Diagnosis of purulent gynecologic diseases

Peripheral blood indices reflect the stage of acuteness of the inflammatory process and the depth of intoxication. Thus, if at the stage of acute inflammation the characteristic changes are leukocytosis (mainly due to band and young forms of neutrophils) and an increase in ESR, then during remission of the inflammatory process the first thing that attracts attention is a decrease in the number of erythrocytes and hemoglobin, lymphopenia with normal neutrophil formula indices and an increase in ESR.

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

Mild intoxication is typical for patients with a short-term process and uncomplicated forms, and severe and moderate intoxication is typical for patients with so-called conglomerate tumors that have a remitting course and require long-term 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 stress on the patient’s immune system.

Immune reactions are the most important link in the pathogenesis of purulent inflammation, largely determining the individual characteristics of the course and outcome of the disease. The authors believe that purulent inflammation is accompanied by a complex restructuring of immune homeostasis, affecting almost all stages of differentiation and proliferation of immunocompetent cells, and 69.2% of patients have absolute and relative lymphopenia.

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

It is claimed that during acute primary inflammation the most pronounced changes in the content of Ig M are observed, and during exacerbation of the chronic process - Ig G. An increased level of Ig A is 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, an increase in the amount of all three types of immunoglobulins is noted, while in the gonorrheal process, the level of only Ig A and Ig G decreases.

Only in severe forms of purulent-septic infection of the internal genitalia is a decrease in the concentration of Ig G and an increase in the level of Ig M observed, and the level of Ig G changes significantly during the course of the disease: during an exacerbation of inflammation, it decreases, and during relief, it increases.

A deficiency of the entire immune system is noted, manifested by deviations from the norm of most factors, in particular a decrease in the level of Ig A and Ig G. In these cases, most immunity indicators do not reach the norm even after treatment.

In long-term purulent processes accompanied by severe intoxication, we noted immunodepression, while a decrease in Ig G was a prognostically reliable unfavorable factor indicating the development of complications.

Non-specific protective factors include:

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

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

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

In 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, resulting in the appearance in the circulating blood of numerous functionally defective populations lacking phagocytic activity.

In patients with severe forms of purulent inflammation, the phagocytic index in 67.5% had high values (from 75 to 100%), which indicated maximum mobilization of the body's defenses and extreme depletion of reserve capabilities, while the phagocytic number was increased and fluctuated from 11 to 43%, which reflected the incompleteness of phagocytosis. In 32.5% of patients, the phagocytic activity of monocytes was extremely suppressed (the phagocytic index was reduced from 46 to 28%).

The level of circulating immune complexes (CIC) was elevated in almost all patients (93.6%) - from 100 to 420 units with a norm of up to 100, and the increase occurred due to CIC of medium and small sizes, i.e. the most pathogenic and indicating progressive cellular destruction.

However, a sharp decrease in the level of CIC is a prognostically unfavorable factor that reliably indicates the development of dangerous complications, in particular the formation of genital fistulas.

Complement is a complex multicomponent system of blood serum proteins, which is also one of the main factors of non-specific protection. The level of complement in healthy adults is a constant value, and changes depend on the severity of the inflammatory process.

In the conditions of the whole organism, complement activation occurs in parallel with the increase in the level of antimicrobial enzymes in the inflammation focus. In acute infectious salpingitis, at the height of the exudative process, the complementary system is activated. This activation is also noted in cases of exacerbation of the inflammatory process in purulent tubo-ovarian formations, although in this case significant fluctuations in the complement titer are sometimes observed at different stages of inflammation.

The level of complement is directly dependent on the duration of the process: thus, in patients with an acute course of the inflammatory process with a disease duration of 1 to 3 months, complement and its components, especially C-3, were significantly increased (from 100 to 150 units). In patients with a purulent process duration of 3 to 6 months, the complement indicator 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 purulent process lasting from 6 months to 5 years, a significant decrease in the complementary activity of the blood serum was noted (from 40 to 20 units and below) with a norm of 78 units, and the indicator was lower the longer the course of the disease.

The most severe chronic adhesive processes, especially with the involvement of neighboring organs in the inflammatory process, as well as recurrent and long-term purulent processes, are characterized by insufficiency of the entire immune system, manifested, in particular, in a decrease in the complement titer. The researcher believes that correction of changes in nonspecific reactivity factors in these patients is always difficult.

Among the indicators of non-specific immunity, lysozyme has a higher sensitivity, which has an important diagnostic value. Acute salpingo-oophoritis is accompanied by a decrease in the lysozyme activity of the blood serum.

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

It was found that 96.1% of patients with acute inflammatory diseases of the pelvic organs have elevated levels of C-reactive protein.

According to research data, the reaction to CRP is always positive in tubo-ovarian abscesses and can be used for differential diagnosis of inflammatory diseases of the uterine appendages, and the accuracy of this method exceeds 98%.

According to our data, all patients with purulent inflammatory diseases of the pelvic organs had a positive reaction to C-reactive protein, and in patients with uncomplicated forms, the protein concentration did not exceed ++, and when abscesses formed 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 lesions 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 repeating 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 the research data, with successful treatment, the CRP concentration significantly decreased by the 3rd-4th day in patients without tubo-ovarian abscesses and by the 6th-8th day in patients with tubo-ovarian abscesses and reached normal values in both groups on the 18th-21st day. Changes in the clinical condition corresponded to changes in the CRP level. Based on this, it was concluded that determining the CRP level is more diagnostically reliable than monitoring 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 antibacterial therapy begins to decrease by the third day of treatment and decreases significantly by the sixth day, reflecting the clinical response to therapy faster than other methods, which can be useful for obtaining a short-term prognosis for the treatment. The persistence of pathogens and the chronicity of the process were characterized by an initial decrease in the CRP level by less than 20% per day with subsequent stabilization of quantitative CRP indicators.

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

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

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

It is believed that the leading role in the development of interferon system deficiency is played by bacterial flora. At the same time, the presence of viruses in the association of bacteria and chlamydia presumably stimulates the body's immune response at the initial stage, and long-term exposure to bacterial infection (without viruses) leads to a more pronounced decrease in interferon levels.

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

There are contradictory data in the literature on changes in the level of the Ca-125 marker in inflammatory diseases of the pelvis. Thus, it was found that in patients with acute salpingitis, the levels of Ca-125 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 established, which correlated with the severity of inflammation of the uterine appendages, and its decrease during treatment. Others did not find reliable changes in Ca-125 in patients with inflammatory diseases of the small pelvis.

A long-term purulent process is always accompanied by dysfunction of almost all organs, i.e. multiple organ failure. This primarily concerns parenchymatous organs.

Most often, the protein-forming function of the liver suffers, and an “isolated urinary syndrome” appears, expressed 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 severity.

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

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

The method is most effective (information content up to 90%) in pronounced processes, when there is a fairly large formation, however, even experienced specialists allow for underdiagnosis, and the number of false positive results reaches 34%.

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

In patients with inflammatory diseases of the pelvic organs, transvaginal echography has advantages over transabdominal echography. Transvaginal echography data (determination of the volume of pyosalpinx/pyovars and the amount of free fluid in the recto-uterine pouch) positively correlated with the concentration of C-reactive protein and the ESR value. The researchers recommend mandatory use of the method 3 months after an acute episode in all patients.

The sensitivity of ultrasound in patients with acute inflammatory diseases of the pelvic organs is very high - 94.4%. According to the researchers, the most common finding is dilation of the fallopian tube - 72.2%. Signs of endosalpingitis were found in 50% of patients, fluid in the Douglas pocket - in 47.2%. Scientists believe that careful ultrasound screening will improve the diagnosis of purulent inflammatory diseases in patients with clinical signs of infection.

The results of using color Doppler echocardiography are described. A decrease in the pulsatory index (PI) of the uterine arteries was noted, which positively correlated with the concentration of C-reactive protein. The PI values 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 differential diagnostics of inflammatory tumor-like 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 ultrasound.

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

Doppler ultrasound is believed to be an accurate method for excluding malignant tumors, but in cases of differentiating them from inflammatory tumors, some errors may occur.

Currently, there is no research method in obstetrics and gynecology that is as important as echography. For patients with complicated forms of inflammation, echography is the most accessible, highly informative, noninvasive research method. To determine the extent of the spread of the purulent process and the depth of tissue destruction, it is advisable to combine transabdominal and transvaginal techniques and use modifications (contrast of the rectum).

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

According to research data, if the above conditions are met, the accuracy of the echography method in assessing purulent inflammatory diseases of the internal genital organs is 92%, pre-perforation conditions - 78%, purulent fistulas - 74%.

Other modern diagnostic methods - computed tomography, MRI or MRI (magnetic resonance imaging) allow with high accuracy (90-100%) to differentiate tumors and tumor-like formations of the ovaries, but, unfortunately, these methods are not always available.

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

According to research, the diagnostic value of MRI in assessing adnexal structures is 87.5%. The authors consider this diagnostic method to be a second-choice tool replacing CT.

Similar data are provided by MD'Erme et al. (1996), who believe that the diagnostic accuracy of MRI in patients with tubo-ovarian formations is 86.9%.

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

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

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

The effectiveness of CT in detecting purulent fistulas is 95.2%, and when performing fistulography, the information content increases to 100%.

Some authors point to the need to search for new methods of 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-80s, laparoscopy was primarily a diagnostic procedure; currently, this method allows for various surgical interventions in gynecology, including hysterectomy.

Laparoscopic examination allows to confirm or reject the diagnosis of inflammatory disease, to identify concomitant pathology of internal genitalia. There are reports in the literature about successful treatment of patients with acute purulent inflammation.

However, laparoscopy has a number of contraindications, especially in cases of extensive adhesions and repeated laparotomy. 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 availability of such highly informative diagnostic methods as ultrasound, CT, and MRI currently makes diagnostic laparoscopy inappropriate and even risky. We use this method of examination as a component of surgical treatment after examining a patient in the case of acute purulent inflammation with a history of the process of no more than 3 weeks, i.e. with loose adhesions in the small pelvis.

Laparoscopy is contraindicated for patients with complicated forms of purulent inflammation, since examination in the context of a purulent-infiltrative process does not provide any additional information, and attempts to separate adhesions can lead to severe intraoperative complications (injury to the intestine, bladder), requiring emergency laparotomy and worsening the already severe condition of patients.

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

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

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