{"id":267,"date":"2013-03-14T09:36:32","date_gmt":"2013-03-14T09:36:32","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=267"},"modified":"2013-06-09T13:16:17","modified_gmt":"2013-06-09T13:16:17","slug":"6-2","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=267","title":{"rendered":"6 Diagnostika"},"content":{"rendered":"

6.1 Klinick\u00e9 vy\u0161et\u0159en\u00ed<\/h3>\n

S v\u00fdjimkou auskultace j\u00edcnu, p\u0159i kter\u00e9 lze n\u011bkdy sly\u0161et charakteristick\u00fd zvuk p\u0159i polyk\u00e1n\u00ed b\u011bhem pr\u016fniku tekutiny do \u017ealudku, kter\u00fd v\u0161ak p\u0159\u00edli\u0161 nepom\u016f\u017ee up\u0159esnit diagn\u00f3zu, nejsou j\u00edcen a kardie p\u0159\u00edstupny p\u0159\u00edm\u00e9mu vy\u0161et\u0159en\u00ed. Z celkov\u00e9ho z\u00e1kladn\u00edho vy\u0161et\u0159en\u00ed ve vztahu k diferenci\u00e1ln\u00ed diagnostice onemocn\u011bn\u00ed j\u00edcnu je v\u00fdznamn\u00fd stav v\u00fd\u017eivy, zn\u00e1mky malignity, jatern\u00edho onemocn\u011bn\u00ed apod. Nejd\u016fle\u017eit\u011bj\u0161\u00ed jsou v\u0161ak pro na\u0161i po\u010d\u00e1te\u010dn\u00ed rozvahu anamnestick\u00e9 \u00fadaje. I kdy\u017e subjektivn\u00ed stesky nemocn\u00fdch s j\u00edcnov\u00fdm onemocn\u011bn\u00edm nejsou zcela specifick\u00e9 a prov\u00e1zej\u00ed i jin\u00e9 choroby gastrointestin\u00e1ln\u00edho traktu, lze se mnohdy na z\u00e1klad\u011b jejich rozboru velmi p\u0159esn\u011b p\u0159ibl\u00ed\u017eit spr\u00e1vn\u00e9 diagn\u00f3ze. \u010casto se setk\u00e1v\u00e1me s ne zcela jednotn\u00fdm ch\u00e1p\u00e1n\u00edm a v\u00fdkladem jednotliv\u00fdch symptom\u016f jak nemocn\u00fdmi, tak l\u00e9ka\u0159i, p\u0159esto\u017ee jsou vcelku p\u0159esn\u011b pops\u00e1ny [1, 2, 3, 4, 5].<\/p>\n

Dysfagie<\/strong> je porucha polyk\u00e1n\u00ed, pocit v\u00e1znut\u00ed sousta \u010di p\u0159ek\u00e1\u017eky v j\u00edcnu bez sou\u010dasn\u00e9 bolesti, kter\u00e1 m\u016f\u017ee b\u00fdt vystup\u0148ov\u00e1na a\u017e v \u00faplnou nemo\u017enost polyk\u00e1n\u00ed \u2013 afagii. Pokud je porucha polyk\u00e1n\u00ed prov\u00e1zena sou\u010dasnou bolest\u00ed, mluv\u00edme o odynofagii. M\u00edsto poruchy pas\u00e1\u017ee dovedou nemocn\u00ed \u010dasto pom\u011brn\u011b p\u0159esn\u011b ur\u010dit. V klinice rozli\u0161ujeme typ horn\u00ed (orofarynge\u00e1ln\u00ed) a doln\u00ed (j\u00edcnov\u00e9 dysfagie). Dysfagie m\u016f\u017ee b\u00fdt trval\u00e1, intermitentn\u00ed nebo i z\u00e1chvatovit\u00e1 a jako paradoxn\u00ed typ ozna\u010dujeme poruchu polyk\u00e1n\u00ed tekutin, zat\u00edmco po\u017eit\u00ed tuh\u00fdch pokrm\u016f ne\u010din\u00ed obt\u00ed\u017ee.<\/span><\/p>\n

Od dysfagie lze ji\u017e anamnesticky odli\u0161it tzv. globus hystericus<\/b>. Je to pocit ciz\u00edho t\u011blesa v krku a zvl\u00e1\u0161t\u011b ve faryngu, kter\u00fd m\u016f\u017ee b\u00fdt trval\u00fd nebo prov\u00e1z\u00ed polyk\u00e1n\u00ed, kter\u00e9 v\u0161ak nen\u00ed poru\u0161eno. P\u0159\u00edznak je \u010dast\u011bj\u0161\u00ed u \u017een, zv\u00fdraz\u0148uje se sp\u00ed\u0161e p\u0159i polyk\u00e1n\u00ed na pr\u00e1zdno.<\/p>\n

Pyr\u00f3zou<\/strong> neboli p\u00e1len\u00edm \u017e\u00e1hy rozum\u00edme pal\u010div\u00fd pocit (nikoliv bolest) v epigastriu, propaguj\u00edc\u00ed se za sternum a n\u011bkdy a\u017e do faryngu. Jde o reakci j\u00edcnu na p\u0159\u00edtomnost dr\u00e1\u017ediv\u00fdch sekret\u016f, vnikaj\u00edc\u00edch ze \u017ealudku do j\u00edcnu p\u0159i patologick\u00e9m refluxu. Vznik\u00e1 zejm\u00e9na v z\u00e1vislosti na po\u017eit\u00ed ur\u010dit\u00e9 stravy a zv\u00fd\u0161en\u00ed intraabdomin\u00e1ln\u00edho tlaku.<\/span><\/p>\n

Bolest<\/strong> charakterizuj\u00ed nemocn\u00ed jako pal\u010divou, \u0159ezavou, ale mnohdy jde i o tup\u00fd nebo sv\u00edrav\u00fd pocit. Lokalizov\u00e1na b\u00fdv\u00e1 v epigastriu, za sternem a vz\u00e1cn\u011bji na krku. Iradiace do zad \u010di ramene nen\u00ed typick\u00e1, ale bolest za sternem b\u00fdv\u00e1 nemocn\u00fdm \u010dasto ozna\u010dov\u00e1na jako bolest u srdce. Kombinace bolesti s pyr\u00f3zou, zejm\u00e9na u refluxn\u00ed nemoci j\u00edcnu, je \u010dast\u00e1 a jejich odli\u0161en\u00ed m\u016f\u017ee b\u00fdt mnohdy obt\u00ed\u017en\u00e9. Oba symptomy b\u00fdvaj\u00ed \u010dasto nejen nemocn\u00fdmi, ale i l\u00e9ka\u0159i sm\u011b\u0161ov\u00e1ny. Bolest je podm\u00edn\u011bna funk\u010dn\u00edmi poruchami j\u00edcnu a jeho akutn\u00ed dilatac\u00ed. U malign\u00edch onemocn\u011bn\u00ed m\u016f\u017ee b\u00fdt p\u0159\u00ed\u010dinou pror\u016fst\u00e1n\u00ed n\u00e1doru do mediastina.<\/span><\/p>\n

Regurgitac\u00ed<\/strong> rozum\u00edme spont\u00e1nn\u00ed n\u00e1vrat \u017ealude\u010dn\u00edho, respektive j\u00edcnov\u00e9ho obsahu nad strikturou, do dutiny \u00fastn\u00ed. Na rozd\u00edl od zvracen\u00ed nen\u00ed k vybaven\u00ed nutn\u00e9 zv\u00fd\u0161en\u00ed intraabdomin\u00e1ln\u00edho tlaku s uplatn\u011bn\u00edm b\u0159i\u0161n\u00edho lisu. Proces nen\u00ed ovl\u00e1d\u00e1n v\u016fl\u00ed na rozd\u00edl od <\/span>merycizmu, kdy voln\u011b doch\u00e1z\u00ed k n\u00e1vratu potravy do \u00fast a jej\u00edmu op\u011btovn\u00e9mu p\u0159e\u017evykov\u00e1n\u00ed a polknut\u00ed spolu s p\u0159\u00edjemn\u00fdm pocitem pro nemocn\u00e9ho. Z tohoto d\u016fvodu tento p\u0159\u00edznak nemocn\u00ed \u010dasto taj\u00ed. <\/span>Ruminace je obdobn\u00fd proces, kter\u00fd v\u0161ak nen\u00ed ovl\u00e1d\u00e1n v\u016fl\u00ed, mezi ob\u011bma symptomy mohou b\u00fdt p\u0159echodn\u00e9 formy.<\/span><\/p>\n

Ructus<\/strong> znamen\u00e1 voln\u00ed nebo mimovoln\u00ed \u00fanik \u2013 vy\u0159\u00edhnut\u00ed spolykan\u00e9ho vzduchu ze \u017ealudku nebo j\u00edcnu spojen\u00e9 s typick\u00fdm zvukov\u00fdm fenom\u00e9nem. Je \u010dast\u00fd u refluxn\u00ed nemoci j\u00edcnu, ale m\u016f\u017ee j\u00edt i o jev fyziologick\u00fd a je podm\u00ednkou i pro tvorbu tzv. j\u00edcnov\u00e9ho hlasu.<\/span><\/p>\n

Zejm\u00e9na refluxn\u00ed obt\u00ed\u017ee jsou \u010dasto vyvol\u00e1ny nebo zhor\u0161eny zved\u00e1n\u00edm t\u011b\u017ek\u00fdch b\u0159emen, v p\u0159edklonu, vle\u017ee a za v\u0161ech okolnost\u00ed zvy\u0161uj\u00edc\u00edch nitrob\u0159i\u0161n\u00ed tlak. Hovo\u0159\u00edme o postur\u00e1ln\u00edm zhor\u0161en\u00ed.<\/p>\n

Mezi dal\u0161\u00ed symptomy, kter\u00e9 mohou prov\u00e1zet j\u00edcnov\u00e1 onemocn\u011bn\u00ed, pat\u0159\u00ed: nep\u0159\u00edjemn\u00fd pocit pachu z \u00fast ze stagnuj\u00edc\u00ed potravy v divertiklu nebo u dilatovan\u00e9ho j\u00edcnu, zv\u00fd\u0161en\u00e9 slin\u011bn\u00ed (v\u011bt\u0161inou jako d\u016fsledek regurgitace) ka\u0161el, chrapot a jin\u00e9 respira\u010dn\u00ed p\u0159\u00edznaky vznikaj\u00edc\u00ed z refluxu, regurgitace a aspirace sekretu a potravy do d\u00fdchac\u00edch cest. Pocit klokot\u00e1n\u00ed v hrdle p\u0159i pit\u00ed ud\u00e1vaj\u00ed n\u011bkte\u0159\u00ed nemocn\u00ed u Zenkerova divertiklu. Poruchy srde\u010dn\u00edho rytmu a jin\u00e9 \u201epseudokardi\u00e1ln\u00ed\u201c obt\u00ed\u017ee lze vysv\u011btlit z tlaku divertiklu, hi\u00e1tov\u00e9, zejm\u00e9na paraezofage\u00e1ln\u00ed hernie \u010di dilatovan\u00e9ho j\u00edcnu na srdce. Obdobn\u011b lze vysv\u011btlit singultus z dr\u00e1\u017ed\u011bn\u00ed frenick\u00e9ho nervu.<\/p>\n

6.2 Rentgenov\u00e9 vy\u0161et\u0159en\u00ed<\/h3>\n
Klasick\u00e9 rentgenov\u00e9 vy\u0161et\u0159en\u00ed v minulosti a dnes<\/h6>\n

Vedle rozboru anamn\u00e9zy bylo v ezofagologii dlouho z\u00e1kladn\u00edm diagnostick\u00fdm postupem rentgenov\u00e9 vy\u0161et\u0159en\u00ed. Na nativn\u00edm sn\u00edmku hrudn\u00edku nelze j\u00edcen diferencovat od okoln\u00edch struktur. S v\u00fdjimkou kojenc\u016f a mal\u00fdch d\u011bt\u00ed neobsahuje za norm\u00e1ln\u00edch okolnost\u00ed vzduch ani tekutinu. Vzduchov\u00e1 n\u00e1pl\u0148 nebo tekutina v j\u00edcnu sv\u011bd\u010d\u00ed pro jeho dilataci p\u0159i achal\u00e1zii nebo striktu\u0159e. Dilatace ezofagu m\u016f\u017ee zp\u016fsobit na nativn\u00edm sn\u00edmku hrudn\u00edku roz\u0161\u00ed\u0159en\u00ed mezihrud\u00ed doprava a imitovat tak mediastin\u00e1ln\u00ed tumor. Setkali jsme se s t\u00edmto p\u0159\u00edznakem u megaezofagu. P\u0159i perforaci m\u016f\u017eeme prok\u00e1zat pneumomediastinum, pneumotorax, exud\u00e1t v pleur\u00e1ln\u00ed dutin\u011b apod.<\/p>\n

P\u0159i kontrastn\u00edm vy\u0161et\u0159en\u00ed horn\u00ed \u010d\u00e1sti tr\u00e1vic\u00ed trubice u\u017e\u00edv\u00e1me nej\u010dast\u011bji suspenzi baryumsulf\u00e1tu. Pouze p\u0159i podez\u0159en\u00ed na perforaci \u010di p\u0159i nebezpe\u010d\u00ed aspirace do plic je nutno u\u017e\u00edt vodn\u00e9ho roztoku jodov\u00e9 kontrastn\u00ed l\u00e1tky (gastrografin). Vy\u0161et\u0159en\u00ed umo\u017e\u0148uje dobr\u00e9 posouzen\u00ed anatomick\u00fdch zm\u011bn j\u00edcnu a jeho peristaltiky, stejn\u011b jako vyprazd\u0148ovac\u00ed a samo\u010distic\u00ed schopnosti. Velmi d\u016fle\u017eit\u00fd je pr\u016fkaz gastroezofage\u00e1ln\u00edhorefluxu. Spolehlivost jeho zachycen\u00ed stoup\u00e1 ze 40 % p\u0159i konven\u010dn\u00edm postupu a\u017e na 85 % u\u017eit\u00edm r\u016fzn\u00fdch provoka\u010dn\u00edch man\u00e9vr\u016f, zejm\u00e9na zaveden\u00edm Donnerovy metody vy\u0161et\u0159en\u00ed acidifikovan\u00fdm baryem [6]. Posouzen\u00ed ezofagitidy a jemn\u011bj\u0161\u00edch slizni\u010dn\u00edch zm\u011bn je mimo dosah konven\u010dn\u00edho postupu. V\u00fdt\u011b\u017enost vy\u0161et\u0159en\u00ed zv\u00fd\u0161\u00ed u\u017eit\u00ed makropulverizovan\u00e9ho barya a dvoj\u00edho kontrastu. Dos\u00e1hneme ho pod\u00e1n\u00edm vzduchu nebo oxid uhli\u010dit\u00fd uvol\u0148uj\u00edc\u00ed substance v tablet\u011b \u010di pr\u00e1\u0161ku (\u0161umiv\u00fd pr\u00e1\u0161ek) b\u011bhem vy\u0161et\u0159en\u00ed, nebo se nemocn\u00fd po p\u0159edchoz\u00ed aplikaci barya napije vody. Dal\u0161\u00ed mo\u017enost\u00ed zp\u0159esn\u011bn\u00ed vy\u0161et\u0159en\u00ed je u\u017eit\u00ed hypotonie. Nemocn\u00e9mu aplikujeme intraven\u00f3zn\u011b spazmolytikum, nej\u010dast\u011bji buscopan nebo glukagon. Ob\u011b metody m\u016f\u017eeme u\u017e\u00edt samostatn\u011b, nebo je kombinovat. Aplikace spazmolytik pom\u016f\u017ee rovn\u011b\u017e v diferenci\u00e1ln\u00ed diagnostice p\u0159i vy\u0161et\u0159en\u00ed ezofagogastrick\u00e9ho p\u0159echodu u achal\u00e1zie a p\u0159i diferenciaci organick\u00fdch a funk\u010dn\u00edch z\u00fa\u017een\u00ed j\u00edcnu. Osv\u011bd\u010dila se i inhalace amylnitritu, po jeho\u017e aplikaci doch\u00e1z\u00ed k uvoln\u011bn\u00ed spastick\u00e9ho sev\u0159en\u00ed ezofagokardi\u00e1ln\u00edho p\u0159echodu u nep\u0159\u00edli\u0161 pokro\u010dil\u00fdch achal\u00e1zi\u00ed. Typick\u00e1 je rovn\u011b\u017e reakce achalatick\u00e9ho j\u00edcnu na parenter\u00e1ln\u00ed pod\u00e1n\u00ed cholinergn\u00edho mecholylu (acetyl-metylcholin-chlorid) [7]. Za n\u011bkolik minut po subkut\u00e1nn\u00ed aplikaci vznikaj\u00ed mohutn\u00e9 kontrakce j\u00edcnu a antiperistaltika, kter\u00e9 nemocn\u00ed poci\u0165uj\u00ed \u010dasto a\u017e bolestiv\u011b. P\u0159i masivn\u00ed dilataci ezofagu m\u016f\u017ee b\u00fdt mecholylov\u00fd test fale\u0161n\u011b negativn\u00ed a naopak fale\u0161n\u011b pozitivn\u00ed u karcinomu kardie.<\/p>\n

Detailn\u011bj\u0161\u00ed posouzen\u00ed j\u00edcnov\u00e9 motility usnadnilo pou\u017eit\u00ed techniky rychl\u00e9ho sledu sn\u00edmk\u016f (kinematografie, spot-kamera). P\u0159esn\u011bj\u0161\u00ed zhodnocen\u00ed samo\u010distic\u00ed schopnosti j\u00edcnu umo\u017e\u0148uje aplikace acidifikovan\u00e9ho barya sondou do doln\u00ed t\u0159etiny j\u00edcnu a rentgenologick\u00e9 sledov\u00e1n\u00ed jeho vypr\u00e1zdn\u011bn\u00ed [8]. Selektivn\u00ed angiografie lev\u00e9 gastrick\u00e9 arterie byla u\u017e\u00edv\u00e1na ve sporn\u00fdch p\u0159\u00edpadech p\u0159i diagnostice kr\u00e1tk\u00e9ho j\u00edcnu [9].<\/p>\n

V posledn\u00edch dvaceti letech minul\u00e9ho stolet\u00ed se z\u00e1sadn\u011b zm\u011bnila diagnostika onemocn\u011bn\u00ed za\u017e\u00edvac\u00edho traktu, a t\u00edm i j\u00edcnu. Konven\u010dn\u00ed radiodiagnostika ustoupila do pozad\u00ed ve prosp\u011bch endoskopie. Standardn\u011b se vyu\u017e\u00edvaj\u00ed dal\u0161\u00ed specializovan\u00e9 metody, kter\u00e9 dovedou zodpov\u011bd\u011bt n\u011bkter\u00e9 ot\u00e1zky p\u0159esn\u011bji ne\u017e rentgenov\u00e9 vy\u0161et\u0159en\u00ed, jako pH-metrie u refluxu \u010di j\u00edcnov\u00e1 manometrie u funk\u010dn\u00edch poruch j\u00edcnu. Klasick\u00e9 kontrastn\u00ed rentgenov\u00e9 vy\u0161et\u0159en\u00ed j\u00edcnu je \u010dasto nahrazov\u00e1no vy\u0161et\u0159en\u00edm CT. P\u0159esto m\u00e1 kontrastn\u00edm vy\u0161et\u0159en\u00ed j\u00edcnu v n\u011bkter\u00fdch p\u0159\u00edpadech, zvl\u00e1\u0161t\u011b pro klinika a z hlediska n\u00e1zornosti v didaktick\u00e9m vyu\u017eit\u00ed, nad\u00e1le velk\u00fd v\u00fdznam [10]. Nesporn\u011b se takto l\u00e9pe orientujeme nap\u0159. p\u0159i klasifikaci hi\u00e1tov\u00fdch herni\u00ed \u010di p\u0159i posouzen\u00ed stupn\u011b dilatace j\u00edcnu, velikosti divertikl\u016f apod.<\/p>\n

V\u00fdpo\u010detn\u00ed tomografie (CT ) a magnetick\u00e1 rezonance (MRI)<\/h6>\n

Technick\u00e9 zdokonalen\u00ed v\u00fdpo\u010detn\u00ed tomografie, zaveden\u00ed virtu\u00e1ln\u00edho zobrazen\u00ed spolu s magnetickou rezonanc\u00ed (MRI), ultrasonografi\u00ed (USG) a pozitronovou tomografi\u00ed (PET) pak znamenalo na p\u0159elomu tis\u00edcilet\u00ed sou\u010dasnou renesanci radiodiagnostick\u00fdch a dal\u0161\u00edch zobrazovac\u00edch metod [11].<\/p>\n

V\u00fdznamn\u00fd pokrok v p\u0159\u00edprav\u011b k vy\u0161et\u0159en\u00ed p\u0159edstavuje peror\u00e1ln\u00ed pod\u00e1n\u00ed osmoticky aktivn\u00edch roztok\u016f. Vy\u0161et\u0159ovac\u00ed postupy se orientuj\u00ed na specifick\u00e9 protokoly pro jednotliv\u00e9 org\u00e1ny a skupiny diagn\u00f3z, diferencovan\u011b se vyu\u017e\u00edv\u00e1 i zp\u016fsob aplikace kontrastn\u00ed l\u00e1tky endolumin\u00e1ln\u011b \u010di intraven\u00f3zn\u00ed cestou.<\/p>\n

Indikac\u00ed k vy\u0161et\u0159en\u00ed CT jsou dnes v\u0161echny patologick\u00e9 stavy tr\u00e1vic\u00ed trubice. U onemocn\u011bn\u00ed j\u00edcnu je mo\u017eno nejv\u011bt\u0161\u00ed p\u0159\u00ednos spat\u0159ovat u stagingov\u00e9ho vy\u0161et\u0159en\u00ed n\u00e1dor\u016f j\u00edcnu a u hodnocen\u00ed poopera\u010dn\u00edch stav\u016f.<\/p>\n

Pro staging karcinomu j\u00edcnu je dnes na n\u011bkter\u00fdch pracovi\u0161t\u00edch pou\u017e\u00edv\u00e1na i magnetick\u00e1 rezonance (MRI). V sou\u010dasnosti v\u0161ak nep\u0159in\u00e1\u0161\u00ed vyu\u017eit\u00ed t\u00e9to metody p\u0159\u00ednos proti konven\u010dn\u00edmu zobrazen\u00ed CT a nen\u00ed standardn\u011b za\u0159azov\u00e1na do diagnostick\u00e9ho sch\u00e9matu [12, 13]. Praktick\u00e9 p\u0159\u00edklady t\u011bchto vy\u0161et\u0159en\u00ed jsou v p\u0159\u00edslu\u0161n\u00fdch kapitol\u00e1ch speci\u00e1ln\u00ed \u010d\u00e1sti t\u00e9to knihy.<\/p>\n

6.3 Pozitronov\u00e1 emisn\u00ed tomografie (PET) a hybridn\u00ed zobrazen\u00ed PET\/CT<\/h3>\n

Na p\u0159elomu minul\u00e9ho a sou\u010dasn\u00e9ho stolet\u00ed se za\u010d\u00edn\u00e1 v diagnostice onemocn\u011bn\u00ed tr\u00e1vic\u00edch org\u00e1n\u016f vyu\u017e\u00edvat molekul\u00e1rn\u00ed zp\u016fsob zobrazov\u00e1n\u00ed, uplat\u0148uj\u00edc\u00ed metabolick\u00fd pohled na chov\u00e1n\u00ed tk\u00e1n\u00ed. P\u0159i vy\u0161et\u0159en\u00ed se vyu\u017e\u00edv\u00e1 radionuklid\u016f nav\u00e1zan\u00fdch na l\u00e1tku vstupuj\u00edc\u00ed do r\u016fzn\u00fdch metabolick\u00fdch proces\u016f zejm\u00e9na u n\u00e1dor\u016f a z\u00e1n\u011bt\u016f. Nej\u010dast\u011bji se dnes vyu\u017e\u00edv\u00e1 radionuklid 18<\/span>F a hlavn\u00edm nosi\u010dem vyu\u017e\u00edvan\u00fdm v diagnostick\u00e9m zobrazen\u00ed je 18<\/span>F-fluorodeoxygluk\u00f3za-18<\/span>FDG. Tato metoda, ozna\u010dovan\u00e1 jako pozitronov\u00e1 emisn\u00ed tomografie (PET), se uplat\u0148uje p\u0159edev\u0161\u00edm u stagingu a restagingu n\u00e1dorov\u00fdch onemocn\u011bn\u00ed tr\u00e1vic\u00ed trubice. Velmi vysoce se 18<\/span>FDG akumuluje zejm\u00e9na v tk\u00e1n\u00edch karcinomu j\u00edcnu, v\u011bt\u0161iny kolorekt\u00e1ln\u00edch karcinom\u016f a lymfom\u016f tr\u00e1vic\u00ed trubice. Hybridn\u00ed zobrazen\u00ed PET\/CT integruje morfologick\u00e9 a metabolick\u00e9 zobrazen\u00ed. My\u0161lenka na spojen\u00ed t\u011bchto dvou vy\u0161et\u0159en\u00ed vznikla p\u0159edev\u0161\u00edm z d\u016fvod\u016f n\u00edzk\u00e9ho prostorov\u00e9ho rozli\u0161en\u00ed PET a je samoz\u0159ejm\u00e9, \u017ee tato metabolick\u00e1 informace podstatn\u011b zvy\u0161uje vypov\u00eddaj\u00edc\u00ed hodnotu CT vy\u0161et\u0159en\u00ed [11, 12]. V sou\u010dasnosti roste v\u00fdznam vyu\u017eit\u00ed pozitronov\u00e9 emisn\u00ed tomografie (PET), zpravidla v kombinaci s CT (PET\/CT), v p\u0159edopera\u010dn\u00ed diagnostice karcinomu j\u00edcnu. V p\u0159edopera\u010dn\u00edm stagingu je p\u0159ednost\u00ed t\u00e9to metody detekce generalizace, posouzen\u00ed efektu neoadjuvantn\u00ed l\u00e9\u010dby a nezastupiteln\u00fd v\u00fdznam m\u00e1 PET\/CT p\u0159i diagnostice recidivy a generalizace karcinomu j\u00edcnu v poopera\u010dn\u00edm sledov\u00e1n\u00ed [15].<\/p>\n

6.4 Endoskopick\u00e1 sonografie<\/h3>\n

Konven\u010dn\u00ed perkut\u00e1nn\u00ed ultrasonografie m\u00e1 u onemocn\u011bn\u00ed j\u00edcnu v\u00fdznam jen p\u0159i posouzen\u00ed kr\u010dn\u00edch uzlin u karcinomu v t\u00e9to lokalizaci. Lokoregion\u00e1ln\u00edmu stagingu n\u00e1dor\u016f j\u00edcnu slou\u017e\u00ed vedle CT i endoskopick\u00e1 sonografie [16, 17]. C\u00edlem diagnostick\u00e9ho postupu je stanovit p\u0159esn\u00e9 stadium onemocn\u011bn\u00ed, co\u017e m\u00e1 v\u00fdznam pro stanoven\u00ed progn\u00f3zy a spr\u00e1vnou strategii l\u00e9\u010dby. V\u0161echna u\u017e\u00edvan\u00e1 klasifika\u010dn\u00ed sch\u00e9mata se zakl\u00e1daj\u00ed na stanoven\u00ed hloubky n\u00e1dorov\u00e9 infiltrace ve st\u011bn\u011b j\u00edcnu a metastatick\u00e9m posti\u017een\u00ed uzlin v okol\u00ed j\u00edcnu, \u010do\u017e dovede endosonografie j\u00edcnu velmi dob\u0159e zobrazit. Byla provedena cel\u00e1 \u0159ada srovn\u00e1vac\u00edch studi\u00ed mezi r\u016fzn\u00fdmi zobrazovac\u00edmi metodami, zejm\u00e9na CT a endoskopickou sonografi\u00ed, ani\u017e bylo dosa\u017eeno jednozna\u010dn\u00e9 shody o v\u00fdhodnosti a spolehlivosti t\u00e9 \u010di on\u00e9 metody. V\u011bt\u0161inou je doporu\u010dov\u00e1na kombinace vy\u0161et\u0159en\u00ed k dosa\u017een\u00ed co nejp\u0159esn\u011bj\u0161\u00edho diagnostick\u00e9ho z\u00e1v\u011bru [18, 19].<\/p>\n

6.5 Endoskopie<\/h3>\n

Hlavn\u00ed v\u00fdznam endoskopie tkv\u00ed v posouzen\u00ed morfologick\u00fdch zm\u011bn sliznice j\u00edcnu. Diferenci\u00e1ln\u011b diagnosticky pom\u016f\u017ee rozli\u0161it funk\u010dn\u00ed a organick\u00e9 zm\u011bny. Spolu s biopsi\u00ed \u010di cytologick\u00fdm odb\u011brem umo\u017en\u00ed p\u0159esnou kvalitativn\u00ed diagn\u00f3zu a v n\u011bkter\u00fdch p\u0159\u00edpadech m\u016f\u017ee b\u00fdt ihned proveden i terapeutick\u00fd v\u00fdkon. Exaktn\u00ed diagn\u00f3za ezofagitidy bez endoskopie a biopsie nen\u00ed zpravidla mo\u017en\u00e1. P\u0159i vy\u0161et\u0159en\u00ed lze prok\u00e1zat i reflux a hi\u00e1tovou hernii [20, 5], av\u0161ak zji\u0161t\u011bn\u00ed nemus\u00ed b\u00fdt p\u0159esn\u00e9. Klasick\u00fd rigidn\u00ed ezofagoskop, mezi jeho\u017e p\u0159ednostmi byla uv\u00e1d\u011bna nap\u0159. lep\u0161\u00ed mo\u017enost hlubok\u00e9 biopsie, byl vytla\u010den p\u0159\u00edstroji s vl\u00e1knitou optikou.<\/p>\n

Ke stanoven\u00ed kvalitativn\u00ed diagn\u00f3zy u slizni\u010dn\u00edch zm\u011bn je nejspolehliv\u011bj\u0161\u00ed endoskopick\u00fd odb\u011br materi\u00e1lu bioptick\u00fdmi kl\u00ed\u0161\u0165kami a jeho histologick\u00e9 vy\u0161et\u0159en\u00ed. Tam, kde nelze pro z\u00fa\u017een\u00ed proniknout bezprost\u0159edn\u011b k m\u00edstu nejv\u011bt\u0161\u00edch patologick\u00fdch zm\u011bn, je mo\u017eno prov\u00e9st nejprve dilataci nebo z nitra striktury odebrat materi\u00e1l alespo\u0148 k cytologick\u00e9mu vy\u0161et\u0159en\u00ed pomoc\u00ed speci\u00e1ln\u00edho kart\u00e1\u010dku zasunut\u00e9ho do nitra striktury a prov\u00e9st abrazi ze sliznice. Vy\u0161et\u0159ov\u00e1n\u00ed vy\u017eaduje spolupr\u00e1ci se zku\u0161en\u00fdm cytologem. Slep\u00e1 biopsie z j\u00edcnu i p\u0159i hodnocen\u00ed zku\u0161en\u00fdm odborn\u00edkem m\u00e1 zpravidla jen men\u0161\u00ed v\u00fdt\u011b\u017enost.<\/p>\n

Dnes je endoskopick\u00e9 vy\u0161et\u0159en\u00ed j\u00edcnu z\u00e1kladn\u00ed diagnostickou metodou p\u0159i j\u00edcnov\u00e9 symptomatologii a v diagnostick\u00e9m algoritmu je kladeno p\u0159ed vy\u0161et\u0159en\u00ed rentgenov\u00e1. K dispozici je rozs\u00e1hl\u00e1, p\u0159edev\u0161\u00edm gastroenterologick\u00e1, odborn\u00e1 na\u0161e i zahrani\u010dn\u00ed literatura zab\u00fdvaj\u00edc\u00ed se touto tematikou [21, 22].<\/p>\n

6.6 pH-metrie<\/h3>\n

K vy\u0161et\u0159en\u00ed gastroezofage\u00e1ln\u00edho refluxu je nejspolehliv\u011bj\u0161\u00ed metodou pH-metrie, kter\u00e1 umo\u017e\u0148uje jeho pr\u016fkaz v\u00edce jak v 90 %. P\u0159i vy\u0161et\u0159en\u00ed je pH elektroda zavedena do dist\u00e1ln\u00edho j\u00edcnu. Zm\u011bny pH jsou registrov\u00e1ny po provoka\u010dn\u00edch man\u00e9vrech nebo dlouhodob\u011b, nejl\u00e9pe v pr\u016fb\u011bhu 24 hodin. M\u011b\u0159en\u00ed lze prov\u00e1d\u011bt i p\u0159i endoskopick\u00e9m vy\u0161et\u0159en\u00ed [23, 24, 25, 26, 27]. Za pomoci p\u0159enosn\u00e9ho za\u0159\u00edzen\u00ed se m\u016f\u017ee nemocn\u00fd s pH elektrodou zavedenou nosem voln\u011b pohybovat a b\u00fdt i v dom\u00e1c\u00edm prost\u0159ed\u00ed. M\u011b\u0159en\u00e9 hodnoty jsou registrov\u00e1ny a pozd\u011bji vyhodnoceny, nebo je mo\u017eno data vys\u00edlat p\u0159enosn\u00fdm vys\u00edla\u010dem a pr\u016fb\u011b\u017en\u011b registrovat a vyhodnocovat v p\u0159ij\u00edmac\u00ed jednotce um\u00edst\u011bn\u00e9 v nemocnici [25]. Ve sv\u011bt\u011b byla tato diagnostick\u00e1 metoda u\u017e\u00edv\u00e1na v klinick\u00e9 praxi ji\u017e v 70. letech minul\u00e9ho stolet\u00ed. V Olomouci na II. chirurgick\u00e9 klinice jsme 24hodinovou pH-metrii do klinick\u00e9 praxe zavedli u nemocn\u00fdch s refluxn\u00ed nemoc\u00ed j\u00edcnu (RNJ) od 90. let minul\u00e9ho stolet\u00ed.<\/p>\n

6.7 Manometrie<\/h3>\n

J\u00edcnov\u00e1 manometrie je z\u00e1kladn\u00edm a nejd\u016fle\u017eit\u011bj\u0161\u00edm vy\u0161et\u0159en\u00edm pro posouzen\u00ed motility j\u00edcnu, tj. j\u00edcnov\u00e9 peristaltiky a kontraktibility j\u00edcnov\u00fdch sv\u011bra\u010d\u016f. Z\u00e1klady j\u00edcnov\u00e9 manometrie byly polo\u017eeny na po\u010d\u00e1tku 50. let minul\u00e9ho stolet\u00ed a vych\u00e1zej\u00ed ze zku\u0161enost\u00ed Sencheze [28] z\u00edskan\u00fdch p\u0159i srde\u010dn\u00ed a c\u00e9vn\u00ed katetrizaci. P\u016fvodn\u00ed studie byly uskute\u010dn\u011bny s dr\u00e1\u017ediv\u00fdmi balonkov\u00fdmi kat\u00e9try [29, 30, 31, 32, 33]. Hlavn\u00ed zdokonalen\u00ed p\u0159esnosti p\u0159enosu tlakov\u00fdch zm\u011bn z r\u016fzn\u00fdch et\u00e1\u017e\u00ed j\u00edcnu p\u0159ineslo zaveden\u00ed infuzn\u00edch m\u011b\u0159ic\u00edch kat\u00e9tr\u016f (open-typ) [34]. Z nich se tlakov\u00e9 hodnoty, mechanicky sn\u00edman\u00e9 pomoc\u00ed kapil\u00e1rn\u00edho m\u016fstku tekutiny prot\u00e9kaj\u00edc\u00ed kat\u00e9trem do j\u00edcnu, p\u0159ev\u00e1d\u011bj\u00ed ve Stathamov\u011b transduceru na elektricky registrovan\u00fd impulz a jsou d\u00e1le graficky zn\u00e1zorn\u011bny. Code, Fyke a Pope [35, 30, 36, 37] zjistili poprv\u00e9 manometrick\u00fdmi m\u011b\u0159en\u00edmi vy\u0161\u0161\u00ed tlakovou z\u00f3nu v oblasti doln\u00edho j\u00edcnov\u00e9ho sv\u011bra\u010de. Podrobn\u011b byla j\u00edcnov\u00e1 manometrie d\u00e1le rozpracov\u00e1na Winansem, Cohenem, Harrisem, Heitmannem a dal\u0161\u00edmi [38, 39, 40, 41]. Od po\u010d\u00e1tku 70. let minul\u00e9ho stolet\u00ed se za\u010dalo vyu\u017e\u00edvat toto vy\u0161et\u0159en\u00ed i v klinice p\u0159edev\u0161\u00edm sou\u010dasn\u00fdm sn\u00edm\u00e1n\u00edm tlak\u016f t\u0159emi infuzn\u00edmi kat\u00e9try v r\u016fzn\u00fdch et\u00e1\u017e\u00edch j\u00edcnu. P\u0159i pr\u016ftahov\u00e9 manometrii zaveden\u00e9 Waldeckem je infuzn\u00ed kat\u00e9tr ta\u017een konstantn\u00ed rychlost\u00ed ze \u017ealudku do j\u00edcnu, co\u017e umo\u017e\u0148uje registraci d\u00e9lky z\u00f3ny zv\u00fd\u0161en\u00e9ho tlaku v oblasti doln\u00edho j\u00edcnov\u00e9ho sv\u011bra\u010de [42]. K lokalizaci DJS u n\u011bkter\u00fdch komplikovan\u00fdch stav\u016f, jako jsou striktury a endobrachyezofagus, lze kombinovat rentgenov\u00e9 vy\u0161et\u0159en\u00ed s manometri\u00ed (radiomanometrie). M\u011b\u0159en\u00ed intralumin\u00f3zn\u00edho tlaku umo\u017e\u0148uje posoudit funk\u010dn\u00ed zdatnost DJS a zejm\u00e9na jeho tzv. funk\u010dn\u00ed rezervu (viz kapitoly 9 a 11). GER lze manometricky prok\u00e1zat jen nep\u0159\u00edmo jako \u201ecommon cavity\u201c fenom\u00e9n, kdy p\u0159i vzestupu intragastrick\u00e9ho tlaku stoup\u00e1 i tlak v j\u00edcnu. K objektivn\u00edmu p\u0159enosu tlakov\u00fdch hodnot z j\u00edcnu byly vyvinuty i mikrotransducery, kter\u00e9 jsou sou\u010d\u00e1st\u00ed c\u00e9vky zaveden\u00e9 do j\u00edcnu [43].<\/p>\n

P\u0159es omezen\u00e9 mo\u017enosti z\u00edskat pot\u0159ebn\u00e9 technick\u00e9 vybaven\u00ed si v\u00fdznam tohoto vy\u0161et\u0159en\u00ed pro operace zejm\u00e9na u funk\u010dn\u00edch poruch j\u00edcnu olomou\u010dt\u00ed chirurgov\u00e9 uv\u011bdomovali ji\u017e v 60. letech minul\u00e9ho stolet\u00ed [31]. J\u00edcnovou manometrii s u\u017eit\u00edm perfundovan\u00fdch kat\u00e9tr\u016f jsme rutinn\u011b zavedli do klinick\u00e9 praxe na na\u0161em pracovi\u0161ti v Olomouci od roku 1979 s vlastn\u00ed zde sestavenou aparaturou. Vych\u00e1zeli jsme p\u0159edev\u0161\u00edm z metodiky vypracovan\u00e9 Waldeckem a Siewertem [42]. Technika pr\u016ftahov\u00e9 a trojbodov\u00e9 manometrie vy\u017eaduje p\u0159i b\u011b\u017en\u00e9m proveden\u00ed dvoj\u00ed sondov\u00e1n\u00ed nemocn\u00e9ho a vy\u0161et\u0159ov\u00e1n\u00ed dv\u011bma typy kat\u00e9tr\u016f. Vy\u0161et\u0159en\u00ed jsme modifikovali tak, \u017ee jsme zav\u00e1d\u011bli v jednom sezen\u00ed trojcestnou sondu, kter\u00e1 m\u011bla t\u0159i otvory vzd\u00e1len\u00e9 od sebe p\u011bt centimetr\u016f, z nich\u017e horn\u00ed se nach\u00e1zel v j\u00edcnu, st\u0159edn\u00ed v oblasti DJS a doln\u00ed v \u017ealudku. Po vy\u0161et\u0159en\u00ed klidov\u00e9ho z\u00e1znamu z t\u011bchto et\u00e1\u017e\u00ed byla sonda vytahov\u00e1na rychlost\u00ed 7,5 cm za minutu z j\u00edcnu a simult\u00e1nn\u011b tak byly z\u00edsk\u00e1v\u00e1ny t\u0159i kontinu\u00e1ln\u00ed pr\u016ftahov\u00e9 manometrick\u00e9 z\u00e1znamy sukcesivn\u011b po sob\u011b. Tuto metodiku jsme nazvali kombinovanou manometri\u00ed [44]. Trojcestn\u00e1 sonda byla b\u011bhem vy\u0161et\u0159en\u00ed trvale prom\u00fdv\u00e1na destilovanou vodou, dod\u00e1vanou v mno\u017estv\u00ed 2 ml za minutu ze t\u0159\u00ed line\u00e1rn\u00edch d\u00e1vkova\u010d\u016f. Impulzy registrovan\u00e9 ve Stathamov\u00fdch transducerech se po p\u0159edzes\u00edlen\u00ed ode\u010d\u00edtaly a fotografovaly z obrazovky pomalub\u011b\u017en\u00e9ho osciloskopu v podob\u011b t\u0159\u00ed manometrick\u00fdch k\u0159ivek. \u010ctvrt\u00fdm transducerem byl p\u0159iv\u00e1d\u011bn pneumografick\u00fd z\u00e1znam ze st\u011bny b\u0159i\u0161n\u00ed, sn\u00edman\u00fd upravenou man\u017eetou tonometru. Dechov\u00e1 k\u0159ivka slou\u017e\u00ed srovn\u00e1n\u00edm k ur\u010den\u00ed m\u00edsta tzv. bodu zvratu tlaku (PIP \u2013 pressure inversion point). Toto m\u00edsto le\u017e\u00ed u v\u011bt\u0161iny osob v \u00farovni br\u00e1nice a je p\u0159edstavov\u00e1no obr\u00e1cen\u00edm dechov\u00e9 tlakov\u00e9 amplitudy, kter\u00e1 je v dutin\u011b hrudn\u00ed negativn\u00ed proti dutin\u011b b\u0159i\u0161n\u00ed.<\/p>\n

Touto metodou jsme provedli do po\u010d\u00e1tku roku 1982 celkem 278 vy\u0161et\u0159en\u00ed u 197 osob. \u0160lo o 124 mu\u017e\u016f a 63 \u017een v pr\u016fm\u011brn\u00e9m v\u011bku 49,3 let. Zji\u0161t\u011bn\u00e9 hodnoty tlaku v oblasti DJS v s\u00e9rii prvn\u00edch 129 vy\u0161et\u0159en\u00ed jsou shrnuty v tab. 1 a obr. 1.<\/p>\n\n\n\n\n\n\n\n
Tab. 1<\/span>
\n Historick\u00e1 sestava v\u00fdsledk\u016f manometrick\u00fdch vy\u0161et\u0159en\u00ed j\u00edcn\u016f u r\u016fzn\u00fdch skupin nemocn\u00fdch na na\u0161em pracovi\u0161ti z 80. let minul\u00e9ho stolet\u00ed [44]<\/span><\/span><\/td>\n<\/tr>\n
<\/td>\nKontroln\u00ed skupina<\/strong><\/td>\nAchal\u00e1zie<\/strong><\/td>\nRNJ<\/strong><\/td>\nDivertikly
\nZenker. Epifren.<\/strong><\/td>\n<\/tr>\n
Klidov\u00fd tonus DJS kPa\/mm Hg<\/td>\n2,8\/21<\/td>\n6,7\/50,7<\/td>\n1,4\/10,3<\/td>\n6,0\/44,9<\/td>\n7,3\/55<\/td>\n<\/tr>\n
D\u00e9lka DJS (mm)<\/td>\n19<\/td>\n26<\/td>\n11,7<\/td>\n23,8<\/td>\n10<\/td>\n<\/tr>\n
St\u0159ed DJS od horn\u00edch \u0159ez\u00e1k\u016f (mm)<\/td>\n401<\/td>\n411<\/td>\n414<\/td>\n406<\/td>\n425<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

.<\/span><\/p>\n

\"Obr.<\/a>

Obr. 1 \u2013 Klidov\u00fd tonus DJS podle v\u00fdsledk\u016f manometrick\u00e9ho vy\u0161et\u0159en\u00ed na na\u0161em pracovi\u0161ti z 80. let minul\u00e9ho stolet\u00ed [44]<\/p><\/div>\n

Manometrick\u00e1 vy\u0161et\u0159en\u00ed pomoc\u00ed modern\u00edho technick\u00e9ho vybaven\u00ed jsme pak v ezofagologick\u00e9 laborato\u0159i II. chirurgick\u00e9 kliniky v Olomouci prov\u00e1d\u011bli od 90. let minul\u00e9ho stolet\u00ed.<\/p>\n

Studium tlakov\u00fdch zm\u011bn v oblasti horn\u00edho j\u00edcnov\u00e9ho sv\u011bra\u010de nar\u00e1\u017e\u00ed z technick\u00e9ho hlediska na mnohem v\u011bt\u0161\u00ed obt\u00ed\u017ee. Je to d\u00e1no zna\u010dn\u00fdmi tlakov\u00fdmi zm\u011bnami v sagit\u00e1ln\u00ed rovin\u011b v \u00farovni krikofarynge\u00e1ln\u00edho p\u0159echodu (viz kap. 5.2.2). Byly u\u017e\u00edv\u00e1ny stacion\u00e1rn\u00ed i pr\u016ftahov\u00e9 manometrick\u00e9 syst\u00e9my s n\u00edzkou komplianc\u00ed (schopn\u00e9 registrovat rychl\u00e9 zm\u011bny tlaku). Pou\u017eit\u00ed speci\u00e1ln\u00edch balonkov\u00fdch kat\u00e9tr\u016f m\u00e1 tu v\u00fdhodu, \u017ee je v oblasti HJS sn\u00edm\u00e1n v\u017edy maxim\u00e1ln\u00ed tlak bez ohledu na radi\u00e1ln\u00ed asymetrii tlakov\u00fdch hodnot.<\/p>\n

V dal\u0161\u00edch letech byly vyvinuty speci\u00e1ln\u00ed elektronick\u00e9 miniaturn\u00ed manometry, kter\u00e9 jsou sou\u010d\u00e1st\u00ed zav\u00e1d\u011bn\u00e9ho kat\u00e9tru (Miniatur-Elektro-Seitentipmano-meter) [43]. Lze u\u017e\u00edvat i syst\u00e9my s perfundovan\u00fdm kat\u00e9trem s n\u00edzkou komplianc\u00ed [45]. S pomoc\u00ed t\u011bchto vy\u0161et\u0159en\u00ed je mo\u017eno analyzovat pom\u011brn\u011b dob\u0159e jak klidov\u00fd tlak, tak i zm\u011bny b\u011bhem polyk\u00e1n\u00ed v oblasti HJS. P\u0159i b\u011b\u017en\u00e9 stacion\u00e1rn\u00ed manometrii [46] se hodnot\u00ed funk\u010dn\u00ed zm\u011bny j\u00edcnu b\u011bhem asi 10 polknut\u00ed. Dal\u0161\u00ed zlep\u0161en\u00ed p\u0159in\u00e1\u0161\u00ed zaveden\u00ed 24hodinov\u00e9 ambulantn\u00ed manometrie [47], kter\u00e1 umo\u017e\u0148uje hodnocen\u00ed motoriky j\u00edcnu v pr\u016fb\u011bhu 24 hodin u v\u00edce jak 1000 polknut\u00ed. Vyu\u017eit\u00ed t\u00e9to metody tak m\u016f\u017ee odhalit motorick\u00e9 poruchy i tam, kde nebyly rozpozn\u00e1ny p\u0159i stacion\u00e1rn\u00ed manometrii [48].<\/p>\n

Pro manometrick\u00e9 studium motility tubul\u00e1rn\u00edho j\u00edcnu se u\u017e\u00edv\u00e1 sn\u00edm\u00e1n\u00ed tlak\u016f z n\u011bkolika et\u00e1\u017e\u00ed j\u00edcnu manometrick\u00fdmi syst\u00e9my s n\u00edzkou komplianc\u00ed [49, 50]. Vyu\u017eit\u00ed po\u010d\u00edta\u010dov\u00e9ho zpracov\u00e1n\u00ed dat a technick\u00fd rozvoj a zdokonalov\u00e1n\u00ed manometrie vedlo k zaveden\u00ed dal\u0161\u00edch modern\u011bj\u0161\u00edch metod vy\u0161et\u0159ov\u00e1n\u00ed. U\u017eit\u00ed tzv. sleeve senzor\u016f [51] a zaveden\u00ed high-resolution manometrie [52, 53] umo\u017e\u0148uj\u00ed dal\u0161\u00ed detailn\u00ed anal\u00fdzu funk\u010dn\u00edch parametr\u016f j\u00edcnu.<\/p>\n

6.8 Scintigrafie<\/h3>\n

K pr\u016fkazu gastroezofage\u00e1ln\u00edho refluxu lze u\u017e\u00edt i scintigrafii pomoc\u00ed 99<\/span>Technecia. P\u0159ednost\u00ed metody je jej\u00ed neinvazivnost, ale senzitivita a specifita pro ur\u010den\u00ed RNJ je ni\u017e\u0161\u00ed, ud\u00e1v\u00e1na kolem 65 % [54]. Dal\u0161\u00ed scintigrafickou metodou u\u017e\u00edvanou pro pr\u016fkaz endobrachyezofagu bylo vy\u0161et\u0159en\u00ed 99<\/span>Techneciem [55]. Vy\u0161et\u0159en\u00ed je zalo\u017eeno na tezauraci izotopu v cylindrocelul\u00e1rn\u00ed metaplazii dist\u00e1ln\u00edho j\u00edcnu. Spolehlivost pr\u016fkazu proti ezofagoskopii s biopsi\u00ed je v\u0161ak ud\u00e1v\u00e1na men\u0161\u00ed [56].<\/p>\n

6.9 Bernstein\u016fv test (perfuzn\u00ed test kyselinou chlorovod\u00edkovou)<\/h3>\n

P\u0159i t\u00e9to zkou\u0161ce je j\u00edcen prom\u00fdv\u00e1n pomoc\u00ed tenk\u00e9 sondy 0,1 N HCl [57]. Vznikl\u00e9 subjektivn\u00ed pot\u00ed\u017ee nemocn\u00e9ho (bolest za sternem, p\u00e1liv\u00fd pocit) jsou v\u00fdrazem p\u0159ecitliv\u011blosti j\u00edcnu na kyselinu. Koncem 60. let a po\u010d\u00e1tkem 70. let minul\u00e9ho stolet\u00ed jsme prov\u00e1d\u011bli toto vy\u0161et\u0159en\u00ed rutinn\u011b u v\u0161ech na\u0161ich nemocn\u00fdch s j\u00edcnov\u00fdmi onemocn\u011bn\u00edmi, v\u011bt\u0161inou v jeho zjednodu\u0161en\u00e9 modifikaci navr\u017een\u00e9 na na\u0161em pracovi\u0161ti Korhon\u011bm. Od jeho u\u017eit\u00ed jsme postupn\u011b ve shod\u011b i se zku\u0161enostmi jin\u00fdch upou\u0161t\u011bli. Test nen\u00ed specifick\u00fd pro p\u0159\u00edtomnost gastroezofage\u00e1ln\u00edho refluxu a ezofagitidy a a\u017e v 10 % je pozitivn\u00ed i u zdrav\u00fdch jedinc\u016f [58] a jin\u00fdch onemocn\u011bn\u00ed gastrointestin\u00e1ln\u00edho traktu. \u010cast\u00e1 je i fale\u0161n\u00e1 negativita p\u0159i jinak prok\u00e1zan\u00e9 refluxn\u00ed ezofagitid\u011b.<\/p>\n

Modifikac\u00ed t\u00e9to zkou\u0161ky je exaktn\u00ed kvantitativn\u00ed posouzen\u00ed o\u010distn\u00e9 schopnosti j\u00edcnu pomoc\u00ed vy\u0161et\u0159en\u00ed clearence. Tenkou sondou se aplikuje do j\u00edcnu 0,1 N roztok HCl a pH-metricky se registruje po\u010det polknut\u00ed, kter\u00fd je pot\u0159ebn\u00fd k o\u010di\u0161t\u011bn\u00ed ezofagu od kyseliny. V\u00edce ne\u017e patn\u00e1ct polknut\u00ed je pova\u017eov\u00e1no za patologick\u00e9. I tato zkou\u0161ka je v\u0161ak m\u00e1lo specifick\u00e1 pro refluxn\u00ed ezofagitidu a je \u010dasto pozitivn\u00ed i u extraezofage\u00e1ln\u00edch onemocn\u011bn\u00ed.<\/p>\n

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    6.1 Klinick\u00e9 vy\u0161et\u0159en\u00ed S v\u00fdjimkou auskultace j\u00edcnu, p\u0159i kter\u00e9 lze n\u011bkdy sly\u0161et charakteristick\u00fd zvuk p\u0159i polyk\u00e1n\u00ed b\u011bhem pr\u016fniku tekutiny do \u017ealudku, kter\u00fd v\u0161ak p\u0159\u00edli\u0161 nepom\u016f\u017ee up\u0159esnit diagn\u00f3zu, nejsou j\u00edcen a kardie p\u0159\u00edstupny p\u0159\u00edm\u00e9mu vy\u0161et\u0159en\u00ed. Z celkov\u00e9ho z\u00e1kladn\u00edho vy\u0161et\u0159en\u00ed ve vztahu k diferenci\u00e1ln\u00ed diagnostice onemocn\u011bn\u00ed j\u00edcnu je v\u00fdznamn\u00fd stav v\u00fd\u017eivy, zn\u00e1mky malignity, jatern\u00edho onemocn\u011bn\u00ed apod. Nejd\u016fle\u017eit\u011bj\u0161\u00ed […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":65,"menu_order":30,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-267","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/267","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=267"}],"version-history":[{"count":24,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/267\/revisions"}],"predecessor-version":[{"id":1021,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/267\/revisions\/1021"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/65"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=267"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}