RU2342079C2 - Forecasting method of acute diverticulitis relapse - Google Patents

Abstract

FIELD: medicine; coloproctology.

SUBSTANCE: presence or absence of clinicodiagnostic criteria, which were given the ball characteristic is examined and at presence of criterion the sign "+" is conferred, at absence - the sign "-" is conferred: presence of the expressed inflammatory changes of a wall of the sigmoid intestine, clinically shown by formation of the inflammatory tumour defined by palpation or according to laparoscopy is "±8 points"; the presence at the first survey of intensive, constant pains is "+9 points", intensive paroxysmal pains is "+5 points", the moderate constant ones is "+2 points" and the moderate paroxysmal pains is "-6 points"; occurrence of the first episode of acute diverticulitis in the age till 60 is "±5 points"; the presence of radiological attributes of proof rising of a tonus in the sigmoid intestine - a functional component is "±5 points"; Radiological attributes of the sustained inflammatory process in the sigmoid intestine, revealed for more than 2 weeks from the moment of the beginning of conservative treatment is "±5 points"; localization of diverticulums only in the left parts of the colonic intestine is "±4 points". Thus if the score makes the number similar or exceeding 13, occurrence of relapse of inflammatory process is prognosticated with probability of more than 90%, and at a score (-13) and less - relapse of inflammatory process will not be prognosticated with probability of more than 90%. In the same case if the score makes from -13 up to +13 - information for forecasting of inflammation relapse is not sufficient.

EFFECT: increase of acute diverticulitis relapse forecasting accuracy.

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Description

The invention relates to medicine, namely to coloproctology, and for predicting the occurrence of a relapse of the inflammatory process after conservative therapy for an episode of acute diverticulitis.

The substrate of diverticulosis of the colon are “false” diverticula, the wall of which does not include the muscular membrane of the intestinal wall. The occurrence of colon diverticulosis in the general adult population of economically developed countries ranges from 35% to 50%, reaching 80% among patients over 70 years of age.

Among patients with diverticulosis of the colon, clinical manifestations occur in 20-25% of cases, widely varying from a feeling of slight discomfort to severe abdominal pain, severe inflammatory complications and profuse intestinal bleeding. These symptoms, in combination with the data of instrumental research methods, make up a diverticular disease (DB) of the colon.

Acute inflammatory complications occur among patients suffering from DB in 10-25% of cases. These complications include acute diverticulitis (OD), inflammatory para-intestinal infiltrate (AFP), diverticulum perforation with the development of peritonitis and make up 70.0-75.0% among patients hospitalized with DB complications. The most common complication of diverticular disease is acute diverticulitis, accounting for 15-25% of all clinical manifestations and 70-75% of acute inflammatory complications of DB.

By the nature of the course, acute diverticulitis is an inflammatory complication that lends itself well to conservative therapy. However, according to the literature, the occurrence of a relapse of the inflammatory process after stopping this complication is noted from 25% to 45% of cases. Moreover, among patients who have recurred an inflammatory process, the occurrence of repeatedly repeated episodes of an acute inflammatory process occurs in 55-68% of cases, and the development of life-threatening inflammatory complications is noted in 15-23% of cases.

The problem of predicting relapse of the inflammatory process is very relevant. However, nowhere in the available literature have we been able to find an algorithm that would allow the treatment of the first attack of acute diverticulitis to predict the occurrence of the following episodes.

The objective of the invention was: to identify risk factors for recurrence of the inflammatory process after conservative therapy for the first episode of acute diverticulitis.

The technical result is a series of signs that we identified, which allows us to isolate a group of patients prognostically dangerous in relation to the development of a repeated episode of acute inflammation during treatment for the first episode of acute diverticulitis.

To accomplish our task, we analyzed the results of treatment of 223 patients with acute diverticulitis (M-60 (26.9%), Zh-163 (73.1%)) aged 34 to 92 years. The average age was 69.0 ± 10.4 years. All patients underwent conservative anti-inflammatory therapy, which was effective in 100% of cases. Long-term treatment results were analyzed in 187 (83.9%) of 223 patients (observation period ranged from 2 to 14 years, an average of 7.4 ± 5.5 years).

We found that conservative therapy does not eliminate the cause of the complication. Repeated attacks of acute diverticulitis were detected by us in 74 (39.6%) patients. Moreover, a continuously recurring course of complication (occurrence of a third, etc. episode) was noted in 68.9% of cases (51 patients). More severe complications (infiltration, para-intestinal cavity) occurred in 12 (16.2%) cases.

We studied the immediate and long-term results of treatment in patients with a relapse-free course of acute diverticulitis and in patients who recurred acute diverticulitis. At the same time, we identified the factors most significant for predicting the occurrence of a relapse of the acute inflammatory process.

1. The onset of the first episode of acute diverticulitis under the age of 60;

2. Characteristics of pain at admission: the presence of intense constant pain.

3. The presence of pronounced inflammatory changes in the wall of the sigmoid colon, clinically manifested by the formation of an inflammatory tumor of the sigmoid colon, determined by palpation or according to laparoscopy;

4. Localization of diverticula only in the left parts of the colon;

5. The presence of radiological signs of a persistent increase in tone in the sigmoid colon (functional component);

6. X-ray signs of the inflammatory process in the sigmoid colon, detected more than 2 weeks from the start of treatment.

Each of these signs was assigned diagnostic coefficients, the sum of which is the number subjected to comparison with a threshold value of 13 points.

If, as a result of their summation, the obtained value is equal to or exceeds the threshold (13 points), then in this patient one should expect the development of a relapse of the inflammatory process with a probability of more than 90%. If the total score is equal to or less than minus thirteen (-13), there will be no relapse of the inflammatory process with a probability of more than 90%.

In the event that the total score is a number from -13 to +13, then there is insufficient information for a statistically reliable prognosis of a relapse.

Diagnostic signs were ranked in accordance with their significance for predicting the development of a relapse of the inflammatory process. If there is a sign, the corresponding mark is assigned a sign (+), in the absence - a sign (-).

1. The presence of pronounced inflammatory changes in the wall of the sigmoid colon, clinically manifested by the formation of an inflammatory tumor of the sigmoid colon, determined by palpation or according to laparoscopy (± 8 points);

2. The presence at the first examination of a patient of intense persistent pain (+9 points), intense paroxysmal pain (+5 points), moderate constant (+2 points) and moderate paroxysmal pain (-6 points).

3. The onset of the first episode of acute diverticulitis under the age of 60 years (± 5 points);

4. The presence of radiological signs of a persistent increase in tone in the sigmoid colon (functional component) (± 5 points);

5. Radiological signs of the inflammatory process in the sigmoid colon, detected more than 2 weeks from the start of conservative treatment (± 5 points);

6. Localization of diverticula only in the left parts of the colon (± 4 points).

The implementation of the proposed method for predicting the recurrence of acute diverticulitis is illustrated by the following clinical example.

Patient O., 66 years old, and / b 9537/96 (f / d-21). Complaints upon admission: pain in the left abdomen, constant, intense (+9 points), without irradiation, fever up to 39.5 ° C.

From the anamnesis it is known: considers himself a patient for 5 days, when there were abdominal pains. After 3 days, she noted a temperature increase to febrile numbers. In connection with the intensification of pain, she asked for help, was taken to the clinic and hospitalized.

Upon admission: satisfactory condition; heart rate 72 beats / min. HELL 130/80 mm RT. Art. The tongue is moist, the abdomen is not swollen, soft, painful in the left iliac region, where the tumor formation is palpable, dense, painful, up to 6x8 cm (+8 points). There is also some tension in the muscles of the anterior abdominal wall. There are no peritoneal symptoms.

Per vaginum: in a bimanual examination, the lower pole of the formation of a soft-elastic consistency, up to 8 cm in diameter, painful, mobile, is palpated to the left of the uterus.

Per rectum: pathological formations are not determined, with palpation through the front wall of the rectum, pain is determined.

The diagnosis of the admission department was formulated: sigmoid blastoma with perifocal inflammation?

The patient underwent conservative treatment: (antibiotics, antispasmodics, liquid paraffin). On the 12th day from the start of antibiotic therapy, the patient underwent irrigoscopy, according to which: the colon was of normal size and shape. In the left parts of the colon, multiple diverticula were revealed, the distribution of which is limited by the distal section of the sigmoid colon (+4 points). The contours of the intestine in these departments are fuzzy, there is a "symptom of a stockade," a persistent increase in tone (+5 points). In the remaining sections, the contours of the intestine are clear, the hustration is symmetrical, preserved. After bowel movement: the relief of the mucous membrane is not changed, the folds of the mucosa are somewhat thickened. There is a fixation of diverticula between themselves and in the surrounding tissues (+5 points). When inflated with air, all departments straighten well, the walls are elastic, the lumen is uniform, signs of increased tone are noted in the sigmoid colon. The data obtained are additionally confirmed by sigmoscopy with biopsy. In this case, signs of inflammation of the mucous membrane of the sigmoid colon were revealed, data for tumor growth were not obtained.

The patient was discharged under the supervision of a coloproctologist on an outpatient basis.

Over the next 3 years, the patient experienced intermittent pain in the left iliac region, and unstable stools disturbed her. 8 months after the first episode of acute diverticulitis, the patient again had pains in the left iliac region, accompanied by a rise in temperature to 38.0 ° C; was treated independently. A similar episode was repeated after 2 years, the patient was hospitalized in hospital No. 31, where the diagnosis of a diverticular disease of the colon with symptoms of acute sigmoid diverticulitis was confirmed. It was treated conservatively with a positive effect.

In the course of the study, we performed a retrospective analysis of the criteria we identified. The likelihood of developing a recurrence of acute diverticulitis after the first episode was more than 90% (31 points).

Given the repeated episodes of diverticulitis, during the study, the patient was offered surgical treatment, in connection with which she was hospitalized at the SSC Coloproctology, and / b 937/99 (f / d-23).

Based on complaints, anamnesis and clinical and instrumental examination, the patient was diagnosed with diverticular colon disease with a primary lesion of the left departments, complicated course; recurrent diverticulitis. Given the recurrent nature of the course of acute diverticulitis, the patient underwent resection of the left parts of the colon with the formation of a descent-rectal anastomosis.

The postoperative period was uneventful, against the background of conservative therapy. In satisfactory condition on the 13th day the patient was discharged.

In a pathomorphological study of the removed preparation No. 3304-18-1999: the length of the resected section of the colon was 17 cm, its wall was thickened, especially in the middle part. In the thickness of the intestinal wall, many bag-shaped protrusions are determined. Heavy mesentery fiber, dense. Microscopic examination: pseudodiverticula were found in the wall of the colon. Severe manifestations of sclerosis in the mesentery fiber.

In the future, the patient was followed up for 6 years: the chair regularly, without enemas and laxatives, no complaints.

The developed forecasting method was tested on a prospective sample of 29 patients with acute diverticulitis (including M-8, Zh-21) who were treated from 2000 to 2001. Among these 29 patients, a relapse of the inflammatory process occurred in 16 (55.2%) cases, and a relapse-free course of the disease was observed in 13 (44.8%) patients. Testing of this sample of patients showed the following results. Among 16 patients in whom a relapse of the inflammatory process occurred, the total score exceeded the threshold (13 points) - in 15 (93.8%) cases. In one case, the total score was 8, indicating a lack of information to predict the development of relapse. There were no cases of erroneous diagnosis.

Among 13 patients whose recurrence of the inflammatory process did not occur in the future, in 2 cases the total score was (-13) and (-24) points, which indicates a predicted disease-free progression. In 10 patients, the total score was in the range from (-13) to (+13), which indicates insufficient information and forms a group of patients who are shown dynamic observation. The sum of points exceeded the threshold number (13) in one (7.7%) of 13 cases.

Thus, the forecast turned out to be correct in 92.3% of cases. The hyperdiagnosis of the recurrence of acute diverticulitis, available in one observation, indicates that, possibly, a relapse of acute diverticulitis in this patient may develop in the future, and he is also shown a dynamic observation.

Thus, the use of the proposed method for predicting the recurrence of acute inflammatory process allows conservative treatment of the first episode of acute diverticulitis to identify a group of patients who are prognostically unfavorable with respect to the possibility of developing a relapse of the inflammatory process.

This indicates the need for dynamic follow-up of these patients and, in the event of a repeated episode of acute inflammation, recommending them planned surgical treatment.

Claims (1)

A method for predicting the recurrence of acute diverticulitis, which consists in examining the presence or absence of clinical diagnostic criteria, each of which is assigned a scoring characteristic, with a criterion assigned a “+” sign, and in the absence a “-” sign: the presence of pronounced inflammatory changes in the wall sigmoid colon, clinically manifested by the formation of an inflammatory tumor, determined by palpation or according to laparoscopy "± 8 points"; the presence at the first examination of intense, constant pain “+9 points”, intense paroxysmal pain “+5 points”, moderate constant pain “+2 points” and moderate paroxysmal pain “-6 points”; occurrence of the first episode of acute diverticulitis under the age of 60 years "± 5 points"; the presence of radiological signs of a persistent increase in tone in the sigmoid colon - a functional component of "± 5 points"; X-ray signs of the inflammatory process in the sigmoid colon, detected more than 2 weeks from the start of conservative treatment "± 5 points"; localization of diverticula only in the left parts of the colon "± 4 points"; at the same time, if the total score is a number equal to or greater than 13, then the occurrence of a relapse of the inflammatory process is predicted with a probability of more than 90%, and if the total score is -13 or less, the relapse of the inflammatory process will not be more likely to be more than 90%; in the same case, if the total score is from -13 to +13, there is not enough information to predict the occurrence of a relapse of inflammation.