Www.vnmu.edu.ua
Ministry of public health of Ukraine
Vinnitsa National medical university
in memorial of M.I.Pirogov
“Approve”
Head of the chair of Internal medicine
of medical faculty № 2,
MD., prof. Zhebel V.N.
«___»____________ 2012 р.
Methodical elaborate plan
of practical lesson with the students
|Subject |Laboratory diagnostics |
|Modul № |1 |
|Content of the modul № |2 |
|The topic of the practical class |Laboratory and functional diagnostics of bronchial asthma and COPD |
|Educational year |4 |
|faculty |pharmacy |
Vinnitsa 2012
1. Importance of the topic
Bronchial asthma and chronic obstructive pulmonary disease (COPD) are widely spread internal diseases. They produce serious problems with health. Prevalence of COPD a-is increasing from year to year and now it is one from frequent cause of death in the world. Ability to recognizing COPD and bronchial asthma is very important for every doctor or student, because sometimes these diseases appear with emergency life-threatened condition that should be resolved immediately.
2. Concrete aims:
─ Study main symptoms and signs of the bronchial asthma
─ Learn main instrumental methods that can help to establish bronchial asthma
─ Learn classification of bronchial asthma
─ Study main symptoms and signs of COPD
─ Learn instrumental and functional exanimation patients with COPD
3. Basic training level
|Previous subject |Obtained skill |
|Normal anatomy |Anatomy of the airways and lungs, their blood supply and innervations |
|Normal physiology |Mechanics of breathing, gas exchange in the lung and tissues of system organs |
|Histology |Ontogenesis of the respiratory tract, histological structure of the respiratory tract and |
| |alveoli |
|Propedeutics to internal medicine |Subjective, objective and instrumental examinations of the respiratory patients |
4. Task for self-depending preparation to practical training
4.1. List of the main terms that should know student preparing practical training
|Term |Term |
|Bronchial obstruction |Hyperinflation |
|Reversibility of obstruction |Respiratory failure |
|Emphysema |Asthma attack |
4.2. Theoretical questions:
1. Definition of bronchial asthma
2. Causes of bronchial asthma and its classification
3. Symptoms of bronchial asthma
4. Signs of bronchial asthma
5. Instrumental and laboratory methods of examination of patients with bronchial asthma
6. Definition of COPD
7. Symptoms and signs of COPD
8. Data of additional methods of examination of patients with COPD.
9. Classification of COPD.
4.3. Practical task that should be performed during practical training
1. Revealing and assessment of symptoms and signs of bronchial asthma
2. Revealing and assessment of symptoms and signs of COPD
3. Revealing and assessment of functional data at patients with bronchial asthma and COPD
Bronchial asthma is a chronic inflammatory disease of the airways resulting in airflow obstruction secondary to airway edema, increased mucus production, bronchospasm and infiltration of the airway with leukocytes (eosinophils, lymphocytes and neutrophiles). It is usually reversible either spontaneously or with treatment. May be allergic and non-allergic and genetic burden.
Clinical presentation:
Episodic dyspnea
Wheezing
Cough dry and nocturnal or morning or episodic as asthma attack equivalent
Episodic chest tightness
Signs of reversible bronchial obstructive syndrome
Visual examination:
The patient sits upright and leans on the edge of the table or chair with hands. This position mobilizes accessory respiratory muscles, does exhalation active and facilitates breathing. There is cyanosis, tachypnea and lengthened exhalation. Auxiliary muscles take part in breathing. If patient is sick during 5 or more year his chest has barrel shape.
Palpation of the chest
Vocal fremitus is diminished. Potenzher symptom is negative and pleural points are painless. Chest has increased resistance.
Percussion of the chest
Comparative percussion: There is resonant percussion sound over chest. Because account of air in lung increases due to dysfunction of breathing.
Topographic percussion: The lower borders of the lungs descend down and apexes of lungs lift up. There is dimension of lower lung border excursion.
Auscultation of the lung
There is diminished rough vesicular breathing with prolonged exhalation, polyphonic wheezes due to narrowing of airways of differing caliber.
Investigations:
Lung function tests: pre- and post-bronchodilator test – FEV1 is increased by> 12% and > 200 ml.
Peak expiratory flow rate: difference of > 20% between morning and afternoon PEF may suggest asthma
Bronchoprovocation test: test for airway hyperreactivity. Test positive if FEV1 drop to 20%.
Classification of bronchial asthma:
I step – Intermittent symptoms rare than 1 a week and night symptoms less than 1 a 2 week (PEF, FEV1> 80%)
II step – mild persistent - symptoms rare than 1 a day and night symptoms less than 1 a 2 week (PEF, FEV1> 80%)
III step – moderate persistent – daily symptoms and night symptoms one a week (PEF, FEV1 80-60%)
IV step – severe persistent – continua day symptoms and frequent night symptoms
(PEF, FEV1130mmHg) in conjunction with bilateral retinal haemorrhages and exudates; papilloedema may or may not be present. Symptoms are common eg headache ± visual disturbance. Alone it requires urgent treatment. However, it may precipitate acute renal failure, heart failure, or encephalopathy which are hypertensive emergencies. Untreated, 90% die in 1yr; treated, 70%: survive 5yrs. Pathological hallmark is fibrinoid necrosis. It is more common in younger patients and in Blacks. Look hard for any underlying cause.
Risk factors
Family history, race (most common in blacks), stress, obesity, a high intake of saturated fats or sodium, use of tobacco, sedentary lifestyle, and aging are risk factors for essential hypertension.
Causes of the secondary hypertension -5% of cases:
1. Renal disease: The most common secondary cause. 3/4 are from intrinsic renal disease:
- glomerulonephritis,
- polyarteritis nodosa (pan),
- systemic sclerosis,
- chronic pyelonephritis, or polycystic kidneys.
1/4 are due to renovascular disease:
- most frequently atheromatous (elderly male cigarette smoker; eg with peripheral vascular disease)
- rarely fibromuscular dysplasia; (young female).
2. Endocrine disease:
- Cushing's syndromes
- Conn's syndromes
- Phaeochromocytoma
- Acromegaly
- Hyperthyreoidism
- Hyperparathyroidism.
3. Coarctation of the aorta
4. Pregnancy;
5. Neurologic disorders;
6. Use of oral contraceptives or other drugs, such as cocaine, epoetin alfa, and cyclosporine, steroids.
Signs and symptoms
• Cerebral symptoms: headache, dizziness, buzzing in the ears and head, irritation (due to disorders of vessel tone, their widening is changed spasm. It results in disorders of cerebral circulation. There is an irritation of the cerebral vessels by increased BP).
• Cardiac symptoms: heart pain, palpitation and interruption of the heart bit
• General symptoms: fatigue, sleep disorders, decreasing work ability
Visual examination: flush of the face and sclera. Pulse is hard, intense.
Apex bit is heaving, undisplaced to the left, and resistant. The left border of relative heart dullness drifts left due to hypertrophy left ventricle.
On auscultation diminished S1 (muscle component) on the apex, and accented S2 on the aorta (high pressure) are heard.
Investigations
Serial blood pressure measurements that are greater than 140/90 mm Hg in people under confirm hypertension
We can use a dairy BP monitoring: measuring BP every 15 min during day and every 30 min during night with following computer reading.
Ophthalmoscopy reveals arteriovenous nicking and, in hypertensive encephalopathy, papilledema.
Hypertensive retinopathy
I. Tortuous arteries with thick shiny walls (silver or copper wiring)
II. a-v nipping (narrowing where arteries cross veins)
III. Flame haemorrhages and cotton wool spots
IV. Papilloedema.
11. Urinalysis: The presence of protein, red blood cells, and white blood cells may indicate glomerulonephritis.
Only proteinuria means renal complication of hypertension
12. Excretory urography: Renal atrophy indicates chronic kidney disease; one kidney that is more than 5/8 (1.5 cm) shorter than the other suggests unilateral kidney disease.
13. Serum potassium: Levels less than 3.5 mEq/L may indicate adrenal dysfunction (primary hyperaldosteronism).
14. Blood urea nitrogen (BUN) and serum creatinine levels: A BUN level that is normal or elevated to more than 20 mg/dl and a serum creatinine level that is normal or elevated to more than 1.5 mg/dl suggest kidney disease.
Other tests help detect cardiovascular damage and other complications:
Electrocardiography may show left ventricular hypertrophy or ischemia (depressed ST segment and negative T-wave in I, II, AVL, V4-6).
Chest X-ray may show cardiomegaly.
Echocardiography may show left ventricular hypertrophy. There are thickened left ventricular walls, interventricular septum.
Renal arteriography may show renal artery stenosis.
Classification and clinical presentation of the essential hypertension:
• I stage – episodic elevation of BP with cerebral, cardiac and general symptoms without any other signs except high BP
• ІІ stage: Permanent symptoms and signs of affect of the target organs without their failure:
Heart – left ventricle hypertrophy ( sings, ECG, Ehocardiography, X-Ray)
eye grounds- hypertensive retinopathy I-II
Kidney – proteinuria, increased blood creatinine (male 115-133 mcmol/l or 1,3-1,5 mg/dl, female 107-124 mcmol/l or 1,2-1,4 mcmol/l)
• ІІІ stage - Permanent symptoms and signs of affect of the target organs with their failure (complicated stage)
Heart – myocardial infartion, heart failure ІІ-ІІІ st.
Brain - cerebrovascular accident, chronic hypertensive encephalopathy ІІІ st. and vassel dementia
Eye grounds- hypertensive retinopathy III- IV
Kidney – proteinuria, increased blood creatinine (male >133 mcmol/l or >1,5 mg/dl, female >124 mcmol/l or >1,4 mcmol/l), chronic renal failure
Vassels– aortic dissecting aneurysm
Clinical presentation of the hypertensic crisis
Sudden increasing BP in the patients with hypertension which is accompanied significant change in the target organs.
There are two types of the hypertensic crisis I type (adrenal crisis) and II type (nor-adrenal crisis)
І type
• Occur during I or II stage of hypertension
• Fast beginning (several hours)
• SBP > DBP
• Intensive vegetative disorders (headache, trembling, palpitation, flush, frequent urination)
• Visual examination: flush of the face and sclera
• Duration: several hours, usually complications are absent.
ІІ type
• Occur during II or III stage of hypertension
• Slow developing (dozens hours or several days)
• DBP>SBP
• Continuing dairy
• Symptoms: disorders of eyesight, limb numbness, nausea, vomiting, headache, nose bleeding
• There are the target organs complications: brain: cerebrovascular accident, retina: blindness, heart: myocardial infarction, acute heart failure, pulmonary oedem,kidneys: proteinuria, edema and renal failure.
Reference source
Olga Kovalyova, Tetyana Ashcheulova Propedeutics to internal medicine, Part 1. – Vinnytsya: NOVA KNYHA, 2006. – p. 220-227
Materials for self-control (added)
1. Which level of the blood pressure is corresponded to mild hypertension?
A. > 140/< 90 mm Hg.
B. 140-159/90-99 mm Hg.
C. 160-179/100-109 mm Hg.
D. ≥ 180/≥ 110 mm Hg.
E. ≥155/≥100 mm Hg
2. Risk factors of essential hypertension:
A. Family history, race (blacks), stress, obesity, a high intake of saturated fats or sodium, use of tobacco, sedentary lifestyle.
B. Family history, stress, obesity, a high intake of saturated fats or sodium, use of tobacco, hepatitis, sedentary lifestyle.
C. Family history, stress, obesity, a high intake of saturated fats or sodium, cardiac arrhythmia, sedentary lifestyle.
D. Stress, obesity, a high intake of saturated fats or sodium, use of tobacco, hepatitis, sedentary lifestyle.
E. Family history, race (blacks), cardiac arrhythmia, sedentary lifestyle.
3. What arterial pressure is corresponded to moderate hypertension?
A. > 140/< 90 mm Hg.
B. 140-159/90-99 mm Hg.
C. 160-179/100-109 mm Hg.
D. ≥ 180/≥ 110 mm Hg.
E. ≥155/≥100 mm Hg
4. What are the pulse properties at patients with arterial hypertension?
A. Hard, intense.
B. Hard.
C. Frequent.
D. Intense, frequent.
E. Arrhythmic, slow.
5. What is the commonest symptom at patients with essential hypertension?
A. Sleep disorders.
B. Headache.
C. Myalgia.
D. Arrhythmia.
E. Edemas
6. How are the heart borders displaced at patient with the 2nd stage of essential hypertension?
A. Shift to the right.
B. Shift to the left.
C. Shift to the left and up.
D. Shift to the right, left and up.
E. Not changed.
7. During auscultation of patients with prolonged arterial hypertension you can hear:
A. Diminished S1 at the apex, and accented S2 at the aorta.
B. Loud S1 at the apex, and accented S2 at the aorta.
C. Increased S1 at the apex, and diminished S2 at the aorta.
D. Diminished S1 at the apex and S2 at the aorta.
E. Normal heart sounds
8. ECG sign of the left ventricular hypertrophy:
A. High R at the V3, V4.
B. High R at the V1, V2.
C. High R at the V5, V6.
D. Deep S at the I lead.
E. High R at the III lead.
9. Which organs are considered target at the patients with arterial hypertension?
A. Heart, liver, lungs and brain
B. Liver, brain, kidney, eyes
C. Heart, brain, kidney, eyes, vessels
D. Heart, liver, lungs and kidney
E. Liver, brain, kidney, eyes, heart.
10. Criterions of the ІI stage of essential hypertension:
A. Episodic elevation of BP with cerebral, cardiac and general symptoms without any other signs except high BP.
B. Permanent symptoms and signs of the target organs affecting without their failure.
C. Permanent symptoms and signs of the target organs affecting with their failure (complicated stage)
D. Frequent hypertonic crisis.
E. Lack of effect of the medication treatment.
11. What blood pressure is corresponded to severe hypertension?
A. > 140/< 90 mm Hg.
B. 140-159/90-99 mm Hg.
C. 160-179/100-109 mm Hg.
D. ≥ 180/|≥ 110 mm Hg.
E. >160/>100 mm Hg.
12. How is color of skin changed at the patient with arterial hypertension?
A. Flush of the face and sclera.
B. Flush of the foot.
C. Flush of the stomach.
D. Flush of the back
E. Flush of the hands
13. What blood pressure is corresponded to isolated systolic hypertension?
A. > 140/< 90 mm Hg.
B. 140-159/90-99 mm Hg.
C. 160-179/100-109 mm Hg.
D. ≥ 180/|≥ 110 mm Hg.
14. How is apex bit changed at patient with prolonged arterial hypertension?
A. Heaving displaced to the right, and resistant.
B. Heaving, displaced to the left, and not resistant.
C. Heaving, displaced to the left, and resistant.
D. Not changed, normal
E. Displaced to the right and not resistant.
15. How are the heart borders displaced at patient with the 1st stage of essential hypertension?
A. Shift to the right.
B. Shift to the left.
C. Shift to the left and up.
D. Shift to the right, left and up.
E. Not changed.
16. During auscultation of patients with hypertonic crisis you can hear:
A. Diminished S1 at the apex, and accented S2 at the aorta.
B. Loud S1 at the apex, and accented S2 at the aorta.
C. Increased S1 at the apex, and diminished S2 at the aorta.
D. Diminished S1 at the apex and S2 at the aorta.
E. Normal heart sounds
17. Which investigation is the most informative for establishing arterial hypertension?
A. Daily BP monitoring.
B. Daily EKG monitoring.
C. Coronarography.
D. Echocardiography
E. Tredmill test.
18. Criterions of the ІIІ stage of essential hypertension:
A. Episodic elevation of BP with cerebral, cardiac and general symptoms without any other signs except high BP.
B. Permanent symptoms and signs of the target organs affecting without their failure.
C. Permanent symptoms and signs of the target organs affecting with their failure (complicated stage)
D. Frequent hypertonic crisis.
E. Lack of effect of the medication treatment.
19. Which diseases can be accompanied with arterial hypertension?
A. Renal diseases
B. Endocrine disease
C. Coarctation of aorta.
D. Nephropathy of pregnancy
E. all mentioned above
20. EchoCG sign of the left ventricular hypertrophy:
A. Widening of the cavity of left ventricular.
B. Widening of the cavity of right ventricular.
C. Widening of the posterior wall of the left ventricle.
D. Widening of the left atrium cavity.
E. Low ejection fraction.
Control questions:
13. Definition, classification and risk factors of the arterial hypertension.
14. Symptoms and signs of arterial hypertension.
15. Data of additional methods of investigation at patients with arterial hypertension.
16. Definition and classification of the essential hypertension.
17. Complication of the uncontrolled arterial hypertension.
18. Main symptoms and signs of the hypertonic crisis.
Practical skills
1. Collecting symptoms at patient with arterial hypertension
2. Revealing signs of the arterial hypertension
3. Assessing data of ECG, Echocardiography and laboratory examination of the patient with arterial hypertension.
Ministry of public health of Ukraine
Vinnitsa National medical university
in memorial of M.I.Pirogov
“Approve”
Head of the chair of Internal medicine
of medical faculty № 2,
MD., prof. Zhebel V.N.
«___»____________ 2012 р.
Methodical elaborate plan
of practical lesson with students
|Subject |Laboratory diagnostics |
|Modul № |1 |
|Content of the modul № |2 |
|The topic of the practical class |Laboratory and functional diagnostics of gastritis and ulcer of stomach. |
|Educational year |4 |
|faculty | pharmacy |
Vinnitsa 2012
Chronic gastritis, peptic stomach and duodenum ulcers are widely spread diseases of the gastrointestinal tract. They produce serious problems with health. Ability to recognizing gastritis, peptic ulcers is very important for every doctor or student, because sometimes these diseases cause emergency life-threatened complications that should be resolved immediately, usually by sugary intervention.
2. Concrete aims:
─ To study main symptoms and signs of the chronic gastritis, stomach and duodenum peptic ulcers
─ To learn main instrumental methods that can help to establish chronic gastritis, stomach and duodenum peptic ulcers
─ To learn laboratory features of the gastric juice at patients with hyper- and hyposecretion
─ To study complications of the peptic ulcer
3. Basic training level
|Previous subject |Obtained skill |
|Normal anatomy |Anatomy of the stomach, duodenum, their blood supply and innervations |
|Normal physiology |Digestion in the stomach and duodenum |
|Histology |Ontogenesis of the stomach and duodenum, histological structure of them |
|Propedeutics to internal medicine |Subjective, objective and instrumental examinations of the gastrointestinal patients |
4. Task for self-depending preparation to practical training
4.1. List of the main terms that should know student preparing practical training
|Term |Term |
|Hyposecretion |Achylia |
|hypersecretion |Achlorhydria |
|Computer pH-metry |Bilious dyspepsia |
|penetration |Perforation |
4.2. Theoretical questions:
10. Definition and classification of the chronic gastritis
11. Main syndromes of the chronic gastritis
12. Clinical presentation of the gastritis A
13. Clinical presentation of the gastritis B
14. Instrumental and laboratory methods of examination of patients with chronic gastritis and peptic ulcers
15. Methods of the revealing H.pylori infection
16. Clinical presentation of the gastric peptic ulcer
17. Clinical presentation of the duodenum peptic ulcer
18. Complications of the peptic ulcers
4.3. Practical task that should be performed during practical training
4. Revealing and assessment of symptoms and signs of chronic gastritis
5. Revealing and assessment of symptoms and signs of peptic ulcers
6. Revealing and assessment of instrumental and laboratory data at patients with chronic gastritis, peptic ulcers.
Topic content
Diagnostics of chronic gastritis, peptic gastric and duodenal ulcers
Complications of peptic ulcer
Chronic gastritis is the chronic inflammatory process of mucous membrane of stomach, which is accompanied with the changes of cellular regeneration, progressive atrophy of glandular epithelium, disorders of secretory, motor and incretory functions of stomach.
Functions of stomach
1. Secretory
a. Synthesis of acid
b. Synthesis of pepsin
2. Motor and evacuation
3. Incretory (synthesis of prostoglandines and gastrointestinal hormones)
4. Mucus production
5. Absorption
6. Exretory
Types of chronic gastritis
• Chronic gastritis type A (autoimmune, atrophy)
• Chronic gastritis type B (bacterial)
• Chronic gastritis type C (chemical, reflux-gastritis)
• Chronic gastritis of the mixed type
Reasons of development of chronic gastritis
• Autoimmune inflammation
• Bacterial infection (H. pylori)
• Reflux of duodenal content into a stomach
• Use of medicines (steroid and nonsteroid anti-inflammatory drugs), irritating substances (alcohol, cigarette smoke, and environmental agents).
• Pathological hypersecretion (gastrinoma, hypercalciaemia)
• Combination of the mentioned causes.
Main syndromes of chronic gastritis
1. Pain (early pain, connected with meal, in an epigastric region)
2. Gastric dyspepsia (disorders of appetite, nausea, vomiting, belch, heaviness in an epigastric region, heartburning)
3. Intestinal dyspepsia (diarrhea, constipation depending on the type of secretion)
4. Asthenoneurotic (vegetative) – (weakness, fatigue, bad sleep, disorders of mood, irritability, vegetative disorders)
Features of the chronic gastritis type A
• Develops more frequent at the young patients
• More frequent at men
• Affects cardial part and body of stomach
• Formation of autoantibodies to the glandular cells of stomach
• Diffuse and deep atrophy process with development of severe secretory insufficiency of stomach (hyposecretion, hypoaciditas, anaciditas, achylia, histamine refractory achlorhydria)
• Combination with В12- deficiency anemia
• Combination with polyposis of stomach
• Combination with other immune diseases (rheumatoid arthritis, thyroiditis, vitiligo, connective tissue diseases)
Clinical presentation:
Pain is a dull, boring, and early with sensation of stomach overfilling and heaviness even if patient has eaten small portion of food. Patient complains of a chronic nausea, belch with rotten eggs odor, sometimes vomiting relieving pain and gastric heaviness, frequent diarrhea, diminished or absent appetite. Patient loses weight and has a lot of aesthetic symptoms. Vitamin deficiency signs (gingival hemorrhage, angular cheilosis, hyperkeratosis, nail fragility, hear loss and smooth bright crimson tongue), pale skin are observed at visual inspection. Superficial palpation reveals moderate painfulness at the epigastric region.
Features of chronic gastritis type B
• Develops in any age
• It can be at the persons of any sex
• The prepyloric (antrum) part of stomach is affected
• Absence of formation of autoantibidies to the gastric cells
• Related to the H. pylori infection
• The secretion of stomach is normal or increased (normosecretion, normaciditas, hypersecretion, hyperaciditas)
• Does not combine with anemia, polyposis of stomach, immune diseases
Clinical presentation:
Pain is a boring and sometimes burning, with sensation of heaviness. Hunger pain may be relieved by small meal. Patient complains of nausea; belch with acid odor, heartburning, acid taste in mouth, sometimes vomiting relieving pain and gastric heaviness, frequent constipation, increased appetite. Patient has normal or over weigh. Superficial palpation reveals moderate painfulness at the pyloric region.
Methods of verification (confirmation) of chronic gastritis
1. General clinical (anamnesis, general visual examination, palpation, percussion, auscultation)
2. Fibrogastroduodenoscopy (atrophy processes of mucous membrane of stomach in different departments, polyposis of stomach)
3. Biopsy is histological and cytological research of tissue sample for confirming and specifying gastritis type and severity. It should be taken from 5 different places of stomach (cardia, fundus, small curve, greater curve, pylorus).
4. Methods of the H. Pylori revealing:
• Serology tests
• Histological assessment of H.pylori presentation if tissue sample
• Cytological assessment of H.pylori presentation in smear from stomach
• Cultural investigation
• Acute ureasa test (using medicine that rapidly reveals ureasa production by H. pylori)
• Fecal antigen test
• 13С-urea breath tests
5. Revealing of autoantibodies to the glandular cells of stomach
6. Endogastric pH-metry (in norm the pH in stomach is 1,6-2,2)
7. Fractional investigation of the gastric secretion
8. X-Ray examination of stomach
PEPTIC ULCER is inflammation of mucous membrane of gastroduodenal area with forming of local erosive damage of mainly infectious or noninfectious origin in reply to disorders of endogenous balance between the local agents of «aggression» and «protection».
Types of peptic ulcer –
• Peptic gastric ulcer
• Peptic duodenum ulcer
Syndromes of peptic ulcer
1. Pain
2. Dyspeptic syndrome (gastric dyspepsia, duodenal dyspepsia)
3. Intestinal dyspepsia (diarrhea, constipation, flatulence)
4. Asthenoneurotic (vegetative) syndrome
5. Syndrome of complications
• Bleeding
• Perforation
• Penetration
• Malignization
• Stenosis of pylorus
Features of peptic gastric ulcer
• Pain is related to eating, early (10 min - 1 hour), in an epigastric region, intensive, periodic, seasonal is intensification in spring and in autumn.
• Gastric dyspepsia
• Intestinal dyspepsia (diarrhea, flatulence)
• Type of secretion – hyposecretion is more frequent, rarer – normal or hypersecretion
Features of duodenum peptic ulcer
• Pain is late after meal (1,5-2 hours), night, fasting, intensive, burning, acute, periodic, seasonal.
• Dyspepsia of duodenal type (nausea, vomiting, belch, heartburning, bloating)
• Intestinal dyspepsia (constipations)
• Type of secretion – always hypersecretion
Methods of verification (confirmation) of peptic ulcer.
1. General clinical (anamnesis, general visual examination, palpation, percussion, auscultation)
2. Fibrogastroduodenoscopy (ulcerative defect of mucous membrane of different parts in stomach and duodenum, features of bleeding)
2. Biopsy (histological and cytological investigation of tissue samples from stomach or duodenum, brash-biopsy smear)
3. Methods of the H. Pylori revealing:
✓ Serology tests
✓ Histological assessment of H.pylori presentation if tissue sample
✓ Cytological assessment of H.pylori presentation in smear from stomach
✓ Cultural investigation
✓ Acute ureasa test (using medicine that rapidly reveals ureasa production by H. pylori)
✓ Fecal antigen test
✓ 13С-urea breath tests
4. Endogastric pH-metry (in a norm the pH in stomach is 1,6-2,2)
5. Fractional investigation of the gastric secretion
6. X-Ray barium contrasting examination of stomach and duodenum (recess symptom)
COMPLICATIONS OF PEPTICAL ULCER
Acute Gastrointestinal Bleeding occurs due to injury of gastrointestinal vessel by ulcerative process. Main symptoms and signs:
✓ Vomiting with maintenance of bright red blood or “coffee-grounds” - Haematemesis
✓ Melena mean black motions, often like tar (signifying altered blood, which has a characteristic smell)
✓ Symptoms of collapses (palpitation, pallor, tachycardia, low blood pressure)
✓ Posthemorrhagic anemia
Perforation is a rapture of ulcer into abdominal cavity
✓ “Dagger” pain
✓ Forced position in a bed with feet claps to abdomen
✓ The Grekov’s Symptom - bradycardia in the first hour after the perforation
✓ Wooden belly, abdomen does not participate in breathing
✓ Symptoms of irritation of peritoneum (pneumoperitoneum, peritonitis)
✓ The Klarka’s Symptom is disappearance of hepatic dullness at percussion
✓ Leukocitosis
✓ “Sickle” symptom is air under the right cupula of diaphragm at the X-ray film of abdomen
Penetration is a rapture of ulcer into neighboring organ (liver, gallbladder, pancreas, transversum)
✓ Change of typical rhythm of pain, it becomes more gnawing.
✓ Pain is resistant to treatment
✓ Appearance of pain irradiation
✓ Leykotcitosis
✓ Specific symptoms depend on organ where ulcer penetrated.
Stenosis of Pylorus is narrowing of pylorus or beginning part of duodenum due to scarry deformation after repeated ulcers.
✓ Belch with rotten eggs odor
✓ Vomiting, including by the food used the day before
✓ Weight loss
✓ Prolonged ulcerous anamnesis
✓ Visible antiperistaltics in an epigastric region
✓ Positive Vasylenko symptom (noise of splash at tapping the wall of abdomen near the stomach in 7-8 hours after a meal)
✓ Downward displacement of the lower stomach border.
Malignization is a transformation of ulcerative defect to tumor.
Usually long-term gastric ulcer transforms. We can suppose tumor if pain has become less intensive, but permanent, loss seasonable. Patient suddenly lost weight and appetite or changes of taste and favour products.
Reference source
o Olga Kovalyova, Tetyana Ashcheulova Propedeutics to internal medicine, Part 1. – Vinnytsya: NOVA KNYHA, 2006. – p. 318-319, 327-328,341-342, 347-349,351-357.
o Handbook of diseases.-.2nd ed.- Springhouse Corporation, 2000.
Test for self-control
1. What types of the chronic gastritis do you know?
A. Autoimmune (types A).
B. Bacterial (Type B)
C. Alcohol, toxic (type T)
D. Answers A and B
E. Answers B and C
2. What types of the chronic gastritis do you know?
A. Mixed types
B. Bacterial (Type B)
C. Chemical (type C)
D. Answers A and B
E. Answers A, B and C
3. What features does pain in epigastria have at patient with chronic atrophic gastritis?
A. boring, hunger and burning, accompanied with heartburn, belch with acid odor
B. boring, dull, and early accompanied with nausea, vomiting, epigastric pain, belch with rotten eggs odor
C. periodic, intensive, unbearable, early accompanied with abdominal swelling, diarrhea
D. periodic, intensive, night, fasting, acute accompanied with acid taste, vomiting, constipation
E. Dagger, intensive, unbearable.
4. What features does pain in epigastria have at patient with chronic bacterial gastritis?
A. boring, hunger and burning, accompanied with heartburn, belch with acid odor
B. boring, dull, and early accompanied with nausea, vomiting, epigastric pain, belch with rotten eggs odor
C. periodic, intensive, unbearable, early accompanied with abdominal swelling, diarrhea
D. periodic, intensive, night, fasting, acute accompanied with acid taste, vomiting
E. Dagger, intensive, unbearable.
5. What dyspeptic symptoms can be at patient with bacterial gastritis?
A. Vomiting, nausea, stomach overfilling, diarrhea.
B. Vomiting, nausea, belch with bile, diarrhea and constipation.
C. Heartburning, vomiting, nausea, acid taste, constipation
D. Vomiting, dysphagia, odynophagia, regurgitation, constipation
E. Northing from above.
6. What dyspeptic symptoms can be at patient with autoimmune gastritis?
A. Vomiting, nausea, stomach overfilling, diarrhea.
B. Vomiting, nausea, belch with bile, diarrhea and constipation.
C. Heartburning, vomiting, nausea, acid taste, constipation
D. Vomiting, dysphagia, odynophagia, regurgitation
E. Northing from above.
7. Visual inspection of a patient with autoimmune gastritis reveals …
A. Blush cheek, normal weight, good muscle developing
B. Pale skin, gingival hemorrhage, nails fragility, bright crimson tongue
C Normal skin color, normal or over weight, white tongue with hypertrophied lingual papillas
D. Jaundice, weight loss, scratching on skin, spider naevi.
E. Pale, dry skin, bruises, rush, oedema.
8. Visual inspection of a patient with bacterial gastritis reveals …
A. Blush cheek, normal weight, good muscle developing
B. Pale skin, gingival hemorrhage, nails fragility, bright crimson tongue
C Normal skin color, normal or over weight, white tongue with hypertrophied lingual papillas
D. Jaundice, weight loss, scratching on skin, spider naevi.
E. Pale, dry skin, bruises, rush, oedema.
9. Which investigation is the best for confirming chronic gastritis?
A. Serological with determination of autoantibodies to stomach cells
B. Cultural with obtaining H.pylori
C. Fibrogastroscopy with biopsy
D. Endogastric pH-metry
E. X-ray examination of stomach
10. The most popular and accurate examination for H.pylori revealing is…
A. Serology tests
B. Histological tests
C. Cytological tests
D. 13C-urea breath tests
E. Cultural investigation
11. Peptic ulcers have…
A. inflammatory origin
B. neoplastic origin
C anatomy abnormal origin
D. all mentioned above
E. northing from above
12. What pathogen can cause peptic ulcer?
A. H. pylori
B. Candida albicans
C Herpes zoster
D. Shigella spp.
E. All mentioned above
13. What features does pain in epigastria have at patient with Stomach Peptic Ulcer?
A. boring, hunger and burning, accompanied with heartburn, belch with acid odor
B. boring, dull, and early accompanied with nausea, vomiting, epigastric pain, belch with rotten eggs odor
C. periodic, intensive, unbearable, early accompanied with abdominal swelling, diarrhea
D. periodic, intensive, night, fasting, acute accompanied with acid taste, vomiting, constipation
E. Dagger, intensive, unbearable.
14. What features does pain in epigastria have at patient with duodenum peptic ulcer?
A. boring, hunger and burning, accompanied with heartburn, belch with acid odor
B. boring, dull, and early accompanied with nausea, vomiting, epigastric pain, belch with rotten eggs odor
C. periodic, intensive, unbearable, early accompanied with abdominal swelling, diarrhea
D. periodic, intensive, night, fasting, acute accompanied with acid taste, vomiting, constipation
E. Dagger, intensive, unbearable.
15. What syndromes are developed at patients with peptic ulcers?
A. Abdominal pain
B. Stomach dyspepsia
C Intestinal dyspepsia
D. Vegetative
E. all mentioned above
16. What method is the best for confirming peptic ulcer?
A. Fibrogastroscopy
B. X-ray examination of stomach
C. Fractional investigation of the gastric secretion
D. Endogastric pH-metry
E. All mentioned above.
17. Rapture of ulcer into neighboring organ is named…
A. perforation
B. acute gastrointestinal bleeding
C. penetration
D. malignization
E. pylorostenosis
18. Rapture of ulcer into abdominal cavity is named…
A. perforation
B. acute gastrointestinal bleeding
C. penetration
D. malignization
E. pylorostenosis
19. If patient has belch with rotten eggs odor, vomit with the food used the day before, weight loss, prolonged ulcerous anamnesis, visible antiperistaltics in an epigastric region he suffers from …
A. perforation
B. acute gastrointestinal bleeding
C. penetration
D. malignization
E. pylorostenosis
20. If patient has vomiting with “coffee-grounds”, melena, collapses, ulcerous anamnesis he suffers from
A. perforation
B. acute gastrointestinal bleeding
C. penetration
D. malignization
E. pylorostenosis
Control questions:
1. Definition and classification of the chronic gastritis
2. Main syndromes of the chronic gastritis
3. Clinical presentation of the gastritis A
4. Clinical presentation of the gastritis B
5. Instrumental and laboratory methods of examination of patients with chronic gastritis and peptic ulcers
6. Methods of the revealing H.pylori infection
7. Clinical presentation of the gastric peptic ulcer
8. Clinical presentation of the duodenum peptic ulcer
9. Complications of the peptic ulcers
Practical task
1. Revealing and assessment of symptoms and signs of chronic gastritis
2. Revealing and assessment of symptoms and signs of peptic ulcers
3. Revealing and assessment of instrumental and laboratory data at patients with chronic gastritis, peptic ulcers.
Ministry of public health of Ukraine
Vinnitsa National medical university
in memorial of M.I.Pirogov
“Approve”
Head of the chair of Internal medicine
of medical faculty № 2,
MD., prof. Zhebel V.N.
«___»____________ 2012 р.
Methodical elaborate plan
of practical lesson with students
|Subject |Laboratory diagnostics |
|Modul № |1 |
|Content of the modul № |2 |
|The topic of the practical class |Laboratory and functional diagnostics of cholecystitis,biliary stone disease, bile ducts |
| |dyskinesias. |
|Educational year |3 |
|faculty | pharmacy |
Vinnitsa 2012
Gallbladder and biliary tract diseases are widely spread diseases of the gastrointestinal tract. They produce serious problems with health. Ability to recognizing gallstones, chronic cholecystitis and cholangitis is very important for every doctor or student, because sometimes these diseases appear with emergency life-threatened condition that should be resolved immediately, usually by sugary intervention.
2. Concrete aims:
─ Study main symptoms and signs of the biliary tract diseases
─ Learn main instrumental methods that can help to establish chronic cholecystitis and cholangitis
─ Learn laboratory features of the bile at patients with gallstones
3. Basic training level
|Previous subject |Obtained skill |
|Normal anatomy |Anatomy of the biliary tract, their blood supply and innervation |
|Normal physiology |Mechanics of bile formation and extraction |
|Histology |Ontogenesis of the biliary tract, histological structure of the bale ducts and gall-bladder |
|Propedeutics to internal medicine |Subjective, objective and instrumental examinations of the gastrointestinal patients |
4. Task for self-depending preparation to practical training
4.1. List of the main terms that should know student preparing practical training
|Term |Term |
|Hepatic or biliary colic |6-staging chromatic duodenal intubation |
|Gallstones |Biliary tract dyskinesia |
|Gall-bladder signs |Bilious dyspepsia |
4.2. Theoretical questions:
19. Main syndromes at biliary tract affecting
20. Data of the objective examination of the patients with biliary tract diseases
21. Provocative symptoms of the gall-bladder affecting
22. Main principles and purposes of the 6-staging chromatic duodenal intubation. It’s diagnostic importance.
23. Instrumental and laboratory methods of examination of patients with gall-bladder and billiary tract diseases.
24. Definition of chronic cholecystitis, its causes, main symptoms and signs.
25. Definition of the cholelitiasis, its causes, main symptoms and signs.
4.3. Practical task that should be performed during practical training
7. Revealing and assessment of symptoms and signs of chronic cholecystitis
8. Revealing and assessment of symptoms and signs of Hepatic colic
9. Revealing and assessment of instrumental and laboratory data at patients with gallstones
Topic content
Main syndromes
1. Pain syndrome (depends on the type of dyskinesia)
• Localizes in the right subcostal region, in point of projection of the bottom of gall-bladder (the Makenzy point). It arises up after fat and fried food, in 3-5 hours later eating, irradiates into the right shoulder, under the right subscapularic region, in the region of heart (Botkyn’ symptom or cholecysto-cardial symptom)
• It can be the severe, sharp brief or dull aching, required emergency care
• Mechanism of pain appearence:
• increase of internal pressure in the gall-bladder,
• spasm of the gall-bladder muscles,
• expansion walls of gall-bladder,
• increasing pressure in extra- and intrahepatic and biliary channels (compression by the stones in the area of large duodenal papilla).
2. Biliary dyspepsy - bitter taste in the mouth at mornings, vomiting with bile without relief, intolerance of fat and fried food, regurgitation (belching) by air, nausea, heartburn.
3. Intestinal dyspepsy - related to the unstable selection of bile - alternation of diarrheas with constipations, flatulence, abdominal swelling.
4. Syndrome of premenstrual tension at women – biliary diskinesia symptoms appear last week before menses
5. Astheno-neurotic (vegetative) syndrome – bad mood, irritation, nervousness, weakness, fatigue
Data of physical examination
• Jaundice -yellowish skin and mucous, tracks from scratching due to skin itch (sign of intrahepatic holestasis, calculesis)
• Pigmentation in right subcostal region (tracks from a hot-water bottle)
• At general examination a gall-bladder is not determinated and can be visible at examination and palpation if patient has:
1. gallstones
2. gall-bladder cancer
3. hydropsy of gall-bladder
4. empiema (abscess) of gall-bladder
5. cancer of pancreas head (the Kurvuasie’s symptom)
Provocative symptoms allow exposing pathology of gall-bladder
▪ the Kerr’s sign (pain at deep palpation of gall-bladder bottom)
▪ the Ortner’s sign (pain at percussion over the right costal arch
▪ the Lepene-Vasylenko’s sign (pain at percussion on the front wall of stomach on the right parallel to the right costal arch)
▪ the Mussy-Georgyevskiy’s sign (frenicus) - pain at deep palpation between the legs of right m.sternocleidomastoideus
▪ the Merphy’s sign (pain and breaking (stop) of inspiration during deep palpation of projection point of the gall-bladder bottom)
Investigations:
Full blood analysis (leukocytosis, shift to the left at leukocytal formula, increasing ESR)
Duodenal intubation with bile examination (6-staging chromatic duodenal intubation)
• 6-staging chromatic duodenal intubation
• 1 stage is the basal secretion of bile (duration 20-25 minutes, amount 20-25 ml)
• 2 stage is the stage of hold-up of biliary excretion due to closed Oddi’s sphincter (duration 2-7 minutes, amount – 0 ml)
• 3 stage is the stage of closed Lyutkens’s and opened Oddi’s sphincter, excretion bile from bile duct( duration – 3-6 minutes, amount 3-6 ml is portion A)
• 4 stage is a cystic bile, excretion bile from gal bladder (duration 20-30 minutes, amount 30-60 ml is portion B)
• 5 stage is a intrahepatic bile, excretion bile from common hepatic duct, secreting during examination in liver (duration 20-25 minutes, amount 20-25 ml is portion C)
• 6 stage is a remaining cystic bile, final contraction of gall bladder in 2-2,5 hours of examination (duration – 10-15 minutes, amount 10-15 ml).
Ultrasound examination of the lever, bile ducts and gall bladder in a rest and after bile-expelling breakfast.
Radiologic investigation
o Plain abdominal X-ray examination(it is possible to see stone in a gall-bladder and bile ducts)
o Oral cholecystography - oral contrasting X-Ray examination (patient accepts the contrasting material in pills)
o IV cholecyatography - infusion intravenous contrasting X-Ray examination (the contrasting material is entered intravenously)
o Retrograde duodenocholecystocholangiopancreatography (a contrast is entered through a catheter entered by fybrogastroduodenoscope)
CHRONIC CHOLECYSTITIS is the chronic inflammatory disease of gall-bladder related with functional disorders (dyskynesia and dyscholia)
DIAGNOSTICS
• Clinical symptoms (see upper)
• positive provocative symptoms of palpation (6 symptoms mentioned above)
Duodenal intubation - the change of time and amount of 4 stages of cystic bile (portion B) – in a norm: amount 40-70 ml, time of selection 20-30 minutes.
1. decline of specific gravity of bile (norm value– 1016 ±1)
2. change of pH of bile into sour reaction (norm value – 7,3 ± 0,1)
3. decline of maintenance of bile acids in a cystic bile
4. increase of concentration of cholesterol in a cystic bile (norm value 8,04 ± 0,72 mmol/l)
5. decline of cholato-cholesterol coefficient (norm value - 29 ± 2)
6. increase of concentration of bilirubin (norm value 3,8 ± 0,38 mmol/l)
7. increase of concentration of sialic acids (norm value 130 ± 12 units)
8. determination of the C-reactive protein (norm is negative)
9. (+) bacteriological culture of cystic bile (in a norm a bile is sterile)
Results of ultrasound examination:
1. increasing thickness of gall-bladder wall more than 4 mm (< 4 mm in a norm)
2. (+) sonografic Merphy’s sign
3. increasing gall-bladder sizes more than 5 sm is higher than upper boder of norm for this age
4. presence of shade from the gall-bladder walls
presence of paravisceral echo-negative shade (exudate)
Gall-Stone Disease or Cholelithiasis
Risk factors is “sign of 5 “F” – Female, Forty age, Fertile, Fat (obesity) Fair (complexion)
Reasons of development
• infection
• stagnation of bile in a gall-bladder
• congenital anomalies
• features of food
• heredity
• adynamy, decreased physical activity
A main pathological sign is forming of stones in the gall bladder (calcium, cholesterol, bilirubin, mixed)
Stones can be silent (if they are located in a body and bottom of gall bladder) and active (if they are located in the bladder neck and ducts).
The clinical signs appear only if stones become active. A main symptom (syndrome) is a hepatic (biliary) colic.
Symptoms and signs of biliary colic:
• intensive increased pain in right subcostal region, with a tendency to distribution
• a reason of appearing - use of fat, fried food, alcohol, after physical exercise, jolting jorney
• the pain is appeared in 3-4 hours after eating (more frequent in a night-time)
• irradiation – upwards, in a right shoulder, in a right clavicula, in a right subscapular region, sometimes – in the region of heart (the Botkin’s symptom) lake as angina pectoris
• vomiting with bile does not relief patient’s condition
• fever, chill, trembling, anxiety,
• vegetative storm (diarrhea, constipation, swelling of stomach)
• Jaundice
Investigation of gallstones:
1. Ultrasonography reflects stones in the gall bladder with 96% accuracy.
2. Endoscopic retrograde cholangiopancreatography
3. Plain abdominal X-ray identify calcified but not cholesterol stones with 15% accuracy.
4. Oral cholecystography shows stones in the gallbladder and biliary duct obstruction.
7. Reference source
o Handbook of diseases.-.2nd ed.- Springhouse Corporation, 2000 – P.197-200.
Test for self-control
1. The pain due to gall-bladder and biliary ducts diseases appear after meal in:
f. ½ -1 hours;
g. 1-2 hours;
h. 7-8 hours;
i. 3-4 hours;
j. 2-6 hours.
2. What kinds of foods can cause the pain due to biliary disorders?
f. Milk porridge
g. Fried potatoes
h. Boiled vegetables
i. Boiled fish
j. Apple pie
3. Where does the pain radiate due to biliary disorders?
f. Umbilicus region
g. Epigastric region
h. Left subcostal region
i. Right subscapularic region
j. Pubic region
4. If pain in the heart region appears at patient with biliary tract disorder it names …
f. Angina pectoris
g. Vegetative cardialgia
h. Cholecystocardil symptom
i. Stomach cardialgia
j. Northing from above
5. What syndromes may be at patient with biliary tract disorders?
f. Pain syndrome
g. Asthenovegitative symdromes
h. Biliary dyspepsia
i. Syndrome of premenstrual tension
j. All mentioned above
6. What syndromes cannot be at patient with biliary tract disorders?
a. Pain syndrome
b. Asthenovegitative symdromes
c. Nephrotic syndrome
d. Syndrome of premenstrual tension
e. Biliary dyspepsia
7. What symptoms characterize biliary dyspepsia?
a. Dysphagia, odynophagia, heartburn, hematemesis
b. Nausea, vomiting, hematemesis, early satiety
c. Diarrhea, constipation, abdominal swelling
d. Heaviness in the right subcostal region, nausea, bitter taste, vomiting
e. Northing from mentioned above
8. What symptoms characterize intestinal dyspepsia?
a. Dysphagia, odynophagia, heartburn, hematemesis
b. Nausea, vomiting, hematemesis, early satiety
c. Diarrhea, constipation, abdominal swelling
d. Heaviness in the right subcostal region, nausea, bitter taste, vomiting
e. E.Northing from mentioned above
9. If patient has biliary tract or gall-bladder disease during visual inspection you can find…
f. Weight loss, pale skin;
g. Yellowish skin and mucous, tracks from scratching due to skin itch;
h. Hyperemia of abdomen and chest, overweight;
i. Diffuse cyanosis, visible peristaltic;
j. Northing from mentioned above
10. If patient has biliary tract or gall-bladder disease during visual inspection you can find…
a. Anasarca, pale skin, swelled abdomen;
b. Pigmentation in right subcostal region (tracks from a hot-water bottle);
c. Hyperemia of abdomen and chest, overweight;
d. Diffuse cyanosis, visible peristaltic;
e. All mentioned above
11. When may gall-bladder be palpated?
a. Gallstones
b. gall-bladder cancer
c. hydropsy, empiema (abscess) of gall-bladder
d. cancer of pancreas head (the Kurvuasie’s symptom)
e. all mentioned above
12. When cannot gall-bladder be palpated?
a. Gallstones
b. gall-bladder cancer
c. in a norm
d. hydropsy, empiema (abscess) of gall-bladder
cancer of pancreas head (the Kurvuasie’s symptom)
13. What provocative sign named Merphys?
f. pain at deep palpation of gall-bladder bottom
g. pain at deep palpation between the legs of right m.sternocleidomastoideus
h. pain and breaking inspiration during deep palpation of projection point of the gall-bladder bottom
i. pain at percussion over the right costal arch
j. pain at percussion on the front wall of abdomen on the right parallel to the right costal arch
14. What provocative sign named Ortner’s?
a. pain at deep palpation of gall-bladder bottom
b. pain at deep palpation between the legs of right m.sternocleidomastoideus
c. pain and breaking inspiration during deep palpation of projection point of the gall-bladder bottom
d. pain at percussion over the right costal arch
e. pain at percussion on the front wall of abdomen on the right parallel to the right costal arch
15. Duodenal intubation is used for …
f. assessment shape and size of the gall-bladder
g. Function of the gall-bladder and biliary tract
h. Disintoxication function of the liver
i. Assessment shape and size of the biliary tract
j. All mentioned above
16. The cystic bile during duodenal intubation is received at …
a. the 1 stage
b. the 3 stage
c. the 2 stage
d. the 5 stage
e. the 4 stage
17. Ultrasound examination of the abdomen is used for …
a. assessment shape and size of the gall-bladder
b. Function of the gall-bladder and biliary tract
c. Assessment structure, shape and size of the liver
d. Assessment shape and size of the biliary tract
e. All mentioned above
18. If patient has cholecystitis what changes if his bile may be found?
a. specific gravity of bile is 1016
b. pH of bile is 7,3
c. C-reactive protein
d. Bilirubin is 3,5 mmol/l
e. cholato-cholesterol coefficient 27
19. Ultrasound signs of chronic cholecystitis are…
a. increasing thickness of gall-bladder wall more than 4 mm
b. (+) sonografic Merphy’s sign
c. increasing gall-bladder sizes more than 5 cm is higher than upper boder of norm
d. presence of shade from the gall-bladder walls
e. all mentioned above
20. What investigation is the most accurate for revealing gallstones?
a. Ultrasonography of the gall bladder and the liver
b. Endoscopic retrograde cholangiopancreatography
c. Plain abdominal X-ray
d. Oral cholecystography shows stones in the gallbladder and biliary duct obstruction
e. All mentioned above
Control questions:
1. Main syndromes at biliary tract affecting
2. Data of the objective examination of the patients with biliary tract diseases
3. Provocative symptoms of the gall-bladder affecting
4. Main principles and purposes of the 6-staging chromatic duodenal intubation. It’s diagnostic importance.
5. Instrumental and laboratory methods of examination of patients with gall-bladder and billiary tract diseases.
6. Definition of chronic cholecystitis, its causes, main symptoms and signs.
7. Definition of the cholelitiasis, its causes, main symptoms and signs.
Practical task that should be performed during practical training
1. Revealing and assessment of symptoms and signs of chronic cholecystitis
2. Revealing and assessment of symptoms and signs of Hepatic colic
3. Revealing and assessment of instrumental and laboratory data at patients with gallstones
Ministry of public health of Ukraine
Vinnitsa National medical university
in memorial of M.I.Pirogov
“Approve”
Head of the chair of Internal medicine
of medical faculty № 2,
MD., prof. Zhebel V.N.
«___»____________ 2012 р.
Methodical elaborate plan
of practical lesson with the third-year students
|Subject |Laboratory diagnostics |
|Modul № |1 |
|Content of the modul № |2 |
|The topic of the practical class |Laboratory and functional diagnostics of anemias. General blood test. |
|Educational year |4 |
|faculty | pharmacy |
Vinnitsa 2012
Full blood test is the commonest test of patient’s examination. Its changes reflect activity of inflammatory process, disorders of the hematopoietic system, immune system, malignant process. Anemias are the most prevalent diseases of hematopoietic system influencing to course and treatment different diseases of internal organs. Knowledge about anemias, normal and changed full blood test is very important for physicians of every specialty.
2. Concrete aims:
─ To study mains parameters of full blood test
─ To study main symptoms and signs of anemic syndrome
─ To study classification and clinical features of the different anemias
3. Basic training level
|Previous subject |Obtained skill |
|Normal anatomy |Anatomy of the bone marrow and hematopoietic system |
|Normal physiology |Function of the blood cells, hemopoiesis |
|Histology |Ontogenesis and histological structure of the bone marrow and hematopoietic system |
|Biochemistry |Hemoglobin and iron metabolism |
4. Task for self-depending preparation to practical training
4.1. List of the main terms that should know student preparing practical training
|Term |Term |
|Erythremia |Eosinophylia |
|Leukopenia |Lymphocytosis |
|Leukocytosis |Hemolysis |
4.2. Theoretical questions:
26. What parameters are investigated by full blood test?
27. Normal value of hemoglobin and erythrocytes, changes in pathology.
28. Normal value of leukocytes, changes in pathology
29. Anemia, definition, classification.
30. Clinical presentation of the iron-deficiency anemia
31. Clinical presentation of the pernicious anemia
32. Clinical presentation of the hemolytic anemia
33. Clinical presentation of the post hemorrhagic anemia
34. 4.3. Practical task that should be performed during practical training
10. Assessment of full blood test
11. Revealing and assessment of different anemias
Topic content
Full blood test
Red blood (breathing function is executed (oxygen is carried)
Haemoglobin – 120-160 g/l
Erythrocytes – 3,5-5,5 x 1012 / l
Color index of blood– 0,8 – 1,05
Reticulocytes – 2-12 0/00
Haemoglobin and erythrocytes – reduced at anaemias, increase at polycythemia vera (primary) secondary - chronic pathology of lungs due to chronic hypoxia, tumors of kidney, liver, ovary, uterus due to increase erythropoietin and others.
The coloured index is reduced at iron-deficiency anaemia, is increased – at в12-deficiency anaemia
Reticuloctes – their level is reduced at iron-deficiency anaemia and в12-deficiency anaemia, increassed – at acute posthaemorragic anaemia and gemolitic anaemias.
White blood (function of defence is executed)
Leucocytes – 4-9 x 109 /l
band – 1-6%
Segmented – 47-72%
Eosinophils – 1-5%
Basophils – 0-1%
Lymphocytes – 19-37%
Monocytes – 3-11%
Erythrocyte sedimentation rate (esr) – 2-10 mm/h (at men), 2-15 mm/h (at women)
Physiological leucocytosis:
• After eating
• After the physical exercise
• After hot or cold water procedures
• During a 2-d half of pregnancy
• During delivery
Pathological leucocytosis:
• Leucosises
• Acute infectious diseases
• General and local infectious processes (pathology of internal organs, surgical and gynaecological pathology)
• Sepsis
• Streptocooccus skin inflammation
• Cerebro-spine meningitis
• Tumour of marrow (haematosarcoma)
• After loss blood
• Myocardial infarction
• Burns
• Tumours
• Lymphogranulomatosis
• Agony
Leucopenia (distruction leucocytes and depression of the marrow by somethings)
• Action of radiation (radiation illness)
• Typhoid
• Flu
• Pox
• Measles
• Miliary tuberculosis
• Heavy sepsis
• Action of toxic poisons
• The byrmer’s anaemia
• Chronic splenomegaly
• Aplastic anaemias
• Reception of sulphanilamid preparations, amidopyryn, butadion
Basophilia (take part in formation and accumulation of heparin)
• Myeloid leucosis (bazophilic-eosinophilic association)
Eosinophilia:
• Intestinal worm invasion
• Tumour of liver (cysts)
• Tumour of spleen (cysts)
• Allergic illnesses
• Increase of activity of parasimpatic department of the vegetative nervous system)
• Chronic myeloleucosis (bazophilic-eosinophilic association)
Eosinopenia:
• Acute infectious diseases
• Typhoid
• Acute leucosis
• The byrmer's anaemia
Lymphocytosis:
• Typhoid
• The byrmer's anaemia
• Flu
• Chronic splenomegaly
• Endocrine diseases
• Avitaminosises
• Starvation (голодание)
• In the period of reconvalescence after acute infections
• Of good course of tuberculosis
• Of good course of syphilis
• Mononucleosis infectious
• Lympholeucosis
Lymphopenia:
• Chronic myeloleucosis
• Sepsis
• Heavy infections
• Measles (корь)
• Destruction of lymphoid tissue (sarcoma, cancer, tuberculosis of lymphatic nodes)
Monoсytosis (function of moving and fagocytosis, formation of antibodies):
• In the period of reconvalescence (recover) after acute infections
• After the attack of recurrent typhus
• During the attack of malaria
• At a chronic malaria
• Intestinal worm invasion
• Chronic infections (syphilis, tuberculosis, chronic sepsis)
• Chronic septic endocarditis
• Monocytar angina (infectious mononucleosis)
Monocytopenia:
• Heavy sepsis
• Myeloleucosis
• Lympholeucosis
Syndrome of anaemia – it is clinic-laboratory symptomocomplex, which is related to hypoxia (oxygen starvation) of organs and tissues due to decline of haemoglobin and red blood cells in unit of blood volume.
Anaemic complaints
• Cardial: pain, palpitation, interruptions, breathlessness
• Cerebral: pain, dizziness, syncopal states (syncope), appearance of “beauty-spot” before eyes, noise at ears
• General: weakness, rapid fatigueability, myalgias (pain in the muscles)
Objective data at anaemic syndrome
• Pallor of skin and mucous membranes,
• Becoming thin, weight loss
• Languor of muscles, unsteady gait
• Tachycardia, tachyarrhythmia, blood pressure low, a pulse is small, soft, frequent, expansion of borders of cardiac dullness, weakening of 1 heart sound on an apex, on the botkyn’s point, weakening of 2 tone heart sound on an aorta and pulmonary artery (in heavy cases simultaneous weakening 1 and 2 heart sounds), functional systole noise above all points of auscultation, „noise of top” on a v. Jugularis
Instrumental researches at the syndrome of anaemia
• ECG - tachycardia, tachyarrhythmia, disorders of excitability, decline of voltage (height) of waves , change of eventual part of ventricle complex (depression or elevation st, pathological т)
• Echocardiography - decline of ejection fraction (in the norm 62-67%)
Acute posthemorrhagic anemia – is the pathological state which arises up due to of rapid loss (during 1 day) more than 1 liter of blood
Etiology
1. Pulmonary bleeding
2. Gastro-intestinal bleeding
3. Traumas of thorax, abdominal region, breaks of liver, spleen
4. Hemorrhagic diathesis
5. Gynaecological bleeding
According to the time after development of the blood-losing this type of anemia can has 3 phases. They are:
➢ The reflex phase of compensation (first 1-2 hours after hemorrhage (loss of blood)) is the symptoms of basic disease + tachycardia, tachyarrhythmia, pallor, the common blood analyses (cba) indexes in a norm.
➢ Hydremic phase (from a 2 o'clock of to 2 days after hemorrhage (loss of blood)) – clinically syndrome of anaemia + changes in full blood test: ↓ hb, ↓ erythrocytes (red (blood) cells), color index in a norm, reticulocytes, platelets, leukocytes (white blood cells) and their formula – in a norm, erythrocyte sedimentation rate (esr) in norm.
➢ Bone-cerebral phase (from 2 days and > hemorrhage (loss of blood)) – clinically there is the improvement (улучшение) of the state + in changes in cba: ↓ hb, ↓ erythrocytes (red (blood) cells), colord index in a norm, ↑↑reticulocytes, ↑↑ platelets, ↑↑leukocytes (white blood cells) and change of formula to the left, ↑↑erythrocyte sedimentation rate (esr)
Iron-deficiency anemia
Is the polyetyologycal disease with the development of the deficit of iron in a body and formation of the disorders of synthesis of haemoglobin and development of trophy changes in different tissues.
Etiology
1. Chronic hemorrhage (loss of blood)
2. Promoted necessity in a iron (pregnancy, lactation)
3. Diminishment of receipt of iron with a meal (starvation)
4. Decline of suction of iron in gastro-intestinal system
5. Disorders of transport of iron
Clinical syndromes:
а) anaemic,
б) sideropenic (iron-deficiency syndrome) - disorders from the side of skin and its appendages, muscular, muscle defeats, the gastro-intestinal defeats, changes of sense of smell, central nervous system)
• Search source of bleeding (fybrogastroduodenoscopy, rectoromanoscopy, fybrocolonoscopy, x-ray examination of the gastro-intestinal system, analysis of excrement on the hidden blood, gynaecological inspection)
• Decline of serum iron (n = 12-30 mcмoll/l)
Picture of peripheral blood
• Hypochromia of erythrocytes
• Anisocytosis
• Poikylocytosis
• Shysocytosis
• Polychromatophylia
Pernicious anaemia (в12 - deficiency anaemia) –
Is the polyetyologycal disease with the development of the deficit of vitamin b12 in an organism and formation of the disorders of synthesis of desoxyribonucleic acid of the nucleus of the erythrocytes (dna) and development of changes in different tissues and systems.
Etiology
1. Disorders of absorption of the vitamin в12
2. Сompetition absorption of the vitamin в12 (intestinal worm invasion, dysbaсteriosis)
3. Disorders of receipt of the vitamin в12 with a meal (starvation)
4. Disorders of transport of the vitamin в12
Clinical syndromes
А) anaemic,
Б) gastro-intestinal syndrome (atrophy of mucous along all tract) defeat,
В) neurological syndrome (funicular myelosis – syndrome of defeat of back and lateral posts of spinal cord)
Diminishment of maintenance of the vitamin в12 in the whey of blood
(in a norm = 0,4-0,9 мкг%)
Common blood analysis – anaemia, hyperchromia of erythrocytes, hyporegeneration, ovalomacrocytosis, megalocytosis, basophilic pigmentation of red corpuscles, the kebbot’s ring, golly’s bodies, hypersegmentation of neutrophils, trombocytopenia
Sternal biopsy - advantage of basophilic forms – „dark blue marrow”
Hemolytic anemia - are the group of the pathological states with the development of predominance of blood destruction above blood formation due to action of hemolytic poisons, increase of the activity reticulo-endotelial system (res), and also there is the result of innate or acquired erythropathy. Hemolytic anemia may be congenital and acquired
Microsferotcytosis (the Mynkovskiy-Shoffara illness) – inherited disease related to formation of inferior membrane of red corpuscles and synthesis of red corpuscles of less than in the norm of size (less than 6 microns)
• Clinical symptoms are anaemia, icterus, splenomegaly
• Haematological symptoms are anaemia + decline of osmotic resistance of erythrocytes, mycrocytosis, reticulocytosis
• Biochemical indexes – hyperbilirubinemia, increase of the level of urobilin in urine, increase of the level of sterkobilin in an excrement
Acquired hemolytic anaemias
• Clinical symptoms are anaemia, icterus, splenomegaly
• Haematological symptoms are anaemia + normal osmotic resistens of red corpuscles, normal form and diameter of red corpuscles, reticulocytosis
• Biochemical indexes - hyperbilirubinemia, increase of the level of urobilin in urine, increase of the level of sterkobilin in an excrement
• Positive tests on red anticorpuscles antibodies
7. Reference source
Olga Kovalyova, Tetyana Ashcheulova propedeutics to internal medicine part 1. – vinnytsya: nova knyha, 2006. – p. 407-417.
Control questions:
1. What parameters are investigated by full blood test?
2. Normal value of hemoglobin and erythrocytes, changes in pathology.
3. Normal value of leukocytes, changes in pathology
4. Anemia, definition, classification.
5. Clinical presentation of the iron-deficiency anemia
6. Clinical presentation of the pernicious anemia
7. Clinical presentation of the hemolytic anemia
8. Clinical presentation of the post hemorrhagic anemia
Practical task
1. Assessment of full blood test
2. Revealing and assessment of different anemias
Ministry of public health of Ukraine
Vinnitsa National medical university
in memorial of M.I.Pirogov
“Approve”
Head of the chair of Internal medicine
of medical faculty № 2,
MD., prof. Zhebel V.N.
«___»____________ 2012 р.
Methodical elaborate plan
of practical lesson with students
|Subject |Laboratory diagnostics |
|Modul № |1 |
|Content of the modul № |2 |
|The topic of the practical class |Laboratory and functional diagnostics of leukemias. |
|Educational year |4 |
|faculty | pharmacy |
Vinnitsa 2012
2. Importance of the topic
The leukemias are a heterogeneous group of diseases characterized by infiltration of the blood, bone marrow, and other tissues by neoplastic cells of the hematopoietic system. The leukemias comprise a spectrum of malignancies that, untreated, range from rapidly fatal to slowly growing. Based on their untreated course, the myeloid leukemias have traditionally been designated acute or chronic. The diseases usually have long time latent course and unspecific clinical presentation. But every doctor must remember about them and know symptoms, objective and hematologic signs of the acute and chronic leucosis, because they are fatal diseases affecting young and old people.
2. Concrete aims:
─ To study symptoms and signs of acute leucosis
─ To study symptoms and signs of chronic myeloid leucosis
─ To study symptoms and signs of chronic lymphoid leucosis
3. Basic training level
|Previous subject |Obtained skill |
|Normal anatomy |Anatomy of the bone marrow and hematopoietic system |
|Normal physiology |Function of the blood cells, hemopoiesis |
|Histology |Ontogenesis and histological structure of the bone marrow and hematopoietic system |
4. Task for self-depending preparation to practical training
4.1. List of the main terms that should know student preparing practical training
|Term |Term |
|ossalgia |Leukemic gap |
|sternalgia |Blasts |
|chloroma |Eosinophilic basophilic dissociation |
4.2. Theoretical questions:
35. What is hyperplastic syndrome?
36. The main clinical symptoms and signs of the hyperplastic syndrome.
37. What is acute leukemia? Symptoms and signs according to stages, blood test changes and features of myelogram.
38. Clinical presentation of the chronic myeloid leukemia.
39. Clinical presentation of the chronic lymphoid leukemia.
4.3. Practical task that should be performed during practical training
12. To assess blood test at patients with the acute leukemia
13. To assess blood test at patients with the chronic myeloid leukemia
14. To assess blood test at patients with the chronic lymphoid leukemia
Topic content
Hyperplastic syndrome is a hyperproduction of tumor hematopoietic tissue and its dissemination into extramedullar hematosis loci. Its clinical presentation:
• Ossalgia, sternalgia (spontaneous, percussion)
• Hepatomegaly
• splenomegaly
• lymphoadenopathy
• Syndrome of replacement of the normal marrow with pathologic leukemic clone:
─ Anemia (depressing of erythrocytes hematosis)
─ Hemorrhagic syndrome (depressing of thrombocytes hematosis)
─ Intoxication syndrome - (depressing of leucocytes hematosis, agranulocytosis)- ulcer-necrotic and trophy changes of skin and mucosa
• Leukemia is malignant disease of blood cells with primary affecting marrow and entrance of the pathologic clone into peripheral blood
Acute leukemia is disease characterized with a malignant proliferation of white blood cell precursors (blasts) in bone marrow or lymph tissue and their accumulation in peripheral blood, bone marrow, and body tissue. The diagnosis of AML is established by the presence of 20% myeloblasts in blood and/or bone marrow according to the World Health Organization (WHO) classification. Hematosis is stopped at the forth class of the blood cell differentiation.
Clinical presentation of the acute leukemia
Main syndromes: anemia, hemorrhage, hyperplastic, intoxication, replacement normal bone marrow with pathologic clone.
Stages:
initial – mild unspecific clinical symptoms, changes in full blood test and myelogram (myeloblasts).
full-scaled - complete developing all clinical syndromes, in full blood test anemia, thrombocytopenia, ↑ ESR
terminal – severe bleeding, infections, exhausted patient, severe anemia, thrombocytopenia, „leukemic gap” – 10-90% blasts
Patients with acute leukemia most often present with nonspecific symptoms that begin gradually or abruptly and are the consequence of anemia, leukocytosis, leukopenia or leukocyte dysfunction, or thrombocytopenia. Nearly half have had symptoms for 3 months before the leukemia was diagnosed. Half mention fatigue as the first symptom, but most complain of fatigue or weakness at the time of diagnosis. Anorexia and weight loss are common. Fever with or without an identifiable infection is the initial symptom in _10% of patients. Signs of abnormal hemostasis (bleeding, easy bruising) are noted first in 5% of patients. On occasion, bone pain, lymphadenopathy, nonspecific cough, headache, or diaphoresis is the presenting symptom. Rarely patients may present with symptoms from a mass lesion located in the soft tissues, breast, uterus, ovary, cranial or spinal dura, gastrointestinal tract, lung, mediastinum, prostate, bone, or other organs. The mass lesion represents a tumor of leukemic cells and is called a granulocytic sarcoma, or chloroma.
Physical Findings Fever, splenomegaly, hepatomegaly, lymphadenopathy, sternal tenderness, and evidence of infection and hemorrhage are often found at diagnosis.
Hematologic Findings Anemia is usually present at diagnosis and can be severe. The degree varies considerably irrespective of other hematologic findings, splenomegaly, or the duration of symptoms. The anemia is usually normochromic normocytic. Decreased erythropoiesis often results in a reduced reticulocyte count, and erythrocyte survival is decreased by accelerated destruction. Active blood loss also contributes to the anemia.
Changes of the white blood cells: Leucocytosis more than 50*109/l leucocytes is named leukemia, leucocytosis 10-50*109/l - subleukemia, normal or less than normal level of the white blood cells – aleukemia. Acute leukemia is characterized with „leukemic gap” – 10-90% blasts and lower level of mature blood cells without transitional forms of leucocytes.
Platelet counts ................
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