Diagnostic technique for infected pancreonecrosis with establishing indications for surgical intervention

FIELD: medicine.

SUBSTANCE: invention describes a diagnostic technique for infected pancreonecrosis with establishing the indications for a surgical intervention by examining a patient, wherein acetic, propionic, butyric and isovaleric acids are measured in the blood by gas chromatography, and if the acetic acid concentration is more than 0.11 mmole/l enables stating infected pancreonecrosis, and if the concentration of any of three acids: propionic more than 0.095 mmole/l, butyric more than 0.0035 mmole/l, isovaleric acid more than 0.0003 mmole/l enables stating infected pancreonecrosis with active development of an anaerobic infection requiring one of versions of the surgical intervention.

EFFECT: invention enables providing the objective and accurate diagnosing of pancreonecrosis transformation into the stage of infection by using the qualitative parameters with no undesired side effects.

2 ex

 

The invention relates to medicine, namely to surgery.

In recent decades, acute pancreatitis the rate of growth began to emerge on the first place among urgent surgical diseases. In 10-20% of cases the course of acute pancreatitis is severe destructive nature. The prognosis largely depends on the amount of necrosis of the pancreas and infection. Septic complications as a result of infection foci of necrosis remains a major cause of death. Identification of the transition of pancreatic necrosis in the infected form is carried out by clinical and laboratory data, markers of damage to the pancreas, the systems for assessing the severity of the patient, the results of instrumental methods of examination (Savel'ev V. S., Filimonov M. I., Burnevik S. Z. Pancreonecrosis. M: Honey. INF. AG, 2008. P. 36-49).

However, these criteria are not always specific and sensitive for the early diagnosis of infectious process. So up to the present time early diagnosis of infected pancreatic necrosis represents a significant challenge. Diagnostic errors in infectious complications of pancreatic necrosis occur in 40% of cases, leading to delay in the execution of surgical intervention, the development of sepsis and high mortality. Therefore, it is important RA�the development and introduction of new effective infection markers in a comprehensive diagnosis of infected pancreatic necrosis.

In recent years, much attention is paid to the definition of patients with various pathologies of the content of volatile fatty acids, which are metabolites of anaerobic and aerobic microorganisms. Method of gas-liquid chromatography for determining the concentration of volatile fatty acids in various biosubstrates features high accuracy, sensitivity, availability, and speed of obtaining results (minushkin., Ardatskaya M. D. Opportunities and perspectives for the study of short-chain fatty acids in the pathology of gastrointestinal tract for example, diseases of the intestines and organs of the hepatobiliary system // Clin. lab. diagnosis. 2004. No. 2. C. 19-20, 31-36).

Found that volatile fatty acids inhibit immune system, reducing the activity of the main links of the anti-infective protection: epithelial, tissue macrophages, T - and b-cells as well as intercellular interactions and the production of inflammatory mediators (Beloborodova N. In., Beloborodov CM. Metabolites of anaerobic bacteria and the reactivity of the microorganism // Antibiotics and chemotherapy. 2000. No. 2. Pp. 28-36).

Studies of the concentration of volatile fatty acids and other toxic metabolites by gas chromatography with mass spectrometry detection in biopsies of the pancreas and the blood proved the role of anaerobic non-clostridial infection in FLA�TII infected pancreatic necrosis. However, in the peripheral blood was examined only the total concentration of volatile fatty acids, which are metabolites only anaerobic microorganisms. Thus it was not defined the meaning of the individual volatile fatty acids, which are metabolites not only anaerobic but also aerobic microorganisms, which is also actively involved in the infection foci of pancreatic necrosis. Besides used complicated and inaccessible chromato-mass-spectrometric method. Therefore, determining the significance of the performance of individual volatile fatty acids for the timely diagnosis of infected pancreatic necrosis and the establishment of indications for an operative intervention to date was conducted.

The technical result of the offered method is achieved in that determine the content of acetic, propionic, butyric and isovaleric acids in the blood. When the acetic acid concentration is more 0,11 mmol/l establish the presence of infected pancreatic necrosis, and when the concentration of any one of three acids: propionic more 0,0095 mmol/l, more oil 0,0035 mmol/l isovaleric more to 0.0003 mmol/l to establish the presence of infected pancreatic necrosis with active development of anaerobic infections requiring one of the options of surgical intervention.

Avtolyubitelej gas chromatographic method for the concentration of acetic, propionic, butyric and isovaleric acids in the blood in patients with verified diagnosis of pancreatic necrosis. The authors found a statistically significant substantial increase in the average concentrations of these acids in the blood in patients with infected pancreatic necrosis compared with patients with sterile pancreatic necrosis (p<0,05). Most informative were the indicators M-m (the difference in mean concentrations and standard errors). They were selected as diagnostic criteria.

Comprehensive treatment in the ICU remains a priority in necrotizing pancreatitis. Performing surgery in sterile pancreatic necrosis is invalid because it often leads to serious complications. At the same time, despite ongoing conservative treatment, the transition to the stage of pancreatic necrosis infection can be a indication for minimally invasive or open extensive intervention, timely execution which largely improves the prognosis of this disease. To determine the indications for surgical treatment of infected pancreatic necrosis is ongoing research aimed at the development of the most informative criteria of timeliness and validity of the intervention.

Volatile fatty acids (VFA) are: TPU� the main bacterial products. They are therefore used as markers of infection. Leading role in the infection of pancreatic necrosis plays an aerobic-anaerobic Association of microorganisms entering through translocation from the gastrointestinal tract. Acetic acid is produced by aerobic and anaerobic flora, and propionic, butyric and isovaleric acids are primarily products of the metabolism of anaerobic bacteria. The beginning of infection of pancreatic necrosis is accompanied by an increase in the number of LFP in the affected lesions of the pancreas and in the blood. The level of LFP is possible to monitor the effectiveness of conservative treatment: a persistent decline in LFP indicates the effectiveness of exposure to areas of infection, and a further increase is about the progression of the infectious process. Therefore, determining the level of LFP, which are markers of infection may be diagnostic criterion stage of pancreatic necrosis requiring surgical treatment.

The method is carried out as follows. After a detailed examination and diagnosis of pancreatic necrosis on an empty stomach produce venous blood sampling from a peripheral vessel in a volume of 0.5 ml. Then on the background of the treatment over time (5-7 days and indications) are repeated blood samplings. Sample preparation includes the addition of UCF�the specified amount of blood 1 drop of 10% sulfuric acid. Gas-liquid chromatography for the quantitative determination of acetic, propionic, butyric and isovaleric acids is performed on a glass column (length 1 m, diameter 3 mm, filled with "Porapak" Q (USA) coated with phosphoric acid under isothermal conditions at a temperature of 200°C. the Chromatograph MESH, model 3700. The detector is a flame ionization detector, the carrier gas is helium. Identification and quantification of the acids was carried out using analytical standards.

The applied method enables the objectification stage of pancreatic necrosis and determines the algorithm further surgical treatment: continuation of intensive therapy or surgery. The use of this method improves the accuracy of diagnosis of infected pancreatic necrosis by quantitative parameters, and furthermore, this diagnosis does not entail complications.

To prove the accuracy of the diagnosis of infected pancreatic necrosis have compared the results obtained using the proposed method and the conventional methods. The diagnosis of pancreatic necrosis and its complications set in accordance with the modern domestic and foreign guidelines.

We examined 45 patients with confirmed diagnosis of pancreatic necrosis: 25 patients with sterile form of pancreatic necrosis and 20 patients inficirovannym pancreatic necrosis. In 26 patients performed various surgical procedures. The age of patients ranged from 21 to 72 years.

The proposed method has allowed to establish the transition to the stage of pancreatic necrosis infection of pancreatic necrosis in 19 of 20 patients (match final diagnosis was 95%).

Consequently, the concentration of acetic, propionic, butyric and isovaleric acids in the blood can be used for the diagnosis of transition to the stage of pancreatic necrosis infection. An example of applying the method in patients with sterile pancreatic necrosis.

Patient S., aged 24. Admitted to the hospital with a diagnosis of sterile pancreatic necrosis", parapancreatic infiltrate. Disease duration - 10 days: suddenly after drinking alcohol appeared intense pain in the upper abdomen, nausea, repeated vomiting, began to grow weak. With the onset of the disease was treated in RSD at the place of residence.

Ultrasound examination revealed changes in the pancreas in type of acute pancreatitis, the infiltrate in the projection of the omental Bursa and left the middle of the abdomen. Against the background of conservative therapy without improvement. The patient for further treatment directed to the Ivanovo regional clinical hospital.

At admission the General condition heavy, the complaints expressed weakness, moderate constant pain in�rhna the abdomen. Body temperature - 37,6° C, heart rate (HR) is 100 / minute, respiratory rate of 24 / minute, blood pressure (BP) is 140/80 mmHg.PT. On palpation, the abdomen is swollen, moderately painful and tense in the epigastrium and left hypochondrium, where palpable infiltration. In General, the analysis of a blood: erythrocytes - 4,1·1012/l, hemoglobin 114 g/l, leucocytes - 23,5·109/l (eosinophils - 4%, stab neutrophils - 2%, segmented neutrophils - 81%, monocytes - 3%, lymphocytes - 10%), toxic granularity of neutrophils +++, ESR - 30 mm/h. Amylase blood - 252 units, C-reactive protein - 100 mg/l. the Severity of the condition on a scale APACHE II - 11 points. With ultrasound, MSCT (with intravenous contrast) revealed a picture of a macrofocal with infiltrative necrotizing pancreatitis exudative component propagating in the region of the omental Bursa and left pararenal space with the transition to the region of the transverse colon with signs of summany fluid in these zones.

Also conducted to determine the content of acetic, propionic, butyric and isovaleric acids by gas chromatography in the blood. The following results are obtained: acetic acid 0.1 mmol/l, propionic - 0,0056 mmol/l, oil - 0,0025 mmol/l isovaleric - 0,00015 mmol/L. After the complex of intensive therapy, including in an intensive care Department�Oia, the patient's condition significantly improved: pain and fever disappeared, weakness decreased significantly. Decreased levels of amylase to 54 units and C-reactive protein of 5 mg/l, white blood cells to 5.5·109(eosinophils - 2%, stab neutrophils - 0%, segmented neutrophils - 63%, monocytes - 8%, lymphocytes - 27%). Ultrasound and CT-control positive dynamics visualized in the form of a significant reduction in infiltrative and exudative component, marked by the formation of the parapancreatic pseudocyst on the leading edge of the body and tail of the pancreas.

Re-examined the content of volatile fatty acids every 7 days, a significant reduction: acetic acid - up to 0.015 mmol/l, propionic - 0.001 mmol/l, oil - to 0,00052 mmol/l isovaleric - to 0,000077 mmol/L. the Patient was discharged on the 28th day in a satisfactory condition. Clinical, instrumental, laboratory, and chromatography data in a patient sterile form of pancreatic necrosis, confirming the results of the claimed method of diagnosis.

An example of applying the method in a patient with infected pancreatic necrosis.

Patient P., 38 years old. Transferred to the Ivanovo regional clinical hospital in the surgical Department of the NRB at the place of residence, where he was the medical�tion with a diagnosis of infected pancreatic necrosis, abscess of the omental Bursa". Disease duration - 12 days: after drinking alcohol for the first time noted the expressed pain in the upper abdomen zoster character, nausea, repeated vomiting. A day after the onset of the disease hospitalised in TSRB in serious condition with the clinic pancreatogenic shock. Was held conservative therapy, compared with 10 days the patient appeared febrile fever, began to increase abdominal pain and weakness. Ultrasound examination revealed liquid formation in the projection of the omental Bursa.

Upon admission to the Ivanovo regional clinical hospital the General condition heavy, the complaints of moderately expressed weakness, constant pain in upper abdomen, fever to 39.0° C with chills. Body temperature is 38.0° C, heart rate of 96 / minute, respiratory rate is 20-22 per minute, BP is 130/70 mm Hg.PT. On palpation, the abdomen is swollen, moderately painful in the epigastrium and left hypochondrium. In General, the analysis of a blood: erythrocytes - 2,86·1012/l, hemoglobin of 100 g/l, leucocytes - 19,8·109/l (eosinophils - 1%, stab neutrophils - 10%, segmented neutrophils - 78%, monocytes - 6%, lymphocytes - 11%), ESR - 56 mm/h. Amylase blood - 148, C-reactive protein - 152 mg/l. the Severity of the condition on a scale APACHE II - 12 points. MSCT (with intravenous contrast) revealed Subtotal picture of pancreatic necrosis with infiltr�tion parapancreatic tissue, encysted fluid in the omental Bursa, left-sided pleurisy.

Conducted to determine the content of acetic, propionic, butyric and isovaleric acids in the blood by gas chromatography. The following results are obtained: acetic acid and 0.29 mmol/l, propionic - 0,084 mmol/l, oil - 0,0042 mmol/l isovaleric - 0,00043 mmol/L.

Given the persistent hyperthermia and the ineffectiveness of conservative therapy, on the 3rd day after the transfer was urgently performed operation - DUJOTEKANA laparotomy, omentoplasty, necrosectomy, drainage and plugging stuffing bags and abdominal cavity. When interference is detected: abdominal effusion no, in the sphere of small and large glands - a large number of steatocranus. In the omental Bursa opened the abscess with purulent contents by volume to 800 ml. Large part of the body and tail of the pancreas nekrotizirovanne with sequestration, sequesters removed. The rest of the gland is increased in size, with areas of necrosis black, contact bleeding. Parapancreatic tissue with areas of necrosis and abundant thick purulent discharge. Conclusion: infected Subtotal pancreatic necrosis, parapancreatic abscess, abscess of the omental Bursa. The result of seeding of biopsy specimens of the pancreas: Escherichia coli, Bacteoides fragilis.

A day after surgery, a significant reduction in the concentration of volatile fatty acids in the blood: acetic acid - 0,11 mmol/l, propionic - 0,036 mmol/l, oil - 0,0019 mmol/l isovaleric - 0,00023 mmol/l At follow-up was performed five times remedial program relaparotomy with an interval of 2-3 days. Also in an intensive care unit was conducted a complex of intensive therapy, including the use of antimicrobial drugs: Meronem, ciprofloxacin, metrogyl (in relation to aerobic-anaerobic Association of microorganisms in the nidi). Marked by a gradual cleansing of necrosis, the wound was actively grained with scanty serous discharge. At last relaparotomy performed partial suturing of surgical wounds with drainage of the residual cavity. The patient's condition significantly improved: pain and fever disappeared. Decreased levels of amylase to 33% and C-reactive protein to 2 mg/l, white blood cells to 5.5·109/l (eosinophils - 1%, stab neutrophils - 2%, segmented neutrophils - 78%, monocytes - 6%, lymphocytes - 11%). Ultrasound and CT-control visualized positive dynamics in the absence of encysted fluid in the abdominal cavity and retroperitoneal space.

Repeated studies of the content of volatile fatty acids provodilis� every 7 days a significant decrease in the level of acetic acid - to 0,048 mmol/l, propionic - to 0,0058 mg/l, oil - to 0.0015 mmol/l isovaleric - up to 0.0002 mmol/L. the Patient was discharged from hospital on the 37th day in a satisfactory condition for outpatient therapy. Clinical, instrumental, laboratory, and chromatography data in a patient diagnosed as infected pancreatic necrosis with active development of anaerobic infection, which confirms the result of the application of the claimed method of diagnosis.

Therefore, the claimed method is objective and informative. Using the clinical signs of the disease and the concentration of acetic, propionic, butyric and isovaleric acids in the blood, it is possible to diagnose the infection foci of pancreatic necrosis.

This method allows to increase the objectivity and accuracy of diagnostics of the transition to the stage of pancreatic necrosis infection through the use of quantitative parameters without the appearance of undesirable side effects.

Method for the diagnosis of infected pancreatic necrosis with the establishment of indications for surgical intervention by examination of the patient, characterized in that the gas chromatographic method to determine the blood content of acetic, propionic, butyric and isovaleric acids, and at a concentration of at�ssnoi acid more 0,11 mmol/l establish the presence of infected pancreatic necrosis, and the same concentrations of any of three acids: propionic more 0,0095 mmol/l, more oil 0,0035 mmol/l isovaleric more to 0.0003 mmol/l to establish the presence of infected pancreatic necrosis with active development of anaerobic infections requiring one of the options of surgical intervention.



 

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EFFECT: higher efficiency and accuracy of detection.

3 ex

FIELD: medicine, gastroenterology.

SUBSTANCE: it has been suggested a new method to detect pharmacological sensitivity to preparations as acidosuppressors. After the intake of the preparation a patient should undergo fibrogastroduodenoscopy 3 h later, then, through endoscopic catheter one should introduce 0.3%-Congo red solution intragastrically and the test is considered to be positive at keeping red color that indicates good sensitivity to the given preparation, and in case of dark-blue or black color the test is considered to be negative that indicates resistance to this preparation. The suggested innovation widens the number of diagnostic techniques of mentioned indication.

EFFECT: higher efficiency of diagnostics.

2 ex

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