RU2427837C1 - Method of diagnosing destructive pancreatitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: once admitted to hospital, a patient is examined for blood serum C-reactive protein (CRP) and α₂-macroglobulin (MG) to determine a CRP to MG concentration ratio. The CRB/MG ratio exceeding 2 corresponds to acute destructive pancreas inflammation, and the CRB/MG ratio being 2 and lower indicates reduction or absence of inflammatory process in the pancreas.

EFFECT: more instant diagnostics.

2 ex

Description

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

Differential diagnosis of acute pancreatitis 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. - With 58-62].

Diagnosis of acute pancreatitis is a very difficult problem and at present 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 laparotomy 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 the 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.

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, PMSmanilo, A.V. Kuznetsov, S.I. Mkeev . Optimization of diagnostic methods in patients with acute pancreatitis // Medetsina emergency conditions, 2007. - No. 1 (8). - S. 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:

- C-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 ≥16 000;

- hypocalcemia <2 mmol / L.

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

Standard laboratory tests can diagnose acute pancreatitis, as well as differentiate 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 method 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, studies conducted in the early days are completely 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 to this expensive, fraught with complications associated with the introduction of a contrast medium, and accompanied by a rather high radiation dose, the 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, which most often hospitalize patients with destructive lesions of the pancreas and gall bladder,

- difficulty finding early signs of destructive changes in the pancreas and gall bladder.

The inaccessibility of computed tomography in medical institutions of district, city, and sometimes even 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 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; Miroshnichenko A.G. et al. The method of differential diagnosis of acute pancreatitis // Patent of the Russian Federation No. 2306850 from 2005.44.12; Gordetsov A.S. et al. The method of differential diagnosis of acute pancreatitis // RF Patent No. 2253868 of 2005].

In the diagnosis of many destructive conditions, the C-reactive protein (CRP) and α ₂ -macroglobulin (MG), which, according to the researchers, are considered to be acute phase proteins, have proven themselves well, therefore, reflect the stage of tissue destruction [Shramko SV, Zorina V .N., 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 necrosectomies and lavage) under the influence of several reputable clinical studies were minimized [Buechler M.W., Gloor B., Muller C.A. et al., 2000. Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann. Surg., 232 (5) 619-626].

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 current possibilities of both conservative and surgical therapy based on evidence-based medicine give these patients a much greater chance of survival.

As a prototype taken the method of differential diagnosis of pancreatitis, described by A. Gordetsov 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 C-reactive protein and α ₂ -macroglobulin in blood serum are much more promising in this direction.

The aim of the invention is to improve the accuracy of diagnosis of destructive forms of acute pancreatitis.

The goal of the invention is achieved by examining the level of C-reactive protein and α ₂ -macroglobulin in the patient’s blood serum upon admission to a hospital, determining the ratio of CRP and MG concentrations, while CRP / MG ratio above 2 corresponds to acute destructive inflammation of the pancreas glands, and a CRP / MG coefficient below 2 indicates a decrease or absence of the inflammatory process in the pancreas.

The concentration of C-reactive protein and α ₂ -macroglobulin in blood serum was determined by the method of radial immunodiffusion (mg / l) in 182 patients with acute pancreatitis upon admission, immediately on the day of surgery, 3-5 days after surgery and upon discharge of patients.

A clear dependence of the concentration of C-reactive protein and MG on the degree of the destructive process in the pancreas was established. In dynamics, the level of C-reactive protein increases upon admission to 24.9 ± 6.6 mg / L (P <0.01) and decreases during treatment, while the MG level during inflammation is reduced to 834 ± 180 mg / L (P <0.01) and is restored with successful treatment, which should be used in the differential diagnosis of destructive pancreatitis. A significant decrease in MG levels in acute pancreatitis can probably be explained by its functional relationship with a group of proteolytic enzymes. This is probably why a significant decrease was found in severe acute pancreatitis, when pancreatic enzymes are activated. The revealed phenomenon of multidirectional changes in the concentrations of MG and CRP is an indicative test in the diagnosis of acute pancreatitis. The significance of this phenomenon is enhanced by the introduction of a numerical coefficient of the ratios of multidirectional concentrations of CRP and MG.

K = C _CRP / C _MG × 100 before treatment 25/834 × 100 = 2.9;

- after treatment, 17.2 / 1258 × 100 = 1.3.

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

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 182 patients with acute pancreatitis. Based on the created scoring, 86% of the examined patients were diagnosed with acute pancreatitis. The following are examples of testing.

Example 1. Patient M., 40 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 that appears after an error in the diet, intake of fatty foods, on the 4th day from the onset of the disease.

Objectively: the condition is satisfactory. Heart - rhythmic tones, 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, calculi from 0.4 to 0.7 cm, the pancreas is enlarged, increased echogenicity.

Diagnosed with cholecystitopancreatitis. 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 ° С. An increased level of MG is 980 mg / l, CRP is 23 mg / l, the coefficient is 2.3, and therefore was diagnosed with acute pancreatitis.

Treatment. Table No. 0, cold on the stomach, bilateral perinephral block with a solution of novocaine 25% - 100.0 antispasmodics, infusion therapy, analgesics, heparin, kontrikal 25000 units × 2 times a day. After the treatment, the condition improved, the pains disappeared, the CRP / MG coefficient is 1.1.

Example 2. Patient P., 50 years old, 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 the diet, intake of fatty foods.

Objectively: a state of moderate severity. Moderate pallor of the skin, dry mouth, single vomiting of bile. Heart - rhythmic tones, 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 - increased echogenicity, slightly increased.

The low level in the blood serum of MG is 760 mg / l, CRP is 28 mg / l, the coefficient is 3.6 - the 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 × 2 times a day. After the treatment, the condition improved, the pains disappeared. The recovery of MG values to 980 mg / l, a decrease in CRP to 16 mg / l, a coefficient of 1.6 at the time of recovery were noted. Discharged after 10 days in satisfactory condition.

Using the proposed method, it is possible to achieve:

- reliable differential diagnosis of acute pancreatitis (differential diagnosis between acute pancreatitis and acute cholecystitis);

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

- diagnosis of latently occurring destructive conditions in which patients need surgical treatment;

- reduction of time and economic costs by reducing preoperative preparation, eliminating attempts at unsuccessful conservative therapy and repeated hospitalizations, and eliminating expensive computer screening;

- achieving a higher quality of safety by eliminating unwanted radiation exposure to the patient and staff.

Claims (1)

A method for diagnosing destructive pancreatitis by examining blood serum, characterized in that the level of C-reactive protein and α ₂ -macroglobulin in the patient’s blood serum is examined upon admission to the hospital, the ratio of CRP and MG concentrations is determined, and the CRP / MG ratio is above 2 corresponds to acute destructive inflammation of the pancreas, and a CRP / MG coefficient below 2 indicates a decrease or absence of the inflammatory process in the pancreas.