Ozonotherapy in the Correction of Endogenous Intoxication and Lipid Metabolism Disorders in Acute Experimental Pancreatitis (Experimental Study)

The dissertation is devoted to the experimental investigation of the therapeutic potential of infusion ozonotherapy for the correction of endogenous intoxication and lipid metabolism disorders in acute pancreatitis. The investigation was conducted at the Research Institute of General Pathology and Pathophysiology of the Russian Academy of Medical Sciences (Moscow) and encompasses a complex of experimental studies on models of acute pancreatitis using ozonated isotonic sodium chloride solution. The author has investigated the interrelationships between the development of endotoxication, the activation of lipid peroxidation processes, the elevation of phospholipase activity, and the impairment of detoxification liver function. It has been established that ozonotherapy exerts membrane-protective, lipid-regulating, and hepatoprotective action, attributable to the reduction of oxidative stress intensity and the restoration of adaptive mechanisms of cellular regulation. The obtained data are of significance for the improvement of pathogenetic therapy of acute pancreatitis and may be utilized for the inclusion of indicators of endogenous intoxication and lipid metabolism in the system of diagnostic criteria for assessing the severity of the disease and the efficacy of treatment.

Current Concepts of the Etiology and Pathogenesis of the Disease. 13

1.2. Destruction of Cellular Membranes and Activation of Lipid Peroxidation Processes in Membrane Lipids — the Most Early and Leading Mechanism of Endotoxicosis Development in Acute Pancreatitis. 20

1.3. The Liver as a Target Organ of Pancreatogenic Toxemia. Pathogenesis of Impaired Detoxification Function of the Liver. 33

1.4. The Role of Adaptive-Accommodative Processes in Maintaining the Homeostasis of the Organism in Acute Pancreatitis. Pathogenetic Therapy of the Disease as a Means of Restoring the Systems of Natural Defense of the Organism at the Molecular, Cellular, and Organ Levels. 38

1.5. Mechanisms of the Implementation of the Protective Action of Infusion Ozonotherapy. 46

Relevance of the Problem. Acute pancreatitis currently occupies a leading position among diseases of the pancreas and in the structure of emergency surgical pathology as a whole (Kostychenko A. L., Filin V. I., 2000; Beger N. G., Ran V., 1995). At the same time, the morbidity rate shows no tendency to decrease, and the duration of inpatient treatment remains significant. Despite the diversity of various options for both conservative and surgical treatment, the constant improvement of diagnostic and therapeutic methods, high mortality persists in destructive forms of the disease (Beriashvili Z. A. et al., 2001; Fugger R. et al., 1995; Harris J. A. et al., 1995).

Meanwhile, in the available literature, the pathogenic mechanisms of acute pancreatitis development are still not sufficiently clearly defined, and researchers' opinions differ substantially (Boyko Yu. G., Prokopchik P. I., 1992; Fedorov V. D. et al., 1999; Glosbrener V., Adler G., 1993; Zhou W., Ohashi K., 1994). This circumstance determines the imperfection of therapy for this disease and the constant search for new methods of both pharmacological and surgical treatment (Briskin B. S. et al., 2001; Glushko V. A., Gostishchev V. K., 2001; Scholmerich J., Gross V., 1993). Understanding the pathogenic mechanisms of acute pancreatitis development and its complications creates the basis for subsequent effective therapy. The tactics of treatment and the prognosis of the disease depend on the correct interpretation of clinical and laboratory indicators and the results of instrumental investigations performed with consideration of possible pathogenic mechanisms (Vladimov V. G., 1984; Gubergrits N. B., Khristich T. N., 2000).

The principal cause of complications involving various organs and systems in acute pancreatitis, up to the development of multiple organ insufficiency and often a fatal outcome, is endogenous intoxication caused by the entry into the blood of degradation products of biological structures, which contributes to the disruption of microcirculation and the blocking of enzymatic systems of cells of organs and tissues (Filin V. I., Kostychenko A. L., 1994; Greenberg A. A., 2002; Schulz N., Schulz E., 1990).

Increasing significance in the development of the endogenous intoxication syndrome in acute pancreatitis in recent years has been attributed to the intensification of free radical lipid oxidation processes and the elevation of phospholipase activity, which are the principal factors of cell membrane destabilization and lead to the impairment of functions not only of individual cells, tissues, and organs, but of the organism as a whole (Titova G. N., Permyakov N. K., 1995; Vlasov A. P. et al., 1999; Podshivalov V. Yu. et al., 2001).

In acute pancreatitis, insulin resistance develops, the intensity of carbohydrate metabolism decreases, an energy deficit arises in tissues, and insufficiency of the organism's antioxidant defense is formed, which further intensifies free radical oxidation processes (Vlasov A. P. et al., 2000; Kostychenko A. L., Filin V. I., 2000).

The bilateral anatomophysiological interaction of the pancreas and liver determines the role of the latter as the first and most frequently affected target organ in the pathway of spreading inflammatory and destructive processes in the pancreas, subjecting the liver to a massive attack of pancreatogenic toxins, which subsequently leads to insufficiency of its functions (Rad M. R., 1993; Sotnichenko B. A., 1995; Sugeno K., et al., 1987; Lankisch P. G. et al., 1997).

The possibilities of pharmacological therapy of acute pancreatitis against the background of the severe general condition of the organism, associated with endogenous intoxication and discoordination of homeostasis, are limited; therefore, the problem of searching for new effective methods of treatment that provide correction of the most important links in the pathogenesis of this disease, having a minimum of side effects and being economically accessible, is of considerable importance.

At present, researchers are paying increasing attention to ozonotherapy, whose positive action is associated with the restoration of adaptive mechanisms of regulation of disrupted cellular functions. The method attracts not only by its high efficacy, broad spectrum of action, and accessibility, but also by the practically complete absence of side effects (Kolesova O. E. et al., 1992; Alekhina S. G., Shcherbatyuk T. G., 2003).

For the normalization of homeostatic reactions in acute pancreatitis, there arises a necessity for the correction of oxidative-reductive processes in the organism, which contributes to the restoration of protein-synthetic function of the liver, the elimination of tissue hypoxia, the reduction of manifestations of the systemic inflammatory syndrome and endogenous intoxication, and the activation of rehabilitative-regenerative processes. It has been demonstrated that the application of ozonotherapy in this disease exerts a modulating influence on lipid peroxidation processes and antioxidant protection, phospholipase A2 activity, and is therefore pathogenetically justified (Novomlinsky V. V., 1995; Chudnykh S. M. et al., 1995; Boyarov G. A. et al., 1998; Rilling S., 1993).

The use of oxidative ozone therapy in the complex treatment of acute pancreatitis makes it possible to reduce the volume of antifungal and antibacterial therapy, the administration of infusion solutions, and immunomodulators; it provides a broad spectrum of clinical effects: the general condition improves, hemodynamic indicators and immunological status stabilize; a decrease in the frequency of development of multiple organ insufficiency and mortality is noted, and the treatment outcomes for patients in this category improve.

However, the mechanisms of changes in the homeostasis of the organism in patients with acute pancreatitis under the influence of ozonotherapy remain insufficiently studied. Due to the aforementioned circumstances, there has arisen a necessity for in-depth investigations of both the molecular mechanisms of the development of homeostasis disorders in this disease and the influence of ozonotherapy on their correction. Only an understanding of the pathogenic picture of the disease will subsequently allow the development of optimal comprehensive treatment schemes, including the application of ozonotherapy, to increase the efficacy of acute pancreatitis treatment and avoid its complications.

The aim of this investigation was to study the interrelationship between the development of endogenous intoxication, lipid metabolism disorders, detoxification function of the liver, and the activation of lipid peroxidation processes in acute pancreatitis, and to establish the possibility of correcting the arising disorders with the aid of infusion ozonotherapy.

Within the framework of the stated aim, the following tasks were addressed:

1. To study the influence of infusion ozonotherapy on the severity of indicators of endogenous intoxication using the model of acute experimental pancreatitis.

2. In acute experimental pancreatitis, to identify disturbances in the qualitative and quantitative composition of lipids in liver tissue and in blood plasma and to demonstrate the possibility of their correction with ozonotherapy.

3. To assess the influence of ozonated isotonic sodium chloride solution on indicators of the functional state of the liver in acute experimental pancreatitis.

4. To investigate the efficacy of intravenous infusions of ozonated isotonic sodium chloride solution on the intensity of lipid peroxidation processes and phospholipase A2 activity in liver tissue and in blood plasma.

Scientific Novelty.

1. Experimental investigations have established the therapeutic efficacy of intravenous infusions of ozonated isotonic sodium chloride solution in acute pancreatitis, which is determined by the positive dynamics of clinical and laboratory indicators and the increase in animal survival rate.

2. It has been established that the pharmacological efficacy of infusion ozonotherapy in acute experimental pancreatitis is associated with its ability to reduce the severity of endogenous intoxication and restore lipid metabolism.

3. It has been shown that the membrane-protective activity of ozonated isotonic sodium chloride solution is due to its ability to reduce the intensity of lipid peroxidation processes and decrease phospholipase A2 activity.

4. It has been established that one of the significant components of the realization of the positive effects of infusion ozonotherapy in acute experimental pancreatitis is its ability to restore the functional activity of the liver.

5. It has been established that the clinical and laboratory positive effects of ozonated isotonic sodium chloride solution arise after the third administration and are the result of the restoration of adaptive mechanisms of regulation of disrupted cellular functions in acute experimental pancreatitis.

Theoretical and Practical Significance of the Work.

The fact of therapeutic efficacy of the application of ozonated isotonic sodium chloride solution in the treatment of acute experimental pancreatitis has been established. It has been demonstrated that ozonotherapy possesses a broad spectrum of action, which lies at the basis of the correction of homeostasis disorders. The scientific data of the dissertation work are considered important in their conceptual basis and significant for practical medicine, as they make it possible to determine directions for further investigations on the improvement of acute pancreatitis therapy. Moreover, the obtained information may serve as a basis for including indicators of the severity of endogenous intoxication and lipid metabolism of blood plasma in the list of diagnostic tests assessing the severity of the pathology and the efficacy of therapy, and having prognostic significance.

Propositions Submitted for Defense.

1. The application of ozonated isotonic sodium chloride solution in acute experimental pancreatitis exerts a number of beneficial effects. When it is used, the severity of endogenous intoxication decreases and the qualitative and quantitative composition of lipids in liver tissue and blood plasma is restored, which contributes to preventing the progression of the pathological process and reducing animal mortality.

2. The use of infusion ozonotherapy exerts a lipid-regulating action and contributes to a more rapid restoration of the qualitative and quantitative composition of lipids in liver tissue and blood plasma.

3. The basis of the ability of ozonated isotonic sodium chloride solution to influence lipid metabolism lies in the possibility of reducing the intensity of lipid peroxidation processes and phospholipase A2 activity.

4. The membrane-stabilizing capacity of infusion ozonotherapy in the investigated pathology manifests after the third administration of the preparation.

5. A number of effects of ozonated isotonic sodium chloride solution are realized through the restoration of functional activity of the liver.

Implementation in Practice.

The developed dissertation propositions have been included in the training program for students at the departments of faculty surgery and pathological physiology of the Medical Faculty of the State Educational Institution of Higher Professional Education «Morovian State University named after N. P. Ogarev».

Validation of the Work.

The main results of the work were reported and discussed at the Ogarev Readings — annual scientific-practical conferences of the Morovian State University named after N. P. Ogarev (Saransk, 2001-2004); scientific conferences of young scientists of the Morovian State University named after N. P. Ogarev (Saransk, 2000-2005); the II International Conference «Pathophysiology and Modern Medicine» (Moscow, RUDN, 2004); the XIV Scientific Readings in Memory of Academician N. N. Burdenko «Actual Questions of Modern Clinical Medicine» (Penza, 2004); the III Russian Congress on Pathophysiology «Disequilibrium Pathology of Organs and Systems (Experimental and Clinical Pathophysiology)» (Moscow, 2004); the All-Russian Scientific-Practical Conference with International Participation «Efferent, Immunocorrecting, and Intensive Therapy in Clinical Practice» (Izhevsk, 2004); the XI International Conference of Russian and CIS Hepatological Surgeons (Moscow, 2004); the 7th International Slavic-Baltic Scientific Forum «Saint Petersburg — Gastro-2005» (Saint Petersburg, 2005).

Publications. Sixteen scientific works have been published on the topic of the dissertation.