The Ministry of Health of the Republic of Uzbekistan Tashkent Medical Academy The department of internal diseases №3 of medical an Medical Pedagogical Faculty

2. Motivation

The majority of patients with postcholecystectomy syndrome, a disease of the operated stomach, first seek medical help general practitioners (GPs). In this situation, the effort is directed at the GP diagnosis of diseases for medical care in a GWP (AEP) in the direction of specialized hospitals. These and other conditions are the basis for the inclusion of this subject in the training of GPs.

3. Interdisciplinary communication and Intra

The teaching of this subject is based on the knowledge of students osnovAnatomiya, histology and cytology with embryology, biology, normal physiology, biochemistry,. Pathological Anatomy, Pathological Physiology, Topographic anatomy and operative surgery, internal medicine Propedeutics, Tuberculosis. Oncology, Radiology and Nuclear Medicine, Physiotherapy, Endocrinology, Faculty Therapy, Hospital Therapy, Orthopedics.

4. The theoretical part

When parsing the theme focuses on the following points lessons:

Typical diseases that occur after surgical removal of the gall bladder and neposredstveenno associated with the operations are: 1) the lack of gall bladder syndrome, and 2) the cystic duct stump syndrome, and 3) constrictive cholangitis and papillitis.

Clinic postcholecystectomical syndrome is characterized by dull pain in the right upper quadrant, the repeated attacks of biliary colic (the formation of stones), the symptoms of cholangitis. The diagnosis can be confirmed vnutrivennoyholegrafiey, retrograde cholangiopancreatography. There may be symptoms of cholestasis, and the predominance of the inflammatory process - simtomy cholangitis. Often marked diarrhea and intestinal disorders, especially with an abundant use of fatty foods and sent messages. Treatment is similar to treatment of biliary dyskinesia and cholecystitis, with the presence of stones and strictures of reoperation.

There are early and late disease operated stomach. These include: Dumping syndrome, hypoglycemic syndrome, afferent loop syndrome, peptic ulcer of anastomosis. When dumping syndrome usually in 10-15 minutes after eating (especially sweet and dairy foods) suddenly appear severe weakness, sweating, hypotension, tachycardia, headache, rapid heartbeat, severe muscle hypotonia, there is an overwhelming desire to lie down. Sometimes abdominal pain cutting nature, rumbling, culminating diarrhea. When there is a sudden hypoglycemic syndrome weakness, dizziness, sudden sensation of hunger after 2-3 hours after a meal, tremors, palpitations, tachycardia, hypotension. In the blood of hypoglycemia. Improve after a meal. When afferent loop syndrome can be a pain in the epigastric region, in the right upper quadrant, profuse vomiting, bringing relief. Because of the frequent vomiting after eating, patients limit themselves to food.

The disease is treated by strength of the stomach	The mechanism of development	The clinical picture	diagnosis	treatment
Dumping syndrome. Occurs in approximately 30-40% of patients after gastric resection Billroth II.	Accelerated gastric emptying and rapid passage of food through the small intestine mass → in the initial part of the small intestine is created unphysiologically high concentration of osmotically active substances → flow of fluid from the blood into the lumen of the small intestine and a decrease in the bcc → irritation niempresso and volyumoretseptorov vascular → release of catecholamines , serotonin, acetylcholine, bradykinin	During the meal or after 5-20 minutes after it, especially after receiving the sweet and dairy foods, the patient has a significant weakness, sweating, palpitations, lethargy, pallor or flushing of the face, dizziness, hypotension, increased blood pressure less frequently, sometimes fainting. There have heaviness and discomfort in the epigastric region, nausea and sometimes vomiting, belching, bloating, and diarrhea. Over time, decreased appetite, weight loss occurs; develop fatigue, mental depression, loss of interest in work and family. Often there is a diencephalic syndrome with sudden bouts of weakness, palpitations, paresthesia. Ends attack copious urine and feces. Duration of attack of from 10 minutes to several hours.	The characteristic symptoms. When X-ray: a fast evacuation of barium suspension ("reset") of the gastric stump and rapid passage through the small intestine.	The diet excludes digestible carbohydrates, milk soups, very hot or cold food. Swapped first and second courses. After the meal, it is desirable to lay in bed or recline in a chair for 30 minutes. Appointed by antiserotoninovym drugs (reserpine, peritol.) In severe cases that can not be treated conservatively, is shown gastroeyunoduodeno reconstructive plastic.
The hypoglycemic syndrome (late dumping syndrome.) Occurs in 5% of patients after gastric resection.	In the jejunum falls once a large number of ready-to-absorption of carbohydrates → increase in the concentration of sugar in the blood → → excessive release of insulin subsequent hypoglycemia.	Develops after 2-3 hours after a meal. There are painful feelings of hunger, sucking pain in the epigastric region, weakness, sweating, palpitations, dizziness, blackouts, feeling the heat, shaking the whole body, sometimes loss of consciousness. The patient must lie down. Reduced blood pressure, blood sugar drops to low numbers. Heavy lasts from a few minutes to 2 hours	The characteristic clinical picture. Glycemic curve after glucose load. There have been rapid and steep rise and a sharp drop in blood sugar below the initial level.	Relief of hypoglycaemic attacks. The patient is forced to carry sugar or cookies in order to escape the painful manifestations of HS.
Afferent loop syndrome. Occurs in 5-10% of cases after gastrectomy Billroth II.	Due to the violation evacuation of duodenal contents of the food eaten hits the abductor, and leads to a loop of jejunum.	Patients complain of a feeling of heaviness in the right hypochondrium and in the epigastric region, nausea, copious, containing a lot of bile, a liquid vomit after 30 minutes - 1 hour after meals. After vomiting brings relief. Persistent vomiting can result in loss of electrolytes, maldigestion and weight loss.	Radiologists-cal signs are long delay of contrast in the resulting loop of jejunum, the violation of its motility, the expansion of the loop.	After the meal, it is recommended to lie on your left side to reduce the casting of food resulting in a loop. Applied prokinetic agent (metoclopramide, loperamide, bromoprid). In severe cases resort to reconstructive surgery.
Afferent loop syndrome. Occurs in 5-10% of cases after gastrectomy Billroth II. Postgastrorezektsionnaya anemia. Detected in 15% of patients who underwent resection of the stomach.	Iron deficiency anemia can occur due to bleeding from a peptic ulcer of anastomosis, which often take place secretly. It contributes to the development of a violation of ionization and the resorption of iron due to accelerated passage through the small intestine and atrophic enteritis. Loss of production of intrinsic factor lowers the recycling of vitamin B | 2 → development hyperchromic anemia.	The clinical picture of anemia.	The results of diagnostic-ray studies in anemia.	Used iron sulfate, iron lactate, ferrokal, Ferroplex, Feramid, ferro-gradumet, tardiferon etc. ferrotherapy combined with oral ascorbic acid. When deficiency of vitamin B12 - oksikobalamin or cyanocobalamin.

The manifestation of PHES	The clinical picture	treatment
No gall bladder syndrome (spasm of the common bile duct or sphincter of Oddi)	It is believed that after cholecystectomy in about 50% of the operated dominant hypertonic sphincter of Oddi. With his spastic condition is usually seen with a brief sharp pain radiating to the typical. There is poor tolerance of fat. The pain is often triggered by psycho-emotional stress. Even when there is no expressed pain fever, jaundice, pruritus	In periods of acute pain shows antispasmodics. Important light diet (№ 5, subject to individual tolerance), frequent meals. Showing the thermal baths, electrophoresis with Novocain, and magnesium sulfate, diathermy, inductothermy UHF.
Obstructive syndrome. It may be due to the "neglected stones" (in 97% of cases) and the newly formed bile duct stones (3% of cases), stenosis of the common bile duct due to chronic pancreatitis, cystic duct stump diverticulum.	The clinical picture is characterized by choledocholithiasis paroxysmal pain in the right upper quadrant, sometimes radiating to the right shoulder and right shoulder blade. Pain are the same as before the removal of the bladder. Attacks of colic usually accompanied by dark urine, itching, jaundice and sometimes discolored feces. In attacks may occur with fever chills. In the interictal period marked persistent pain in the upper abdomen or in the right upper quadrant, heaviness in the pit of stomach after eating.	Approximately 50% of the common bile duct stones depart spontaneously within 4 6ned if their diameter is less than 1 cm Local irrigation (lavage) via a T-shaped drainage and local destruction of the stones (lithotripsy) may accelerate the stone passage. In the presence of jaundice, bile duct extending more than 1 cm in diameter, clinical cholangitis resolved the issue in favor of the choledochotomy.
Excess cystic duct stump	Symptomatology has a certain specificity. Most often, there are attacks of pain in the right upper quadrant, sometimes with fever, jaundice.	Pain and symptoms of biliary hypertension is an indication for reoperation: need to remove the excess length of the cystic duct stump.

The method of "round table".

Purpose: Engage in the discussion of all groups of students with simultaneous control of their knowledge.

The main provisions of methods.

On a circle of paper embarks on a mission. Each student writes a one of the correct in his view of options and passes to the next participant, who must continue to answer to their goal. During the discussion, cross out the wrong answers, that is taken into account when placing the final evaluation at the end of class.

1. Write a common disease, occurring after surgical removal of the gallbladder.

2. Clinic postcholecystectomical syndrome.

3. Studies in postcholecystectomy syndrome.

4. Write a disease of the operated stomach.

Answers:

1. Syndrome without gallbladder, cystic duct stump syndrome, stenosing papillitis and cholangitis, etc.

2. Clinic postcholecystectomical syndrome is characterized by dull pain in the right upper quadrant, the repeated attacks of biliary colic (the formation of stones), the symptoms of cholangitis.

3. Intravenous holegrafiya, retrograde cholangiopancreatography.

4. There are early and late disease operated stomach. These include: Dumping syndrome, hypoglycemic syndrome, afferent loop syndrome, peptic ulcer of anastomosis.

The evaluation criteria

The maximum score 20-19	18-17 point	16-15 point	14-13 point	12 point
Perfect	Good	Satisfactorily	Unsatisfactorily	bad
100%-86%	85%-73%	70-56%	53%-46%	43% and less

4.1 The analytical part

Case Studies:

1. A patient 34 years appealed to the GP complaining of heaviness and bursting pain in the epigastric region and in the right upper quadrant after eating, periodic vomiting and copious vomiting (vomitus painted bile) that brings relief. From history 6 months ago, was operated on for gastric ulcer (gastric resection Billroth 2). On examination: general state of moderate severity, the patient malnutrition, Heart of: high tones sonorities, rhythmic. Pulse 98 beats. 1 min. Blood pressure 100/60 mm Hg. In the lungs auscultated vesicular breathing. The abdomen was soft, a little pain in the epigastric region, soon after ingestion observed swelling in the right hypochondrium, disappearing immediately after vomiting. The liver and spleen were not zoom. The chair is prone to constipation.

1.Perechislite least 4 postoperatsionyhoslozhneny in which there is the above mentioned symptoms;

2. A presumptive diagnosis;

3. Informative research methods;

4. The most informative method of investigation and the changes in it;

5. Tactics GPs.
answers:

№	answers:	point
1	Dumping syndrome, hypoglycemic syndrome, afferent loop syndrome, peptic ulcer of anastomosis.	15
2	afferent syndrome	25
3	Fluoroscopy with barium, EFGDS	20
4	Fluoroscopy with barium: antiruflyuksnoe reduction of afferent loop	20
5.	A referral to a surgeon for surgery	20

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2. Patient K. 38 years, appealed to the GP complaining of bouts of severe weakness in a cold sweat, dizziness, nausea, palpitations after 10-15 min. after meals, especially after the sweets. From history: the patient was operated on for BU 12 sc The patient's condition improved in a horizontal position, and therefore tries to lie down immediately after eating. On examination, the patient malnutrition, skin and mucous membranes pale and clean. In the lungs auscultated vesicular breathing. Heart of: high tones sonorities, rhythmic. Pulse of 100 beats. 1 min. Blood pressure 100/60 mm Hg At the root of the tongue is coated with white bloom. The abdomen was soft, painful in the epigastric region. The liver and spleen were not zoom.

1. A presumptive diagnosis;

2. Additional methods of research;

3. The tactics of the GP with a detailed description of administration (medical and non-medical) patients;

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 3. The patient, 29 years old, turned to the GP with complaints of epigastric pain after 30-40 minutes. after eating, pain intensity and duration than before the operation, accompanied by nausea, heartburn. From history: the patient 2 months. ago had surgery - gastric resection with imposing gastroenteroanastomosis. Objectively: the patient moderate power, the skin and mucous normal color, clean. Cor - high tones sonorities, rhythmic. Pulse 80 beats. 1 min. Blood pressure 120/60 mm Hg In the lungs auscultated vesicular breathing. Tongue coated with white bloom. The abdomen was soft, local pain in the epigastric region. The liver and spleen were not zoom. The chair is prone to constipation.
1. In what three diseases are observed above mentioned symptoms and complaints;

 2. A presumptive diagnosis;

 3. Survey methods;

 4. The tactics of the GP with a detailed description of administration (medical and non-medical) patients;

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4. Patient X. 35 years, appealed to the GP complaining of feeling pressure and colicky pain in the right upper quadrant, occasionally nausea and bloating after eating for the last 2 months. From history: six months ago, surgery for gall - stone disease (cholecystectomy). Objective: t -36,6 C. Cor-high tones sonorities, rhythmic. Pulse 80 beats. 1 min. Blood pressure 110/70 mm Hg. In the lungs auscultated vesicular breathing. The abdomen was soft and painless in the right upper quadrant. Symptoms Ortner, frenikus right negative. The liver and spleen were not zoom. KLA and OAM without deviation.

1.Perechislite at least four diseases in which there is the above mentioned symptoms;

2. A presumptive diagnosis;

3. Informative research methods;

4.Taktika GP;

5. Patient X 36 years, appealed to the GP with complaints of dull nagging pain in the right upper quadrant radiating to the right shoulder blade after a meal, unstable chair, worse after a fatty food or overeating. From history: six months ago, surgery for gall - stone disease (cholecystectomy). 3 Months concerned about the above complaints. When viewed from Cor-tones average sonority, rhythmic. Pulse 70 beats. 1 min. Blood pressure 120/60 mm Hg. In the lungs auscultated vesicular breathing, the abdomen is soft, tenderness in the right upper quadrant. The liver and spleen were not enlarged. Symptoms Ortner, frenikus right negative. KLA and OAM without deviations.
1.Perechislite at least four diseases in which there is the above mentioned symptoms;

2. A presumptive diagnosis;

3. Informative research methods;

4. Specify an additional method of investigation makes the difference to be for confirmation of the disease;

5.Taktika GP;

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6. Sick '31 appealed to the GP complaining of dull, recurrent epigastric pain, bitterness and dryness in the mouth, belching, nausea, loss of appetite. From history 2 months ago operated on for ulcer of the stomach (gastrectomy Billroth 2). On examination: Heart of: high tones sonorities, rhythmic. Pulse 80 beats. 1 min. Blood pressure 110/60 mm Hg In the lungs auscultated vesicular breathing. The abdomen was soft, epigastric pain diffuse character. The liver and spleen were not enlarged.

1.Perechislite at least four diseases in which there is the above mentioned symptoms;

2. A presumptive diagnosis;

3. Informative research methods;

4. The tactics of the GP with a detailed description of administration (medical and non-medical) patients;

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7. Patient X 35, appealed to the GP with complaints of epigastric pain radiating to the back, and sometimes the nature of herpes, worse after a fatty meal, heartburn, feeling of dryness in the mouth, belching, nausea, vomiting, loss of appetite, diarrhea. From history: six months ago, surgery for gall - stone disease (cholecystectomy). After the operation concerned about the complaints listed above. On examination, the patient malnutrition, Heart of: the tones are muted, rhythmic. Pulse 90 beats. 1 min. BP -110 / 60 mm Hg In the lungs, vesicular breathing. The abdomen was soft, painful in the epigastric region. The liver and spleen were not zoom. Frenikus positive sign on the left.
1.Perechislite least five zabolevaniineny in which the above mentioned symptoms are observed;

2. A presumptive diagnosis;

3. Informative research methods;

4. What changes are typical in the stool;

5. The tactics of the GP;

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8. Patient N., 54 years old, turned to the GP complaining of the recent emergence of unmotivated weakness, lack of appetite, weight loss, a feeling of heaviness and vague epigastric pain, darkening of the color of feces to "degteoobraznogo." Over the years, suffering from gastric ulcer. 2 years ago, was operated on for peptic ulcer of the stomach (gastrectomy Billroth 1). The last 10 years of exacerbations was not. 20 years ago suffered hepatitis "A". An objective examination of the patient malnutrition. The skin and mucous membranes are pale, determined by an increase in lymph nodes in the left supraclavicular region. Cor-tones are muffled, rhythmic. Pulse 95 beats. 1 min. Blood pressure 100/70 mm Hg. In the lungs auscultated vesicular breathing. Tongue coated dirty gray patina. The abdomen was soft, painful on palpation in the pyloric department.

1. List at least two diseases, and at least three complications are observed above signs and symptoms;

2. Preliminary diagnosis (main complication);

3.Informativnye survey methods;

4. What is the medical check-up should be at the GP at the initial stages of the disease in this patient;

5. Tactics GP

TESTS.

Tests with one correct answer

1. For early postrezektsionnogodemping syndrome is not characterized by:

a) tachycardia postprandial

b) postprandial slabocti

c) weight loss

d) Tremor postprandial

d) epigastric pain after ingestion
2. Manifestations of early postrezektsionnogodemping syndrome marked

a) 60 minutes after a meal

b) 5-20 minutes after eating

b) 3 hours after eating

g) 120 minutes after meal

d) 5 hours after the meal
3. The patient, 16 days ago operated on for a perforated stomach ulcer, there were febrile fever, pain in the right side. On physical examination of the lungs revealed no pathology. When X-ray - right hemidiaphragm pulled kverhu.V this situation, it can be assumed: