Documente Academic
Documente Profesional
Documente Cultură
GR.T.POPA IAI
FACULTATEA DE MEDICIN
TEZ DE DOCTORAT
CONDUCTOR TIINIFIC,
PROF.UNIV.DR. TEFAN MIHALACHE
DOCTORAND,
POROCH VLADIMIR
IAI
2010
TEZ DE DOCTORAT
DIAGNOSTICUL I TRATAMENTUL MODERN AL
ULCERULUI DUODENAL COMPLICAT
CONDUCTOR TIINIFIC,
PROF.UNIV.DR. TEFAN MIHALACHE
DOCTORAND,
POROCH VLADIMIR
IAI
2010
CUPRINS
PARTEA GENERAL
CAPITOLUL I. DATE EMBRIOLOGICE
-
DATE FILOGENETICE
DATE ONTOGENETICE
EVOLUIA ANSEI DUODENALE I A MEZODUODENULUI DORSAL
STRUCTURA DUODENULUI
ACTIVITATEA ELECTRIC A MUCHIULUI NETED INTESTINAL
CONTROLUL NERVOS AL FUNCIEI GASTROINTESTINALE
TIPURI DE NEUROTRANSMITORI SECRETAI DE CTRE NEURONII
ENTERICI
HIPERSECREIA GASTRIC
DIMINUAREA REZISTENEI MUCOASEI
INFECIA CU HELICOBACTER PYLORI
ALI FACTORI DE MEDIU
FACTORUL GENETIC
DIAGNOSTICUL CLINIC
DIAGNOSTICUL PARACLINIC
DIAGNOSTICUL DIFERENIAL
DIAGNOSTICUL COMPLICAIILOR
MEDICAIA ANTISECRETORIE
MEDICAIA ANTIACID
ANTICOLINERGICELE
BLOCANII RECEPTORILOR H2
INHIBITORII POMPEI DE PROTONI
MEDICAIA MUCOPROTECTOARE
ERADICAREA INFECIEI CU HELIOBACTER PYLORI
STRATEGIA TRATAMENTULUI MEDICAL I REZULTATELE
TERAPEUTICE
TRATAMENTUL IGENODIETETIC
INDICAII
OBIECTIVE
VAGOTOMIA
TRONCULAR
SELECTIV
SUPRASELECTIV
REZECIILE GASTRICE; METODE DE RESTABILIRE A TRANZITULUI
DIGESTIV
ANASTOMOZA ROUX
STUDIUL PERSONAL
CAPITOLUL VIII. ASPECTE EPIDEMIOLOGICE I
ETIOPATOGENICE SEMNIFICATIVE
-
VIII.1. FRECVENA
VIII.2. SEXUL
VIII.3. VRSTA
VIII.4. RELAIA SEX-VRST
VIII.5. PREDISPOZIIA FAMILIAL
VIII.6. OBICEIURILE ALIMENTARE I TOXICE
VIII.6.1. CONSUMUL DE ALCOOL
VIII.6.2. CONSUMUL DE CAFEA
VIII.6.3. FUMATUL
VIII.6.4. CONSUMUL DE ANTIINFLAMATORII NESTEROIDIENE
VIII.6.5. ADMINISTRAREA DE ANTICOAGULANTE
VIII.7. DISTRIBUIA SEZONIER
X.5. COMPLICAII
X.6. NUMRUL ZILELOR DE SPITALIZARE
X.7. DECESE
CAPITOLUL
DISCUII
XI.
CONCLUZII
BIBLIOGRAFIE
PRELUCRAREA
STATISTIC
DATELOR;
REZUMAT
AL
TEZEI DE DOCTORAT
CONDUCTOR TIINIFIC,
PROF.UNIV.DR. TEFAN MIHALACHE
DOCTORAND,
POROCH VLADIMIR
IAI
2010
Figura 1.
n cei aproximativ 6 ani de studiu, din cei 842 de pacieni diagnosticai cu ulcer
duodenal s-a constatat un numr de 380 cazuri de ulcer duodenal hemoragic (UDH), 188
cazuri de ulcer duodenal perforat (UDP), 12 cazuri de ulcer duodenal cu hemoragie i
perforaie i 262 cazuri de ulcer duodenal far hemoragie i far perforaie (tabel 1).
Tip de ulcer
Nr. pacieni
Procent
UD hemoragic
380
45,1%
UD perforat
188
22,3%
UD cu hemoragie i perforaie
12
1,4%
262
31,2%
Din numrul total de 842 pacieni cu UD s-a constatat c ulcerul duodenal acut cu
hemoragie era prezent la 367 pacieni (43,59%), UD acut cu perforaie la 168 pacieni
(19,95%), UD acut cu hemoragie i perforaie la 9 pacieni (1,07%), UD acut far hemoragie
i far perforaie la 122 pacieni (14,49%), UD cronic/ nespecificat cu hemoragie la 13
pacieni (1,54%), UD cronic/ nespecificat cu perforaie la 20 pacieni (2,38%), UD cronic/
nespecificat cu hemoragie i perforaie la 3 pacieni (0,36%), UD cronic far hemoragie i
far perforaie la 78 pacieni (9,26%), iar UD nespecificat acut/ cronic far hemoragie i far
perforaie la 62 pacieni (7,36%) (tabel 2, fig.2).
Tip ulcer
Nr. pacieni
Procent
UD acut cu hemoragie
367
43,59%
UD acut cu perforaie
168
19,95%
1,07%
122
14,49%
UD cronic/nespecificat cu hemoragie
13
1,54%
UD cronic/nespecificat cu perforaie
20
2,38%
0,36%
78
9,26%
62
7,36%
UD acut
20
UD cronic
10
0
1
Figura 2.
Tip ulcer
2009
TOTAL
UDH
(pana la
31.10)
UD acut cu H
17
39
23
52
79
89
68
367
UD cronic/nespecificat cu H
13
TOTAL
17
43
27
54
79
89
71
380
Tabel 3.
40
20
0
2002 2003 2004 2005 2006 2007 2008 2009 2010
Figura 3.
2009
2008
2007
2006
(pana la
31.10)
TOTAL
UDP
UD acut cu P
18
22
18
24
30
31
25
168
UD acut cu H cu P
UD cronic/nespecificat cu P
11
20
UD cronic/nespecificat cu H,
cu P
TOTAL
19
27
30
26
37
34
27
200
Tabel 4.
20
15
10
5
0
2002
2003
2004
2005
2006
2007
2008
2009
2010
Figura 4.
n urma analizei privind distribuia pe ani a numrului de bolnavi cu UD cu perforaie
internai s-a remarcat faptul c numrul cel mai mare de pacieni a fost n anul 2005, i anume
37, ceea ce reprezint 1,62% din numrul total de pacieni internai n anul respectiv.
Analiza procentual a ponderii hemoragiei i a perforaiei raportat la numrul total de
ulcere duodenale internate este prezentat n tabelul 5.
Anul
Nr. pacieni
cu UD
UD cu
hemoragie
Procent
UD cu
perforaie
Procent
2003
160
71
44,37%
27
16,87%
2004
162
89
56,17%
34
20,98%
2005
159
79
52,83%
37
23,27%
2006
120
54
46,66%
26
21,66%
2007
90
27
31,11%
30
33,33%
2008
96
43
46,87%
27
28,12%
2009 (pna la
31.10.2009)
55
17
30,90%
19
34,54%
Total
842
380
46,55%
200
23,75%
Tabel 5.
Analiznd distribuia pe ani a ulcerelor duodenale hemoragice se constat c ponderea
hemoragiei s-a situat ntre 31,11% n anul 2007 i 56,17% n anul 2004, cu o medie de
46,55%. n cazul ulcerelor duodenale cu perforaie se remarc o pondere ntre 16,87% n anul
2003 i 34,54% n 2009, cu o medie de 23,75% din totalul ulcerelor duodenale internate.
II.2. SEXUL
Repartiia pe sexe a celor dou complicaii, respectiv hemoragia i perforaia, aprute
n evoluia ulcerului duodenal arat afectarea cu precdere a sexului masculin. Astfel, se
constat un numr de 738 de cazuri de ulcer duodenal cu hemoragie i/ sau perforaie la sexul
masculin, ceea ce reprezint 87,6% din numrul total de ulcere duodenale, fa de 104 cazuri
la sexul feminin, reprezentnd 12,4% din numrul total de UD cu hemoragie i/ sau perforaie
(tabel 6, fig. 5).
Sexul
Nr. Pacieni
Procent
Brbai
738
87,6%
Femei
104
12,4%
12,40%
brbai
femei
87,60%
Figura 5.
Se poate observa c hemoragia este complicaia cea mai frecvent ntlnit n ulcerul
duodenal, att la sexul masculin, ct i la cel feminin, totalul cazurilor cu ulcer duodenal
hemoragic fiind de 584 pacieni. Cealalt complicaie a ulcerului duodenal, adic perforaia,
este ntlnit ntr-o pondere mai mic fa de hemoragie la ambele sexe, n total fiind un
numr de 258 de cazuri de ulcer duodenal perforat.
n figura 6 se poate observa diferena n funcie de sex a numrului de pacieni cu
ulcer duodenal hemoragic, precum i ulcer duodenal cu perforaie.
600
521
Brbai cu UD hemoragic
500
Femei cu UD hemoragic
400
300
200
100
217
63
Brbai cu UD cu
peritonit
41
Femei cu UD cu
peritonit
0
1
Figura 6.
Sexul, ca factor epidemiologic implicat n boala ulceroas, indic n lotul luat n studiu
ponderea mult mai mare a sexului masculin, ajungndu-se la un raport barbai / femei de
aproximativ 7/1 (738 barbai, 104 femei), raport care este n concordan cu datele din
literatura de specialitate care evideniaz predominana leziunilor ulceroase la sexul masculin.
7
II.3. VRSTA
Repartiia ulcerului duodenal cu hemoragie n funcie de grupele de vrst este
prezentat n tabelul 7 i fig. 7. Se poate observa faptul c incidena cea mai mare este la
grupa de vrst cuprins ntre 30 i 39 de ani, cu o pondere de 11,4% din numrul total de
ulcere duodenale (842 cazuri).
Vrsta
<20 ani
Nr. cazuri cu UD
hemoragic
4
20-29 ani
75
8,9%
30-39 ani
96
11,4%
40-49 ani
89
10,6%
50-59 ani
51
6,1%
60-69 ani
37
4,4%
70-79 ani
17
2,1%
>80ani
11
1,3%
Total
380
0,5%
Tabel 7.
<20
ani
30-39
ani
50-59
ani
70-79
ani
Figura 7.
Repartiia n funcie de grupele de vrst a ulcerului duodenal perforat este prezentat
n tabelul 8 i figura 8.
Vrsta
<20 ani
20-29 ani
47
5,58%
30-39 ani
50
5,93%
40-49 ani
42
4,98%
50-59 ani
23
2,73%
60-69 ani
17
2,01%
70-79 ani
11
1,30%
>80ani
0,71%
Total
200
23,75%
Tabel 8.
n cazul ulcerului duodenal cu perforaie se constat faptul c cele mai multe cazuri
sunt la grupa de vrst 30- 39 de ani, cu o pondere de 5,93% din numrul total de ulcere
duodenale.
Se poate remarca faptul c dup vrsta de 50 de ani procentul de ulcere duodenale cu
perforaie scade treptat, nct se ajunge ca la grupa de vrst mai mare de 80 de ani procentul
s fie de 0,71% din numrul total de UD.
50
47
42
40
30
23
20
17
11
10
i
>8
0a
n
an
i
70
-7
9
an
i
60
-6
9
an
i
50
-5
9
an
i
an
i
40
-4
9
30
-3
9
20
-2
9
<2
an
i
an
i
Figura 8.
Vrsta medie a pacienilor cu ulcer duodenal este diferit n funcie de sex, astfel c la
sexul masculin vrsta medie este de 47,8 ani, iar la cel feminin este de 50,3 ani..
Se constat faptul c vrsta medie a pacienilor cu UD cu hemoragie este 42,1 ani n
cazul sexului masculin i de 51,8 ani pentru sexul feminin (tabel 9). n cazul ulcerului
duodenal cu perforaie vrsta medie pentru sexul masculin este de 38,4 ani, n timp ce pentru
sexul feminin vrsta medie este de 49,6 ani (tabel 10).
Sex
Brbai
42,1 ani
Femei
51,8 ani
Brbai
38,4 ani
Femei
49,6 ani
Tabel 10. Vrsta medie a pacienilor cu ulcer duodenal perforat n funcie de sex
Brbai cu UD hemoragic
Procent
<20 ani
1,7%
20-29 ani
72
20,9%
30-39 ani
86
25,2%
40-49 ani
73
21,2%
50-59 ani
43
12,5%
60-69 ani
34
9,9%
70-79 ani
16
4,7%
>80ani
2,6%
339
10
86
72
73
43
nr. pacieni
34
16
6
<20
ani
Figura 9.
La sexul feminin ponderea cea mai mare a ulcerului duodenal hemoragic se constat la
grupa de vrst 40 49 de ani, fiind nregistrate 15 cazuri, cu un procent de 36,6% din
numrul total de UD cu hemoragie la sexul feminin (tabel 12, fig. 10).
Vrsta
Femei cu UD hemoragic
Procent
<20 ani
2,5%
20-29 ani
11,2%
30-39 ani
17,4%
40-49 ani
15
36,8%
50-59 ani
14,9%
60-69 ani
9,6%
70-79 ani
2,5%
>80ani
5,1%
Total
41
100%
11
36,80%
35,00%
30,00%
25,00%
20,00%
15,00%
0,00%
14,90%
11,20%
10,00%
5,00%
procent
17,40%
9,60%
2,50%
<20 ani
20-29
ani
2,50%
30-39
ani
40-49
ani
50-59
ani
60-69
ani
70-79
ani
5,10%
>80ani
Figura 10.
n cazul ulcerului duodenal cu perforaie corelaia sex vrst se efectueaz asupra
celor 200 de pacieni cu UD perforat. Se constat c ulcerul duodenal cu perforaie predomin
la sexul masculin, nregistrndu-se un numr de 166 pacieni, iar grupa de vrst cea mai
afectat este cea cuprins ntre 30 39 de ani, cu un numr de 44 cazuri i o pondere de
26,4% din numrul total de UD la sexul masculin (tabel 13, fig. 11).
Varsta
Brbati cu UD perforat
Procent
<20 ani
2,4%
20-29 ani
41
24,1%
30-39 ani
44
26,4%
40-49 ani
33
19,5%
50-59 ani
18
10,5%
60-69 ani
15
9%
70-79 ani
5,2%
>80ani
2,9%
Total
166
100%
12
24,69%
26,50%
20,00%
19,87%
Procent
15,00%
10,84%
10,00%
9,03%
5,42%
5,00%
0,00%
2,40%
<20 ani
20-29
ani
30-39
ani
40-49
ani
50-59
ani
60-69
ani
70-79
ani
3,01%
>80ani
Figura 11.
La sexul feminin ponderea cea mai mare a ulcerului duodenal perforat se constat la
grupa de vrst 40 49 de ani, cu un numr de 9 cazuri i un procent de 26,47% din numrul
total de UD cu perforaie la sexul feminin (tabel 14, fig. 12).
Vrsta
<20 ani
20-29 ani
30-39 ani
40-49 ani
50-59 ani
60-69 ani
70-79 ani
>80ani
Total
Femei cu UD perforat
0
6
6
9
5
2
2
1
34
Procent
0%
19,4%
19,4%
29%
16%
6,5%
6,5%
3,2%
100%
<20 ani
8
7
6
20-29 ani
30-39 ani
40-49 ani
5
4
50-59 ani
2
1
0
60-69 ani
1
70-79 ani
>80ani
Femei cu UD perforat
Figura 12.
13
Procent
UD hemoragic
10%
UD cu perforaie
8%
Fr antecedente heredo-colaterale
82%
Nr. pacieni
Procent
Pacieni consumatori
316
54,5%
Pacieni neconsumatori
264
45,5%
Total
580
100%
14
264
Pacieni consumatori
Pacieni neconsumatori
316
Figura 13.
Tip ulcer
Procent
UD perforat
135
42,7%
Total
316
100%
UD hemoragic
57,3%
181
200
135
150
UD hemoragic
100
UD perforat
50
0
UD hemoragic
UD perforat
Figura 14.
II.6.2. CONSUMUL DE CAFEA
Alt factor de risc implicat n ulcerogenez este reprezentat de consumul de cafea. S-a
constatat faptul c din cei 580 de pacieni cu ulcer duodenal hemoragic i perforat, un numr
de 135 pacieni sunt consumatori de cafea, reprezentnd 23,3% din numrul total de cazuri cu
UD hemoragic i perforat (tabel 18, fig. 15).
15
UD
Nr. pacieni
Procent
Pacieni consumatori
135
23,3%
Pacieni neconsumatori
445
76,7%
Total
580
100%
23,30%
Pacieni consumatori
Pacieni neconsumatori
76,70%
Figura 15.
Din numrul de 135 de pacieni consumatori de cafea, se constat ca 78 dintre aceti
prezint ulcer duodenal hemoragic, iar 57 sunt internai pentru ulcer duodenal perforat (tabel
19, 20).
UD hemoragic
Nr. pacieni
Procent
78
20,5%
302
79,5%
Total
380
100%
Nr. pacieni
Procent
57
28,5%
153
71,5%
Total
200
100%
16
II.6.3. FUMATUL
S-a constatat c din numrul total de 580 pacieni cu ulcer duodenal hemoragic i
perforat, un numr de 309 pacieni fumeaz mai mult de 10 igarete/ zi, ceea ce reprezint o
incidena de 53,3% (tabel 21, fig. 16). Din numrul de 309 pacieni fumtori, se constat c
183 dintre aceti prezint ulcer duodenal hemoragic, iar 126 sunt internai pentru ulcer
duodenal perforat.
UD hemoragic si perforat
Nr. pacieni
Procent
Pacieni fumtori
309
53,3%
Pacieni nefumtori
271
46,7%
Total
580
100%
Tabel 21. Numrul i procentul pacienilor fumtori din totalul UD hemoragice i perforate
271
Pacieni
nefumatori
Pacieni nefumatori
309
Pacieni fumatori
250
260
270
280
290
300
Pacieni fumatori
310
Figura 16.
II.6.4. CONSUMUL DE ANTIINFLAMATORII NESTEROIDIENE (AINS)
Din anamnez a rezultat faptul c din numrul total de 580 pacieni cu ulcer duodenal
hemoragic i perforat, un numr de 180 pacieni, adic 31,1%, erau consumatori de
antiinflamatorii nesteroidiene (AINS) (tabel 22, fig.17). S-a remarcat c din cei 180 pacieni
consumatori de AINS, 154 de pacieni prezentau ulcer duodenal hemoragic, iar 26 prezentau
ulcer duodenal perforat.
UD hemoragic i/ perforat
Nr. pacieni
Procent
180
40,5%
400
59,5%
Total
580
100%
Tabel 22. Numrul i procentul pacienilor consumatori de AINS din totalul cazurilor de UD
hemoragic i/ perforat
17
Pacieni
neconsumatori
de AINS
59,50%
Pacieni
consumatori de
AINS
0,00%
Pacieni neconsumatori de
AINS
Pacieni consumatori de
AINS
40,50%
20,00%
40,00%
60,00%
Figura 17.
II.6.5. ADMINISTRAREA DE ANTICOAGULANTE
n urma datelor anamnestice s-a constatat c din numrul total de 580 pacieni cu ulcer
duodenal hemoragic i perforat, un numr de 61 pacieni, adic 10,5%, se aflau sub tratament
cu anticoagulante (tabel 23, fig. 18).
S-a remarcat c din cei 61 pacieni care se aflau sub terapia cu anticoagulante, 56 de
pacieni prezentau ulcer duodenal hemoragic, iar 5 prezentau ulcer duodenal perforat.
UD hemoragic / perforat
Nr. pacieni
Procent
Administrare de anticoagulante
61
10,5%
Fr anticoagulante
519
89,5%
Total
580
100%
Tabel 23. Numrul i procentul pacienilor aflai sub tratament cu anticoagulante din totalul
cazurilor de UD hemoragic sau perforat
18
519
600
Administrare de
anticoagulante
500
400
300
200
100
0
Fr anticoagulante
61
Administrare de
Fr
anticoagulante anticoagulante
Figura 18.
Numr cazuri
Procent
Primvara
201
34,7%
Vara
116
20%
Toamna
159
27,4%
Iarna
104
17,9%
Total
580
100%
19
Primvara
Vara
Toamna
Iarna
27,40%
20%
Figura 19.
n tabelul 25 i figura 20 se poate observa faptul c numrul cel mai mare de pacieni
este n luna aprilie, fiind internai 81 de pacieni cu ulcer duodenal hemoragic i perforat,
avnd o inciden de 14%. A doua lun n care au fost internai muli pacieni este octombrie,
unde se constat un numr de 68 de cazuri, cu o pondere de 11,7%.
Luna
Nr. pacieni
Procent
Ianuarie
27
4,7%
Februarie
48
8,3%
Martie
60
10,3%
Aprilie
81
14%
Mai
59
10,2%
Iunie
42
7,2%
Iulie
35
6%
August
39
6,7%
Septembrie
52
9%
Octombrie
68
11,7%
Noiembrie
39
6,7%
Decembrie
30
5,2%
Total
580
100%
20
Ianuarie
Februarie
Martie
100
Aprilie
81
80
60
60
40
48
27
Mai
68
59
Iunie
52
42
35
39
Iulie
39
30
20
August
Septembrie
Octombrie
Noiembrie
Decembrie
Figura 20.
21
CAPITOLUL III
ANALIZA PARAMETRILOR SPECIFICI LOTULUI DE
PACIENI CU ULCER DUODENAL HEMORAGIC
Cei 380 cu ulcer duodenal hemoragic s-au prezentat la spital pentru acuznd
urmatoarele simptome: hematemez, melen i asocierea hematemez melen. Astfel s-a
constatat c 42 de pacieni s-au prezentat pentru hematemez, 139 pentru melen, iar un
numr de 199 pacieni s-au prezentat pentru asocierea hematemez melen (tabel 26, fig.
21).
Forma de debut
Nr. pacieni
Procent
Hematemez
42
11,1%
Melen
139
36,6%
Hematemez + melen
199
52,3%
Total
380
100%
52,30%
50,00%
36,60%
40,00%
Hematemez
30,00%
20,00%
Melen
11,10%
Hematemez + melen
10,00%
0,00%
Hematemez
Melen
Hematemez +
melen
Figura 21.
22
Numr pacieni
Procent
231
60,8%
1 episod
93
24,5%
2 episoade
39
10,2%
> 2 episoade
17
4,5%
Total
380
100%
39
17
Nici un episod
1 episod
2 episoade
> 2 episoade
93
231
Figura 22.
Numr pacieni
Procent
45
11,8%
6-12 ore
233
61,3%
12-24 ore
79
20,8%
> 24 ore
23
6,1%
Total
380
100%
Tabel 28. Distribuia pacienilor cu ulcer duodenal hemoragic n funcie de intervalul debut
HDS prezentare la spital.
23
n tabelul 28 i figura 23 se poate observa faptul c cei mai muli pacieni s-au
prezentat la spital ntre 6-12 ore de la debutul simptomatologiei HDS, totaliznd un numr de
233 pacieni. S-a constatat c pacienii care s-au prezentat la spital ntre 6-12 ore de la debutul
HDS au un procent de 61,3% din numrul total de pacieni cu ulcer duodenal hemoragic.
250
< 6 ore
200
6-12 ore
150
100
50
0
12-24 ore
79
45
< 6 ore
> 24 ore
23
6-12 ore
12-24 ore
> 24 ore
Figura 23.
Nr. pacieni
Procent
10-120 minute
11,7%
< 24 ore
21
30,9%
> 24 ore
39
57,4%
Total
68
100%
24
39
40
30
10-120 minute
21
< 24 ore
20
> 24 ore
10
0
10-120 minute
< 24 ore
> 24 ore
Figura 24.
Nr. pacieni
Procent
TAs < 90 mm Hg
FC > 100 b/ min
241
63,4%
TAs > 90 mm Hg
FC < 100 b/min
139
36,6%
Total
380
100%
Tabel 30. Valoarea tensiunii arteriale sistolice i a frecvenei cardiace la pacienii cu UD hemoragic.
25
TAs > 90
mmHg, FC <
100 b/ min
36,60%
TAs < 90
mm Hg, FC
> 100 b/ min
0,00%
63,40%
Figura 25.
Nr. pacieni
Procent
Efectuat
363
95,5%
Neefectuat
17
4,5%
Total
380
100%
Endoscopie efectuat
60,00%
40,00%
Endoscopie neefectuat
4,50%
20,00%
0,00%
Figura 26.
26
Nr. pacieni
Procent
oc hipovolemic
47,1%
Refuz
35,3%
Nu poate fi efectuat
17,6%
Total
17
100%
Nr. pacieni
Procent
Forrest I
59
16,3%
304
83,7%
Total
363
100%
83,70%
100,00%
80,00%
Forrest I
60,00%
40,00%
16,30%
20,00%
0,00%
Forrest I
50,00%
42,90%
40,00%
17,90%
30,00%
procent
20,00%
10,00%
0,00%
Hb>9 mg/dl,
Ht>35%
Hb 7-9 mg/dl, Ht
25-35%
Hb<7 mg/dl,
Ht<25%
Figura 28.
III.7.TRATAMENT
Din numrul total de 380 de pacieni cu ulcer duodenal hemoragic, n urma
examenului clinic i a explorrilor paraclinice, la 242 pacieni s-a instituit tratament
conservator (tabel 35, fig. 29).
Tip tratament
Nr. pacieni
Procent
Conservator
242
63,7%
Endoscopie intervenional
70
18,4%
Chirurgical
68
17,9%
Total
380
100%
68
Conservator
Endoscopie intervenional
Chirurgical
70
242
Figura 29.
S-a constatat c endoscopia intevenional a fost aplicat la 79 pacieni (reprezentnd
un procent de 20,8% din numrul total de cazuri cu ulcer duodenal hemoragic), metoda avnd
succes doar la 70 pacieni. n tabelul 36 se poate remarca faptul c din cei 79 de pacieni la
care s-a folosit endoscopia intervenional, la cei mai muli s-au injectat substane sclerozante.
Endoscopia intervenional
Nr. pacieni
Procent
Hemoclipuri
7,6%
70
88,6%
3,8%
Total
79
100%
Nr. pacieni
Procent
Eficient
70
88,6%
Ineficient
11,4%
Total
79
100%
29
70
80
60
Eficient
Ineficient
40
20
0
Eficient
Ineficient
Figura 30.
Nr. pacieni
Procent
13,2%
oc hipovolemic
11,8%
51
75%
Total
68
100%
Tabel 38. Motivele pentru care s-a intervenit chirurgical la pacienii cu UD hemoragic.
La cei 68 de pacieni la care s-a intervenit chirurgical au fost folosite diferite tehnici
operatorii. S-a constatat c la un numr de 49 de pacieni a fost efectuat sutura n X cu
hemostaz in situ, aceast tehnic fiind folosit la cei mai muli pacieni (tabel 39, fig. 31).
Tipul operaiei
Nr. pacieni
Procent
49
72%
Rezecie
18
26,5%
1,5%
68
100%
49
Sutur n X cu hemostaz in
situ
50
Rezecie
40
18
30
20
Sutur n X cu hemostaz in
situ i ligatur a arterei gastroduodenale
10
0
Figura 31.
Tipul interveniilor chirurgicale din cadrul rezeciilor efectuate la pacienii cu ulcer
duodenal hemoragic este prezentat n tabelul 40.
Tipul operaiei
Bulbantrectomie gastric, cu VT bilateral
subdiafragmatic, urmat de anastomoz tip Pan
Bulbantrectomie gastric, cu VT bilateral
subdiafragmatic, urmat de anastomoz tip Reichel
Polya
Bulbantrectomie gastric, cu VT bilateral
subdiafragmatic, urmat de anastomoz tip Pan i
ligatura arterei gastro-duodenale
Nr.
pacieni
13
Procent
5,6%
22,2%
72,2%
18
100%
Total
Tabel 40. Numrul de pacieni i procentul pentru fiecare tehnic operatorie folosit n
cadrul rezeciilor.
Au fost efectuate transfuzii sangvine la toi pacienii care aveau hemoglobina mai
mic de 7 mg/dl, acetia fiind n numr de 68, precum i la 39 din cei 163 pacieni care aveau
hemoglobina ntre 7-9 mg/dl (tabel 41, fig. 32).
Valoarea Hb
Nr. pacieni
Procent
Hb<7 mg/dl
68
63,6%
Hb 7-9 mg/dl
39
36,4%
Total
107
100%
31
36,4%
Hb<7 mg/dl
Hb 7-9 mg/dl
63,6%
Figura 32.
n funcie de statusul hemodinamic i de starea general a celor 107 pacieni s-a
stabilit numrul de uniti de snge care trebuie transfuzate. La cei mai muli dintre pacieni
au fost transfuzate 1-2 uniti de snge, numrul acestora fiind de 69 de pacieni (tabel 42).
Numr uniti transfuzate
Numr pacieni
Procent
1-2 U
69
64,5%
3-4 U
26
24,3%
>4 U
12
11,2%
Total
107
100%
Numr pacieni
Procent
1-2 uniti
33
48,5%
3-4 uniti
23
33,8%
>4 uniti
12
17,7%
Total
68
100%
32
Numr pacieni
Procent
3 zile
19
7,9%
4 zile
38
15,7%
5 zile
60
24,8%
6 zile
63
26%
7 zile
30
12,4%
8 zile
21
8,7%
>8 zile
Total
11
242
4,5%
100%
Tabel 45. Repartiia numrului de pacieni tratai conservator n funcie de numrul zilelor de
spitalizare.
33
4,5%
8 zile
8,7%
7 zile
12,4%
26%
24,8%
6 zile
5 zile
15,7%
4 zile
7,9%
0,0%
5,0%
10,0%
3 zile
15,0%
20,0%
25,0%
30,0%
Figura 33.
III.10. DECESE
Din numrul total de 380 de pacieni cu ulcer duodenal hemoragic s-a nregistrat un
numr de 7 pacieni care au decedat. Dintre acetia, la 3 s-a intervenit chirurgical, decesul
survenind n urma apariiei complicaiilor (tabel 46).
Decese
Nr. cazuri
Procent
Pacieni operai
42,9%
Pacieni neoperai
57,1%
Total
100%
Numr pacieni
a. Pacieni operai
Fistul digestiv
Bronhopneumonie
b. Pacieni neoperai
Bronhopneumonie
Total
7
Tabel 47. Cauzele deceselor la pacienii cu ulcer duodenal hemoragic.
34
Nr. pacieni
Procent
Contractur abdominal
161
80,5%
Aprare muscular
37
18,5%
Durere abdominal
1%
200
100%
Total
Tabel 48. Constatrile examenului clinic abdominal la pacienii cu ulcer duodenal perforat.
Simptomele constatate la examenul clinic al
pacienilor cu UD perforat
200
161
150
Contractur abdominal
100
50
0
Aprare muscular
37
Durere abdominal
Contractur
Aprare
Durere
abdominal muscular abdominal
Figura 34.
Nr. pacieni
Procent
Pneumoperitoneu prezent
194
97%
Pneumoperitoneu absent
3%
200
100%
Total
97%
60%
Pneumoperitoneu prezent
40%
20%
Pneumoperitoneu absent
3%
0%
Pneumoperitoneu
Pneumoperitoneu
prezent
absent
Figura 35.
Din numrul total de 200 pacieni, ecografia abdominal a fost realizat la un numr
de 164 pacieni. n tabelul 50, precum i n figura 36, se poate remarca procentul pacienilor la
care ecografia abdominal a obiectivat prezena lichidului din cavitatea peritoneal, acest
procent (68,9%) fiind aproape dublu fa de procentul pacienilor la care lichidul nu a fost
vizualizat (31,1%).
Ecografie abdominal
Nr. pacieni
Procent
Lichid prezent
113
68,9%
Lichid absent
51
31,1%
Total
164
100%
113
120
100
51
80
Lichid absent
60
40
20
0
Lichid prezent
Lichid prezent
Lichid absent
Figura 36.
36
Numr pacieni
Procent
0-6 ore
78
39%
6-12 ore
92
46%
12-24 ore
15
7,5%
24-48 ore
4%
>48 ore
3,5%
200
100%
Total
46%
0-6 ore
39%
40%
6-12 ore
30%
12-24 ore
20%
7,5%
10%
0%
0-6 ore
6-12 ore
24-48 ore
4%
3,5%
>48 ore
>48 ore
Figura 37.
IV.4. TRATAMENT
Din numrul total de 200 pacieni cu ulcer duodenal perforat, la 130 dintre ei a fost
necesar intervenia chirurgical, n timp ce 70 de pacieni au fost tratai conform metodei
Taylor. Succesul terapeutic a fost nregistrat la 54 de pacieni, ceea ce reprezint un procent
de 77,1% din numrul total de pacieni la care s-a aplicat metoda Taylor (tabel 52, fig. 38).
37
Metoda Taylor
Nr. pacieni
Procent
Succes terapeutic
54
77,1%
Eec terapeutic
16
22,9%
Total
70
100%
54
60
50
40
Succes terapeutic
30
16
20
10
Eec terapeutic
0
Succes terapeutic
Eec terapeutic
Figura 38.
Dei numrul iniial era de 130 de pacieni operai, dup eecul tratamentului folosind
metoda Taylor la un numr de 16 pacieni, n final au rezultat 146 pacieni la care intervenia
chirurgical a fost necesar.
n tabelul 53 i figura 39 se observ c proporia pacieni operai / pacieni tratai
utiliznd metoda Taylor este de 2,7 :1, semnificativ mai mare n favoarea pacienilor operai.
Procentul pacienilor operai este de 73%, mult mai mare dect al celor tratai conform
metodei Taylor, al crei procent este de 27%.
Tip tratament
Nr. pacieni
Procent
Chirurgical
146
73%
Metoda Taylor
54
23%
Total
200
100%
38
23%
Chirurgical
Metoda Taylor
73%
Figura 39.
n ceea ce privete tratamentul chirurgical al pacienilor cu ulcer duodenal perforat,
cea mai folosit tehnic operatorie a fost sutura simpl a ulcerului, urmat de
epiploonoplastie, efectuat la 94 pacieni. A doua tehnic mai des utilizat a fost sutura simpl
a ulcerului, fiind aplicat la 18 pacieni (tabel 54, fig. 40).
Tipul interveniei
Nr.pacieni
Procent
94
64,4%
Sutur simpl
18
12,3%
Excizie+sutur
6,2%
Excizie-sutur+epiploonoplastie
5,5%
Rezecie
4,8%
Laparoscopic
10
6,8%
Total
146
100%
4,8%
5,5%
6,8%
Sutur simpl i
epiploonoplastie
Sutur simpl
6,2%
Excizie+sutur
Excizie-sutur+epiploonoplastie
12,3%
64,4%
Rezecie
Laparoscopic
Figura 40.
39
Trebuie menionat faptul c rezeciile au constat n 3 variante. Una dintre variante este
bulbantrectomia gastric, cu vagotomie (VT) subdiafragmatic bilateral, ce a fost efectuat la
un numr de 4 pacieni.
Celelalte dou variante sunt reprezentate de hemigastrectomie i de rezecia gastric
2/3 au o pondere de 14,3%, respectiv 28,6% din totalul pacienilor cu ulcer duodenal perforat
la care a fost efectuat rezecia (tabel 55).
Tip rezecie
Nr. pacieni
Procent
57,1%
14,3%
28,6%
Total
100%
Bulbantrectomie gastric,
bilateral
Hemigastrectomie
cu
VT
subdiafragmatic
Nr. pacieni
Procent
Generalizat
128
87,7%
Localizat
18
12,3%
Total
146
100%
87,7%
100,0%
80,0%
Generalizat
60,0%
Localizat
40,0%
12,3%
20,0%
0,0%
Generalizat
Localizat
Figura 41.
40
S-a constatat c din cei 146 pacieni operai, 127 prezentau peritonit chimic, iar 19
peritonit purulent. n tabelul 57 i figura 42 se poate remarca faptul c ponderea pacienilor
la care s-a constatat peritonita chimic este de 87% din numrul total de pacieni operai, n
timp ce cazurile cu peritonit purulent au o pondere de 13%.
Tip peritonit
Nr. pacieni
Procent
Chimic
127
87%
Purulent
19
13%
Total
146
100%
19
Chimic
Purulent
127
Figura 42.
Tot intraoperator s-a stabilit localizarea ulcerului i dimensiunile acestuia. Procentul
pacienilor la care leziunea ulceroas este situat anterior este de 74,7%, iar cel al cror
leziune este posterioar este de 25,3% (tabel 58, fig. 43).
Localizarea ulcerului
Nr. pacieni
Procent
Faa anterioar
109
74,7%
Faa posterioar
37
25,3%
Total
146
100%
41
25,3%
Faa posterioar
Faa posterioar
74,7%
Faa anterioar
Faa anterioar
0,0%
20,0%
40,0%
60,0%
80,0%
Figura 43.
n tabelul 59 este evideniat procentul pacienilor n funcie de dimensiunea ulcerului.
Astfel, s-a constatat c 78,7% din numrul total de pacieni operai au un ulcer mai mic de 0,5
cm, iar 19,2% au dimensiunea ulcerului ntre 0,5-1 cm.
Dimensiunea ulcerului
Nr. pacieni
Procent
<0,5 cm
115
78,7%
0,5-1 cm
28
19,2%
1-2 cm
1,4%
>2 cm
0,7%
Total
146
100%
IV.5. COMPLICATII
n cazul celor 54 de pacieni tratai prin metoda Taylor au aprut complicaii generale
la un numr de 5 pacieni, reprezentnd un procent de 9,3% (tabel 60).
Metoda Taylor-complicaii
Nr. Pacieni
Bronhopneumonie
Total
5
Tabel 60. Distribuia pacienilor n funcie de complicaiile metodei Taylor.
42
Din numrul total de 146 de pacieni la care s-a intervenit chirurgical, la 23 dintre
acetia au aprut complicaii postoperatorii att generale, ct i locale.
Procentul fiecrei complicaii locale i generale din numrul total de pacieni la care
au aprut complicaii este prezentat n tabelul 61.
Complicaii postoperatorii
Nr. Pacieni
Procent
A. Locale
Supuraii de plag
Fistul digestiv
Ocluzie intestinal secundar
Pancreatit acut
Abces intraabdominal
B. Generale
9
1
2
2
1
39,7%
4,3%
8,6%
8,6%
4,3%
Bronhopneumonie
Infarct miocardic
Insuficien renal acut
3
2
1
13%
8,6%
4,3%
Embolie pulmonar
Accident vascular cerebral
1
1
4,3%
4,3%
Total
23
100%
Numr pacieni
Procent
3 zile
11
5,5%
4 zile
21
10,5%
5 zile
38
19%
6 zile
43
21,5%
7 zile
46
23%
8 zile
24
12%
>8 zile
17
8,5%
Total
200
100%
Tabel 62. Repartiia pacienilor cu ulcer duodenal perforat n funcie de numrul zilelor de
spitalizare.
43
>8 zile
12,0%
8 zile
23,0%
7 zile
6 zile
21,5%
procent
19,0%
5 zile
10,5%
4 zile
5,5%
3 zile
0,0%
5,0%
10,0%
15,0%
20,0%
25,0%
Figura 44.
IV.7. DECESE
Din numrul total de 200 pacieni cu ulcer duodenal perforat s-a nregistrat un numr
de 3 pacieni care au decedat. La toi cei 3 pacieni s-a intervenit chirurgical, decesul
survenind n urma apariiei complicaiilor (tabel 63, fig. 45).
UD perforat
Tratament eficient
Decese
Total
Nr. cazuri
Procent
197
98,5%
1,5%
200
100%
197
200
Tratament eficient
150
Decese
100
50
0
Tratament eficient
Decese
Figura 45.
Din cei 3 pacieni, unul a decedat n urma sepsisului, iar ceilali doi n urma apariiei
postoperatorii a unei bronhopneumonii i respectiv a unui infarct miocardic acut.
44
CONCLUZII
45
11. Injectarea de substane sclerozante a reprezentat modalitatea cea mai utilizat n cadrul
procedurilor de endoscopie intervenional pentru obinerea hemostazei la pacienii cu
ulcer duodenal hemoragic. Eecul terapiei endoscopice cu reluarea sngerrii a
reprezentat o indicaie pentru tratament chirurgical.
12. n cadrul interveniilor chirurgicale pentru ulcer duodenal hemoragic sunt preferate
interveniile chirurgicale minime, tehnica operatorie cea mai utilizat fiind hemostaza
in situcu sutura cu fire n X.
13. Cei mai muli pacieni cu ulcer duodenal perforat s-au prezentat la spital n intervalul
6-12 ore de la debutul simptomatologiei, manifestarea clinic cea mai frecvent fiind
contractura abdominal. Cea mai mare parte a pacienilor cu ulcer duodenal perforat
au prezentat peritonit chimic.
14. Radiografia abdominal simpl pe gol rmne modalitatea imagistic cea mai
utilizat pentru diagnosticul ulcerului duodenal perforat i care relev
pneumoperitoneul cu o mare acuratee. Ecografia abdominal reprezint explorarea
secundar n stabilirea diagnosticului de perforaie prin precizarea prezenei lichidului
intraperitoneal. Computer tomografia rmne rar indicat n stabilirea diagnosticului,
radiografia i ecografia stabilind diagnosticul n peste 96% din cazuri.
15. Pentru pacienii cu ulcer duodenal perforat s-a recurs cel mai frecvent la tratament
chirurgical de urgen (n primele 6 ore), ns numrul cazurilor tratate conservator
(metoda Taylor) a nregistrat o cretere semnificativ n ultimii ani.
16. n cazul tratamentului chirurgical pentru ulcerul duodenal perforat se observ aceeai
tendin pentru gesturi minime, tehnica cea mai frecvent utilizat fiind sutura simpl a
ulcerului cu epiploonoplastie.
17. Tratamentul laparoscopic pentru ulcerul duodenal perforat a reprezentat o soluie
terapeutic fiabil cu rezultate foarte bune. Durata interveniei a fost identic cu cea a
operaiei clasice datorit n principal dificultii lavajului peritoneal extensiv. Evoluia
post operatorie a fost simpl, pacienii beneficiind de avantajele laparoscopiei (durere,
agresiune operatorie diminuate, avantaj cosmetic), n schimb durata spitalizrii a fost
aproximativ egal cu cea a operaiei clasice (tratamentul peritonitei).
18. Cea mai frecvent localizare a ulcerului hemoragic duodenal a fost faa posterioar a
bubului duodenal, iar n cazul perforaiei, faa anterioar.
19. n cazul ulcerului duodenal perforat factori de predicie puternici pentru evoluia
ulterioar a pacienilor sunt reprezentai de momentul operator, gradul peritonitei,
observndu-se o rata mai mare a complicaiilor i o cretere a numrului zilelor de
spitalizare pentru pacienii care s-au prezentat tardiv n serviciul de chirurgie
(perforaie veche).
20. Pentru toi pacienii cu ulcer duodenal complicat, factori de predicie puternici pentru
evoluia ulterioar sunt reprezentai de vrst i comorbiditi, pacienii vrstnici, cu
multiple comorbiditi ajungnd mai frecvent la tratement chirurgical i avnd o rat
mai mare a complicaiilor.
21. Infecia cu Helicobacter pylori a fost diagnosticat n cea mai mare parte a cazurilor.
Tratamentul a presupus administrarea de inhibitori ai receptorului H2, inhibitori de
46
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