PANCREATITE

PANCREATITA ACUT~

• DEFINI|IE:

LEZIUNE NECROTIC~ TRADUS~

PRIN DURERI + SEMNE GENERALE.
• INCIDEN|~:
 250-750 LA 1 MILION FEMEI
 110-500 LA 1 MILION B~RBA|I
• CAUZE:
1. obstructive - biliar` 40-60%
2. toxice - 30-50%
3. traumatice
4. metabolice
5. vasculare
10%
6. infec\ioase
7. ereditare
8. idiopatice
 FIZIOPATOLOGIE
1. - conflict secre\ie excre\ie
- obstruc\ie
- expunere la toxice
- cre]terea permeabilit`\ii ductelor
- hipersecre\ie
2. activarea prematur` a enzimelor
3. ischemia duce la P. necrotic`
• Tripsinogen  tripsin`  fosfolipaza A2
surfactant
elastaz`  vase
complement + chinine  CID
kalikreina  bradikinina
 kalidina
lipaza  gr`simea peripancreatic`
Activarea tripsinogenului
↓
Tripsina

Leziuni pancreatice inflamatie

Sistemica MOF Deces

 ANATOMIE PATOLOGIC~
1. FORMA EDEMATOAS~
a) MACRO: - M~RIRE, INDURARE
- EDEM, HIPEREMIE
- LUCIOS, FRIABIL
b) MICRO: - EDEM
- INFILTRARE LIMFOCITAR~
- HEMORAGII
- NECROZE
 ANATOMIE PATOLOGIC~
2. FORMA NECROTIC~
a) MACRO: - MAS~ INFLAMATORIE
- TACHE DE BOUGIE
b) MICRO: - SUPURA|IE-NECROZ~ DE
COAGULARE
- CHISTURI
- FIBROZ~
 CLINIC~
1. FORMA U}OAR~
a) DURERI EPIGASTRICE
b) IRADIERE T12-L2
c) V~RS~TURI
2. FORMA SEVER~
a) DURERE INTENS~
b) V~RS~TURI PERSISTENTE
c) AP~RARE ABDOMINAL~
d) REDUCEREA PERISTALTICII
 DIAGNOSTIC

1. DURERE – brutala (litiaza)

2. V~RS~TUR~, ILEUS

3. AMILAZE, LIPAZE, 3N ALAT - 3N

4. IMAGISTIC~ CT,RMN

5. TRIPSINOGENUL 2
F. ETIOLOGICI
BACTERII

INFLAMA|IE HIPOPERFUZIE NECROZ~ ABCES

PANCREAS

METABOLI|I
METABOLI|I {N S^NGE
{N PERIT

EXUDARE
PERIPANCREATIC~
•}OC
•DETRES~ RESP
•I. RENAL~ Ac.
PSEUDOCHIST •CID
 COMPLICA|II LOCALE

1. ICTER OBSTRUCTIV

2. FISTULE

3. OBSTRUC|IA DUODENULUI
 COMPLICA|II SISTEMICE
1. PIELE - NECROZ~
2. ARTRITE
3. LEZIUNI OSOASE
4. DIABET
5. PLEUREZIE, PNEUMONIE
6. }OC
7. CID
8. PSIHIATRIE
MORTALITATE 5-10% (OBEZI 40%)

PSEUDOCHISTURI 10%
 SCORURI DE SEVERITATE
CRITERIILE RANSON

LA PREZENTARE LA 48 ORE
• V@rsta > 55 ani • Hematocrit  10%
• L> 16.000/mmc • Ureea  5mg%
• Glucoz` > 220mg • PaO2 < 60mmHg
• LDH > 350U/l • Ca < 8mg%
• ALAT > 350U/l • Deficit de fluide > 6l
 SEVERITATE CT
NECROZ~
INFLAMA|IE
PANCREATIC~
PANCREATIC~/PERI F~R~- 0 pct
A. NORMAL < 30% - 2 pct
B. M~RIRE LOCAL~ SAU
DIFUZ~ - 1 pct
30-50% - 4 pct
C. HETEROGEN - 2 pct
> 50% - 6 pct
D. COLEC|IE UNIC~ - 3 pct
E. COLEC|II MULTIPLE - 4 pct
 SCORUL APACHE II
• Insuficienta de organ :

- soc TA < 90 mmHg

- pulmonara Pa O2 < 60 mmHg

- renala creatinina > 2 mg%

 SCORUL APACHE II
• Complicatii sistemice :
Coagulare intravasculara diseminata
- Trombocite < 100.000/mm3
- Fibrinogen < 100mg %
- F.D.P > 80μg/ml
Tulburarai metabolice
- Ca < 7,5 mg%
 PROGNOSTIC

SCOR MORTALITATE

<3 3%
4-6 6%
7-10 18%
 TRATAMENT - INTERNARE
1. FORMA U}OAR~
a) ANTIALGICE
b) ASPIRA|IE
2. FORME COMPLICATE
a) ARDS - evacuare pleural`
b) }oc - hidratare
c) IR ac. - dializ`
d) Hr`nire parenteral` 1,5 N
 NECROZA PANCREATIC~
• CT cu substan\` de contrast
• RM cu gadolinium

 suprainfectare 35-70%
quinolone, imipinem dup` punc\ie ghidat`
 DRENAJ

• CHIRURGICAL

• PERCUTANAT

• MIXT

• ENDOSCOPIE + PAPILOTOMIE
 PANCREATITA CRONIC~
DEFINI|IE: INFLAMA|IE CRONIC~
CARACTERIZAT~ PRIN DISTRUC|IE
IREVERSIBIL~ CE PRODUCE DURERI }I
ALTERARE PERMANENT~ A FUNC|IILOR
PANCREASULUI.
 ETIOLOGIE TIGAR-O
1. TOXIC 3. GENETIC~
METABOLIC a) AUTOSOMAL DOMINANT~
• alcool • gena trisinogenului cationic C7
• tabagism b) AUTOSOMAL RECESIV~
• hiper Ca • gena SPINK-1 C1
• hiper L • gena CFTR
• deficit 1AT
• medicamente
2. IDIOPATIC~
4. AUTOIMUNE
- IZOLATE
- COEXIST^ND CU: - S. SICA
- MICI
- CBP
5. ACUTE RECIDIVANTE
- P. Ac. NECROZANT~
- P. Ac. RECIDIVANT~
- ISCHEMIC~
- IRADIEREA
6. OBSTRUCTIVE
- TUMORI
- STENOZE
- P. DIVISUM
- DISKINEZIE ODDI
 PREZENTARE CLINIC~
1. DURERE
a) puseu acut
b) durere cronic`: - chist
- compresie
 Dispare la 85% dup` 5 ani.
2. STEATOREE
3. DIABET
 PATOGENIE

1. PRECIPITARE

2. STRESS OXIDATIV

3. EFECT TOXIC DIRECT

 DIAGNOSTIC

1. CLINIC - DURERE

2. FUNC|IONAL

3. IMAGISTIC
 TESTE FUNC|IONALE

a) SECRETIN~

b) SECRETINA-PANCREOZIN

c) PR^NZ LUNDH

d) BENZOIL-TIROZIL-PAB

e) STEATOREE
 IMAGISTIC

• ECHO CALCIFIC~RI

• CT PSEUDOCHISTE

• ERCP CANALE NEREGULATE

 EVOLU|IE - COMPLICA|II
Mortalitate 7 ani  50%

• UD
• STEATOREE
• DIABET ZAHARAT
• MALIGNITATE
 TRATAMENT

1. STEATOREE

2. DURERE
- CHIRURGICAL

- ENDOSCOPIC
PANCREATITA AUTOIMUNA
• Anomalii autoimne – anticorpi anti AC II
lactoferina
• Hipergamaglobulinemie (Ig 4)
 ANATOMIE PATOLOGICA
• Marire
• Indurare
• Masa in parenchim
• Guler de limfocite
 CLINICA
• Icter 65%
• Durere abdominala 40%
• Manifestari extrapancreatice - noduli
pulmonari si adenopatii; - insuficienta
renala discreta
 DIAGNOSTIC IMAGISTIC

• CT - ASPECT CARIAT
- HALOU PERIGLANDULAR
- DISPARITIA LOBULILOR
- ADENOPATII REGIONALE
• ERCP –INGUSTARE FOCALA,
SEGMENTARA, DIFUZA
• ECHOENDOSCOPIE - MARIRE DIFUZA
- HIPOECHOIC