RU2197728C1 - Method for diagnosing chronic cholecystitis exacerbation - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves analyzing gall drop preliminarily dried in standard way by means of microscope. Dendrite structure of crystals being detected in the central zone, chronic cholecystitis exacerbation is to be diagnosed. The central zone being slightly structured or amorphous, no chronic cholecystitis exacerbation is to be diagnosed. EFFECT: high sensitivity and specificity of the method.

Description

 The invention relates to medicine, namely to gastroenterology.

 The prevalence of gallstone disease (cholelithiasis) is very high. Currently, almost one in five women and one in ten men suffer from this pathology. Moreover, in recent years, the ZhKB has become very "younger". The results of a study by domestic authors indicate that the number of patients for each subsequent ten years doubles. The number of cholecystectomies performed is second only to the number of appendectomies [2].

The main methods of treatment for gallstone disease:
1. litholytic therapy (chenodeoxycholic and / or ursodeoxycholic acid preparations);
2. extracorporeal shock wave lithotripsy;
3. a combination of litholytic therapy and extracorporeal shock wave lithotripsy;
4. transdermal transverse litholytic (contact) therapy;
5. laparoscopic cholecystectomy;
6. cavity cholecystectomy.

 At present, sparing endoscopic interventions [10] and organ-preserving methods of treating cholelithiasis are finding wider application.

 Endoscopic cholecystectomy was first performed in France in 1987 (Ph. Mouret). In Russia, a similar operation was performed by Yu.I. Gallinger and A. D. Timoshin in 1991 [2].

The advantages of the method include the following:
- low invasiveness;
- reduction in the length of hospital stay of patients;
- reduction of the period of rehabilitation;
- improving the quality of life of patients;
- good cosmetic effect;
- a decrease in mortality in the group of elderly and senile patients with severe concomitant diseases.

 In connection with the widespread use of organ-preserving methods for the treatment of cholelithiasis, it became important not only to state the presence or absence of stones, but also to determine the degree of inflammation activity in the mucous membrane of the gallbladder, since the choice of treatment method and tactics of patient management depend on this. In addition, the process of stone formation in the biliary tract is closely associated with inflammation, these processes reinforce each other. Inflammation in the mucous membrane of the gallbladder is one of the factors leading to the formation of gallstones, which changes the chemical composition of bile [4]. In turn, the presence of stones in the gallbladder leads to the onset or intensification of the inflammatory process.

 According to many authors, endoscopic interventions are indicated for chronic cholecystitis without exacerbation, when the degree of activity of inflammation of the gallbladder wall is less than for acute cholecystitis.

 For the correct choice of the method of treatment and the choice of a favorable moment for the operation, it is necessary to know whether there is an exacerbation of chronic cholecystitis.

 Diagnosis in patients with cholecystitis is carried out on the basis of the study of complaints, medical history, clinical picture of the disease. These data are not informative enough. For example, elderly people often have a mismatch between the clinical manifestations of cholecystitis and the severity of inflammation in the gallbladder.

Closest to the proposed invention is a method for determining the active reaction of bile. The concentration of H ⁺ ions and hydroxide ions OH ^- is one of the important factors determining the physical and chemical state of bile and the crystallization process itself. Many authors have noted that with inflammation, the pH of bile is shifted to the acid side [4, 6, 7, 9, 10]. But about normal indicative pH of cystic bile, the opinions of different authors differ greatly. V.A. Maximov et al. consider that the normal pH is 6.5-7.5 [12]. According to S.P. Chupina et al. cystic bile is stable within strict boundaries of pH 4.0–8.3 [13].

 The most reliable assessment of the degree of activity of inflammation in the gallbladder wall is possible using morphological methods for studying the gallbladder wall. But morphological diagnosis cannot be carried out before the operation, since the technique for taking a biopsy of the gallbladder mucosa has not been developed.

 Since none of the existing methods can reliably assess the state of the gallbladder mucosa, this makes it difficult to choose treatment tactics for calculous cholecystitis. Therefore, the task of the invention is to increase the information content and accuracy of the results of the study of bile and to ensure the selection of an adequate treatment method.

 New diagnostic methods are known. Crystallography of bile is most interesting, since bile is a specific product of the activity of liver cells; its study provides extensive information on the functioning of hepatocytes and the hepatobiliary system as a whole [5]. Since bile has a complex physicochemical structure, inflammation in the gallbladder quickly leads to its significant changes, which can be characterized by crystallography data [11].

 We used the method of dehydration self-organization of biofluid under standard conditions on a solid substrate. After the drop has dried, the amount of salts increases from the periphery to the center, and the amount of organic substances increases from the center to the periphery [14]. In addition to identifying zonal structures in diagnostics, the shape of crystals in the central zone of the dried drop is of importance [15]. However, from the point of view of assessing inflammation in the mucous membrane of the gallbladder, this method was not used.

 The shape of the crystal is determined by the gradient between the crystal-forming elements and the elements of the environment. With pathology, in particular with inflammation, there is a change in the quality and quantity of organic molecules, which leads to the emergence of new forms of crystals. This is possible with a change in the viscosity of the medium, the appearance in it of a large number of products of incomplete metabolism, elements of tissue degradation, and so on. Based on the foregoing, it can be assumed that the shape of the crystal is a natural system for indicating the chemical composition of a biofluid.

 We examined 40 patients with cholelithiasis aged 33 to 76 years who underwent classical or laparoscopic cholecystectomy. Cystic bile was investigated by the method of dehydration self-organization. The removed gallbladders were fixed in 10% neutral formalin, pieces from the body, the bottom and the neck of the bladder were dehydrated in ascending alcohols, embedded in paraffin. Sections were stained with hematoxylin and eosin, Alcian blue and Schiff's reagent. According to morphological analysis, an exacerbation of chronic cholecystitis was noted in 17 patients (micrograph B in figure 1, magnification 7x40), in 23 patients - no exacerbation (micrograph A in figure 1, magnification 7x20). In most patients, exacerbation of chronic cholecystitis was absent, they could have undergone organ-preserving surgery or prescribed conservative treatment, that is, to keep the gall bladder.

When comparing the crystallographic picture of cystic bile and the morphological picture of the wall of the gallbladder, it turned out that the structure of the central zone of the dried drop of bile is different in different groups of patients. In the absence of exacerbation of cholecystitis, the central zone was poorly structured, it was impossible to isolate individual crystalline structures, or small crystals scattered on a structureless substrate were visible (micrograph A in Fig. 2, magnification x40). With exacerbation of cholecystitis in the central zone there were crystalline structures in the form of dendrites branching at an angle of 60 or 90 ^o (micrograph B in figure 2, magnification x40).

 Based on this, a method for the diagnosis of exacerbation of chronic cholecystitis was developed, including sampling of the cystic bile in a patient (duodenal sounding or puncture of the gallbladder) and its study by the method of dehydration self-organization. In the presence in the central zone of a dried crystal drop in the form of dendrites, a conclusion is made about the exacerbation of cholecystitis.

 The method is simple, affordable and cheap.

 As an illustration of the claimed diagnostic technology, we give examples confirming the industrial application of this technique.

 Example 1. Patient N., 58 years old (medical history 4987), was taken to the emergency room on 01/01/2000 with the first attack of biliary colic. Complained of intense pain in the right hypochondrium with irradiation in the right scapula, dry mouth, belching with bile. An injection of antispasmodics. According to ultrasound data, the wall of the gallbladder is up to 3.5 mm thick, in the lumen there is one calculus with a diameter of 18 mm, there is no obstruction of the outlet duct. A patient with a diagnosis of acute simple calculous cholecystitis (the attack is relieved) was hospitalized in a surgical hospital. General blood test data within normal limits. In connection with the concomitant pathology: hypertension IIIa, condition after ischemic stroke, dyslexia, the question arose about the choice of treatment tactics: surgical or conservative. According to the control ultrasound, the contractile function of the gallbladder is good. Duodenal sounding performed. Crystallography of the gallbladder portion of bile by the method of dehydration self-organization showed the absence of a structured middle zone of the dried drop, that is, the absence of exacerbation of chronic cholecystitis. The final diagnosis: chronic calculous cholecystitis. Conservative treatment with ursodeoxycholic acid according to the scheme has been shown and begun.

 Example 2. Patient A., 47 years old (medical history 4563), was taken to hospital by ambulance on 10/17/2000 with a second attack of biliary colic. She complained of intense pain in the right hypochondrium with radiation to the right shoulder blade and shoulder, nausea, and vomiting of bile. By injection of antispasmodics and infusion of glucose-novocaine mixture, the attack was stopped. With ultrasound, the wall of the gallbladder is about 3.8 mm, there is a calculus with a diameter of 1.8 cm in the lumen, there is no obstruction of the output section. General blood test data within normal limits. Duodenal sounding was performed. Crystallography of the gallbladder portion of bile by the method of dehydration self-organization showed the presence of dendritic-like crystalline structures in the middle zone of the dried drop, that is, the presence of exacerbation of chronic cholecystitis. The final diagnosis: acute calculous cholecystitis. The operation was performed cholecystectomy.

Sources of information
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Claims (1)

 A method for diagnosing an exacerbation of chronic cholecystitis according to the results of a study of a portion of gallbladder bile, characterized in that, using a microscope, the structure of a bile drop preliminarily dried in a standard manner is analyzed and, in the presence of crystals in the form of dendrites, an exacerbation of chronic cholecystitis is diagnosed in the central zone, and in the case of poorly structured or amorphous the central zone is diagnosed with no exacerbation of chronic cholecystitis.

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