PANCREATITA ACUT

Prof. Mircea DICULESCU

Centrul de Gastroentrologie si
Hepatologie Fundeni

DEFINIIE
inflamaie acut
a pancreasului exocrin produs de
activarea intrapancreatic a enzimelor
care determin
autodigestie triptic a glandei
edem, necroz, hemoragie

ISTORIC
Ambroise Par 1579

EPIDEMIOLOGIE
incidena (SUA), vrsta
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 - litiaz, brbai - alcool)

ANATOMIE. HISTOLOGIE

ETIOLOGIE
FRECVENTE (90%) RARE (10%)
40% litiaza biliar
30% alcool
20% idiopatic

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
PH 7

FIZIOPATOLOGIE
CONSECINE
proteoliz
activare chinine
degradare mastocite i
eliberare de histamin
radicali liberi
necroze esut adipos cu
fixare Ca2+

EFECTE
local: edem, inflamaie,
necroz, hemoragie,
tromboz, hemoliz
regional: pete de
citosteatonecroz
sistemic: AV, TA,
durere, ileus, Ca2+

AMILAZA = marker inocent

FIZIOPATOLOGIE
OBSTRUCIE - SECREIE
litiaz, bride, calcul, tumor, ascarizi
presiunea n amonte

REFLUX
din duoden prin relaxare Oddi
din cai biliare (OBSTRUCIE)

ALCOOL
leziuni acelule acinoase, steatoz
secreia, vscozitateadop (OBSTRUCIE)

ISCHEMIE disfuncie mecanism secreie

LIPIDE prnz lipidic
INFECIOS bacterian, viral (oreion, VHB)

CLASIFICARE
1. EDEMATOS INTERSTIIAL

AP - edem, inflamaie

2. NECROTIC

AP - necroz

3. SUPURATIV

FLEGMON PERIPANCREATIC - AP - difuz,

ABCES PANCREATIC - AP - colecie

4. PSEUDOCHISTIC

AP - steril sau suprainfectat

HISTOPATOLOGIE

PANCREATIT NECROTIC

MANIFESTRI CLINICE
DEPIND DE TIPUL HISTOPATOLOGIC

DEBUT
brutal, obezi, prnz hiperlipidemic plus alcool

DIGESTIV

durere abd sup, n bar, iradiat posterior

vom, ileus
echimoze (Gray Turner-flanc, Cullen-ombilic)
HDS

EXTRADIGESTIV

febr (piretogen - proteaze, bacterii)

tahicardie / bradicardie (PIC), TA, oc
detres respiratorie, pleurezie (stnga)
tetanie ( Ca2+)
encefalopatie (enzime, alcool)

MANIFESTRI CLINICE
CULLEN

GRAY TURNER

COMPLICAII
LOCALE

GENERALE

~ digestive

~ extradigestive

abces
pseudochist
perforaie
HDS

Insuficiena respiratorie
Insuficiena renal
Encefalopatie
Coagulopatie
... ale MSOF

LABORATOR
AMILAZA
AMILAZEMIE

30 U Wolgemuth, 25 UI/ l, 100 U Somogy

x 100 - 1000 ori, 6 ore - 5 zile
= necroz, nu se coreleaz cu gravitatea
fals+ : insuf renal, ocl intest, UD perforat, salivar
fals - : <6 ore, > 5 zile, fulminant, PC parenchim redus

AMILAZURIE x 3
LICHID PLEURAL, ASCIT = semn cert

LIPAZA x 3, 10 zile, 70% sensibilitate, 99% specificitate

ELASTAZA 10 zile, RIA, n fecale

LABORATOR
AST, ALT x 2-5 N
LDH > 200 UI
leucocitoz 10 - 16000 necomplicat, > 16000
supuraie
Ca2+ , Mg2+
glicemie, lipidemie
uree (polipeptid pancreatic)
PCR ( IL6)

IMAGISTIC
Rx torace
ARDS
lq pleural stnga

Rx abdominal pe gol
ansa santinel
colon amputat

IMAGISTIC
CT
pancreatit acut necrotic

IMAGISTIC
Ecografie abdominal, EUS
criterii de pancreatit acut, colecii, litiaz

COLECIE RETROGASTRIC

MANAGEMENT
Suspiciune
Diagnostic diferenial (eliminare alte diagnostice)
Diagnostic pozitiv (confirmare)
Evaluare cauz: biliar sau non-biliar
Evaluare severitate
Tratament adecvat cauzei i severitii

MANAGEMENT
Suspiciune
debut brusc
prnz lipidic plus alcool (Merry Christmas!)
APP litiaz biliar (FAT, FEMALE, FIFTY)
durere "n bar"
lichid n baza stng

MANAGEMENT
Diagnostic diferenial (eliminare alte diagnostice)
(DURERE, HDS, AMILAZE, ...)

DIGESTIV
Abdomen acut chirurgical
UGD - durere, HDS (EDS), ...

T pancreas - (EUS)

EXTRADIGESTIV
Abdomen acut "medical"
IMA inferior , colic renal, saturnin, criz Addison, porfirie
acut intermitent, ...

MANAGEMENT
Diagnostic pozitiv (confirmare)
clinic (durere)
laborator (amilaze)
imagistic (modificri pancreas ECO, CT)

MANAGEMENT
Evaluare cauz: biliar sau non-biliar
Scor Blamey (ssb 60%, spec 90%)

sex feminin (FEMALE)

vrsta > 50 ani (FIFTY)
fosfataza alcalin
ALAT precoce
amilaze foarte

0 factori - 5%, 5 factori - 100%

IMAGISTIC: Rx, ECO, EUS, CT

MANAGEMENT
Evaluare severitate
clinic
funcii vitale (cord, pulmon, rinichi, ficat)
PCR
scor RANSON (clinic + laborator)
ssb 70%, spec 70%

scor BALTAZAR (CT la 48 de ore)

MANAGEMENT
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

scdere Ht >10%
cretere uree >5mg/dl
pO2 >60 mmHg
Ca2+ >8mg/dl
scdere bicarbonat >4
mEq/l
sechestrare lq >6l

0-2 pct - 4% PA sever, 1% Mt, 7-8 pct 100% PA sever, 100% Mt

MANAGEMENT
Evaluare severitate - BALTAZAR (suma 2 col, max 10)
GRAD

PANCREAS

SCOR

NECROZ (contrast SCOR

vascular)

normal

absent

mrit

< 1/3 gland

infiltrare grsime
peripancreas

1/3 < dar <1/2

gland

magm necrotic

>1/2 gland

magm necrotic
extins n abd

0-3 pct - 8% PA sever, 3% Mt, 7-10 pct 92% PA sever, 17% Mt

MANAGEMENT
Tratament adecvat cauzei i severitii
PA biliar - ERCP i sfincterotomie n primele 48
de ore de la debut i ulterior colecistectomie
laparoscopic
PA sever - transfer i management n ATI

ERCP terapeutic - sfincterotomie

ERCP terapeutic

TRATAMENT

susinere funcii vitale

post alimentar, alimetaie parenteral / enteral
durere
vom incorecibil sond nasogastric
PA sever profilaxie antibiotic
colecii puncie percutan pt diagnostic infecie
infecie drenaj nchis, chirurgie limitat
NU EXIST TRATAMENT PATOGENIC
CUNOSCUT

TRATAMENT
susinere funcii vitale
CARDIOVASCULAR, RENAL
soluii cristaloide (ap - NaCL 0,9%, Ringer lactat)
soluii coloide (efect osmotic - in apa n vas - plasm,
dextran)
electrolii
RESPIRATOR
O2, trat ARDS (IOT + ventilaie mecanic)

TRATAMENT
post alimentar, alimetaie parenteral / enteral
parenteral caz ileus, enteral dup reluare tranzit
necesar suplimentar pt PA sever (stare catabolic)
realimentare dup 48 ore fr durere i lipaze < 3 x

durere
durerea are i efect ocogen
Nu morfin (spasm sfincter Oddi)
tramadol, mialgin, xilin

vom incorecibil sond nasogastric

Nu de rutin

TRATAMENT
PA sever profilaxie antibiotic
? la toi

colecii puncie percutan pt diagnostic infecie

ghidat ECO, EUS, Rx

infecie drenaj nchis, chirurgie limitat

chirurgia majora cu rezecii largi are rezultate
nefavorabile (Mt i Mb crescut)

CHIRURGIE - drenaj

ALTE MSURI
INHIB SECREIA

INDIRECT (nu stimul)

ALIMENTE - sond ng
ACID - anti H2, IPP
DIRECT
GLUCAGON
CALCITONIN
SOMATOSTATIN
(Sandostatin)

ANIHILEAZ SECREIA
APROTININA (Trasylol)
inhib enzimele (tripsina,
chemotripsina, kalicreina)
dar nu influeneaz necroza

ANTIFIBRINOLITICE
EACA

ANTI FOSFOLIPAZA A
EDTA

ALTE MSURI
ANTIINFLAMATOR
ANTAGONIST PAF
(Lexipafant)
ANTIOXIDANI
vitamina E
Superoxid dismutaza
(SOD)

EVOLUIE
PA edematoas
infecie 1%
mortaliatae 1%

PA necrotic
infecie 30 - 50%
mortalitate 30% caz necroz infectat

TOT CE E BUN N VIA

E IMORAL,
E ILEGAL,
NGRA
...SAU D
PANCREATIT ACUT