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Curs 10 Patologia chirurgicala a cailor biliare II

Tumori veziculare
Tumori benigne (rare):
- polipi
- adenoame (
( elemente papilare)
- Hplaz. adenomatoas
adenomatoas (adenomiomatoz
(adenomiomatoz)
- fibroame
- lipoame
- leiomioame
Tumori maligne (carcinoame)

Tumori veziculare benigne


Simptom:
Simptom: proprie rar
rar i nespecific
nespecific (litiaz
(litiaz?)
Diagn:
Diagn: VBRx (lacun
(lacun), eco (ecogenit fix
fix f
fr umbr
umbr)
Evol:
Evol: de regul
regul lent
lent, dar 20% din adenoame
cancere
Tratam:
Tratam: VBect indicat
indicat n:
- polipi >1cm(inciden
1cm(inciden cancer >)
- polipi cu litiaz
litiaz

- polipi clar simptomatici


Polipii 0,5cm sunt monitoriza
monitorizai eco la 3 luni

Tumori veziculare maligne


4% din cancere, loc 5/cancere digestive:
- 85% au litiaz
litiaz VB
- maxim ntre 50-70 ani
- sex ratio f:b = 4:1
Morfopat:
Morfopat: adenok-90%(schir-65%,papilifer, mucipar), k epidermoid, k anaplazic, sarcom

Clinic:
Clinic: 5% diagn preoper, simpt de mprumut:
- durere epigastru-hipoc dr
- gre
greuri/v
uri/vrs
rsturi
- icter
- mas
mas palpabil
palpabil n hipoc dr

Tumori veziculare maligne - diagn


Paraclinic:
Paraclinic: modif bio nespecif
nespecificter
icterCA 19-9

Stadiu TNM:
TNM:
T 1a

muc, 1b

musc

T 2-tot peretele, 32cm de perete, 4 >...


N 1-gg cistic, periCBP, hil hepatic
N 2-gg peripc, dd, celiaci, mezent sup
M 1-metastaze
Progn:
Progn: suprav la 5 ani 5-15%

Tumori veziculare maligne Tratament


Chir:
Chir: 95% diagnostic cu ocazia VBect
VBect + rez pat hep + gg pediculari
paliativ pt icter (deriva
(derivaii, stent CBP)
Adjuvant:
Adjuvant:
- RxRp (uneori Rxsens, poate remite icterul)
- ChRp (10% amelior
ameliorri tempor)

Icterul mecanic
= sdr.manif.prin color.galben
color.galben a tegum., muc.
muc.i umorilor det.de BR>
BR>2.5mg dat. obstruc
obstruciei
biliare, beneficiind de Rp chir.

Clasificare ictere:
- prehepatice (hemolitice)
- hepatice (hepato-celulare)
- posthepatice (obstructive=mecanice=chirurgicale)

Clasificare ontogenetic
ontogenetic:
- congenitale (Hb-patii, def.enzim, malforma
malformaii CB)
- dobndite (alte hemolize, hepatite, obstr.nonmalf.)

Etiologia icterului mecanic


Cauze congenitale:
congenitale:
- agenezia/atrezia c
cilor biliare
- malforma
malformaii ectaziante intra/extrahepatice
- colestaza benign
benign recurent
recurent

Cauze dobndite:
dobndite:
- mecanice (trauma, litiaz
litiaz, parazi
parazii, compresii extrins)
- inflamatorii (stenoze, colangite, ulcer, pancreatite, gg)
- tumorale (papiloame, cancere hep/CBP/pancr/dd)
- iatrogene (stenoze/ligaturi CBP, corpi str
strini, oddite)
Patogenia icterului mecanic
Pozi
Poziia obstacolului n raport cu peretele CB:
CB:
- endoluminal
- parietal
- extrinsec

Pozi
Poziia anatomic
anatomic a obstacolului:
- intrahepatic
- hilar
- pedicular (hepatic comun, coledoc Sdd/retroddpc)
- oddian

Diagnosticul icterului mecanic

Clinic:
Clinic: debut, evolu
evoluie, asocieri (prurit, febr
febr)
Sindr:
Sindr: icter, Hcolal, dispep, neo,alerg, -vitam.AK
Bio:
Bio: BR, UBG, FA, enz, HLG, mark T&imuno
Rx:
Rx: hipoc.dr, tranzitBa, colangioR...
Alte imag:
imag: eco(Doppler, 3D/4D, elasto), CT, RMN (ficat, colangio) , scint (hep99mTc, cole131I)
Endo:
Endo: EDS, CPRE, CBPscopie
TestRp Kohler (TP=N/adm p/ent K n icter obstr)
Dg IO:
IO: viz/palp/instr, punc
puncii, bio, Rx, eco

Diagnostic diferen
diferenial icter mecanic

Alte ictere:
ictere:
- hemol (Hb<
(Hb<+spl>
+spl>, sc+urin
sc+urin HCr, BRi+UBG >, hepatic N)

- hepatocelulare(hep>
hepatocelulare(hep>,sc N+urin
N+urin HCr, pb hep, Kohler-)

icter - color galben tegum (caroten, hemocr...)


- scaune decolor (steatoree, Ba)
- Urin
Urin Hcrom
Hcrom (deshidr, Hb/Mburie,
melanurie, ocronoz
ocronoz, hematurie
nalt
nalt, ingestie AF, SSz, Rf, Nf)

Icter mecanic: Complica


Complicaii
Ale afect cauzale - peritonite/fistule biliare, ileus
- abcese hep, pancreatite
- fenom alergice, meta
Inflec
Inflecioase - angiocolita
- colecistita acut
acut
Toxice - ciroza biliar
biliar sec
- intox SNC (icter nuclear)
Disfunc
Disfuncionale - steatoree
- snger
sngerri prelg
- dureri osoase
- prurit

Icter mecanic: Atitudine


Obiective chir:
- decomprimare biliar
/ocolire obst, evac ext)
biliar (suprimare
(suprimare/ocolire
- reintroducerea bilei n circuitul digestiv (implicit
(implicit/supr obst)

Preg
Pregtire: perf, vitam (A,D,E, K), AB, Rp asoc, diet
diet

Supr obst: CBP-litotomie, sf-tomie, rez segm; For


Forare obst (mpingere calcul, foraj
transT/stent, dilat-tutorizare stenoz

)
stenoz

Deriva
Derivaii bil: ext, biliodig (VB/CBP/CBIHG/D/J
(VB/CBP/CBIHG/D/JsauJY)

&: - VBect
- cura KHH (
(parazit+Lagrot/KHdigestA/hepatect regl)
- rezec
rezecii G de excludere, deriv G i pancreatice
...Laparotomie exploratorie

Litiaza CBP

Etiopat:
Etiopat: c.veziculari (c.sec.=colest) naturaliz, c.primitivi CBP (pigmentari
(pigmentariCa), c.din CBIH
10-20% din cei VBect pt lit.VB au i lit.CBP

HP:
HP: rar unici (=prim.), frecv.multipli mpietruire,
oval/fa
oval/faet.sunt pasabili (3-5mm) sau nu (
(>5mm), se bloch. n pct.critic Baraya sau n papil
papil
(5%)

Clinic:
Clinic: icter (33-70%), durere (>
(>80%) febr
febr

Ff.clin:
Ff.clin: clasic
clasic, intrapapilar
intrapapilar, VBit
VBit ac.sec, cu pancreatit
pancreatit, cu angiocolit
angiocolit, dureroas
dureroas pur
pur,
febril
febril pseudopaludic
pseudopaludic, dispeptic
dispeptic, ca
caectizant
ectizant, ...mut
...mut

Litiaza CBP:
CBP: diagnostic

Bio:
Bio: L, VSH, fbgen, colestaza (mai ales FA)

Rx:
Rx: cc. Rxopaci, colangioTPH

Imag:
Imag: eco, CT, RMN(colangio), colescint Tc99m

Endo:
Endo: papila, CPRE, CBPscopie

IO:
IO: palpare pedicul, colangioIO, eco, instrum/CBP, CBPscopie
Cnd?:
Cnd?: - lit.VBveche, c.<
c.<, cistic larg, episod de icter, colestaz
colestaz f
fr icter.

Litiaza CBP:
CBP: tratament

Endo:
Endo: CPRE cu sf.tomie endoscopic
endoscopic

Obiective chir:
chir: - abla
ablaia VB (surs
(surs de cc.)
- dezobstr.complex
dezobstr.complex CBP
- asig. drenaj bil

Abordul
Abordul CBP e /cistic, /CBPtomie/retrograd

Drenajul
Drenajul e extern (Kehr), biliodig, /papil
/papil

Control colangioRx IO i la 10-14 zile (pt a certifica vacuitatea i etan


etaneitatea CBP

Angiocolitafr./colangitaeng. acut
acut

Def:
Def: infec
infecie bacter. acut
acut a CBIH/CBEH caract de 3ada Charcot (1877): icter, durere hc,
febr
febr/frison

Etiopat:
Etiopat:
obstruc
obstrucie biliar
biliar:
- litiaza CBP (80%)
- stenoze benigne CBP sau Oddiene

- stenoze maligne (neo CBP, VB, periamp, pancr)


- parazi
parazii (hidatidocolie, ascarizi eratici n CBP)
- malform (boala Caroli, chiste congenitale CBP)
- iatrogenii (Oddite, corpi str
strini, CPRE, anast nef
nefx.)

germeni: E.coli, Klebs, enterococi, B.fragilis, clostridii


Angiocolita: diagnostic

3ada Charcot: durere, frison/febr


frison/febr, icter + alter st.gen, obnubil, oligurie, d/ChauffartRivet

Bio (=L
(=L, enz, BR, FA, uree/creat, hemoculturi):

Imagistic:
Imagistic:

Eco (dilat CBP/CBIH, obstacol: loc, natur


natur)
CT, RMN, scint (eval patol tumoral
tumoral, colangioRM/scint)
colangio (transparieto/omfalo, CPRE)
Forme clinice (acut
(acut, supurat
supurat, torpid
torpid, anicter, complicate, particulare: recurent
recurent,
parazitar
parazitar)

Angiocolita: evolu
evoluie, tratament
Complica
Complicaii:
ii:

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insuf hepatorenal
hepatorenal (st. tox,oligo/anurie)...MSOF
tox,oligo/anurie)...MSOF

abdomen acut (ileus, pancreatit


pancreatit, peritonit
peritonit)

Atitudine:
Atitudine:

reechilibrare (H2O, electro, metab, corectare tare)

AB (penemi, Fquin, lactam, NH2glicoz, metro, clinda)

decompresie biliar
biliar (percutan
(percutan, endo, chir)

opera
operaie seriat
seriat (rezolvarea obstacolului)

Tumori CBP

Def:
Def: T localizate la niv CHD/S, CHS, coledoc

T benigne:
benigne: papilom/atoz
papilom/atoz, adenom, mioblastom

T maligne:
maligne:

mai rare (1:2-3) ca TMVB, v =


/brba
rbai)
60, predom /b

& cu litiaza?; & parazit, RCUH, chiste CBP, b.Caroli)


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HP:maj adenoK90%; K.epid,K.coloid,carcinoid,sarcom

Macroscopic: infiltrativ, nodular, papilar

Local:CHC/jonc
Local:CHC/jonc.(Klatskin),distale,pedicul; Difuze

Propagare ductal
ductal/limfatic
/limfatic/nervoas
/nervoas/hemato/perito

Tumori CBP:
CBP: diagnostic
Preicter (
(tscurt
jen hc.dr
scurt, dispepsie, inapet, jen

Icter: , durere continu


continu, febr
febr(angiocolit
(angiocolit) prurit, hepatospleno>
hepatospleno>, s.Courvoisier-Terrier

Paraclinic: colestaz
colestaz; eco, CT, colangioRMN, colangioRx TPH, CPRE, coledoscopie
retrograd
retrograd

Dg stadial (TNM):
T1 (perete: 1a=muc,1b=musc), T2 (adv), T3 (organe v.)
No (f
(fr adenopatie), N1 (adenopatie regional
regional)
Mo (f
(fr meta), M1 (cu meta)
Stadiu I T1N0, II T2N0, III T1-2N1, IVa T3NM0, IVb TNM1

Tumori CBP:
CBP: tratament

Medical &: AB, analg, reechilibr.(H+E+M), vit.K


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Decompr.bil.min.inv
Decompr.bil.min.inv (percutan, retrograd transT)

Chirurgical:
Chirurgical:

Paliativ (anastomoze bilio-digestive, drenaj biliar extern)

Radical prox: rezec


rezecie hilar
hilar+HJ(Y)A n placa hilar
hilar

Radical mediu: rezec


rezecie CBP+HCA/HJ(Y)A

Radical distal: CBP-duodenopancreatect.cefalic


CBP-duodenopancreatect.cefalic+...A

Prognostic:
Prognostic: suprav.medie e de 2-8luni/paliativ, 2 ani/radical; la 5 ani suprav.<
suprav.<5%!

Tumori (Vateriene) periampulare


= T dezv.din structuri AV, dd, CBPt, W
HP:
HP: benigne<
benigne<10% (adenom, papilom) ce se pot maligiza; maligne: maj=carcinoame

Clinic:
Clinic: prodroame, icter / , prurit, HDS+ anemie, dureri, dispepsie, febr
febr/frison

Bio:
Bio: Hb, Fe, colestaz
colestaz, CA 19-9

Imag:
Imag: RxBa-ddgr.hton
RxBa-ddgr.hton:/s.Frossberg, colangioRx prea frumoas
frumoas n remisiuni, eco, CT,
RMN, colangioRMN, colescint Tc99m , EDS, biopsie

Tumori Vateriene: stadializare & Rp


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Dg stadial:
stadial:
T1 AV, T2 perete dd, T3 <2cm pc, T4 >2cm

Min.inv: foraj edo transT, drenaj ext percutan

Paliativ: deriva
derivaie biliar
biliar, ampulect

Radical: ampulect, ddpancreatect.cefalic


ddpancreatect.cefalic

Progn: suprav >

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