Spezifische Parameter im Blut und Bauchpunktat zur Ermittlung des Schweregrades von intestinaler Ischämie bei Kolikpferden

Zusammenfassung:

Ziel: Zur Beurteilung von intestinaler Ischämie wurden spezifische Parameter im Blut und Bauchpunktat (BP) bei Pferden mit verschiedenen Kolikformen untersucht. Material und Methoden: Bei acht gesunden und 26 Kolikpferden (Dislocatio coli [geringgradige Ischämie], n = 14; Dünndarmstrangulation [hochgradige Ischämie], n = 12) erfolgte im Blut und/oder BP die Bestimmung folgender Parameter: Leukozytenzahl, Hämatokrit (HK), pH-Wert, Basenüberschuss, Harnstoff, Kreatinin,Totalprotein (TP), Albumin, Laktat, LDH, AP, CK und C-reaktives Protein (CRP). Für TP, Albumin, Laktat, LDH, AP, CK, CRP wurde das Verhältnis der Werte in BP und Blut (BP/B-Ratio) berechnet und mit den Light-Kriterien zum Nachweis eines Exsudatsverglichen. Eine Differenzierung und Beurteilung der Leukozyten im BP nach spezifischen Apoptose- und Ne- krosemerkmalen erfolgte an gefärbten Ausstrichen. Die Statistik beinhaltete u. a. die Prüfung auf Zuverlässigkeit der Light-Kriterien und die Berechnung der Korrelationen der Parameter zum Ischämiegrad. Ergebnisse: Mit zunehmendem Schweregrad der Kolik ergab sich eine signifikante Erhöhung und positive Korrelation von Laktat, LDH und CK im Blut sowie von TP, Albumin, Laktat, LDH, AP, CK und CRP im BP. Auch die BP/B-Ratio dieser Parameter korrelierte signifikant mit dem Ischämiegrad. Nur bei Pferden mit Dünndarmstrangulation entsprach das BP bezüglich der Light-Kriterien einem Exsudat. Die Wahrscheinlichkeit, dass ein BP ein Exsudat darstellte, war bei einer LDH-Aktivität von > 200 U/l am größten. Die CRP-Konzentration im BP stieg bei Pferden mit hochgradiger Ischämie signifikantan. Die Leukozytenbeurteilung ergab bei allen Kolikpferden einen erhöhten prozentualen Anteil apoptotischer Zellen, v. a. polymorphkerniger Zellen, und eine signifikante Zunahme nekrotischer Leukozyten im BP bei Pferden mit Dünndarmstrangulation. Schlussfolgerung und klinische Relevanz: TP, Albumin, Laktat, LDH, AP, CK im BP und die BP/B-Ratio dieser Parameter sind für die Beurteilung ischämischer Prozesse hilfreich. CRP im BP und die Light-Kriterien können zur Charakterisierung hochgradiger intestinaler Schädigungen genutzt werden. Eine gesteigerte Apoptose und Nekrose der Leukozyten im BP stellen Indikatoren für intraabdominale Entzündungen dar.

Summary:

Objective: Specific parameters of blood and peritoneal fluid of horses with different types of colic were evaluated to indicate the degree of intestinal ischemia. Material and methods: Following physical examination of eight healthy and 26 colic horses (14 with large colon displacement [mild ischemia], 12 with small intestinal strangulating obstruction [severe ischemia]) blood and peritoneal fluid (PF) samples were taken to analyze WBC, PCV, pH, base excess, urea, creatinine, total protein (TP), albumin, lactate, LDH, AP, CK, and C-reactive protein (CRP). Furthermore, the ratio of PF and blood values (PF/B ratio) of TP, albumin, lactate, LDH, AP, CK, CRP was calculated to distinguish PF into transudate or exudate according to the Light's criteria. Differentiation of leukocytes of stained PF smears, and the classification into morphological normal, apoptotic and necrotic cells was performed. Statistical analysis included the verification of the reliability of Light's criteria and the calculation of the correlation of parameters and the severity of ischemia. Results: In all colic horses activities of blood lactate, LDH, CK as well as TP, albumin, lactate, LDH, AP, CK and CRP of PF were significantly increased and positively correlated depending on the severity of colic. The PF/B ratio of these parameters also had a correlation to the degree of ischemia. Regarding the Light's criteria only PF of horses with small intestinal strangulating obstruction represented an exudate. The probability of PF to be an exudate was greatest if LDH activity exceeded 200 U/l. CRP was significantly increased in PF of horses with severe ischemia. The percentage of apoptotic cells, especially of PMN was increased in all colic horses. Only horses with small intestinal strangulating obstruction had a significantly increased percentage of necrotic cells. Clinical relevance and conclusions: The values of TP, albumin, lactate, LDH, AP, CK of PF, as well as the PF/B ratio of these parameters are helpful to evaluate ischemic injuries. An increased CRP of PF as well as the Light's criteria can be used to detect severe intestinal injuries. An increased percentage of PF leukocyte apoptosisand necrosis indicates abdominal inflammatory processes.

Schlüsselwörter:

Exsudat - Light-Kriterien - LDH - CK - C-reaktives Protein - Apoptose - Nekrose

Key words:

Exudate - Light's criteria - LDH - CK - C-reactive protein - apoptosis - necrosis

• Literatur

• 1 Adams SB, Fessler JF, Rebar AH. Cytologic interpretation of peritoneal fluid in the evaluation of equine abdominal crisis. Cornell Vet 1980; 70: 232-46.
• 2 Arden WA, Stick JA. Serum and peritoneal fluidphosphate concentrations as predictors of major intestinal injury associated with equine colic. J Am Vet Med Assoc 1988; 193: 927-31.
• 3 Bansal S, Kaur K, Bansal AK. Diagnosing ascitic etiology on a biochemical basis. Hepatogastroenterol 1998; 45: 1673-7.
• 4 Barton MH, Collatos C. Tumor necrosis factor and Interleukin-6 activity and endotoxin concentration in peritoneal fluid and blood of horses with acute abdominal disease. JVet Intern Med 1999; 13: 457-64.
• 5 Brownlow MA, Hutchins DR, Johnston KG. Reference values for equine peritoneal fluid. Equine VetJ 1981; 13: 127-30.
• 6 Bürger W, Ewald C, Fennert E-M. Increase in C-reactive protein in the serum of piglets (pCRP) following ACTH or corticosteroid administration. J Vet Med 1998; 45: 1-6.
• 7 Buttke TM, Sandstrom PA. Oxidative stress as amediator of apoptosis. Immunol Today 1994; 15: 7-10.
• 8 Caglayan F, Caglayan O, Gunel E, et al. Intestinal ischemia-reperfusion and plasma enzyme levels. Pediatr Surg Int 2002; 18: 255-7.
• 9 Calikoglu M, Sezer C, Unlu A, et al. Use of acute phase proteins in pleural effusion discrimination. TuberkToraks 2004; 52: 122-9.
• 10 Castano Vidrialis JL, Amores Antequera C. Use of pleural fluid C-reactive protein in laboratory diagnosis of pleural effusions. Eur J Med 1992; 1: 201-7.
• 11 Cervicel MH, Ozgun H, Boylu S. et al. C-reactiveproteinmaybeamarkerof bacterial translocation in experimental intestinal obstruction. ANZ J Surg 2004; 74: 900-4.
• 12 Colotta F, Re F, Polentarutti N, et al. Modulation of granulocyte survival and programmed cell death by cytokines and bacterial products. Blood 1992; 80: 2012-20.
• 13 Connally HE. Cytology and fluid analysis of the acute abdomen. Clin Tech Small Anim Pract 2003; 18: 39-44.
• 14 DeLaurier GA, Ivey RK, Johnson RH. Peritoneal fluid lactic acid and diagnostic dilemmas in acute abdominal disease. Am J Surg 1994; 167: 302-5.
• 15 Ekblad E, Bauer AJ. Role of vasoactive intestinalpeptide and inflammatory mediators in enteric neuronal plasticity. Neurogastroenterol Motil Suppl 2004; 16: 123-8.
• 16 Freden GO, Provost PJ, Rand WM. Reliability of using results of abdominal fluid analysis to determine treatment and predict lesion type and outcome for horses with colic: 218 cases (1991-1994). J Am Vet Med Assoc 1998; 213: 1012-5.
• 17 Froscher BG, Nagode LA. Origin and importance of increased alkaline phosphatase activity in peritoneal fluid of horses with colic. Am J Vet Res 1981; 42: 888-91.
• 18 Fujishima S, AIkawa N. Neutrophil-mediated tissue injury and its modulation. Intensive Care Med 1995; 21: 277-85.
• 19 Garma-Avina A. Cytology of 100 samples of abdominal fluid from 100 horses with abdominal disease. Equine Vet J 1998; 30: 435-44.
• 20 Genn HJ, Hertsch B. Die diagnostische und prognostische Bedeutung des Laktatwertes im Blut sowie in der Bauchhöhlenflüssigkeit bei der Kolik des Pferdes. Dtsch Tierärztl Wschr 1982; 89: 295-9.
• 21 Gitter AH, Bendfeldt K, Schulzke JD, et al. Leaks in the epithelial barrier caused by spontaneous and TNF-a-induced single-cell apoptosis. FASEB J 2000; 14: 1749-53.
• 22 Grulke S, Benbarek H, Caudron I, et al. Plasma myeloperoxidase level and poly- morphnuclear leukocyte activation in horses suffering from large intestinal obstructionrequiringsurgery:preliminaryresults. Can J Vet Res 1999; 63: 142-7.
• 23 Haslett C. Granulocyte apoptosis and inflammatory disease. Br Med Bull 1997; 53: 669-83.
• 24 Hebert MJ, Takano T, Holthöfer H. et al. Sequential morphologic events during apoptosis of human neutrophils. J Immunol 1996; 157: 3105-15.
• 25 Iwasaki A, Kelsall BL. Mucosal immunity and inflammation: mucosal dendritic cells: their specialized role in initiating T cell response. Am J Physiol 1999; 276: G1074-8.
• 26 Jesch NK, Vieten G, Tschernig T, et al. Minilaparotomy and full laparotomy, but not laparoscopy, alter hepatic macrophage populations in a rat model. Surg Endosc 2005; 19: 804-10.
• 27 Kanwar S, Hickey MJ, Kubes P. Postischemic inflammation: arole for mast cells in intestine butnot in skeletal muscle. Am J Physiol 1998; 275: 212-8.
• 28 Kobayashi SD, De Leo FR. An apoptosis differentiation programme in human polymorphnuclear leucocytes. Biochem Society Transactions 2004; 32: 474-6.
• 29 Kopf N. Indikationen, Ergebnisse und Aussichten operativer Kolikbehandlung beim Pferd - eine Analyse von 149 klinischen Fällen. Wien Tierärztl Mschr 1994; 71: 43-169.
• 30 Kraft W, Dürr UM. Klinische Labordiagnostik in der Tiermedizin, 6. Aufl. Stuttgart, New York: Schattauer; 2005
• 31 Larsen J. Acid-base and electrolyte balance in horses with various gastrointestinal disorders. Proc Equine Colic Res Symp, Athens Georgia 1994; 5: 9.
• 32 Latson KM, Nieto JE, Beldomenico PM, et al. Evaluation of peritoneal fluid lactate as amarker of intestinal ischaemia in equine colic. Equine Vet J 2005; 37: 342-6.
• 33 Lee A, Whyte MK, Haslett C. Inhibition of apoptosis and prolongation of neutrophil functional longevity by inflammatory mediators. J Leukoc Biol 1993; 54: 283-8.
• 34 Liao XP, She YX, Shi CR, et al. Changes in body fluid markers in intestinal ischemia. J Pediatr Surg 1995; 30: 1412-5.
• 35 Light RW, Mac Gregor MI, Luchsinger PC. et al. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med 1972; 77: 507-13.
• 36 Magdesian KG. Monitoring the critically ill equine patient. Vet Clin Equine Pract 2004; 20: 11-39.
• 37 Matthews S, Dart AJ, Reid SWJ. et al. Predictive values, sensitivity and specificity of abdominal fluid variables in determining the need for surgery in horses with acute abdominal crisis. Aust Vet J 2002; 80: 132-6.
• 38 McMichael M, Moore RM. Ischemia-reperfusion injury pathology. Part I. J Vet Emerg Crit Care 2004; 14: 231-41.
• 39 Meschter CL, Tyler DE, White NA, et al. Histologic findings in the gastrointestinal tract ofhorses with colic. Am J Vet Res 1986; 47: 598-606.
• 40 Milne EM, Doxey DL, Gilmour JS. Analysis ofperitoneal fluid as a diagnostic aid in grass sickness (equine dysautonomia). Vet Rec 1990; 127: 162-5.
• 41 Moore JN, Owen RR, Lumsden JH. Clinical evaluation of blood lactate levels in equine colic. Equine Vet J 1976; 8: 49-54.
• 42 Moore JN, Traver DS, White FJ, et al. Lactic acid concentration in peritoneal fluid of normal and diseased horses. Res Vet Sci 1977; 23: 117-8.
• 43 Moore RM, Muir WW, Granger DN. Mechanisms of gastrointestinal ische- mia-reperfusion injury and potential therapeutic interventions: a review and its implications in the horse. J Vet Intern Med 1995; 9: 115-32.
• 44 Morris DD, Moore JN, Crowe N. Serum tumornecrosisfactoractivityinhorses with colic attributable to gastrointestinal tract disease. Am J Vet Res 1991; 52: 1565-9.
• 45 Mukai M, Tamaki T, Noto T, et al. A new mechanism of serum creatine phos- phokinase elevation in strangulated small bowel obstruction: an experimental rat model. J Intern Med Res 1995; 23: 184-90.
• 46 Nappert G, Johnson PJ. Determination of the acid-base status in 50 horses admitted with colic between December 1998 and May 1999. Can Vet J 2001; 42: 703-7.
• 47 Nusbaum P, Laine C, Seveau S, et al. Early membrane events in poly- morphnuclear cell (PMN) apoptosis: membrane blebbing and vesicle release, CD43 and CD16 down-regulation and phosphatidylserine externalizati- on. Biochem Society Transactions 2004; 32: 477-9.
• 48 Oishi K, Machida K. Inhibition of neutrophil apoptosis by antioxidants in culture medium. Scand J Immunol 1997; 45: 21-7.
• 49 Pepys M, Baltz ML. Acute phase proteins with special reference to C-reac- tive protein and related proteins (pentaxins) and serum amyloid A protein. Adv Immunol 1983; 34: 141-212.
• 50 Perdue MH. Mucosal immunity and inflammation: III. The mucosal antigen barrier: cross talk with mucosal cytokines. Am J Physiol 1999; 277: G1-5.
• 51 Petersen HH, Nielsen JP, Heegaard PMH. Application of acute phase protein measurements in veterinary clinical chemistry. Vet Res 2004; 35: 163-87.
• 52 Povoa P. C-reactive protein: avaluable marker of sepsis. Intensive Care Med 2002; 28: 235-43.
• 53 Reeves MJ, Curtis CR, Salman MD, et al. Multivariable prediction model for the need for surgery in horses with colic. Am J Vet Res 1991; 52: 1903-8.
• 54 Roth M, Jaquet PY, Rohner A. Increase of creatine kinase and lactate dehydrogenase in the serum of rats submitted to experimental intestinal infarction. Clin Chim Acta 1989; 183: 65-9.
• 55 Saik JE. Cytologic evaluation of peritoneal fluid for the equine practitioner. Proc Am Assoc Equine Pract 1992; 444-8.
• 56 Saulez MN, Cebra CK, Tornquist SJ. The diagnostic and prognostic value of alkaline phosphatase activity in serum and peritoneal fluid from horses with acute colic. J Vet Intern Med 2004; 18: 564-7.
• 57 Shidham VB, Gupta DK, Liu C, et al. Apoptotic leukocytes in peripheral blood smears. Am J Clin Pathol 1997; 108: 345.
• 58 Sodhi D, Arora N. Serum inorganic phosphate levels in experimental intestinal ischemia. Indian J Med Sci 1993; 7: 259-63.
• 59 Squier MKT, Sehnert AJ, Cohen JJ. Apoptosis in leukocytes. J Leukocyte Biol 1995; 57: 2-10.
• 60 Swanwick RA, Wilkinson JS. A clinical evaluation of abdominal paracentesis in the horse. Aust Vet J 1976; 52: 109-7.
• 61 Takigushi M, Fujinaga T, Naiki M, et al. Isolation, characterization, and quantitative analysis of C-reactive protein from horses. Am J Vet Res 1990; 51: 1215-20.
• 62 Thoefner MB, Ersboll BK, Jansson N. et al. Diagnosticdecision rule for support in clinical assessment of the need for surgical intervention in horses with acute abdominal pain. Can J Vet Res 2003; 67: 20-9.
• 63 Thompson JS, Bragg LE, West WW. Serum enzyme levels during intestinal ischemia. Ann Surg 1990; 211: 369-73.
• 64 Turay Y, Yildirim Z, Turkoz Y, et al. Use of pleural fluid C-reactive protein in diagnosis of pleural effusions. Respir Med 2000; 94: 432-5.
• 65 Van der Linden MA, Laffont CM, Sloet van Oldruitenborgh-Oosterbaan MM. Prognosis in equine medical and surgical colic. J Vet Intern Med 2003; 17: 343-8.
• 66 Van Hoogmoed L, Rodger LD, Spier SJ. et al. Evaluation of peritoneal fluid pH, glucose concentration, and lactate dehydrogenase activity for detection of septic peritonitis in horses. J Am Vet Med Assoc 1999; 214: 1032-6.
• 67 Yamashita K, Fujinaga T, Okumura M. et al. Serum C-reactive protein (CRP) in horses: the effect of aging, sex, delivery and inflammations on its concentration. J Vet Med Sci 1991; 53: 1019-24.
• 68 Yarbrough JB, Snyder JR, Harmon FA, et al. Evaluation of myeloperoxidase concentrations in experimental induced equine colonic ischemia and reperfusion. Equine Vet J 1994; 26: 67-9.
• 69 Yasui K, Kobayashi N, Yamazaki T, et al. Superoxide dismutase (SOD) as a potential inhibitory mediator of inflammation via neutrophil apoptosis. Free RadicRes 2005; 39: 755-62.