RU2617068C1 - Method for diagnosing motor-evacuation disorders of gastrointestinal tract for patients with suspected acute appendicitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention can be used for diagnosis of motor-evacuation disorders of the gastrointestinal tract for patients with suspected acute appendicitis. Computer phono enterograph (CPEG) is used to record the sound effects at the anterior abdominal wall in the right iliac region. Then, motor-evacuation disorders are evaluated based on the power spectrum density distribution. If the integral index of the area under the graphic curve is less than or equal to 1143.9, acute appendicitis is diagnosed. If the integral index of the area under the graphic curve is greater than or equal to 1495.48, the patient does not have acute appendicitis. If the integral index of the area under the graphic curve is greater than 1143.9, but less than 1495.48, no decision on acute appendicitis can be made based on CPEG data.

EFFECT: method allows to diagnose motor-evacuation disorders of the gastrointestinal tract for patients with suspected acute appendicitis by means of phono enterography, power spectrum density distribution estimation based on the integral area indicator under the graphic curve.

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Description

The invention relates to medicine, namely to surgery, gastroenterology, and can be used to diagnose motor-evacuation disorders of the gastrointestinal tract in patients with suspected acute appendicitis.

Acute appendicitis is one of the most common diseases in urgent abdominal surgery. Surgery for inflammation of the appendix is 20-50% (Levitsky V.D., Gulyaev A.A., Yartsev P.A., Rogal M.L. Modern approaches to the diagnosis and treatment of acute appendicitis (literature review). Endoscopic surgery . - 2011. - T. 17, No. 1. - P. 51-54; Kovalev S.V. Endoviosurgical technologies for the treatment of patients with acute appendicitis and its complications in the conditions of the regional center: Abstract of thesis ... Candidate of Medical Sciences. Great Novgorod 2008; 24). Mortality in acute appendicitis (OA) remains at the level of 0.1-0.2% when performing surgical interventions (Kochukov V.P., Lozhkevich A.A., Kazmin I.A., Ostroverkhova E.G. Laparoscopic appendectomy in acute appendicitis. Kremlin medicine. 2011; No. 4. P. 36-38; Yartsev PA, Ermolov AS, Pakhomova GV et al. Laparoscopy in the diagnosis and treatment of acute appendicitis. Surgery. 4. 2010 P. 21-25; Tarasenko S.V., Kochukov V.P. Selected lectures on hospital surgery. Ryazan, 2007, 154 pp.). The cause of deaths is most often an unfavorable, complicated course of the postoperative period of the disease, regardless of the stage of inflammation of the distant appendix.

It should be noted that acute appendicitis is a disease of young people, i.e. able-bodied population, therefore, the problem of acute appendicitis and today has high practical significance.

The classic clinical picture of acute appendicitis is straightforward. However, a wide variety of clinical masks under which the disease can occur, often causes difficulties in diagnosis, which leads to late surgical interventions or, conversely, to overdiagnosis and unnecessary operations (Levitsky V.D., Gulyaev A.A., Yartsev P.A. ., Rogal ML Modern approaches to the diagnosis and treatment of acute appendicitis (literature review). Endoscopic surgery. - 2011. - V. 17, No. 1. - P. 51-54; Gazizullin Z. Laparoscopic appendectomy using high-intensity laser radiation (clinical experiment ntal research): Abstract of thesis ... Candidate of Medical Sciences. Ufa 2008; 24).

Despite the use of traditional diagnostic methods for suspected acute appendicitis, the frequency of diagnostic errors in acute appendicitis, according to different authors, ranges from 17% to 47%, and does not tend to decrease (Levitsky V.D., Gulyaev A.A. , Yartsev PA, Rogal ML Modern approaches to the diagnosis and treatment of acute appendicitis (literature review). Endoscopic surgery. - 2011. - V. 17, No. 1. - P. 51-54; Kochukov V.P. ., Lozhkevich A.A., Kazmin I.A., Ostroverkhova E.G. Laparoscopic appendectomy in acute appendicitis Kremlin medicine. 2011; No. 4. P. 36-38).

If hypodiagnosis is from 12% to 16.7%, then overdiagnosis is often encountered - from 13% to 30% (Kamanin A.A., Clinical and economic analysis of modern medical technologies in the diagnosis and treatment of acute appendicitis and diseases simulating acute appendicitis: Abstract of thesis ... Candidate of Medical Sciences, St. Petersburg 2011; 263; Plekhanov, AN Ultrasound investigation in the diagnosis of acute appendicitis / AN Plekhanov and others // Ambulance. - 2004 T. 5, No. 3; Sedov VM, Appendicitis. Medical literature from the publisher: ELB I-SPb; p. 232), and if an unchanged vermiform appendix is found during an operation, an audit of the abdominal cavity and small pelvis is necessary, which inevitably leads to trauma to the parietal and visceral peritoneum and the subsequent emergence of a dangerous complication - adhesive disease. In 70% of patients with adhesive disease, the first operation was appendectomy for “simple” appendicitis (Loymoyeva BC Acute appendicitis. Ways to prevent unjustified operations: Abstract of thesis ... Ph.D. in medical sciences 2006; 127; Sakhautidinov, V.G. Unresolved issues in the diagnosis of acute appendicitis / V. G. Sakhautidinov, M. M. Murdanov // Surgery. 1984. - No. 12. - S. 28-32). These patients, in the future, undergo repeated surgical interventions and often become disabled. When studying the long-term results of appendectomies, it was found that after operations performed with an unchanged vermiform appendix, poor results are observed in 5.7% of cases (Loymoyeva BC Acute appendicitis. Ways to prevent unreasonable operations: Abstract of thesis ... Candidate of Medical Science 2006; 127; Kalish, Yu.I., Hyperdiagnosis in surgery for acute appendicitis / Yu.I. Kalish, G.V. Khan, B.M. Mirzakhmedov // Ambulance. 2004. - V. 5, No. 3. - C . 31). In 35% of patients after unnecessary appendectomies, pain in the lower abdomen remains, and the true cause remains unsolved, in 14-32.7% of these patients, examination in the postoperative period revealed other diseases that simulated acute appendicitis (Loymoyeva BC Acute appendicitis. Warnings of prevention unreasonable operations: Abstract of thesis ... candidate of medical sciences 2006; 127; Andreev, G.N. No. 4. - S. 18-23). 27.1% of women suffering from gynecological diseases and infertility had undergone appendectomy in the past for simple appendicitis (Loymoyeva BC Acute appendicitis. Ways to prevent unjustified operations: Abstract of thesis ... Candidate of Medical Sciences 2006; 127; Sovtsov S.A. , Podshivalov V.Yu. // Ambulance. - 2004. - V. 5, No. 3. P. 54-55).

Therefore, today, when the possibilities for diagnosing acute appendicitis are expanding, it is necessary to identify it and undergo surgical treatment as early as possible and reduce the number of unjustified surgical interventions with "simple appendicitis."

According to some authors, for various surgical diseases, including acute appendicitis, motor-evacuation functions of the gastrointestinal tract are often found (Safronov B.G. Diagnosis and correction of motor-evacuation disorders of the gastrointestinal tract in children with surgical diseases, accompanied by pain abdominal syndrome: Abstract of thesis ... of a doctor of medical sciences M 2007; 45; Roshal LM et al. Laparoscopic surgery in childhood using ultrasonic harmonic rocks . Pel Endoscopic Surgery 2004; 1:74)

Among the variety of modern research methods used in the diagnosis of acute surgical diseases and in the diagnosis of acute appendicitis, in particular, today there is a method of computer phonoenterography (CFEG) that allows you to objectively evaluate the motor-evacuation function of the gastrointestinal tract. Compared to diagnostic laparoscopy, which allows one to clearly distinguish between destructive appendicitis and the initial stage of inflammation of the appendix, this method is safe and non-invasive. But until now, the CFEG method has allowed only the total acoustic activity of the abdominal cavity to be evaluated. Currently, based on the spectral analysis of sounds, it has become possible to distinguish between motility of the small and large intestines. Thus, with the systematic use of this method in the clinic, it is possible to expand the diagnostic capabilities of CFEG in patients with suspected acute appendicitis.

The technical result of the proposed method is that a computer phonoenterograph records sound phenomena from the anterior abdominal wall in the right iliac region, then motor evacuation disorders are assessed by the distribution of the power density of the spectrum, and if the integral index of the area under the graphical curve is less than or equal to 1143.9 , then the patient is diagnosed with acute appendicitis, if the integral index of the area under the graphical curve is greater than or equal to 1495.48, then the patient has no data for acute appendectomy itsit if the integral index of the area under the graphic curve is greater than 1143.9, but less than 1495.48, then decide on a patient acute appendicitis according CPEG impossible.

The proposed method is as follows: examination of patients using CFEG is carried out in a horizontal position, lying on his back. The sensor is superimposed on the anterior abdominal wall in the right iliac region. Peristaltic noise is recorded in 5 sessions of 1 minute. Then, motor evacuation disturbances are assessed by the distribution of the spectrum power density, and if the integral index of the area under the graphic curve is less than or equal to 1143.9, then the patient is diagnosed with acute appendicitis, if the integral indicator of the area under the graphic curve is greater than or equal to 1495.48, then the patient does not have data for acute appendicitis, if the integral indicator of the area under the graphical curve is more than 1143.9, but less than 1495.48, then it is impossible to decide on the patient’s acute appendicitis according to CFEG strechalis in 10% of cases).

We conducted a study of the motor-evacuation function of 90 patients, divided into 3 groups: 30 patients with acute appendicitis, 30 patients with abdominal pain, whose diagnosis of acute appendicitis was not confirmed, and 30 patients with varicose veins of the lower extremities, who made up the control group. There were no gender differences in the groups.

We plotted the power density distribution of the spectrum of acoustic activity of the abdominal cavity in patients admitted with suspected acute appendicitis, the diagnosis of which was confirmed, in patients with a similar diagnosis at admission, but in whom the cause of abdominal pain was a different nosology and control group, which included patients with varicose veins of the lower extremities, without concomitant pathology from the organs of the gastrointestinal tract.

We found that in the frequency range from 50 to 1750 Hz, the spectral power density of patients with acute appendicitis is lower than in patients of the control group and patients in whom the diagnosis of acute appendicitis was not confirmed. Thus, we found that in patients with acute appendicitis, the activity of the intestinal sections is reduced, both thick and thin, given that the power density of the spectrum of sounds of the large intestine is in a lower frequency range than the power density of sounds of the small intestine ( see drawing).

The spectral power density of all three groups of patients is presented in the table.

, где a, b - основания трапеции, h - высота трапеции. Применительно к нашим вычислениям а и b - плотности спектральной мощности в выбранных диапазонах частот (таблица), h - постоянное число, равное 50. При сложении площадей под графической кривой пациентов с острым аппендицитом интегральный показатель площади равен 1143,9, пациентов с другой причиной абдоминальных болей - 1589,80, пациентов контрольной группы - 1495,48. Исходя из полученных результатов мы выделяем следующие значения интегральных показателей площадей под графической кривой: меньше или равно 1143,9 и больше или равно 1495,48, которые позволяют диагностировать или исключать острый аппендицит по данным КФЭГ.Based on the results obtained, in order to identify the diagnostic criterion for patients with acute appendicitis according to CFEG, we chose the integral area indicator under the graphical curve. The latter is measured in the same units as the spectral power density. To calculate this indicator, we offer numerical integration using the trapezoidal method. Integration is performed on a site in the frequency range from 50 to 1750 Hz, which is divided into equal intermediate segments of 50 Hz. The area of the trapezoid, as you know, is calculated by the formula

where a, b are the bases of the trapezoid, h is the height of the trapezoid. For our calculations, a and b are the spectral power densities in the selected frequency ranges (table), h is a constant number equal to 50. When adding the areas under the graphical curve of patients with acute appendicitis, the integral area indicator is 1143.9, patients with another cause of abdominal pain - 1589.80, patients in the control group - 1495.48. Based on the results obtained, we distinguish the following values of the integral indicators of the areas under the graphical curve: less than or equal to 1143.9 and greater than or equal to 1495.48, which allow diagnosing or eliminating acute appendicitis according to CFEG.

Clinical example 1

Surveyed B., 38 years old, was admitted to the surgical department with complaints of constant aching pain in the right iliac region, nausea, and dry mouth. From the anamnesis: considers himself ill for about 8 hours, when the cutting pains in the epigastrium first appeared, gradually shifted to the right iliac region. Also noted the appearance of nausea and dry mouth. I myself took 1 tablet of no-shpa - no effect. In connection with the preservation of the pain syndrome, he called an ambulance (SMP), the brigade of which was delivered to the surgical department. From the anamnesis of life: from past illnesses - acute respiratory viral infections, flu. Concomitant pathology does not indicate. There were no injuries or operations. Blood transfusions were not performed. There were no allergic reactions to the introduction of drugs. Objectively: general state of moderate severity, axillary temperature 37.2 ° С, rectal temperature - 38.1 ° С. The tongue is dry, with a white coating on the root. The abdomen is not swollen, participates in the act of breathing, when palpated it is soft, painful in the right iliac region. There is no symptom of muscle tension. Symptom Shchetkina-Blumberg negative. Appendicular symptoms (Kocher, Voskresensky, Razdolsky, Rowzing, Sitkovsky) are positive. The bottom of the gallbladder is not palpable. Hepatic dullness saved. Chair in the morning on the day of admission (decorated, brown). From other organs and systems - without pathology. A general blood test, general urinalysis, chest x-ray, electrocardiography, and CFEG were performed at the admission department. In a general blood test: red blood counts are within normal limits, white blood counts: white blood cells - 10.3 G / l, segmented neutrophils - 79%, lymphocytes - 17%, monocytes - 5%. Urinalysis, chest x-ray, electrocardiogram - without pathology. KFEG result: integral index of the area under the graphical curve 1029.2 ms ² . The patient has a clinical and laboratory picture of acute appendicitis, which is an indication for surgical treatment. Consent for the operation is received. Appendectomy performed. Diagnosis: acute phlegmonous appendicitis.

Conclusion: coincidence of the results of CFEG, clinical and laboratory picture and intraoperative findings.

Clinical example 2

Surveyed N., 30 years old, was admitted to the surgical department with complaints of constant aching pain in the lower abdomen, more to the right. From the anamnesis: he considers himself ill for about two days when, for no apparent reason, gradually growing aching pains appeared in the lower abdomen, more to the right. I did not seek medical help, I was not treated on my own. In connection with the intensification of the pain syndrome, she caused an SMP, whose team was delivered to the surgical department. From the anamnesis of life: from past illnesses - colds. Concomitant pathology: chronic gastritis. There were no injuries. From operations - cesarean section. Blood transfusions were not performed. According to the patient, there is an allergic reaction to antibiotics of the penicillin series in the form of urticaria. Objectively: general state of moderate severity, axillary temperature 36.8 ° С, rectal temperature - 37.4 ° С. The tongue is dry, with a white coating on the root. The abdomen is not swollen, participates in the act of breathing, with palpation is soft, moderately painful in the lower abdomen, more on the right. There is no symptom of muscle tension. Symptom Shchetkina-Blumberg negative. The appendicular symptoms are negative. The bottom of the gallbladder is not palpable. Hepatic dullness saved. A chair the night before (without special features). From other organs and systems - without pathology. A general blood test, general urinalysis, chest x-ray, electrocardiography, and CFEG were performed at the admission department. In the general blood test: red blood counts are within normal limits, white blood counts: leukocytes - 19.0 G / l, stab neutrophils - 1%, segmented neutrophils - 78%, lymphocytes - 13%, monocytes - 7%. Urinalysis, chest x-ray, electrocardiogram - without pathology. The integral indicator of the area under the graphical curve is 1591.5 ms ² . Due to the inability to exclude acute appendicitis in the patient, it was decided to perform video laparoscopy to clarify the diagnosis. Consent for the operation is received. Diagnosis after surgery: rupture of an endometrioid cyst of the right ovary.

Conclusion: the patient has no data for acute appendicitis according to CFEG.

Clinical example 3

Surveyed G., 27 years old, was admitted to the surgical department with complaints of persistent, non-intense abdominal pain, localized in the right iliac region. From the anamnesis: considers himself ill since yesterday, for the apparent reason the above complaints appeared. Previously, similar pains - 6 months ago (the patient suffered acute mesadenitis). Due to the persistence of pain, she independently turned to the surgical department. From the anamnesis of life: from past illnesses - colds. Concomitant pathology does not indicate. There were no injuries or operations. Blood transfusions were not performed. There were no allergic reactions to the introduction of drugs. Objectively: general state of moderate severity, axillary temperature 36.8 ° С, rectal temperature - 37.2 ° С. The tongue is dry, with a white coating on the root. The abdomen is not swollen, participates in the act of breathing, with palpation is soft, painful in the right iliac region, There is no symptom of muscle tension. Symptom Shchetkina-Blumberg negative. The appendicular symptoms are negative. The bottom of the gallbladder is not palpable. Hepatic dullness saved. The chair last night - no features. From other organs and systems - without pathology. A general blood test, urinalysis, chest x-ray, electrocardiography, ultrasound, ultrasound, and CFEG were performed at the admission department. In a general blood test: red blood counts are within normal limits, white blood counts: white blood cells - 15.8 G / L, eosinophils 1%, stab neutrophils - 1%, segmented neutrophils - 73%, lymphocytes - 14%, monocytes - 11% . Urinalysis, chest x-ray, electrocardiogram - without pathology. Ultrasound: the dome of the cecum is fixed in the pelvis, its wall is swollen. The appendix is not visible. Lymph nodes are not detected. The integral index of the area under the graphical curve is 1346.04 ms ² . For the purpose of differential diagnosis, the patient was prescribed infusion, antispasmodic therapy, dynamic monitoring, and control of analyzes. After the infusion, antispasmodic therapy, abdominal pain decreased. By organs and systems without negative dynamics. The abdomen is not swollen, participates in the act of breathing, when palpated it is soft, painful in the right iliac region. There is no symptom of muscle tension. Symptom Shchetkina-Blumberg negative. The appendicular symptoms are negative. Given the presence of an unclear clinical picture, an ultrasound scan of the patient proposed diagnostic laparoscopy with possible appendectomy. However, she refused the proposed diagnosis and treatment option; she was warned of possible consequences. Conservative parenteral therapy is carried out. On re-examination: abdominal pain is much less disturbing. For organs and systems - without negative dynamics. The abdomen is not swollen, participates in the act of breathing, with palpation is soft, slightly painful in the right iliac region. There is no symptom of muscle tension. Symptom Shchetkina-Blumberg negative. The appendicular symptoms are negative. Subsequently, when observing the patient, the diagnosis of acute appendicitis was withdrawn. Conclusion: it is impossible to decide on the presence of acute appendicitis in the patient according to CFEG.

Claims (1)

A method for the diagnosis of motor-evacuation disorders of the gastrointestinal tract in patients with suspected acute appendicitis based on spectral analysis of acoustic signals of the abdominal cavity, characterized in that a computer phonoenterograph (CPEG) records sound phenomena from the anterior abdominal wall in the right iliac region, then assesses motor-evacuation disturbances in the distribution of the power density of the spectrum, and if the integral index of the area under the graphical curve is ≤1143.9, then I will diagnose the patient acute appendicitis, if the integral indicator of the area under the graphic curve is ≥1495.48, then the patient has no data for acute appendicitis, if the integral indicator of the area under the graphic curve is> 1143.9, but <1495.48, then decide on the patient’s presence acute appendicitis according to CFEG is impossible.

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