SITUATIONAL PROBLEM K003228

1. NSAIDs – associated gastropathy: erosive and ulcerative lesions of the stomach, complicated by ongoing gastrointestinal bleeding. Posthemorrhagic anemia of mild degree. IHD: stable angina II FC, PICS on the anterior wall and apex of the left ventricle. LCA stenting, permanent residence, CHF III FC (NYHA)

2. A patient suffering from coronary heart disease and receiving dual antiplatelet therapy (DAPT): Aspirin and Clopidogrel has several risk factors for the development of NSAID-associated gastropathy in him (old age, coronary artery disease, history of duodenal ulcer, DAPT for 1.5 years , lack of indications for the use of antisecretory agents against the background of DAPT). NSAIDs – associated gastropathy is represented by multiple gastroduodenal erosions and / or ulcers, characterized by little or asymptomatic course and a high frequency of manifestation with the development of complications – bleeding. The patient has convincing diagnostic criteria for this diagnosis: gastric dyspepsia syndrome, an episode of gastrointestinal bleeding, the presence of clinical signs of anemia

(tachycardia, decrease in hemoglobin, red blood cells, decrease in MCH and MCHC in the general blood test).

3. In addition to the examination, the patient is recommended: FGDS with a biopsy of the gastric mucosa from the affected area (ulcer) and standard biopsy areas in order to assess the stage of gastritis, clarify the nature of the lesion of the mucous membrane of the gastroduodenal zone; diagnosis of the presence of H.pylori infection by a morphological method, or detection of H.pylori antigen in feces by ELISA, or detection of H.pylori DNA in feces by PCR. The use of the serological method is impractical, since it is not known whether eradication therapy for duodenal ulcer was carried out in the past. In accordance with the Standard for the provision of medical care for PU and DU, a biochemical blood test is recommended (bilirubin, ALT, AST, glucose, and serum iron, total serum iron-binding capacity, ferritin), ultrasound examination of internal organs, fecal occult blood test.

4. The choice of treatment tactics, including the decision on the need for inpatient treatment, should be carried out taking into account the results of an endoscopic examination of the patient. The standard for the treatment of NSAID-associated gastropathy is the appointment of antisecretory therapy in order to correct the factors of aggression that affect the gastric mucosa. The drugs of choice are proton pump inhibitors (PPIs), used in standard doses in the acute stage of the pathological process in the gastroduodenal zone and in maintenance doses as a prophylactic. The patient is indicated for continuous PPI therapy in combination with continuous DAPT.

In the period of acute manifestations of NSAID gastropathy in combination with PPIs, therapy with gastroprotectors (Bismuth tripotassium dicitrate, Rebamipide, Sucralfate) is indicated for at least 4 weeks.

If H. pylori infection is detected, the patient is shown eradication of the infection in order to reduce the risk of ulcerogenic effects on the mucous membrane of the gastroduodenal zone with continued therapy with aspirin and clopidogrel.

The patient is prescribed permanent therapy for coronary artery disease: in addition to DAPT, it is recommended to take a lipid-lowering agent (Atorvastatin, Rosuvastatin), a selective b-blocker (Bisoprlol), a diuretic (Veroshpiron, Torasemide), an ACE inhibitor due to the presence of symptoms of heart failure and taking into account the level of arterial pressure.

If sideropenia is detected, iron therapy is indicated until the level of normal hemoglobin values is reached.

Drug therapy should be carried out against the background of the use of diet therapy. The diet is shown within the framework of table 1 during the period of exacerbation for 4-6 weeks, followed by an individual expansion within the framework of table 5p.

5. The choice of PPI should be guided by information on drug interactions. Given the need to use combination therapy, including Clopidogrel, PPIs with the least drug interactions should be selected:

the optimal choice is Pantoprazole 40 mg twice daily or Rabeprazole 20 mg twice daily for at least 4 weeks, then the PPI can be used at half the dose.

As a scheme for the eradication of H. pylori infection, it is possible to use 10-day triple therapy with the addition of Bismuth tripotassium dicitrate, followed by prolongation of the cytoprotector course up to 4 weeks.

4-week courses of cytoprotectors (Rebamipide) should be repeated 3-4 times a year.

CASE STUDY 48 [K003232]

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

Main part

A 45-year-old woman consulted a doctor with complaints of general weakness, dull, aching pain in the right hypochondrium, aggravated after eating fatty, fried foods, physical activity; pain radiates to the right shoulder, right shoulder blade, right half of the neck; notes bitterness in the mouth, belching with air, nausea, unstable stool, loss of appetite.

From history. He considers himself ill for four years, when general weakness first appeared, aching pain in the right hypochondrium, aggravated after errors in diet, physical activity, bitterness in the mouth, belching with air, unstable stool (with a tendency to constipation). She did not seek medical help. When a pain syndrome appeared, she took allochol, pancreatin, analgin; noted a temporary improvement in well-being. A real exacerbation within a month, when, after eating a large amount of fatty foods, pain appeared in the right hypochondrium, bitterness in the mouth, belching with air. There were no operations or blood transfusions.

Does not abuse alcohol. From the family history it is known that the patient’s mother suffered from cholelithiasis.

On examination: satisfactory condition, height 170 cm, weight – 72 kg; BMI 24.9 kg/m2. The skin is clean, normal color. Vesicular breathing in the lungs, no wheezing, respiratory rate – 16 per minute. Heart sounds are rhythmic, muffled. Heart rate – 72 in 1 min; BP – 130/80 mm Hg. Tongue wet, lined with white coating at the root. The abdomen is soft, moderately painful on palpation in the right hypochondrium. Liver dimensions according to Kurlov: 9×8×7 cm; palpation of the liver is difficult due to pain, mainly at the point of the gallbladder. Soreness is determined at the Mackenzie point, positive symptoms of Ker, Murphy, Ortner, Lepen, Mussi-Georgievsky on the right. The spleen is not palpable. There is no dysuria. The symptom of tapping in the lumbar region is negative.

Research results:

Complete blood count: erythrocytes – 4.6×10¹²/l; leukocytes – 11.2 × 109/l; segmented neutrophils – 75%; stab neutrophils – 2%; lymphocytes – 19%; monocytes

– 3%; eosinophils – 1%; basophils – 0%; Hb – 141g/l; platelets – 215×109/l; ESR – 19 mm / h. Blood biochemistry: total bilirubin – 18 µmol/l; indirect bilirubin – 16.0 µmol/l; direct bilirubin – 2.0 µmol/l; ALT – 28 units/l; AST – 23 units/l; GGTP – 25 units/l; ALP – 102 units/l; glucose – 5.2 mmol / l; creatinine – 64 µmol/l; urea – 3.2 mmol / l; total protein – 72 g/l; amylase – 42 units/l; CS – 5.2 mmol / l.

Plain radiography of the abdominal organs revealed no pathology. Ultrasound of the abdominal organs: the liver is not enlarged, the contours are even, echogenicity is not increased, the structure is not changed. The gallbladder is enlarged (up to 3.5 cm in diameter), deformed, with a kink in the neck; revealed diffuse thickening of its walls up to 5 mm, their compaction. A suspension (“stagnant bile”) is visualized in the lumen of the gallbladder. Ductuscholedochus 7 mm. The pancreas is of normal size and shape, echogenicity is not increased. The pancreatic duct is not dilated. Duodenal probing (microscopic examination of bile): in portion “B” an accumulation of mucus, leukocytes, cell epithelium, cholesterol crystals, calcium bilirubinate was detected.

Urinalysis: within normal limits. ECG – no pathological changes; esophagogastroduodenoscopy – without pathological changes; enzyme immunoassay for the detection of helminths: opisthorchiasis, giardiasis, ascariasis, toxacariasis – negative. Feces on worm eggs (three times) – negative.

Questions:

1. Suggest the most likely diagnosis.

2. Justify your diagnosis.

3. Draw up and justify a plan for an additional examination of the patient.

4. Justify the appointment of drug and non-drug treatment for this patient.

5. When revisiting a doctor 1 month after treatment, the patient notes an improvement in well-being, the disappearance of general weakness, pain in the right hypochondrium, bitterness in the mouth, nausea, belching with air, normalization of the stool. Objectively: the tongue is moist, not coated; the abdomen is soft, painless. Symptoms of Ortner, Carey, Murphy, Lepene, Mussi-Georgievsky on the right are negative. Complete blood count – within normal limits. Blood biochemistry is within the normal range. Ultrasound of the abdominal organs showed no pathological changes. What is your next treatment strategy? Justify your choice.

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