RU2482483C1 - Method for identifying risk of developing complications in acute biliary pancreatitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: difference of the successive white blood values taken at admission and 24 hours after the beginning of a therapy is determined, including: Ostrovskiy's leukocytic intoxication index (LII), a segmented neutrophil to lymphocyte index (SLI), a neutrophil to monocyte index (NMI). If two of the three derived values occur to be positive, a high risk of developing complications is stated; and the two negative values of the three ones above enables stating a low risk of developing complications.

EFFECT: method enables objective and quick evaluation of the risk of complications of the pathological process, further correction of the initial treatment, stating the need of surgery and in cases of the high risk of complications, prescription of the enhanced antibacterial and detoxification therapy.

6 tbl

Description

 The invention relates to medicine, namely to surgery, and can be used in surgery and resuscitation.

Known common systems for integrated assessment of the severity of the patient's condition and prognosis of acute pancreatitis scales: In Ranson, APACHE II.

The Ranson scale is the most accessible and widely used, however, the disadvantage of the scale is the impossibility of its use in dynamics [1].

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 [3, 4]. Using the APACHE II scale is time consuming and costly.

Closest to the proposed method is to determine the level of activity of C-reactive protein, interleukin-6 and 10, neutrophil elastase, trypsinogen-activating protein and procalciotonin in the patient’s blood in the dynamics of the disease. However, the complexity and cost of biochemical laboratory methods limits their implementation in wide clinical practice [5].

The objective of the invention is the early prediction and identification of complications in patients with acute pancreatitis of biliary etiology.

The problem is solved due to the fact that they determine the differences of successive indicators of the white blood formula taken upon admission and 24 hours after the start of therapy, namely: the Ostrovsky leukocyte intoxication index (LII), the index of the ratio of segmented neutrophils to lymphocytes (ISL), the index the ratio of neutrophils to monocytes (ISNM), upon receipt of positive values from two of the three above indicators, conclude that there is a high risk of complications.

The method is as follows: use the results of detailed analyzes of peripheral blood (RAC) taken upon admission, 24 hours after the start of treatment and determine the following indicators:

a) leukocyte intoxication index for Ostrovsky LII [2],

LII = (mts + u + p / i + s / i) / (lf + mn)

b) the ratio index of segmented neutrophils to lymphocytes ISL

LIS = (s / i) / (lf)

c) the ratio index of segmented neutrophils to ISNM monocytes

ISNM = (s / i) / (mn)

where mc is the percentage of myelocytes, u is the percentage of young neutrophils, p is the percentage of stab neutrophils, s is the percentage of segmented neutrophils, e is the percentage of eosinophils, lf is the percentage of lymphocytes, mn is the percentage of monocytes, pl - the percentage of plasma cells in a smear of peripheral blood.

The following indices are then determined.

dLINE = LII (n + 1) -LINEn,

dISL = LIS (n + 1) -ISLn,

dISNM = ISNM (n + 1) -INSNn,

where dLII - change LII; dISL - ISL change, dИCHM - ISNM change; n and (n + 1) are the indices of the previous and subsequent indicators. Expanded blood tests must be performed on the day the patient enters the hospital before treatment and daily during therapy. A retrospective review of 105 case histories of patients diagnosed with acute pancreatitis for the period from 2007 to 2010, who were hospitalized in the surgical department of the Road Clinical Hospital, was carried out.

The diagnosis was confirmed on the basis of clinical and laboratory data, examination results and ultrasound examination.

All patients received traditional therapy (infusion, antispasmodic, antisecretory therapy). The age of most patients with acute pancreatitis ranged from 23 to 76 years.

The analysis of integral hematological parameters: leukocyte intoxication index according to Ostrovsky (LII), the index of the ratio of neutrophils to monocytes (ISNM), the index of the ratio of segmented neutrophils to lymphocytes (ISL). Depending on the dynamics of the indicators, all patients were divided into two clinical groups: a high degree of development of complications and a low degree of development of complications. The data obtained are presented in table No. 1.

Table number 1 The risk of complications in acute pancreatitis Indicator High risk of complications Low risk of complications LII dLINE> 0 dLINE <0 LIS dISL> 0 dISL <o ISNM dCHM> 0 dISNM <0

In patients admitted with a mild severity of the pathological process, postoperative complications and mortality were not observed. The average hospital bed for them was 7.12 ± 0.5 days.

In patients admitted to a hospital with a severe degree of the pathological process, in 48 cases, a transition to destructive forms was noted. The cause of mortality in 8 cases was the development of multiple organ failure, against the background of pancreatogenic shock, in 16 cases the cause of death was the development of late purulent complications. The average bed day for patients in this group was 36.70 ± 2.0 days.

Table 2 shows the presence of complications, mortality in various degrees of severity of acute pancreatitis.

Table number 2 The presence of complications, mortality with various degrees of severity of acute pancreatitis Indicator Number of patients Complications (transition to destructive forms) Mortality Wed bed day Low risk of complications 54 (51.4%) Not noted Not noted 7.12 ± 0.5 High risk of complications 51 (48.6%) 48 (94.12%) 24 (48.0%) 36.70 ± 2.0

A control group was created of 90 people who were treated in the first surgical unit of the Road Clinical Hospital at the Krasnoyarsk station in 2011, with a diagnosis of acute pancreatitis. We evaluated the risk of complications according to our methodology, as well as the assessment of a completed clinical case. To evaluate the proposed method, we used a step-by-step discriminant analysis and logistic regression, odds ratio or odds ratio (OR) with a 95% confidence interval. The results are presented in table No. 3,

Table number 3 The characteristic of the proposed method in comparison with the assessment of the completed clinical case. YPRES IOR Decision maker ENT Clinical Case Assessment 17 70 2 one

where IPR is a truly positive result; IOR is a truly negative result; Decision-maker - false positive result; ENT is a false negative result. Thus, when comparing the proposed method with the assessment for the completed clinical case, IPR - 17, IOR - 70, LPR - 2, ENT - 1, the determined severity and risk assessment of complications were also confirmed by laboratory and instrumental examination, the level of enzyme markers, and also was observed throughout the entire period of inpatient treatment.

To evaluate the proposed method, such indicators as sensitivity, specificity, accuracy, prognostic value of a positive result (PZPR), prognostic significance of a negative result (PZOR) were calculated. The data obtained are presented in table No. 4.

Table number 4 The main characteristics of the proposed methodology. Sensitivity Specificity Accuracy PZPR REVIEW Clinical Case Assessment 99.4% * 97.2% * 96.7% * 89.5% * 98.5% * * - p <0.05

When assessing the finished clinical case: sensitivity - 99.4%, specificity - 97.2%, accuracy - 96.7%, PZPR - 89.5%, PZOR - 98.5%.

An unfavorable course of the disease, from the point of view of changes in the performance of a detailed blood test, is considered to be one of the following conditions:

dLINE> 0, and dINL> 0 (1);

dLINE> 0, and dCHM> 0 (2);

dISL> 0, and dISNM> 0 (3).

If one of the above conditions is met, the risk of developing complications and severe forms of acute pancreatitis of biliary etiology without obstructive jaundice reaches 89.5%.

The low risk of complications is indicated by one of the following conditions:

dLINE <0, and dINL <0 (1);

dLINE <0, and dCHM <0 (2);

dISLD <0, and dISNM <0 (3).

If one of the above conditions is met, the risk of developing complications and severe forms of acute pancreatitis of biliary etiology without obstructive jaundice is low and amounts to 1.5%.

Thus, we can judge the relationship of the clinical course of the disease with the dynamics of changes in integral hematological parameters. High specificity and PZOR allow using the proposed method as an express method for choosing starting therapy and assessing the risk of complications in patients with acute pancreatitis of biliary etiology, which is not accompanied by obstructive jaundice in the first 24 hours after the start of treatment.

Clinical example No. 1. A 58-year-old patient was urgently admitted to the emergency room of the Road Clinical Hospital at the Krasnoyarsk station with a diagnosis of Acute pancreatitis. The diagnosis is confirmed by ultrasound of the hepatopancreatoduodenal zone. The integral hematological indices were determined: upon receipt of LII - 2.15, ISL - 6.48, ISNM - 18, 20. Infusion, antispasmodic, antisecretory therapy was prescribed. On the first day after the start of conservative therapy, LII - 1.78, LIS - 5.96, ISNM - 15, 45. Thus: dLIA - (-0.37), dISL - (-0.48), dISNM - (- 2.75), which indicates a low risk of complications. According to hematological parameters, the risk of complications is low. The pain syndrome was stopped on the 3rd day. Laboratory indicators returned to normal on the 5th day. With ultrasound control, the pancreas is within normal limits. The patient was discharged on the 7th day in a satisfactory condition.

Clinical example No. 2. Patient I., aged 64, was admitted to the emergency room of the Road Clinical Hospital at the Krasnoyarsk station with a diagnosis of Acute pancreatitis. Peritonitis. According to ultrasound, pronounced edema in the head of the pancreas, a slight effusion in the lateral canals of the abdominal cavity. The integral hematological indices were determined: LII - 5.76, ISL - 8.92, ISNM - 21.19. Conservative treatment was prescribed against the background of the therapy on the first day: LII - 7.94, LIS - 11.26, ISNM - 23.08. Thus, dLI - 2.18, dISL - 2.34, dISNM - 1.89. According to hematological parameters, a high risk of developing complications of the pathological process is set. After preoperative preparation, the patient underwent an emergency operation: laparotomy, pancreatic abdomination, marsupilization, flowing drainage of the omental bursa, drainage of the abdominal cavity. In the postoperative period, the patient was in the intensive care unit. Massive antibacterial, detoxification, immunocorrective therapy was carried out. On the 5th day after the operation, the patient was transferred to the surgical department. The drains were removed on the 7th day, the sutures were removed on the 11th day, and on the 36th day was discharged for outpatient treatment in satisfactory condition.

Clinical example No. 3. Patient T., 67 years old, was urgently admitted to the emergency room of the Road Clinical Hospital at the Krasnoyarsk station with a diagnosis of Acute pancreatitis. Peritonitis. At the time of the examination, the patient's condition is serious, there is a pronounced pain syndrome, tachycardia is noted. According to ultrasound, pronounced edema of the pancreas, effusion along the lateral canals of the abdominal cavity. The integral hematological indices were determined: LII - 6.33, ISL - 9.26, ISNM - 19.85. Conservative treatment was prescribed against the background of the therapy on the first day: LII - 10.74, LIS - 13.48, ISNM - 21.14. Thus, dLI - 4.41, dISL - 4.22, dICHM - 2.29. According to hematological parameters, a high risk of developing complications of the pathological process is set. After massive infusion and antibiotic therapy, the patient's condition did not improve. The patient underwent surgery: laparotomy, pancreatic abdominization, cholecystostomy, marsupilization, flowing drainage of the omental bursa, drainage of the abdominal cavity. In the postoperative period, the patient was in the intensive care unit, the phenomena of pancreatogenic shock developed. Massive antibacterial, detoxification therapy and mechanical ventilation were performed, against which no improvement was noted. On the 7th day after the operation, in connection with increasing multiple organ failure, symptoms of pancreatogenic shock, the patient died.

The following advantages distinguish a method for identifying the risk of complications in acute pancreatitis of biliary etiology using integral hematological parameters:

1) the convenience and simplicity of the proposed method;

2) any laboratory of a surgical hospital can perform a comprehensive blood test;

3) the ability to clearly predict the course of the pathological process 24 hours after the start of treatment, which allows effective correction of starting therapy.

The proposed method allows you to objectively and quickly assess the risk of developing complications of the pathological process, subsequently correct starting therapy, identify the need for surgical intervention and, in cases of high risk of complications, prescribe enhanced antibacterial and detoxification therapy.

Used Books

1. Herbenko G.I., Smanilo P.M., Kuznetsov A.V. Optimization of diagnostic methods in patients with acute pancreatitis // Medicine emergency conditions, 2007. - No. 1 (8). - S. 117.

2. Karabanov G.N. The use of leukocyte blood counts to assess the severity of intoxication // Vestn. surgery. - 1989. - 4. - P.146-149.

3. Imrie C. Prognosis of acute pancreatitis // Ann. Ital. Chir. - 1995 .-- Vol.66. - No. 2. - P.187-189.

4. Knaus W.A., Draper E.A., Wagner D.P. APACHE II. A severity of disease classification system // Crit. Care Med. - 1985. - Vol.13. - P.818-829.

5. RF patent No. 2266055, A61B 10/00, BIPM No. 35, December 20, 2005.

Claims (1)

A method for identifying the risk of complications in acute pancreatitis of biliary etiology, including conducting an extensive blood test, characterized in that the differences in successive white blood counts taken at admission and 24 hours after the start of therapy are determined: leukocyte intoxication index according to Ostrovsky LII, ratio index of segmented neutrophils to lymphocytes ISL, the index of the ratio of neutrophils to monocytes ISNM, when receiving positive values of two of the three above indicators conclude about a high risk of complications, when receiving negative values of two of the three above indicators conclude that there is a low risk of complications.