Patologia Pancreasulu1

7/25/2019 Patologia Pancreasulu1

1/25

Cuprins PATOLOGIA PANCREASULUI

Teste utile n diag. bolilor pancreatice................................................................................................................3Examenul radiologic...........................................................................................................................................4

Radiografia abdominal pe gol..............................................................................................................4

Echografia..............................................................................................................................................4 CT - cea mai bun metod de diagnostic...............................................................................................4 CPER, CPRM.........................................................................................................................................4

iopsia pancreatic sub ghida! Rx......................................................................................................................4"tudiul func#iilor pancreasului exocrin...............................................................................................................4

iochimia $i fi%iologia pancreasului exocrin......................................................................................................4"ecre#ia de ap $i electroli#i................................................................................................................................4"ecre#ia en%imatic..............................................................................................................................................4

PANCREATITA ACUT.........................................................................................................................................5Etiologie..............................................................................................................................................................5Manifestri clinice...............................................................................................................................................5Morfopatologie....................................................................................................................................................5Tablou clinic & 'namne%a....................................................................................................................................6Tablou clinic( simptomatologie...........................................................................................................................6

)*RERE ')+M'/ 'C*T/.........................................................................................................6 0RE1*R, 2/R"/T*R.........................................................................................................................6 "imptomatologie.....................................................................................................................................6

Examen obiecti3(.................................................................................................................................................6A. "emne locale.......................................................................................................................................6

. "itua#ii particulare.............................................................................................................................6C. "emne generale..................................................................................................................................6

n3estiga#ii de laborator......................................................................................................................................7 Modificri en%imatice.............................................................................................................................7 Modificri metabolice.............................................................................................................................7 Modificri hematologice.........................................................................................................................7 "corul R'"+......................................................................................................................................7

Explorri imagistice............................................................................................................................................8Radiografia abdominal pe gol......................................................................................................................8Radiografia toracic.......................................................................................................................................8Ecografia abdominal....................................................................................................................................8Tomografia computeri%at..............................................................................................................................8

ERCP..............................................................................................................................................................8Complica#ii pancreatice......................................................................................................................................8Complica#ii extrapancreatice..............................................................................................................................9

)iagnostic diferen#ial..........................................................................................................................................9Tratament.............................................................................................................................................................9

PANCREATITA CRONIC.......................................................................................................................... ......... .9

)iagnostic dificil.......................................................................................................................................10 Clinic.........................................................................................................................................................10 Morfologic.................................................................................................................................................10 4unc#ional.................................................................................................................................................10 Etiologie....................................................................................................................................................10 Tablou clinic..............................................................................................................................................10

56 )urerea abdominal........................................................................................................................1076 nsuficien#a exocrin........................................................................................................................1086 nsuficien#a endocrin......................................................................................................................10

Examen obiecti3........................................................................................................................................11 Paraclinic..................................................................................................................................................11 Explorri paraclinice................................................................................................................................11

'. Explorri biologice...........................................................................................................................11. Explorri imagistice.........................................................................................................................11C. Teste pentru aprecierea func#iei pancreatice exocrine.....................................................................12

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Complica#ii................................................................................................................................................12 +p#iuni terapeutice...................................................................................................................................12

56 msuri generale................................................................................................................................1276 tratament medical .............................................................................................................................1386 tratament inter3en#ional...................................................................................................................1696 tratament chirurgical .......................................................................................................................16

:6 transplant de celule pancreatice......................................................................................................17Cancerul pancrea!c................................................................................................................................................17

4actori de risc...................................................................................................................................................17Morfopatologie..................................................................................................................................................17Tablou clinic......................................................................................................................................................17

)urerea abdominal.............................................................................................................................17 "cderea ponderal..............................................................................................................................18 cterul obstructi3 neopla%ic..................................................................................................................18

Examen obiecti3................................................................................................................................................18Cancerul pancreatic ; Metasta%e(................................................................................................................18Cancerul pancreatic cefalic..........................................................................................................................18Cancerul pancreatic corporeal.....................................................................................................................18

Cancerul pancreatic caudal..........................................................................................................................18Explorri diagnostice........................................................................................................................................18a6 Probe de laborator ...........................................................................................................................19b6 Explorri imagistice.........................................................................................................................19

"plen#$e%al!!le......................................................................................................................................................19Clinic.................................................................................................................................................................19

Paraclinic..........................................................................................................................................................19Etiologie............................................................................................................................................................19

&!per'plen!'$........................................................................................................................................................20)efini#ie.............................................................................................................................................................20Cau%e.................................................................................................................................................................20

"!n(r#$ul ane$!c..................................................................................................................................................20"imptome $i semne.............................................................................................................................................20

"imptome...........................................................................................................................................................21"emne.................................................................................................................................................................21Explorarea sindromului anemic........................................................................................................................21Clasificare.........................................................................................................................................................21

'nemia feripri3.....................................................................................................................................................21Cau%e.................................................................................................................................................................21Tablou clinic......................................................................................................................................................21

Examen de laborator.........................................................................................................................................2256 Examenul s


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#r%an rer#per!#neal) %reu a*#r(a*!l pre+a'cular) ,na!nea c#l#ane! +ere*rale runc-!ul p#r#$e/ener!c c#nac !n!$ aec!n!

!nla$a#r!! acue ! cr#n!ce u$#rale e#cr!n ! en(#cr!n

pancrea!a acu +!n(ecare 'au e!u' pancrea!a cr#n!c pr#ce' !nla$a#r cr#n!c) care 'e p#ae eacer*a c#$pl!ca!! c#$une (!a%n#'!cul (e PC pancrea!a cr#n!ca'e pune ar(!+) an! (e la (e*u

Teste utile n diag. bolilor pancreatice En%ime pancreatice n lichide org.

a$!la/a 'er!c e' 'creen!n% p. PA a$!la/a l!c-!( a'c!

:65u;l 'u'pec pancr ac.:130u;l (%. pr#*a*!l:3N 'a*!le'c (%.

an'a 'an!nel? !leu' l#cal!/a =e=un !leu' %eneral!/a) cu n!+. -!(r#aer!ce 'e$n (e a$puare a c#l#n ran'+er' (!'en'!a (u#(en cu n!+ele -!(r#aer!ce p'eu(!c-!'@ $a' u$#ral

calc!!cr! pancrea' PC Echografia PA

pancrea' $r! p'eu(#c-!'

cancer pancrea' :3c$ $a' -!p#ec-#%en) '#l!() l#cal!/a CT - cea mai bun metod de diagnostic

$r!rea c#nur pancrea'(!'#r'!#narea c#nur pancrea'/#ne c#n!nu l!c-!(!an

CPER, CPRM pancrea!a cr#n!c ,n%u'are lu$en nere%ular!! ale '!'e$ulu! canal!cular 'en#/e) (!lar!) eca/!!

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#*'ruc!a canal pancrea' pr!n (epuner! (e calc!uBiopsia pancreatic sub ghidaj RxStudiul funciilor pancreasului exocrin

'!$ularea (!rec a pancrea'ulu! peru/!! !.+ cu 'ecre!n 'au 'ecre!n) CCBa$!la/e ,n c#n. (u#(en

'!$ularea !n(!rec a pancrea'ulu! cu 'u*'. nur!!+e 'au AAC) ac!/! %ra! $'urarea en/!$el#r pr#e#l!!ce) l!p#l!!ce) %l!c#l!!ce

'. pr#(u! !nralu$!nal (e (!%e'!e c-!$!'$ $aer!! ecale $'urarea en/. pancr. ecale c-!$#r!p'!na

Biochimia i fiiologia pancreasului exocrin 'ecre 15003000$l;/! l!c-!( !/##'$#!c ! alcal!n) c#n!ne 20 en/!$e c#nr#l -#r$#nal ! ner+#'

ac!( %a'r!c '!$ulea/a el!*. "ecre!n '!$ulea/a 'ecre!a 'uc pancrea!c *#%a,n ap ! elecr#l!!

ac. %ra! lan lun%) AAC e'en!al! CCB 'ecre!e pancrea!c *#%a ,n

en/!$e '!$ulare +a%ale el!*erare IP '#$a#'a!n !n-!* 'ecre!a pancrea'

Secreia de ap i electrolii : !$p#ran *!car*#naul neural!/area pr#(ucer!! ac!( %a'r!c ! p& a(ec+a

penru ac!+area en/!$el#r pancrea!ceSecreia enimatic

en/!$e %l!c#l!!ce a$!la/a -!(r#l!/ea/ a$!(#n #l!%#/a-ar!(e en/!$e l!p#l!!ce l!pa/a) #'#l!pa/a A) c#l!ne'era/a 'rur!le *!l!are

!n-!* l!pa/a ac!+ea/ #'#l!pa/a A ! c#l!ne'era/a

en/!$ele pr#e#l!!ceen(#pep!(a/a r!p'!na) c-!$#r!p'!nae#pep!(a/a a$!n#pep!(a/eener#D!na/a r!p'!n#%en r!p'!n

au#(!%e'!a pancrea' ,$p!e(!ca pr!n'#carea en/. pr#e#l!!ce 'u* #r$ (e precur'#r!'!ne/ (e !n-!*!#r! (e pr#ea/

PANCREATITA ACUT

>e*uul *ru'c) a%#n!a !n!$!a*!l ! $#ral!aea care # ,n'#e'c) ac ca pancrea!a acu 'repre/!ne cea $a! #r$!(a*!l caa'r#?F#Gn!-an)1925

Definiie

Ac!+area !nra%lan(ular a en/!$el#r pancrea!ceH

Proces inflamator acut al pancreasuluiH

Au#(!%e'!a pancrea!c per!pancrea!cH

URERE ACUT E ETAJ AKOFINAL "UPERIOR MI &IPERAFILAEFIE 3 N

en/!$ele pr#e#l!!ce 'un ac!+ae ,n pancrea'

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acti!ate "tripsina# elastae# fosfolipaa$

(!%e'!a e'. pancrea!c ! per!pancrea!c

en/!$ele ac!+e (!%er $e$*rana celular

pr#e#l!/) e(e$) -e$#ra%!! !ne'!nale.) le/!un! +a'culare

necr#/ (e c#a%ulare) necr#/ %ra') necr#/a celulel#r parenc-!$a#a'emoartea celulelor

el!*erare en/!$e ac!+ae

ca'ca( (e e+en!$ene pancrea! acu necr#!cEtiologie

#*'ruc!a acu a c!l#r pancrea!ce PA *!l!ara*u/ (e ean#l PA alc##l!cerau$a!'$e ERCP) acc!(ene) #pera#rcau/e $ea*#l!ce -!perr!%!cer!(e$!ecau/e +a'culare) +a'cul!e$e(!ca$ene (!ure!ce) an!*!#!ce) 'ula$!(ecau/e !nec!#a'ePA ere(!arPA !(!#pa!c 1015Ip#e/e recene ac!+area !nrapancrea!c a /!$#%en!l#r # ac -!(r#la/ele l!/#/#$ale ,n celulele

pancrea!ce

!'c-e$!a;-!p#peru/!a p# '!n%ure ac!+a r!p'!n#%enul le/!un! pancrea!ce%anifestri clinice (urerea a*(#$!nal '!$p#$ $a=#r al PA) !ra(!ere) !nen' %reur!) +r'ur!) (!'en'!e a*(#$!nal

%orfopatologie PA e(e$a#a' PA necr#!c#-e$#ra%!c

Tablou clinic & 'namnea E!l!'$ Anece(ene (e l!!a/ *!l!ar

Tablou clinic( simptomatologie )*RERE ')+M'/ 'C*T/

e*u *ru'c la 26 #re (up # $a' *#%a ,n %r'!$! ! alc##l ,n PA ean#l!ce'au (up # c#l!c *!l!ar ,n PA *!l!ar

L#cal!/are ep!%a'ru) $e/#%a'ru Ira(!ere ,n *ar) 'e$!cenur) 'pre c#l#ana +ere*ral 'au l#$*e Caracer #are !nen') c#n'an) c#n!nu) re/!'en la anal%!ce u/uale Qac#r! a$el!#ran! le!a runc-!ulu!) p#/!!a %enupec#ral

0RE1*R, 2/R"/T*R prec#ce

a*un(ene al!$enare ! *!l!#a'e) n!c!#(a ecal#!(e

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nu cal$ea/ (urerea ce(ea/ la a'p!ra!e na/#%a'r!c

"imptomatologie ran/! !ne'!nal #pr! !leu' paral!!c #c ,n #r$ele 'e+ere e*ra !cer

Examen obiecti!(A. "emne locale = CONTRA"T NTRE "IFPTOFATOLOSIA RAFATIC MI

"EFNELE AKOFINALE MTER"E In'pec!e a*(#$en (e'!n') $#*!l re'p!ra#r Palpare 'en'!*!l!ae la palparea a*(#$enulu! 'uper!#r) NU r!%!(!ae $u'cular Percu!e -!per'#n#r!ae !$pan!c) $a!ae (epla'a*!l pe lancur!) a*la (e a- A'cula!e (!$!nuarea /%#$#el#r !ne'!nale

B. "itua#ii particulare

'bdomen peritonitic aprare $u'cular Klu$*er% p#/!!+

=emoragie retroperitoneal Cullen per!#$*!l!cal SraGTurner lancur!

leus paralitic (!'en'!e a*(#$!nal a*'ena /%#$#el#r !ne'!nale

). "emne generale

5. 4orme moderate Qe*r Ta-!car(!e An!eae Icer

7. 4orme se3ere Enceal#pa!e pancrea!c &!p#en'!une) pul' !l!#r$ P#l!pnee Ol!%#anur!e

*n!estigaii de laborator Modificri en%imaticea$!la/e$!e;a$!la/ur!e

a &!pera$!la/e$!a 3N +al#are (!a%n#'!c cree ,n pr!$ele 2472 (e #re per'!' 35 /!le creer! al'p#/!!+e ulcer per#ra) c#lec!'! acu) #clu/!e !ne'!nal)

!narc $e/ener!c* &!pera$!la/ur!a

cree paralel cu a$!la/e$!a per'!' 710 /!le

l!pa/a 'er!c 2030 N

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#'#l!pa/a A2 'er!cr!p'!na 'er!cela'a/a1

+',-'RE' '%*,'E%*E* /0 SE )-RE,E'1 )0 SE+ER*T'TE' B-,**2 3*4ER'%*,'E%*' 5 6 / 'RE 7-'R +',-'RE 7*'8/-ST*)1!

Modificri metabolice &!per%l!ce$!e &!p#calce$!e &!per*!l!ru*!ne$!e Creerea TSP Creerea L& Ac!(#/ $ea*#l!c &!p#nare$!e)-!p#p#a'e$!e) -!p#$a%ne/e$!e

Modificri hematologice &e$#c#ncenra!e prec#ce

Ane$!e 'ecun(ar -e$#ra%!e! rer#per!#neale Leuc#c!#/ $#(era

"corul R'"+ ,a internare

1. r'a2. Sl!ce$!a3. L&4. TSO5. SA

7up 9: de ore

6. &7. Uree8. Calce$!a9. PaO210. e!c! (e *a/e11. "ec-e'rare (e l!c-!(e cu

(e!c! l!c-!(!a Prognostic > criterii Ranson!nluenea/ ne%a!+ 'upra+!eu!rea PA

la 'a*!l!rea (!a%n#'!culu! +,r'a :55 an! SA :16.000;$$c %l!ce$!a :200$%;(l L& 'er!c : 400UI;l A"T 'er!c : 250UI;l

,n pr!$ele 48- H& :10 'ec-e'rare l!c-!( : 400$l -!p#calce$!e 1)9$$#l;l 8$% -!p#e$!e PO2 60$$&%


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c#l!c! renale IFA ane+r!'$ (!'ecan (e a#r ce#ac!(#/a (!a*e!c *#l! ale e'. c#n=unc!+ cu +a'cul!e

Explorri imagistice1 Ra(!#%ra!a a*(#$!nal '!$pl2 Ra(!#%ra!a (!%e'!+ cu 'u*'an (e c#nra'3 Ra(!#%ra!a #rac!c4 Ec#%ra!a a*(#$!nal5 T#$#%ra!a c#$puer!/a6 Re/#nana $a%ne!c nuclear7 C#lan%!#pancrea#%ra!a en(#'c#p!c rer#%ra( ERCP8 K!#p'!a pancrea!c percuan 'u* %-!(a= CT9 Lapar#'c#p!a (!a%n#'!c

Radiografia abdominal pe gol Ileu' l#cal!/a >an'a 'en!nel? Ileu' %eneral!/a n!+ele -!(r#aer!ce !'en'!a %a/#a' a c#l#nulu! ran'+er' cu #*'ruc!a 'a la n!+elul un%-!ur!l#r -epa!c

! 'plen!c >c#l#n a$pua?Radiografia toracic

Opac!ae l!c-!(!an 'n% 'au *!laeral pleure/!e A'cen'!#narea -e$!(!ara%$ulu! 'n% In!lrae pul$#nare al+e#lare *!laerale

Ecografia abdominal Creerea (!$en'!un!l#r cu er%erea c#nurulu! pancrea'ulu! e(e$ Calcul! *!l!ar! A'c!a pancrea!c P'eu(#c-!! pancrea!c!

Tomografia computeri%at >"an(ar(ul (e aur? "a*!l!rea 'c#rulu! pr#%n#'!c ! a !n(!ca!!l#r #pera#r!!

ERCP ?C#lan%!#pancrea#%ra!a en(#'c#p!c rer#%ra( PA *!l!ar '!ncer##$!e en(#'c#p!c ! era%erea calcululu!

)omplicaii pancreatice Necr#/ !neca P'eu(#c-!' pancrea!c A*ce' pancrea!c Qle%$#n pancrea!c A'c!a pancrea!c

)omplicaii extrapancreatice Pleur#pul$#nare pleure/!e) "RA Car(!#+a'culare #c) per!car(!) !n'u!c!en car(!ac Renale IRA !%e'!+e -e$#ra%!! (!%e'!+e) ulcere &e$a#l#%!ce CI "plen!ce rupur (e 'pl!n) !narc 'plen!c

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Neur#p'!-!ce enceal#pa!e pancrea!c "ea#necr#/e '!'e$!ce 'u*cuan) $(u+ #'#a' Fea*#l!ce -!per%l!ce$!e) ac!(#/) -!p#calce$!e

7iagnostic diferenial56 *lcer perforat

anece(ene ulcer#a'e c#nracur a*(#$!nal pneu$#per!#neu

76 +clu%ie intestinal (urere !ner$!en +r'ur! ecal#!(e #pr!rea ran/!ulu! n!+ele -!(r#aer!ce

86 nfarct entero-me%enteric aec!une car(!#+a'cular

'caune 'an%u!n#leneREINEI!

80 (!n PA alc##l!'$ul ! l!!a/a *!l!ar urerea a*(#$!nal '!$p#$ $a=#r Palpare a*(#$en 'en'!*!l (!u/) r r!%!(!ae !a%n#'!c a$!la/e$!e 3 N Pr#%n#'!c

"c#r Ran'#n CT

Tratament

8590 PA e'e au#l!$!a re$!ere 'p#nan la 37 /!leraa$en c#n+en!#nal

anal%e/!ce penru (urere lu!(e !+ ! c#l#!/! penru $en!nerea +#l. !nra+a'cular N #pr!re ap#r al!$enar #ral re%!$ -!(r!c 36a /! (!e N 57 /! a'p!ra!e na/#%a'r!c an!*!#!ce

raa$en a*ce' pancrea!c

necr#/ pancrea' p'eu(#c-!' a'c! ! re+r'a pleural

PANCREATITA CRONIC*#ala !nla$aa#r!e cr#n!ca $an!e'aa pr!n ep!'#a(e !nla$a#r!! acue a unu!pancrea' aeca aner!#r) cu (urere per'!'en ! $ala*'#r*!emanifestare inflamatorie care produce modificri permanente ale structurii

pancreasului# conduc;nd la disfuncie exocrin i endocrin


10/25

Clinic (urer! a*(#$!nale recurene 'au per'!'ene 'c(ere p#n(eral 'ea#ree (!a*e /a-ara

Morfologic !nla$a!e cr#n!c 'cler#/Var#!a parenc-!$ulu! %lan(ular 4unc#ional !n'u!c!en pancrea!c e# ! en(#cr!n Etiologie

Alc##l!'$ul cr#n!c 4080 (!n ca/ur! c#n'u$ul $e(!u /!ln!c 150% alc##l;/! (uraa c#n'u$ulu!

1012 an! e$e! 1718 an! *r*a!

a'#c!erea cu (!ea -!p#pr#e!c ! -!perl!p!(!c Tul*urr! $ea*#l!ce

-!percalce$!e -!perl!p#pr#e!ne$!e I)I)

Q!*r#/a c-!'!c cea $a! rec+en cau/ (e PC la c#p!l PC ere(!ar A PC r#p!cal Qac#r! #*'ruc!+! calcul!) p'eu(#c-!!) pancrea' (!+!'u$) cancer pancrea' PC au#!$un PC !(!#pa!c 1030 (!n ca/ur!Tablou clinic1 urere a*(#$!nal

2 In'u!c!en e#cr!n3 In'u!c!en en(#cr!n

56 )urerea abdominal "!$p#$ $a=#r "e(!uep!%a'ru) -!p#c#n(rul 'n%) $e/#%a'ru Ira(!ere ,n >*ar?) ran'!!an) ,n 'pae Te$p#ral 2 !pur! (e PC rec!(!+an) recuren Cal!a!+ 'ur() nec#l!ca!+ Can!a!+ +ar!a*!l'e+er Ce pr#+#ac@ al!$ena!a) !n%e'!a (e alc##l

Ce cal$ea/@ aplecarea ,na!ne) p#/!!a e/n(76 nsuficien#a exocrin up 1020 (e an! (e e+#lu!e a PC Cn(@ parenc-!$ re'an


11/25

!a*e /a-ara cl!n!c $an!e'c#$pl!ca!e rec+en -!p#%l!ce$!a

Examen obiecti! "en'!*!l!ae la palparea a*(#$enulu! puncul FalleSuG e!c! p#n(eral

"u*e*r!l!ae Icer $ecan!c

4araclinic u exist nc testul ideal, cu sensibilitate $i specificitate maxim, ieftin, lipsit de

riscuri, cu disponibilitate larg care s stabileasc diagnosticul de PC n stadiiprecoce $i s fac diagnosticul diferen#ial cu neoplasmul de pancreas@@@

Explorri paraclinice'. Explorri biologice

A$!la/a ! l!pa/a 'er!c < Tr!p'!n#%enul 'er!c H

P#l!pep!(ul pancrea!c H T#lerana la %luc#/ H Te'ul "c-!ll!n% V $ala*'#r*!a (e +!a$!n K 12 Q#aaa/a alcal!n < K!l!ru*!na 'er!c

Patologia Pancreasulu1

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