1. GERD. Chronic reflux esophagitis, exacerbation.

2. Structure of the esophagus, bleeding from esophageal ulcers, Barrett’s esophagus, esophageal adenocarcinoma.

3. FEGDS, histological examination, pH-metric examination, esophageal manometry, X-ray examination, impedancemetry. Test with Gaviscon for relief of pain.

4. Weight loss, smoking cessation, sleep with the head of the bed raised, avoid taking drugs that reduce the tone of the lower esophageal sphincter (theophyllines, nitrates, calcium channel inhibitors, antidepressants) that cause inflammation of the esophageal and stomach mucosa (NSAIDs, Doxycycline).

Do not eat at night, do not lie down for 40-60 minutes after eating, avoid acidic fruit juices, fats, chocolate, coffee, garlic, onions, peppers, alcohol, hot, cold and spicy foods, carbonated drinks.

5. Proton pump inhibitors (Omeprazole, Rabeprazole), prokinetics (Motilium, Ganaton), antacids (Almagel, Maalox), alginates (Gaviscon, Gaviscon forte).

CASE STUDY 157 [K002060]


Main part

A 55-year-old man, an alcohol abuser, a smoker, came to the office of a district general practitioner with complaints of pain in the depths of the abdomen, spreading upwards, occurring more often 1.5-2 hours after a plentiful, spicy or fatty meal, lasting up to 3 hours, intensifying in the supine position, decreasing in the sitting position with an inclination forward, pulling the legs to the chest.

Sometimes the pain radiates to the left side of the chest. Also notes nausea, lack of appetite, bloating.

After each meal for 1 hour there is a mushy, sometimes watery stool containing drops of fat.

Notes weight loss.


1. Formulate the most likely preliminary diagnosis.

2. List the possible complications of this disease.

3. What examination methods are used to confirm and clarify the diagnosis?

4. What are the main objectives of the conservative management/treatment of patients with this disease?

5. List the main drug and non-drug treatment measures indicated for this patient.


1. Chronic alcoholic pancreatitis of moderate severity with exocrine pancreatic insufficiency.

2. Formation of pseudocysts, subhepatic jaundice, secondary biliary cirrhosis of the liver, compression and thrombosis of the superior mesenteric and portal veins, portal hypertension, erosive esophagitis, Mallory-Weiss syndrome, gastroduodenal ulcers, chronic duodenal obstruction, pancreatic cancer, infectious complications: inflammatory infiltrates , purulent cholangitis, septic conditions, deficiency of fat-soluble vitamins, osteoporosis, endocrine insufficiency.

3. Determination of the level of amylase in the blood and urine, scatological examination, determination of the level of elastase-1 in the feces, abdominal radiography, CT, MRI / MRCP, ERCP, ultrasound, endo-ultrasound,

4. 1. Cessation of alcohol consumption, smoking.

2. Determination of the cause of pain and an attempt to reduce its intensity.

3. Treatment of exocrine pancreatic insufficiency.

4. Identification and treatment of endocrine pancreatic insufficiency.

5. Nutritional support.

6. Screening for adenocarcinoma.

5. Refusal to drink alcohol.

Diet low in fat, high in protein and carbohydrates 5-10 times a day NSAIDs (Paracetamol) 30 minutes before meals.

With inefficiency – Tramadol.

Replacement enzyme therapy with Lipase (20-45000 for the main meal and 10-25 for the intermediate).

If symptoms persist, add proton pump inhibitors.

CASE STUDY 158 [K002061]


Main part

A 38-year-old patient, an engineer, applied to a general practitioner with complaints of repeated attacks of palpitations that occur without any reason, without any connection with movement, excitement, food intake, accompanied by tightness in the chest, lack of air, trembling of the whole body. Seizures stop on their own. After stopping one of the attacks of palpitations, there was a short-term loss of consciousness. Outside the attack, weakness, fatigue, dizziness worries.

The patient considers himself for a year. It all started with malaise, prolonged subfebrile condition, arthralgia, interruptions in the work of the heart. The diagnosis of myocarditis was made, she was treated in a hospital. At discharge, the doctors recommended taking belladonna preparations, because there was a constant tendency to bradycardia – the pulse rate was in the range of 50-55 per minute.

Three months ago, the first attack of palpitations occurred, then it recurred three weeks later, and recently attacks have been 3-4 times a week. ECG picture during an attack:

Anamnesis of life: in the past, she was practically healthy, there were no serious diseases, she was always physically active, went skiing, went to the pool.

Gynecological history without features, childbirth 1 without complications.

Objectively: at the time of examination the patient’s condition is satisfactory. Pulse – 48 per minute, non-rhythmic (5-7 drops, or pauses, per minute). BP – 130/70 mm Hg. Art.

Limits of relative cardiac dullness in the 5th intercostal space along the midclavicular line. Vesicular breathing in the lungs, no wheezing. The abdomen is soft, painless on palpation, the liver is not enlarged. There are no edema.

On the ECG immediately after examining the patient:


1. Your presumptive underlying diagnosis.

2. Criteria for the main diagnosis

3. With what conditions should a differential diagnosis be made?

4. Specify additional examination methods to clarify the diagnosis.

5. Medical tactics.

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