Tumori veziculare

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

Tumori veziculare benigne

Simptom: proprie rar i nespecific (litiaz?) Diagn: VBRx (lacun), eco (ecogenit fix fr umbr) Evol: de regul lent, dar 20% din adenoame cancere Tratam: VBect indicat n: - polipi >1cm(inciden cancer >) - polipi cu litiaz - polipi clar simptomatici Polipii 0,5cm sunt monitorizai eco la 3 luni

Tumori veziculare maligne

4% din cancere, loc 5/cancere digestive: - 85% au litiaz VB - maxim ntre 50-70 ani - sex ratio f:b = 4:1 Morfopat: adenok-90%(schir-65%,papilifer, mucipar), k epidermoid, k anaplazic, sarcom Clinic: 5% diagn preoper, simpt de mprumut: - durere epigastru-hipoc dr - greuri/vrsturi - icter - mas palpabil n hipoc dr

Tumori veziculare maligne - diagn

Paraclinic: modif bio nespecificterCA 19-9 Stadiu TNM: T 1a muc, 1b musc T 2-tot peretele, 32cm de perete, 4 >... N 1-gg cistic, periCBP, hil hepatic N 2-gg peripc, dd, celiaci, mezent sup M 1-metastaze Progn: suprav la 5 ani 5-15%

Tumori veziculare maligne (Rp)

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

Icterul mecanic

= sdr.manif.prin color.galben a tegum., muc.i umorilor det.de BR>2.5mg dat. obstruciei biliare, beneficiind de Rp chir. Clasificare ictere: - prehepatice (hemolitice) - hepatice (hepato-celulare) - posthepatice (obstructive=mecanice=chirurgicale) Clasificare ontogenetic: - congenitale (Hb-patii, def.enzim, malformaii CB) - dobndite (alte hemolize, hepatite, obstr.nonmalf.)

Etiologia icterului mecanic

Cauze congenitale: - agenezia/atrezia cilor biliare - malformaii ectaziante intra/extrahepatice - colestaza benign recurent Cauze dobndite: - mecanice (trauma, litiaz, parazii, compresii extrins) - inflamatorii (stenoze, colangite, ulcer, pancreatite, gg) - tumorale (papiloame, cancere hep/CBP/pancr/dd) - iatrogene (stenoze/ligaturi CBP, corpi strini, oddite)

Patogenia icterului mecanic

Poziia obstacolului n raport cu peretele CB: - endoluminal - parietal - extrinsec Poziia anatomic a obstacolului: - intrahepatic - hilar - pedicular (hepatic comun, coledoc Sdd/retroddpc) - oddian

Diagnosticul icterului mecanic

Clinic: debut, evoluie, asocieri (prurit, febr) Sindr: icter, Hcolal, dispep, neo,alerg, -vitam.AK Bio: BR, UBG, FA, enz, HLG, mark T&imuno Rx: hipoc.dr, tranzitBa, colangioR... Alte imag: eco(Doppler, 3D/4D, elasto), CT, RMN (ficat, colangio) , scint (hep Tc, cole I) Endo: EDS, CPRE, CBPscopie TestRp Kohler (TP=N/adm p/ent K n icter obstr) Dg IO: viz/palp/instr, puncii, bio, Rx, eco
99m 131

Diagnostic diferenial icter mecanic

Alte ictere: - hemol (Hb<+spl>, sc+urin HCr, BRi+UBG >, hepatic N) - hepatocelulare(hep>,sc N+urin HCr, pb hep, Kohler-) icter - color galben tegum (caroten, hemocr...) - scaune decolor (steatoree, Ba) - Urin Hcrom (deshidr, Hb/Mburie,
melanurie, ocronoz, hematurie nalt, ingestie AF, SSz, Rf, Nf)

Icter mecanic: Complicaii

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

Icter mecanic: Atitudine

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

Pregtire: perf, vitam (A,D,E, K), AB, Rp asoc, diet Supr obst: CBP-litotomie, sf-tomie, rez segm; Forare obst
(mpingere calcul, foraj transT/stent, dilat-tutorizare stenoz)

Derivaii bil: &: - VBect

ext, biliodig (VB/CBP/CBIHG/D/JsauJY)

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

Litiaza CBP

c.veziculari (c.sec.=colest) naturaliz, c.primitivi CBP (pigmentariCa), c.din CBIH 10-20% din cei VBect pt lit.VB au i lit.CBP rar unici (=prim.), frecv.multipli mpietruire, oval/faet.sunt pasabili (3-5mm) sau nu (>5mm), se bloch. n pct.critic Baraya sau n papil (5%)

Etiopat: HP:

Clinic: icter (33-70%), durere (>80%) febr Ff.clin: clasic, intrapapilar, VBit ac.sec, cu

pancreatit, cu angiocolit, dureroas pur, febril pseudopaludic, dispeptic, caectizant, ...mut

Litiaza CBP: diagnostic

Bio: L, VSH, fbgen, colestaza (mai ales FA) Rx: cc. Rxopaci, colangioTPH Imag: eco, CT, RMN(colangio), colescint Tc99m Endo: papila, CPRE, CBPscopie IO: palpare pedicul, colangioIO, eco, instrum/CBP, CBPscopie Cnd?: - lit.VBveche, c.<, cistic larg, episod de icter, colestaz fr icter.

Litiaza CBP: tratament

Endo: CPRE cu sf.tomie endoscopic Obiective chir: - ablaia VB (surs de cc.) - dezobstr.complex CBP - asig. drenaj bil Abordul CBP e /cistic, /CBPtomie/retrograd Drenajul e extern (Kehr), biliodig, /papil Control colangioRx IO i la 10-14 zile (pt a certifica vacuitatea i etaneitatea CBP

Angiocolitafr./colangitaeng. acut

Def: infecie bacter. acut a CBIH/CBEH caract de 3ada Charcot (1877): icter, durere hc, febr/frison Etiopat: obstrucie biliar: - litiaza CBP (80%) - stenoze benigne CBP sau Oddiene - stenoze maligne (neo CBP, VB, periamp, pancr) - parazii (hidatidocolie, ascarizi eratici n CBP) - malform (boala Caroli, chiste congenitale CBP) - iatrogenii (Oddite, corpi strini, CPRE, anast nefx.) germeni: E.coli, Klebs, enterococi, B.fragilis, clostridii

Angiocolita: diagnostic

3ada Charcot: durere, frison/febr, icter + alter st.gen, obnubil, oligurie, d/Chauffart-Rivet Bio (=L, enz, BR, FA, uree/creat, hemoculturi): Imagistic:
Eco (dilat CBP/CBIH, obstacol: loc, natur) CT, RMN, scint (eval patol tumoral, colangioRM/scint) colangio (transparieto/omfalo, CPRE)

Forme clinice (acut, supurat, torpid, anicter,

complicate, particulare: recurent, parazitar)

Angiocolita: evoluie, tratament

Complicaii:

insuf hepatorenal (st. tox,oligo/anurie)...MSOF abdomen acut (ileus, pancreatit, peritonit) reechilibrare (H2O, electro, metab, corectare tare) AB (penemi, Fquin, lactam, NH2glicoz, metro, clinda) decompresie biliar (percutan, endo, chir) operaie seriat (rezolvarea obstacolului)

Atitudine:

Tumori CBP

Def: T localizate la niv CHD/S, CHS, coledoc T benigne: papilom/atoz, adenom, mioblastom T maligne:
mai rare (1:2-3) ca TMVB, =60, predom /brbai) & cu litiaza?; & parazit, RCUH, chiste CBP, b.Caroli) HP:maj adenoK90%; K.epid,K.coloid,carcinoid,sarcom Macroscopic: infiltrativ, nodular, papilar Local:CHC/jonc.(Klatskin),distale,pedicul; Difuze Propagare ductal/limfatic/nervoas/hemato/perito

Tumori CBP: diagnostic

Preicter (tscurt, dispepsie, inapet, jen hc.dr Icter: , durere continu, febr(angiocolit)

prurit, hepatospleno>, s.Courvoisier-Terrier

Paraclinic:

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

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

Tumori CBP: tratament

Medical &: AB, analg, reechilibr.(H+E+M), vit.K Decompr.bil.min.inv (percutan, retrograd transT) Chirurgical:
Paliativ (anastomoze bilio-digestive, drenaj biliar extern) Radical prox: rezecie hilar+HJ(Y)A n placa hilar Radical mediu: rezecie CBP+HCA/HJ(Y)A Radical distal: CBP-duodenopancreatect.cefalic+...A

Prognostic: suprav.medie e de 2-8luni/paliativ,

2 ani/radical; la 5 ani suprav.<5%!

Tumori (Vateriene) periampulare

= T dezv.din structuri AV, dd, CBPt, W HP: benigne<10% (adenom, papilom) ce se pot maligiza; maligne: maj=carcinoame Clinic: prodroame, icter / , prurit, HDS+ anemie, dureri, dispepsie, febr/frison Bio: Hb, Fe, colestaz, CA 19-9 Imag: RxBa-ddgr.hton:/s.Frossberg, colangioRx prea frumoas n remisiuni, eco, CT, RMN, colangioRMN, colescint Tc99m , EDS, biopsie

Tumori Vateriene: stadializare & Rp

Dg stadial: T1 AV, T2 perete dd, T3 <2cm pc, T4 >2cm Min.inv: foraj edo transT, drenaj ext percutan Paliativ: derivaie biliar, ampulect Radical: ampulect, ddpancreatect.cefalic Progn: suprav >