RU2395085C1 - Method of differential diagnosis of acute pancreatitis and acute cholecystitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: level of α₂-macroglobulin in blood serum is examined at admission to in-patient department. Then levels for each nosology are determined. At that levels of α₂-macroglobulin equal to 200 mg/l are taken as 1 point, respectively levels of 800 mg/l are taken for 4 points and at that acute pancreatitis is diagnosed, and at the level of α₂-macroglobulin in excess of 800 mg/l acute cholecystitis is diagnosed.

EFFECT: improvement of accuracy of differential diagnosis of acute pancreatitis and acute cholecystitis.

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Description

The invention relates to medicine, namely surgery, and can be used for the differential diagnosis of acute pancreatitis and acute cholecystitis.

Differential diagnosis of acute pancreatitis and acute cholecystitis is complex and not always accurate. It is based on a thorough history taking, objective physical data, laboratory tests, X-ray and computed tomographic examinations. However, none of these positions gives a reliable diagnostic result [Savelyev B.C., Filimonov MI, Gelfand BR, Burnevich SZ, Orlov BB, Saganov VP Clinical and morphological characteristics of pancreatic necrosis in the light of surgical treatment / Annals of surgery 2001. - No. 3. - P.58-62].

Diagnosis of acute pancreatitis is a very difficult problem at the present time. The criteria for early preoperative diagnosis of various forms of pancreatic necrosis and indications for surgical treatment are not sufficiently developed, and therefore unnecessary diagnostic laparotomies and open drainage operations are often performed, which, in turn, increases the frequency of purulent-inflammatory diseases and leads to high mortality, 2-3 % with edematous form and from 18-20% to 25-80% with destructive forms of pancreatitis [Mitkov V.V. Clinical Guide to Ultrasound Diagnostics / V.V.Mitkov. - M., 1996. - 322 p.].

Assessing the severity of the disease is based on the analysis of clinical and laboratory scales, which can improve the accuracy of predicting the outcome of the disease and the development of purulent-septic complications. The most common systems for assessing the severity of a patient's condition and prognosis are the Ranson (1974), Glasqow (1984), and Apache-2 (1984) scales.

As shown, the Ranson scale has a sensitivity of 54-85%, specificity of 68-85% and a negative prognostic value in the diagnosis of acute pancreatitis - 92-95%. The disadvantage of the scale is the inability to use it in dynamics. Nevertheless, its simplicity made it possible to widely use it on the first day of the disease and accurately predict the severity of OP in 46 examined patients (85.2%) [G.I. Herbenko, P.M. Smanilo, A.V. Kuznetsov, S.I. Mkeev. Optimization of diagnostic methods in patients with acute pancreatitis // Medicine emergency conditions, 2007. - No. 1 (8). - C.117].

The APACHE II scale is based on the determination of 12 physiological parameters, age and data on previous diseases for a general determination of the severity of the disease [Knaus W.A., Draper E.A., Wagner D.P., Zimmerman J.E. APACHE II. A severity of disease classification system // Crit. Care Med. - 1985. - Vol.13. - P.818-829].

The following parameters were recognized as the most sensitive, indicating a high probability of necrotizing pancreatitis:

- With reactive protein> 15 mg / L [Ranson J.H., Rifkind K.M., Roses D.F. et al. (1974) Prognostic signs and the role operative management in acute pancreatitis. Surg. Gynecol. Obstet., 139: 69-81];

- the interval between the onset of pain and a patient seeking help for less than 24 hours indicated a high probability of developing pancreatic necrosis [Brown A., Baillargeon J.D., Hughes M.D., Banks P.A. (2002) Can fluid resuscitation prevent pancreatic necrosis in severe acute pancreatitis? Pancreatology, 2 (2): 104-107];

- hyperglycemia ≥125 mg / dl [Lankisch P.G., Blum T., Bruns A. et al. (2001) Has blood glucose level measured on admission to hospital in a patient with acute pancreatitis any prognostic value? Pancreatology, 1 (3): 224-229];

- increase in hematocrit> 44% [Brown A., Orav J., Banks P.A. [2000] Hemoconcentration is an early marker for organ failure and necrotizing pancreatitis Pancreas, 20 (4): 367-372];

- leukocytosis ≥16000;

- hypocalcemia <2 mmol / L.

In addition, it is not uncommon for destructive processes in the pancreas and gall bladder to proceed latently and are diagnosed with already developed complications.

Standard laboratory tests allow you to diagnose acute pancreatitis and acute cholecystitis, as well as to differentiate them among themselves in 35% -45% of cases. These indicators are greatly influenced by accuracy, as well as the timeliness of conducting, on the one hand, accessible and at the same time highly informative examination methods. The number of discrepancies in diagnoses reaches 10-15% [Radiation diagnosis of acute pancreatitis / A.V. Arablinsky and others) // Med. visualization. - 2000. - P.2-14. Gubergrits N.B. Clinical and pathogenetic assessment of information content and modern possibilities of optimizing ultrasound diagnostics of chronic recurrent pancreatitis / N.B. Gubergrits, N.E. Barinova, V.V. Belyaev // Med. visualization. - 2002. - No. 1. - S. 48-58].

The difficulty in diagnosing acute pancreatitis, and especially its destructive forms, is due to the polymorphism of clinical manifestations, their low specificity, as well as the absence of clear laboratory parameters that would unambiguously indicate an inflammatory process in the pancreas.

Currently, the most reliable diagnostic technique in identifying destructive conditions is computed tomography (CT), which allows you to establish the destructive process in the pancreas and gall bladder in 94%.

However, as it turned out, studies conducted in the early days are absolutely ineffective both in terms of diagnosis and in terms of prognosis of the disease, a more or less clear picture with CT can be obtained only by the 7-10th day of the disease. That is why the attitude towards this expensive, fraught with complications associated with the introduction of a contrast medium, and accompanied by a fairly high radiation dose technique has recently become very critical [Munoz-Bongrand N., Panis Y., Soyer P. et al. (2001) Serial computed tomography is rarely necessary in patients with acute pancreatitis: a prospective study in 102 patients. J. Am. Coll. Surg., 193 (2): 146-152].

The main disadvantages of computer tomographic diagnostic techniques are:

- unwanted radiation exposure to the patient and staff;

- the complexity of the process of processing the results;

- the bulkiness and high cost of equipment and, as a consequence, the high cost of research;

- lack of equipment in small clinics and hospitals, where patients with destructive lesions of the pancreas and gall bladder are most often hospitalized;

- it is difficult to search for early signs of destructive changes in the pancreas and gall bladder.

The inaccessibility of computed tomography in medical institutions of district, city, and sometimes, regional subordination, the high cost of the study and the patient’s unwillingness to undergo radiation exposure prompt many patients to refuse such an examination, and researchers to look for other reliable diagnostic tests.

Known methods for the differential diagnosis of acute pancreatitis and cholecystitis [Kozlova V.A et al. The method of differential diagnosis of acute pancreatitis // Patent of the Russian Federation No. 2033747 from 1995.04.30; Sayfudinov et al. The method of differential diagnosis of acute calculous cholecystitis and exacerbation of stoneless cholecystitis // RF Patent No. 2140189 from 1997.07.16; Gribanov et al. A method for the differential diagnosis of destructive changes in acute cholecystitis // RF Patent No. 210935 from 2000.04.14; Salekhov S.A. The method of differential diagnosis of the abdominal form of myocardial infarction and acute cholecystitis // RF Patent No. 210347 of 2002.10.10; Gordetsov A.S. et al. The method of differential diagnosis of acute pancreatitis // RF Patent No. 2253868 from 2005].

In the diagnosis of many destructive conditions, α ₂ -macroglobulin (MG) has proven itself, which, according to researchers, is considered an indicator of tissue destruction [Shramko S.V., Zorina V.P., Bazhenova L.G. A method for the diagnosis of purulent-necrotic process in inflammatory diseases of the uterus // Patent of the Russian Federation No. 2295134 from 03.10.07].

The approach to surgical treatment of necrotizing forms of acute pancreatitis today is undergoing its next and, apparently, final “conservative” phase. Indications for surgical intervention (usually limited to economical necrosectomy and lavage) under the influence of several reputable clinical trials were minimized [Buechler M.W., Gloor B., Muller S.A. et al. (2000) Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann. Surg., 232 (5) 619-626].

The only valid indication for surgical treatment of necrotizing pancreatitis today is infected pancreatic necrosis in combination with increasing sepsis (Lee VT, Chung AY, Chow PK et al. (2006) Infected pancreatic necrosis - an evaluation of the timing and technique necrosectomy in a Southeast Asian population. Ann. Acad. Med. Singapore, 35 (8): 523-530).

All of the above allows us to conclude that, despite the absence of radically new approaches to solving the problem of acute necrotizing pancreatitis, the available options for both conservative and surgical therapy based on evidence-based medicine give these patients a much greater chance of survival.

As a prototype, the differential diagnosis method described by A. Gordetsov was taken. et al. [RF patent No. 2253868 of 2005]. The essence of the method is as follows: initially, a sample is prepared from the patient’s blood serum by drying and suspension in liquid paraffin, then infrared spectroscopy of the sample is carried out on a spectrophotometer with absorption spectra recorded in the range of 1200-1000 cm ^-1 and peak heights of absorption bands are recorded with maxima at 1170 ; 1165; 1123; 1105; 1100; 1070; 1060; 1050; 1025 cm ^-1 . However, the above method is quite laborious, technically difficult, which prevents its use in a wide network of medical institutions.

In this regard, methods of immunochemical determination of the concentration of a ₂ -macroglobulin in blood serum are much more promising in this direction.

The aim of the invention is to improve the accuracy of the differential diagnosis of acute pancreatitis and acute cholecystitis.

The goal of the invention is achieved by the fact that upon admission to the hospital they examine the level of α ₂ -macroglobulin in serum, determine the scores for each nosology, while the value of α ₂ -macroglobulin 200 mg / l is taken as 1 point, respectively, the level is up to 800 mg / l Accepted for 4 points - acute pancreatitis is judged, and at an α ₂ -macroglobulin level exceeding 800 mg / l, acute cholecystitis is judged.

The concentration of MG in serum was determined in 82 patients with acute pancreatitis and 215 patients with acute cholecystitis on admission, immediately on the day of surgery, 3-5 days after surgery and upon discharge of patients by radial immunodiffusion (mg / l), α ₂ concentrations were studied -macroglobulin.

A clear dependence of the concentration of MG on the degree of the destructive process in the pancreas or gall bladder has been established. In dynamics, the level of MG (increases with acute cholecystitis and decreases during treatment, while with acute pancreatitis, the level of MG with inflammation is reduced and recovers with successful treatment) should be used in the differential diagnosis of acute pancreatitis and acute cholecystitis. The argument for the possibility of using MG for the differential diagnosis of acute pancreatitis and acute cholecystitis was its high reliability in the diagnosis of destructive conditions in other nosological forms.

Statistical processing of the results using Student's t test.

For ease of interpretation of the results, the numbers of serum MG within the range from 0 to 200 mg / l are taken as 1 point.

The results of immunochemical testing of MG are compared with the data of a general clinical examination showed that when patients with acute pancreatitis were admitted, the MG level was reduced to 800 mg / L (P <0.01) (4 points), and in acute cholecystitis it was increased to 1150 mg / L (P < 0.01) (6 points).

The proposed method was introduced into the work of the surgical department of the City Clinical Hospital No. 3 of Astrakhan and was used to examine 82 patients with acute pancreatitis and 215 patients with acute cholecystitis. Based on the created scoring in 56% of the examined patients admitted to the hospital with a preliminary diagnosis of acute cholecystopancreatitis, the diagnosis was clarified: acute cholecystitis or acute pancreatitis. The following are examples of testing.

Example 1. Patient S., 47 years old (IB No. 7680), was admitted to the surgical department in a planned manner with complaints of periodic pain in the right hypochondrium, bitterness in the mouth, appearing after an error in the diet, intake of fatty foods, by 4 day after the onset of the disease.

Objectively: the condition is satisfactory. Heart sounds are rhythmic, muffled, pulse 86 beats / min, blood pressure - 130/80 mm / Hg. In the lungs, vesicular breathing, no wheezing. The abdomen is not swollen, normal configuration, soft, painless.

The liver and spleen are not enlarged, the gall bladder is not palpable, there are no symptoms of peritoneal irritation. Pasternatsky’s symptom is negative on both sides. Stool and diuresis are normal. On ultrasound, the liver is not enlarged, common bile duct - 0.7 cm, gall bladder 8.9 × 2.8 cm, stones from 0.4 to 0.7 cm, the pancreas is not enlarged, normal echogenicity.

Diagnosed with chronic calculous cholecystitis. The study was conducted: ECG - without features, leukocytosis - 5.6 × 10 ⁹ , blood and urine amylase, ALT, ACT - within normal limits, urinalysis without features, ESR - 9 mm / h, temperature - 36.7. An increased level of MG is 1280 mg / l (6 points), in connection with which a preliminary diagnosis of cholecystitis was made.

The patient underwent cholecystectomy, drainage of the abdominal cavity. Access - upper median laparotomy. Macroscopically: The gall bladder is swollen, enlarged 9.0 × 4.0 cm, the walls are sharply thickened, with a touch of fibrin, in the cavity there are many stones up to 1.0 cm in diameter. Postoperative diagnosis: "cholelithiasis. Acute calculous phlegmonous cholecystitis. " The histological picture of phlegmon of the gallbladder.

In the postoperative period, infusion, antibiotic therapy, anti-inflammatory, metabolic therapy were performed. During treatment, a study of MG in serum was carried out, a decrease to 807 mg / l was noted. Discharged 12 days after surgery.

Example 2. Patient X., 50 years old (IB No. 7680), was admitted to the surgical department on the second day after the illness with complaints of pain in the epigastrium, right hypochondrium, radiating to the back, which appeared after an error in diet, admission greasy food.

Objectively: a state of moderate severity. Moderate pallor of the skin, dry mouth, single vomiting of bile. Heart sounds are rhythmic, muffled, pulse 86 beats / min, blood pressure - 130/80 mm / Hg. In the lungs weakened breathing, no wheezing. The abdomen is not swollen, the usual configuration, soft, moderately painful in the epigastrium and right hypochondrium. The liver and spleen are not enlarged, the gall bladder is not palpable, there are no symptoms of peritoneal irritation. Pasternatsky’s symptom is negative on both sides. Stool and diuresis are normal.

Diagnosed with acute cholecystopancreatitis. Examination was performed: urine diastasis - 64 units, ECG - without features, leukocytosis - 7.6 × 10 ⁹ , ALT, ACT - within normal limits, urinalysis without features, ultrasound - there are no stones in the gall bladder, the walls are not thickened, pancreas of increased echogenicity, slightly enlarged.

The low level in the blood serum of MG is 760 mg / l (4 points), a preliminary diagnosis of acute pancreatitis.

Clinical diagnosis: Acute pancreatitis, edematous form.

The treatment was prescribed: Table No. 0, cold on the stomach, bilateral perirenal blockade with a solution of novocaine 25% - 100.0 antispasmodics, infusion therapy, analgesics, heparin, 25,000 units kontrikal. × 2 times a day. After the treatment, the condition improved, the pains disappeared. The recovery of MG values to 980 mg / l (5 points) by the time of recovery was noted. Discharged after 10 days in satisfactory condition.

Using the proposed method, it is possible to achieve:

- reliable differential diagnosis of acute pancreatitis and acute cholecystitis even when diagnosis by other instrumental and laboratory methods is difficult;

- for diagnosis, special conditions and patient preparation are not needed;

- has sufficient accuracy even when the differential diagnosis of acute pancreatitis and acute cholecystitis by other instrumental and laboratory methods is difficult;

- they will make it possible to diagnose latently occurring destructive conditions requiring surgical treatment, thereby reducing economic costs by reducing preoperative preparation, excluding attempts at unsuccessful conservative therapy and repeated hospitalizations;

- reduce economic costs by reducing preoperative preparation, excluding expensive computer screening, attempts at unsuccessful conservative therapy and repeated hospitalizations;

- exclusion of unwanted radiation exposure to the patient and staff.

Claims (1)

A method for the differential diagnosis of acute pancreatitis and acute cholecystitis by examining blood serum, characterized in that upon admission to the hospital they examine the level of α ₂ -macroglobulin in the serum, determine the scores for each nosology, while the values of α ₂ -macroglobulin 200 mg / l are taken as 1 point , respectively, the level of up to 800 mg / l is taken as 4 points - they are judged for acute pancreatitis, and with an α ₂ -macroglobulin level exceeding 800 mg / l, they are judged for acute cholecystitis.