RU2236680C1 - Method for predicting clinical course of acute destructive pancreatitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves evaluating oxidation level. Ceruloplasmin oxydase activity level and ceruloplasmin concentration are determined in plasma. Specific ceruloplasmin oxydase activity is calculated as ratio between ceruloplasmin oxydase activity in plasma and ceruloplasmin concentration in plasma. Specific ceruloplasmin oxydase activity value being ≥0.12 units/mcg, unfavorable clinical course of the disease is to be predicted.

EFFECT: simplified method.

Description

The invention relates to medicine, namely to predict the course of an inflammatory disease - acute destructive pancreatitis and can be used in clinical practice.

Currently, acute pancreatitis takes 3rd place among acute diseases of the abdominal organs. This disease is “polyetiological”, but “monopathogenetic”. The relationship of destructive and inflammatory changes in the pancreas is very diverse and has a certain staging (phase) development. The nature of local and general complications depends on the features of the gland lesion: the attachment of a purulent infection (infection), DIC, multiple organ failure syndrome (SPON), immunodeficiency states. Mortality due to various purulent-septic complications in the first 4 weeks of the disease is 19-40% and 0-8% when complications develop within a period of more than 1 month from the onset of the disease (Gelfand B.R., 1997). In the early stages of the development of the disease, the cumulative effect of exogenous and endogenous factors that determine the severity of the disease plays a decisive role. This is the stage of pancreatic edema, which is reversible and in 75-85% of cases characterized by a mild, favorable course. Subsequently, the process in the gland becomes avalanche-like, independent of its causes, and in 20-25% of cases pancreatic necrosis of various lengths and severity forms. After the formation of necrosis, the destructive process in the gland stops on its own, and the further course of the process is already determined by the severity of the inflammatory reaction from the focus of necrosis.

The presence of a staged disease course, the speed of transformation of edema into pancreatic necrosis, as a rule, is directly proportional to the severity of the disease, the development of complications and inversely proportional to the reversibility interval, during which an effective therapeutic “break” of the pathological process is possible (Vashenko R.V., Tolstoy A.D. ., Kurygin A.A., Sytko Yu.M., Krasnogorov VB Acute pancreatitis and pancreatic injuries: a guide for physicians. S.-Pb.: Publishing House "Peter", 2000). Properly selected treatment tactics allows you to get a favorable outcome even with the most severe acute destructive pancreatitis, reduce the degree of development of complications, and reduce mortality in this category of patients.

The use of one or another therapeutic tactic, including proactive therapy, depends on the ability to predict the course of the disease. The search for prognostic tests and schemes to determine the nature of the course of the disease in the early stages, the likelihood of developing complications and choose the optimal treatment strategy for destructive pancreatitis is a very urgent task.

The existing prognostic schemes for acute destructive pancreatitis are mainly based on the registration of “markers of necrosis” and risk factors that add up to the multi-parameter systems SASP and ARRASNE (Pocket Guide for Anesthetists. Edited by V. Gologorsky and B. M. Gelfand, 1998, p. 150). They involve many indicators of the functional state of the body, some methods of replacement therapy; determination of blood α-amylase, alkaline phosphatase, leukocytes, potassium and sodium, glucose, urea, hematocrit.

The Chinese forecasting system includes 6 criteria: shock, albumin content less than 30 g / l, bilirubinemia above 7 mmol / l, hyperglycemia above 11 mmol / l, pathological analysis of urine and ρO ₂ below 8.6 kPa (Chen DZ, Wan SQ, Zufhg XY Prognostic factors and treatment of severe acute pancreatitis // Chung Huako Tsachin. - 1991, - v.30 (2), - p. 82-85).

The St. Petersburg School of Pancreatology has developed a simplified and expanded system for scoring (from 0 to 13) prediction of the course of pancreatic necrosis, which allows the use of therapeutic tactics for cutting off the development of the disease (Vashetko R.V., Tolstoy A.D., Kurygin A.A., Sytko Yu. M., Krasnogorov VB Acute pancreatitis and pancreatic injuries: a guide for doctors. S.-Pb .: publ. "Peter", 2000).

Attention is drawn to the low absolute number of lymphocytes as a sign of poor prognosis (Yamamoto M., Takeyama Y., Ueda T. Surgical treatment for severe acute pancreatitis // Hepatogastroenteral - 1997, - v. 44 (8), - p. 156-164 )

Based on the role of calcium in the pathogenesis of destructive pancreatitis, monitoring of a marker of systemic inflammation, procalcitonin, has been proposed for early diagnosis of pancreaticcrosis infection. An increase in the level of procalcitonin indicates infection of pancreatic necrosis and its purulent-septic complications (Gelfand B.R., Sergeeva N.A., Burnevich SZ, Brazhnik M.B. Abstracts of the VIII All-Russian Congress of Anesthesiologists and Resuscitators. September 11-15 2000, - p. 193-194).

Closest to the technical nature of the present invention is the assessment of the level of parameters indicative of “oxidative stress”. These include the determination of lipid peroxidation substrates (malondialdehyde, diene conjugates, etc.). (Tsai K., Wang SS, Chen TS Oxidative stress: an important phenomenon with pathogenetic significance in the progression of acute pancreatitis // Gut. - 1998, - v. 42 (6), - p.850-855; Wereszczynska Siemistrowska U Oxidative stress a some early prognostic factor in acute pancreatitis // Pancreas. - 1998, - v.l7 (2), - p.163-168).

One of the factors of the body's antioxidant defense is an enzyme of blood plasma - ceruloplasmin, which is a typical protein of the acute phase of the body. The concentration and enzymatic activity of ceruloplasmin increase with inflammatory diseases and stress, in recent years, particular importance is attached to the specific activity of ceruloplasmin, i.e. the ratio of enzymatic activity to the concentration of ceruloplasmin. It was shown that this parameter changes in various pathological conditions, in particular, increases in inflammatory diseases (Louro O., Cocho JA, Mera A., Tutor JC Immunochemical and enzymatic study of ceruloplasmin in rheumatoid arthritis // J. Trace Elem. Med. Biol . - 2000, - v.l4 (3), - p. 174-178). The content and activity of ceruloplasmin reflect the balance of the oxidative / antioxidant systems of the body, since there is evidence that under a number of conditions ceruloplasmin is able to exhibit prooxidant, i.e. potentially harmful action.

The problem solved by the invention is the expansion of the range of methods for predicting the course of acute destructive pancreatitis.

The technical result from the use of the invention is a simplification of the method for predicting the course of acute destructive pancreatitis.

This result is achieved by the fact that when assessing the level of oxidative stress, the plasma oxidase activity and the concentration of ceruloplasmin are determined using antibodies, the specific oxidase activity of ceruloplasmin is calculated, and if its value exceeds ≥0.12 u / μg, an unfavorable course of the disease is predicted.

The method is as follows. Determine the oxidase activity of the plasma or serum of the patient using the following methods. In 2 tubes, 100 μl of the test serum and 3.85 ml of 0.1 M sodium acetate buffer solution, pH 5.45, pre-heated to a temperature of 37 ° C. Then, 2 ml of a solution of para-phenylenediamine hydrochloride (3 mg / ml) is added to the tubes, noting the time of addition using a stopwatch. Samples are incubated at a temperature of 37 ° C. The reaction is stopped by adding 50 μl of a 1.5 M sodium azide solution, 5 and 15 minutes after the start of incubation, adding sodium azide first to the first, then to the second tube. Instead of plasma, 100 μl of buffer solution was added to the control sample, immediately stopping the reaction by adding sodium azide. The optical density of the samples is measured against the control at a wavelength of 530 nm and an optical layer of 10 mm on an SF-26 spectrophotometer (LOMO, St. Petersburg). Oxidase activity is calculated as the ratio of the difference in optical density of samples with different incubation times to the difference in incubation times ((D ₁₅ -D ₅ ) / 10). The unit of activity is defined as the amount of CPU that changes the optical density of the solution by 0.001 per minute.

In the same plasma samples of the patient, the quantitative content of ceruloplasmin is determined using antibodies to it, using commercial test systems, or antibodies to ceruloplasmin obtained by immunizing animals according to standard methods. To determine the use of the method of radial immunodiffusion according to Mancini (Immunological methods. Ed. Fremel H. M .: Mir, 1979, S. 49-52).

The specific oxidase activity of ceruloplasmin is calculated as the ratio of the oxidase activity of the patient's plasma to the concentration of ceruloplasmin in it. The course of the disease is predicted to be severe if the patient's specific plasma activity is ≥0.12 u / μg.

Example 1. An extract from the medical history No. 753. Patient A., 43 years old, was admitted for treatment at MLPU City Hospital of Emergency Medicine in Nizhny Novgorod with a diagnosis of acute pancreatitis. She fell ill acutely after an error in the diet. The state of moderate severity, girdle abdominal pain, nausea, repeated vomiting. Objectively; pale skin, tachycardia, blood pressure - 120/80 mm Hg, vesicular breathing in the lungs, abdomen on palpation is soft, painful in the epigastric region, there are no symptoms of peritoneal irritation. Peristalsis is heard, the gases go away. Ultrasound - echoscopic signs of destructive pancreatitis. In blood tests - blood α-amylase - 39.6 mmol / l, bilirubin 17.6 mmol / l, total protein - 86.2 g / l, prothrombin index - 100%, plasma Ca ²⁺ - 2.13 mmol / l, AlAT - 0.41, AcAT - 0.41, glucose - 4.8 mmol / l, leukocyte intoxication index - 8.5 units, hemoglobin - 150 g / l, leukocytes - 8.6 × 10 ⁹ , ESR - 8 mm / h, urea - 4.8 mmol / l, oxidative stress indicator - medium molecules - 0.39 units.

Plasma oxidase activity of 37 units / ml, ceruloplasmin concentration of 510 μg / ml, specific activity of ceruloplasmin - 0.073 units / μg, which allows to predict a favorable course of the disease.

The patient was hospitalized in the intensive care unit, where intensive care was started: abactal 800 mg / day, metrogil 200 mg / day, octreatide 0.3 mg / day, contrikal 80 units / day, pentoxifylline, reopoliglyukin. Surgical treatment is not indicated. As a result of the therapy, a marked improvement in the condition: relief of pain, intoxication phenomena. He was transferred to the surgical department for treatment, the intensive care unit was 1 day, and was discharged from the hospital on the 6th day with a diagnosis of moderate acute pancreatitis in satisfactory condition.

Example 2. An extract from the medical history No. 1548. Patient C., 45 years old, was admitted for treatment at the Moscow City Pediatric Emergency Hospital, Nizhny Novgorod 06.06.02 with a diagnosis of infected pancreatic necrosis, diffuse enzymatic peritonitis, retroperitoneal parapancreatic phlegmon. He fell ill acutely after alcohol abuse for 4 days. Severe condition, anxiety, severe abdominal pain, vomiting, low-grade fever. The face is sharply hyperemic, hepatic signs on the skin; tongue dry, covered with white coating. The abdomen is enlarged, tense, with palpation sharply painful in the epigastric region, infiltrate is palpated there. Peristalsis is doubtful. In blood tests: C-reactive protein - 240, increase in blood α-amylase to 26.0 mg / ml and bilirubin to 48.3 μmol / L, total protein - 99 g / L, prothrombin index - 65%, AlAT - 1 45, AcAT - 0.93, leukocyte intoxication index - 11.0, hemoglobin - 164 g / l, glucose - 6.7 mmol / l, urea 9.2 mmol / l, oxidative stress indicator - medium molecules - 0, 4.

The plasma oxidase activity was 110 units / ml, the concentration of ceruloplasmin was 610 μg / ml, the specific activity of ceruloplasmin was 0.18 units / μg, which allows us to predict an unfavorable course of the disease.

Intensive therapy has begun: abactal 800 mg / day, metrogyl 200 mg / day, octreatide 0.3 mg / day, kontrikal 100 units / day, actovegin 600 mg / day, pentoxifylline, fraxiparin, reopoliglukin. 06/07/02 operation: laparoscopic sanitation of the abdominal cavity, bursomentostomy, bursoscopy, drainage of the omental bursa. 06/08/02 developed delirium of mixed genesis with symptoms of pulmonary edema. Stopped by appropriate therapy. On June 17, 02 a second operation was performed - bursomentoscopy, necrosecvestrotomy, lumboscopy, rehabilitation of paracolic phlegmon. 06/18/02, a plasmapheresis session was performed to stop endotoxemia. Treatment in the intensive care unit was carried out for 16 days. In total, 6 surgical laparoscopic interventions were performed during the treatment. The total bed day was 70 bed days. Discharged in satisfactory condition.

Thus, our proposed method allows us to predict the course of acute destructive pancreatitis and quickly prescribe therapy adequate to the patient's condition.

Claims (1)

A method for predicting the course of acute destructive pancreatitis, including assessing the level of oxidative stress, characterized in that the plasma determines the oxidase activity of ceruloplasmin and the concentration of ceruloplasmin using antibodies, calculate the specific oxidase activity of ceruloplasmin as the ratio of the oxidase activity of ceruloplasmin in plasma to the concentration of ceruloplasmin and plasma exceeding its value ≥0.12 units / μg predict an unfavorable course of the disease.