Method of assessment the course of acute destructive pancreatitis

 

(57) Abstract:

The invention relates to medicine, diagnosis. Explore the capillary blood flow in symmetric points Zhang-men. To do this, hold the laser Doppler flowmetry. Determine the volumetric flow, the amplitude-frequency characteristics and parameters of microcirculation. Judged by the data obtained localization process, about the nature of the pathological state of cancer and stage of disease. The method improves the accuracy of diagnosis. 4 C.p. f-crystals, 5 tab., 6 Il.

The invention relates to the topic of medicine and can be used in surgery to diagnose the condition of patients with acute pancreatitis.

Among the most pressing diseases of the abdominal cavity acute pancreatitis took 3rd place, behind only acute appendicitis and acute cholecystitis. In an 18.4 32.4% of acute pancreatitis occurs in the form of pancreatic necrosis with mortality rates of 25 to 95% according to different authors (Kadouch Y. T., 1988; Kubyshkin C. A., Skoropad C. Yu, 1989). Timely assessment of the nature of the course of acute pancreatitis, the degree of violation of the General condition of the organism and its response to therapeutic measures as moments that determine survival, an issue of great importance.

In Najer pathological process, stage of the disease.

A known method for the diagnosis of acute destructive pancreatitis (CCT) is a computed tomography (Todua F. I. Fedorov, C. D., M. Kuzin, I., 1991 ), which clearly describes the nature of the process in the pancreas and surrounding tissues. If this method does not allow to assess the degree of General reactions to the local process, and due to the large radial load and high cost it is almost not used for dynamic observation and monitoring treatment plans.

Another known method is laparoscopic study to indirectly, by the nature of the effusion in the abdominal cavity, the foci of fat necrosis in the greater omentum and the peritoneum to diagnose CCT (Sokolov, C. I.,1998 ). However, the method relates to invasive, operative pulmonary embolism can cause complications (gas embolism), does not give direct information about the state of the pancreas, is not informative for the General reactions of the body, cannot be used to monitor therapeutic measures.

Non-invasive and safe for the patient way that allows diagnosis of acute pancreatitis is ultrasonography (Zatevakhin I. I., Krylov, L. B., Galician, A., 1988). Ultracute method is the closest analogue of the invention, because it gives the greatest possible dynamic monitoring during the pathological process in the pancreas. This way in 82% of cases does not reveal the pancreas even in healthy people. To get a clear echogram difficult in obese patients and is not possible with flatulence, which often occurs when the CCT in connection with the development of dynamic obstruction. As a method of visualization, this method does not provide information about the General condition of the patient, not suitable for emergency treatment.

The proposed method for the diagnosis and evaluation of acute destructive pancreatitis allows not only to judge the presence of pathological process in the pancreas and its localization, but also to determine the General reaction of the organism, until the shock stage of the development process, immediate prognosis and treatment efficacy.

The method is based on the study of capillary blood flow using laser Doppler flowmetry. The study was conducted in a symmetric biologically active points of the Zhang-men and Hae-GU.

It is known that biologically active points, being the area offices on the surface of the skin HV the diagnosis, criterion is the detection of pain points, changes in temperature or conductivity (Y. Nakatani, 1950; S. Yanagiya, 1956; Vohralik Century A.D., 1961; Vohralik Century, Vohralik M. C., 1978; Gabaa luvsan, 1980; R. Voll, 1994). Our method is based on the study of geometrically in biologically active points using laser Doppler flowmetry.

Study of capillary blood flow (microcirculation - MC) produced by the apparatus of the LACC-01 (SPE "Lazma", Russia). Record dopplergram was carried out for 3 minutes with the patient lying on his back in the points ZHANG-MEN (the free end 1 edges) - a signal point of the Meridian of the pancreas, and HAE-GU (on the ulnar surface 2 metacarpal bone at the junction of the diaphysis of the proximal epiphysis). In acupuncture diagnosis of these points are related to the transverse colon the colon and its mesentery. However, in recent times they are used as the check-in area common reactions. Analyzed metrics: the average value of the index of microcirculation (PM), medium square deviation (RMSE), coefficient of variation (Kv), the ratio of maximum amplitudes of the cardiac and high frequencies to the maximum amplitude of the low h is B>maxCF+ AmaxHF). Amplitude-frequency analysis revealed the maximum frequency and amplitude in the range of low, high and cardiocytes and normalized indicators amplitude rhythmic components of flaccomio (Amax100%/3CKO and Amax100%/M) in all the studied frequencies. Spent breathing (DP) and postural tests (PP).

To determine the normal parameters of microcirculation at selected points held laser Doppler flowmetry in 22 healthy volunteers aged 20 to 40 years. The results obtained are presented in table 1.

When evaluating LDF-grams in healthy people showed small variance of the indicators in corporeal points Zhang - men and the absence of pronounced asymmetry of the right and left, which makes them promising not only for study of the microcirculation, but also offers the potential to determine the lateralization of the pathological process.

The results of the study were processed using the computer program LDF 1.18 and recorded in the form of laser dopplerography (LDFG) and histograms (LDF YY) is the result of frequency analysis. In Fig. 1 presents LDFG and LDF YY healthy person. Education is so The emergence of the BIENNIUM respiratory waves and high cardiovas indicates the inclusion of compensatory mechanisms in the process of moving blood through the capillaries.

Observing patients with pancreatogenic shock and given that the shock is profound depression of the circulation, and, primarily, at the microcirculatory level, have given this place a failure of the primary functions of the microcirculation - transcapillary exchange of identified violations we have qualified as microcirculatory insufficiency (NMC). Exploring the MC by LDF and analyzed more than 1.5 thousand LDF-grams and LDF GG patients with acute destructive pancreatitis, we identified 4 types of NMS. The basis for the selection of these options is based on the following criteria:

1. PM is the most important integral indicator.

2. Registration for the BIENNIUM high S-wave, which indicates the increase of the volumetric blood flow velocity in capillaries with increasing pulse pressure in the arterial system.

3. Registration for the BIENNIUM high H-wave, indicating that the increase volumetric blood flow velocity on the inhale.

option 1 is characterised by a marked increase in the amplitude of cardiocytes: LDF YY appear high S-wave, the frequency of which coincides with the my region and may be different. In acute destructive pancreatitis this variant was recorded after edema syndromes critical state, often at the stage of purulent-septic complications. In Fig. 2 presents typical option 1 LDFG and LDF YY.

option 2 was characterized by the absence of detectable cardiocerebral, the appearance of high-amplitude N-waves and increased PM. When destructive pancreatitis this option MC was revealed when giperdinamicheskim stage pancreatogenic shock. High lability patterns of slow oscillations with the appearance of abnormal rhythms (X-wave) completed the picture complete disruption of geometrically in these cases (Fig. 3).

option 3 was characterized by a low rate MC; LDF YEARS recorded the highest N-waves and the absence of S-waves (Fig.4)

This option LDF YEARS required for their interpretation of the clinical associations, as met with a favorable current, then the outcome of the disease he was born With a wave. In other cases during follow-up there was a further decrease in microcirculation and amplitude of all frequency bands of the LDF YEARS with episodes 4 options MC.

4 variant was characterized by very low neterminalna state (Fig.5).

Comparison 4 presents options violations MC with the processes in the pathological focus (based on ultrasound, laparoscopy, CT) and disease (critical condition favorable for the recovery or critical state - exitus) has allowed us to develop an algorithm for estimating medical center for diagnosis and evaluation of acute destructive pancreatitis.

The determination of the degree of NMS, in the preceding algorithm for diagnosis of disorders MC spectral analysis LDF GG and analysis of functional tests, promotes rapid and clear orientation in the studied material.

In 48 patients with CCT explored the microcirculation in the background standard treatment in 3, 5, 7 day of the disease, at the end of the second and third weeks, and before discharge from hospital. Reviewed Protocol data LDFG and LDF). The results obtained by the methods of mathematical statistics (correlation analysis) were compared with data characterizing the nature of the pathological process in the pancreas and surrounding tissues in CT, laparoscopy, ultrasound echography (presence of degradation; localization process, foci of purulent fusion; the development of fibrotic changes). Learn what she nonspecific adaptive reactions (ONAR), signs of renal, respiratory failure, symptoms of coma.

The results of the correlation analysis revealed a high-level coefficients (to 0.75) indicators LDF at the point of Zhang-men with the characteristics of the pathological process in the seat of the disease.

Comparison of the figures in the left and right points of the Zhang-men credibly testified about the lateralization process. So in destructive process in the head of the pancreas, retroperitoneal infiltration of fiber in the course of the duodenum, the involvement of the round ligament of the liver, the effusion in the right lateral channel indicators in the right spot Zhang-men exceeded those in the left point. In the localization process in the body and tail and the adjacent peripancreatic tissue, inflammatory changes in the mesentery of the left half of the transverse colon and left lateral channel indicators in the left point of the Zhang-men were significantly higher than in the right. To a greater extent this tendency was observed in relation to indicator Amax100%/M in all frequency ranges.

Mid-level correlation (coefficients of 0.43 and 0.68) was found between the level ONE, the severity of organ failure and b is I the above indicators point Zhang-men characterized by the pathological process in the pancreas, comparison LDF-grams in the right and left points of the Zhang-men allows to judge about the localization process. Capillary blood flow at the point Hae-GU reflects MC-processes at the system level.

In tables 1, 2 and 3 presents the results of the LDF, which will give an idea about the dynamics of the MC on different stages of the disease: M - integral index, AmaxCF/AmaxLFand AmaxHF/AmaxLFallow us to provide snow is cardiac and respiratory mechanisms in the promotion of blood through the capillaries;max100/M in all frequency ranges required for the amplitude analysis, and the results of DP and PP for the assessment of Central and peripheral level of sympathetic innervation. The analysis of the presented data were correlated with the period of the disease.

3 the day. CT, laparoscopy and ultrasound reliably diagnosed destructive process in the pancreas. The General state of moderate severity. Laser Doppler flowmetry at the point Hae-GU noted the decrease in microcirculation (M), accompanied by a decrease in the amplitude of oscillations in the range of slow frequencies (Amaxa100%/M, AmaxLF100%/M), a slight turning of the heart and respiratory compensatory mechanisms (AmaxCF/AmaxLFabout impact (EI) and the weakening of local vasoconstrictor mechanism (PP). On the organ level - a significant increase microcirculation involved both compensatory mechanism with the prevalence of respiratory (AmaxCF/AmaxLFTHAT IS , AmaxHF/AmaxLF, Amax/M : , LF, HF, CF). Thus, at the organ level to be signs of an inflammatory reaction with amplification and active, and compensatory mechanisms of MC - NMCZhang-menoption 2, on the periphery of the reduction of capillary blood flow due to high influence of the Central sympathetic innervation, with moderate inclusion of compensatory mechanisms - NMCHae-GU1 or 3 option. Comparison of peripheral and organ MC indicates the centralization of blood circulation as response to destabilizing factor (destructive process - the initial signs of pancreatogenic shock.

5 day. Critical condition with manifestations of pancreatogenic shock and coma (according to the monitoring of the main physiological parameters in the conditions of reanimation). In the study of the microcirculation was observed loss of Central and peripheral level of sympathetic regulation (DP, PP - perverted - 172% from baseline), dehiscence of all vessels (MZhang-men, MHae-GUand signs of dominance UB>maxCF/AmaxLF- N, AmaxCF100%/M - N). Promotion of blood through the capillaries, both at the organ level, and the periphery is mainly due to respiratory mechanism (AmaxHF/AmaxLF, AmaxHF100%/M, AmaxHF100%/SCO. Violations at the organ level is worse compared to the third day. At the point the he-GU - NMCHae-GUoption 2, at the point of Zhang-men - NMCZhang-menoption 2. The overall picture MC corresponds giperdinamicheskim stage of septic shock.

7 day. The General state of moderate severity, systemic hemodynamics stable, comatose symptoms cropped. In the study of microcirculation in point Zhang-men - essentially unchanged - NMCZhang-menoption 2; system MC is restored (PMHae-GU- N), also restored Central sympathetic regulation (PD - N). In the mechanisms of capillary blood flow at the organism level remains reduced the value of active mechanisms of MC (Amaxa100%/M, AmaxLF100%/M), the contribution of increased respiratory mechanism (AmaxHF/AmaxLFand significantly increases the value of the pulse wave (AmaxCF/AmaxLF) - SRCHae-GU1 or 2 option. The reduction of active mechanisms of capillary blood flow, as well as Knymi neuromuscular structures on the background of endotoxemia.

The next 2-3 weeks of the disease occurred at the background of compensated system MC and was characterized by the development of suppurative complications (clinical picture, data, ultrasound, CT). The study of microcirculation in point Hae-GU revealed normal levels of PM, analysis of the LDF GG showed the predominant importance of the cardiac mechanism in the implementation of capillary blood flow, Nmthe-GU 1 option. At the point of Zhang-men noted a moderate participation in MC both compensatory mechanisms with a gradual decrease in the contribution of respiratory and increase the contribution of cardiac (at 2 weeks, AmaxCF/AmaxLF, AmaxCF100%/M , AmaxHF/AmaxLF, AmaxHF100%/M ; on week 3 ANDmaxCF/AmaxLF, AmaxCF100% , AmaxHF/AmaxLF, AmaxHF100%/M) - SRCZhang-men2 or 3 option. Central sympathetic influence 2 times higher than normal, peripheral neuro-regulatory mechanism is not functioning (PP - 423,563,7%). The PM increase reflected the levels of inflammatory reactions in the pathological focus, reduction PM testified to the development of the process of fibrosis and prognostically was more favorable sign.

Analyzing the data LDF research with clinical recovery (statement Islami reduced PM that was a measure of disease outcome in fibrosis and complied with ultrasound - NMCZhang-menoption 3. Systemic disturbance MC manifested by decreased functionality of microvascular neuromuscular apparatus (Amaxa100%/M, AmaxLF100%/M, PP - 257,66,4%), which in some cases was offset by the increase in the values of the cardiac contribution to the mechanism of MC (AmaxCF/AmaxLF) - SRCSe-Se1 or 0 option.

The proposed method can also be applied to evaluate the response to therapy. In Fig. 6 presents hour drift LDF YY when infusion gemodeza. The disappearance of the background transfusion gemodeza H-wave and the appearance of S-waves, i.e. the SMC transition from option 2 to option 1 indicates a positive response to ongoing medical event.

Thus, the proposed method of assessment the course of acute destructive pancreatitis allows dynamic monitoring during the pathological process in the pancreas, to assess the reaction of the body up to identify manifestations of shock, in some cases to predict the course and outcome of the disease. The method can be used for emergency remedy selection and correction is waiting for data analysis imaging wherein investigate capillary blood flow in symmetric points Zhang-men by the laser Doppler flowmetry (LDF) with the definition of volumetric blood flow, amplitude-frequency indicators and options microcirculatory failure, they will judge the localization process, the nature of the pathological state of cancer and stage of disease.

2. The method according to p. 1, characterized in that it further examine the capillary blood flow in symmetric points Hae-GU and the severity of its changes assess the overall reaction to the disease.

3. The method according to PP.1 and 2, characterized in that diagnose pancreatic shock.

4. The method according to p. 1, characterized in that in the localization process in the head of the pancreas, retroperitoneal infiltration of fiber in the course of the duodenum, the involvement of the round ligament of the liver, the effusion in the right lateral channel indicators in the right spot Zhang-men exceed those in the left point.

5. The method according to p. 1, characterized in that in the localization process in the body and tail of the pancreas and adjacent peripancreatic tissue, inflammatory changes in the mesentery Levasseur those in the right spot.

 

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