Method of diagnosing destructive forms of acute cholecystites

FIELD: medicine.

SUBSTANCE: in order to realise the method level of ferritin in blood serum and bile bladder tissue, rang point is defined, and ferritin values in serum from 0 to 10 ng/ml, and bile bladder from 0 to 0.25 mg/l - are taken for 1 point, respectively, level of ferritin in serum 70 ng/ml is taken as 7 points, and in bile bladder tissue 0.75 mg/l is taken as 3 point, and if sum is 10 points, conclusion is made about non-destructive cholecystitis, and if sum is from 10 points conclusion about destructive cholecystitis is made.

EFFECT: application of invention allows to increase accuracy of diagnostics of bile bladder tissue destruction in acute cholecystitis.

3 ex

 

The invention relates to medicine, namely surgery, and can be used for the diagnosis of destructive forms of acute cholecystitis.

Currently, acute cholecystitis (OH) is one of the most common acute surgical diseases of abdominal cavity organs (Borisov, AU, Excavation, VP, Levin, L.A. and other current treatment of acute cholecystitis. // Journal of surgery imprecise. 2001. T, No. 6. Pp.92-95; Kuznetsov, N.A., Aronov PS, Kharitonov SV, etc. the Choice of tactics, timing and method of surgery for acute cholecystitis. // Surgery. 2003. No. 5. P.35-40; Kimura, Y., Takada, T., Kawarada, Y. et al.: Definition, pathophysiology and epidemiology of cholangitis and cholecystitis. // J. Hepatobiliary Pancreat Surg (2007) 14: 15-26). A significant increase in the number of patients OH, celebrated in the last decade, accompanied by an increase in the proportion of patients of elderly and senile age. The prevalence of this pathology persisted despite the improvement of surgical tactics. The level of mortality and postoperative complications (Keus, F., Breeders, I.A.M.J., van Laarhoven, C.J.H.M. Gallstone disease: Surgical aspects of symptomatic cholecystolithiasis and acute cholecystitis. // Best Pract Res Clin Gastroenterol. 2006; 20(6); 1031 - 51.), cause not only medical but also the social significance of this problem.

Development of reliable methods for timely diagnosis of acute cholecystitis is an urgent problem which modern medicine. Important lab panels assessment of the severity and the severity of the pathological process in chronic or hidden flowing forms of the disease. It is based on careful history taking, objective physical findings, laboratory tests, x-ray and CT studies. However, none of these positions does not give a reliable diagnostic results. So accuracy is only historical and objective data in the diagnosis of a destructive state does not exceed 57,19% (Sviatoslavsky. Prognostic factors are detection of acute destructive cholecystitis).

According to a report by the world organization of gastroenterologists and endoscopists (OMGE), the accuracy of diagnosis of the causes of abdominal pain to the beginning of the XXI century was only 50%, the time interval between the appearance of pain in the abdomen and verification of diagnosis, including malignant neoplasms ranged from 8 to 37 weeks. Half of the patients after the initial examination, the cause of the pain remained outstanding, and the frequency of negative results of diagnostic laparotomy was 60% (Glasgow RE, Mulvihil SJ. Abdominal pain, including the acute abdomen. Sleisenger&Fordtrans's Gastroentestinal and Liver Disease. Philadelphia-London-Toronto-Monreal-Sydney-Tokyo 2003; 1: 80-90.) In addition, not infrequently (up 31%) destructive processes in introducing forms of the hall is istita in the gallbladder occur latent and are diagnosed when already developed complications.

To assess the functional state of the liver, biliary tract in clinical laboratory diagnostics is used quite a lot of biochemical tests and markers (Kokuyeva O. Diagnostic value of the components of bile in chronic gallstone cholecystitis. Modern trends in the development of gastroenterology. Proc. Dokl. ).[. - Izhevsk, 1995, s-92).

However, the abundance of separate indicators of liver function had not solved the problem of quality of laboratory diagnosis in abdominal surgery. In surgical practice, the diagnosis of acute cholecystitis is usually made based on history and physical examination. Of laboratory diagnostic methods used in clinical analysis of blood, where the rate of the disease is the number of leukocytes. In typical cases, the number of leukocytes is 10-15 109/l-shift formula of blood left. Also slightly increased bilirubin (50 g/l) in 45% of patients and transaminases (5 times) in 25% of patients (Arseny A.K. Diagnosis of acute inflammatory diseases of the abdominal cavity. - Chisinau. 1982. Page 76, 84, 95, 175. Jürg Hegglin. Surgical exploration. - M., 1980, Page 195. Lida A.G. Symptomatic diagnosis of surgical diseases. 1973. P.57. Astapenko VG Guide to diagnosis and differential diagnosis of surgical diseases. - Minsk, 1988. With R)

The success of treatment of patients with acute cholecystitis depend on the accuracy of diagnosis of pathological changes of the gallbladder wall, which define the tactics of treatment and the urgency of implementation of operative intervention. Standard laboratory tests to diagnose acute cholecystitis 75%. For an objective assessment of pathological changes of the gallbladder wall with a high degree of informativeness is applied ultrasound. Now, with the emergence of a new class of diagnostic equipment, the opportunity of studying the degree of inflammatory changes in the gallbladder wall using Doppler techniques. This gives the possibility to exclude from the plan of survey of a predominant number of patients with invasive and expensive methods of investigation of the vascular bed of the gallbladder (Musaev PPM Is Doppler examination methods in the diagnosis of diseases of the gall bladder.: Abstract. dis. Kida. the honey. Sciences. - M - 1997. - 21 S.)

According to the authors similar to our proposed method is a common clinical analysis of a blood.

Currently, the most reliable diagnostic technique in identifying destructive States is computed tomography (CT), which allows you to set a destructive process in the pancreas and biliary pusy the e in 94%.

However, as it turned out, the research conducted for the first time days, completely ineffective both in terms of diagnosis and prognosis of the disease, more or less clear picture of the CT can only get to 7-10 th day of the disease. That is why the attitude to this expensive, fraught with complications associated with administration of a contrast agent, and is accompanied by relatively high radiation exposure methodology in recent years has become very critical. (Munoz-Bongrand N., Panis Y., P. Soyer et al. (2001) Serial computed tomography is rarely necessary in patients with acute pancreatitis: a prospective study in 102 patients. J. Am. Coll. Surg., No. 193(2): P.146-152).

The main disadvantages of computerized tomographic diagnostic methods are:

- unwanted radiation exposure to patient and staff,

- the complexity of the process,

- the complexity and high cost of equipment and, as a consequence, the high cost of research,

- lack of equipment in small clinics and hospitals, where the most frequently hospitalized patients with acute cholecystitis.

The inaccessibility of computer tomography in medical institutions of the district, the city, and, sometimes, regional subordination, the high cost of research and the unwillingness of the patient to be subjected to radial load encouraged many patients to refuse such examination, and researchers to find other among Ernie diagnostic tests.

The last time it was designed and implemented several methods for the diagnosis of acute cholecystitis (Shatokhina Svetlana, Shcherbina, Tatyana V. Shabalin Vladimir Nikolaevich. The method of differential diagnosis of chronic acalculous and calculous cholecystitis. // RF patent 228934 from 03.12.04; Maskin Andrey Mikhailovich. The method of rapid diagnosis of destructive changes of the gallbladder in acute cholecystitis. // Patent RF №2269299 from 26.11.06; Sybil NR. E.N. Mokhov. Kargapolov A.V. Method of differential diagnosis of destructive changes in the various forms of acute cholecystitis. // Patent RF №2247379 from 07.07.03; Suzdaltsev Igor Vladimirovich. A comprehensive method for the diagnosis and surgical treatment of acute cholecystitis in patients with high surgical anesthetic risk. // Patent RF №2199957 from 10.08.00).

At the same time in the diagnosis of many destructive conditions proved to ferritin, which, according to many researchers, is considered an indicator of the destruction of tissue. So ferritin embedded in the diagnosis of a destructive state of traumatology and orthopedics (Korablev S. B., Lebedev, M., Tenjin N.A. Method of differential diagnosis of recurrent degenerative bone cysts and residual bone cavities. // Patent RF №2086985 from 05.1994), in the diagnosis of traumatic brain injury (Sumn what I D.B. et al. The way to diagnose the severity and course of traumatic brain injury. // Patent RF №2213967 from 22.07.02), tuberculosis (Malysheva O.K., et al. The method of differential diagnosis of pulmonary tuberculosis. // Patent RF №2027191 from 29.12.90), liver disease (Parshikov V.V. Zherikhin, V.V. Nemov Way of assessing the degree of liver damage. // Patent RF №2132071 from 21.04.98), thyroid gland (Panova T.N., Epenetos M.A. the Method of differential diagnosis of malignant tumors of the thyroid gland and nodular non-toxic goiter. // Patent RF №2075085 from 26.05.93).

In-depth study of the pathogenesis of acute cholecystitis (OH) and its complications requires a search for new methods of evaluating changes in homeostasis in these diseases. Analysis of the literature shows that currently there is an accumulation of information about the biological and clinical significance of metalloproteinase - ferritin.

Metalloprotein proteins serum involved in the pick up, transport and disposal of ions of metals of variable valence. The interest in the study of these proteins significantly increased in recent years due to their role in the functioning of the antioxidant system of the organism (White O.L., Fomin I.G., Baider L.M., etc. Influence bioflavonoid of divertida on antioxidant system ceruloplasmin/transferrin and lipid peroxidation in patients with stable f is Rami coronary heart disease with dyslipidemia. The wedge. the honey. - 2006. No. 7. - P.46-50; Century Halliwell, Gutteridge M. The antioxidant of increasing interest among human fluids. Arch. Biochem. Biophys. - 1990. - Vol.280. - N 1. - P.1-8. Orino, K., Tsuji Y., Torti, F.M., Torti, S.V. Adenovirus E1A blocks oxidant-dependent ferritin induction and sensitizes cells to pro-oxidant cytotoxicity. FEBS Lett. 1999; 461: 334-338), and can be used as biochemical markers of the acute phase of inflammation (Adamyan, A.I., Gulyaev, A.A., Ivanina, T.A. and other Ostrofsky response and blood plasma proteins in acute cholecystitis. The wedge. lab. diagnosis. - 1997. No. 11. - P.8-10; 2. Aleshkin, V., Novikova, LI, Lyutov, A.G. and other acute phase Proteins and their clinical significance. The wedge. the honey. - 1988. No. 8. - P.39-48; Boqueria, L.A., Ethologica, Majickova. Acute-phase markers of the pathological process in the prediction of the nature of the clinical course of exudative pericardial effusion after cardiac interventions. APAR. medicine: theory and practice - 2004. No. 4. - C.2-8; Ilyukevich, GV, Smirnova, L.A. Paraprotein as markers of systemic inflammatory response in acute widespread peritonitis. Vestsi NAS of Belarus. Ser. honey-balnaves. - 2002. No. 2. - C.23-25; Al-Delaimy, W.K., Jansen, E.H. Reliability of biomarkers are of iron status, blood lipids, oxidative stress, vitamin D, C-reactive protein and fructosamme in two Dutch cohorts. - Biomarkers are. - 2006. - 11(4): 370-382).

As a prototype we have used the method of differential diagnosis of chronic cholecystitis and acute cholecystitis by examining the General analysis of blood, which includes the study of concentration of the hemoglobin in 1 μl of blood, counting the number of red blood cells in 1 μl of blood, calculation of the color index, counting the number of cells in 1 μl of blood, the study of leukocyte formula (percentages of various leukocytes) and determination of the erythrocyte sedimentation rate in millimeters per hour (Reference "Laboratory methods in the clinic" / Ed. by Prof. Riv. - M.: Medicine, 1987, p.106-125).

But this method has disadvantages, the number of cells varies under the influence of seasonal, climatic, physiological state of the organism, as well as in a variety of pathologies, which indicates a small informative this way, and it is impossible to assess with it the degree of the inflammatory destruction of the gallbladder

The aim of the invention is to improve the accuracy of diagnosis destruction of the tissue of the gallbladder in acute cholecystitis.

Put in the invention the objective is achieved by the fact that at the time of hospitalization examine the level of ferritin in the serum and tissues of the gallbladder, determine the ranking score, the values of serum ferritin from 0 to 10 ng/ml, and in the tissue of the gallbladder from 0 to 0.25 mg/l - take 1 point, respectively, the level of ferritin in the serum of 70 ng/ml is taken for 7 points, and in the tissue of the gallbladder 0.75 mg/l is taken for 3 credits, and in the amount of 10 points judged on nondestructive who cholecystitis, and with the amount from 10 points judge destructive cholecytitis.

The first stage involved a survey of the level of ferritin in the serum of patients with acute cholecystitis (80 patients), chronic cholecystitis (56 patients). Set clear dependence of the concentration of tissue ferritin from highly disruptive process. Received high numbers of ferritin in patients with complicated destructive process. The argument for the possibility of using ferritin for the diagnosis of destructive state was the highest reliability in the diagnosis of destructive conditions when other nosological forms. Prior to surgery in these patients, we investigated the levels of ferritin serum. In the determination of ferritin in the serum of patients do not abstain from eating, no special preparations are not required. Collected normal blood by venipuncture in vacutainer and separating the serum from the cells by centrifugation after the formation of a clot.

The concentration of ferritin in the serum was determined by indirect ELISA in ng/ml of commercial test systems CJSC Biohimik" (Moscow), in the tissue of the gallbladder was determined by radial immunodiffusion. Determination of tissue ferritin was performed after homogenization of the investigated tissues. Homogenization was carried out trace is accordingly. The pathological gallbladder removed during cholecystectomy, were crushed and mixed with glass powder to a creamy consistency. For the destruction of cell membranes and structures was carried out 3 times thawing and freezing of the homogenate. Then there was the extraction of dissolved proteins in a physiological solution at a ratio of 3 volumes on 1 g of tissue.

For the identification of ferritin in tissue biopsies used the same standard test system, which determines the equivalent ratio of known antigen and the corresponding antibody. Changes in the concentration of ferritin in the serum of most patients patients correlated with the levels of the mediator in the tissues.

Fluctuations ferritin, serum varied in catarrhal from 50 to 60 ng/ml, and when flegmonozna cholecystitis - up to 306 ng/L.

The statistical processing of the results using student's criterion t. The level of serum ferritin was higher in destructive forms of acute cholecystitis and amounted to (306,0±62,3 ng/ml, p<0.01), which corresponds to 30 points compared with the level in a non-destructive forms of chronic cholecystitis 6 points (59,3±15,23 ng/ml, p<0.05) and the control level of 2 points (21,9±1,35 ng/ml, p<0,01).

In the second phase of the study included determining the ranges of ferritin in TC is no gall bladder and blood serum in 56 patients with chronic cholecystitis. Destructive condition was diagnosed by a score of 10 or more. All patients with such amount of points made sanitizing operations cholecystectomy. Inflammatory destruction confirmed in all patients by visual characteristic operating discoveries and subsequent histological examination. Among the operated were those patients, diagnosis of a destructive condition in which traditional methods was difficult, and operational research confirmed the need for and timing of surgical treatment.

Our proposed method is embedded in the work of the surgical Department of GB No. 6 Astrakhan and used in the survey of 56 patients with chronic cholecystitis and 80 patients with acute cholecystitis. Below are examples of approbation.

Example 1. Patient D., 60 years old, was admitted to the surgical Department with complaints of pain in the right hypochondrium, dry mouth, vomiting bile, after 7 days from the moment of disease. The pain came after errors in diet.

Study: diastasis urine - 58 units, ECG - without features, leukocytosis 12,2×109, ALT, ACT - within normal limits, ESR - 21 mm/h, urine analysis without features on ultrasound in the gall bladder concretions up to 1.9 mm After inspection and examination, she was diagnosed with acute cholecystitis.

The study showed the concentration of f is retina of 82.5 ng/ml (8-points). Treatment: antispasmodics, infusion therapy, analgesics, heparin, blockade paraumbilical.

After the treatment, the condition has improved, the pain passed, the ferritin level decreased to 68 ng/ml.

After 5 days, the patient was again pains, the temperature rose to 37 degrees in the right hypochondrium was palpable painful infiltrate was noted the increase in ferritin concentration up to 92.5 ng/ml (9-points). Sick of the proposed operation.

Access in the right upper quadrant incision Fedorov. In the subhepatic space is expressed, loose infiltration. Stupid way of infiltration selected gallbladder, cholecystectomy from cervical, summed up the drainage to Winslow hole. The peritoneal cavity is drained, postoperative wound sutured in layers.

Microreport: the gallbladder is a dark crimson color, with the imposition of fibrin, wall abruptly thickened in the cavity 4 of ureteral stones with a diameter of 1.9 mm, the concentration of ferritin in tissue 8.2 mg/l (32 points) in the amount of 41 points Postoperative diagnosis: "GCB. Acute calculous, gangrenous cholecystitis, infiltration in the gall bladder".

Postoperative period was unsatisfactory, kept subfebrile temperature up to 37,3, worried about the pain in the postoperative wound was conducted anti-inflammatory and immunokorrigiruyuschy therapy.

Discharged after 19 days in a satisfactory condition. Examined after 6 months, notes the improvement, leads a normal life, laboratory values without features.

Example 2. Patient A., 50 years old, was admitted to the surgical Department rez 7 days from the date of disorders clinic with acute cholecystitis. From the anamnesis: with coronary artery disease, angina.

The study showed the concentration of ferritin 150,5 ng/ml (15-points), and therefore the us was the preliminary diagnosis flegmonoznih cholecystitis.

After preoperative preparation: infusion therapy, gemodez, glucose, R.-R. ringer, vitamins, drugs, potassium patient surgery cholecystectomy, abdominal drainage. Access - verkhnesadinsky laparotomy. Gallbladder edema, increased to 9.0×4.0 cm, wall abruptly thickened in places imposition of fibrin in the cavity many concretions up to 0.6-0.8 mm in diameter, the concentration of ferritin in tissues of 4.66 mg/l (18 points) in the amount (32-point).

Postoperative diagnosis: "GCB. Acute calculous, flegmonoznih cholecystitis, infiltration in the gall bladder". In the postoperative period was conducted infusion, anti-inflammatory, metabolic therapy. In the process of treatment was the reduction of elevated quantities of antigens: f-40 ng/ml (4 points).

Discharged after 13 days p the following operations. Examined after six months, no complaints, leads a normal life. Laboratory values within normal limits.

Example 3. Patient G., 55 years old, was admitted to the surgical Department in a planned manner with complaints of recurrent pain in the right hypochondrium, bitter taste in the mouth when errors in diet.

Performed outpatient study: diastasis urine - 58 units, ECG - without features, leukocytosis of 9.2×109, ALT, ACT - within normal limits, ESR - 14 mm/h, urine analysis without features on ultrasound in the gall bladder concretions up to 1.9 mm After inspection and examination, she was diagnosed with JCB chronic calculous cholecystitis.

The study showed the concentration of ferritin and 68.5 ng/ml (7-points). The patient made a planned operation.

Access in the right upper quadrant incision Fedorov. In the subhepatic space is determined by the gall bladder into the lumen palpable concretions produced cholecystectomy from cervical, summed up the drainage to Winslow hole. The peritoneal cavity is drained, postoperative wound sutured in layers.

Microreport: the gall bladder is not increased, the wall is not thickened in the cavity 4 of ureteral stones with a diameter of 1.9 mm, the concentration of ferritin in tissue 0.5 mg/l (2 points) in the amount of 9 points Postoperative diagnosis: "GCB. JCB chronic calculous cholecystitis".

Postoperative period was without the person who values.

Discharged after 8 days in a satisfactory condition. Examined after 6 months, notes the improvement, leads a normal life, laboratory values without features.

When using our proposed method can achieve:

a reliable diagnosis of a destructive state of the gall bladder even when other instrumental diagnostics and laboratory methods difficult

for diagnostics do not need special conditions and preparation of the patient

- will allow you to diagnose latent flowing destructive condition requiring surgical treatment

- reduce economic costs by reducing pre-operative preparation, eliminating costly computer examination, unsuccessful conservative therapy and re-hospitalization

- eliminate unwanted radiation exposure to patient and staff.

A method for the diagnosis of destructive forms of acute cholecystitis by studies of biological tissues, characterized in that in patients with acute cholecystitis when admitted to hospital, examined the level of ferritin in the serum and tissues of the gallbladder, determine the ranking score, the values of serum ferritin from 0 to 10 ng/ml and in the tissue of the gallbladder from 0 to 0.25 mg/l accepted for 1 point, respectively, the level of ferrite is on in the serum of 70 ng/ml is taken for 7 points and in the tissue of the gallbladder 0.75 mg/l take 3 points, and if the sum is 10 points judged non-destructive cholecystitis, and with the amount from 10 points judge destructive cholecystitis.



 

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5 tbl

FIELD: medicine, biochemistry.

SUBSTANCE: at testing one should precipitate high-molecular compounds with acetonitrile and register supernatant's spectral characteristics. Supernatant should be applied onto a paper filter, dried and put into solution containing aromatic aldehyde, acetone and concentrated hydrochloric acid taken at weight ratio of 70:5:1 to be kept for 2-3 min. Then it should be once again dried up to detect qualitative and semiquantitative content of oxidized tryptophan metabolites by intensity and chromatic shades. Moreover, by chromatic shades of yellow dyeing it is possible to detect the content of hydroxylated metabolites and by chromatic shades of violet dyeing - that of unhydroxylated ones.

EFFECT: higher significance of detection.

3 ex

FIELD: medicine, anesthesiology, resuscitation.

SUBSTANCE: in patients one should study the content of lactoferrin in peritoneal exudates during the 1st d of postoperational period and at decreased value being below 3500 ng/ml on should predict unfavorable result. The suggested method provides correction of possible postoperational complications that deteriorate the flow of peritonitis and lead to lethal result.

EFFECT: higher accuracy of prediction.

3 ex

FIELD: veterinary medicine.

SUBSTANCE: method involves determining low and middle molecular mass substances content in blood plasma and erythrocytes and general blood plasma albumin concentration. Integral index is calculated on basis of obtained values using formula II=100*S238-298(plasma)/S238-298(erythrocytes)*GAC, where S238-298(plasma) and S238-298(erythrocytes) are the low and middle molecular mass substances content in blood plasma and erythrocytes, respectively, determined from area of figures restricted by spectral curves in wavelength range of 238-298 nm and abscissa axis (conditional units2); GAC is the general blood plasma albumin concentration (g/l). The value being from 2.1 to 3.0, the first endotoxicosis degree is diagnosed. The value being from 3.1 to 4.5, the second endotoxicosis degree is diagnosed. The value being from 4.5 to 6.0, the third endotoxicosis degree is diagnosed. The value being greater than 6.0, the fourth endotoxicosis degree is diagnosed. The normal value is equal to 0.5-2.0.

EFFECT: high accuracy of diagnosis.

1 dwg, 1 tbl

FIELD: medicine.

SUBSTANCE: method involves separating blood serum proteins into fractions, determining albumins and alpha-2-globulins content and controlling their content changes during the disease development process. Gamma-globulin content is determined in per cent ratio with respect to total protein quantity. Then, changes in the fractions content are controlled from the first to the third week. Albumin content being in norm and alpha-2-globulins content becoming greater to the end of the first week by 30-50% when compared to normal value and dropping to norm at the second week end and gamma-globulin content increasing from norm by 10-30% to the second or the third week, high inflammatory process activity is to be diagnosed. Albumin content dropping by 10-30% from normal value at the second week, alpha-2-globulins content growing by 10-20% of norm and gamma-globulin content dropping by 30-50% at the second or the third week when compared to norm, low inflammatory process activity is to be diagnosed.

EFFECT: high accuracy and reliability of diagnosis.

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