RU2477482C1 - Differential diagnostic technique of chronic hepatitis and hepatic cirrhosis of alcoholic aetiology - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: there are additionally studied electromotor activity of stomach, common bile duct and descending large intestine, and if observing slow wave frequency of stomach EMA 9.8-11 a minute, common bile duct EMA 7-8.3 a minute and descending large intestine EMA 8-9.8 a minute, and if observing hepatic elastometry being 3, alcoholic cirrhosis is diagnosed; if observing slow wave frequency of stomach EMA 11.1-13.7 a minute, common bile duct EMA 9-12 a minute and descending large intestine EMA 10-13.5 a minute, and if observing hepatic elastometry being 1-2, chronic hepatitis of alcoholic aetiology is diagnosed.

EFFECT: improved diagnostic accuracy.

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Description

The invention relates to medicine and can be used as a method for the differential diagnosis of chronic hepatitis and liver cirrhosis of alcoholic etiology.

A known method for the diagnosis of hepatitis C using the FibroScan apparatus, taken as an analogue (1 - Kettaneh A. et al. Features associated with seiscass rate and performance of FibroScan, measurements for the duiagnosis of cirrhosis in HCV patients: A prospective study of D35 patients. J Hepatol. 2007; 46: 628-634).

A known method for the diagnosis of polyviral hepatitis by detecting markers of viral infection, adopted for the prototype (2 - Nousbaum JB, Pol S., Nalpas B. et al. Hepatitis C virus type 1b (II) infection in France and Italy. Collaborative Study Group. Ann Intern Med. 1995 Feb 1; 122 (3): 161-8). However, this method does not have sufficient accuracy in the differential diagnosis of chronic hepatitis and liver cirrhosis of alcoholic etiology.

The aim of the invention is to improve the accuracy of the differential diagnosis of chronic hepatitis and liver cirrhosis of alcoholic etiology.

The technical result is achieved by the additional study of the electromotor activity of the stomach, common bile duct and the descending part of the colon and with an increase in the frequency of slow waves EMA of the stomach 9.8-11 per min, EMA of the bile duct 7-8.3 per min and the descending part of the colon 8 -9.8 min, and also with a value of liver elastometry 3, alcohol cirrhosis is diagnosed; and with a value of the frequency of slow waves EMA of the stomach 11.1-13.7 per min, EMA of the common bile duct 9-12 per min and the descending part of the colon 10-13.5 min, as well as with a value of liver elastometry 1-2, chronic hepatitis is diagnosed etiology.

The method is implemented as follows.

Upon admission, complaints of weakness, nosebleeds, hand tremors, gait changes, memory impairment, pain in the right hypochondrium are noted. Enlarged liver appeared several years ago. Observed for chronic hepatitis, unspecified etiology.

At admission: general condition of moderate severity. Proper nutrition. The skin is hyperpigmented, the mucous membranes are subicteric. Multiple telangiectasias. Speech is difficult, aphonia. Thinking and reaction are slowed down, comes into contact with difficulty, monosyllables. Gait is broken. With auscultation, vesicular breathing, no wheezing. Heart sounds are clean, the rhythm is correct. Blood pressure and heart rate are within normal limits. The abdomen is soft, painful on palpation in the right hypochondrium. The liver protrudes from under the edge of the costal arch. The spleen is enlarged. Ascites and no edema.

Survey Results:

Ultrasound examination: Liver - the structure of the parenchyma is homogeneous, echogenicity is evenly increased, the vascular pattern is preserved. The portal vein is not dilated (12 mm). Intrahepatic bile ducts are not dilated. Gall bladder: the dimensions are slightly increased, the echogenicity of the wall is increased, around the gall bladder there is a hypoechoic zone. The spleen is enlarged. The splenic vein is dilated with collaterals.

Conclusion Signs of diffuse liver damage. Portal hypertension. Severe splenomegaly.

Endoscopy: on the surface of the mucous membrane of the esophagus, the presence of varicose veins is noted. The mucous membrane is hyperemic, no erosive changes have been identified. With the removal of the fiberscope, a slight contact bleeding of the mucosa of the terminal esophagus is noted.

Conclusion - varicose veins of the esophagus.

Liver elastometry: the degree of development of fibrosis 1-3.

A liver biopsy was not performed due to the risk of bleeding.

Diagnosis: Active liver cirrhosis, alcoholic etiology. Child-Pugh class A-C liver failure. Varicose veins of the esophagus 2-4 tbsp. Splenomegaly with the phenomena of hypersplenism.

Patient's history: drinking alcohol 2 times a week. Gout was revealed, took allopurinol for 3-4 years. Violation of the diet, after which he drew attention to the appearance of jaundice. On examination: an increase in ALT, ACT, GGTP, cholesterol and uric acid. Ultrasound hepatosplenomegaly. Diffuse changes in the liver and pancreas. Objectively: the condition is satisfactory. The skin and mucous jaundice. Gynecomastia On the skin of the legs - hyperemic rash. In the lungs, vesicular breathing, no wheezing. Heart sounds are muffled, the rhythm is correct. Blood pressure and heart rate are within normal limits. The language is clean. The abdomen is soft, painless in all departments. The spleen is not palpable.

SURVEY DATA: Ultrasound: Liver - enlarged, heterogeneous structure, echogenicity of liver tissue increased, echo signals are compact. The vascular pattern is depleted. The portal vein gauge is enlarged, so does the splenic vein. The walls of the gallbladder are thickened, their echogenicity is increased, the structure is heterogeneous, no echoes were detected within the contour. The pancreas is not enlarged, the contours are uneven, clear, the echogenicity of the tissue is increased, the structure is heterogeneous. Wirsung duct is not visible. The spleen is enlarged 172 × 81 mm (area 79 cm square). Sound properties of the kidneys are normal. There is no free fluid in the abdominal cavity. Conclusion: diffuse liver damage (fatty degeneration of the liver). Portal hypertension. Chronic cholecystitis. Chronic pancreatitis. UZDG - Portal hypertension.

Endoscopy: pass the esophagus. The cardia closes. Peristalsis saved. The mucous membrane of the stomach is pink, swollen, sometimes moderately hyperemic. Folds straighten out with air. Peristalsis is observed. The angle of the stomach is not changed. The gatekeeper is round in shape. The duodenal bulb is medium in size, not deformed, the walls are smooth, elastic. The mucous membrane of the bulb of the duodenum and postbulbar light pink, medium-sized folds, elastic. Peristalsis is traced. The area of the Vater's nipple without pathological changes. Conclusion: chronic gastritis, duodenogastric reflux. X-ray examination of the chest organs: on the overview x-ray of the chest organs, the pulmonary fields are transparent, the pulmonary pattern is strengthened. The roots of the lungs are structural. The aperture is not changed. The sinuses are free. The heart is enlarged, the aorta is compacted.

In addition, a study of the electromotor activity of the stomach, common bile duct and the descending part of the colon and with an increase in the frequency of slow waves EMA of the stomach 9.8-11 per min, EMA of the bile duct 7-8.3 per min and the descending part of the colon 8-9.8 min, and also with a value of liver elastometry 3, alcohol cirrhosis is diagnosed; and with a value of the frequency of slow waves EMA of the stomach 11.1-13.7 per min, EMA of the common bile duct 9-12 per min and the descending part of the colon 10-13.5 min, as well as with a value of liver elastometry 1-2, chronic hepatitis is diagnosed etiology.

Against the background of the therapy, a positive dynamics in the well-being of the patient was noted: the pain syndrome was stopped. Significant positive dynamics of blood indicators of blood is noted. It is discharged in satisfactory condition. The prognosis is favorable for refusing alcohol. The treatment results confirmed the correctness of the differential diagnosis according to the method.

The method is further explained by examples of its implementation.

Example 1

Patient I., 48 years old, was admitted with complaints of periodically occurring pain in the left hypochondrium, rarely in the right, bleeding of the nasal mucosa.

In the anamnesis: OVH was not ill, alcohol intake periodically. There was no blood transfusion. Four years ago, the sclera ictericity appeared, was hospitalized, and was discharged with a diagnosis of fatty hepatosis. A year ago, jaundice reappeared. Hospitalized, diagnosed with cirrhosis. Since that time, disabled person III gr. Periodically takes ursosan, phosphogliv, pancreatin, festal. Recently, pains in the hypochondrium began to bother.

Upon admission: satisfactory condition. Proper nutrition. The skin is hyperpigmented, the mucous membranes are subicteric. Multiple telangiectasias. In the lungs, vesicular breathing, no wheezing. NPV 16 min Heart sounds are sonorous, rhythmic, heart rate 84 in min. HELL 150 and 80 mm Hg The language is clean. The abdomen is regular in shape, soft, and painless on palpation. Liver +3 cm, spleen-palpated edge. CM striking neg. at both sides.

Survey data: Ultrasound: Liver - increased in size (thickness of the right lobe - 138 mm, thickness of the left lobe - 72 mm), the structure is heterogeneous, the echogenicity of the liver tissue is increased. The vascular pattern is significantly depleted. The portal vein gauge is 14 mm (expanded), the splenic vein is 10 mm (expanded). Choledoch - 3 mm. The gall bladder is not changed, 68 × 32 mm, the walls of the bladder are not changed 1.0 mm, their echogenicity is average, the structure is homogeneous, no echoes were detected within the contour. Pancreas: dimensions are not increased (head 23 mm, body 13 mm, tail 20 mm), the contours are uneven, clear, the echogenicity of the tissue is increased, the structure is heterogeneous. Wirsung duct is not expanded - 1.0 mm The spleen is enlarged - 147 × 68 mm (area 74 cm square). Sound properties of the kidneys are normal. There is no free fluid in the abdominal cavity. Conclusion: diffuse liver damage. Portal hypertension. Chronic pancreatitis. Chronic pancreatitis.

Endoscopy: pass the esophagus. In the lower third of the esophagus, several dilated veins are visible that do not leave the plane of the mucosa 0.3 cm in diameter. The cardia closes. Peristalsis saved. The mucous membrane of the stomach is light pink. Folds straighten out with air. Peristalsis is observed. The gatekeeper is free to pass. The mucous membrane of the duodenal bulb is light pink. Conclusion: varicose veins of the esophagus 1 degree. Fibroscan - the development of cirrhosis 3.

Additionally, a study of the electromotor activity of the stomach, common bile duct and the descending part of the colon is carried out. The increase in the frequency of slow waves of EMA of the stomach is 9.8 per min, EMA of the common bile duct 7 per min and the descending section of the colon 8 min Fibroelastometry of the liver - F3 liver elasticity according to METAVIR - alcoholic cirrhosis.

ECG: EOS deviation to the left. Sinus rhythm, correct. Heart rate 82 per minute. Immunological research. IgM - 130 mg% (50-150), IgG - 1000 mg% (500-1500), IgA - 400 mg% (90-250). RW, HIV is denied.

TREATMENT: Table 5, karsil, mezim-forte, no-shpa, nitrosorbide.

Against the background of the therapy, a positive dynamics of the biochemical parameters of the blood and the patient's health was noted: the abdominal pains passed. It is discharged in satisfactory condition.

Example 2

Patient T., 47 years old, was admitted with complaints of general weakness, fatigue, insomnia, pain in the right hypochondrium, constant, aching nature, shortness of breath when walking.

In the anamnesis: OVH was not ill, there was no blood transfusion, periodically - alcohol intake. Since 1998, duodenal ulcer. Since that time, hepatomegaly has been noted, which was regarded as fatty degeneration of the liver. A biochemical study revealed: albumin 30, bilirubin 52.3, direct 50, ALT - 48, AST - 110, GGTP - 184, alkaline phosphatase - 164. Diagnosed with cirrhosis of the liver, moderate activity. Treatment with a positive effect. During the year, on the recommendation of the local doctor, she took 2 tablets of veroshpiron per day. Deterioration two years ago, when there were pains in the right half of the abdomen, loose stools up to 3-4 times, pain in the left hypochondrium, weakness increased. She was hospitalized, and thrombocytopenia (40 thousand) was noted during the examination. A thromboconcentrate transfusion was performed. EGDS - varicose veins of the esophagus 1 degree. Recently, pain in the right hypochondrium, insomnia began to bother.

At admission: general condition of moderate severity. Proper nutrition. The skin is hyperpigmented, the mucous membranes are subicteric. Multiple telangiectasias. Speech is difficult, aphonia. Thinking and reaction are slowed down, comes into contact with difficulty, monosyllables. Gait is broken. In the lungs, vesicular breathing, no wheezing, NPV 16 per min. Heart sounds are muffled, rhythmic, heart rate 64 min. HELL 160 and 90 mm Hg The tongue is covered with a thin white coating. The abdomen is increased in volume due to s / c fatty tissue, small ascites, soft, painless. The liver will stand 4-5 cm from the edge of the costal arch. The spleen +2 cm is palpated. at both sides. No swelling on the legs.

SURVEY DATA:

Ultrasound: Liver - increased in size (thickness of the right lobe - 139 mm, thickness of the left lobe - 74 mm), the structure is heterogeneous, the echogenicity of the liver tissue is significantly increased. The vascular pattern is significantly depleted. The portal vein gauge is 14 mm, the splenic vein is 10 mm (enlarged). Choledoch - 4 mm. The gallbladder is not changed, 56 × 23 mm, the walls of the bladder are not changed, 1.5 mm, their echogenicity is average, the structure is homogeneous, no echoes were detected within the contour. The pancreas is normal (head 26 mm, body 15 mm, tail 22 mm), the contours are uneven, clear, the echogenicity of the tissue is increased, the structure is heterogeneous. Wirsung duct 1.5 mm. The spleen is enlarged 154 × 72 mm (area 70 cm square). A small amount of free fluid in the abdominal cavity. Conclusion: Diffuse liver damage. Portal hypertension. Ascites. Chronic pancreatitis.

Ultrasound - control of ascites - no signs of free fluid in the abdominal cavity.

TSCh - 92 sec, which corresponds to II st encephalopathy.

Endoscopy: upon examination of the esophagus, the mucous membrane of the esophagus is pale pink. The cardia gapes, an axial hernia is visible. The mucous membrane of the terminal esophagus is swollen, whitish. It also found moderately dilated, convoluted veins of blue color, not protruding into the lumen of the esophagus. The gastric mucosa is pink, swollen, diffusely hyperemic. The folds are medium sized, elastic. Peristalsis is observed. The angle of the stomach is not changed. In the antrum, several erosions were found, ranging in size from 0.1 to 0.4 cm, covered with a brown coating. The gatekeeper is round in shape. The duodenal bulb is medium in size, not deformed. The mucous membrane of the bulb of the duodenum, the mucosa of the postbulbar section is pink, swollen, medium-sized folds, elastic. Peristalsis is traced. Vater's nipple area is not changed. Conclusion: hernia of the esophageal opening of the diaphragm, varicose veins of the esophagus 1 tbsp., Moderately expressed reflux esophagitis. Chronic gastroduodenitis.

A study of the electromotor activity of the stomach, common bile duct and the descending part of the colon. With an increase in the frequency of slow waves of EMA of the stomach 11 per minute, EMA of the common bile duct 8.3 per minute and the descending section of the colon 9.8 minutes. Fibroelastometry of the liver - F3 liver elasticity according to METAVIR - alcoholic cirrhosis.

X-ray examination of the chest organs: on the overview radiograph of the chest organs, the pulmonary fields are transparent, the pulmonary pattern is strengthened in the n / departments. The roots of the lungs are structural. The diaphragm is usually located. The sinuses are free. The shadow of the heart without features, the aorta is deployed.

ECHO KG - the global function of the left ventricle is impaired. LV systolic function is moderately reduced. LV diastolic dysfunction. The walls of the aorta and the valves AK and MK moderately compacted. The heart chambers are expanded. There is no violation of local LV contractility. There is no fluid in the pericardial cavity. No leaf vegetation. MR 1 tbsp., AR 1 tbsp.

ECG: semi-vertical position of the EOS, sinus rhythm, correct. Heart rate 64 min. Moderately pronounced diffuse changes in the myocardium.

Revealed cirrhosis, alimentary etiology, minimal activity. Child-Pugh Class B (8 points). Portal hypertension. Hepatosplenomegaly, hypersplenism. Encephalopathy

The treatment reduced the severity of cirrhosis, which confirmed the correctness of the differential diagnosis.

Example 3

Patient I., 49 years old. In the anamnesis: alcohol intake 2 times a week. During the examination: ALT - 89, ACT - 124, GGTP - 2278, cholesterol - 7.97, uric acid - 443. Ultrasound-hepatosplenomegaly. Diffuse changes in the liver and pancreas. Objectively: the condition is satisfactory. The skin and mucous jaundice. Gynecomastia Tattoos On the skin of the legs - hyperemic rash. In the lungs, vesicular breathing, no wheezing. Heart sounds are muffled, the rhythm is correct. HELL - 130/80 mm Hg Heart rate 72 per minute. The language is clean. The abdomen is soft, painless in all departments. The liver is +2 cm. The spleen is not palpable.

SURVEY DATA: Ultrasound: Liver - enlarged (thickness of the right lobe - 137 mm, thickness of the left lobe - 68 mm), the structure is heterogeneous, the echogenicity of the liver tissue is increased, the echo signals are compact. The vascular pattern is depleted. The portal vein gauge is 14 mm (expanded), the splenic vein is 10 mm (expanded). Choledoch - 4 mm. The gall bladder is not changed, 58 × 23 mm, the walls of the bladder are thickened - 3 mm, their echogenicity is increased, the structure is heterogeneous, no echoes were detected within the contour. The pancreas is not enlarged (head 24 mm, body 13 mm, tail 21 mm), the contours are uneven, clear, the echogenicity of the tissue is increased, the structure is heterogeneous. Wirsung duct is not visible. The spleen is enlarged 172 × 81 mm (area 79 cm square). Sound properties of the kidneys are normal. There is no free fluid in the abdominal cavity. Conclusion: diffuse liver damage (fatty degeneration of the liver). Portal hypertension. Chronic cholecystitis. Chronic pancreatitis. UZDG - Portal hypertension.

Endoscopy: pass the esophagus. The cardia closes. Peristalsis saved. The mucous membrane of the stomach is pink, swollen, sometimes moderately hyperemic. Folds straighten out with air. Peristalsis is observed. The angle of the stomach is not changed. The gatekeeper is round in shape. The duodenal bulb is medium in size, not deformed, the walls are smooth, elastic. The mucous membrane of the bulb of the duodenum and postbulbar light pink, medium-sized folds, elastic. Peristalsis is traced. The area of the Vater's nipple without pathological changes. Conclusion: chronic gastritis, duodenogastric reflux. X-ray examination of the chest organs: on the overview x-ray of the chest organs, the pulmonary fields are transparent, the pulmonary pattern is strengthened. The roots of the lungs are structural. The aperture is not changed. The sinuses are free. The heart is enlarged, the aorta is compacted.

Gastrointestinal electromyography: the frequency of slow waves of EMA of the stomach is 11.1 per minute, EMA of the common bile duct - 9 per minute and the descending part of the colon 10 per minute;

Fibroelastometry of the liver - F1 liver elasticity according to METAVIR - alcoholic hepatitis.

Immunological research: HBsAg - neg, anti HCV - neg. IgM - 120 mg% (50-150), IgG - 950 mg% (500-1500), IgA - 220 mg% (90-250). RW, HIV is denied.

TREATMENT: Table 5, essential in / in, mezim-fort, carlsil. Drop glucose and vit. B6 and C.

Against the background of the therapy, a positive dynamics in the well-being of the patient was noted: the pain syndrome was stopped. Significant positive dynamics of blood indicators of blood is noted. It is discharged in satisfactory condition, which confirms the correctness of the differential diagnosis of chronic hepatitis and cirrhosis.

Example 4

Patient S., 63 years old, was admitted with complaints of heartburn, belching.

In the anamnesis: OVH was not ill. There was no blood transfusion. Since 2003, drinking beer daily 3-4 liters. In March 2008, jaundice appears. Hospitalized. (Endoscopy - erosive gastritis. VRVP 1 tbsp. Ultrasound - ascites. Chronic pancreatitis). Portal hypertension: VRVP 1 tbsp. In 2008, re-treatment. Discharged with a diagnosis of chronic hepatitis, alcohol etiology, minimal activity with cholestasis. GERD. He took carlsil. In July 2009, re-hospitalization (F2 fibroscan. ACT - 164, ALT - 284, cholesterol - 11.9, GTP - 880). The last month has been abusing alcohol. Hospitalized.

Upon receipt, the condition is satisfactory. Proper nutrition. The skin and mucous membranes of normal color. Rashes around the mouth. In the lungs, vesicular breathing, no wheezing. NPV 16 min Heart sounds are sonorous, rhythmic, heart rate of 92 per minute. HELL 130 and 80 mm Hg The language is clean. The abdomen is regular in shape, soft, and painless on palpation. The liver + 3-4 cm, the spleen is not palpable. CM striking neg. at both sides.

SURVEY DATA: Ultrasound: Liver - enlarged (thickness of the right lobe - 138 mm, thickness of the left lobe - 74 mm), the structure is heterogeneous, the echogenicity of the liver tissue is increased, the echo signals are compact. The vascular pattern is significantly depleted. The portal vein gauge is 11 mm (not dilated), the splenic vein is 7-8 mm (not dilated). Choledoch - 3 mm. Gall bladder - in the body area there is an incomplete transverse bend, 57 × 23 mm, the walls of the bladder are thickened, 2.5-3 mm, their echogenicity is increased, the structure is heterogeneous, no echo signals were detected within the contour. The pancreas is not enlarged (head 23 mm, body 13 mm, tail 20 mm), the contours are uneven, clear, the echogenicity of the tissue is increased, the structure is heterogeneous. Wirsung duct is not expanded - 1.0 mm. The spleen is not enlarged 117 × 56 mm (area 41 cm square.). There is no free fluid in the abdominal cavity. Conclusion: fatty liver. Chronic cholecystitis. Deformation of the gallbladder. Chronic pancreatitis.

Liver fibroelastometry - liver elasticity corresponds to F2 according to METAVIR - mild fibrosis.

Endoscopy: pass the esophagus. The cardia does not completely close. Periodically, part of the gastric mucosa prolapses into the esophagus. Peristalsis saved. The mucous membrane of the stomach is light pink. Folds straighten out with air. Peristalsis is observed. The gatekeeper is free to pass. The mucous membrane of the duodenal bulb is light pink.

Conclusion: a hiatal hernia. Cardia insufficiency. X-ray examination of the chest organs: on the overview x-ray of the chest organs, the pulmonary fields are transparent, the pulmonary pattern is not changed. The roots of the lungs are structural. The aperture is not changed. The sinuses are free. The boundaries of the heart are within normal limits.

The value of the frequency of slow waves of EMA of the stomach is 13.7 per minute, EMA of the cholis of the stomach is 12 per minute and the descending part of the colon 13.5 minutes, and also with chronic elastometry of the liver 2, chronic hepatitis of alcoholic etiology is diagnosed.

Immunological research: HBsAg - neg, anti HCV - neg. IgM - 140 mg% (50-150), IgG - 1400 mg% (500-1500), IgA - 600 mg% (90-250). RW, HIV is denied.

TREATMENT: Table 5, Methadoxyl, Karsil, Mezim-Fort, Vit. B1 and C, gastal, tserukal.

Against the background of the therapy, there was a significant positive dynamics in the patient’s well-being: heartburn, belching, weakness, nausea in the morning, diarrhea up to 4 times a day, sometimes with mucus, as well as blood biochemical parameters: bilirubin, ACT, alkaline phosphatase normalized, significantly decreased ALT, GGTP. It is discharged in satisfactory condition. The prognosis is favorable with a complete rejection of alcohol.

Differential diagnosis of chronic hepatitis and liver cirrhosis in 62 patients was carried out. Subsequent successful treatment confirmed the achievement of the purpose of the invention is to increase the accuracy of the differential diagnosis of chronic hepatitis and liver cirrhosis of alcoholic etiology.

Claims (1)

A method for the differential diagnosis of chronic hepatitis and liver cirrhosis of alcoholic etiology by means of a biochemical study of blood serum, characterized in that it additionally conducts a study of the electromotor activity of the stomach, common bile duct and the descending part of the colon and with an increase in the frequency of slow waves EMA of the stomach 9.8-11 per min, EMA choledoch - 7-8.3 per min and the descending part of the colon 8-9.8 min, and also with a value of liver elastometry 3, alcohol cirrhosis is diagnosed; and with a value of the frequency of slow waves of EMA of the stomach 11.1-13.7 per min, EMA of the common bile duct - 9-12 per min and the descending part of the colon 10-13.5 min, as well as with a value of liver elastometry 1-2, chronic hepatitis is diagnosed alcohol etiology.