| WO1994007417A1 | 1994-04-14 |
| EP0500023A1 | 1992-08-26 |
| CLAIMS 1. An evolution for the diagnosis of duodenal disease by real time transabdominal ultrasonography. 2. This invention is claimed as claim 1 wherein real time transabdominal Ultrasonography is an effective non-invasive method for diagnosing primary or secondary, benign or malignant duodenal lesions. 3. This invention is claimed as claim 1 & 2, wherein some extra efforts taken during all routine & emergency abdominal real time transabdominal ultrasonography examinations can help to diagnose primarily hitherto unsuspected & undiagnosed benign & malignant duodenal diseases. 4. This invention is claimed as claim 1,2 & 3, wherein real time transabdominal ultrasonographic studies can diagnose duodenal lesions; & for that indigenous secretions were used in the emergency patients & plain drinking water was used in routine patients to distend the duodenum, a hollow viscous organ, by asking patients in various suitable & comfortable positions like, supine, convex supine, sitting, erect, recumbent, RT. Lateral, RT. Oblique & LT. Lateral position etc.; 5. This invention is claimed as claim 1,2 & 3, wherein real time transabdominal ultrasonography studies can diagnose duodenitis with wall edema causing increase in echogenicity, with loss of normal layering pattern and luminal compromise and on real time study hypomotility and intermittent spasm. 6. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography studies can diagnose Duodenal Ulcer on same ultrasonographic findings of duodenitis like wall edema, hypomotility, reduced distensibility due to spasm and in addition persistence of concave speck of air in the mucosal layer of the duodenal wall is seen.. Minimal free fluid may be seen around the duodenum or in the hepato-duodenal pouch. On transabdominal ultrasonography Duodenal wall mucosal ulcers can be differentiate in to further types like, superficial i.e. pertaining to superficial mucosal layer only; deep penetrating duodenal ulcer which is seen reaching to the deeper layers beyond submucosa; Impending perforation is a deep penetrating ulcer which has seen penetrated more that half of the width of the duodenal wall at the site of ulcer; Chronic duodenal ulcer disease can be diagnosed by inspite of overnight fasting, presence of food and/or fluid residue seen in the stomach, with was used as the criteria for diagnosing Duodenal outlet obstruction and are due to post-ulcer strictures and show thickened, narrowed, aperistaltic and hypoechoic wall, with deformity, narrowing and strictures.. 7. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography studies can diagnose Duodenal Ulcer perforation on same ultrasonographic findings of duodenitis like wall edema, hypomotility, reduced distensibility due to spasm and in addition persistence of concave speck of air in the mucosal layer of the duodenal wall is seen, but here the Ulcer has been seen reaching to the outer serosal layer of the duodenum causing leaking air & fluid in the peritoneal cavity leading to pneumoperitoneum & ascites. 8. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography studies can diagnose naturally sealed Duodenal Ulcer perforation on same ultrasonographic findings of duodenitis like wall edema, hypomotility, reduced distensibility due to spasm and in addition persistence of concave speck of air in the mucosal layer of the duodenal wall is seen & this Ulcer has been seen reaching to the outer serosal layer of the duodenum causing leaking air & fluid in the peritoneal cavity leading to pneumoperitoneum & ascites, but here the edematous omentum is seen adherent to the site of perforation or wall defect, with encysted fluid collection around the duodenum. Minimal pneumoperitoneum &/or Minimal ascites may or may not be seen. I claim that real time transabdominal ultrasonography can differentiate between sealed and frank perforation 9. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography studies can diagnose the location of the Duodenal lesions, Ulcer, whether it has been located along its antero- superior wall or postero-medial wall. The postero-medial wall ulcers, depending on its depth may cause focal or generalized pancreatitis or retroperitoneal inflammation. 10. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography study can diagnose benign intramural submucosal tumour by well defined margins and usually not protruding in to the lumen & no cystic component seen. 11. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography study can diagnose Duodenal Diverticulum of two types, True is thin walled fluid filled outpouching with narrow neck arising from otherwise normal duodenal wall and can be seen in any part of the duodenum, while pseudo diverticulum is an irregular shallow mucosal depression in the first part of the duodenum and may be associated with active ulcer crater. 12. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography study can diagnose Duodenal Polyp as an intra-luminal, but usually non-obstructing mass lesion arising from normal Duodenal wall and may show calcifications, however no cystic component usually may not be seen. 13. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography study can diagnose Duodenal intramural Haematoma in Trauma or Bleeding Disorders as a long segment large heterogenous hypoechoic intramural mass lesion eccentrically pushing and compressing the lumen of the duodenum. 14. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography study can diagnose Round worms in the Duodenal lumen or within the Ampulla of Vater and reaching upto the common bile duct or pancreatic duct causing signs of pancreatitis or common bile duct obstruction. 15. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography study can diagnose Stents in the 2nd part of the Duodenum - either Biliary or Pancreatic. Stents may prolapse to erode duodenal wall leading to actively bleeding ulcer. 16. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography study can diagnose Small mobile Foreign Body may be seen transiently in the Duodenum. 17. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography study can diagnose segment of duodenum may be involved in Necrotising Entero-Colitis along with Jejunum and shows circumferential intramural fluid and air collection, with loss of peristalsis and distensibility. Minimal free fluid may be seen around it. Pneumoperitoneum may or may not be seen. 18. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography study can diagnose Duodenal Crohn's disease diagnosed by long segment involvement with thickened and hypoechoic wall and show absent peristalsis, loss of distensibility and specifically showing narrowing with central echogenic lumen. 19. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography study can diagnose Annular Pancreas with normal pancreatic tissue mass seen encircling the second part of the duodenum, however the visualized duodenal wall shows normal layering pattern, its echogenicity & peristalsis, however distensibility is bit hampered with an hour glass appearance. 20. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography study can diagnose Duodenal Tuberculosis by long segment thickened aperistaltic wall, with loss of normal layering pattern; and often with multiple skip lesions, with may be additional involvement of ileo- caecal junction would favor tuberculosis. Gross narrowing of the involved segment seen. Shouldering effect at the ends of stricture is less common feature. Early signs of obstruction like delayed emptying of the stomach, as fibrosis is a common feature of Koch's. Enlarged lymphnodes & fluid collection may also be seen around. 21. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography study can diagnose pathologies & anomalies of Ampulla of Vater for prolapse, benign or infiltrating mass involving second part of the duodenum or obstructed calculi causing obstructive jaundice. 22. This invention is claimed as claim 1,2,3 wherein real time transabdominal ultrasonography study can diagnose Malignant Duodenal lesion as usually a short segment involvement, & shows irregularly thickened, hypoechoic & aperistaltic wall with loss of normal layering pattern. It is usually a solitary stricture & has eccentric irregular luminal narrowing. Enlargement of the involved segment seen. Shouldering effect at the ends of stricture is most common feature. Enlarged lymphnodes & fluid collection around may be seen. Primary arising from wall it self & secondary are invasion from peri- Ampullary malignancy or distant metastasis. 23. This invention is claimed as claim 1,2,3 wherein This study is designed as a single blinded prospective study to define the diagnostic accuracy of duodenal lesions by transabdominal ultrasonography. 24. This invention is claimed to use above 23 claims to develop or alter or reconstruct an ultrasound machine or its standard or optional accessories for better visualization of normal Duodenum & its benign & malignant pathologies. 25. This invention is claimed to use above 23 claims to develop an ultrasound research & educational training program to learn better visualization of normal Duodenum & its benign & malignant pathologies on transabdominal & endoscopic sonography. 26. 1 claim, Transabdominal Sonography of the Duodenum is proved to be of better diagnostic value than Duodenal Endoscopy where the disease has been reached to more deeper layers than Mucosa. 7. 1 claim, Transabdominal Sonography of the Duodenum is proved to be of better diagnostic value than Duodenal Endoscopy where the endoscope can not negotiate through the benign or malignant stricture or narrowing or when the basic architecture of the duodenum has been altered either genetically or prior surgical intervention. |
Detailed description of the invention
Duodenum is the C shaped part that joins stomach & small intestines - jejunum. Duodenal Bulb has rounded triangular shape and rest duodenum is a hollow tubular structure that joins duodenal bulb with Jejunum and shows normal wall thickness, echogenicity of the wall and normal layering pattern and normal peristalsis & distension is well appreciated on real time study. Ultrasonography is an effective non-invasive method for diagnosing primary duodenal lesions. Some extra efforts taken during all ultrasonography examinations can help to diagnose primarily hitherto unsuspected & undiagnosed benign & malignant duodenal diseases. Sincerely ultrasonography should be investigation of choice for diagnosing various benign & malignant duodenal diseases.
Duodenitis was diagnosed by findings like wall edema causing increase in echogenicity, with loss of normal layering pattern and luminal compromise and on real time study hypomotility and intermittent spasm.
Shallow Duodenal Ulcer was diagnosed on same ultrasonographic findings of duodenitis like wall edema, hypomotility, reduced distensibility due to spasm and in addition persistence of speck of air is seen. However air trapping in the Ulcer crater is more reliable in deep ulcers. Minimal free fluid may be seen around the duodenum or in the hepato-duodenal pouch.
In Deep Penetrating Ulcers, air trapping seen in the ulcer crater is now penetrating to deeper layers along with all signs of duodenitis like wall edema, hypomotility, reduced distension due to inflammatory spasm.
In Chronic Duodenal Ulcer reduced distensibility with deformity is the prominent feature along with persistence of speck of air in the edematous wall. To differentiate between spasm and deformity intravenous anti-spasmodic drugs were given to see change in the diameter.
Ulcers are usually at the Anterior wall, but are also seen at the posterior wall. Posterior wall deep penetrating ulcers may or may not accompany with focal pancreatitis.
Inspite of overnight fasting, presence of food and/or fluid residue seen in the stomach, with changes as seen in the chronic duodenal ulcer disease was used as the criteria for diagnosing Duodenal outlet obstruction and are due to post-ulcer strictures and show thickened, narrowed, aperistaltic and hypoechoic wall, with deformity, narrowing and strictures. These patients underwent gastrojejunostomy after confirmation by Upper GJ. Endoscopy. Perforated Ulcers were diagnosed on all signs of deep penetrating ulcers, but here intramural air trapping in the Ulcer crater is now seen extending outside the duodenum or even well defined defect in the wall seen reaching outside the duodenum causing pneumoperitoneum & also shows associated findings like variable wall oedema and fluid collection around the Duodenum and increasing echogenic ascites may also seen.
Sealed Perforated Ulcer was diagnosed on same finding of perforation like wall oedema, intramural fluid and air collection also air trapping in perforated ulcer crater, but here the edematous omentum is seen adherent to the site of perforation or wall defect, with encysted fluid collection around the duodenum. Minimal pneumoperitoneum may or may not be seen. These patients were treated conservatively.
Benign intramural submucosal tumour shows well defined margins and is usually not protruding in to the lumen & no cystic component seen.
Duodenal Diverticulum are of two types, True is thin walled fluid filled outpouching with narrow neck arising from otherwise normal duodenal wall and can be seen in any part of the duodenum, while pseudo diverticulum is an irregular shallow mucosal depression in the first part of the duodenum and may be associated with active ulcer crater.
Duodenal Polyp is an intra-luminal, but usually non-obstructing mass lesion arising from normal Duodenal wall and may show calcifications, however no cystic component seen.
Duodenal intramural Haematoma in Trauma or Bleeding Disorders appears as a long segment large heterogenous hypoechoic intramural mass lesion eccentrically pushing and compressing the lumen of the duodenum.
Round worms are seen in the Duodenal lumen or within the Ampulla of Vater and into the common bile duct or pancreatic duct causing signs of pancreatitis or common bile duct obstruction.
Stents seen in the 2 nd part of the Duodenum - either Biliary or Pancreatic. Stents may prolapse to erode duodenal wall leading to actively bleeding ulcer.
Small mobile Foreign Body may seen transiently in the Duodenum.
Long segment of duodenum may be involved in Necrotising Entero-Colitis along with Jejunum and shows circumferential intramural fluid and air collection, with loss of peristalsis and distensibility. Minimal free fluid may be seen around it. Pneumoperitoneum may or may not be seen.
Duodenal Crohn's disease was diagnosed by long segment involvement with thickened and hypoechoic wall and show absent peristalsis, loss of distensibility and specifically showing narrowing with central echogenic lumen. Annular Pancreas can be diagnosed as normal pancreatic tissue mass seen encircling the second part of the duodenum, however the visualized duodenal wall shows normal layering pattern, its echogenicity & peristalsis, however distensibility is bit hampered with an hour glass appearance.
Duodenal Tuberculosis was diagnosed by long segment thickened aperistaltic wall, with loss of normal layering pattern; and often with multiple skip lesions, with additional involvement of ileo-caecal junction would favor tuberculosis. Gross narrowing of the involved segment seen. Shouldering effect at the ends of stricture is less common feature. Early signs of obstruction like delayed emptying of the stomach, as fibrosis is a common feature of Koch's. Enlarged lymphnodes & fluid collection may also be seen around.
Ampulla of Vater was examined for prolapse, benign or infiltrating mass involving 2 nd part of the duodenum or obstructed calculi causing obstructive jaundice.
Malignant Duodenal lesion is usually a short segment involvement, & shows irregularly thickened, hypoechoic & aperistaltic wall with loss of normal layering pattern. It is usually a solitary stricture & has eccentric irregular luminal narrowing. Enlargement of the involved segment seen. Shouldering effect at the ends of stricture is most common feature. Enlarged lymphnodes & fluid collection around may be seen. Primary arising from wall it self & secondary are invasion from peri-Ampullary malignancy or distant metastasis.
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