Diagnostics of stomach secretory functions

To determine the character of secretory (acid-forming) stomach functions extraction of gastric contents with a thin tube can be used. The length of this tube is 1,5 m, external diameter 3-5 mm, internal 2-4 mm. Onthe side of blind end there are two oval holes. Using this thin tube gastric juice is takenby fractions, every 15 minutes (Katch’s method–every 10 minutes) within 2 h. Each portion of juice is pumped out with 10 or 20 gr syringe, collected into separate container and is tested for total acidity, amount of free hydrochloric acid, pepsin, slime and other components of gastric juice.For fractional method of diagnostics of gastric contents for tested breakfast more often 7% decoction of dried cabbage (Ryss-Petrova method) or 200 ml of cabbage juice (Leporsky method) is used. 5% ethanol solution (Erman method) or beef broth (Zimnitsky method) is used less. Recently for diagnostics of gastric secretion, besides enteral, parenteral stimulants of gastric secretion (insulin, histamin, pentagastrin) are widely used.

Duodenal probing

Duodenal probing–is a relatively safeprocedure. However, not in all cases.Contraindications for duodenal probing are acute cholecystitis, exacerbation of gastric and duodenum ulcer, esophageal stenosis caused by tumour or cicatrixes, esophageal varicose veins dilatation.

In 2-3 days before it the patient’s nutrition excludes food products causing meteorism: cabbage, potato, easily digestible carbohydrates, whole milk, etc. Before the diagnostics the patient takes atropine in drops (10 drops of 0,1% solution).

Duodenum contents is taken by means of duodenal probe, which is a rubber tube 4-5 mm in diameter and about 1,5 m in length. To its distal end an oval metal or plastic olive is attached. This olive has holes which are connected to the canal of the tube.

The probe has 3 marks: I – 45cm (is equal to the distance to cardinal part of stomach); II - 70 cm (distance to the enterofpylorus); III - 90 cm (distance to duodenum).

Duodenal probe is introduced into the stomach the same way as gastric tube. Gradually as a result of swallowing the probe is introduced up to the first mark. The first mark specifies that the olive is in stomach. Position of the probe insidethe stomach is checked by aspiration of its contents with a syringe. When it is evident that the olive is in stomach, the probe is gradually introducedup to the second mark. To speed up the transit of olive through pylorus the patient slowly walks across the room for 15-20 minutes. Then the patient lies on a couch on his right side under which a soft cushion is placed,and a hot-water bottle is put under the gallbladder. After that the patient slowly swallowsthe probe up to the third mark.

To check the position of an olive it is allowed to introduce air into the probe with a syringe. If an oliveis insidethe stomach the patient feels friction, and characteristic noise (gurgle) is audible. If the probe is inside duodenum these sensations and sounds are absent. However, most precisely the position of olive can be detected usingradioscopy. In correct position of the probe the olive should be located in the initial department of duodenum. In case of long stop of olive before the pylorus the patient drinks 30 ml of 10% warm solution of sodium hydrocarbonate.

During the diagnostics there are 3 portions of bile (A, B and C).

Portion A (duodenal bile) enters the container on its own (it can also be taken by pumping out the contentswith a syringe during the first 10-15 minutes). The first fractions of bile are usually rather turbid, contain admixture of gastric contents). Normallyin 20-30 minutes 15-40 ml of bile is taken.

Portion B (bladder bile). To take this portion through the probe one of the agents thatcausecontraction of gallbladder (30-50 ml of warm 33% solution of magnesium sulfate, vegetable oil, 10% solution of sodium chloride, 10% solution of glucose, etc.) is introduced. It is also possible to introduce hormones - cholecystokinin (75 IU into 10 ml of sodium chlorideisotonic solution, intravenously) or pituitrin (5 IU, intramuscular), which cause significantcontractions of gallbladder. After introduction of one of the solutions the probe is pinchedwith Moor’s clamp (pinchcock) for 5 minutes. Then the probe is released and a more dense bile of dark-olive colour flows from it. Bladder bile is excreted freely for 20-30 minutes.During this time about 50-60 ml of bile can be taken.

Portion C (hepatic bile) starts after bladder bile. It is transparent, less concentrated, yellow-golden in colour, without admixtures of flakes. Duration of excretion is 20-30 minutes; quantity 15-20 ml. After portion C the probe is slowly removed.

It is necessary to remember that not all patients tolerate the solution of magnesium sulfate, which is applied to produce the reflex (contraction) of gallbladder. This solution is not recommended in colitis with predisposition to diarrhea. In this case it is necessary to replace the solution of magnesium sulfate with concentrated sugar solution or glucose, under the influence of these solutions reflectory contraction of gallbladder is weaker, but there are no side effects.

However, despite the fact that the preparation for diagnostics was good in some cases during or right after itthere arise various complications. Most frequent –are abdominal pains, weakness, vomiting, diarrhea. These phenomena are caused more often by the introduction of magnesium sulfatethrough the probe into duodenum. Concentrated (33%) solution of magnesium sulfate causes not only emptying of gallbladder, but strongly stimulates centres of vegetative nervous system, and as a result patients can feel weak, vertigo, fall of blood pressure, palpitation etc. To eliminate the specified complications it is necessary to have necessary medicines at hand,first of all calcium chloride, which is an antagonist of magnesium sulfate. For emergency help it is necessary to have 0,1% atropine sulfate solution, 1 ml is introduced subcutaneously.

Enema

- introductionof various fluids into the inferior segment of large intestine through anal orifice with medical and diagnostic purpose. Enemas can be cleansing, oily, hypertonic, emulsive, siphon, nutrient, medicinal and droplet.

Cleansing enema. It isused to removefecal masses and gases in case of feces retention from inferior segment of intestine; preparation for X-ray; before surgery, delivery, artificial abortion; before application of medicinal clysters.

Contraindicationsfor enema application are acute inflammatory diseases in the area of anus, bleeding hemorrhoids, rectum tumours in disintegration stages, gastrointestinal bleeding.

For cleansing enema Esmarchmugis used; it is a1-2 l reservoir (glass, enameled or rubber). The bottom of the mug has a connector to which a thick-walled rubber tube is attached; this tube is 1,5 m long and 1 cm in diameter. By means of a valve on one end of the tube the flow of liquid into intestine is controlled. On the other end of the tube a glass, ebonite or plastic tip 8-10 cm long is put. After use the tip is washed with soap under running warm water and then boiled. Afterthe mug is filled with water of the required temperature, the cork or clamp is released in order to fill the tube with water and let the air out. The patient lies on the left side on edge of the bed or couch with his feet pressed to abdomen; this promotes relaxation of abdominal muscles and makes fluid introduction easier. Under the pelvis of the patient an oilcloth is placed,then a bedpan is put on this oilcloth. The tip is checked for integrity, lubricated with vaseline and, afterpushing buttocks apart, it is introduced into anal orifice with easy rotary movements. The first 3-4 cm the tip is inserted towards the navel, and then 5-8 cm deeper in parallel with coccyx. It is forbidden to introduce the tip with force!

Esmarchmug is hung 1 m above the patient, the valve is then opened and water under pressure enterslarge intestine.

If the tip isstuck with fecal masses it is taken out, cleaned and introduced again.

Fast inflow of water can cause pains, urge to defecate. The colderthe water, the more it stimulates intestine and increases peristalsis. Use of cold water can cause enterospasms, abdominal pains and retention of defecation in spastic constipations. In constipations accompanied by atonia of intestinal muscles cool (20°С, less frequent 16-14°С) enemas are applied. For treatment of spastic constipations hot (40°С) clysters are used. It is desirable, that the patient holds water for 10 minutes.

Oily clyster

- It is appliedin persistent constipations. For this purpose sunflower seed, olive, hempseed orvaseline oil is used. For one clyster 50-100 ml of warmed up to 37-38°С oil is taken. The oil is introduced with a usual rubber bulb or Janet's syringe through catheter which is introduced 10 cm deep intothe rectum. If after 10-12 h(morning)there is no effect, it is necessary to apply standard cleansing enema.

Emulsive clyster

- hasa good emptying effect. An emulsion is made as follows: mix 2 glasses of camomile decoction, an egg yolk, one teaspoon of sodium hydrocarbonate and 2 tablespoonfuls of vaseline oil or glycerol.

Hypertonic clyster

- causes intensifying of peristalsis and intestine emptying.Hypertonic solutions of sulfuric magnesia, sulfuric sodium (20-30% solution or 2 tablespoonfuls of salt is dissolved in 1 glass of water) or 10 % solution of sodium chloride are usually used. Hypertonic clysters cause abundant liquid stool. Because such clysters significantly stimulate intestinal mucosa, they are done seldom.

Siphon clyster

-if usual cleansing enemas do not give effect, siphon clysters are applied. They are usedin intestinal impassability, and also for removalof products of fermentation and rotting from the intestine, in poisonings and to remove gases. For siphon clyster a sterilised tube 1 m long and 1,5cm in diameteris used; a funnel containing about 1 l of fluidis put on its one of its ends; a jug; 10-12 l of clear water or weak solution of potassium permanganate, solution of sodium hydrocarbonate, which has been warmed up to 38°С;a bucket or a basin for washing waters. The patient lies on his left side, an oilcloth is placed under breeches, and bucket for drainage and jug with liquid is put near the bed. The end of the tube which is introduced into the rectum is abundantly lubricated with vaseline and pushed 20-30 cmforward. The funnel is held a little above the patient in inclined position. Then, gradually filling the funnel with liquid it is raised 1 m over the patient. Water enters the intestine. As soon as the water level reachesthe neck of the funnel, it is lowered to the basin, without turning it upside down, until the water from intestine fills the funnel. Holding the funnel like this it is easy to see air bubbles and bits feces in it. Then funnel contents are poured intothe basin, it is filled with water once again and the whole procedureis repeated several times until the water coming from intestine is clean and there are no gases. Siphon clyster may require up to 10-12 l of water. After the procedure the funnel is taken off, washed and boiled, and the rubber tube is left inside the rectum for 10-20 minutes, with its other end inside the basinto release the remaining liquid and gases.

Medicinal clyster

-30-40 minutes before medicinal clyster a cleansing enema is applied and only after emptying of intestine a medicine is introduced. Medicinal clysters basically are microclysters, because their volume should not exceed 50-200 ml. Medicine is taken into Janet's syringe or rubber bulb, from 50 to 200 ml volume, the temperature of medicine should be no less than 35-38°С,because at lower temperatures the patient can feel urges to defecate and the medicine will not have time to absorb.

The droplet clyster

-droplet clysters are appliedto compensatemassive loss of blood or fluid. Usually 5% solution of glucose with sodium chloride isotonic solution is introduced. Droplet clyster uses the same systemas cleansing only the rubber tube, which connectsthe tipandEsmarch mug, has a droplet system with a clamp. This clamp is adjusted in such a way that fluid from the tube enters rectum not with a stream, but by drops. The clamp allows to controlthe frequency of drops (more often 60-80 drops per minute, i.e. 240 ml/h). The mug with solution is hung 1 m abovethe bed. The nurse should check that the patient is well covered and doesn’t feel discomfort lying in this position, the tube is not bent too much and water flow is steady. The solution which is introduced should be 38-40°С, for this purpose to the back of Esmarchmug a hot-water bottle is attached and regularly changed to keep it warm all the time.

Nutrient enema.

When it is impossible to introduce nutrients through mouth, they can be introduced through rectum and that is one type of artificial feeding. Application of nutrient enemas is very limited, as in the inferior region of large intestine, where the contents of enema are introduced, only water, sodium chloride isotonic solution, glucose solution and alcohol can be absorbed. Proteins and amino acids are partially absorbed. Nutrient enemas can only serve as an additional method of nutrients introduction. 30-40 minutes before the nutrient enema a cleansing enema is applied in order to empty the intestine. The nutrient enema volume should not exceed 200 ml.

Flatus tube –is a soft thick-walled rubber tube 30-50 cm long, 3-5 mm in diameter. The end of the tube which is introduced into intestine, is rounded near the central opening, the other end is cutslant-wise. The tube is boiled, lubricated with vaseline and introduced into anal orifice 20-30 cm deep so that its external endsticks from anus 5-6 cm. The tube should be introduced slowly, with rotary movements. The tube remains inside intestine until the gases are released. The procedure lasts for no more than 2 h, then the tube is removed and if necessary introducedonce again.