RU2762491C1 - Method for early diagnosis of acute destructive cholecystitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely surgery, and can be used to diagnose destructive forms of acute calculous cholecystitis. Determination of the concentration of immunoglobulins in the blood serum is carried out: IgG, IgA, IgM, calculation of total immunoglobulin by the sum of the concentrations of IgG, IgA, IgM is carried out. When the value of total immunoglobulin is more than 450 IU/ml, destructive forms of acute calculous cholecystitis are diagnosed, and when the value of total immunoglobulin is from 0 to 450 IU/ml, non-destructive.

EFFECT: method makes it possible to diagnose destructive forms of acute calculous cholecystitis by determining the concentration of IgG, IgA, IgM in the blood serum, which makes it possible to determine the development of acute cholecystitis at an early stage of the disease and timely choose the most rational treatment tactics.

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Description

The invention relates to clinical medicine, namely to surgery, and can be used to diagnose destructive forms of acute calculous cholecystitis, based on indicators of humoral immunity.

Cholelithiasis is the cause of serious complications leading to serious consequences, as well as death. One of the dangerous complications of cholelithiasis is acute calculous cholecystitis, which can be complicated by the destruction of the gallbladder, the development of peritonitis, abscesses, obstructive jaundice, etc. In this regard, the search for new diagnostic criteria for the timely diagnosis of acute destructive cholecystitis remains relevant. At the same time, the lack of effective methods for the early diagnosis of destructive forms of acute cholecystitis leads to tactical errors and the development of severe complications (Shchegolev A.A. . I. Pirogov ". - M .: RNIMU, 2015. - 35 p. ISBN 5-38784-122-8).

Currently, mortality in acute cholecystitis reaches 7-10%. Conservative and surgical treatment of cholelithiasis / Yu.S. Vinnik, E.V. Serova, R.I. Andreev [et al.] // Fundamental research. - 2013. - No. 9-5. - S.954-957).

A known method for the differential diagnosis of destructive changes in acute cholecystitis (Pat. 2170935 Russian Federation, IPC ⁷ G01N 33/66; G01N 33/70. Method for differential diagnosis of destructive changes in acute cholecystitis / Gribanov G.A. et al.; Applicant and patent holder State educational institution of higher professional education "Tver State Medical Academy" (GOU VPO TGMA Roszdrav) - No. 2000109607/14; application. 14.04.00; publ. 20.07.01. - 6 p.). The method is based on the determination of changes in the autolytic process of the following biochemical parameters in the blood serum: glucose, total protein and fractions, seromucoids, thymol test, urea, creatinine, uric acid, cholesterol, triglycerides, β-lipoproteins and a number of enzymes: aspartate aminotransferase, alanine aminotransferase, alkaline aminotransferase phosphatase, lactate dehydrogenase and its thermostable subunit, α-amylase γ-glutamate transferase and cholinesterase. The disadvantage of this method is the complexity due to the large number of diagnostic parameters.

A known method for the diagnosis of destructive cholecystitis (Pat. 2423706 C1 Russian Federation, IPC ⁷ G01N 33/53. Method for the diagnosis of acute cholecystitis / Kchibekov E.A. et al .; applicant and patent holder State educational institution of higher professional education "Astrakhan State Medical Academy of the Federal Agency on health care and social development "(GOU VPO AGMA Roszdrav) - No. 2009145842/15; filed. 10/12/09; publ. 10/07/11). To implement the method, the level of lactoferrin in the blood serum is examined, the rank point is determined, while the values of lactoferrin in the serum from 200 are taken as 1 point, respectively, the level of lactoferrin in the serum is below 8 points allows one to judge about a non-destructive form, with a level of lactoferrin from 8 to 10 points are judged about the catarrhal form, and at a level above 10 points about destructive cholecystitis. EFFECT: use of the invention improves the accuracy of diagnostics of destruction of gallbladder tissue in acute cholecystitis. However, the application of this method is limited due to the inaccessibility of this method and equipment for a general medical network.

The closest in technical essence is the patent - (Pat. 2395085 C1 Russian Federation, IPC ⁷ G01N 33/48. Method for differential diagnosis of acute pancreatitis and acute cholecystitis / Zurnadzhiants V.A. et al .; applicant and patentee State educational institution of higher professional education "Astrakhan State Medical Academy of the Federal Agency for Healthcare and Social Development" (GOU VPO AGMA Roszdrav) - No. 2009114201/15; app. 09.04.09; publ. 20.07.10), which is taken as a prototype. This method is based on the study of serum a-macroglobulin with the determination of points for each nosology. The α-macroglobulin value of 200 mg / l is taken as 1 point, respectively, the level up to 800 mg / l is taken as 4 points - indicates acute pancreatitis, and if the α-macroglobulin level is above 800 mg / l, acute cholecystitis is assumed. The disadvantage of this method is that it is informative for the differential diagnosis of acute cholecystitis and acute pancreatitis and is not accurate enough for the early diagnosis of acute destructive cholecystitis.

To diagnose destructive forms of acute cholecystitis, the concentration of immunoglobulins A, G, M (IgG, IgA, IgM) is determined in the blood serum; calculate the total immunoglobulin (Σ _{IgA, IgG, IgM} ) according to the formula Σ _{IgA, IgG, IgM} = IgG + IgA + IgM and if the value of Σ _{IgA, IgG, IgM is} above 450 IU / ml, a destructive form of acute calculous cholecystitis is diagnosed, and if value 0 to 450 IU / ml - non-destructive cholecystitis.

The method is carried out as follows.

Determinations of IgA, IgG, IgM were carried out by Lorey immunoelectrophoresis using a set of reagents "Monospecific diagnostic sera against IgG (H + L), IgA (H), Ig M (H) human, dry".

When a patient is admitted to the hospital with suspected acute cholecystitis, the concentration of immunoglobulins in the blood serum was determined by Lorey immunoelectrophoresis using a set of reagents "Monospecific diagnostic sera against IgG (H + L), IgA (H), Ig M (H) human, dry ". Then the total immunoglobulin (Σ _{IgA, IgG, IgM} ) was calculated. Σ _{IgA, IgG, IgM} = IgG + IgA + IgM. If the value of Σ _{IgA, IgG, IgM is} more than 450 IU / ml, a destructive form of acute calculous cholecystitis was diagnosed, with a value of Σ _{IgA, IgG, IgM} from 0 to 450 IU / ml, acute cholecystitis without signs of destruction.

Examples of specific implementation.

Example 1. A 56-year-old patient was admitted on an emergency basis with severe pain syndrome. Preliminary diagnosis: Acute cholecystitis? Conclusion of ultrasound: the gallbladder is enlarged in size up to 34 cm ³ , the wall is 6 mm, there are many calculi in the lumen, fluid is not detected in the abdominal cavity. OAK: leukocytes - 12.9 × 109, n-10, s-65, m-13, l-12. The patient took blood for an immunological study (IgG, IgA, IgM). According to the results of the study, IgG - 112 IU / ml, IgA - 176 IU / ml, IgM - 128 IU / ml. Σ _{IgA, IgG, IgM} = 416 IU / ml. Diagnosed with acute catarrhal cholecystitis. Given the absence, according to our data, of signs of destruction, multicomponent conservative therapy was prescribed. By the 4th day, the gallbladder decreased in size by palpation, the pain syndrome was completely arrested. By the 7th day, there is a positive trend. Body temperature returned to normal. Ultrasound control on day 7: the gallbladder is 15 cm ³ , the wall is 3 mm, there are many calculi in the lumen, there is no fluid in the abdominal cavity. Laboratory indicators are normal. Discharged on the 8th day with recovery.

Example 2. Patient 46 years old. Preliminary diagnosis: acute cholecystitis. On admission, an ultrasound scan was performed: the gallbladder was enlarged up to 53 cm, the wall was 9 mm, there were a lot of calculi in the lumen, and no fluid was detected in the abdominal cavity. OAK: leukocytes - 9.5 × 10 ⁹ , n-13, s-62, m-10, l-15. The patient took blood for an immunological study (IgG, IgA, IgM). According to the results of the study, IgG - 198 IU / ml, IgA - 176 IU / ml, IgM - 195 IU / ml. Σ _{IgA, IgG, IgM} = 569 IU / ml. Diagnosed with acute destructive cholecystitis. Based on the diagnosis, an active surgical tactic was undertaken - laparoscopic cholecystectomy and drainage of the abdominal cavity were performed. Intraoperatively: the gallbladder is enlarged in size up to 40 cm ³ , tense, the serous membrane is dull with many foci of black-brown necrosis. In the postoperative period, multicomponent conservative therapy was carried out. By the 6th day, there is a positive trend. Body temperature returned to normal. Laboratory indicators are normal. Discharged on the 7th day with recovery. The histological conclusion: “The gallbladder is open, 6 × 3 × 4 cm, the serous membrane is gray, cyanotic with scraps of adhesions, in the area of the wall bed up to 0.9 cm in size, the mucous membrane is ulcerated, atrophic. In the lumen there are calculi up to 1 cm. Micro: the mucous membrane of the gallbladder is atrophic in places and covered with a single-layer columnar epithelium with focal hemorrhages, against the background of active venous hyperemia, focal lymphoid infiltration. Proliferation of the mucous membrane with the formation of a papillomatous structure is noted. The lamina propria is infiltrated with lymphocytes, with the formation of lymphoid follicles and segmented leukocytes, hypertrophy of the muscle layer, Lyushka's passages partially penetrate into the muscular membrane with unevenly expressed fibrosis of all layers, fragmentation of the muscle layer, small-caliber connective tissue layers. Sclerosis of the serous membrane with the presence of connective tissue adhesions. Diagnosis: Acute gangrenous cholecystitis.

Example 3. Patient 72 years old. Preliminary diagnosis: acute cholecystitis. On admission, an ultrasound scan was performed: the gallbladder was enlarged up to 49 cm, the wall was 12 mm layered, there were a lot of calculi in the lumen, and no fluid was detected in the abdominal cavity. OAK: leukocytes - 8.4 × 10 ⁹ , n-16, s-59, m-10, l-15. The patient took blood for immunological

research (IgG, IgA, IgM). According to the results of the study, IgG - 230 IU / ml, IgA - 164 IU / ml, IgM - 178 IU / ml. Σ _{IgA, IgG, IgM} = 572 IU / ml.

Diagnosed with Acute destructive cholecystitis. An urgent operation has been proposed. Despite repeated explanations, the patient categorically refused surgery. Conservative therapy was continued. On the 4th day from the moment of admission, the patient's condition worsened, symptoms of intoxication, abdominal pain increased, signs of peritonitis appeared (muscle tension, symptoms of peritoneal irritation). In peripheral blood, leukocytosis with a shift of the formula to the left. For health reasons, laparotomy, cholecystectomy, drainage of the abdominal cavity was performed. Intraoperatively: there is a moderate amount of bile in the abdominal cavity, the gallbladder is enlarged up to 67 cm ³ , tense, the serous membrane is dull with many foci of black-brown necrosis and perforation in the neck area. In the postoperative period, multicomponent conservative therapy was carried out. By the 11th day, there is a positive trend. Body temperature returned to normal. Laboratory indicators are normal. Discharged on the 12th day with recovery. The histological conclusion: “The gallbladder was opened, 9 × 3 × 3 cm, the serous membrane is gray, cyanotic with scraps of adhesions, in the area of the wall bed up to 0.8 cm in size, the mucous membrane is ulcerated with perforation in the cervical region, atrophic appearance. In the lumen there are calculi up to 2 cm. Micro: the mucous membrane of the gallbladder is atrophic in places and covered with a single-layer columnar epithelium with focal hemorrhages, against the background of active venous hyperemia, focal lymphoid infiltration. Proliferation of the mucous membrane with the formation of a papillomatous structure is noted. The lamina propria is infiltrated with lymphocytes, with the formation of lymphoid follicles and segmented leukocytes, hypertrophy of the muscle layer, Lyushka's passages partially penetrate into the muscular membrane with unevenly expressed fibrosis of all layers, fragmentation of the muscle layer, small-caliber connective tissue layers. Sclerosis of the serous membrane with the presence of connective tissue adhesions. Diagnosis: Acute gangrenous cholecystitis.

Example 4. A 89-year-old patient was admitted on an emergency basis with severe pain syndrome. Preliminary diagnosis: Cholelithiasis. Acute cholecystitis? The conclusion of the ultrasound: the gallbladder is enlarged in size up to 36 cm ³ , the wall is 8 mm layered with fluid inclusions, there are many calculi in the lumen, the fluid is not detected in the abdominal cavity. OAK: leukocytes - 18.5 × 10 ⁹ , n-8, s-62, m-15, l-15. The patient took blood for immunological examination (IgG, IgA, IgM). According to the results of the study, IgG - 110 IU / ml, IgA - 126 IU / ml, IgM - 115 IU / ml. As a result of counting Σ _{IgA, IgG, IgM} = 351 IU / ml. Diagnosed with acute catarrhal cholecystitis. Taking into account the ultrasound data, where there are pronounced destructive changes, the patient undergoes diagnostic laparoscopy under local anesthesia. Intraoperatively: there is no effusion in the abdominal cavity, the gallbladder is enlarged up to 30 cm ³ , tense, the serous membrane is shiny with a minor vascular injection. Intraoperatively diagnosed with Acute catarrhal cholecystitis. Considering the age, it was decided to continue the multicomponent conservative therapy. By the 10th day, there is a positive trend. Body temperature returned to normal. Laboratory indicators are normal. Discharged on the 11th day with recovery. This method has been tested on 90 patients and the sensitivity of the method is 97.7%, and the specificity is 98.9%.

Claims (1)

A method for diagnosing destructive forms of acute calculous cholecystitis, including determining the concentration of immunoglobulins in the blood serum: IgG, IgA, IgM, calculating the total immunoglobulin by the sum of the concentrations of IgG, IgA, IgM, and if the total immunoglobulin value is more than 450 IU / ml, destructive forms of acute calculous cholecystitis are diagnosed , and with a value of total immunoglobulin from 0 to 450 IU / ml - not destructive.