Method for the diagnosis of chronic ischemia of the colon in atherosclerotic lesions of the inferior mesenteric artery
The invention relates to medicine, namely to angiology and proctology, and is intended for the diagnosis of chronic ischemia of the colon in atherosclerotic lesions of the inferior mesenteric artery. Conduct ultrasonic angioscanning the inferior mesenteric artery and colonoscopy with simultaneous biopsy of the colon and stenosis of more than 60% of the diameter of the NBA and the development of destructive processes in the tissue components of the mucosa of the colon establish the diagnosis. The method is effective, harmless for both investigational and allows early detection of chronic ischemia of the colon before the appearance of symptoms of the disease. 3 table. The invention relates to medicine and relates to methods of examination ballroom in angiology and proctology.In recent years, interest has grown in ischemic lesions of the colon, which is not surprising, given the prevalence of vascular diseases. Have accumulated a lot of facts explaining the etiology and pathogenesis of vascular disorders of the colon and gives criteria for their recognition. Despite this, this pathology is more common than diagnosed.In connection with the increasing number of operas is receiving some medications (digitalis, ephedrine, epinephrine, vasopressin, penicillin, streptokinase, estrogensoderjashie contraceptives and other) increased frequency of ischemia of the colon /9/. Ischemia of the left half of the colon after elective, reconstructive surgery of the aorta is 4.4-10%, mortality at this varies from 10 to 25% /3/.Chronic ischemia of the colon (HID) reported in the literature from different perspectives, but some aspects remain unexplored: the severity of clinical manifestations, morphological changes of the mucosa of the colon depending on the degree of stenosis of the inferior mesenteric artery (NBA). Therefore, the search for new methodological verification chronic ischemia of the colon is particularly relevant during operations on the aorta, visceral arteries, the large intestine.Known methods for the diagnosis of chronic ischemia of the colon, combining physical examination, colonoscopy for macroscopic evaluation of the mucosa and biopsy for morphological studies, thermometry of the intestinal mucosa, x-rays of the colon throughout, panoramic radiography, barium enema, angiography of the aorta and visceral branches, ultrasonic dopplerography nightnight 20-25 minutes after eating and last for 2-2,5 hours This is true for the defeat of all three visceral arteries, when the defeat of the inferior mesenteric artery pain occur only in 8% of cases. To defeat the NBA typical localization of pain in the left iliac region, pain is reduced with a sharp restriction of food intake (syndrome of low food). When occlusion of the mesenteric artery in 70% of cases occur bowel dysfunction. With the defeat of the inferior mesenteric artery violated the evacuation of the colon. At first it appears as an unstable chair, then diarrhea alternate with constipation. In the future you receive bloating, stool becomes loose, contains undigested write mucus. On the background of the "syndrome of low food violation of secretory and absorptive function of the intestine develops progressive weight loss of the patient. Because the blood supply to the colon is provided collateral connections three fairly large vascular collectors - superior mesenteric, inferior mesenteric and internal iliac artery, isolated chronic lesion of blood flow through the inferior mesenteric artery can occur without striking clinical manifestations. Clinical manifestations occur while defeat mesenteric art is stop  . Clinical manifestations depend on the combination of vascular disease, resulting in the clinical picture and patient complaints are very varied, the syndrome of chronic abdominal ischemia can be neutralized due to the prevalence of ischemic manifestations from other affected blood pools. For example, the combined lesion of the inferior mesenteric artery of the terminal aorta (occlusion, stenosis, aneurysm and iliac arteries can be observed in 69.3% of patients with lesions of the visceral arteries /4/. In fact, this syndrome Leriche, supplemented impermanent symptoms of chronic insufficiency of blood flow in the inferior mesenteric artery - kolopatii (pain in the left half of the abdomen, diarrhea, constipation or alternating).Of special methods of research used survey radiography. This is a simple x-ray doesn't always make sense. The diagnosis becomes clear when the background gas-filled loops of intestine is determined by the "thumbprint" /17/. Studies with barium enema is considered by some authors as one of the most valuable methods of diagnosis of ischemic colitis /9/. Changes that can be detected by over depend on the stage of the disease: the imprint of scale for several weeks, education sacs. X-ray of the large intestine for precise motor function. In a healthy person, barium suspension after 25-30 min fills skinny intestine, after 1.5-2 h - ileum, 3-4 - blind, 24 hours - the entire large intestine. In normal ascending colon is filled after 4-6 h, the transverse - 10-12 h, descending colon - after 16-18 h, sigmoid and straight - through 20-24 h, the complete emptying occurs within 48-72 h /10/. In violation of the evacuation function say dyskinesia of the large intestine that can cause both Hypo - and hypermutation type. The presence of dyskinesia in a patient is not the only and pathognomonic signs HITCH, and conducting fluoroscopy requires time to assess the final results of the study.Contrast arteriography (RCAG) is a classic method of visualization of the aorta and its branches. Angiographic picture syndrome chronic abdominal ischemia is characterized by signs of defeat themselves visceral arteries and symptoms that characterize collateral circulation. The main undisputed signs of abdominal atherosclerosis are: incomplete filling of the lumen suck shadenet its contours, the expansion and increased tortuosity of its visceral branches /12/. For atherosclerosis inferior mesenteric artery is characterized by changes in the initial segment of the artery, the distal direction, as a rule, remains free. Along with these direct signs of infection are of great importance and indirect signs, in particular symptoms of collateral circulation. Occlusion of the inferior mesenteric artery blood flow goes through the arc of Riolan, which operates in this case in Caudalie direction. First contrastives superior mesenteric, and then the branches of the inferior mesenteric artery. When isolated occlusion of the inferior mesenteric artery can be detected on rectal mesenteric anastomosis. Angiographic study provides an opportunity to establish the correct diagnosis. Today, however, the method does not satisfy the needs of researchers. Although modern RCAG in General is considered a safe method, the procedure is not without risk and discomfort to patients /14/. Possible complications include bleeding, pseudoaneurysm, dissection of the arterial wall, infection, thrombosis, arterio-venous fistula, which in some cases require surgical treatment. Systemic side effects to the sufficiency, contrast-induced renal failure /13/.The level of perfusion of the intestinal mucosa depends on its temperature, a measurement which allows you to indirectly assess the blood flow in the test body /2/. In norm the lowest temperature of the mucosa is observed in the region of the splenic flexure and is 37,46oC, Sigma and rectum - 37,88 and 37,74oC, respectively. According to centuries mourachko et al. /11/, in patients with atherosclerosis statistically significant reduction in the temperature of the mucous membrane in all surveyed areas. The test with nitroglycerin authors have noted mild temperature effect on ad sample. In the control group temperature of the mucosa of the colon when conducting ad samples increases 0.870,10oWith that in patients with atherosclerosis and chronic ischemia of the colon temperature mucosa after administration of nitroglycerin increases the maximum 0.180,05 (p < 0,01). This method has not found wide application in medical practice, because it has little diagnostic value. This pathology observed is too small to change the team. In addition, the contact method of the temperature measurement does not exclude functional effect (e.g., nutrient loading) on the vascular system of sensors that can lead to some deviation of the obtained figures from the true temperature.Endoscopic technique that is used for the diagnosis of atherosclerotic lesions of colon cancer is a colonoscopy.In chronic ischemia of the colon endoscopy are transient disturbances attach and without attaching inflammation (changes unstable, removetime) and persistent morphological changes in the growth of connective tissue in the submucosal layer (radiographically it is a symptom of imprint 1 finger). When the endoscopic mucous membrane crimson-cyanation, biopsy bleeding virtually no, normal mucous relief violated. At the onset of rejection of the mucosa endoscopically on protivovirusnoi wall formed ulceration of a length greater than the lateral dimension, the bottom is lined with bleeding granulations /l6/.Fibrocolonoscopia, giving a clear macroscopic picture, rubs to have a number of complications, the most terrible is perforation of the colon, kinoti for detection of ischemic diseases of the large intestine was opened with the introduction into clinical practice of fibrocolonoscopia with simultaneous biopsy.Morphological changes in chronic ischemia of the colon are of a different nature depending on the phase of the process. So, for histological pattern of ischemic colitis in the acute phase is characterized by desquamation and necrosis of the mucosa, hemorrhage or macrophages containing hemosiderin in its plate mucosa, vascular thrombosis /19/. Atrophy of the crypts, hyalinosis own plates mucosa, inflammatory cell infiltration, fibrosis of the submucosal occur in the chronic phase of ischemic colon /19/. Histological changes are often limited to the mucosa, but may cover the entire thickness of the intestinal wall. Apart from the typical hemorrhages occur phenomena similar to membranophones and pseudomembranous colitis where pathological changes are in the form of spots. Therefore, the deepening of our knowledge about the nature of various clinical forms of ischemia of the colon will allow much easier to diagnose them at an early stage of the disease before joining a secondary infection, masking of symptoms of primary vascular process.As the prototype took way ultrasound evaluation of the vascular bed of the inferior mesenteric artery. Elsveta vessel and the degree of narrowing, detecting the presence or absence of atherosclerotic plaques in the lumen of the artery patency of the vessel, the measurement of linear and volumetric flow velocity, type of flow, the calculation of the index of resistance of the vascular wall /6/. This technique is non-invasive examination method is not inferior to the accuracy and clarity of radiological methods of the vascular bed /14/. The absolute advantage of ultrasonic methods is security, the widespread prevalence. High-resolution duplex scanning with color mapping of blood flow allows non-invasive to clarify the etiology, to determine the localization, and with a high degree of accuracy to judge the hemodynamic significance of the lesion of blood vessels.Disadvantages duplex scanning is the fact that the method does not allow one to assess the condition of the vascular system in General: information consists of separate sections with length not more than 1 see, There are certain difficulties associated with deep location of the vessel, the presence of noise, the large extent of the vascular bed. However, the use of duplex scanning allows surgeons and proctologists prehospital and chronic ischemia of the colon.This objective is achieved in that in the implementation of the method for the diagnosis of chronic ischemia of the colon in atherosclerotic lesions NBA conducting ultrasonic angioscanning the inferior mesenteric artery and colonoscopy with simultaneous biopsy of the colon and stenosis of more than 60% of the diameter of the NBA and the development of destructive processes in the tissue components of the mucosa of the colon establish the diagnosis.Check blood flow in the inferior mesenteric artery was carried out by ultrasonic duplex scanning using system Toshiba - 140A", with the frequency of the sent ultrasonic signal of 3.75 and 7.5 MHz. In the available literature we did not find data on length, diameter, thickness of the vascular wall NBA defined by USDG, but in accordance with radiological investigations Puddle (1973), the length of the inferior mesenteric artery is 4.2 cm (2.0 to 7,3), diameter 3,30.06 mm (3 to 5 mm) /8/. The resistance index in persons not suffering from vascular diseases, equal 0,9590,045. This indicator characterizes the elasticity of the vascular wall, its calculation is possible only if unchanged, the main type of blood flow. Dannydanny /15/.In addition, due to increased operations of the aorta, the large intestine is of practical interest, the degree of morphological changes in the mucosa of the colon depending on the degree of stenosis of the NBA. Erroneous determination of the boundaries of colon resection on the background of impaired blood flow in the NBA leads to repeated surgical interventions in connection with the ongoing necrosis and dehiscence of the anastomosis. Therefore, assessment of blood flow in the NBA and microvasculature of the mucosa of the colon will help to improve the results of surgical treatment of these patients. The need for such proposals is primarily due to the difficulties of early diagnosis of patients with chronic ischemia of the colon, which are often redundant or uninformative studies and that this pathology is not well-known to a wide circle of practitioners.The method is as follows. Ultrasound NBA and colonoscopy with biopsy of the mucosa of the colon was performed after a preliminary diagnosis of chronic ischemia of the colon based on history and obscenites examination methods.
waves, occur after a meal, interfere with the study. For constipation, flatulence sometimes requires additional research (compliance with besshlakovaya diet, cleansing enemas).The main signs of lesions of the NBA when USDG are thickening and hardening of artery walls, increasing the resistance index of the vascular wall, the presence of atherosclerotic plaques, incomplete coverage of the lumen of the vessel with ultrasound Doppler mapping, the change in the spectrum of the Doppler curve and the type of flow (main-modified, retrograde collateral).The degree of stenosis NBA was assessed by the ratio between diameter located distal section of the artery (md) and diameter of the stenotic area of the artery (mind) to the diameter located distal section of the artery (md), determined using ultrasonic duplex angiotenzinovye by the formula a /B/:Endoscopic technique that is used to diagnose lesions of colon cancer is a colonoscopy. Used colonopenbracket company "Olympus" model JF-type 30 L, length 130 cm, which allowed us to examine the colon to bauhinias valve. The study trevali the preparation of patients for colonoscopy preparation, "Fortran", proposed State scientific center of Coloproctology health Ministry. On the day preceding the study, with 15 to 17 h, the patient takes 2 dose packages, the contents of each sachet diluted in 1 l of water and the liquid drunk for 2 h, about 1 Cup every 10 minutes for About 19 h stool will become liquid and can take a light dinner (semolina, fruit jelly). About 21-22 hours the urge for defecation caused by contractions of the intestine, stop. At this time you can drink any amount of liquid without restrictions (water, herbal tea). On the day of research from 7 to 9 h of fasting should drink 2 litres of drug dissolved in the water as before. Colonoscopy is performed on an empty stomach and should refrain from Smoking on the day of the study.During fibrocolonoscopia estimated the tone of the intestinal wall, the lumen diameter, the elasticity of the intestinal wall, Australia, the height of the folds, active motility, vascular pattern, mucosa, presence of pathological formations, ulcers, erosions, diverticula, bleeding.Biopsy is performed from the area of the splenic angle of the sigmoid and rectum. Drugs are fixed in 10% neutral pH buffered solution formationen method 1. Patient H., 71, I. B. 3063. Was admitted to the hospital 15.04.99 with complaints of constipation for 3 days, flatulence.X-ray of the colon during: after 12 h the barium fills the transverse colon before the half, after 36 hours of barium in the ampulla of the rectum.USDG aorta and the inferior mesenteric artery. The aorta at the proximal 1.9 cm, in the area of the bifurcation of 1.6 see Wall to 1.4 mm thick, in the lumen of the isolated atherosclerotic plaques. The inferior mesenteric artery with a diameter of 3.5 mm at the mouth is narrowed due to atherosclerotic plaques to 1.6 mm, wall thickened, dense 1,1 mm Length of the vessel 4,2 see the main Flow is changed, the maximum blood flow velocity of 0.45 m/s, diastolic component is absent. Volume cots 0,45 l/min. and the resistance Index calculation is not subject.Clinical diagnosis of atherosclerosis of the abdominal aorta, hemodynamically insignificant stenosis (54,2%) of the NBA.Fibrocolonoscopia. Ileocecal valve cecum triangular hypertrophied (biopsy 3615 - moderately expressed phenomena of chronic colitis). The opening of the vermiform process is typically, ascending, transverse, descending, sigmoid, rectum examined throughout. The lumen of them not of the basic elements of connective tissue, folds thinned, common areas, vascular pattern is reinforced, haustra saved, shallow. From the area of the splenic angle, sigmoid, rectum taken cutters mucosa for morphological study.Protocol 5 description of the mucous membrane of the splenic angle, Sigma, the rectum, the patient Including , 71 years. The epithelium of the mucous membrane of the investigated intestine is not modified. The epithelial cells cylindrical, brush the rim of the saved, cytoplasm weakly basophilia. Nuclei are basal localization, sharply basophils. In the composition of the epithelial layer are numerous goblet cells, morphological structure which has no significant differences from the norm. The basal membrane of the epithelium is well expressed. Own record mucosa presents loose loose fibrous connective tissue that has a typical organization and cellular structure, well vascularized, and contains numerous capillaries, which are separate the formed elements of blood: in the biopsy of splenic angle of the red blood cells in large numbers. The walls of the crypts lined by predominantly goblet cells. The General structure stored in a single crypts nabludaetsya reaction to glycosoaminoglycan in the brush border of epithelial cells of the mucosa. The cytoplasm of goblet cells is characterized by a pronounced color on Allenby blue and moderately positive CHIC-reaction. The levels of secretory activity of goblet cells is homogeneous and does not differ significantly from the norm.2. Patient A. , 67, I. B. 10180 enrolled in the clinic with complaints of "alternating lameness" less than 50 m, night pain in the right lower limb, decreasing when lowering the legs down, chilly feet, gipostesia, swelling of the right foot. Flatulence, abdominal pain, constipation denies.X-ray of the colon along: barium after 12 h reaches the splenic angle of the colon, after 36 h fills the colon before half of the descending colon, through 42 h barium reaches the sigmoid colon.USDG aorta and its branches: the aorta is narrowed in distal 45% of total external iliac artery narrowed left by 48%, right on 34%, the blood flow in them in the trunk. The right common femoral artery (BOTH) narrowed by 32%, shrimp backbone-modified; superficial femoral artery (PBA) to the right is narrowed to 64%, in the average Department to 77%, turbulent blood flow in the distal right femoral artery is not colored. Left BOTH left and PBA narrowed to 41 and 32%, respectively, the blood flow in them mnom Doppler mapping is not colored, its clearance is uneven, narrowed from 4.3 to 1.5 mm, the wall of the artery dense, uneven thickness of 1.7 mm In the aorta in the area of the mouth of the NBA has atherosclerotic plaque, which contains elements of fibrosis and calcification dimensions 1.5 x 0.9 cm, registered mild collateral blood flow.Clinical diagnosis of atherosclerosis, syndrome Leriche, stenosis-occlusion of the right PBA, KHAN 111 Art. right foot; hemodynamically significant stenosis (65%) of the NBA.Total fibrocolonoscopia. The dome of the caecum, liver bending strain due to adhesions from the abdominal cavity. Dolichosigmoid. The tone of the walls of the colon uneven: in the left parts are not changed, in the left - reduced. The mucosa throughout the colon thinned. The vascular pattern is reinforced in the area of the splenic angle hyperemia of the mucous folds of the colon in all departments have the typical direction.Protocol 11 description of the mucous membrane of the splenic angle, Sigma, rectum A. patient, 67 years of age. The epithelium of the mucous membrane of the investigated intestine is not modified. The epithelial cells of cylindrical shape. Brush the rim of the saved, cytoplasm weakly basophilia. Nuclei are basal localization, sharply basophils. As part epithelialising differences from the norm. The basal membrane of the epithelium is well expressed. Own record mucosa presents loose loose fibrous connective tissue that has a typical organization and cellular structure, well vascularized, and contains numerous capillaries, which are separate the formed elements of blood. Expressed disturbances of microcirculation: diabetes under the basal membrane of the epithelium, lymphocytic infiltration, stagnation of blood in small vessels. The walls of the crypts lined by predominantly goblet cells. The General structure stored in a single crypts there is destruction of individual goblet and camchatix cells.When stained with alcian blue observed a positive reaction to glycosoaminoglycan in the brush border of epitheliocytes mucosa. The cytoplasm of goblet cells is characterized by a pronounced color on Allenby blue and moderately positive CHIC-reaction. The levels of secretory activity of goblet cells is homogeneous and does not differ significantly from the norm.The proposed diagnostic method was tested on 52 patients with chronic ischemia of the colon in age from 33 to 85 years (34 patients male, 18 female). Hemodynamically insignificant the s patients: patients with atherosclerotic lesions of the NBA and stenosis of 60% of the diameter of the artery (hemodynamically insignificant lesions) and more than 60% (hemodynamically significant). Atherosclerosis of abdominal aorta and its branches stenosis NBA diagnosed us 33 (63.5 per cent) patients, occlusion in 19 (36.5 per cent), which correlates with the literature data /15/.In the comparison group consisted of 35 people aged from 24 to 85 years without clinical manifestations of chronic ischemia of the colon and with distinct ripple of peripheral arteries to the level of the arteries of the feet. The maximum linear velocity of blood flow in our data in the comparison group was equal to - 0,67Oh,025 m/s Volumetric flow in the NBA comparison group was 0.1of 0.005 l/minIn atherosclerotic lesions NBA thickness of its walls ranged from 0.9 to 1.7 mm and averaged a 1.3 mm Maximum blood flow velocity at the stenosis was increased immediately after narrowing and was in the first group of 0.750.01 m/s (p < 0,01). Volumetric blood flow decreased with hemodynamically insignificant stenosis NBA to 0,0590,0025 l/min (p < 0,001). When occlusion of the maximum blood flow velocity was decreased up to 0.0160.08 m/s (p < 0,001), volumetric blood flow was reduced to 0,0090.02 l/min (p > 0,001) (table 1, 2). The type of blood flow in the NBA in 19 patients was magicmoments mucosa in chronic ischemia of the colon, developed on the background of atherosclerosis NBA. Studied 42 mucosal biopsy of splenic angle of the colon, Sigma, rectum. The material processed in accordance with conventional morphological methods.As a result of the studies found that patients with hemodynamic insignificant lesions NBA major structural changes are observed in the tissue of the splenic angle of the colon. The surface epithelium of the intestine is not significantly changed. The epithelial cells cylindrical, brush the rim of the saved, cytoplasm without obvious changes, the cores have a typical organization and are characterized by increased basophilia. In the composition of the epithelial layer are goblet cells, the structure of which has no significant differences from the norm. The basal membrane of the epithelium good konturirovany own record of the mucous membrane has a typical organization. In the intercellular substance separate the formed elements of blood (monocytes, lymphocytes). Own record mucous enough vascularized, the sanguineous vessels. Moreover, some of the congestion in the microvasculature, accompanied by the release of red blood cells into the surrounding tissue is Cherie there is swelling, leukocyte infiltration and the development of destructive processes in the various tissue components of the mucosa of the colon.Thus, it can be stated with a high degree of relation (r= 0,77) between the level of hemodynamics in the inferior mesenteric artery and microvasculature of the mucosa of the colon, causing morphological changes (table 3) determine the goodness of fit (X2The CHI square) by the formula (Kaminsky HP, 1959) /5/.r=0,77 Proposed method is effective, harmless for the study, enables its use for the diagnosis of chronic ischemia of the colon in atherosclerotic lesions of the inferior mesenteric artery. The inclusion of Doppler ultrasound in the diagnostic complex together with fibrocolonoscopia and morphological studies of biopsies of the mucosa of the colon contributes to early detection of chronic ischemia of the colon before the appearance of symptoms of this severe disease and its complications. This technique can be used for differential diagnosis of the Finance of this category of patients in outpatient conditions.SOURCES of INFORMATION
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Method for the diagnosis of chronic ischemia of the colon in atherosclerotic lesions of the inferior mesenteric artery, klukowo angioscanning the inferior mesenteric artery and colonoscopy with simultaneous biopsy of the colon and stenosis of more than 60% of the diameter of the NBA and the development of destructive processes in the tissue components of the mucosa of the colon establish the diagnosis.
SUBSTANCE: method involves measuring cardio- and hemodynamic values, calculating estimates of the values and displaying the estimates on monitor. Measuring and calculating each cardio- and hemodynamic value is carried out during basic periods of their oscillations corresponding to heart contraction cycle and respiratory cycle related to absolute time.
EFFECT: high accuracy of estimation.
4 dwg, 1 tbl