RU2311120C2 - Method for predicting functional pathology in intestinal ileocecal department - Google Patents

Abstract

FIELD: medicine, gastroenterology.

SUBSTANCE: the present innovation deals with complex diagnostics of functional pathology in intestinal ileocecal department. For this purpose one should endoscopically fulfill intubation of large intestine (LI) and terminal department of ileum (TDI). Through the endoscope into TDI lumen a catheter should be introduced to fulfill outputmanometry. Then one should determine a minute output of liquid perfusion in TDI at phase I (Ph I) that is characterized with instable values of output, and in phase II (Ph II) being characterized with stabilization of minute output values. Coefficient of α-output should be detected as the ratio of output in Ph II against output in Ph I. Due to comparing the results of outputmanometry in Ph I and Ph II against the results of experimentally obtained normal values of output in TDI one should state upon hyperkinetic type of motor activity of TDI. Pressure gradient β between LI and TDI should be determined as the pressure in TDI minus the pressure in LI. At β=0 in combination with hyperkinetic type of TDI motorics in Ph II and α being below 1 it is possible to diagnose ileocecal failure degree I in compensated stage. The innovation provides the chance for significant early diagnostics of functional pathology in intestinal ileocecal department due to objective apparatus-based measurements.

EFFECT: higher accuracy of diagnostics.

2 dwg

Description

The method relates to medicine, is applicable for the diagnosis of functional disorders of the intestine, mainly the sphincter apparatus of the colon and terminal ileum.

It is known [11] that the gastrointestinal tract of mammals and humans has two sections: upper and lower. The upper section consists of the oropharynx, esophagus, stomach and duodenum. The lower section consists of a small and large intestine.

The small intestine is represented by the jejunum and ileum.

The large intestine contains the cecum, appendix, colon and rectum.

The large intestine is located around the perimeter of the abdominal cavity. The large intestine begins in the right ileal region with the cecum. In the right half of the abdominal cavity, the colon runs from the bottom up (from the pelvis to the liver), in the upper part of the abdominal cavity crosses it from right to left (from the liver to the spleen) and in the left half of the abdominal cavity goes down from the spleen into the pelvic cavity.

The terminal ileum (TOPC) flows into the cecum. At the place of its confluence, a physiological valve is located, including the ileocecal valve or sphincter. The sphincter acts as a check valve and prevents the antiphysiological reflux of the contents of the cecum back into the ileum [11].

Throughout the gastrointestinal tract are several dozen of these sphincters that regulate the movement of food masses along the digestive tract from top to bottom. Violation of their functioning causes a variety of diseases.

Normally, food masses, being in different stages of digestion, move from the stomach to the small intestine, and from there to the large intestine. With various pathological conditions, the work of the intestinal sphincters is disrupted and, in turn, the movement of the food chyme is disrupted. The food chyme moves in the antiphysiological, reverse direction - from the large intestine to the small intestine, causing dysbiosis, flatulence, colic, soreness, and with prolonged existence - and morphological changes in the small intestine mucosa.

Known research methods [1-6, 13, 14] used in medicine for the diagnosis of functional intestinal pathology:

- X-ray examination (X-ray irrigoscopy),

- ultrasonic irrigoscopy,

- colonoscopy.

X-ray examination of the colon is performed according to standard methods [14]. An radiopaque suspension and air are introduced into the lumen of the colon. Survey and targeted x-rays are taken of all departments of the colon in different positions of the patient. Then, after removal of the radiopaque suspension and air from the colon, the relief of the intestinal mucosa is examined. The injection of contrast medium into the ileum serves as the basis for the diagnosis of insolvency of the ileocecal valve, the sphincter. Depending on the amount of contrast medium abandoned and the extent of reflux, the degree of insolvency of the ileocecal valve is distinguished [2, 3, 10, 12].

The disadvantages of this method are:

- radiation exposure to which the patient and the doctor are exposed;

- a large number of false-positive diagnostic results, due to the regular opening of the valve during tight filling of the canopy of the cecum with contrast and its overextension during deep palpation, massage and contraction during bowel movements;

- the impossibility, in some cases, to contrast the terminal ileum and determine the nature of the inflammatory changes in this segment;

- lack of clear criteria and objective indicators of the functional inferiority of the ileocecal valve.

Modern literature indicates the inconsistency and low informativeness of the method in the diagnosis of ileocecal valve insufficiency [13].

A known method of transabdominal ultrasound diagnosis of ileocecal valve insufficiency [5].

Transabdominal ultrasound irrigoscopy is performed after filling the colon with an echo-conducting medium [4, 6].

Moreover, ileocecal valve insufficiency is diagnosed only in cases of absolute valvular insufficiency according to the relevant criteria: the presence of a diagnostic environment in the ileum and the constant gaping of the opening of the ileocecal sphincter valve during the study [6]. The disadvantages of this method are:

- insufficient informational content of the diagnosis of inflammatory changes in the colon and ileum due to the lack of clear criteria and objective indicators of the functional inferiority of the ileocecal valve;

- lack of biopsy if necessary:

- the presence of the likelihood of developing volemic disorders due to the large volume of fluid introduced into the lumen of the colon and an increase in intraluminal pressure;

- the appearance in most patients of the urge to defecate and discomfort;

- the inability to register echocriteria of valve failure in the phase of relative, reversible valve failure.

Known endoscopic method for the diagnosis of ileocecal insufficiency [1].

At the same time, the endoscopist in diagnostics has to focus not on objective indicators of instrumental measurements, but on the visual picture of indirect signs of ileocecal valve insufficiency: persistent Hirsch sphincter spasm, the presence of a large amount of liquid chyme in the cecum, irritation of the cecum and ascending gut with rough, high folds hyperemic, edematous, sometimes with lymphofollicular hyperplasia of the mucous membrane of the valves of the ileocecal valve. Only with wide-open lips of the ileocecal valve with a gaping hole does the endoscopic diagnosis acquire independent significance.

The disadvantages of this method are:

- inaccuracy of diagnosis due to the lack of specific criteria for ileocecal insufficiency,

- the inability to determine the causes of inflammatory changes in the ileocecal region,

- inaccuracy of diagnosis due to the ambiguous interpretation of the terminal ileum and the presence of pain in the absence of inflammatory changes in the mucosa of the ileocecal region,

- subjectivity of interpretation

Thus, the condition of the intestine, for example, pathology in the form of loss of the closure function of the ileocecal valve, according to endoscopic examination, is diagnosed very limitedly - only in cases of absolute failure.

Closest to the proposed invention is a method of manometry using an ileo- or colostomy [16]. In this case, two multi-lumen catheters are used. One catheter is inserted through the stoma into the cecum, another catheter is inserted through the stoma into the TOC. The location of the catheters in the intestine is controlled radiologically. After installation, the catheters are connected to pressure sensors, liquid is injected through the catheters at a speed of 0.15 ml / min and pressure is recorded in the cecum, ileocecal valve — sphincter, TOPK.

Signals from pressure sensors are recorded and interpreted. The disadvantages of the method [16] are:

1. The complexity of the execution - the method is feasible only after surgery.

2. The implementation of the method is traumatic for the patient.

3. Limited applicability.

4. The complexity of the design of catheters, measuring instruments and their operation.

5. The need for x-ray control over the location of the catheters and is accompanied by irradiation of the patient and the doctor.

In addition, an assessment of the degree of functional disorders of the ileocecal sphincter, terminal ileum and ascending intestine with this method is not carried out due to the fact that this method does not allow to determine the criteria for ileocecal insufficiency. The authors obtained only averaged pressure values in the ileocecal sphincter in a small sample and only in healthy patients.

According to domestic and foreign literature [7], the diagnosis of pathophysiological conditions from the side of the TPK, ileocecal valve - sphincter and colon has not been thoroughly developed.

Due to disadvantages, the known analogues and prototype have limited use and do not provide the necessary accuracy and reliability of the diagnosis.

The proposed method is intended to improve the accuracy and reliability of the diagnosis of diseases of this department. The essence of the proposed method is as follows.

The patient is laid horizontally on his back. Colonoscopy is performed according to a traditional technique. The endoscope reaches the dome of the cecum, perform ileoscopy. A catheter is inserted into the lumen of the TPOK through an endoscope, debitomanometry is performed, the time and normalization option are determined, as well as the type of TOPK motility, pressure indicators are recorded in the TOPK. Investigate the flow rates before and after normalization of the motility of the TOPK. The catheter is removed into the lumen of the ascending colon and the pressure in the ascending colon is measured. According to the results of manometry, the pressure difference (pressure gradient) in the ascending part of the colon and TOPK is calculated.

The proposed method is carried out, for example, as follows.

Debitomanometry is performed using a catheter with a removable cannula, a syringe without a piston, a vertical centimeter ruler and a stopwatch. The catheter is made, for example, of a transparent polymeric material, with a length not less than the length of the endoscope, with an outer diameter that allows it to be freely passed through the instrument channel of the endoscope. The catheter, centimeter ruler is N cm long, a removable cannula, a syringe with a volume of M ml with a division price of at least 1 ml and a stopwatch are standard.

Debitomanometry is performed in the process of colonoscopy. The patient is laid horizontally on his back. Colonoscopy is performed according to the traditional technique [9]. A flexible endoscope is passed through the entire colon and reaches the dome of the cecum. Then the endoscope is passed through the ileocecal valve into the lumen of the terminal ileum (TOPC), and ileoscopy is performed. A catheter is inserted through the instrument channel of the endoscope into the lumen of the TPOK with the distal end forward, so that the end of the catheter is at least 10 cm from the ileocecal valve and is outside the high pressure zone of the ileocecal transition [16]. This allows you to record the true pressure in the ileum.

During the study, visually through the endoscope monitor the correct location of the distal end of the catheter in the observed area - according to the corresponding marking.

A cannula is connected to the proximal end of the catheter, with which the catheter is fixed to the syringe. The syringe is pre-attached to the vertical ruler so that the cannula is at the bottom and is located at a height of 40 cm from the level of the colon canopy (zero reference point).

The syringe is filled with a colored liquid, for example, isotonic sodium chloride solution, room temperature, in a volume of R ml. After a part of the liquid (at least 5 ml) by gravity through a catheter enters the lumen of the TOPK, the stopwatch is started. Every minute take indicators of fluid perfusion (flow rate) by TOPK for at least 10 minutes. This time is necessary for the normalization of the motor activity of TOPK after intubation with an endoscope and is sufficient for an objective assessment of its motor activity. The perfusion rate is measured, for example, in ml / min. For greater reliability of the results, the study is performed twice.

Then measure the pressure in the TOPK. Using a syringe and cannula, the catheter is filled with a colored liquid, for example, isotonic sodium chloride solution, at room temperature. The outer end of the catheter with the cannula is disconnected from the syringe and fixed on a vertical ruler. In this case, the zero reference point on the ruler should be located at the level of the dome of the cecum. When measuring pressure in the TOC, the inner end of the catheter is positioned in the TOC cavity. Pressure is measured in cm of water. Art.

To record the pressure in the ascending colon, the inner end of the catheter is removed from the TPOK into the lumen of the cecum and placed opposite the ileocecal valve. Registration of pressure in each section of the intestine is performed three times. This allows you to avoid obtaining false results due to accidental interference - the ingress of mucus, air, chyme into the distal end of the catheter and its "suction" to the intestinal wall.

The pressure in the ascending part of the colon is determined similarly to the determination of pressure in the TOPK.

The performance debitomanometry in the TOPK is schematically illustrated in Figure 1. The patient is laid horizontally on his back (not shown on the diagram). Colonoscopy is performed according to a traditional technique. A flexible endoscope 1 is carried out along the entire large intestine 2 and reaches the dome of the cecum 3. Then the endoscope is passed through the ileocecal valve 4 into the lumen of the terminal ileum (TOPC) 5, and ileoscopy is performed (position a). Through the instrument channel of the endoscope, a catheter 6 is inserted into the lumen of the TOPK 5 with the distal end 7 forward, so that the distal end of the catheter 7 is at least 10 cm from the ileocecal valve 4.

A cannula 9 is connected to the proximal end 8 of the catheter 6, with which the catheter 6 is fixed to the syringe 10. The syringe 10 is pre-attached to the vertical ruler 11 so that the cannula 9 is at the bottom and located 40 cm above the level of the colon 3 dome (zero point reference).

The syringe 10 is filled with a colored liquid 11, for example, an isotonic solution of sodium chloride at room temperature in a volume of R ml. After part of the fluid 11 (at least 5 ml) by gravity through the catheter 6 enters the lumen of the TOPK 5, a stopwatch (not shown in the diagram) is turned on. Every minute take indicators of fluid perfusion.

A pressure measurement is performed in the TPOK and colon. This is schematically illustrated in FIG. 2. The patient continues to lie on his back (not indicated on the diagram).

The endoscope 1 continues to remain in the lumen of the colon 2, while the endoscope end is located in the dome of the cecum 3, the distal end 7 of the catheter 6 is located in the lumen of the TOPK 5 at a distance of not less than 10 cm from the ileocecal valve 4.

The catheter 6 is filled with a syringe 10 and a cannula 9 with a colored liquid 11, for example, isotonic sodium chloride solution at room temperature (position a). After that, the outer end of the catheter 8 with the cannula 9 is disconnected from the syringe 10. The outer end of the catheter 8 with a length of at least 40 cm is fixed on a vertical ruler 12 (position c). In this case, the zero reference point on the ruler should be at the level of the dome of the cecum 3.

The measurement of pressure in the colon is performed similarly to the measurement of pressure in the TOC, with the catheter being placed in the colon.

The results of debitomanometry are shown on the example of ileocecal insufficiency.

The experimentally determined normal flow rates in TOPK are on average Q ± z ml / min. According to the minute rate indicators, the motor activity of TOPK is determined. Two phases are distinguished depending on the flow rate.

Phase I - characterized by unstable flow rates. This phase is unnatural, antiphysiological and occurs in response to retrograde irritation of the TPOK with an endoscope, catheter and fluid (provocative test), which corresponds to the flow of contents from the colon into the small intestine in case of ileocecal insufficiency (cecoileal reflux). This phase is characterized by different in frequency and amplitude of the wave reduction TOPK and minute-by-minute flow rates.

Phase II - is characterized by stabilization of fluid flow rates and indicates the normalization of the motility of the TOPK. This phase is characterized by waves of TOPK contractions that are identical in frequency and amplitude and have similar flow rates.

Then evaluate the compensatory function of the TOPK during the provocative test. To do this, the average rate in the I and II phase calculate the rate of production. The production rate α is equal to the ratio of the production rate of the II phase to the production rate of the I phase. That is, α = phase II flow rate / phase I flow rate.

By the value of α, the nature of the intestinal pathology is diagnosed.

In this case, for example:

the case α <1 is characteristic of the preserved compensatory function of the TOPK.

the case α> 1 is characteristic of a decreased compensatory function of the TOPK.

In each phase, according to the results of debitomanometry, the type of motor activity of TOPK is distinguished:

Hypokinetic type - the rate of fluid perfusion is less than the normal flow rate.

Normokinetic type - the rate of fluid perfusion does not go beyond the boundaries of the normal flow rates.

Hyperkinetic type - the rate of fluid perfusion exceeds the value of normal flow rate.

By the type of motor activity, TOPK is diagnosed with pathology, for example, as follows:

- the hyperkinetic type indicates the predominance of fast phase contractions of TOPK, observed, for example, in patients in the compensated stage of ileocecal insufficiency.

The pressure gradient β between the colon and TOPK is determined as:

β = pressure in the ileum minus pressure in the colon.

The gradient can be negative, zero or positive depending on the state of the intestine.

For example, with β = 0 in patients, a reduced sphincter function of the ileocecal valve is determined.

Depending on the relationship of the specified parameters - flow rate coefficient α, type of motor activity of the TPOK, pressure gradient β, the degree (stage) of ileocecal insufficiency (ICI) is diagnosed. For example, an ICI of the 1st degree (compensated stage) is diagnosed at β = 0 in combination with the hyperkinetic type of motility of the TPOK in phase II and the rate of production α is less than unity.

In addition, a condition of tonus in the colon is diagnosed. For example, when the pressure in the ascending colon exceeds the value of normal pressure, a subgroup with a predominance of spastic ascending colitis is diagnosed.

Examples of the implementation of the invention show that its use allows you to qualitatively and quantitatively analyze the condition of the intestine based on objective instrumental measurements, and not just subjective observations of a doctor. Thus, the application of the invention improves the accuracy and reliability of the diagnosis.

The advantages of the proposed diagnostic method:

The method of research and diagnosis is safe for the patient.

Diagnostics is performed using publicly available equipment and is available for widespread use.

The method provides a higher, in comparison with known methods, the reliability of diagnostic results.

The method allows to obtain previously undetectable quantitative and qualitative parameters of the intestine and diagnose early forms of pathologies.

The method significantly expands the capabilities and reliability of the diagnosis of intestinal pathology.

The method allows to predict the risk of developing functional pathology of the ileocecal section of the intestine and to select an adequate treatment method with an effect on the main links of pathogenesis.

USED SOURCES

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2. Beloselsky N.N. Clinical and radiological examination of the ileocecal region with visualization of the ileocecal valve is normal and in some diseases. - Abstract. Cand. Diss. - M., 1991-27 p.

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Claims (1)

A method for complex diagnostics of the functional pathology of the ileocecal intestine, including endoscopic intubation of the colon (TC) and terminal ileum (TOPC), insertion of a catheter into the lumen of the TPOK through the endoscope, and performing a debitomanometry, characterized in that the minute perfusion rate of the fluid perfusion in the TPOK is determined phase I (Ф I), characterized by unstable flow rates, and in phase II (Ф II), characterized by stabilization of minute output values, determine the flow rate “Α” as the ratio of flow rate in Ф II to flow rate in Ф I, then, by comparing the results of flow rate metering in Ф I and Ф II with the results of experimentally determined normal flow rates in TOPK, the hyperkinetic type of motor activity of TOPK is revealed, pressure gradient β between the colon is determined and TPOK, as the pressure in the TPOK minus the pressure in the colon, and when β = 0, in combination with the hyperkinetic type of motility of the TPOK in F II and "α" less than one, Ileocecal insufficiency of the 1st degree in the compensated stage is diagnosed.

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