Documente Academic
Documente Profesional
Documente Cultură
Redactor ef
Acad. Prof. Dr. Leonida Gherasim
Redactor Executiv
Prof. Dr. I. Bruckner
Secretar de redacie
Conf. Dr. D. Isacoff
Redactori:
Corina Homentcoschi
Adriana Gurghean
Ilinca Svulescu-Fiedler
Colegiul de redacie
Prof. Dr. Dan Andronescu (Bucureti), Prof. Dr. J. Ph. Assal (Elveia), Prof. Dr.
Aurel Babe (Oradea), Conf. dr. tefan Blaj (Bucureti), Prof. Dr. Miron Bogdan
(Bucureti), Prof. Dr. Horaiu Bolosiu (Cluj), Prof. Dr. Emilian Carasc (Cluj),
Prof. Dr. Dan Chea (Bucureti), Prof. Dr. Tudorel Ciurea (Craiova), Prof. Dr.
Adrian Covic (Iai), Prof. Dr. Radu Cristodorescu (Timioara), Prof. Dr.
Georgeta Datcu (Iai), Prof. Dr. Mircea Deac (Sibiu), Prof. Dr. Mircea Diculescu
(Bucureti), Prof. Dr. Andrei Gheorghe Dan (Bucureti), Dr. J.V.Elte
(Danemarca), Dr. A. G. Frazer (UK), Prof. Dr. Carmen Ginghin (Bucureti),
Prof. Dr. Mircea Grigorescu (Cluj), Prof. Dr. Alexandru Incze (Tg. Mure), Dr.
A. Ionescu (UK), Prof. Dr. Cezar Macarie (Bucureti), Prof. Dr. Gabriel
Mircescu (Bucureti), Prof. Dr. Ingrid Mlhauser (Germania), Prof. Dr.
Minerva Muraru (Bucureti), Prof. Dr. Delia Mut-Popescu (Bucureti), Prof. Dr.
Dan Olteanu (Bucureti), Prof. Dr. Oliviu Pascu (Cluj), Prof. Dr. Maria Puchi
(Arad), Prof. Dr. Maria Rdoi (Braov), Prof. Dr.Victor Stoica (Bucureti), Prof.
Dr. Adrian Strainu-Cercel (Bucureti), Prof. Dr. Stefanita Tnseanu (Bucureti),
Prof. Dr. Coman Tnsescu (Bucureti), Prof. Dr. Mirela Tomescu (Timioara),
Prof. Dr.Ioan intoiu (Bucureti), Prof. Dr. Gabriel Ungureanu (Iai), Conf. Dr.
Ana-Maria Vldreanu (Bucureti), Prof. Dr. Mihai Voiculescu (Bucureti),
Prof. Dr. Florea Voinea (Constana).
Editor Coordonator
Andreea Manea
Editor
Coloseum Events
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Toate drepturile asupra articolelor aprute n aceast publicaie sunt rezervate
Societii Romne de Medicin Intern 2007.
ISSN: 1220-5818
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CUPRINS
NR. 6 / 2007
ANUN LUCRRI TINERI INTERNITI
ANUN NSCRIERE CU TARIFE PENTRU 2008
CUVNTUL PREEDINTELUI
MEDICINA INTERN N SECOLUL XXI - I Bruckner
STUDII ORIGINALE
ENDOTELIUL: CHEIA CTRE O MAI BUN DEFINIRE A
RISCULUI CARDIOVASCULAR ? - Ana-Maria Vintil, Alexandra
Popescu, Simona Avram, Ioana Culea, Minerva Muraru, I Bruckner
INVESTIGATING THE RELATIONSHIP BETWEEN
AGGRESSION, IMPULSIVITY, SENSATION SEEKING, SELFREPORTED ORAL HEALTH STATUS, ORAL HEALTHRELATED BEHAVIORS IN ROMANIA - A L Dumitrescu, B
Dogaru , C Dogaru
EVALUAREA ECOCARDIOGRAFIC A FUNCIEI
DIASTOLICE A VENTRICULULUI STNG N
HIPERTIROIDISM LA DEBUT - Camelia Scrneciu, H Rus, I
Scrneciu
CUM DIAGNOSTICM ?
EVALUAREA TESTELOR DIAGNOSTICE: SENSIBILITATE,
SPECIFICITATE, CURBA ROC I RAPOARTE DE
PROBABILITATE - C Bicu, Anda Bicu, Autor corespondent
REFERATE GENERALE
FACTORII DE RISC PENTRU LITIAZA BILIAR
COLESTEROLIC - Simona-Elena Trziu, Monica Acalovschi
CONFERIN MONOTEMATIC:
MANIFESTRILE EXTRADIGESTIVE ALE HIPERTENSIUNII
PORTALE - Carmen Fierbineanu - Braticevici, D Isacoff et al
PREZENTRI DE CAZURI
SINDROMUL FEBRIL PRELUNGIT LA VRSTNICI:
PROVOCAREA REPREZENTAT DE ARTERIT
GIGANTOCELULAR - I Parac, O Suciu, L Dobre
COMPLICAII NTR-UN CAZ DE CIROZ HEPATIC Manuela Popescu, D L Dumitracu, C Puia
ANUN CONGRES LUCRRI
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CUVNTUL PREEDINTELUI
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STUDII ORIGINALE
REZULTATE
Analiza demografic a lotului studiat a pus n eviden
prezena n proporii egale a celor dou sexe (30 brbai, 30
femei). Dei selecia pacienilor a fost aleatoare, s-a constatat
o diferen semnificativ statistic ntre vrstele medii ale
loturilor de brbai, respectiv femei, acestea din urm fiind
mai n vrsta n medie cu 12 ani (70 ani femei vs 58 ani
brbai., p=0.0064) (figura 1).
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STUDII ORIGINALE
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STUDII ORIGINALE
INVESTIGATING THE
RELATIONSHIP BETWEEN
AGGRESSION, IMPULSIVITY,
SENSATION SEEKING,
SELF-REPORTED ORAL HEALTH
STATUS, ORAL HEALTH-RELATED
BEHAVIORS IN ROMANIA
A L Dumitrescu, B Dogaru , C Dogaru
University of Medicine and Pharmacy "Carol Davila",
Bucharest, Romania
Address of the author responsible for correspondence:
Alexandrina L. Dumitrescu,
Department of Periodontology,
School of Dental Medicine,
University of Medicine and Pharmacy "Carol Davila",
Address: Aleea Dumbravita nr.2, bloc 28, scara B, etaj 1,
ap.49, sector 6, Bucuresti 66, R.O.U. 061572
Phone: (00)40-722 352 504
E-mail: alexandrina_l_dumitrescu@yahoo.co.uk
Rezumat
Acest studiu evalueaz impactul tipului
A de
personalitate, agresivitate, impulsivitate, sensation
seeking asupra statusului snattii orale i
comportamentului legat de sntatea oral pe un lot de
198 de studeni romni aflai n primul an de studii
medicale. Diferene semnificative au fost gsite n ceea ce
privete ostilitatea de percepie a sntii dentare, a
cariilor curente netratate, a ultimei dureri dentare i a
sngerrilor gingivale. Studenii cu scoruri nalte de
agresivitate i impulsivitate au tendina de a-i peria dinii
mai puin de o dat pe zi, n schimb folosesc aa dentar i
apa de gur zilnic. De asemenea, au vizitat medicul dentist
cu mai puin de o lun n urm, mai ales atunci cnd exist
durere sau necesitatea unui tratament. Analiza regresiei
lineare a artat c exist o puternic asociere ntre
agresivitatea verbal a studenilor, furie, ostilitate i
comportamentul legat de sntatea oral. Rezultatele
sugereaz c agresivitatea, furia, ostilitatea i
impulsivitatea ar putea constitui factori ce influeneaz
statusul sntii orale.
Cuvinte cheie: tipul A comportamental, agresivitate,
impulsivitate, sntate oral.
ABSTRACT
This study examined the impact of type A personality
pattern, aggression, impulsivity, sensation seeking on
self-reported oral health status and oral-health-related
behaviors in a sample of 198 first year medical students in
Romania. Significant differences were found on hostiliy
according to perceived dental health, current non-treated
caries, satisfaction by appearance of own teeth, toothache
last time and self-reported gum bleeding. Students with
higher aggression and impulsivity scores were more
likely to brush their teeth less once a day, but to floss their
teeth everyday, to use mouthrinses everyday, to visit
their dentist less than one month ago, but mainly when
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this study and addressed the following: (1) sociodemographic factors (age, gender, smoking); (2) perceived
oral health status (dental health, non-treated caries,
extracted teeth, satisfaction by appearance of own teeth,
dental pain, gingival condition, gum bleeding); (3) oral
health habits (toothbrushing, flossing, mouthrinse
frequency, dental visiting) (Honkala & Al-Ansari 2005,
Christensen et al. 2003, Sthlnacke et al. 2003). Subjects were
classified as smokers, past-smokers and non-smokers. The
questionnaire contained also three questions concerning
stress, anxiety and depression, namely "do you feel anxious
(depressed or stressed) in your every day life" with the
response alternatives, (1) no, never, (2) yes, sometimes and
(3) yes, often. Measure of The Type A behaviour pattern
(TABP) included the Bortner scale (Bortner, 1969). Among
the most widely used questionnaire measures of the TABP,
the Bortner Rating Scale has the advantage of being brief
(Nabi et al. 2005). The original version consists of 14 bipolar
items, each graduated from 1 to 24, whereas the items of the
version used with the present study were graduated from 1
to 6, adding up to scores ranging from 14 to 84 (Nabi et al.
2005). In the present study the Bortner scale had a coefficient
alpha of 0.758.
The Buss-Perry Aggression Questionnaire (AQ), a selfrating scale was published in 1992, and has quickly become
the gold-standard for the measurement of aggression. The
AQ comprises 29 items of a five-point Likert format from
one ('extremely uncharacteristic of me') to five ('extremely
characteristic of me'). The four widely used subscales of the
questionnaire, established on the basis of factor analyses,
were Physical Aggression (PA, nine items), Verbal
Aggression (VA, five items), Anger (AN, seven items) and
Hostility (HS, eight items) (Buss& Perry, 1992). The
subscales were reported to have alpha coefficients of 0.72 to
0.85, indicating adequate internal consistency, and test-retest
coefficients of 0.72 to 0.80, showing acceptable reliability
(Buss& Perry, 1992). In the present study AQ had a
coefficient alpha of 0.848.
The Barratt Impulsiveness Scale (BIS) is one of the most
commonly used scales to measure the construct of
impulsivity. The BIS is a 30- item, self-rating scale measuring
aspects of impulsivity. The items form three nonoverlapping scales that showgood reliability: non-planning
(BISnp), motor impulsivity (BISm), and attentional
impulsivity (BISa) (Patton et al. 1995). Items are rated on a 4point Likert-type scale (1 = rarely/never, 4 = almost always).
The BIS has been demonstrated to have good reliability and
validity in normal and clinical populations of several
neuropsychiatric conditions characterized by increased
impulsivity, including bulimia, bipolar disorder,
kleptomania and borderline personality disorder (Paul et al.
2002; Swann et al. 2001; Dougherty et al. 1999; Bayle et al.
2003). A 15-item short form of the BIS (BIS 15) is presented
that retains the 3-factor structure (non-planning, motor
impulsivity, and attention impulsivity), and maintained
good reliability and validity (Spinella, 2007). In the present
study BIS had a coefficient alpha of 0.635.
The Brief Sensation Seeking Scale (BSSS) was created by
adapting items from the Form V of the Sensation Seeking
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STUDII ORIGINALE
Table 1. Correlations between type A personality pattern, aggression, impulsivity, sensation seeking subscales
Table 2. Comparison of type A personality pattern, aggression, impulsivity, sensation seeking scales (Mean S.D.) according
to some outcome variables
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Table 3. Comparison of type A personality pattern, aggression, impulsivity, sensation seeking scales (Mean S.D.) according
to self-reported oral-health status
In order to assess the relationship between Type A
personality pattern, aggression, impulsivity, sensation
seeking and oral health-related behaviours several
outcome variables were used: toothbrushing, flossing,
mouthrinse frequency and pattern of dental visit (Table 4).
Students with higher aggression and impulsivity scores
were more likely to brush their teeth less once a day, but to
floss their teeth everyday (P<0.05), to use mouthrinses
everyday, to visit their dentist less than one month ago,
but mainly when treatment is needed or when pain occurs.
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STUDII ORIGINALE
Table 4. Comparison of type A personality pattern, aggression, impulsivity, sensation seeking scales (Mean S.D.) according
to self-reported oral-health habits
behaviours multiple linear regression analyses were
performed. The results indicated that the current model
significantly predicted self-reported oral health status
(R2=0.18, F=2.85, P=0.001) and behaviours (R2=0.12, F=1.75,
P<0.05). (Table 5)
DISCUSSION
The results of the current study demonstrate several
interesting and significant findings. Of the four
Table 5. Independent determinants of self-reported oral health status, gingival status and oral health behaviors
(continued on page 18)
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Table 5. Independent determinants of self-reported oral health status, gingival status and oral health behaviors
teeth significantly more often and to have better oral
hygiene compared with those with the highest cynical
hostility level. The association of cynical hostility with the
toothbrushing frequency and oral hygiene seems to be
partly dependent on the level of education (Mettovaara et
al. 2006). Aggression (Sher et al. 2005), anger (Kerby et al.
2003; Fraguas et al. 2007), hostility (Whiteman et al. 1997;
Hampson et al. 2007), impulsivity (Diergaarde et al. 2007;
Doran et al. 2007) and sensation seeking (Gurpegui et al.
2007) have been found to increase the prevalence of
smoking, and smoking, in turn, results in a poor level of
oral hygiene, a finding that is also supported by the health
behaviour model (Leiker & Hailey, 1988). In addition, it
was also showed that aggressive behavior was common
among individuals experiencing depression, stress and
anxiety (Sher et al. 2005; Ferguson et al. 2005).
Psychological research on disease has also focused on
inhibition and repressive coping. It has been previously
reported that inhibited subjects displayed low levels of
Type A behavior, anger, and hostility, but also
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STUDII ORIGINALE
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
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33.
34.
35.
36.
37.
38.
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40.
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43.
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45.
46.
47.
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49.
50.
51.
52.
53.
54.
55.
56.
57.
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STUDII ORIGINALE
EVALUAREA ECOCARDIOGRAFIC
A FUNCIEI DIASTOLICE A
VENTRICULULUI STNG N
HIPERTIROIDISM LA DEBUT
Camelia Scrneciu, H Rus, I Scrneciu
Universitatea Transilvania" Braov
Rezumat
n acest studiu este evaluat funcia diastolic ventricular
a unui grup de pacieni diagnosticai cu hipertiroidism la
debut. Rezultatele evideniaz creterea circulaiei
sanguine transmitrale i o cretere a velocitii undei E'. n
concluzie, n hipertiroidism exist o mbuntire a
funciei diastolice ventriculare. Velocitatea undei E' i
TDE sunt cei mai buni indicatori ai hipertiroidismului i se
coreleaz cu nivelul hormonilor tiroidieni. Velocitatea
undei E' este cel mai bun indicator al funciei diastolice n
tahicardie.
Cuvinte cheie: velocitate und E', hipertiroidism, funcie
diastolic.
Abstract
In this study we evaluate diastolic function on a grup of
patients with hyperthyroidism in debut. The results
shows an increase of transmitral blood circulation and an
increase of E' wave velocity. In conclusion, in
hyperthyroidism is present an improvement of diastolic
function. The E' wave velocity and TDE are the best
pointers for hyperthyroidism and they are corelated with
thyroid hormons level. E' wave velocity is the best pointer
for diastolic function in tahicardia.
I. INTRODUCERE
Prima parte a diastolei clinice, relaxarea izovolumetric,
se caracterizeaz prin scderea rapid a presiunii
intraventriculare fiind un proces activ consumator de
energie i dependent de irigaia sangvin. n tireotoxicoz
crete viteza relaxrii diastolice (efect lusitrop pozitiv) cu
creterea consumului miocardic de oxigen i energie.
A doua parte a diastolei, este ns un proces pasiv,
dependent de calitaile vscoelastice ale miocardului.
Hipertrofia miocardic, care se produce n tireotoxicoz,
crete rigiditatea miocardic prin ngroarea pereilor.
Dilataia ventricular ns, prin deplasarea spre dreapta a
relaiei presiune volum, o scade. In tireotoxicoz se
produce ngroarea pereilor ventriculari i creterea
volumului cavitii ventriculare fr modificarea
presiunilor.
Pe de alt parte, datorit scderii duratei diastolei prin
tahicardie, este posibil mpiedicarea umplerii diastolice
din faza a doua, ceea ce creeaz o mare dependen a
umplerii ventriculare de sistola atrial.
Evaluarea funciei diastolice este prin excelen ecografic,
prin evaluarea fluxului transmitral i determinarea
velocitii undei E' prin examen Doppler color, pulsat sau
tisular.
II. MATERIAL I METOD
S-a realizat un studiu prospectiv pe pacieni aduli, sub 50
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Bibliografie
1.
Braunwald - Heard disease - Tratat de boli cardiovasculare, vol.I si vol.II,
dupa ediia a V-a Editura M.A.S.T., 2000.
2.
Bernadette Biondi, Emiliano A.Palmieri, Gaetano Lombardi, Deradino
Fazio, Effects of Thyroid Hormone on Cardiac Function: The Relative Importance
of Heart Rate, Loading Conditions, and Myocardial Contractility in the
Regulation of Cardiac Performance in Human Hyperthyroidism, 2002, The
Journal of Clinical Endocrinology & Metabolism 87(3): 968-974
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Craiu E., Ghinghin C., Tintoiu I., Voicule C. Certitudini n cardiologia
modern. Vol I+II, Ed. Dobrogea, 2001.
4.
Michael C Sheppard CardiacDysrhythmias and Thyroid dysfunction; The
Hiden Menace?, The Journal of Clinical Endocrinology & Metabolism , 87(3) 963967, 2002.
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Faizel Osman, Jayne A Francklyn, Jacquline Daykin et all , Heart rate
variability and Turbulence in hyperthyroidism before, during and after treatment,
The American Journal oif Cardiology, vol 94, No 4, August 2004.
6.
Odemuyiwa O, Malik M, Farrel T, et all, Coparison of the predictive
characteristics of heart rate variability index and left ventricular ejection fracton
for all-cause motality, arrhythmic events and sudden death after acute myocardial
infarction. Am J. Cardiol 1991;68(5): 434-9.
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CUM DIAGNOSTICM ?
EVALUAREA TESTELOR
DIAGNOSTICE: SENSIBILITATE,
SPECIFICITATE, CURBA ROC I
RAPOARTE DE PROBABILITATE
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CUM DIAGNOSTICM ?
2
3
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REFERATE GENERALE
REZUMAT
Litiaza biliar este o afeciune cu o prevalen de pn la
20% n rile europene, calculii de colesterol reprezentnd
80% din totalul cazurilor de litiaz biliar. Factorii de risc
care favorizeaz litogeneza au fost evaluai de-a lungul
timpului n studii largi epidemiologice. Vrsta naintat,
sexul feminin, sarcina i factorul genetic constituie factori de
risc de teren (nemodificabili). Cercetrile recente s-au
ndreptat spre identificarea genelor de susceptibilitate la
formarea calculilor biliari la om pornind de la harta genetic
murin a locusurilor litogenice (lith). Descoperirea
repertoriului uman de locusuri litogenice Lith, de gene
candidate i a funciei lor n patogeneza litiazei biliare
deschide noi orizonturi de prevenire a formrii calculilor
biliari de colesterol. Factorii de risc de mediu sunt
reprezentai de obezitate, scderea brusc n greutate,
dislipidemiile, diabetul zaharat, dieta bogat n
hidrocarburi rafinate i srac n fibre vegetale, fumatul sau
sedentarismul.
Cuvinte cheie: calculii biliari colesterolici, locusuri
litogenice, susceptibilitate genetic, factori de risc
ABSTRACT
Gallstone disease has a prevalence of up to 20% in Western
countries and cholesterol gallstones constitute more than
80% of biliary stones. Many epidemiologic studies have
evaluated the risk factors that compete for lithogenesis. Age,
gender, pregnancy and genetic factors are constitutional
(unmodifiable) factors. Recent researches have been
directed to identify gallstones susceptibility genes based on
the murin gallstone map of the lith locus. In the future, the
discovery of the entire spectrum of lithogenic candidate
genes" and their function in gallstone pathogenesis will
provide new targets for the prevention of gallstone disease.
Environmental risk factors are obesity, rapid weight loss,
hypertriglyceridaemia, diabetes mellitus, diet rich in
refined sugars and poor in fiber, smoking and physical
inactivity.
Key words: cholesterol gallstones, lithogenic locus,
genetic susceptibility, risk factors
INTRODUCERE
Litiaza biliar este o afeciune complex, n cele mai multe
cazuri fiind rezultatul interaciunilor dintre gene multiple
i al interaciunii genelor cu un mediu litogenetic precum
dieta, multiparitatea, obezitatea, medicamente (1-5).
Exist dou categorii de factori de risc implicai n
litogenez: factori de risc de teren i factori de risc de
mediu (tabel 1) (6):
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REFERATE GENERALE
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REFERATE GENERALE
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
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CONFERIN MONOTEMATIC
MANIFESTRILE EXTRAHEPATICE
ALE HIPERTENSIUNII PORTALE
Carmen Fierbineanu-Braticevici
Clinica Medical II i Gastroenterologie, Spitalul Universitar
Bucureti
Hipertensiunea portal este un sindrom clinic datorat
creterii patologice a presiunii n sistemul port. n mod
normal, presiunea port este cuprins ntre 5-10 mmHg,
iar fluxul sanguin portal este de 1-1,5 l/min.
Hipertensiunea portal apare atunci cnd gradientul de
presiune ntre vena port i vena cav inferioar
(gradientul portal de presiune) crete peste limita normal
de 5 mmHg. Cnd acest gradient are valori cuprinse ntre
6-10 mmHg apare hipertensiune portal subclinic, n
timp ce, hipertensiunea portal se manifest clinic atunci
cnd gradientul portal depete valoarea prag
reprezentat de 10 mm Hg.
Manifestrile hipertensiunii portale constau n
dezvoltarea varicelor gastroesofagiene, ascitei, disfunciei
renale i cardiace, encefalopatiei portosistemice,
hipersplenismului i a sindromului hepatopulmonar. Din
aceast cauz, valori ale gradientului portal de presiune
peste 10-12 mmHg, definesc hipertensiunea portal
semnificativ din punct de vedere clinic.
n mod normal, n orice sistem vascular, presiunea este
determinat de produsul dintre
fluxul sanguin i
rezistena vascular. Iniial, hipertensiunea portal este
determinat de creterea rezistenei n sistemul port, iar
ulterior este agravat de creterea influxului portal venos.
Etiologia hipertensiunii portale presupune toate
afeciunile care determin obstrucia fluxului sanguin la
orice nivel n interiorul sistemului port. n funcie de
localizarea anatomic a obstacolului, hipertensiunea
portal se clasific n prehepatic (afeciuni ale venelor
splenice, mezenterice sau porte), intrahepatic (afeciuni
acute sau cronice hepatice) i posthepatice (afeciuni ale
venelor suparahepatice).
Ciroza este cea mai frecvent cauz a hipertensiunii
portale, urmat de schistosomiaza hepatic; toate celelalte
afeciuni reprezint sub 10% din cauzele hipertensiunii
portale, motiv pentru care sunt ncadrate n
hipertensiunea portal noncirotic.
Importana hipertensiunii portale const n frecvena i
severitatea complicaiilor: sngerare gastrointestinal,
encefalopatie hepatic, hipoxemie arterial, insuficien
renal, bacteriemie. Aceste complicaii sunt cauzele
majore de deces i reprezint principala indicaie pentru
transplantul hepatic al pacienilor cu ciroz.
Ciroza este un proces difuz caracterizat prin fibroz cu
modificarea arhitecturii normale hepatice ntr-o structur
anormal de tip nodular. n ciroz, modificrile
arhitecturii hepatice intereseaz att parenchimul ct i
sistemul vascular, ambele componente anatomice
contribuind la tulburarea fluxului n vena port. Venele
hepatice, tributarele lor i ramurile venei porte sunt
comprimate de nodulii parenchimatoi de regenerare, iar
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Figura 1. NO n ciroz
Factorul care moduleaz creterea rezistenei
intrahepatice din ciroz este dezechilibrul dintre
eliberarea sczut a substanelor endogene
vasodilatatoare i producia crescut a substanelor
vasoconstrictoare i a rspunsului vascular la aciunea
acestora.
n stadiile avansate ale hipertensiunii portale apare o
modificare hemodinamic caracteristic afeciunilor
cronice hepatice, un fenomen multifactorial care
intereseaz circulaia intrahepatic, sistemic i circulaia
colateral portosistemic. La aceste modificri
hemodinamice contribuie mecanisme neurale, umorale i
locale (Benoit i Granger,1989).
SINDROMUL HIPERKINETIC DIN HIPERTENSIUNEA
PORTAL
O caracteristic a bolilor severe hepatice este dezvoltarea
unui status vascular hiperdinamic n circulaia splanhnic
i sistemic. Modificrile reactivitii vasculare
(vasoconstricia circulaiei hepatice /vasodilataia
circulaiei sistemice) au rol central n patogeneza
hipertensiunii portale contribuind la creterea rezistenei
intrahepatice, circulaia hiperdinamic i expansiunea
circulaiei colaterale. Sindromul circulator hiperdinamic
este un exemplu de cercetare al crui punct de plecare a
fost obsevaia clinic a pacienilor cu ciroz; n 1953,
Kowalski i Abelman au postulat ipoteza c n ciroz
exist un sindrom circulator hiperdinamic susinut de
observaia clinic a pacienilor cirotici: extremiti calde,
stelue vasculare, presiunea pulsului mare, puls capilar
unghial. n ultimii 50 de ani cercetrile au evoluat de la
observaia clinic la nivelul molecular al acestui sindrom,
folosind ca staie intermediar modelele experimentale
care nc servesc ca surs de nelegere a acestui sindrom.
(Figura 2)
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39
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CONFERIN MONOTEMATIC
Bibliografie:
1. Pagliaro LD, Amico G, Pasta L, Tine F, Aragona E, Politi F, Malizia G, et al.
Efficacy and efficiency of treatments in portal hypertension. In: deFranchis R, ed.
Portal Hypertension II. Proceedings of the Second Baveno International
Consensus Workshop on Definitions, Methodology and Therapeutic Strategies.
Oxford: Blackwell Science, 1996:159 -179.
2. Chalasani N, Kahi C, Francois F, Pinto A, Marathe A, Bini EJ, Pandya P,et al.
Improved patient survival after acute variceal bleeding: a multicenter, cohort
study. Am J Gastroenterol 2003;98:653- 659.
3. Loureiro-Silva Mauricio R, Cadelina Gregory W, Groszmann Roberto J.Deficit
in nitric oxide production in cirrhotic rat livers is located in the sinusoidal and
postsinusoidal areas. Am J Physiol Gastrointest Liver Physiol 2003;284:G567G574.
4. Burroughs AK, Groszmann R, Bosch J, Grace N, Garcia-Tsao G, Patch
D,Garcia-Pagan JC, et al. Assessment of therapeutic benefit of antiviral therapy in
chronic hepatitis C: is hepatic venous pressure gradient a better end point? Gut
2002;50:425- 427.
5. Groszmann RJ, Garcia-Tsao G, Makuch R, Bosch J, Planas R, Escorsell A,
Garcia-Pagan JC, et al. Multicenter randomized placebo-controlled trial of nonselective beta-blockers in the prevention of the complications of portal
hypertension: final results and identification of a predictive factor [abstract].
HEPATOLOGY 2003;38(Suppl 1):206A.
6. Lebrec D, Nouel O, Corbic M, Benhamou JP. Propranolola medical treatment for
portal hypertension? Lancet 1980;2:180 -182.
7. Groszmann RJ, Bosch J, Grace N, Conn HO, Garcia-Tsao G, Navasa M, Albert J,
et al. Hemodynamic events in a prospective randomized trial of propranolol vs
placebo in the prevention of a first variceal hemorrhage. Gastroenterology
1990;99:1401-1407.
8. Feu F, Garcia-Pagan JC, Bosch J, Luca A, Teres J, Escorsell A, Rodes J. Relation
between portal pressure response to pharmacotherapy and risk of recurrent
variceal hemorrhage in patients with cirrhosis. Lancet 1995;346: 1056-1059.
9. Myers JD, Taylor WJ. An estimation of portal venous pressure by occlusive
catheterization of a hepatic venule. J Clin Invest 1951;30:662- 663.
10. Bosch J, Mastai R, Kravetz D, Navasa M. Rodes J. Hemodynamic evaluation of
patients with portal hypertension. Semin Liver Dis 1986;6:309- 317.
11. Boyer TD, Triger DR, Horisawa M, Redeker AG, Reynolds TB. Direct
transhepatic measurement of portal vein pressure using a thin needle: comparison
with wedged hepatic vein pressure. Gastroenterology 1977;72(4
part 1):584 -589.
12. Moreno AH, Burchell AR, Rousselot LM, Panke WF, Slafsky F, Burke JH.
Portal blood flow in cirrhosis of the liver. J Clin Invest 1967;46:436-445.
13. Kotelanski B, Groszmann R, Cohn JN. Circulation times in the splanchnic and
hepatic beds in alcoholic liver disease. Gastroenterology 1972;63:102- 111.
14. Cohn JN, Khatri IM, Groszmann RJ, Kotelanski B. Hepatic blood flow in
alcoholic liver disease measured by an indicator dilution technic.AmJ Med
1972;53:704-714.
15. Groszmann RJ, Kotelanski B, Cohn JN. Different patterns of porta-systemic
shunting in cirrhosis of the liver studied by an indicator dilution technique. Acta
Gastroenterol Latinoam 1971;3:111-116.
16. Groszmann RJ, Vorobioff J, Riley E. Splanchnic hemodynamics in
portalhypertensive
rats: measurement with gamma-labeled microspheres. Am J Physiol
1982;242:G156-G160.
17. Vorobioff J, Bredfeldt JE, Groszmann RJ. Hyperdynamic circulation in portalhypertensive rat model: a primary factor for maintenance of chronic portal
hypertension. Am J Physiol 1983;244:G52-G57.
18. Vorobioff J, Bredfeldt JE, Groszmann RJ. Increased blood flow through the
portal system in cirrhotic rats. Gastroenterology 1984;87:1120-1126.
19 Piscaglia F, Gaiani S, Gramantieri L, Zironi G, Siringo S, Bolondi L. Superior
mesenteric artery impedance in chronic liver diseases: relationship with disease
severity and portal circulation. Am J Gastroenterol 2000;95: 551-552.
20. Abraldes JG, Iwakiri Y, Loureiro-Silva M, Haq O, Sessa WC, Groszmann RJ.
Mild increases in portal pressure up-regulate VEGF and eNOS in the intestinal
microcirculation leading to hyperdynamic state. Am J Physiol Gastrointest Liver
Physiol 2006. In press.
21. Tsai MH, Iwakiri Y, Cadelina G, Sessa WC, Groszmann RJ. Mesenteric
vasoconstriction triggers nitric oxide overproduction in the superior mesenteric
artery of portal hypertensive rats. Gastroenterology 2003;125
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CONFERIN MONOTEMATIC
EVALUAREA ECOGRAFIC A
MANIFESTRILOR
EXTRADIGESTIVE DIN
HIPERTENSIUNEA PORTAL
neinvaziv i reproductibil de diagnostic al HTPo, oferindune totodat informaii referitoare la etiologia acesteia.
Alturi de semnele de ciroz (ficat cu ecostructur granular,
margine neregulat vizibil n lichidul de ascit - foto 1aspect de ficat "mncat de molii" i raport lob caudat/lob
drept >0,65) ecografia evideniaz i complicaiile HTPo:
splenomegalia, ascita (foto 1) i circulaia colateral, mai ales
n hilul splenic (circulaie colateral spleno-renal - foto 2),
precum i permeabilizarea venei ombilicale (foto 3).
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CONFERIN MONOTEMATIC
HIPERTENSIUNEA
PORTOPULMONAR - DIAGNOSTIC
I TRATAMENT
Ioana Tudor, Clinica Medical Colea
Adres de coresponden:
Dr. Ioana Tudor
Clinica Medical Colea,
e-mail: ioanatudor68@yahoo.com
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transplant1.
Proiecte de viitor 6
1) Predispoziia genetic i mutaiile asociate cu
HTPP trebuie caracterizate.
2) Trebuie fcute eforturi pentru a identifica
mediatorii vasculari circulani i concentraiile
lor n sngele venos porto-hepatic i n circulaia
pulmonar.
3) Trebuie fcute studii clinice randomizate legate
de eficacitatea i sigurana unor noi molecule, ca
antagonitii receptorilor de edotelin cu
administrare oral, inhibitorii de fosfodiesteraz,
inhibitori ai transportului de serotonin sau
prostanoizii pe cale inhalatorie.
4) Identificarea unor subgrupuri de pacieni la care
se poate face TH precoce i urmrirea pe termen
lung a acestora.
Bibliografie:
1. Rohit Budhiraja and Paul M. Hassoun. Portopulmonary Hypertension: A Tale
of Two Circulations. Chest 2003;123;562-576
2. Michael J. Krowka. Pulmonary Hypertension, (High) Risk of Orthotopic Liver
Transplantation, and Some Lessons From "Primary" Pulmonary Hypertension.
Liver Transplantation,Vol 8,No 4 (April),2002: pp 389-390
3. Michael A.E. Ramsay. Perioperative Mortality in Patients With
Portopulmonary Hypertension Undergoing
Liver Transplantation. LiverTransplantation,Vol 6, No 4 ( July), 2000: pp 451452
4. Michael J. Krowka, Karen L. Swanson, Robert P. Frantz, Michael D. McGoon
and Russell H. Wiesner Portopulmonary Hypertension: Results From a 10-Year
Screening Algorithm.Hepatology 2006;44:1502-1510.
5. Michael J. Krowka. Portopulmonary Hypertension: Understanding Pulmonary
Hypertension in the Setting of Liver Disease. Advances in Pulmonary
Hypertension, Summer 2004, Vol 3, No 2
6. R. Rodriguez-Roisin, M.J. Krowka, Ph. Herve, M.B. Fallon. ERS Task Force.
Pulmonary-Hepatic vascular Disorders (PHD). Eur Respir J 2004; 24: 861-880
7. Feigenbaum's Echocardiography. Hemodynamics, p.214,6th edition, 2005
8. P Giannuzzi, A Imparato, PL Temporelli, F de Vito, PL Silva, F Scapellato, and
A Giordano et al., Doppler-derived mitral deceleration time of early filling as a
strong predictor of pulmonary capillary wedge pressure in postinfarction patients
with left ventricular systolic dysfunction. J Am Coll Cardiol, 1994; 23:1630-1637.
9. Kuo PC, Johnson LB, Plotkin JS, et al. Continuous intravenous infusion of
epoprostenol for the treatment of portopulmonary hypertension. Transplantation
1997; 63:604-606
10. McLaughlin VV, Genthner DE, Panella MM, et al. Compassionate use of
continuous prostacyclin in the management of secondary pulmonary
hypertension: a case series. Ann Intern Med 1999; 130:740-743
11. Torregrosa M, Genesca J, Gonzalez A, et al. Role of Doppler echocardiography
in the assessment of portopulmonary hypertension in liver transplantation
candidates. Transplantation 2001; 71:572-574
12. Swanson KL, McGoon MD, Krowka MJ. Survival in portopulmonary
hypertension. Am J Respir Crit Care Med 2003; 167: A683 (abstract).
13. W. Neuhofer,V. Glberg and A. L. Gerbes, Endothelin and endothelin receptor
antagonism in
portopulmonary hypertension, European Journal of Clinical Investigation(2006),
36,(Suppl. 3), 54-61
14. Hoeper MM, Halank M, Marx C, Hoeffken G, Seyfarth HJ, Schauer J et al.
Bosentan therapy for portopulmonary hypertension. Eur Respir J 2005;25:502-8
15. Heikki Makisalo, Anu Koivusalo, Anne Vakkuri, and Krister Hockerstedt.
Sildenafil for Portopulmonary Hypertension in a Patient Undergoing Liver
Transplantation (Liver Transpl 2004;10:945-950.)
16. F. Reichenberger, R. Voswinckel, E. Steveling, B. Enke, A. Kreckel,H.
Olschewski, F. Grimminger, W. Seeger and H.A. Ghofran. Sildenafil treatment for
portopulmonary hypertension, Eur Respir J 2006; 28: 563-567
17. Eric T Wittbrodt and Amina Abubakar, Sitaxsentan for Treatment of
Pulmonary Hypertension, Ann Pharmacother 2006;40:100-5.
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COMPLICAII CARDIOPULMONARE
N BOALA CRONICA HEPATIC
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concentraia NA serice i
toxicitatea alcoolului
disfuncia SN vegetativ
diselectrolitemia
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SINDROMUL HEPATOPULMONAR
Dan Isacoff
Adresa coresponden: Dr D Isacoff, Clinica Medical Colea
isacoff@coltea.ro
Una dintre manifestrile hipertensiunii portale i a
circulaiei hiperdinamice care caracterizeaz cirozele
hepatice evoluate este sindromul hepatopulmonar.
Sindromul hepatopulmonar este definit ca lrgirea
gradientului alveolo-arterial al oxigenului >15 mm Hg sau
>20 mm Hg la pacienii cu vrsta > 64 ani, mpreun sau
fr hipoxemie rezultat din vasodilataia
intrapulmonar n prezena disfunciei hepatice sau a
hipertensiunii portale (1).
Aceast definiie are importan practic, deoarece pentru
recunoaterea bolnavilor cu sindrom hepatopulmonar
semnificativ trebuie efectuat analiza gazelor sanguine
arteriale pentru a identifica pacienii cu hipoxemie
semnificativ (PaO2<70 mmHg). Astzi nu se mai
recomand excluderea altor cauze cardiopulmonare de
hipoxemie pentru stabilirea diagnosticului de sindrom
hepatopulmonar (2) deoarece acest sindrom poate coexista
cu afeciuni cardiopulmonare i contribuie semnificativ la
tulburrile de hematoz pulmonar (3,4 ). Gradientul
alveolo-arterial al oxigenului (AaPaO2) crete cu vrsta i
poate varia semnificativ la adulii sntoi i este
recomandabil folosirea valorilor corectate pentru vrst
pentru a preveni supradiagnosticarea sindromului
hepatopulmonar.
Caracteristica patogenetic major a sindromului
hepatopulmonar este dilataia microcirculaiei arteriale
pulmonare, care rezult din tonus arteriolar precapilar
sczut sau poate asocia i alte mecanisme ca angiogenez,
remodelare i vasculogeneza (5). La oamenii cu sindrom
hepatopulmonar, vasodilataia ar rezulta din producia
excesiv de substane vasodilatatoare endoteliale i, n
special, de oxid nitric (NO). Producia excesiv de NO este
susinut de existena nivelurilor crescute de NO n aerul
expirat de bolnavii cu sindrom hepatopulmonar i care,
dup transplant hepatic, s-au normalizat odat cu
remiterea sindromului hepatopulmonar (6,7,8). n plus,
inhibarea produciei de NO cu NG-nitro-arginin metil
ester (LNAME) sau inhibarea aciunii NO cu un inhibitor
al cGMP ca albastru de metil, pot ameliora temporar
sindromul hepatopulmonar (9,10,11.). Cu toate acestea,
nebulizarea de L-NAME nu a produs ameliorarea
vasodilataiei intrapulmonare i ridic posibilitatea
contribuiei altor factori, n afara NO, pe tonusul vascular
pulmonar.
Nu sunt bine cunoscute mecanismele exacte ale creterii
produciei endogene de NO i ale relaiei cu prezena
hipertensiunii portale, circulaiei hiperdinamice i cu
gradul afectrii hepatice. De asemenea, nu a fost stabilit
clar participarea altor substane vasodilatatoare cum ar fi
CO derivat din hemoxidaza n apariia vasodilataiei
intrapulmonare i s explice astfel absena ameliorrii
sindromului hepatopulmonar prin inhibiia NO la unii
bolnavi.
Manifestri clinice
Manifestrile tipice ale SHP sunt reprezentate de
simptome respiratorii asociate cu semne ale bolii hepatice
cronice.
Bolnavii cu SHP se plng cel mai frecvent de dispnee de
efort care se instaleaz progresiv. Clasic, exist n afara
dispneei progresive de efort platipnee (dispnee
accentuat de ortostatism i ameliorat de clinostatism) i
ortodeoxie (hipoxemie agravat de ortostatism) care apar
prin creterea fluxului sanguin produs de gravitaie n
vasele pulmonare dilatate de la bazele plmnilor (12). Dei
ortodeoxia poate fi ntlnit i n alte situaii (defectul
septal atrial, tromboembolismul pulmonar recurent, postpneumectomie) n prezena bolii hepatice devine foarte
specific pentru SHP (13). Sensibilitatea ortodeoxiei pentru
sindromul hepatopulmonar este relativ mic, dar crete n
cazul formelor severe ale sindromului hepatopulmonar
(14,15)
.
Steluele vasculare sunt frecvent ntlnite la bolnavii cu
SHP i par s indice prezena unei vasodilataii pulmonare
mai mari i gradient alveolo-arterial al oxigenului mai
mare dect la cei fr aceste leziuni cutanate (16).
Hipocratismul digital i cianoza extremitilor la pacienii
cu boal hepatic cronic i/sau cu hipertensiune portal
ridic suspiciunea de SHP. (17)
Diagnosticul SPH
Diagnosticul SHP se bazeaz pe prezena bolii hepatice
sau a hipertensiunii portale, lrgirea gradientului alveoloarterial al oxigenului corectat pentru vrst i pe
demonstrarea prezenei vasodilataiei intrapulmonare.
Diagnosticul SHP este dificil n prezena coexistenei unei
afeciuni pulmonare sau cardiace i, astfel devine necesar
evaluarea dispneei (prin anamnez i examen clinic) la
bolnavul cu boal hepatic cronic i/sau hipertensiune
portal. Acest tip de evaluare poate conduce la
considerarea unor afeciuni dintre care mai frecvente sunt
BPOC, insuficiena cardiac congestiv, ischemia
miocardic. Dac pot fi excluse cauzele frecvente de
dispnee i dac exist platipnee i/sau hipocratism digital
se face evaluarea mai departe a SHP.
a) Oxigenarea arterial
Puls oximetria este un test screening simplu i neinvaziv
pentru evidenierea hipoxemiei i prezena scderii SaO2
va determina efectuarea analizei gazelor sanguine
arteriale la bolnavii hepatici cu dispnee sau hipocratism
sau la cei care sunt evaluai pentru transplantul hepatic.
Dac SaO2 este 97% sau dac SHP sau hipoxemia sunt
sugerate de anamnez i examenul fizic (indiferent de
valorile SaO2) se recomand analiza gazelor sanguine. n
SHP analiza gazelor sanguine evideniaz lrgirea
gradientului alveolo-arterial al oxigenului cu sau fr
hipoxemie. Limita superioar a gradientului alveoloarterial al oxigenului la o anumit vrst se poate calcula
dup ecuaia lui Harris (18): AaPO2 = [(0,26xV) - 0,43] +10.
Dac a fost detectat hipoxemia, n continuare se
efectueaz radiografia toracic i testele funcionale
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25. Lange PA, Stoller JK. The hepatopulmonary syndrome: effect of liver
transplantation. Clin Chest Med 1996; 17: 115-123
26. Krowka MJ, Porayko MK, Plevak DJ, Pappas SC, Steers JL, Krom RA,
Wiesner RH. Hepatopulmonary syndrome with progressive hypoxemia as an
indication for liver transplantation: case reports and literature review. Mayo Clin
Proc 1997; 72:44-53.
27. Philit F, Wiesendanger T, Gille D, Boillot O, Cordier J. Late resolution of
hepatopulmonary syndrome after liver transplantation. Respiration 1997; 64:
173-175.
28. Mandell MS, Groves BM, Duke J. Progressive plexogenic pulmonary
hypertension following liver transplantation. Transplantation 1995; 59: 14881490.
29. Abrams GA, Rose K, Fallon MB, et al. Hepatopulmonary syndrome and
venous emboli causing intracerebral hemorrhages after liver transplantation: a
case report. Transplantation 1999; 68: 1-3
30. Scott V, Mira A, Kang Y, et al. Reversibility of the hepatopulmonary
syndrome by orthotopic liver transplantation. Transplant Proc 1993; 25: 17871788.
31. Abrams GA, Fallon MB. Treatment of hepatopulmonary syndrome with
Allium sativum (garlic): a pilot trial. J Clin Gastroenterol 1998; 27: 232-235.
32. Brussino L, Bucca C, Morello M, Scappaticci E, Mauro M, Rolla G. Effect on
dyspnoea and hypoxaemia of inhaled NG-nitro-Larginine methyl ester in
hepatopulmonary syndrome. Lancet 2003; 362: 43-44.
33. Schenk P, Madl C, Rezale-Majd S, Lehr S, Muller C. Methylene blue improves
the hepatopulmonary syndrome. Ann Int Med 2000; 133: 701-706.
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SINDROMUL HEPATORENAL
61
glomerulonefrita acut
glomerulonefrita cronic
nefropatia cu Ig A
sindromul nefrotic
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PREZENTRI DE CAZURI
REZUMAT
Arterita gigantocelular (AGC) (boala Horton, arterita
temporal) este o suferin rar a vrstnicului (0,5/100.000 de
locuitori), a crei inciden este n continu cretere. La
manifestrile ei tipice (cefalee, sindrom febril, claudicaie
masticatorie, tulburri tranzitorii ale vederii) se asociaza
frecvent (30-50%) cele ale polimialgiei reumatice. Alteori,
exist simptome i semne clinice ori de laborator
(subfebriliti, slbire progresiv, VSH accelerat, anemie
.a.) greu ncadrabile i atribuite senilitii, unor tratamente
anterioare, ori a unui cancer ocult, nu rareori prezent. Boala
Horton poate fi, de altfel, o manifestare paraneoplazic. Ea
poate avea complicaii severe: orbirea, necroza scalpului i
limbii, accidentele vasculare cerebrale.
Autorii prezint 4 cazuri de AGC diagnosticate i urmrite n
ultima perioad, avnd ca una dintre manifestrile
principale sindromul febril prelungit (SFP) al vrstnicului. n
primele dou, diagnosticul definitiv s-a bazat pe histologia
pozitiv din artera temporal; n cel de-al treilea, avnd SFP
i o oligoartrit cu microcristale de pirofosfat de calciu
(manifestare rar n cadrul AGC), asocierea n evoluie a
PMR a determinat afirmarea AGC i instituirea
corticoterapiei n dozele recomandate acestei boli. Ultimul
caz, cu manifestri cefalice minore, investigat ca i cele dou
precedente, n direcia unei infecii i a cancerului ocult, a
reacionat favorabil la corticoterapia asociat fortuit ntr-un
moment critic (tendina la colaps) al evoluiei. Biopsia arterei
temporale nu a fost efectuat, dar rezultatul corticoterapiei se
dovedete excelent n evoluie. Pozitivitatea biopsiei nu este
obligatorie, arterele interesate efectiv putnd fi situate n
profunzime. Tratamentul de elecie este corticoterapia de
durat avnd drept int normalitatea VSH i negativitatea
proteinei C-reactive. Metotrexatul promite a fi o alternativ
valabil la aceste persoane vrstnice avnd, oricum,
osteoporoz de menopauz i/sau senil.
CUVINTE CHEIE: sindrom febril prelungit, vrstnic,
arterit gigantocelular, arter temporal, biopsie,
corticoterapie. Diagnosticul sindromului febril prelungit
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74
Medicina Interna 2007; 6 (6) - www.srmi.ro
Stimate coleg,
SOCIETATEA ROMN@ DE MEDICIN@ INTERN@ v` invit`
s` v` publica]i articolele [tiin]ifice \n
Revista de MEDICINAINTERNA
Articolele acceptate vor fi structurate astfel:
Studii originale
Prezent`ri de cazuri
Referate generale
Actualit`]i diagnostice [i terapeutice
Puncte de vedere