1. Put the preliminary diagnosis.

2. Make a plan of inspection.

3. Make a treatment plan.

Answer

1. In the absence of subjective and objective data, witness sponding the presence of liver disease in a patient, but at the same time HBsAg detection and a slight increase in ALT, should think about chronic viral hepatitis B.

2. Repeat the complete biochemical analysis of blood. Explore the full range of blood markers of hepatitis B virus (HBsAg, HBeAg, anti-HBe, anti-HBc IgM anti-HBc IgGDNA ). Perform ultrasound of the abdomen. If any signs of portal hypertension recommend esophagogastroduodenoscopy, to clarify the activity and stage of the disease - or needle biopsy of the liver elastography.

3. With the ever-higher levels of ALT, AST, detecting HBeAg index of liver fibrosis, and 2 more advisable course of antiviral therapy (including those without a liver biopsy).

hepatitis C

Task 1

The patient, 34 years, economist, physician directed clinic consul-commutative hepatic center with a diagnosis of "hepatitis C". It was examined ambulatory before surgery on the right ovarian cyst. Feeling sick is good, no complaints. Serum antibodies to the HCV, ALT - 78 U / L, AST - 26 IU / L, bilirubin - 12 mmol / l.

From the epidemiological history: 8 years ago urgent deliveries complicated atonic uterine bleeding, for she which received blood transfusion.

Objectively: skin is clean, no jaundice, "spider veins" Noperipheral edema can not be detected. The belly of the usual form, is not increased in the volume, palpation soft, painless in all departments. The liver is enlarged, its edge protrudes from under the right hypochondrium to 2 cm in the midclavicular line, elastic consistency. The spleen is not enlarged. The lungs and heart without pathology.

1. Put the preliminary diagnosis. Justify.

2. Does the patient's hospitalization is necessary?

3. What studies it is advisable to carry out?

4. Map out a plan of treatment.

Answer

1. The preliminary diagnosis: chronic hepatitis C. This is illustrated by laboratory tests (detection of antibodies to the HCV and the increase in ALT levels), enlarged liver and epidemiological history (transfusion 8 years ago) at the satisfactory state of health of the patient-enforcement.

2. Hospitalization of the patient is not practical.

3. The need to conduct a general analysis of blood, a blood serum test for the detection of RNA HCV determining the genotype of the virus, the detection of genotype 1 - quantitative study RNA HCV, total protein and protein fractions, ultrasound of the abdomen, holding a needle biopsy of the liver.

4. Tactics antiviral therapy will be determined by the results of liver biopsy, genotyping and other laboratory tests. Before a decision on the appointment of antiviral drugs it is advisable to use hepatic and antioxidants (Silimar * Tykveol *, vitamin E, and others.)

Task 2

The patient, 49 years old, was admitted to the infectious hospital with suspected acute viral hepatitis. 2 days ago she was ill, acutely, after eating fatty food nausea will be, was 2-fold vomiting, felt discomfort in the right upper quadrant, succeeding shortly painful sensations in the field. The pain was severe, continuous, radiating to the right lumbar region. On the morning of hospitalization drew attention to the change in urine color (dark color) and yellowness of the sclera. She came to the clinic, inspected the local doctor and sent for hospitalization.

On examination: complains of constant nausea and aching pain in the right upper quadrant of moderate intensity. It notes the poor tolerability of fatty, spicy and fried foods during the last 3 years. Enhanced power (body mass index 32), the skin is clean, clear skin yellowness and sclera, "spider veins" Not present, peripheral edema is not detected. Abdomen increased in volume due to the subcutaneous fat, palpation soft, painful in the right upper quadrant. Symptoms of peritoneal irritation there. The liver is slightly increased, its edge protrudes from under the right hypochondrium to 2 cm in the midclavicular line, elastic texture, edge of the liver sensitive to palpation. The spleen is not enlarged.

In the study of blood parameters revealed increased levels of bilirubin (free fraction - 26 mmol / l related - 84 mmol / l) and the level of enzymes: AST - 250 IU / L, ALT - 436 IU / L (normal up to 40 U / L) AP - 970 IU / l (normal 300). Leukocytes - 14.7 x 109 / L, stab - 11% segmented - 77% monocytes - 4% lymphocytes - 8%. Markers of viral hepatitis were found.

1. Put the preliminary diagnosis, justify it. Is there any evidence for the presence of viral hepatitis? Is it advisable to hospitalization of patients in hospital infection?

2. Map out a plan of additional examination and management of patients.

Answer

1. Diagnosis: exacerbation of chronic calculous cholecystitis, obstructive jaundice, obesity III degree. The emergence of pain and dyspeptic syndromes after errors in diet, the data history of poor tolerability of fatty, spicy and fried foods in recent years, dark-colored urine and jaundice after the pain, leukocytosis with a left shift, increased ALT and AST activity, not exceeding 10 standards, the increase in the level of alkaline phosphatase, the lack of markers of viral hepatitis, overweight testify in favor of this diagnosis. Clinical and laboratory and epidemiological data for viral hepatitis do not exist. Hospitalization of patients in hospital infection in a typical clinical picture of obstructive jaundice, which developed against the background of an exacerbation of chronic cholecystitis, impractical.

2. The ultrasound of the abdomen, the surgeon's advice to decide on the transfer of the patient in the surgical hospital.

Task 3

The patient, 43 years old, a plasma donor. At the next blood donation first observed increased activity of enzymes cytolysis (AST - 450 IU / L, ALT - 1286 IU / L) at the level of bilirubin 18 umol / L. HBsAg and anti-HCV were detected. Sent to the Hepatology Centre with suspected viral hepatitis, with complaints of weakness and a small decrease in appetite.

OBJECTIVE: condition is satisfactory, the skin of normal color, no jaundice. The belly of the usual form, is not increased in volume, palpation soft, painless in all departments. The liver is enlarged, protruding from under the costal edge of 2 cm. The spleen percussion slightly increased. urine and stool color is not changed. Changes from other organs and systems there.

Markers of viral hepatitis A, B and C are not detected: anti-HAV IgM - negative, anti-HCV - negative, HBsAg - negative, anti-HBc IgM - negative.