RU2619334C1 - Method for prediction of course of obstructive jaundice of various genesis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: level of blood bilirubin and total protein is determined by three-point assessment of the total bilirubin level: <60 mcmol/l - 1 point, 60-200 mcmol/l - 2 points, ≥200 mcmol/l - 3 points, total serum protein level: ≥65 g/l - 1 point, 64-55 g/l - 2 points, <55 g/l - 3 points, and disease genesis. In addition, data on the patient's age, presence of diabetes mellitus, concomitant pathology, at that, patient's age, presence of diabetes mellitus and concomitant pathology are assessed on a three-point score: patient's age of 30 to 50 years - 1 point, 50 to 70 years - 2 points, 70 to 90 years - 3 points, diabetes mellitus: no data - 1 point, compensated pathology - 2 points, decompensated pathology - 3 points, concomitant pathology: no data - 1 point, compensated pathology - 2 points, decompensated pathology - 3 points , disease genesis: benign pathology - 0.2 points, malignant pathology: I stage - 0.4 points, II stage - 0.6 points, III stage - 0.8 points, IV stage - 1 point, with the following calculation according to the formula: PD=((Bilirubin+Protein+Age+Diabetes mellitus+ concomitant pathology)×0.33))×(disease genesis×0.2)×100%.

EFFECT: method allows to quickly calculate the course of mechanical jaundice of various genesis, speed up and simplify the diagnosis.

3 tbl, 2 ex

Description

FIELD OF THE INVENTION

The invention relates to medicine, in particular to a method for predicting the course of obstructive jaundice of various origins, and can be used in surgery, oncology, gastroenterology and anesthesiology-resuscitation.

State of the art

A known method for predicting the development of postoperative hepatic failure in patients with obstructive jaundice is that arterial-sinusoidal perfusion is determined in the subject prior to surgery, for which measuring electrodes are applied in the area of the main liver array, the interelectrode distance, the body area of the subject are additionally measured, test with passive venous return by raising the lower extremities at an angle of 30 ° for 1 min and after 1 min after termination of the sample is calculated liver index (PI) and the index of the volume of fluid in the hepatic sinusoids (IOZHPS) by the formulas:

PI = (L2⋅Ad⋅Ти⋅ЧCC) / (Z2⋅S⋅1000), where

PI - hepatic index (l / min / m);

- blood volume resistance constant - 150 Ohm 150cm;

L is the interelectrode distance (cm);

Ζ - base impedance (Ohm);

Ad is the amplitude of the differential rheogram (Ohm / s);

Ti - time of expulsion of blood (s);

Heart rate - number of heart contractions (min);

S - body area (m ² );

1000 - indicator for translation in liters; IOPS = (L2) / (Z2⋅S⋅1000);

then determine the index of arterialization of the hepatic sinusoids IAPS = PI / IOPS, and with the value of IAPS equal to or less than 0.34 units, the development of liver failure in the postoperative period is predicted (see US Pat . RU No. 2357663, class A61B 5/053, publ. June 20, 2009).

The disadvantages of this method are the complexity, high cost, non-use of data of biochemical blood parameters, the genesis of the disease and data on the presence of concomitant pathology.

A known method for predicting and identifying early postoperative complications, including using the results of detailed analyzes of peripheral blood taken before surgery and at different times of the postoperative period, characterized in that the quotients are calculated from the differences in white blood counts, namely, the number of peripheral blood leukocytes, leukocyte intoxication index by I.Ya. Kalf-Kallifu, the stress index proposed by L.X. Harkavi, who divide each other, when receiving negative values of two of the three above indicators, conclude that there is a high risk of developing postoperative complications (see Pat . RU No. 2190216, class G01N 33/49, published on September 27, 2002).

The disadvantages of the method is the lack of data on biochemical blood parameters, the genesis of the disease and the presence of concomitant pathology.

A known method for predicting complications in the early postoperative period in patients with obstructive jaundice, including the study of biological environments of the body, characterized in that the biological environment is bile, samples of which are examined three times: intraoperatively and twice in the early postoperative period on the 3rd and 10th the 24th day, each sample is dried, potassium bromide is added, pressed, the IR spectrum is removed from the pressed sample and with the absorption intensity at frequencies of 1020-1040, 1350-1410 cm ^-1 , appearance or increase peak intensities relative to control parameters at frequencies of 1060-1085, 1700-1720 cm ^-1 and peak structuring at 1580, 1625, 1660 cm ^-1 predict the development of possible complications in the form of liver failure, residual choledocholithiasis or a protracted recovery period of complications (see Pat . RU No. 13080, class G01N 33/50, publ. May 15, 2003).

However, the above method has its indications, they are laborious, expensive and without taking into account the genesis of the disease.

Known work Guseva MA, Gusev K.A. "Prediction of complications in patients with obstructive jaundice of non-tumor genesis using hematological leukocyte indices." In this work, 331 cases of obstructive jaundice were analyzed, GLI was assessed: blood leukocyte shift index (LSCI), neutrophil to lymphocyte ratio index (LIS), granulocyte-granulocyte index (ILH), neutrophil to monocyte ratio index (LISM), correlation index lymphocytes and monocytes (LISM), immunoreactivity index (IRR). The reliability of the results was evaluated using t-student test. Results: complications with obstructive jaundice of non-tumor etiology occurred in 22 cases (9%), mortality was 9 cases (2.7%). The values of ISLK, ISLN, ISNM in comparison with the control group did not have significant differences. ILH, ISLM, and IRR had significant differences both in comparing the results with the control group and with each other (p <0.01). The average ILH value was 1.54 ± 0.22, ISLM - 4.38 ± 1, IIR - 4.83 ± 1.05 (see Guseva MA, Guseva K.A “Prediction of complications in patients with obstructive jaundice non-tumor genesis using hematological leukocyte indices (Bulletin of medical Internet conferences, 2014. V. 4. - No. 5. - P. 830).

This work calculates the prognosis of complications in patients with obstructive jaundice of non-tumor genesis due to the leukocyte shift index, neutrophil to lymphocyte ratio index, lymphocyte-granulocyte index, neutrophil to monocyte ratio index, lymphocyte to monocyte ratio index, and immunoreactivity index. In this work, patients with obstructive jaundice of benign origin were studied. The disadvantages of this work are the non-use of biochemical blood parameters and data on the presence of concomitant pathology.

The closest in technical essence and the achieved positive effect and accepted by the authors for the prototype is the work of Halperin E.I., Momunova O.N. "Classification of the severity of obstructive jaundice." To assess and predict postoperative results E.I. Halperin in 2012 developed a classification of obstructive jaundice, allowing assessment of the severity of the disease (Halperin E.I. Classification of severity of obstructive jaundice. Annals of surgical hepatology, 2012; 2: P. 26-34). A three-stage scoring of the total bilirubin level was performed: <60 μmol / L - 1 point, 60-200 μmol / L - 2 points, ≥200 μmol / L - 3 points, as well as the level of total serum protein: ≥65 g / L - 1 point, 64-55 g / l - 2 points, <55 g / l - 3 points. Each complication, as well as the malignancy factor (genesis of the disease), was rated 2 times higher than the bilirubin score. The classification also included complications of obstructive jaundice as signs that enhance its severity: cholangitis, renal failure, liver failure, signs of encephalopathy, gastrointestinal bleeding, sepsis. Complications of obstructive jaundice were evaluated compared to bilirubin level by a factor of 2. Addition of two or more complications doubled or proportionally increased the number of points. Sepsis is presented as 2 or more complications. With such a combination of assessment factors, patients with a score of ≤5 were included in class A (obstructive jaundice “mild”), patients in class B (moderate obstructive jaundice) with a score of 6–15, and class C with a score of> 16 . The prognosis of surgical intervention in patients with class A obstructive jaundice is favorable, class B is different, depending on the general condition of the patients and the duration of purulent or tumor intoxication. The prognosis of operations with obstructive jaundice of class C is poor (see Halperin EI, Momunova ON, “Classification of the severity of obstructive jaundice”, Surgery, 2014; 1: P. 1-9).

The disadvantage of this method is the low reliability, since data on biochemical parameters, the presence of concomitant pathology, diabetes mellitus, the age of the patient, and data on the genesis of the disease are not included.

Disclosure of invention

The objective of the invention is to develop an optimal method for predicting the course of obstructive jaundice of various origins, which includes data on biochemical parameters, the presence of concomitant pathology, diabetes mellitus, the age of the patient, and data on the genesis of the disease.

The technical result, which can be obtained using the proposed method, is reduced to a quick calculation of predicting the course of obstructive jaundice of various origins and taking into account all the necessary indicators for accurate prediction.

The technical result is achieved using a method for predicting the course of obstructive jaundice of various origins, including determining the level of blood bilirubin and total protein by a three-point assessment of the level of total bilirubin: <60 μmol / L - 1 point, 60-200 μmol / L - 2 points, ≥200 μmol / l - 3 points, the level of total serum protein: ≥65 g / l - 1 point, 64-55 g / l - 2 points, <55 g / l - 3 points, and the genesis of the disease, with the subsequent calculation of predicting the course of mechanical jaundice, while additionally introducing into the prediction calculation data on the age of the pain the presence of diabetes mellitus, concomitant pathology, while the patient’s age, the presence of diabetes mellitus and concomitant pathology are evaluated by a three-point assessment: the patient’s age from 30 to 50 years - 1 point, from 50 to 70 years - 2 points, from 70 to 90 years - 3 points, diabetes mellitus: lack of data - 1 point, compensated pathology - 2 points, decompensated pathology - 3 points, concomitant pathology: lack of data - 1 point, compensated pathology - 2 points, decompensated pathology - 3 points, disease genesis: benign patol ogia - 0.2 points, malignant pathology: Stage I - 0.4 points, Stage II - 0.6 points, Stage III - 0.8 points, Stage IV - 1 point, followed by the calculation of the prognosis of obstructive jaundice according to the formula:

PZ = ((Beals + Bel + B + SD + SP) × 0.33)) × (G × 0.2) × 100%,

Where:

- PZ - disease prognosis;

- Bil - blood bilirubin, µmol / l;

- Bel - total blood protein, µmol / l;

- In - age, years;

- diabetes - diabetes;

- SP - concomitant pathology;

- G - the genesis of the disease;

- 0.33 and 0.2 - the probability of occurrence of the aforementioned prognostic factor, respectively.

Every year the number of patients with diseases of the organs of the biliopancreatoduodenal zone, which are accompanied by the development of obstructive jaundice (Halperin, E.I. Guidelines for biliary tract surgery / E.I. Halperin, P.S. Vetshev. - M., 2009. - 568. from.). The frequency of development of obstructive jaundice, according to various authors, ranges from 12.0 to 45.2%, and for benign diseases this level varies from 4.8% to 22.5%, and for malignant lesions - from 36.6% to 47.0% (Patyutko, Yu.I. Surgery of cancer of the organs of the biliopancreatoduodenal zone / Yu.I. Patyutko, A.G. Kotelnikov. - M., 2007. - 448 s). Most often, the cause of obstructive jaundice is stones in the bile ducts (50%) and neoplasms of the ducts, large duodenal nipple, pancreas, gall bladder (40%) (Diagnosis and surgical tactics for obstructive jaundice syndrome / Yu.L. Shevchenko [et al. ] // Annals of surgical hepatology. - 2008. - No. 4. - S. 96-105). Mechanical jaundice can be caused by other causes (10%) - stenosis of the large duodenal nipple, duct stricture, atresia of the biliary tract, cholangitis, pancreatitis, liver tumors (Diagnosis and treatment of obstructive jaundice syndrome of benign origin / N.A. Maistrenko [et al. ] // Annals of surgical hepatology. - 2011. - No. 3. - S. 26-34).

The essence of the method for predicting the course of obstructive jaundice of various origins is as follows.

The level of blood bilirubin and total protein is determined by a three-point assessment of the level of total bilirubin: <60 μmol / L - 1 point, 60-200 μmol / L - 2 points, ≥200 μmol / L - 3 points, total serum protein level: ≥65 g / l - 1 point, 64-55 g / l - 2 points, <55 g / l - 3 points, and the genesis of the disease, followed by the calculation of prediction of the course of obstructive jaundice, while the patient’s age is additionally introduced into the prediction calculation, the presence of diabetes mellitus, concomitant pathology, while the age of the patient, the presence of diabetes mellitus and concomitant stalemate Urology is evaluated by a three-point assessment: the patient's age from 30 to 50 years - 1 point, from 50 to 70 years - 2 points, from 70 to 90 years - 3 points, diabetes mellitus: lack of data - 1 point, compensated pathology - 2 points, decompensated pathology - 3 points, concomitant pathology: lack of data - 1 point, compensated pathology - 2 points, decompensated pathology - 3 points, genesis of the disease: benign pathology - 0.2 points, malignant pathology: Stage I - 0.4 points, II stage - 0.6 points, stage III - 0.8 points, stage IV - 1 point, followed by Babe prognosis of obstructive jaundice by the formula:

PZ = ((Beals + Bel + B + SD + SP) × 0.33)) × (G × 0.2) × 100%,

Where:

- PZ - disease prognosis;

- Bil - blood bilirubin, µmol / l;

- Bel - total blood protein, µmol / l;

- In - age, years;

- diabetes - diabetes;

- SP - concomitant pathology;

- G - the genesis of the disease;

- 0.33 and 0.2 - the probability of occurrence of the aforementioned prognostic factor, respectively.

Brief description of drawings and other materials

Table 1 gives a method for predicting the course of obstructive jaundice of various origins, prognostic factors, scores.

In table 2, the same, the genesis of the disease, the interval between the minimum and maximum values.

In table 3, the same, forecast, values,%.

The implementation of the invention

Examples of specific implementation of the method for predicting the course of obstructive jaundice of various origins.

It was found that the following factors are statistically significant factors in the prognosis of the disease (p <0.05): patient age, presence or absence of concomitant pathology, diabetes mellitus, biochemical parameters (bilirubin and total blood protein), disease genesis (cytological or morphological study). For analysis, these factors are encoded in points (see table. 1). The probability of prognostic factors (blood bilirubin, total blood protein, patient age, data on concomitant pathology and diabetes mellitus) is 0.33 (3), because these factors have 3 (1/3) criteria. The likelihood of a prognostic factor (the genesis of the disease) is 0.2, because this factor has 5 (1/5) criteria. For ease of calculation, a simple arithmetic calculation was performed: benign pathology = 0.2 × 0.2 = 0.04 points; I stage = 0.4 × 0.2 = 0.08 points; II stage = 0.6 × 0.2 = 0.12 points; III stage = 0.8 × 0.2 = 0.16 points; IV stage = 1 × 0.2 = 0.2 points;

A prediction of the course of obstructive jaundice of various origins was carried out. The interval between the minimum and maximum values in the first part of the formula ((Beal + Bel + B + SD + SP) × 0.33) was 1.65-4.95. Next, the calculation is carried out depending on the benign or malignant nature of the disease, which is given in table. 2. The prognosis of the disease can be: favorable or good (prognosis bona), doubtful (prognosis dubia), unfavorable or poor (prognosis mala), very poor (prognosis pessima) or directly indicating the inevitability of a fatal outcome (prognosis letalis). Given this formula, the prognosis of the disease is presented in table 3 in percent.

The proposed method was developed in a retrospective assessment of clinical data, data of cytological and histological studies, as well as the results of tracking 38 patients with the presence of obstructive jaundice of benign or malignant genesis.

EXAMPLE 1. S., 53 years (2 points). Clinical diagnosis: Pancreatic cancer IV T4N × M0, obstructive jaundice. Morphological verification: adenocarcinoma (0.2 points). Upon admission to the hospital, the blood bilirubin index was 367 μmol / L (3 points), the total blood protein was 57 μmol / L (3 points). Of the concomitant pathology, the presence of arterial hypertension was noted (drug-compensated form, 2 points). There is no data for the presence of diabetes mellitus (1 point).

Substituting the data in the above formula, calculate the value of the PP.

PZ = ((3 + 3 + 1 + 2 + 2) × 0.33)) × 0.2 × 100% = 72.6%. The obtained value corresponds to an unfavorable forecast.

In a patient in a hospital, percutaneous transhepatic drainage of bile ducts is performed under ultrasound control. Use the common Seldinger technique. The study is performed on an empty stomach. 30 minutes before the transdermal transhepatic procedure, the patient is intramuscularly injected with 1.0 ml of a 2% solution of promedol and relanium, then the bile ducts are tightly filled with a contrast agent with a Chiba needle and, without removing the needle, one of the intercostal spaces is punctured one or more ribs with a long needle with a diameter of 1.5-1.7 mm, along which a wire conductor is then passed. They try to spend the end of the conductor distal to the narrowing, and only then expand the narrowing point with the bougie along it and install a drainage tube. This manipulation is completed by fixing the drainage tube to the skin and washing the bile ducts with sterile solutions (physiological saline, 0.25% novocaine solution, etc.).

After biliary drainage, the blood bilirubin index was 190 μmol / L (2 points), and the total blood protein was 61 μmol / L (3 points). Substituting the data in the above formula, we calculate the value of the PP.

PZ = ((2 + 3 + 1 + 2 + 2) × 0.33)) × 0.2 × 100% = 66%. The obtained value corresponds to an unfavorable forecast.

The patient was discharged in satisfactory condition with the presence of drainage of the bile ducts with the recommendations of symptomatic therapy and the supervision of an oncologist and therapist at the place of residence. The patient died 6 months after treatment in a hospital.

EXAMPLE 2. Patient Α., 49 years old (1 point). Clinical diagnosis: Bile duct stricture, obstructive jaundice (0.04 points). Upon admission to the hospital, the blood bilirubin index was 120 μmol / L (2 points), and the total blood protein was 66 μmol / L (1 point). From concomitant pathology, the presence of chronic pancreatitis and gastritis was noted (drug-compensated form, 2 points). There is no data for the presence of diabetes mellitus (1 point).

Substituting the data in the above formula, calculate the value of the PP.

PZ = ((1 + 2 + 1 + 2 + 1 × 0.33)) × 0.04 × 100% = 9.2%. The obtained value corresponds to a favorable forecast.

In a patient in a hospital, percutaneous transhepatic drainage of bile ducts is performed under ultrasound control. Use the common Seldinger technique. The study is performed on an empty stomach. 30 minutes before the transdermal transhepatic procedure, the patient is intramuscularly injected with 1.0 ml of a 2% solution of promedol and relanium, then the bile ducts are tightly filled with a contrast agent with a Chiba needle and, without removing the needle, one of the intercostal spaces is punctured one or more ribs with a long needle with a diameter of 1.5-1.7 mm, along which a wire conductor is then passed. They try to spend the end of the conductor distal to the narrowing, and only then expand the narrowing point with the bougie along it and install a drainage tube. This manipulation is completed by fixing the drainage tube to the skin and washing the bile ducts with sterile solutions (physiological saline, 0.25% novocaine solution, etc.).

After conducting biliary drainage, the blood bilirubin index was 88 μmol / L (2 points), and the total blood protein was 68 μmol / L (3 points). Substituting the data in the above formula, we calculate the value of the PP.

PZ = ((1 + 2 + 1 + 2 + 1 × 0.33)) × 0.04 × 100% = 9.2%. The obtained value corresponds to a favorable forecast.

The patient was discharged in satisfactory condition with the presence of drainage of the bile ducts with recommendations for appearance after 1 month to remove biliary drainage. Since hospitalization, the patient is alive 32 months to the present.

Thus, the calculations according to the above formula, which can be performed using a calculator or Microsoft Exel program, allows you to determine the value of the PZ and predict the prognosis of obstructive jaundice with high accuracy.

The invention in comparison with the prototype and other known technical solutions has the following advantages:

- fast and accurate prediction of the course of obstructive jaundice of various origins;

- accounting of all necessary indicators for accurate forecasting.

Continuation of table 1

A method for predicting the course of obstructive jaundice of various origins

Claims (11)

A method for predicting the course of obstructive jaundice of various origins, including determining the level of blood bilirubin and total protein by a three-point assessment of the level of total bilirubin: <60 μmol / L - 1 point, 60-200 μmol / L - 2 points, ≥200 μmol / L - 3 points , the level of total serum protein: ≥65 g / l - 1 point, 64-55 g / l - 2 points, <55 g / l - 3 points, and the genesis of the disease, with the subsequent calculation of predicting the course of obstructive jaundice, characterized in that additionally enter into the prediction calculation data on the age of the patient, the presence of diabetes mellitus, concomitant pathology, while the patient’s age, the presence of diabetes mellitus and concomitant pathology are assessed by a three-point assessment: the patient’s age from 30 to 50 years - 1 point, from 50 to 70 years - 2 points, from 70 to 90 years - 3 points, diabetes : lack of data - 1 point, compensated pathology - 2 points, decompensated pathology - 3 points, concomitant pathology: lack of data - 1 point, compensated pathology - 2 points, decompensated pathology - 3 points, genesis of the disease: benign pathology - 0.2 points malignant pa ologiya: I step - 0.4 points, II step - 0.6 points, III stage - 0.8 points, IV stage - 1 point, followed by calculation of the flow prediction jaundice by the formula: PZ = ((Beals + Bel + B + SD + SP) × 0.33)) × (G × 0.2) × 100%, Where: - PZ - disease prognosis; - Bil - blood bilirubin, µmol / l; - Bel - total blood protein, µmol / l; - In - age, years; - diabetes - diabetes; - SP - concomitant pathology; - G - the genesis of the disease; - 0.33 and 0.2 - the probability of occurrence of the aforementioned prognostic factor, respectively.