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Transcript of PANCREATITIS AGUDA y CRONICA.pptx
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PANCREATOPATIAS
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PENSAR EN LO MAS FRECUENTE
DESCARTAR LO MAS GRAVE
CRITERIO CLINICO
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SENTIDO COMUN
INFORMACION
VIVENCIA
CRITERIO CLINICO
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PANCREATITIS AGUDA
PANCREATITIS CRONICA
CANCER DE PANCREAS
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PANCREATITIS AGUDA
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PANCREATITIS AGUDA
PROCESO INFLAMATORIO AGUDO DEL PÁNCREAS CON VARIABLE EXTENSIÓN A ÓRGANOS O ESTRUCTURAS VECINAS O DISTANTES
Atlanta 1992
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PANCREATITIS AGUDAETIOLOGÍA I
o LITIASIS (“barro biliar”)o TÓXICAS ( alcohol - drogas: ac. Valproico- Fursemida - estrógenos)o TRAUMÁTICAS (Accidental - CPREo post-operatoria )o METABÓLICAS: ( hipertrigl. - hipercalc.)
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PANCREATITIS AGUDA
ETIOLOGÍA II
INFECCIOSAS (Parásitos: Áscaris-Virales: Parotiditis-Rubéola-Hepatitis-CMV-VEB- HIV)VASCULARES (isquemia-hipo-perfusion: cirugía cardíaca-Vasculitis)
INFECCIOSAS (Parásitos: Áscaris-Virales: Parotiditis-Rubéola-Hepatitis-CMV-VEB- HIV)VASCULARES (isquemia-hipo-perfusion: cirugía cardíaca-Vasculitis)
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PANCREATITIS AGUDA
ETIOLOGÍA III
MISCELÁNEAS (Tumores Pancreáticos-Cuerpo extraño- Páncreas Divisum-Anomalías de la convergencia bilio-pancreático-Fibrosis Quística)IDIOPÁTICAS
MISCELÁNEAS (Tumores Pancreáticos-Cuerpo extraño- Páncreas Divisum-Anomalías de la convergencia bilio-pancreático-Fibrosis Quística)IDIOPÁTICAS
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Pancreatitis ETIOLOGIA
• LITIASIS
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VESICULA BILIAR
23,8 % MUJERES15,5 % VARONES
PREVALENCIA DE LITIASIS
20%
23,8 15,5
RESONANCIAS DE ABDOMEN
80
20 1
2
23,8
15,5
PREVALENCIA DE LITIASIS
80%
20%20%
80%
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Pancreatitis Aguda
FISIOPATOLOGIALITIASIS
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Pancreatitis AgudaETIOLOGIA
LITIASIS-BARRO BILIAR
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Pancreatitis AgudaETIOLOGIA
LITIASIS
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Pancreatitis AgudaETIOLOGIAASCARIASIS
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PANCREATITIS AGUDA
FISIOPATOLOGIA
Obstrucción ductal
Alteración
metabólica
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PANCREATITIS AGUDA
FISIOPATOLOGIA
Activación enzimática intracelular
Activación enzimática intraductal
Liberación de citoquinas: IL-1, IL-6, IL-8 TNF, PAF, PMN-elastasa.
Oxido Nítrico
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ACTIVACIÓN ENZIMATICA:EFECTOS SOBRE EL PANCREAS
ENZIMA ACTIVADOR CONOCIDO EFECTOS
TRIPSINA ENTEROQUINASA-TRIPSINA
EDEMA-NECROSIS-HEMORRAGIA
QUIMOTRIPSINA TRIPSINA IGUAL TRIPSINA
ELASTASA TRIPSINA DAÑO ARTERIOLAR-HEMORRAGIA
FOSFOLIPASA TRIPSINA ALT. MEMBRANA CEL.-NECROSIS
LIPASA NO NECESITA ESTEATONECROSIS
AMILASA NO NECESITA NINGUNO
CARBOXIPEPTIDASA TRIPSINA NINGUNO
KALIKREINA TRIPSINA VASODILATACION-AUMENTO PERM. CAPILAR
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Clínica Laboratorio Diagnóstico por Imágenes
PANCREATITIS AGUDA
DIAGNOSTICO
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PANCREATITIS AGUDA
CLINICA
DOLOR INTENSO DE COMIENZO BRUSCOHEMIABDOMEN SUPERIOR “EN BARRA”
VOMITOS
ICTERICIA
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DIAGNÓSTICO DE LA PANCREATITIS AGUDA
AMILASEMIA AMILASURIA LIPASEMIA GLICEMIA
LABORATORIO
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FACTORES PRONÓSTICOS DE RANSON
P.A. AlcohólicaY otras
P.A. Biliar
IngresoEdad >55 Años >70 años
Leucocitos (U/Mm.)
>16000 >18000
Glucosa (mg/dl)
>200 >220
LDH (U/I) >350 >400
AST (U/I) >250 >250
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FACTORES PRONÓSTICOS DE RANSON
P.A. AlcohólicaY otras
P.A. Biliar
48 horasDescenso hematocrito
>10% >10%
Elevación Urea (mg/dl)
>5 >2
Calcemia (mg/dl) <8 <8
Presión art. Oxig. (mm.Hg)
<60
Déficit de base (mEq/l)
>4 >5
Secuestro de líquidos
>6 litros. >4 litros
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PANCREATITIS AGUDADIAGNÓSTICO POR IMÁGENES
• Rx. DIRECTA DE ABDÓMEN
• ECOGRAFIA
• T.A.C.
• R.M.I.
• C.P.E.R.
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PANCREATITIS AGUDA
DIAGNÓSTICO POR IMÁGENES
eco
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PANCREATITIS AGUDA
DIAGNÓSTICO POR IMÁGENES
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GRAVEDAD EN PANCREATITIS
INICIAL – SISTEMICA - INSUFICIENCIA
MULTIPAREN- QUIMATOSA
TARDÍA – NECROSIS - INFECCIÓN- -PSEUDOQUISTE –ABSCESO
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PANCREATITIS AGUDA LEVE
ASOCIADA CON MÍNIMA DISFUNCIÓN
ORGÁNICA Y HABITUAL RECUPERACIÓN
SIN COMPLICACIONES
< 3 signos de Ranson < 8 signos de Apache II
Atlanta 1992
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PANCREATITIS AGUDA SEVERA
ASOCIADA CON INSUFICIENCIA PLURI-
PARENQUIMATOSA Y/O COMPLICACIONES
LOCALES TALES COMO SEUDOQUISTE,
NECROSIS O ABSCESO .
> 3 SIGNOS DE Ranson > 8 signos de Apache II
Atlanta1992
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REUNION DE CONSENSO
ATLANTA 1992
PANCREATITIS AGUDA
Y SUS
COMPLICACIONES
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COLECCION LIQUIDA AGUDA
SE PRODUCE TEMPRANAMENTE EN EL CURSO
DE UN A P.A. DENTRO O RODEANDO EL
PANCREAS SIN UNA PARED DEFINIDA
PRESENTE EN UN 30-50% P.A. SEVERAS50% INVOLUCIONAN50% EVOLUCIONAN A SEUDOQUISTE O ABSCESO ATLANTA 1992
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COLECCION LIQUIDA AGUDA
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PSEUDOQUISTE
COLECCION DE JUGO PANCREÁTICO RODEADO
POR UNA PARED FIBROSA DE TEJIDO DE
GRANULACIÓN BIEN DEFINIDA, DEMOSTRABLE
POR DIAGNÓSTICO POR IMÁGENES
ATLANTA 1992
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PSEUDOQUISTE
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NECROSIS PANCREATICA
AREA LOCALIZADA O DIFUSA DE PARENQUIMA
PANCREATICO NO VIABLE, ASOCIADA CON
NECROSIS GRASA PERIPANCREÁTICA
SE DIAGNOSTICA CON T.A.C. C/CONTRASTE
ATLANTA 1992
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NECROSIS PANCREATICA
ECO
TAC
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PANCREATITIS AGUDA
NECROSIS PANCREÁTICA
NECROSIS MENOR:
* < DEL 50%
NECROSIS EXTENSA:
* DEL 50 AL 100%
ALTA MORBI-MORTALIDAD
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NECROSIS INFECTADA
ES UNA ENFERMEDAD BACTERIANA DIFUSA DE TEJI-
DOS PANCREATICOS Y PERIPANCREATICOS NECROTICOS,
SIN NINGUNA COLECCIÓN SIGNIFICATIVA DE PUS.
EN LA FAZ AGUDA DE LA ENFERMEDAD TIENE SIGNOS
DE SEPSIS Y LABORATORIO DE P.A. GENERALMENTE
EN LAS DOS PRIMERAS SEMANAS
ATLANTA 1992
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NECROSIS INFECTADA
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PANCREATITIS AGUDA
COLECCIÓN INTRAABDOMINAL DE PUS USUALMENTE
PRÓXIMA AL PÁNCREAS CON MUY POCO TEJIDO
NECRÓTICO EN SU INTERIOR .
SE FORMA A PARTIR DE LA 4º SEMANA.
D.D. CON NECROSIS INFECTADA.
ABSCESO DEL PANCREAS
ATLANTA 1992
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.
ABSCESO
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PANCREATITIS AGUDA
TRATAMIENTO
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PANCREATITIS AGUDA
TRATAMIENTO
ALIVIO DEL DOLOR
MANTENER LA VOLEMIA-ELECTROLITOS Y
NUTRIENTES
TRATAR INSUF. MULTIORGANICAS
INVESTIGAR CAUSA
DIAG. Y TRAT. DE LAS COMPLICAC.
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RAPIDOD.D. ALGORITM
OS DIAGNOSTI
COS
2004
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PANCREATITIS AGUDA
TRATAMIENTO
SEUDOQUISTE
CONDUCTA EXPECTANTE
DRENAJE PERCUTANEO
CIRUGIA
DRENAJE ENDOSCOPICO
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PANCREATITIS AGUDA
TRATAMIENTO
NECROSIS INFECTADA
CIRUGIA
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PANCREATITIS AGUDA
TRATAMIENTO
ABSCESO
DRENAJE PERCUTANEO
CIRUGIA
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PANCREATITIS CRONICA
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PANCREATITIS CRONICA
DEFINICIÓN
ES UNA ENFERMEDAD INFLAMATORIA
PROLONGADA, CARACTERIZADA POR
ANOMALIAS MORFOLOGICAS Y
FUNCIONALES IRREVERSIBLES.
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PANCREATITIS CRÓNICA CLASIFICACIÓN
PANCREATITIS ALCOHÓLICA
PANCREATITIS OBSTRUCTIVA
PANCREATITIS AUTOINMUNE
PANCREATITIS IDIOPÁTICA
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PANCREATITIS CRÓNICA CLASIFICACIÓN
PANCREATITIS LITOGENICA) (calcificante) AlcohólicaPrimaria nutricional-TropicalHiperparatiroidismo
PANCREATITIS NO LITOGÉNICAObstructiva - Anomalías ductales Hereditaria - Enf. FibroquísticaAutoinmuneIdiopática
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PANCREATITIS CRÓNICA CLASIFICACIÓN
• PANCREATITIS ALCOHÓLICA
• PANCREATITIS NO ALCOHÓLICA Obstructiva - Anomalías
ductales Hereditaria - Enf. Fibroquística Autoinmune Tropical Idiopática
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PANCREATITIS CRONICA ALCOHOLICADISTRIBUCION UNIVERSAL
FRANCIA
ARGENTINA ???
ITALIA
KUWAIT
BRASIL
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PANCREATITIS CRONICA
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PANCREATITIS CRONICA
FISIOPATOLOGIA
ALTERACIÓN SECRECIÓN
AGRESIÓN ACINAR
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PANCREATITIS CRONICA
FISIOPATOLOGIA
• LITOSTATINA
• TAPONES PROTEICOS
• LITIASIS DUCTAL
• DILATACION WIRSUNG
• METAPLASIA DUCTAL
• FIBROSIS FOCAL
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FISIOPATOLOGIA
TEORIA NECROSIS - FIBROSIS
LA PANCREATITIS CRONICA ALCOHOLICA ES EL RESULTADO DE VARIOS EPISODIOS DE PANCREATITIS AGUDA CON NECROSIS Y HEMORRAGIA QUE LLEVA A FIBROSIS PROGRESIVA
G. KLOPPEL 1993
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FISIOPATOLOGIA
TEORIA NECROSIS-FIBROSIS
OBJECIONES
DIFÍCIL DE CONSIDERAR ESTA SECUENCIA EN PACIENTES PORTADORES DE P. CR. ALCOHÓLICA INDOLORA ( 1O % DE LOS CASOS). LAS P. AGUDAS BILIARES SEVERAS (NECROTIZANTES) NO TIENEN ESTA EVOLUCIÓN.
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PANCREATITIS CRONICA
DIAGNOSTICO
CLINICA
ALTERACIONES FUNCIONALES
ALTERACIÓN MORFOLOGICAS
BIOPSIA
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PANCREATITIS CRONICA
DIAGNOSTICO POR IMAGENES
POUSSEE AGUDA
PERIODO DE ACALMIA
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PANCREATITIS CRONICA
DIAGNOSTICO POR IMAGENES
MORFOLOGÍA( forma, tamaño, contorno)
ESTRUCTURA
CALCIFICACIONES
CONDUCTO DE WIRSUNG
ESTRUCTURAS VECINAS
COLECCIONES LÍQUIDAS
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PANCREATITIS CRONICA
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PANCREATITIS CRONICA
HISTORIA NATURAL
PERIODO ACTIVO (5 años)
• CRISIS DOLOROSAS
• POUSSEE AGUDA
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PANCREATITIS CRONICA
HOMBRE
JOVEN
ETILISTA
DOLOR ABDOMINAL
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PANCREATITIS CRONICA
HISTORIA NATURAL
PERIODO INTERMEDIO (5 - 10 años)
EPISODIOS AGUDOS MENOS FRECUENTES
DILATACION DEL CONDUCTO DE WIRSUNG
CALCIFICACIONES
SEUDOQUISTES
DIABETES
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PANCREATITIS CRONICA
HISTORIA NATURAL
PERIODO INTERMEDIO
(5 - 10 años)
CALCIFICACIONES
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PANCREATITIS CRONICA
INTERMEDIO
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PANCREATITIS CRONICA
INTERMEDIO
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PANCREATITIS CRONICA
HISTORIA NATURAL
PERIODO SECUELAS
SEUDOQUISTES (57%)
DIABETES (80%)
ESTEATORREA
DESAPARICIÓN DEL DOLOR
EXCLUSION FUNCIONAL
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• PANCREAS ATROFICO
• WIRSUNG MUY DILATADO
• LITIASIS MULIPLE
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PANCREATITIS CRONICA
PERIODO SECUELAS
ECO TAC
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TRATAMIENTO
SUPRESION DE LA CAUSA
TRATAR DOLOR
INSUFICIENCIA EXOCRINA
DIABETES
PANCREATITIS CRONICA
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PANCREATITIS CRONICA AUTOINMUNE
Clínica: variable: dolor c/s ictericia.
Anteced: Sjogren. CU. CEP. CBP LES.
DXI: Variable Simula moe páncreas
Laborat: IGG. IGG4 marcad. Lactoferrina
Tratam: remisión con corticoides
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