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INVENTION
Patent of the Russian Federation RU2140632
METHOD FOR PREDICTION OF BLEEDING RECURRENCE FROM DUODENAL LAW
The name of the inventor: Korytsev V.K.
The name of the patentee: Korytsev Vladimir Konstantinovich
Address for correspondence: 443100, Samara, Novo-Sadovaya str., 8, ap. 108, Korytsevu V.K.
Date of commencement of the patent: 1998.05.18
The invention can be used in medicine, namely, in surgery. Define diagnostic criteria: localization and size of the ulcer, characteristic of the bottom of the ulcer, severity of blood loss by AI Gorbashko, indices of systolic arterial blood pressure, the presence of a history of ulcer and gastrointestinal bleeding in the past, the sex and age of the patient, Rh-factor of blood and The sum of 11 points and above, calculated according to the well-known Bayes formula, a bleeding recurrence is predicted. The method provides increased accuracy of prediction.
DESCRIPTION OF THE INVENTION
The invention relates to medicine, namely, to surgery, and can be used in the treatment of patients with ulcerous duodenal bleeding.
There is a known method for predicting bleeding from duodenal ulcers (Park KGM, Steele RJC, Mollison J. et al., Prediction of recurrent bleeding after endoscopic haemostasis in non-variceal upper gastrointestinal haemorrhage, Brit J. J. Surg., 1994.-Vol. 81 .-N10.-P. 1465-1468), which is based on the analysis of three factors: the localization of the ulcer on the back wall of the duodenum, the obesity of the patient, the pulse rate in the patient upon admission.
The disadvantage of this method is that the authors give a low accuracy of evaluation ("more than 50%") of the probability of bleeding recurrence and do not take into account in the forecasting such important parameters as the size of the ulcer and the characteristic of the bottom of the ulcer. In a patient with a duodenal ulcer of 0.5 cm in diameter covered with fibrin, the probability of bleeding is low, even if it is obese and when he receives it, tachycardia is noted as a response to the transferred blood loss.
Another method for predicting bleeding from duodenal ulcers (Grinberg AA, Zatevakhin II, Schegolev AA Surgical tactics for ulcerative gastroduodenal bleeding - M., 1996) is taken by us for a prototype.
The essence of this method is reduced to the analysis of three integral indicators: the size of the ulcer, the intensity of bleeding, the characteristics of the bottom of the ulcer. According to the authors, the critical size of the duodenal ulcer, at which the frequency of repeated bleeding increases, is 0.8 cm. The second parameter, which is dangerous for recurrence of bleeding, suggests a high bleeding intensity. To characterize the bottom of the ulcer, it is recommended to take into account the following symptoms: a visible arthro-vessel in the bottom of the ulcer or the use of endoscopic methods to stop bleeding. If the patient has two of the three parameters proposed for analysis, the probability of a repeat bleeding is high (96%) and the patient should be operated urgently.
The disadvantage of this method is that such an important indicator as localization of an ulcer is not taken into account. A patient with two factors out of three - the intensity of bleeding and the size of the ulcer 0.8 cm or more, - with localization of the ulcer on the front wall may have a low probability of recurrence of bleeding. And operations in a deferred order have better results than operations in an emergency. Therefore, patients with a low probability of recurrence of bleeding are preferable to operate (if there are indications) in a delayed manner.
It is an object of the present invention to improve the accuracy of the prediction of rebleeding in patients with duodenal ulcers.
The essence of the present invention is that each patient is elucidated having a history of ulcer, gastrointestinal bleeding in the past, the sex and age of the patient, performing fibrogastroduodenoscopy with the definition of ulcer localization and size, ulcer bottom characteristics, measuring the systolic blood pressure, Blood loss by AI. Gorbashko and Rh-factor of blood. Each estimated indicator - diagnostic criterion (Dk) - corresponds to the number of points depending on its effect on the probability of repeated bleeding, which was calculated according to the Bayes formula (Gubler EV Mathematical methods of analysis in the recognition of pathological processes - L .: Medicine, 1978) 
Where a is the number of cases of unreliably stopped bleeding in the presence of this symptom; B - total number of cases of unreliable bleeding; C - the number of cases of reliably stopped bleeding in the presence of this sign; D - total number of cases of reliably stopped bleeding.
The obtained DK was rounded to within 1 point. The probability of recurrence of bleeding in the patient was calculated as a percentage, depending on the sum of the points obtained as a result of the addition of Dk.
Diagnostic criteria for determining the likelihood of recurrence of bleeding from duodenal ulcers are presented below:
1. Localization of the ulcer: posterior wall (+) 4 points
Front wall (-) 3 points
"Mirror" ulcers (-) 8 points
2. Size of the ulcer: 10 mm or more (+) 3 points
6-9 mm (-) 1 point
Not more than 5 mm (-) 5 points
3. Characteristics of the bottom of the ulcer: thrombus (+) 2 points
Fibrin (-) 6 points
4. Severity of blood loss: severe (+) 5 points
Average (+) 1 point
Easy (-) 10 points
5. Intensity of hemorrhage: AKD not more than 100 mm Hg. Art. (+) 4 points
AKD 101-120 mm Hg. Art. 0 points
More AKD 120 mm Hg. Art. (-) 1 point
6. Stomach ulcer: yes (+) 1 point
No (-) 1 point
7. Gastrointestinal bleeding in the past: yes (+) 1 point
No 0 points
8. The patient's age: 41-60 years (+) 1 point
Over 60 years old 0 points
Up to 40 years (-) 1 point
9. Sex of the patient: male 0 points
Female (-) 1 point
10. Rh-factor of the patient's blood: Rh (-) (+) 1 point
Rh (+) 0 points
At the sum of points:
А) 11 and more - the probability of bleeding recurrence is 90.2%. An urgent operation is indicated;
B) from 0 to 10 points - the probability of recurrence of bleeding is 36.2%. Repeated prognosis is shown the day after admission to hospital if bleeding does not continue.
C) less than 0 points - the probability of bleeding recurrence is 2.7%. Conservative treatment was shown.
If there is a visible ulcer in the posterior wall of the duodenum, covered with a loose thrombus, the indications are given for urgent surgery without determining the probability of bleeding recurrence according to the sum of the diagnostic criteria (Dobosz M., Babicki A., Marczewski R. et al. Bleeding duodenal peptic Ulcer: injection versus operation // Brit J. Surg .- 1993. - Vol. 80.-9, Suppl. -S. 82-82.), Since in this situation there is a 100% chance of rebleeding.
Example. Patient K., a 54-year-old man entered urgently into the city hospital N1 with complaints of weakness, dizziness, melena, vomiting coffee grounds. There was a brief loss of consciousness. These symptoms appeared a little over 1 day ago. Ulcerous anamnesis in the patient is absent, gastrointestinal bleeding in the past denies. Blood pressure = 120/80 mm Hg. V., Pulse 104 beats per minute. At admission the patient had the following indicators of red blood: hemoglobin 70 g / l, erythrocytes 2300000 in 1 μl. When the endoscopic examination revealed an ulcer of the posterior-upper wall of the duodenum with a diameter of 10 mm, covered with a loose thrombus, there was no bleeding at the time of examination of the data. The patient was diagnosed with: exacerbation of duodenal ulcer, complicated by bleeding with severe blood loss. The probability of bleeding recurrence was assessed. The score was (+) 13 points, the probability of recurrence was 90.2%; Bleeding was found unreliable stopped. Preoperative preparation has begun, including the introduction of hemostatics, transfusion of 5% glucose and Ringer solutions. The patient was transfused with 800 ml erythrocyte mass in order to replenish blood loss and 100 ml anti-hemophilic plasma A (2) Rh (+) with a hemostatic purpose. After the preoperative preparation, the patient is immediately taken to the operation. The operation revealed an ulcer of the posterior wall of the duodenum about 10 mm in diameter, penetrating into the pancreas. The operation of a 2/3 resection of the stomach according to Bilrot-1 with a termolateral anastomosis was performed. The postoperative period proceeded without any peculiarities, the wound healed by primary tension. The patient was discharged in a satisfactory condition on the 10th day.
This method was developed on the experience of treatment of 539 patients with duodenal ulcer bleeding, of which 101 people were operated.
The proposed method determines the probability of recurrence of hemorrhage from duodenal ulcers in patients of the 6th and 7th surgical departments of the Samara City Hospital N1 named after I. NI Pirogov, which is the center for the treatment of patients with gastrointestinal bleeding.
Clinical approbation of the method showed that in all cases of application it allows predicting repeated bleeding with great accuracy (90.2%) and avoiding operations for bleeding recurrence, which give the highest mortality rates.
Thus, the use of the proposed method for predicting bleeding recurrence from duodenal ulcers allows to improve the results of treatment of patients with bleeding duodenal ulcers, to reduce the rates of postoperative lethality in this group of patients, to reduce the economic costs of treatment by reducing the average bed / day and reducing the number of transfused blood and Its components in order to replenish blood loss.
CLAIM
A method for predicting the recurrence of bleeding from a duodenal ulcer, which includes determining the size of the ulcer, the characteristics of the bottom of the ulcer, the intensity of bleeding, which is further characterized by the localization of the ulcer, the severity of blood loss by AI. Gorbashko, ulcer history, gastrointestinal hemorrhage in the past, sex, patient's age, Rh-factor of the blood, and then calculate the sum of all diagnostic criteria, calculated according to the well-known Bayes formula, and with an amount equal to 11 and more, predict a relapse of bleeding And put the testimony to urgent surgical intervention.
print version
Date of publication 28.03.2007gg
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