RU2301653C1 - Method for treating patients with chronic calculus-free cholecystitis - Google Patents

Abstract

FIELD: medicine, gastroenterology.

SUBSTANCE: the present innovation deals with carrying out complex medicinal therapy and laser therapy simultaneously. Laser therapy should be prescribed differentially. At disease duration being under 7 yr and light degree of disease flow one should carry out daily laseroreflexotherapy due to contact technique. 10 procedures/course. Wave length being 1.3 mcm, radiation power 1 mW, modulation frequency 2.4 Hz. Points V19, F14, VC12, VB24 should be affected daily. The impact upon the points G14, E36, E25 should be symmetrically alternated every other day at affecting the points MC6 and RP6 symmetrically. At disease duration being above 7 yr and either average or severe degree of disease flow it is necessary to fulfill intravenous laser blood irradiation at wave length being 0.63 mcm, radiation power at a light guide's edge being 1.5-2.0 mW, the duration of the procedure - 20 min, therapy course - 7 procedures. The innovation shortens terms of therapy, widens the chance for applying noninvasive methods and increases the efficiency of medicinal therapy conducted.

EFFECT: higher efficiency of therapy.

2 ex, 6 tbl

Description

The invention relates to medicine, namely to the section "gastroenterology", and for the treatment of patients with chronic stoneless cholecystitis (CBC).

Given the high prevalence of chronic cholecystitis in the general population (data currently range from 26.6 to 45.5 per 1000 population), the growth of drug allergies among the population and the high cost of modern drugs used to treat this disease, the use of non-invasive methods becomes very relevant treatments, one of which is low-intensity laser therapy (LILT). As experimental and clinical studies show, LILT has anti-inflammatory and antispasmodic effects, relieves pain, activates microcirculation, helps correct metabolic disorders, and stimulates the body's immune responses.

There is a method of treating patients with CBC using intravenous laser irradiation of blood (VLOK) (Moskvin S.V., Azizov G.A. Intravenous laser irradiation of blood. - M .: NPC “Technique”, 2003, p.27). The disadvantage is the appointment of VLOK procedures without taking into account clinical and instrumental data and the severity of CBC, without assessing the effectiveness of the therapeutic effects of this method.

There is a method of treating patients with CBC using cutaneous exposure to laser therapy (Builin VA Laser device "Mustang". Guidelines for use. Moscow. 1999. S. 37-38), when patients are exposed to the right and left hypochondria, on segmental zones paravertebrally in the region of Th _VII -Th _XII using ALT "Mustang".

The disadvantage of this method of treatment is the impact only on the pain points on the anterior abdominal wall, without taking into account the possibility of using laser puncture on the points normalizing the contractility of the gallbladder, as well as the lack of a differentiated approach to the treatment of chronic cholecystitis and objective monitoring of the treatment results.

There is a method of treating patients with CBC using both the cutaneous effect on the fields on the anterior abdominal wall and laser puncture (Illarionov V.E. Technique and methods of laser therapy procedures. - M .: Center, 2001. - P. 48-49).

The disadvantage of this method is that there is no pathogenetic conditionality when prescribing laser therapy, evaluation of treatment results and there is also no differential approach to prescribing laser therapy procedures.

The closest set of essential features to the claimed invention is a method for the treatment of patients with chronic cholecystitis, taken as a prototype (Maksutova G.Sh. The use of infrared and red laser radiation in the complex treatment of chronic cholecystitis: Abstract of thesis. Candidate of Medical Sciences. - M. , 2000, - p. 7-8), including the use of various RT methods: local skin exposure, intravenous laser irradiation of blood, which leads to relief of the pain syndrome, activates microcirculation, promotes section of metabolic disorders, has an anti-inflammatory effect.

However, the disadvantage of the prototype is the lack of a differentiated approach in the appointment of various methods of laser therapy, that is, there is no justification for the appointment of one or another selected method of laser exposure. The appointment of the cutaneous method, VLOK is carried out without taking into account the duration and severity of the course of the disease, the presence of concomitant gastroduodenal and extra-abdominal pathology. The possibility of using laser reflexotherapy as a method for correcting gallbladder motility disorders is not taken into account.

The invention is aimed at solving the problem of creating a method for the differentiated treatment of patients with chronic stoneless cholecystitis in the acute phase.

The solution to this problem provides a reduction in clinical manifestations, a shorter hospitalization period for patients, expands the possibility of using non-invasive treatment methods, increases the effectiveness of drug therapy and provides a rationale for the effectiveness of laser therapy in the complex treatment of CBC in the acute phase, taking into account one of the important pathogenetic links in the development of this disease.

To achieve this technical result, the claimed invention of a method for treating patients with chronic stoneless cholecystitis includes the following essential features - laser therapy is carried out differentially: with a disease duration of less than 7 years and a mild course of the disease, reflexology is carried out daily with a course of 10 procedures, which is carried out in contact, with a wavelength of 1.3 μm, a radiation power of 1 mW, a modulation frequency of 2.4 Hz, moreover, the points V19, F14, VC12, VB24 are exposed daily, and the effects on the points G14, E3 6, E25 symmetrically alternate every other day with impact on points MC6 and RP6 symmetrically; with a disease duration of more than 7 years and moderate or severe severity of the disease, an intravenous laser irradiation of blood is performed with a wavelength of 0.63 microns, a power at the end of the fiber of 1.5-2.0 mW, for 20 minutes, a treatment course of 7 procedures.

In relation to the prototype, the claimed invention has the following distinctive features - RT in case of chronic stoneless cholecystitis is prescribed differentially: with a disease duration of less than 7 years and a mild course of the disease, reflexology is carried out; with a disease duration of more than 7 years and moderate or severe disease severity, an intravenous laser blood irradiation is performed. Laser reflexotherapy is used in the treatment, as a method for correcting gallbladder dyskinesia. As a result of the application of the proposed method, there is a reduction in the duration of hospitalization, an increase in the quality of treatment.

The following causal relationship exists between the distinguishing features and the technical result: due to the differentiated treatment of patients with CBC in the exacerbation phase, more specific treatment methods are prescribed that are shown to each individual patient, which improves the quality of treatment and has a regulatory effect on the functional systems of the body, which it is expressed in the normalizing and correcting effect on the motility of the gallbladder, increases the effectiveness of the drug Therapy, reduces the length of hospitalization.

According to the information available to the authors, the set of essential features characterizing the essence of the claimed invention is unknown, which allows us to conclude that the invention meets the criterion of "novelty."

According to the authors, the essence of the claimed invention does not follow explicitly from the known level of medicine, since it does not reveal the above differential approach to the appointment of laser therapy procedures that distinguish the claimed invention from the prototype, which allows us to conclude that its criterion is “inventive step”.

The set of essential features characterizing the essence of the invention, in principle, can be used repeatedly in medicine with obtaining a technical result, which consists in increasing the effectiveness of laser therapy for patients with CKB, which allows us to conclude that the invention meets the criterion of "industrial applicability".

This method is as follows.

All patients with chronic stoneless cholecystitis undergo complex drug therapy (antispasmodics, choleretic drugs, vitamin therapy, antibiotics - if a portion of B microflora is found in the bacteriological culture) with the simultaneous use of a course of laser therapy.

The proposed differentiated approach in the treatment of patients with chronic stoneless cholecystitis was used in 92 patients. All patients were divided into 3 groups. In the 1st (control) group (30 people), traditional drug therapy was used for treatment, in the 2nd group (32 people) and III group (30 people), laser therapy was prescribed in addition to drug treatment. In the II group - a course of intravenous laser therapy. The third group of patients received a course of laser puncture (according to the above methods).

The course of laser reflexology was carried out with a wavelength of 1.3 μm, a radiation power of 1 mW with a modulation frequency of 2.4 Hz according to a contact-stable technique for acupuncture points of the basic prescription (points are indicated in the order of their stimulation: Monday, Wednesday, Friday - G14, E36 symmetrically , VC12; Tuesday, Thursday, Saturday: MC6 and RP6 symmetrically, VC12 with the addition of points on the anterior abdominal wall and rear surface of the body), exposure for one point for 15 seconds, with a course of 10 daily procedures.

An intravenous RT course was conducted with a wavelength of 0.63 μm, a radiation power of 1.5–2.0 mW at the end of the fiber, daily, the duration of one procedure was 20 minutes, 7 courses per course).

The appointment of various radiotherapy methods was carried out differentially, taking into account the severity of the course and duration of the disease.

Indications for the appointment of laser reflexotherapy were: the duration of the disease is less than 7 years, a mild severity of the course of the disease.

Indications for the appointment of VLOK were: the duration of the disease is more than 7 years, the average and severe severity of the disease.

In patients with chronic stoneless cholecystitis in the exacerbation phase, the dynamics of clinical symptoms were studied (see data in Table 1).

Table 1 The dynamics of clinical symptoms in patients with CBC in the acute phase during treatment Study Dates Group of patients The number of patients,% Symptom Pain syndrome Positive symptom kera Nausea Flatulence Stool disorders Before treatment I gr 30 people (100%) 30 people (100%) 27 people (90%) 30 people (100%) 17 people (57%) II gr. 32 people (100%) 32 people (100%) 29 people (91%) 32 people (100%) 20 people (63%) III gr. 30 people (100%) 30 people (100%) 27 people (90%) 29 people (97%) 19 people (63%) 2-3 day of therapy I gr 27 people (90%) 30 people (100%) 24 people (80%) 30 people (100%) 15 people (50%) II gr. 27 people (85%) 29 people (91%) 24 people (75%) 32 people (100%) 19 people (59%) III gr. 21 people (70%) 20 people (67%) 20 people (67%) 25 people (83%) 13 people (43%) 5-6 day of therapy I gr 10 people (33%) 14 people (47%) 10 people (33%) 10 people (33%) 7 people (33%) II gr. 8 people (25%) 10 people (31%) 8 people (25%) 7 people (22%) 8 people (25%) III gr. 5 people (17%) 6 people (20%) 4 people (13%) 5 people (17%) 4 people (13%) After the end of the course of therapy I gr 4 people (13%) 4 people (13%) 0 4 people (13%) 3 people (10%) II gr. 2 people (6%) 2 people (6%) 0 2 people (6%) 2 people (6%) III gr. 0 1 person (3%) 0 0 1 person (3%)

Before the treatment, all the examined patients had pain in the right hypochondrium of varying intensity, in some patients with irradiation under the right scapula. Patients were also disturbed by nausea, flatulence, and stool disorders (often constipation).

The study shows that, as a result of treatment, the elimination of pain and other symptoms studied was observed earlier in patients with CBC receiving drug therapy and laser surgery (group III). So, only in patients of the III group there was an elimination of pain, flatulence, nausea in 100% of cases, compared with patients of the I group (control group receiving only drug therapy), who still had the above symptoms after the course of treatment ( pain syndrome, nausea, flatulence - in 13%, stool disorders - in 10%), in patients of group II (receiving drug therapy and intravenous laser blood irradiation) at the end of the course of therapy also remained the studied symptoms, only in a lower percentage ratio (see table 1).

With chromatic duodenal sounding, initially in 64 patients, which accounted for 70%, there was dyskinesia of the gallbladder according to the hypokinetic type, and in 28 patients (30%) according to the hyperkinetic type.

The dynamics of changes in the parameters studied during chromatic duodenal sounding during treatment are presented in table 2.

As can be seen from table 2, in patients with chronic stoneless cholecystitis in the exacerbation phase, only in the III group of patients there is a reliable normalization of all the studied indicators of motor activity of the gallbladder: change in time of the second phase of bile secretion, rate of excretion of cystic bile and volume of gallbladder bile. So, in patients of this group with a hypokinetic type of gallbladder dyskinesia, the time of the second phase of bile secretion was 59 ± 1.6 min before treatment, 40 ± 0.9 min after treatment (p <0.05); in patients with a hyperkinetic type of gallbladder dyskinesia 11 ± 1.35 min and 18 ± 1.05 min, respectively (p <0.05). The rate of cystic bile excretion in patients with CBC with a hypokinetic type of gallbladder dyskinesia was 10.6 ± 1.2 ml before treatment and 20.5 ± 0.9 ml after treatment (p <0.05); in patients with hyperkinetic type, 25.3 ± 0.6 ml and 20.5 ± 0.9 ml, respectively (P <0.05).

table 2 Changes in gallbladder function in patients with CBC in the exacerbation phase according to chromatic duodenal sounding before and after treatment The studied indicators Group Inspection Dates Type of gallbladder dyskinesia Hypokinetic Hyperkinetic Time II phase of bile secretion I gr before treatment 58 ± 1.5 min 11 ± 1.2 min after treatment 55 ± 1.3 min 13 ± 1.1 min II gr. before treatment 59 ± 1.2 min 12 ± 1.4 min after treatment 50 ± 1.1 min * 16 ± 1.35 min III gr. before treatment 59 ± 1.6 min 11 ± 1.35 min after treatment 40 ± 0.9 min * 18 ± 1.15 min * The rate of allocation of gallbladder bile (ml in 5 min) I gr before treatment 9.1 ± 0.3 ml 28.5 ± 0.5 ml after treatment 10.3 ± 0.9 ml 25.4 ± 0.7 ml II gr. before treatment 9.5 ± 0.9 ml 24.5 ± 0.6 ml after treatment 12.2 ± 1.6 ml 22.6 ± 0.8 ml * III gr. before treatment 10.6 ± 1.2 ml 25.3 ± 0.6 ml after treatment 15.6 ± 1.4 ml * 20.5 ± 0.9 ml * Gallbladder volume I gr before treatment 100.5 ± 5.0 ml 50.8 ± 4.2 ml after treatment 90.6 ± 5.6 ml 52.6 ± 3.8 ml II gr. before treatment 125.2 ± 6.2 ml 57.4 ± 6.2 ml after treatment 110.4 ± 8.7 ml 70.3 ± 5.9 ml III gr. before treatment 108.1 ± 6.9 ml 52.3 ± 5.3 ml after treatment 75.2 ± 9.8 ml * 69.5 ± 6.1 ml * * p <0.05 - when comparing indicators before and after treatment.

The volume of cystic bile in patients with CBC with a hypokinetic type of gallbladder dyskinesia before treatment was 108.1 ± 6.9, after treatment, 75.2 ± 9.8 ml (p <0.05); in patients with a hyperkinetic type of gallbladder dyskinesia, 52.3 ± 5.3 ml and 69.5 ± 6.1 ml, respectively (p <0.05).

It should also be noted that in patients of the second group, against the background of intravenous laser blood irradiation, the time indicators of the second phase of bile secretion also significantly changed in the presence of the hypokinetic type of gallbladder dyskinesia - 59 ± 1.2 min before treatment and 50 ± 1.1 min after treatment (p <0.05). In patients of the same group with a hyperkinetic type of dyskinesia, the rate of bile secretion significantly decreased 24.5 ± 0.6 ml and 22.6 ± 0.8 ml, respectively (p <0.05), while in patients of the I (control) group, the indicators characterizing the motor function of the gallbladder remained virtually unchanged.

Thus, our data indicate that low-intensity laser therapy contributes to the normalization of gallbladder motility, regardless of the initial type of disorder.

Gallbladder motility was also studied by ultrasound with a choleretic breakfast, which in 100% of cases confirmed the presence of gallbladder motility disorders that were obtained with duodenal sounding. The generally accepted ultrasound criterion for cholecystitis is a thickening of the gallbladder wall due to hypertrophy of the muscle layer, proliferation of connective tissue, inflammatory infiltration and swelling of the wall.

The dynamics of changes in the parameters studied with ultrasound with choleretic breakdown during treatment are presented in table 3.

As can be seen from table 3, in all the patients examined by us, the gallbladder wall thickness was initially significantly higher before treatment than in healthy patients and amounted to 3.4 ± 0.3 mm in group I and 3.2 ± 0.1 in group II mm, in group III 3.1 ± 0.4 mm when compared with the group of healthy patients, where this indicator was 1.8 ± 0.2 mm.

Table 3 Dynamics of ultrasound with choleretic breakdown in patients with CBC The studied indicators Inspection Dates Group Healthy I gr II gr. III gr. The thickness of the walls of the gallbladder, mm before treatment

1.8 ± 0.2 3.4 ± 0.3 * 3.2 ± 0.1 * 3.1 ± 0.4 * after treatment 3.2 ± 0.2 2.9 ± 0.3 2.6 ± 0.2 ** ^; *** The initial volume of the gallbladder, ml before treatment
35.5 ± 3.6 38.3 ± 2.3 37.1 ± 1.5 38.5 ± 1.6 after treatment 37.9 ± 2.1 36.9 ± 1.3 37.4 ± 1.4 The volume of the gallbladder at the end of the choleretic test, ml before treatment
14.8 ± 1.4 15.3 ± 1.2 14.5 ± 1.4 15.9 ± 1.5 after treatment 13.4 ± 1.2 12.6 ± 1.5 8.8 ± 1.7 ** ^; *** * p <0.05 - when comparing the indicators of I, II or III groups and healthy patients, ** p <0.05 - when comparing indicators within the group before and after treatment, *** p <0.05 - when comparing indicators after treatment in groups I and III.

During treatment, the largest percentage reduction in gallbladder wall thickness within groups was observed in groups II and III - 3.2 ± 0.1 mm and 2.9 ± 0.3 mm and 3.1 ± 0.4 mm and 2, 6 ± 0.2 mm, respectively, however, these changes are not reliable. At the same time, after treatment, only in the III group of patients there was a significant decrease in wall thickness compared with patients in the control group. So, in patients of the control group the wall thickness at the end of treatment was 3.2 ± 0.2 mm, in patients of the III group 2.6 ± 0.2 mm (p <0.05).

These data allow us to believe that the inclusion of laser radiation in the complex of therapeutic measures helps to reduce the wall thickness of the gallbladder, and primarily by eliminating inflammatory infiltration and edema, while traditional drug therapy is not accompanied by a significant decrease in wall thickness. The absence of a decrease in wall thickness may indicate incompleteness against the background of traditional drug therapy of inflammatory infiltration, which may be one of the causes of frequent relapse of the disease.

Comparing the initial gallbladder volume in healthy patients and in patients in all three groups, it can be noted that this indicator did not differ significantly among them.

When assessing the volume of the gallbladder at the end of the choleretic test, its significant decrease was revealed only in patients of group III receiving laser puncture. So, in these patients, the volume of the gallbladder at the end of the choleretic test was 15.9 ± 1.5 (with a norm of 14.8 ± 1.4) before treatment; after treatment, 8.8 ± 1.7 (p <0.05).

Thus, the study indicates the undoubted advantages of including patients with CKB in the phase of exacerbation of laser irradiation in complex therapy. In such patients, pain in the right hypochondrium and dyspeptic symptoms disappeared earlier than in patients receiving only traditional drug therapy, and the fastest positive dynamics was observed in patients receiving laser puncture. Obviously, this is due to the fact that the effect of laser radiation on acupuncture points has a normalizing effect on the motility of the gallbladder, bile ducts, thereby reducing stagnation of bile in the gallbladder, lowering intravesical pressure, eliminating all existing clinical symptoms of the disease, and more quickly improving condition of patients.

The data of our study also show that in all patients the number of blood leukocytes was within the physiological norm and ranged from 3.4 · 10 ¹² to 6.4 · 10 ¹² / L. However, we noted that both in the control and in the main groups, with an increase in the number of leukocytes, the parameters of lipid peroxidation products increased. So, before treatment, when the number of leukocytes <5.0 · 10 ¹² / l, the amount of malondialdehyde (MDA) in the control group was 22.17 ± 0.59 μmol / l (with a norm of 16.0-18.0 μmol / l) hydroperoxides - 17.45 ± 0.48 μmol / L (with a norm of 11.0-13.0 μmol / L). When the number of leukocytes> 5.0 · 10 ¹² / l, these same indicators were higher and amounted to 23.37 ± 0.42 μmol / l and 18.72 ± 0.85 μmol / l, respectively. A similar picture was observed in the main groups - with the number of leukocytes <5.0 · 10 ¹² / l - the MDA values in the II subgroup were 22.20 ± 0.68 μmol / l, hydroperoxides 16.9 ± 0.53 μmol / l, in the III group - 21.24 ± 0.59 μmol / l and 17.32 ± 0.72 μmol / l. (see table 4).

Table 4 The dynamics of lipid peroxidation indicators depending on the number of leukocytes in the control and main groups before and after treatment I (control) group Before treatment After treatment Before treatment After treatment White blood cells less than 5.0 · 10 ¹² / l White blood cells over 5.0 · 10 ¹² / l MDA, μmol / L 22.17 ± 0.59 21.61 ± 0.63 23.37 ± 0.42 22.34 ± 0.49 Hydroperoxides, μmol / L 17.45 ± 0.48 16.53 ± 0.65 18.72 ± 0.85 16.93 ± 0.72 II (main) group Before treatment After treatment Before treatment After treatment White blood cells less than 5.0 · 10 ¹² / l White blood cells over 5.0 · 10 ¹² / l MDA, μmol / L 22.2 ± 0.68 20.8 ± 0.52 23.36 ± 0.72 21.9 ± 0.81 Hydroperoxides, μmol / L 16.9 ± 0.53 16.29 ± 0.61 17.88 ± 0.86 15.92 ± 0.84 III (main) group Before treatment After treatment Before treatment After treatment White blood cells less than 5.0 · 10 ¹² / l White blood cells over 5.0 · 10 ¹² / l MDA, μmol / L 21.24 ± 0.59 19.93 ± 0.55 24.24 ± 0.87 22.6 ± 0.82 Hydroperoxides, μmol / L 17.32 ± 0.72 15.93 ± 0.70 19.15 ± 0.69 17.56 ± 0.72

After treatment, a decrease in lipid peroxidation products was observed in all groups. In patients of the control group with a white blood cell count less than 5.0 · 10 ¹² / l, the MDA level decreased from 22.17 ± 0.59 to 21.61 ± 0.63 (p> 0.05), and with a white blood cell count of more than 5, 0 · 10 ¹² / l from 23.37 ± 0.42 to 22.34 ± 0.49 (p> 0.05). In the main group, these changes also did not significantly differ from those in the control group, and when the number of leukocytes was less than 5.0 · 10 ^l2 / l, the MDA level in the II group was 22.20 ± 0.68 before treatment and 20.38 ± 0.52 after treatment (p> 0.05), in group III - 21.24 ± 0.59 μmol / L and 19.93 ± 0.55 μmol / L, respectively, and with a white blood cell count of more than 5.0 · 10 ¹² / l in the II group - 23.36 ± 0.72 and 21.9 ± 0.81, respectively (p> 0.05), in the III group - 24.24 ± 0.87 and 22 , 6 ± 0.82, respectively (p> 0.05) (see table 4).

Further, analyzing the data of antioxidant protection enzyme indices, we came to the conclusion that initially, before treatment, a decrease in their activity is observed, after treatment, both in the control and in the main groups there is a reliable activation of these enzymes.

Table 5 Dynamics of antioxidant enzyme parameters before and after treatment Catalase, mkat / l Superoxide dismutase, units / ml I (control) group Before treatment 205.4 ± 1.5 1.2 ± 0.11 After treatment 235.6 ± 1.8 * 1.6 ± 0.09 * main group 2nd gr. Before treatment 203.5 ± 1.4 1.25 ± 0.08 After treatment 240.6 ± 1.3 * 2.3 ± 0.09 * III c. Before treatment 203.3 ± 1.7 1.23 ± 0.075 After treatment 237.5 ± 1.6 * 2.26 ± 0.07 * * p <0.05 - when comparing indicators before and after treatment.

The indicators were distributed as follows (see table 5), the catalase level in the control group before treatment was 205.4 ± 1.5 mkat / l, after treatment 235.6 ± 1.8 mkat / l (p <0.05 ), in the II group 203.5 ± 1.4 mkat / l and 240.6 ± 1.3 mkat / l, respectively (p <0.05), in the III group 203.3 ± 1.7 and 237.5 ± 1.6, respectively (p <0.05). The level of superoxide dismutase was within the control group before treatment, 1.2 ± 0.11 units / ml, after treatment, 1.6 ± 0.09 units / ml (p <0.05), in group II 1.25 ± 0.08 units / ml and 2.3 ± 0.09 units / ml, respectively (p <0.05), in the III group 1.23 ± 0.075 and 2.26 ± 0.07, respectively (p < 0.05).

Thus, despite the decrease in the level of LPO during the treatment process, their level after treatment still remained elevated. However, at the same time there was a reactivation of the antioxidant enzymes. Therefore, in general, we consider the tendency we observed to decrease lipid peroxidation processes with a simultaneous increase in the activity of antioxidant enzymes as a favorable process, indicating the normalization of processes in the LPO system - antioxidant system.

As can be seen from table 6, in patients with chronic stoneless cholecystitis in the exacerbation phase before treatment, a decrease in the phagocytic activity of leukocytes is noted. So, we noted a decrease in the activation index (in N> 3) both in the control and in the main groups (2.56 ± 0.7 and 2.48 ± 0.12 and 2.51 ± 0.65, respectively), percent phagocytosis (normal 62-92%) - 59.96 ± 2.5 and 61.91 ± 2.1 and 58.98 ± 2.3, respectively, as well as the index of completion of phagocytosis (normal> 1) - 0.86 ± 0.02 and 0.89 ± 0.04 and 0.87 ± 0.03, respectively.

The impaired functional activity was due to both a decrease in the percentage of active neutrophils in relation to the total circulating pool (percentage of phagocytosis) and a suppression of the function of directly acting cells (index of completion of phagocytosis).

Table 6 The dynamics of indicators of the functional activity of leukocytes in patients with chronic stoneless cholecystitis in the acute phase before and after treatment Activation Index (OK> 3) The percentage of phagocytosis (normal 62-92%) Phagocytosis completion index (normal> 1) I group Before treatment 2.56 ± 0.7 59.96 ± 2.5 0.86 ± 0.02 After treatment 3.24 ± 0.1 72.7 ± 1.8 * 1.21 ± 0.02 II group Before treatment 2.48 ± 0.12 61.91 ± 2.1 0.89 ± 0.04 After treatment 4.14 ± 0.09 * 88.7 ± 1.4 * 2.4 ± 0.1 * III group Before treatment 2.51 ± 0.65 58.98 ± 2.3 0.87 ± 0.03 After treatment 4.61 ± 0.8 * 86.54 ± 1.8 * 2.2 ± 0.09 * * p <0.05 - when comparing indicators before and after treatment.

However, in the future, during treatment, we revealed various dynamics of phagocytosis in the main and control groups of patients. In patients of the control group after treatment, an insignificant increase in the indicators of the functional activity of neutrophils is noted: the activation index increases from 2.56 ± 0.7 before treatment and 3.24 ± 0.1 after treatment (p> 0.05); the index of completion of phagocytosis - 0.86 ± 0.02 and 1.21 ± 0.02 - before and after treatment, respectively (p> 0.05). In this group of patients, only the percentage of phagocytosis significantly increased, 59.9 ± 2.5% and 72.7 ± 1.8%, before and after treatment, respectively (p <0.05). In the II and III groups after treatment, all indicators of the functional activity of neutrophils significantly increase. So, the activation index in the II group increases from 2.48 ± 0.12 to 4.14 ± 0.09 after treatment (p <0.05), in the III group from 2.51 ± 0.65 to 4, 61 ± 0.8, respectively (p <0.05), the percentage of phagocytosis before and after treatment in group II was 61.91 ± 2.1% and 88.75 ± 1.4%, respectively (p <0.05) ), in the III group 58.98 ± 2.3% and 86.54 ± 1.8, respectively (p <0.05). The index of completion of phagocytosis also significantly increased in the II group 0.89 ± 0.4 - before treatment and 2.4 ± 0.1 - after treatment, (p <0.05), III group 0.87 ± 0 , 03 and 2.2 ± 0.09, respectively (p <0.05).

Our correlation analysis revealed a positive relationship between the level of MDA and the phagocytic activity of leukocytes in both groups of patients. So, in patients of the control, main groups (II and III groups), the correlation coefficient for the activation index was 0.5, 0.5 and 0.5, respectively; for the percentage of phagocytosis of 0.4, 0.5 and 0.5, respectively, for the index of completion of phagocytosis of 0.5; 0.5 and 0.5, respectively.

The data in table 6 show that against the background of traditional drug therapy, the phagocytic activity of leukocytes is not fully restored. In this group of patients, normalization of the activation index and the completion index of phagocytosis, as shown above, is unreliable. At the same time, in the main groups, changes in all indicators of phagocytic activity were reliable.

Thus, summing up the data of our study, we can conclude that the traditional drug therapy of patients with chronic stoneless cholecystitis in the acute phase is not effective enough. Therefore, in patients with chronic stoneless cholecystitis in the exacerbation phase, laser irradiation should be used, since it has a normalizing and corrective effect on the motility of the gallbladder, and also increases the effectiveness of complex therapy, contributes to the early reduction of the symptoms of the disease. The inclusion of a course of laser therapy in the complex therapy of chronic stoneless cholecystitis leads to a decrease in LPO activity and to an increase in the functional potential of leukocytes, i.e. promotes the correction of one of the important cellular non-specific factors of the immune system - phagocytosis and can be considered as a way to increase the functional potential of leukocytes in order to correct the failure of the phagocytosis system. The most effective in the complex therapy of chronic stoneless cholecystitis is the laser puncture method, which should be prescribed in the early stages of CBC development, with a mild course, with the aim of earlier correction of motor dysfunction of the gallbladder. Correction of the impaired function of the gallbladder with a more severe course of CBC practically does not occur, possibly with the development of irreversible sclerotic changes in the gallbladder wall itself.

To illustrate the differentiated use of RT, as well as the normalizing effect of laser reflexotherapy on the dynamics of clinical data, the motor function of the gallbladder and lipid peroxidation products with the participation of the leukocyte link, we provide a brief extract from the medical history No. 592.

Example 1

Patient S., 40 years old, housewife. Received 1.03.05, the gastroenterological department with complaints of a feeling of heaviness, and sometimes dull pain in the right hypochondrium, dryness, bitterness in the mouth, nausea, rarely - vomiting without an admixture of bile, weight loss (5 kg over the last 2 months), constipation . Over the past 6 years, it has been periodically treated on an outpatient basis for chronic stoneless cholecystitis. Pain in the right hypochondrium rarely occurs, only after errors in the diet, there have never been severe pains. Recently, the patient cannot indicate the apparent reasons for the occurrence of complaints.

Objectively: with palpation of the abdomen, pain is noted at the projection point of the gallbladder. The liver is not enlarged, its edge is soft, painless. Symptoms of Ortner, Mussi-Georgievsky are moderately positive. From other organs and systems of pathology it is not revealed.

In blood tests: the stab shift of the leukocyte formula to the left (stab leukocytes - 10%) with a normal content of the total number of leukocytes of 4.2 · 10 ⁹ / l, ESR 20 mm / hour. In the biochemical analysis of blood: the content of bilirubin, total protein, fibrinogen, amylase, ALT, ACT is normal. In the general analysis of urine - without pathology.

When duodenal sounding revealed a hypokinetic type of motor function of the gallbladder (time of the second phase of bile secretion increased to 58 minutes, the rate of excretion of cystic bile was reduced to 11 ml in 5 minutes, the volume of cystic bile was also increased to 127 ml). Microscopic examination of bile of portion B revealed accumulations of epithelial cells and leukocytes. When bacteriological examination - sowing bile portion B is sterile.

Ultrasound examination of the gallbladder revealed its deformation (kink in the neck), thickening of the walls (thickness 3.3 mm), while the initial volume of the gallbladder was 38 ml, at the end of the choleretic sample 17 ml.

The lipid peroxidation indices before treatment were: MDA 21.4 μmol / L, hydroperoxides - 17.7 μmol / L. The levels of antioxidant enzymes were in the range of catalase - 201.4 mkat / l, superoxide dismutase - 1.3 units / ml.

A decrease in the phagocytic activity of leukocytes was noted. So, the activation index was 2.69, the percentage of phagocytosis was 60.3%, the index of completion of phagocytosis was 0.89.

A patient undergoing diet, drug therapy (choleretic and cholecystokinetic drugs) underwent a course of laser acupuncture according to the above methodology - one session per day, 10 treatment sessions.

The patient on the 4th day of the therapy noted that nausea no longer bothered her, the pain in the right hypochondrium decreased, and the stool returned to normal.

After completing the course of pain therapy, the feeling of heaviness in the right hypochondrium stopped, nausea, vomiting no longer repeated.

With repeated duodenal sounding, the normokinetic type of motor function of the gallbladder was observed (time of the second phase of bile secretion 40.5 min, the rate of excretion of cystic bile 16 ml in 5 min, the volume of cystic bile 77.6 ml). Microscopic examination of bile of portion B revealed single white blood cells.

After treatment, there was a decrease in the levels of MDA, which was 19.8 μmol / L and hydroperoxides - 15.3 μmol / L. The indices of antioxidant enzymes, on the contrary, increased and amounted to: catalase - 238.4 mkat / l, superoxide dismutase - 2.29 units / ml.

An increase in the phagocytic activity of leukocytes was noted. So, the activation index was 4.64, the percentage of phagocytosis was 86.6%, the index of completion of phagocytosis was 2.24.

In this clinical example, a case of chronic stoneless cholecystitis in the acute stage is considered. Examination according to duodenal and ultrasound revealed hypomotor-type dyskinesia of the gallbladder, an increase in lipid peroxidation products and a decrease in the level of antioxidant enzymes and the functional activity of leukocytes.

During the treatment, the normalizing effect of laser puncture on the motility of the gallbladder, a positive effect on the clinical signs of exacerbation of the disease, balancing the parameters in the LPO system - antioxidant system, increasing the functional potential of white blood cells, i.e. correction of the failure of the phagocytosis system.

Example 2

Patient S., 60 years old, retired. Suffers from chronic stoneless cholecystitis for 20 years. She was repeatedly hospitalized in the gastroenterological department. The last 2 years the patient is diagnosed with concomitant hepatitis. Suffers from chronic gastritis, hypertension (receives enam in a dosage of 5 mg 3 times a day).

At present, upon admission to the hospital, she complained of constant dull pain, against the background of which there are sometimes sharp cramping pains in the right hypochondrium, belching, bitter nausea, bitterness in the mouth, often in the morning, general weakness, and fatigue.

Objectively: the skin is of normal color, the sclera is icteric, there are no peripheral edema. Respiratory organs within the physiological norm. The boundaries of relative cardiac dullness are extended to the left (along the mid-clavicular line in the 5th intercostal space). Auscultatory: I tone of sufficient sonority, II tone accent above the aorta, systolic murmur at the apex, heart rate of 70 beats per 1 minute. HELL 150/90 mm Hg

There is palpation of pain in the gallbladder, skin hyperesthesia in the right hypochondrium. The liver is palpated 1.5 cm below the costal arch, moderate soreness. The spleen is not palpable.

In blood tests: the stab shift of the leukocyte formula to the left (stab leukocytes - 15%) with a normal content of the total number of leukocytes 5.3 · 10 ⁹ / l, ESR 24 mm / hour. In the biochemical analysis of blood: the content of total bilirubin is increased - 40 μmol / l, ACT 0.62 μmol / l - which is also increased, ALT, total protein, fibrinogen, amylase are normal. In the general analysis of urine - without pathology.

When duodenal sounding revealed a hypokinetic type of motor function of the gallbladder (time of the second phase of bile secretion was increased to 60 minutes, the rate of excretion of cystic bile was reduced to 10.5 ml in 5 minutes, the volume of cystic bile was also increased to 118 ml). Microscopic examination of bile of portion B revealed accumulations of epithelial cells and leukocytes, calcium bilirubinate crystals. When bacteriological examination - in the sowing of bile portion B enterococci.

Ultrasound examination of the gallbladder revealed its deformation (kink in the body), thickening of the walls (thickness 3.2 mm) and other signs of chronic stoneless cholecystitis, as well as an increase in liver echogenicity, i.e. signs of reactive hepatitis.

The lipid peroxidation indices before treatment were: MDA 24.4 μmol / L, hydroperoxides - 18.6 μmol / L. The levels of antioxidant enzymes were within the limits of catalase - 202.2 mkat / l, superoxide dismutase - 1.3 units / ml.

A decrease in the phagocytic activity of leukocytes was noted. So, the activation index was 2.50, the percentage of phagocytosis was 72.2%, the index of completion of phagocytosis was 0.92.

Given the long history, severity of the disease, the presence of two concomitant diseases, a course of intravenous laser therapy was prescribed for 7 days according to the above method. Laser therapy was carried out against the background of the use of medications (carsil, ampicillin, vitamin therapy).

By the end of the course of therapy in the patient, the pain syndrome completely stopped, nausea, flatulence were also not bothered. In addition, the patient noted that by the 5th procedure of laser therapy, the level of blood pressure decreased (up to 130/80 mm Hg) and the patient refused to take the antihypertensive drug in the daytime.

The results of additional studies after treatment.

In a general blood test, normalization of the leukocyte formula. In the biochemical analysis of blood - ALT 0.17 μmol / L, total bilirubin 19.6 μmol / L.

Data of repeated duodenal sounding: the time of the second phase of bile secretion 51.3 min, the rate of excretion of cystic bile 13.3 ml in 5 min, the volume of cystic bile 103.2 ml). Microscopic examination of bile of portion B revealed single white blood cells and calcium bilirubinate crystals. Sowing bile portion B - sterile.

After treatment, there was a decrease in the levels of MDA, which was 20.6 μmol / L and hydroperoxides - 14.8 μmol / L. The indices of antioxidant enzymes, on the contrary, increased and amounted to: catalase - 241.4 mkat / l, superoxide dismutase - 2.3 units / ml. An increase in the phagocytic activity of leukocytes was noted. So, the activation index was 4.26, the percentage of phagocytosis was 69.4%, the index of completion of phagocytosis was 2.4.

In this clinical example of a severe course of chronic stoneless cholecystitis, functional changes were revealed in the liver, in the motility of the gallbladder, in the LPO system - the antioxidant system, as well as the phagocytic activity of leukocytes. As can be seen from the above observation, complex treatment using intravenous laser therapy had a beneficial effect on the motility of the gallbladder and the functional state of the liver, immunocorrective effect on the phagocytosis system and contributed to the normalization of free radical processes in the body of this patient, in addition, had a positive effect on the course of concomitant disease (hypertension).

Clinical and laboratory studies of the proposed method for the treatment of patients with chronic stoneless cholecystitis compared with the known method (prototype) showed the effectiveness of the proposed method of treatment, the possibility of correcting functional changes that occur with this pathology, improving the results of drug therapy, reducing treatment time.

Claims (1)

A method of treating patients with chronic stoneless cholecystitis, including the simultaneous conduct of complex drug therapy and laser therapy, characterized in that laser therapy is prescribed differentially: for a disease duration of less than 7 years and a mild course of the disease, laser reflex therapy is carried out daily with a course of 10 procedures, which is carried out by contact, wavelength 1.3 μm, a radiation power of 1 mW, a modulation frequency of 2.4 Hz, moreover, the points V19, F14, VC12, VB24 are exposed daily, and the impact on G14, E36, E25 glasses symmetrically alternate every other day with exposure to the MC6 and RP6 points symmetrically, with a disease duration of more than 7 years and a moderate or severe degree of the course of the disease, intravenous laser irradiation of blood with a wavelength of 0.63 μm, radiation power at the end of the fiber 1 , 5-2.0 mW, the duration of the procedure is 20 minutes, the course of treatment is 7 procedures.