RU2338195C1 - Prediction method of acute pancreatitis outcome - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, and can be used for prediction of acute pancreatitis outcome. Method is realised as follows. Once admitted to hospital patient is tested for ascorbate content in blood serum. If it is more than 0.94±0.09 mmol/l, prognosis is considered to be favourable. Content less than 0.45±0.06 mmol/l indicates unfavourable prognosis. Intermediate value shows doubtful prognosis.

EFFECT: higher prediction accuracy of acute pancreatitis outcome.

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Description

The invention relates to medicine, namely to surgery, to the section for assessing the severity of the destructive process in acute pancreatitis (OP), and can be used to predict the outcome of this disease.

It is known that acute pancreatitis, especially its destructive forms, are one of the urgent problems of emergency abdominal surgery. Despite the large number of studies devoted to the diagnosis, prognosis and treatment of acute destructive pancreatitis (ODP), mortality in this pathology remains very high and reaches 40-70% (Vashetko R.V. et al., 2000; Kostyuchenko A.L. Filin V.I., 2000).

TIR develops very dynamically, often with tragic swiftness, which requires a quick determination of the prognosis of the disease and the selection of an adequate volume of treatment (N. Yaitsky et al., 2003).

In the literature studied, the work on predicting the course of OP is based on the integrated use of ultrasound, laparoscopy, angiography (Savelyev BC et al, 1988, 1993), integrated scales: multi-parameter systems Ranson (Ranson JHC, 1982), Glasgow (Blamey S. et al. , 1984), prognostic severity index (Karimov Sh.N., 1993), biochemical index (Belyaev AM et al., 2004), study of pH and blood gases (Kon E.M. et al., 2000), infrared spectral analysis blood serum (Petrov M.S., 2004), the ratio of albumin and lipoprotein indicators (Shalae and TI, 2003), laser correlation spectroscopy (Kovalchuk Yu, 2006).

As a prototype, we took the forecasting method proposed by A. Belyaev. et al. (2004). The essence of the method lies in the fact that they determine the biochemical index by the formula: BI = Gl + M + AcT + Cr, where BI is the biochemical index; Hl - glucose level, mmol / l; M - urea level, mmol / l; ACT - aspartate aminotransferase, mmol / l; Cr - creatinine level, mmol / l, and with a BI value> 23.6, a high probability of an early death is predicted.

The above method is based on the analysis of four biochemical markers that reflect the state of the insular apparatus, the degree of hepatocyte cytolysis, and impaired renal function. However, the preexisting pathology of any of these systems may violate the objectivity of this biochemical index. In addition, the ability to perform all four studies in urgent mode can present technical difficulties for a number of clinics.

The novelty of the proposal is the determination of the concentration of ascorbic acid (ascorbate) in the blood serum of a patient with OP upon admission to the hospital.

A significant difference is that upon admission to the patient’s hospital, the level of ascorbate in the blood serum is determined, and if its indicators are above 0.94 ± 0.09 mmol / L, the prognosis is assessed as favorable, below 0.45 ± 0.06 mmol / L - as unfavorable, with intermediate indicators, the forecast is dubious.

Violation of the mechanisms of regulation of free radical oxidation is the main cause of damage to biological membranes under extreme conditions (hypoxia, stress), leading to the development of a chain reaction that can oxidize various substrates and thereby damage proteins and lipids of biomembranes, inactivate enzymes, change the structure of macromolecules, integrity cells and intracellular organelles, leading to the development of tissue destruction in the focus of inflammation (Vladimirov Yu.A., Archakov AI, 1972). The important role of lipid peroxidation processes in the pathogenesis of OP is known (Vladimirov Yu.A., 1998., Roth E., 2004). The pronounced activation of lipid peroxidation during OP leads to the rapid depletion of factors of the antioxidant system, primarily ascorbic acid (AK), a key antioxidant in blood plasma (Sweiry J.H., 1996). Severe OP is accompanied by a decrease in the level of AK in the blood by a factor of ten (Scott P., 1993).

The methodology of the proposed method consists in the fact that upon admission to treatment the patient was sampled OP 5.0 ml of peripheral venous blood, which was centrifuged to obtain serum. The ascorbic acid concentration was determined by the colorimetric method with Folin reagent (commercial) (Jagota S.K., Dani H.M., 1982). 0.5 ml of test serum and 0.5 ml of 10% trichloroacetic acid were placed in a test tube. The control sample instead of serum contained 0.5 ml of distilled water. The tubes were placed for 5 minutes in an ice bath, followed by centrifugation at 3000 rpm for 10 minutes. The supernatant was placed in a 10 mm cuvette with the addition of 0.2 ml Folin reagent diluted 2 times and left for 10 minutes at room temperature. A standard sample was prepared by diluting 25 mg of Labtech dry ascorbic acid powder in 100 ml of distilled water, 0.5 ml of the standard was mixed with 0.5 ml of a 10% trichloroacetic acid solution. 0.5 ml of the resulting solution was placed in a cuvette and 0.2 ml of Folin reagent was added. The optical density of the samples was determined at a wavelength of 760 nm on an Apel PD-303 UV spectrophotometer (Japan).

The calculation of the concentration of ascorbic acid was carried out according to the formula

C = ((E sample) / (E standard)) × 2.5 mg /%,

where C is the concentration of ascorbic acid;

E samples - the optical density of the experimental sample,

E standard - the optical density of a standard sample,

2.5 mg /% - the concentration of ascorbic acid in the standard.

As a control of the content of ascorbic acid in the blood serum, the results of blood tests of 20 practically healthy human donors aged 27-40 years were taken. The normal content of ascorbate in the blood serum was 3.4 ± 0.29 mg /%.

A study was made of the level of ascorbic acid in 73 patients with OP, which were retrospectively divided into two groups comparable in main parameters: group I - survivors (45 patients), group II - patients with fatal outcome (28 patients). Upon admission, all patients received standard therapy (infusions, pancreatic secretion blockers, antispasmodics, antibiotics). According to indications, surgical interventions (laparoscopic drainage, laparotomy) were performed. Patients who underwent surgery received the same multicomponent intensive therapy in the postoperative period, including active infusion-transfusion therapy, the use of pancreatic secretion blockers, antibiotics, and extracorporeal detoxification methods.

Additionally, the severity of pancreatitis was determined according to the Glasgow scale (1984). The severity index was determined on a SAPS II (1993) scale.

The data obtained are presented in the table.

Ascorbate, mmol / L Glasgow (average) SAPS II (average) Norm 3.4 ± 0.29 - - I group 0.94 ± 0.09 * 2.7 29.4 II group 0.45 ± 0.06 ** 2.9 33.6 * The difference is significant in relation to the norm (mmol / l, p <0.01).
** The difference is significant in relation to group I and to the norm (mmol / l, p <0.01)

An analysis of the results indicates a significant decrease in the level of ascorbic acid in the blood serum in both groups compared with the norm and a significant difference between the groups. In 18 patients, ascorbate concentrations had intermediate values, 8 of them survived, having suffered severe forms of OP, 10 patients died (see drawing).

A strong direct correlation was found between the change in the ascorbate level in the groups and the Glasgow (r = 0.92) and SAPS II (r = 0.91) indicators.

Clinical example No. 1.

Patient S., 46 years old. Diagnosis: Acute total hemorrhagic pancreatic necrosis, diffuse serous-hemorrhagic peritonitis. Laparoscopy after 56 hours from the moment of admission due to an increase in the peritoneal clinic. Performed drainage of the stuffing bag, rehabilitation and drainage of the abdominal cavity. Recovery. Discharged with an emerging pancreatic tail cyst. The level of ascorbate in the blood serum upon receipt of 1.32 mmol / L.

Clinical example No. 2.

Patient K., 54 years old. Diagnosis: Acute total hemorrhagic pancreatic necrosis, diffuse serous-hemorrhagic peritonitis. Laparoscopy 30 hours after admission due to increased intoxication and peritoneal clinic. Performed endoscopic cholecystostomy, drainage of the omental bursa, rehabilitation and drainage of the abdominal cavity. On the 11th day, laparotomy, lumbotomy on the left, opening, drainage of parapancreatic phlegmon and paracolic phlegmon on the left were performed. The postoperative period is difficult, 4 sanitation revisions of the stuffing bag were performed. Recovery. The level of ascorbate in the blood serum upon receipt of 0.58 mmol / L.

Clinical example No. 3.

Patient O., 39 years old. Diagnosis: Acute total hemorrhagic pancreatic necrosis, diffuse serous-hemorrhagic peritonitis. Laparoscopy 42 hours after admission due to increased intoxication and peritoneal clinic. Performed endoscopic cholecystostomy, drainage of the omental bursa, rehabilitation and drainage of the abdominal cavity. On the 9th day laparotomy, lumbotomy on the left, autopsy, drainage of parapancreatic phlegmon and paracolic phlegmon on the left were performed. The postoperative period is difficult, 3 readjustment revisions of the stuffing bag, left retroperitoneal space were performed. Fatal outcome on the 20th day from pancreatogenic sepsis. The level of ascorbate in serum upon receipt of 0.25 mmol / L.

Thus, the proposed method is effective, simple, affordable, allows you to accurately predict the outcome of OP, which allows you to adequately optimize the treatment tactics for this disease.

Literature

1. Belyaev A.M. et al. A method for predicting early deaths of severe destructive pancreatitis in the early stages of the disease. RF patent No. 2004131310, 2004.

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3. Vladimirov Yu.A. Free radicals and antioxidants // Vestnik RAMS. - 1998. - No. 7. - S. 43-51

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Claims (1)

A method for predicting the outcome of acute pancreatitis by examining blood serum, characterized in that upon admission to a patient’s hospital, the level of ascorbate is determined, and if it is above 0.94 ± 0.09 mmol / L, the prognosis is assessed as favorable, below 0.45 ± 0 , 06 mmol / l - as unfavorable, with intermediate indicators, the prognosis is dubious.

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