RU2474381C1 - Differential diagnostic technique in constipations - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns medicine, particularly diagnostics. A method involves clinical research and electromotor activity (EMA) examination of descending intestine. If the EMA slow wave frequency is 9-10.2 a minute and the spike frequency is 5-5.5 per one slow wave, dissynergic defecation is diagnosed. If the EMA slow wave frequency is 5.8-6.4 a minute and the spike frequency is 2.5-2.8 per one slow wave, functional constipation is diagnosed. If the EMA slow wave frequency is 4-4.4 a minute and the spike frequency is 2.0-2.2 per one slow wave, constipation associated with inert colon is diagnosed.

EFFECT: technique provides higher accuracy of differential diagnosing of constipations.

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Description

The invention relates to medicine, namely to methods for the differential diagnosis of constipation.

A known method for the diagnosis of constipation (1 - Drossman D.A. The functional gastrointestinal disorders and the Rome III process. Gastroenterol. 2006; 130 (5) 1377-90), including determining the duration of constipation, the nature of feces and the frequency of bowel movements per week. This method is taken as an analog.

A known method for the diagnosis of constipation (2 - Bharucha F.B. Constipation. Best practice res clin gastroenterol. 2007; 21 (4): 709-731), adopted as a prototype. According to the method, the diagnosis of constipation is carried out using stimulating defecation samples.

However, the accuracy of the diagnosis of constipation in the prototype method is relatively limited, since it has an insufficient response to stimulant and laxative substances.

The aim of the invention is to improve the accuracy of the differential diagnosis of constipation.

The technical result is achieved by the fact that an additional study of the electromotor activity (EMA) of the descending part of the colon is performed, and when the frequency of slow waves is EMA of 9-10.2 per min and the frequency of spikes of 5-5.5 per slow wave is diagnosed with dissergic defecation; with a value of the frequency of slow waves of an EMA of 5.8-6.4 per min and a frequency of spikes of 2.5-2.8 per slow wave, functional constipation is diagnosed and with a value of a frequency of slow waves of an EMA of 4-4.4 per min and frequency of spikes 2 , 0-2.2 per slow wave are diagnosed with constipation in an inert colon.

The method is implemented as follows.

Patients are admitted with a diagnosis of chronic constipation. Chronic gastroduodenitis. Cardia insufficiency. They come with complaints of constipation for at least 6 months with difficulty defecating in at least 25% of cases, with solid feces and the number of bowel movements less than 3 per week. Patients also complain about the lack of an independent stool, an insufficient response to stimulating nutrients and, in some cases, the uselessness of a cleansing enema and the possibility of defecation in an unusual position.

Ultrasound OBP - echographic signs of pathology of the gallbladder, liver, spleen, kidneys were not detected. Diffuse changes in pancreatic tissue.

EGDS - the mucous membrane of the esophagus is pink, the cardia does not close. There is a moderate amount of clear contents in the stomach cavity. The mucous membrane of the stomach is pink; it is hyperemic in the antrum. Folds of medium height, elastic. The angle of the stomach is not changed. The gatekeeper is going through. The duodenal bulb is medium in size, not deformed, the mucous membrane of the duodenum is pink. The mucosa of the post-bulbar department is whitish on the tops of the folds. Conclusion: chronic gastroduodenitis. Cardia insufficiency. Biopsy of the mucous membrane of the bulbous region. Histology - the mucous membrane of 12 p. Intestines of the usual structure. Colonoscopy - the apparatus was performed in the dome of the cecum. The Bauginieva damper is polypous in shape, closed, oriented to the dome. The sigmoid colon is elongated, convoluted, forms loops. The transverse colon sags. The mucous membrane of the colon throughout is pink, smooth, shiny. The vascular pattern is distinct, correct. The folds of the mucosa are high. Gut lumen is not deformed. Intestinal tone is maintained or reduced. In some cases, there is a high tone of the sphincter of the anus and prolapse of the mucous membrane of the rectum.

Conclusion: functional constipation or inert colon, or dysinergic defecation.

X-ray examination of the esophagus, stomach, small intestine - the act of swallowing is not broken. The esophagus and cardia are freely passable. The tone and mucosa of the esophagus are not changed. The stomach is empty on an empty stomach, the gas bubble is small. With semi-hard and tight filling, the stomach is long, its contours are clear, even. The walls of the stomach are elastic. The relief of the mucosa is represented by convoluted folds. Peristalsis is deep, symmetrical. Evacuation is timely. The bulb is of normal shape, the duodenal ring is not deployed. After a portioned intake of 400 ml of barium suspension, filling the loops of the small intestine is uniform, timely. The width of the lumen and the relief of the jejunum mucosa are not changed; in the vertical position, the loops of the jejunum are located below the level of the iliac crests. In the ileum, areas of persistent narrowing of the reconstructed relief were not detected. After 2.5 hours from the start of the study (after eating), the contrast highlights the right sections of the colon. The terminal ileum is not changed. The passage of barium is slowed down the descending part of the colon, which in some cases forms loops with a decrease in tone. The tone of the anal sphincter is increased.

Conclusion: Indirect signs of colon dilatation with impaired evacuation function.

Hepatologist consultation - the clinical picture of the disease corresponds to the presence of steatohepatitis. In favor of this diagnosis is a transient increase in ALT, ACT. The elasticity of the liver is not changed (performed ultrasound elastometry). Conclusion: non-alcoholic steatohepatitis.

Neurologist consultation - somatoform disorder; gross focal symptoms at the time of examination were not detected. Recommended: observation by a neurologist, mode of work and rest.

Additionally, a study of the electromotor activity (EMA) of the descending part of the colon is carried out, and with a value of the frequency of slow waves of EMA of 9-10.2 per min and frequency of spikes of 5-5.5 per one slow wave, dissergic defecation is diagnosed; with a value of the frequency of slow waves of an EMA of 5.8-6.4 per min and a frequency of spikes of 2.5-2.8 per slow wave, functional constipation is diagnosed and with a value of a frequency of slow waves of an EMA of 4-4.4 per min and frequency of spikes 2 , 0-2.2 per slow wave are diagnosed with constipation in an inert colon.

The treatment was carried out, including the use of dietary fiber, stimulating laxatives, osmotic laxatives such as lactulose, forlax.

Discharged home in satisfactory condition. The patient’s state of health somewhat improved - there are no abdominal pains, the stool is periodically independent, the weight gain is insignificant.

The method is further explained by examples of its implementation.

Example 1

Patient P., 28 years old, was admitted with a diagnosis of chronic constipation. Chronic gastritis. Cardia insufficiency. Upon receipt, complains: pain in the left iliac region, bloating, rumbling in the intestine. Stool - a tendency to constipation up to 3 days. Weakness.

From the anamnesis it is known that she suffered from constipation. Abdominal pains bother. Endoscopy: cardia failure. Chr. superficial gastritis. Colonoscopy: examined to the dome of the cecum. Conclusion: irritable bowel syndrome.

Ultrasound of the abdominal cavity: no pathology detected.

Upon admission, a state of moderate severity, low nutrition, skin of normal color and humidity, swelling of the leg. The lungs have vesicular breathing, no wheezing, NPV - 15. Heart sounds are rhythmic, blood pressure 110/60 mm Hg, heart rate 70 beats. in minutes The abdomen on palpation is soft, slightly swollen, painful on palpation along the projection of the colon, more left departments. The liver and spleen are not enlarged. The gall bladder is not palpable. The symptom of striking is negative on both sides. There are no dysuric disorders.

ECG: normal position of EOS. Sinus rhythm, regular heart rate 62 Mild diffuse changes in the myocardium. Sigmoidoscopy - a rectoscope introduced 15 cm, then cal. Zakl .: pathology is not revealed.

Endoscopy: chronic gastritis. Cardia insufficiency.

Laboratory data

hemoglobin 132 red blood cells 4.5 white blood cells 4.8 eosinophils one PO Box 2 S / i 49 lymphocytes 40 monocytes 8 Platelets 252 ESR 9 mm / h glucose 5.0 Total protein 77 O. bilirubin eleven cholesterol 6 ALT 34 AST 28 Alkaline phosphatase 144 GGTP 19

Prothrombin - 102%.

Urinalysis: includes, density - 1014, reaction - acid, protein - no, glucose - no, epithelium - moderate, leukocytes - single in n / a.

Fecal analysis: reaction to occult blood is denied. Muscle fibers are few. Plant fiber is one.

Additionally conduct a study of electromotor activity (EMA) of the descending colon. The frequency of slow waves of EMA is 5.8 per min and the frequency of spikes of 2.5 per slow wave is diagnosed with functional constipation. Eating increases the frequency of slow waves of EMA to 6.4 per minute and the frequency of spikes to 2.8 per one slow wave.

As a result of the treatment, the condition improved: pain does not bother. Discharged in satisfactory condition. The tongue is wet, clean. The stomach is soft. Painless on palpation. The liver and spleen are not palpable. There are no dysuric disorders. The results of the treatment confirmed the correctness of the diagnosis.

Example 2

Patient N., 35 years old, was admitted with a diagnosis of chronic constipation. Chronic gastroduodenitis. Gallbladder dyskinesia. On admission, she complains of periodic pain in the lower abdomen, more in the right iliac region, bloating, rumbling in the intestine. Stool - stool delay up to 5 days, takes laxatives (gutalax, weak, candles with glycerin). Appetite is reduced, does not lose weight. Heartburn, often nausea, rarely vomiting. Heart palpitations. Headaches, dizziness. General weakness.

Medical history. From childhood, a chair delay of up to 3 days was observed. No treatment has been performed. Recently, the chair 1 time in 5 days. Received for examination and treatment.

The condition is satisfactory. The skin and visible mucous membranes are pale, clean. With topographic percussion: the boundaries of the lungs are within normal limits. On auscultation: vesicular breathing, no wheezing. Respiratory rate: 17 in 1 min. Heart sounds: muffled, rhythmic. Pulse 78 beats. in minutes HELL 115/80 mm Hg Oral mucosa: clean. The pharynx is clean. The tongue is moist, with a bloom on the root at the root. The stomach is not swollen. With superficial palpation, soft, painful during palpation along the projection of the colon. There are no symptoms of peritoneal irritation. The gall bladder is not palpable. Bubble symptoms: negative. The liver and spleen are not palpable. There are no dysuric disorders.

Ultrasound: The size of the liver is not enlarged, the capsule is not compacted. The edge of the liver is smooth. The structure is homogeneous, the overall echogenicity is average. The diameter of the portal vein is 10 mm, the lumen is uniform, the blood flow is preserved. Vascular pattern saved. Pancreas: fuzzy outline, smooth surface. The sizes are not increased (PZR = 26 mm), the structure is diffusely uniform, the echogenicity of the tissue is average. Pancreatic duct is not expanded. Parapancreatic fiber without pathological changes. Gall bladder: irregularly shaped. The dimensions are not increased 6 × 3 × 3.5 cm. The walls are thin, of a homogeneous structure. In the cavity of the bubble, homogeneous content is determined, there are no calculi. Intrahepatic bile ducts are not dilated. The common bile duct is not expanded, the maximum diameter is 3.5 mm, the walls are even. The spleen is not changed.

Endoscopy: the esophagus is freely passable, pink mucosa. Vascular pattern saved. The socket of the cardia does not close. In the lumen of the stomach, a moderate amount of light fluid and mucus. Pleats of medium height straighten. The mucous membrane is moderately hyperemic at the tops of the folds. The angle is not changed. Peristalsis is traced. The gatekeeper will close, we pass. The duodenal bulb is medium-sized, its pink mucosa. The zalukovy department - without features. Conclusion: Superficial gastritis. Cardia insufficiency.

Sigmoidoscopy. With an external examination, a digital examination, no pathology was detected. The sphincter tone is normal. The rectoscope is inserted at 17 cm. The mucous pink, thinned, shiny. The vascular pattern is reinforced. No ulcers, polyps, tumors were detected. When the apparatus is removed in typical places, internal hemorrhoidal nodes are moderately expressed, with no signs of inflammation. Conclusion: Internal hemorrhoids without exacerbation.

Colonoscopy The apparatus was carried out in the dome of the cecum. The Bauginev damper is closed, oriented to the dome, the intestines are lowered, crimped. The mucous membrane of the colon in the examined areas is pink, smooth, shiny. Sigma forms loops, tone is reduced.

Laboratory data

hemoglobin 11.3 red blood cells 4.6 white blood cells 5.3 eosinophils 2 PO Box 2 S / i 60 lymphocytes thirty Monocytes 6 Basophils one Platelets 350 glucose 5.2 Total protein 72.0 O. bilirubin 9.3 Cholesterol 6.5 ALT 32 ACT 38 Urea 2.9

Prothrombin 90%. MHO - 1.3. AT HIV - negative. R. Wasserman - negative, HBS neg. ATHCV - Neg. Urinalysis: Relates. the density is 1017, the reaction is acidic, the protein is od., glucose is not, the epithelium is a moderate amount, leukocytes are 1-3 in s / sp. Red blood cells - no.

Fecal analysis: reaction to occult blood is denied. Muscle fibers are few, plant fiber is one. No worm eggs were found.

Additionally, a study of the electromotor activity of the descending colon is carried out. Determine the value of the frequency of the slow waves of the EMA - 4-4.4 per min and the frequency of the spikes of 2.0-2.2 per slow wave. Diagnosed with constipation with an inert colon.

Conducted treatment. A repeated study of the electromotor activity of the descending colon. The value of the frequency of slow waves of EMA is determined - 4.4 per min and the frequency of spikes - 2.2 per one slow wave, which confirms the diagnosis of constipation in an inert colon.

Example 3

Patient M., 22 years old, was admitted with a diagnosis of chronic constipation for 15 years. Non alcoholic steatohepatitis.

Received complaints of delayed stool up to 7 days. Defecation relieves pressure on the perineum. A cleansing enema is in most cases useless.

EGDS - superficial gastritis, moderate bulbitis, cicatricial deformity of the duodenal bulb, duodeno-gastric reflux; Ultrasound OBP - deformation of the gallbladder; Ultrasound of the thyroid gland - diffuse moderately pronounced changes in the parenchyma.

Heredity: the mother has chronic constipation. My father has pancreatitis.

Upon admission, the patient's condition is satisfactory, of poor nutrition, skin of normal color, visible mucous membranes of normal color, peripheral lymph nodes are not enlarged. Heart sounds are clear, rhythmic, blood pressure - 110/70 mm Hg, heart rate - 68 beats / min, vesicular breathing in the lungs, BH - 17 per min, abdomen of the usual configuration, is involved in breathing, palpation of the stomach is soft weakly painful. The liver and spleen are not enlarged, the gall bladder is not palpable, the cystic symptoms are negative. Chair - 1 time in 7 days.

An. blood: HB - 11.5, E - 3.53, L - 3.1, p - 1, s - 50, e - 2, L - 40, m - 7, ESR - 5. Blood test for discharge of HB - 13.0, E - 3.87, L - 3.4, T - 216, p - 1, s - 53, e - 2, l - 40, m - 4, ESR - 6. Urine analysis - specific weight - 1007, r.-k., there is no protein and sugar, L is one. Analysis of feces for occult blood - neg.

Blood biochemistry upon admission: total protein - 62.6 g / l, albumin - 40.2 g / l, total. bilirubin - 13.9 μmol / L, direct bilirubin - 2.8 μmol / L, glucose - 4.2 μmol / L, cholesterol - 4.1 μmol / L, HDL cholesterol - 1.5 mmol / L, LDL-C - 2.1 (2.1-3.3) mol / L, triglycerides - 1.0 mmol / L, urea - 7.6 μmol / L, ACT - 35.3 (5-31) U / L, ALT - 43.0 (5-34) U / L, GGTP - 22.0 U / L, S.F. - 40 U / L, amylase - 110 (28-100) U / L.

RMP is negative. No HIV AT detected. Markers of viral hepatitis: HBs hypertension not detected. AT to NSI not detected. AT to gliadin and tissue transglutaminase are negative. Immunoglobulins - M - 105 mg%, GI - 1315 mg%, A - 145 mg%.

EGDS - the mucous membrane of the esophagus is pale, the cardia does not close. There is a moderate amount of clear contents in the stomach cavity. The mucous membrane of the stomach is pale, in the antrum is covered with a gray coating. The gatekeeper is going through. The duodenal bulb is medium in size, not deformed, the mucous membrane of the duodenum is pink. The mucosa of the post-bulbar department is whitish on the tops of the folds. Conclusion: chronic gastroduodenitis. Cardia insufficiency. Colonoscopy - the apparatus was performed in the dome of the cecum. The Bauginieva damper is polypous in shape, closed, oriented to the dome. The sigmoid colon is elongated, convoluted, forms loops. The tone of the transverse colon is preserved. The vascular pattern of the colon is distinct, regular. Gut lumen is not deformed. The tone of the muscles of the anal sphincter and pelvic floor is changed.

Hepatologist consultation - the clinical picture of the disease corresponds to the presence of steatohepatitis. In addition, there is a transient increase in ALT, ACT. Conclusion: non-alcoholic steatohepatitis.

Additionally, a study of the electromotor activity of the descending colon is carried out. The frequency of slow waves of EMA is 9 per minute and the frequency of spikes is 5 per one slow wave. Diagnosed with dissergic defecation.

The treatment was carried out, including the use of dietary fiber, biofeedback therapy, osmotic laxatives such as lactulose, forlax.

After treatment, the frequency of slow waves of EMA was 10.2 per min and the frequency of spikes was 5.5 per one slow wave.

Discharged home in satisfactory condition. The patient’s state of health improved somewhat - abdominal pain decreased, stool - 1 time in 5 days, weight gain - about 1 kg per month.

According to the claimed method, a differential diagnosis of constipation in 56 patients. The positive effect of treatment proves the correctness of the differential diagnosis.

Claims (1)

A method for the differential diagnosis of constipation, including a clinical examination, characterized in that it additionally conducts a study of the electromotor activity (EMA) of the descending part of the colon and with a frequency of slow waves of EMA of 9-10.2 per minute and spike frequency of 5-5.5 per slow the wave is diagnosed with dissergic defecation; with a value of the frequency of slow waves of an EMA of 5.8-6.4 per minute and a frequency of spikes of 2.5-2.8 per slow wave, a functional constipation is diagnosed and with a value of the frequency of slow waves of an EMA of 4-4.4 per minute and a frequency of spikes 2 , 0-2.2 per slow wave are diagnosed with constipation in an inert colon.