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15MEDICAL SCIENCES
INTESTINAL FATTY ACID BINDING PROTEIN (I-FABP) AS A MARKER FOR ACUTE INTESTINAL ISCHEMIA IN PATIENTS WITH BOWEL OBSTRUCTION
Fuss J.
Regional hospital in Pustomyty, general surgeon, Ph.D
Voloboyeva A.
Communal Municipal Clinical Hospital 8, anesteziologist
Polovyj V.
Bukovinian medical university, chief of department of general surgery, doctor of medicine
Yaremkevych R.
Lviv state medical university, Department of surgery and transplantology, Ph.D
Abstract
Background: The results of recent studies indicate a close relationship between increased levels of I-FABP and the degree of damage to the small intestine, both inflammatory and ischemic. Currently, mortality from acute mesenteric ischemia (AMI) and its complications ranges from 50-70% in leading clinics to 90-100% in district and small urban hospitals. Currently studied: cardiac fraction of fatty acid binding protein (H-FABP), liver fraction - L-FABP, brain fraction - B-FABP, and intestinal fraction I-FABP. The intestinal fraction of the protein that binds fatty acids is contained in the epithelial cells of the small intestine, and the epithelium of the small intestine also contains another fraction of this protein, similar to L-FABP.
Methods: The study included 96 patients who were hospitalized in Pustomyty Central District Hospital, KNP 8th MCL in Lviv and KMKLSHMD. Plasma concentrations were measured using enzyme-linked immunosorbent assay kit for fatty acid binding protein 2, intestinal FABP2 (Uscn Life Science Inc.). Diagnosis was based upon findings at surgery and histopathological examination of the intestine specimen. Statistical processing of the study results was performed using a set of statistical programs Statistics 6.0.
Results: 96 patients out of the 56 were diagnosed to have intestinal ischemia. Mean values of serum IFABP levels were significantly higher in patients diagnosed with intestinal ischemia (65.94pg/ml in the non-ischemic group vs 673.53pg/ml in the ischemic group P=0.0002). Cut off chosen in diagnosing intestinal ischemia in this study was 187.59pg/ml. Sensitivity was 95.7% and specificity 88%.
Conclusions: Serum I-FABP can be used for the diagnosis for intestinal ischemia. It is specific and sensitive marker to detect early bowel ischemia.
Keywords: Acute mesenteric ischemia, Bowel ischemia, I-FABP
INTRODUCTION
The results of recent studies indicate a close relationship between increased levels of I-FABP and the degree of damage to the small intestine, both inflammatory and ischemic. The problem of acute disorders of mesenteric blood flow is one of the most pressing and difficult to solve in modern emergency surgery. This is due to a number of specific points that complicate it. First, acute disorders of mesenteric circulation in the initial stage have erased clinical symptoms, which can simulate many diseases in which emergency surgery is not indicated. Second, the rapid development of intestinal necrosis has severe and usually fatal consequences for the patient's body [1,2].
Currently, mortality from acute mesenteric ischemia (AMI) and its complications ranges from 50-70% in leading clinics to 90-100% in district and small urban hospitals.
Routine diagnostic methods, which include classic laboratory and instrumental research methods, such as clinical blood test, general urine test, biochemical blood test, abdominal radiography, abdominal ultrasound, have low specificity because they reflect only indirect signs of this pathology [3].
Thus, according to the literature, the sensitivity of neutrophilic leukocytosis in AMI is from 70 to 80%, and the specificity is about 30%. Ultrasound Doppler of
the abdominal cavity allows you to reliably visualize blood flow in the mesenteric arteries only in 20-30% of cases.
In this regard, often only the experience and intuition of the doctor can help in making a correct diagnosis. Unfortunately, as a rule, the operation is performed at the stage of diffuse peritonitis and often ends fatally [4,5].
In this regard, the search and implementation of methods for early non-invasive diagnosis of this pathology are very important.
Over the past 10 years, the diagnostic value of a new clinical and laboratory indicator - fatty acid binding protein (FABP), which is one of the intracellular proteins and is involved in the transport and metabolism of long-chain fatty acids. The FABP family of proteins has good diagnostic characteristics: 1) soluble in the cytoplasm; 2) highly specific to the tissue from which they originate; 3) contained in the cell in high concentrations; 4) have a low molecular weight (15 kDa) [6,7].
These characteristics allow the use of the appearance of this marker in the peripheral blood as a sensitive and specific marker of tissue damage. Currently studied: cardiac fraction of fatty acid binding protein (H-FABP), liver fraction - L-FABP, brain fraction - B-FABP, and intestinal fraction I-FABP. The intestinal
fraction of the protein that binds fatty acids is contained in the epithelial cells of the small intestine, and the epithelium of the small intestine also contains another fraction of this protein, similar to L-FABP [8].
Materials and methods.
The study included 96 patients who were hospitalized in Pustomyty Central Hospital, Communal Municipal Clinical Hospital 8 in Lviv and Lviv medical state university. The age of patients ranged from 33 to 85 years (mean age 75.5), of which 64 (66%) were women and 32 (34%) were men. 18 (19%) patients were diagnosed with irritable bowel syndrome with constipation, 22 (23%) - irritable bowel syndrome with diarrhea, 33 (34%) patients underwent colectomy (17 patients left, 14 patients right), 23 (24%) patients were diagnosed with erosive gastritis and were not detected according to clinical, instrumental and laboratory studies of intestinal lesions.
Plasma concentrations were measured using enzyme-linked immunosorbent assay kit for fatty acid binding protein 2, intestinal FABP2 (Uscn Life Science Inc.) EDTA plasma samples were collected from suspected patients, centrifuged and stored at -80°C.
The total number of leukocytes was increased in both groups with a mean of 13.5 * 10 in patients with ischemia and 12 * 10 in patients without ischemia. Se-
Samples were collected within 1hour of suspicion of ischemia. The detection cutoff for plasma I-FABP was 31.5pg/ml.
Blood was collected in EDTA tubes and centrifuged for 20minutes at approximately 1000*g. Freshly prepared plasma stored in deep freezer at -80°C for analysis. Repeated freeze/thaw cycles were avoided.
Routine Blood investigations CBC, blood urea, creatinine, serum electrolytes was done, serum amylase and lipase were sent to rule out pancreatitis and to determine any correlation. Serum lactate value was determined as it was the only available marker for intestinal ischemia and its levels were correlated with that of IFABP. Diagnosis was based upon findings at surgery and histopathological examination of the intestine specimen. Statistical processing of the study results was performed using a set of statistical programs Statistics 6.0.
Results. The main symptom in hospitalized patients was pain, lasting an average of 3.78 days in patients with ischemia and 6.03 days in patients without ischemia. Melena was present in all patients with ischemia.
Table 1
rum amylase and lipase levels were elevated in the ischemia-free group and were 168.18 U / L and 155.59 U / L. In the group with ischemia, the values were 74.59 U / l and 47.59 U / L, respectively.
Table 2
Biochemical parameters Ischemia P
Yes No
TLC (cells/mm3) 12565.22 11858.82 0.525
Amylase (U/L) 74.59 (25-262) 168.18 (27-780) 0.073
Liapse (U/L) 47.59 (10-139) 155.59 (15-930) 0.976
Serum lactate (mg/dL) 34.933 (14.01-85) 23.4182 (11.98-36.2) 0.015
Serum I-FABP (pg/mL) 673.53 (136.85-2000) 65.9415 (0-253.78) 0.0002
Symptoms ischemia P
Yes (n=66) No (n=30)
Flatulence
0-5 60 30 0.165
6-10 6 0
Fever 0,9
Present 8 7
Absent 58 23
Melena 0,002
Present 66 4
Absent 0 26
Guarding 0,2
Present 58 21
Absent 8 9
Radiological diagnosis 0,886
Positive 9
Negative 57
Serum lactate already a proven marker for intestinal ischemia was found to be elevated in this ischemic group with a mean of 34.93mg/dl and 23.41mg/dl in the non-ischemic group with a significant P value of 0.015. The sensitivity of serum lactate was 87% and specificity was 41%. Serum Intestinal Fatty Acid Binding Protein (IFABP) was significantly elevated in the ischemic group with a mean of 673.53pg/ml versus 65.94pg/ml in the non-ischemic group with a P value of 0.0002.
Of the 56 patients diagnosed with ischemia, 55 were operated on. One patient had radiographic signs of ischemia, received anticoagulants, and was discharged. Diagnostic laparotomy was performed in 55 patients, ischemic or gangrenous segment of the intestine was resected and sent for histological examination. All histopathological results corresponded to gangrene or ischemia.
There were 14 patients had ischemia of the jejunum (25.5%), ileum in 19 patients (34.5%), jejunum and ileum in 9 patients (16.5%), colon in 7 patients (13%), colon and ileum in 4 patients (7%) and jejunum, ileum and colon in 2 patient (3.5%). Mortality in the ischemic group was 13 patients (23.7%) and non-ischemic group was 1 patient (1.8%).
Conclusion.
Intestinal ischemia is a surgical emergency and warrants immediate surgical intervention. Quicker diagnosis aided by serum I-FABP levels will enable us to intervene in such patients quickly reducing morbidity and mortality among patients. Author concluded that serum I-FABP is a specific, sensitive, quick and cost-
effective indicator of intestinal ischemia. It can identify ischemic changes in bowel at an early stage which will enable us to intervene early and reduce morbidity and mortality. If bowel ischemia is detected earlier, there may be a scope to preserve the bowel by removal of the offending agent, however, this analysis is beyond the scope of present study.
References
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2. Dayton MT, Dempsey DT, Larson GM, Posner AR. New paradigms in the treatment of small bowel obstruction. Current Prob Surg. 2012;49:642-717.
3. Delhom E, Aufort S, Shrembi V, Lonjon J, Bruel JM, Gallix B. Acute mesenteric ischemia: value of cross-sectional imaging. J Radiol. 2011;92:1060-1064
4. Dunphy JE. Abdominal pain of vascular origin. Am J Med Sci. 1936;192:109-13.
5. Elliot JW. The operative relief of gangrene of intestine due to occlusion of the mesenteric vessels. Ann Surg. 1895;21(1):9-23.
6. Lange H, Jackel R. Usefulness of plasma lac-tate concentration in the diagnosis of acute abdominal disease. Euro J Surg. 1994;160(6-7):381-4.
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8. Wilson C, Imrie CW. Amylase and gut infarction. Brit J Surg. 1986;73(3):219-21.
MATERNAL TOXIC HEPATITIS, STRUCTURAL AND FUNCTIONAL FORMATION OF THE LEAN INTESTINE OF THE OFFSPRING IN THE DYNAMICS OF EARLY POSTNATAL
ONTOGENESIS
KhasanovB.
Bukhara State Medical Institute, Department of Histology, Cytology and Embryology,
Bukhara, Uzbekistan
Abstract
There was investigated the effect of toxic heliotrinic hepatitis in female rats on the formation of the lean intestine of the offspring in the dynamics of early postnatal ontogenesis. It was established that the negative effect of chronic toxic hepatitis in females, leading to a lag in the formation of the lean intestine in the period of early postnatal ontogenesis, progressing to the transition of rat pups to mixed and definitive nutrition.
Keywords: intestine, formation, lactation, chronic hepatitis, ontogenesis, offspring.
It is known that the neonatal period is especially important for the development of the body, since after birth, babies are immediately exposed to a large number of microorganisms. The high rates of morbidity and mortality observed in the first months of life due to infectious diseases such as otitis media, upper and lower respiratory tract infections, gastroenteritis, sepsis and meningitis are caused, among other things, by significant quantitative and qualitative deficiencies in various components of the immune system. To compensate for this immunological immaturity inherent in the period of the fetus and newborn, as well as the first months of life, nature has developed mechanisms of adaptive protection provided by the mother, represented by trans
placental transmission of antibodies, anti-infectious resistance factors in the amniotic fluid, and after birth, in colostrum and milk. However, this whole system of harmonious genetically determined processes inherent in the physiological course of pregnancy ceases to work in the event of the influence of unfavorable factors, infectious effects and extra genital pathology of the mother. Particularly, it was found that the effect of alcohol and chronic hepatitis of pregnant women has an adverse effect on the offspring - it delays its physical development, reduces resistance, inhibits the development of structural and cytochemical properties of the stomach, intestines, kidneys [6,7,9,10]. At the same time, the question: what effect does maternal hepatitis
