RU2256922C1 - Method of early recognition of choledocholithiasis - Google Patents

Abstract

FIELD: analytical diagnostics.

SUBSTANCE: biochemical examination of blood and endoscopic ultrasonography are performed. When alkaline phosphatase activity is increased by 150% and more relative to normally occurred values, alanineaminotransferrase by 250% and morem and amylase by 150% and more, and when level of conjugated bilirubin is increased by 150% and more relative to normal level, while diameter of common bile duct is 7 mm and more, choledocholithiasis is diagnosed.

EFFECT: increased early recognition accuracy.

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Description

The invention relates to medicine and can be used as a method for the early diagnosis of choledocholithiasis.

A known method for the diagnosis of choledocholithiasis by ultrasound of the liver and biliary tract, taken as an analogue (1).

A known method for the diagnosis of choledocholithiasis, adopted as a prototype (2), by radiography of the abdominal cavity.

However, the prototype method does not provide early diagnosis of choledocholithiasis.

The aim of the present invention is to improve the accuracy of the early diagnosis of choledocholithiasis.

The technical result is achieved by the determination of serum alkaline phosphatase, alanine aminotransferase, amylase and bilirubin and endoscopic ultrasonography and with an increase in alkaline phosphatase activity by 150% or more, alanine aminotransferase by 250% or more and amylase by 150% or more and increase in the content conjugated bilirubin is 150% or more compared to normal and with a diameter of the common bile duct of 7 mm or more, choledocholithiasis is diagnosed.

The method is as follows.

Upon admission, the patient is paid attention to the presence of pain, subiktericity of the sclera and integument, subfebrile condition and, in older people, physical and mental exhaustion. In the anamnesis, especially in patients with obesity, flatulence, dyspepsia, intolerance to fatty foods are noted. Less commonly, the disease is asymptomatic. Palpation of the epigastric region is painful.

Stones of the terminal section of the common bile duct cannot be detected by ultrasound.

In the biochemical analysis of blood, an increased activity of alkaline phosphatase is noted at 439.6 units / L (150% and above the norm), Alanine aminotransferase - 79.3 units / L (250% and above the norm), Amylase - 383.6 units / L (150 % and above the norm), the content of conjugated bilirubin is 37.4 μmol / L (150% or more than the norm) and with a diameter of the common bile duct of 7 mm or more, choledocholithiasis is diagnosed.

The method is confirmed by the following examples.

Example 1

Patient R-sky, 25 years old, was admitted with complaints of flatulence, poorly stopped with medication, and subictericity of sclera.

When viewed from the skin of normal color, the sclera is somewhat icteric. Palpation of the epigastric region is painful.

An ultrasound examination of the abdominal cavity indicates the presence of hyperechoic particles in the cavity of the gallbladder and an expansion of the common bile duct of 7 mm. The size of the liver is normal, the echogenicity of the liver tissue is not changed.

The biochemical analysis of blood shows an increased activity of alkaline phosphatase of 439.6 units / L (150% higher than normal), Alanine aminotransferase - 79.3 units / L (250% higher than normal), Amylase - 383.6 units / L (150% higher norms), the content of conjugated bilirubin is 37.4 μmol / L (150% higher than normal).

Based on the obtained biochemical data and ultrasound of the hepatobiliary system, DS: choledocholithiasis was delivered.

The patient underwent etiopathogenetic treatment. After a course of treatment, the presence of hyperechoic particles in the cavity of the gallbladder is not observed. The diameter of the common bile duct is 5 mm. Biochemical analysis of blood: alkaline phosphatase activity - 285.0 units / liter, AlAt - 37 units / liter, amylase - 230 units / liter; conjugated bilirubin - 22 μmol / l.

The patient was discharged in a state of clinical and laboratory remission.

Example 2

Patient S-va, 55 years old, was admitted with complaints of intolerance to fatty foods and rapid physical fatigue. A patient with increased nutrition (with growth of 163 cm weight - 95 kg). The skin and sclera of normal color. There is increased sweating, hyperhidrosis of the palms. Palpation of the epigastric region is sensitive. Liver - at the edge of the costal arch, the edge of the liver is smooth, soft.

With ultrasound sonography, against the background of the unchanged gallbladder wall, a heterogeneous echostructure of the contents of the gallbladder is noted. The diameter of the common bile duct is 10 mm. The liver is echogenic homogeneous, the dimensions are normal, there are no foci of calcification.

Biochemical analysis of blood: alkaline phosphatase activity of 455.0 units / liter, alanine aminotransferase - 85.0 units / liter, amylase - 453.0 units / liter, the content of conjugated bilirubin - 43.0 μmol / liter.

Based on the data obtained from a biochemical study of blood serum and an ultrasound study of the hepatobiliary system, DS: choledocholithiasis was delivered.

The patient refused treatment. She was again admitted six months later with sharp abdominal pains. Upon admission, icteric sclera is noted. Palpation of the epigastric region and the right hypochondrium is impossible due to sharp pain.

Ultrasound examination of the liver tissue is echogenic homogeneous, the size of the liver is not changed. The wall of the gallbladder is thickened to 4.5 mm, in the lumen - multiple small stones with a diameter of 3-4 mm. In the lumen of the common bile duct is a round calculus with a diameter of 2 mm.

The patient underwent cholecystectomy with papillosphincterotomy. After conducting control studies, the patient was discharged in satisfactory condition.

Example 3

Patient Ch, 18 years old, was admitted to the military registration and enlistment office for a medical examination with DS: jaundice of unknown origin. From the anamnesis it is known that the patient does not tolerate paracetamol. Jaundice occurs periodically after intercurrent infections. There are no complaints upon receipt, ictericity of the skin and sclera, including palms. Palpation of the epigastric region is painless.

Ultrasound examination of the liver and bile ducts did not change the echostructure of the liver, the gall bladder without features, the common bile duct expanded to 12 mm.

During a biochemical blood test, an increased activity of alkaline phosphatase is 440.0 units / L, alanine aminotransferase - 89.0 units / L, aspartate aminotransferase - 79.0 units / L, amylase - 415.0 units / L; the content of conjugated bilirubin is 39.0 μmol / l.

Given intolerance to paracetamol, recurring jaundice and an increase in the level of conjugated bilirubin and the activity of alkaline phosphatase, AlAT and amylase, as well as an expansion of the common bile duct, the diagnosis was made of choledocholithiasis, Gilbert's disease.

To clarify the diagnosis of Gilbert's disease, the patient underwent a fasting test (an increase in serum bilirubin during fasting), a test with nicotinic acid (intravenous administration of nicotinic acid, which reduces the osmotic resistance of red blood cells, causes an increase in bilirubin content). Both tests are positive, which indicates the patient has Gilbert's disease.

To clarify the presence of choledocholithiasis, endoscopic ultrasonography was performed, according to which two small calculi of the common bile duct with a diameter of 3 and 4 mm were revealed.

The patient underwent planned endoscopic cholangiography, papillosphincterotomy, the stones were removed, and antibiotic therapy was performed. The patient was discharged on the 8th day in satisfactory condition.

Example 4

Patient K., 67 years old, was admitted with complaints of a feeling of heaviness in the epigastrium, heartburn. From the anamnesis it is known that for many years the patient suffers from chronic gastroduodenitis, for which he is observed by a gastroenterologist of the district clinic. 2 years ago, ultrasound revealed multiple calculi in the gallbladder. She refused the proposed surgical treatment. For 2 years, satisfactory state of health was maintained. At the next dispensary examination at the next biochemical analysis of blood, an increase in AlAT activity was detected up to 81.0 units / L, AcAT - up to 53.0 units / L, and therefore was hospitalized.

Objectively upon admission: satisfactory condition. The skin is pale pink, clean, moderately moist. In the lungs, vesicular breathing, no wheezing, respiratory rate - 16 per min. Heart sounds are sonorous, rhythmic, heart rate - 68 rpm, blood pressure 130/80 mm Hg The abdomen is soft, with palpation - moderately painful in the right hypochondrium and gastroduodenal zone. The liver and spleen are not enlarged. Symptom Ortner weakly positive.

In a clinical blood test: hemoglobin - 134 g / l; red blood cells - 4.3 million; white blood cells - 5.7 thousand; PO Box - 1; s / s - 58; lymphocytes - 31; monocytes - 9; ESR - 10 mm / h; in the biochemical analysis of blood: bilirubin - 38 μmol / L, cholesterol - 5.8 mmol / L, alkaline phosphatase - 452 units / L, AsAT - 47.5 units / L, AlAT - 81 units / L; total protein - 78.0 g / l, albumin - 47.5 g / l.

Ultrasound examination - the liver is not enlarged, echogenicity is diffusely increased, the vascular pattern is not changed, the right hepatic duct is 2 mm, choledoch is 10 mm. Visualization of the distal section of the common bile duct is difficult due to increased pneumatization of the intestinal loops. The size of the gallbladder is 4 × 7 cm, the wall is 3.5 mm, in the lumen there is a layer of displaceable stones from 6 to 9 mm, with an acoustic shadow.

Thus, according to clinical, laboratory and ultrasound examinations, the patient did not receive convincing data for the presence of choledocholithiasis. An endoscopic ultrasonography revealed: the wall of the gallbladder is thickened to 3.6 mm, in the lumen there are calculi from 6 to 9 mm giving an acoustic shadow, thick inhomogeneous bile, the choledoch lumen is 13.5 mm wide, in its distal section a clot of putty-like bile 8 mm in size , 5 mm calculus with an acoustic shadow.

Based on the study, the patient was diagnosed with gallstone disease, choledocholithiasis. The patient underwent surgical treatment. Discharged on the 21st day in satisfactory condition.

A diagnosis of 65 patients was carried out according to the proposed method. Subsequent treatment confirmed an increase in the accuracy of the early diagnosis of choledocholithiasis.

Sources of information

1. P.Ya. Grigoriev, E.P. Yakovenko. A brief form guide to gastroenterology and hepatology. M., Medicine, 2000, 524 p.

2. There.

Claims (1)

A method for the early diagnosis of choledocholithiasis, including a diagnostic study, characterized in that a biochemical blood test and endoscopic ultrasonography are performed and when the alkaline phosphatase activity is increased by 150% or more, alanine aminotransferase by 250% or more and amylase by 150% or more and with an increase in the content of conjugated bilirubin by 150% or more compared to the norm and with a diameter of the common bile duct of 7 mm or more, choledocholithiasis is diagnosed.