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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3256_Библиотеки_им_академика_М_И_Перельмана
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III group of disability is determined in connection with the limi-
tation of the ability to self-service, movement, work activity of the
1st stage, patients with chronic hepatitis II stage of a slowly progres-
sive course with exacerbations lasting 4-6 weeks, occurring 2-3 times
a year, the activity of the process of the 1st stage. , dysfunction of the
liver of mild, less often moderate, and patients with chronic hepatitis
IV stage. (liver cirrhosis, stage A according to Child-Pugh) with the
same frequency and duration of exacerbations, the degree of activity
and severity of liver dysfunctions, with portal hypertension stage II,
mild hypersplenism syndrome without hemorrhagic manifestations,
working in contraindicated types and working conditions and in this
regard, those in need of transfer to work in another, accessible profes-
sion, or a signicant decrease in the volume of production activities.
The II disability group is determined in connection with the limi-
tation of the ability to self-service, movement, work activity of the II
degree, patients with chronic hepatitis II and III stages of intermit-
tent recurrent course with frequent (up to 4-5 times a year) prolonged
(6-8 weeks) exacerbations , activity of II degree, dysfunction of the
liver of moderate or severe degree, severe extrahepatic (systemic)
manifestations, as well as patients with chronic hepatitis IV. (Child-
Pugh stage B liver cirrhosis) with the same frequency and duration
of exacerbations, the degree of activity and severity of liver dysfunc-
tions, with grade III portal hypertension, severe manifestations of hy-
persplenism syndrome (anemia, leukopenia, thrombocytopenia). In
some cases, work may be recommended in specially created condi-
tions (at home).
I group of disability is determined in connection with the limita-
tion of the ability to self-service, movement, work activity III stage,
patients with chronic hepatitis III stage of a rapidly progressive, con-
tinuously recurrent course, with activity III stage, the development of
severe liver failure, systemic lesions with severe dysfunction of the
pancreas , kidneys, other organs, exhaustion, as well as patients with
chronic hepatitis IV Art. (stage C liver cirrhosis according to Child -
Pugh), with activity II – III stage, severe liver failure, portal hyperten-
sion stage IV, intoxication and encephalopathy.
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212
Dispensary observation. With CVH, it is necessary to undergo
dispensary observation at least twice a year for life. With an exac-
erbation of the disease, hospitalization is advisable. After discharge,
clinical, biochemical and serological indicators must be monitored,
the frequency of the examination will be determined by the doctor. If
necessary, the patient can be relieved of heavy physical exertion (by
decision of the VC); business trips and work on the night shift are
also not recommended. Students can be exempted from physical edu-
cation, participation in competitions, physical activity. If the routine
examination reveals HBsAg or anti-HCV, it is necessary to undergo
an in-depth clinical and laboratory examination. Further observation
is carried out after 3 months and then 2 times a year during the entire
period of detection of HBsAg, anti-HCV.
When HBsAg is re-detected 3, 6 and 12 months after its initial
detection, as well as in the presence of minimal clinical and biochemi-
cal changes, the diagnosis of “Chronic viral hepatitis” is established.
Carriers of HBsAg are removed from the register when the HB-
sAg test is 3-fold negative with an interval of 3 months within one
year. Deregistration of carriers of anti-HCV is carried out individu-
ally after an in-depth clinical and laboratory examination with the nor-
malization of immunological, serological and biochemical parameters
within 1 year. The most rational is the examination for markers of viral
hepatitis (antibodies to hepatitis), which signicantly accelerates the
detection of active forms of viral hepatitis.
Indications for consultation of narrow specialists: examination
by an ophthalmologist - to exclude vasculitis and other pathologies
of vision; examination by an endocrinologist - to exclude autoim-
mune thyroiditis, hypothyroidism, hyperthyroidism; examination of
the surgeon - with pain syndrome, gastrointestinal bleeding, ascites,
anasarca; examination by a transplant surgeon - for a possible liver
transplant; examination by a gastroenterologist - in case of malnutri-
tion, concomitant diseases of the gastrointestinal tract; examination
by a hematologist - with a decrease in peripheral blood indicators;
examination by an oncologist - if a neoplastic process is suspected.
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213
Clinical case No. 7
1. What is the preliminary diagnosis?
Preliminary diagnosis: chronic pancreatitis.
2. What additional tests would you recommend to the patient,
and what are the expected results?
Laboratory research
Basic (mandatory) diagnostic examinations: general blood test,
general urine analysis and urine diastase, blood glucose determina-
tion, microreaction, determination of blood group, Rh factor, bilirubin
and fractions, AST and ALT, creatinine, urea, alkaline phosphatase,
amylase and lipase blood (recommendation level A), coagulogram
(prothrombin index, clotting time, bleeding time, brinogen, APTT),
LDH, total protein and protein fraction. Dynamic ultrasound of the
abdominal organs, EFGDS, CT of the abdominal organs (if indicated).
Additional diagnostic examinations: indicators of acid-base (ba-
sic) blood state (if indicated); blood gases (if indicated); survey ra-
diography of the abdominal organs; plain chest x-ray; intraoperative
cholangiography; retrograde cholangiopancreaticography; dynamic
CT of the abdominal organs (rst examination at 1 week of illness and
subsequent CT if indicated) (recommendation level B); MRI of the
abdominal organs (if indicated); diagnostic laparocentesis; diagnostic
laparoscopy; bacteriological examination, consultation of specialists
in the presence of concomitant pathology
Traditionally used in clinical practice is the determination of amy-
lase in urine. As an additional test, amylase is determined in peritoneal
exudate during laparoscopy. The Wolgemut method (determination of
the total amylolytic activity of urine), according to which the normal
level of amylase in the urine is 16–64 units, makes it possible to detect
various levels of its increase - from 128 to 1024 units. and more. This
test is not informative enough in relation to pancreatic alpha-amylase,
since it reects the total nature of glycolytic enzymes that are con-
tained in the biological environment sent for research.
The study of the spectrum of hepatic enzymes in patients with
CP, complicated by the development of hepatocellular failure, which
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214
is most characteristic of pancreatic necrosis, reveals a high level of
ALT and ASAT. A signicant increase in the concentration of LDH
indicates large-scale damage to pancreatic cells.
It must be remembered that similar laboratory changes are char-
acteristic of acute myocardial infarction, extensive intestinal infarc-
tion, hepatitis of various etiologies.
With biliary pancreatitis due to choledocholithiasis, as well as
with the development of a predominant lesion of the pancreas head,
the formation of cholestasis syndrome is characteristic, which is ex-
pressed in hyperbilirubinemia with a predominance of the direct
(bound) fraction of bilirubin, high activity of AST and ALP.
The pronounced changes in the water-electrolyte balance are
evidenced by: hemoconcentration, deciency of potassium, sodium,
calcium. With extensive forms of pancreatic necrosis, a decrease in
calcium concentration is due to its deposition in foci of steatonecrosis
in the form of bile salts.
Additional laboratory methods that are used in the complex of the
diagnostic program in patients with pancreatitis are the determination
of the concentration of C-reactive protein and procalcitonin (PCT)
in the blood. C-reactive protein, along with haptoglobin and alpha-
1-antitrypsin, is a protein of the acute phase of inammation. In acute
pancreatitis, its concentration in the blood reects the severity of the
inammatory and necrotic process, which makes it possible to use this
indicator as a diagnostic test to dierentiate, on the one hand, edema-
tous pancreatitis and pancreatic necrosis, on the other hand, sterile
and infected pancreatic necrosis. Thus, the level of C-reactive protein
above 120 mg / l testies in favor of necrotic lesions of the pancreas,
while an increase in its concentration in the dynamics of the disease
by more than 30% from the initial level, together with other clinical
and laboratory data, reliably conrms the development of pancreato-
genic infection.
Instrumental research. At the present stage of the development
of imaging methods in surgery, a complex of instrumental techniques
is used to improve the diagnosis of CP and its various forms, includ-
ing ultrasound data, laparoscopy, CT, the results of transcutaneous
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punctures of necrosis zones of dierent localization under the control
of ultrasound and CT, endoscopic retrograde cholangiopancreatogra-
phy (ERCP). Based on the results of these examination methods in the
dynamics of the disease and treatment, a clear verication of the clini-
cal and morphological forms of acute pancreatitis is achieved.
Ultrasound is an aordable and minimally invasive method of
visual diagnostics in comparison with other instrumental methods,
which makes it possible to recommend it as a screening method for
suspected acute pancreatitis. Ultrasound provides an assessment of the
state of the pancreas, biliary system (cholecystolithiasis, signs of bili-
ary hypertension), abdominal (aneurysm of the abdominal aorta) and
pleural cavities. Informativeness of ultrasound in acute pancreatitis
is 40–86%, but it does not always help to reliably verify the clini-
cal and morphological form of acute pancreatitis, to characterize the
state of the retroperitoneal tissue. The disadvantages of the method are
low information content in the development of gastrointestinal pare-
sis, which is observed in 25-30% of cases of acute pancreatitis. The
leading ultrasound signs of acute pancreatitis are: an increase in the
size of the head, body and tail of the pancreas, the heterogeneity of its
echostructure and uneven contours, visualization of uid formations
of various sizes in the parapancreatic zone and abdominal cavity. In-
volvement of the technique for measuring hemodynamic parameters
in the visceral vessels, the density of the pancreas and retroperitoneal
tissue makes it possible to increase the specicity, sensitivity and ac-
curacy of ultrasound in pancreatonecrosis. The diagnostic value of
ultrasound in dierentiating interstitial pancreatitis and pancreatic ne-
crosis is signicantly lower than that of CT.
CT is currently the most sensitive method of visual examination
(“gold diagnostic standard”), providing versatile information about
the state of the pancreas and various areas of the retroperitoneal space.
In the comparative aspect of visual diagnostics, CT, in contrast to
ultrasound, makes it possible to clearly dierentiate dense necrotic
masses (necrotic phlegmon) from uid formations (abscess, pseudo-
cyst) of various localization, to provide information about their in-
terposition, involvement in the inammatory-necrotic process of BV,
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the underlying vascular structures and departments of the gastrointes-
tinal tract. CT should be performed in the dynamics of treatment of
a patient with pancreatic necrosis to obtain the necessary information
about the prevalence of the pathological process and the development
of its complicated forms.
Laparoscopy is an important and widely available diagnostic and
treatment method, especially when pancreatic necrosis is suspected.
Modern endovideoscopic equipment makes it possible to expand the
range of diagnostic and therapeutic procedures performed in patients
with acute pancreatitis. The high diagnostic information content of
video laparoscopy makes it one of the traditional methods for diag-
nosing acute pancreatitis and peritonitis of unknown etiology. Lapa-
roscopy is indicated for: patients with peritoneal syndrome, including
those with ultrasound signs of free uid in the abdominal cavity; if
necessary, dierentiation of the diagnosis with other diseases of the
abdominal organs. If it is impossible to conduct laparoscopy, laparo-
centesis is shown, which partially solves the tasks.
Endoscopic retrograde cholangiopancreatography (ERCP) and
endoscopic papillosphinterotomy (EPST) are indicated for acute bili-
ary pancreatitis with obstructive jaundice syndrome (choledocholi-
thiasis, TOX stricture), taking into account the ultrasound imaging of
the dilated common bile duct within 72 hours. Patients with signs of
cholangitis, EPST or stenting of the common bile duct should be per-
formed urgently.
The method of magnetic resonance imaging (MRI) has been de-
veloping in emergency pancreatology in recent years. The advantages
of MRI over CT in pancreatitis are the better dierentiation of solid
and liquid formations localized in the pancreas and retroperitoneal tis-
sue, and less radiation exposure to the medical sta. With all the ad-
vantages of diagnostic research, the diculties of transporting severe
patients and the high cost of research limit the widespread use of CT
and MRI in the practice of surgical hospitals and intensive care units.
X-ray diagnostic methods have not lost their signicance in the
complex of methods for examining patients with pancreatitis and,
rst of all, in the dierential diagnosis of acute pancreatitis from
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perforation of a hollow organ and mechanical intestinal obstruction.
On plain X-ray of the abdominal organs, nonspecic symptoms of
acute pancreatitis are: pneumatization of the transverse colon, the
presence of small-sized uid levels in the small intestine. Chest X-ray
reveals pleural eusion and basal atelectasis, elevation of the dome
of the diaphragm, most often synchronous with the defeat of the cor-
responding region of the retroperitoneal tissue.
EGD is used to exclude gastroduodenal ulcers and to identify in-
direct signs of acute pancreatitis.
3. What is the patient’s management?
Drug treatment: basic complex of intensive care (treatment of
mild acute pancreatitis); pain relief with non-narcotic analgesics; intra-
muscular or intravenous administration of antispasmodics (drotaverin,
etc.), antispasmodics (metamizole sodium and its analogs) and anti-
cholinergics.
Infusion therapy focused on the relief of water-electrolyte disor-
ders in a volume of 40 ml per 1 kg of the patient’s body weight. Forced
diuresis, session with the achievement of the rate of diuresis of at least
2 ml / kg of the patient’s body weight / h during the rst 24–48 hours
of the session. The use of antibiotic prophylaxis for mild acute pan-
creatitis does not reduce the incidence of septic complications. Early
antisecretory and antienzyme therapy.
Specialized treatment (indicated for patients with severe pancre-
atitis in addition to the basic complex):
1. Antisecretory therapy (the optimal period is the rst three days
of the disease): - the drug of choice - Octreotide 100 μg × 3 r subcu-
taneously; - reserve drugs - Famotidine (40 mg × 2 p iv); Fluorouracil
(5% 5 ml IV). In large-scale randomized trials, the eectiveness of
octreotide has not been proven.
2. Infusion therapy with rheologically active drugs (dextrans, hy-
droxyethylated starch - (up to 50 ml / kg / day, etc.).
3. Reimbursement of plasma losses (correction of water-electro-
lyte, protein losses, etc.: a total of at least 40 ml of the corresponding
infusion funds per 1 kg of body weight; the ratio of colloidal and crys-
talloid solutions is 1: 4).
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4. Pain relief - prolonged epidural analgesia with local anesthetics
(lidocaine, bupivacaine, ropivacaine), if necessary - with the addition
of narcotic analgesics (morphine, fentanyl) 1-2 times a day.
5. Antibacterial chemotherapy - parenteral administration of anti-
biotics tropic to the pancreas. The advantages for the prevention of pu-
rulent complications are: antimicrobial agent from the group of uoro-
quinolones (peoxacin) + metronidazole; cephalosporins of the third
generation, preferably with a dual mechanism of excretion - urine-bile
- Ceftriaxone or cefoperazone + metronidazole; IV generation cepha-
losporins (Cefepime) or Cefoperazone + [Sulbactam] + metronida-
zole; drugs of the carbapenem group. The duration of the course of
prophylactic antibiotic therapy should not exceed 7-14 days. In case
of infected pancreatic necrosis, antibiotics are prescribed based on the
results of a ne-needle aspiration biopsy (puncture), taking into ac-
count the sensitivity of the ora.
The eectiveness of prophylactic antibiotic therapy in mild pan-
creatitis and selective decontamination of the gastrointestinal tract has
not been proven, therefore, it cannot be recommended for the treat-
ment of OP.
Nutritional support. When restoring the function of the gastro-
intestinal tract in patients with pancreatic necrosis, it is advisable to
carry out enteral nutrition (nutritional mixtures), which is carried out
through a nasojejunal probe, installed distal to the Treitz ligament en-
doscopically, or during surgery.
Detoxication: plasmapheresis (hardware or discrete) in a vol-
ume of at least 50% of the patient’s plasma volume and replacement
with donor plasma; in the course there are 2-3 sessions with an inter-
val of 24-48 hours.
4. Medical and labor expertise. Dispensary observation.
Temporary disability. Criteria and indicative terms of VUT. VUT
criteria: exacerbation of the process (recurrent form); severe pain syn-
drome (painful form); excretory and endocrine insuciency (diges-
tive dysfunction); severity of complications.
Estimated terms of VUT: with conservative treatment, depending
on the stage - from 2 weeks to 3 months; during the surgical treatment
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219
of VUT depends on the method and scope of the operation, its eec-
tiveness, the degree of insuciency of the gland function and diges-
tion.
After eective surgical treatment (elimination of obstruction of
the biliary tract, normalization of the outow of pancreatic secretion,
elimination of pseudocyst) without dysfunction of the pancreas or
mild degree of disruption of VUT - up to 10 months. In all other cases
(eective surgical treatment, but pronounced or pronounced dysfunc-
tion of the pancreas or digestive function; ineective surgical treat-
ment) VUT - up to 4 months, followed by referral to MSEC.
Permanent disability. Moderate limitation of vital activity is de-
termined by patients with stage II of the disease, patients after surgical
treatment without complications, without impairment or with a mild
degree of impairment of the pancreas functions in contraindicated pro-
fessions and the impossibility of rational employment without a de-
crease in qualications or a decrease in the volume of production ac-
tivity (disabled persons of group III).
A pronounced limitation of vital activity is determined by patients
with stage III of the disease, with frequent repeated bleeding and with
the failure of intensive care, patients after surgical treatment with ex-
ternal biliary and pancreatic stulas, patients with large pseudocysts
(II group of disability).
A pronounced limitation of vital activity is determined by patients
with pronounced exocrine and endocrine insuciency, with a pro-
nounced dysfunction of digestion, cachexia, alimentary dystrophy
with the need for constant outside care (I group of disability).
Dispensary observation. Patients with CP are subject to dispensa-
ry observation. With a mild course, a second examination and exami-
nation in an outpatient setting is carried out twice a year. Appointed
2 times a year: clinical blood test; general urine analysis; determina-
tion of amylase, lipase in blood serum; coprogram.
Ultrasound of the biliary system, pancreas once a year. With
a course of moderate severity, examinations are carried out 3 times
a year, consultation of a gastroenterologist is required.
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220
Appointed 2 times a year and in case of exacerbation: clinical
blood test; general urine analysis; determination of glucose, amylase,
lipase, bilirubin, transaminase in blood serum; coprogram.
Therapy is carried out “on demand”: the patient himself, when
complaints appear, takes enzyme, antisecretory drugs, antispasmodics
against the background of adherence to the diet.
In severe CP, the patient is observed by the local therapist and
gastroenterologist 4-6 times a year. The volume of research is the
same as in CP of moderate severity, as well as the analysis of daily
urine for sugar.
In case of persistent remission - examination by a therapist once
a year, by a gastroenterologist - according to indications.
Clinical case No. 8
1. What is the preliminary diagnosis?
Preliminary diagnosis: Chronic viral hepatitis D, high activity,
stage F4 (METAVIR). Liver cirrhosis, decompensation, severity class
C (Child-Pugh). Portal hypertension. Ascites. Hepatic encephalopathy
of the II degree. Varicose veins of the esophagus.
2. What additional tests would you recommend to the patient,
and what are the expected results?
Laboratory research
KLA: anemia (often B12-folate-decient), pancytopenia - a com-
bination of erythrocytopenia, leukopenia and thrombocytopenia (with
hypersplenism syndrome), ESR acceleration.
OAM: increased bilirubin, urobilin in hepatic jaundice.
Biochemical blood test: hepatocellular failure syndrome - a de-
crease in the level of total protein, albumin, prothrombin, brinogen,
cholesterol; intrahepatic cholestasis syndrome - increased levels of
bilirubin, cholesterol, alkaline phosphatase (ALP), γ-glutamyl trans-
peptidase (γ-GTP), hypercholesterolemia, hypertriglyceridemia;
syndrome of mesenchymal inammation - hyper-γ-globulinemia, in-
creased thymol test; cytolysis syndrome - an increase in serum as-
partate aminotransferase (ASAT), alanine aminotransferase (ALT),
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