The method of treatment of violations of the enterohepatic circulation of bile in patients with external drainage of the bile ducts

 

(57) Abstract:

The invention relates to medicine, to surgery, to methods for treating disorders enterohepatic circulation of bile in patients with external drainage of the bile ducts. Administered drugs chenodesoxycholic acid in the dose of 10 mg/kg per day, starting from the third day after dewatering, during the whole period of decompression. This invention facilitates rapid and complete recovery of violations of the enterohepatic circulation of bile after decompression.

The invention relates to medicine, namely surgery.

Treatment of patients with mechanical jaundice is the actual problem in surgery of the biliary tract. Generally accepted is the use of endoscopic decompression of the biliary tract as a method of temporary or permanent correction of violations of biliar flow-out. While the obvious advantage have different ways of internal or external-internal drainage of the biliary tract, as they contribute to the full or partial restoration of the natural passage of bile. In some cases it is necessary to use various forms of outdoor diversion of bile to reduce provenivano provided long-term existence leads to an increase in energy costs hepatic synthesis of bile acids and profound disturbances of homeostasis due to violations of the enterohepatic circulation of bile.

Known way to restore recepter by collecting and extracorporeal purification of native bile (,And. Godovikov, L. A. igolkina, I. N. Klimovich. Theoretical background, rationale and factual information on the use of holesale in the treatment of hepatic failure in patients with mechanical jaundice// New technologies in surgical Hepatology: Mater. the third conference of surgeons-hepatologists. -SPb., 1995. -S. 416-417) and then return it to the patient.

The prototype disadvantages: this method is poorly tolerated and is traumatic enough, in addition, in vitro clearance of bile, along with toxins, removes a significant amount of bile acids, impaired enterohepatic circulation which causes mainly clinical and laboratory manifestations of biliary insufficiency.

The invention is directed to solution of the task: improve portability of patient procedures, improving efficiency and reducing the complexity of the method.

This is accomplished by oral administration of drugs chenodesoxycholic acid (for example, hinosan, generalk, Henkel) at a dose of 10-30 mg/kg depending on the amount of loss of bile DV the persons as follows: the patient, which made external drainage of the bile ducts, give oral drugs chenodesoxycholic acid at a dose of 10-30 mg/kg depending on the amount of loss of bile 2 times daily, starting 3 days after drainage during the entire period of the external decompression.

Examples of specific applications

Example No. 1. Patient S., 62, N history 10213.

Diagnosis: Tumor of the pancreatic head T4N1M0, subhepatic abscess, secondary biliary hepatitis, obstructive jaundice, renal failure, stage of subcompensation.

Hospitalized with complaints of weakness, fever to 38.0oWith, skin itching, jaundice. Ill for 14 days. 4 months ago operated on an emergency basis for acute gangrenous cholecystitis, generalized biliary peritonitis. When entering a state of moderate severity, the skin is intensely jaundiced. Bilirubin figure of € 256.4 µmol/L. ultrasound: liver large size, choledoch to 14 mm, the calculus does not contain, the pancreas is not increased. ERCP - choledoch up to 16 mm, abruptly narrowed in intrapancreatic part, concrements are not. Data for the volume process in the pancreatic head. Made endoscopies is irubin 327,9 µmol/l, temperature 39,3oC, leukocytosis 18,6109/L. Surgery for a life-saving emergency procedure. Operations found that there is a subhepatic abscess, formed as a result of leakage of bile from the bandaged during cholecystectomy stump of the cystic duct. Elements hepatoduodenal ligaments are not differentiated. In the region of the pancreatic head is defined by a dense formation up to 5.0 cm in diameter. Produced by the opening of the abscess, external drainage of the choledochus through the stump of the cystic duct, drainage of the abdominal cavity.

Bacteriological examination of the bile has identified E. coli 10 CFU/ml of bile. Bactericidal activity of bile - 2,27%, the level of bile acids - 10.2 g/l

When conducting research on the 3rd day after decompression found bacteriology - E. coli (109CFU/ml), Citrobacter (105CFU/ml) and Str. faecalis (105CFU/ml). Bactericidal activity of bile was 1.94%, the concentration of bile acids - 6,84 g/L.

When fistulas cholangiography receipt of contrast medium into the duodenum no, the daily loss of bile 500-850 ml.

Patient assigned generalk 30 mg/kg 2 times per day 3 days after decompression of the biliary tract. Motility Kish is hurt) received the growth of E. coli (103CFU/ml), bactericidal activity of bile - 7,38%, the level of bile acids - 12.3 g/l

Example No. 2. Patient N., 86, N history 10019.

Diagnosis: JCB, chronic calculous cholecystitis, choledocholithiasis, suppurative cholangitis, obstructive jaundice, secondary biliary hepatitis, liver failure, stage of subcompensation. Parapatrically diverticulum of the duodenum. Generalized atherosclerosis. Postinfarction koronarokardioskleroze. Hemiparesis on the left. Bronchial asthma, hormone-dependent exacerbation of N 3.

Hospitalized on an emergency basis with complaints of jaundice, itching, shortness of breath. A serious condition due to severe manifestations of pulmonary-cardiac insufficiency. Bilirubin 126,0 µmol/L.

Ultrasound: the Gallbladder is enlarged, it lazerous concrements from 5 to 15 mm. Choledoch 15 mm, it is determined by education, giving hyperechoic shadow. Conclusion: JCB, calculous cholecystitis, choledocholithiasis.

ERCP was unsuccessful due to the presence parameterising diverticulum of duodenum. During the 4 days were held conservative therapy. In the dynamics of the noted increase in bilirubin level to 205,8 µmol/l increase t monografias.com control, stood out to 150 ml of dark bile with flakes of fibrin, small concretions pigment type.

Bacteriological examination of bile detected growth Klebsiellaellae pneum (109CFU/ml) and B. Fragilis (107CFU/ml). The level of bile acids 9.3 g/l, the bactericidal activity of bile 2,31%. If fistulography found stones in the gall bladder and choledocho, WPC kontrastnoe substance is quite low. Daily loss of bile in the period of hospital stay from 350,0 to 600,0 ml.

Patient assigned hinosan 20 mg/kg 2 times per day and 3 days after cholecystostomy. The level of bilirubin in the serum normalized on the 7th day, the motility of the bowel has recovered fully on the 4th day. At the time of discharge (the 12th day after decompression) bactericidal activity of bile - 9,04%, the level of bile acids - 16.3 g/l, the growth of microflora in the bile is not received.

From surgical treatment decided to abstain due to severe comorbidity, distinct positive dynamics of the disease and a good adaptation of the patient to cholecystostomy.

Example No. 3. Patient D., 69, N history 11204.

Diagnosis: JCB, acute flegmonoznih calculous cholecystitis, cicatricial stenosis CD 3 Steinway in an emergency order in 2 days from the occurrence of abdominal pain. A state of moderate severity in the right upper quadrant is palpated infiltration. Bilirubin 96,4-72,2-24,2 µmol/L. ERCP Performed, which detected cicatricial stenosis CD 3 degrees. Performed endoscopic papillotomy. In the dynamics of the condition has improved, bilirubin decreased to 32.7 μmol/L. According to the ultrasonic thickened gallbladder wall, it defines multiple concretions from 0.5 to 1.0 cm in diameter. Operated in a delayed manner. During the operation revealed dense infiltration in the subhepatic space, selecting the gallbladder occurred intersection of the choledochus 0.3 cm below the bifurcation. Performed cholecystectomy, hepaticojejunostomy for Ru on transretinoic drains. In the study of ductal bile during the operation, the resulting growth Str. faecalis (104CFU/ml), bactericidal activity - 3.21% of the level of bile acids - 7.5 g/l

Postoperative period was heavily in connection with the development of liver failure and bilateral pneumonia. Conducted a comprehensive detoxification, antibacterial therapy. The amount of bile, separated by drainage for the day - 150,0-300,0 ml.

With 3 days after surgery the patient is assigned hinosan 10 mg/kg per day. Motility of cichecki the period of growth of the microflora is not detected, bactericidal activity - 9,65%, the level of bile acids - 14.9 g/L. Drains recompressed on the 12th day. Discharged 18 days after surgery.

The method of treatment of violations of the enterohepatic circulation of bile in patients with external drainage of the bile ducts by means of filling in bile, characterized in that it is injected drugs chenodesoxycholic acid in the dose of 10 mg/kg per day, starting 3 days after drainage, during the whole period of decompression.

 

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The invention relates to salts of compounds of formula (I) in the case where these compounds contain aminopentyl, in particular with hydrochloric acid, Hydrobromic acid, nitric, sulfuric, phosphoric, acetic, formic, propionic, benzoic, maleic, fumaric, succinic, tartaric, citric, oxalic, Glyoxylic, aspartic acids, alkanesulfonyl, such as methane - and ethane-sulfonic acids, arylsulfonate, such as benzene and paratroop-sulfonic acids, and arylcarbamoyl acids, and, when the compounds of formula (I) contain an acid function, the salts of alkali, alkaline earth metals and ammonium, optionally substituted
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