MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION

STATE MEDICAL UNIVERSITY

DEPARTMENT OF SURGICAL DISEASES №2

Head of Department: Professor

Sick:Diagnosis:Cholelithiasis, acute cholecystitis

Curator-student:4thcourse7 semester groups

Team leader

curation:frombeforeCase history No.: Teacher's mark on the test:

GENERAL INFORMATION ABOUT THE PATIENT

Full name of the patient:

Age: 48 years old

Address:

Floor: Female

Place of work:

Receipt date:

Entry method: emergency

Curation date:

Diagnosis: Cholelithiasis, acute cholecystitis

Operation: Laparoscopic cholecystectomy. Drainage

abdominal cavity(10/14/2005 at 9:40 am)

Anesthesia: endotracheal

Blood type: A(II) Rh+

Outcome of the disease: improvement

Employability: restoration in progress

COMPLAINTS OF THE PATIENT

(At the time of curation)

The patient complains of severe pain in the right hypochondrium. According to the patient, the pain occurs spontaneously, for no apparent reason (rarely after eating). The duration of pain is 0.5 - 2 hours. In addition, the patient also complains of dry mouth, nausea, vomiting, general weakness.

HISTORY OF ILLNESS (Anamnesismorbi)

He considers himself ill for 14 hours, when severe pain began to appear in the right hypochondrium. The pain sometimes went away on its own and sometimes after eating (I stopped it with mezim and took activated charcoal). Didn't go to doctors. There was a severe headache, then sweat started, and after that it started, vile, there was an increase in blood pressure = 150/100, the temperature did not bother. There was also nausea and vomiting. Deterioration of the condition was noted for the last 4 hours. Irradiation of pain in the heart and in the right lumbar region.

ANAMNESIS OF LIFE(Anamnesisvitae)

General biographical information: was born in the year, in a prosperous family, the sixth child in a row. Growth and development according to age. In childhood suffered colds disease. She was an excellent student at school. Marital status: married with 3 children. Living conditions: satisfactory, lives in a 3-room apartment. There are 3 people in the family, material security is satisfactory. Regular meals during work. Free time mode: sleep is not calm (disturbed), physical. culture and sports are not involved. AT this moment: calm sleep, without headaches.

Working condition: From the postponed diseases: hron. pancreatitis, appendectomy (1981), ischemic heart disease, cholelithiasis. Bad habits: no. Diabetes mellitus, hepatitis, AIDS denies

Family hereditary history: not weighed down.

Allergic history: allergic r-th denies.

DATA OF OBJECTIVE STUDY(statuspraesens)

GENERAL INSPECTION

General condition of the patient: satisfactory

Consciousness: clear

Position: active

Gait: straight

Posture: straight

Height: 165 cm.

Weight: 80kg..

Brocca index: 80*100%/165-100=123.07% (strong physique)

Pinier index: 165-(80+82)=3 (strong physique)

Quetelet index: 80/(1.65)2=29.38 (strong physique)

Body type: hypersthenic

Body temperature: 36.6

facial expression: calm

Tongue: moist, white coated

Teeth condition: satisfactory

Mucous sclera of the eye, nose, mouth, ear: clean without discharge (without features) - satisfactory.

Face shape: oval, eyes not dilated

Skin: Pale pink color. Areas of pigmentation, rashes, spider veins, hemorrhages were not detected.

Scars: In the right iliac region postoperative (appendectomy)

Hair type: female type.

Skin turgor: preserved, elastic.

Skin Moisture: Dry.

Nails: regular shape (pink color).

Subcutaneous fat: strongly developed.

Edema: no.

Lymph nodes: not enlarged

Muscular system: Painless, satisfactory degree of development (dynamic and static action is satisfactory).

Skeletal system: The ratio of the bones of the skeleton is proportional. The shape of the bones is correct, without thickening, and deformations. There is no pain on palpation. The symptom of "drum fingers" is absent.

Joints: Of normal shape and size. Pain when bending the knee joint on the right and left in the region of the medial epicondyle. Full movement.

RESPIRATORY SYSTEM

Inspection: Nose: Normally shaped, mucous clear without discharge.

Larynx: without deformities and swelling.

Form gr. class: hypersthenic, symmetrical.

Above and Subclavian fossa: moderately pronounced, the same on both sides.

Width of intercostal spaces: 1.5 cm.

Epigastric angle: acute.

Lateral ribs: Moderately oblique.

The fit of the shoulder blades to Ch. class: tight, and located on the same level excursion class class: 3cm.

Type of breathing: predominantly abdominal, gr.cl. participates in the act of breathing evenly. Breathing is performed silently, without the participation of auxiliary muscles.

BH: 18 in 1 minute.

Breathing: medium depth, rhythmic.

The ratio of the phases of inhalation and exhalation: not broken.

Palpation: Epigastric angle: acute.

Ribs: intact.

Resistance (elasticity): Elastic, elastic, supple.

Soreness: when feeling the ribs, intercostal spaces, pectoral muscles were not detected.

Percussion: Comparative: a clear pulmonary sound is determined over the entire surface of the lungs.

Topographic:

topographic line

Right lung

Left lung

Upper bound

Height of tops in front

3 cm above the collarbone

3 cm above the collarbone

Standing height of the tops at the back

7 cervical vertebra

7 cervical vertebra

Bottom line

Along the peritoneal line

Top edge 6 ribs

not defined

Along the mid-clavicular line

not defined

Along the anterior axillary line

Along the mid-axillary line

Along the posterior axillary line

Along the shoulder line

Along the spinal line

Spinous process 11 chests. vertebra

Width of fields of a krening: 4 cm. at both sides.

Respiratory mobility of the lower edge of the lungs:

Mid-axillary line: 7cm right and left

On the midclavicular lines: on the right 5 cm on the left is not determined

On the scapular lines: 5 cm. right and left

Auscultation: visicular breathing is determined above the lung on both sides. Adverse breath sounds and pleural rub are not heard. Bronchophony is not changed on both sides.

circulatory system

Inspection: Increased pulsation of the carotid arteries (carotid dance), swelling of the jugular veins, no visible pulsations of the veins were found.

Protrusion of the region of the heart, visible pulsations (apical and cardiac impulse, epigastric pulsation) are not visually determined.

Palpation: The apex beat is located in the V intercostal space 1 cm medially from the left midclavicular line, width 1 cm, low, moderate strength. The phenomenon of diastolic and systolic trembling in the pericardial region, epigastric pulsation is not palpable. On palpation in the region of the heart, pain is not determined.

Percussion:

Relative stupidity

Absolute stupidity

4th intercostal space 0.5 - 1 cm to the right of the edge of the sternum

4th intercostal space on the left side of the sternum

5th intercostal space 1 cm medial to the left midclavicular line

From the area of ​​the apical impulse move to the center (1.5 cm medially)

Parasternal line 3rd intercostal space

4 intercostal space

Cross section blunt: 12cm.

The width of the vascular bundle is 6 cm, 2nd intercostal space on the left and right.

Heart configuration: normal. Ascultation: Tones: - rhythmic heartbeats

The number of heartbeats - 76

First tone of normal sonority

Second tone of normal sonority

Additional tones are not heard

Murmurs: not audible, pericardial rub is not audible.

Arterial pulse on the radial arteries: symmetrical, elastic, frequency = 76 beats. In 1 min., rhythmic, moderate tension, full.

Arterial pressure on the brachial arteries: 120/70 mm. rt. Art.

DIGESTIVE SYSTEM

Examination of the oral cavity.

There is no smell; the mucous membrane of the inner surface of the lips, cheeks, soft and hard palate of normal color; rashes, ulcerations are absent; gums do not bleed; tongue of normal size and shape, moist, not furred; filiform and fungiform papillae are well expressed; pharynx of normal color; the palatine arches are well contoured; tonsils do not protrude beyond the palatine arches; the mucous membrane of the pharynx is not hyperemic, moist, the surface is smooth. Sclera of normal color.

Dental formula:

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

Legend:6 - carious tooth, 6 - extracted tooth, 6 - sealed tooth, 6 - prosthetic tooth.

Examination of the abdomen.

The abdomen is of normal shape, symmetrical, collaterals on the anterior surface of the abdomen and its lateral surfaces are not expressed; there is no pathological peristalsis; the muscles of the abdominal wall are involved in the act of breathing. When viewed in a vertical position, hernial protrusions were not found. In response to coughing, there is no increase in pain in the epigastrium.

Abdominal circumference 90 cm.

Approximate percussion of the abdomen.

Tympanitis of varying severity is determined, dullness in the sloping areas of the abdomen is not noted.

Approximate superficial palpation of the abdomen.

Moderate pain in the area of ​​the right hypochondrium is determined, Shchetkin-Blumberg's symptom is negative. When researching " weaknesses”anterior abdominal wall (umbilical ring, aponeurosis of the white line of the abdomen, inguinal rings) hernial protrusions are not formed.

With deep methodical sliding palpation of the abdomen according to the Obraztsov-Strazhesko-Vasilenko method:

The sigmoid colon is palpable in the left inguinal region on the border of the middle and outer thirds of the linea umbilicoiliaceae sinistra for 15 cm, cylindrical in shape, diameter - 2 cm, densely elastic consistency, with a smooth surface, mobility within 3-4 cm, painless, not purring; the caecum is palpated in the right inguinal region at the border of the middle and outer thirds of the linea umbilicoiliaceae dextra in the form of a cylinder with a pear-shaped extension downwards, soft-elastic consistency, 3-4 cm in diameter, slightly rumbling on palpation. The remaining parts of the intestine could not be palpated.

Palpation of the stomach and determination of its lower border:

By percussion, by stetoacoustic palpation, the lower border of the stomach is determined 3 cm above the navel.

It was not possible to determine the lower border of the stomach by deep palpation of the greater curvature of the stomach, by the splash noise method.

Lesser curvature and pylorus are not palpable; splash noise to the right of the midline of the abdomen (Vasilenko's symptom) is not determined.

Auscultation of the abdomen.

Abdominal auscultation reveals normal peristaltic bowel sounds.

Determination of the boundaries of absolute hepatic dullness.

The percussion method determines:

upper bound

on the right anterior axillary line - 7th rib

on the right midclavicular line - 6th rib

on the right parasternal line - 5th rib

bottom line

on the right anterior axillary line - 2 cm down from the 10th rib. on the right midclavicular line - 4 cm downward from the costal arch

on the right parasternal line - 5 cm downwards from the costal arch

along the anterior midline - 9 cm downward from the base of the xiphoid process left border hepatic dullness protrudes beyond the peristernal line along the edge of the costal arch by 2 cm.

dimensions of hepatic dullness:

on the right anterior axillary line - 15 cm,

on the right midclavicular line - 15 cm

along the peristernal line - 13 cm

along the anterior median line - 13 cm

oblique size (according to Kurlov) - 9 cm

the liver is palpable 1 cm below the edge of the costal arch (along the right midclavicular line); the edge of the liver is dense, even, with a smooth surface, slightly pointed; the liver is painless; the gallbladder is not palpable; pain on palpation at the point of projection of the gallbladder, the symptoms of Ortner, Zakharyin, Vasilenko, Murphy, Georgievsky-Mussi are weakly positive.

Percussion of the spleen.

Along the line passing 4 cm posteriorly and parallel to the left costoarticular line, the boundaries of splenic dullness were determined:

upper - at the level of the 9th rib;

the lower one is at the level of the 11th rib.

the anterior border of the splenic dullness does not go beyond the linea costoarticularis sinistra.

dimensions of splenic dullness: diameter - 6 cm; length - 8 cm.

The spleen is not palpable.

Examination of the pancreas.

The pancreas is not palpated; pain on palpation in the Chauffard zone and Desjardin's pancreatic point is absent; Mayo-Robson's symptom is negative.

Examination of the rectum.

When examining the anus, maceration, hyperemia of the skin of the perianal region is absent. On digital examination: normal sphincter tone, no tumors, inflammatory infiltrates, compacted hemorrhoids. The prostate gland is of normal shape, consistency and size, painless.

URINARY SYSTEM

Inspection: Lumbar region: skin hyperemia, swelling,

there is no smoothing of the contours.

Suprapubic region: limited bulging was not found.

Percussion: Lumbar region: Pasternatsky's symptom is negative.

Palpation: The kidneys in the supine position and standing are not palpable.

The bladder is painless, elastic, palpated in the form of a soft elastic spherical formation above the pubic joint. Penetrating palpation of the kidneys and ureters on both sides is painless (ureteral and costal vertebral points).

GENERAL SYSTEM.

Inspection: Hair type according to the female type. The voice is low. Breast glands without pathological changes (no edema, hyperemia, retractions ...).

ENDOCRINE SYSTEM.

Inspection and palpation: Physical and mental development corresponds to age. Secondary sexual characteristics correspond to sex. Tremor of the eyelids, tongue and fingers are not defined.

The shape of the neck is normal, the contours are even, painless on palpation. The thyroid gland is not enlarged, painless, mobile. Obesity is negligible.

NERVOUS SYSTEM AND SENSORS

Inspection: Memory, attention, sleep are saved. Mood - cheerful, aptimestic. Restriction of motor activity: no. There are no deviations in the sensitive area.

The state of the psyche - consciousness is clear, normally oriented in space, time and situation.

Intelligence corresponds to the level of development.

Behavior is appropriate.

Balanced, sociable.

No deviations are observed

Motor sphere: Stable gait,

painless.

Cramps and muscle contractures are not determined.

Reflexes: corneal, pharyngeal, tendon-

saved. Pathological (Babinsky and

Rossolimo) are absent.

Exophthalmos and enophthalmos are absent.

PRELIMINARY DIAGNOSIS

RATIONALE FOR THE DIAGNOSIS

According to the following data, the patient can be suspected of having cholelithiasis: the patient complains of pain in the epigastrium and right hypochondrium, of moderate intensity, lasting 0.5–2 hours, nausea, vomiting, general weakness, the patient considers himself about 14 hours.

Objective examination: pain at the projection point of the bladder, absence of protective tension in the abdominal muscles. Symptoms of Carey, Murphy, Ortner are weakly positive

SURVEY PLAN

3. Wasserman reaction

4. ECG in 12 leads

5. Chest X-ray

6. Study of gastric contents by fractional method

7. Duodenal sounding

8. Analysis of feces (scatological, for dysbacteriosis, protozoa, bacterium.)

9. Urine diastasis, blood amylase

10. Renoscopy of the stomach and intestines with targeted radiographs

11. Irrigoscopy

12. Esophagoscopy

13. Gastroduodenoscopy with biopsy

14. Sigmoidoscopy, colonoscopy

15. Blood biochemistry

16. Urine test for urobilin and bilirubin

17. Examination of feces for stercobilin

18. Cholecystography

19. Radioisotope and ultrasound scanning of the liver and spleen, pancreas

20. Determination of the class of blood immunoglobulins

21. Blood test for HbS antigen

22. CT scan of the abdominal organs

23. The study of serological reactions (RW, antibodies to HIV, markers of viral hepatitis, including antibodies to the HBs antigen)

24. Determination of blood group, Rh factor

General blood analysis

Indicators

Data

135 g/l

123 g/l

Leukocytes (9.10.2005)

Erythrocytes (10.10.2005)

9.0 10 9 /l

8.8 10 9 /l

8.0 10 9 /l

6.3 10 9 /l

4.2 10 12 /l

3.8 10 12 /l

Myelocytes

Metamyelocytes

Stab neutrophils (12.10.2005)

Segmented neutrophils (12.10.2005)

Eosinophils (12.10.2005)

Basophils

Lymphocytes (12.10.2005)

Monocytes

Plasma cells

19 mm/h

Analysis of urine.

10.10.2005

Indicators

Data

Yellow

Transparency

moderately

Relative density

neutral

Negative

Epithelium :

Flat

3-3-2 in sight

Leukocytes

2-1 in sight

Urats 11

Biochemical blood test

12.10.2005

Indicators

Data

total protein

70 g/l

Creatinine

61 mmol/l

total bilirubin

10.8 µmol/l

BLOOD TYPE DETERMINATION 12.10.2005

PTI 12.10.2005

MICROREACTION WITH CARDIOLIPIN ANTIGEN 12.10.2005

NEGATIVE

ECG 10.10.2005

Conclusion: Sinus rhythm with heart rate=75, EOS deflected to the left, symptoms of left ventricular myocardial hypertrophy with signs of dystrophies.

SPIROGRAPHY 13.10.2005

Conclusion: - Violation of bronchial patency was not detected, without signs of expiratory narrowing of the airways.

VC within the normal range.

The condition of the ventilation apparatus is within normal limits.

FIBROESOPHAGOGASTRODOUDENOSCOPY 11.10.2005

The esophagus is freely passable. The socket of the cardia closes completely. The stress test is negative. In the stomach there is a moderate amount of transparent yellowish bile, the folds are convoluted, juicy. Perilstaltics can be traced in all departments. The gastric mucosa is hyperemic, moderately thinned. The gatekeeper of a rounded shape is passable, the mucous membrane of the bulb is 12 p.k. strewn with small whitish colored rashes like “semolina”.

Conclusion: Biliary dyskinesia. Superficial subtrophic gastritis. Endoscopic picture of pancreatitis.

ultrasound Liver: Visualized in fragments through the intercostal space, increased echogenicity.

Gallbladder: After eating, it increases to 100 * 36 mm., The wall is thickened up to 4 m.. In the cavity, stones are up to 14 mm. One of which is fixed at the mouth. CBP is not expanded.

Pancreas: an increase in the body area up to 23 mm., increased echogenicity, heterogeneous.

Kidneys: Topography and dimensions are normal. Sealing of deformations of the walls of the CLS. The outflow of urine is not disturbed. Single well-marked hyperchromic inclusions up to 1-3 mm.

Spleen: not enlarged.

Conclusion: Echo signs of acute calculous cholecystitis are not excluded? Stone at the mouth.

CLINICAL DIAGNOSIS

Cholelithiasis. Acute cholecystitis.

RATIONALE FOR THE DIAGNOSIS

According to the following data, the patient may be suspected of having cholelithiasis: the patient complains of pain in the epigastrium and right hypochondrium, of moderate intensity, lasting 0.5–2 hours, nausea, vomiting, general weakness, the patient considers himself about 14 hours.

To confirm the diagnosis, the following studies were carried out:

Objective examination: pain at the bladder projection point, absence of protective tension of the abdominal muscles. Symptom Carey, Murphy, Ortner weakly positive

Instrumental research methods also prove the correctness of the diagnosis:

The conclusion of the ultrasound specialist: there are signs of acute calculous cholecystitis, the gallbladder is enlarged up to 100 * 36 mm., the wall is thickened up to 4 mm., the presence of stones in the cavity up to 14 mm in size. and at the mouth of the gallbladder. CBP is not expanded.

DIFFERENTIAL DIAGNOSIS

Gallstone disease must be differentiated from the following diseases: chronic pancreatitis, chronic gastritis, duodenitis, peptic ulcer of the stomach and duodenum, acalculous cholecystitis, tumor of the right half of the colon, gallbladder cancer. Since the symptoms and clinical course of the above diseases are similar and an error in diagnosis can lead to severe complications due to incorrectly chosen treatment tactics. Consider separately the differences between each of the above diseases from cholelithiasis:

Peptic ulcer of the duodenum: This disease is characterized by the presence of periods of exacerbation and remission, and there is no dynamic course in cholelithiasis.

Pain in duodenal ulcer are daily and rhythmic in nature (hungry, night pain), during an exacerbation, prolonged pain lasting 3-4 weeks is characteristic. Cholelithiasis is characterized by pain associated with the intake of fatty, "heavy" food, pain is relieved by taking antispasmodics, and is of a short duration. Soreness is usually localized at the point of projection of the gallbladder, the symptoms of Ortner, Georgievsky - Mussi are positive.

With duodenal ulcer, body temperature, as a rule, remains normal, and with cholelithiasis, it is often subfebrile in nature.

The blood parameters for duodenal ulcer are as follows: ESR is normal, increases with complications, the picture of white blood is normal, with complications of bleeding, anemia is observed. In cholelithiasis, ESR increases, leukocytosis is observed with a shift to the left.

Vomiting after eating 2–2.5 hours after eating, which brings relief, is characteristic of duodenal ulcer, and with cholelithiasis, vomiting does not bring relief, it has an admixture of bile. The secretory function of the stomach, as a rule, remains normal, and with duodenal ulcer, a hyperacid state is usually observed.

Bleeding in duodenal ulcers usually have characteristic manifestations: vomiting of the "coffee grounds" type, melena, blanching of the skin, and they do not occur with cholelithiasis.

Esophagogastroduodenoscopy data with histological examination of selected biopsy specimens and X-ray examination of the stomach allow more accurate diagnosis. This patient does not have esophagogastroduodenoscopy data in favor of peptic ulcer. Examination of the gastric mucosa revealed atrophic gastritis, and examination of papillae faterii revealed no bile leakage.

Differential diagnosis between gastric ulcer and gallstone disease:

With gastric ulcer pain occurs immediately after eating or 15-45 minutes after eating. Relief in this condition can bring the evacuation of gastric contents. In cholelithiasis, pain is usually associated with the intake of fatty, fried, spicy foods and vomiting does not bring relief, it contains impurities of bile.

Localization of pain in peptic ulcer, as a rule, between the xiphoid process and the navel, more often to the left of the midline, irradiation to the left half of the chest, to the interscapular region. With cholelithiasis, pain is localized in the right hypochondrium, radiating to the right shoulder blade, right shoulder. Soreness is located at a characteristic point - the projection point of the gallbladder, the symptoms of Ortner, Georgievsky-Mussi are also positive.

The acidity of gastric juice with peptic ulcer changes, and with cholelithiasis it is normal.

The patient has no characteristic signs for peptic ulcer of the stomach and duodenum.

Differential diagnosis between acalculous chronic cholecystitis and cholelithiasis:

The clinical picture of acalculous chronic cholecystitis is similar to that in chronic calculous cholecystitis, however, pain in the right hypochondrium is not so intense, but differs in duration, almost constant character, intensification after dietary disorders (fatty, fried foods, especially in excessive amounts). For diagnosis, the most informative methods are ultrasound and cholecystocholangiography.

The patient's pain is intermittent, of moderate intensity. Ultrasound diagnostic data confirm the presence of structures of increased echogenicity.

Differential diagnosis between gallbladder tumor and cholelithiasis.

In a tumor of the gallbladder and bile ducts, signs of generalization of the cancer process are revealed: general signs, such as weakness, fatigue, lack of appetite, weight loss, anemia; combined with local symptoms - an enlarged tuberous liver, ascites and jaundice.

In this patient, the presence of a tumor process is rejected by ultrasound data.

Differential diagnosis between acute appendicitis and cholelithiasis.

The nature of the pain: in the epigastrium, moderate intensity (pulling constant), then moves to the right iliac region. Other complaints: nausea, vomiting, stool retention, fever. Development: acute. Objective examination: soreness and muscle tension in the right iliac region, irritation of the peritoneum, Voskresensky, Rozdolsky, Obraztsov, Ravzing, Sitkovsky, pronounced intoxication. Additional examinations: a change in the CBC indicating inflammation.

Differential diagnosis between renal colic and cholelithiasis.

The nature of the pain: in the lower back (paroxysmal), extremely intense with irradiation in the groin, reduced by the use of antispasmodics. Other complaints: possible dysuria. Anamnesis: urolithiasis. Development: acute. Objective examination: palpation of the abdomen is usually painless, positive s-m Pasternatsky, there is no intoxication. Additional examinations: erythrocyturia.

ETIOLOGY AND PATHOGENESIS

The morphological substrate of cholelithiasis is the calculi of the gallbladder of the biliary tract. Gallstones are made up of the usual components of bile - bilirubin, cholesterol, and calcium. Most often there are mixed stones, however, with the predominance of any one component, they speak of cholesterol, pigment or calcareous calculi.

There are three main reasons for their formation: a violation of the physico-chemical balance of the composition of bile, inflammatory changes in the epithelium of the gallbladder and stagnation of bile.

Violation of the physico-chemical balance of the composition of bile.

With cholelithiasis, there is a change in the normal content of cholesterol, lecithin, and bile salts in bile. Micellar structures, consisting of bile acids and lecithin, contribute to the dissolution of cholesterol in bile, which is part of the micelles. In micellar structures, there is always a certain margin of cholesterol solubility. When the amount of cholesterol in bile exceeds its solubility limits, the bile becomes supersaturated with cholesterol and it begins to crystallize and precipitate. The lithogenicity of bile is characterized by the lithogenicity index, which is determined by the ratio of the amount of cholesterol in this bile to the amount of cholesterol that can be dissolved at a given ratio of bile acids, lecithin, and cholesterol.

Bile becomes lithogenic with the following changes in the ratio of its components:

1) an increase in the concentration of cholesterol (hypercholesterolemia)

2) decrease in the concentration of phospholipids

3) decrease in the concentration of bile acids.

The reasons leading to a decrease in the flow of bile acids into bile can be divided into three groups:

1) Decrease in the synthesis of bile acids and disruption of feedback mechanisms, as well as mechanisms regulating the synthesis of bile acids: impaired liver function, taking hormonal drugs (corticosteroids, oral contraceptives, etc.), pregnancy, increased levels of estrogen hormones, poisoning with hepatotoxic poisons.

2) Violation of the enterohepatic circulation of bile acids (significant losses of bile acids occur during resection of the distal small intestine, diseases of the small intestine).

3) Drainage of bile acids from the gallbladder, which is observed with atony of the gallbladder, prolonged starvation.

Stagnation of bile

Violation of the coordinated work of the sphincters of the biliary tract causes various dyskinesias in nature. Allocate hypertonic and hypotonic dyskinesia of the bile ducts and gallbladder.

With hypertonic forms of dyskinesia, there is an increase in the tone of the sphincters. Spasm in the common part of the sphincter of Oddi causes hypertension in the ducts and in the gallbladder.

In hypotonic forms of dyskinesia, the sphincter of Oddi relaxes, followed by reflux of the contents of the duodenum into the bile ducts, and infection of the ducts occurs. With dyskinesia, there is a violation of the evacuation of bile from the gallbladder and ducts, which is a predisposing factor for stone formation.

Biliary tract infections

Essential in the process of cholesterol crystallization and subsequent growth of calculi is the state of the gallbladder mucosa, which performs a selective exchange of inorganic and organic ions, as well as the motor-evacuation function, in violation of which the turbulence of the bile duct decreases and conditions are created for the retention of crystals. As a result of inflammation, microparticles enter the lumen of the bladder, which are a matrix for the deposition of crystals of a substance in a supersaturated solution on them.

Mechanisms of formation of pigment gallstones

Pigment stones can form under several conditions:

When the liver is damaged, bile containing pigments of an abnormal structure is secreted from it. The latter precipitate, which happens with cirrhosis of the liver.

With the release of pigments of a normal structure, but in an excessive amount - more than it can dissolve in a given volume of bile.

· When normal excreted pigments are converted into bile into insoluble compounds, which can occur under the influence of pathological processes in the biliary tract.

Much remains unclear in the question of the primacy of the trigger mechanism of cholelithiasis. AT recent times, despite numerous confirmations of the hypothesis of metabolic disorders of bile formation, the role of local, extrahepatic factors of lithogenesis began to be emphasized again. It has been shown that a decrease in the enzymatic conversion of cholesterol, a change in the composition and pool of bile acids, the secretion of defective vesicles due to a lack of inclusion of phospholipids in them are important, but not the main reasons for the development of cholelithiasis, since the acceleration of nucleation processes naturally manifests itself in the cystic, and not in the hepatic bile. The most likely factor in increasing the activity of activators and inhibiting the activity of nucleation inhibitors in gallbladder bile is the inflammatory process in the gallbladder and the associated hypersecretion of glycoproteins and protein, products of proteolysis and lipid peroxidation, leukotrienes, as well as impaired metabolic function of the gallbladder.

Judging by the experimental data, with any methods of cholelithiasis induction, stone formation occurs against the background of the indicated morphological changes in the gallbladder wall.

TREATMENT

conservative treatment includes :

¨ Compliance with the diet within the 5th table, namely limiting the use of foods that enhance the secretory activity of the stomach, pancreas, bile secretion;

¨ Taking anticholinergic antispasmodics (No-Spa, Baralgin, Spazmogard, Spazmalgin, Papaverine, Platifillin);

¨ Means that regulate the peristalsis of the gastrointestinal tract, such as Cerucal, Raglan;

¨ Pain relievers are used to reduce pain: non-narcotic analgesics and spasmoanalgesics (analgin, baralgin, and so on).

Sol. Papaverini hydrochloridi- 2.0 ml X 3 times a day intramuscularly

Sol. "No-Spa" - 2.0 ml X 3 times a day intramuscularly

¨ Ampicillini - 1.0 ml X 4 times a day intramuscularly

¨ Vicasoli- 1.0 ml X 3 times a day intramuscularly

¨ Gastrocepini - 2.0 ml X 2 times a day intramuscularly

¨ Tab. Maninili - 2 tablets 2 times a day

Sol. NaCl 0.9% - 500.0 ml

Sol. Ac. Ascorbinici 5% - 5.0 ml

Cocarboxylasae - 150.0 mg

Operational

Preoperative epicrisis:

The ball room was admitted on an emergency basis with complaints of pain in the right hypochondrium, erigastria, dry mouth, nausea, vomiting, and general weakness.

Examined according to ultrasound data: Gallbladder: After eating, it increases to 100 * 36 mm., The wall is thickened up to 4 m.. Stones in the cavity up to 14 mm. One of which is fixed at the mouth. CBP is not expanded.

Exhibited clinical diagnosis: Cholelithiasis. Acute cholecystitis.

Due to the presence in the anamnesis of attacks of pain in the right hypochondrium during meals, the presence of signs hron. cholecystitis in order to prevent possible complications and sanitation of the biliary tract, the patient is shown surgical treatment. Planned laparoscopic cholecystectomy. The patient agrees to the operation, the possibility of conversion is warned.

Blood type: A(II) Rh+ Lech. Doctor: N. Protocol of operations No. 255.

FULL NAME: Salmanova Alfira Fazalovna

Age : 48 years old. Bolt source no.: 22540.

Diagnosis: Cholelithiasis. Acute cholecystitis.

Operation: Laparoscopic cholecystectomy. Drainage of the abdominal cavity.

Surgeons: Timerbullatov M.V., Garifullin.

Anesthetist: A/S: Date: . Start of operations: 9:40 . Duration: 25 minutes.

Under endotracheal anesthesia after processing the surgical field, trocar laparocentesis was introduced into the umbilical region. With the help of an insufflator, a tense carboxyperitoneum was produced. A video laparoscope and manipulation trocars were introduced into the abdominal cavity at 4 standard points. During the revision of the abdominal organs, it was revealed that the liver was not enlarged, homogeneous, the gallbladder 8 * 4 * 4 cm was not enlarged, the wall was not enlarged up to 4 mm. with signs of chronic inflammation. The gallbladder was isolated from the adhesions, the elements of the Calot triangle were identified, the cystic duct was separated separately, and the arteries were sutured and cut off. Produced cholecystectomy from the neck with coagulation hemostasis bed of the gallbladder. The gallbladder was evacuated from the epigastric access. The subhepatic space was sanitized and drained by tubular drainage. Hemostasis control. Stitches on the wound. Aseptic bandage. A macropreparation - the gallbladder contains stones 2.5 * 10 mm., Was sent for histological examination.

A DIARY

THE DATE

The patient's condition

The general condition is relatively satisfactory, complaints of weakness, vesicular breathing. The tongue is dryish with a white coating, the abdomen is soft, not swollen, painless, diuresis is not disturbed, the stool is formed.

The patient after operations, the condition corresponds to the operations performed, consciousness is clear, complaints of pain in the wound, weakness, dyspepsia, no breathing and hemodynamics is satisfactory, the abdomen is soft, not swollen

The patient is concerned about low-intensity pain in the epigastrium and right hypochondrium, the temperature is 36.8°C. There was no chair. Urination is not disturbed.

Objectively: the patient's condition is currently moderate. Vesicular breathing in the lungs, pulse - 78 beats per minute, symmetrical, regular rhythm. BP - 130/80 mm Hg. Art. The tongue is moist, covered with a whitish coating. The abdomen is moderately swollen, does not participate in the act of breathing. Protective muscle tension is not detected. The gallbladder is not palpable, Shchetkin Blumberg's symptom is negative.

Curator – Zalikin M.A.

The patient's condition has improved over the past period. The pain of the patient is no longer disturbed during the last 2 days. Temperature - 36.7 ° С. The chair is normal. Urination is not disturbed.

Objectively: the patient's condition is currently satisfactory. Vesicular breathing in the lungs, pulse - 80 beats per minute, symmetrical, regular rhythm. BP - 130/80 mm Hg. Art. The tongue is moist, covered with a whitish coating. The abdomen is moderately swollen, does not participate in the act of breathing. Protective muscle tension is not detected. The gallbladder is not palpable, Shchetkin-Blumberg's symptom is negative.

Curator – Zalikin M.A.

FORECAST

Health prognosis: recovery

Forecast for life: favorable.

Forecast for work: workable.

EPICRISIS

Staged: continuation of treatment in City Clinical Hospital No. 21 in 1 surgical department.

TEMPERATURE SHEET

BIBLIOGRAPHY

1. Diagnosis of diseases of internal organs. Volume 1. A.N. Okorov. Minsk 2001.

2. Propaedeutics of internal diseases. V.Kh.Vasilenko. Moscow "Medicine" 1983.

3. Clinical classifications of diseases of internal organs. BSMU. Ufa 1996.

4. Medicines. M.D. Mashkovsky. Moscow "Medicine" 1986.

5. Pharmacology. D.A. Kharkevich. Moscow 2001.

6.Surgical diseases Kuzin M.I. Moscow 2000

7. Rodionov V. V., Filimonov M. I., Moguchev V. M. Calculous cholecystitis. - M.: Medicine, 1991. - 320 p.

8. Shaposhnikov A. V. Cholecystitis. Pathogenesis, diagnosis and surgical treatment. - Publishing house of Rostov University, 1984. - 224 p.

9. Movchun A. A., Koloss O. E., Oppel T. A., Abdullaeva U. A. Surgical treatment of chronic calculous cholecystitis and its complications. - Surgery, 1998, No. 1, p.8.

Passport part

Age: 52 years old

Gender Female

Permanent residence: Moscow

Profession: engineer

Complaints

At the time of curation, the patient complains of prolonged intense paroxysmal pain. Occurring after eating, after 2 hours. Localized in the right hypochondrium, radiating to the lower back. Pain stops on its own. Nausea, dry mouth.

History of present illness

She considers herself ill since October 2, when she felt unwell. Weakness, nausea, dry mouth. The next day she went to the clinic, during the examination of the abdominal organs, stones in the gallbladder were found.

In February 2000, the patient first noted the appearance of acute, intense, diffuse pain in the right hypochondrium, radiating to the lower back. The attack lasted 20-25 minutes and passed on its own. Nausea, vomiting, fever were not observed. The patient was at home for 2 days, she was not treated on her own. The next day I went to the clinic. Examination of the abdominal cavity revealed no pathology. With suspicion of a pathology of the biliary tract, the patient was prescribed treatment, an antibiotic, Essentiale Forte. The patient was treated for a month, after which the condition stabilized.

On the evening of October 5, after eating, sharp intense diffuse pains suddenly appeared in the right hypochondrium radiating to the lower back. There was an increase in temperature up to 37.5 degrees, nausea, dryness.

in the mouth. In this connection, the patient called an ambulance and was taken to the City Clinical Hospital with a diagnosis of acute cholecystitis. Cholelithiasis.

Life story

Brief biographical information:

Born in 1942, the third child in the family. She grew and developed without any special features, she did not lag behind her peers. Higher education.

Family and sex history:

The menstrual cycle appeared at the age of 12, with a frequency of 23 days, a duration of 6 days, the number of compartments is moderate. She got married at the age of 40. No kids. Climax at 50. Currently married, no children.

Labor history:

She started working at the age of 24 in Moscow as a laboratory assistant, at a scientific research institute. At the age of 26 she graduated from the institute and continued to work there as an engineer until retirement age. Conditions and working conditions are satisfactory. Does not note occupational hazards.

Household history:

She lives in a 2-room apartment with all amenities with her husband. Staying in ecological disaster zones denies.

Food:

The regime does not comply, high-calorie rich in fatty foods, not regular.

Bad habits:

Smoking, drug use, substance abuse, alcohol denies.

Past illnesses:

In childhood, she suffered: measles, rubella, scarlet fever, diphtheria, influenza, acute respiratory infections.

Venereal diseases, tuberculosis, hepatitis denies. The blood has not been transfused before.

Allergic history:

Adverse reactions from medicines, foods, serums denies.

Heredity:

The mother died at the age of 71 from acute renal failure. My father died at the front in 1942. Heredity is not burdened.

Present state

General inspection

The general condition is satisfactory.

Consciousness is clear.

The position is active.

Build hypersthenic type (height 164 cm, weight 95 kg.) Straight posture, slow gait.

Body temperature 36.7 C.

Facial expression is calm.

Skin, nails, visible mucous membranes are cyanotic. No pigmentation or depigmentation. There are no rashes, spider veins, hemorrhages, trophic ulcers, visible tumors.

Skin moisture is normal, turgor is preserved.

Nails of the correct form, longitudinal striation, "watch glasses" are not noted. Mucous membranes are pink, moist, there are no rashes. Hair type according to the female type.

Subcutaneous fat is moderately developed.

There are no edema. A small deposition of fat is noted on the abdomen, thighs, buttocks. There is no pain on palpation.

Lymph nodes (occipital, parotid, submandibular, cervical, supraclavicular, subclavian, ulnar, inguinal, patella) are not palpable.

The pharynx and tonsils are of normal color, there is no swelling and edema.

Bones: there is no deformation, swelling, pain when feeling and tingling.

Joints: the configuration is not changed. Movement within the normal range, pain, no crunch.

Respiratory system

Inspection

Nose: the shape of the nose is not changed. Breathing through the nose is free. Separated moderate. No nosebleeds. There is no hyperemia on visible mucous membranes.

Rib cage: hypersthenic type, expressed above and subclavian fossae, the width of the intercostal spaces is moderate. The epigastric angle is straight. Clavicles and shoulder blades protrude moderately. The chest is symmetrical, no spinal curvature was detected. Circumference 80 cm, with a maximum exhalation 74 cm. Excursion of the chest 6 cm.

Breath: mixed type, the number of respiratory movements 18 per minute. Breathing rhythmic, medium depth. Inhalation is longer than exhalation.

Palpation

The chest is elastic. There are no painful areas. Voice trembling in symmetrical areas is the same.

Percussion

Comparative: on symmetrical parts of the chest - a clear percussion pulmonary sound.

Topographic:

Upper border of the lungs: right left

the height of the tops in front is 2 cm. 2cm

standing height of the apexes at the level of the 7th cervical vertebra

the width of the Krenig fields is 5 cm. 4cm

Inferior border of the lungs:

along the parasternal line edge of the 6th rib 6th rib

on the midclavicular 7 children. Not defined.

on the anterior axillary 7 reb. 7 children

on the middle axillary 8 reb. 8 children

on the back axillary 9 reb. 9 children

on the scapular 10 reb. 10 children

on the paravertebral 11 reb. 11 children

Excursion of the lower edge of the lungs 3 cm. 3 cm.

Auscultation

Vesicular breathing is heard over the entire surface of the chest, in symmetrical areas. Adverse breath sounds were not detected. There is no pleural friction noise. Bronchophony is the same on both sides.

Circulatory system

Inspection

The veins of the neck do not bulge, there is no positive venous pulse, there is no “carotid dance”. There are no protrusions in the region of the heart. There is no visible pulsation in the region of the apex beat, in the epigastric region, in the region of the ascending aorta, the aortic arch, or the pulmonary artery. There are no tremors in the region of the heart, pain on palpation, and no zones of hyperesthesia.

Palpation

The apex beat is localized in the 5th intercostal space 1 cm outward from the left midclavicular line, not reinforced, not lifting. The cardiac impulse is not determined. Epigastric pulsation weakens at the height of deep inspiration, associated with pulsation of the abdominal aorta. Pulsation in the area of ​​the ascending aorta and arch, no pulmonary artery. There is no pulsation at an additional point to the left of the sternum. There is no systolic trembling in the aorta and no diastolic trembling at the apex.

Percussion

Relative dullness of the heart:

Limits of relative dullness of the heart

• right - 1 cm. outward from the right edge of the sternum
• left - 1 cm. from the inside of the left midclavicular line
• upper - at the level of 3 ribs
• diameter - 13 cm.
• the width of the vascular bundle is 5 cm.

The configuration of the heart is normal.

Absolute dullness of the heart:

Abs limits. dullness of the heart

• right - on the left side of the sternum
• left - 1 cm. medially from the left border of relative dullness
• upper - at the level of 4 ribs

Auscultation

Rhythmic heart sounds, heart rate 78 per minute.

1 tone - muted at the top

2 tone - accented on the aorta

There is no splitting of tones, no additional tones. Noises are not heard. There is no pericardial friction noise. There is no gallop rhythm.

Pulse study

The pulsation of the temporal, carotid, radial, popliteal arteries is preserved. The wall of the arteries is smooth and elastic. The pulsation of the aorta in the jugular fossa is not determined, the double tone of Traube and the double Vinogradov-Durozier on the femoral arteries are not heard. Arterial pulse on both arms is symmetrical, frequency 78 beats per minute, rhythmic, good filling, tension. Hell 130\80 mm. rt. Art. Neck veins, c. class, the abdominal wall is not expanded. There are no seals and soreness of the veins.

Digestive system

Gastrointestinal tract

Complaints

For intense, prolonged, paroxysmal pain in the right hypochondrium, radiating to the lower back, arising after eating after 2 hours, stopping on its own.

Nausea, dry mouth.

There are no complaints about vomiting, belching, heartburn, bloating.

Appetite saved.

The chair is not regular, decorated, brown.

Complaints about vomiting blood, coffee grounds', black chair no.

Inspection

Oral cavity:

The tongue is dry, covered with white coating at the root, pink, the papillary layer is preserved, there are no ulcers and cracks.

Teeth require sonation.

The gingiva is without pathological changes.

The belly of the correct form, symmetrical, participates in the act of breathing. There is no visible peristalsis of the intestines, stomach, venous collaterals. The circumference of the abdomen at the navel is 92 cm.

Percussion

A tympanic sound is determined over the entire surface of the abdominal cavity. There is no free fluid in the abdominal cavity.

Palpation

Surface indicative:

The abdomen is soft, painful in the region of the right hypochondrium, there is no tension in the muscles of the abdominal wall. There is no divergence of the rectus abdominis muscles. Palpable tumor-like formations were not detected. Symptom of Shchetkin-Blumberg, Mendel is negative.

Methodical deep sliding palpation according to Obraztsov-Strozhesko

The sigmoid colon is palpated in the left iliac region in the form of an elastic cylinder, 3 cm in diameter. with a smooth surface, painless, does not growl.

The caecum is palpated in the right iliac region in the form of a small elastic cylinder, 3.5 cm in diameter. With a smooth surface, painless, easily displaced, rumbling on palpation. Ascending colonic and descending, 3 cm in diameter. On palpation, they are painless, displaced within 2 cm. The transverse colon is located 2 cm below the stomach. Dense with a smooth surface, painless, 4 cm in diameter. The greater curvature of the stomach is 4 cm. above the navel, smooth, even, painless. The gatekeeper is not palpated.

Auscultation

Live peristalsis is heard over the entire surface of the abdomen. The noise of friction of the peritoneum, vascular noise is not auscultated.

Liver, gallbladder

Complaints

For intense prolonged paroxysmal pain in the right hypochondrium, radiating to the lower back, occurring after eating after 2 hours, copying independently. Nausea, dry mouth. There are no complaints about vomiting, belching, jaundice, skin itching, changes in the color of urine and feces.

Inspection

Protrusions in the right hypochondrium, there is no restriction in breathing.

Percussion

Borders of the liver according to Kurlov:

The upper border of the liver of absolute dullness along the right midclavicular line at the level of the 6th rib.

The lower border of the liver abs. dullness along the right mid-clavicular line at the edge of the costal arch. Along the anterior midline at the border of the upper and middle third of the distance from the navel to the xiphoid process. Along the lava costal arch at the level of the 9th rib (left parasternal line).

Tapping on the right costal arch: Ortner's symptom is positive.

Palpation

The lower edge of the liver does not protrude beyond the costal arch, rounded, soft, painful.

The surface of the liver is not enlarged.

The size of the liver according to Kurlov:

Along the edge of the mid-clavicular line - 10 cm.

On the anterior median line - 7 cm.

On the left costal arch - 6 cm.

The gallbladder is sharply painful on palpation, slightly enlarged, somewhat compacted, poorly displaced. Symptoms: Kera, phrenicus symptom, Murphy, Mussy, Ortner, Lepene positive.

Auscultation

There is no peritoneal friction noise in the right hypochondrium.

Spleen

Inspection

There is no limited protrusion in the region of the left hypochondrium. There is no respiratory restriction in this area.

Percussion

Longitudinal size - 6cm. (along the 10th rib)

The transverse dimension is 5cm.

Palpation

Not palpable.

Auscultation

The noise of friction of the peritoneum in the region of the left hypochondrium is not heard.

Pancreas

Complaints

Complaints of pain in the upper abdomen on the left, nausea, vomiting, flatulence, diarrhea, constipation no.

Palpation

On palpation, the gland is painless, not enlarged, not compacted. Mayo-Robson's s-ohm is negative.

urinary system

Complaints

There are no complaints of pain in the lumbar region, no urination disorders, no edema.

Inspection

Swelling, swelling. There is no hyperemia of the skin, asymmetry in the lumbar and under the pubic region.

Percussion

Tapping in the lumbar region is painless. Above the pubis there is a tympanic percussion sound.

Palpation

Kidneys and bladder not palpable. There is no pain along the ureter and in the costovertebral point.

reproductive system

Complaints

There are no complaints about pain in the lower abdomen, in the groin, lower back, sacrum, or in the area of ​​the external genital organs. Sexual function is normal. The mammary glands are moderately developed, the skin is pale pink. Pigmentation, local edema, in the form of a "lemon peel", retractions are not observed.

Endocrine system

Complaints

There are no complaints about impaired growth, physique, weight loss, thirst, hunger, feeling hot, sweating, chills, cramps, or muscle weakness.

Inspection

Violation of growth, physique, disproportionate parts of the body, obesity, acromegaly no.

Palpation

On palpation of the thyroid gland, it is not enlarged, painless.

Nervous system

There are no complaints of headaches, dizziness. Sleep disturbance, sensitivity was not detected.

Data of instrumental and laboratory research methods

Rectal examination

The sphincter is tonic. There is no pathology at the height of the finger. The ampoule is free. Feces on a regular color glove.

Gynecological examination

The vagina is capacious. The vaults do not hang, without pain. Traction for the cervix is ​​painless. There are no infiltrative changes. There were no data for acute pathology. There are no divisions.

Preliminary diagnosis

Acute calculous cholecystitis. Cholelithiasis.

Survey plan

Based on the preliminary diagnosis, in order to establish the final clinical and differential diagnosis, the patient was prescribed:

• general blood analysis
• blood chemistry
• general urine analysis
• Ultrasound of the abdominal organs
• Chest x-ray
• therapist consultation
• duodenal sounding

Data of laboratory, instrumental research methods and consultations of specialists

General blood analysis:

• erythrocytes - 4.0 * 10 / l
• hemoglobin - 140 g/l
• col. Indicator - 0.9
• leukocytes - 9000/mkl
• stab - 3%
• segmented - 55%
• eosinophils - 2%
• basophils - 0
• lymphocytes - 37%
• monocytes - 5%
• ESR - 16 mm/h

General urine analysis:

• color - straw yellow
• transparency - cloudy
• relative density - 1016
• reaction is sour
• protein is missing
• epithelium - single in the field of view
• glucose is absent.
• beaten ruby ​​- absent.
• urobilin - absent.
• acetone - absent.
• leukocytes - 0-2 in p.z.
• erythrocytes - single
• mucus - absent.
• salts - oxalates in a small amount

Blood chemistry:

• total protein - 64.7 g / l
• albumins - 62.1 g/l
• residual nitrogen - 20.4 mmol/l
• urea - 3.6 mmol/l
• creatinine - 0.14 mmol/l
• urinary acid - 0.21 mmol/l
• fibrinogen - 2.0 g/l
• glucose - 4.2 mmol/l
• lipids total - 5 g/l
• triglycerides - 2.7 mmol/l
• total cholesterol - 20 mmol/l
• phospholipids total - 1.1 mmol / l
• bilirubin total - 16.8-0-16.8
• alkaline phosphatase - 155 nmol / s * l
• ALT- 140 nmol/s*l
• AST- 65 mmol/l
• Amylase - 14.2 g/l

EGDS

Pathology from the upper gastrointestinal tract was not revealed.

Chest radiograph:

The shadow is uniform without features. Lung fields are transparent. The roots are not expanded. The diaphragm is movable.

Therapist's advice:

Data for therapeutic pathology was not revealed.

Sinus rhythm 70 beats per minute. Normal position of the electrical axis of the heart. Moderate myocardial ischemia.

Ultrasound of the abdominal organs:

Clinical diagnosis and its rationale

Main disease:

Cholelithiasis. Reversible attack of hepatic colic.

The diagnosis was made on the basis of:

1. The patient complains of intense, prolonged, paroxysmal pain in the right hypochondrium, radiating to the lower back. Occurring after eating after 2 hours, stopping on their own. Nausea, dry mouth. These complaints indicate a pathological process in the abdominal cavity. and severe pain syndrome.

2. Anamnestic data: errors in diet, irregular diet, sedentary lifestyle, sedentary work. These factors contribute to the stagnation of bile and favor the formation of stones.

3. General examination data: the patient's age, hypersthenic physique, overweight (weight 95 kg with height 164 kg), fat deposition on the abdomen, thighs, buttocks. On palpation of the abdomen, there is pain in the right hypochondrium. Tongue coated with white coating due to damage to the gastrointestinal tract.

4. Laboratory data: biochemical blood test - total cholesterol 20 mmol/l, triglycerides 2.7 mmol/l, phospholipids 1.1 mmol/l. Ultrasound - in the lumen of the gallbladder stones with a diameter of -1.6 and 1.0 cm.

The above data indicate a lesion of the gallbladder of a patient diagnosed with cholelithiasis, a stopping attack of hepatic colic.

Differential Diagnosis

Gallstone disease, an attack of hepatic colic is accompanied by a number of main clinical manifestations: paroxysmal intense pain in the right hypochondrium, after an error in the diet, radiating to the lower back, stopping with antispasmodics or on its own. Nausea, vomiting that does not bring relief, the appearance of subfebrile temperature of 37 degrees or normal, moderate tachycardia of 100 beats per minute, the tongue is wet with white coating, on examination, some bloating is noticeable, the right half of the abdominal wall lags behind in the act of breathing. On palpation of the abdomen, there is a sharp pain in the right hypochondrium, especially in the area of ​​the projection of the gallbladder. Positive symptoms of Ortner, Mussy, Lepene, Kera, Murphy are detected, there are no symptoms of peritoneal irritation, the number of leukocytes in the blood is normal. From the above data on the clinical picture, the following diseases can be differentiated:

O. gastritis - pain appears a few minutes or (30-40 minutes) after eating and is localized directly under the xiphoid process.

Pancreatitis - intense pain, encircling nature, often localized in the left half of the epigastric region.

Perforated ulcer of the stomach and duodenum 12 - a sharp constant "dagger" pain in the epigastric region or in the right hypochondrium. Symptoms of peritoneal irritation are positive. There is an increase in body temperature.

Renal colic - acute paroxysmal pains suddenly begin and suddenly disappear. Localized in the lower back, with damage to the right kidney, can be given to the right hypochondrium. Pain radiates down to the groin, genitals. Dysuric phenomena are noted.

Myocardial infarction, posterior wall of the left ventricle - intense, paroxysmal "dagger" pain in the xiphoid process. It can radiate to the right hypochondrium, neck, under the shoulder blade. Fear of death, palpitations, shortness of breath. The pain is not stopped by nitroglycerin, antispasmodics.

O. calculous cholecystitis - intense prolonged (several days), paroxysmal pain in the right hypochondrium that occurs after eating after 2 hours, radiating to the lower back. Hyperthermia, leukocytosis, increased ESR.

Right-sided pleurisy - acute intense pain in the lower half of the chest. Aggravated by breathing, especially when bending the patient in a healthy direction. On auscultation, pleural friction rub, leukocytosis.

O. gastritis - no pathology of the gastrointestinal tract was found on endoscopy. Consultation of the therapist - therapeutic pathology was not revealed.

Pancreatitis - Mayo-Robsan's symptom is negative. Blood test - no symptom of inflammation, biochemistry is not changed. Ultrasound showed no changes.

Perforated ulcer of the stomach and duodenum 12 - ultrasound pathology was not detected.

Renal colic - ultrasound of the abdominal organs without pathology. Urinalysis without features. On palpation, pain in the lumbar region is not noted.

Myocardial infarction - ECG - pathologies from the side of the heart vascular system not found. Consultation of the therapist - no therapeutic pathology was found.

O. calculous cholecystitis - analysis of total blood, blood biochemistry unchanged. Ultrasound of the abdominal organs - the bladder wall is not thickened, echogenicity is not increased.

Right-sided pleurisy - on roentgenoscopy of the respiratory organs, pathology from the lungs was not revealed. Consultation of the therapist - no therapeutic pathology was found.

Based on the comparison of the clinical picture with the clinical signs of these similar diseases, the patient was diagnosed with cholelithiasis. An attack of stopping hepatic colic.

Etiology and pathogenesis

The morphological substrate of cholelithiasis is the calculi of the gallbladder and bile ducts. Gallstones are made up of common components of bile - bilirubin, cholesterol, calcium. Most often there are mixed stones containing a greater or lesser proportion of these ingredients. With a significant predominance of one of the components, they speak of cholesterol (about 90%), pigment or calcareous calculi. Their sizes vary widely from 1-2 mm to 3-5 cm. The shape can be round, oval, in the form of a polyhedron, etc.

The main place of formation of gallstones is the gallbladder, less often - the biliary tract. There are three main reasons for their formation: metabolic disorders, inflammatory changes in the epithelium of the gallbladder and bile stasis. In case of metabolic disorders, it is not so much the magnitude of hypercholesterolemia that is of primary importance, but the change in the ratio in bile of the concentration of cholesterol, phospholipids (lecithin), and bile acids. Bile becomes lithogenic, i.e. supersaturated with cholesterol, which easily precipitates from the disturbed colloid of bile in the form of crystals, with an increase in the concentration of cholesterol in it and a decrease in the concentration of phospholipids and bile acids. More often, cholelithiasis develops in patients with diseases such as metabolism, diabetes, obesity, hemolytic anemia.

Damage to the gallbladder wall is also of no small importance in the genesis of cholelithiasis. In the vast majority of patients, bile is infected. Infection leads to damage to the wall of the gallbladder, desquamation of its epithelium. In this case, the so-called primary nuclei of precipitation arise (bacteria, lumps of mucus, epithelial cells), which serve as the basis for the precipitation in the form of crystals of the main parts of bile, which were previously in the colloid state. In addition, damage to the gallbladder wall disrupts the absorption of some components of bile, changes their physico-chemical ratio, which contributes to stone formation. The formed stones in the gallbladder contribute to the violation of the outflow of bile from the gallbladder, thereby causing a pain attack (an attack of hepatic colic). Prolonged stagnation of bile plays a certain role in lithogenesis, facilitating precipitation into crystals. constituent parts future calculus, their long stay in the lumen of the bladder. In addition, with cholestasis, the concentration of cholesterol, bilirubin, and calcium may also increase, which increases the lithogenicity of bile. This is facilitated by the intake of fatty, salty foods, as well as a sedentary lifestyle, hereditary predisposition.

Treatment plan.

In an acute attack of hepatic colic, in the absence of symptoms of peritonitis, conservative treatment is carried out aimed at stopping pain in the gallbladder or bile ducts. For this purpose, antispasmodics (platifillin, no-shpu, baralgin, papaverine) are administered intramuscularly. An ice pack is placed on the area of ​​the right hypochondrium. For detoxification and parenteral nutrition, infusion therapy is prescribed in general, in a volume of at least 2.0 - 2.5 liters. solution per day. With frequently recurring severe attacks, surgical treatment is performed during the period of remission. An endoscopic papillotomy is also used.

Crushing stones with ultrasound, if the stones are small and in small quantities.

If within two days the patient's condition does not improve, despite the ongoing intensive treatment, surgical treatment is performed to prevent gangrenous, perforative cholecystitis and the development of biliary peritonitis. In this case, it is necessary to take into account the age of the patient and the presence of concomitant diseases.

With a latent form of the disease, the basis of treatment is diet therapy (diet No. 5, exclusion from the diet of spices, smoked meats, animal fats, fractional meals up to 5-6 times a day, mineral water). For pain, cold is shown on the gallbladder area, antispasmodics.

Physiotherapeutic methods of treatment are used: UHF, diathermy, inductothermy, mud therapy and mineral baths.

In the absence of signs of exacerbation - sanatorium treatment (Essentuki, Borjomi, Truskavets, etc.).

Treatment prescribed:

conservative:

Bed mode

Relief of pain syndrome

papaverine 2.0 * 3 rubles; platifillina hydrotartrate 1.0 * 3 p. intramuscularly.

- Ice on the area of ​​the right hypochondrium.

— Detoxification therapy —

alkaline mineral waters, intravenous drip of Ringer's solution 400, 5% r - ora glucose 400 ml, vitamins - B1, B6 3.0 each

A diary.

1. 16. 2000

The general condition of the patient is satisfactory. No new complaints. Notes a significant decrease in pain compared with the onset of the disease.

Temperature - 36.7 °. AD 130/80 mm. Hg Pulse - 84 beats per minute, rhythmic, intense.

Tongue wet, lined with white coating. The abdomen is soft, slightly painful. With deep palpation in the right hypochondrium - mild pain. Symptoms of peritoneal irritation are negative.

Symptom Ortner "+".

Physiological functions are independent.

1. 17 . 2000

The general condition of the patient is satisfactory. Complaints of aching pain in the right hypochondrium.

The tongue is moist, covered with a white coating at the root. The abdomen is soft, painless on palpation, except for the right hypochondrium, where pain is noted. Physiological functions are independent.

1. 18 . 2000

The general condition is satisfactory. No complaints about aching pain in the right hypochondrium.

Temperature - 36.6 °. AD 130/80 mm. Hg Pulse - 82 beats per 1 minute, satisfactory filling, rhythmic.

The tongue is moist, covered with a white coating at the root. The abdomen is soft, painless on palpation. Physiological functions are independent.

Epicrisis.

Patient X., aged 58, was admitted to the surgical department on 06.10.2000 with complaints of intense prolonged paroxysmal pain in the right hypochondrium, 2 hours after eating. Radiating to the lower back. With a diagnosis of GSD. About calculous cholecystitis.

An examination was carried out in the hospital.

Clinical diagnosis: cholelithiasis, an attack of stopping hepatic colic.

Conservative treatment is carried out, aimed at stopping the pain syndrome, removing intoxication, and normalizing blood pressure.

The patient's condition improved. There are no indications for emergency surgery. A planned operation, cholecystectomy is indicated.

Bibliography:

Big medical encyclopedia.

Educational literature.

ROSTOV STATE MEDICAL UNIVERSITY

DEPARTMENT OF SURGICAL DISEASES №2

Head department:

Professor, MD Cherkasov M.F.

Teacher:

PhD Kharagezov A. D.

Curator:

4th year student of LPF

14 groups of Kirillov A.N.

DISEASE HISTORY

Bugrimenko Nikolai Nikolaevich

The main diagnosis: gallstone disease. Chronic calculous cholecystitis.

Start of curation 10/19/99

The ending 1.11.99

Passport data.

1. Full name of the patient:
2. Age:
3. Nationality:
4. Place of residence:
5. Profession:

Clinical diagnosis.

Basic: Cholelithiasis. Chronic cholecystitis.

Complications of the main: Cholangitis.

Accompanying illnesses: Peptic ulcer of the duodenum.

Outcome of the disease: improvement.

Complaints.

On intense arching pains in the right hypochondrium, spreading to the epigastric region, appearing after eating fatty foods and physical activity, stopping after the injection of no-shpa and in the supine position on the left side; nausea, passing after artificially induced vomiting; feeling of bitterness, dryness in the mouth; weakness, fatigue.

Disease history.

He considers himself ill since 1993, when for the first time after physical exertion similar pains appeared in the right hypochondrium and after ultrasound was diagnosed with calculous cholecystitis. Subsequently, a relapsing course of the disease was observed with exacerbations once every 1-2 years, followed by periods of complete absence of symptoms. In 1999, there was an increase in exacerbations. The real exacerbation began on October 7, 1999, when constant intense pain appeared in the right hypochondrium, accompanied by a rise in body temperature to 39C from October 10 to 13, 1999, in connection with which the patient was hospitalized in the clinic of the Russian State Medical University.

Anamnesis of life.

Was born on time. Fed on mother's milk. Grew and developed in accordance with age. He does not remember childhood illnesses. Appendectomy in 1966.

In adulthood, SARS 1-2 times a year. Peptic ulcer of the duodenum, complicated by perforation in 1976, for which the perforated ulcer was sutured. Mental illness, viral hepatitis, sexually transmitted diseases, tuberculosis denies.

Heredity is not burdened.

Working and living conditions are normal.

There were no blood transfusions.

There are no allergic reactions.

There are no bad habits.

Contact with infectious patients, stay in areas endemic for infectious diseases, intestinal infections during the previous 40 days denies.

Data from an objective study.

The patient's condition is satisfactory, consciousness is clear, the position is active. The physique is normosthenic, subcutaneous fatty tissue is moderately developed, height is 176 cm, weight is 95 kg. Subicteric skin and sclera are observed, skin turgor is preserved, there are postoperative scars along the white line of the abdomen above the navel (12 cm, not soldered to surrounding tissues, painless, mobile) and in the right iliac region (7 cm, not soldered to surrounding tissues, painless, mobile). Edema is not observed. Lymph nodes, accessible to palpation, are not enlarged, densely elastic consistency, painless, mobile, not soldered to each other and to the surrounding tissue, the skin over them is not changed. Bones and joints are not deformed. The muscles are well developed, the tone is normal.

Respiratory system.

Breathing is normal, no shortness of breath is observed, respiratory rate is 8 per minute, the type of breathing is abdominal. The chest is normosthenic, both halves are equally involved in the act of breathing, elastic, pain on palpation is not observed. Voice trembling is carried out in the same way in symmetrical areas. Percussion clear pulmonary sound. Topographic percussion: the height of the tops on the left and right is 3 cm above the clavicle, the width of the Krenig fields on the left and right is 5 cm.

Inferior borders of the lungs

Topographic linesLeft lungRight lungParasternal-5th intercostal spaceMidoclavicular-6th ribAnterior axillary7th rib7th ribMiddle axillary8th rib8th ribPosterior axillary9th rib9th ribScapula 10th rib10th ribParavertebralTh XITh XI

Active mobility of the lower edge of the lungs

Topographic lines Left lung Right lung Mid-clavicular-4 cm Middle axillary 6 cm 6 cm Scapular 4 cm 4 cm

Auscultatory vesicular breathing over the entire surface of the lungs.

The cardiovascular system.

When examining the area of ​​the heart and blood vessels, no pathological pulsations were found. Apex beat in the 5th intercostal space 1 cm medially from the left midclavicular line, normal height, strength, resistance, area 1 cm2. There is no symptom of cat purring. The pulse on the radial arteries is the same, rhythmic, satisfactory filling and tension, there is no pulse deficit, HR=PS=72 beats/min. Percussion of the borders of relative dullness of the heart: the right border in the 4th intercostal space 1 cm outward from the right edge of the sternum, the left border in the 5th intercostal space 1 cm inward from the left midclavicular line, the upper border at the level of the 3rd rib. The configuration of the heart is normal. The size of the diameter of the heart is 12 cm. The size of the vascular bundle in the 2nd intercostal space is 6 cm. Percussion of the boundaries of absolute dullness of the heart: the right one in the 4th intercostal space along the left edge of the sternum, the left one in the 5th intercostal space 1.5 cm medially from the left border of relative dullness, the upper one is the 4th rib . On auscultation, the heart sounds are clear, rhythmic, there are no pathological tones and noises. Blood pressure 130/90 mm Hg. Art. Stange test 50 seconds.

Digestive organs.

Percussion of the liver:

Percussion of the spleen:

Upper border 9 rib

Lower 11 rib

anteroposterior 8 cm

On palpation, the abdomen is soft, there is pain in the epigastric region and right hypochondrium. With deep palpation: the sigmoid colon is smooth, painless, dense elastic consistency, does not growl, diameter 2.5 cm, mobility 4 cm; the descending part of the colon is smooth, painless, densely elastic consistency, does not growl, diameter is 2 cm; the caecum is smooth, painless, dense elastic consistency, growls, diameter 2.5 cm, mobility 4 cm; the ascending colon is smooth, painless, of dense elastic consistency, does not growl, diameter is 2 cm; the terminal segment of the ileum, the greater curvature of the stomach, the pyloric part of the stomach are not palpated; the transverse colon is smooth, painless, dense elastic consistency, does not growl, diameter 2.5 cm; the lower edge of the liver at the level of the lower edge of the costal arch, soft, rounded, tenderness is observed on palpation; spleen, pancreas, gallbladder are not palpable. There are no peritoneal symptoms. Murphy's symptom is positive, Ortner's, Kera's, Mussi-Georgievsky's symptoms are negative.

Peristaltic noises on auscultation.

Urogenital organs.

When examining the lumbar region, redness, protrusions were not detected. Percussion of the kidneys and bladder are not defined. The symptom of tapping is negative. The kidneys are not palpable. Urination is free, painless, diuresis is adequate.

Neuropsychic status.

Consciousness is clear, the patient easily comes into contact, correctly answers questions, there is no lability of emotions. Dermographism pink, limited, quickly appears, quickly disappears. Pupil reflex to light D=S. Tendon reflexes are alive, symmetrical. Stable in the Romberg position.

local status.

The mucous membrane of the oral cavity is of normal color, without defects and rashes, the tongue is moist, covered with a yellowish coating at the root. The belly of the correct form, participates in the act of breathing. There is tympanitis on percussion, there is no dullness in sloping places.

Percussion of the liver:

Topographic lines Upper limit Lower limit Size of hepatic dullness Parasternal 5 intercostal space 2 cm below the costal arch 9 cm Midclavicular 6 rib along the edge of the costal arch 10 cm Anterior axillary 7 rib 10 rib 11 cm Liver dimensions according to Kurlov 10 cm, 8 cm, 10 cm

Percussion of the spleen: upper border of the 9th rib

lower 11 rib

Spleen dimensions: upper lower 6 cm

anteroposterior 8 cm

On palpation, the abdomen is soft, there is pain in the epigastric region and right hypochondrium. With deep palpation: the sigmoid colon is smooth, painless, densely elastic

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Federal Agency for Education

Federal State Budgetary Educational Institution of Higher vocational education“National Research Nuclear University “MEPhI”

Obninsk Institute of Atomic Energy (IATE)

Faculty of Medicine

Department of Surgical Diseases

Disease history

Kateneva Henrietta Evgenievna, 79 years old

Main diagnosis: ZhKB. Chronic calculous cholecystitis, exacerbation. Complicated severe pancreatitis of biliary origin. Aseptic pancreatic necrosis with a primary lesion of the right type. Condition after percutaneous transhepatic drainage.

Concomitant disease diagnosis: duodenal ulcer, hypertension II stage.

Diagnosis of complications: Choledocholithiasis. mechanical jaundice. Acute fluid accumulation in the head of the pancreas. Incomplete external pancreatic fistula.

Completed: 4th year student

Groups LD-3B-09

Nasrullaeva D.K.

Checked by: Anaskin S.G.

Obninsk 2012

Passport part

1. Surname: *

2.Name: *

3. Middle name: *

4.Age: *

5.Marital status: *

6.Profession: *

7. Home address: *

8. Date and time of admission to the hospital: 06.10.12, 11:29, urgently.

9. Diagnosis of referring institution: acute cholecystitis

10. Diagnosis at admission: acute cholecystitis

11. Clinical diagnosis: cholelithiasis. Chronic calculous cholecystitis, exacerbation. Complicated severe pancreatitis of biliary origin. Aseptic pancreatic necrosis with a primary lesion of the right type. Condition after percutaneous transhepatic drainage. Incomplete external pancreatic fistula.

12. Date of curation: 10/26/12 - 11/06/12

13. Blood type: I (0), Rh (+) positive

Main complaints

At the time of hospitalization, the patient complained of constant severe pain of a pressing nature in the right hypochondrium, which eventually spread to the entire abdomen. She noted yellowness of the skin. In addition, the patient was worried about general weakness, nausea, headaches. At the time of curation no complaints.

Anamnesis Morbi

The patient considers herself ill since October 5, 2012, when she developed cramping acute pains in the epigastric region, the appearance of pain is associated with an error in the diet. Against the background of the pain syndrome, the patient limited herself in food, these days she did not notice an increase in temperature, there was repeated vomiting, yellowness of the skin and sclera. On the morning of October 6, 2012, there was no improvement, the patient caused ambulance, the paramedic provided medical assistance in the form of an intramuscular injection of no-shpa, then the patient was taken by ambulance to the emergency department of hospital No. 8 and then was hospitalized in XO-1.

Anamnesis Vitae

Born in Kharkov. She started attending school at the age of seven. Finished 10 classes. Physical and neuropsychic development corresponds to age. She studied at the Kazakhstan Agronomic College, received a secondary technical education as an agronomist. In 1958-1961. worked by profession, then for 5 years worked as a teacher at a school. In 1959 she married, in 1959 and 1965. gave birth to two sons, did not work anywhere. cholecystitis genesis drainage exacerbation

In 1969, she and her family moved to Obninsk, and together with her husband, she worked at a construction site; physical work. Living conditions throughout the entire period of the patient's life are satisfactory. Hygienic regime is observed. Nutrition is satisfactory, of high quality, balanced in terms of proteins, fats, carbohydrates, with a sufficient content of vitamins. He tries to stick to a diet, avoids eating: spicy, fried, bitter, smoked, salty. Food is taken approximately 4-5 times a day.

Drug history: The patient does not smoke, does not drink alcohol. Does not take sleeping pills, tranquilizers, antidepressants.

Labor history: Currently unemployed, retired.

Past illnesses:

Operations - appendectomy (1969), hemorrhoidectomy (2000). Postoperative periods without complications.

Sick of SARS about 1 time per year.

Chronic diseases: hypertension II degree (1973), duodenal ulcer (1983) (exacerbations in the autumn-winter period, every year, conservative therapy).

Allergic history: without features.

Epidemiological history: tuberculosis, malaria, HIV, sexually transmitted diseases, mental illness denies. Hemotransfusion denies. Over the past 6 months, contact with infectious patients denies. Has not been bitten by insects or rodents. Travel outside the permanent place of residence in the last 6 months denies.

Gynecological history: Menses from the age of 14, painless, moderate. Two pregnancies proceeded normally. Childbirth proceeded without complications. Two children.

Hereditary history: He denies oncological and other hereditary diseases in close relatives. The father died as a result of myocardial infarction.

Status preasens objectives

The patient's condition is moderate. Temperature 37.2 C. Clear consciousness. The position is active. The physique is correct appearance age appropriate. Anthropometric data: height 160 cm, weight 61 kg. Normosthenic type of constitution.

Skin: normal color, clean, dry, no scars or spider veins. Skin turgor is reduced. Nails are oval, brittle, there is no deformation of the nail plates. Visible mucous membranes are pale pink. Subcutaneous adipose tissue is moderately developed, evenly distributed. There are no edema. The thickness of the subcutaneous fat fold in the navel is about 4 cm.

Peripheral lymph nodes: parotid, submandibular, cervical supraclavicular and subclavian, axillary, ulnar, inguinal, popliteal - not enlarged, painless, normal density, mobile.

The pharynx is clean, the tonsils are not enlarged, their mucous membrane is pink.

The muscular corset is well developed, the tone and strength of the muscles are preserved, the same on both sides. The bones are not deformed. Joints of the correct form, movements in full, painless. The nail phalanges of the fingers are not changed. The skull is rounded, medium in size. The spine has physiological curves.

Respiratory system

Both halves of the chest are equally involved in the act of breathing. Type of chest breathing. Breathing through the nose is free. No nosebleeds. The sense of smell is not changed. The chest is normosthenic, symmetrical, there is no retraction of the chest on one side. There are no curvature of the spine. The supraclavicular and subclavian fossae are moderately pronounced, the same on both sides. The course of the ribs is normal. Breathing is correct, shallow, rhythmic, respiratory rate is 20/min. The width of the intercostal spaces is 1.5 cm; there is no bulging or retraction during deep breathing. The maximum motor excursion is 4 cm. The chest is elastic, the integrity of the ribs is not broken. There is no pain on palpation. There is no voice tremor enhancement. With comparative percussion over the lung fields, a clear pulmonary sound is heard.

Topographic percussion:

Inferior border of the lungs:	Right lung:	Left lung:
Lin. parasternalis	5th intercostal space
Lin. clavicularis	VI intercostal space
Lin. axillaris ant.
Lin. axillaris med.
Lin. axillaris post.
Lin. paravertebralis	spinous process XI vert. Thor	Spinous process XI vert. thor.

The height of the tops of the lungs:

Krenig margin width:

Vesicular breathing is heard over the lung fields on auscultation. Bronchial breathing is heard over the larynx, trachea and large bronchi.

Bronchovesicular breathing is not heard. No wheezing, no crepitus. Strengthening of bronchophony over the symmetrical areas of the chest was not detected.

The cardiovascular system:

The apex beat is palpated at the level of the lower edge of the VI rib, 1.5 cm outward from the left mid-clavicular line, with an area of ​​3 cm 2, normal strength, average height. The heart hump is not defined. There is no diastolic and systolic trembling (symptom of "cat's purr") in the area of ​​the apex and at the site of the projection of the aortic valve.

Percussion:

The contours of the cardiovascular bundle are determined:

	1, 2 intercostal space 2.5 cm	formed by superior vena cava
	3 intercostal space 3 cm;
	4th intercostal space 3.5 cm from the midline to the right.	formed by the right atrium
	1, 2 intercostal space 3 cm;	Formed by the aortic arch and pulmonary artery
	3rd intercostal space5 cm;	Formed by the auricle of the left atrium
	4 intercostal space 8 cm	Formed by the left ventricle
	5th intercostal space 10 cm from midline to the left.

Auscultation of the heart

The rhythm of the heart is correct. Heart rate 125 beats per minute. At five classical auscultation points, 2 tones and two pauses are heard. The tones are rhythmic. Noises and pathological rhythms are not heard. There is no pericardial friction noise.

Examination of the main vessels of large and medium caliber

During examination and palpation of the aorta (in the region of the jugular notch and in the epigastric region), its pulsation is determined. Visually, on the anterolateral region of the neck, there is no pathological pulsation of the carotid arteries (“dance of the carotid”), swelling and visible pulsation of the cervical veins are absent. On palpation of the femoral and popliteal arteries, the artery of the dorsal foot, the posterior tibial artery, their pulsation is detected on both sides.

Study of the arterial pulse

The pulse is the same on the right and left radial arteries in terms of filling and time of appearance of pulse waves. The pulse rate is -125 per minute. The rhythm is right. Pulse of medium tension and filling, medium size, normal shape. There is no pulse deficit. The wall of the radial artery is elastic and uniform. The pulsation of the temporal, carotid, ulnar, radial, subclavian, axillary, brachial, popliteal arteries is determined. Their wall is elastic. Capillary pulse is negative. Arterial pressure 130/70 mm. rt. Art.

Organ system p digestion

mucous cheeks, lips, solid sky pale Pink colour. The gums are pink, normal moisture, do not bleed, without inflammation. Inspection of the tongue: tongue of normal size, pale pink, moist, lined with white bloom, papillae preserved.

The tonsils do not protrude beyond the palatine arches. The mucous membrane of the pharynx is moist, pink, clean. There are no cracks in the corners of the mouth, rashes, herpetic vesicles on the lips.

Stomach. The abdomen is not enlarged, not swollen, symmetrical on both sides, participates in breathing, the surface is even. On superficial palpation, it is soft, moderately painful in the right hypochondrium. Shchetkin-Blumberg's symptom is negative.

With approximate percussion, the presence of free gas and fluid in the abdominal cavity was not detected.

Stomach. The greater curvature of the stomach by balloting palpation is determined 3 cm above the navel. The splash noise is not detected.

Auscultation: normal intestinal peristalsis. Intestines. Feeling along the colon is painless, splashing noise is not detected.

Deep palpation:

The sigmoid colon is palpated in the left iliac region, cylindrical in shape, the surface is even elastic, soft, mobile, painless.

The caecum is palpable in the right iliac region, cylindrical in shape, the surface is even elastic, soft, mobile, painless.

Studies of the liver and gallbladder. When viewed at the level of the projection of the liver, there is no bulging. The liver is palpated 1 cm below the edge of the costal arch (along the right midclavicular line), the lower edge of the liver is dense, even, rounded, with a smooth surface, painless.

	Upper bound	Bottom line	Hepatic dullness height
Anterior - axillary right	7th rib	X rib
Mid-clavicular right		costal margin
Parasternal right	at the level of the upper edge of the 5th rib	2 cm below the edge of the costal arch
Anterior median		4 cm below the base of the xiphoid process of the sternum	according to Kurlov 8 cm
Left lobe border	on the left parasternal along the edge of the costal arch	oblique size (according to Kurlov) 7.5 cm

The gallbladder is not palpable. There is pain on palpation at the point of the gallbladder. Symptom of Ortner and Obraztsov - Murphy are positive.

The pancreas is not palpable.

Spleen studies . There are no complaints. Palpation of the spleen in the supine position and on the right side is not determined. There is no pain on palpation.

Percussion of the spleen: Length - 6 cm; diameter - 4 cm.

urinary system

On examination, there is no protrusion above the pubis and in the region of the kidneys. There is no hyperemia.

With superficial palpation, pain is not determined.

With deep methodical palpation according to Obraztsov-Strazhesko, the kidneys are not palpated.

The upper and lower ureteral points on both sides are painless.

With percussion on both sides, Pasternatsky's symptom is negative. Urination is free. There are no edema.

Nervous system

The patient is restrained, treats the surrounding world with interest, the ability to concentrate is preserved, sociable, oriented in time and space, does not suffer from insomnia, no dizziness, no fainting, no hallucinations, no obsessions.

There are no pathological reflexes. Pain and temperature sensitivity is preserved. Vision, hearing, smell are normal. There are no taste disturbances.

Pupillary reaction to light is friendly.

Provisional diagnosis:

The main diagnosis: Acute pancreatitis. GSD, chronic calculous cholecystitis, exacerbation.

Diagnosis of concomitant disease: duodenal ulcer, hypertension II st.

Diagnosis of complications: Obstructive jaundice.

1) Based on the patient's complaints of constant moderate pain in the epigastric region along the pancreas, radiating to the right hypochondrium, having a constant aching character, nausea, dry mouth; discomfort in the right hypochondrium along the gallbladder, nausea;

2) based on the data of an objective study: the skin and mucous membranes are pale, the tongue is dry, lined with a white coating, the gallbladder is dense and painful on palpation;

3) Based on the history of the disease, which revealed the appearance of pain against the background of general well-being

Examination plan:

Laboratory research:

1. Clinical blood test.

2. General analysis of urine.

3. Blood type, Rh factor

4. Biochemical analysis of blood (level of protein and protein fractions, dysproteinemic tests, residual nitrogen and its components, mineral metabolism in the blood, activity of blood enzymes (AST, ALT, LDH), acid-base state of the blood).

5. Coagulogram

6. HbsAg, HIV, RW

7. Diastasis of urine and blood

8. Analysis for amylase of discharge from the drainage

Instrumental Methods:

1. Chest fluorography.

2. Ultrasound of the abdominal organs

3. ERCP

4. ECG.

5. FGDS

6. CT scan of the abdominal organs

Results of analyzes and special research methods

Laboratory data

1. Clinical blood test

Component under study
red blood cells	4.61*10 12/L	4,67*10 12	3,84*10 12	3,5-5*10 12
Average volume of erythrocytes		89.8 fl	95.6 fl
Hematocrit
platelets	183*10 9/l	181*10 9/l	393*10 9/l
Platelet index
Leukocytes	18.3*10 9/l	20.2*10 9/l	7,3*10 9/l	3.5-10*10 9/l
Hemoglobin			120g/l
			327g/l
stab
Segmented
Lymphocytes
Monocytes

2. Biochemical blood test

Date 08.10.12

Component under study	Result
Alkaline phosphatase
Bilirubin total	18.9 µmol/l	8.55-20.52 µmol/l
	5.8 mmol/l	3.9-6.4mmol/l
total protein
Urea	10.39 mmol/l	2.5-8.3 mmol/l
Creatinine	86 µmol/l	44-106 µmol/l
Cholesterol	4.79 mmol/l	0.0-5.2 mmol/l

3. Coagulogram

Date 08.10.12

APTT 38 per second

Prothrombin time 89%

Fibrinogen 2.8g/l

4. Analysis for blood diastasis, date 06.10.12

Blood diastasis 1700 units/l

5. Analysis of urine diastasis, date 08.10.12

Urine diastasis 2100u/l

6. Urinalysis

Date 08.1012

Quantity - 200 ml.

Specific gravity - 1020

Protein - traces

Sediment microscopy:

Leukocytes -45-50 in the field of view.

Erythrocytes - no.

Cylinders are not.

Khimich study:

stercobilin - no

no blood

7. Blood group I (0), Rh +

8. Microreaction to syphilis - negative

Anti-HIV 1.2, HbsAg, Anti-HCV sum - negative

9. Analysis of discharge by drainage. Date 26.10.12

Amylase 1112.0

Instrumental examination methods

1. Rn overview of the abdomen. Date 06.10.12

moderate cluster gas in a single dilated loop of the small intestine on the left. Suspicion of lung tissue infiltration in the lower lung. Chest x-ray recommended

2. Rn chest x-ray. Date 11.10.12

Darkening of the basal sections of the right lung up to the 8th rib is determined due to infiltration of the lung tissue and pleural changes. In the left lung pneumosclerosis. The heart is not enlarged.

Conclusion: right-sided pleuropneumonia.

3. Rn chest x-ray. Date 15.10.12

Compared to previous data, there is a positive trend. Infiltrative changes in the basal parts of the right lung have resolved, are not currently detected. The contour of the dome of the diaphragm became clear, its position is high. The rest of the picture is the same.

4. Ultrasound of the abdominal organs, date 08.10.12

Liver not enlarged, choledoch 5.3 mm. In the cavity of the gallbladder stones up to 12 mm. The pancreas was examined in fragments. The spleen is normal.

Conclusion: a small amount of fluid is determined anterior to the stomach

5. Ultrasound of the abdominal organs, date 10/16/12

The liver is not enlarged, choledochus is 5.7 mm. The gallbladder is usually located, the echogenicity of the wall is normal, the contents are homogeneous, stones are determined up to 12 mm. The pancreas is enlarged, head 31 mm, body 21 mm, tail 20.8 mm. Echogenicity is increased. The spleen is normal.

Conclusion: fluid is still determined anterior to the stomach and between the pancreas and the stomach.

6. Ultrasound of the abdominal organs, date 10/30/12

Liver not enlarged, choledoch 4 mm. Stones in the gallbladder were not detected. The pancreas is enlarged, head 30 mm, body 23 mm, tail 25 mm. An area of ​​reduced echogenicity (33.6x19.6 mm) is determined anterior to the head. The spleen is normal.

7. ECG, date 08.10.12

Conclusion: severe sinus tachycardia, heart rate 125 beats/min, EOS horizontal. Violation of intraventricular conduction. Changes in the myocardium of the inferior LV wall

8. Computed tomography of the abdominal cavity. Date 11.10.12

The choledochus is expanded throughout to 1.1 cm. A calculus is not excluded in the distal section, the gallbladder is enlarged, contains layered calculi, the pancreas has a thickened head with fuzzy contours, there is infiltration and effusion upward from the head of the gland, between the stomach and the transverse colon.

Conclusion: Signs of chronic calculous cholecystitis. Cholangioectasia. There is a calculus in the distal part of the common bile duct. Acute pancreatitis without signs of destruction.

9. ERCP. Date 12.1012.

Retrograde contrasted choledochus and partially intrahepatic ducts and gallbladder. Stones in the bladder. Air in the hepatic ducts (due to the procedure). The choledochus is expanded to 1.5 cm in diameter, the outlet section is narrowed. In the lumen of the common bile duct, there are calculi, the largest 1.1x1.3 cm, after the end of the procedure, the calculus is not visible. Ultrasound guidance is recommended.

10. Endoscopic papillosphincterotomy. Date 12.10.12

Choledocholithiasis. EPST was performed to correct biliary hypertension. Signs of biliary cirrhosis.

Appointments: bed rest, cold on the stomach, hunger, drinking is allowed. amylase tests.

Clinical diagnosis

ZhKB. Chronic calculous cholecystitis, exacerbation. Complicated severe pancreatitis of biliary origin. Aseptic pancreatic necrosis with a primary lesion of the right type. Condition after percutaneous transhepatic drainage. Incomplete external pancreatic fistula.

Substantiation of the diagnosis

1) Based on the patient's complaints of constant moderate pain in the epigastric region along the pancreas, radiating to the right hypochondrium, having a constant pressing, aching character, nausea, dry mouth; discomfort in the right hypochondrium along the course of the gallbladder, nausea based on data from an objective study: the skin and mucous membranes are pale, the tongue is dry, lined with a white coating, the gallbladder is dense and painful on palpation;

2) Based on the history of the disease, which revealed the appearance of pain against the background of general well-being

3) Based on objective research data:

With superficial palpation of the abdomen, there is severe pain in the epigastric region along the pancreas and in the projection of the gallbladder (the angle at the intersection of the right costal arch and the outer edge of the rectus abdominis muscle). Obraztsov-Murphy's positive symptoms are noted (sharp pain when the hand is inserted into the right hypochondrium at the height of inspiration), Ortner's symptom (pain when the edge of the hand is tapped along the right costal arch), Kera's symptom (increased pain on inspiration during palpation of the gallbladder with the thumb along the same technique as for palpation of the liver).

4) based on laboratory data: leukocytosis with a shift to the left, elevated ESR (28 mm/h), blood diastasis 1700 U/l, urine diastasis 491 U/l, amylase in the drainage discharge 1112.0, pancreatic amylase in the blood 319 ,2.

5) taking into account the data of the instrumental examination:

Ultrasound: revealed a change in the contours of the gallbladder, thickening of the walls, the presence of stones up to 1.2 cm in size localized in the body of the gallbladder; uneven, fuzzy contours of the enlarged pancreas, its increased echogenicity, a fluid accumulation was found in front of the stomach and between the stomach and pancreas.

CT scan of the abdominal organs: the choledochus is expanded throughout to 1.1 cm. A calculus is not excluded in the distal section, the gallbladder is enlarged, contains layered calculi, the pancreas has a thickened head with fuzzy contours, there is infiltration and effusion upward from the head of the gland, between stomach and transverse colon;

ERCP: there are calculi in the bladder, the choledochus is enlarged, there are calculi in the lumen of the choledochus, after the end of the procedure the stones are not visible

Differential diagnosis

Differential diagnosis is carried out with biliary dyskinesia, duodenal ulcer. Biliary dyskinesia unite a variety of functional disorders of the biliary system, in which clinical signs of organic lesions (inflammation or stone formation) are not established.

The development of dyskinesia is based on violations of the complex innervation of the sphincters of the biliary tract.

Clinically, biliary dyskinesias are characterized by recurrent biliary colic, which can be significant and simulate gallstone disease. Pain attacks often occur due with strong emotions and other and neuropsychiatric moments less often they appear under the influence of significant physical exertion.

With biliary dyskinesia, the connection between the onset of pain syndrome and negative emotions, the absence of tension in the abdominal wall during biliary colic, negative results of duodenal sounding, and mainly data from contrast cholecystography, which does not reveal calculi, stand out more clearly.

Peptic ulcer of the duodenum intestines is a chronic relapsing disease characterized by seasonal exacerbations with the appearance of an ulcer in the duodenal wall.

Pain is the leading symptom of peptic ulcer disease. Her distinctive features: connection with food intake, its quality and quantity, seasonality, increasing character, decrease after vomiting, food intake, application of heat, anticholinergics. Differential diagnostic features that make it possible to distinguish atypical pain in peptic ulcer disease, in particular in duodenal ulcer, from cholelithiasis, are a characteristic anamnesis, detection with deep palpation according to V. P. Obraztsov a dense, sharply painful cord corresponding to a spastically reduced pyloroduodenal region. X-ray examination provides significant data for the diagnosis.

Seizures calculous cholecystitis is not always easy to differentiate from acute cholecystitis or chronic exacerbation. In acute cholecystitis, the onset of an attack is usually not as violent as in cholelithiasis, and despite severe pain, patients are calmer. Attacks of hepatic colic should also be differentiated from colic of another origin: renal, intestinal, appendicular. With renal colic, unlike hepatic, pain usually radiates to the inguinal region, at the time of an attack of pain, pollakiuria is noted. Attacks of hepatic colic can in rare cases be caused by helminths (hepatic fluke, ascaris, etc.), the passage of blood clots through the biliary tract. Of decisive importance in all cases is cholecystography and cholegraphy. Obstructive jaundice caused by obstruction of the common bile duct by a stone, in some cases, especially in the elderly, is difficult to differentiate from jaundice resulting from compression or germination of the duct by a tumor of the pancreatic head. In the last. case, usually immediately before the onset of jaundice, a typical attack of biliary colic is not observed, there is a general exhaustion of the patient, a sharp increase in ESR is characteristic.

Etiology and pathogenesis

Gallstone disease should be considered as a metabolic disorder, and the formation of stones as a consequence of these disorders. The question of the mechanism of stone formation has not been finally resolved. Currently, in the development of cholelithiasis, three main factors are attached importance: metabolic disorders, infection and stagnation of bile. As a rule, gallstones do not contain calcium bilirubinate, cholesterol monohydrate, amorphous or crystalline calcium carbonate, but the content of these substances in gallstones varies from person to person. Great importance has a violation of cholesterol metabolism with hypercholesterolemia, which is observed in atherosclerosis, diabetes, obesity and some other diseases, since most stones contain cholesterol. It has been proven that hypercholesterolemia and the resulting increase in the concentration of cholesterol in bile contribute to the formation of cholesterol stones. Just as naturally (in 30--70% of cases), the formation of pigment stones is observed when bile is oversaturated with bilirubin as a result of increased hemolytic processes in the body. It has now been proven that overproduction and impaired bile flow are of decisive importance in the formation of stones.

Auxiliary, the infectious factor is important, if the initial formation of cholesterol and pigment stones can occur in sterile bile, then the addition of infection contributes to their further growth. With inflammation of the gallbladder, the release of protein-rich exudate from its wall further disrupts the colloidal and chemical composition bile, resulting in the loss of bilirubin, cholesterol and calcium and the formation of mixed stones, typical of calculous cholecystitis.

Prerequisites for the formation of stones create stagnation of bile, as it increases the content of cholesterol and bilirubin in bile (10-12 times), disorders of the neurohumoral regulation of the contractile function of the gallbladder and ducts (dyskinesia), as well as anatomical changes in the biliary system (bends, scars, adhesions). Other causes include pregnancy, persistent constipation, prolapse of internal organs, sedentary lifestyle. Hereditary factors are of some importance.

Acute pancreatitis is a degenerative-inflammatory lesion of the pancreas caused by various causes. The disease is based on autolysis of pancreatic tissues due to exposure to its own activated proteolytic enzymes- this is an enzymatic-chemical process, to which an infection can join for the second time.

Activation of enzymes can contribute to:

1. Increased pressure in the biliary tract - biliary hypertension (considered the main cause), which may be based on diseases of the gallbladder, which in 63% of cases are accompanied by spasm of the sphincter of Oddi, especially the calculous process - gallbladder stones and choledochus, strictures of the choledochus. In the presence of a common ampulla of the choledochus and the Wirsung duct, bile is thrown into the latter - biliary reflux, causing the activation of trypsinogen and its transition to trypsin, followed by autolysis of the pancreatic tissue. Pancreatitis of this genesis, in accordance with the decision of the conference in Kyiv in 1988, is called biliary pancreatitis, they account for about 70% of all acute pancreatitis. All other pancreatitis are referred to as idiopathic.

2. Stagnation in the upper parts of the digestive tract; gastritis, duodenitis, duodenostasis contribute to insufficiency of Oddi's sphincter and the casting of intestinal contents containing enzymes into the pancreatic duct - duodenal reflux, which also contributes to the activation of trypsinogen with the development of acute pancreatitis - the theory of duodenal reflux.

3. Metabolic disorders, especially fat, overeating - lead to disturbances in the system of proteolytic enzymes and their inhibitors. With age, the activity of inhibitors decreases, which, with provocative moments (overeating, diet violations), leads to the activation of trypsinogen - a metabolic theory. Hence the name acute pancreatitis - "glutton's disease", the disease of "well-fed life". During the war years, there were almost no pancreatitis during the Leningrad blockade; they appeared after the blockade was broken, primarily among the suppliers, head. canteens.

4. Circulatory disorders in the gland, ischemia of the organ, most often due to atherosclerotic changes, hypertension, diabetes, alcoholism, also lead to imbalance in the "enzyme-inhibitor" system. In pregnant women, circulatory disorders may be associated with the pressure of the pregnant uterus on the vessels - the vascular theory.

5. Food and chemical poisoning - alcohol, acids, phosphorus, medicines(tetracycline series, steroid hormones), helminthic invasions also contribute to the activation of enzymes - a toxic theory.

6. General and local infection, especially of the abdominal cavity - biliary tract, with peptic ulcer, especially with penetration of ulcers - an infectious theory.

7. Injuries of the pancreas - directly with wounds, blunt trauma, as well as operating (during operations on the duodenum, biliary tract) can also lead to acute pancreatitis. The frequency of postoperative pancreatitis reaches 6-12% - a traumatic theory.

8. Allergic theory - has a particularly large number of supporters in recent years. When using various serological reactions in patients with acute pancreatitis, many researchers found antibodies to the pancreas in the blood serum, which indicates autoaggression.

In practice, there is a combination of several of the listed causes with the prevalence of any, so acute pancreatitis should be considered a polyetiological disease.

Under the influence of one of the above reasons or a combination of them, the activation of the pancreas' own enzymes and its autolysis occurs; surrounding tissues are gradually involved in the process. When the acinar cells of the pancreas are damaged, the cellular enzyme cytokinase begins to be released, which also contributes to the activation of trypsinogen. The outcome of activation depends on the state of the "trypsin-inhibitor" system. If the body's compensatory reactions are sufficient, activated trypsin is neutralized by inhibitors and the balance in the system is restored; with a significant number of cytokinases or insufficient reactivity of the body, an inhibitor deficiency occurs and the balance is disturbed, self-digestion of the pancreas occurs, and acute pancreatitis develops.

The process proceeds in two phases:

1st phase trypsin (proteolytic) - activated trypsin, which penetrates from the tubules of the parenchyma of the gland and kallikrein is released, which causes pancreatic edema and hemorrhage, adsorbed by venous blood and lymph, enters the blood stream, causes an increase in the permeability of the vascular wall, diapedesis, stasis of erythrocytes and their death with the release of cytokinases. Edema and hemorrhagic impregnation of the gland develops,

Phase 2 - lipase - with the progression of the process, lipases are released from the destroyed cells of the gland, which are activated by trypsin and bile acids. Lipases emulsify fats, cause fatty necrosis of the pancreas (fat breaks down into glycerol and fatty acid, which form soaps with calcium, and crystals with tyrosine, which causes the appearance of spots of fatty or "stearic necrosis".

These changes in the gland itself and its surrounding tissues lead to "chemical", aseptic, enzymatic peritonitis (in 67% of cases).

When an infection is attached, abscess formation occurs, purulent fusion of the gland tissue and peritonitis becomes purulent. Severe forms of acute pancreatitis are accompanied by symptoms of multiple organ failure.

Plan and methods of treatment

I. Conservative treatment:

1. Diet number 0 and then #5

2. Mode: bed.

3. Creation of mental and physical rest for the patient.

5.Drug therapy:

1. Glucose 5% -400ml IV, drip

2. Novocain 0.25-200ml

3. Ringer's solution 1000 ml IV, drip

4. Antispasmodics - to relieve and reduce pain

Rep: Sol. No-spa 2% - 2 ml

D.S. 2 ml intramuscularly

5. Antiallergic therapy:

Rp: Sol. Dimedroli 2% - 2 ml

D.S. 2 ml intramuscularly, 1 time per day.

6. Metronidazole IV 3 times a day

7. Gentamicin 80 mg 2 times a day IM

8. Promedol

9. Ciprofloxacin 100.0 2 times a day IM

10. Nefotaxin 1.0 3 times a day IM

II. Surgery

24.10.12 was held h sharp transhepatic drainage of a liquid formation in the abdominal cavity under ultrasound control, under local anesthesia.

Preoperative epicrisis

On October 24, 2012, a patient Kateneva Genrietta Egenievna, 79 years old, was prepared for surgery, she was admitted to the CS-1 on emergency indications on October 6, 2012 with a clinic of acute pancreatitis, choledocholithiasis. She received conservative therapy. The diagnosis was made on the basis of complaints of constant aching, pressing pains in the epigastric region, which appeared against the background of general well-being, episodes of nausea and vomiting after an error in the diet. On palpation, pain in the abdomen in the region of the right hypochondrium

ERCP was performed, as a result of which calculi were found in the gallbladder and in the lumen of the common choledochus, the largest 1.1x1.3 cm, after the end of the procedure, the calculus was not visible.

Ultrasound of the abdominal cavity in dynamics determined an increase in liquid formation in the right hypochondrium.

The diagnosis is a relative indication for surgery.

Of the comorbidities, duodenal ulcer is noted.

The operation is planned.

Planned percutaneous drainage of the abdominal cavity under ultrasound guidance, under local anesthesia. Blood type I(0), Rh+.

Consent received. Surgeon Sokolov operates.

Operation protocol

Date 10/24/12. Start 13:30. end 13:50

Operation: percutaneous drainage of the liquid formation of the abdominal cavity.

Type of anesthesia: local anesthesia Sol/ Novocaini 0.5%-20 ml.

Description of the operation: a liquid formation was drained according to Ivshin with a 12F catheter (polyethylene). Received 100 ml of brownish liquid. 1 drain installed. An aseptic bandage was applied.

Observation diaries

Complaints of moderate pain in the right hypochondrium. The condition is satisfactory. Consciousness is clear. Breathing is carried out in all fields. t=36.6. Pulse 80 beats/min, BP 120/70. The abdomen is soft, painful in the right hypochondrium and at the site of surgical intervention. There are no peritoneal symptoms. Physiological functions are normal. Through drainage 50 ml of clear discharge. .

Complaints of pain in the right hypochondrium. The condition is satisfactory. Consciousness is clear. Breathing is carried out in all fields. t=36.7. Pulse 80 beats/min, BP 120/70. The abdomen is soft, painful in the right hypochondrium. There are no peritoneal symptoms. Physiological functions are normal. Through drainage 50 ml of clear discharge.

Complaints of moderate pain in the right hypochondrium. The condition is satisfactory. Consciousness is clear. Breathing is carried out in all fields. t=36.8. Pulse 80 beats/min, BP 120/70. The abdomen is soft, painful in the right hypochondrium. There are no peritoneal symptoms. Physiological functions are normal. Through drainage 50 ml of clear discharge.

Continue conservative therapy.

Pain in the abdomen decreased, the condition is satisfactory. Consciousness is clear. Breathing is carried out in all fields. t=36.6. Pulse 80 beats/min, BP 120/70. The abdomen is soft, painful in the epigastrium and at the site of surgical intervention. There are no peritoneal symptoms. Physiological functions are normal. Through drainage 100 ml of clear discharge.

Clinical blood test

Component under study	Result
red blood cells	4.01*10 12/l
Average volume of erythrocytes
Hematocrit
platelets	290*10 9/l
Platelet index
Leukocytes	5.7*10 9/l	3.5 - 10 9/l
Hemoglobin
The average concentration of hemoglobin in erythrocytes		310.0 - 380.0 g/l
stab
Segmented
Lymphocytes
Monocytes

Blood chemistry

Component under study	Result
Alkaline phosphatase
Bilirubin total	6.3 µmol/l	8.55-20.52 µmol/l
	5.88 mmol/l	3.9-6.4mmol/l
total protein
Urea	3.75 mmol/l	2.5-8.3 mmol/l
Creatinine	44 µmol/l	44-106 µmol/l
Cholesterol	6.92 mmol/l	0.0-5.2 mmol/l

General urine analysis

Quantity - 200 ml.

Specific gravity - 1020

Color - straw-yellow, transparent.

Protein - no

Sugar, ketone bodies were not detected.

Sediment microscopy:

The epithelium is squamous -3-4 in the field of view.

Leukocytes -13-15 in the field of view.

Erythrocytes -1-2

Cylinders are not.

Khimich research:

pH alkaline

stercobilin - no

no blood

Continue conservative therapy

Ultrasound of the abdominal organs, date 10/30/12

The liver is not enlarged, choledochus is 4 mm. Stones in the gallbladder were not detected. The pancreas is enlarged, head 30 mm, body 23 mm, tail 25 mm. An area of ​​reduced echogenicity (33.6x19.6 mm) is determined anterior to the head. The spleen is normal

Continue conservative therapy

There are no complaints. The condition is closer to satisfactory. Consciousness is clear. Breathing is carried out in all fields. t=36.5. Pulse 76 beats/min, BP 120/70. The abdomen is soft, painful in the epigastrium and at the site of surgical intervention. There are no peritoneal symptoms. Physiological functions are normal. Drainage cloudy discharge.

Continue conservative therapy

1.11.12.

Complaints of moderate pain in the right hypochondrium. The condition is satisfactory. Consciousness is clear.

Continue conservative therapy

Complaints of pain in the right abdomen, the intensity of which increased, t = 36.6 °C. The condition is closer to satisfactory. Breathing is carried out in all fields. t=36.6. Pulse 76 beats/min, BP 120/60. The abdomen is soft, painful in the right sections. There are no peritoneal symptoms. Physiological functions are normal. Drainage 20 ml cloudy discharge.

Diagnosis: Acute pancreatitis. Pancreatic necrosis. Condition after external drainage of fluid accumulation.

3.1 1.12

Complaints of moderate pain in the right hypochondrium. The condition is satisfactory. Consciousness is clear. Breathing is carried out in all fields. t=36.6. Pulse 80 beats/min, BP 120/70. The abdomen is soft, painful in the right hypochondrium. There are no peritoneal symptoms. Physiological functions are normal. Through drainage 50 ml of clear discharge.

Continue conservative therapy

Breathing is carried out in all fields. t=36.6. Pulse 80 beats/min, BP 120/70. The abdomen is soft, painful in the right hypochondrium. There are no peritoneal symptoms. Physiological functions are normal. Through drainage 50 ml of clear discharge.

Continue conservative therapy

Complaints of moderate pain in the right hypochondrium. The condition is satisfactory. Consciousness is clear. Breathing is carried out in all fields. t=36.6. Pulse 80 beats/min, BP 120/70. The abdomen is soft, painful in the right hypochondrium. There are no peritoneal symptoms. Physiological functions are normal. Through drainage 50 ml of clear discharge.

Continue conservative therapy

The condition is closer to satisfactory. There are no complaints. Breathing is carried out in all fields. t=36.6. Pulse 76 beats/min, BP 130/70. The abdomen is soft, painful in the epigastrium and at the site of surgical intervention.

There are no peritoneal symptoms. Physiological functions are normal. On a drainage scanty transparent discharge.

Continue conservative therapy

Forecast

The prognosis for health is doubtful, due to morphological changes in the pancreas. Given the positive dynamics in the patient's condition, the prognosis for life and working capacity is favorable.

Epicrisis

Patient Kateneva G.E., is hospitalized in XO-1 CB No. 8 from 06.10.12 with a diagnosis of cholelithiasis. Chronic calculous cholecystitis, exacerbation. Complicated severe pancreatitis of biliary origin. Aseptic pancreatic necrosis with a primary lesion of the right type. Condition after percutaneous transhepatic drainage. Complications: Choledocholithiasis. mechanical jaundice. Acute fluid accumulation in the head of the pancreas. Incomplete external pancreatic fistula.

The diagnosis was confirmed by laboratory and instrumental studies. Receives treatment: antispasmodics, anticholinergics, antibiotics, regulators of water and electrolyte balance, infusion therapy. Against the background of ongoing therapeutic measures, the patient's condition improved (pain in the epigastric region and right hypochondrium decreased, nausea disappeared).

24.10.12. a planned operation was performed: percutaneous transhepatic drainage of a liquid formation in the abdominal cavity, under ultrasound control. The postoperative period proceeds without features.

It is planned to continue drug therapy. Recommended:

1. strict adherence to the diet

2. spa treatment

3. periodically conduct a course of antispasmodics

4. without exacerbation, to improve digestion, taking drugs containing pancreatic enzymes (festal, mezim-forte).

Posted on Аllbest.ru

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Page 1

General information about the patient:

FULL NAME. Eltsova Valentina Avtonomovna.

Retired since 1989.

Home address: Lunacharskogo Ave., 1, building 2, apt. 13.

Delivered by ambulance.

Diagnosis when sent to the hospital: cholelithiasis, chronic calculous cholecystitis, exacerbation.

At the time of examination, the patient complains of a feeling of heaviness in the right hypochondrium, weakness, fatigue, sweating, headache, dizziness, and shortness of breath at rest.

At the time of admission, the patient complained of a feeling of heaviness in the right hypochondrium after taking fatty and spicy foods, weakness, fatigue, dizziness.

He considers himself ill for forty years, during which, at different intervals, he notes bouts of pain in the right hypochondrium, which he associates with errors in nutrition (reception of fried and fatty foods). The pains were aching. The patient during pain attacks took festal, no-shpu and cinorizine. I visited the clinic, where a sparing diet was recommended. In September 1988, she was hospitalized for acute cholecystitis-pancreatitis. Was carried out conservative treatment.

The onset of this attack is acute. The patient associates the onset of an attack with a violation of the diet (fatty, fried foods). In the evening, the patient felt heaviness and aching, pulling pains in the right hypochondrium. The patient also felt nausea. At night, nausea was accompanied by repeated vomiting. Taking drugs - no effect. In the morning the patient called an ambulance and was taken to the hospital.

Born in Leningrad in 1934. only child in family. She grew and developed normally. She studied at the College of Cinematographers. After graduating from a technical school and until retirement, she worked in her specialty as a cameraman. There were no occupational hazards.

Of the past diseases, he notes: colds, chicken pox, suffers from hypertension 2 stages. There were no strokes or heart attacks. Viral hepatitis, sexually transmitted diseases, tuberculosis denies.

Past operations: resection of 2/3 of the stomach (perforated stomach ulcer) - 1987, ovariectomy - 1981.

There were no injections, blood transfusions in the last 6 months. Contact with infectious patients denies. She did not travel outside of St. Petersburg. Emotional-nervous-psychic anamnesis is not burdened. Gynecological history: menstruation from the age of 15 was painless, moderate, menopause occurred at the age of 53, there was no childbirth. Pregnancies - 6, miscarriages - 6. Bad habits - smoking (1 pack per day). Allergic anamnesis is free, drug intolerance is not noted. Heredity is burdened by the father - peptic ulcer of the stomach. Insurance history: pensioner. She lives alone in a separate apartment. No kids. Eats satisfactorily, in the fresh air is often.

General inspection

Condition of moderate severity, position in bed - forced, in an inclined position. Consciousness is clear.

Body temperature 36.5 C.

The skin is pale pink in color, elastic. Humidity is maintained. Nails and hair unchanged.

Tissue turgor is slightly reduced.

Visible mucous membranes and sclera are clean, normal in color, without rashes, moisture is preserved.

The layer of subcutaneous fat is enlarged, unevenly distributed. Painless on palpation Edema - absent on the legs. With a constant horizontal position, they practically do not form.

Peripheral lymph nodes:

Occipital, behind the ear, submandibular, submental, anterior cervical, posterior cervical, supraclavicular, subclavian, cubital, popliteal - not palpable. Axillary, inguinal, submandibular palpable: single, 7-8 mm., elastic, painless, not soldered to the skin and surrounding tissues. The skin over them is not changed.

The muscular system is developed sufficiently, evenly, symmetrically. Muscle tone is preserved, strength is slightly reduced. On palpation, the muscles were painless, no indurations were found. The shape of the head, chest, spine and limbs is normal.

The bones are painless on palpation and percussion. Their form has not been changed.

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