RU2407017C1 - Method of diagnosing destructive forms of acute cholecystites - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: in order to realise the method level of ferritin in blood serum and bile bladder tissue, rang point is defined, and ferritin values in serum from 0 to 10 ng/ml, and bile bladder from 0 to 0.25 mg/l - are taken for 1 point, respectively, level of ferritin in serum 70 ng/ml is taken as 7 points, and in bile bladder tissue 0.75 mg/l is taken as 3 point, and if sum is 10 points, conclusion is made about non-destructive cholecystitis, and if sum is from 10 points conclusion about destructive cholecystitis is made.

EFFECT: application of invention allows to increase accuracy of diagnostics of bile bladder tissue destruction in acute cholecystitis.

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Description

The invention relates to medicine, namely surgery, and can be used to diagnose destructive forms of acute cholecystitis.

Currently, acute cholecystitis (OH) is one of the most common acute surgical diseases of the abdominal cavity (Borisov, A.E., Zemlyanoy, V.P., Levin, L.A. et al. Current status of the treatment of acute cholecystitis. // Bulletin of surgery named after Grekov. 2001. V.160, No. 6. P.92-95; Kuznetsov, N.A., Aronov L.S., Kharitonov S.V. et al. Choice of tactics, timing and method surgery in acute cholecystitis. // Surgery. 2003. No. 5. P.35-40; Kimura, Y., Takada, T., Kawarada, Y. et al .: Definition, pathophysiology and epidemiology of cholangitis and cholecystitis. / / J. Hepatobiliary Pancreat Surg (2007) 14: 15-26). A significant increase in the number of patients with OH observed in recent decades is accompanied by an increase in the proportion of elderly and senile patients. The prevalence of this pathology is continuing, despite the improvement of surgical tactics. Mortality and postoperative complications (Keus, F., Breeders, IAMJ, van Laarhoven, CJHM Gallstone disease: Surgical aspects of symptomatic cholecystolithiasis and acute cholecystitis. // Best Pract Res Clin Gastroenterol. 2006; 20 (6); 1031 - 51. ), determine not only the medical, but also the social significance of this problem.

The development of reliable methods for the timely diagnosis of acute cholecystitis is an urgent problem in modern medicine. The creation of laboratory panels for assessing the severity and severity of the pathological process during exacerbation of chronic or latent forms of this disease is important. It is based on a thorough history taking, objective physical data, laboratory tests, X-ray and computed tomographic examinations. However, none of these items provides a reliable diagnostic result. So the accuracy of only anamnestic and objective data in the diagnosis of destructive conditions does not exceed 57.19% (S.V. Yakubovsky. Prognostic factors for the detection of acute destructive cholecystitis).

According to the report of the World Organization of Gastroenterologists and Endoscopists (OMGE), the accuracy of diagnosing the causes of abdominal pain by the beginning of the 21st century was only 50%, the time interval between the appearance of abdominal pain and verification of the diagnosis, including malignant neoplasms, was from 8 to 37 weeks. In half of the patients after the initial examination, the cause of the pain remained unclear, and the frequency of the negative result of the diagnostic laparotomy reached 60% (Glasgow RE, Mulvihil SJ. Abdominal pain, including the acute abdomen. Sleisenger & Fordtrans's Gastroentestinal and Liver Disease. Philadelphia-London-Toronto-Monreal Sydney-Tokyo 2003; 1: 80-90.) In addition, it is not uncommon (up to 31%) that destructive processes with purulent forms of cholecystitis in the gallbladder proceed latently and are diagnosed with already developed complications.

To assess the functional state of the liver, biliary tract in clinical laboratory diagnostics, a lot of biochemical tests and markers are used (O. Kokueva, Diagnostic informational content of bile components in chronic cholelithiasis. Current trends in the development of gastroenterology. Abstract. Scientific-practical conference. - Izhevsk, 1995, p. 91-92).

However, the abundance of indicators of individual liver functions did not solve the problems of high-quality laboratory diagnostics in abdominal surgery. In surgical practice, the diagnosis of acute cholecystitis is usually made according to the history and physical examination. Of the laboratory diagnostic methods, a clinical blood test is used, where the indicator of the disease is the number of leukocytes. In typical cases, the number of leukocytes is 10-15 10 ⁹ / l with a shift in the blood count to the left. Also, bilirubin (50 g / l) is slightly increased in 45% of patients and transaminase (5 times) in 25% of patients (Arseniy AK Diagnosis of acute inflammatory diseases of the abdominal cavity. - Chisinau. 1982. P. 76, 84, 95 , 175. Jurg Hegglin, Surgical examination. - M., 1980, p. 195. Lidsky AG, Symptomatic diagnosis of surgical diseases. 1973. P. 57. Astapenko VG Handbook for the diagnosis and differential diagnosis of surgical diseases. Minsk, 1988. Page 96)

The success of treatment of patients with acute cholecystitis depends on the accuracy of the diagnosis of pathological changes in the gallbladder wall, which determine the treatment tactics and the urgency of surgical intervention. Standard laboratory tests can diagnose acute cholecystitis 75%. For an objective assessment of pathological changes in the gallbladder wall with a high degree of informativeness, ultrasound is used. Currently, with the advent of a new class of diagnostic equipment, it has become possible to study the degree of inflammatory changes in the gallbladder wall using Doppler techniques. This makes it possible to exclude from the examination plan the predominant number of patients with invasive and expensive methods for studying the vascular bed of the gallbladder (Musaeva M.D. Importance of Doppler research methods in the diagnosis of diseases of the gallbladder: Abstract of thesis. Candidate of Medical Sciences. - M. - 1997. - 21 p.)

According to the authors, the analogue of our proposed method is a general clinical blood test.

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 for the first time days are absolutely ineffective both in terms of diagnosis and in terms of disease prognosis, 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., No. 193 (2): S.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 acute cholecystitis are most often hospitalized.

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.

Recently, a number of techniques for the diagnosis of acute cholecystitis (Shatokhina Svetlana Nikolaevna, Shcherbina Tatyana Vasilievna, Shabalin Vladimir Nikolaevich. Method for differential diagnosis of chronic stoneless and calculous cholecystitis. Differential diagnosis // Patent RF 228934 dated 12/03/04; Mashkin Andrey Mikhailovich. Express method -diagnostics of destructive changes of the gallbladder in acute cholecystitis. // RF patent №2269299 from 11/26/06; Sibilev VN Mokhov EN Kargapolov AV Method for differential diagnosis of destructive changes pr and various forms of acute cholecystitis. // RF Patent No. 2247379 dated 07/07/03; Suzdaltsev Igor Vladimirovich. A comprehensive method for the diagnosis and surgical treatment of acute cholecystitis in patients with high operational and anesthetic risk. // RF Patent No. 2199957 from 10.08.00).

At the same time, in the diagnosis of many destructive conditions, ferritin, which, according to many researchers, is considered an indicator of tissue destruction, has proven itself well. So ferritin is introduced in the diagnosis of destructive conditions in traumatology and orthopedics (Korablev SB, Lebedev M.Yu., Tenilin NA A method for differential diagnosis of relapse of dystrophic bone cysts and residual bone cavities. // RF Patent No. 2086985 from 05.1994) , in the diagnosis of traumatic brain injury (Sumnaya DB et al. Method for diagnosing the severity and course of traumatic brain injury. // RF Patent No. 2213967 dated 07.22.02), tuberculosis (OK Malysheva et al. Method for differential diagnosis of tuberculosis lungs // RF Patent No. 2027191 of 12/29/90), the disease liver disease (Parshikov V.V., Nemov V.V. Method for assessing the degree of damage to the liver. // RF Patent No. 2132071 of 04/21/98), the thyroid gland (Panova T.N., Epinetov M.A. Method for differential diagnosis of malignant neoplasms of the thyroid gland and nodular non-toxic goiter. // RF Patent No. 2075085 from 05.26.93).

An in-depth study of the pathogenesis of acute cholecystitis (OX) and its complications requires the search for new methods for assessing changes in homeostasis in these diseases. An analysis of the literature indicates that currently there is an accumulation of information about the biological and clinical significance of metalloproteins - ferritin.

Metalloproteins - serum proteins involved in the deposition, transport and disposal of metal ions of variable valency. Interest in the study of these proteins, which has grown significantly in recent years, is due to their role in the functioning of the antioxidant system of the body (Belaya OL, Fomina I.G., Baider L.M. et al. Effect of the bioflavonoid diquertin on the antioxidant system ceruloplasmin / transferrin and lipid peroxidation in patients with stable forms of coronary heart disease with dyslipidemia. Clin. honey. - 2006. - No. 7. - P.46-50; Halliwell B., Gutteridge M. The antioxidant of human extracellular fluids. Arch. Biochem. Biophys. - 1990. - Vol.280. - N 1. - P.1-8. Orino, K., Tsuji Y., Torti, FM, Torti, SV Adenovirus E1A blocks oxidant-dependent ferritin induction and sensitize s cells to pro-oxidant cytotoxicity. FEBS Lett. 1999; 461: 334-338), as well as the possibility of using as biochemical markers of the acute phase of inflammation (Adamyan, A.I., Gulyaev, A.A., Ivanina, T.A. . and other acute phase response and plasma proteins in acute cholecystitis. Clinical laboratory diagnosis. - 1997. - No. 11. - C.8-10; 2. Aleshkin, VA, Novikova, LI, Lyutov, A.G. and other Proteins of the acute phase and their clinical significance. Wedge. honey. - 1988. - No. 8. - S. 39-48; Bockeria, L.A., E.Z. Golukhova, M.A. Chichkova. Acute-phase markers of the pathological process in predicting the nature of the clinical course of exudative pericarditis after cardiac surgery. Lying. medicine: theory and practice - 2004. - No. 4. - C.2-8; Ilyukevich, G.V., Smirnova, L.A. Ferroproteins as markers of a systemic inflammatory response in acute peritonitis. Vesci NAS Belarus. Ser. medical bi-science. - 2002. - No. 2. - C.23-25; Al-Delaimy, W.K., Jansen, E.H. Reliability of biomarkers of iron status, blood lipids, oxidative stress, vitamin D, C-reactive protein and fructosamme in two Dutch cohorts. - Biomarkers. - 2006 .-- 11 (4): 370-382).

As a prototype, we took a method for the differential diagnosis of chronic cholecystitis and acute cholecystitis by examining a general blood test, which includes examining the concentration of hemoglobin in 1 μl of blood, counting the number of red blood cells in 1 μl of blood, calculating the color index, counting the number of leukocytes in 1 μl of blood, research leukocyte formula (percentage of different leukocytes) and the determination of the erythrocyte sedimentation rate in millimeters per hour (Reference "Laboratory methods of research in the wedge ke "/ Edited by Prof. V.V.Menshikova -... M .: Medicine, 1987, s.106-125).

But this method has drawbacks, the number of leukocytes varies under the influence of seasonal, climatic, physiological conditions of the body, as well as with various pathologies, which indicates the low information content of this method, and the impossibility of assessing with its help the degree of inflammatory destruction of the gallbladder

The aim of the invention is to improve the accuracy of diagnosis of destruction of gallbladder tissue in acute cholecystitis.

The goal of the invention is achieved by the fact that upon admission to the hospital, the level of ferritin in the blood serum and gallbladder tissue is examined, a rank score is determined, while the values of ferritin in the serum are from 0 to 10 ng / ml, and in the gallbladder tissue from 0 to 0 , 25 mg / l - taken as 1 point, respectively, a serum ferritin level of 70 ng / ml is taken as 7 points, and 0.75 mg / l in the gallbladder tissue is taken as 3 points, and when a total of 10 points are judged non-destructive cholecystitis, and with a total of 10 points, destructive cholecitis is judged.

At the first stage, a study was made of the level of ferritin in the serum of patients with acute cholecystitis (80 patients), chronic cholecystitis (56 patients). A clear dependence of the concentration of tissue ferritin on the degree of the destructive process was established. High ferritin numbers were obtained in patients with a complicated destructive process. The argumentation of the possibility of using ferritin for the diagnosis of a destructive state was its high reliability in the diagnosis of destructive states in other nosological forms. Before surgery, serum ferritin levels were examined in these patients. When determining serum ferritin, patients did not refrain from eating, no special preparations were required. Blood was collected by conventional venipuncture into vacutainers and the serum was separated from the cells by centrifugation after clot formation.

The concentration of ferritin in the blood serum was determined by indirect enzyme-linked immunosorbent assay in ng / ml by commercial test systems of BioChemMak CJSC (Moscow), in the gallbladder tissue was determined by radial immunodiffusion. The determination of tissue ferritin was carried out after homogenization of the studied tissues. Homogenization was carried out as follows. A pathologically altered gallbladder removed during cholecystectomy was crushed and ground with a glass powder to a creamy consistency. To destroy cell membranes and structures, 3-fold thawing and freezing of the homogenate was performed. Then, the dissolved proteins were extracted with physiological saline at the rate of 3 volumes per 1 g of tissue.

To identify ferritin in tissue biopsies, the same standard test system was used that determines the equivalent ratio of a known antigen and its corresponding antibodies. Changes in serum ferritin concentration in most examined patients correlated with tissue mediator levels.

Fluctuations in ferritin in blood serum varied with catarrhal from 50 to 60 ng / ml, and with phlegmonous cholecystitis - up to 306 ng / l.

Statistical processing of the results using Student's t test. The level of serum ferritin was higher with destructive forms of acute cholecystitis and amounted to (306.0 ± 62.3 ng / ml p <0.01), which corresponds to 30 points compared with the level for non-destructive forms of chronic cholecystitis 6 points (59.3 ± 15.23 ng / ml, p <0.05) and a control level of 2 points (21.9 ± 1.35 ng / ml, p <0.01).

At the second stage of the study, the determination of ferritin tiers in the gallbladder tissue and blood serum was performed in 56 patients with chronic cholecystitis. The destructive state was diagnosed with a total score of 10 or more. All patients with this sum of points performed sanitizing cholecystectomy. Inflammatory destruction was confirmed in all patients with visual characteristics of surgical findings and subsequent histological examination. Among those operated, there were also those patients whose diagnosis of the destructive state by traditional methods was difficult, and surgical findings confirmed the need and timeliness of surgical treatment.

Our proposed method was introduced into the work of the surgical department of GB No. 6 in Astrakhan and was used to examine 56 patients with chronic cholecystitis and 80 patients with acute cholecystitis. The following are examples of testing.

Example 1. Patient D., 60 years old, was admitted to the surgical department with complaints of pain in the right hypochondrium, dry mouth, vomiting of bile, 7 days after the moment of illness. Pain appeared after an error in the diet.

The study was conducted: urine diastasis - 58 units, ECG - without features, leukocytosis - 12.2 × 10 ⁹ , ALT, ACT - within normal limits, ESR - 21 mm / h, urine analysis without features, on ultrasound - in the gall bladder stones up to 1.9 mm. After examination and examination, a diagnosis was made: acute cholecystitis.

The study showed a ferritin concentration of 82.5 ng / ml (8 points). The treatment was carried out: antispasmodics, infusion therapy, analgesics, heparin, paraumbilical block.

After the treatment, the condition improved, the pains disappeared, the level of ferritin decreased to 68 ng / ml.

After 5 days, the patient again had pain, the temperature rose to 37 degrees, a painful infiltrate began to palpate in the right hypochondrium, an increase in the concentration of ferritin to 92.5 ng / ml was noted (9 points). The patient is offered surgery.

Access in the right hypochondrium by Fedorov's cut. In the subhepatic space, a pronounced, loose infiltrate is determined. The gallbladder was isolated bluntly from the infiltrate, cholecystectomy was made from the neck, and drainage was made to the Vinslov hole. The abdominal cavity is drained, the postoperative wound is sutured in layers.

Macrodrug: gall bladder of dark crimson color, with the application of fibrin, the walls are sharply thickened, in the cavity there are 4 calculi with a diameter of up to 1.9 mm, the concentration of ferritin in the tissue is 8.2 mg / l (32 points) in the amount of 41 points Postoperative diagnosis: " ZhKB. Acute calculous, gangrenous cholecystitis, infiltrate in the gallbladder. "

The postoperative period was unsatisfactory, subfebrile temperature was maintained up to 37.3, pain in the postoperative wound disturbed, anti-inflammatory and immunocorrective therapy was carried out.

Discharged after 19 days in satisfactory condition. Examined after 6 months, notes improvement, leads a normal lifestyle, laboratory indicators without features.

Example 2. Patient A., 50 years old, was admitted to the surgical department for 7 days from the moment of illness with a clinic of acute cholecystitis. From the anamnesis: IHD, angina pectoris suffers.

The study showed a ferritin concentration of 150.5 ng / ml (15 points), and therefore we made a preliminary diagnosis of phlegmonous cholecystitis.

After the preoperative preparation: infusion therapy - hemodesis, glucose, ringer's solution, vitamins, potassium preparations, the patient underwent surgery cholecystectomy, drainage of the abdominal cavity. Access - upper median laparotomy. The gall bladder is swollen, enlarged 9.0 × 4.0 cm, the walls are sharply thickened, in some places fibrin is applied, there are many stones in the cavity up to 0.6-0.8 mm in diameter, the concentration of ferritin in the tissue is 4.66 mg / l (18 points) in total (32 points).

Postoperative diagnosis: "cholelithiasis. Acute calculous, phlegmonous cholecystitis, infiltrate in the gallbladder. " In the postoperative period, infusion, anti-inflammatory, metabolic therapy was performed. During treatment, a decrease in increased amounts of antigens was noted: F-40 ng / ml (4 points).

Discharged 13 days after surgery. Examined after six months, no complaints, leads a normal lifestyle. Laboratory indicators are within normal limits.

Example 3. Patient J., 55 years old, was admitted to the surgical department in a planned manner with complaints of periodic pain in the right hypochondrium, bitterness in the mouth with errors in the diet.

An outpatient study was performed: urine diastasis - 58 units, ECG - without features, leukocytosis - 9.2 × 10 ⁹ , ALT, ACT - within normal limits, ESR - 14 mm / h, urinalysis without features, ultrasound - in gall bladder stones up to 1.9 mm. After examination and examination, the diagnosis was made: cholelithiasis chronic calculous cholecystitis.

The study showed a ferritin concentration of 68.5 ng / ml (7 points). The patient underwent a planned operation.

Access in the right hypochondrium by Fedorov's cut. In the subhepatic space, the gall bladder is determined in the lumen, calculi are palpated, a cholecystectomy from the neck is made, drainage to the Vinslov hole is summed up. The abdominal cavity is drained, the postoperative wound is sutured in layers.

Macro drug: the gall bladder is not enlarged, the walls are not thickened, in the cavity there are 4 calculi with a diameter of up to 1.9 mm, the concentration of ferritin in the tissue is 0.5 mg / l (2 points) in the amount of 9 points Postoperative diagnosis: "cholelithiasis. ZHKB chronic calculous cholecystitis ".

The postoperative period was uneventful.

Discharged after 8 days in satisfactory condition. Examined after 6 months, notes improvement, leads a normal lifestyle, laboratory indicators without features.

Using the method we have proposed, we are able to achieve:

- reliable diagnosis of destructive conditions of the gallbladder even when diagnosis by other instrumental and laboratory methods is difficult

- special conditions and patient preparation are not needed for diagnosis

- will allow to diagnose latent leaking destructive conditions that need surgical treatment

- reducing 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 diagnosing destructive forms of acute cholecystitis by examining biological tissues, characterized in that in patients with acute cholecystitis, upon admission to the hospital, the level of ferritin in the blood serum and gallbladder tissue is determined, a rank score is determined, and the values of serum ferritin from 0 to 10 ng / ml and in the gallbladder tissue from 0 to 0.25 mg / l is taken for 1 point, respectively, the serum ferritin level of 70 ng / ml is taken for 7 points, and in the gallbladder tissue 0.75 mg / l is taken for 3 points, and with a total of 10 points the court It is about non-destructive cholecystitis, and with a total of 10 points, destructive cholecystitis is judged.