RU2545990C2 - Differential diagnostic technique for hepatic steatosis and steatohepatitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention represents a method for the differential diagnostics of hepatic steatosis and steatohepatitis by biochemical tests characterised by measuring blood serum phospholipase A2, nitrogen oxide and endotoxin; if phospholipase A2 is 199.7-252.5 ng/ml, nitrogen oxide is 93-94.6 mcmole/l and endotoxin is 2.2-2.6 EU/ml, hepatic steatosis is diagnosed; if phospholipase A2 is 412.5-576.5 ng/ml, nitrogen oxide is 137.5-168.5 mcmole/l and endotoxin is 3.32-4.18 EU/ml, steatohepatitis is diagnosed.

EFFECT: higher accuracy of differential diagnostics and reduced analysis injuries.

4 ex

Description

The invention relates to medicine and can be used for the differential diagnosis of liver steatosis and steatohepatitis.

A known method for the diagnosis of liver steatosis, including microscopic examination of biological material by puncture biopsy of the liver followed by morphological examination of punctate (1 - Severov MV, Namestnikov E. et al. Liver biopsy: feasibility, contraindications and complications. Journal "Doctor" No. 10 , 2002, p. 36-38). This method is taken as an analog.

A known method for the diagnosis of liver steatosis according to which a microscopic examination of biological material is carried out, in which blood serum is taken strictly on an empty stomach, is kept for 24 hours at a temperature of 5-8 ° C, then applied to the surface of low-fat glass in the form of a drop in the amount of 0 , 01-0.02 ml, dried at a temperature of 18-30 ° C at a relative humidity of 55-65% for 18-24 hours and in the presence of at least one area of enlightenment along radial cracks in the form of gaps in the marginal zone of the facies the diagnosis styryl hepatic steatosis without elements of inflammation, and in identifying additional triangular-shaped structures in the white edge region facies diagnose hepatic steatosis with inflammation elements (2 - Patent №2292043, G01N 33/49, 2004).

However, the prototype method is relatively traumatic and not always accurate.

The aim of the invention is to reduce the invasiveness of the method while increasing the accuracy of diagnosis.

The technical result is achieved by the fact that phospholipase A2, nitric oxide and endotoxin are determined in blood serum and with phospholipase A2 199.7-252.5 ng / ml, nitric oxide 93-94.6 ncmol / l and endotoxin 2.2-2 , 6 EU / ml diagnose liver steatosis, and with phospholipase A2 412.5-576.5 ng / ml, nitric oxide 137.5-168.5 ncmol / L and endotoxin 3.32-4.18 EU / ml diagnosed steatohepatitis.

The method is implemented as follows.

Patients are admitted with a diagnosis of non-alcoholic fatty liver disease in the stage of steatosis or steatohepatitis, cholelithiasis: cholecystolithiasis. Adenomyomatosis of the gallbladder.

Complaints at admission: an increase in the abdomen in volume, bloating, periodic pain in the epigastric region. Appetite saved. Anamnesis of the disease: cholelithiasis, cholecystolithiasis. Ultrasound: diffuse changes in the liver, pancreas, deformity and gallbladder stone.

Deterioration of health in recent years, when there is an increase in the abdomen in volume.

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 16-19 in a minute. Heart sounds are muffled, the rhythm is correct. Heart rate - 65-85 per min. HELL from 100/60 to 160/95 mm Hg. Art. The tongue is coated with white plaque. The abdomen is soft, moderately painful in the right hypochondrium. The liver is at the edge of the costal arch, the spleen is not palpable. The symptom of "striking" is negative on both sides. There are no peritoneal symptoms.

Examination:

Ultrasound of the abdominal organs, kidneys: The liver is not enlarged. The structure of the parenchyma is homogeneous. Echogenicity is increased. Vascular pattern saved. 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. Gall bladder: with constriction and kink in the neck. The walls are thickened. In the cavity of the bladder is a mobile calculus. The paravesical region is not changed. The pancreas is of normal size. 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. 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.

Conclusion: Diffuse changes in the liver. Chronic cholecystitis. Cholecystolithiasis. Liver steatosis.

In patients with a diagnosis of non-alcoholic fatty liver disease in the stage of steatohepatitis, dyslipidemia. Arterial hypertension. Impaired fasting glycemia. Obesity 2 tbsp., Exogenous-constitutional.

Complaints at admission: pain in the right hypochondrium after eating, sometimes at night, when walking intensifies, heartburn, belching, bitterness in the mouth, bloating, recovered by 5 kg in 1 month. Appetite saved.

From the anamnesis it is known that for several years episodically - hyperbilirubinemia, increased ALT, ACT, alkaline phosphatase. With ultrasound, hepatomegaly, diffuse changes in the pancreas, liver, cholecystitis.

For several years, suffers from hypertension with a maximum increase in blood pressure to 160/100 mm Hg. Dyslipidemia.

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. Heart sounds are muffled, etching rhythm. The tongue is coated with white plaque. The abdomen is soft, moderately painful in the right hypochondrium. The liver is at the edge of the costal arch, the spleen is not palpable. The symptom of "striking" is negative on both sides. There are no peritoneal symptoms.

Examination:

With ultrasound of the abdominal cavity. The liver is enlarged. The structure of the parenchyma is heterogeneous. Echogenicity is increased significantly. The vascular pattern is 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. Gall bladder: S-shaped. Walls - 3 mm and more. The content is uniform or the presence of calculi. There are no additional entities. The paravesical region is not changed.

Conclusion Enlarged and diffuse changes in the liver (steatohepatitis). Chronic cholecystitis.

Endoscopic endoscopy: 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 cardia gapes. 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 content mixed with bile. The gastric mucosa is edematous, moderately hyperemic in places, the relief of the gastric mucosa is nodular-granular. Folds of medium size, crimped, longitudinally oriented, elastic. Peristalsis is satisfactory, can be traced in all departments. The angle is not changed. The gatekeeper is round, closed, we pass. The duodenal bulb is medium in size, not deformed, the walls are smooth, elastic, pink mucous. Postbulbar sections: the mucous membrane of the descending part of the duodenum is pink, the folds are medium-sized, elastic, active motility. The area of the Vater's nipple is not visually changed. Biopsy: on HP for a urease test - negative. Conclusion: Chronic gastritis, cardia failure, duodenogastric reflux.

ECG: Semi-vertical position of the EOS. Sinus rhythm, correct. Heart rate 65-85 per min. Weakly expressed diffuse changes in the myocardium.

Phospholipase A2, nitric oxide and endotoxin are determined in blood serum, and with a value of phospholipase A2 199.7-252.5 ng / ml, nitric oxide 93-94.6 ncmol / L and endotoxin 2.2-2.6 EU / ml are diagnosed hepatic steatosis, and with phospholipase A2 412.5-576.5 ng / ml, nitric oxide 137.5-168.5 ncmol / L and endotoxin 3.32-4.18 EU / ml, steatohepatitis is diagnosed.

The method is further explained by examples of its implementation.

Example 1

Patient Z. 1949, was admitted with a diagnosis of non-alcoholic fatty liver disease in the stage of steatosis, cholelithiasis: cholecystolithiasis. Adenomyomatosis of the gallbladder. Chronic pancreatitis, remission.

Complaints upon admission: an increase in abdomen in volume, bloating, periodic pain in the epigastric region, stool - 1 r / day, designed without pathological impurities. Appetite saved. Anamnesis of the disease: From 38 years - ZhKB: cholecystolithiasis, without bouts of colic.

In 2008 - pain in the left ileal region, was hospitalized with a diagnosis of Diverticular colon disease, chronic hemorrhoids. Examination: Irrigoscopy: the colon is full of barium, sigma diverticulosis. Ultrasound: diffuse changes in the liver, pancreas, deformity and gallbladder stone. Ultrasound: without pathology. Antibacterial therapy was carried out - with a positive effect.

Deterioration of health since the summer of 2011, when she began to notice an increase in the abdomen while following a diet and moderate physical exertion, belching, bloating, and a tendency to obstruct stools intensified. Took mezim, mukofalk with a small positive effect. Hospitalized.

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 17 per minute. Heart sounds are muffled, the rhythm is correct. Heart rate - 70 per min. HELL 110/70 mm Hg The tongue is coated with white plaque. The abdomen is soft, moderately painful in the left iliac cavity, lower parts. There are no peritoneal symptoms. The liver is at the edge of the costal arch, the spleen is not palpable. The symptom of "striking" is negative on both sides.

Examination:

Ultrasound of the abdominal organs, kidneys: The liver is not enlarged. Right lobe: CWR 14.8 cm (N up to 15.0 cm). Left lobe: 5.7 cm thick (N up to 6.0 cm). The structure of the parenchyma is homogeneous. Echogenicity is increased. Vascular pattern saved. 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: with constriction and kink in the neck. Dimensions 7.3 × 3.2 cm. Walls - 2.8-3.0 mm, adenomyomatosis in the neck. In the cavity of the bladder, a mobile calculus of 28 mm with a shadow. The paravesical region is not changed. Pancreas: usually located. Head 27 mm (N up to 30 mm), body 11 mm (N up to 20 mm), tail 19 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 1.5 mm. There are no additional entities. Spleen: location is normal. The contours are even, clear, the capsule is not changed. Dimensions 106 × 42 mm. The parenchyma is homogeneous. Echogenicity is average. The splenic vein is not dilated. There are no additional entities. The kidneys are typically located. Corticomedullary differentiation is not changed. The pyelocaliceal system is expanded. There are no calculi. There are no additional entities. Paranephric fiber is not changed. The adrenal gland is not changed. There is no free fluid. There are no limited accumulations of fluid. Loops of the intestines are not expanded. Conclusion: Diffuse changes in the liver. Chronic cholecystitis. Cholecystolithiasis. Adenomyomatosis of the gallbladder. Liver steatosis.

Contractile function of the gallbladder. Gall bladder: V-22 ml, KO after 60 minutes - 50% (norm 50-75%). Conclusion: Normal contractile function of the gallbladder.

Endoscopic endoscopy: 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 cardia gapes. 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 content mixed with bile. The gastric mucosa is edematous, moderately hyperemic in places, the relief of the gastric mucosa is nodular-granular. Folds of medium size, crimped, longitudinally oriented, elastic. Peristalsis is satisfactory, can be traced in all departments. The angle is not changed. The gatekeeper is round, closed, we pass. The duodenal bulb is medium in size, not deformed, the walls are smooth, elastic, pink mucous. Postbulbar sections: the mucous membrane of the descending part of the duodenum is pink, the folds are medium-sized, elastic, active motility. The area of the Vater's nipple is not visually changed. Biopsy: HP test for urease test is negative. Conclusion: Chronic gastritis, cardia failure, duodenogastric reflux. Sigmoidoscopy: A rectoscope tube was drawn at a distance of 16 cm from the anus. The rectal mucosa in the examined areas is pink, smooth, shiny. The vascular pattern is distinct, correct. There is no contact bleeding. Conclusion: In the examined areas of the organic pathology from the rectum was not detected. Colonoscopy: A colonoscope was drawn into the dome of the cecum. The Bauginieva damper is polypous in shape, closed, oriented to the dome. The mucous membrane of the colon in the examined areas is pink, smooth, shiny. The vascular pattern is distinct, correct. Folds of the mucous membrane of medium size, elastic. Gut lumen is not deformed. The bowel tone is normal. Diverticula 0.2-0.3 cm in diameter are visualized in the sigmoid colon, with no signs of inflammation. Conclusion: Diverticulosis of the sigmoid colon.

ECG: Semi-vertical position of the EOS. Sinus rhythm, correct. Heart rate 83 per minute. Weakly expressed diffuse changes in the myocardium.

Surgeon consultation: Patient with cholelithiasis, chronic calculous cholecystitis. Scheduled hospitalization in CW is shown.

Proctologist consultation: Perianal area is not changed. External hemorrhoidal nodes are not determined. Willpower is weak. With a digital examination, the sphincter tone is preserved. Internal hemorrhoidal nodes are expressed slightly at 3,7,11. When straining, the rectum prolapses (falls out). Rectoscope was performed for 12 s, pink mucosa, no inflammatory changes. No ulcers, polyps, erosion. Conclusion The omission of the pelvic organs. The insufficiency of the anal sphincter of 2 tbsp. Prolapse of the rectum. Recommendations: 1) Physiotherapy, exercise therapy. Regulation of stool with a diet, if necessary, taking laxatives based on lactulose.

Clinical blood test. HB - 123, E - 4.25, Ht - 35.3; Thrombus - 210, Lake - 4.9; S / N - 1, oz - 2, Lim - 30, Mon - 5, ESR - 6.

Blood chemistry. Total protein - 66.8. Urea - 5.98. Total bilirubin - 12.9. ALT - 22.3. ACT - 22.1. GGTP - 15.8. Alkaline phosphatase - 63.2. CS - 6.24. Glucose - 5.86.

A blood test for RW, HIV is negative. Urinalysis: Rel. density - 1037, acid reaction, protein, no glucose, lake. - 1-3 in par. Sp.

Determine serum phospholipase A2, nitric oxide and endotoxin. The values of phospholipase A2 are 252.5 ng / ml, nitric oxide is 94.6 ncmol / l and endotoxin is 2.6 U / ml is liver steatosis.

Example 2

Patient P., born in 1968 was admitted with a diagnosis of liver steatosis. Chronic gastritis, not associated with HP infection, in the acute stage. Gastroesophageal reflux disease is endoscopically negative. Duodenal ulcer in remission. Chronic cholecystitis in remission. Pancreatic lipomatosis. Diverticular disease of the colon without diverticulitis. Hypertension II tbsp., 2 tbsp. risk. Atherogenic dyslipidemia IIa. Obesity 2 tbsp., Exogenous-constitutional.

EPICRISE. Complaints of heaviness and discomfort in the upper abdomen; tendency to loose stools - alternating periods of diarrhea up to 5 times a day and periods of a mushy stool, burning in the anus against the background of diarrhea: rumbling and transfusion in the stomach; 6 kg weight gain in 3 years. Weight 133 kg, height 193 cm. The appetite is lowered.

Anamnesis of the disease: In the late 1990s, an ulcer of 12 bp was first detected, exacerbations were annual until 2001. In 2009, after an attack of renal colic, I began to notice the appearance of a / c complaints. Deterioration since December 2011, when the stool became more frequent, the discomfort in the stomach intensified, and frequent urination appeared. 03/15/12 an attack of acute pain in the left hypochondrium. With an ultrasound scan of the ICD (multiple hyperechoic formations in the left kidney up to 4.3 mm), enlargement of the CLS is signs of a violation of urodynamics.

Sharp pains in the right hypochondrium were noted. Ultrasound of the kidneys revealed no pathology. After a week, the pain in the right hypochondrium decreased. In b / x: glucose 6.2, transaminases normal, cholesterol 6.7. With endoscopy: Cardia insufficiency. Reflux esophagitis. Erosive gastroduodenitis. Cicatricial inflammatory deformity of the duodenal bulb.

Objectively: the condition is satisfactory. The skin and visible mucous membranes are clean, normal in color. In the lungs, vesicular breathing, no wheezing. Heart sounds are muffled, rhythmic. Heart rate - 72. HELL - 140/100 mm Hg. The abdomen is soft, moderately painful in the epigastrium and along the colon. Liver +2 cm. The spleen is not palpable.

Survey data:

Esophagogastroduodenoscopy: An 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 cardia outlet closes periodically, the dentate line is 3 cm above the level of the esophageal opening of the diaphragm. The lumen of the stomach is not deformed, with insufflation it is easily straightened. In the lumen of the stomach on an empty stomach, a moderate amount of s / d contents, liquid mixed with a small amount of bile. The mucous fluid is pale pink; it has a spotty appearance in the antrum. Folds of medium size, convoluted, longitudinally oriented. Peristalsis is satisfactory, symmetrical. The angle is not changed. The gatekeeper is round. Bulb 12 p.k. medium-sized, scarred, mucous pale pink. Postbulbar departments: the mucous membrane of the duodenum is pale pink, active motility. The OBD in a typical place, when viewed from the device with the end-face optics, is not visually changed. Conclusion: GPOD 1 Art. Antral gastritis. Cicatricial-ulcerative deformation of the duodenal bulb. The urease test after 15 min is denied.

Ultrasound examination: In the examined areas the echostructure is homogeneous, echogenic, elevated, vascular pattern preserved. Gall bladder 8.1 × 2.9 cm, wall 3 mm, the contents are homogeneous. The pancreas is of normal shape, head 36 mm (normal up to 30 mm), body 16 mm, tail 26 mm, contours uneven, fuzzy, diffuse, heterogeneous structure, echogenicity significantly increased. Kidneys - not changed. The spleen is 13.8 × 5.5 cm, area 68 sq. Cm, echo-homogeneous. Severe pneumatization of the colon. Conclusion: Diffuse changes in the liver. Chronic cholecystitis. Diffuse changes in the pancreas (lipomatosis). Enlarged spleen (constitutionally determined). Severe pneumatosis of the colon.

Colonoscopy: the apparatus was performed in the dome of the cecum. Lip-shaped Bauginia damper, closed damper, oriented to the dome. In the lumen of the colon, 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, correct. The folds of the mucous membrane of medium size, the lumen of the intestine is not deformed. The bowel tone is moderately elevated. In the distal third of the sigmoid colon, single forming diverticula with a mouth diameter of 0.1-0.2 cm without signs of inflammation are determined. Conclusion: Diverticulosis of the sigmoid colon.

ECG: semi-vertical position of the EOS. Sinus rhythm, correct. Heart rate 80.

General urine analysis: beats. carried - 1021, protein - no, sugar - no, white blood cells - denied. in s / sp.

An.kala: reaction to occult blood - neg., Muscle fibers - nezn., Grows, fiber - a little, starch - no, I worm - no, protozoa - no. yeast mushrooms - no.

HBsAg - neg., Anti HC NS V - neg., PB - neg., AT HIV - neg. from 05/15/12

Glucose tolerance test: blood glucose up to a load of 5.29 mmol / L. After a load of 4.12 mmol l.

Immunological blood test for persnos: IgM.G.A - antibodies to yersinia were not found.

Determine serum phospholipase A2, nitric oxide and endotoxin. The values of phospholipase A2 - 199.7 ng / ml, nitric oxide - 93 ncmol / l and endotoxin - 2.2 EU / ml - liver steatosis.

Example 3

Patient M., born in 1960, was admitted with a diagnosis of Non-alcoholic fatty liver disease in the stage of steatohepatitis with minimal activity. Chronic gastroduodenitis, exacerbation, gastroesophageal reflux disease in the stage of esophagitis. Chronic cholecystitis, exacerbation. Chronic pancreatitis, remission.

Nodular goiter 2 tbsp., Euthyroidism. Dyslipidemia. Arterial hypertension. Bronchial asthma, mild course, remission. Osteochondrosis. Impaired fasting glycemia. Obesity 2 tbsp., Exogenous-constitutional.

Complaints upon admission: pain in the right hypochondrium after eating, sometimes at night, when walking intensifies, heartburn, belching, bitterness in the mouth, bloating, stool - relaxation up to 8 r / day during the day after eating, without pathological impurities, weight - recovered by 8 kg per month. Appetite saved.

Anamnesis of the disease: Over the course of several years, episodically hyperbilirubinemia up to 60, takes ursosan, creon courses (last course in December 2012). Ultrasound: hepatomegaly, differential. changes in the pancreas, liver, cholecystitis. From concomitant and transferred diseases: for 1 year, suffers from arterial hypertension with a maximum increase in blood pressure to 160/95 mm Hg. Dyslipidemia.

Thyroid gland: nodular goiter, bronchial asthma since 1995

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 19 in minutes Heart sounds are muffled, etching rhythm. Heart rate - 85 per minute. HELL 165/95 mm RT. Art. The tongue is coated with white plaque. The abdomen is soft, moderately painful in the right hypochondrium. There are no peritoneal symptoms. The liver is at the edge of the costal arch, the spleen is not palpable. The symptom of "striking" is negative on both sides.

Examination:

Ultrasound of the abdominal organs, kidneys. The liver is enlarged. Right lobe: CWR 17.0 cm (N up to 15.0 cm). Left lobe: 5.7 cm thick (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 expanded, diameter 12 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: S-shaped. Dimensions 7.0 × 2.4 cm. Walls - 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 28 mm (Ν up to 30 mm), body 14 mm (Ν up to 20 mm), tail 22 mm (Ν up to 25 mm). The contours are uneven, fuzzy. The structure of the parenchyma is heterogeneous. Echogenicity is increased significantly. Wirsung duct not expanded, diameter 1.3 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 126 × 52 mm, area 53 cm square. (norm up to 47). 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 (steatohepatitis). Chronic cholecystitis. Diffuse changes in the pancreas. Slightly enlarged spleen. Abdominal Doppler ultrasound: The portal blood flow is normal.

Endoscopic endoscopy: 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, whitish in the lower third. The socket of the cardia closes periodically, the dentate line is located at the level of the esophageal opening of the diaphragm. 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 mucous contents. The mucous membrane of the stomach is pale pink; it has a spotty appearance in the antrum. Folds of medium size, convoluted, longitudinally oriented. Peristalsis is satisfactory symmetrical. The angle is not changed. The gatekeeper is round. Bulb 12 p.k. medium-sized, mucous pale pink, in the lumen of bile. The exit from the bulb is free. Postbulbar sections: mucosa 12 pc pale pink, active motility, large duodenal papilla - in a typical place, when viewed with an end-optic device, it is not visually changed. Conclusion: Reflux esophagitis. Superficial gastritis. The urease test is negative.

Sigmoidoscopy: A rectoscope tube was drawn at a distance of 25 cm from the anus. The rectal mucosa in the examined areas is pink, smooth, shiny. The vascular pattern is distinct, correct. There is no contact bleeding. When the apparatus is withdrawn, internal hemorrhoidal nodes are visualized without signs of inflammation.

Conclusion In the examined areas of organic pathology from the rectum was not detected. Colonoscopy: A colonoscope was drawn into the dome of the cecum. Bauginieva damper closed, oriented to the dome. The mucous membrane of the colon in the examined areas is pink, smooth, shiny. The vascular pattern is distinct, correct. Folds of the mucous membrane of medium size, elastic. Gut lumen is not deformed. The bowel tone is normal. Conclusion: Organic pathology from the colon was not detected.

ECG: Semi-vertical position of the EOS. Sinus rhythm, correct. Heart rate 73 per minute. Weakly expressed diffuse changes in the myocardium.

Endocrinologist consultation: Impaired fasting glycemia. Obesity 2 tbsp., Exogenous-constitutional. Nodular goiter 2 tbsp., Euthyroidism. Recommended: 1) Diet 9. 2) Control of glycemia. 3) Blood test for TSH, ultrasound of the thyroid gland - 1 time per year. 4) Observation of the endocrinologist.

Clinical blood test. HB - 150, E - 4.67, Ht - 42; Thrombus - 221, Lake - 8.3; PO Box - 1, PO Box - 61, Eos - 2, Lim - 31, Mon - 5, ESR - 9.

Blood chemistry. Total protein - 74.9. Urea - 3.15. Total bilirubin-36.1. ALT - 48.3. AST - 51. GSTP - 133.1. Alkaline phosphatase - 113.3. CS - 7.21. Glucose - 6.53.

A blood test for RW, HIV is negative. Urinalysis: Rel. density - 1020, acid reaction, protein, no glucose, lake. - 15-30 p. Sp.

Determine serum phospholipase A2, nitric oxide and endotoxin. Values: phospholipase A2 412.5 ng / ml, nitric oxide 137.5 nkmol / L and endotoxin 3.32 U / ml diagnose steatohepatitis.

Discharged in satisfactory condition.

The labor forecast, subject to the recommendations, is favorable.

Example 4

Patient K., born in 1964, was admitted with a diagnosis of Steatohepatitis of a high degree of activity, chronic cholecystitis. Chronic pancreatitis in remission. Gastroesophageal reflux disease in the stage of esophagitis. Arterial hypertension. Dyslipidemia. Type 2 diabetes mellitus, moderate. Obesity 2 tbsp. exogenous constitutional.

Complaints on admission: heartburn, nausea, dry mouth, a feeling of fullness in the stomach after eating. Unformed stool up to 5 times a day, a gradual increase in weight over 7 years by 25 kg. Anamnesis: Considers herself a patient for 5 years, when a biochemical blood test revealed an increase in transaminases: ACT to 285, ALT to 331. She took ursosan courses. karsil. Essential with unstable and incomplete positive effect - a decrease in transaminases by 2 times without reaching normal values. With endoscopy revealed erosion in the stomach.

From concomitant and transferred diseases: over the course of 25 years, an increase in blood pressure to 145/90 mm Hg has been noted. adapted to 130/80. Type 2 diabetes.

Objectively: The condition is satisfactory. Height is 172 cm. Weight is 110 kg. The skin is pale pink, of moderate humidity. No swelling. In the lungs, vesicular breathing, no wheezing. Heart sounds are clear, the rhythm is correct. HELL 180/110 mm Hg, Ρ 78 per min. The abdomen is soft, painful on palpation in the epigastric region, in the right hypochondrium. Liver on the edge of the costal arch. The symptom of "striking" is negative on both sides. Follow-up: endoscopy: esophagus is not deformed, freely pass. The mucous membrane of the esophagus is pink, smooth, shiny, swollen in the terminal region, whitish, the cardia gapes, a small zonal hernia is visible. The lumen of the stomach is not deformed. In the stomach lumen on an empty stomach, a moderate amount of mucous contents and bile. The gastric mucosa is edematous, moderately hyperemic. Folds of medium caliber, crimped, longitudinally oriented. The angle of the stomach is not changed. The gatekeeper is round. Peristalsis is satisfactory. The gatekeeper is round. Bulb 12 p.k. medium size. Her mucous is pale pink. Conclusion: chronic gastritis, axial hernia POD. Catarrhal reflux esophagitis, duodeno-gastric reflux. Ultrasound: Liver enlarged: CWR of the right lobe 17.2 cm, thickness of the left lobe 7.9 cm. The structure is heterogeneous. Echogenicity is significantly increased. The vascular pattern is depleted. The portal vein is expanded, diameter 14 mm. Gall bladder 6.9 × 2.7 cm. Wall 2.8 mm. Content is uniform. Choledoch 4 mm in diameter, no calculi. The pancreas is of normal form. 30 × 16 × 27 mm, the structure is diffusely heterogeneous. Echogenicity is increased. Wirsung duct is not expanded. The spleen is usually located, the contours are even, clear, 115 × 51 mm, an area of 48 cm2, a foreign parenchyma. Conclusion: an increase and diffuse changes in the liver, signs of portal hypertension, chronic cholecystitis, diffuse changes in the pancreas, a slight increase in the spleen. Doppler ultrasound: portal blood flow is within normal limits. Fibroelastomatology: F2 according to Metavir. moderate fibrosis.

Sigmoidoscopy: rectoscope held at a distance of 8 cm from the anus (hereinafter contents). The rectal mucosa in the examined areas is pink, smooth, shiny. The vascular pattern is distinct, correct. Conclusion: in the examined areas of organic pathology from the rectum was not detected.

Colonoscopy: an endoscope is placed in the dome of the cecum. Polyaugy-shaped bauginium damper, closed, oriented to the dome. There is a moderate amount of content in the lumen. The mucous membrane throughout is pink, smooth, shiny. Vascular distinct, correct. Folds of the mucous membrane of medium size. Gut lumen is not deformed.

Intestine tone saved. Conclusion: no organic pathology from the colon.

Endocrinologist: Type 2 diabetes mellitus, moderate, subcompensated. Diabetic distal polyneuropathy, sensory type. Diabetic angiopathy of limbs. Obesity 2 tbsp., Exogenous-constitutional. Glycemic profile: 6.3; recommended: cancel glucophage. Glycemic profile: 9.21-7.08-9.2 - recommended prolonged insulin d-ill n / a. 8 units at 21 hours

Consultation: Diagnosis: NAFLD. High activity steatohepatitis (metabolic component), the presence of drug damage is not excluded. Type 2 diabetes mellitus, subcompensation. Obesity 2 tbsp.

ECG: sinus rhythm, correct. Semi-horizontal position of the EOS. Heart rate - 9, pronounced diffuse changes in the myocardium.

Laboratory research:

Clinical blood test. HB - 143, E - 4.35, Ht - 44; Thrombus - 247, Lake - 8.3; PO Box - 1, PO Box - 60, Eos - 3, Lim - 30, Mon - 6, ESR - 10.

Blood chemistry. Total protein - 73.8. Urea - 3.12. Total bilirubin - 35.6. ALT - 53.3. ACT - 57. GGTP - 138. APF - 125. CS - 7.3. Glucose - 7.2.

Determine serum phospholipase A2, nitric oxide and endotoxin. Values: phospholipase A2 - 576.5 ng / ml, nitric oxide - 168.5 ncmol / L and endotoxin - 4.18 EU / ml diagnose steatohepatitis.

Against the background of the therapy: a positive trend is noted: heartburn, nausea, intestinal dyspepsia are not disturbing.

The patient is discharged in satisfactory condition.

Differential diagnosis of steatosis and steatohepatitis was carried out in 28 patients. Subsequent treatment confirmed the achievement of the goal - reducing the invasiveness of the method while improving the accuracy of diagnosis.

Claims (1)

A method for the differential diagnosis of liver steatosis and steatohepatitis by biochemical research, characterized in that phospholipase A2, nitric oxide and endotoxin are determined in blood serum and with phospholipase A2 199.7-252.5 ng / ml, nitric oxide 93-94.6 μmol / l and endotoxin 2.2-2.6 EU / ml diagnose liver steatosis, and with phospholipase A2 412.5-576.5 ng / ml, nitric oxide 137.5-168.5 μmol / l and endotoxin 3, 32-4.18 EU / ml diagnose steatohepatitis.