RU2372619C1 - Method for prediction of progression of hepatic failure in intrahepatic cholestasis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: progression of hepatic failure in intrahepatic cholestasis is predicted by biochemical screen of blood serum. There are ratios evaluated as follows: bile acids to cholesterol, bile acids to triglycerides, bile acids to low density lipoproteids, bile acids to high density lipoproteids. If the BA/Ch in the patients suffering from hepatic failure class A is less than 3, class B is 3 to 8, class C is more than 8; and if the BA/TG in the patients suffering from hepatic failure class A is less than 20, class B 20-30 and class C is more than 30; if the BA/LDLP in the patients suffering from hepatic failure class A is less than 5, class B 5-10, class C is more 10; if the BA/HDLP in the patients suffering from hepatic failure class A is less than 20, class B is 20-50, class C is more than 50, progression of hepatic failure is predicted.

EFFECT: higher accuracy of prediction of progression of hepatic failure in intrahepatic cholestasis.

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Description

The invention relates to medicine, namely to hepatology, and can be used as a method for predicting the progression of liver failure with intrahepatic cholestasis.

A known method for predicting the progression of liver failure by analyzing calcium metabolism (1 - Blyuger AF, Novitsky IN Practical hepatology. - Riga, 1984). This method is taken as an analog.

A known method for predicting the progression of liver failure by analyzing copper metabolism (2 - Blyuger AF, Novitsky IN Practical hepatology. - Riga, 1984). This method is adopted as a prototype.

However, the accuracy of predicting the progression of liver failure with intrahepatic cholestasis in this method is limited.

The aim of the present invention is to improve the accuracy of predicting the progression of liver failure with intrahepatic cholestasis.

The technical result is achieved by the fact that in the blood serum the ratio of bile acids to cholesterol, bile acids to triglycerides, bile acids to low density lipoproteins, bile acids to high density lipoproteins and when the value of FA / cholesterol in patients with liver failure class A less than 3, class B from 3 to 8, class C more than 8; and when the value of FA / TG in patients with liver failure class A less than 20, class B 20-30 and class C more than 30; when the value of LC / LDL in patients with liver failure class A less than 5, class B 5-10, class C more than 10; when the value of LC / HDL in patients with class A liver failure is less than 20, class B 20-50, class C more than 50, liver failure is predicted to progress.

The method is as follows.

Patients are admitted with varying degrees of severity of liver failure (A, B, and C according to Childe Pugh) with the presence of skin itching, yellowness of the skin and sclera, and the presence of telangiectosis and hepatic palms. From the anamnesis it is known that patients were infected with hepatitis B and C viruses or suffered from primary sclerosing cholangitis, primary biliary cirrhosis, as well as alcoholic liver disease or steatohepatitis.

On palpation, compaction and tenderness of the edge of the liver are noted. With ultrasound, the liver and spleen are enlarged. An endoscopic examination revealed varicose veins of the esophagus. Biochemical studies show an increase in bile acids, an increase in cholesterol, triglycerides, low density lipoproteins and high density lipoproteins. In addition, there is a decrease in the platelet count, prothrombin and protein fractions.

Ultrasound and computer studies show an increase in the size of the liver, an increase in its echogenicity, dilatation of the portal and splenic veins, and in severe cases, dilatation of the veins of the anterior abdominal wall.

The ratio of bile acids to cholesterol, bile acids to triglycerides, bile acids to low density lipoproteins, bile acids to high density lipoproteins and when the value of LC / cholesterol in patients with liver failure class A less than 3, class B from 3 to 8 is determined in blood serum. , class C more than 8; and when the value of FA / TG in patients with liver failure class A less than 20, class B 20-30 and class C more than 30; when the value of LC / LDL in patients with liver failure class A less than 5, class B 5-10, class C more than 10; when the value of LC / HDL in patients with liver failure class A less than 20, class B 20-50, class C more than 50 predict the progression of liver failure.

The method is confirmed by the following examples.

Example 1

Patient D., born in 1952, was admitted with a diagnosis of primary biliary cirrhosis, chronic cholecystitis remission, chronic pancreatitis. From the anamnesis it is known that 5 years ago, due to an increase in the level of alkaline phosphatase and transaminases, a chronic hepatitis of an unknown etiology was diagnosed.

Upon receipt, the condition is satisfactory, complaints of periodic mild skin itching. Appetite, weight stable, stool - constipation. The skin is pigmented, subicteric sclera. In the lungs, vesicular breathing, no wheezing. BH 17 per minute. Heart sounds of normal sonority, rhythmic, heart rate 64 min. HELL 120/80 mm Hg The abdomen is soft, painless. The liver along the edge of the costal arch, the spleen is not palpable.

Ultrasound: The liver is not enlarged (thickness of the right lobe is 126 mm, left - 57 mm), the structure of the parenchyma is heterogeneous, echogenicity is increased. The portal vein is not dilated. The bile ducts are not dilated. Choledoch 3 mm. The gall bladder is not deformed, the dimensions are not changed. The walls are thickened, up to 2.5 mm. Content is uniform. The pancreas is usually located, the dimensions are not changed. The contours are uneven, fuzzy. The structure of the parenchyma is heterogeneous. Echogenicity is increased. Wirsung duct not expanded, diameter 1 mm. The spleen is usually located, the contours are even, clear. The sizes are not changed: the area is 46 sq. see Splenic vein is not expanded. The kidneys are typically located. The contours are even, clear. The right kidney is 106 × 43 mm, the left kidney is 106 × 43 mm. Conclusion: Diffuse changes in the liver. Chronic cholecystitis. Chronic pancreatitis.

ECG: Deviation of the electrical axis of the heart to the left. Sinus rhythm, correct. Heart rate 83 per minute. Moderately pronounced diffuse changes in the myocardium.

X-ray examination of the upper gastrointestinal tract: cardia failure.

UZDG: Indicators of portal blood flow within normal limits.

Elastometry: fibrosis index according to METAVIR F3.

LABORATORY DATA

LABORATORY DATA upon enrolment At discharge upon enrolment at discharge Hemoglobin 139 142 bilirubin 34.2 (pr 5, b) 29 (D 4.8) Red blood cells 4.1 3.9 cholesterol 7.3 7.1 Platelets 290 272 Alkaline phosphatase 551 414.4 White blood cells 4.1 4.9 TG 1,54 1,5 PO Box 2 2 GGTP 425 289.2 s / i 62 60 AST 78.3 65,4 Eosinophils one one Alt 131.6 117.2 Lymphocytes 29th 29th Glucose 5.5 5,6 Monocytes 6 8 Gall acid 20 mmol / l ESR 35 thirty Total protein 77.4 79,4 Albumin 40,4 44.1 Prothrombin 75 80 Urea 3,5 4.2 LDL 4.1 4.0 HDL 1,6 1.7 General urine analysis: beats. weight - 1029, protein - 0.1 (normal to 0.2), sugar - no, white blood cells are absent.

The ratio of bile acids to cholesterol, bile acids to triglycerides, bile acids to low density lipoproteins, bile acids to high density lipoproteins is determined in blood serum. The ratio of LC / cholesterol in a patient with class A liver failure is 20 / 7.1 = 2.8 (less than 3); ratio LCD / TG 20 / 1.54 = 12.9 (less than 20); the ratio of LCD / LDL 20 / 4.1 = 4.8 (less than 5); the ratio of LCD / HDL 20 / 1.6 = 12.5 (less than 20). The values of the coefficients allow us to predict liver failure class A according to Child-Pugh.

Example 2

Patient Z., 36 years old, was admitted with a diagnosis of liver cirrhosis of alcoholic etiology. Acute alcoholic hepatitis from February 2008. Portal hypertension. Splenomegaly. Edematous ascites syndrome. Hemorrhagic syndrome. Chronic pancreatitis in the stage of subsiding exacerbation. Alcoholic cardiomyopathy and nephropathy. Anemia of mixed genesis of moderate severity. Encephalopathy 2-3 tbsp. Peripheral polyneuropathy. Psychoorganic syndrome.

Upon receipt of a complaint about the weakness of the arms and legs, a feeling of numbness and cramps, abdominal pain in the navel, pressing pains in the temporal region. Appetite is reduced. The chair is regular, decorated without pathological impurities. Sick for 2 months, when, against the background of alcohol abuse, he noted the appearance of weakness, an increase in the volume of the abdomen, and an increase in temperature to 38 ° C.

At admission: a state of moderate severity. The skin is icteric, single telangiectasias, palmar erythema, icteric sclera. In the lungs, vesicular breathing, weakened in the lower parts, no wheezing. BH 18-20 per min. Heart sounds of normal sonority, rhythmic. Heart rate 100 per minute. HELL 90/60 mm Hg The abdomen is soft, significantly increased in size due to ascites and flatulence, moderately painful on palpation in the upper sections. Palpation of the liver and spleen is impossible due to severe ascites. There is no dysuria. No swelling.

Ultrasound Acoustic access is difficult due to flatulence and ascites. The size of the liver is increased (the thickness of the right lobe is 18.2 mm, the left is 9.0 mm), a significant increase in echogenicity, the vascular pattern is preserved. The gall bladder is physiologically reduced. The common bile duct is within normal limits. The size of the pancreas: head - 46 mm, body - 22 mm, tail - 27. Echogenicity is mixed, the contours are even. The size of the spleen is increased (area 99 cm), there are collaterals. The portal vein gauge is 1.6 cm, the splenic one is 1.1 cm. The sound properties of the kidneys are normal. Big ascites. Conclusion: diffuse changes in the liver and pancreas. Ascites. Signs of portal hypertension, expansion of the portal and splenic veins, collateral, splenomegaly.

X-ray examination of the chest. On the chest radiograph in a direct projection of focal and infiltrative changes in the lungs was not noted. The pulmonary pattern is somewhat enhanced due to the vascular component. The roots of the lungs are structural. The diaphragm is located usually. The thoracic aorta is sealed. The shadow of the heart is somewhat widened to the left.

EGDS: Chronic, moderate gastritis of the antrum.

Neurologist consultation. The patient has a clinical picture of toxic encephalopathy in the stage of subcompensation with cephalgic syndrome, cognitive impairment, ataxia.

ECHOKG. Conclusion: a slight increase in the left atrium. Systolic function of the left ventricle is reduced. The diastolic function of the left ventricle is impaired. Vegetation on valve flaps was not detected.

LABORATORY DATA Upon enrolment At discharge Upon enrolment At discharge Hemoglobin 8.7 9.9 Bilirubin 119 (D 53, b) 82 (D 31.8) Red blood cells 3.07 3.33 Cholesterol 4.1 4.41 Platelets 286 237 Alkaline phosphatase 241 244 White blood cells 13.1 eleven TG 1,2 PO Box 10 2 GGTP 132.1 154.9 s / i 74 78 AST 102.5 72.9 Eosinophils 2 2 Alt 49.4 62 Lymphocytes 8 fourteen Glucose 6.9 5.08 Monocytes 6 four Bile acids 54 mmol / l ESR 34 fourteen Total protein 64,4 62,4 Fibrinogen 1.8 2.0 Albumin 22.8 29.4 Prothrombin 34.3 35,2 Urea 7.0 2.88 Transferrin 177.7 175 LDL 2.5 Ferritin 72 70 HDL 0.8 General urine analysis: beats. weight - 1029, protein - 0.1 (normal to 0.2), sugar - no, white blood cells

The ratio of bile acids to cholesterol, bile acids to triglycerides, bile acids to low density lipoproteins, bile acids to high density lipoproteins is determined in blood serum. The ratio of FA / cholesterol in a patient with liver failure is 54 / 4.1 = 13.1 (more than 8); LCD / TG ratio 54 / 1.2 = 45 (greater than 30); the ratio of LCD / LDL 54 / 2.5 = 21.6 (more than 20); the ratio of LCD / HDL 54 / 0.8 = 67.5 (more than 50). The values of the coefficients allow predicting class C liver failure according to Child-Pugh.

Example 3

Patient V., born 1937 was admitted with a diagnosis of primary biliary cirrhosis. Portal hypertension. Varicose veins of the esophagus II degree. Cytopenic syndrome. Cardia insufficiency. Diffuse pneumosclerosis. Emphysema. Encephalopathy II degree.

Upon admission: satisfactory condition. The skin is pale pink. In the lungs, vesicular breathing, wheezing ket. Heart sounds are clear, rhythmic, heart rate of 72 per minute. HELL 120/70 mm Hg The abdomen on palpation is painless in all departments. The liver + 2-3 cm from the edge of the costal arch, the spleen is not palpable. Palpation ascites is not determined. There is no swelling of the lower extremities.

ECG: semi-vertical position of the electrical axis of the heart. Sinus rhythm, correct, heart rate 53 per minute. Decrease in voltage of teeth. Marked diffuse changes in the myocardium.

Ultrasound The liver is enlarged (thickness of the right lobe 14.2 cm, left 7.8 cm), the structure of the parenchyma is heterogeneous. Echogenicity is increased. The vascular pattern is significantly depleted. Signs of focal pathology were not detected. The intrahepatic ducts are not dilated. Gate century 14 mm. Choledoch 3 mm. The gall bladder is 5 × 2.1 cm, its walls are not changed, the wall thickness is 1.5 mm. The pancreas is of the usual form. Head 22 mm, body 11 mm, tail 18 mm. Contours are fuzzy. The structure is homogeneous, fine-grained, echogenicity is reduced. The size of the spleen is increased, the area is 104 square meters. see Splenic vein of 11 mm. Sonographic properties of the kidneys without features. Conclusion: diffuse changes in the liver. Portal hypertension.

X-ray examination of the chest. On the survey roentgenogram, fresh focal and infiltrative changes were not noted. The diaphragm is usually located, its contours are even. On the right pleurodiaphragmatic spike. The thoracic aorta is sealed. The shadow of the heart is expanded to the left. Conclusion - calcified primary complex on the right.

Endoscopy. When examining the esophagus in the lower and middle third, thin varicose veins in places with nodes with a diameter of up to 0.4 si. The cardia socket closes. The mucous membrane of the stomach in places is somewhat swollen, in the antrum it has a mottled appearance. Folds straighten out with air. Peristalsis is normal. The gatekeeper is free to pass. The mucous membrane of the duodenum is light pink, elastic folds. Conclusion: varicose veins of the esophagus of the 2nd degree. Chronic gastritis.

LABORATORY DATA Upon enrolment At discharge Upon enrolment At discharge Hemoglobin 12.5 12.1 Bilirubin 82.9 (D 38.4) 71.8 (D 31.4) Red blood cells 4.13 3.9 Cholesterol 4.22 4.15 Platelets one hundred 120 Alkaline phosphatase 332 414.4 White blood cells 1.8 2.0 TG 1,5 1.4 PO Box 6 one GGTP 164 213 s / i 37 45 AST 39.3 47.0 Eosinophils 5 2 Alt 23,2 37.6 Lymphocytes 48 48 Glucose 5.35 5,0 Monocytes four four Bile acids 30 μmol / l 28 μmol ESR 36 thirty Total protein 60.5 55,4 Albumin 33.9 30.8 Prothrombin 67.8 80 Urea 3.2 3.6 LDL 6.0 5.8 HDL 1,5 1.55 General urine analysis: beats. weight - 1013, protein, sugar - no, white blood cells are absent.

The ratio of bile acids to cholesterol, bile acids to triglycerides, bile acids to low density lipoproteins, bile acids to high density lipoproteins is determined in blood serum. The ratio of LCD / cholesterol in a patient is 30 / 4.2 = 7.1 (3-8), the ratio of LCD / TG 30 / 1.5 = 20 (20-30), the ratio of LCD / LDL 30/6 = 5 (5 -10), the ratio of LCD / HDL 30 / 1.5 = 20 (20-50). The values of the coefficients allow us to predict liver failure class B by Child-Pugh.

Example 4

Patient I., born in 1939, was admitted with a diagnosis of primary sclerosing cholangitis. Cytopenic syndrome. Hepatic encephalopathy II degree.

Upon admission: satisfactory condition. The skin is icteric, sclera icteric. In the lungs, vesicular breathing, wheezing ket. Heart sounds are muffled, rhythmic. Heart rate 68 per minute. HELL 110/70 mm Hg Palpation of the right hypochondrium is painful. Liver +2 cm from the edge of the costal arch. There is no swelling of the lower extremities.

ECG: semi-vertical position of the electrical axis of the heart. Sinus rhythm, correct, heart rate 66 per min. Decrease in voltage of teeth. Marked diffuse changes in the myocardium.

Ultrasound The liver is enlarged (the thickness of the right lobe is 15.4 cm, the left is 8.1 cm), the structure of the parenchyma is heterogeneous. Echogenicity is increased. The vascular pattern is depleted. Signs of focal pathology were not detected. Intrahepatic ducts are narrowed. Portal vein 16 mm. Choledoch 4 mm. The gall bladder is 6 × 3 cm, its walls are not changed, the wall thickness is 2 mm. The pancreas is of the usual form. Head 24 mm, body 13 mm, tail 18 mm. Contours are fuzzy. The structure is homogeneous, fine-grained, echogenicity is increased. The size of the spleen is increased, the area is 110 square meters. see Splenic vein 13 mm. Conclusion: diffuse changes in the liver. Portal hypertension.

X-ray examination of the chest. On the survey roentgenogram, fresh focal and infiltrative changes were not noted. The diaphragm is usually located, its contours are even. The aortic arch is sealed. The shadow of the heart is expanded to the left. Calcified primary complex on the right.

Endoscopy. When examining the esophagus in the lower and middle third, thin varicose veins in places with nodes with a diameter of up to 0.3 cm. The cardia outlet does not close. The mucous membrane of the lower third of the esophagus and stomach in places is somewhat swollen, and mucosal hyperemia is noted in the antrum of the stomach. Peristalsis is increased. The gatekeeper is free to pass. The mucous membrane of the duodenum is light pink, elastic folds. Conclusion: varicose veins of the esophagus of the 2nd degree. Chronic gastritis.

The ratio of bile acids to cholesterol, bile acids to triglycerides, bile acids to low density lipoproteins, bile acids to high density lipoproteins is determined in blood serum. The ratio of LCD / cholesterol in a patient is 40/5 = 8 (3-8), the ratio of LCD / TG 40 / 1.33 = 30 (20-30), the ratio of LCD / LDL 40/4 = 10 (5-10), the ratio of LC / HDL 40 / 0.8 = 50 (20-50). The values of the coefficients allow us to predict liver failure class B by Child-Pugh.

Prediction of the progression of liver failure with intrahepatic cholestasis of various etiologies in 78 patients was carried out. Tests have confirmed the achievement of the purpose of the invention is to increase the accuracy of predicting the progression of liver failure with intrahepatic cholestasis. Follow-up observations confirmed the accuracy of the prognosis of the course of the disease in each patient.

Claims (1)

A method for predicting the progression of hepatic insufficiency in intrahepatic cholestasis by biochemical examination of blood serum, characterized in that the ratio of bile acids to cholesterol, bile acids to triglycerides, bile acids to low density lipoproteins, bile acids to high density lipoproteins and when the value of LC / cholesterol in patients with liver failure of class A less than 3, class B from 3 to 8, class C more than 8; and when the value of FA / TG in patients with liver failure class A less than 20, class B 20-30 and class C more than 30; when the value of LC / LDL in patients with liver failure class A less than 5, class B 5-10, class C more than 10; when the value of LC / HDL in patients with liver failure class A less than 20, class B 20-50, class C more than 50 predict the progression of liver failure.