubation is one of the methods of functional diagnostics in gastroenterology. With its help, the physician is able to assess the condition of the duodenum and bile contents.

In the process, the doctor uses a special probe - a long elastic hollow tube, at the end of which there is a hollow metal olive. The diameter of the tube is no more than 5 millimeters, its length is 1.5 meters. The olive has the shape of a small olive, 20 millimeters long and 5 millimeters wide. Its rounded shape and small size should make it easier for the patient to swallow the probe.

What can the procedure show? Ten to fifteen years ago, only with the help of duodenal intubation it was possible to confirm the presence of stones in the gallbladder and its ducts. Today, such a diagnosis does not require probing; it can be detected during ultrasound examination. A specific procedure is performed to obtain a sample of duodenal contents from the duodenum, as well as to assess the condition of the gallbladder, pylorus and sphincter of Oddi.

General concepts of the anatomy and function of the liver and gallbladder

The liver, together with the gallbladder, forms a special system - part of the digestive tract. In addition to processing food, the liver also belongs to the immune system; in addition, it performs a protective function, and partially the function of hematopoiesis.

Anatomically, the liver is located in the abdominal cavity, it is formed by two parts - the left and right lobes. Most of it is located in the upper right part of the peritoneum. The left lobe partially passes into the left half of the abdominal cavity.

The location of the liver is under the diaphragm. The upper border of the organ is located at chest level, it is convex and follows the shape of the diaphragm. The lower edge is 1-2 centimeters below the arch of the ribs, concave in appearance, as it comes into contact with other internal organs.

The right lobe of the liver is approximately 6 times larger than the left. The mass of the organ ranges from one and a half to two kilograms.

In the middle part of the internal surface of the organ, the hepatic hilum is located - at this point the hepatic artery enters the liver, from there exit the portal vein and the hepatic duct, which removes bile from the liver.

The gallbladder is “hidden” under the gate of the organ - a small hollow organ similar to a sac. It is adjacent to the outer edge of the liver and lies on the duodenum. The normal length of the organ is from 12 to 18 centimeters. The structure of the bladder is represented by the bottom, body and neck, which passes into the cystic duct.

The liver is responsible for the secretion of bile, a fluid that breaks down fats, enhances intestinal motility and the action of pancreatic and intestinal enzymes. Bile also helps neutralize the acidic environment of the bolus of food that leaves the stomach, and helps absorb cholesterol, calcium salts and fat-soluble vitamins.

The liver is involved in all metabolic processes in the body - protein, fat, carbohydrates.

The organ also produces hormones, stimulates the production of hormones by the adrenal glands, thyroid and pancreas.

In addition, the liver is a huge protective filter that neutralizes the effects of toxins, poisons, medications, and allergens.

The bile produced by the liver passes into the gallbladder, where it accumulates until the food that it is needed for digestion enters the body.

What types of procedures can be performed

Duodenal intubation may differ depending on how it is performed. Doctors highlight:

• blind probing, when the patient does not have to swallow the probe - liquid is used for the procedure;
• fractional or multi-stage: in this case, collection of intestinal contents is carried out at a certain interval, for example, every five minutes;
• chromatic sounding implies that before diagnosis, a dye is injected into the patient;
• a minute-long procedure makes it possible to assess the condition and functioning of the sphincters.

Indications and contraindications: when is it necessary and in what cases should probing not be performed?

The procedure, due to its specificity and the discomfort it causes to the subject, can be performed only if there are indications for it - special symptoms or suspicion of certain diseases.

Indications for duodenal intubation are:

• feeling of bitterness in the mouth;
• pain and discomfort in the right hypochondrium;
• bile stasis diagnosed based on ultrasound results;
• constant nausea and bouts of vomiting;
• change in urine color to yellow-brown or brown, discoloration of feces;
• the need to establish a primary or confirm an existing diagnosis;
• suspicion of an inflammatory process in the gallbladder;
• diseases of the bile ducts and liver.

The procedure is not performed if the patient has:

• coronary insufficiency;
• acute cholecystitis;
• stomach and duodenal ulcers;
• cancer of the digestive tract;
• exacerbation of chronic cholecystitis;
• varicose veins of the esophagus.

Probing is also not recommended for pregnant and lactating women.

Features of preparation for diagnostics

The duodenal intubation procedure can only be carried out strictly on an empty stomach, so the patient should not eat 8-10 hours before it, and should refrain from drinking liquid 3-4 hours before.

As part of patient preparation, dietary restrictions are required five days before the scheduled procedure. The following must be excluded from the menu:

• high-content fruits and vegetables, raw and cooked;
• bread, pastries;
• confectionery;
• and dairy products;
• legumes;
• fatty meats and fish.

This diet is introduced to reduce the level of gas formation in the intestines.

Preparation for the procedure also requires stopping the use of the following medications during the same period:

• choleretic (Barberin, Tsikvalon, Allochol, Flamin, Holosas and others);
• antispasmodics like No-Shpa, Spazmalgon, Papaverine, Beshpan;
• laxatives;
• vasodilators;
• enzyme-containing (Pancreatin, Creon, Festal).

On the eve of the study, the patient must take 8 drops of Atropine in a 0.1% solution. The substance can also be administered subcutaneously. In addition, you can drink a warm glass with 30 grams of xylitol dissolved.

The objectivity of the results obtained directly depends on how carefully the patient follows all the preparation requirements.

How is the liver and gallbladder examined?

The procedure algorithm may include several diagnostic techniques:

• classic duodenal intubation;
• fractional sounding.

The first method involves performing a three-stage study, and is considered somewhat outdated. During classical intubation, portions of bile are collected in three phases:

• from the duodenum;
• from the bile ducts and gallbladder;
• from the liver.

The technique consists of phases A, B and C.

Stage A. The patient is seated on a chair, he needs to tilt his head forward, open his mouth wide and stick out his tongue. The doctor performing the procedure places a metal olive on the root of the patient’s tongue, with which one end of the probe ends. Next, the patient must swallow, while the doctor advances the probe into the esophagus. The saliva released by the subject flows into a special tray, which he holds in his hands.

To understand that the probe is in the esophagus and not in the trachea, the doctor asks the patient to make deep breathing movements. If the subject can breathe deeply and freely, then the probe is positioned correctly.

By the marks on the probe, the doctor understands how deep the probe goes and when the olive reaches the stomach. The contents of the probe are pumped out with a syringe to check - if a cloudy liquid enters the syringe, it means that the probe is located in the stomach.

To move the probe tube into the duodenum, the patient must be placed on his right side, placing a warm heating pad under him. The “sideways” position is required to prevent saliva from entering the trachea.

Light yellow, slightly cloudy liquid entering the cavity of the tube indicates that the probe has reached the duodenum. This moment is the beginning of stage A - contents are collected from the duodenum for analysis. It contains bile, intestinal and pancreatic enzymes.

In about half an hour, from 15 to 40 milliliters of liquid is collected in a special container. If the tube is wrapped in the stomach, the contents cannot be collected. In this case, the probe tube is pulled out to the previous mark, after which it is carefully inserted again until it reaches the duodenum.

Stage B. After the first stage of collecting fluid for analysis is completed, substances that promote irritation of gastric secretion are introduced into the intestine: sorbitol, oxygen, xylitol or magnesium sulfate. The probe tube is pinched for a few minutes. After 7-10 minutes, the clamp is removed from the probe, after which, if all manipulations are done correctly, vesicular contents enter the cavity of the tube - thick green-yellow bile. In about half an hour, it is possible to collect up to 60 milliliters of liquid.

Stage C. Gradually, the color of the liquid in the tube becomes bright yellow, which means that liver bile is entering it. For analysis you will need no more than 10-15 milliliters. At the end of collecting secretions for analysis, the probe is slowly removed from the esophagus.

Technique for fractional duodenal intubation

In this case, duodenal contents are pumped out every 5-10 minutes. At the first stage, a portion of fluid is collected from the duodenum - it contains bile, pancreatic and intestinal enzymes, and partly gastric juice. The stage lasts about 20 minutes.

At the second stage, a solution of magnesium sulfate is supplied into the intestine through a probe tube. The secretion of bile from the spasm of the sphincter of Oddi stops. This stage lasts 4-6 minutes.

At the third stage, the release of the contents of the intrahepatic bile ducts begins within 3-4 minutes.

During the fourth phase, the gallbladder is emptied and its contents (thick brown or brown-yellow bile) are collected with a probe.

At the end of the process of separating the thick dark contents, the fifth phase begins, when the liquid in the probe tube again acquires a golden yellow color. The collection lasts up to half an hour.

What happens to the resulting contents: collection and examination of duodenal fluid

Each portion of the test substance is sent into a separate sterile test tube, with strict adherence to all sterility rules, including burning the edges of the test tubes on a gas burner before and after collecting bile.

Containers with liquid must be sent to the laboratory for examination as soon as possible after collection, since proteolytic enzymes of the pancreas tend to destroy leukocytes, in addition, cooling the liquid makes it difficult to detect Giardia in the duodenal contents: when the temperature drops, they stop moving.

To prevent cooling, the test tubes are lowered into a glass of water, which has a temperature of 39-40 degrees Celsius.

The analysis is interpreted by a diagnostician with the appropriate qualifications. All results are recorded in a written doctor’s report.

If a large number of leukocytes are present in the collected fluid, this may indicate the presence of an inflammatory process. In this case, diagnosticians conduct an analysis with bile culture: the substance is sown on special nutrient media. This method helps to identify Escherichia coli or Pseudomonas aeruginosa, and some other pathogens.
The presence of epithelial cells in the bile indicates that a pathological process is present in the stomach or duodenum.
The content of red blood cells indicates possible microtrauma to the inner layer of organs, which could be caused by the probe.

Crystals of bilirubin and cholesterol are not normally found in the duodenal contents, but if they are detected, it means that the colloidal properties of bile are impaired, and the patient may be prone to cholelithiasis.

Blind probing: features of the procedure

To perform blind duodenal intubation, the patient does not need to swallow the probe. In this case, he will need to purchase a liquid that stimulates the secretion of bile - for this purpose, hawthorn decoction, Borjomi or Essentuki mineral water, a solution of sorbitol or xylitol, Epsom salt or magnesium sulfate can be used.

The irritant is taken in the morning on an empty stomach. A person needs to lie down on his right side, placing a warm heating pad under him. The chosen remedy must be drunk slowly. Usually up to one and a half liters of liquid is used. Legs must be bent at the knees and tucked under you. Next, you need to take several deep breaths, inflating your stomach, and when exhaling, drawing it in. The duration of the procedure is from 40 minutes to two hours. All this time you need to lie in a relaxed state, ideally fall asleep.

Half an hour after finishing, you are allowed to have breakfast, and the food should be light. On this day you need to give up fatty, spicy and fried foods.

What is chromatic sensing?

This type of probing is used for the most accurate recognition of bile from the gallbladder. Approximately 12 hours before the start of the study, usually in the evening before bed, and no earlier than 2 hours after the last meal, the patient needs to drink a capsule with 0.15 grams of methylene blue.

During probing, the bile collected from the bladder turns out to be blue-green. In this case, the diagnostician pays attention to the volume of bile released, and the time that passes from the moment of administration of the irritating substance until the appearance of a portion of bile belonging to stage B.

Probing in children: how it is done

All procedures using a probe are quite difficult for children to tolerate. The procedure and technique are practically no different from the procedure in adults, with the exception of some indicators.

In children, probing is performed using a probe of a smaller diameter. For newborn babies, the tube is inserted to a depth of approximately 25 centimeters. Children 6 months old - to a depth of 30 centimeters. For a one-year-old child, the probe is inserted to a depth of up to 35 centimeters, from 2 to 6 years old - to 40-50 centimeters, for older children - up to 55 centimeters.

The amount of magnesium sulfate introduced into the intestine is calculated at 0.5 milliliters of a 25 percent solution per kilogram of body weight.

Duodenal intubation is an unpleasant procedure for the subject; moreover, it lasts, in some cases, 40-50 minutes. Usually the patient is conscious, but if the patient has no contraindications or allergies to anesthesia, probing can occur under anesthesia. Therefore, preparatory measures should include not only physiological medical measures, but also psychological preparation.