CURSUL 12

Durerea abdominala. Sindromul dureros abdominal de cauze

medicale- etiologie, criterii de gravitate, abordare
diagnostica si terapeutica in urgenta.
Urgentele gastrointestinale
Abdomenul dureros acut nechirurgical : colica biliara, colecistita acuta, pancreatita acuta,
HDS?
Encefalopatia portala
Uptodate 2008
1.Abdomenul dureros acut
Prevalenta crescuta (raspuns la chestionare):
Tineri studenti : 75%
Adulti : 50%
Cauze complexe :
Benigne , autolimitate sau responsive la tratament simptomatic
Potential primejdioase care impun investigatii serioase si supraveghere atenta
Manifestari nespecifice si greu de incadrat etiologic
1.Abdomenul dureros acut
abordare diagnostica
Istoric/anamneza :
Localizarea durerii si iradierea durerii
Factori care exacerbeaza sau amelioreaza simptomele: alimentatie, antiacide, effort, defecatie, etc
Simptome asociate : febra, frisoane, scadere sau crestere in greutate, greata, varsaturi, diaree,
constipatie, hematochezia, melena, icterul, modificarile de culoare ale urinei sau fecalelor,
modificarile de forma si dimensiune a fecalelor
Istoric medical de interventii chirurgicale abdominale, factori de risc pentru bolile CV
Consum de alcool, de medicamente : AINS, anticoagulante, etc
Calendarul menstrual si uzul de contraceptive la femeie
1.Abdomenul dureros acut
abordare diagnostica
Examenul fizic :
TA, AV, temperatura
Examinarea ochilor si a tegumentelor
Ascultatia si percutia toracelui
Auscultatia abdomenului pentru zgomotele intestinale
Palparea abdomenului : mase tumorale, sensibilitate, semne peritoneale
Tuseu rectal si testul pentru hemoragii oculte
Examinarea pelvisului la femeia cu dureri abdominale joase
1.Abdomenul dureros acut
abordare diagnostica
Abdomenul acut chirurgical
Peritonita :
Durere la decompresiune
Durere la percutie
Rigiditatea peretelui abdominal
Rezistenta la antialgice
Other subtle signs of peritonitis that can be pursued include diminished bowel sounds and
pain worsened when an examiner lightly bumps the stretcher. The absence of this "shake
tenderness" can reassure the examiner that peritonitis is unlikely to be present.
Sindromul de obstructie
1.Abdomenul dureros acut
abordare diagnostica
Abdomenul acut chirurgical
1.3.1. Peritonita
1.3.2. Sindromul de obstructie intestinala
Dureri abdominale
Balonare
Varsaturi bilioase, fecaloide
Oprirea tranzitului pentru gaze si materii fecale
Disparitia zgometelor intestinale
1.Abdomenul dureros acut
abordare diagnostica
1.3.3. Investigatii de urgenta :
HL, electrolitii, uree, creatinina, glicemie, TGP,TGO, fosfataza alcalina , bilirubina,
amilaza, lipaza, examenul de urina, testul de sarcina,
Hemoculturi, uroculturi daca sunt prezente febra sau semnele de instabilitate vitala
Radiografia abdominala simpla : pneumoperitoneu, anse intestinale dilatate
Ultrasonografia
CT abdominal
1.Abdomenul dureros acut
abordare diagnostica
Durerea de hipocondru drept : ficat, cai biliare, durere iradiata
Colica biliara, colecistita, angiocolita, hepatita acuta, ficatul de staza
Investigatii biologice de urgenta : HL, electroliti, uree, creatinina, glicemie, TGP,TGO,
bilirubina, fosfataza alcalina, lipaza
Investigatii imagistice : ultrasonografia, colangiopancreatografia RMN sau
endoscopica retrograda
1.4.1. Colica biliara :
diagnostic si tratament
1.4. Durerea de hipocondru drept
1.4.1. Colica biliara : manifestari clinice
Una din cele mai intense dureri intalnite in practica medicala
Localizata in hipocondru drept sau epigastru cu iradiere specifica (spate, umarul drept)
Apare dupa abuzuri alimentare (dupa cateva ore, nu in timpul mesei!)
Atinge punctul culminanat in cateva minute/<1h si se mentine in platou >1h
Durata limitata : ore ; > 4-6h de gandit la colecistita
Se repeta la intervale neregulate de timp
Greata, varsaturile, balonarea pot fi prezente
In absenta colecistitei, abdomenul poate fi suplu si nedureros la palpare
1.4.1. Colica biliara :
diagnostic si tratament
1.4.1. Colica biliara :
modificarri paraclinice HL, TGP,TGO, BT si BD, amilazemia de obicei in limite normale
Ultrasonografia
1.4.2. Colica biliara : tratament
Tratament simptomatic :
Ketorolac (30 to 60 mg adjusted for age and renal function given in a single
intramuscular dose) Treatment usually relieves symptoms within 20 to 30 minutes.
Patients are then prescribed ibuprofen 400 mg orally to be taken during
subsequent attacks, until definitive treatment can be accomplished.
Meperidina IV ( caused more adverse events mainly in the form of nausea and
dizziness)
Tratament chirurgical : colecistectomia
Terapie farmacologica de disolutie : simptome usoare, absenta complicatiilor, risc operator
crescut
1.4.2. Colecistita acuta :
definitie
Sindrom dureros de hipocondru drept, febra si leucocitoza prin
Inflamatia colecistului determinata de obicei cu litiaza biliara
Colecistita alitiazica apare de obicei la pacientii cu boli severe si reprezinta aproximativ 10%
din cazurile de colecistita acuta
1.4.2. Colecistita acuta :
manifestari clinice
Manifestari clinice :
Durere in hipocondrul drept sau epigastru
Iradiere in umarul drept sau in spate
Characteristically, acute cholecystitis pain is steady and severe
Prelungita : >4-6ore
Simptome asociate : nausea, vomiting, and anorexia.
Cauze dclansante : There is often a history of fatty food ingestion about one hour or more
before the initial onset of pain.
Simptome care nu sugereaza etiologia biliara :
fatty food intolerance not in the form of pain,
nausea not in association with pain,
pain only a few minutes after a meal,
irregular bowel habits, or belching
1.4.2. Colecistita acuta :
examen fizic
Examenul fizic :
Stare influentata
febrile, and
tachycardic,
and lie still on the examining table because cholecystitis is associated with true local parietal
peritoneal inflammation that is aggravated by movement.
Abdominal examination usually demonstrates voluntary and involuntary guarding.
Elicitation of "Murphy's sign" may be a useful diagnostic maneuver. While palpating the
area of the gallbladder fossa just beneath the liver edge, the patient is asked to inspire
deeply, causing the gallbladder to descend toward the examining fingers. Patients with
acute cholecystitis commonly experience increased discomfort and may have an associated
inspiratory arrest. The sensitivity of Murphy's sign may be diminished in the elderly [18].
1.4.2. Colecistita acuta:
complicatii
Gangrena :
mai frecventa la varstnici, diabetici sau maltratati
presence of a sepsis-like picture in addition to the other symptoms of cholecystitis should
suggest the diagnosis, but gangrene may not be suspected preoperatively.
Perforation :
Secundara gangrenei
Adeseori localizat cu aspect de abces pericolecistic
Rareori perforatie in peritoneu asociata cu mortalitate crescuta
Fistula colecistoenterica
Perforatia colecistului in duoden sau jejun
Ileus mecanic
Colecistita emfizematoasa
Infectia paretelui colecistic cu organisme formatoare de gaz (such as Clostridium welchii)
[22,23]. Other organisms that may be isolated include Escherichia coli (15 percent),
staphylococci, streptococci, Pseudomonas, and Klebsiella [23].
1.4.2. Colecistita acuta:
diagnostic
Acute cholecystitis should be suspected when a patient presenting with the clinical manifestations
outlined above is found to have gallstones on an imaging study. However, the mere presence of
gallstones is not a sine qua non for acute cholecystitis, since asymptomatic cholelithiasis is a
common condition in the general population. Thus, confirmation of the diagnosis must be based
upon a combination of physical findings, laboratory studies, and imaging tests (show algorithm 1).
The basis for this recommendation was underscored in a systematic review that focused on 17
studies examining the role of the history, physical examination and/or laboratory tests in adults with
abdominal pain or suspected acute cholecystitis [28]. No single clinical or laboratory finding was
sufficiently accurate to rule-in or rule-out the diagnosis. The most accurate physical finding was a
positive Murphy sign (positive likelihood ratio (LR) 2.8, 95% CI 0.8 to 8.6) and right upper quadrant
tenderness (negative LR 0.4, 95% CI 0.2 to 1.1). On the other hand, the correct diagnosis (confirmed
at surgery) was frequently achieved by the clinical impression in which the history, physical
examination, laboratory and radiologic findings were considered together (LR ranging from 25 to
30).
1.4.2. Colecistita acuta:
studii imagistice
Ultrasonography — The presence of stones in the gallbladder in the clinical setting of right upper
quadrant abdominal pain and fever supports the diagnosis of acute cholecystitis but is not
diagnostic (show radiograph 2). Additional sonographic features include:
Gallbladder wall thickening (greater than 4 to 5 mm) or edema (double wall sign).
A "sonographic Murphy's sign", which is similar to the Murphy's sign elicited during abdominal
palpation, except that the positive response is observed during palpation with the ultrasound
transducer. This is more accurate than hand palpation because it can confirm that the gallbladder is
being pressed by the imaging transducer when the patient displays the inspiratory arrest. Magnetic
resonance cholangiography — Magnetic resonance cholangiography (MR cholangiography) is a
noninvasive technique for evaluating the intrahepatic and extrahepatic bile ducts. Its role in the
diagnosis of acute cholecystitis was evaluated in a series that included 35 patients with symptoms of
acute cholecystitis who underwent both ultrasound and MR cholangiography prior to
cholecystectomy [6]. MR cholangiography was superior to ultrasound for detecting stones in the
cystic duct (sensitivity 100 versus 14 percent) but was less sensitive than ultrasound for detecting
gallbladder wall thickening (sensitivity 69 versus 96 percent). At the present time its role in the
diagnosis of acute cholecystitis should remain within clinical trials. (See "Magnetic resonance
cholangiopancreatography").
CT scan — Abdominal computed tomography (CT) is usually unnecessary in the diagnosis of acute
cholecystitis, although it can easily demonstrate gallbladder wall edema associated with acute
cholecystitis (show radiograph 1). Other CT findings include pericholecystic stranding and fluid, and
high-attenuation bile [40,41]. CT can be useful when complications of acute cholecystitis (such as
emphysematous cholecystitis or gallbladder perforation) are suspected or when other diagnoses are
considered