RU2537229C1 - Method of treating non-alcoholic fatty liver disease - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine and aims at treating the non-alcoholic fatty liver disease. Increasing a transaminase level to three normal values inclusively requires applying essential phospholipids for 2-3 months twice a year that is followed by using statin 10-20 mg in a combination to ursodeoxycholic acid 15-20 mg/kg for 3-6 months. If the transaminase level exceeds three normal values, the treatment is isolated and includes ursodeoxycholic acid 15-20 mg/kg for 3-6 months.

EFFECT: method enables providing the higher clinical effectiveness of the non-alcoholic fatty liver disease.

3 ex

Description

The invention relates to medicine, namely to methods for treating non-alcoholic fatty liver disease.

There is a method of treating non-alcoholic fatty liver disease with lipid-lowering drugs (1 - Guidelines for atherosclerosis and coronary heart disease. Edited by E.I. Chazov, V.V. Kukharchuk, S.A. Boytsov. M: Media Medica, 2007). This method is taken as an analog.

The prototype of the present invention is a method of treating non-alcoholic fatty liver disease through the use of statins (2 - Oganov R.G., Aronov D.M., Bubnova M.G. The use of statins is a paradigm for the prevention and treatment of atherosclerotic diseases. Cardiovascular. Ter. And prophylaxis. 2006; 5 (6): 4.8). This method is adopted as a prototype.

However, the isolated use of statins can lead to an increase in transaminases (hepatotoxic effect).

The aim of the invention is to increase the effectiveness of the treatment of non-alcoholic fatty liver disease while reducing side effects.

The technical result is achieved by the fact that when the level of transaminases is increased to three norms, inclusive, essential phospholipids are used for 2-3 months twice a year, followed by the use of statin at a dose of 10-20 mg in combination with ursodeoxycholic acid at a dose of 15-20 mg / kg for 3-6 months; with an increase in the level of transaminases more than three times compared with the norm of treatment, ursodeoxycholic acid is carried out in isolation at a dose of 15-20 mg / kg for 3-6 months.

The method is implemented as follows.

Upon admission, the patient complains of pain in the right hypochondrium, bloating, heartburn. An objective examination shows signs of exogenous constitutional obesity, chronic obstructive pulmonary disease, slight pasty of the legs, feet; angina pectoris, functional class II-III, the liver protrudes from under the edge of the costal arch by 3-5 cm.

Examination:

Ultrasound of the abdominal cavity: the liver is enlarged. The structure of the parenchyma is heterogeneous. Echogenicity is increased. The vascular pattern is significantly depleted. The portal vein is not dilated. There are no volume formations. The bile ducts are not dilated. There are no calculi. There are no additional entities. The gall bladder is enlarged or within normal limits. Content is uniform. There are no additional entities. The paravesical region is not changed. The pancreas is enlarged. The contours are uneven, fuzzy. The structure of the parenchyma is heterogeneous. Echogenicity is increased. Wirsung duct is not expanded. There are no additional entities. Transmission pulsation from the aorta is carried out. Spleen: location is normal. The contours are even, clear, the capsule is not changed. The parenchyma is homogeneous. Echogenicity is average. The splenic vein is not dilated. There are no additional entities. Conclusion: Enlarged and diffuse changes in the liver. Diffuse changes in the pancreas (chronic pancreatitis).

Endoscopic endoscopy (transnasal): the lumen of the esophagus is not deformed; when insufflated, it straightens well. The mucous membrane of the esophagus is pink, smooth, shiny. The socket of the cardia closes periodically. The lumen of the stomach is not deformed, with insufflation with air it is easily straightened. In the stomach lumen on an empty stomach, a moderate amount of fluid mixed with mucus. The gastric mucosa is moderately hyperemic in the body along the tops of the folds, in the antrum it has a spotty appearance. Multiple xanthomas from 0.3 to 0.5 cm are visualized in the body and in the antrum of the stomach. Medium folds, convolutions, are longitudinally oriented. Peristalsis is satisfactory, symmetrical. The gatekeeper is round, spasmodic, we pass. Bulb of the duodenum of medium size, mucous pale pink, in the lumen of bile. Postbulbar sections: the duodenal mucosa is pale pink, active peristalsis. Conclusion: Multiple xanthomas of the stomach. The spasm of the pylorus.

Indirect ultrasound elastometry: liver elasticity corresponds to the degree of fibrosis F 3 according to Metavir, which corresponds to 3 degrees of fibrosis. Doppler ultrasound of the vessels of the abdominal cavity: forming portal hypertension.

Chest x-ray: lungs are emphysematous, without foci and infiltrates. Pulmonary pattern can be traced to the edges of the fields. Mooring overlays in the anterior part of the rib-phrenic sinus on the left. Hypoventilation SIV-V on the left in the upper lobe. The roots are differentiated. The contours of the diaphragm are smooth. The anterior section of the rib-phrenic sinus on the left is sealed. The aorta is sealed, the descending section is bent. The heart is of normal size and shape, within age-related changes. Conclusion: Age-related pulmonary emphysema, against this background, hypoventilation of SIV-V on the left, mooring overlays in the anterior part of the rib-phrenic sinus. Aortocardiosclerosis.

X-ray examination of the upper gastrointestinal tract: the act of swallowing is not broken. The esophagus and cardia are passable. The abdominal esophagus prolapses into the mediastinum. The stomach is usually located. Normotonic. Fasting fluid. Edematous mucosa is represented by convoluted longitudinal folds. With tight filling, the contours are smooth. Peristalsis can be traced in all departments. Shallow depression on the back of the stomach. Evacuation function is not impaired. The duodenal bulb of normal size. Its mucosa and proximal half of the slightly expanded duodenum are slightly swollen. Passage of barium suspension along the proximal loops of the jejunum is not impaired. Conclusion: A hiatal hernia. Gastroduodenitis. Signs of chronic pancreatitis.

ECG: horizontal position of the EOS. Sinus rhythm, correct. Heart rate 68-88 per minute. Cicatricial changes.

A patient with morbid obesity has a non-alcoholic fatty liver disease in the stage of steatohepatitis. Given the pronounced cytolytic component, dyslipidemia with a high coronary risk (in the history of acute myocardial infarction), the appointment of lipid-lowering therapy in combination with hepatoprotectors is necessary.

Puncture biopsy of the liver: the material is highly fragmented. The portal tracts are dilated, moderately infiltrated by lymphocytes and moderately fibrosed. Connective tissue septa connect adjacent portal tracts. Follicle-like accumulations of lymphocytes and areas of ductal hyperplasia in individual portal tracts. In some portal tracts, the integrity of the border plate is impaired and lymphocytic infiltrate spreads between the hepatocytes deep into the lobules. Large-drop fatty infiltration of hepatocytes. Severe cell hyperplasia of the reticuloendothelial system. Conclusion: Chronic portal and periportal hepatitis of moderate degree of activity.

Non-alcoholic fatty liver disease in the stage of steatohepatitis, a moderate degree of activity. Chronic pancreatitis, remission. Hernia of the esophagus. Multiple xanthomas of the stomach.

Ischemic heart disease. Postinfarction cardiosclerosis. Angina pectoris. FC II. Dyslipidemia. Obesity of the third century, exogenously constitutional. COPD Chronic obstructive bronchitis, remission. Emphysema. Diffuse pneumosclerosis. DN 0.

Complaints at admission: rare bitterness in the mouth, rare bloating.

From the anamnesis it is known that statins were taken for a month, after which an increase in transaminases from 2 to 5 norms in a biochemical blood test began to be noted.

With an increase in transaminases to three norms, essential phospholipids are used for 2-3 months twice a year, followed by the use of statin at a dose of 10-20 mg in combination with ursodeoxycholic acid at a dose of 15-20 mg / kg for 3-6 months; with an increase in the level of transaminases more than three times compared with the norm of treatment, ursodeoxycholic acid is carried out in isolation at a dose of 15-20 mg / kg for 3-6 months.

The patient was discharged in satisfactory condition. The forecast is favorable.

The method is confirmed by the following examples.

Example 1

Patient A., born in 1953, was treated with a diagnosis of Non-alcoholic fatty liver disease in the stage of steatohepatitis, a moderate degree of activity.

Ischemic heart disease. Postinfarction cardiosclerosis (2005). Angina pectoris. FC II. FC III. Dyslipidemia. Obesity of the third century, exogenously constitutional. COPD Chronic obstructive bronchitis, remission. Emphysema. Diffuse pneumosclerosis. Complaints at admission: rare bitterness in the mouth, rare bloating.

Anamnesis of the disease: in childhood - hepatitis A. In 1974 - salmonellosis. After 3 months, statins were prescribed - taken for a month, after which there was an increase in transaminases in the biochemical analysis of blood to 2.5 norms. Acceptance of statins is canceled. A blood test for hepatitis B, C markers is negative.

From concomitant and transferred diseases: for 20 years, suffers from arterial hypertension with a maximum increase in blood pressure to 180/100 mm Hg, adapted to blood pressure 140/90 mm Hg Ischemic heart disease. Angina pectoris. In 2005 - AMI.

Objectively upon admission: satisfactory condition, hypersthenic physique. The skin is dark, visible mucous subicteric. Slight pastiness of legs, feet. In the lungs, vesicular breathing, side breathing noises are not heard. BH 17 per minute. Heart sounds are muffled, the rhythm is correct. Heart rate - 78 per minute. HELL 150/100 mm Hg The tongue is densely lined with white-yellow bloom. The abdomen is enlarged due to the pancreas, soft, sensitive in the right hypochondrium. There are no peritoneal symptoms. The liver is +4 cm, the spleen is not palpable. The symptom of "striking" is negative on both sides.

Examination:

Ultrasound of the abdominal cavity: the liver is enlarged. Right lobe: CWR 16.6 cm (N up to 15.0 cm). Left lobe: 7.1 cm thick (N up to 6.0 cm). The structure of the parenchyma is heterogeneous. Echogenicity is increased. The vascular pattern is significantly depleted. The portal vein is not dilated, diameter 11 mm. There are no volume formations. The bile ducts are not dilated. Choledoch 4 mm. There are no calculi. There are no additional entities. Gall bladder: dimensions 9.2 × 2.9 cm. Walls - 2.6 mm. Content is uniform. There are no calculi. There are no additional entities. The paravesical region is not changed. Pancreas: usually located. Head 35 mm (N up to 30 mm), body 19 mm (N up to 20 mm), tail 22 mm (N up to 25 mm). The contours are uneven, fuzzy. The structure of the parenchyma is heterogeneous. Echogenicity is increased. Wirsung duct not expanded, diameter 1 mm. There are no additional entities. Transmission pulsation from the aorta is carried out. Spleen: location is normal. The contours are even, clear, the capsule is not changed. Dimensions 98 × 46 mm. The parenchyma is homogeneous. Echogenicity is average. The splenic vein is not dilated. There are no additional entities. Loops of the intestines are not expanded. Conclusion: Enlarged and diffuse changes in the liver. Diffuse changes in the pancreas (chronic pancreatitis).

Endoscopic endoscopy (transnasal) from 06/10/09: the endoscope is freely held in the esophagus and then into the stomach. The lumen of the esophagus is not deformed; when insufflated with air, it straightens well. The mucous membrane of the esophagus is pink, smooth, shiny. The socket of the cardia closes periodically. The lumen of the stomach is not deformed, with insufflation with air it is easily straightened. In the stomach lumen on an empty stomach, a moderate amount of fluid mixed with mucus. The gastric mucosa is moderately hyperemic in the body along the tops of the folds, in the antrum it has a spotty appearance. Multiple xanthomas from 0.3 to 0.5 cm are visualized in the body and in the antrum of the stomach. Medium folds, convolutions, are longitudinally oriented. Peristalsis is satisfactory, symmetrical. The gatekeeper is round, spasmodic, we pass. Bulb of the duodenum of medium size, mucous pale pink, in the lumen of bile. Postbulbar departments: 12pc mucosa pale pink, active motility, large duodenal papilla - in a typical place, without features. Conclusion: Multiple xanthomas of the stomach. The spasm of the pylorus.

Indirect ultrasound elastometry from 06/15/09: liver elasticity corresponds to the degree of fibrosis F 2 according to Metavir, which corresponds to 2 degrees of fibrosis. Abdominal Doppler ultrasound: forming portal hypertension.

Chest x-ray: lungs are emphysematous, without foci and infiltrates. Pulmonary pattern can be traced to the edges of the fields. Mooring overlays in the anterior part of the rib-phrenic sinus on the left. The roots are differentiated. The contours of the diaphragm are smooth. The anterior section of the rib-phrenic sinus on the left is sealed. The aorta is sealed. A heart of ordinary size and shape. Conclusion: Age-related pulmonary emphysema, aortocardiosclerosis.

X-ray examination of the upper gastrointestinal tract: Esophagus and cardia passable. The abdominal esophagus prolapses into the mediastinum. The stomach is usually located. Normotonic. Fasting fluid. Edematous mucosa is represented by convoluted longitudinal folds. With tight filling, the contours are smooth. Peristalsis can be traced in all departments. Evacuation function is not impaired. The duodenal bulb of normal size. Its mucosa and proximal half of the slightly expanded duodenum are slightly swollen. Passage of barium suspension along the proximal loops of the jejunum is not impaired. Conclusion: A hiatal hernia. Gastroduodenitis. Signs of chronic pancreatitis.

ECG: horizontal position of the EOS. Sinus rhythm, correct. Heart rate 72 per minute. Cicatricial changes in the anterior septal area.

A patient with morbid obesity has a non-alcoholic fatty liver disease in the stage of steatohepatitis (mixed genesis: dysmetabolic and medicinal - statin). Given the pronounced cytolytic component, dyslipidemia with a high coronary risk (in the history of acute myocardial infarction), the appointment of lipid-lowering therapy in combination with hepatoprotectors is necessary.

Puncture biopsy of the liver: portal tracts are enlarged, moderately infiltrated by lymphocytes and moderately fibrosed. Connective tissue septa connect adjacent portal tracts. Follicle-like accumulations of lymphocytes and areas of ductal hyperplasia in individual portal tracts. In some portal tracts, the integrity of the border plate is impaired and lymphocytic infiltrate spreads between the hepatocytes deep into the lobules. Large-drop fatty infiltration of hepatocytes. Steatosis Index - 1. Severe cell hyperplasia of the reticuloendothelial system. METAVIR A2 F2. Conclusion: Chronic portal and periportal hepatitis of moderate degree of activity.

Laboratory research.

General clinical blood test:

HB Eritre Ht Thrombus Lake PO Box S / i Eos Lim. Mon ESR 177 5.72 50,2 198 8.7 2 61 3 27 7 four 175 5,4 47.3 175 9.2 one 49 2 43 5 2

Blood chemistry:

06.06 11.06 17.06 06/25 07/07 Norm Total protein 88.8 89.1 88.5 84.1 66.0-87.0 g / l Albumen 43.8 35-52 g / l Urea 4.3 5.27 5.14 1.7-8.3 mmol / L Creatinine 74-110 μmol / L Uric acid 208.3-428.4 μmol / L Bilirubin obi 22.5 12.5 11.6 13.5 3.4-21.0 μmol / L Straight bilirubin 4,5 4,5 0-3.4 μmol / L ALT 112.2 96.9 87.2 81.1 5-45 units / l ACT 87.1 79.9 74.5 63.5 5-35 U / L GGTP 95.3 64.9 59.7 36.5 7-38 units / l Alkaline phosphatase 91.9 94.1 96.1 78.5 30-120 units / l Amylase 28-100 units / l Lipase 21-67 U / L Cholesterol 6.05 5.06 4.2 3,5 1.4-5.2 mmol / L HS-HDL 0.87 0.86 0.82 1.1-2.3 mmol / L hs-LDL 4.35 3.29 2.87 2.1-3.3 mmol / L Triglycerides 1.82 2.01 1.13 0-1.7 mmol / L Potassium 3.5-5.1 mmol / L Sodium 136-146 mmol / L Calcium 2.2-2.7 mmol / L Iron 30,4 10.7-32.2 μmol HDD 39.6 27.8-53.7 μmol OZhSS 70 44.8-71.6 μmol STFe 43,4 15-50% Copper 72.1 70-140 mcg / dl Glucose 6.2 5.66 5.13 5.63 4.1-6.4 mmol / L Fibrinogen 0.88 2-4 g / l APTTV 28.8 25-35 sec Mho 1,03 0.9-1.2 Prothrombin 87.8 70-130%

Blood type: A (II). Rh + (positive). Kell antigen - (negative)

Blood test for RW, HIV negative.

A blood test for HBsAg, HCV antibodies is negative.

Urinalysis: Rel. density 1019, acidic reaction, protein, no glucose, lake. 1-3 p / sp. The analysis of feces for occult blood is negative.

The treatment was carried out: essential phospholipids were used in a standard dosage (2 tablespoons) for 2 months twice a year, followed by the use of simvastatin at a dose of 10 mg in combination with ursodeoxycholic acid at a dose of 15 mg / kg for 3 months.

The patient was discharged in satisfactory condition. Subsequent follow-up observation of the liver with ultrasound is more homogeneous, the level of ALT and ACT corresponds to the norm.

Example 2

Patient M., born in 1964, was admitted with a diagnosis of non-alcoholic fatty liver disease. Complaints on admission: discomfort in the upper abdomen, not associated with eating, rare heartburn, rare belching of air, rare bloating.

I lost 30 kg in 7 months on the background of a diet.

Appetite saved. Stool up to 3 times a day, decorated, without pathological impurities.

Anamnesis of the disease: in 1991 he had hepatitis A, since then periodically notes aching pain in the right hypochondrium. Ultrasound: signs of hepatosis, lipomatous degeneration of the pancreas, cholecystitis. He took essliver for a month, allohol, but-shpu with a slight positive effect.

From concomitant diseases: for more than 15 years, suffers from arterial hypertension with a maximum increase in blood pressure to 180/140 mm Hg, adapted to blood pressure of 120/80 mm Hg. Accepts: indapamide 2.5 mg, hypothiazide 12.5 mg, egilok 50 mg in the morning.

Type 2 diabetes mellitus since 2003, takes glucophage 850 mg 2 tab. in the morning, 1 tab. in the evening.

In August 2008, a vertebral disc herniation took NSAIDs.

Chronic obstructive bronchitis, sinusitis.

Objectively: the condition is satisfactory. Hypersthenic physique. BMI - 40 kg / m ² . The skin, mucous membranes of normal color. No peripheral edema. In the lungs, vesicular breathing, side breathing noises are not heard. BH 17 per minute. Heart sounds are muffled, the rhythm is correct. Heart rate 78 per minute. HELL 130/80 mm Hg The tongue is coated with white plaque. The abdomen is soft, sensitive in the right hypochondrium. There are no peritoneal symptoms. Liver +2 cm, spleen not palpable. The symptom of "striking" is negative on both sides.

Ultrasound of the abdominal cavity: the liver is enlarged due to the left lobe. Right lobe: CWR 14.3 cm (N up to 15.0 cm). Left lobe: 8.7 cm thick (N up to 6.0 cm). The structure of the parenchyma is heterogeneous. Echogenicity is increased. The vascular pattern is depleted. The portal vein is not dilated, diameter 12 mm. There are no volume formations. The bile ducts are not dilated. Choledoch 6 mm. There are no calculi. There are no additional entities. Gall bladder: dimensions 7.9 × 3.0 cm. Walls - 2.6-2.8 mm. Content is uniform. There are no calculi. There are no additional entities. The paravesical region is not changed. Pancreas: usually located. Head 37 mm (N up to 30 mm), body 21 mm (N up to 20 mm), tail 23 mm (N up to 25 mm). The contours are uneven, fuzzy. The structure of the parenchyma is heterogeneous. Echogenicity is increased. Wirsung duct is not expanded. There are no additional entities. Transmission pulsation from the aorta is carried out. Spleen: location is normal. The contours are even, clear, the capsule is not changed. Dimensions 100 × 54 mm. The parenchyma is homogeneous. Echogenicity is average. The splenic vein is not dilated. There are no additional entities. Loops of the intestines are not expanded. Conclusion: Diffuse changes in the liver (signs of steatosis). Chronic cholecystitis. Diffuse changes in the pancreas.

Endoscopy: the mucous membrane of the esophagus is pale pink, the vascular pattern is preserved. The cardia closes completely. Peristalsis is traced. The stomach has a moderate amount of unclear fluid and a lot of mucus. The folds are medium caliber, elastic. The angle of the stomach is not changed. The mucous membrane is focal hyperemic, edematous. Peristalsis can be traced in all departments. The gatekeeper will close, we pass. The duodenal bulb of medium size, not deformed. The mucous membrane of the duodenum is mottled. The mucous membrane of the postbulbar sections is pink. Conclusion: Chronic gastroduodenitis.

Chest x-ray: lungs without foci and infiltrates. Pulmonary pattern can be traced to the edges of the fields. The roots are poorly differentiated. The contours of the diaphragm are clear. The sinuses are free. The aorta is compacted, slightly elongated. The heart is of normal size and shape, within age-related changes. Conclusion: Mild pneumosclerosis, aortocardiosclerosis.

ECG: normal position of EOS. Sinus rhythm, correct. Heart rate 75 per minute.

Endocrinologist consultation: Type 2 diabetes mellitus, moderate. Obesity 3 cm, exogenously constitutional.

Ophthalmologist Consultation: OU, Diabetohypertensive Angiopathy. Recommended: control once a year, herbal medicine.

Puncture liver biopsy: non-alcoholic fatty liver disease at the stage of steatosis.

General clinical blood test:

HB Eritre Ht Thrombus Lake PO Box S / i Eos L them. Mon ESR 158 4.97 45 258 6.1 2 61 2 29th 6 twenty 143 4.64 40 7.8

Blood chemistry:

11.03 03/16 2303.0 Norm Total protein 80.8 76, 66.0-87.0 g / l Urea 6.07 7.73 1.7-8.3 mmol / L Bilirubin commonly 47.9 30.7 3.4-21.0 μmol /. Straight bilirubin 7.2 6.8 0-3.4 μmol / L ALT 135.1 96.3 5-45 units / l ACT 105.0 86 5-35 U / L GGTP 113.7 108.9 7-38 units / l Alkaline phosphatase 60.9 48,2 30-120 units / l Cholesterol 4.62 3.66 1.4-5.2 mmol / L HS-HDL 1.73 1.44 1.1-2.3 mmol / L HS-LDL 2.01 1.72 2.1-3.3 mmol / L Triglycerides 1.93 1,1 0-1.7 mmol / L Glucose 6.12 4.68 4.1-6.4 mmol / L Fibrinogen 3,54 2-4 g / l APTTV 29.8 25-35 sec Mho one 0.9-1.2 Prothrombin 91.5 70-130%

Blood type: 0 (I). Rh + (positive). Kell antigen - (negative)

Blood test for RW, HIV negative.

A blood test for HBsAg, HCV antibodies is negative.

Urinalysis: Rel. density 1013, acid reaction, protein, no glucose, lake. 1-3 p / sp.

Treatment: lecithin at a dose of 3 tablespoons per day for 3 months twice a year, followed by the use of simvastatin at a dose of 20 mg in combination with ursodeoxycholic acid at a dose of 20 mg / kg for 6 months.

After the treatment, there was a positive trend: no abdominal pain, no heartburn, no burping, a decrease in the level of ALT, GGTP, bilirubin, cholesterol, triglycerides, LDL was noted in the blood chemistry.

Discharged in satisfactory condition.

Example 3

Patient N., born in 1941, was admitted with a diagnosis of steatohepatitis, which developed against the background of non-alcoholic fatty liver disease, of a moderate degree of activity. Chronic cholecystitis, remission. Chronic pancreatitis, remission. Chronic gastroduodenitis with erosion in the stomach, exacerbation (upon discharge - remission). Polyp of the duodenal bulb. Polyp of the sigmoid colon.

Hypertension II Art. Ischemic heart disease. Angina pectoris. FC II. Coronary artery envelope stenting. CHF IIA. FC II. Atherogenic dyslipidemia IB. High coronary risk. Impaired glucose tolerance. Obesity of the second century, exogenously constitutional.

Complaints on receipt of dry mouth, rare nausea.

Medical history: in 2003, stenting of the envelope of the artery was performed. Since then, he has been taking statins (simgal, atoris 20 mg / day), while taking statins cholesterol-5.9, triglycerides-2.16, HDL-2.33. According to the extract from the IKK named after A.L. During the last year, Myasnikov noted an increase in the level of liver enzymes (ALT, ACT) by more than 3 times. From concomitant diseases: for 15 years, suffers from arterial hypertension with a maximum increase in blood pressure up to 170/100 mm Hg, adapted to blood pressure 110-120 / 80 mm Hg.

Objectively upon admission: satisfactory condition. The skin, mucous membranes of normal color. No peripheral edema. In the lungs, vesicular breathing, side breathing noises are not heard. BH 18 in minutes Heart sounds are muffled, the rhythm is correct. Heart rate 80 per minute. HELL 140/100 mm Hg The tongue is coated with white plaque. The abdomen is soft, sensitive in the umbilical region. There are no peritoneal symptoms. The liver is not enlarged, the spleen is not palpable. The symptom of "striking" is negative on both sides.

Examination:

Ultrasound of the abdominal cavity, kidney from 04/10/09: acoustic access is difficult due to flatulence. The liver is enlarged. Right lobe: thickness 14.7 cm (N up to 12.0 cm). Left lobe: thickness 6.3 cm (N up to 6.0 cm). The structure of the parenchyma is heterogeneous. Echogenicity is increased significantly. The vascular pattern is depleted. The portal vein is not dilated, diameter 11 mm. There are no volume formations. The bile ducts are not dilated. Choledoch 4 mm. There are no calculi. There are no additional entities. Gall bladder: dimensions 7.2 × 2.6 cm. Walls - 2.6-2.8 mm. Content is uniform. There are no calculi. There are no additional entities. The paravesical region is not changed. Pancreas: usually located. Head 34 mm (N up to 30 mm), body 20 mm (N up to 20 mm), tail 24 mm (N up to 25 mm). The contours are uneven, fuzzy. The structure of the parenchyma is heterogeneous. Echogenicity is increased. Wirsung duct is not expanded, diameter 2 mm. There are no additional entities. Transmission pulsation from the aorta is carried out. Spleen: location is normal. The contours are even, clear, the capsule is not changed. Dimensions 90 × 50 mm. The parenchyma is homogeneous. Echogenicity is average. The splenic vein is not dilated. There are no additional entities. Loops of the intestines are not expanded. Conclusion: Enlarged and diffuse changes in the liver. Chronic cholecitis. Diffuse changes in the pancreas (chronic pancreatitis).

Endoscopy: the mucous membrane of the esophagus is pale pink, the vascular pattern is preserved. The cardia closes completely. Peristalsis is traced. In the stomach, a moderate amount of turbid fluid and mucus with bile. The folds are medium caliber, elastic. The angle of the stomach is not changed. The mucous membrane is spotty, with the presence of erosion in the output section up to 0.3 cm with fibrin. Peristalsis can be traced in all departments. The gatekeeper will close, we pass. The duodenal bulb is medium-sized, not deformed, closer to the output section, a polypoid formation up to 0.6 cm, the mucous membrane above it is hyperemic. Postbulbar departments: pink mucosa. A biopsy was taken (2 fragments from a polyp). The urease test is negative. Conclusion: Erosive gastritis, duodenogastric reflux, duodenal polyp.

Biopsy: Chronic mild duodenitis. Hyperplasia of the Brunner glands.

Endoscopy: pass the esophagus, the mucous membrane of the esophagus is pale pink, the cardia closes. In the stomach cavity, a moderate amount of clear fluid and mucus. The mucous membrane of the stomach is pink, swollen, sometimes slightly hyperemic. The folds are medium sized, elastic. Peristalsis can be traced in all departments. The angle of the stomach is not changed. In the antrum, thickening of the folds is noted. The gatekeeper is round in shape. The duodenal bulb is medium in size, not deformed. Its walls are elastic, smooth. In the output section of the duodenal bulb, a 0.5-0.6 cm polyp was detected. The mucous polyp in some places is slightly hyperemic. The mucous membrane of the duodenal bulb and the mucosa of the postbulbar section are pale pink, the folds are elastic, medium in size. The area of the Vater's nipple without pathological changes. Conclusion: Chronic gastritis. Polyp of the duodenum.

Sigmoidoscopy: With a digital examination, the sphincter is tonic. The rectoscope tube was drawn at a distance of 30 cm from the anus. In the intestinal lumen, a moderate amount of liquid contents. The rectal mucosa in the examined areas is pink, smooth, shiny. The vascular pattern is distinct, correct. Folds of the mucous membrane of medium size Conclusion: Organic pathology from the rectum was not detected.

Colonoscopy: a colonoscope was taken into the dome of the cecum. Bauginieva damper closed, oriented to the dome. In the intestinal lumen, a moderate amount of liquid contents. The mucous membrane of the colon in the examined areas is pink, smooth, shiny. The vascular pattern is distinct. The folds of the mucosa are low. Gut lumen is not deformed. Intestine tone is significantly reduced. In the distal section of the sigmoid colon, a polyp is visualized up to 0.8 cm in diameter, with no signs of inflammation. Conclusion: Polyp of the sigmoid colon. Colon dyskinesia by hypotonic type.

ECG: normal position of EOS. Sinus rhythm, correct. Heart rate 56 per minute. Weakly expressed diffuse changes in the myocardium.

The study of the electromotor activity of the gastrointestinal tract: Hypermotor dyskinesia of the stomach and the descending part of the colon.

Clinical Psychology Laboratory Consultation: No evidence of clinically significant anxiety and depression has been identified. The type of attitude towards the disease is of a mixed type with a predominance of egocentric, anosognosic features.

Daily monitoring of blood pressure from 04/22/09: during monitoring, average blood pressure indicators are within normal limits (per day 126/84, in the active period of time 133/89, in the passive period 107/70, maximum blood pressure 204/120, minimum blood pressure 86/55 ) The normal degree of nighttime decrease in blood pressure (8%). The rate of morning rise in blood pressure is normal (systolic 21.3 mmHg / hour, diastolic 9.4 mmHg / hour). The variability of blood pressure is increased.

Puncture biopsy of the liver: in the portal tracts, moderate fibrosis and lymphocytic infiltration. There is a slight proliferation of ducts, dystrophy of their epithelium. The integrity of the border plate is violated, inflammatory infiltration spreads deep into the lobules. Step necrosis. Thin port-portal and port-central septa. There is a small amount of small intralobular mixed-cell infiltrates. Single lipogranulomas. Large-drop fatty infiltration of hepatocytes. Steatosis index 2. Anisocariosis of hepatocyte nuclei, binuclear hepatocytes, hepatocytes with vacuole-like nuclei. In the lumen of sinusoids, lymphocytes, eosinophils. Perihepatocellular fibrosis. Weakly expressed hyperplasia of RES cells.

Ultrasound of the abdominal organs: the structure of the liver is not broken. Free fluid and its limited accumulations in the abdominal cavity were not detected.

Laboratory research.

General clinical blood test:

HB Eritre Ht Thrombus Lake PO Box S / i Eos L them. Mon ESR 148 4.89 42.3 343 8.9 one 61 one 31 6 23

Blood chemistry:

04/10/09 04/27/09 Norm Total protein 80.7 66.0-87.0 g / l Urea 6.18 1.7-8.3 mmol / L Bilirubin commonly. 9,4 3.4-21.0 μmol / L Bilirubin is straight 1.3 0-3.4 μmol / L ALT 179.4 154.4 5-45 units / l ACT 175.3 67 5-35 U / L GGTP 190.0 157 7-38 units / l Alkaline phosphatase 62.7 76 30-120 units / l Cholesterol 1,1 9.92 1.4-5.2 mmol / L HS-HDL 1.21 1.51 1.1-2.3 mmol / L HS-LDL 7.65 7.05 2.1-3.3 mmol / L Triglycerides 4.88 3 0-1.7 mmol / L Glucose 6.16 4.81 4.1-6.4 mmol / L Coagulogram from 04/15/09: Fibrinogen 4.64 2-4 g / l APTTV 30.8 25-35 sec Mho 0.95 0.9-1.2 Prothrombin 99.7 70-130%

Glycemic profile from 04/22/09: 09.00-5.03, 14.00-7.6, 17.00-5.6 mmol / l

Blood type: 0 (I). Rh + (positive). Kell antigen - (negative)

Blood test for RW, HIV negative.

A blood test for HBsAg, HCV antibodies is negative from 04/10/09.

Urinalysis: Rel. density 1024, acid reaction, protein, no glucose, lake. 1-3 p / sp.

The therapy was carried out: in isolation, ursodeoxycholic acid at a dose of 20 mg / kg for 6 months.

Discharged in satisfactory condition. The forecast is favorable.

According to the claimed method, 38 patients with steatohepatitis were treated. Tests have confirmed the achievement of the purpose of the invention is to increase the effectiveness of the treatment of non-alcoholic fatty liver disease while reducing side effects.

Information sources

1. Guidelines for atherosclerosis and coronary heart disease. Ed. E.I. Chazova, V.V. Kuharchuk, S.A. Boytsova. M .: Media Medica, 2007.

2. Oganov R.G., Aronov D.M., Bubnova M.G. The use of statins is a paradigm for the prevention and treatment of atherosclerotic diseases. Cardiovask. ter. and prophylaxis. 2006; 5 (6): 4.8.

Claims (1)

A method of treating non-alcoholic fatty liver disease through pharmacological therapy, characterized in that with an increase in transaminases up to three norms, essential phospholipids are used for 2-3 months twice a year, followed by the use of statin in a dose of 10-20 mg in combination with ursodeoxycholic acid in a dose of 15-20 mg / kg for 3-6 months; with an increase in transaminase levels of more than three norms, treatment is carried out in isolation with ursodeoxycholic acid at a dose of 15-20 mg / kg for 3-6 months.