Diagnosis of purulent gynecological diseases

The parameters of peripheral blood reflect the stage of acuteness of the inflammatory process and the depth of intoxication. So, if in the stage of acute inflammation the characteristic changes are leukocytosis (mainly due to the stab and nuclear forms of neutrophils) and an increase in ESR, then in the remission of the inflammatory process, first of all, the decrease in the number of erythrocytes and hemoglobin, lymphopenia with normal neutrophil counts and an increase in ESR.

Objective laboratory criteria for the severity of intoxication are the combination of laboratory indicators such as leukocytosis, ESR, the amount of protein in the blood, the level of medium molecules.

An easy degree of intoxication is typical for patients with a short process and uncomplicated forms, and a severe and medium degree for patients with so-called conglomerate tumors that have a remitting flow and require prolonged conservative treatment.

The clinical course of the purulent process is largely determined by the state of the immune system.

Almost all researchers believe that acute inflammatory diseases of the uterine appendages are accompanied by a strain of the immune system of the patient's body.

Immune reactions are the most important link in the pathogenesis of purulent inflammation, which largely determines the individual features of the course and outcome of the disease. The authors believe that with purulent inflammation a complex rearrangement of immune homeostasis occurs, affecting virtually all stages of differentiation and proliferation of immunocompetent cells, and in 69.2% of patients absolute and relative lymphopenia is noted.

Changes in antibody formation depend on the severity of the inflammation, its prescription and etiology.

It is argued that with acute primary inflammation, the most pronounced changes in IgM content are noted, with exacerbation of the chronic process Ig Ig. Elevated IgA levels are observed in almost all patients.

It is noted that the change in the content of immunoglobulins also depends on the etiology of the process: in the septic process, there is an increase in the number of all three types of immunoglobulins; in the gonorrhea, only IgA and IgG levels decrease.

Only in severe forms of purulent-septic infection of the internal genitalia is there a decrease in IgG concentration and an increase in IgM level, with Ig Ig level significantly changing during the course of the disease: when inflammation worsens, it decreases, and when it increases it increases.

The insufficiency of the entire immune system is shown, which is manifested by a deviation from the norm of most factors, in particular, a decrease in IgA and IgG levels. In these cases, most immunity indices do not reach the norm even after treatment.

With long-term ongoing purulent processes accompanied by severe intoxication, we noted immunosuppression, while a prognostically significant adverse factor indicating the development of complications was a decrease in Ig G.

Factors of nonspecific protection include:

• phagocytosis;
• complement system;
• bactericidal system of lysozyme;
• C-reactant protein;
• interferon system.

In acute inflammatory diseases, regardless of the type of pathogen, there is a sharp inhibition of the phagocytic activity of blood neutrophils.

The degree of their oppression depends on the duration of the disease and the activity of the inflammatory process.

With purulent inflammation of the uterine appendages, the number of polymorphonuclear leukocytes and monocytes in the peripheral blood increases, but their phagocytic activity is significantly reduced.

It has been suggested that purulent processes alter the differentiation of immunocompetent cells, as a result of which numerous functionally inferior populations appear in the circulating blood, devoid of phagocytic activity.

In patients with severe forms of purulent inflammation, the phagocytic index in 67.5% had high rates (from 75 to 100%), which indicated the maximum mobilization of the defenses of the organism and the limiting depletion of reserve capacities, while the phagocytic number was increased and ranged from 11 to 43%, which reflected the incompleteness of phagocytosis. In 32.5% of patients, the phagocytic activity of monocytes was extremely inhibited (phagocytic index decreased from 46 to 28%).

The level of circulating immune complexes (CEC) was practically increased in all patients (93.6%) - from 100 to 420 units at a rate of up to 100, while the increase was due to the CEC of medium and small sizes, i.e. Most pathogenic and evidence of progressive cell destruction.

However, the prognostically unfavorable factors that reliably indicate the development of dangerous complications, in particular the formation of genital fistulas, is a sharp decrease in the level of the CEC.

Complement is a complex multicomponent system of serum proteins - it is also one of the main factors of nonspecific protection. The level of complement in healthy adults is constant, the changes depend on the severity of the inflammatory process.

In a holistic organism, complement activation proceeds in parallel with an increase in the level of antimicrobial enzymes in the inflammatory focus. In acute infectious salpingitis in the midst of the exudative process, the complementary system is activated. This activation is also observed in cases of exacerbation of the inflammatory process in purulent tubo-ovarian formations, although in this case there are sometimes significant fluctuations in the complement titre at different stages of inflammation.

The level of complement is directly related to the duration of the process: for example, in patients with acute inflammatory process with a duration of the disease from 1 to 3 months, complement and its components, especially C-3, were significantly increased (from 100 to 150 units). In patients with a prescription of a purulent process from 3 to 6 months, the complement index was within the normal range (relative compensation of the process or transition from the activity of the complement system to its depression).

In patients with a duration of purulent process from 6 months to 5 years, there was a significant reduction in the complementary activity of blood serum (40 to 20 units and below) at a rate of 78 units, the lower the longer the course of the disease.

For the most severe chronic adhesions, especially involving the inflammatory process of neighboring organs, as well as for a recurrent and long-term ongoing purulent process, a deficiency of the entire immune system is typical, manifested, in particular, in the reduction of the complement titer. The researcher believes that correction of changes in factors of nonspecific reactivity in these patients is always difficult.

Of the indices of nonspecific immunity, lysozyme has a higher sensitivity, which has an important diagnostic value. Acute salpingo-oophoritis is accompanied by a decrease in lysozyme activity of serum.

C-reactive protein (CRP) is absent in the serum of healthy individuals and is detected in patients with acute inflammatory processes accompanied by destructive changes in tissues,

Found that 96.1% of patients with acute inflammatory diseases of the pelvic organs have an increased content of C-reactive protein.

According to studies, the response to CRP is always positive for tubo-ovarian abscesses and can be used for differential diagnosis of inflammatory diseases of the uterine appendages, with the accuracy of this method exceeding 98%.

According to our data, in all patients with purulent inflammatory diseases of the pelvic organs, a positive reaction to the C-reactive protein was observed, and in patients with uncomplicated forms the protein concentration did not exceed ++, and when forming abscesses in the acute stage it was ++, and more often +++.

It is believed that the concentration of C-reactive protein positively correlates with the volumes of inflammatory formations determined by ultrasonography. The authors consider it useful to determine the concentration of C-reactive protein, especially when performing a differential diagnosis with non-inflammatory diseases, and recommend a repeat of the study at least 3 months after treatment.

Many authors recommend using CRP to assess the effectiveness of antibiotic therapy for inflammatory diseases of the genital organs.

According to studies, with successful treatment, CRP concentration significantly decreased by 3-4 days in patients without tubo-ovarian abscesses and by 6-8 days in patients with tubo-ovarian abscesses and reached normal values in both groups on day 18-21 . Changes in the clinical state corresponded to changes in the level of CRP. Based on this, it was concluded that the determination of the level of CRP is diagnostic more reliable than monitoring the body temperature and determining the level of leukocytes and ESR.

It is believed that the level of C-reactive protein in patients with acute inflammatory processes with adequate antibiotic therapy begins to decrease by the third day of treatment and significantly decreases by the sixth day, reflecting the clinical response to therapy faster than other methods, which can be useful for obtaining a short-term prognosis on the ongoing treatment. For the persistence of pathogens and the chronization of the process, the initial decrease in the CRP level was less than 20% per day, followed by the stabilization of CRP quantitative indices.

Progressive increase in CRP levels indicated the generalization of infection and the real possibility of sepsis.

Interferon is a protein that appears in the tissues a few hours after infection with the virus and prevents its reproduction. The interferonogenic effect of some bacteria has also been established.

Interferon status in patients with inflammatory diseases is characterized by a sharp inhibition of the functional activity of T-lymphocytes, leading in a number of cases to a complete lack of ability to produce gamma-interferon and to a partial suppression of the alpha-link of the interferon system.

It is believed that the leading role in the development of insufficiency of the interferon system is played by bacterial flora. In this case, the presence of viruses in the association of bacteria and chlamydia, presumably at the initial stage, stimulates the immune response of the organism, and the long-term exposure to bacterial infection (without viruses) leads to a more pronounced decrease in the level of interferon.

The degree of suppression of the production of alpha and gamma interferon indicates the severity of the disease and the need for intensive care.

In the literature there are conflicting data on the level of the Ca-125 marker in inflammatory pelvic diseases. Thus, it was found that in patients with acute salpingitis Ca-125 levels exceeded 7.5 units, and patients with levels of more than 16 units had purulent salpingitis.

An increase in the concentration of this marker was found, which correlated with the severity of inflammation of the uterine appendages, and a decrease in it during the treatment. Others found no significant changes in Ca-125 in patients with pelvic inflammatory disease.

A prolonged course of the purulent process is always accompanied by a disruption of the function of almost all organs, i.e. Multiple organ failure. First of all, this concerns the parenchymal organs.

The protein-forming function of the liver most often suffers, "isolated urinary syndrome manifests itself in proteinuria, leukocyturia and cylindruria, and is" ... The debut of severe kidney damage. "

Multiple organ failure accompanies the course of all generalized forms of infection and the outcome of the process depends on the degree of its expression.

Thus, purulent inflammatory diseases of the pelvic organs are polyethiologic diseases that cause severe disturbances in the system of homeostasis and parenchymal organs and require appropriate pathogenetic therapy along with surgical intervention.

The main method of diagnosis, used in all patients with purulent inflammation of the pelvic organs, is echography.

The method is most effective (informative up to 90%) with pronounced processes, when there is enough volume formation, however even experienced specialists admit hypodiagnosis, and the number of false positive results reaches 34%.

The method was less sensitive in endometritis (25%), as well as in the determination of small amounts of purulent fluid (less than 20 ml) in the rectum-uterine space (33.3%).

In patients with inflammatory diseases of the pelvic organs, the advantages of transvaginal ultrasound before transabdominal echography were revealed. Data of transvaginal echography (determination of the volume of pyosalpinx / pyovar and the amount of free fluid in the rectal-uterine cavity) positively correlated with the concentration of C-reactive protein and the value of ESR. Researchers recommend mandatory use of the method 3 months after the acute episode in all patients.

The sensitivity of echography in patients with acute inflammatory diseases of the pelvic organs is very high - 94.4%. Most often, according to researchers, an expansion of the fallopian tube is found - 72.2%. Signs of endosalpingitis were found in 50% of patients, fluid in the douglas pocket - in 47.2%. Scientists believe that a thorough ultrasound screening will improve the diagnosis of purulent inflammatory diseases in patients with clinical signs of infection.

The results of the application of echoscopy with color Doppler mapping are described. There was a decrease in the pulsator index (PI) of the uterine arteries, which positively correlated with the concentration of the C-reactive protein. The values of the pulsatory index (PI) returned to normal when the infection was stopped. In the case of chronic infection, PI remained low and did not increase, despite clinical remission.

It should be noted that the differential diagnosis of inflammatory tumoral formations and true tumors of the uterine appendages is often difficult, and the accuracy in determining the nosological affiliation of the disease is insufficient even when using color Doppler.

A number of researchers report on the similarity of changes in the parameters of ultrasound color Dopplerometry in patients with pelvic inflammatory diseases and tumors of the uterine appendages.

It is believed that Doppler echography is an accurate method for eliminating malignant formations, but in cases of their differentiation with inflammatory formations, some errors may occur.

At present, there is no research method in obstetric-gynecological practice, and the importance of equal echography. For patients with complicated forms of inflammation, echography is the most accessible highly informative non-invasive method of investigation. To determine the extent of the purulent process and the depth of tissue destruction, it is advisable to combine transabdominal and transvaginal techniques and use modifications (contrasting of the rectum).

In patients with complicated forms of purulent inflammation, ultrasound should be performed on devices using a sectoral and transvaginal sensor in a two-dimensional visualization mode and with color Doppler mapping, since the sensitivity and accuracy of the diagnosis are thereby significantly increased.

According to the research, if the above conditions are met, the accuracy of the echography method in assessing purulent inflammatory diseases of the internal genitalia is 92%, the conditions of preperforation - 78%, purulent fistula - 74%.

Other modern diagnostic methods, such as computed tomography, NMR or MRI (magnetic resonance imaging), can differentiate tumors and tumor-like ovarian formations with great accuracy (90-100%), but, unfortunately, these methods are not always available.

It is believed that MRI is a new promising non-invasive technique. The diagnostic accuracy of MRI in patients with purulent inflammatory diseases of internal genital organs was 96.4%, sensitivity - 98.8%, specificity - 100%. According to the author, the information obtained with MRI is in good agreement with the results of ultrasound and pathomorphological studies. The use of quantitative parameters of the relative signal intensity (IC) index, relaxation time (T 2) and proton density (PP) helps to presumably determine the nature of the disease.

According to the research, the diagnostic value of MRI in the appraisal of appendages is 87.5%. The authors consider this method of diagnostics as a means of the second choice, which replaces CT.

Similar information leads M.D'Erme et al. (1996), who believe that the diagnostic accuracy of MRI in patients with tubo-thoracic formations is 86.9%.

Efficiency of using magnetic resonance in patients with acute inflammatory diseases of the pelvic organs: sensitivity - 95%, specificity - 89%, full accuracy - 93%. The diagnostic value of transvaginal echography was 81.78, and 80%, respectively. The authors concluded that the image with MRI more accurately than with transvaginal ultrasound, provides differential diagnosis, and, consequently, this method reduces the need for diagasic laparoscopy.

Computed tomography (CT) is a highly effective method, but in view of the low availability it can be used only in a limited number of the most severe patients or if the diagnosis does not clear up after an ultrasound examination.

It is believed that the puerperas with inflammatory processes that do not respond to antibacterial therapy should be examined by CT. Thus, in patients with postpartum sepsis using CT in 50% of cases, the authors identified tubo-ovarian abscesses, in 16.7% - vein thrombosis and in 33.3% - panmetritis.

The effectiveness of CT in detecting purulent fistula is 95.2%, while in fistulography, the information content is increased to 100%.

Some authors point to the need to search for new methods for the differential diagnosis of inflammatory tubo-ovarian formations.

In recent years, endoscopic diagnostic methods have been widely used in gynecology.

JPGeorge (1994) notes that until the mid-1980s, laparoscopy was predominantly a diagnostic procedure, at present this method allows performing various surgical interventions in gynecology, including extirpation of the uterus.

Laparoscopic examination allows confirming or rejecting the diagnosis of an inflammatory disease, revealing the concomitant pathology of the internal genitalia. In the literature there are reports of successful treatment of patients with acute purulent inflammation.

Nevertheless, laparoscopy has a number of contraindications, especially in cases of extensive adhesions and repeated intubation. Thus, JPGeorge (1994) describes two cases of laparoscopic treatment of patients with pyosalpinx and tubo-ovarian abscess. In the postoperative period, both patients developed partial intestinal obstruction.

The presence of such highly informative diagnostic methods as ultrasound, CT, NMR, currently makes diagnostic laparoscopy inappropriate and even risky. This method of research we use as a component of surgical treatment after examination of the patient in case of acute purulent inflammation with a prescription period of no more than 3 weeks, i.е. With loose fusion in the small pelvis.

For patients with complicated forms of purulent inflammation, laparoscopy is contraindicated, since examination in conditions of a purulent-infiltrative process does not give any additional information, and attempts to disjoin seizures can lead to severe intraoperative complications (wound of the intestine, bladder) requiring emergency laparotomy and worsening the already severe condition of patients.

Summing up, one can come to the conclusion that at present there is no single research method that would allow to determine the inflammatory nature of the pelvic lesion with great certainty, and only complex research can determine not only the fact of purulent inflammation, but also determine the severity and extent of damage tissues of genitals and adjacent organs, as well as to choose the optimal tactics for conducting a particular patient.

The intraoperative implementation of the surgical benefit plan after a comprehensive examination of patients with modern non-invasive methods was possible in 92.4% of women with complicated forms of purulent inflammation.

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