Documente Academic
Documente Profesional
Documente Cultură
y manejo quirrgico
Roberto Oleas Narea
Universidad Espritu Santo
Objetivos
Hospital B:
Paciente disneico con distencin abdominal.
Abdomen tenso a la palpacin, tumefacto a nivel de
flanco, fosa iliaca y regin lumbar izquierda.
Signo de Grey Turner.
Ingreso UCI.
HR
110 lpm
RR
28 rpm
38,3
BP
120/70
mmHg
Masha L, Bernard S. Grey Turner's sign suggesting retroperitoneal haemorrhage. Lancet 2014; 383:1920.
CBC
WBC 15,170
80 % PMN
HB 6,2 HTO 20
TP 12 TTP 30
INR 1,26
AB
G
pH 7,41
PCO2 35
HCO3 22,41
SAT O 97
PAFI 365
AN
ALIS
IS
Glicemia 103
CR 0,8
BUN 30
Na 139
K 3,96
Cl 100
P 3,1
Ca 8,1
Lactato 1,6
AMILASA 274 ( 3-110)
LIPASA 1610 (23-300)
HDL 45 LDL 120
COLESTSICAS NEGATIVAS. GOT GPT FA GGT
Pancreatitis aguda
Kumar, V., Abbas, A., Fausto, N., & Aster, J. (2010). Patologa estructural y
funcional: Robbins y Cotran. Barcelona: ELSEVIER.
Kumar, V., Abbas, A., Fausto, N., & Aster, J. (2010). Patologa estructural y funcional: Robbins y Cotran. Barcelona: ELSEVIER.
FISIOPATOLOGA
CT scan of acute
interstitial
edematous
pancreatitis
2. Necrotizing pancreatitis
Pancreatic pseudocyst
4. Pancreatic pseudocyst
An encapsulated collection of fluid with a well defined inflammatory wall usually outside the pancreas with minimal or no
necrosis. This entity usually occurs more than four weeks after onset of interstitial edematous pancreatitis to mature.
Contrast-enhanced computed tomography criteria:Well circumscribed, usually round or oval
Homogeneous fluid density
No non-liquid component
Well defined wall (ie, completely encapsulated)
Maturation usually requires >4 weeks after onset of acute pancreatitis; occurs after interstitial edematous pancreatitis
Pancreatic pseudocyst
A well-circumscribed fluid collection that is usually round or oval
The fluid collection is typically extra-pancreatic
Homogenous fluid density
No non-liquid components within the fluid
A well-defined wall that completely encapsulates the fluid collection.
Walled-off pancreatic fluid collections can produce a wide range of clinical problems
depending on the location and extent of the fluid collection and whether the fluid
collection is infected.
Expansion of the fluid collection can produce abdominal pain, duodenal or
biliary obstruction, vascular occlusion, or fistula formation into adjacent
viscera, the pleural space, or pericardium
Spontaneous infection can develop
Digestion of an adjacent vessel can result in a pseudoaneurysm, which can
produce a sudden, painful expansion of the cyst or gastrointestinal bleeding due
to bleeding into the pancreatic duct (hemosuccus pancreaticus)
Pancreatic ascites or pleural effusion can result from disruption of the
pancreatic duct with fistulization to the abdomen or chest, respectively
Pancreatic
abscess
CT scan in a patient with abdominal
pain, fever, and jaundice shows air
(thin arrow) in the central pancreas,
which is necrotic and largely
replaced by an acute fluid collection
(thick arrows), leaving only a small
residual pancreatic head (P).
CT
scan
of
acute
necrotizing pancreatitis
complicated by infected
pancreatic necrosis
The
presence
of gas bubbles is a
pathognomonic
sign of infection of
the necrosis.
Valoracin y pronstico
AGA
Predictor de severidad: APACHE II mayor a 8,
ingreso a UCI.
Apache II 8 + falla orgnica en 78 horas:
tomografa computada con contraste para valorar
grado de necrosis.
Prueba de laboratorio: PCR 150 mg/dL en 48
horas.
APACHE II + Criterio clnico + PCR
Manejo
Tratamiento de soporte:
- Hidratacin:
- Liquidos IV especialmente en las primeras 24 horas con correcin de
electrolitos.
Tenner S, Baillie J, Dewitt J, Vege SS. American College of Gastroenterology guideline: Management of acute
pancreatitis. Am J Gastroenterol 2013
AP:
Moderada: recuperan en 3- 7 das.
Tratamiento de soporte:
- Dolor ( morfina fenatil) bomba de analgesia.
- Fluidos intravenosos 24 horas primordialmente + control electrolitos.
- Dieta de poco residuio, baja en grasa, blanda cuando no hay ileo, nausea, vomito, dolor e inflamacion ha bajado
Severa:
Monitoreo invasivo en busca de falla orgnica transitoria ( < 48 horas) o persistente ( > 48 horas) y complicaciones.
Nutricin enteral por medio de sonsa nasoyeyunal colocada por endoscopia en vez de nutricion parenteral. (GRADO
IB)
Acute peripancreatic fluid collections and acute necrotic collections (ANC) may develop
less than four weeks after the onset of pancreatitis,
pancreatic pseudocyst and walled-off necrosis usually occur more than four weeks
after the onset of acute pancreatitis.
Both ANC and WON are initially sterile but may become infected. The occurrence of
pancreatic infection is a leading cause of morbidity and mortality in acute necrotizing
pancreatitis. Infected necrosis should be suspected in patients with pancreatic or
extrapancreatic necrosis who deteriorate
(clinical instability or sepsis physiology, increasing white blood cell count, fevers) or fail
to improve after 7 to 10 days of hospitalization.
In patients with suspected infected necrosis, we suggest empiric antibiotics rather than
CT-guided fine needle aspiration (Grade 2C)
In patients with infected necrosis who fail to respond to antibiotics or who are clinically
unstable, we recommend pancreatic debridement rather than continued conservative
management (Grade 2B). Where possible we attempt to delay intervention until four
weeks after initial presentation to allow the infected necrosis to become walled off.
We perform necrosectomy with minimally invasive methods and reserve open surgical
debridement for patients who are clinically unstable or if minimally invasive debridement
is not possible or fails.
In patients with gallstone pancreatitis, we recommend urgent (<24 hours)
endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy for
patients with cholangitis (Grade 1B). CHOLECYSTECTOMY SHOULD BE PERFORMED AFTER
RECOVERY in all operable patients with gallstone pancreatitis.
MANEJO QUIRRGICO
Treatment options for walled-off pancreatic fluid collections include surgical drainage,
endoscopic transmural drainage, transpapillary stent placement (for pseudocysts), and
percutaneous drainage.
Transmural puncture through the gastric or duodenal wall into the cyst can be performed
in patients who have a large, symptomatic walled-off pancreatic fluid collection that is
compressing the stomach or duodenum when there is close apposition of the fluid
collection to the bowel lumen.
The management of a walled-off pancreatic fluid collection depends on the patient's symptoms,
characteristics and location of the fluid collection, and whether complications such as a
pseudoaneurysm have developed:
In patients with a walled-off pancreatic fluid collection with minimal or no symptoms and no
pseudoaneurysm, we suggest expectant management rather than a drainage procedure (Grade 2C).
Limited natural history data suggest that up to 40 percent of walled-off pancreatic fluid collections
resolve without intervention.
If a pseudoaneurysm is present but the patient has minimal or no symptoms, we recommend
embolization of the aneurysm followed by expectant management.
For patients who are symptomatic, we suggest a drainage procedure rather than expectant
management (Grade 2C). The choice of drainage procedure is largely determined based on local
expertise and the location of the fluid collection. In centers with the appropriate expertise, pancreatic
fluid collections that abut the stomach or duodenum are often approached via an endoscopic approach,
reserving surgical drainage procedures for endoscopic failures, for recurrence following successful
endoscopic drainage, or for those not meeting criteria for endoscopic or percutaneous drainage.
RESUMEN Y RECOMENDACIONES
The dry formal lecture never, or at any rate rarely, touches the
heart, but it is in [the] conversational method of the seminar, or
in the quiet evening at home, with a select group and a few good
editions of a favorite author, that the enthusiasm of the teacher
becomes contagious.
Sir. William Osler