Method for treating cholangitis in case of mechanical jaundice

FIELD: medicine, surgical gastroenterology.

SUBSTANCE: as a curative preparation one should apply a pectin-containing powder product of table beet out of sublimated raw material. For reducing the powder before application one should apply low-mineralized low-alkaline amicrobial solution of electrochemically activated catholyte. Supernatant transparent fraction of this solution should be constantly introduced by drops into nasobiliary probe, residual fraction should be applied for peroral additional enterosorption. The method provides sanitation of biliary ducts by preventing duodenocholedochous reflux, and enterosorption that decreases portal toxemia.

EFFECT: higher efficiency of therapy.

2 cl, 1 ex

 

The invention relates to the topic of medicine, namely to surgery, and can be used for the treatment of cholangitis with mechanical jaundice by intraluminal rehabilitation of the biliary tract and enterosorption.

There are various methods of surgical treatment of cholangitis by draining and rinsing of the biliary tract, including through nasobiliary probe (NBD), conducted through choledochoduodenostomy (HD) (Vstavali, Vmenu, Mielcarski, “Guide to clinical endoscopy”, Moscow, “Medicine”, 1985, p. 346). The authors complement simultaneous internal and external drainage of the biliary tract with the purpose of decompression washing with solutions of antiseptics and antibiotics for 3-4 sessions that were cut short by the phenomenon of anastomotic and cholangitis.

The shortcomings of the method is the following. Traumatic method, as performed in open surgery under General anesthesia, which exacerbates the severity of the General condition of patients. HDA is the reason duodenojejunal reflux (DGR), especially in the early postoperative period, which provokes a continuation of cholangitis, with toxic bile, once in the intestines, contributes to the poisoning. Antibiotics and antiseptics entered into the biliary tract, may cause sensitization to him, allergic reactions and cause local irritation. Outside of otvedeny the bile through the NBD leads to the loss of the body it contains useful components.

The prototype of the invention is less invasive and more effective treatment of cholangitis by decompression of the biliary tract endoscopic papillotomy (ECPS) with setting NBD endoscopically and washing of the biliary tract with 0.9% NaCl solution at 30-40 ml with aminoglycosides and cephalosporins 4 times a day for 7 days, which leads to the resolution of cholangitis (Egismatullin “Mechanical jaundice nonneoplastic Genesis”, Minsk, harvest, 2000, s).

The disadvantages of this method is the presence of duodenojejunal reflux and the release of toxic bile into the intestine in the early, after endoscopic surgery, the period, the loss of bile through the NDS and the introduction of antibiotics in the bile ducts.

The objective of the invention is to improve the treatment of cholangitis with mechanical jaundice.

This is achieved by continuously flowing the washing of the biliary tract through the NBD to resolve duodenojejunal reflux and loss of bile out, create microblog environment in the biliary tract, decontamination and detoxification of bile cholangiohepatitis and, in addition, detoxification of the intestinal contents enterosorption to reduce portal bacterial plankton and toxemia.

For this task we used the solution of the powder product beetroot in brackish alkaline amicro the s catholyte. Used the supernatant fraction solution for introduction into the biliary tract through NBD constantly drip for 5 days, the remaining part was used for oral enterosorption. The supernatant fraction was used in connection with the best fluidity and absence of suspended particles in solution.

Powder product beetroot is manufactured using a sublimation according to THE 9199-013-00353158-97 (developed for the first time), certificate No. P, the technology of a product protected by the patent No. 2154969 issued by Rospatent. The product has a high sorption activity and capacity at the expense of pectins (up to 6.4 wt%) and protopectin (up to 20.0 wt%) For therapeutic purposes is usually applied of 0.25-2% pectin aqueous solution as a solvent to create microblog slightly alkaline (pH 8,0-9,0) environment, having an affinity for bile, used brackish (0.5 g/l) aqueous solution of NaCl as Catolica obtained by electrochemical activation at the “Stelae” NGOs “Screen” (Russia, Moscow).

The method is as follows.

Patient mechanical jaundice is performed endoscopic retrograde retrograde cholangiopancreatography (ERCP). After verification of the mechanical nature of jaundice (in our study this choledocholithiasis) performed endoscopic papillotomy estimated form cholangio mind released bile (fibrinous, purulent, mixed), and when Cytology is performed to remove stones from the choledochus and installation of NDS. If you can not remove stones - only NBD. The distal end of the drainage is carried out under x-ray control above the confluence of the equity of the ducts of the liver in one of them. The day before this was prepared by ~1% pectin (13 g powder per 100 g of Catolica) solution powder product beetroot in slightly alkaline brackish microbeam aqueous solution of Catolica at the rate of 3 litres per patient per day. For 12-24 hours at room temperature (18-22 degrees Celsius) the temperature of the solution fractionized on sediment and supernatant, i.e. not containing suspension components. The supernatant fraction is separated into a sterile bottle and poured in NBD through a single system for blood transfusion. Sedimentary part drank patients portions in 3-4 doses. The course of treatment is 5 days. By this time the evaluation of bile visually and cytologically phenomena cholangitis were allowed.

The powder product was applied in the form of aqueous suspensions, oral, fractionally, at a daily dose of 80-100 g of dry substance in the complex treatment of 59 patients with mechanical jaundice and cholangitis in the background of choledocholithiasis. All performed endoscopic papillotomy (ECPS), lithoextraction, including 20 with nasobiliary drainage (NBD), impossible when removing Cam the her - choledocholithotomy with drainage on Kera. Drains used for flow cholangiogram when cholangitis. All patients were treated perioperatively pectin containing the drug (SRP) with the aim of enterosorption.

If cholangitis is additionally carried out a reorganization of the biliary tract and prevention duodenojejunal reflux (DHR) flow drip cholangiocarcinoma the supernatant fraction of the powder product beetroot, restored brackish slightly alkaline (for tropism to bile) aqueous solution of Catolica obtained at the “Stelae 10H-120-01” NPO “Screen”. To assess the effectiveness of treatment used ultrasound examination of the liver, bile ducts and portal vein (ultrasound and Doppler ultrasound), clinical and biochemical data, morphological examination of the mucous areas of the Epte and the mucosa of the terminal segment of the choledochus. When cholangitis visually assessed the transparency of bile. In the primary group for this was interrupted by lavage of the biliary tract for 1.5-2 hours. The results were compared with those in a similar group of patients paired sample who received standard treatment without SRP. For a conventional norm diameter and volumetric blood flow of the portal vein taken data of 10 healthy volunteers.

In both groups of patients the source marked decrease in the density of the liver to 42±10,4% Hausfeld the ri normal 50-70% Patients of both groups before treatment marked dilatation of the portal vein to 1.4±0.1 cm compared with the conventional norm of 0.9±0,1, see Volumetric flow source, respectively 1647±100 ml/min and 1236±100 ml/min, We believe this is a consequence of portal hypertension due to increased intrahepatic resistance to blood flow in the background of biliary hypertension, inflammatory reaction and stagnation in the parenchyma of the liver and intrahepatic bile ducts. The increased volumetric flow consider adverse prognostic factor, because the background of Kalemie and absence of bile in the intestine develops intestinal failure with indigestion and intestinal wall permeability to toxins and microbes. Possible colonization of the small intestine colonic flora. All this reinforces the damaging effect on the liver portal blood by increasing portal toxemia and probably bacteremia. On the 5th day of treatment in the main group the diameter of the portal vein decreased to 1.1±0.1 cm, i.e. by 21.4%, volumetric blood flow decreased to 1326±100 ml/min, i.e. by 19.0%. In the comparison group only on the 10th day, these figures are almost equal. At discharge patients on 15-18 day these indicators to conditional rules are not decreased. This fact we consider the indication for continuation of hepatotropic therapy on an outpatient basis. Biochemical for the simple in the main group had already improved at 1-3 days and normalized to 5-7. In the comparison group, respectively, at 3-5 and 10-12. There is an analogy here with the dynamics of portal blood flow and diameter of the portal vein. Transparency of bile in the main group recovered within 3-5 days in the comparison group at 7-8. Morphologically phenomena cholangitis 10 days were allowed in the main group and decreased in the comparison group. In the comparison group indicated a more active due to mucosa duodenal ulcer epithelization designated Epte. Complications of applying the SRP is not marked. He is well accepted by patients.

The positive effect of SRP on portal blood flow and blood biochemical parameters we associate with entero - and hepatoprotective, nutritive effect and sorption activity. Faster resolution of cholangitis and epithelization region Epte - with anti-inflammatory and local reparative action, as well as a lack DHR acute cholangitis due to the constant flow washing of the biliary tract.

Intraductal introduction pectin containing powder product beetroot from freeze-dried raw material is an effective method for the treatment of cholangitis with mechanical jaundice.

Clinical example. Patient T., 54 years old, medical History, No. 1380, enrolled in 1 surgical Department GCB No. 50 19.01.2002 years with a diagnosis of Cholelithiasis, OST the first calculous cholecystitis, obstructive jaundice. Started conservative therapy examination. Data ultrasound from 20.01.2002 year: choledoch 21 mm, biliary network expanded, the pancreas is not increased, homogeneous, diffuse sealed. Gall bladder gives an acoustic shadow length 4,5 see unconjugated Bilirubin 58,0, direct - 135,0 mmol/L. Data endoscopic retrograde cholangiopancreatography from 22.01.2002 year: fatherof nipple up to 3 mm in diameter, mucous it is not changed, made his canulate. When the contrast study revealed that choledoch to 20 mm in diameter, it ureteral stones up to 10 mm in diameter, biliary network expanded. Performed typical endoscopic papillotomy for 10 mm, in the choledoch put the basket of Dormia, calculus removed. From choledochus is allocated muddy purulent bile with threads of fibrin. When the control cholangiography concretions were found, reset contrast into the duodenum good. Taken gall to research, set nasobiliary drainage. The diagnosis of Choledocholithiasis, fibrinous-purulent cholangitis. In the study of bile: yellow, opaque, alkaline pH, leukocytes 38-40 in the field of view, there are clusters of up to 20, erythrocytes 5-6 in the field of view. Ultrasound from 23.01.2002 year - aeropole - sign duodenojejunal reflux. Started running cholangioscopy to complement the school oral enterosorption the course of 5 days. When the control ultrasonic studies from 24-25.01.2002 year aerocali not marked. 28.01.2002 year when ultrasonography study choledoch decreased to 12 mm in diameter, total bilirubin blood of 22.0 mmol/l, taken bile for follow-up research. The study of bile from 28.01.2002 year - yellow, transparent, alkaline pH, leukocytes 2-4 in sight, no erythrocytes. Obstructive jaundice and cholangitis was resolved. Removed nasobiliary drainage. Prepared for elective cholecystectomy.

1. A method of treatment of cholangitis with mechanical jaundice, including the introduction biliary tract drugs, characterized in that the quality of drug use supernatant fraction solution powder beetroot obtained with the use of sublimation, the electrochemically activated solution Catolica.

2. The method according to claim 1, wherein the solution is injected drip constantly through nasobiliary drainage.

3. The method according to claims 1 and 2, characterized in that the sedimentary fraction of the solution are additionally administered orally.



 

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