RU2462715C1 - Differential diagnostic technique for endogenous intoxication - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: differential diagnosing of endogenous intoxication is calculated by an endogenous intoxication coefficient (EIC) by formula: EIC=(SPEi:SPEk)(Ii:Ik) wherein SPEi is the sorption power of patient's erythrocyte, standard units, SPEk is the sorption power of control erythrocyte, standard units, Ii is the amount of patient's serum indican, mg %, Ik is the amount of control serum indican, mg %. If the EIC value is (M±2σ) 1.00+0.37, the absence of endogenous intoxication is stated. The gain of each of the equation component (SPEi, Ii) exceeding the control values separately, the EIC value in whole changes in min. 2 times as compared with the average control EIC values that testifies to the extraintestinal origin of endogenous intoxication. The combined gain of EICi and the level of patient's serum indican, the EIC values becomes more than 2.0 that enables stating the presence of endogenous intoxication of the colonic origin.

EFFECT: use of the given method enables determining the origin of endogenous intoxication that allows specifying the therapeutic approach to the patient, and thereby improving the clinical effectiveness.

1 tbl, 2 dwg, 3 ex

Description

The invention relates to medicine, namely to laboratory diagnostics, and can be used in coloproctology and gastroenterology.

Of great importance for assessing the severity of the patient's condition and prognosis of the disease already in the early stages of the development of pathology is the syndrome of endogenous intoxication (EI). EI syndrome is a complex pathogenetic phenomenon, accompanied by excessive catabolism, impaired functioning of the mechanisms of natural detoxification, and the development of depression of the body’s immune systems [Karpishchenko AI Reference book “Medical laboratory diagnostics (programs and algorithms)”. - St. Petersburg: Intermedika, 2001. - 544 p.]. Its occurrence is accompanied by the processes of accumulation in the patient's body of an excessive amount of intermediate and final metabolites that have a toxic effect on organs and life support systems. EI is one of the most common pathophysiological conditions in clinical practice and is observed in a wide variety of diseases.

Chronic colon diseases, which affect up to 70% of all patients who turn to gastroenterologists, are in one way or another associated with a violation of the processes of fermentation and absorption of various protein metabolism products, as a result of which the organism develops intestinal agents [Karbovnitskaya L.P., Savchenko Yu.P. . Chronic colostasis, clinic, diagnosis, treatment. Krasnodar. - 1998. - 80 p., Karpishchenko A.I. Reference book “Medical laboratory diagnostics (programs and algorithms)”. - St. Petersburg: Intermedika, 2001. - 544 p.]. For abdominal surgical practice, it is important to determine the leading mechanism for the development of EI syndrome, therefore, the search continues for differential diagnostics of EI of resorption origin of intestinal origin from other primary mechanisms of its development (production, reperfusion, retention, infectious), which is necessary for the timely selection of rational tactics for managing patients with partial intestinal obstruction, impaired by a hernia, colostasis, congenital intestinal diseases (megacolon, dolichosigma ), And other conditions where there is an activation of the microflora of the digestive system.

Toxic products, entering the bloodstream, are primarily adsorbed on the surface of red blood cells due to their multiplicity and the architectonics of their membranes, which reduce their functional activity and physico-chemical properties, including changing the selective permeability of biomembranes. Based on this, the degree of EI of any origin can be indirectly judged by the change in the permeability of the plasma membrane of erythrocytes and their reduction properties [Togaybaev AA, Kurguzkin AV, Rikun IV, Karibzhanova P.M. A method for determining endogenous intoxication. // Lab. A business. - 1988. - No. 9. - S.22-24].

One of the representatives of toxic products that cause the development of EI syndrome is indole. A number of studies show that the indole content in muscle tissue and the colon mucosa in patients with chronic colitis and constipation is significantly higher than in healthy individuals [Lincoln J., Crowe R., Kamm M., Burnstock G., Lennard-Jones J. Serotonin and 5-hydroxyindoleacetic acid are increased in the sigmoid colon in severe idiopathic constipation. Gastroenterology, 1990, May; 98 (5 Pt 1): 1219-25], which can be used for differential diagnosis of the type of EI, determining the concentration of indican in the blood serum of the examined patient. Indican is a potassium or sodium salt of indoxylsulfuric acid, which is formed in the liver during the neutralization of indole. Like other toxic substances, indole appears in the intestine during the decay of amino acids [Kolb V.G., Kamyshnikov B.C. Clinical biochemistry. // Minsk, 1976. - S.65-67.].

A known method for determining the degree of endogenous intoxication according to the method Pavlyuchenko II, Dynko Yu.V., Potemina S.N., Basova A.A., Pavlyuchenko E.V. - "A method for the diagnosis of endogenous intoxication in abdominal pathology" // Bulletin of intensive care. " - 1999. - No. 5-6. Section 4. - P.164-165, based on the determination of the sorption capacity of red blood cells (SSE) using vital dye (methylene blue). SSE is calculated by the formula: A (%) = (100-100 · C: B): N, where

And - the amount of absorbed dye, conv. units;

In - the optical density of the control solution of the dye, in units of optical density;

C is the optical density of the supernatant after incubation of the blood of the test and vital dye, in units of optical density;

100 - mathematical coefficient, corresponds to 100% optical density;

N is the number of red blood cells in the blood of the subject in units of optical density.

The absorption rate of the vital dye - SSE - is 252.51 ± 7.62 srvc. units, which is established on conditionally healthy donors, with an increase in this indicator, one can judge the presence of EI of general genesis and its severity.

The number of red blood cells is determined by the method of [Ressel L.K., Todorov I. Clinical laboratory studies in pediatrics. - Sofia, 1961. - 259 p.].

The disadvantage of this method is:

a) it can be used to determine the presence and level of EI, but it is impossible to differentiate the origin of EI, that is, to distinguish EI of resorption origin of intestinal origin from other primary mechanisms of its development (production, reperfusion, retention, infectious), which limits the possibilities of its use in abdominal surgical practice when choosing management tactics for patients with increased putrefactive processes in the digestive system and impaired fermentation processes;

b) the rate of SSE is affected by the administration of drugs that, getting into the bloodstream, affect the state of the plasma membranes of red blood cells, adsorbing on them and changing the processes of free radical oxidation in the bilipid layer of cell membranes (drugs with prooxidant and antioxidant properties), which can distort the result determination of EI by this method.

For the closest analogue, the method for determining serum indican in intestinal obstruction and in acute renal failure according to [Kamyshnikov B.C. Handbook of clinical and biochemical laboratory diagnostics: In 2 vol. T.1. - Mn .: Belarus, 2000. - S.333-335]. The principle of the method is based on the acid (in the presence of hydrochloric acid) hydrolysis of indican (potassium salt of indoxylsulfuric acid) followed by oxidation of the resulting indoxyl and thymol with ferric chloride to indigo lignon, a pink-violet compound whose intensity determines the indican content by multiplying 0.88 (mmol / l) by the multiplicity of dilution (quotient from dividing the final volume of chloroform by the initial volume). When the value of the indicator is equal to 0.22-0.88 μmol / L, it is said that there is no EI associated with an excess of indican, when the value of the indicator is more than 0.88 μmol / L, the presence of intoxication and its degree are judged.

The disadvantages of this method are:

a) studies are carried out separately, without evaluating the dynamics over time, which does not reflect the correlation between the general degree of intoxication and the direct source of endogenous intoxication, that is, it does not allow to assess the level of EI;

b) they do not determine the severity of the damaging effect of endotoxic substances on the cellular structures of the body (for example, red blood cells, which are among the first to respond to toxic effects and quickly exhaust their compensatory capabilities [Roitman EV, Dementieva II, Azizova OA , Nikitina N.A., Gagaeva E.V., Lopukhin Yu.M. Change in blood rheological properties and osmotic resistance of red blood cells upon activation of free radical processes // Clinical laboratory diagnostics. - 2001. - No. 3. - p. 42- 43]), which is necessary for an objective assessment the degree of the body at the cellular level of EI.

The objective is to objectify the assessment of endogenous intoxication in patients with chronic diseases of the colon at various stages of treatment, the differential diagnosis of this pathological condition to determine the treatment tactics and laboratory control of intoxication in patients with chronic diseases accompanied by the development of EI syndrome.

The technical result of the proposal is:

a) the use of this simple and inexpensive method allows the most accurate determination of the source of endogenous intoxication, which is of great medical and social importance when choosing treatment tactics for patients with chronic colon diseases, to differentiate patients with chronic endogenous intoxication of another etiology according to the primary mechanisms of its development, choose a reasonable tactics of patient management and, thus, increase the effectiveness of treatment,

b) the ability to determine the severity of the damaging effect of endotoxic substances on the cellular structures of the body (for example, red blood cells), which are among the first to respond to toxic effects and quickly exhaust their compensatory capabilities [Roitman EV, Dementieva II, Azizova O.A. ., Nikitina N.A., Gagaeva E.V., Lopukhin Yu.M. Change in the rheological properties of blood and osmotic resistance of red blood cells upon activation of free radical processes // Klinich. lab. diagnostics. - 2001. - No. 3. - p.42-43]), reflecting the changes occurring in tissue structures, which is important for an objective assessment of the degree of organism EI at the cellular level,

c) the implementation of differential diagnosis between EI of resorption origin of intestinal origin and other primary mechanisms of its development (production, reperfusion, retention, infectious) seems to be important for use in abdominal surgical practice when choosing tactics for managing patients with increased activity of putrefactive processes in the gastrointestinal tract.

The essence of the method for differential diagnosis of endogenous intoxication, which includes determining the sorption ability of red blood cells by the degree of absorption of vital dye in a venous blood sample based on recording the optical density of the dye solution in the supernatant before and after incubating it with a suspension of red blood cells, characterized in that it is simultaneously in the same blood sample of patients in serum determine the level of indican and by similar indicators of red blood cells and blood serum of the control group of conditionally healthy donors calculate the coefficient of endogenous intoxication (CEI) according to the formula:

CEI = (SSEi: SSEk) · (Ii: Ik),

where SSEi is the sorption ability of the red blood cell of the subject, in conv. units

SSEk - sorption ability of a red blood cell of the control group, in conv. units

Ii - the amount of indican serum of the subject, in mg%,

Ik - the amount of indican of serum of the control group, in mg%,

and with a value of the calculated indicator of 1.00 ± 0.37, the absence of endogenous intoxication is judged, when each of the components of the equation (CCEi, II) increases above the control values individually, the CEI indicator as a whole changes by no more than 2 times, which indicates extraintestinal the origin of endogenous intoxication, and with a simultaneous increase in SSEi and the level of indica, the CEI indicator becomes more than 2.0, which allows us to ascertain the presence of endogenous intoxication of colonic origin.

The method is as follows. The optical density of the supernatant obtained after centrifugation of the reaction mixture, including 1 ml of whole blood of the subject and 3 ml of vital dye, such as methylene blue, is determined in comparison with the optical density of the initial solution of vital dye according to the method [Pavlyuchenko II, Dynko Yu.V. , Patemin S.N., Basov A.A., Pavlyuchenko E.V. A method for the diagnosis of endogenous intoxication with abdominal pathology // Bulletin of intensive care. - 1999. - No. 5-6, sect. 4. - S.164-165]. SSE is calculated by the formula: A (%) = (100-100 · C: B): N, where

And - the amount of absorbed dye in arbitrary units, conv. units;

In - the optical density of the control solution of the dye, in units of optical density;

C is the optical density of the supernatant after incubation of the blood of the test and vital dye, in units of optical density;

100 - mathematical coefficient, corresponds to 100% optical density;

N is the number of red blood cells in the blood of the subject in units of optical density.

The number of red blood cells is determined by the method of [Ressel L.K., Todorov I. Clinical laboratory studies in pediatrics. - Sofia, 1961. - 259 p.].

To determine the normal rate of SSE, measurements were made on donated blood (n = 65). In the study of erythrocyte suspension by our method, the absorption rate of the vital dye - SSE - amounted to 252.51 ± 7.62 srvc. units

Definition of indican is based on hydrolysis of it with hydrochloric acid, followed by oxidation of the formed indoxyl and thymol with chloric iron into indigoligion, a pink-violet compound. Pure chloroform is then added to this liquid until the color disappears. The content of indican in a test tube with traces of paint corresponds to the value obtained by multiplying 0.022 by dilution, the quotient of dividing the final volume of chloroform by its initial volume. The content of indican in the blood of healthy donors ranges from 0.022 to 0.044 mg%.

In the process of monitoring these indicators, you can additionally build a schedule that allows you to visually assess the dynamics of changes in these indicators at various stages of treatment.

The degree of endogenous intoxication we determine in arbitrary units by the formula:

CEI = (SSEi: SSEk) · (Ii: Ik), where

CEI - coefficient of endogenous intoxication, in fractions of a unit.

SSEi - sorption ability of the red blood cell of the subject, in conv. units

SSEk - sorption ability of a red blood cell of the control group, in conv. units

Ii - the amount of indican serum of the subject, in mg%,

Ik - the amount of indican of serum of the control group, in mg%,

and with a value of the calculated indicator of 1.00 ± 0.37, the absence of endogenous intoxication is judged, with an increase in each of the components of the equation (SSEi, II) above the individual control values, the CEI indicator as a whole changes by no more than 2 times, which indicates extraintestinal the origin of endogenous intoxication, and with a simultaneous increase in SSEi and the level of indica, the CEI indicator becomes more than 2.0, which allows us to ascertain the presence of endogenous intoxication of intestinal origin.

The table shows the change in CEI depending on the SSE and indicator values. The table shows that when each of the components of the equation (SSE, I) increases above the control values individually, the CEI indicator as a whole changes by no more than 2 times, which indicates the extraintestinal origin of EI. With a simultaneous increase in SSE and the level of indica, the CEI indicator increases 4 times or more, which allows us to talk about the intestinal origin of EI with CEI more than 2.0.

The results of determining the level of EI by the indicators of CEI are additionally reflected in the graph, see Fig. 1. Fig. 1 graphically shows the mathematical modeling of changes in CEI depending on the level of SSE and the level of indicator, the numerical values of which are shown in the table (columns 1-12).

In connection with the foregoing, in order to prove the intestinal origin of EI, studies of EI indicators were carried out in dynamics on the change in SSE and indican in patients with endotoxemia due to the presence of chronic colon diseases. A survey and observation of 37 patients with signs of cologenic intoxication against chronic colonic stasis (CTS) was performed. Initial SSE indicators in patients with CTS syndrome were 295.98 ± 17.47 conv. units, indica - 0.092 ± 0.01 mg%, CEI - 3.27 ± 0.23. The calculations show that the values of CEI in patients before surgery are greater than 2.0 (CEI = 3.27 ± 0.23), which confirms the intestinal origin of EI. In the process of preparing the intestines of patients for surgical treatment, the phenomena of EI of cologenous origin decreased (Fig. 2), although the overall level of EI remained elevated. The SSE indicator as a parameter reflecting the presence of EI generally remained elevated and amounted to 270.65 ± 15.09%. The indican content in this case corresponded to the lower limit of the norm - 0.022 mg% (p <0.01), and CEI = 0.71 ± 0.04 (less than 2.0), which indicates the absence of EI of intestinal origin.

In the first day of the postoperative period, the SSE level increased compared with preoperative indicators to 293.25 ± 21.84 conv. units (p <0.01), which, in our opinion, is explained by an increase in total EI, accompanied by the accumulation of toxic products in the general bloodstream due to surgical intervention associated with anesthesia intoxication and trauma to body tissues. The indican level still remained at the lower limit of the norm - 0.022 mg%, CEI = 0.77 ± 0.06 (less than 2.0), which indicates the absence of EI of intestinal origin. By the 15th day of the postoperative period, the patients had a complete restoration of the motor-evacuation function of the gastrointestinal tract, a daily regular independent stool appeared and normalization of SSE parameters (250.92 ± 19.06%, p <0.01) and serum indican content ( 0.022 mg%), which led to the disappearance or significant reduction of all symptoms of chronic colostasis. CEI was 0.66 ± 0.05 (less than 2.0), which indicated the absence of EI of both intestinal origin and EI in general.

Figure 2 shows the dynamics of SSE and serum indica in patients with CTS during the treatment of colostasis.

The long-term results of surgical treatment of patients with CTS in the clinic were tracked on 61 patients in the period from 6 months to 20 years. It should be noted that in none of these cases, colorectal cancer was diagnosed. The SSE and indica indices in the patients examined by us, from 7 months to 14 years after the corrective surgery for CTS syndrome, were within normal limits (SSE - 255.37 ± 5.56; indican - 0.032 ± 0.01, CEI = 0 , 98 ± 0.02 (less than 2.0), which indicates the absence of EI of intestinal origin).

Example 1. Patient G., 22 years old. Complaints: pain and bloating, persistent headaches, joint pain, general weakness, stool retention of 7 or more days. The presence of constipation notes since childhood. It was examined and treated in hospitals, sanatoriums of a gastroenterological profile for biliary dyskinesia. Repeatedly treated by a neurologist about discirculatory encephalopathy. Conservative methods of treatment (diet, laxatives, enemas) have recently been ineffective. The loss of body weight over the past year was 12 kg. Upon admission, body weight was 47 kg with a height of 173 cm. Functional irrigography established: dolichomegacolon, cecum in the pelvis, ascending and transverse colon form an inflection in the form of a “double-barreled shotgun”. The transverse colon sags, the left bend of the colon has a high location with a pronounced double-barreled phenomenon. The sigmoid colon has 2 loops of considerable length located in the pelvis. Initial SSE indicators - 316.03 conv. units; indica - 0.1 mg%, CEI = 3.79 (greater than 2.0), which confirms the intestinal origin of EI. Diagnosis: Chronic colonic stasis, left-sided stasis colitis. An operation was performed - correction of the colon with left-sided hemicolectomy and fixation of the colon according to the author's method [Method for the surgical treatment of chronic colostasis [Text]: patent RU 2174370, IPC. А61В 17/00, А61В 17/11 / Gurdzhiyan M.D., Slavov A.I., Potemin S.N., Gumenyuk S.E .; applicant and patent holder Gurdzhiyan M.D., Slavov A.I., Potemin S.N., Gumenyuk S.E. - No. 98119107/14; declared 10/19/1998; publ. 10/10/2001. - B. No. 28. - 5 p.]. The postoperative course is smooth. On the 4th day, the chair is independent. SSE indicators - 260.45 conv. units, indica - 0.022 mg%, CEI = 0.69 (less than 2.0), which indicates the absence of EI of intestinal origin. When discharged, she feels good, no complaints. SSE indicators - 251.32 conv. units, indica - 0.022 mg%, CEI = 0.66 (less than 2.0), which indicates the absence of EI of intestinal origin. 6 months after the operation, the patient feels well, independent stool, daily. I gained 5 kg in weight. Headaches do not bother. The result of the treatment is regarded as excellent.

For a comparative study of the mechanisms of EI, the SSE indices, the indican content and CEI were studied in patients without a clinic for resorption EI of intestinal origin, the results of which are presented in the examples below.

Example 2. Patient S., 34 years old. Diagnosis: Type 1 diabetes mellitus, severe course, decompensation. Ketosis Complications: Diabetic polyneuropathy, diabetic lower limb angiopathy, diabetic nephropathy III, CRF-1 st. In the biochemical analysis of blood at admission, hyperglycemia (19-28 mmol / L), in the general analysis of urine - glucosuria, ketone bodies (5 mmol / L). The initial indicators of SSE amounted to 406.49 conv. units; indica - 0.38 mg%, CEI = 1.85 (above the physiological value 1.00 ± 0.37, but less than 2.0), which confirms the presence of diabetes mellitus in this patient with production (hypercatabolic syndrome) and / or reperfusion (violation of microcirculation) primary developmental mechanism and indicates the absence of EI of intestinal origin (resorption origin). After the treatment (infusion therapy, insulin therapy, correction of electrolyte disturbances) after 12 days, the SSE indices amounted to 276.81 conv. units; indicana - 0.31 mg%, CEI = 1.03 (less than 2.0 and within the physiological value of 1.00 ± 0.37), which confirms in this patient with diabetes mellitus a decrease in the effects of endotoxemia during therapy and indicates lack of EI of intestinal origin (resorption origin).

Example 3. Surveyed K., 27 years old (donor). General analysis of blood and biochemical analysis of blood, general analysis of urine without pathobiochemical changes (within physiological values). The initial indicators of SSE amounted to 256.74 conv. units; indicana - 0.26 mg%, CEI = 0.80 (less than 2.0 and within the physiological value of 1.00 ± 0.37), which confirms the absence of EI, including intestinal origin (resorption origin) in the subject.

This invention allows:

1) to determine the severity of the damaging effect of endotoxic substances on the cellular structures of the body (for example, red blood cells), reflecting changes in tissue structures and biological fluids of the body, which is important for an objective assessment of the degree of EI of the body at the cellular level,

2) carry out differential diagnostics between the EI of the resorption genesis of intestinal origin and other primary mechanisms of its development (production, reperfusion, retention, infectious), which is necessary in abdominal surgical practice when choosing tactics for managing patients with increased activity of putrefactive processes in the gastrointestinal tract.

The practical result of the proposal is the use of a new method for the diagnosis of EI, which allows you to accurately determine the source of endogenous intoxication, which is of great medical and social importance in the selection of patients with chronic colonic stasis syndrome for a particular treatment method, and also helps to differentiate patients with chronic endogenous intoxication with another etiology.

Claims (1)

A method for differential diagnosis of endogenous intoxication, including determining the sorption ability of red blood cells by the degree of absorption of vital dye in a venous blood sample based on recording the optical density of the dye solution in the supernatant before and after incubating it with a suspension of red blood cells, characterized in that simultaneously in the same blood sample of patients in serum determine the level of indican and by the same indicators of red blood cells and blood serum of the control group of conditionally healthy donors I count factor endogenous intoxication (KEI) by the formula:
CEI = (SSEi: SSEk) · (Ii: Ik),
where SSEi is the sorption ability of the red blood cell of the subject, srvc. units
SSEk - sorption ability of a red blood cell of the control group, conv. units
Ii - the amount of indican serum of the subject, mg%,
Ik is the amount of indicated serum of the control group, mg%, and when the value of the calculated indicator (M ± 2σ) is 1.00 ± 0.37, the absence of endogenous intoxication is judged, with each of the components of the equation (SSEi, Hi) increasing individually above the control values the CEI indicator as a whole changes by no more than 2 times compared with the average value (M) of the CEI of the control group, which indicates the extra-intestinal origin of endogenous intoxication, and with a simultaneous increase in the SSEi and the level of the serum of the subject (II), the CEI becomes more than m 2.0, which allows us to ascertain the presence of endogenous intoxication of colonic origin.

Images