Ascites u ordinaciji obiteljskog liječnika – važnost primjene ultrazvuka

Ema Dejhalla, David Zahirović, Tina Zavidić

Cilj ovoga rada je prikazati slučaj bolesnice s kliničkom prezentacijom ascitesa kao znaka novotvorina jajnika, s naglaskom na važnost korištenja orijentacijskog ultrazvuka u ordinacijama obiteljske medicine. 72-godišnja bolesnica javlja se u ordinaciju obiteljske medicine zbog bolova u abdomenu unazad tri dana. Posljednjih mjesec dana primijetila je povećanje opsega trbuha i započela s dijetnom prehranom. Inače boluje od arterijske hipertenzije, kroničnoga bubrežnog zatajenja te ima hijatalnu herniju. Obiteljska anamneza je bez osobitosti. Prilikom fizikalnog pregleda abdomen je iznad razine toraksa, napete stijenke, bezbolan na palpaciju. Peristaltika je čujna, a koža i sluznice prokrvljene. Učine se laboratorijske pretrage u kojima se izdvaja povišen CRP. Učini se ultrazvuk abdomena koji pokazuje masivni ascites. Ne uspijeva se prikazati prostor male zdjelice te se hitno upućuje na odjel gastroenterologije. Daljnja obrada bolničkih specijalista uključuje CT abdomena i zdjelice, RTG grudnih organa, EGDS i kolonoskopiju. Indicira se analiza ascitesa te tumorski markeri i serumski albumini. Biokemijskom analizom ascitesa zaključuje se da je sadržaj tipa eksudata. U laboratorijskom nalazu povišene su razine CEA i CA 19-9. CT abdomena i zdjelice pokazuje u području zdjelice cističnu ekspanzivnu tvorbu sa septama i manjom solidnom komponentom koja ima polazište od desnog jajnika te ispunjava cijeli abdomen, što prvenstveno odgovara ovarijalnom seroznom cistadenomu. Nalazi ostalih dijagnostičkih postupaka bili su uredni. Bolesnica je upućena na daljnje kirurško liječenje na odjel ginekologije. Novotvorine jajnika imaju nespecifične simptome. Uz redovite ginekološke preglede, treba istaknuti važnost temeljite anamneze i fizikalnog pregleda u ordinacijama obiteljske medicine te potrebu da se poveća dostupnost ultrazvučnih pregleda u ordinacijama obiteljske medicine.

The aim of this paper is to present the case of a patient with the clinical presentation of ascites as a sign of ovarian neoplasms, emphasizing the importance of using point-of-care ultrasound in family medicine practices. The 72-year-old female patient visited the family medicine office because of abdominal pain for the past three days. In the last month, she noticed an increase in the growth of her stomach and started a diet. She has a hiatal hernia, chronic renal failure and arterial hypertension. The family history is unremarkable. During the physical examination the abdomen was above the level of the thorax, the wall was taut, painless. Peristalsis was audible, and the skin and mucous membranes were well perfused. Following laboratory testing, an increased CRP was identified. Abdominal ultrasound was performed which showed massive ascites. It was not possible to display the area of the lesser pelvis. The patient was urgently referred to the gastroenterology department. CT scans of the abdomen and pelvis, X-ray of chest organs, EGDS, and colonoscopy were performed. Ascites analysis, tumor markers, and serum albumins test were indicated. Biochemical analysis of ascites concluded that the content was of the exudate type. CEA and CA 19-9 levels were elevated. CT scans of the abdomen and pelvis showed a cystic expansion formation in the pelvic region with septa and a smaller solid component that originated from the right ovary and filled the entire abdomen, which primarily corresponded to an ovarian serous cystadenoma. Other diagnostic procedures were normal. The patient was sent to the gynecology department for further surgical treatment. The symptoms of ovarian neoplasms are nonspecific. In addition to routine gynecological examinations, family medicine offices should emphasize the value of a comprehensive physical examination and history, as well as the necessity of expanding the availability of ultrasound examinations.