SITUATIONAL PROBLEM K003232

1. Chronic acalculous cholecystitis of bacterial etiology, exacerbation phase.

2. The diagnosis of “chronic acalculous cholecystitis of bacterial etiology, exacerbation phase” was established on the basis of the patient’s complaints of general weakness, dull, aching pain in the right hypochondrium, aggravated after eating fatty, fried foods, radiating to the right shoulder, right shoulder blade; bitterness in the mouth, belching with air, nausea, unstable stools; (typical of chronic cholecystitis). The diagnosis of “chronic cholecystitis” is confirmed by the data of anamnesis, objective examination (moderate pain on palpation in the right hypochondrium, pain at the Mackenzie point, positive symptoms of Ortner, Kerr, Murphy, Mussi-Georgievsky on the right).

The general blood test revealed inflammatory changes: leukocytosis (up to 11.2×109/l); increase in ESR – up to 19 mm / h.

Ultrasound of the abdominal cavity organs visualizes an enlarged up to 3.5 cm, deformed gallbladder with a kink in the neck, which indicates a chronic process. Thickening (up to 5 mm) and thickening of the gallbladder walls, the presence of “stagnant” bile, which is typical for chronic cholecystitis, were revealed. The diagnosis of “chronic cholecystitis” is confirmed by duodenal sounding data (with microscopy of bile, accumulations of mucus, leukocytes and cellular epithelium are determined).

The parasitic etiology of chronic cholecystitis was excluded: (ELISA for the detection of helminths: opisthorchiasis, giardiasis, ascariasis, toxacariasis – negative); as well as a negative result of the analysis of feces for eggs of the worm (three times).

3. The examination plan should include ultrasonic cholecystography to clarify the functional capacity of the gallbladder; bacteriological examination of bile to determine the causative agent of chronic cholecystitis.

4. Recommended diet (table number 5 according to Pevzner). Exclude alcohol, fatty, fried, spicy, smoked, salty, coffee, carbonated drinks, cocoa, nuts. Frequent fractional meals are shown (up to 5-6 times a day). It is important to reduce the proportion of animal fats in the diet and increase vegetable fats. To prevent bile stasis and improve the passage of chyme through the intestines, dishes are enriched with dietary fiber in the form of wheat bran.

The patient is shown the appointment of antibacterial drugs:

Fluoroquinolones: Ciprofloxacin 500 mg twice daily after meals for 7 days.

Correction of antibiotic therapy is carried out after receiving a culture of bile on the microflora and determining its sensitivity to the antibiotic.

To relieve pain, the appointment of a selective myotropic antispasmodic Mebeverine hydrochloride (Duspatalin) at a dose of 200 mg 2 times a day for 2-4 weeks is indicated.

In order to eliminate dyspeptic symptoms, it is recommended to prescribe Domperidone (Motilium) at a dose of 10 mg 30 minutes before meals 3 times a day for 14 days.

The appointment of cholekinetics is shown, which increase the muscular contraction of the gallbladder and the flow of bile into the duodenum (Sorbitol, Xylitol, Magnesium sulfate, Karlovy Vary salt, Cholecystokinin, Holosas);

– Holosas 1 teaspoon (5 ml) 15 minutes before meals 3 times a day for 1 month.

5. As a result of treatment, the patient showed positive dynamics. Disappeared manifestations of asthenic, pain, dyspeptic syndromes. An objective examination – “bubbly” symptoms are negative.

Inflammatory changes in the blood leveled off. According to the ultrasound of the abdominal organs, a positive trend was also noted.

The patient was advised to follow a diet. Exclude alcohol, fatty, fried, spicy, smoked, salty, coffee, carbonated drinks, cocoa, nuts, dough products (especially rich), creams, meat broths. Exclude foods containing a large amount of cholesterol (liver, brains, egg yolks, mutton and beef fats, etc.). Frequent fractional meals are shown (up to 5-6 times a day). To prevent bile stasis and improve the passage of chyme through the intestines, dishes are enriched with dietary fiber in the form of wheat bran. The energy value of the diet should be 2500-2900 kcal with the optimal content of proteins, fats, carbohydrates and vitamins. Avoid physical and emotional stress.

In the remission phase, therapeutic exercises are shown, as well as spa treatment, which is carried out in Essentuki, Zheleznovodsk, Pyatigorsk, Truskavets, Belokurikha, Morshyn, Jermuk, etc.

Dispensary observation at the therapist, gastroenterologist.

CASE STUDY 49 [K003233]

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

Main part

A 49-year-old man went to the doctor with complaints of general weakness, increased fatigue, decreased performance, almost constant dull pain in the right hypochondrium, and nausea.

From history. Considers himself ill for two years, when he first appeared general weakness, fatigue, a feeling of heaviness in the right hypochondrium. He did not seek medical help. Periodically took Essentiale forte 2 capsules three times a day, enzyme preparations: Creon 25,000 units. twice a day; did not notice any improvement in well-being. A real exacerbation within a month, when, after significant physical exertion, pain in the right hypochondrium intensified, general weakness increased. I took baralgin, there was no positive effect. There were no operations or blood transfusions. He does not abuse alcohol, he did not take hepatotoxic drugs, he was a donor.

On examination: the condition is satisfactory; height-177 cm, weight -79 kg, BMI 25.2 kg/m2. The skin is icteric in color, the sclera are icteric, telangiectasias are detected on the chest, shoulders and back. Vesicular breathing in the lungs, no wheezing. RR 16 per min. Heart sounds are rhythmic, muffled. Heart rate 72 in 1 min; AD-130/80 mm Hg Tongue wet, lined with white coating. The abdomen is soft, moderately painful on palpation in the area

right hypochondrium. Liver dimensions according to Kurlov: 12 (+3) × 8 × 7 cm; with deep palpation, the liver has a dense consistency, moderate pain on palpation is determined. The spleen is not enlarged. There is no dysuria. The symptom of tapping in the lumbar region is negative.

Research results: complete blood count: erythrocytes – 4.5×10¹²/l; leukocytes – 6.5 × 109 / l; neutrophils – 4.5 × 109 / l; lymphocytes – 1.3×109/l; monocytes – 0.44×109/l; eosinophils – 0.2×109/l; basophils – 0.06×109/l; Hb – 145g/l; platelets – 232×109/l; ESR – 23 mm / h.

Blood biochemistry: total bilirubin – 35 µmol/l; indirect bilirubin – 29.5 µmol / l; direct bilirubin – 5.5 µmol / l; ALT – 230 units/l; AST – 155 units/l; GGTP – 83 units/l; ALP – 143 units/l; glucose – 5.1 mmol / l; creatinine – 72 µmol/l; urea – 3.2 mmol / l; albumin – 39 g/l; total protein – 71 g/l; alpha-1-globulins – 3.0 g/l; alpha 2 globulins

– 5.5 g/l; beta globulins – 6.0 g/l; γ-globulins – 17.5 g/l; TSH – 0.94 IU / l; alpha-fetoprotein – 3.2 units/l; ferritin – 53 µg/l; transferrin – 2.5 g/l; potassium – 3.9 mmol / l; Na–138 mmol/l; amylase – 43 units/l; iron – 21.3 µmol/l; cholesterol – 5.0 mmol/l; ceruloplasmin – 185 mg / l. PTI – 55%.

ELISA (determination of markers of hepatitis B, C, D in blood serum): HBsAg (+); anti-HBs (-); anti-HBcIgG (+); HBeAg(-); anti-HBe (+); anti-HBcIgM (-); anti-HDV (-); anti-HCV (-); anti-HIV – negative.

Immunological study: the concentration of Ig class G in the blood serum-7.0 g/l; – molecular biological studies: PCR: HBV DNA – positive; quantitative analysis of HBV DNA – 61000 IU / ml. Feces for occult blood – negative. Urinalysis: within normal limits. Elastometry of the liver: stage F4 (according to the METAVIR scale), cirrhosis of the liver. Ultrasound of the abdominal organs revealed hepatomegaly, diffuse dystrophic changes in the liver parenchyma. X-ray examination of the lungs: no pathological changes; ECG – without pathological changes; number connection test – within the normal range.

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. After 6 months of continuous treatment, the concentration of HBV DNA is 10 IU / ml. – Serological examination (ELISA): HBsAg (-); anti-HBs (+); anti-HBcIgG (+); HBeAg(-); anti-HBe (+); anti-HBcIgM (-).-Blood biochemistry: ALT – 78 U/l, AST – 52 U/l, GGTP

– 26 units/l; total bilirubin – 34 µmol/l; PTI – 60%; creatinine – 72 µmol / l. Complete blood count – within normal limits. What is your next treatment strategy? Justify your choice.

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