SITUATIONAL PROBLEM K000160

1. Chronic alcoholic pancreatitis, exacerbation. Alcoholic steatosis of the liver. GSD, latent course.

2. 1) The diagnosis of “chronic alcoholic pancreatitis, art. exacerbations” was set on the basis of complaints (a sharp pain of a constant nature in the epigastric region with irradiation to the back, to the left half of the abdomen, nausea, vomiting of food eaten that does not bring relief, moderate bloating, general weakness, lack of appetite, greasy, with a greasy sheen, fetid stool 2-3 times a day); anamnesis (the day before there were errors in the diet – taking spicy food, alcohol; similar pains were about a year ago, also arose after errors in the diet, stopped after taking Noshpa, has been abusing alcohol for the past seven years); objective examination (the abdomen is somewhat swollen, moderately painful on palpation in the epigastric region); laboratory data (general blood count: leukocytes – 9.6 × 109 / l, ESR – 16 mm / h; fecal analysis: steatorrhea, creatorrhea, amylorrhea).

2) The diagnosis of “alcoholic steatosis of the liver” was made on the basis of an objective examination (the liver is dense on palpation, painless, near the edge of the costal arch, the size according to Kurlov is 10 × 9 × 8 cm); Ultrasound of the OBP (the liver is enlarged, with periportal seals).

3) The diagnosis of “GSD, latent course” was made on the basis of: ultrasound of the OBP – gallbladder 75 × 35 mm, in the lumen of a calculus 8 mm in diameter, with an acoustic track.

3. Biochemical blood test (glucose, lipase, trypsin, amylase, ALT, AST, GGTP). Consultation of a surgeon.

Coprogram, analysis of feces for D-elastase to confirm exocrine pancreatic insufficiency.

Biochemical blood test: bilirubin and its fractions, alkaline phosphatase to exclude cholestasis.

Repeated blood test for the presence of increased glucose, if necessary – glycemic profile, glycated hemoglobin (exclude diabetes mellitus). CT scan of the abdominal cavity (exclude the presence of pancreatic cysts, tumors of the pancreas).

FGDS (exclude duodenal ulcer).

4. 1. Peptic ulcer of the stomach and duodenum – ulcerative anamnesis, alternation of light intervals with periods of exacerbation, absence of diarrhea, seasonality of pain, connection of pain with food intake, “hungry” pains are characteristic. The disease is characterized by hypersecretion, increased acidity of gastric juice, x-ray – the presence of a niche, with fibrogastroscopy – the presence of an ulcer.

2. Dysfunction of the sphincter of Oddi – characterized by dull pain in the right hypochondrium with irradiation to the right shoulder, shoulder blade. When examining patients, pain is found at the Kerah point, sometimes muscle tension in the right hypochondrium, positive symptoms of Ortner, Murphy, Mussi-Georgievsky. In biochemical samples of the liver, an increase in the content of cholesterol, β-lipoproteins, alkaline phosphatase is observed. Characteristic changes in the gallbladder on ultrasound (thickening and compaction of the walls, increase in size).

5. Hospitalization is indicated. 1) Complete rejection of alcohol. 2) Diet: table number 5p according to Pevzner. 3) Antispasmodic drug (for example, Drotaverine 4 ml (80 mg) 2 times a day / m). 4) Analgesics (for example, Baralgin 250 mg orally 2 times a day, Paracetamol) for pain. 5) Out of exacerbation: enzyme preparations with a substitution purpose. 6) Correction of glycemia in case of its detection.

CASE STUDY 84 [K000161]

Instructions: READ THE SITUATION AND GIVE DETAILED ANSWERS TO THE QUESTIONS

Main part

Patient Z., aged 22, complains of weakness, dizziness, fatigue, attacks of severe pain in the right hypochondrium.

Anamnesis of the disease: from the age of 11, the patient notes recurrent icterus of the skin, followed by pallor. These attacks were accompanied by severe weakness. In the last 8 years, the patient began to be disturbed by pain in the right hypochondrium of a paroxysmal nature, accompanied by jaundice. Objectively: the state is satisfactory, consciousness is clear. The skin and visible mucous membranes are icteric against a generally pale background, the sclera are icteric.

Peripheral lymph nodes are not enlarged. In the lungs, breathing is carried out in all fields, there are no wheezing. NPV – 17 per minute. Heart sounds are rhythmic, a blowing murmur is heard at the apex of the heart. Heart rate – 84 beats per minute. On palpation, the liver has a normal consistency, painful, the edge is rounded, protrudes 2.5 cm from under the edge of the costal arch. Dimensions according to Kurlov – 12×10×9 cm. The spleen protrudes 3 cm below the left costal arch. On superficial palpation, the abdomen is soft and painless.

Results of additional research.

Complete blood count: erythrocytes – 3.2 × 1012 / l, hemoglobin – 91 g / l, color index – 0.85, reticulocytes – 14.8%, average diameter of erythrocytes – 4 μm, leukocytes – 11 × 109 / l, stab neutrophils – 11%, segmented neutrophils – 59%, lymphocytes – 30%, monocytes – 10%, ESR – 20 mm/h. Osmotic resistance of erythrocytes (ORE) – 0.78-0.56% (normal min. ORE – 0.44-0.48%, max. ORE – 0.28-0.36%).

Biochemical blood test: bilirubin – 111.2 µmol/l, direct – 17.1 µmol/l, indirect – 94.1 µmol/l. Coombs test is negative.

Questions:

1. Express the expected preliminary diagnosis.

2. Justify your diagnosis.

3. Make a plan for an additional examination.

4. Differential diagnosis.

5. Treatment plan.

Be First to Comment

Leave a Reply

Your email address will not be published.