Curs
PANCREATITA
ACUTA
Definitie
- inflamatie acuta a
pancreasului exocrin produs de activarea intrapancreatica a enzimelor care determina autodigestie triptica a glandei edem, necroza, hemoragie
Epidemiologie
incidenta
(SUA), varsta
- 3 / 100.000 locuitori < 15 ani
- 270 / 100.000 locuitori < 45
ani
- 540 / 100.000 locuitori < 65
ani
rasa
- negri /
albi = 3 / 1
sex
- 1:1 (femei - litiaza, barbati - alcool)
Etiologie
FRECVENTE
(90%)
40%
litiaza biliara
30%
alcool
20%
idiopatica
RARE
(10%)
mecanice
(obstructie)
tumori,
duoden, ERCP, traumatic
externe
infectios
(VHB, urlian)
toxice (scorpion)
medic
(corticoizi, tiazide)
vasculare -
aterom, LES, PAN
endocrine -
hiperPTH, sarcina
metabolice -
hiperlipid I, IV, V
imune -
hiperSSB, rejet
Fiziopatologie
TRIPSINOGENUL se transforma
in TRIPSINA la un ph de 7
CHEMOTRIPSINOGENUL se
transforma in CHEMOTRIPSINA
PROELASTAZA se transforma in
ELASTAZA
KALICREINOGENUL se transfroma
in KALICREINA
PROCARBOXIPEPTIDAZA se
transforma in CARBOXIPEPTIDAZA
CONSECINTE
proteoliza
activare
chinine
degradare
mastocite si
eliberare de histamina
radicali
liberi
necroze tesut adipos cu fixare Ca2+
EFECTE
local:
edem, inflamatie,
necroza, hemoragie, tromboza, hemoliza
regional:
pete de citosteatonecroza
sistemic: ↑AV,
↓TA, durere, ileus, ↓Ca2+
AMILAZA marker inocent
OBSTRUCTIE
- SECRETIE
litiaza, bride, calcul, tumora, ascarizi
↑presiunea in amonte
REFLUX
din
duoden prin relaxare Oddi
din
cai biliare (OBSTRUCTIE)
ALCOOL
leziuni
acelule acinoase, steatoza
↑secretia, ↑vascozitatea→dop
(OBSTRUCTIE)
ISCHEMIE
disfunctie mecanism secretie
LIPIDE
pranz lipidic
INFECTIOS
bacterian, viral (oreion, VHB)
Clasificare
Edematos interstitialaAP - edem, inflamatie
Necrotica AP -
necroza
Supurativa = FLEGMON
PERIPANCREATIC - AP - difuz,
ABCES PANCREATIC - AP
- colectie
Pseudochistica AP -
steril sau suprainfectat
MANIFESTARI CLINICE:DEPIND
DE TIPUL HISTOPATOLOGIC
DEBUT
- brutal,
obezi, pranz hiperlipidemic plus alcool
DIGESTIV
durere
abd sup, in
bara, iradiata posterior
voma, ileus
echimoze
(Gray Turner-flanc, Cullen-ombilic)
HDS
EXTRADIGESTIV
febra (piretogen - proteaze, bacterii)
tahicardie /
bradicardie (PIC), ↓TA, soc
detresa respiratorie, pleurezie (stanga)
tetanie (↓
Ca2+)
encefalopatie
(enzime, alcool)
Complicatii
LOCALE~ digestive
abces
pseudochist
perforatie
HDS
GENERALE~ extradigestive
Insuficienta respiratory
Insuficienta renala
Encefalopatie
Coagulopatie
ale
MSOF
Laborator
-AMILAZA
AMILAZEMIE
30
U Wolgemuth, 25 UI/ l, 100 U Somogy
x 100 - 1000 ori, 6 ore - 5 zile
=
necroza, nu se coreleaza cu gravitatea
fals+ : insuf renala,
ocl intest, UD perforat, salivara
fals - : <6 ore, > 5 zile,
fulminanta,
PC parenchim redus
AMILAZURIE ↑
x 3
LICHID PLEURAL, ASCITA ↑ = semn cert
LIPAZA x
3, 10 zile, 70% sensibilitate, 99% specificitate
ELASTAZA 10
zile, RIA, in
fecale
AST, ALT x 2-5 N
LDH > 200 UI
leucocitoza 10
- 16000 necomplicata,
> 16000 supuratie
↓ Ca2+ , Mg2+
↓ glicemie, ↓ lipidemie
↑ uree (polipeptid pancreatic)
↑ PCR ( IL6)
Imagistic
Rx
torace
ARDS
lq pleural stanga
Rx
abdominal pe gol
ansa santinela
colon amputat
CT
pancreatita
acuta necrotica
Ecografie
abdominala,
EUS
criterii de pancreatita acuta, colectii, litiaza
Management
Suspiciune
Diagnostic diferential (eliminare alte
diagnostice)
Diagnostic pozitiv (confirmare)
Evaluare cauza: biliara sau non-biliara
Evaluare severitate
Tratament adecvat cauzei si severitatii
Suspiciune
debut
brusc
pranz
lipidic plus alcool (Merry Christmas!)
APP litiaza biliara (FAT, FEMALE, FIFTY)
durere in bara
lichid in baza stanga
Diagnostic diferential
(eliminare alte diagnostice)
(DURERE, HDS, ↑AMILAZE, )
DIGESTIV
Abdomen acut chirurgical
UGD - durere, HDS (EDS)
T pancreas - (EUS)
EXTRADIGESTIV
Abdomen acut 'medical'
IMA inferior ,
colica renala, saturnina, criza Addison,
porfirie acuta
intermitenta
Diagnostic pozitiv (confirmare)
clinic
(durere)
laborator (↑amilaze)
imagistic
(modificari pancreas ECO, CT)
Evaluare cauza:
biliara sau non-biliara
Scor Blamey (ssb 60%, spec 90%)
sex
feminin (FEMALE)
varsta
> 50 ani (FIFTY)
fosfataza
alcalina
ALAT ↑ precoce
amilaze
foarte ↑
0 factori - 5%, 5 factori -
100%
IMAGISTIC: Rx, ECO, EUS, CT
Evaluare severitate
clinica
functii
vitale (cord, pulmon, rinichi, ficat)
PCR
scor
RANSON (clinic + laborator)
ssb
70%, spec 70%
scor BALTAZAR (CT la 48 de ore)
Evaluare severitate - RANSON (fiecare 1 pct,
max 11)
LA INTERNARE
> 55 ani
leucocite
> 16000/mmc
glicemie
> 200 mg/dl
LDH > 1,5
x N
ASAT > 6 x N
LA 48 DE ORE
scadere Ht
>10%
crestere
uree >5mg/dl
pO2 >60 mmHg
Ca2+ >8mg/dl
scadere
bicarbonat >4 mEq/l
sechestrare lq
>6l
|
GRAD
|
PANCREAS
|
SCOR
|
NECROZA(contrast vascular)
|
SCOR
|
|
A
|
normal
|
|
absenta
|
|
|
B
|
marit
|
|
<1/3 glanda
|
|
|
C
|
infiltrare grasime peripancreas
|
|
1/3 <dar <1/2 glanda
|
|
|
D
|
Magma necrotica
|
|
>1/2 glanda
|
|
|
E
|
Magma necrotica extinsa in abd
|
|
|
|
-0-3 pct-8% PA severa,3%
Mt,7-10 pcte 92%PA severa,17 %Mt
Tratament
adecvat cauzei si severitatii
PA
biliara - ERCP si sfincterotomie in primele 48 de ore de la debut si ulterior colecistectomie
laparoscopica
PA
severa - transfer si management in ATI
ERCP terapeutic -
sfincterotomie
Tratament
sustinere
functii vitale
post
alimentar, alimetatie
parenterala /
enterala
durere
voma incorecibila →
sonda nasogastrica
PA severa →
profilaxie antibiotica
colectii →
punctie percutana pt diagnostic infectie
infectie →
drenaj inchis, chirurgie limitata
NU EXISTA TRATAMENT PATOGENIC CUNOSCUT
sustinere
functii vitale
CARDIOVASCULAR, RENAL
- solutii
cristaloide (apa -
NaCL 0,9%, Ringer lactat)
- solutii coloide (efect
osmotic - tin
apa in vas - plasma, dextran)
- electroliti
RESPIRATOR
- O2, trat ARDS
(IOT + ventilatie
mecanica
post
alimentar, alimetatie
parenterala /
enterala
- parenteral caz
ileus, enteral dupa
reluare transit
- necesar
suplimentar pt PA severa
(stare catabolica
- realimentare
dupa 48 ore fara durere si lipaze < 3 x
durere
- durerea
are si efect socogen
- Nu morfina (spasm sfincter Oddi)
- tramadol,
mialgin, xilina
voma incorecibila →
sonda nasogastrica
Nu de rutina
- PA severa →
profilaxie antibiotica
? la toti
- colectii → punctie percutana pt diagnostic infectie
ghidata
ECO, EUS, Rx
- infectie → drenaj inchis, chirurgie limitata
chirurgia
majora cu rezectii
largi are rezultate nefavorabile (Mt si
Mb crescuta
Alte masuri
INHIBA
SECRETIA
INDIRECT (nu stimul)
ALIMENTE - sonda ng
ACID - anti H2, IPP
DIRECT
GLUCAGON
CALCITONINA
SOMATOSTATIN (Sandostatin)
ANIHILEAZA
SECRETIA
APROTININA (Trasylol)
inhiba
enzimele (tripsina, chemotripsina, kalicreina) dar nu influenteaza necroza
ANTIFIBRINOLITICE
EACA
ANTI FOSFOLIPAZA A
EDTA
ANTIINFLAMATOR
ANTAGONIST PAF (Lexipafant)
ANTIOXIDANTI
vitamina E
Superoxid
dismutaza (SOD
Evolutie
PA edematoasa
infectie
mortaliatae
PA necrotica
infectie
mortalitate
30% caz necroza
infectata
TOT CE E BUN IN
VIATA=E IMORAL, E ILEGAL,
INGRASASAU
DA
PANCREATITA
ACUTA
