RU2275860C1 - Method for predicting complicated flow of chronic calculosis cholecystitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: one should evaluate morphological signs of blood serum: the area of peripheral region, the number of fissures and crystallization region, and ultrasound features, as well: the structure of cholecyst's wall, choledochus' diameter, availability of free liquid in abdominal cavity and hemodynamics in cholecyst's wall in points according to certain criteria. According to the sum of points a patient should be referred to the group of low risk for the development of complications to carry out repeated investigation in 6-8 h, or to the group of moderate risk for the development of complications to carry out repeated investigation in 3 h, or to the group of high risk for the development of complications being an indication for conducting urgent operation. The innovation provides earlier detection of complicated flow of chronic calculosis cholecystitis and helps to carry out correction of curative algorithm in due time. It, also, improves results of therapy and shortens the terms of rehabilitation.

EFFECT: higher accuracy of diagnostics.

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Description

The invention relates to medicine and can be used in surgery, therapy, radiation diagnostics.

There are two main methods for diagnosing the complicated clinical course of chronic calculous cholecystitis (GCX), when phlegmonous cholecystitis, empyema of the gallbladder wall, dropsy of the gallbladder, perforation of the wall with the occurrence of biliary peritonitis develop. The first method of diagnosis is clinical and laboratory, when, based on palpation (symptoms of Kera, Murphy, Ortner, etc.) and the results of a general blood test (leukocytosis, leukocyte shift to the left, accelerated ESR), biochemical analysis (bilirubin, alkaline phosphatase ), the level of stercobilin in the feces, urobilin in the urine, a conclusion is made about the complicated clinical course of XCX and the patient is sent for emergency surgical treatment (Galleev MA, Timerbulatov V.M. Gallstone disease and cholecystitis.- M .: MEDpress-inform , 2001 .-- 280 s.).

The second technique: clinical and instrumental monitoring of the state of the gallbladder, bile ducts of the liver in the form of various combinations of endoscopic, laparoscopic, ultrasound, x-ray computer-assisted imaging of the above organs. The ultrasound diagnostic technique is most often used, where the dimensions of the bladder, the structure of the bladder wall, the state of calculi in the lumen of the bladder, the diameter of the intra- and extrahepatic bile ducts, the presence of free fluid in the abdominal cavity, etc. are evaluated. Based on the dynamics of these indicators (at least two studies), a conclusion is drawn about the presence of complications of chronic gastric cancer or about their high potential likelihood of development. Based on this information, the surgeon decides on the timing of cholecystectomy and measures for the correction of drug treatment (V.V.Mitkov. Guide to ultrasound diagnostics in 5 volumes. Volume I, publishing house. Vidor, 1996 - 200 s.)

Common shortcomings of these two methods are late diagnosis of complications, when only surgeries become an alternative, and the possibilities of therapeutic measures are completely exhausted. Also high is the percentage (up to 30-39%) of the presence of false positive and false negative errors due to the non-specificity of laboratory and instrumental indicators. Clinical manifestations, especially in elderly patients, are also insignificant and cannot help to clarify the diagnosis. Thus, new diagnostic programs for the complicated clinical course of HXC are required.

The aim of the invention is the creation of a method that provides early detection of the complicated course of HX, timely correction of the treatment algorithm, improvement of treatment results, reduction of hospitalization.

The essence of the method for the early diagnosis of the complicated course of HXC is that, along with the traditional clinical, laboratory and instrumental monitoring, a patient with an exacerbation of chronic calculous cholecystitis additionally undergoes a comprehensive dynamic assessment of morphological signs of blood serum, including the area of the peripheral zone, the number of cracks, the crystallization zone, and ultrasonic signs, including the structure of the wall of the gallbladder, the size of the gallbladder, the diameter of the common bile duct, the presence of free fluid awns abdominal hemodynamics in the wall of the gall bladder, the morphological characteristics of the blood serum was scored on the following criteria:

peripheral area: stable - 1 point; increased by 10% - 2 points; increased by 20% - 3 points; increased by 30% - 5 points; reduced - 0 points. number of cracks: stable - 1 point; unstable - 2 points; reduced - 3 points; increased - 0 points; crystallization zone: uniform - 0 points; heterogeneous - 3 points; stable -1 point; unstable - 3 points.

and ultrasound signs are evaluated according to the following criteria:

gallbladder wall structure: saved - 0 points; broken - 2 points; unstable - 3 points. gall bladder sizes: stable - 2 points; increased - 3 points; reduced - 0 points. bile duct diameter: determined by - 0 points; not determined - 2 points; diameter> 10 mm - 3 points; diameter 6-10 mm - 1 point. the presence of free fluid in the abdominal cavity: in the area of the lateral canal - 6 points; in the subhepatic space - 5 points; not determined - 0 points. hemodynamics in the gallbladder wall: weakened - 0 points; saved -1 point; absent -3 points; pathological - 2 points; stable -1 point; unstable - 3 points.

If there are at least two signs of the morphological picture of blood serum and two signs in the description of the ultrasound picture and the sum of their scores from 1 to 8 patients are assigned to the group with a low risk of developing complications; with a score of 9 to 14 patients are assigned to a group with a moderate risk of complications; with a score of 15 to 30, to a group with a high risk of complications.

The risk group determines further diagnostic and treatment tactics: emergency surgery is necessary for high risk, repeated research after 3 hours at moderate risk, repeated research after 6-8 hours with minimal risk, with a similar assessment of the result.

The creation of a two-component system for assessing the risk of complicated course of GCX in the form of a semi-quantitative assessment of ultrasound signs describing the gallbladder and bile ducts on the one hand and morphological changes in the structure of a blood serum drop on the other hand is justified by the presence of a large number of scientific papers on this issue.

All these methods (ultrasound tomography and morphology of biological fluids) individually bear the disadvantages inherent in laboratory and instrumental diagnostics in general, however, their combination in a single information unit qualitatively changes the accuracy of diagnosis

The method is as follows: when a patient enters a medical institution, an ultrasound study is urgently performed on him according to a standardized method for describing an ultrasound image and blood is taken from a peripheral vein. 1 ml of blood is centrifuged (speed 1500 rpm, time - 3 min), the obtained serum is applied in the form of 3 drops (the volume of blood serum in each drop is 10 μl) on a glass slide located strictly horizontally. The diameter of each drop is 5-7 mm. The drop is dried at a temperature of 20-25 degrees and a relative humidity of 65-70% with minimal ambient air mobility (Shabalin V.N., Shatokhina S.N. Morphology of biological fluids. - Moscow, 2001. - 304 s.) The duration of the drying period is 3-4 hours. Then evaluate the morphological picture of blood serum using standardized criteria.

If there is a nonspecific clinical picture, data from traditional laboratory criteria (general blood test, biochemical blood test) and ultrasound examination, the treatment algorithm consists of standard drug therapy by order of the Ministry of Health of the Russian Federation No. 125 of 04/17/1998.

The diagnostic algorithm consists in repeated ultrasound and morphological examination of blood serum after 3-5 hours according to a unified program for evaluating the results described above.

When assessing a double ultrasound study and the first morphological study of blood serum, the number of points is summed up and the risk is assessed: for high risk surgery is necessary on an emergency basis, for moderate risk - a second analysis of fluid morphology after 3-4 hours and a third ultrasound with a new risk assessment, minimum risk - planned clinical, laboratory and instrumental observation after 6-8 hours. In this case, after 6-8 hours, the diagnostic cycle is repeated.

Clinical example No. 1: Patient N., 54 years old, medical history No. 1305, was admitted to the surgical department on 04/22/04 with complaints of cramping pain in the right hypochondrium for 1.5 hours that arose after errors in the diet, bitterness, dry mouth, weakness. About 4 days later, the patient began to notice moderately expressed, aching pains, a feeling of heaviness in the right hypochondrium. It was treated independently with herbs.

Preliminary diagnosis: Chronic calculous cholecystitis in the acute stage.

The patient received blood from a vein for admission to study the morphology of blood serum, ultrasound of the abdominal organs was done. The risk of a complicated course was assessed using the above diagnostic algorithm: it was found that the total score of the morphological criteria is 4 points (the peripheral area increased by 10% - 2 points; the number of cracks is unstable - 2 points; the crystallization zone is homogeneous - 0 points), ultrasonic signs - 7 points (the structure of the gallbladder wall is broken - 2 points; the size of the gallbladder is increased - 3 points; bile duct diameter 6-10 mm - 1 point; free fluid in the abdominal cavity is not determined - 0 points; hemodynamics in the wall gallbladder preserved - 1 point). The total score of morphological and ultrasound criteria was 11 points, the patient was assigned to the group of moderate risk of complications. After 3 hours, an ultrasound scan and a morphological study were repeated. The total score of morphological criteria was 8 points (the peripheral area increased by 20% - 3 points; the number of cracks decreased - 3 points; the crystallization zone was stable - 1 point), ultrasound signs were 10 points (the structure of the gallbladder wall is unstable - 3 points; size gall bladder increased - 3 points; bile duct diameter is not determined - 2 points; free fluid in the abdominal cavity is not determined - 0 points; pathological hemodynamics in the gallbladder wall - 2 points). The total score of morphological and ultrasound criteria was 18 points, the patient was assigned to the group of high risk of complications.

The patient decided to perform an emergency cholecystectomy. Conclusion - phlegmonous cholecystitis.

Clinical example No. 2: Patient P., 63 years old, medical history No. 865, was admitted to the surgical department on 2.03.04 with complaints of intense pain in the right hypochondrium for 6 hours that arose after errors in the diet, bitterness, dryness during mouth weakness. About a week ago, a similar attack was noted, which was stopped by the use of antispasmodics.

Preliminary diagnosis: Acute cholecystitis.

The patient received blood from a vein for admission to study the morphology of blood serum, ultrasound of the abdominal organs was done.

The risk of a complicated course was assessed according to the above diagnostic algorithm: it was found that the total score of the morphological criteria is 9 points (the area of the peripheral zone is increased by 20% - 3 points; the number of cracks is reduced - 3 points; the crystallization zone is inhomogeneous 3 points), ultrasonic signs - 10 points (the structure of the wall of the gallbladder is unstable - 3 points; the size of the gallbladder is increased - 3 points; the diameter of the common bile duct is not determined - 2 points; free fluid in the abdominal cavity is not determined - 0 points; hemodyne mika in the gallbladder wall is pathological - 2 points). The total score of morphological and ultrasound criteria was 19 points, the patient was assigned to the group of high risk of complications. The patient decided to perform emergency cholecystectomy. During the operation, gangrene of the gallbladder wall was detected.

Clinical example No. 3: Patient S., 40 years old, medical history No. 2654, was admitted to the surgical department on September 22, 2003 with complaints of aching pain in the right hypochondrium for 3 days that arose after errors in the diet, bitterness in the mouth, fever. History of ZhKB.

Preliminary diagnosis: Chronic calculous cholecystitis in the acute stage.

The patient received blood from a vein for admission to study the morphology of blood serum, ultrasound of the abdominal organs was done. The risk of a complicated course was assessed according to the above diagnostic algorithm: it was found that the total score of the morphological criteria was 3 points (the peripheral zone area was stable - 1 point; the number of cracks was stable - 1 point; the crystallization zone was stable 1 point), ultrasonic signs - 4 points ( the structure of the gallbladder wall is preserved - 0 points; the size of the gallbladder is stable - 2 points; the diameter of the choledochus is 6-10 mm - 1 point; free fluid in the abdominal cavity is not determined - 0 points; hemodynamics in the wall of the bile th bubble retained - 1 point). The total score of morphological and ultrasound criteria was 7 points, the patient was assigned to the group of low risk of complications. Conservative treatment was carried out.

We examined 44 people with cholelithiasis, who were admitted to the surgical department of the Clinical Hospital No. 1 Clinical Hospital No. 1 in 2004 with a diagnosis of exacerbation of HX. Patients were divided into 2 groups: group 1 (n = 19) - where the proposed method of risk assessment was used and group 2 (n = 25) - the traditional diagnostic algorithm was used as a control, consisting of a combination of a clinic, standard blood tests and ultrasound observation. All patients received standard medication (detoxification, broad-spectrum antibiotics, antispasmodics, etc.). 5 patients of the 1st group were assigned to the group at high risk of complications (3 hours after admission), operated - the prognosis was fully confirmed (in 2 patients - empyema of the gallbladder, in 1 - phlegmonous cholecystitis, in 2 - gangrenous cholecystitis); 8 patients of group 1 (moderate risk group) were observed, with repeated ultrasound and morphological examination in 2 patients there was a change in the risk degree to high, during the operation they revealed phlegmonous cholecystitis. Emergency and urgent surgical interventions were performed 6-8 hours after admission to the hospital. In 8 patients of group 2, a complicated course of HX was observed (complications were revealed in 2 patients after 8 hours, in 5 - after 14 hours, in 1 - on the second day.

Thus, the use of a scoring of morphological and ultrasonic signs according to standardized protocols of ultrasound diagnostics and blood serum morphology in case of nonspecific changes in the clinic, laboratory parameters made it possible to conduct early detection of complicated course of GCX and, in turn, to timely correct the treatment algorithm and avoid biliary peritonitis , improve treatment results, shorten hospitalization.

Claims (1)

A method for diagnosing the development of a complicated course of chronic calculous cholecystitis by a comprehensive assessment of morphological signs of blood serum, including the area of the peripheral zone, the number of cracks, crystallization zone, and ultrasound signs, including the structure of the gallbladder wall, the size of the gallbladder, choledochus diameter, the presence of free fluid in the abdominal cavity hemodynamics in the wall of the gallbladder, characterized in that they conduct a dynamic study of morphological features of serum cro and evaluated in scores according to the following criteria: the area of the peripheral zone: stable - 1 point is increased by 10% - 2 points has been increased by 20% - 3 points is increased by 30% - 5 scores decreased - 0 points; number of cracks: stable - 1 point, unstable - 2 points, increased - 0 points, reduced - 3 points; crystallization zone: homogeneous - 0 points, heterogeneous - 3 points, stable - 1 point, unstable - 3 points; and ultrasound signs, evaluated by the following criteria: structure of the gallbladder wall: saved - 0 points, broken - 2 points, unstable - 3 points; sizes of the gallbladder: stable - 2 points, increased - 3 points, reduced - 0 points; diameter of the common bile duct: determined - 0 points, not determined - 2 points, diameter more than 10 mm - 3 points, diameter 6-10 mm - 1 point; the presence of free fluid in the abdominal cavity: in the region of the lateral canal - 6 points, in the subhepatic space - 5 points, not determined - 0 points; hemodynamics in the gallbladder wall: weakened - 0 points, saved - 1 point, absent - 3 points, pathological - 2 points, stable - 1 point, unstable - 3 points; with a total score of signs from 1 to 8, the patient is referred to the group with a low risk of developing complications and a repeated examination is conducted after 6-8 hours; with a score of signs from 9 to 14, to the group with a moderate risk of complications with re-examination after 3 hours; with a total score of signs from 15 to 30, to a group with a high risk of developing complications, which is considered as an indication for emergency surgery.