RU2408251C1 - Method of combined esophagus chromoscopy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: for combined chromoscopy of esophagus endoscopic examination of mucous membrane of esophagus is carried out. Mucous membrane of esophagus is processed with 2 ml of 1.5% acetic acid, in 1-2 min visual estimation of mucous membrane is carried out. After that irrigation of mucous membrane with 2 ml of 1% water Lugol's solution is performed with estimation of evenness of esophagus mucosa staining, clearness and location of esophagus epithelium location. Lugol's solution is washed off with 20-40 ml of water. Mucosa is irrigated with 2 ml of 1% of water solution of methylene blue, in 2-3 min dye is washed off with water in volume up to 1 l. Introduction of acetic acid, water Lugol's solution, water solution of methylene blue is realised at the height of peristaltic wave in esophagus, when catheter end is fully surrounded by esophagus mucosa.

EFFECT: method allows to improve quality and efficiency of diagnostics, is simple Available, does not require considerable time consumption and financial expenditure.

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Description

The invention relates to medicine and can be used to improve the diagnosis of complications of gastroesophageal reflux disease (GERD), Barrett's esophagus, dysplasia of varying severity.

The value of GERD is determined not only by its prevalence, but also by the weighting of the course. (A.V. Kalinin 2003). The most common complication of GERD is the formation of Barrett's esophagus (PB), which according to various authors is found in 5-30% (Kalinin A.V., I.V. Maev 2003). According to various authors, Barrett's syndrome occurs in 8-20% of patients with reflux esophagitis, while the risk of cancer increases by a factor of 30-40 (data by A.V. Kalinina, B.D. Starostina 2003). PB prevalence has been recorded in many regions of the world. At present, approximately 5-10% of patients with GERD are diagnosed with BP. (M.F. Osipenko 2005)

According to pathological and anatomical statistics, for every known case there are 20 unrecognized. This indicates that in most patients the course of the disease during the development of PB is no different from the course of uncomplicated GERD, and in some patients there are no clinical manifestations at all. An endoscopic examination of the upper gastrointestinal tract is the main diagnostic method for Barrett's epithelium, as it allows you to suspect PB, and most importantly - to take material for histological, histochemical and other studies. At the same time, histological confirmation of Barrett's esophagus based on visual signs allows confirming the diagnosis by no means in all patients. However, there are no algorithms and methods for using vital dyes and their combinations for chromoscopy.

A known method of staining with Lugol's solution, which allows to increase the sensitivity, specificity and accuracy of endoscopic examination of Barrett's esophagus by 89%, 93%, and 91%, respectively (Filin A.V., Myaukina L.M., Rybalkin Yu.I. Application of chromoscopy methods in endoscopic studies of the upper digestive tract.Internet journal “Bulletin of endoscopy”, September 2002. http://www.endoscopy.ru/doctor/articles,html). Lugol staining is applicable to clarify the boundaries of epithelial regeneration in patients with Barrett's esophagus who underwent mucosal resection, photodynamic therapy, or bipolar electrocoagulation. The method consists in irrigating a solution of Lugol with 5.0 ml of the mucosa of the lower third of the esophagus during gastroscopy and assessing the changes after 1-2 minutes.

The disadvantage of this method is the lack of the ability of Lugol's solution to stain foci of intestinal metaplasia with Barrett's esophagus.

A known method of irrigation with acetic acid to visualize minimal changes in the distal esophagus to detect intestinal metaplasia in patients with Barrett's esophagus (Davydov M.I., Poddubny B.K., Kuvshinov Yu.P. et al. Possibilities of endoscopic methods of chromoscopy and surgical treatment patients with Barrett’s esophagus. Thoracic and cardiovascular surgery No. 1, 2003, p.69). The method consists in irrigating a solution of 1.0-1.5% acetic acid with 5.0 ml of the mucosa of the lower third of the esophagus during gastroscopy and visual assessment of the changes after 1-2 minutes.

The disadvantages of the method are the short duration of the action of a solution of vinegar for a visual assessment of changes, its aggressiveness, lack of ability to stain foci of metaplasia and dysplasia. All this limits the possibility of using it for diagnostic purposes.

The closest is the "Method of stepwise combined chromoscopy of the esophagus" (Korotkevich A.G. et al. Endoscopy in the diagnosis of Barrett's esophagus, Medicine in Kuzbass, No. 3, 2008, pp. 23-29).

The method includes an endoscopic examination with the treatment of the mucous membrane of the esophagus 2 ml of 1.5% acetic acid with a visual assessment of the mucosa after 1-2 minutes, irrigation of the mucosa with 2 ml of a 1% aqueous solution of Lugol with the assessment of the uniformity of staining of the mucous membrane of the esophagus, the clarity and location of the border of the esophageal epithelium washing the Lugol solution with water, irrigating the mucosa with 2 ml of a 1% aqueous solution of methylene blue, after 2-3 minutes washing the dye with water.

The method does not determine the amount of water for washing the coloring solutions. Excess water leads to a violation of the formation of a new color scheme and changes the sensitivity of the method.

Not specified conditions for the introduction of coloring solutions.

The objective of the invention is the creation of a simple, inexpensive and effective method for the diagnosis of complications of gastroesophageal reflux disease (GERD).

The task is achieved by a method of combined chromoscopy of the esophagus, including endoscopic examination with treatment of the mucous membrane of the esophagus 2 ml of 1.5% acetic acid with a visual assessment of the mucosa after 1-2 minutes, irrigation of the mucosa with 2 ml of a 1% aqueous solution of Lugol with an assessment of the uniformity of staining of the esophageal mucosa , the clarity and location of the border of the esophageal epithelium, washing the Lugol solution with water, irrigating the mucosa with 2 ml of a 1% aqueous solution of methylene blue, after 2-3 minutes washing the dye with water.

The introduction of acetic acid, an aqueous solution of Lugol, an aqueous solution of methylene blue is carried out at the height of the peristaltic wave in the esophagus, when the end of the catheter is completely covered by the mucous membrane of the esophagus. Wash Lugol's solution with water in a volume of 20-40 ml, wash a solution of methylene blue with water in a volume of up to 1 liter.

The compliance of the proposed technical solution to the criterion of "novelty" is confirmed by the presence of the following features.

- The introduction of acetic acid, an aqueous solution of Lugol, an aqueous solution of methylene blue is carried out at the height of the peristaltic wave in the esophagus, when the end of the catheter is completely covered by the mucous membrane of the esophagus.

- Wash the Lugol solution with water in a volume of 20-40 ml, wash a solution of methylene blue with water in a volume of up to 1 liter.

The combination of essential features allows to ensure the effectiveness of the method and to obtain a new technical result.

The introduction of each solution at the height of the peristaltic wave in the esophagus, when the end of the catheter is completely covered by the mucous membrane of the esophagus, significantly improves the quality of staining of the mucous membrane by ensuring uniform application of the solution in close contact with the catheter during peristalsis and ensures the formation of a color gamut throughout the distal end of the catheter. The volume of water for washing solutions does not violate the formation of a new color scheme and provides the necessary sensitivity of the method.

The consistent use of dyes, washing them with a certain amount of water allows you to get a new quality of contrast and color, which increases the sensitivity, specificity and reliability of the diagnosis.

A change in the color of the foci of gastric metaplasia of the mucosa with a combination of solutions of Lugol and methylene blue to intensely dark allows you to see very small foci of intestinal metaplasia of bright color that are indistinguishable to the eye under optical fibroscopy.

The method is as follows.

After diagnostic esophagogastroduodenoscopy, when detecting visual signs of chronic esophagitis and foci of red mucosa, chromoscopy is prescribed. In the patient’s position on the left side after local anesthesia of the oropharynx, a diagnostic fibrogastroscope or video endoscope is inserted into the esophagus. After a second examination of the mucous membrane of the esophagus, the most likely foci of changes in the mucosa are determined. A catheter with a spray head is inserted into the instrument channel of the endoscope. The catheter is installed in the field of view of the endoscope, but above the border of the identified changes in the mucosa. Air is aspirated to reduce the lumen of the esophagus and on a peristaltic wave, covering the free end of the catheter, a solution of acetic acid is introduced in an amount of 2 ml with a concentration of 1.5%. Then air is insufflated and the surface of the mucous membrane is inspected to identify “fish scales” and foci of bleeding in a period of no more than 2 minutes. Air is aspirated to reduce the lumen of the esophagus and on a peristaltic wave, covering the free end of the catheter, a Lugol solution is introduced. Immediately after the introduction of Lugol's solution, 20-40 ml of water is introduced through the same catheter to remove residual solution and the mucous membrane is assessed: localization and area of light yellow and dark brown areas, clarity and location of the border of the esophageal epithelium, structure of the painted surface in relation to the detected foci when stained with a solution of vinegar. Air is aspirated to reduce the lumen of the esophagus and on a peristaltic wave, covering the free end of the catheter, a solution of methylene blue is introduced, the exposure time is maintained for 2-3 minutes. Then air is insufflated and up to 1 liter of water is introduced through the same catheter to remove residual solution and the mucous membrane is evaluated: the appearance of foci of lilac-brown color, the appearance of foci of bright blue color, from which a targeted biopsy is taken. Foci of lilac-brown color correspond to gastric metaplasia. Foci of bright blue are diagnosed as intestinal metaplasia with Barrett's esophagus.

The invention is based on the diagnostic results of 49 patients with GERD. The stage of combined chromoscopy made it possible to identify foci of Barrett's esophagus that were not visually diagnosed in 31%: at the stage of staining with a solution of vinegar in 7%, a solution of Lugol - in 15%, a solution of methylene blue - in 9%.

Figure 1, 2, 3 presents the results of combined chromoscopy of patients in examples 1, 2, 3.

On Figa, 2A, 3A - before staining. In Fig.1B, 2B, 3B - after irrigation with a solution of vinegar. In Fig.1B, 2B, 3B - after irrigation with a solution of Lugol. In Fig.1G, 2G, 3G - after staining with a solution of methylene blue.

Example 1. Patient P., 45 years old, underwent FGDS on an outpatient basis. After an endoscopic examination, signs of chronic esophagitis (thickening of the mucosa in the lower third of the esophagus, smoothness of the dentate line) were revealed. FIG. 1A. After irrigation with a solution of acetic acid, foci of whitish scaly layers on the mucosa of Fig. 1B were revealed. After irrigation with Lugol's solution, additional foci of lilac-brown metaplasia were revealed Fig. 1B. Staining with a solution of methylene blue revealed the boundaries of intestinal metaplasia of a bright blue color Fig.1G, not coinciding with the visual assessment of Fig.1A. Identified changes are confirmed histologically. The patient is recommended endoscopic mucosal resection.

Example 2. Patient M., 54, was referred by a general practitioner for combined chromoscopy after preliminary HDF with a diagnosis of chronic distal reflux esophagitis, cardiac insufficiency 2-3 tbsp., Barrett's esophagus? Polyp of the lower third of the esophagus? Early cancer of the lower third of the esophagus? Figa.

After irrigation with a solution of acetic acid, increased bleeding of the mucosa, the appearance of white scaly layers of Fig.2B. When irrigated with Lugol's solution, staining of the mucosa was not obtained, which indicated the absence of the esophageal epithelium of Fig.2B. When stained with a solution of methylene blue, drainage foci of intestinal metaplasia of a bright blue color were detected, foci of dysplasia were not detected Fig.2G. A biopsy was taken from the changed sites. The diagnosis of early cancer is rejected. The diagnosis of a long segment of Barrett's esophagus and pseudo-inflammatory polyp of the lower third of the esophagus has been confirmed.

Example 3. Patient S., 43 years old, earlier with gastroscopy revealed signs of reflux disease and chronic reflux esophagitis (worn dentate line, “tongues of flame” of the gastric epithelium, lack of vascular pattern) Fig.3A. Directed to exclude intestinal metaplasia in patients with Barrett's esophagus. After irrigation with a solution of acetic acid, a clear boundary of the esophagus and gastric epithelium Fig.3B. When stained with Lugol's solution, a clear boundary of the epithelium of the esophagus and stomach was revealed, intense staining in the abdominal segment of the esophagus of the drainage foci of metaplasia Fig.3B. After staining with methylene blue solution, changes were detected in the lower third of the esophagus - the lilac color of the foci of gastric metaplasia, the spot foci of bright blue, characteristic of the emerging Barrett's esophagus against chronic esophagitis. Dynamic follow-up, conservative treatment of GERD is recommended.

Thus, the proposed method is highly efficient, simple, affordable and does not require a significant expenditure of time and material costs. The consistent use of dyes, their introduction at the height of the peristaltic wave in the esophagus, a certain amount of water for washing dyes enhance the intensity and brightness of the stained areas, which improves the quality of diagnosis and the efficiency of the method.

Claims (1)

The method of combined chromoscopy of the esophagus, including endoscopic examination with treatment of the mucous membrane of the esophagus 2 ml of 1.5% acetic acid with a visual assessment of the mucosa after 1-2 minutes, irrigation of the mucosa with 2 ml of a 1% aqueous Lugol solution with an assessment of the uniformity of staining of the mucous membrane of the esophagus, the clarity and location of the border of the esophageal epithelium, washing the Lugol solution with water, irrigating the mucosa with 2 ml of a 1% aqueous solution of methylene blue, after 2-3 minutes washing the dye with water, characterized in that the introduction of usnoy acid aqueous solution of Lugol, aqueous solution of methylene blue is performed for adjustment of the peristaltic wave of the esophagus when the catheter is completely covered by the end of the esophageal mucosa, Lugol's solution was washed with water in a volume of 20-40 ml, of methylene blue solution was washed with water in a volume to 1 liter.

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