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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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381
then for six months, one injection is carried out once every two weeks.
The B12 level in the blood will reach the desired value in about 1.5-
2 months, the neurological symptoms will disappear in six months. In
case of intestinal malabsorption, lifelong treatment is required. With
timely initiation of therapy, the prognosis is favorable.
4. Medical and labor expertise. Dispensary observation.
Disability criteria.
III group of disability is determined in case of moderate iron de-
ciency anemia with rare exacerbations and prolonged remissions,
moderate dysfunctions of the nervous and cardiovascular systems,
leading to a limitation of the ability to work, self-service grade 1, in
the presence of contraindicated factors in the nature and conditions of
work and cases of the need for rational employment with a decrease in
qualications or a decrease in the volume of production activities, if
rational employment is impossible on the conclusion of medical com-
mission.
Group II disability is dened in severe iron deciency anemia
with frequent relapses and short-term incomplete remissions, severe
HF, damage to the nervous system (funicular myelosis), ineective-
ness of treatment, leading to a limitation of the ability to self-service,
movement, learning, labor activity II Art. In some cases, patients can
work in specially created conditions, at home, taking into account pro-
fessional skills.
Disability group I is dened in severe deciency anemia, with
frequent relapses, pernicious crises and severe neurological disorders
(paralysis of the lower extremities, pelvic disorders), ineectiveness
of treatment, leading to a limitation of the ability to self-care, move-
ment, and work activity of the III degree.
Dispensary observation. Persons with latent iron deciency are
not subject to medical examination. If IDA is a consequence of some
pathological process, then special dispensary observation is not re-
quired, because patients have already been included in the underlying
disease. The local doctor is monitoring the patients with IDA. The
frequency of observations in the acute period is 1-2 times a year.
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382
Primary prevention of IDA is reduced to the timely diagnosis and
treatment of diseases accompanied by blood loss. These are diseases
such as hemorrhoids, peptic ulcer disease, erosive gastritis, ulcerative
colitis, uterine bromatosis, hiatal hernia, intestinal tumors.
Secondary prevention of iron deciency is indicated for those
patients in whom the cause leading to iron deciency is irreparable.
Patients with an enteral iron deciency anemia should be advised to
take iron supplements for 7-10 days each month. With heavy men-
struation, iron supplements must be used monthly for the same period.
The beginning of their application should be timed to coincide with
the appearance of menstruation.
Prophylactic use of iron preparations is necessary for donors who
constantly donate blood, for pregnant women in cases where pregnan-
cy was preceded by heavy menstruation or when pregnancies follow
one after another.
Clinical case No. 6
1. What is the preliminary diagnosis?
B12-deciency anemia, grade 2.
The diagnosis was made on the basis of complaints of general
weakness, fatigue, palpitations, shortness of breath on exertion, nau-
sea, belching, heaviness in the epigastrium; anamnesis data: signs of
gastric dyspepsia for about 15 years; objective examination data: the
general condition of moderate severity, the skin is pale, slight yellow-
ness of the skin and sclera of a lemon shade, the face is puy, the bor-
ders of the heart are expanded to the left by 1 cm, the tones are slightly
mued, the tongue is crimson, the papillae are smoothed, the liver is
+1 cm; laboratory examination: hemoglobin - 70 g / l, erythrocytes -
2.9 × 1012 / l, CP - 1.3, reticulocytes - 0.1%, leukocyte formula with-
out features, ESR - 30 mm / h, MCV - 70 . The blood smear revealed
hyper segmented neutrophils, Jolly’s little bodies and Kebot’s rings.
2. What additional tests would you recommend to the patient, and
what are the expected results?
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383
¾ Study of serum iron: the norm for men is 0.6–1.7 mg / l (13–
30 µmol / l); the norm for women is 0.5–1.6 mg / l (12–25 µmol / l).
With IDA, serum iron is reduced. Determination of serum ferritin is
the most sensitive and specic laboratory sign of iron deciency: the
norm for men is 20–350 μg / l; the norm for women is 10–150 mcg / l.
With IDA, a decrease in serum ferritin levels.
¾ Total serum iron-binding capacity (TIBC) reects the degree
of serum starvation. The norm is 30–85 μmol / l. With IDA, the value
of the indicator increases. The latent iron-binding capacity of serum
is on average 50.2 μmol. With IDA, the indicator increases. The last
two tests are rarely used in clinical practice. The ratio of the iron index
to the total iron-binding capacity of serum, expressed as a percentage,
reects the degree of saturation of transferrin with iron (the norm is
16-50%). The IDA is characterized by a decrease in this indicator.
Desferal test (desferal complexone, which binds iron and excretes
it in the urine). After intravenous administration of desferal in the
urine, 0.8 to 1.2 mg of iron is normally excreted. With IDA - 0.2 mg
and below.
¾ In the punctate of the bone marrow, as a rule, without
signicant changes: some irritation of the red sprout (with bleeding);
a decrease in the number of sideroblasts; determining the cause of
iron deciency.
Instrumental research
According to indications, ECG, ultrasound of internal organs,
EGDS / colonoscopy are performed.
3. What is the patient’s management?
It is necessary to determine the cause of anemia: nutritional de-
ciency - insucient intake of not only meat, but also dairy prod-
ucts and eggs, impaired absorption of vitamin B12 from food into the
blood, absorption of vitamin B12 by microorganisms (intestinal bacte-
ria or worms - round or atworms), increased intake of vitamin B12 -
any malignant tumor, increased secretion of vitamin B12 - insucient
binding to blood proteins, liver and kidney disease. This requires the
following studies: myelogram; - biochemical blood test for ALT, AST,
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384
bilirubin. creatinine, CRP; - determination of vitamin B12 by radio-
immunological method; - determination of the level of folic acid in
the peripheral blood; - determination of methylmalonic and propionic
acids in urine and / or blood.
Treatment: intramuscular injections of vitamin B12 at a dosage of
500 mcg 2 times a day (Cyanocobalamin, Oxycobalamin, Adenosyl-
cobalamin).
4. Medical and labor expertise. Dispensary observation.
Disability criteria.
III group of disability is determined in case of moderate iron de-
ciency anemia with rare exacerbations and prolonged remissions,
moderate dysfunctions of the nervous and cardiovascular systems,
leading to a limitation of the ability to work, self-service grade 1, in
the presence of contraindicated factors in the nature and conditions of
work and cases of the need for rational employment with a decrease in
qualications or a decrease in the volume of production activities, if
rational employment is impossible on the conclusion of medical com-
mission.
Group II disability is dened in severe iron deciency anemia
with frequent relapses and short-term incomplete remissions, severe
HF, damage to the nervous system (funicular myelosis), ineective-
ness of treatment, leading to a limitation of the ability to self-service,
movement, learning, labor activity II Art. In some cases, patients can
work in specially created conditions, at home, taking into account pro-
fessional skills.
Disability group I is dened in severe deciency anemia, with
frequent relapses, pernicious crises and severe neurological disorders
(paralysis of the lower extremities, pelvic disorders), ineectiveness
of treatment, leading to a limitation of the ability to self-care, move-
ment, and work activity of the III degree.
Dispensary observation. After achieving remission, the patient
should remain under the supervision of a family doctor, since it is
important to diagnose the possibility of relapse in time. With the
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385
outpatient use of these drugs, it is mandatory to control the blood com-
position 2 times a week.
Primary prevention is reduced to the timely diagnosis and treat-
ment of diseases accompanied by blood loss. These are diseases such
as hemorrhoids, peptic ulcer disease, erosive gastritis, ulcerative coli-
tis, uterine bromatosis, hiatal hernia, intestinal tumors.
Secondary prophylaxis is indicated for those patients in whom
the cause leading to iron deciency is irreparable. Timely treatment
of chronic diseases is necessary. With heavy menstruation, iron sup-
plements must be used monthly for the same period. The beginning
of their application should be timed to coincide with the appearance
of menstruation.
Clinical case No. 7
1. What is the preliminary diagnosis?
Aplastic anemia, severe.
2. What additional tests would you recommend to the patient,
and what are the expected results?
Biochemical blood test: total protein, albumin, total bilirubin, di-
rect bilirubin, creatinine, urea, ALaT, ASaT, glucose, C-reactive pro-
tein, alkaline phosphatase, studies of iron metabolism, vitamin B12
and folic acid content, coagulogram, blood group and rhesus -factor.
ELISA for markers of viral hepatitis and HIV markers.
Immunological tests (immunophenotyping to exclude paroxys-
mal nocturnal hemoglobinuria).
Histological examination of the trepan biopsy of the iliac crest.
Instrumental studies according to indications: ECG; Ultrasound
of the abdominal organs (liver, spleen, pancreas, gallbladder, lymph
nodes, kidneys), in women - small pelvis; chest x-ray.
3. What is the patient’s management?
The treatment of aplastic anemia is a very dicult task. 1. Treat-
ment with glucocorticoids is eective if it is caused by autoimmune
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386
mechanisms, the appearance of antibodies against blood cells. 2.
Treatment with anabolic drugs stimulates hematopoiesis. 3. Treatment
with androgens has an anabolic eect and stimulates erythropoiesis. 4.
Treatment with cytostatics (immunosuppressants) - is prescribed only
if there is no eect from other methods of treatment in patients with an
autoimmune form, including with partial red cell aplasia. 5. Splenec-
tomy 6. Treatment with anti-lymphocytic globulin is recommended
in the absence of eect from splenectomy and other methods of treat-
ment. 7. Treatment with cyclosporine. Cyclosporin A (sandimmune)
has an immunosuppressive eect, selectively inhibits the transcription
of the interleukin-2 gene in T-lymphocytes, inhibits the production
of interferon Gam and tumor necrosis factor alpha. 8. Bone marrow
transplant. The main and only pathogenetic method for the treatment
of aplastic anemia, which makes it possible to count on saving the pa-
tient’s life, is bone marrow transplantation from a compatible donor.
If it is impossible to nd a donor, palliative therapy is performed. It
is built according to the following scheme. The immunosuppressant
ciclosporin A is used as a basic drug. In patients with mild aplastic
anemia, the use of this drug allows us to count on success in a number
of cases. In addition, the use of cyclosporin A is also advisable from
the standpoint that glucocorticoids, androgens and antilymphocytic
globulin can improve the state of hematopoiesis in patients with mild
aplastic anemia, but, however, the increased risk of subsequent devel-
opment of clonal bone marrow diseases should be taken into account.
The use of cyclosporin A minimizes this risk. It should also be noted
that in some patients with mild aplastic anemia who have overcome
the 6-month survival threshold, spontaneous improvement may oc-
cur even if they have not received any immunosuppressive therapy.
The eect of immunosuppressive therapy in patients with severe and
extremely severe aplastic anemia is questionable. 9. Treatment with
stimulating factors or myeloid growth factors - these are glycoproteins
that stimulate the proliferation and dierentiation of dierent types
of hematopoietic progenitor cells. 10. Transfusion of erythrocytes in-
dications are severe anemia, signs of cerebral hypoxia, hemodynam-
ic disturbances.
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387
All patients with aplastic anemia require replacement transfusion
therapy with erythrocyte and / or platelet mass. The volume of transfu-
sion therapy is determined by the parameters of peripheral blood and
clinical manifestations of the disease. In addition, antibacterial and
mycostatic therapy is carried out to prevent or treat infectious com-
plications.
4. Medical and labor expertise. Dispensary observation.
Indications for referral to the ITU Bureau.
y The need for rational employment of patients with aplastic anemia;
y II, III, IV stages of the disease;
y transformation into a malignant form;
y the progression of the disease or its complications.
The required minimum examination for referral to the ITU bu-
reau: blood test, platelets and reticulocytes, myelogram, Immuno-
phenotyping of blood lymphocytes, total protein and fractions, chest
x-ray, ultrasound of the abdominal organs, consultation with an oph-
thalmologist and neurologist, a hematologist’s conclusion.
Disability criteria.
III group of disability is established for patients with I, II stages
of the disease, in the absence of its progression, limitation of the abil-
ity to work, I st., With the aim of rational employment, retraining or
reducing the amount of work performed.
II group of disability is established for patients with III-VI stage
of the disease, requiring specic treatment, due to severe dysfunc-
tions, limitation of the ability to self-service, independent movement
of the 2nd degree, labor activity of the 2nd degree. Labor is available
only in specially created conditions.
Group I disability is established for patients with stage IV disease
in the presence of severe anemia and thrombocytopenia, persistent se-
vere infection and complications; with the rapid progression of the
disease, transformation into a malignant form, limitation of the ability
to self-service 3 tbsp., independent movement of 3 tbsp., and an unfa-
vorable prognosis.
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388
Dispensary observation. Patients with a conrmed diagnosis of
aplastic anemia are under dynamic observation by a hematologist-
oncologist. A blood test is performed every 1-3-6 months. Supportive
cytostatic therapy is prescribed if necessary.
Prophylaxis. To date, there is no specic prophylaxis for aplas-
tic anemia.
Clinical case No. 8
1. What is the preliminary diagnosis?
Chronic post hemorrhagic iron deciency anemia of grade 3.
2. What additional tests would you recommend to the patient,
and what are the expected results?
The study of serum iron: the norm for men - 0.6-1.7 mg / l (13-
30 μmol / l); the norm for women is 0.5–1.6 mg / l (12–25 µmol / l).
With IDA, serum iron is reduced. Determination of serum ferritin is
the most sensitive and specic laboratory sign of iron deciency: the
norm for men is 20–350 μg / l; the norm for women is 10–150 mcg / l.
With IDA, a decrease in serum ferritin levels.
Total serum iron-binding capacity (TIBC) reects the degree of
serum starvation. The norm is 30–85 μmol / l. With IDA, the value of
the indicator increases. The latent iron-binding capacity of serum (cal-
culated by the formula OZhSS - Fe serum) is on average 50.2 μmol.
With IDA, the indicator increases. The last two tests are rarely used in
clinical practice. The ratio of the iron index to the total iron-binding
capacity of serum, expressed as a percentage, reects the degree of
saturation of transferrin with iron (the norm is 16-50%). The IDA is
characterized by a decrease in this indicator. Desferal test (desferal
complexone, which binds iron and excretes it in the urine). After in-
travenous administration of desferal in the urine, 0.8 to 1.2 mg of iron
is normally excreted. With IDA - 0.2 mg and below.
In the punctate of the bone marrow, as a rule, without signicant
changes: some irritation of the red sprout (with bleeding); a decrease
in the number of sideroblasts; determining the cause of iron deciency.
t.me/medicina_free
389
Instrumental research
According to indications, ECG, ultrasound of internal organs,
EGDS / colonoscopy are performed.
3. What is the patient’s management?
IDA treatment in women of reproductive age
1. Women of reproductive age with moderate (mild or moderate)
IDA should receive iron supplements at the rate of 120 mg of elemen-
tal iron per day (60 mg x 2 times a day) for 3 months.
2. For women of reproductive age with severe IDA, iron prepara-
tions are prescribed at the rate of 180 mg of elemental iron per day (60
mg x 3 times a day) for 3 months.
3. Folic acid for women of reproductive age with IDA is pre-
scribed in a dose of 0.4 mg daily for 3 months.
4. Iron preparations are best taken between meals, it is advisable
to drink it with juice or boiled water. It is forbidden to drink tea, cof-
fee.
5. Evaluation of adherence to therapy is carried out 14 days after
the start of treatment.
6. 4 weeks after the start of IDA treatment, Hb should be re-de-
termined. If there is a positive result on the prescribed treatment (any
increase in Hb compared to the baseline level before the start of treat-
ment), then the treatment should be continued for another 2 months.
The general course of treatment with iron is 3 months, followed by
a transition to a prophylactic regimen of weekly supplementation
(see above).
7. In the absence of a positive result from the treatment (an in-
crease in hemoglobin compared with baseline values before the ap-
pointment of iron preparations), the doctor should determine the possi-
ble reasons for the lack of improvement: insucient dose of elemental
iron, irregular intake or refusal to take iron supplements. If errors in
treatment are excluded, the woman should be referred to a therapist or
hematologist (in TB, OB) to clarify the form of anemia.
8. Women with severe anemia (Hb below 70 g / l) should be con-
sulted by a physician or hematologist.
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390
9. In severely emaciated women, anemia is often severe. How-
ever, oral iron therapy should not be started until the woman’s appetite
is restored and she begins to gain weight. If appetite or weight is not
normalized, the patient should be referred to a hematologist for fur-
ther examination.
4. Medical and labor expertise. Dispensary observation.
Disability criteria.
III group of disability is determined in case of moderate iron de-
ciency anemia with rare exacerbations and prolonged remissions,
moderate dysfunctions of the nervous and cardiovascular systems,
leading to a limitation of the ability to work, self-service grade 1, in
the presence of contraindicated factors in the nature and conditions of
work and cases of the need for rational employment with a decrease in
qualications or a decrease in the volume of production activities, if
rational employment is impossible on the conclusion of medical com-
mission.
Group II disability is dened in severe iron deciency anemia
with frequent relapses and short-term incomplete remissions, severe
HF, damage to the nervous system (funicular myelosis), ineective-
ness of treatment, leading to a limitation of the ability to self-service,
movement, learning, labor activity II Art. In some cases, patients can
work in specially created conditions, at home, taking into account pro-
fessional skills.
Disability group I is dened in severe deciency anemia, with
frequent relapses, pernicious crises and severe neurological disorders
(paralysis of the lower extremities, pelvic disorders), ineectiveness
of treatment, leading to a limitation of the ability to self-care, move-
ment, and work activity of the III degree.
Dispensary observation.
Timely diagnosis of the disease, prescription of pathogenetic
therapy, exclusion of risk factors, anti-relapse treatment. Social and
labor rehabilitation includes training and retraining of patients with
an accessible profession, the denition of a work recommendation,
rational employment, and the preparation of an IPR.
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