Method for the diagnosis of dysfunction of the autonomic nervous system in children with pathology of the upper parts of the gastrointestinal tract

 

The invention relates to medicine, in particular functional diagnostics. In children with pathology of the upper parts of the gastrointestinal tract at the same time carry out the daily check of the pH in the esophagus and stomach ECG. Analyze the time and SpectraLine indicators of heart rate in groups with gastroesophageal reflux (GER) and without GER. The ratio of the analyzed indicators reveal vegetative disfuncio on sympathicotonia or vacatoncustom type. The method allows to diagnose the type of autonomic dysfunction in the early stage of the disease. table 2.

The invention relates to medicine, namely to a gastroenterologist.

The prevalence of gastro-intestinal tract (GIT) is more than 100 per 1,000 child population. Among the diseases of the digestive system a significant share of acid disease and illness developed as a result of motor-evacuation disorders. The relevance of studying this problem is associated with a high incidence of this pathology, and the presence of recurring exacerbations, complications, sometimes severe course of the disease.

The clinic is very often seen societyy another, formed a vicious circle of chronic diseases. It is therefore important to identify and normalize autonomic dysfunction in the pathology of the digestive tract. Without this, the doctor will be hard to achieve success in the treatment of diseases of the digestive system.

As a counterpart of the proposed method, the authors propose a method for recording the electrocardiogram (ECG) during the day, so-called Holter monitoring (HM), using the "Cartotecnica-4000" assessment of heart rate variability (HRV) ("Assessment of heart rate variability during HMM", "Bulletin of Arrhythmology", 11, 1999, S. 52-78).

The analysis of HRV is an important method for assessing the functional state of the ANS. He uses various indicators temporary (SDNN, SDAN, rMSSD, pNN50, and others ) and spectral analysis (ULF, LF, HF, LF/HF, and others). These indicators are automatically calculated by a computer program "Cartotecnica-4000" for the entire period of the survey and for short randomly selected time periods, which are marked on the trend curves as periods. In the literature are the tables with the developed standards for the above mentioned indicators for the 24-hour and 5-minute intervals calculation. (L. M. Makarov. Holter monitorirovaniya as in the changes of indexes of temporal analysis, and in changing the ratios of the capacities of different parts of the spectrum. The weakening of the parasympathetic leads to reduced HF power, increase in LF power, the increase of the ratio LF/HF. It is known that in healthy young people parasympathetic influence on the heart rate are at a high level.

The disadvantage of this method is equivalent, according to the authors, is the need for re-examination for the diagnosis of autonomic dysfunction in patients in whom a significant portion of the trend curves are unsuitable for analysis due to the presence of artifacts. The share of daily monitoring ECG with trend curves, unsuitable for qualitative analysis, is, according to different authors, up to 30% of the total number of studies. The occurrence of artifacts when conducting HMM caused by movements of the person in the course of his life, violating the close contact of the electrodes with the skin and leading to entry into the registering device does not have sufficient quality of an electrical signal. Indicators of HRV, circadian index or not calculated by the program at all, or are calculated with large errors, which can lead to incorrect assessment Unsane, described in the article by A. Yu shishlova and M. A. Dymshits "Simultaneous pH and ECG monitoring in gastroesophageal reflux disease and coronary heart disease". (The book "Actual problems of internal medicine and pedagogy". M.: Russian physician, 2000, S. 132-136). Adult patients with complaints stenocarditiceski pains to ascertain their nature during the day was held simultaneous pH monitoring and ECG system "Astroscan-24" (Russia) and "Spacelabs" (USA). Nasogastric pH-metric probe with 3 sensors were installed in the position of the esophagus-cardia-body of the stomach under radiological control. Watch both devices are synchronized. In the course of monitoring patients kept diaries in which it noted the emerging complaints.

The analysis of the obtained data on the pH-grams were recorded periods of time of occurrence of GERD. Next, we analyzed the ECG during these periods of time were considered ST segment elevation below contours, indicating the presence of myocardial ischemia, the presence of arrhythmias during the occurrence of GER and within 10-15 minutes after that.

The objective of the study was to find out the true or false nature of the strokes, the definition of the role of GER in the origin of pain in the heart. As a result, 11% - their combination.

The disadvantage of the prototype method, according to the authors, is the lack of HRV analysis and assessment of ANS in the examined patients. In this study considered only the displacement of the ST segment and the presence of arrhythmias during the occurrence of GERD. This significantly narrows the diagnostic capabilities of the survey, it is not possible to study the functioning of the ANS, the pathology of which is one of the leading causes of GER.

The authors propose a method for the diagnosis of ANS dysfunction in children with pathology of the upper gastrointestinal (GI), in which the patient is simultaneously carried out two studies: daily pH-metry and Holter ECG that provides the hands of the doctor new diagnostic capabilities. It is possible the detection of autonomic dysfunction in children with gastrointestinal pathology, based on the calculation of indices of HRV for short standardized intervals, the choice of which is not affected by the presence of a large interval of the daily trend curves, not suitable for analysis because of the presence of artifacts. Standardization of selected intervals based on their determination of the presence of GERD. ANS - universal regulatory system in the body that are sensitive to different kinds of stimuli. the 200 or more per day. During this period, the ANS responds to GER. This is particularly clearly manifested in patients with autonomic dysfunction, which have the ANS is unbalanced, stressed state. When calculating indices of HRV for short randomly selected intervals autonomic dysfunction in the early stages of the disease may not emerge. At the same time, stress, unbalanced state of the ANS manifests itself during the period of the stimulus (GER).

Before the examination watches on the monitors (Astroscan-24", "Cartotecnica-4000") and watch on your computer are reconciled and synchronized. Then you enter transnasal pH-metric probe, sensors are installed in 1 standard position (esophagus-cardia-body of the stomach). Control the correct application of the electrodes is made radiographically. Then connect the devices for carrying daily pH-metry and Holter ECG in accordance with conventional methods. Both studies are carried out simultaneously during the day. In the course of monitoring patients keep detailed diaries, which mark the time of the occurrence and nature of complaints and their activities during the day, sleep, eating, being in the prone position. Then use the computer is In the future, the authors propose to evaluate the state of GNH indicators of HRV, designed for short intervals of time. This does not prevent the presence of areas with poor records of the trend curves. The high incidence of gastro-esophageal transitions during the day allows you to use professionally recorded plots of the trend curves. On the pH-gram changes the acidity in the esophagus are recorded at 5-minute intervals, not accompanied by the occurrence of GER and similar intervals corresponding to the occurrence of reflux. Then these intervals in the programme HMM marked as loading periods. The number of marked intervals can be arbitrary, but preferably not less than 8 episodes without GER and 8 episodes of GER. For them automatically, using a computer program calculated fashion, the variation magnitude (Delta X), standard deviation SDNN, the power spectrum in three bands (HF, LF, VLF), the ratio LF/HF. In further calculated the average values of these indicators separately for the group of time intervals without GER and for a group of time intervals with GER. Alterations of these parameters upon the occurrence of GERD. Functional analysis of GNH indicators calculated over short intervals of time possible and with quality Sizikov, 61 girls) aged 8 to 15 years with abnormal upper GI (chronic gastroduodenitis, esophagitis, gastric ulcer and duodenal ulcer). The survey included simultaneous daily monitoring of pH and ECG, clinical methods, esophagogastroduodenoscopy, cardiointervalography, clinorotation sample, determination of the baseline autonomic tone tables A. M. Wayne in the modification, Was Osokina. The results of the examination, the children were divided into 3 groups: group 1 - 37 children with pathology of the upper gastrointestinal (GI), not accompanied by SVD.

group 2 - 52 children with abnormal upper GI and vegetative dysfunction syndrome (VDS) sympathicotonia type; group 3 - 41 children with pathology of the upper gastrointestinal (GI) and SVD on vacatoncustom type; the Groups were matched by sex and age (table.1).

In the analysis of the survey results was that in the group of children without SVD has been a significant change in performance over time with GER in comparison with the same indicators for periods of time without GER. SDNN increased to 82.7 MS compared with 62.3 MS (125% of the original value), Delta X increased to 0.48 MS compared with 0,41 MS (122% of the original), madalas the same pattern: increased HF-component, decreased LF component. To determine significant deviations of the spectral indices, the authors expected their threshold level equal to M2s (M - arithmetic mean in each group of time intervals, s - standard deviation). 87% of children from group 1 reject HF and LF components were significant, that is, change their values when comparing performance over time intervals without GER and GER beyond a threshold level.

The foregoing suggests that the ANS is actively responding to the occurrence of gastro-esophageal reflux, its reserve capacity saved, the function of the dispersion is high, the parasympathetic influence on heart rhythm saved. During normal functioning of the ANS, there are marked changes in the time indicators and the ratio of the capacities of different parts of the spectrum in response to the occurrence of GER: In 2 children with gastrointestinal pathology and VDS in sympathicotonia type growth of temporal parameters of the function scatter (SDNN, Delta X) during the occurrence of GER was absent. The fluctuations in the values of indices SDNN, Delta X and fashion Mo was in the range of 1-5%, compared with the original values calculated for intervals of BP is here a function of the variation of the heart rhythm.

All children from 2 groups reject HF and LF components were not significant, i.e. change their values when comparing performance over time intervals without GER and GER did not extend beyond the threshold level M2s. Pronounced spectral dynamics of the indicators in this group of children was not observed.

Thus, the emergence of rigidity function of the variation in heart rate, no significant dynamics of spectral data indicate the presence of autonomic dysfunction. ANS is in an unbalanced condition, works with high voltage, and therefore does not adequately respond to the action of the stimulus. The function of the dispersion is reduced, indicating a decrease in parasympathetic influences on the heart rhythm. The specified process in the norm should not be (PL.2).

When comparing the values of temporal parameters was found that in group 2 children, they were lower than in group 1, and were equal SDNN=68,411,2, Delta X= 0,280,15, Mo= 0,660,12. In addition, for this group were characterized by higher values of LF-component of the spectrum and low values of the HF component of the spectrum (compared to the norm), the ratio LF/HF Balta X, HF-component spectrum, the reduced function of the variation of the heart rhythm, increasing function of the concentration of the heart rhythm, high values of the LF-component spectrum, the ratio LF/HF > 2.

In 3 children with gastrointestinal pathology and VDS in vacatoncustom type changes in temporal parameters of the function scatter (SDNN, Delta X) during the occurrence of GER was absent. The fluctuations in the values of indices SDNN, Delta X and fashion Mo was in the range of 1-5%, compared with the original values calculated for time intervals without GER. This lack of a pronounced temporal dynamics of indicators can be considered as the rigidity function of the variation of the heart rhythm.

All children from 3 groups reject HF and LF components were not significant, i.e. change their values when comparing performance over time intervals without GER and GER did not extend beyond the threshold level M2s. Pronounced spectral dynamics of the indicators in this group of children was not observed.

Thus, the emergence of rigidity function of the variation in heart rate, no significant dynamics of spectral data indicate the presence of autonomic dysfunction. ANS is in an unbalanced condition, works with vymennych indicators were, 3 a group of children were higher than in group 1, and were equal SDNN=83,712,4, Delta X= 0,60,16, Mo= 0,790,17. In addition, for this group were characterized by a higher value of the HF component of the spectrum and low values in the LF component of the spectrum (compared to the norm), the ratio LF/HF ratio less than 1.5.

Thus, in favor of the IRS on vacatoncustom type say high values of SDNN, Delta X, HF-component spectrum, the gain function of the variation in heart rate, decrease in function of concentration, low values of the LF-component spectrum, the ratio LF/HF ratio less than 1.5.

Therefore, analyzing the values of HRV indices calculated over short periods of time, you can determine the type of autonomic dysfunction. The unfavourable prognosis of the disease are reduced temporal analysis (SDNN and others), reducing power HF, the increase in the LF power, the increase of the ratio LF/HF.

As a result of one survey with simultaneous use of two methods, the physician receives a greater amount of information than when conducting these surveys on different days. In the present method, there is a new opportunity to diagnose autonomic dishonnest spectrum in three bands) for short periods of time. This is a new indicator of autonomic dysfunction "rigidity features scatter" of the heart rhythm. Her identification, and the absence of significant dynamics of spectral data indicate the presence of autonomic imbalance. The type of autonomic dysfunction can be defined by the values of the temporal and spectral indices calculated for short intervals of time. It is important to assign further differentiated treatment.

When using HMM and pH-metry separately, on different days, the physician receives a conclusion only on indicators of acidity in the esophagus, cardia, body of the stomach and the standard data for the HMM. Losing the ability to diagnose autonomic dysfunction in HRV indices in the case of poor signal recording when the CHILLER, which is often up to 30% of cases. When the present method eliminates the need for repeated daily surveys. When calculating indices of HRV for short randomly selected intervals autonomic dysfunction in the early stages of the disease may not emerge. But stress, unbalanced state of the ANS manifests itself in the time of the stimulus, which the authors suggest th at the same time carried out by pH-metry. This method of examination combines the diagnostic capabilities of the daily pH-metry and Holter ECG, providing additional criteria for the detection of autonomic dysfunction.

As a result of application of the method proposed by the applicants, the doctors will be able to determine how he reacts not only heart, but also the ANS on the occurrence of GER, will be able to establish a clear relationship between the occurrence of clinical symptoms in the patient (pain in the heart, arrythmia, cough, bronchospasm, and others ) and the processes occurring in the body (GER, arrhythmia, myocardial ischemia). Patients with gastrointestinal pathology for complex examination conducted both daily monitoring, as pathology ANS very often accompanies gastrointestinal pathology, aggravating it. To break this vicious circle is one of the most important tasks, so a joint examination of the gastrointestinal tract and the ANS is important for the diagnosis and subsequent successful treatment.

Clinical example. B-Neu Sergey P., age 14, (IB 68/487) was admitted for examination and treatment in gastroenterology unit of children's hospital 1, Tver, diagnosed with chronic gastroduodenitis, acute stage. Catarrhal esophagitis. GER? Upon receipt bothered complaining of severe pain in the epigastric region (on an empty stomach what with fatigue, disturbed sleep, irritability. As a result of simultaneous daily monitoring of acidity in the upper GI and Holter ECG was established that the patient has an increased acidity in the body of the stomach, pathological acid GER (67 transitions during the day). Their appearance in the daytime was accompanied by the appearance of heartburn, was provoked abundant food, torso. The recording signal when the CHILLER was poor, 40% of the total research time unsuitable for analysis because of artifacts, VRS program does not calculate. For calculation of HRV indices were selected 16 5-minute intervals 9.38-9.43, 10.35-10.40, 10.56-11.01, 11.10-11.15, 12.45-12.50, 13.02-13.07, 18.40-18.45, 19.10-19.15, 23.12-23.17, 00.19-00.24 and so forth All match the areas of trend curves, suitable for analysis. According to the daily pH-metry half of the selected time intervals were periods without GER, and the other half with GER. The trend curves all periods were selected periods. Computer program "Cartotecnica-4000 automatically calculated values for indicators of fashion Mo, variational scale, SDNN standard deviation. Then for the selected time intervals were calculated the average values of these parameters from the observed. When GER SDNN=67,3 (104% of the level without GER), Delta X= 0,31 (102% of the initial value), Mo=0,65 (99% of the original). The rigidity function of the dispersion was regarded as a manifestation of autonomic dysfunction. The level values of the temporal parameters testified in favor sympathicotonia type SVD. In addition, when assessing the dynamics of spectral indices was found that fluctuations in HF, LF did not extend beyond the threshold level. For periods GER indicators averaged: LF=1843 MS2(OK 1170416), HF=504 MS2(OK 975203), LF/HF=3,66 (in the norm of 1.5-2.0), i.e. there was a decrease in the power of the HF component, the increase in the LF power, the increase of the ratio LF/HF. Thus, the patient was diagnosed with autonomic dysfunction in sympathicotonia type. Based on the results of surveys son was diagnosed with a clinical diagnosis of GERD with esophagitis. Chronic duodenitis, acute stage. SVD on sympathicotonia type. Patient to standard therapy, anti-inflammatory and antacids were added prokinetic motilium, seduxen 5 mg/day, nootropil 0.5 g/day and "electrosleep" recommendations on diet and behavior.

Preimum to diagnose the type of autonomic dysfunction in the early stage of the disease on the basis of calculation of indicators of HRV for short periods of time; - provides diagnosis of autonomic dysfunction when recording HMM with a large number of artifacts; - eliminates the need for repeated daily ECG monitoring; - use the new marker of autonomic dysfunction "rigidity features scatter";
- allows you to identify the immediate reaction of the ANS, heart on the occurrence of GER;
- allows to establish the relationship between clinical symptoms (pain in the heart, heartburn, cough, bronchospasm, and others) and the processes occurring in the body (GER, arrhythmia, ST segment depression);
- allows you to assign a differentiated treatment.


Claims

Method for the diagnosis of dysfunction of the autonomic nervous system in children with pathology of the upper parts of the gastrointestinal tract, including simultaneous monitoring of pH in the esophagus, stomach and ECG, characterized in that the pH-gram in the esophagus record at least 8 episodes, corresponding to the occurrence of gastroesophageal reflux (GER) and at least 8 episodes without GER, lasting 5 min each, similar to the periods of time noted on the ECG as periods, for each episode count values of the temporary - fashion Mo, West spectrum in three bands - HF, LF, VLF, the ratio LF/HF, calculate and compare the averaged values of these parameters for groups of episodes without GER and GER, and in the absence of detectable changes in indicators of temporal and spectral analyses establish the presence of autonomic dysfunction, and at low values of the indices SDNN (68,4±11,2), δ X (0,28±0,15), HF, and at high values of the indicators Mo (0,66±0,12), LF, LF/HF>2, the reduction function of variance of heart rate and strengthening the functions of the concentration of the heart rhythm diagnose the syndrome of vegetative dysfunction in sympathicotonia type, and at high values of the indices SDNN (83,7±12,4), δ X (0,6±0,16), HF, and at low values of the indicators Mo (0,79±0,17), LF, LF/HF<1.5, the amplification function of the variation in heart rate and lowering function of the concentration of the heart rhythm syndrome of vegetative dysfunction in vacatoncustom type.

 

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