Documente Academic
Documente Profesional
Documente Cultură
CIJEVSCHI PRELIPCEAN
CTLINA
MIHAI
NOIUNI DE
GASTROENTEROLOGIE
I HEPATOLOGIE
PENTRU STUDENI
Refereni tiinifici:
Prof. Univ. Dr. Mircea DICULESCU, Universitatea de Medicin i Farmacie
Carol Davila Bucureti
Prof. Univ. Dr. Dan DUMITRACU, Universitatea de Medicin i Farmacie Iuliu
Haieganu Cluj Napoca
Toate drepturile asupra acestei lucrri aparin autorului i Editurii Gr.T. Popa" Iai. Nici o
parte din acest volum nu poate fi copiat sau transmis prin nici un mijloc, electronic sau
mecanic, inclusiv fotocopiere, fr permisiunea scris din partea autorului sau a editurii.
Prefa
Hipocrate spunea c toate afeciunile au originea n tubul digestiv.
Cartea Noiuni de gastroenterologie i hepatologie pentru studeni a aprut
din necesitatea de a prezenta ntr-o manier succint cunotinele de baz din
gastroenterologie i hepatologie, noiuni pe care orice medic trebuie s le
cunoasc i aplice n practica clinic curent.
Aa cum sugereaz i titlul, cartea se adreseaz n primul rnd
studenilor Facultii de Medicin dar n acelai timp credem c va fi un
instrument apreciat de ctre medicii rezideni gastroenterologi i din alte
specialiti nrudite, doctoranzi i practicieni cu experien care doresc s i
actualizeze cunotinele n domeniu.
Din punct de vedere al coninutului lucrarea este structurat ntr-o
manier clasic, parcurgnd principalele afeciuni digestive, de la
epidemiologie la tratament. ntr-o specialitate n care progresele se deruleaz
rapid, am ncercat s integrm noiunile clasice cu cele mai noi achiziii
tiinifice, eliminnd elementele perimate i punnd accent pe noile modaliti
de diagnostic i tratament, n concordan cu ghidurile i recomandrile
actuale.
Spre deosebire de cursurile clasice, originalitatea este dat de formatul
crii: pe de o parte prezentarea schematic, succint, a noiunilor teoretice iar
pe de alt parte spaiile libere alturate care permit cititorului s fac adnotri,
completri, precizri, facilitnd procesul de cunoatere.
Editarea acestei cri nu a fost o munc uoar. Mulumim
colaboratoarelor noastre dr. Mihaela Dranga i dr. Iulia Pintilie pentru
ajutorul dat n tehnoredactare. Din punctul nostru de vedere cartea a fost un
exerciiu, n care am regsit ceea ce spunea Seneca: nvei nvnd pe alii.
Sperm ca i din punct de vedere al cititorilor cartea s fie un instrument util n
formarea medical.
Cristina Cijevschi Prelipcean
Ctlina Mihai
ABREVIERI
5 ASA: 5 aminosalicilic
Ac: anticorpi
AFP: alfafetoprotein
Ag: antigen
ALT: alaninaminotransferaza
EEG: electroencefalogram
AST: aspartataminotransferaza
AZT: azatioprin
GGTP: gamaglutamiltranspeptidaza
HCC: hepatocarcinom
COX: ciclooxigenaz
PMN: polimorfonucleare
Ps: prednison
RBV: ribavirin
IFN: interferon
Il: interleukin
LDH: lacticdehidrogenaza
MTS: metastaze
CUPRINS
METODE DE EXPLORARE A TRACTULUI DIGESTIV ............................ 1
DISPEPSIA .................................................................................... 15
HELICOBACTER PYLORI DUP MASTRICHT IV ................................ 21
BOALA DE REFLUX ESOFAGIAN ..................................................... 29
TULBURRI MOTORII ESOFAGIENE ............................................... 41
CANCERUL ESOFAGIAN ................................................................ 49
ULCERUL GASTRIC I DUODENAL .................................................. 53
CANCERUL GASTRIC ..................................................................... 71
PATOLOGIA INTESTINULUI SUBIRE.............................................. 85
COLONUL IRITABIL ....................................................................... 97
BOLILE INFLAMATORII INTESTINALE ............................................105
CANCERUL COLORECTAL .............................................................125
HEPATITA CRONIC VIRAL C ......................................................137
HEPATITA CRONIC VIRAL B......................................................145
FICATUL GRAS NONALCOOLIC .....................................................155
BOALA HEPATIC ALCOOLIC ......................................................161
HEPATITELE AUTOIMUNE ............................................................167
CIROZA HEPATIC .......................................................................173
METODE DE EXPLORARE A
TRACTULUI DIGESTIV
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Introducere
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Indicaii:
simptomatologie dispeptic la persoane n vrst sau cu
simptome de alarm (hemoragie gastrointestinal,
scdere ponderal, vrsturi sugernd insuficien
evacuatorie gastric, anemie etc. ) sau rebel la
tratament
disfagie
ingestie de corpi strini, substane caustice
hemoragie digestiv superioar (acut i cronic)
durere abdominal cronic
boal inflamatorie intestinal (boal Crohn)
suspiciune de neoplazie
confirmare examen radiologic
supraveghere leziuni preneoplazice
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Contraindicaii:
refuzul pacientului
pacient necooperant, agitat
suspiciune de perforaie intestinal
pacient n stare de oc (EDS se va efectua dup
echilibrare volemic)
afeciuni severe asociate (infarct de miocard
recent, accident vascular cerebral)
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! Consimmnt informat
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Pregtirea pacientului:
repaus alimentar de cel puin 6 ore
n urgen (HDS) splturi gastrice anterior
explorrii
anestezie topic faringian xilin
decubit lateral stng
sedare iv midazolam 2-5 mg
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proteze
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polipectomii
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mucosectomie endoscopic
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Complicaii:
majore la 1/1000 - 1/3000 de endoscopii
perforaii ale esofagului, stomacului
hemoragie
aspiraie pulmonar (mai frecvent la EDS cu sedare)
aritmii cardiace severe
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Indicaii:
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Contraindicaii:
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aceleai ca la endoscopie +
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megacolon toxic
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Pregtire:
- Evacuarea colonului (fortrans, picoprep, clisme
evacuatorii)
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Complicaii
Complicaii majore
Perforaia
Hemoragia
< 1% din colonoscopii, mai frecvent n cele terapeutice
(polipectomii)
Alte complicaii
Aritmii cardiace
Reacii vasovagale
Hipotensiune, insuficien cardiac (pregtire
colonoscopie)
Reacii la medicamentele folosite pentru sedare
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Colangiopancreatografia endoscopic
retrograd - ERCP
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- stentare endoscopic
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Enteroscopia
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CAPSULA ENDOSCOPIC
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Metod
Pacient a jun de cel puin 8 ore
Ingerare capsul cu un pahar cu ap
interzis fumatul modific culoarea mucoasei
gastrice
nu se administrez:
antiacide ader la mucoas mpiedic
vizualizarea
antispastice ncetinesc tranzitul intestinal
sucralfat
preparate de fier
narcotice
La 2 ore de la ingestie sunt permise lichidele, la 4 ore
o gustare
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Indicaii
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- boala Crohn
- hemoragia gastrointestinal de cauz obscur
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Indicaii relative
- boala celiac
- suspiciunea unei tumori maligne de intestin subire
- polipoza intestinal ereditar (sindromul PeutzJeghers, polipoz juvenil familial)
- leziunile vasculare intestinale
- enteropatia indus de AINS
- diareea cronic
- durerea abdominal (suspiciune de boal
organic)
- transplantul de intestin subire (diagnosticul
rejetului de gref)
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Contraindicaii
Stenoz, obstrucie, fistul (orice segment al tractului
gastrointestinal)
Intervenii chirurgicale majore anterioare
abdominale/pelvine
Tulburri de deglutiie
Pseudo-obstrucie intestinal
Pacemaker cardiac sau alt dispozitiv electromedical
implantat
Contraindicaii relative: sarcin, diverticul Zenker,
gastroparez, diverticuloz intestinal (diverticuli
numeroi i voluminoi)
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Complicaii
1. Impactarea capsulei la nivelul unei stenoze
intestinale nediagnosticate anterior
2. Aspiraia traheal a capsulei
3. Impactarea capsulei la nivel cricofaringian
4. Retenia capsulei n diverticul Zenker
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Concluzii
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EXAMENUL RADIOLOGIC
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Ecografia abdominal
Accesibil
Ieftin
Neinvaziv
Repetabil
Diagnostic pozitiv, diagnostic diferenial, supraveghere,
puncii ecoghidate diagnostice i terapeutice
Ficat, colecist, pancreas, splin, rinichi, pelvis, tub
digestiv, cavitate peritoneal, vase
Ecografie Doppler vascularizaie, flux vascular
Ecografie cu substan de contrast caracterizarea
vascular a formaiunilor expansive, traumatismelor etc
Ecoendoscopia profunzimea invaziei tumorale a
tubului digestiv, diagnosticul etiologic al icterului
obstructiv, permite manevre terapeutice (drenare
pseudochisturi pancreas etc)
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Computer tomografia
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Rezonana magnetic
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Indicaii:
Evaluarea inflamaiei, steatozei i fibrozei n hepatitele cronice
virale, cu implicaii terapeutice i prognostice
Formaiuni expansive hepatice (ecoghidat)
Diagnosticul bolilor colestatice, granulomatozelor hepatice
Post-transplant hepatic n cazul rejetului de gref
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Contraindicaii:
Timp de protrombin crescut, INR > 1.6
Trombocitopenie < 60.000/mmc
Ascit (se prefer calea transjugular)
Hemangioame hepatice
Suspiciune de chist hidatic
Pacient necooperant
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Complicaii
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includ:
- elastografia n timp real HiRTE sau ARFI
- elastografia tranzitorie Fibroscan-ul
- elastografia prin rezonan magnetic
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Poate fi efectuat:
- aparat Hitachi Hitachi Real Time Tissue
Elastography (Hi RTE) evalueaz relativ elasticitatea
hepatic printr-o scal de culori: cu ct esutul hepatic
este mai dur va predomina culoarea albastr
- aparat Siemens Acoustic Radiation Force Impulse
(ARFI) elasticitatea tisular este cuantificat ntr-o arie
predefinit fiind exprimat n m/s
Aceste dou metode au avantajul determinrii elasticitii
tisulare n continuarea unei ecografii standard
Necesit n continuare studii pentru validare n practica
clinic curent
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Elastografia RMN
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Fibrotest/Actitest
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FibroMax
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FibroMax
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FibroMax
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Manometria
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Indicaii:
- tulburri motorii esofagiene
- durere toracic non-cardiac
- BRGE sever, pentru evaluarea peristalticii i a SEI
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Bilitech
- aprecierea refluxului alcalin
- colecistectomizai, stomac operat
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Alte explorri
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DISPEPSIA
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Definiie
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Epidemiologie
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Clasificare i etiologie
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A.
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B. Dispepsia funcional
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Fiziopatologie
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Diagnostic pozitiv ( 1- 4)
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1) simptomele de alarm
- scderea ponderal
- vrsturile incoercibile
- HDS (hematemez, melen)
- sindromul anemic
- disfagia
- icterul
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+
- examen baritat cu
suspiciuni de diagnostic
- mas abdominal
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Diagnostic diferenial
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2) colonul iritabil
- asociaz n 50 % din cazuri simptomatologie
dispeptic
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Principii de tratament
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Regimul igienodietetic
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Tratamentul medicamentos (1 5)
eradicarea Hp
tratament antisecretor
medicamente cu efecte asupra activitii motorii i reflexe
medicamente cu efect antinociceptiv
terapii alternative
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1. Eradicarea Hp
- eradicarea Hp are, comparativ cu tratamentul
antisecretor, efect benefic mic
- singurul argument (cercettori japonezi ) pentru care se
indic eradicarea Hp este legat de profilaxia ulcerului
peptic i a cancerului gastric noncardial
2. Medicaia antisecretoare
- este superioar tratamentului de eradicare Hp n
dispepsie
- durata tratamentului este de 2-8 sptmni
- aciunea benefic se bazeaz pe diminuarea aciditii
i sensibilitii duodenale
- IPP > inhibitorii H2 > placebo
- beneficii > ca prim linie de tratament n epigastric
pain syndrome comparativ cu postprandial dystress
syndrome
19
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Eritromicina
macrolid, agonist al receptorilor motilinici
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Tegaserod
agonist al receptorului 5 hidroxitriptaminic
administrat 6 mg x 2/zi accelereaz evacuare gastric
pe voluntarii sntoi i la pacienii cu dispepsie
Levosulpiride
antagonist dopaminergic cu efecte favorabile n special
n dispepsia prin dismotilitate
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HELICOBACTER PYLORI
DUP MASTRICHT IV
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Helicobacter pylori
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Istoric
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Teste noninvazive:
- confirm primo-infecia
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Ag n scaun
- de prim intenie la persoane < 45 ani, cu sindrom dispeptic,
dar fr semne de alarm sau istoric de cancer familial
- reduce numrul de endoscopii
- specificitate 98%
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Serologia
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Teste invazive:
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- metod laborioas
- incubare n medii speciale 3-5 zile
- indicat n: - cazurile n care rezistena la antibiotic este peste 15
20% n aria geografic respectiv
- dup eecul a 2 cure de eradicare
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Ag n scaun
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Indicaii
UD/UG (activ sau complicat)
Limfom tip MALT
Gastrita atrofic
- pangastrit atrofie i metaplazie intestinal
adenocarcinom
- reversibilitatea leziunilor dup eradicare subiect
controversat
Gastrita de bont (stomac operat pentru cancer gastric)
Pacienii cu rude de gradul I cu istoric de cancer gastric
La cererea pacientului (consultarea prealabil a medicului
curant)
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Dispepsia functional
Boala de reflux gastroesofagian (BRGE)
Antiinflamatorii nesteroidiene (AINS)
Pediatrie
Alte afeciuni (trombocitopenie idiopatic, anemia prin deficit
de fier, deficitul de vitamin B12)
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23
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Dispepsia funcional
_____________________________________
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BRGE
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24
_____________________________________
Populaia pediatric
Ulcerul peptic
Copiii cu antecedente heredocolaterale de ulcer peptic
sau cancer gastric - testai i tratai
Anemia neexplicat i colica abdominal recurent testare Hp
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Alte afeciuni
Trombocitopenia idiopatic (TIP)
- > 50% din cei cu TIP au infecie Hp
- eradicarea infeciei Hp se nsoete de remisiunea
parial sau total a trombocitopeniei (explicat prin
reactivitatea ncruciat ale Ag de suprafa ale plachetei
i Hp)
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general.
_____________________________________
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CLARITROMICINA
METRONIDAZOL
AMOXICILINA
_____________________________________
_____________________________________
_____________________________________
_____________________________________
1.
IPP
500mg x 2/zi
2.
IPP
500mg x 2/zi
1000 mg x 2/zi
_____________________________________
_____________________________________
500 mg x 2/zi
_____________________________________
Qvadrupla terapie: SUBCITRAT DE BISMUT COLOIDAL 140mg x4/zi +
METRONIDAZOL 125 mg x4/zi+
TETRACICLINA 125 mg x4/zi+
IPP (20mgx2/zi) (pastil unic!)
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25
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_____________________________________
_____________________________________
Efecte secundare:
- dispepsie, diaree
- diareea este de obicei tranzitorie i autolimitat (cazuri rare cu
Clostridium difficile); se recomand folosirea probioticelor
- sunt mai frecvente n combinaia Claritromicin - Amoxicilin
(20%) comparativ cu Claritromicina i Metronidazol, motiv
pentru care se recomand Metronidazolul n zonele n care
rezistena la acesta este <15-20%
- unele probiotice i prebiotice mbuntesc rezultatele
tratamentului prin efectelor secundare
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_____________________________________
Complian redus
Rezisten primar la antibiotice
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_____________________________________
_____________________________________
_____________________________________
Bismut
Subcitrat de
bismut 120
mg x 4/zi
sau
Amoxicilin
1g x 2 / zi
Tetraciclin
Metronidazol
_____________________________________
_____________________________________
500 mg x 3/zi
500 mg x 3/zi
_____________________________________
_____________________________________
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_____________________________________
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26
_____________________________________
_____________________________________
_____________________________________
Rezistena secundar:
- metronidazol 60-70%
- claritromicin 30 %
Cea de-a doua linie de tratament determin eradicarea
infeciei Hp n 75% din cazuri
n zonele cu rezisten la claritromicin dup eecul
qvadruplei terapii se recomand tripla terapie cu
levofloxacina
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Terapia secvenial
_____________________________________
_____________________________________
_____________________________________
93%
94%
_____________________________________
_____________________________________
_____________________________________
Fr efecte secundare
_____________________________________
Terapia secvenial - eradicare semnificativ mai mare
comparativ cu terapia convenional 10 zile.
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27
_____________________________________
Reinfecia
_____________________________________
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Vaccinarea pentru Hp
_____________________________________
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Concluzii
_____________________________________
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28
BOALA DE REFLUX
GASTROESOFAGIAN
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Definiie:
_____________________________________
_____________________________________
_____________________________________
Ali termeni:
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Epidemiologie
_____________________________________
- extrem de frecvent
- n rile dezvoltate
-25% din populaie pirozis - o dat / sptmn
-7% pirozis - o dat / zi
- prevalena n cretere - dublarea n ultimele 2 decade
- distribuia - egal pe sexe
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29
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Etiopatogenie
_____________________________________
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Patogenie
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
III. ntrzierea evacurii gastrice (tulburri de motilitate gastroduodenale relaxarea tranzitorie SEI)
_____________________________________
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_____________________________________
Tablou clinic
_____________________________________
_____________________________________
I. Manifestri digestive
Pirozis (arsur retrosternal, accentuat de alcool, alimente
iritante, fierbini, clinostatism)
_____________________________________
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30
II . Manifestri extradigestive
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Explorri paraclinice
_____________________________________
_____________________________________
I. Endoscopia
- indicat la toi pacienii cu simptome de alarm pentru
BRGE ct i la cei care nu rspund la tratament
- specificitate foarte bun (90-95%), diagnostic etiologic i
al complicaiilor BRGE
- exclude afeciuni asociate (ulcere gastrice, duodenale)
- permite tratamentul n unele complicaii ale BRGE
(stenoze, esofag Barrett)
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31
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V. Scintigrafia
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32
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VI. BILITECH
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Diagnosticul complicaiilor
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33
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complicaie a EB
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Diagnostic diferenial
_____________________________________
I. Afeciuni esofagiene
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34
_____________________________________
Tratament
_____________________________________
BRGE necomplicat
_____________________________________
Obiective:
_____________________________________
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Regimul igieno-dietetic
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Interzicerea fumatului
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35
_____________________________________
Tratamentul medicamentos
_____________________________________
1. Medicatia antiacid
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
Avantaje: - ieftine
- aciune favorabil imediat
- perioade scurte de timp, remisie de moment a
simptomatologiei
_____________________________________
_____________________________________
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_____________________________________
2 . Medicaia antisecretorie
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36
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_____________________________________
Efectele secundare
Minore: cefalee, diaree
Severe: - precipit osteoporoza fracturi osoase
- nefrite interstiiale
- hepatite
- atrofie gastric, polipi
- precipit evoluia colitei cu Clostridium difficile
Noi ageni terapeutici
Dexlansoprazolul (SUA) (tb 30mg) cu eliberare lent.
- tratamentul simptomelor de reflux vindecare esofagit
indiferent de severitate dup 8 sptmni de tratament
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_____________________________________
Medicaia prokinetic
_____________________________________
Determin acentuarea golirii gastrice, creterea presiunii
SEI,creterea clearance-ului esofagian
Metoclorpramida (10 mgx 3/zi)
- amelioreaz acuzele
- cu 30 min nainte de mese
subiective
- utilizare limitat efecte de tip
- nu amelioreaz
Extrapiramidal i psihotrop (vrstnic)
aspectul
Domperidonul (10mgx3/zi)
endoscopic i
- efecte secundare mai puine
histopatologic
_____________________________________
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_____________________________________
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_____________________________________
Sucralfatul 1000 mg x 4 / zi
cu 30 minute nainte de mese i la culcare (pelicul
protectoare)
esofagita de grad III sau IV
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37
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Tratament chirurgical
_____________________________________
_____________________________________
Indicaii:
_____________________________________
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_____________________________________
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
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_____________________________________
Tratamentul endoscopic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
- s-a renunat n prezent la injectarea de substane nonabsorbabile la nivelul jonciunii pentru ngustarea lumenului
(lipsa de standardizare)
Complicaii - n general uoare
- rar, complicaii severe: pneumonii de aspiraie,
mediastinit i hemoragie digestiv superioar
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38
_____________________________________
Tratamentul complicaiilor
_____________________________________
_____________________________________
Stenoze esofagiene:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Esofagul Barrett
_____________________________________
_____________________________________
Chemoprevenia pentru a mpiedica progresia displaziei aspirin i inhibitori COX2 (fr standardizare)
_____________________________________
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Esofagita alcalin
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39
40
TULBURRI MOTORII
ESOFAGIENE
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Etiologie
_____________________________________
I. Primare
II. Secundare
Afeciuni metabolice (diabet zaharat)
Intoxicaii (alcoolism)
Afeciuni endocrine(hipo i hipertiroidie)
Afeciuni neurologice (accidente vasculare cerebrale,
pseudobulbarism, Parkinson)
Afeciuni musculare (miastenia gravis)
Colagenoze (lupus eritematos sistemic, sclerodermie)
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Cu afectarea relaxrii
jonciunii eso-gastrice
- Absena peristalticii
- Peristaltic hipotensiv
(intermitent, frecvent)
- Peristaltic hipertensiv
- Esofagul sprgtor de nuci
- Spasmul esofagian
(segmentar sau difuz)
_____________________________________
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41
_____________________________________
ACALAZIA CARDIEI
_____________________________________
Definiie:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Epidemiologie
_____________________________________
_____________________________________
- 20-60 de ani
-F B
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Etiopatogenie
_____________________________________
Teorii :
- viral (varicela zoster, rujeol)
- toxic
- genetic (mai frecvent la pacienii cu sindrom Down,
sindrom AAA: acalazie, alacrimie, Adisson)
- autoimun (cea mai acceptat teorie infiltrarea
plexului mienteric cu limfocite CD3 CD8 pozitive, Ac
IgM, activarea complementului)
Modificri la nivelul sistemului nervos:
- afectarea selectiv a neuronilor inhibitori de la nivelul
plexului mienteric, cu producerea de VIP, NO i infiltrat
inflamator - disfuncia SEI
- modificri degenerative la nivelul nucleului dorsal al
vagului i a ramurilor vagale
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Tablou clinic
_____________________________________
1.
Disfagia
- localizare la nivelul esofagului inferior, retroxifoidian
- debut insidios, sau brusc dup stress
- poziii care cresc presiunea intratoracic (Valsalva,
ridicarea braelor, ndreptarea spatelui)
- 50% disfagie paradoxal
2. Durerea toracic anterioar
- de obicei la nceput, nainte de dilatarea esofagului
- iradiaz la nivel cervical i omoplai
- acalazia viguroas
3. Regurgitaia
- alimente nedigerate, amestecate cu saliv (NU cu acid
sau bil)
_____________________________________
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42
_____________________________________
_____________________________________
_____________________________________
4. Pirozisul
- produs de acidul lactic ce rezult din fermentaia
alimentelor i nu de RGE
_____________________________________
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_____________________________________
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Diagnostic paraclinic
_____________________________________
_____________________________________
EDS
Manometria
Examenul radiologic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
EDS
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
de
_____________________________________
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43
_____________________________________
Manometrie
_____________________________________
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44
_____________________________________
Examenul radiologic
_____________________________________
Rx.torace
- nivel hidro-aeric mediastinal
- dispariia camerei cu aer a stomacului
- complicaii pulmonare
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Diagnostic diferenial
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Complicaii
_____________________________________
Esofagiene
- esofagit
- HDS
- cancer esofagian (risc de 7x ! comparativ cu populaia
general, att pentru carcinom scuamos, ct i
adenocarcinom, n special la sexul masculin); nu exist
ghiduri pentru screening!
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Pulmonare
- bronite, broniectazii
- infiltrate pulmonare
- abces pulmonar
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
45
_____________________________________
Tratament
_____________________________________
_____________________________________
_____________________________________
MEDICAL
_____________________________________
_____________________________________
ENDOSCOPIC
CHIRURGICAL
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Tratament medical
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Tratament endoscopic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
46
Tratament endoscopic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Tratament chirurgical
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
EDS:
inele etajate
exclude alte cauze de disfagie
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
47
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Diagnostic diferenial:
- achalazia cardiei( manometrie, EDS, examen radiologic)
- cancer esofagian
- stenoza esofagian peptic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Tratament
- relaxante musculare (nitrai, nifedipin)
- IPP (legtur RGE SDE?)
- anxiolitice, antidepresive
_____________________________________
_____________________________________
_____________________________________
48
CANCERUL ESOFAGIAN
_____________________________________
_____________________________________
Epidemiologie
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Cancer esofagian
1. Adenocarcinom
2. Scuamos
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Factori de risc
Adenocarcinom
_____________________________________
_____________________________________
_____________________________________
_____________________________________
- obezitatea
_____________________________________
_____________________________________
_____________________________________
49
Factori de risc
_____________________________________
Carcinom scuamos
- fumat, alcool
- marii fumtori-risc de 5x> comparativ cu nefumtorii
- alcoolici risc de 20-50X >
- tutunul+ alcoolul (efect sinergic) x100 >
- statusul socio-economic precar
- diet srac n legume, fructe, vitamine (B,C), Mg, Zn,
proteine
- afeciuni esofagiene: acalazia cardiei, stenozele esofagiene,
sindrom Plummer Vinson
- cancer ci aero-digestive superioare
- tyloza (keratodermie plantar i palmar, papiloame
esofagiene i cancer esofagian) se transmite autosomal
dominant
- factori posibili implicai: concentraia de molibden din sol,
petrol, solveni, virusul papilomatos uman, boala celiac
- radiaiile toracice pentru cancer de sn cresc de 10x riscul de
cancer esofagian
Tablou clinic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Explorri paraclinice
_____________________________________
EDS
CE precoce (limitat la mucoas i submucoas fr
metastaze ganglionare): zon supradenivelat minim,
ulceraie superficial, polip
- cromoscopia, magnificaia, narrow band imaging
(NBI) cresc calitatea diagnosticului endoscopic
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
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50
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Explorrile biologice
nu aduc date suplimentare pentru diagnostic
anemie
teste hepatice alterate n cazul metastazelor
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
CT torace i abdomen - are rezultate identice cu RMN-ul stadializeaz cancerul, metastazele locoregionale i la distan
Tomografia cu emisie de pozitroni (PET) indicat n cazuri
selecionate pentru decelarea disminrilor la distan
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Evoluie, prognostic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Tratament
_____________________________________
Chirurgical
Endoscopic
Radioterapie
Chimioterapie
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
51
_____________________________________
Tratament chirurgical
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Tratament endoscopic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Radioterapia, chimioterapia
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
52
ULCERUL GASTRIC
I DUODENAL
_____________________________________
Definiie
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Epidemiologie
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Etiopatogenie (1 9)
_____________________________________
1.
_____________________________________
2.
_____________________________________
3.
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
4. Alimentatia
- anumite alimente pot favoriza dispepsia dar nu exist
relaie direct diet ulcer, inclusiv pentru alcool i cafea
53
_____________________________________
_____________________________________
5. Stress - ul
- relatie ntre peptidele cerebrale i tubul digestiv prin
influenarea secreiei i motilitii gastrice
- stress - ul acut - ulcere de stress
- gastrita hemoragic acut
- stress - ul cronic factor ulcerogen
6. Boli asociate
- asociere cert: mastocitoza sistemic, boli pulmonare
cronice, IRC, CH, litiaza renal, deficitul de alfa-1 antitripsin
- asociere probabil: hiperparatiroidismul, bolile coronariene,
policitemia vera, pancreatita cronic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
7. Factorul genetic
- Rudele de grd I ale pacienilor cu UD risc de 3 x >
- grupul sanguin O(I) , nesecretor - risc 1,5 x >
_____________________________________
Rol HP?
_____________________________________
_____________________________________
_____________________________________
8.
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
9. Cauze rare
- infecii: citomegalovirus, herpes simplex
- medicamente: bisfosfonaii, chimioterapia, clopidogrel,
glucocorticoizii, clorura de potasiu
- alte afeciuni: boli mieloproliferative, obstrucie duodenal
(ex. pancreas inelar), ischemie, radioterapie, sarcoidoz,
boal Crohn
_____________________________________
Fiziopatologie
_____________________________________
Factori de agresiune
Factori de aprare
Acidul clorhidric
Preepitelial
- masa celulelor parietale
- mucus
- tonusul vagal
- bicarbonat
- hipersecreia i sensibilitatea la gastrin
- eliberare crescut de histamin
Epitelial
Pepsina
- refacerea esuturilor
- pepsinogenul I
- celule epiteliale
Refluxul duodeno gastric
- prostaglandine
- factor epidermal de
cretere
- sruri biliare
- secreia pancreatic
Subepitelial
- secreia intestinal
- flux sanguin
(microcirculatie)
- aport nutritiv
- oxigenare
54
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Morfopatologie
_____________________________________
_____________________________________
Macroscopic
- majoritatea unice; 5% - 10% - ulcere duble/multiple
- localizarea UD - peretele anterior sau posterior duodenal
- UG - mica curbur vertical (cel mai frecvent)
- forma - rotund / ovalar; pot fi - triunghiulare, n halter,
n rachet de tenis
- dimensiuni minime gigante (3-4 cm)
- pliuri convergente spre craterul ulceros
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Microscopic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Tablou clinic
- Durerea epigastric
- ritmicitatea - UD - tardiv post alimentar (90 min 3 h)
- trezete pacientul noaptea (0 3 am)
- UG la 30 min 1h postprandial
- periodicitate primvara , toamna
- calmat de alimente n UD, poate fi accentuat n UG
- Greuri , vrsturi acide
- Scderea n greutate i anorexia UG
- Nu exist corelaie clinico lezional
- Pot debuta printr-o complicaie
Examen obiectiv
- facies ulceros supt, cu pomei proemineni
- complicaii paloare, tahicardie, abdomen de lemn, clapotaj
- palpare sensibilitate epigastric sau paraombilical drept
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Diagnostic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
EDS
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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55
_____________________________________
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_____________________________________
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_____________________________________
Nia
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
Diagnostic diferenial
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
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56
_____________________________________
_____________________________________
_____________________________________
Dispepsia de tip ulceros
- simptome identice
- diagnostic - endoscopic - absena leziunilor ulceroase
_____________________________________
_____________________________________
_____________________________________
Esofagita de reflux
- formele cu pirozis
- accentuarea simptomelor n clinostatism
- cedarea rapid la antiacide
- endoscopie - prezena esofagitei
- absena ulcerului
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Duodenita
- poate avea simptomatologie ulceroas
- endoscopic - modificri de duodenit (edem, congestie,
eroziuni)
- tratament antiulceros eficient
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Colonul iritabil
- n formele cu predominena durerilor epigastrice
- asociaz tulburri de tranzit
- lipsa modificrilor endoscopice
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Cancerul gastric
_____________________________________
_____________________________________
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_____________________________________
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57
_____________________________________
Evoluie. Complicaii
_____________________________________
_____________________________________
_____________________________________
Complicaii
_____________________________________
_____________________________________
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_____________________________________
Evaluarea preendoscopic
_____________________________________
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58
_____________________________________
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za de cafeasngerare recent - 3%
_____________________________________
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Putere discriminatorie
_____________________________________
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_____________________________________
Factorii clinici:
_____________________________________
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
59
Evaluarea endoscopic
(recurena i prognosticul Forrest, Laine, Peterson)
_____________________________________
_____________________________________
Frecvena
resngerrii
55%-90%
IA
IB
IIA
Prelingere continu,
nepulsatil a sngelui dintro leziune
Vase vizibile nesngernde
40%-55%
IIB
Cheag aderent
10%-33%
IIC
7%-10%
Fr stigmate de sngerare
3%-5%
III
_____________________________________
_____________________________________
_____________________________________
_____________________________________
55%-90%
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Tratamentul HDS
_____________________________________
_____________________________________
_____________________________________
Medicamentos
Endoscopic
Chirurgical
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Tratament medicamentos
(antisecretorii i substane vasoactive)
_____________________________________
Antisecretorii
Agregabilitatea plachetar, stabilitate cheag pH>6
Inhibitorii H2 nu reduc statistic semnificativ i susinut
aciditatea
IPP: bolus 80mg
+
perfuzie 8mg/or 72 ore
Meninerea constant
Inhibare rapid i
complet a pompei
a concentraiei IPP n
de protoni
snge, pH>6
_____________________________________
_____________________________________
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60
Tratamentul endoscopic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
Tratament chirurgical
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Perforaia
_____________________________________
_____________________________________
perforatia
Factori favorizani:
persoane n vrst
consumul de AINS
fumatul
localizarea - faa anterioar a bulbului n UD
- mica curbur UG
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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61
Tablou clinic
durere
- intensitate mare (lovitur de pumnal), difuz,
iradiaz n abdomenul inferior
- nsoit de stare de oc
- poate aprea n plin sntate sau n cursul
unei perioade de activitate
- acompaniat de grea, vrsturi
Examen obiectiv
- pacient anxios, ghemuit de durere, polipneic, tahicardic,
eventual subfebril
- aprare muscular ; abdomen de lemn
- dispariia matitii hepatice
- dispariia zgomotelor hidroaerice
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
_____________________________________
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_____________________________________
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_____________________________________
Examene de laborator
- VSH
- leucocitoz
- penetraie - pancreas - amilaze serice i urinare
- ci biliare bilirubinei
- hepatic - transaminazelor
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Rx abdominal simpl
- aer n cavitatea peritoneal (subdiafragmatic):
pneumoperitoneu
- examen baritat, gastroscopie - contraindicate
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
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_____________________________________
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62
_____________________________________
Examen obiectiv
- diminuarea esutului adipos (uneori emaciere)
- deshidratare tegumente uscate, elasticitate redus
- sensibilitate epigastric
- evidenierea peristalticii gastrice
- clapotaj a jeune
Examene de laborator
- anemie
- hipoproteinemie cu hipoalbuminemie
- sindrom Darrow: tulburri ale echilibrului acido bazic
alcaloz, hipopotasemie, hiponatremie, retenie azotat
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
EDS
- metoda de elecie
- de preferat s se efectueze dup golirea stomacului
- se poate aprecia
- gradului stenozei
- posibilitile terapeutice: dilatarea
endoscopic a stenozei
- se pot evidenia ulcerele gastrice/pilorice
Examen radiologic
- Rx simpl - nivel hidroaeric gastric
- Rx cu bariu dilatarea stomacului (stomac n chiuvet)
- reziduu important (fulgi de zpad)
- lipsa de pasaj duodenal
- stagnarea substanei de contrast n stomac
_____________________________________
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
PRINCIPII DE TRATAMENT
N ULCERUL PEPTIC NECOMPLICAT
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Are n vedere :
ameliorarea simptomatologiei
vindecarea ulcerului peptic: eradicare Hp, neutralizarea i
inhibarea secreiei clorhidropeptice
prevenirea complicaiilor
scderea frecvenei recderilor
_____________________________________
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63
_____________________________________
Regimul igienodietetic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
evitarea fumatului!
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Terapia medicamentoas
_____________________________________
_____________________________________
_____________________________________
Eradicarea Hp
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Inhibitori ai aciditii
Antiacide
Antagoniti receptori H2
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Protectori ai mucoasei
_____________________________________
Sucralfat
_____________________________________
Prostaglandine
_____________________________________
Preparate de bismut
_____________________________________
_____________________________________
64
_____________________________________
Antiacidele
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Antiacidele
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Antisecretoriile
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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65
_____________________________________
Antagonitii H2
_____________________________________
_____________________________________
Medicament
Doz
Cimetidina
Ranitidina
Famotidina
40 mg sau 20 mg x 2/zi
Nizatidina
Observaii
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Nu interfer cu
metabolismul
citocromului P450
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
reduse
inhib receptorii H2 i din alte organe (de exemplu inim
tulburri de ritm - bradicardie i tulburri de conducere)
efect antiandrogenic ginecomastie, impoten
central, n special la vrstnici: ameeli, somnolen
sindrom moderat de citoliz
legat de citocromul P450 interfer cu unele medicamente:
teofilina, fenitoina, lidocaina
leucopenie
rash
constipaie sau diaree
cimetidina i ranitidina interfer cu alcool dehidrogenaza
(scade tolerana la alcool)
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
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66
_____________________________________
_____________________________________
_____________________________________
Efecte secundare :
Pneumonii (atenie la vrstnici!)
Infecii intestinale (Clostridium difficile!)
Malabsorbie: vitamina B12, Fe, magneziu, calciu (cresc riscul
de osteoporoz!)
Nefrit acut interstiial foarte rar
Interfer cu alte medicamente metabolizate prin citocromului
P450 (morfina, fenitoina, clopidogrel)
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Omeprazolul 40 mg /zi
Lansoprazolul 30 mg/zi
Pantoprazolul 40 mg/zi
Esomeprazolul 40 mg/zi
_____________________________________
Forme de prezentare:
- Granule sau tablete cu nveli enteric
- Lansoprazolul comprimate cu dezintegrare n cavitatea oral (utile n
disfagie!)
- Pantoprazolul, Omeprazolul, Esomeprazolul forme injectabile
- Omeprazolul granule fr nveli enteric cu bicarbonat de sodiu sub
form de pulbere poate fi administrat pe sond naso-gastric
_____________________________________
Viitor:
Tenatoprazol: nlocuirea inelului benzimidazolic cu unul
imidazopiridinic inhibarea ireversibil a pompei de protoni
Compui potasici care vor neutraliza pompa (H, K, ATP-aza) prin
legare competitiv
_____________________________________
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67
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Sucralfatul
_____________________________________
Prostaglandinele
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Sucralfatul
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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68
_____________________________________
Sucralfatul
_____________________________________
_____________________________________
Important!
este la fel de eficient ca i inhibitorii H2 n tratamentul ulcerului
peptic
efecte foarte bune n :
- gastrita indus prin consum de AINS
- esofagita eroziv
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Prostaglandinele
_____________________________________
Misoprostol (Cytotec R)
- se administreaz n 2 sau 4 prize (tb 200 mg), 800
mg/24 ore
- n special n ulcerele i eroziunile gastrice legate de
tratamentul cu AINS
_____________________________________
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_____________________________________
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69
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Tratament chirurgical
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Indicaii:
- electiv: ulcerul refractar
- n urgen: HDS, perforaia, insuficiena
evacuatorie gastric
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Complicaii postoperatorii
_____________________________________
_____________________________________
Ulcerul recurent
Sindromul de ans aferent
Sindromul Dumping
Diareea postvagotomie
Gastropatia de reflux biliar
Maldigestia, malabsorbia
Cancerul de bont gastric
_____________________________________
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70
CANCERUL GASTRIC
_____________________________________
_____________________________________
Date generale
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Epidemiologie
extrem de frecvent n Japonia (40 de decese/100.000
locuitori/an), Europa de Est
frecven sczut n America de Nord i Europa de Vest
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
brbai:femei 2:1
_____________________________________
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71
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
1.
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
2. Dieta
factori de risc
alimentele srate, conservate, afumate (conin
hidrocarburi policiclice)
nitraii - sub aciunea nitrat-reductazelor sunt
transformai n nitrii (aceast transformare este blocat
prin congelarea produselor alimentare ceea ce explic
parial scderea incidenei CG n ultimii 50 de ani)
fumatul
efect protector
dieta bogat n legume, fructe, lapte, fibre, vitamine din
grupul B i n special vitamina C ( inhib transformarea
nitrailor n nitrii )
posibil: carotenul , alfatocoferolul i seleniul
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72
3. Leziunile precanceroase
Anemia Biermer
atrofia gastric - factor favorizant pentru CG
puini bolnavi cu anemie Biermer fac CG
(supravegherea endoscopic la aceti pacieni este
controversat)
Gastrita cronic atrofic cu metaplazie intestinal
cascada precanceroas Pelayo Correa
factorii dietetici (exces de sare, nitrosamine, deficitul
de fructe, etc) i infecia cronic cu Hp determin
inflamaie local gastrit superficial atrofie
gastric (pierderea glandelor) metaplazie de tip
intestinal displazie cancer
Ulcerul gastric
UG se poate transforma n CG, procesul de
malignizare ncepe n marginile ulcerului
rol important revine infeciei Hp
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4. Factorii ereditari
componenta genetic
rudele de gradul I ale pacienilor cu CG dezvolt mai
frecvent gastrit atrofic (34%) i CG
pacienii cu polipoz adenomatoas familial ( FAP)
adenoame gastrice n proporie de 35-100%
CG este de 10 ori mai frecvent comparativ cu
populaia general
polipoza juvenil se nsoete de CG ntr-o proporie
de12-20%
pacienii cu cancer colorectal nonpolipozic (HNPCC)
pot avea n 10% din cazuri i CG de tip intestinal
grupa sanguin A mai frecvent afectat
mutaie CDH1 n CG ereditar difuz
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Clasificare
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Stadializare
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Tablou clinic
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Examen obiectiv
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inspecie
tegumente palide sau icterice la un pacient
emaciat, cu facies suferind
semne de iritaie meningeal (n metastazele
meningeale)
formaiune care bombeaz n epigastru
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palpare
formaiune palpabil epigastric
hepatomegalie tumoral (metastaze hepatice)
ascit (carcinomatoz peritoneal)
splenomegalie (HTP segmentar)
prezena adenopatiilor supraclaviculare stngi
sau axilare
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Diagnostic paraclinic
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I)
II)
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V. Echoendoscopia (EUS)
identific profunzimea invaziei CG
deceleaz ganglionii limfatici perigastrici cu
acuratee comparabil cu CT
delimiteaz CG precoce de cel avansat:
- n CG precoce invazia este limitat la
mucoas i submucoas
- n CG avansat procesul tumoral penetreaz
toate straturile peretelui gastric
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VI.
Echografia abdominal
- poate evidenia ngroarea peretelui gastric (peste 8 mm)
- neoplasmul antral n seciune sagital imagine n
cocard, de dimensiuni mari, cu zon hipoechogen
periferic groas care nconjoar o alta central
hiperreflectogen (aer gastric)
- metastaze ganglionare, hepatice, ascit carcinomatoas
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Diagnostic pozitiv
Circumstane de diagnostic
- simptomatologie clinic trenant de tip dispeptic,
rebel la tratament, asociat cu semne de alarm
(scdere ponderal, inapeten, etc) la pacieni peste
45 de ani
- antecedente de ulcer gastric, polipi gastrici, gastrit
Menetrier, FAP etc
- examen radiologic cu suspiciune de CG
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Diagnostic diferenial
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Evoluie. Prognostic
diseminare prin : contiguitate, limfatic, hematogen
prognostic sever: vrsta tnr, localizarea nalt, tipul
histologic infiltrativ difuz
n Japonia la 5 ani supravieuirea este de
89% n cancerul precoce
46% n cancerele gastrice avansate
CG cu metastaze hepatice, fr tratament
supravieuire de 4-6 luni
carcinomatoza peritoneal supravieuire de 4-6
sptmni
rezecie gastric - supravieuire la 5 ani:
90% n stadiul I
50% n stadiul II
10% n stadiul III
1% n stadiul IV
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Complicaii
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Screeening i supraveghere
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Tratament
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CG precoce
mucosectomia endoscopic are viz curativ
indicaii: tipul I < 10 mm, IIa < 20 mm, IIb
pentru CG precoce ulcerat se prefer intervenia
chirurgial
CG avansat
tratament chirurgical
radioterapie
chimioterapie
tratament suportiv
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Tratamentul chirurgical
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Radioterapia
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Chimioterapia
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Tratamentul suportiv
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Tratamentul durerii
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LIMFOMUL GASTRIC
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Tablou clinic
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Explorri paraclinice
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82
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Tratament
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Principii :
abordare complex, multidisciplinar: gastroenterolog,
hematolog i chirurg
tratament difereniat, ntruct acest grup de neoplasme este
extrem de heterogen
iniierea tratamentului se face dup:
stabilirea tipului de limfom i a gradului de malignitate
stadializarea bolii
stabilirea particularitilor ( form localizat, difuz)
evaluarea complicaiilor
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83
84
PATOLOGIA
INTESTINULUI SUBIRE
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Simptomatologie
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Durerea abdominal
Greurile, vrsturile (ocluzie)
Hemoragia digestiv (melen, rar hematemez, sngerri
oculte, anemie)
Tulburrile de tranzit (diaree, constipaie)
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Examen obiectiv
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General
faciesul peritoneal
atitudini antalgice uneori caracteristice
paloarea tegumentelor
emaciere
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85
Inspecia abdomenului :
- modificri de volum: bombare - simetric (meteorism),
- asimetric (tumori)
- imobilitatea peretelui (peritonit)
- micri antiperistaltice (ocluzie)
Palparea superficial: abdomen flasc (malabsorie); aprare
sau contractur abdominal (iritaie peritoneal)
- profund identificare formaiuni tumorale
Percuia
- hipersonoritate (meteorism)
- matitate - fix (tumori); deplasabil (ascita)
Ascultaia
- zgomote hidroaerice (ocluzii)
- linite (ileus dinamic, peritonite)
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Tueul rectal
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Examene paraclinice
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Explorarea imagistic
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Videocapsula de elecie
Enteroscopia permite prelevarea de biopsii + terapie
EDS (duoden), colonoscopie (ileon terminal)
Examenul radiologic abdominal pe gol
Examenul radiologic baritat (tranzit, clism baritat)
Examenul echografic
CT i/ sau RMN (enterografie CT, RMN)
Scintigrafia
Arteriografia
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86
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MALABSORBIA
Definiie: perturbarea absorbiei substanelor nutritive
necesare vieii
1. Anomalii ale mucoasei intestinului subire: carena
dizaharidic, deficitul de vitamin B12 i folai, sprue
nontropical, ileojejunitele nongranulomatoase,
amiloidoz, boala Crohn localizat intestinal, enterita de
iradiere, abetalipoproteinemie
2. Suprafa de absorbie improprie: sindrom de intestin
scurt, by pass-ul jejunoileal
3. Infecii: sprue tropical, boala Whipple , enteritele
infecioase acute, parazitozele intestinului subire
4. Obstrucii limfatice: limfoamele, tuberculoza,
limfangectazie
5. Boli cardiovasclare: ischemie mezenteric
6. Drog indus (colestiramina, colchicina, laxativele iritante)
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Tablou clinic
Manifestri digestive: diareea steatoree, greuri, vrsturi,
meteorism, flatulen, dureri abdominale (de tip ocluziv,
pancreatic sau vascular)
Manifestri extradigestive (sindrom carenial):
-deficit ponderal
-semne de caren vitaminic (anemie, glosit, stomatit,
nevrite, osteomalacie, sindrom hemoragipar, hemeralopie,
xeroftalmie)
-edeme careniale
-deficiene hormonale (tulburri de cretere, hipogonadism,
insuficien corticosuprarenal)
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87
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Principii de tratament
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BOALA CELIAC
Definiie: enteropatie autoimun indus de ingestia de
gluten la persoane predispuse genetic
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Epidemiologie
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Etiopatogenie
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Predispoziie genetic:
- HLA DQ2 fixeaz preferenial o peptid din gliandin i o
prezint prin celule prezentatoare (limfocite B, macrofage,
celule dendritice) drept antigen ctre limfocitele T.
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Morfopatologie
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89
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Simptomatologie clinic
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90
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Diagnostic pozitiv
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Complicaii
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Jejunoileita ulcerativ
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Tratament
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Diet fr gluten
rspuns clinic favorabil n 3-6 sptmni
rspuns morfopatologic cu restitutio ad integrum n 35 ani
excludere complet din alimentaie a finei de gru,
secar, orz i ovz
cartofii, fina de orez i de mlai sunt permise
dureaz indefinit n timp
Tratamentul medicamentos se aplic n cazurile
avansate, cnd dieta singur nu este eficace
Corticoizi per os, 10-20 mg de 2x/zi, 4-8 sptmni
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91
TUMORILE INTESTINULUI
SUBIRE
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Simptomatologia clinic
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Apare tardiv
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- n stadiile
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Explorarea imagistic
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Ultrasonografia
- modificri ale lumenului intestinal, cocard patologic
i ngroarea excentric a peretelui IS > 2mm
- cile biliare dilatate
- metastaze hepatice sau limfatice
- permite puncia cu ac fin cu prelevare de esut pentru
examen histopatologic
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Explorarea umoral-biochimic
- anemie hipocrom feripriv; teste pozitive pentru hemoragii
oculte
- sindrom de colestaz (n cazul tumorilor periampulare)
- teste hepatice modificate (metastaze)
- teste de malabsorbie
- tumori carcinoide: dozarea serotoninei i a metabolitului urinar
5 - hidroxi indolacetic
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Forme clinice
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Tumorile benigne
sunt frecvente
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Tumorile maligne
primitive (adenocarcinom, limfom, leiomiosarcom)
secundare (metastaze de la melanom malign)
prognostic rezervat datorit diagnosticului tardiv
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- Adenocarcinomul
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- Sarcoamele
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- Tumorile carcinoide
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Tratament
Tratamentul chirurgical
- curativ sau paliativ
- enterectomie segmentar cu rezecie
limfadenectomie
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mezenteric pentru
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n tumorile carcinoide
- octreotid (analog sintetic al somatostatinei): inhib eliberarea
de peptide endogene
- chimioterapia- rezultate modeste
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95
96
COLONUL IRITABIL
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Definiie:
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Date generale
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Tablou clinic
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97
Diagnostic pozitiv
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98
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Diagnostic diferenial
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Diagnosticul diferenial:
- afeciuni inflamatorii (RCUH, BC)
- neoplazii
- infecii (colita pseudomembranoas, infeciile parazitare,
bacteriene)
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Tratament
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1. Psihoterapia
y eficient n special n sindromul dureros
y calmarea bolnavului - esenial, cancerofobie
y evitarea strilor conflictuale
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4. Acupunctura
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1. Tratamentul psihotrop
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absorbante:
crbune medicinal 5g/zi
sab simplex (dimeticon) cp = 80 mg, 1cp x 3-5 ori/zi
fermeni digestivi:
- amilaz + tripsin + lipaz (Triferment)
+ hemiceluloz, bil bovin (Cotazim, Panzcebil,
Festal, Digestal)
bromelin (Nutrizim)
+ derivate porcine de enzime pancreatice (Creon)
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y laxative:
- de volum (mucilaginoase, hidrofile care si cresc
volumul, stimularea mecanic: metilceluloza (Colagel)
2g x2/zi, tare
- osmotice: - sulfat de magneziu n administrare unic
(5g = laxativ, 30 g = purgativ)
- magnezia usta 1 g la o administrare
- hidroxid de magneziu1 tb (300 mg)x4/zi
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BOLILE INFLAMATORII
INTESTINALE
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RECTOCOLITA ULCEROHEMORAGIC
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Definiie
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Epidemiologie
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Etiologie
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Fiziopatologie
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Tablou clinic
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I. Manifestri digestive:
- episoade de diaree cu snge, mucus i puroi asociate cu
dureri abdominale, crampe, tenesme, durere la palpare pe
traiectul colonului i n hipogastru
- n puseu, de obicei 3-10 scaune/zi, n formele severe numai
emisii de snge, mucus i puroi
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Diagnostic de laborator
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Colonoscopie
tipic: afectarea rectului, extensie proximal la nivelul colonului,
caracterul continuu al leziunilor endoscopice
n puseu mucoasa plnge cu snge, este friabil, cu ulceraii
superficiale, eritem difuz, pierderea desenului vascular,
prezena de mucus i puroi n lumen
n remisiune mucoas cu desen vascular ters sau absent,
sngernd la atingere, pseudopolipi inflamatori
n forme cronice pseudopolipi
Biopsia obligatorie pentru diagnostic
- infiltrat inflamator cu PMN limitat la nivelul mucoasei
- prezena abceselor criptice (caracteristice n faza acut)
- mucoas hiperemic, edemaiat, exulcerat
- n formele cronice pseudopolipi inflamatori
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Clisma baritat
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Forme clinice
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Evolutive
- acut fulminant
- cronic intermitent
- cronic continu (mai rar)
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Diagnostic pozitiv
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Clinic
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Colonoscopie
RCUH
Radiologie
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Ex. histopatologic
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Laborator
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Diagnostic diferenial
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Complicaii
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Megacolonul toxic
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Perforaia
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Cancerul colo-rectal
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Megacolonul toxic
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Megacolonul toxic
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arat
dilatarea
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Explorarea colonoscopic
contraindicate!
sau
irigografic
sunt
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Cancerul colo-rectal
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Factori de risc:
durata evoluiei bolii (riscul neoplazic apare dup 8 ani de
evoluie i crete exponenial dup 20 de ani)
extensia bolii (pancolitele prezint riscul cel mai mare)
asocierea colangitei sclerozante primitive
antecedente familiale de CCR
vrsta tnar la debut
Supravegherea colonoscopic
colonoscopie + cromoendoscopie, cu biopsii multiple dup 8
ani de evoluie
absena displaziei colonoscopie la 2 ani sau anual dac
evoluia bolii este > 20 de ani
displazie sever colectomie
displazie uoar tratament endoscopic (polipectomie,
mucosectomie) i intensificarea supravegherii colonoscopice la
3-6 luni
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Tratament
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Dieta
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Clase de medicamente
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Aminosalicilaii
Corticosteroizii
Agenii imunomodulatori
Terapia biologic (anti TNF)
Alte clase de medicamente: antibiotice, probiotice
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Aminosalicilaii
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Salazopirina
este format din sulfapiridin (molecul lipsit de efecte
terapeutice) i 5 - ASA, legate printr-o legtur azo
tablet de 500 mg; doza 2 4 g/zi
efectele secundare ale salazopirinei:
- dependente de doz i de rata de acetilare
(greuri,vrsturi, cefalee, malabsorbie de folai)
- independente de doz (anemie hemolitic, neutropenie,
infertilitate masculin, erupii cutanate, hepatit colestatic)
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Aminosalicilaii
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Corticosteroizii
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Agenii imunomodulatori
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Terapia biologic
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2. Forme medii:
- Prednison p.o. 40 - 60 mg/zi, cu scderea progresiv a dozelor
(cu 5 - 10 mg/spt)
- se asociaz mesalazin 3- 4 g/ zi care va rmne ca tratament
de ntreinere dup oprirea corticoterapiei
- n formele corticorezistente (nu rspund la corticoterapie),
corticodependente (reactivarea bolii la ncercarea de reducere
sau ntrerupere a corticoterapiei) sau n caz de contraindicaii la
corticoterapie se administreaz Infliximab i/sau ageni
imunmodulatori (azatioprin, 6-mercaptopurin)
3. Forme uoare
- Mesalazin p.o. 1,5-2 g/zi sau Salazopirin p.o. 3-4 g/zi
3. Forme distale (rectosigmoidiene):
-microclisme sau supozitoare cu Mesalazin sau Budesonid
-preparatele topice sunt superioare tratamentului p.o, iar
tratamentul combinat topic i p.o. este superior comparativ cu
fiecare n parte
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Tratamentul chirurgical
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Indicaii:
x complicaii acute: megacolon toxic, perforaie, hemoragie
digestiv sever, complicaii septice
x forme non-responsive la tratament medical, cronice continui
x detectarea displaziei severe, profilaxia malignizrii
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BOALA CROHN
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Definiie
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Localizare
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Epidemiologie
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Etiologie
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Factori genetici
- agregabilitate familial
- concordan la gemenii monozigoi
- mutaiia genei NOD 2
Factori dietetici: dulciuri rafinate, alimentaia srac n
legume i fructe proaspete, oxidul de titaniu
Factori infecioi: Mycobacterium paratuberculosis, virusul
rujeolic i Lysteria monocytogenes
Ali factori: fumat, contraceptive orale, antiinflamatorii nonsteroidiene, statusul socio-economic ridicat
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Fiziopatologie
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Morfopatologie
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Macroscopic
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Morfopatologie
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Microscopic
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Tablou clinic
Simptome intestinale:
- diareea
- durerea abdominal : localizat n flancul sau fosa iliac
dreapt sau difuz
- rectoragiile sunt rar ntlnite
- leziuni perianale : modificri cutanate perianale, leziuni de
canal anal, abcese i fistule
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Manifestri extraintestinale
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Explorri biologice
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Explorarea endoscopic
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Colonoscopia
- leziuni aftoide, ulceraii adnci, liniare
- aspect de piatr de pavaj
- prezena unor zone de stenoz inflamatorie
- fistule
- arii de mucoas normal
- biopsie: granulom, infiltrat limfoplasmocitar
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Clisma baritat
-
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Ecografia
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Clasificarea Montreal
Vrsta n momentul
diagnosticului
Localizare
Forma clinico-evolutiv
(fenotip)
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Diagnostic diferenial
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- colita ischemic
- colita de iradiere
- RCUH
- neoplasmul de colon
- apendicita acut
- tuberculoza intestinal
- limfomul intestinal
- boala Behcet
- afeciuni genitale
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Clinic
RCUH: diaree, rectoragii
BC: diaree, dureri abdominale, febr, mase abdominale
palpabile, fistule i abcese perianale
Colonoscopic
- RCUH: leziuni continui, nu exist arii de mucoas
normal n zona inflamat, mucoas granular, friabil,
ulceraii, pseudopolipi
- BC: leziuni discontinui i asimetrice, ulcere aftoide,
aspect de piatr de pavaj, stenoze
Histologic
- RCUH: inflamaie limitat la muscularis mucosae, criptite,
abcese criptice, ramificarea i scurtarea criptelor
- BC: inflamaie transmural, granulom de tip sarcoid, fisuri
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Radiologic
- RCUH: leziuni continui, spiculi laterali, scurtarea i
dehaustrarea colonului
- BC: leziuni segmentare, interesare intestin subire, piatr
de pavaj, stenoze, fisuri, fistule, abcese
Serologic
- RCUH: ANCA
- BC: ASCA
Complicaii
- RCUH: megacolon toxic, perforaie
- BC: stenoze, abcese, fistule
Tratament chirurgical
- RCUH: colectomia total are viz curativ
- BC: tendin la recidiv postoperatorie
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Complicaii
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Abcese
Fistule
Stenoze
Manifestri perianale
Cancer colo-rectal
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Tratament
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Scop
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Tratament
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Corticosteroizii
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Agenii imunomodulatori
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Derivaii 5-ASA
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eficacitate limitat n BC
pot fi folosii n formele uoare sau medii de BC cu afectare
colonic
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Antibioticele
se folosesc n tratamentul formelor moderate de BC, n
cazul leziunilor perianale, abceselor i fistulelor, pentru
profilaxia recidivelor postoperatorii
se utilizeaz metronidazolul, singur sau n asociere cu
fluorochinolone (Ciprofloxacin 1g/zi)
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Agenii biologici
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Agenii biologici
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123
124
CANCERUL
COLORECTAL
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Epidemiologie
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Epidemiologie
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- 7,3/100.000 sex F
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Factori de risc
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I.
Factori genetici
1. ereditari
- polipoza adenomatoas familial (FAP)
- cancerul colorectal ereditar non-polipozic (HNPCC)
2. istoricul personal sau familial de adenoame sau CCR
II. BII
III. Factorii de mediu
IV. Ali factori
Interaciunea dintre factorii genetici i cei de mediu:
- 75% cancere sporadice (factori de mediu)
- 20% predispoziie familial
- 5% sindroamele de polipoz (FAP, HNPCC, Peutz
Jeghers, Cowden)
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BII
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Factorii de mediu
_____________________________________
_____________________________________
Factori de risc:
- obezitatea (mecanisme:sistemul insulin factor de
cretere insuln-like, adipokine, imunomodulare)
- sedentarismul
- consumul excesiv de alcool
- fumatul (rol controversat)
- carnea roie (n special cea prjit), grsimile,
carbohidraii
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128
_____________________________________
Factorii de mediu
Factori protectivi
- Dieta bogat n fructe, legume i fibre alimentare
(antioxidante, antiproliferative, antiinflamatorii, dilueaz
carcinogenii din lumen, inhib activitatea carcinogenetic
bacterian)
- Calciul, vitamina D
- Vitamine A, B, C, E, acidul folic
- Seleniul
Ali factori de risc
DZ
Acromegalia
Colecistectomia
Anastomoza uretero-colic
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Morfopatologie
_____________________________________
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_____________________________________
_____________________________________
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_____________________________________
Histologic:
- 90 95% adenocarcinoame (variante: carcinomul
mucinos, cu celule n inel cu pecete)
- rar: carcinom cu celule scuamoase, limfom, sarcom,
carcinom nedifereniat
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129
_____________________________________
Stadializarea CCR
_____________________________________
_____________________________________
_____________________________________
Clasificarea Dukes
_____________________________________
Clasificarea TNM
_____________________________________
Invazia tumoral
Afectarea ganglionar
Metastazarea la distan
_____________________________________
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_____________________________________
Clasificarea DUKES:
_____________________________________
_____________________________________
Stadiul A:
_____________________________________
Stadiul B1:
_____________________________________
Stadiul B2:
_____________________________________
_____________________________________
Stadiul C2:
_____________________________________
Stadiul D:
Stadiul C1:
_____________________________________
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_____________________________________
_____________________________________
Clasificarea TNM
_____________________________________
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130
_____________________________________
Stadiul
TMN
Dukes
Supravieuirea
la 5 ani
_____________________________________
>95%
_____________________________________
_____________________________________
Std 0
Tis
No
Mo
Std II
T1/T2
No
Mo
80-95%
_____________________________________
Std IIA
T3
No
Mo
72-75%
_____________________________________
Std IIB
T4
No
Mo
65-66%
_____________________________________
Std IIIA
T1/T2
N1
Mo
55-60%
_____________________________________
Std IIIB
T3/T4
N1
Mo
35-42%
Std IIIC
Oricare T N2
Mo
25-27%
Std IV
Oricare T Oricare N M1
0-7%
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_____________________________________
Diagnostic clinic
_____________________________________
Pacieni simptomatici:
_____________________________________
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- formaiune palpabil
_____________________________________
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Tueu rectal!
_____________________________________
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Explorri paraclinice
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131
Diagnostic diferenial
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Evoluie. Prognostic
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Tratament
_____________________________________
Tratament chirurgical
Colectomie, cu excizia tumorii, margine de siguran de
2 5 cm, excizia mezenterului, a grsimii pericolice i a
ganglionilor de drenaj
n FAP colectomie total cu anastomoz ileoanal/rectal
Obstucie, perforaie colostom, cu restabilirea
continuitii dup 4 8 sptmni
Colectomia laparoscopic scurteaz spitalizarea,
necesarul medicaiei postoperatorii nu se practic n
mod curent
Tratamentul MTS hepatice: rezecie, hepatectomie,
alcoolizare, ablaie prin radiofrecven
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132
Tratament
_____________________________________
Chimioterapia
Adjuvant (dup intervenia chirurgical) n stadiul III,
controversat n stadiul II
Schema standard: 5 fluorouracil asociat cu acid folinic i
oxaliplatin, 6 luni
Capecitabina, Irinotecan linia a II-a
Agenii biologici
- Cetuximab: anticorp monoclonal care blocheaz receptorul
factorului epidermal de cretere asociat cu ligandul su
- Bevacizumab: anticorp monoclonal recombinat umanizat
al factorului de cretere al endoteliului vascular blocheaz
angiogeneza
n cancerul avansat: 5 fluorouracil + acid folinic + irinotecan
sau oxaliplatin + bevacizumab (supravieuire 20 24 luni n
CCR metastatic)
_____________________________________
Tratament
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Profilaxia CCR
_____________________________________
Profilaxia primar
- diet echilibrat, bogat n fructe, legume, fibre,
evitarea crnii roii prjite, combaterea obezitii,
fumatului, consumului excesiv de alcool
- suplimentarea cu calciu, vitamina D, acid folic rol
controversat
- medicamentos:
- aspirina, AINS, inhibitorii COX2
- acidul ursodeoxicolic (colangita sclerozant
asociat BII)
- tratamentul cu derivai 5 ASA n RCUH
- hipolipemiante (simvastatina)
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Screening i supraveghere
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133
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134
Recomandri de screening i
supraveghere
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Categorie de
risc
1-2 adenoame < 1 cm
Istoric
personal
de polip
3 10 polipi sau polip >
1 cm sau polip vilos sau
displazie nalt
> 10 polipi
Metod
Colonoscopie la 5
10 ani
Colonoscopie la 3
ani
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Colonoscopie la < 3
ani
_____________________________________
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_____________________________________
Istoric
personal de
CCR
perioperator
postoperator
Colonoscopie
nainte de operaie
sau n primele 6 luni
dup
_____________________________________
Colonoscopie la 1,
3, 5 ani de la
explorarea
anterioar
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135
_____________________________________
_____________________________________
_____________________________________
Colonoscopie la 5
ani ncepnd de la
40 de ani sau cu 10
ani mai devreme
dect vrsta
diagnosticului rudei
cu CCR
Orice metod de la
risc mediu la 5 ani
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_____________________________________
Recomandri de screening i
supraveghere
_____________________________________
_____________________________________
_____________________________________
Risc nalt
- FAP sigmoidoscopie anual ncepnd de la vrsta de
10- 12 ani
_____________________________________
_____________________________________
_____________________________________
- HNPCC colonoscopie:
- anual sau la 2 ani ncepnd de la vrsta de 20 25
ani sau cu 10 ani mai devreme dect cel mai tnr
membru al familiei diagnosticat
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136
HEPATITA CRONIC
VIRAL C
_____________________________________
_____________________________________
Date generale
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137
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Istoria natural
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_____________________________________
Istoria natural
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Evaluarea pacientului
_____________________________________
Tablou clinic
Umoral biochimic nu sunt elemente caracteristice; de
obicei prezena sindromului de citoliz oblig
investigarea etiologiei!
Markerii serologici
Evaluarea fibrozei hepatice
Metode imagistice: ecografie, EDS la cei cu fibroz
avansat pentru diagnosticul CH i complicaiilor
acesteia
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138
Tablou clinic
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_____________________________________
Markerii VHC
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
2. ARN-VHC
- cel mai bun marker al replicrii virale
- detectabil n sngele periferic la 1-2 sptmni dup
infecie
- difereniaz hepatita acut viral C vindecat de infecia
cronic cu VHC
3. Ac anti-VHC:
- pot fi detectai prin teste uzuale la 7-8 sptmni dup
infecie
- n infecia cronic persist toat viaa
_____________________________________
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3 modaliti:
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139
_____________________________________
Tratament
_____________________________________
Scopuri principale:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Scopuri secundare:
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RVS 50%
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140
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Non-responder:
a. rspuns virusologic nul: lipsa scderii cu 2 log a
ARN - VHC la 12 sptmni
b. rspuns virusologic parial: scderea cu 2 log la 12
sptmni, dar ARN - VHC rmne detectabil
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141
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2011
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142
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Viitor
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143
144
HEPATITA CRONIC
VIRAL B
_____________________________________
_____________________________________
Epidemiologie
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Prevalen:
- sczut (<2%): Europa de Vest, SUA, Canada, Australia, Noua
_____________________________________
Zeeland
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Virusul hepatic B
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Mod de transmitere:
- vertical (mame Ag HBs +)
- orizontal (n special n ariile endemice)
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145
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Tablou clinic
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Teste serologice
Diagnosticul infeciei VHB se bazeaz n general pe
detectarea AgHBs, primul marker viral detectabil n ser
Anticorpii anti-HBc din clasa IgM apar n primele 6 luni de la
infecia acut (pot apare ocazional i n cursul episoadelor de
reactivare a infeciei cronice)
IgG anti HBc apar dup 6 luni, fiind un indicator al infeciei
cronice
Ag HBe/Ac HBe definesc tipul de hepatit cronic (Ag Hbe
pozitiv sau negativ)
Replicarea viral activ este definit de prezena AgHBe
i/sau a ADN VHB
Ac anti HBs reprezint anticorpi protectori, markeri ai
vindecrii i ai imunitii la reinfecie. Pot fi indui de
vaccinarea VHB
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146
Istoria natural
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147
_____________________________________
Complicaii i mortalitate
_____________________________________
Carcinomul hepatocelular
- >10 ori n infecia B fa de populaia general
- risc inclusiv la purttorii cronici inactivi sau la cei cu
clearance Ag HBs!!
Ciroza hepatic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Mortalitatea (5 ani):
n hepatita cronic B 0-1 %;
n ciroza hepatic viral B compensat 14-20%;
n ciroza decompensat 65-85%.
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Prognostic - negativ
Factori legai de virus:
replicarea activ a VHB (no virus, no disease!)
genotipul viral
coinfecia cu VHC, VHD sau HIV
Factori legai de gazd
vrsta diagnosticrii (istoric lung de boal)
sexul masculin
episoadele recurente de reactivare a hepatitei
severitatea bolii hepatice n momentul diagnosticrii
Factori externi
alcoolul
fumatul
carcinogenii din diet (aflatoxinele)
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Evaluarea iniial
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148
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Obiectivele tratamentului
_____________________________________
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Indicaii terapeutice (1 3)
1. Hepatita cronic viral B n faza de activitate imun i
reactivare a replicrii virale (NU se trateaz pacienii
aflai n toleran imun sau purttorii cronici inactivi
conform ghidurilor actuale)
- Ag HBe +: ADN VHB > 20 000 UI/ml (100 000
copii/ml) i
ALT 2xN sau ALT < 2 x N i evidena
prezenei activitii necro-inflamatorii i fibrozei (PBH sau
FibroMax)
- Ag HBe - : ADN VHB > 2000 UI/ml (10 000 copii/ml)
i
ALT 2xN sau ALT < 2 x N i evidena
prezenei activitii necro-inflamatorii i fibrozei (PBH sau
FibroMax)
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149
Indicaii terapeutice
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INTERFERON PEGYLAT
_____________________________________
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Interferon vs analogi
_____________________________________
Interferon
- Avantaje: durat finit a tratamentului, seroconversie >
Ag HBe, Ag HBs (efectul continu i dup ntreruperea
tratamentului), lipsa rezistenei
- Dezavantaje: administrare subcutanat, efecte
secundare multiple
Analogi
- Avantaje: efect antiviral puternic, administrare per os,
efecte secundare minime, se pot administra i n ciroza
hepatic decompensat
- Dezavantaje: durat nedefinit a tratamentului (toat
viaa?), apariia rezistenei ce poate limita terapiile
ulterioare
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150
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Nu induce rezisten
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Ce AN alegem?
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151
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Efecte secundare AN
_____________________________________
Rezistena viral
- ridicat la lamivudin (65-70% la 5 ani!)
- intermediar la telbivudin i adefovir
- joas pentru entecavir i tenofovir
_____________________________________
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Lamivudina
_____________________________________
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Entecavir
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152
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Transplantul hepatic
_____________________________________
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_____________________________________
Pentru
prevenirea
recurenei
infeciei
VHB
posttransplant se administreaz pre i perioperator
imunoglobuline specifice B (HBIG), asociat cu AN cu
barier crescut la rezisten, pre i post - transplant
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Viitor?
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HEPATITA CRONIC
B +D
_____________________________________
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153
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ARN VHD
_____________________________________
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Tratament
La pacienii Ag Hbs pozitiv, Ac HVD pozitiv - criterii de
includere: ALT> 2xN, sau ALT< 2xN cu activitate necroinflamatorie 4 sau fibroz 1 (PBH, FibroMax)
Se determin ARN-VHD:
- pozitiv tratament
- negativ se determin ADN VHB:
> 2000 UI/ml se trateaz la fel ca VHB
< 2000 UI/ml - monitorizare
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FICATUL GRAS
NONALCOOLIC
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Definiie. Termeni
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Epidemiologie
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B>F, albi>negri
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Etiologie
Primar expresia hepatic a sindromului metabolic
(3 din: circumferinei taliei, hipertrigliceridemie, HTA,
glicemiei, HDL colesterolului)
- obezitatea: 40 100%
- hiperglicemia: 25 75%
- hiperlipemia: 20 80%
Secundar:
- medicamente: glucocorticoizi, estrogeni, tamoxifen,
amiodaron
- nutriional: malnutriie, Kwashiorkor, deficien de
colin, by-pas jejuno-ileal, gastroplastie, rezecii de
intestin subire, nutriie parenteral total
- afeciuni hepatice: Wilson, hepatita cronic VHC,
glicogenoze
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Fiziopatologie
First hit insulinorezistena stimuleaz sinteza de
trigliceride i acumularea de acizi grai liberi n ficat
Second hit stress oxidativ - peroxidarea lipidelor
eliberarea de radicali liberi de oxigen atragerea
mediatorilor inflamatori (TNF, citokine inflamatorii)
injurie hepatic
Leptina (hormon citokin like, produs de adipocite i de
celulele stelate hepatice) - n sindromul metabolic rol
n progresia NASH
Adiponectina hormon secretat de grsimea omentalstimuleaz utilizarea glucozei i oxidarea acizilor grai;
se coreleaz invers cu sindromul metabolic, insulinorezistena i NASH
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Clasificarea morfologic
(Matteoni)
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Diagnostic clinic
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Diagnostic paraclinic
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Umoral biochimic
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Diagnostic paraclinic
Imagistic
- ecografia abdominala steatoz difuz sau focal
- computer tomografia (fr substan de contrast)
- rezonana magnetica metoda cea mai sensibil dar
cea mai scump!
Limite: nu difereniaz steatoza de steatohepatit, nu
cuantific inflamaia i fibroza!
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Metode non-invazive:
fibroscan, fibromax,
steatotest etc nu au intrat n practica curent
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Diagnostic pozitiv
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hepatomegalie
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Diagnostic diferenial
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Hepatita alcoolic
Hepatite virale
Hepatita autoimun
Hepatite medicamentoase
Hemocromatoz
Afeciuni tiroidiene
Boal Wilson
Deficitul de alfa 1 antitripsin
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Evoluie. Complicaii.
Prognostic
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Tratament
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1. Scderea n greutate
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Tratament
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4. Hipolipemiante
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5. Transplant hepatic
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BOALA HEPATIC
ALCOOLIC
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Factori de risc
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Sexul i vrsta
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Obiceiuri:
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Diagnostic
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Anamneza
consum de alcool (alcool dependena ) + cuantificare factori de
risc
chestionare pentru alcool dependen i abuzul de alcool :
AVAIT Alcohol Use Disorders Identification Test, MAST
Michigan Alcoholism Screening Test, chestionarul CAGE
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Umoral biochimic
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Explorri imagistice
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nu precizeaz etiologia
evideniaz stadiul evolutiv al afeciunii hepatice :
decompensarea cirozei, hepatocarcinom, etc
explorarea de prim intenie - echografia
CT, RMN - n cazuri selecionate
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PBH
etiologie incert a afeciunii hepatice
dac exist asociat bolii hepatice alcoolice o alt afeciune
hepatic
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Evoluie i prognostic
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Tratament
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Alimentaia
scop: diminuarea efectelor malnutriiei proteocalorice i
vitaminice (thyogamma, Mg, vitamine B,C,E,A etc)
n stri grave alimentaie enteral i parenteral
Corticoterapia - boala hepatic alcoolic i encefalopatia
(fr coafectarea altor organe sau complicaii hepatice HDS, insuficien renal, etc)
- 40 mg/zi, 4 sptmni, cu scderea dozei timp de alte 2 4 sptmni sau oprirea administrrii n funcie de evoluie
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Transplantul hepatic
- dup o perioad de abstinen i consimmnt de meninere
a acesteia indefinit
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166
HEPATITELE AUTOIMUNE
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Diagnostic diferenial
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Absolute:
ALT 10N
ALT 5N + gammaglobuline 2N
Histopatologie - necroz n punte sau multiacinar
Simptome (artralgii, astenie) care determin incapacitatea
calitii normale a vieii
Relative:
Simptome (astenie, artralgii, icter etc.)
Creterea ALT, gamaglobuline < criteriile absolute
Hepatit de interfa
Nu este indicat n ciroza inactiv, comorbiditi severe sau
intoleran
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Tratamentul standard
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3 scopuri principale:
inducere i meninerea imunsupresiei (cu minime efecte
adverse)
prevenirea i tratamentul cirozei hepatice
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Monoterapie (Prednison)
Biterapie (Prednison cu Azatioprin)
- se prefer biterapia cu monitorizare ntruct efectele
secundare sunt reduse comparativ cu monoterapia
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Tratamentul standard
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1.Complet:
- clinic - absena simptomatologiei subiective
- biochimic: bilirubin, albumine, gamma-globuline
normale, ALT<2N
- histologic (remisiune histologic: histologie normal,
hepatit periportal minim)
Durata tratamentului: 2 4 ani!
Conduita:
- se scade prednisonul treptat pn se ntrerupe
- se ntrerupe azatioprina
- se monitorizeaz pentru recdere (transaminaze,
gammaglobuline, bilirubin etc.)
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2. Incomplet:
- ameliorare parial sau lipsa ameliorrii clinice
biologice, histologice
- lipsa rspunsului complet la 3 ani de la iniierea
tratamentului
Conduita: se continu indefinit tratamentul cu doze minime
(fr efecte adverse)
3. Eec:
- agravare clinic, biologic, histologic n timpul
tratamentului imunosupresiv
- creterea transaminazelor
- apariia icterului, ascitei sau encefalopatiei
Conduita: doze mari de prednison (60mg) sau combinaii
(Ps 30mg+AZT 150mg); se reduc dozele lunar (10mg Ps i
50mg AZT); doza de meninere se stabilete funcie de
rspuns
n caz de eec se indic transplantul hepatic
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172
CIROZA HEPATIC
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Definiie
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Clasificare
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- morfologic
- etiologic
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Clasificare
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1.Morfologic
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- micronodular (Laennecs) - noduli <3 mm, cel mai frecvent
n etiologia alcoolic
- macronodular - noduli > 3mm, n etiologia viral B, C
- mixt - asociaz ambele aspecte
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Clasificare
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2. Etiologic
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b. Ciroza viral B, C, D
B Ag HBs, Ac anti HBc, viremie
C Ac anti VHC, viremie
D Ac anti VHD, viremie
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Examen obiectiv
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Explorri paraclinice
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Umoral biochimic:
sindrom de citoliz ( ALT, AST, LDH, fier, vitamina B12,
ornitin carbamil transferaz)
sindrom bilioexcretor ( pigmeni biliari, bilirubina, acizi
biliari, urobilinogen, stercobilinogen)
sindrom de hiperactivitate mezenchimal ( electroforeza
proteinelor, imunoglobulinele serice)
sindrom hepatopriv ( hipoproteinemie cu hipoalbuminemie,
hipocolesterolemie, scderea indicelui de protrombin)
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Explorarea imagistic
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Ecografia
Ficat - pierderea structurii normale hepatice + hipertrofia
lobului caudat (N: max 35 mm). Lobul caudat > 40mm ciroza hepatic n 2/3 din cazuri, n context clinic
cunoscut
Splin - 80% din pacienii cu splenomegalie > 15 cm (N:
12cm)
Semne de hipertensiune portal Doppler (excludere
tromboze VP,VS) - VP > 12mm, VS > 8mm preaortic,
repermeabilizare ven ombilical
Colecist: dedublare perete vezicular (hipoalbuminemie,
staz limfatic, HTP) i litiaz biliar vezicular (de obicei
asimptomatic)
monitorizare HCC: apariie tratament ( alcoolizare,
radiofrecven, etc.) recidiv
8
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Ecografia Doppler
permeabilitate vene suprahepatice, tromboz complet/
incomplet ven port vascularizaie formaiuni hepatice
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175
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Tratament
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Msuri generale
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176
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COMPLICAIILE CIROZEI
HEPATICE
HEMORAGIA DIGESTIV
SUPERIOAR PRIN HIPERTENSIUNE
PORTAL
n ciroza hepatic :
procentul anual de apariie a VE 5 -7 %
1/3 pacieni cu CH fac HDS prin efracie variceal
mortalitatea la fiecare sngerare este de 20%
riscul de resngerare 25%
60% din cirotici au VE n momentul apariiei ascitei
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A. Tratamentul farmacologic
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B. Tratamentul endoscopic
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oprirea sngerrii
Scop: corectarea hipovolemiei
prevenirea complicaiilor sngerrii active
prevenirea deteriorrii funciei hepatice
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1.Msuri generale
- asigurarea 2 -3 linii de abord venos
- intubare orotraheal prevenirea aspiraiei
- corectarea hipovolemiei ( soluii coloidale, albumin)
- prevenirea infeciei bacteriene (precipit resngerarea
imediat i crete mortalitatea intraspitaliceasc). Se
administreaz cefalosporine de generaia a-III-a
- transfuzii de snge
Scopul transfuziei - stabilizarea Hb la 8 g/dl.
Overexpension poate determina creterea presiunii
portale i implicit resngerarea
- meninerea funciei renale (apariia sindromului hepatorenal
deces n 95 % cazuri)
- tratamentul EHP - lactuloz, rifaximin
- nutriie parenteral adaptat strii pacientului
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2.Tratament farmacologic
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3.Tratament endoscopic
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Scleroterapia endoscopic
- injectarea ( intra i/sau paravariceal) a unui agent
scerozant; n prezent nu exist un agent sclerozant optim
sau ideal
- hemostaza se produce n 80 90% din cazuri
- complicaii n 10 -20 % din cazuri: stenoze, perforaii,
hemoragii, ulcere
Ligatura endoscopic
- eficien similar cu scleroterapia, efecte secundare mai
puine
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9.Transplantul hepatic
- curativ
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blocant + ligatur
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COMPLICAIILE CIROZEI
HEPATICE
ASCITA
34
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ASCITA
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Diagnostic clinic
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Examenul fizic:
- abdomen mrit de volum
- icter
- circulaie colateral abdominal
- stelue vasculare
- eritem palmar, plantar
- hernie ombilicala
- edem scrotal sau penian
- matitate deplasabil pe flancuri , semnul valului
- hepatosplenomegalie
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
36
_____________________________________
_____________________________________
Explorri paraclinice
_____________________________________
A . Funcia hepatic:
Alterarea celor
4 sindroame hepatice
_____________________________________
sindromul de citoliz
sindromul bilioexcretor
sindromul hepatopriv
sindromul de iritaie mezenchimal
_____________________________________
_____________________________________
_____________________________________
_____________________________________
C. Ecografie
- evidenierea precoce a lichidului de ascit acumulat n abdomen
(100ml) cu informaii asupra volumului, vechimii ascitei
- semne de ciroz hepatic i eventuale complicaii (hepatom,
tromboz de ven port etc)
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
37
_____________________________________
_____________________________________
F. Paracenteza diagnostic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
38
_____________________________________
_____________________________________
Diagnostic diferenial
_____________________________________
_____________________________________
_____________________________________
_____________________________________
etiologia ascitei:
hepatic: ciroza, insuficiena hepatic, hepatita
alcoolic, tromboza portal, sindromul Budd Chiari,
metastazele hepatice
extrahepatic: insuficiena cardiac congestiv,
hipertensiunea pulmonar, sindromul nefrotic,
tuberculoza, carcinomatoza peritoneal, mixedemul,
pancreatita
_____________________________________
_____________________________________
_____________________________________
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39
184
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
- encefalopatie
- Na seric < 120 mEq/L dup restricie hidric
Diureticele se opresc:
- creatinina > 2 mg/dl
- hiperpotasemie, acidoz metabolic( spironolactona)
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Ascita refractar
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Factori favorizani
- infecii asociate
- tromboz de vena port sau hepatic
- hemoragie digestiva superioara
- PBS
- carcinom hepatocelular
- malnutriie
- factori hepatotoxici: alcool, acetaminofen
- factori nefrotoxici AINS, etc
_____________________________________
_____________________________________
_____________________________________
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185
_____________________________________
Tratamentul ascitei
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
refractar
paracenteze + albumin 6 -8 g/litru lichid extras
diet hiposodat, restricie hidric
unt porto sistemic transjugular
Ideal : Transplant hepatic
- supravieuirea la 12 luni la pacienii cu ascit refractar
- 25%
- supravieuirea la 12 luni la pacienii transplantai 70 -75%
_____________________________________
_____________________________________
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186
COMPLICAIILE CIROZEI
HEPATICE
PERITONITA BACTERIAN
SPONTAN
45
_____________________________________
_____________________________________
Definiie. Etiologie
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Scderea
activitii
fagocitare
n
sistemul
reticuloendotelial, considerat mecanism esenial n
colonizarea i persistena bacteremiei
n ciroza
hepatic
_____________________________________
_____________________________________
_____________________________________
bacterian n
_____________________________________
_____________________________________
47
_____________________________________
187
_____________________________________
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_____________________________________
Confirmai:
_____________________________________
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48
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50
188
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51
_____________________________________
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_____________________________________
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Diagnostic diferenial
_____________________________________
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189
_____________________________________
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_____________________________________
Tratamentul n PBS
_____________________________________
I. Episod acut
II. Profilactic
_____________________________________
_____________________________________
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55
_____________________________________
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190
_____________________________________
Prognosticul n PBS
_____________________________________
_____________________________________
_____________________________________
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57
191
_____________________________________
COMPLICAIILE CIROZEI
HEPATICE
SINDROMUL HEPATO - RENAL
58
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Factori favorizani:
_____________________________________
infeciile bacteriene
hemoragiile digestive
paracentezele voluminoase (>5 l)
interveniile chirurgicale
medicamentele nefrotoxice
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
59
_____________________________________
_____________________________________
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192
_____________________________________
_____________________________________
_____________________________________
_____________________________________
progresiv)
- valori ale creatininei serice > 1,5 2,5 mg/dl
- fr transplant hepatic supravieuirea este de 6-812 luni, direct proporional cu gradul insuficienei
hepatice
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
61
_____________________________________
_____________________________________
Majore:
Afectare hepatic cronic n stadii terminale cu ascit
Creterea creatininei serice > 1,5 mg/dl
Scderea clearanceului de creatinin < 40 ml/min
Absena: strii de oc, infeciilor bacteriene, utilizrii de medicamente
nefrotoxice, pierderilor lichidiene (vrsturi, diaree)
Lipsa de mbuntire a funciei renale la ntreruperea diureticelor i
administrarea a1500 ml de soluie salin izoton
Absena proteinuriei i a oricrei anomalii echografice
_____________________________________
Minore:
Diureza n 24 ore sub 500 ml
Natriureza sub 10 mEq/l
Osmolaritate urinar > osmolaritate plasmatic
Hematurie < 50 elemente/mm3
Natremie<130 mEq/l
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Diagnostic diferenial:
_____________________________________
_____________________________________
_____________________________________
Prognostic
_____________________________________
_____________________________________
_____________________________________
Tratament profilactic
_____________________________________
_____________________________________
63
193
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
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194
66
Hipertensiunea portopulmonar
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Diagnostic paraclinic:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Diagnostic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Diagnostic diferenial:
_____________________________________
_____________________________________
Trombembolism pulmonar
Boal pulmonar interstiial
Boal de esut colagenic
Apnee de somn netratat
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
195
Tratament:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Sindromul hepatopulmonar
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Diagnostic clinic:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
70
_____________________________________
_____________________________________
_____________________________________
Diagnostic paraclinic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
71
196
_____________________________________
_____________________________________
Tratament :
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
197
COMPLICAIILE CIROZEI
HEPATICE
CARDIOMIOPATIA CIROTIC
73
_____________________________________
_____________________________________
_____________________________________
Definiie:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Elemente caracteristice:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
198
COMPLICAIILE CIROZEI
HEPATICE
ENCEFALOPATIA HEPATO
PORTAL (EHP)
76
_____________________________________
Definiie: anomalii
_____________________________________
_____________________________________
_____________________________________
Clasificare
EHP minim
modificari ale testelor psihometrice cu examen
neurologic standard normal la pacienii cu ciroz
hepatic
apare n 50- 60% din cirozele hepatice. Are impact
asupra calitii vieii, condusului vehiculelor,
accidentelor navale, rutiere, etc
EHP : alterri neuropsihice la un pacient cunoscut sau
suspectat de afectare hepatic sever
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
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_____________________________________
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_____________________________________
78
_____________________________________
199
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
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_____________________________________
80
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
200
_____________________________________
_____________________________________
_____________________________________
_____________________________________
2. Semne de HTP:
- circulaie colateral
- varice esofagiene
- ascit
3. Semne neurologice si psihiatrice:
- modificri de personalitate (bizar, iritabil, vulgar)
- modificari ale strii de constien
- modificarea intelectului: scderea capacitii de concentrare,
apraxie, modificarea scrisului
- neurologice: asterix sau flapping tremor
Investigaii paraclinice
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Umoral biochimic
afectare hepatic
- dozarea amoniemiei sanguine; hiperamoniemia pledeaz
pentru EHP, dar valorile normale nu o exclud; nivelul
amoniemiei nu se coreleaza cu gradul EHP
Modificrile EEG
- sunt extrem de rar folosite n practica curent i au specificitate
redus
CT( atrofie cerebrala difuz n etiologia alcoolic)
n cazuri selecionate:
RMN
Spectroscopia de rezonan (structura metabolismului
cerebral)
Tomografia cu emisie de pozitroni
_____________________________________
_____________________________________
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201
_____________________________________
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_____________________________________
tulburri de contien)
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
_____________________________________
85
Principii de tratament
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
c. Evacuarea colonului
- zaharuri neabsorbabile: lactuloza - dizaharid
neabsorbabil - inhib formarea de amoniac de ctre flora
intestinal cu creterea eliminrii fecale de azot
- 15-45 ml la 8-12 ore, per os
- clisma: 300 ml la1 l ap (la pacienii
aflai n com)
- clisma evacuatorie intestinal - n sngerrile
gastrointestinale
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
202
_____________________________________
_____________________________________
4. Metode chirurgicale:
- unturile chirurgicale nu se mai folosesc n prezent
- ideal transplant hepatic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
203
COMPLICAIILE CIROZEI
HEPATICE
HEPATOCARCINOMUL
89
_____________________________________
_____________________________________
_____________________________________
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204
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Prognosticul CH
_____________________________________
_____________________________________
Scor Child-Pugh
_____________________________________
_____________________________________
Encefalopatie
Ascit
absent
stadiul 1-2
stadiul 3-4
1
2
3
_____________________________________
absent
minim( cu rspuns la diuretice)
refractar
1
2
3
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
INR
Albumin (g/dL)
Bilirubina (mg/dL)
< 1.7
1.7-2.3
> 2.3
1
2
3
> 3.5
2.8-3.5
< 2.8
1
2
3
<2
2-3
>3
1
2
3
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
_____________________________________
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_____________________________________
205
206
CANCERUL HEPATIC
PRIMITIV
_____________________________________
_____________________________________
Epidemiologie
_____________________________________
a 3-a cauz de mortalitate prin cancer
consecina afeciunilor cronice hepatice (VHC, VHB, NASH, etc.)
distribuia HCC este neuniform:
- incidena corelat cu vrsta, sexul: Asia S-E i Africa > 20-28 x
comparativ cu Europa N, Australia i America de N
explicaiile posibile: vaccinarea hepatita B
condiiile de igien alimentar superioar
expunere redus la aflatoxine
accesul crescut la tratament
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
_____________________________________
Etiopatogenie
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
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_____________________________________
207
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Ciroza hepatic
indiferent de etiologie, este cel mai important factor de
risc pentru HCC (> 80% din cazuri)
carcinogeneza din CH este un proces multifactorial,
secvenial, multifocal n care displazia hepatocitar i
nodulii displazici sunt factori predictivi de risc pentru HCC
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Hemocromatoza ereditar
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
6
_____________________________________
208
_____________________________________
_____________________________________
_____________________________________
_____________________________________
parasiticus)
- suprancarcare fier (recipiente de preparat/stocat Africa)
- algae blue green (heletee i lacuri) peptide
ciclice hepatotoxice China
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Tutunul
Alcoolul
Contraceptive orale cu doze ridicate de hormoni steroizi
_____________________________________
_____________________________________
7
_____________________________________
Tablou clinic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
209
_____________________________________
Explorarea paraclinic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
3. Markeri tumorali:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
4. Examenul histopatologic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
210
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Diagnostic
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Ecografie (consensuri)
_____________________________________
nodul sub 1 cm
>50% noduli hepatici < 1cm HCC
urmrire ecografic la 3 luni, cu dou posibiliti :
aceleai dimensiuni HCC
suspiciune HCC - monitorizare ecografica + AFP la 6
luni
nodul 1 cm i < 2 cm
biopsie ecoghidat cu ac fin + citologie i/sau examen
histopatologic
folosit nuanat n special n leziunile hepatice focale
cu diagnostic incert i n care tehnicile imagistice
performante nu au reuit s pun diagnosticul
noduli 2 cm
dac tehnicile imagistice stabilesc diagnosticul nu este
necesar biopsia
dozarea AFP - n general > 200 ng/mL
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
211
_____________________________________
Diagnostic diferenial
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Complicaii
_____________________________________
insuficien hepatic
invazie vascular (tromboz de ven port)
extensie intrahepatic sau la distan
hemoperitoneu ( necroz tumoral)
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Factori
Dimensiuni
< 50% din ficat
Dimensiuni
> 50% din ficat
Ascit absent
Scor
supravieuire
0
1
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Ascit prezent
_____________________________________
Albumin seric
> 30 g/l
Albumin seric
< 30 g/l
Bilirubin
< 3 mg/dl
Bilirubin
> 3 mg/dl
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Tratament
_____________________________________
Prevenia primar:
_____________________________________
prevenirea hepatitei B i C;
vaccinarea pentru hepatita B;
expunere redus la aflatoxine;
interzicerea alcoolului, n special la persoanele infectate cu
virus B i /sau C
- tratamentul hepatitei cronice B sau C
- supravegherea cirozei hepatice, indiferent de etiologie
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
19
_____________________________________
212
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
- 10 - 30 % din cazuri
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Ablaia prin radiofrecven, injectare de alcool absolut tehnici invazive percutane care au eficacitate similar
cu chirurgia de rezecie dac indicaia este riguros pstrat
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
22
_____________________________________
213
_____________________________________
_____________________________________
Chimioterapia sistemic
_____________________________________
Terapii moleculare:
(HCC - hipervascularizat)
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
214
PATOLOGIA BILIAR
COLECISTITA ACUT
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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215
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Clasificare i etiologie:
Colecistita acut litiazic: n 90% din cazuri apare prin
suprainfecia litiazei biliare veziculare
Colecistita acut nelitiazic: factorul patogenic cel mai
important este ischemia
stri septicemice, oc chirurgical
posttraumatic (factori precipitani: respiraia
asistat, hipotensiunea, administrarea de opiacee)
postpartum ( factor precipitant: travaliul laborios)
vasculite (lupus eritematos diseminat, sindrom
Sjgren, periarterita nodoas)
parazitoze (foarte rar ascaris lumbricoides)
idiopatice sau primitive, fr cauz decelabil
evident
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Examenul obiectiv
Inspecie:
r subicter sclerotegumentar
stare general influenat
tahipnee, tahicardie
Palpare:
manevra Murphy pozitiv
_____________________________________
Explorri paraclinice
Biologice
VSH accelerat
leucocitoz cu neutrofilie
sindrom moderat de citoliz
sindrom de colestaz (bilirubin, fosfataz alcalin,
gamaglutamiltranspeptidaz crescute)
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216
Explorare imagistic
Radiografia abdominal simpl: poate pune n eviden n
10% din cazuri calculi radioopaci
Echografia :
metoda de elecie pentru diagnostic
colecist cu perei ngroai > 3,5 mm
n interior imagini hiperechogene cu con de umbr
posterior
semnul Murphy echografic este pozitiv
Alte explorri:
scintigram hepatobiliar, tomografie computerizat
sau rezonan magnetic doar n cazuri selecionate
MRCP, ERCP, ecoendoscopie dac suspectm
litiaz coledocian asociat
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Diagnostic pozitiv
coexistena semnelor clinice (colica biliar i/sau
sindromul dispeptic biliar), biologice i imagistice
Diagnostic diferenial
ulcerul gastric sau duodenal n criz dureroas sau
ulcerul perforat
apendicita retrocecal
pneumonia bazal dreapt
pancreatita acut
infarctul de miocard
colica nefretic dreapt
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Evoluie. Complicaii
se poate nsoi de complicaii grave, care necesit
recunoatere i atitudine terapeutic adecvat
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Pancreatita acut
este complicaie evolutiv n colecistita acut
litiazic
poate coexista cu litiaza biliar vezicular
Hidropsul vezicular
complicaie frecvent n litiaza biliar
apare prin inclavarea unui calcul n infundibul sau
n canalul cistic
formaiune ovalar, mobil cu respiraia, elastic,
dureroas la palpare
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Litiaza coledocian
apare prin migrarea calculilor n coledoc cu
obstrucia temporar sau permanent a fluxului biliar
i apariia icterului (caractere clinice i biologice de
icter obstructiv)
ecografic: dilatarea cilor biliare intrahepatice i a
coledocului; calculul coledocian poate fi vizualizat
ecografic n 50% din cazuri
diagnosticul se precizeaz prin MRCP (metoda de
diagnostic preferat datorit caracterului noninvaziv), ERCP, ecoendoscopie
tratament: ERCP cu sfincterotomie i extracie de
calculi
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Perforaia
localizat
clinic se traduce prin plastron colecistic
poate abceda
abces subfrenic
n cavitatea peritoneal
determin coleperitoneul
semne clinice de iritaie peritoneal cu aprare
muscular, durere la tueul rectal, ileus paralitic
n lumenul digestiv
- fistul biliodigestiv (duoden, colon)
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218
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Tratament
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Medical
- repaus la pat
- interzicerea alimentaiei orale
- corectarea dezechilibrelor hidroelectrolitice (aprute
dup vrsturi i interzicerea alimentaiei orale)
- asigurarea unui debit urinar normal
- sond de aspiraie gastric
- administrarea de antibiotice (ampicilin, amoxicilin,
cefalosporine, ciprofloxacin, metronidazol)
Chirurgical de elecie colecistectomie laparoscopic
dup remiterea puseului acut
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219
SINDROMUL
POSTCOLECISTECTOMIE
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221
CANCERUL DE VEZICUL
BILIAR
Date generale
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Factori de risc
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222
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Tablou clinic
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Diagnostic pozitiv
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Umoral-biochimic
- modificarea testelor de citoliz i colestaz
- markerii tumorali: CA19-9 i ACE crescui, dar nespecifici
Explorri imagistice
- Ecografia: sensibilitate de peste 80% - deceleaz mas
intravezicular (polipod de cele mai multe ori), cu ngroarea
peretelui vezicular (suferin veche) calculi invazie locoregional MTS hepatice, ganglionare i vasculare
- MRCP - superior CT n diagnostic i aprecierea extensiei
tumorale
- ERCP n prezent folosit numai terapeutic (plasare de
stent)
- EUS utilizat pentru confirmarea diagnosticului (examen
histopatologic) i stadializare
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Stadializare
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223
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Diagnostic diferenial
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Prognostic
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necaracteristic)!
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Tratament
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Profilactic
- nu se recomand colecistectomie profilactic pentru
litiaza biliar vezicular asimptomatic (risc de cancer )
- colecistectomie: vezica de porelan, polipi > 1cm,
adenomiomatoz, litiaz simptomatic
Tratament chirurgical
- clasic dac diagnosticul este stabilit preoperator sau
prin convertirea laparoscopiei dac diagnosticul a fost
stabilit intraoperator
Radioterapie: extern, intraoperatorie sau brahiterapie,
indiferent de stadiul evolutiv, fr rezultate ncurajatoare
Chimioterapia adjuvant folosete 5 fluorouracilul i
mitomicina C, iar cea paliativ gemcitabina i ageni pe
baz de platinium
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224
Date generale
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Tablou clinic
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Examenul obiectiv:
- icter leziuni de grataj
- hepatomegalie
- vezicul biliar palpabil n localizarea distal a
colangiocarcinomului
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225
Diagnostic pozitiv
_____________________________________
Umoral-biochimic
- sindrom de colestaz
- sindrom de citoliz (afectare hepatic prin colangit)
- markeri tumorali: CA19-9, ACE pot fi crescui fr a
avea specificitate pentru diagnostic
Imagistic
- Ecografia abdominal
- examen de prim intenie
- poate preciza localizarea tumorii, diseminarea
ganglionar i n alte organe
- CT este superioar ecografiei pentru stadializare
- RMN i MRCP - superioare CT, aduc un plus de precizie
n decizia terapeutic
- PET este folosit pentru detectarea tumorilor mici periferice
sau a MTS la distan pre- i postoperator
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Stadializare
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Diagnostic diferenial
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Prognostic
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- rezervat
- n tumorile nerezecabile indiferent de localizare, media
de supravieuire este de 8 12 luni
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226
Tratament
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Chirurgical
- curativ cu extirpare tumoral, datorit extensiei este
rar posibil
- paliativ funcie de sediul tumorii (de obicei drenaj
biliar chirurgical anastomoz bilio-digestiv)
Endoscopic drenaj biliar endoscopic transtumoral,
proteze tumorale plasate endoscopic sau percutan
Radio i chimioterapia singure sau combinate reduc
recurena loco-regional
Transplantul hepatic nu se recomand; recidiv
tumoral n peste 50% din cazuri
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227
228
PANCREATITA ACUT
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Clasificare:
Pancreatita acut edematoas sau interstiial
80%
Inflamaie pancreatic moderat, autolimitant n
majoritatea cazurilor + edem interstiial +
refacerea funciei pancreatice dup remiterea
inflamaiei
Pancreatita necrotico-hemoragic 20%
Inflamaie + necroz de coagulare (pancreas,
esuturi adiacente) pancreatita necroticohemoragic
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Etiologie
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Cauze frecvente
- litiaza biliar
_____________________________________
75 85% din PA
- consumul de alcool
- hipertrigliceridemia
- ERCP
- traumatisme abdominale
- postoperator (intervenii chirurgicale abdominale i nonabdominale, transplant hepatic sau renal)
- medicamente (azatioprin, 6 mercaptopurin,
sulfonamide, estrogeni, tetraciclin, acid valproic,
medicamente anti HIV)
- disfuncia sfincterului Oddi
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Etiologie
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Cauze rare
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Fiziopatologie
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Faza de restituie
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Fiziopatologie
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230
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Diagnostic clinic
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Simptome :
Durerea abdominal
- localizat n epigastru, hipocondrul stng, periombilical,
cu iradiere posterioar, toracic, n flancuri i
abdomenul inferior
- caracter continuu, suprtor, exacerbat n decubit
dorsal, ameliorat n ortostatism i aplecat nainte
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Examenul fizic
- febr, tahicardie, hipotensiune pn la hipovolemie
- icter prin colelitiaz sau compresia coledocului
datorat edemului pancreatic
- semnul Cullen sau Turner (echimoze periombilical
sau pe flancuri)
- abdomen suplu
- matitate alternnd cu hipersonoritate la percuie
(tabl de ah)
- zgomote abdominale diminuate sau abolite (ileus)
- ascit, pleuerzie stng, pneumonie, focare de
citosteatonecroz, tetanie
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Explorri biologice
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Hiperglicemie
Hipocalcemie la 25% din pacieni (fixarea calciului la
nivelul focarelor de steatonecroz)
Bilirubina, fosfataza alcalin, transaminazele pot fi
crescute, cu revenire la normal n 4-7 zile n absena
unei obstrucii coledociene
LDH (prognostic sever)
Hipoalbuminemie
CRP
Hipoxemie arterial la 25% din pacieni
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Extradigestive
Sarcin extrauterin rupt
Anevrism/disecie aort
Insuficien renal
Cetoacidoz diabetic
Arsuri
Afeciuni ale glandelor
salivare
Cancer esofagian,
pulmonar, ovarian
Macroamilazemie
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232
Explorri imagistice
Rx pe gol excludere perforaie intestinal
- Semne nespecifice: ileus, ans santinel, semnul
colonului amputat
Echografia i CT
- Determinarea aspectului i mrimii pancreasului,
extensia inflamaiei i flegmonului, aspectul
tractului biliar, confirmarea colecistitei, colelitiazei,
pseudochisturilor, ascitei
- CT - diagnostic mai exact al necrozei pancreatice;
prezena aerului n parenchim sugereaz
suprainfecia; permite puncia ghidat
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Limitele CT n urgen:
- doar din PA evolueaz cu necroz
- prezena necrozei nu se coreleaz cu insuficienele de
organ
- necroza poate apare dup 24 48 ore
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ERCP n urgen: PA prin obstrucie biliar
- util dup stabilizarea pacientului n diagnosticul
etiologic (pancreas divisum, pancreas anular, cancer
pancreatic, anomalii ductale) i evidenierea comunicrii
ductului pancreatic cu pseudochisturile
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Diagnostic pozitiv
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Diagnostic diferenial
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Colecictita acut
Colic biliar coledocolitiaz
Perforaie intestinal
Ulcer peptic perforat
Ocluzie intestinal acut
Hepatit alcoolic
Hepatit viral
Ischemie/infarct mezenteric
Vasculite
Disecie, anevrism aort
Infarct miocardic
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Pneumonie
Colic renal
Apendicit acut
Cetoacidoz diabetic
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Criteriile Ranson n PA
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La internare
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n primele 48 de ore
Vrst > 55 ani
Leucocite > 15000/mmc
Glicemie > 180 mg/dl (pacient nondiabetic)
Uree seric > 16 mmol/L
PaO2 < 60 mmHg
Ca seric < 8.0 mg/dl
Deficit baze > 4 mEq/L
Sechestrare fluide > 6 L
Albumina seric < 3,2 mg/dL
LDH > 600 U/L
ALT sau AST > 200 U/L
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Dificile, necesit
48 ore pentru
aprecierea
prognostic
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234
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Complicaii
Locale
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Colecii pancreatice
Colecii lichidiene acute (conin suc pancreatic, nu au
perete, apar dup 48 h, rezoluie spontan > 50% din
cazuri)
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235
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Complicaii
Sistemice
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Tratament
La 85-90% din pacienii cu PA afeciunea este
autolimitant i se rezolv spontan; pacienii cu PA
sever sau cu factori de risc (vrstnici, obezi, valori
crescute ale Ht i ureei, pleurezie) necesit internare i
monitorizare n secii de terapie intensiv
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Tratament
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236
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237
238
PANCREATITA CRONIC
_____________________________________
Definiie
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Etiologie-TIGAR-O
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Morfopatologie
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Fiziopatologie
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Fiziopatologie
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Diagnostic clinic
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_____________________________________
1. Durere
2. Malabsorpie
3. Diabet zaharat
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_____________________________________
1. Durerea
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3. Diabetul zaharat
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Examen fizic
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_____________________________________
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_____________________________________
Diagnostic paraclinic
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_____________________________________
1. Explorri biochimice
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2. Explorri imagistice
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Computer tomografia
- gold standardul metodelor imagistice non-invazive
- acuratee superioar comparativ cu ecografia n detectarea
calcificrilor, pseudochistelor, tromboza venei splenice, mas
pancreatic sau episod de PA
4 stadii:
- Normal: dimensiuni, form, omogenitate normal, Wirsung <
2 mm
- Echivoc/uor : 1-2 din : Wirsung 2-4 mm, hipertrofia glandei
(> 2ori), parenchim heterogen
- Moderat: chist < 10 mm, neregulariti ductale, pancreatit
focal, neregulariti de contur, creterea ecogenitii pereilor
ductali
- Sever :1 din criteriile precedente + : chist > 10 mm, defecte
de umplere intraductale, stenoze ductale, neregulariti severe
de contur, calcificri, interesarea organelor adiacente
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Indirecte
Steatoreea: peste 10 g lipide n scaun la un consum de 100
g/zi; n insuficiena pancreatic avansat se poate ajunge la o
excreie de 40-50 g / zi
Elastaza 1 n materiile fecale
Testul la Bentiromid
- administrarea unui polipeptid ataat la PABA (acid
paraaminobenzoic); sub influena chemotripsinei peptidul se
desface de PABA, care se resoarbe i se elimin prin urin
- scderea eliminrii PABA semn indirect de suferin
pancreatic producie sczut de chemotripsin
- sensibilitate de 37-90%
Pancrealauryl test: se inger fluorescein dialaureat (va fi
clivat de estaraza pancreatic) i un prnz standard
Teste respiratorii cu trigliceride mixte sau triolein marcate cu
C13 (utile i n monitorizarea terapeutic a suplimentrii cu
fermeni pancreatici)
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Diagnostic diferenial
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Complicaii
Locale
Pseudochisturi
pancreatice
Abcese
Stenoz coledocian
Obstrucie duodenal
Tromboz de ven port,
splenic
HDS (ulcer peptic,
pseudochist care
erodeaz duodenul,
efracie variceal prin
HTP segmentar)
Cancer pancreas
(risc de 10 x >)
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Sistemice
Secundare malabsorbiei
Ulcer gastric sau
duodenal
Serozite (ascit,
pleurezie, pericardit)
Necroze lipidice
metastatice
Necroze aseptice de cap
femural, humeral
Retinopatie non-diabetic
(deficit de vitamina A, Zn)
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Pancreatita autoimun
form de PC cu trsturi distincte clinice, serologice,
histologice i imagistice
Clasificare:
- tipul 1 afeciune sistemic (se asociaz cu
colangit, sialoadenit, fibroz retroperitoneal,
nefropatie, limfadenit)
- tipul 2 numai cu afectare pancreatic
2/3 din pacieni se prezint cu icter obstructiv sau mas
tumoral pancreatic
lipsesc atacurile recurente de PA
lrgirea pancreasului (sausage shape)
ngustare difuz, neregulat a canalului pancreatic +
anomalii ale ductelor biliare
absena calcificrilor sau chisturilor pancreatice
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Pancreatita autoimun
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Categorie
Criteriu
Histologie
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Serologie
Ig G4
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Afectarea
altor organe
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Rspuns la
corticoterapie
Rezoluia/ameliorarea manifestrilor
pancreatice/extrapancreatice la corticoterapie
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Imagistic
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Tratament
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Tratamentul:
A. Durererii
B. Malabsorbiei
C. Diabetului zaharat
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A. Tratamentul durerii
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Opiuni terapeutice:
- analgetice
- ntreruperea consumului de alcool
- inflamaiei
- presiunii intrapancreatice ( secreiei, ndeprtarea
obstruciei)
- modificarea transmiterii neurale
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Analgetice
-iniial non-narcotice, ulterior narcotice (Tramadol, Morfin)
-dependen!
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Scderea inflamaiei:
- ntreruperea fumatului
- ntreruperea alimentaiei per os, nutriie enteral sau
parenteral total
- antioxidani, inhibitori de radicali liberi de oxigen
- chirurgie n pancreatita obstructiv
- prednison n pancreatita autoimun
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B. Tratamentul malabsorbiei
-
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Suport nutriional
- przuri mici i dese, bogate n proteine
- trigliceride cu lan mediu (MCTs) 40 g/zi
- nutriie parenteral dac cea enteral nu este
tolerat
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C. Tratamentul DZ
-
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CANCERUL PANCREATIC
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Date generale
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Factori de risc
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Demografici
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Genetici
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Condiii medicale
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Alte conditii
cancerul colorectal nonpolipozic
- sindromul Peutz Jeugherz
- ataxia telangiectazia
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Screening n CP
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Tablou clinic
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Examenul obiectiv:
- caexie
- icter tegumentar ( obstructie sau metastaze)
- leziuni de grataj adesea suprainfectate
- n localizrile la nivelui cozii tromboflebita migratorie recidivant
- hepatomegalie
- vezica biliar destins, nedureroas, palpabil (semn Courvoisier
Terrier)
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- scdere ponderal
- icter ( mai puin frecvent)
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- durere intens
- tromboflebit migratorie
- tulburri de glicoreglare
- atenie absena icterului!
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Stadializarea CP
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Investigaii de laborator
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Investigaii imagistice
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Diagnostic diferenial
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Tratament
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Tratament chirurgical
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cu viz curativ
Duodenopancreatectomia
- intervenie cu mortalitate ridicat 25%
- supravieuirea este sub 1 an (medie 11 luni)
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cu viz paleativ
- coledocojejunostomie
- mortalitate operatorie 20%
- supravieuire maxim 5 luni
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BIBLIOGRAFIE SELECTIV
1.
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