RU2393760C1 - Method of early diagnostics of chronic ischemia of large intestine in case of atherosclerotic lesion of inferior mesenteric artery - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to medicine, namely to angiologia and proctology, and is intended for early diagnostics of chronic ischemia of large intestine in case of atherosclerotic lesion of inferior mesenteric artery. Ultrasonic angioscanning of inferior mesenteric artery and fibrocolonoscopy with simultaneous biopsy of large intestine are carried out. In case of stenosis higher than 20% of IMA diametre and development of atrophic colitis in tissue components of mucous membrane of large intestine diagnosis is made. ^ EFFECT: method allows to specify diagnostics of ischemic lesion of large intestine in case of atherosclerotic lesion of inferior mesenteric artery at early stage of disease. ^ 2 tbl, 3 ex

Description

The invention relates to medicine and relates to methods for examining patients in angiology and proctology.

In recent years, interest in ischemic lesions of the colon has increased, due to the prevalence of vascular diseases. Many facts have accumulated that indicate the etiology and pathogenesis of vascular disorders of the colon and give criteria for their recognition. Nevertheless, this pathology is more common than diagnosed.

An increase in the number of operations on the abdominal aorta, ligation of the inferior mesenteric artery during resection of the rectum for cancer, the use of certain medications (digitalis, ephedrine, adrenaline, penicillin, streptokinase, extrogen-containing contraceptives, etc.) affect the frequency of colon ischemia [9]. Ischemia of the left half of the intestine after planned, reconstructive operations on the aorta is 4.4-10%, with mortality ranging from 10% to 25% [4].

Chronic colon ischemia (CITC) has been reported in the literature from various perspectives, but some aspects remain unexplored: the severity of clinical manifestations, morphological changes in the colon mucosa depending on the degree of stenosis of the inferior mesenteric artery (NBA). Therefore, the search for new methodological possibilities for verification of chronic colon ischemia is especially relevant for operations on the aorta, visceral arteries, and colon. The diagnosis of ischemic colitis is possible according to one medical history, when this is a typical case. Thus, N. Buchart-Hansen (1977) found that only 16.6% of patients were diagnosed with chronic digestive ischemia at the first in-patient examination (the diagnosis of CTC is even less common when a patient first visits the hospital). In other cases, this diagnosis was established only after repeated examinations in search of various functional and organic diseases of the abdominal organs. Usually, patients “do” several examination options to a specialized vascular hospital, which is why a different interpretation of the disease is caused:

1) prolonged, repeated diagnostic searches of well-known non-malignant processes in the digestive organs with unsuccessful standard conservative, sanatorium-resort therapy and nonetheless progressive course of the disease;

2) a long examination and often trial laparotomy regarding a suspected malignant neoplasm of the organs of the gastrointestinal tract (however, even during the operation, the visceral arteries are not examined, the diagnosis remains unclear);

3) due to the mismatch of the presented complaints and objective data with known diseases of the gastrointestinal tract, patients are classified as patients with an abdominal form of psychoneurosis;

4) the clinical picture characteristic of distal colopathy, due to occlusion of the inferior mesenteric artery, is associated with the natural involution of the body, aging and age-related features.

5) atrophy of the mucous membrane of the colon with atherosclerotic lesions of the inferior mesenteric artery in the domestic literature is not considered as a manifestation of the stage of subcompensation of HITK [6; 10].

All this requires close attention to this problem.

Known methods for the diagnosis of chronic colon ischemia, combining general clinical examination, fibrocolonoscopy for macroscopic evaluation of the mucosa and biopsy for morphological studies, intestinal mucosal thermometry, radioisotope indication, long-term colon fluoroscopy, radiography, doppler ultrasonography, and aortic angiography of the aorta mesenteric artery.

The classic manifestation of abdominal ischemia is pain: pain occurs 20-25 minutes after eating and lasts 2-2.5 hours. This is typical for the defeat of all three visceral arteries, for the lower mesenteric artery pain occurs only in 8% of cases. NBA lesions are characterized by localization of pain in the left iliac region, pain decreases with a sharp restriction of food intake (small food syndrome). With mesenteric artery occlusion in 70% of cases, intestinal dysfunction occurs, and with damage to the lower mesenteric artery, evacuation from the colon is impaired. At first, this manifests itself in the form of an unstable stool, then diarrhea is replaced by constipation. In the future, bloating appears, the stool becomes unformed, contains poorly digested food, mucus (Dick, Gregg, 1972; Rau, 1973). Against the background of "small food syndrome", a violation of the secretory and absorption functions of the intestine, progressive weight loss of the patient develops. Since blood supply to the colon is provided by the collateral connections of three rather large vascular collectors - the superior mesenteric, inferior mesenteric, and internal iliac arteries, an isolated chronic lesion of blood flow through the inferior mesenteric artery can occur without vivid clinical manifestations. Clinical manifestations occur with simultaneous damage to the mesenteric arteries or the lower mesenteric and iliac arteries, which leads to the failure of collateral circulation [1]. Therefore, the clinical picture and complaints of the patient are very variable, the syndrome of chronic abdominal ischemia can be leveled due to the predominance of ischemic manifestations from other affected arterial pools. For example, a combined lesion of the inferior mesenteric artery, terminal aorta (occlusion, stenosis, aneurysm) and iliac arteries are observed in 69.3% of patients with lesions of the visceral arteries. In fact, this is Lerish’s syndrome, supplemented by an intermittent symptom of chronic blood flow insufficiency in the lower mesenteric artery - colopathy (pain in the left abdomen, diarrhea, constipation or their alternation) [5].

Of the special research methods, panoramic radiography is used. The diagnosis becomes clear when a thumbprint is determined against a background of intestinal loops filled with gas [12; 24]. Studies with barium enema are considered by some authors as one of the most valuable methods for the diagnosis of ischemic colitis [12]. The changes detected by irrigoscopy depend on the stage of the disease: thumbprint, destruction of the mucosa, strictures of various lengths, obliteration of the lumen of the colon for several weeks, the formation of sacs [12]. In a healthy person, barium suspension fills the jejunum after 25-30 minutes, the ileum after 1.5-2 hours, the cecum after 3-4 hours, and the entire colon after 24 hours. Typically, the ascending colon is filled after 4-6 hours, the transverse colon after 10-12 hours, the descending colon after 16-18 hours, the sigmoid and rectum after 20-24 hours, complete emptying occurs after 48-72 hours. In case of impaired evacuation function, they speak of dyskinesia of the colon, which can occur both in terms of hypo-and hyperevacuation type [14]. The presence of dyskinesia in a patient is not the only and pathognomonic sign of HITK, and fluoroscopy takes time to evaluate the final results of the study.

X-ray contrast arteriography (RCAG) is a classic method of visualizing the aorta and its branches. The angiographic picture in chronic abdominal ischemia syndrome is determined by signs of damage to the visceral arteries themselves and symptoms that characterize collateral circulation. The main indisputable signs of abdominal atherosclerosis are: incomplete filling of the lumen of blood vessels, their deformation, the presence of filling defects in the form of an hourglass, the S-shaped curvature of the abdominal aorta and the pitting of its contours, the expansion and increased tortuosity of its visceral branches [16]. Atherosclerosis of the inferior mesenteric artery is characterized by a change in the initial segment of the artery, the distal bed, as a rule, remains free. Along with these direct signs of damage, indirect signs, in particular, symptoms of collateral circulation, are of great importance. With occlusion of the inferior mesenteric artery, the blood supply comes from the Riolan arc, which functions in this case in the caudal direction. First, the superior mesenteric artery contrasts, and then the branches of the inferior mesenteric artery. With isolated occlusion of the inferior mesenteric artery, a rectal-mesenteric anastomosis can be detected. An angiographic study makes it possible to establish the correct diagnosis. Although modern RCAG is generally considered a safe method, the procedure is not without risk and discomfort for patients [8, 9, 17, 18, 19]. Possible complications are bleeding, pseudo-aneurysm, stratification of the artery wall, infection, thrombosis, arteriovenous fistula, which in some cases requires surgical treatment. Systemic side effects on contrast iodine-containing substances can manifest as anaphylactic reactions, angina pectoris and heart failure, contrast-induced renal failure.

Its temperature depends on the level of blood supply to the intestinal mucosa, the measurement of which allows you to indirectly evaluate blood flow in the organ under study. Normally, the temperature of the mucous membrane in the region of the splenic bend is 37.46 °, in the region of sigma and rectum 37.88 ° and 37.74 °, respectively [3; fifteen]. According to V.V. Murashko et al. (1982) in patients with systemic atherosclerosis revealed a statistically significant decrease in mucosal temperature in all studied areas. When conducting a test with nitroglycerin, the authors note a mild temperature effect on the nitroglycerin sample. In the control group, the temperature of the colon mucosa during the nitroglycerin test increases by 0.87 ° +/- 0.10 °, in patients with atherosclerosis and chronic colon ischemia, the temperature of the mucosa after taking nitroglycerin increases by a maximum of 0.18 ° +/- 0 , 05 ° (p. <0.01). For this pathology, too small changes in the temperature of the large intestine mucosa are noted so that they can be determined by existing contact sensors. In addition, the contact temperature measurement method does not exclude the functional effect (for example, food load) on the vascular system of the device’s sensors themselves, which may lead to some deviation of the obtained indicators from the true temperature.

The endoscopic method used to diagnose colon damage is colonoscopy. Fibrocolonoscopy, giving a clear macroscopic picture, can have a number of complications, the most formidable of which is perforation of the colon, in addition, this method does not allow to assess the state of the vascular bed of the large intestine. The importance of early colonoscopy for any patient in the elderly age group in the presence of abdominal pain, the discharge of blood from the rectum is obvious. Characteristic changes in the mucosa quickly subside and the diagnosis may remain unclear if the study is performed late. Endoscopic manifestations in the early stage are characterized by edematous and hemorrhagic segmental inflammatory foci, above and below which the normal mucous membrane is detected. Inflammatory foci are scattered in the affected area. In moderate cases, petechial rashes are determined against the background of a pale mucosa or limited areas of hyperemia, which may be the only manifestation of the pathological process. Polypoid formations are often determined. In the early stages, small ulcers surrounded by a protruding mucosa are sometimes detected, and exudative inflammation predominates in the center of the ulcers. Three endoscopic features were emphasized by Dawson (1971): discoloration to black in small areas of the mucous membrane, a clear boundary between normal and pathological mucosa, little or no bleeding during biopsy. Endoscopic manifestations change rapidly, inflammatory changes subside soon and often without a trace. Within a few days, polypoid bulges disintegrate and leave behind small ulcers, which are restored completely or with minor scars [25, 26, 27].

Morphological changes in chronic colon ischemia are of a different nature, depending on the phase of the process. Thus, the histological picture of ischemic colitis in the acute phase is characterized by desquamation and necrosis of the mucosa, hemorrhages or macrophages containing hemosiderin in its own plate of the mucosa, vascular thrombosis [2, 12, 24, 27, 30]. The following endoscopic signs are characteristic of atrophic colitis: vascular pattern in the form of angiomatous asterisks, with a biopsy, the mucosa does not reach forcepts, mucosal soreness, swelling, and vascular pattern are strengthened [28].

Microscopically atrophic colitis is manifested: a flattening of prismatic epithelium, a decrease in the number of crypts, and hyperplasia of smooth muscle elements. Histolymphocytic infiltration and proliferation of connective tissue predominate in the mucous membrane; in some cases, epithelizing and scarring ulcers are found. Atrophy of crypts, hyalinosis of the lamina propria mucosa, inflammatory cell infiltration, submucosal fibrosis are found in the chronic phase of colon ischemia [30]. Histological changes are often limited only to the mucous membrane, but can cover the entire thickness of the intestinal wall. Along with typical hemorrhages, there are phenomena similar to membranous and pseudomembranous colitis, in which pathological changes are in the form of spots. A biopsy is important, but not specific for ischemic colitis: glandular distortion, fibrosis of the lamina propria and submucosa persist. Later, macrophages rich in hemosiderin are determined. Mucosal changes in ischemic colitis are signs of mucosal atrophy [25, 26, 27].

Expanding our knowledge about the nature of the various clinical forms of colon ischemia allows us to diagnose them in the early stages of the disease before the secondary infection, masking the manifestations of the vascular process.

As a prototype, a method of ultrasonic assessment of the vascular bed of the inferior mesenteric artery was taken. Ultrasonic duplex scanning is a measurement of the length, diameter, thickness of the vessel wall, determination of the lumen of the vessel and its degree of narrowing, detection of the presence or absence of atherosclerotic plaques in the lumen of the artery, patency of the vessel, measurement of linear and volumetric blood flow velocities, determination of the type of blood flow, calculation of the vascular resistance index walls [8, 9]. This technique is a non-invasive research method; it is not inferior in accuracy and visualization to x-ray methods for studying the vascular bed [17, 18, 19]. The undoubted advantage of ultrasonic methods is safety, widespread prevalence. High-resolution duplex scanning with color mapping of blood flow allows non-invasive clarification of the etiology, localization and with a high degree of accuracy to judge the hemodynamic significance of vascular lesions. The disadvantage of duplex scanning is the impossibility of assessing the state of the entire vascular system as a whole: information is composed of its individual sections with a length of not more than 1 cm.There are certain difficulties associated with the deep location of the vessel, the presence of interference, and the large length of the vascular bed. Nevertheless, duplex scanning allows for the development of optimal patient treatment tactics at the prehospital stage.

The purpose of the invention: improving the method for early detection of chronic ischemia of the colon.

This goal is achieved by the fact that when implementing the method of early diagnosis of chronic colon ischemia with atherosclerotic lesions of the NBA, ultrasonic angioscanning of the mesenteric artery and fibrocolonoscopy are performed with simultaneous biopsy of the colon mucosa and with stenosis of more than 20% of the diameter of the NBA and the development of atrophic changes in the tissue components of the mucous membrane of the colon a diagnosis of chronic colon ischemia is made.

Blood flow in the inferior mesenteric artery was recorded by ultrasonic duplex scanning on a Toshiba, SSH-140A apparatus using sensors with a radiation frequency of 3.5 MHz and 7.5 MHz. In the literature available to us, we did not find data on the length, diameter, thickness of the vascular wall of the NBA, determined by the ultrasound scan, but in accordance with the X-ray studies of Puddle (1964), the length of the inferior mesenteric artery is 4.2 cm (2.0-7 , 3), its diameter is 3.3 + \ - 0.06 mm (from 3 to 5 mm). The resistance index in persons not suffering from vascular diseases is 0.959 + \ - 0.045. This indicator characterizes the elasticity of the vascular wall, its calculation is possible only with a constant main type of blood flow. Data on linear and volumetric blood flow velocities are scarce and are given on a statistically unreliable number of studies [19].

In addition, in connection with the increase in the number of operations on the colon and abdominal aorta, the severity of morphological changes in the colon mucosa depending on the size of stenosis of the NBA is of practical interest. The erroneous determination of the boundaries of the colon resection against the background of impaired blood flow in the NBA leads to repeated surgical interventions in connection with the ongoing necrosis and divergence of the anastomosis sutures. Therefore, an assessment of the state of blood flow in the NBA and the microvasculature of the colon mucosa will help improve the results of surgical treatment of this category of patients. The need for such a proposal is due, first of all, to the difficulties in the early diagnosis of patients with chronic colon ischemia, who often perform unnecessary or uninformative studies and that this pathology is not well known to a wide range of medical practitioners.

The method is as follows. An ultrasound study of NBA and fibrocolonoscopy with a biopsy of the colon mucosa was performed after a preliminary diagnosis of chronic colon ischemia was established on the basis of an anamnesis and general clinical examination methods.

Ultrasound of the inferior mesenteric artery is performed on an empty stomach or 4 hours (3-6 hours) after a meal. Peristaltic waves that occur after eating interfere with the study. With constipation, flatulence, additional preparation of the patient for research is sometimes required (adhering to a non-slag diet, cleansing enemas).

The main signs of NBA damage in ultrasound surgery are compaction and thickening of the artery wall, an increase in the index of resistance of the vascular wall, the presence of atherosclerotic plaques, incomplete staining of the lumen of the vessel with ultrasound Doppler mapping, a change in the spectrum of the Doppler curve and a change in the type of blood flow (trunk, retrograde, collateral).

The degree of stenosis of the NBA was evaluated by the ratio of the difference between the diameter of the distal located portion of the artery (max d) and the diameter of the stenosed portion of the artery (min d) to the diameter of the distal located portion of the artery (max d), determined using duplex angioscanning according to the formula [8]:

For the endoscopic method, an Olympus colonofibroscope of the GF type 30L model, length 130 cm, was used, which allows examining the colon to the baugin flap. The study requires the preparation of the intestine. The patient is prescribed a non-slag diet, cleansing enemas, laxatives (preferably castor oil on the eve of the study). Duration of preparation and regimen are selected individually, taking into account clinical manifestations. We used the scheme for preparing patients for colonoscopy with the Fortrans drug proposed by the State Center for Coloproctology of the Ministry of Health of the Russian Federation.

ON THE DAY BEFORE THE STUDY: from 15 to 17 hours the patient takes 2 single-dose packs of the drug, the contents of each bag are diluted in one liter of water, and all the liquid is drunk for 2 hours, approximately one glass every 10 minutes. Around 19 hours, the stool will become liquid and you can take a light dinner (semolina, fruit jelly), by 21-22 hours the urge to defecate caused by a bowel contraction ceases. At this time, you can drink any amount of liquid without restriction (water, herbal tea).

ON THE DAY OF THE STUDY: from 7 to 9 hours on an empty stomach, you need to drink 2 liters of the drug, diluted in water, as well as the day before. Colonoscopy is performed on an empty stomach, you need to refrain from smoking on the day of the study.

During fibrocolonoscopy, the tone of the intestinal wall, the diameter of the lumen, the elasticity of the intestinal wall, gaustration, the height of the folds, the activity of peristalsis, vascular pattern, mucous membranes, the presence of pathological formations, ulcers, erosions, diverticula, bleeding are assessed. A biopsy is performed from the area of the splenic angle, sigmoid and rectum. The preparations are fixed in a 10% pH neutral, buffered formalin solution, followed by staining with hematoxylin-eosin, alcian-blue and stating the SIR reaction.

Examples of the method:

Example No. 1. Patient K., 69 years old, patient No. 2253 was hospitalized in the surgical department with complaints: "intermittent claudication" after 100 m, pain in the right thigh, gluteus, more on the right. A history of gastrectomy for gastric ulcer, right sympathectomy. Upon receipt of dry gangrene 3 fingers of the right foot. There is no ripple in the peripheral arteries from the level of the femoral artery on the right.

Doppler ultrasound of the aorta and NBA: the aorta in the proximal region with a diameter of 2.1 cm in the bifurcation zone of 1.6 cm, narrowed in s / 3 due to atherosclerotic plaques to 1.3 cm. NBA in diameter of 3.4 mm in the area of the mouth, on 3.8 mm long, in the initial section bent at an angle of 90 degrees, the walls are densified, thickened, there are no atherosclerotic plaques in the lumen. The length is 4.2 cm. The main bloodstream is 0.98-0.08 m / s. The resistance index is 0.918. Narrowing due to thickening of the walls and kink of less than 20% (10.5%). According to the ultrasound scan of the arteries of the lower extremities, stenosis-occlusion of the right popliteal artery. Right BOTH is narrowed by 23-25%, PBA on the right by 23%, the type of blood flow is main. Left BOTH is narrowed by 59%.

Clinical diagnosis: Obliterating atherosclerosis of the vessels n / a. Dry gangrene 3 fingers of the right foot. Stenosis-occlusion of the right popliteal artery. KHAN III Art. Hemodynamically insignificant stenosis of NBA (less than 20%).

Fibrocolonoscopy: examination to the dome of the cecum, in the lumen and on the walls of the stool. Rectum: the tone of the sphincters is not broken. The mucous membrane is hyperemic, thinned, the crypts are smoothed, the vascular pattern throughout is strengthened. Folds are thinned throughout the colon. The sigmoid colon is of normal size. The folds are thinned, the mucous membrane of sigma and all overlying departments in the examined areas is pale, dry, the tone of the wall is reduced in all departments. The gut is straightened with air all over easily. The study is sharply painful in the sigmoid colon (in the rectosigmoid junction), in the initial section of the sigmoid colon.

Protocol No. 2 of the morphological description of the mucosa of the splenic angle, sigma, rectum K., 69 years.

The mucous membrane of the investigated intestine (splenic angle, sigmoid colon, rectum) - no visible changes. The mucosal epithelium retains its structure. The brush border is not changed, the cytoplasm is weakly basophilic, the nuclei are localized in the basal part of the cells and are characterized by severe basophilia. The composition of the epithelial layer are goblet cells, the morphological structure of which does not have significant differences from the norm. The basement membrane of the epithelium is clearly structured. The loose fibrous connective tissue of the lamina propria is unchanged. Along with the cells of the fibroplastic series, single shaped blood elements are found in it. Own plate of the mucosa contains numerous capillaries of moderate blood supply. The walls of the crypts have the usual structure, contain numerous goblet and individual limbic cells. In individual crypts, the destruction of goblet and limbic cells is observed. When setting the Schiff reaction, a significant concentration of Schiff-positive material is observed in the cytoplasm of goblet cells located both in the integument epithelium and in the crypts of the intestines studied. A weakly positive Schiff reaction of the intercellular substance of the own plate of the mucosa is also noted. That is due to the content in it of a certain amount of glucose aminoglycans.

Conclusion: morphological signs characteristic of atrophic colitis were not detected. Chronic colitis.

Example No. 2. Patient B., 59 years old, patient of the clinic is sent for outpatient examination by an oncologist at the clinic. Complaints of abdominal pain after eating, which stop on their own after defecation.

X-ray of the colon over: after 12 hours, barium fills the transverse colon to half, after 36 hours, barium in the ampoule of the rectum, which indicates the absence of impaired motor-evacuation function.

USDG of the aorta and inferior mesenteric artery. Aorta in the proximal region 2.0 cm, in the bifurcation region 1.6 cm. There are single atherosclerotic plaques in the lumen. The lower mesenteric artery is 3.2 cm long, the diameter in the area of the mouth is 3.5 mm in the middle section, the lumen is narrowed to 2.3 mm 34.3%. When color Doppler mapping is completely colored, the spectrum of the Doppler curve is not changed. Blood flow velocity in the stenosis area is 0.87 m / s over 0.67 m / s; minimum speed in the area of stenosis of 0.09 m / s over 0.07 m / s. The resistance index is 0.896. Volumetric blood flow 0.062 L / min.

Clinical diagnosis: IHD. Angina pectoris. GB Atherosclerosis of the abdominal aorta, hemodynamically insignificant stenosis (34.3%) of NBA.

Fibrocolonoscopy: examination to the dome of the cecum, the study is somewhat painful. The lumen of the intestine throughout is not changed, the elasticity of the wall is reduced throughout, the peristalsis is sluggish, the mucous of all departments is thinned, as are the folds, dry, pink, with foci of hyperemia, the vascular pattern is clearly contoured. The haustration is not broken. The long sigmoid colon has a single diverticulum, with an entrance gate of 0.2 cm without signs of inflammation. In the descending intestine, sigmoid colon, no polyps were detected. The rectal ampoule is empty, the sphincters are tonic. During the study, pieces of the mucosa were taken from the area of the splenic angle, sigmoid, rectum for morphological study.

Protocol No. 3 of the morphological description of the mucosa of the splenic angle, sigma, rectum. B., 59 years old. (splenic angle, sigma, rectum).

The epithelium of the mucous membrane of the studied intestinal sections is not changed. Cylindrical epithelial cells. The brush border is preserved, the cytoplasm is weakly basophilic. The nuclei have a basal localization, sharply basophilic. The epithelial layer contains numerous endoepithelial unicellular glands (goblet cells), the morphological structure of which does not differ significantly from the norm. The basement membrane of the epithelium is well defined. Own plate of the mucous membrane is represented by loose fibrous unformed connective tissue, has the usual organization and cellular structure, the predominant cellular elements of fibroblasts, along with this formed elements of the blood-red blood cells, in large numbers (diapedesis), monocytes, lymphocytes. Swelling of tissues, leukocyte infiltration, stagnation in the microvasculature. The basement membrane is well vascularized, contains numerous capillaries, in which individual shaped elements of blood are located. The walls of the crypts are lined mainly with goblet cells. The overall structure is preserved.

When stained with Alcian blue, a positive reaction to glucose aminoglycans is observed in the brush border of the mucous epithelial cells. The cytoplasm of goblet cells is characterized by a positive coloration on alcian blue, the concentration of glucose-aminoglycans is moderately reduced, a positive Schiff reaction. The level of secretory activity of goblet cells is homogeneous and does not significantly differ from the norm. Conclusion: chronic colitis with signs of mucosal atrophy.

Example No. 3. Patient A., 67 years old, and.b. No. 10180, was admitted to the hospital with complaints of "intermittent claudication" after 50 m and night pains in the right lower limb, decreasing when lowering the legs down, coldness of the feet, hyposthesia, swelling of the right foot. Flatulence, abdominal pain, constipation denies.

Long-term x-ray of the colon: barium after 12 hours reaches the splenic angle of the colon, after 36 hours it fills the colon to half the descending colon, after 42 hours barium reaches the sieve.

Doppler ultrasound of the aorta and its branches: the aorta is narrowed in the distal section by 45%, the common external iliac arteries are narrowed on the left: by 48%, on the right by 34%, the blood flow in them is main.

The right common femoral artery is narrowed by 32%, the blood flow is main-changed, the superficial femoral artery on the right is narrowed by 64%, in the middle section up to 77% the blood flow is turbulent, in the distal section the right femoral artery is not stained. The left common femoral artery and the left superficial femoral artery are narrowed by 41% and 32%, respectively, and the blood flow in them is main. Constrictions in all arteries due to atherosclerotic plaques.

The inferior mesenteric artery with a length of 4.5 cm does not stain with color Doppler mapping, its lumen with ultrasound Dopplerography is uneven, narrowed from 4.3 mm to 1.5 mm, the degree of stenosis is 65%, the artery wall is dense, uneven, with a thickness of 1, 7 mm. In the aorta in the area of the mouth of the inferior mesenteric artery, there is an atherosclerotic plaque containing 1.5 × 0.9 cm of fibrosis and calcinosis, and mild collateral blood flow is recorded.

Clinical diagnosis: atherosclerosis, Lerish syndrome, stenosis-occlusion of the right PBA, KHAN 3 tbsp. Of the right foot; hemodynamically significant stenosis (65%) of NBA.

Total fibrocolonoscopy. The dome of the cecum, the hepatic bend is deformed due to the adhesive process from the abdominal cavity. Dolichosigma. The tone of the wall of the colon is uneven: in the right sections is not changed, in the left is reduced. The mucous membrane throughout the colon is thinned. The vascular pattern is strengthened, in the area of the splenic angle hyperemia of the mucosa, the folds of the colon in all departments have a typical direction.

Protocol No. 11 of the morphological description of the mucosa of the splenic angle, sigma, rectum, patient A., 67 years old.

The epithelium of the mucous membrane of the studied intestinal sections is not changed. Cylindrical epithelial cells. The brush border is preserved, the cytoplasm is weakly basophilic. The nuclei have a basal localization, sharply basophilic. The epithelial layer contains numerous endoepithelial unicellular glands (goblet cells), the morphological structure of which does not differ significantly from the norm. The basement membrane of the epithelium is well defined. Own plate of the mucosa is represented by loose fibrous unformed connective tissue, has the usual organization and cell structure. It is well vascularized, contains numerous capillaries, in which individual shaped elements of blood are located. The walls of the crypts are lined mainly with goblet cells. The general structure is preserved; in single crypts, destruction of individual goblet and limbic cells is observed. Disturbances of microcirculation: diapedesis under the basement membrane of the epithelium, lymphocytic infiltration, stagnation of blood in small vessels.

When stained with Alcian blue, a positive reaction to glucose aminoglycans is observed in the brush border of the mucous epithelial cells. The cytoplasm of goblet cells is characterized by a pronounced staining for alcian blue and a moderately positive Schiff reaction. The level of secretory activity of goblet cells is homogeneous and does not significantly differ from the norm.

Conclusion: Chronic atrophic colitis.

The proposed diagnostic method was tested in 93 patients with chronic colon ischemia over the age of 65 years (53% of patients are males, 47% are females).

According to the results of 627 morphological studies: staining with hematoxylin-eosin, alcian-blue and stating the SIC reaction, it was found that statistically significantly significant criteria for the diagnosis of chronic colon ischemia of the stage of subcompensation (morphological changes already exist, but not stricture and not necrosis, and atrophic colitis) are: complaints (constipation, blood in the stool); age (elderly); atherosclerotic lesion of the NBA; atherosclerotic lesion of the abdominal aorta; coronary heart disease, hypertension, chronic obstructive pulmonary disease (table No. 1).

Table 1 Prognostic signs of morphological changes in the colon Predictor Group A * (n = 34) Group B * (n = 81) One dimensional analysis Multivariate analysis OSH (95% CI) p ^†

(95%ДИ)OSH

(95% CI) p ^⋆ Age> 65 years old

24 (70.6) 39 (48.1) 2.59 (1.10-6.09) 0,027 - - Patient complaints of constipation 20 (58.8) 27 (33.3) 2.86 (1.25-6.52) 0.011 - - Patient complaints of blood in the feces 2 (2.5) 7 (20.6) 10.24 (2.00-52.32) 0.003 - - Percentage NBA clearance

- <25% 1 (4,5) 53 (74.6) - - - - - 25-50% 11 (50.0) 10 (14.1) 58.3 (6.75-503.39) 0.001 58.3 (6.75-503.39) 0.001 -> 50% 10 (45.5) 8 (11.3) 66.25 (7.45-589.55) 0.001 66.25 (7.45-589.55) 0.001 Damage to the abdominal aorta with atherosclerosis 32 (94.1) 41 (50.6) 15.61 (3.51-69.50) 0.001 Coronary heart disease 31 (91.2) 41 (50.6) 10.08 (2.85-35.63) 0.001 - - Hypertonic disease 19 (55.9) 26 (32.1) 2.68 (1.18-6.10) 0.017 - - Chronic obstructive pulmonary disease 9 (26.5) 11 (13.6) 2.29 (0.85-6.18) 0,096 - - Notes: Where * - Observations of group A - observations with morphological changes in the colon. Observations of group B - observations without morphological changes in the colon. † - The one-dimensional logistic regression procedure was used. ⋆- The reverse logistic regression step-by-step regression procedure was used (n = 93, -2Log Credibility = 63.754, χ ² (model) = 38.003, p <0.001; χ ² (Xocmer-Lemeshov) p <0.001, p = 1,000).

- To select the optimal point of separation of groups by age, an analysis of the ROC curve was used. The value of this trait giving the greatest sum of sensitivity and specificity was chosen as the optimal dividing point.

- To select the optimal separation point of the groups according to the degree of narrowing of the inferior mesenteric artery, the ROC curve analysis was also used. The value giving the greatest sum of sensitivity and specificity was 20%, however, dividing the sample into groups at this point gave a zero frequency of outcome in the group not affected. To eliminate this situation, which does not allow the calculation of OS, the separation point was shifted higher to the level of 25%.

- OShs - odds ratio adjusted taking into account the influence of other factors in multiple logistic regression analysis.

A step-by-step analysis of predictors in decreasing order revealed that an independent prognostic sign of the development of HITK (the occurrence of mucosal atrophy) is the degree of narrowing of the NBA - a critical point of 20% of narrowing of the NBA. In addition, in our study, there was not a single case of morphological changes in the colon mucosa characteristic of atrophic colitis, with a narrowing of the NBA to 20%.

The incidence of morphological changes in the colon, depending on the degree of narrowing of the lumen of the NBA is presented in table No. 2.

Moreover, with a narrowing of the inferior mesenteric artery more than 25%, the odds ratio is 58.3 with a lower limit of 95% confidence interval of 6.75.

In the group of patients (54 patients) with a degree of narrowing of the inferior mesenteric artery less than 20%, cylindrical epithelial cells, brush border preserved, cytoplasm without pronounced changes, nuclei have a typical organization. Mucus vacuoles are absent or are defined as very small inclusions. The composition of the epithelial layer contains goblet cells, the structure of which does not have significant differences from the norm. The basement membrane of the epithelium is well contoured, its own plate of the mucous membrane has a typical organization. In the intercellular substance, individual shaped elements of blood (monocytes, lymphocytes) are located. Own plate of the mucosa is sufficiently vascularized, the vessels are full-blooded.

table 2 The dependence of morphological changes in the colon mucosa, on the degree of narrowing of the lumen of the NBA Percentage NBA clearance Patient count The number of morphological changes in the colon Incidence of morphological changes in the colon (95% CI) Fisher p (2-sided.) <25% 54 one 1.9% (0.1% -11.2%) - 26-50% 21 eleven 52.4% (30.3% -73.6%) <0.001 51% and more eighteen 10 55.6% (31.3% -77.6%) <0.001 Total: 93 22 23.7% (15.7% -33.8%) -

In the group of patients (39 patients) with stenosis of more than 20% narrowing of the inferior mesenteric artery, superficial necrosis and desquamation of the superficial epithelium of the mucous membrane of the colon with preservation of the epithelium of the crypts for a greater extent (epithelial cells are heterogeneous, contain vacuoles in the cytoplasm, are separated from their own in separate areas plates, signs of regeneration in the preserved epithelium, namely, an increase in nuclei, the appearance of mitoses);

reduction or disappearance of goblet cells of the upper parts of the crypts. At the same time, focal lymphoid-cell infiltrates are observed in the superficial layers of the mucous membrane and submucosal layer — a moderate plasmacytic infiltrate of the lamina propria with a small number of segmented leukocytes, single eosinophils, a small number of lymphocytes, plasma cells, and intestinal mucosal lymphocytes of the mucous membrane of the mucous membrane of the superficial layer; thickening and sagging of the basement membrane, submucosal edema. Focal lymphoid cell infiltrates are detected in the submucosal layer; in the surface layers of the mucous membrane and submucosal layer - a moderate plasmacytic infiltrate of the lamina propria with a small number of segmented white blood cells, plasma cells, intraepithelial lymphocytes of single eosinophils, a small number of lymphocytes; thickening and sagging of the basement membrane, submucosal edema. The vessels of the submucosal layer are characterized by the presence of blood clots and fibrin clots in the small arteries, stasis of red blood cells in the vessels of the mucous membrane of the colon, plethora of the blood vessels of the microvasculature, some of them are paretically dilated or, conversely, the tone of both small capillaries and veins is reduced, and the walls are protruded ; stasis, thrombosis of various origin (fibrin, erythroid, mixed), plasmorrhagia, fresh hemorrhage in the surrounding tissue, often the marginal standing of leukocytes in venules.

The comparison group included 81 people of the corresponding age category, without manifestations of atherosclerotic lesions of the aorta and its branches.

The proposed method is effective, harmless to the subject. The non-invasiveness of the method makes it possible to use it in the early diagnosis of chronic colon ischemia with atherosclerotic lesions of the inferior mesenteric artery. The inclusion of ultrasound dopplerography in the diagnostic complex along with fluoroscopy, fibrocolonoscopy and morphological studies of biopsy samples of the colon mucosa contributes to the timely detection of chronic colon ischemia before severe symptoms of this severe pathology and its complications appear. This technique can be used for the differential diagnosis of intestinal pathology. The method can acquire independent significance along with general clinical methods for examining patients with chronic colon ischemia, including in outpatient settings.

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Claims (1)

A method for the early diagnosis of chronic colon ischemia in case of atherosclerotic lesion of the inferior mesenteric artery, including ultrasound assessment of blood flow in the inferior mesenteric artery, characterized in that they perform ultrasound angioscanning of the inferior mesenteric artery and fibrocolonoscopy with simultaneous colon biopsy with a stenosis of more than 20% and a diameter of more than 20% atrophic colitis in the tissue components of the colon mucosa is diagnosed.