RU2475757C1 - Method of predicting severity of postoperative period course in patients with calculous cholecystitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: in order to predict severity of postoperative period course in patients with calculous cholecystitis level of hormone grelin is determined in patients' blood serum before operation. If value of grelin level is 0.8-1.5 ng/ml mild course of postoperative period is predicted, if value of grelin level is >1.5-10.0 ng/ml course of medium severity is predicted. And if grelin level in blood serum increases to >10.0 ng/ml, severe course of postoperative period is predicted.

EFFECT: method makes it possible to increase accuracy of prediction of postoperative period course severity in patients with calculous cholecyctitis in cholecystectomy in order to perform treatment correction.

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Description

The invention relates to medicine, in particular to surgery, and for predicting the severity of the postoperative period in patients with calculous cholecystitis with cholecystectomy.

Known methods for predicting the severity of the postoperative period in patients with calculous cholecystitis with cholecystectomy - leukocytosis with a neutrophilic shift, accelerated ESR, hyperthermia. However, an increase in temperature, an increase in the number of leukocytes, an acceleration of ESR can also be recorded in the absence of systemic inflammation, which does not allow the use of these clinical and laboratory characteristics to predict the severity of the postoperative period in patients with calculous cholecystitis (Ilchenko A.A. Gallstone disease. M .: Anarkharsis , 2004 - 200 p.). Widespread integrated scales (APACHE II and others) have low specificity in terms of individual forecasting.

The closest analogue of the proposed method is the determination of C-reactive protein - PSA in the blood (Warworth et al. Clin. Chim. Acta. - 1984 - Vol.138. - P.69-71).

The disadvantage of this method is that the increase in the level of PSA in the blood is not specific, it may be due to atherosclerosis, inflammation, necrosis, i.e. does not always give objective information about the severity of the postoperative period. In addition, there is no strict correspondence between the severity of the inflammatory process and the level of PSA (Byshevsky A.Sh., Tersenev OA Biochemistry for a doctor. Yekaterinburg, "Ural Worker", 1994 - S.325-332).

Effect: improving the accuracy of predicting the severity of the postoperative period in patients with calculous cholecystitis with cholecystectomy in order to correct treatment.

The result is achieved by determining the serum of patients with calculous cholecystitis before cholecystectomy of the level of the hormone ghrelin. Ghrelin is produced by the endocrine cells of the stomach, in the hypothalamus and other organs. To date, the breadth of its action has been proven. It has a powerful anti-inflammatory effect due to inhibition of the production of pro-inflammatory cytokines, increases the percentage of activated T-helpers, enhances lymphocyte apoptosis, and also has an immunomodulating, anti-inflammatory, regenerative effect (Kojima M., Hosoda H., Date Y. et al. Ghrelin is a. growth-hormone-releasing acylated peptide from stomach. // Nature. - 1999. - Vol. 402. - P.656-660. Wasseem T., Duxbury M, Ito H, Ashley SW, Robinson MK Exogenous ghrelin modulates release of proinflammatory and anti-inflammatory cytokines in LPS-stimulated macrophages through distinct signaling pathways. // Surgery 2008 - Vol.143. - P.334-342). The participation of this hormone in the regulation of energy, carbohydrate, fat, lipid metabolism is proved. Ghrelin stimulates the secretion of hormones by the pituitary, mainly somatotropic, thereby improving regeneration processes. Its role in the rehabilitation of patients after surgical stress is great. In the available literature there is no work on the use of ghrelin to predict the severity of the postoperative period in patients with calculous cholecystitis with cholecystectomy.

The method is as follows. Before surgery, blood is collected in patients with calculous cholecystitis using venipuncture, the blood is centrifuged, serum is obtained, and the ghrelin level is determined in the serum by immunoassay (Fuglsang J., Skjaebaek C., Espelund U, Frystyk J, Fisker S, Flyvbjerg A, Ovesen P: Ghrelin and its relationship to growth hormones during normal pregnancy. // Clin Endocrinol (Oxf) 2005, Vol.62, No. 5. - P.554-559). Normally, fluctuations in its level in healthy individuals are insignificant: 0.5-0.7 ng / ml, since it is involved in maintaining homeostasis.

The serum ghrelin level from 0.8 to 1.5 ng / ml in patients with calculous cholecystitis before surgery indicates that the postoperative period after cholecystectomy will have a mild course, without complications. The serum ghrelin level> 1.5 to 10.0 ng / ml in patients with calculous cholecystitis before surgery indicates that the postoperative period after cholecystectomy will be moderate. The level of ghrelin in blood serum> 10.0 and higher in patients with calculous cholecystitis before surgery indicates that the postoperative period after cholecystectomy will have a severe course in them and timely correction of drug therapy should be carried out. The study of the level of ghrelin in the blood serum of patients with calculous cholecystitis allows us to predict the severity of the postoperative period after cholecystectomy.

Case Studies

Example 1. Patient Ch., 62 years old, suffers from gallstone disease for three years. Concerned about the frequent pain in the right hypochondrium. She was hospitalized for emergency reasons in connection with an attack of "hepatic colic" after 9 hours from the onset of the attack. The state of moderate severity. The skin is subicteric. The tongue is coated with white plaque. The abdomen is not swollen, participates in the act of breathing. On palpation, severe soreness and a small defense in the right hypochondrium. The gall bladder is not palpable. The level of ghrelin in the blood is 20.6 ng / ml (normal 0.5-0.7 ng / ml), white blood cells 8.90 × 10 ⁹ \ l, PSA 0.96 mg / l (normal 0-4.0 mg / l). Operated according to emergency indications after 3.5 hours from admission due to the ineffectiveness of conservative therapy. Based on high hypergrelinemia, a severe course of the postoperative period was predicted, and therefore, antibiotic therapy (cefotaxime intravenously) and detoxification therapy (isotonic sodium chloride solution 500 ml, potassium chloride 10% 5 ml, magnesium sulfate 25% 5 ml drip intravenously were started before surgery. During laparoscopy: the liver is enlarged, the capsule is uneven, dull. In the area of the gallbladder there is a dense infiltrate. The gallbladder is large, tense, partially located intrahepatic. The wall is dense, swollen, mucous I am black in places. During puncture, thick bile and pus were obtained. Cholecystectomy was performed. Two stones up to 6 mm in the neck of the bladder obstructing the cystic duct. Histological examination - cholesterosis, leukocyte infiltration, foci of necrosis and hemorrhage in its wall in the mucous membrane of the gallbladder Conclusion: acute phlegmonous-gangrenous cholecystitis. The patient was transferred to the intensive care unit. The postoperative period was difficult: for four days the fever continued to 38 ° C, unstable hemodynamics: Banya BP from 100/60 to 180/100 mm Hg; polytopic extrasystole appeared. AlAT increased to 68 IU / L (normal 0-35 IU / L), AsAT to 71 IU / L (normal to 45 IU / L). Antibacterial therapy was carried out - cefotaxime 1.0 / day intravenously for 5 days. Conducted infusion therapy. For the prevention of thromboembolic complications immediately after surgery, heparin was used subcutaneously - 4 days. Healing by first intention. The patient was discharged on the 9th day.

Example 2. Patient P., 57 years old, began to notice pain in the right hypochondrium for a month. Sonographically revealed multiple stones in the gall bladder, thickening of the wall. Blood test: ESR 5 mm / hour, lake. 8 × 10 ⁹ l, PSA 0.85 mg / l Planned laparoscopic cholecystectomy was performed. Diagnosis after surgery: gallstone disease; chronic calculous cholecystitis. Histologically, in the wall of the gallbladder lymphoid infiltration, fibrosis. Pathological conclusion: chronic cholecystitis. Ghrelin level before surgery: 0.9 ng / ml, i.e. A favorable prognosis of the course of the postoperative period has been established. Antibiotic prophylaxis with ceftriaxone 1.0 in / 2 times - before and after surgery. Histology: lymphoid infiltration of the gallbladder wall. The postoperative period was uneventful. The temperature is normal. White blood cells are 8.90 × 10 ⁹ l, AlAT before and after surgery, respectively, 20 IU / L, 22 IU / L, AsAT - 19 IU / L and 23 IU / L. Primary healing. Discharged on the 6th day.

Example 3. Patient B., 52 years old, was hospitalized on an emergency basis 5 hours after the onset of an attack of hepatic colic with complaints of pain in the right hypochondrium, nausea, vomiting, weakness. Sonographically during a preventive examination a year ago, gallstones were found. The pain in the hypochondrium did not bother. Upon receipt, the condition is satisfactory. The tongue is wet, coated with a white coating. The abdomen is not swollen, soft, painful on palpation in the right hypochondrium. The gall bladder is not palpable. The liver is not enlarged. White blood cells 7.6 × 10 ⁹ / l; ESR 25 mm / h, AlAT 24.0 IU / L, AcAT 15.0 IU / L; PSA 2.0 mg / L. The ghrelin level is 9.0 ng / ml. Operated according to emergency indications. Gall bladder in inflammatory fusion. In the gall bladder, thick bile and stone with a diameter of 10 mm. The cystic duct is convoluted, clearance up to 3 mm. Pathomorphologically mild sclerosis of the gallbladder wall, cholesterosis of its wall and lymphoid and neutrophilic infiltration. Conclusion: exacerbation of chronic cholecystitis. Given a moderate increase in serum ghrelin, the course of the postoperative period after moderate cholecystectomy was predicted, which was confirmed. The temperature rose to 37.5 ° C, held for three days. Pain was expressed. A ventricular extrasystole was recorded on the ECG. A cytolytic syndrome appeared: ALT 53.7 IU / L, ACT 47.9 IU / L. Cephalosporins have been given antibiotic prophylaxis. Ketonal was administered 2 ml 2 times a day - two days. A drip polarizing mixture was introduced — glucose, insulin, potassium — and an isotonic solution, potassium chloride, and magnesium sulfate. Postoperative wound healing by primary intention. Discharged on the 7th day.

Example 4. Patient B., 45 years old, was delivered to the surgical department with complaints of pain in the right hypochondrium, nausea, weakness. The patient considers himself about two years old, when there were periodic pains in the right hypochondrium. Recently, attacks of pain have become more frequent. An ultrasound of the liver, gall bladder, pancreas was made, and calculous cholecystitis was diagnosed. Yesterday, after eating fatty and spicy foods, pain in the right hypochondrium became intense. The condition is satisfactory. Increased nutrition. The skin is clean, normal color. In the lungs without pathology. Heart sounds are clean, rhythmic. HELL 120/80 mm Hg Tongue coated in white, wet. The abdomen is not swollen, painful in the right hypochondrium. The gall bladder is not palpable. The borders of the liver are normal. ESR 26 mm / h, leukocytosis 5.1 × 10 ⁹ / l; n 6%, s. 37%, l 50%, m 7%. ALT 25 IU / L, ACT 27 IU / L. Fibrinogen 2.63 g / l (norm 2.0-4.0 g / l), prothrombin time 11.8 sec (norm 11-16 sec). The ghrelin level was 1.5 ng / ml. Given a slight increase in the level of ghrelin blood, a mild course of the postoperative period after cholecystectomy was predicted. Therefore, antibiotic prophylaxis with cefotaxime 1.0 was carried out intravenously before and after surgery. The postoperative period was easy. There were no complications. The low-grade fever was on the first day, then normal. The patient refused analgesics (ketonal). Postoperative wound healing by primary intention. Discharged on the 6th day in good condition. Pathomorphologically - in the wall lymphoid infiltration, fibrosis, and in some places the marginal standing of leukocytes in the vessels. Conclusion: exacerbation of chronic cholecystitis.

Prediction of the severity of the postoperative period after cholecystectomy was performed in 25 patients with calculous cholecystitis. The well-being of the operated patients was monitored, temperature, laboratory tests of inflammation, wound healing, hemodynamics, the presence of complications of the operation, the occurrence of a cytolytic syndrome, signs of exacerbation of biliary-dependent pancreatitis. A ghrelin level of up to 1.5 ng / ml indicates that the postoperative period will be easy,> 1.5-10.0 ng / ml will be moderate,> 10.0 ng / ml during the postoperative period is severe.

The value of the proposed method lies in the fact that it allows you to predict the course of the postoperative period in patients with calculous cholecystitis before cholecystectomy, prepare for possible complications, solve practical problems - you need antibiotic therapy or you can limit yourself to antibiotic prophylaxis, plan detoxification therapy, preventive treatment of DIC, and adjust it in time.

Claims (1)

A method for predicting the severity of the postoperative course in patients with calculous cholecystitis by blood testing, characterized in that before the operation, patients take blood from a vein and determine the level of the hormone ghrelin in the serum, and with a value of the level of ghrelin 0.8-1.5 ng / ml a mild course of the postoperative period is predicted, with a ghrelin level> 1.5-10.0 ng / ml, a moderate course is predicted, with an increase in serum ghrelin> 10.0 ng / ml, a severe postoperative period is predicted but.