RU2517163C2 - Method of treating pain syndrome accompanying pancreatitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to gastroenterology, and may be used for treating pain syndrome accompanying pancreatitis in oesophagogastroduodenoscopy. That is ensured by an endoscopic gastric and duodenal pH-metry; and if the derived pH in a duodenal cap and outside is 5 or less, 4% sodium bicarbonate 20-60 ml is introduced intraduodenally, and if the pH value is more than 5, 0.25% novocaine 20-60 ml is introduced.

EFFECT: method enables reducing pain syndrome in 95% patients suffering pancreatitis.

2 ex, 3 dwg, 2 tbl

Description

The invention relates to medicine, namely to gastroenterology, and can be used to treat acute and chronic pancreatitis.

There is a method of treating pain with pancreatitis by suppressing enzyme activity using antienzyme preparations: kontrikala, gordoksa, ε-aminocaproic acid (NB Gubergritz Treatment of pancreatitis. Enzyme preparations in gastroenterology. - M .: MEDPRAKTIKA - M. - 2003. - 100 from.). However, this factor of the occurrence of pain in pancreatitis is important for massive destruction of pancreatic tissue, which is observed only in some patients with pancreatitis. In pancreatitis, the introduction of regulatory peptides is used: somatostatin, calcitonin, dalargin, blockers of cholecystokinin-pancreosimin receptors on acinar cells, sympathomimetics (P.Ya. Grigoriev, E.P. Yakovenko. Diagnosis and treatment of diseases of the digestive system. - M .: Medicine. 1996. . - 515 p.). To stop the pain syndrome in pancreatitis, drugs are prescribed that suppress the stimulating effects on the exocrine function of the pancreas, such as reverse inhibition of pancreatic secretion by the administration of drugs of pancreatic enzymes (G.F. Korotko. A comparative analysis of the inverse of pancreatic secretion from the duodenum experiment. "Physiological Journal named after IM Sechenov, 1993, vol. 79, No. 2, pp. 91-98), using parenteral and enteral nutrition I (B. S. Briskin, G. S. Rybakov. Surgical treatment of acute pancreatitis // Ros. Zhurn. Gastroenterol., Hepatol., Coloproctol. - 2000. - No. 2. P.67-74). For relief of pain by medically reducing acidification of the duodenal cavity, M-anticholinergics, proton pump inhibitors, histamine H ₂ receptor blockers that inhibit the production of hydrochloric acid in the stomach are used (O. Minushkin. Chronic pancreatitis // Ter.arch. - 2001. - No. one. - S. 62-65). However, the main mechanism of duodenal acidification in pancreatitis is a decrease in pancreatic bicarbonate secretion (DLConwell, G. J. Zuccaro, Vargo JET al. An endoscopic pancreatic function test with cholecystokinin-octapeptide for the diagnosis of chronic pancreatitis // Clin.Gastroenterol / Heproenterol. 2003 May; 1 (3): 189-194). These methods are based on the suppression of various physiological mechanisms of pancreatic secretion. Therapy of pancreatitis during esophagogastroduodenoscopy is mainly used for papillostenosis, strictures of the prepapillary section, calculi of the distal part of the main pancreatic duct, when papillosphincterotomy and other endosurgical interventions are performed to restore the outflow from the pancreas (NeuhausHopic Endoscopic Endoscopic Endoscopy. - vol. 36, No. 1. - P.8-16). For functional disorders of pancreatic secretion, due to the increased tone of the sphincter of Oddi, use an endoscopic injection of 100 units. botulinum toxin in the Vater papilla (T. Wehrmann, THSchmitt, A. Amdtetal // Endoscopic injection of botulinum toxin in patients with recurrent acute pancreatitis due to pancreatic sphincter Oddi dysfunction // Aliment. Pharmacol. Ther. - 2000. - Vol.14. - P.1469-1477), pancreatobiliary sphincterotomy and stenting (Treatment of pain in chronic pancreatitis: AGA technical review // Gastroenterology. - 1998. - Vol.115. - P.765-776).

The prototype of the invention is endoscopic drug denervation of the stomach with a mixture of 30% ethyl alcohol with 2% novocaine solution, which allows inhibiting the external secretion of the pancreas through the secretin mechanism (Yu.V. Ivanov, VV Yasnetsov. Some aspects of the pharmacotherapy of acute pancreatitis // Vestn .new medical technology. - 1998. - T.5, No. 2. - P.135-137; Treatment of pain in chronic pancreatitis: AGA technical review // Gastroenterology. - 1998. - Vol. 115. - P. 765-776). The secretion of the enterin hormone secretin by the endocrine cells of the duodenal mucosa is stimulated by acidification of the duodenal cavity, when the pH decreases from 7.0 to 5 or lower. Suppression of the secretion of hydrochloric acid in the stomach reduces the severity of intraduodenal acidification and secretin production. This, in turn, reduces the volume of pancreatic juice, reduces intraductal pressure and eliminates pain. However, in patients with pancreatitis with pain, the secretion of bicarbonates is significantly reduced in response to intravenous administration of secretin (DL Conwell, G. Jr-Zuccaro, Vargo JJ et al. An endoscopic pancreatic function test with cholecystokinin-octapeptide for the diagnosis of chronic pancreatitis / / Clin.Gastroenterol / Hepatol. - 2003 May; 1 (3): 189-194, 2003) and the alkalizing function of duodenal contents is reduced.

The mismatch of the prototype proposed by the authors of the method consists in using several mechanisms for the relief of pain: direct alkalization of the duodenal cavity as replacement therapy with insufficient secretion of bicarbonate by the pancreas or the introduction of a local anesthetic depending on the intraduodenal level of pH.

The authors propose a method for the treatment of pain in acute and chronic pancreatitis by endoscopic measurement of pH in the duodenal cavity and the introduction of an alkalizing solution (4% sodium bicarbonate) at a pH equal to and less than 5.0 and a local anesthetic (0.25% novocaine solution) at pH more than 5.0.

The technical result of the proposed method is to increase the effectiveness of the treatment of pain in acute and chronic pancreatitis through the use of pathogenetically based drugs, reduce their negative overall effect on the body, increase the local effect of drugs on the pancreas by endoscopically introducing them into the cavity of the bulb and the extraclavicular duodenum guts.

The technical result is achieved by the fact that they produce endoscopic pH-measurement of the duodenum, depending on the pH level, 20-60 ml of a 4.0% solution of sodium bicarbonate or 20-60 ml of a solution of 0.25% novocaine are introduced into its cavity. The proposed method is illustrated in tables and Fig. 1-3.

Table 1 The pH level in the cavity of the stomach and duodenum, established using endoscopic pH-metry for pancreatitis Nosological form Fundal department of the stomach Antrum Duodenal ulcer Bulb Extra-bulbous department Norm 1.3-1.5 6.3-7.8 7.3-8.4 7.6-8.7 Pancreatitis n = 45 1.3 ± 0.05 1.4 ± 0.09 5.1 ± 0.25 5.6 ± 0.16 Pancreatitis Duodenal pH <5.0 1.1 ± 0.08 1.4 ± 0.06 4.0 ± 0.32 4.7 ± 0.04 Pancreatitis Duodenal pH> 5.0 1.4 ± 0.04 1.3 ± 0.03 5.9 ± 0.12 6.1 ± 0.16

Table 1 shows a decrease in the alkalizing function of the antrum of the stomach and duodenum in the entire group of examined patients with chronic pancreatitis. In this case, the acidity in the body of the stomach in them corresponds to normacidity. In patients with significant impairment of duodenal alkalization (pH <5), basal hyperacidity was also established. With a tendency toward a decrease in alkalization (pH> 5), basal normocidity was found in the fundus of the stomach.

table 2 The effectiveness of relief of pain in pancreatitis, depending on the pH level in the duodenal bulb Nosological form pH in the duodenal bulb Pain relief time Days Clock Pancreatitis Irrigation: 4% Sodium Bicarbonate 3.9 ± 0.46 1.9 ± 0.29 43.7 ± 7.02 Pancreatitis Irrigation: 0.25% novocaine 5.9 ± 0.18 1.3 ± 0.16 33 ± 3.96

Table 2 shows the effectiveness of therapeutic irrigation of the duodenal cavity, depending on the pH level. With the introduction of a 4% solution of sodium bicarbonate, due to pH <5, the pain syndrome was stopped on average for 1.9 days, and 0.25% solution of novocaine at pH> 5 for 1.3 days.

The method is as follows.

We used endoscopic pH probes and an AGM-03 acidogastrometer manufactured by the Istok-Sistema Scientific Production Enterprise, Fryazino.

The skin electrode for comparison of the pH probe is fixed on the patient’s wrist, after wiping the skin with alcohol and moistening it with PE-2 electrode paste. The measuring electrode of the pH meter is carried out through the biopsy channel of the endoscope to the level of the outlet. The endoscope end must be straightened. When conducting the electrode during endoscopic examination, the biopsy channel of the endoscope is first washed with 20 ml of sterile distilled water, introducing it into the lumen of the channel with a syringe.

Local anesthesia is carried out 10-15 minutes before the procedure. With the help of a spray gun, a 2% solution of dicain is irrigated in the temples, tongue, back wall of the pharynx and the root of the tongue, and the throat and the initial section of the esophagus are lubricated with a cotton swab before examination.

The pH measurement is carried out in the bulb and extra-onion part of the duodenum under visual control with minimal electrode pressure on the mucous membrane (until a funnel-shaped “crater” appears with a diameter of not more than 6 mm and a depth of not more than 2 mm). Contact of the electrode with the mucous membrane for 5-10 seconds. The measurement results are read from the acidogastrometer indicator. Three times the pH is measured at each control point and the average result is calculated.

During an endoscopic examination, after examining the mucosa and measuring the pH, 20-60 ml of 4% sodium bicarbonate solution (at pH less than 5.0) or 0.25% novocaine solution (at pH more than 5.0) is introduced into the cavity of the duodenum. The volume of the drug administered is determined by the severity of dyspeptic syndrome: nausea and vomiting. With their significant severity, the volume of the drug is reduced. In the first 2 hours after the procedure, it is recommended to observe bed rest.

After therapeutic irrigation, the dynamics of the pain syndrome is monitored daily.

Clinical Observations

1. The medical history No. 1289. Patient G.V. Bychkova, born in 1962

I was admitted to the gastroenterological department of the Central City Hospital in Lipetsk on May 28, 2004 with complaints of pain in the left hypochondrium, extending to the back, lower back, and sometimes to the right hypochondrium. Pain occurs after eating. Bitterness and dry mouth are also worrying. The appetite is saved, does not lose weight. Suffers from gastritis from the age of 13. Exacerbations are unfit.

Inpatiently treated once in childhood. In 2001, according to the patient with ultrasound, small calculi were found in the gall bladder. In March 2004, the patient began to worry about pain in the left hypochondrium. March 16, 2004 there were intense abdominal pains, nausea, vomiting, loose stools up to three times a day without impurities, subfebrile temperature for 2 days. Since then, pain remains in both hypochondria, bitterness and dry mouth. Outpatient examination: ultrasound of the abdominal cavity from 04/13/04. Stagnant gall bladder, diffuse changes in the pancreas. EFGDS dated 05.06.04. Superficial reflux gastroduodenitis. Sowing feces for dysentery group and salmonellosis from 05.21.04, negative. Analysis of feces for dysbiosis from 05/17/04 without pathology. Urine diastasis from 04/21/04, 12.5 g / l (normal 1.7-11.5).

Married, has one child. Does not smoke, practically does not consume alcohol. Mensis for 4 days, moderate. There are 5 pregnancies, of which 1 birth, 4 abortions. Previous diseases: surgery for rectocele, appendectomy, acute respiratory viral infections, chronic adnexitis, cystitis. An allergic history and heredity are not burdened.

Objectively: the condition is satisfactory. Consciousness is clear. Asthenic physique, low nutrition. The tongue is lightly coated at the root, moist. The abdomen of the usual form, does not swell, is involved in the act of breathing, soft, painful in the epigastrium, the left hypochondrium and along the large intestine. There are no symptoms of peritoneal irritation. The liver, kidneys and spleen are not palpable. The size of the liver according to Kurlov: 11 × 10 × 9 cm. Pasternatsky’s symptom is negative on both sides. Stool 1 time in 3 days without impurities. Urination is not impaired.

OAK dated 05/31/04 Red blood cells 4.05 × 10 ¹² , Нb 126 g / l, C.p. 0.9, White blood cells 4.8 × 10 ⁹ , stab 6%, segmented 68%, lymphocytes 23%, monocytes 3%, ESR 10 mm / hour.

OAM dated May 31, 2004. Transparent, straw-yellow, acidic, Ud.weight 1005, transitional flat epithelium a little, white blood cells 2-3 in sub.

A coprological study dated 05/31/04, feces formed, soft, brown, fecal pH 7.0, muscle fibers with striated striation of 2-3 in sp., Soap 4-5 in sp., Iodophilic flora moderate amount, white blood cells 2-3 in p.z.

Biochemical research: blood amylase 63 u / l (norm 17-115), urine diastasis 32 units (norm up to 64 units), blood glucose 4.8 mmol / l.

Ultrasound No. 692 of 05/02/04. The structure of the liver tissue without features. The right lobe is 10.4 cm, the left lobe is 5.7 cm. The diameter of the portal vein is 1.3 cm, the common bile duct is 0.3 cm. The gall bladder is 7.5 × 2.2 cm; a form with an inflection, the walls are sealed, not thickened, along the back wall a small layer of condensed bile. The pancreas is 1.8 × 0.9 × 2.1 cm, the contour is uneven, the structure is heterogeneous, echogenicity is increased.

Conclusion: ultrasound signs of congestive gallbladder, diffuse changes in the pancreas.

Esophagogastroduodenoscopy No. 532 of 06/01/04. Conclusion: Superficial duodenitis. Endoscopic pH meter: basal hyperacidity (pH 1.0) of the fundus of the stomach, pH of the duodenal bulb 4.6. An irrigation of the duodenal cavity was performed with 50 ml of a 4% sodium bicarbonate solution.

Clinical diagnosis: Chronic recurrent pancreatitis. Exacerbation phase. Exocrine insufficiency syndrome. Chronic superficial reflux gastroduodenitis. Exacerbation phase. Basal normocide. Gallbladder dyskinesia.

In the dynamics of observations on the eve of the intraduodenal instillation on 05.31.04, the patient was disturbed by pain in both hypochondria, bitterness in the mouth. Palpation of the abdomen revealed pain in both hypochondria. 06/01/04, after endoscopic irrigation in the evening, the pain decreased. 02.06.04, there was pain only in the left hypochondrium. There was no bitterness in the mouth or other dyspeptic symptoms. 06/03/04, rare short-term pain in the left hypochondrium.

2. The medical history No. 1468. Patient Yu.A. Petrishchev, born in 1955

He entered the gastroenterological department of the Central City Hospital of Lipetsk on 06/18/04 with complaints of pain in the epigastrium, mesogastrium and left hypochondrium without irradiation, arising after eating, periodically paroxysmal, bloating, occasionally heartburn. Appetite saved.

Sick since January 2004, when he began to worry about bloating. He turned to the clinic on January 28, 2004, and was treated on an outpatient basis. From 13.02 to 02.03.04, he was treated in the gastroenterological department with a diagnosis of Chronic pancreatitis, exacerbation. 06.06. and 09.06.04, there were two attacks of acute pancreatic abdominal pain. Outpatiently examined. EGDS from 06/11/04, Superficial gastritis. Ultrasound of the abdominal cavity from 06/17/04, diffuse changes in the pancreas, stagnation of bile in the gall bladder. OAK dated 06/11/04. White blood cells 10.3 × 10 ⁹ , ESR 7 mm / hour. Blood glucose 4.9 mmol / l, blood diastasis 16 units.

Married, has two children. Smokes, does not abuse alcohol. History of surgery for right-sided inguinal hernia, arterial hypertension. An allergic history and heredity are not burdened.

General condition is satisfactory. Clear consciousness, normosthenic physique. The tongue is lightly coated, moist. The abdomen is of the usual form, participates in the act of breathing, soft, not swollen, painful in both hypochondria and in the navel. The size of the liver according to Kurlov 13 × 13 × 14 cm. Bubble symptoms are negative. Stool 1-2 times a day without impurities. Urination is not impaired.

OAK dated 06/21/04 Red blood cells 4.53 × 10 ¹² , Нb 138 g / l, CP 0.91, white blood cells 5.5 × 10 ⁹ , stab 7%, segmented 64%, lymphocytes 22%, monocytes 6%, ESR 11 mm / hour.

OAM from 06.23.04. Transparent, yellow, acidic, specific weight 1012, transitional epithelium is small, leukocytes 1-2 in n./sp.

A coprological study dated July 5, 2004. Muscle fibers 3-4 in n / a., Soap 3-4 in n / a, leukocytes 1-2 in n / sp. fecal pH 7.

Biochemical studies of 06.21.04, blood amylase 107 u / l, urine diastasis 32 units.

Ultrasound of the abdominal organs dated June 24, 2004. Liver: right lobe 14.6 cm, left lobe 7.1 cm, echogenicity is diffusely increased, echo signal attenuation in depth, vascular pattern is not changed. Gallbladder 7.0 × 2.6 cm, wall uniformly thickened to 0.4 cm, a large number in the lumen of bile condensed to _^half volume. The pancreas is 1.7 × 1.1 × 2.1 cm, the structure is coarse-grained, echogenicity is diffusely increased.

Conclusion: ultrasound signs of diffuse changes in the liver parenchyma of the type of fatty degeneration, congestive gall bladder, chronic cholecystitis. Diffuse changes in the pancreas.

Endoscopic endoscopy on 06.21.04. Conclusion: the mucous membrane of the esophagus, stomach, and bulb of the duodenum 12 without pathology. pH of the fundus 2, antrum 4.5, duodenal bulb 4.5.

An irrigation of the duodenal cavity was performed with 50 ml of a 4% sodium bicarbonate solution.

In the dynamics of clinical observations, 06/21/04, the pain syndrome is moderate, the abdomen is soft, painful in the epigastrium, the left hypochondrium and along the colon. There are no dyspeptic symptoms. In the future (June 22 and June 23, 04) there were no pains in the upper abdomen. Pain in the left abdomen resumed on June 24, 04

Thus, as a result of endoscopic treatment of pain with pancreatitis according to dynamic clinical observation in the immediate and early stages after it was noted:

a) reduction and disappearance of pain in the epigastrium;

b) the absence of adverse effects and complications associated with the application of the proposed method of treatment.

The claimed invention improves the efficiency of conservative minimally invasive endoscopic treatment of pancreatitis by:

a) the use of drugs: 4% sodium bicarbonate solution, compensating for the insufficient secretion of sodium bicarbonate by the pancreas, and 0.25% novocaine solution, which has a local anesthetic effect;

b) increasing the effectiveness of treatment due to the choice of a medicinal product based on the results of endoscopic pH measurement of the stomach and duodenum;

b) reducing their possible general adverse effect on the body due to their local introduction into the duodenal cavity during endoscopic examination.

Claims (1)

A method of treating a pain syndrome in pancreatitis during an esophagogastroduodenoscopic examination, characterized in that an endoscopic pH measurement of the stomach and duodenum is performed, and at pH values in the bulb and extraclavicular section of the duodenum equal to and less than 5, 20-60 ml of 4% solution is administered intraduodenally sodium bicarbonate, and at a pH of more than 5, 20-60 ml of a 0.25% solution of novocaine are administered.

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