Chronic Diseases Of The Stomach And Pancreatobiliary System Flashcards
Chronic pain syndrome of the abdominal cavity
The main manifestation of chronic recurrent diseases of the abdominal cavity organs.
In pain syndrome of the abdominal cavity it is necessary to carry out thorough analysis of the clinical course of the disease and purposeful additional examination. Analysis of the obtained findings allows making of clinical diagnosis of disease and determination of therapeutic approach.
The most common causes of chronic pain syndrome in the upper part of the abdominal cavity are peptic ulcer (gastroduodenal ulcer), cholelithiasis (gallstone disease), chronic obstructive pancreatitis, pancreatic cyst.
Definition: Peptic ulcer
A disease characterized by making of ulcer in the gastric or duodenal mucous membranes as a result of disorders of the gastric secretion regulating mechanisms with imbalance between acidpeptic factors activity and body defences that arise, as a rule, on the background of Helicobacter pylori infection of the gastric mucosa and local trophic disturbances.
Clinic-statistical classification of peptic ulcer:
ICD10 Diagnosis Code К25 Gastric ulcer
Layout of clinical diagnosis: { ІX } ulcer {of the LX of the stomach}} {КX,} {complicated by ОX}
Endoscopic manifestations of the disease:
I1 active
I2 cicatrizing
I3 cicatrized
Ulcer localization: L1 cardiac part L2 subcardiac part L3 lesser curvature L4 greater curvature L5 pyloric part
Occurrence of Helicobacter pylori invasion:
К1 associated with Нр
К2 unassociated with Нр
Complications:
О1 acute bleeding {ІX}
O2 {ТX degree} blood loss /hemorrhage
O3 perforation {in stage FX}
O4 perforation and bleeding
O5 penetration {into LX}
L1 pancreas
L2 lesser omentum
L3 liver
O6 {IX } stenosis
ICD10 Diagnosis Code К26 Duodenal ulcer
Formula of clinical diagnosis. {IX} ulcer {of LX,} {КX,}{complicated by OX}
Endoscopic manifestations of the disease:
I1 Active
I2 Cicatrizing
I3 Cicatrized
Localization:
L1 duodenal bulb
L2 postbulbar part of the duodenum
Occurrence of Helicobacter pylori invasion:
К1 associated with Нр
К2 unassociated with Нр
Complications:
O1 acute bleeding {IX}
O2 {TX degree} blood loss /hemorrhage
O3 perforation {in stage FX}
O4 perforation and bleeding
O5 penetration {into LX }
(L1) pancreas
(L2) hepatoduodenal ligament
(L3) gallbladder
(L4) liver
(L5) large intestine
O6 {IX} stenosis
I1 compensated
I2 subcompensated
I3 decompensated
Clinical signs and symptoms of peptic ulcer:
А) Patient complaints:
• in duodenal localization of the ulcer:
- pain symptoms;
- intensifies at night and in 2-3 hours after eating;
- is relieved by eating;
- dyspeptic symptoms;
- eructation;
- susceptibility to constipations;
• in gastric localization of the ulcer:
- pain syndrome;
- food provokes pain syndrome increase;
- dyspepsia;
- nausea;
- low appetite;
- vomiting;
• in penetration of the ulcer:
- intensive pain symptoms;
- is not relieved by food intake.
B) Anamnesis is characterized by periodic exacerbation (spring, autumn).
C) Objective findings:
а) physical examination:
- tongue is covered with white-yellow fur;
- carious teeth, parodontosis;
- abdomen is visually unchanged;
b) palpation:
- moderate pain at superficial palpation in epigastric area or to the right of and above the navel;
- slight resistance of the abdominal wall muscles;
- positive Mendel’s sign(aggravation of the local tenderness at balloting palpation in projection of the ulcer);
c) percussion and auscultation are not enough informative.
Making of preliminary diagnosis on the basis of clinical findings.
(Peptic ulcer)
Preliminary diagnosis is made on the basis of patient complaints, anamnesis and objective signs of the disease that confirmed by physical examination methods.
To confirm or specify diagnosis the diagnostic program is made; the program includes the methods of examination that influence on the diagnosis clarification and on identification of the signs of complicated course of disease.
Diagnosis:
Peptic ulcer
A) Detection of the ulcerous defect:
gastroduodenoscopy, in the case of finding a gastric, with biopsy material sampling from 5- 7 zones at the ulcer edge and round the ulcer
B) Determination of the secretary activity of the gastric mucous membrane:
- parietal рН-metry;
- рНmonitoring of gastric secretion.
C) Investigation to detect Helicobacter pylori infection:
• Breath test (the “gold standard” of Helicobacter pylori infection diagnostics):
Concept of the method:
- in the presence of Helicobacter pylori in the stomach, enzymatic hydrolysis of 13Сurea
occurs with 13С02 release.
Procedure:
- a patient is given two special plastic bags marked with figures “0 min” and “30 min”; capacity of each bag is 1300 ml;
- at first the patient exhales into the bag “0 min”, after that drinks 75g of 13С-urea diluted
with 200 ml of orange juice;
- in 30 min the patient exhales into the other bag;
contents of both bags are tested with the help of infrared spectroscope;
- the difference in 13С02 concentration between the first and second bags exceeding 3,5%
evidences of active Helicobacter pylori infection occurrence;
• Rapid urease test (CLOtest):
Concept of the method:
- an indicator changes its colour when interacts with biopsy sample of gastric mucosa containing Helicobacter pylori.
Procedure:
- during endoscopic examination of the stomach two biopsy samples are taken from its antral part;
- both samples are immersed into the standardized indicator solution;
- in the presence of Helicobacter pylori in the gastric mucous membrane, the enzyme urease, which breaks down urea into ammonia and carbon dioxide, arises in the solution;
- ammonia changes рН medium to alkaline (pH shifts to right), as a consequence the solution changes in color;
- colour change into red during 1 hour evidences of considerable infection of gastric mucosa (Н.р. +++), colour change during 2 hours evidences of moderate infection (Н.р. ++) and colour change during longer period of time evidences of negative result of
Helicobacter pylori infection in the mucous of the stomach.
• Morphological investigation of the gastric mucous membrane (cytological and histological methods):
Concept of the method:
- detection of Helicobacter pylori in the preparations coloured in accordance with special techniques.
Cytological procedure: - in cytological (bacterioscopic) method of examination two biopsy samples, obtained at endoscopic examination, are rolled on the microscope slide to receive a touch smear;
- the smear is fixed and stained according to Pappenheim or other dyes for gram-negative bacteria (for instance, according to Giemsa-Romanovsky staining);
- thereafter, the preparation is investigated by means of the light microscope:
- degree of contamination of the gastric mucous membrane is determined as low (less
than 20 microorganisms per highpower field), moderate (20-50 microorganisms per highpower field) and high (50 and above microorganisms per high-power field).
Histological procedure:
- 4-5 biopsy samples are fixed to perform histological examination, thereafter they are to be subject to standard histological processing with subsequent addition into paraffin;
- received paraffin sections are stained with toluidine blue;
- degree of the bacterial contamination of the gastric mucous membrane is assessed in the course of examination of the histological specimens.
D) In the presence of clinical signs of gastric emptying disorder or in case of impossibility of gastroscopy, roentgen examination is prescribed:
- diagnostic roentgen examination of the stomach and duodenum
- roentgen examination of barium contrast passage from the stomach (hourly determination of barium contrast discharge from the stomach).
Differential diagnosis of peptic ulcer:
A) With diseases of the esophagus and stomach:
- gastroesophageal reflux disease;
- chronic gastritis.
B) With diseases of the gallbladder and extrahepatic bile ducts:
- chronic calculous cholecystitis;
- choledocholithiasis.
C) With diseases of the pancreas:
- chronic pancreatitis.
D) With diseases of the large intestine:
- irritable bowel syndrome
Treatment of peptic ulcer:
А) Therapeutic treatment is the main type of the treatment of noncomplicated peptic ulcer:
а) a goal of the peptic ulcer therapy is to cure a patient by means of etiologic treatment performance
and elimination the main cause, first of all Helicobacter pylori infection;
b) tasks of peptic ulcer therapy:
- rapid relief of symptoms of the disease;
- to attain cicatrization of the ulcer;
- prevention of relapses and complications;
- good tolerability of the drugs and safety of the treatment;
c) ways of the goal achievement:
- steady decrease of gastric secretion to the level of рН > 3,0 during 1618 hours per day;
- in the presence of Helicobacter pylori infection in the stomach performance of eradication therapy;
- strict adherence to the treatment regimen;
- simplification of drugs dosage regimen;
d) regimens of peptic ulcer drug therapy:
• (triple therapy during 7-14 days):
- proton pump inhibitors (omeprazole 40 mg, lansoprazole 60 mg, pantoprazole 80 mg, rabeprazole 20 mg, esomeprazole 40 mg) 2 times per day;
- anti-Helicobacter pylori therapy in the presence of Helicobacter pylori infection in the stomach (clarithromycin 500 mg 2 times + amoxicillin 1000 mg 2 times per day or clarithromycin 500 mg 2 times + metronidazole 500 mg 2 times per day);
• rescue quadruple therapy 7 days:
- proton pump inhibitors (omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole) 2 times per day;
- drug containing colloidal bismuth 120 mg 4 times per day;
- metronidazole 500 mg 3 times per day;
- tetracycline 500 mg 4 times per day;
• after completion of the combination eradication therapy or in case of absence of Helicobacter pylori infection in the stomach, treatment with antisecretory preparations is performed:
- proton pump inhibitors (drugs of choice);
- histamine Н2receptor antagonists (H2blockers) for 4-6 weeks in duodenal ulcers and 6-8 weeks in gastric ulcer;
- cytoprotective agents (Denol).
B) Surgical treatment:
а) Indications for surgery in accordance with relative indicators:
- large penetrating ulcers;
- ulcers of the greater curvature of the stomach;
- metaplasia of the mucous membrane of the stomach in case of gastric localization of the ulcer;
- ineffectiveness of adequate pharmacotherapy during 6-8 weeks in duodenal ulcer localization and 8-10 weeks in gastric ulcer localization;
- undergone bleedings and perforation of the ulcer in the setting of the ineffective
pharmacotherapy.
b) Choice of surgical method:
• in the ulcer localized in the duodenum:
- operation of choice – conservative surgery in extent of selective proximal vagotomy with or without drainage of the stomach;
- truncal subdiaphragmatic vagotomy with gastric drainage or with sparing stomach resection;
• in the ulcer localized in the stomach:
- pylorus-preserving (suprapiloric) stomach resection;
- Billroth I stomach resection.
Post-surgical treatment:
Peptic ulcer
For the first 2-5 days the treatment is carried out in intensive care department, subsequently - in surgical department.
Work capacity examination and rehabilitation of operated patients:
(Peptic ulcer)
А) Duration of temporary disability after elective surgery depends on extent of the operation, occurrence of possible complications and type of labour activity.
B) In the course of one year after surgery the patient is followed up by surgeon and therapist or general practitioner.
Definition: Cholelithiasis
Formation of concretions in the gallbladder, hepatic and extrahepatic ducts, as a result of dysmetabolism of cholesterol and bile acids, malfunction of the gallbladder and contamination of bile.
Causes of the concretions formation:
A) Supersaturated concentration of bile in the gallbladder.
B) Gallbladder motility disorder.
C) Infected contents of the gallbladder
Risk factors for gallstone disease:
A) Hepatitis.
B) The use of oral contraceptives.
С) Diabetes mellitus.
D) Previous resection of the ileum.
E) Sickle-cell anemia.
Diagnostics of the gallbladder diseases:
A) Laboratory diagnostics:
- analysis of the duodenal contents received during duodenal intubation:
- microscopic examination of the duodenal contents;
- biochemical examination of the duodenal contents.
B) Instrumental diagnostics:
a) ultrasound investigation determines condition of the gallbladder and its contents, diameter and
condition of the extrahepatic and intrahepatic bile ducts;
b) computed tomography more precise but more expensive method of investigation;
c) endoscopic retrograde cholangiopancreatography:
- visual examination of the stomach, duodenum and major duodenal papilla;
- contrast and roentgenologic fixation of condition of the extrahepatic, intrahepatic ducts and pancreatic ducts;
d) percutaneous transhepatic cholangiography (PTC) under the control of ultrasound investigation:
- in obstructive jaundice, PTC specifies the level of obstruction, its possible causes and provides an opportunity to regulate decompression of the ductal system;
e) roentgen diagnostics (not used nowadays):
- oral cholecystography;
- intravenous cholangiography.
Types of clinical course of gallstone disease:
A) Asymptomatic choledocholithiasis.
B) Chronic calculous cholecystitis.
C) Acute cholecystitis.
D) Choledocholithiasis (stones in the extrahepatic bile ducts).
Definition: Chronic calculous cholecystitis
A chronic inflammation and fibrous thickening of the gallbladder wall with disturbance of the gallbladder functions in consequence of the recurrent influence of gallstones on the gallbladder.
Clinical course of chronic calculous cholecystitis:
A) Complaints:
a) pain syndrome (caused by impaction of the concretions into the cervical region of the gallbladder during its contraction):
- pain is localized in the right hypochondrium;
- irradiates into the right scapula, right shoulder girdle;
- pain occurs periodically;
- pain of varying intensity from dull to sharply expressed, paroxysmal;
b) dyspeptic disorders:
- feeling of heaviness in the epigastric area;
- gaseous eructation (aerophagia);
- digestive disorders in the form of constipations or diarrheas, or constipations changing into diarrheas;
- poor tolerability of fatty and fried foods.
B) Anamnesis:
- aggravation of pain, caused by intake of fatty, fried and spicy foods;
- pain attacks occur, usually, in the evening or at night;
- pain attack is being stopped by itself or due to taking of antispasmodics.
C) Objective signs:
a) physical examination:
- tongue is moist, covered with white fur;
- stomach participates in breathing act;
b) palpation of the abdomen:
- with superficial palpation: the abdomen is soft; moderate resistance of the muscles and moderate pain in the right hypochondrium are possible;
- with deep palpation palpation of the enlarged gallbladder is possible;
c) percussion and auscultation are not enough informative.
Making of preliminary diagnosis according to clinical findings.
(chronic calculous cholecystitis)
The preliminary diagnosis is made on the basis of patient complaints, anamnesis of the disease and its objective signs confirmed by physical methods of examination.
Sonography is performed to confirm or clarify the diagnosis.
Diagnosis:
chronic calculous cholecystitis
A) Instrumental diagnostics:
- ultrasound examination
- oral cholecystography.
B) Laboratory diagnostics (nonspecific):
- CBC and urinalysis;
- blood chemistry;
- blood electrolytes.
Differential diagnosis of chronic calculous cholecystitis:
A) With chronic diseases of the abdominal cavity organs:
- duodenal ulcer, complicated by penetration;
- duodenitis.
B) With therapeutic diseases:
- right-sided pneumonia;
- right-sided pleurisy.
Complications of chronic calculous cholecystitis:
A) Nonfunctioning gallbladder.
B) Hydrops of the gallbladder.
С) Chronic gallbladder empyema.
D) Bedsore of the gallbladder wall.
E) Cholecystocholedochal fistula.
F) Cholecystocolonic fistula.
Clinic-statistical classification of chronic calculous cholecystitis:
ICD10 Diagnosis Code K80.1 Calculus of gallbladder with cholecystitis
Formula of clinical diagnosis: chronic calculous cholecystitis {with dyskinesia of QX type},
{complicated by OX}
Type of dyskinesia:
Q1 hypotonic
Q2 hypertonic
Complications: O1 nonfunctioning gallbladder O2 hydrops of the gallbladder O3 chronic gallbladder empyema O4 bedsore of the gallbladder wall O5 cholecystocholedochal fistula O6 cholecystocolonic fistula
Treatment of chronic calculous cholecystitis.
. Elective surgery is the main method of the treatment:
- laparotomic cholecystectomy;
- laparoscopic cholecystectomy.
