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PANCREATITA ACUTA

Dr. Mihai CIOCÎRLAN


03 Octombrie 2012
Capitole
1) Definitie si incidenta
Clinic
2) Diagnostic pozitiv Biologic
3) Diagnostic de gravitate Imagistic

4) Diagnostic etiologic
5) Diagnostic diferential
6) Principii de tratament
1) Definitie si incidenta
• Definitie = inflamatie acuta a pancreasului din
cauze variate
• Incidenta = 5 – 50 /100.000 locuitori
2) Diagnostic pozitiv
• Clinic
– DURERE (90%)
• Tipica = epig./hcd/bara – irad. post/tot abd., “cocos de pusca”
– VARSATURI (50%)
– ILEUS (30%)
Independent de
gravitatea PA
– SOC (10%), Mt. > 40%
– DISPNEE (15%), Mt. > 30%
– OLIGO/ANURIE (10-15%), Mt. 30-50%

– NEUROLOGIC (5%), Mt. 30%


– INFECTIE (4%), Mt. 15%
– HEMORAGIE (3%), Mt. 20%
2) Diagnostic pozitiv
• Clinic
– Forme atipice, doar DURERE moderata, tranzitorie
2) Diagnostic pozitiv
• Biologic
– Lipaza > 3xN
– Amilaza, de abandonat

PA = (durere abdominala tipica) + (lipaza > 3 x N)


2) Diagnostic pozitiv
• Imagistic
– In caz de certitudine diagnostica, nu este necesar
nici un alt examen

– Dubii? Se recomanda CT abd-pelvis


• Daca functie renala alterata, fara contrast iv
• Daca functie renala OK, cu contrast iv

– Alte teste imagistice pentru dg. pozitiv


• Nu Rx abd pe gol
• Nu ecografie abd-pelvis(da dg etiologic, sistematic)
3) Diagnostic de gravitate
• Clinic
– PA edematoasa, “benigna”
• DURERE, VARSATURI, ILEUS (tipic)
• Doar DURERE moderata (atipic)

– PA necrotica, “severa”
• La fel ca PA edematoasa tipic/atipic +
• SIRS – SOC, SDRA, IRenala
• Complicatii infectioase
• Alte complicatii (digestive, coagulare, neuropsihice,
cutanate)
3) Diagnostic de gravitate
• Clinic
– PA grava – prin SIRS (citokine)
• Cand? Imediat
• Circulator: soc
• Respirator: SDRA – dispnee (si pleurezie)
• Renal: IRenala fct (75%) / organica ? (25%)

– PA grava - prin complicatii infectioase


• 4% PA total, 0% PA benigne, 30% PA grave
• Cand? Nu imediat, la sfarsit S1 – S4
• Ce ? Infectie necoza (translocatie bacteriana)
– Clinic (&biologic) agravare, imagistic bule aer in necroza
– Punctie aspirativa ghidata CT pt. dg. Pozitiv
• Si alte infectii: pulm, urinare, etc; Hemoc, urocult
3) Diagnostic de gravitate
• Clinic
– PA grava – prin alte complicatii
• Digestive: ulcere duoden II +/- HDS, colita ischemica
(soc), fistule interne duodenale, gastrice, ileale, biliare,
colice si alte
• Coagulare: CID
• Hemoragice: peritoneu, intrachistice (eroz. arteriala prin
necorza)
• Neuropsihice: “encefalopatie”: tulb constienta
• Cutanate: citosteatoza sistemica (Christian-Weber):
Cullen, Grey-Turner
3) Diagnostic de gravitate
• Clinic
– Complicatii tardive
• Pseudochiste
– 10-50% din PA
– Cand? S1 – S6
– Asimptomatice / durere abdominala
– 50% rezolutie spontana
– 50% complicatii: suprainfectie, hemoragie, ruptura, compresie
organe de vecinatate (cai biliare, duoden, etc)
– Dg +: CT/ EUS
3) Diagnostic de gravitate
• Biologic
– (PA grava imediat sau agravare ulterioara)
– CRP > 150mg/dl la 48h, apoi // cu evolutia
– Scoruri (cercetare)
• Ranson, specific PA (etanolica)
• Glasgow modificat (Imrie), specific PA
• APACHE II – nespecific PA, pentru mediu ATI

Scor > 3 = PA
severa
3) Diagnostic de gravitate

*Ranson et al. Prognostic signs and the role of operative management in acute pancreatitis. Gynecol Obstetr 1974; 139: 69 – 81.
3) Diagnostic de gravitate

*Blamey SL, Imrie CW, O'Neill J, Gilmour WH, Carter DC. Prognostic factors in acute pancreatitis. Gut. 1984 Dec;25(12):1340-6
3) Diagnostic de gravitate
• Imagistic
– CT +/- contrast > 48h (pt. constituire leziuni)
– Scor Baltasar
3) Diagnostic de gravitate

• Mortalitate 3%(<3 pct.), 6% (4-6 pct.), 17% (7-10 pct.)

*Baltazar. Acute pancreatitis: Value of CT in establishing prognosis. Radiology 1990; 174: 331 – 336.
3) Diagnostic de gravitate
3) Diagnostic de gravitate
• In concluzie:
– PA edematoasa benigna (70 – 80%)
• Sectia “medicala”

– PA necrotica severa (20-30%)


• Sectia ATI, mediu medico-chirurgical & radiologie
interventionala
4) Diagnostic etiologic
• ALCOOL (40%)
– Teren
• Tipic barbat 40 ani, > 100g alcool/zi > 10 ani
• Daca fara istoric de PA/PC, do = puseu inaugural de PC alcoolica
calcifianta (curs urmator)
• Alte stigmate de suferinta alcoolica: hepatopatie cronica,
cardiopatie, Dupuytren, parotide, etc
– Biologic
• Alte stigmate de consum de alcool: GGT, MCV, ASAT/ALAT>1
– Imagistic
• Hepatopatie cronica, cardiopatie, calcificari pancreas (PC)
4) Diagnostic etiologic
• BILIARA (40%)
– Teren
• Tipic femeie 50 ani, supraponderala (3F “fat, female, fifty”),
multiparitate, antecedente familiale de litiaza
• Calculi <3mm/ numar >3, cistic larg
– Biologic
• Peak de ALAT/ASAT>1 pana la x50N, rapid tranzitor in primele 48h
• Daca si bilirubina crescuta = inclavare calcul in ampula Vater
– Imagistic
• ecografie hepato-biliara rapida, odata cu CT,pentru a evidentia o
eventuala litiaza inclavata in ampula Vater (+ angiocolita) ce
necesita dezobstructie / drenaj endoscopic (ERCP)
• Nu totdeauna vizibil la ecografie
4) Diagnostic etiologic
• CAUZE RARE
– tumori maligne sau benigne de pancreas (TIPMP)
• > 50 ani (!), CT/RMN/EUS
– Postoperator
• Chirurgie biliara, gastrica
– post ERCP
• 5%,
• pacienti tineri, pancreas normal, experienta scazuta operator,
numar crescut de opacifieri Wirsung cu presiune crescuta
– post traumatic
• Box, accident de bicicleta sau automobil
4) Diagnostic etiologic
• CAUZE EXCEPTIONALE
– Hiper-trigliceridemie
• >1000mg/dl, 30% din cazuri
– Hiper-calcemie (1%)
• hiperPTH, 5-10% din cazuri
– Medicamente
• Azathioprina/6MP, furosemid, estrogeni, tetraciclina
– Infectioase
• Oreion, CMV context de HIV, VHB, enterovirus
– Autoimuna
• IgG4, Ac. anti lactoferina, Ac. anti anhidraza carbonica
• “pseudotumorala”, asoc cu alte maladii autoimune (Crohn,
Sjogren, alte)
– Canalara (pancreas divisum)
4) Diagnostic etiologic
• IDIOPATICA (10%)
– EUS pancreatico-biliar la distanta, dupa disparitia
edemului, la 4 - 6 saptamani in general:
• Pentru litiaza μveziculara = PA biliara
• Pentru tumori / TIPMP de pancreas
5) Diagnostic diferential
• Cauze de dureri abdominale acute
– Ulcer perforat
– Infarct mezenteric
– Peritonita biliara
– IMA inferior
– Ruptura de anevrism de aorta abdominala
Diagnostic pozitiv

PANCREATITA ACUTA

Diagnostic de gravitate Diagnostic etiologic

Tratament
6) Principii de tratament
• Monitorizare TA, AV, SO2, CVP prin CVC, diureza, …

• ABC - O2, pev. Coloide & cristaloide

• ATI circulator, respirator, renal

• A jeun

• IPP IV (omeprazol 40mg/8-12h) sau PSE); Y/N ?

• SNG doar daca varsaturi

• HBPM profilactic (fraxiparina 0.3ml/24 sau ennoxaparina 0.4ml/24h sc)

• Kinesiterapie, preventie escare


6) Principii de tratament
• Antalgice
– (I) paracetamol (max 4g/24h), nu AINS (fct. renala!)
– (II) tramadol (max 300mg/24h)
– (III) morfina (sc/iv)

• Nutritie
– Parenterala
– Enterala: mai bine, scade translocatia bacteriana (scade % de complicatii
infectioase, scade durata de spitalizare)
– Reluare alimentatie la 7 zile de durere absenta + lipaza < 3 x N, disparitie
voma, reluare tranzit; cu regim sarac in lipide

• AB ? Preventie infectie necroza in PA necrotice Y/N?


– Imipenem 14 zile minim
6) Principii de tratament
• Drenaj
– Necroza infectata (FNA ghidat CT/EUS?)
• Endoscopic : necrozectomie
• Chirurgical
• > 14 zile de la debut

– Abces
• Radiologie interventionala
• Endoscopic
• Chirurgical
6) Principii de tratament
• Tratament etiologic
– PA alcoolica
• stop consum alcool, sevraj (benzodiazepine preventia DT)

– PA biliara severa
• + angiocolita (calcul inclavat), bilirubina >5 mg/dl - ERCP cu extractie de
calculi in 48h
• Colecistectomie inainte de externare, dupa remisiunea PA

– PA autoimuna:
• Corticoterapie ?

– Alte PA: trat. Hypertrigriceridemie, trat hipercalcemie, trat infectiei,


etc

– Trat pseudochist: peste 6cm, peste 6 sapt, simptomatic = drenaj


endosccopi/radio/chir
Take home
• PA = inflamatie acuta +/- importanta, gravitatea = f(necroza);
potential letala, mai ales la tineri! (Mt total 5%, 20% severe)

• Dg+ = durere tipica + lipaza > 3 x N; in caz de dubiu CT =


esential

• Gravitate = clinic-bio, CT>48h; sever sau doar potential sever


= ATI

• Etio = alcool prelungit+migratie calcul biliar

• Trat suportiv (durere, alimentatie)+complicatii+ etiologic