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GASTROENTEROLOGY
INVENTION
Patent of the Russian Federation RU2235325

METHOD FOR IDENTIFICATION OF INFECTIOUS ABSORBASE OF ABDOMINAL CAVITY AND METHOD OF TREATMENT OF DISEASES SUPPORTING WITH THE EXPOSURE TO THE ABDOMINAL CAVITY

METHOD FOR IDENTIFICATION OF INFECTIOUS ABSORBASE OF ABDOMINAL CAVITY AND METHOD OF TREATMENT OF DISEASES SUPPORTING WITH THE EXPOSURE TO THE ABDOMINAL CAVITY

The name of the inventor: M. Ardatskaya. (RU); Minushkin ON (RU); Ikonnikov N.S.
The name of the patent holder: Educational and Scientific Center of the Medical Center of the Presidential Administration of the Russian Federation (RU); Ardatskaya Maria Dmitrievna (RU); Minushkin Oleg Nikolaevich (RU); Ikonnikov Nikolai Sergeevich
Address for correspondence: 125315, Moscow, ul. Usievicha, 18, ap.163, M.D. Ardat
The effective date of the patent: 2002.08.26

The invention relates to the field of medicine, in particular, to gastroenterology, hepatology, surgery and gynecology. The method consists in determining the quantitative and qualitative composition of short-chain fatty acids in the sweat, which allows to verify its infection, to establish the qualitative composition of microorganisms for the purpose of antibacterial agent and to evaluate the effectiveness of the treatment. The technical result: the creation of a method for diagnosing the infection of the effusion in the abdominal cavity and the based method of treating diseases accompanied by effusion into the abdominal cavity (or small pelvis), which is highly accurate in verifying the infection of the effusion and anaerobic-aerobic populations of microorganisms causing infection in each case A sharp reduction in the time of obtaining the results.

DESCRIPTION OF THE INVENTION

The invention relates to the field of medicine, in particular to gastroenterology, hepatology, surgery and gynecology and can be used to diagnose an infected abdominal effusion in order to identify and identify microflora in ascitic fluid and treat diseases accompanied by effusion into the abdominal cavity for the selection of individual therapy Taking into account the received data.

A number of diseases that occur with an infected effusion in the abdominal cavity, for example spontaneous bacterial ascites-peritonitis, which is one of the variants of the primary bacterial peritonitis and involves the penetration of microorganisms into the abdominal cavity by hematogenous or lymphogenous pathway, is difficult to diagnose due to latent clinical symptoms, Timeliness of adequate therapy, in particular the prescription of antibacterial drugs. With another etiology of infection of ascites (the presence of an intra-abdominal cause of infection) treatment is prescribed immediately, but the selection of an antibacterial agent in such patients is sometimes carried out purely empirically, without taking into account the bacterial agents that can be represented by populations of microorganisms of the indigenous microflora. On the other hand, in some cases (for example, the rupture of the cyst of the corpus luteum with the formation of effusion in the abdominal cavity) into therapy, and antibacterial agents are included, which in this case are not shown, which leads to polypharmacy.

The most common way to diagnose bacterial ascites-peritonitis (or other infected effusions in the abdominal cavity or small pelvis) and choose a treatment is to bacteriologic examination of ascitic fluid (or effusion) in order to identify microorganisms, identify them and determine sensitivity to antibacterial agents. For this purpose, the ascendant is sown to nutrient media. Colonies of microorganisms grown on nutrient media subject to generic and species identification to determine their taxonomic affiliation and sensitivity to antibiotics. To do this, assess the possibility of bacterial growth under aerobic and anaerobic conditions, their relationship to Gram staining, growth patterns on selective nutrient media and inhibition by antibacterial agents, etc. (E. Javets, JL Melnik, EA Adelberg Manual on Medical Microbiology, translation from English, edited by Dr. TV Peradze, Moscow: Medicine, 1982, vol. 2, chapter 26, p. 273-292).

The drawbacks of this method are the duration of the results, the use of expensive nutrient media, the need for a sufficient amount of the test material (with the application of 1 ml of ascitic fluid to ordinary media, the sowing rate is only 43%, with the use of special vials for sowing, the sowing rate is 93%), the difficulty of anaerobic cultivation (Yu. Anshelevich, The Problem of Spontaneous Bacterial Peritonitis in Modern Medicine, Therapeutic Archive, No.2, 2000, pp. 69-70, AO Bueverov, Ascites as a Complication of Cirrhosis, Clinical Perspectives of Gastroenterology, Hepatology, 2001, No. 6, pp. 24-28.).

In addition, there is a method for diagnosing spontaneous bacterial ascites-peritonitis, based on a quantitative determination of the neutrophil count in the ascitic fluid. Spontaneous bacterial ascites-peritonitis is diagnosed with a neutrophil count of more than 250 per 1 mm cube. (Or more than 500 in 1 mm cube, regardless of the results of inoculation) and the absence of an intra-abdominal source of infection. (AO Bueverov, Ascit as complication of liver cirrhosis - Clinical perspectives of gastroenterology, hepatology, 2001, №6, pp. 24-28.)

The main drawback of this method, which can be considered as the closest analogue of the invention, is the non-specificity of the results obtained and the impossibility of individual selection of therapy.

It is an object of the present invention to provide a method for diagnosing an infected abdominal effusion, often found in gastroenterological, surgical and gynecological practice, and based thereon a method for treating diseases accompanied by effusion into the abdominal cavity (or small pelvis), highly accurate in verifying the infection of the abdominal cavity and anaerobically -aerobic populations of microorganisms that cause infection in each specific case, with a significant reduction in the time taken to obtain the results, but also to assess the need for prescribing antibacterial drugs and the effectiveness of the treatment in real time, at a low cost of the study.

The method is based on the determination of the quantitative and qualitative composition of short-chain fatty acids, which are metabolites of anaerobic and aerobic populations of the indigenous microflora. Short-chain fatty acids (C 2 -C 6 fractions) include acetic, propionic, isobutyric, butyric, isovaleric, valeric, isocaproic and caproic acids. The result, which can be achieved in the implementation of the method, is the high accuracy of the diagnosis of infection of the contents, the verification of anaerobic and aerobic populations of microorganisms from a small amount of the material under study at the speed of response (35 min), which leads to a timely and demonstrative prescription of antibacterial agents and Real-time treatment at a low cost of the study.

In our work, studies were performed in 32 patients with chronic hepatitis in the stage of cirrhosis with the syndrome of portal hypertension; In 3 patients with rupture of the cyst of the yellow body and in 2 patients with pelvioperitonitis.

The invention is based on the technical result revealed by us that when a total level of short chain fatty acids exceeding the content of 0.9 mg / g is detected in the ascitic fluid (or in the pelvic swelling), the infection of the abdominal cavity effusion (or small Pelvis). Detection of the level of short-chain fatty acids in the sweat less than 0.9 mg / g indicates the aseptic nature of the exudate. An increase in the percentage (percentage) of propionic and butyric acids in the qualitative composition of short-chain fatty acids indicates the presence of anaerobic microorganism populations in the exudate. According to our data, with increasing the percentage of propionic acid by more than 25% and decreasing the percentage of acetic acid by less than 50%, bacteria of the genus Bacteroides are present, with an increase in the percentage of butyric acid by more than 25% and a decrease in the percentage of acetic acid by less than 50% - bacteria of the genus Clostridium and Fusobacterium; The equilateral increase in propionic and butyric acids (more than 25% for each of these acids) and a decrease in the percentage of acetic acid below 50% indicates a mixed anaerobic flora. The prevalence of acetic acid and isomers of short-chain fatty acids is indicative of aerobic flora. In this case, the prevalence of acetic acid (more than 50%) indicates the presence of microorganisms of E. coli, aerobic streptococci and staphylococci; An increase in the percentage of acetic acid (more than 50%) and isomers of short-chain fatty acids (more than 15%) in the qualitative composition indicates the presence of aerobic populations of microorganisms with proteolytic activity in the exudate.

The choice of an antibacterial agent is carried out according to the obtained data on the level and composition of short-chain fatty acids, indicating the presence and nature of microorganism populations.

Against the background of effective antibacterial therapy, there is a change in the quantitative (decrease in the total content) and qualitative composition of short-chain fatty acids in the exudate.

THE METHOD IS PROVIDED AS FOLLOWS:

Patients with suspected infection of the abdominal cavity are exudate (0.5-1.5 ml) from the abdominal cavity (with paracentesis or under the supervision of ultrasound). The quantitative content and the qualitative composition of short chain fatty acids in the resulting contents are examined. According to the results of the study, a conclusion is made about the infection of exudate and the nature of microbial populations (as mentioned above). According to the data received, an antibacterial drug is prescribed. After the course of therapy, a repeated examination of the exudate is performed to evaluate the effectiveness of the treatment.

Below are examples of the definition of infection of the effusion of the abdominal cavity and small pelvis and the way of treating diseases accompanied by effusion into the abdominal cavity (small pelvis), which confirm the possibility of using this method, which is not limited to them.

Example 1

Patient L., 46 years old. Diagnosis: Chronic hepatitis in the stage of cirrhosis of the liver, moderate activity, Class B by Childe-Pugh. Portal hypertension (hepatosplenomegaly, varicose veins of the esophagus, ascites). He complained of pain in the abdomen, change in the nature of sleep (prolonged sleep, night insomnia), weakness, inhibition, changes in the nature and frequency of the stool (propensity to constipation).

From the anamnesis it is known: he considers himself sick since February 2002, when the weakness appeared and began to grow, the stomach increased in size. The present deterioration since May 2002, when abdominal pain has joined the above complaints. At admission: skin and sclera of icteric color. Pastogy of the anterior abdominal wall, shins is noted. Peripheral lymph nodes are not enlarged. In the lungs, the breath is hard. The sotons are clear rhythmic, no noise. The abdomen is enlarged in volume due to unstressed ascites, painful on palpation in the right hypochondrium, along the course of the large intestine. The liver is enlarged, protruding from the edge of the costal arch +5 cm. The spleen is not palpable.

Examination: a general blood test - erythrocytes 4.1 million, hemoglobin 145 g / l, leukocytes 7.9 thousand, platelets 194 thousand, lymphocytes 37% in 1 μl, ESR 15 mm / h. General analysis of urine - without pathology. Biochemical study: sugar 5.2 mmol / l, cholesterol 5.0 mmol / l, total protein 65.0 g / l, albumins 35.0 g / l, globulins 30 g / l, total bilirubin 50.4 μmol / l , Direct bilirubin 20.4 μmol / l, ALT 120 E / L, ACT 115 E / L, alkaline phosphatase 280 U / l.

Ultrasound examination of the abdominal cavity: the liver is enlarged - the right share is 17.7 ґ 14.5 cm (norm 15 ґ 12), the left share is 11.8 ґ 9.6 (the norm is 7 ґ 5). The structure is uniform, ehogennost uneven, intrahepatic vessels and bile ducts are not expanded. The portal vein is 1.4 cm (norm to 1.3), the splenic vein is 0.7 (the norm is up to 0.6 cm). The spleen is 310 cm 3 (the norm is up to 200). Gall bladder up to 34 ml 3 , the walls thickened, compacted. The pancreas and kidneys are without features. In the abdominal cavity there is a free fluid (ascites).

Esophagogastroduodenoscopy. Conclusion: Peptic esophagitis of the lower third of the esophagus. Varicose-dilated veins of the lower third of the esophagus. Superficial gastroduodenitis.

X-ray of the organs of the thorax and mediastinum: No focal and infiltrative changes were detected. Heart and blood vessels within the age limit.

Under the supervision of ultrasound, exudate (1.5 ml) from the abdominal cavity was sampled for quantitative and qualitative analysis of short-chain fatty acids.

In the study of ascitic fluid, the following changes were detected: the level of short-chain fatty acids is more than 5.76 mg / g, which indicates the infection of the ascites content of the abdominal cavity. In the qualitative composition of short-chain fatty acids, an increase in the percentage (62%) of acetic acid and the percentage (15%) of acid isomers was revealed, which indicates the prevalence of aerobic populations of microorganisms: E. coli, strepto- and staphylococci with proteolytic activity.

To the ongoing treatment, including hepatoprotective agents (essential 3 capsules per day), enzyme preparations (mezim forte of 3 others per day), aldosterone antagonists (veroshpiron 100 mg per day), diuretics (furosemide 0.04 g every other day), added Ampicillin 500 mg 4 times a day intramuscularly for 7 days.

On the background of therapy, improvement in the general condition of the patient, relief of abdominal pain syndrome, positive diuresis (+500 ml per day), decrease in the volume of the abdomen are noted.

A control study of ascites showed a decrease in the level of short chain fatty acids of more than 0.85 mg / g and a change in the qualitative composition of short-chain fatty acids: a decrease in the percentage (49%) of acetic acid and 5% of acid isomers, which confirms the effectiveness of the antibiotic therapy.

Example 2

Patient S., 57 years old. Diagnosis: Chronic hepatitis, mixed etiology (viral and alcoholic), in the stage of cirrhosis of the liver, mildly expressed activity, class C in Childe-Pugh. Portal hypertension (hepatosplenomegaly, varicose veins of the esophagus, ascites). Has arrived with complaints: on increase in volume of a stomach, a dyspnea or short wind, edemas of legs or foots, delicacy.

From anamnesis it is known: he considers himself ill about 4 years. Repeatedly she was hospitalized in hospitals with a diagnosis of cirrhosis of the liver. Treatment with hepatoprotective agents, aldosterone antagonists, diuretics was carried out. I did not take constant maintenance therapy. The present deterioration about a week, when intensively began to increase in the volume of the abdomen, dyspnea appeared, swelling increased. At admission: Skin and sclera of normal color and moisture. There is a swelling of the anterior abdominal wall, edema of the shins and feet. Peripheral lymph nodes are not enlarged. In the lungs, the breath is vesicular, weakened in the lower parts. Respiration rate 26 per min. Sotrons are muffled, rhythmic, no noises. Heart rate of 84 in min. The abdomen is enlarged in volume due to strained ascites. The liver is enlarged, stands out from under the edge of the costal arch of +7 cm. The spleen is not palpable.

Examination: a general blood test - erythrocytes - 3.9 million, hemoglobin 110 g / l, leukocytes 5.9 thousand, platelets 125 thousand, lymphocytes 35% in 1 μl, ESR 17 mm / h. General analysis of urine - without pathology. Biochemical study: sugar 5.5 mmol / l, cholesterol 3.3 mmol / l, total protein 61.0 g / l, albumins 32.0 g / l, globulins 29 g / l, total bilirubin 20.4 μmol / l , Direct bilirubin 5.1 μmol / l, ALT 42 E / L, ACT 39.5 E / L, alkaline phosphatase 245 U / l.

Ultrasound examination of the abdominal cavity: The liver is enlarged - the right share is 16.7 ґ 13.5 cm (norm 15 ґ 12), the left share is 10.5 ґ 7.6 (the norm is 7 ґ 5). The structure is uniform, echogenicity is uneven, intrahepatic vessels and bile ducts are not dilated. The portal vein is 1.5 cm (norm to 1.3), the splenic vein is 0.8 (the norm is up to 0.6 cm). The spleen is 290 cm 3 in volume (the norm is up to 200). Gall bladder - the walls are thickened to 0.3 cm, compacted. The pancreas can not be examined due to strained ascites. Kidneys without features.

Esophagogastroduodenoscopy. Conclusion: Varicose veins of the lower third of the esophagus. Superficial gastroduodenitis.

X-ray of the organs of the thorax and mediastinum: No focal and infiltrative changes were detected.

Under the supervision of ultrasound, exudate (1.0 ml) was taken from the abdominal cavity for quantitative and qualitative analysis of short-chain fatty acids.

In the study of ascitic fluid, the following changes were detected: the level of short-chain fatty acids in ascites fluid 0.34 mg / g indicates the aseptic nature of the exudate.

Taking into account the obtained data of laboratory-instrumental research methods and the results of the study of short-chain fatty acids in ascites content, it can be concluded that the severity of clinical manifestations is due to non-curable hypoalbuminemia.

To the treatment, including hepatoprotective agents (essential 3 capsules per day), aldosterone antagonists (veroshpiron 100 mg per day), diuretics (furosemide 0.04 g every other day), intravenous fluids of the albumin solution 10% -100 ml N7 were added.

On the background of therapy, the general condition of the patient, a positive diuresis (+500 ml per day), a decrease in the volume of the stomach and a decrease in the intensity of the edematous syndrome are noted.

Example 3

Patient M., 51 years old. Diagnosis: Chronic hepatitis in the stage of cirrhosis of the liver, moderate activity, Class B by Childe-Pugh. Portal hypertension (hepatosplenomegaly, varicose veins of the esophagus, ascites). Has acted with complaints: on a pain in a stomach, rise in a temperature of a body to 37,8 ° C, increase in volume of a stomach, a vomiting, diarrheas (up to 4 times a day). From the anamnesis it is known: he considers himself to be ill for 3 days, when after receiving large doses of alcohol he noted a sharp deterioration of the condition and the above complaints. At admission: Skin and sclera of icteric color. Pastogy of the legs and feet is marked. Peripheral lymph nodes are not enlarged. In the lungs, the breath is vesicular with a stiff hue. The sotons are clear rhythmic, no noise. The abdomen is enlarged in volume due to unstressed ascites, painful on palpation in the right hypochondrium, along the course of the large intestine. The liver is enlarged, protruding from the edge of the costal arch +2 cm. The spleen is not palpable.

Examination: a general blood test: erythrocytes 4.5 million, hemoglobin 155 g / l, leukocytes 8,1 thousand, platelets 310 thousand, lymphocytes 39% in 1 μl, ESR 13 mm / h. General analysis of urine: without pathology. Biochemical study: sugar 5.7 mmol / l, cholesterol 4.7 mmol / l, total protein 75.0 g / l, albumins 50.0 g / l, globulins 25 g / l, total bilirubin 45.8 μmol / l , Direct bilirubin 18.4 μmol / l, ALT 135 E / L, ACT 127 E / L, alkaline phosphatase 295 E / l.

Ultrasound examination of the abdominal cavity. The conclusion: hepatosplenomegaly. Portal hypertension, ascites. Esophagogastroduodenoscopy. Conclusion: Varicose veins of the lower third of the esophagus. Superficial gastritis. Erosive bulbite.

X-ray of the organs of the thorax and mediastinum: No focal and infiltrative changes were detected. Heart and blood vessels within the age limit.

Stool examination: no pathogenic bacteria of the intestinal group were detected.

Under the supervision of ultrasound, exudate (1.5 ml) from the abdominal cavity was sampled for quantitative and qualitative analysis of short-chain fatty acids.

In the study of ascites fluid the following changes were detected: the level of short-chain fatty acids - 5.1 mg / g indicates the infection of the abdominal cavity. In the qualitative composition of short-chain fatty acids, an increase in the percentage (29.2%) of propionic acid was observed with a decrease in the percentage of acetic acid 42%, which indicates the presence in the exudate of anaerobic flora represented by bacteria of the genus Bacteroides.

To the treatment, including hepatoprotective agents (essential 3 capsules per day), enzyme preparations (mezim forte of 3 others per day), aldosterone antagonists (veroshpiron 100 mg per day), diuretics (furosemide 0.04 g every other day), added Metronidazole 500 mg 3 times a day intravenously for 7 days.

On the background of therapy, improvement in the general condition of the patient, relief of abdominal pain syndrome, normalization of body temperature, positive diuresis (+350 ml per day), decrease in abdominal volume, normalization of frequency and character of stool are noted.

A control study of ascitic fluid showed a decrease in the level of short chain fatty acids more than 0.75 mg / g and a change in the qualitative composition of short chain fatty acids: a decrease in the percentage (22.3%) of propionic acid and an increase in the percentage (49%) of acetic acid, Antibacterial therapy.

The reliability of the method is confirmed when compared with a traditional bacteriological study. The sensitivity of the method is 94 ± 2%. Specificity of the method is 92 ± 2%. The reproducibility of the results is 96 ± 2%.

Thus, the proposed method for determining the infected effusion of the abdominal cavity and the based method of treating diseases accompanied by effusion into the abdominal cavity (or a small pelvis) allows to achieve high accuracy of verification of infection of the abdominal cavity and anaerobic-aerobic populations of microorganisms causing infection in each specific case From a small amount of the investigated material with a significant reduction in the time of obtaining the results, but also to assess the necessity and effectiveness of the treatment in real time, at a low cost of the study.

CLAIM

1. A method for determining an infected abdominal effusion, comprising examining an effusion, characterized in that the concentration of short-chain fatty acids is determined therein, while the concentrations of short-chain fatty acids are more than 0.9 mg / g about the infection of the abdominal effusion.

2. A method according to claim 1, characterized in that the qualitative composition of the short-chain fatty acids is determined.

3. Method according to claim 2, characterized in that the predominance of the percentage of propionic and butyric acids in the qualitative composition of short-chain fatty acids indicates the presence of anaerobic microorganism populations in the exudate.

4. A process according to claim 3, characterized in that an increase in the percentage of propionic acid of more than 25% and a decrease in the percentage of acetic acid of less than 50% indicates the presence of bacteria of the genus Bacteroides.

5. A process according to claim 3, characterized in that an increase in the percentage of oleic acid of more than 25% and a decrease in the percentage of acetic acid of less than 50% indicates the presence of bacteria of the genera Clostridium and Fusobacterium.

6. A process according to claim 3, wherein the equilateral increase in propionic and butyric acids (more than 25% for each of said acids) and a decrease in the percentage of acetic acid of less than 50% indicates a mixed anaerobic flora.

7. The method of claim 2, wherein the predominance of acetic acid and short-chain fatty acid isomers indicates the presence of an aerobic microflora.

8. The method of claim 7, wherein an increase in the percentage of acetic acid of more than 50% indicates the presence of microorganisms of E. coli genera, aerobic streptococci and staphylococci.

9. A process according to claim 7, characterized in that an increase in the percentage of acetic acid (more than 50%) and an increase in the percentage of short chain fatty acid isomers of more than 15% indicates the presence of aerobic populations of microorganisms possessing proteolytic activity.

10. A method for treating diseases accompanied by effusion into the abdominal cavity of the body, including puncture of the cavity and antibacterial therapy, characterized in that the punctate examines the concentration and qualitative composition of short-chain fatty acids, and antibacterial therapy is carried out with an increase in the concentration of short-chain fatty acids more than 0.9 mg / G and at the same time choose an antibacterial preparation in accordance with the flora, established according to the qualitative composition of short-chain fatty acids.

11. The method of claim 10, characterized in that during the treatment, its effectiveness is monitored in terms of the quantitative and qualitative composition of the short-chain fatty acids.

print version
Date of publication 29.03.2007gg