Protein edema is

Protein edema of unspecified genesis

Hello!
My father-in-law is 65 years old in the last yearbegan to appear edema n / to, they themselves disappeared, were not pronounced. More left leg was swollen. Have made ultrasound veins permeability complete, varicose insignificant. Uzi small pelvis-BPH. ECG, ECHO-kg-by age, without any serious pathology. There is a slight hypertension, took enalapril, is now canceled due to hypotension. In the course of the last month, swelling sharply increased, there were swelling on the trunk, hands, stopped walking, ascites appeared. He himself did not complain that he had diarrhea, but often went to the toilet, constant urge to defecate and spasms in the abdomen. A chair with the words of the patient slices, but liquid in the main.
Has grown thin much more than 30 kg for 2 years. The condition is now heavy, lay in the local hospital, drippers were carried out with albumin every other day-only 7 pieces. Today we take it out of the hospital, since there is no diagnosis, there is no treatment, it was not possible to interest the doctor. The chair became better-about 3 times a day, cacheted.

In the anamnesis: hr. pancreatitis (seizures were in his youth, when he drank, then he did not drink 17 years, after his wife's death he drank a couple of times strongly in the hospital with pancreatitis, then did not drink for half a year, sometimes there was a "paralysis" from drinking.) Legs do not go (alcoholic polyneuropathy ?), parkinsonism syndrome.In the lungs, the right lobe of the left lung was a cancer operation in 2008.-Without relapses.Sah diabetes with 2000 g of medium severity, takes diabetes, now the sugar was abolished in the hospital was 2.2.

Colonoscopy 28/12/13-in the anushemorrhoidal nodes at 4 and 7 hours with signs of thrombosis. Sharply painful crack on the posterior wall up to 1.2 cm. The intestinal mucosa is smooth and mobile. The large intestine is inspected to the hepatic flexure with focal atrophy in the lumen of the mucus. Colon tone increased. Gaustration saved. oc: xp external hemorrhoids. Fissure of the anal canal. Xp colitis.

EGDU 29/12/13: In the prepyloric department, a single complete erosion. mucous bulb 12 fingers of the intestine with signs of xp inflammation. oc: xr erosive antral gastritis. Chr duodenitis. Duodenogastric reflux.

CT of the lungs 29/12/13: Restructuring of pulmonary tissue by the type of centricacinar emphysema, the zone of pneumosclerosis, focal formations, focal and infiltrative formations is not revealed. Mediastinum is not biased. Trachea and bronchi are not deformed. l / u not enlarged, calcified bronchopulmonary l / y on the left. In the left pleura
the minimum cavity is the minimum amount of liquid.

CT Org of the abdominal cavity: A significant amount of liquid contents is visualized in the abdominal cavity. There is a thickening of the walls of the stomach. Perigastric fiber is unevenly compacted. The liver is not enlarged. structure of the parenchyma is uniform, 54-58 uN. The female ducts are not dilated. Pancreas with clear contours, parenchyma is atrophic. the spleen is not enlarged. contours are clear. Aorta-norm. Kidneys without features. The renal system is not enlarged. In the renal cups of both kidneys, multiple concretions are visualized. Ascites, thickening of the wall of the stomach? hr indirative pancreatitis.

Cons Gastroenterologist: Dz: Anasarca. Ascites. Hypoalbuminemia of unknown origin. Malabsorption? Whipple's Disease? hr erosive gastritis. Chronic toxic pancreatitis. Xp colitis. Xp external hemorrhoids. Diabetes is a type 2 diabetes. Celiac disease?

Urgent hospitalization is recommended.
They put him in the hospital 29/12 /. Improvement is small only in terms of improving the stool.
Lives with me, does not drink more than half a year in general, the last 2-3 years 1-2 times a year for 100 ml max. Poorly tolerates alcohol. Many people salt food, like spicy, fatty. Eats very much.

An excerpt from the hospital will be tomorrow.

Questions:
1) what to do next? The doctor from the hospital does not know where to send us, recommended to make a passage of barium.
2) albumin continue to drip and how much?
3) where to apply for a consultation in the light of the fact that the patient hardly walks. We can take, but only 1-2 times. Poorly tolerates travel, weak. It would be better to call home.

A patient from Belarus, a citizen of Belarus, does not have Russian citizenship.
Money for paid hospitalization is small, but it will be found if we find a profile department.

Catherine, tell me, the version of alcoholic cirrhosisliver of the treating doctor was voiced? According to the description, it is very likely. When discussing a clinical case in a hidden part of the forum, doctors suggest that you do not hide the patient's alcoholic past from his treating doctors.
In order to clarify the diagnosis - ultrasound of the abdominal cavity in order to determine the diameter of the portal and splenic veins and the size of the spleen.
From biochemical tests: blood on GGTP, fibrinogen, prothrombin, alkaline phosphatase, type 4 collagen, as far as possible determination of NH4, ferritin, transferrin, OJSS, serum iron.
In therapy, in addition to the absolute elimination of alcohol and salt, the dose of veroshpiron is increased (only by agreement with the doctor) to 400 mg per day plus torasemide (diuret) not less than 10 mg per day.

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Always yours, Olga Leonidovna.

I apologize for interfering with the topic. At once I will say that I do not have sufficient experience of managing patients with hepatic encephalopathy. BUT.

In my subjective opinion, the main problem is precisely hepatic insufficiency. One of the main problems is encephalopathy.

Tell me, please, what mood does the patient have, how does he feel about the disease, what is the general mood? What dream? Is there a lack of sleep at night, the need to sleep during the day?

It is also necessary to pass this test. For this, print the file on A4 sheet, the patient should, if possible, inscribe himself first and foremost. Next, you need to note the time for which the patient can connect (as quickly as possible) all the numbers from 1 to 25.
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It is also advisable to determine the level of creatinine urine and ammonia of blood serum (these tests are not done anywhere).

As a specific treatment for hepatic encephalopathy, lactulose is used (Dufalac, Normaise) - this is a laxative. Perhaps decontamination of the intestine is necessary.

An extremely important diet with reduced the content of animal proteins, calorie content of not less than 2000kcal (which is quite difficult on the background of diabetes mellitus)

The factor that aggravates the course of encephalopathy is gastrointestinal bleeding, so it is important to heal erosions and ulcers.

The synthesis of albumin by the liver is reduced, thereforethere are edemas with which it is necessary to fight diuretics. Albumin infusion brings a short-term effect. When taking spironolactone (veroshpirona) you need control of potassium blood, when taking torasemide control of creatinine.

And whether there can be a cirrhosis without augmentation of a liver?

During the course of the disease, the liver with cirrhosis decreases in the sizes.


In general, the problem is complex, requires an integrated approach and great diligence. And the effectiveness is poor. Good luck to you. I hope more adequate specialists will correct me.

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Disce, sed a doctis, indoctos ipse doceto.

Well no. I do not consider this edematic syndrome liver. The patient has the consequences of long-term chronic alcoholic pancreatitis. There are signs of severe exocrine and endocrine pancreatic insufficiency. You can not exclude amyloidosis of the small intestine and, as a consequence, malabsorption syndrome. As a consequence, protein and multivitamin deficiency. + patient's non-compliance with salt-free regime. Here you have a clinical picture.
In the post-examination: a test for pancreatic elastase in the feces and a co-program, the level of vit B 12 in the blood
In treatment - in my opinion, the dose of enzymes is not enough. I do not see the correction of multivitamin deficiency.
Treatment of edematous syndrome is inadequate. Does diuresis change?
We have such patients.


Comments on the message:

angio approved. "In the post-examination: a test for pancreatic elastase in the feces and a co-program, the level of vit B 12 in the blood" + "non-compliance with salt-free regime"

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Sincerely, Oleg Vyacheslavovich Zaitsev.