Transcript
Luis Gerardo Caballero Romero.EPG MCPA
PANCREATITIS.UNIVERSIDAD DE GUADALAJARA
CENTRO UNIVERSITARIO DE CIENCIAS DE LA SALUD
Dr. Benjamín Robles MariscalProfesor: Dr. Héctor Virgen Ayala
Surgical Clinics.
• Non-bacterial disease, caused by interstitial release and activation of pancreatic enzymes that perform the self digestion of the pancreas, the process is accompanied by morphological and functional changes.
CAUSES
• Biliar Lithiasis 40%choledocholithiasis 25%
• Alcoholic Pancreatitits in the USA causes more of the 40%
• Hypercalcemia
• Hyperlipidemia
• familiar pancreatitis
• protein deficiencies
• postoperative pancreatitis (iatrogenic)
• Drug pancreatitis corticosteroidssteroidal contraceptivesazathioprinethiazide diureticstetracyclines
• Obstructive pancreatitis
• idiopathic pancreatitis and for different reasons.
PATHOGENY
• Phospholipase A (Able to create necrotizing pancreatitis severe)
• Trypsin (not attack living tissue, but activates phospholipase A).
• Elastase (can digest blood vessels)
• Lipase
SYSTEMIC MANIFESTATIONS
• Acute respiratory distress syndrome (ARDS)
• Myocardial depression
• Renal insufficiency
• Gastric ulcerComplement C5
ACUTE PANCREATITIS
• Sudden epigastric pain
• Nausea, vomiting
• High concentrations of amylase
• Edematous condition
• Bleeding form Similar disease processes and treatment
• Edematous condition: interstitial fluid congestion, infiltrated by inflammatory cells surrounding small areas of parenchymal necrosis.
• Bleeding form: Effusion of blood into the parenchyma and extensive pancreatic necrosis
SIGNS AND SYMPTOMS
• Acute attacks after a hearty meal
• epigastric pain radiating to back
• Vomiting and retching.
• According to gravitydeep dehydrationtachycardiahipertencion posturalDecreased myocardial function
1 to 2% Grey Turner's sign (bluish discoloration flanc)Cullen's sign (bluish Periumbilical)
LABORATORY STUDIES• Hematocrit - Bleeding Pancreatitis
(by dehydration)
• Hematocrit - Bleeding Pancreatitis(For bleeding into the abdomen)
• Moderate leukocytosis
• Normal liver function tests
• In the first 6 hours up to twice amylase 1000 IU / dl
• Lipase - alcoholic pancreatitis
• Amylase - calculous pancreatitis
IMAGING STUDIES
• Abnormalities were observed up to 66% of cases More often an isolated dilated bowel segment (loop Sentinel).
• Sometimes it is remarkable glandular calcification.
• TC
• ERCP (Endoscopic Retrograde cholangiopancreatography)
RANSON CRITERIA IN TERMS OF SEVERITYCriterios Iniciales Criterios de
Evolución en 24 Hrs
EDAD > 55 DISMINUCION DEL HEMATOCRITO
> 10%
CUENTA DE LEUCOSITOS
> 16,000 AUMENTO DEL BUN >8 mg/dl
GLUCOSA 200 mg/dl Ca EN SUERO < 8mg/dl
LDH EN SUERO >350 IU/L Po2 ARTERIAL < 60 mmHg
AST (GOT) > 250 IU/dl DEFICIT BASALCALCULO DE LIQUIDOS
>4mg/L>600 mL
AST ---ASPARTATO TRASNAMINASA
•Chronic pancreatitis
• Persistent abdominal pain
• Pancreatic calcification observed in radiographs.
• Pancreatic insufficiency, malabsorption and diabetes mellitus
• Common cause alcohol
SIGNS AND SYMPTOMS
• Asymptomatic in many cases.
• Malabsorption.
• DM
• Epigastric abdominal pain (deep, radiating to back, increases and decreases from one day to another, episodic lasting days or weeks and then disappears for months)
LABORATORY STUDIES
• Amylase (in acute exacerbations)
• Exocrine function tests of the pancreas
• DM (75% of calcific pancreatitis px and px 30% of pancreatitis without calcification).
• Biliary obstruction
• Phlebothrombosis.
COMPLICATIONS
• Pancreatic pseudocyst.
• Biliary obstruction
• Duodenal obstruction.
• Malnutrition
• DM
TREATMENT
• Medical treatment:
Malabsorption and steatorrhea are treated with supportive measures.
You must leave the consumer to insist on Alcohol
Psychiatric treatment is beneficial.
• Surgical Treatment:It consists of a treatment that facilitates pancreatic duct drainage, or resection of the affected portion of pancreas.
SURGICAL TREATMENT:
• Drainage Procedure:
Dilatation of the ductal systemis used for alcoholic calcific pancreatitis.
Dilated duct (1 to 2 cm)with sites of stenosis ("Chain of Lakes")
Tx: pancreaticojejunostomy (Pastow Procedure)
PANCREATECTOMY:
• Pancreaticoduodenectomy (Whipple procedure)
Pain Relief in 80% of patients.
• Total pancreatectomy
Contraindicated in patients who do not leave alcohol.
CELIAC PLEXUS BLOCK:
• Thoracoscopic splanchnicectomy:
Splanchnic resection of major and minor nerve.
•Pancreatic pseudocyst.
• Mass and epigastric pain
• Grade fever and leukocytosis
• High concentration of amylase
• Cyst demonstrated by ultrasound.
• Accumulation of fluid in capsules containing large amounts of enzymes.
• Pseudocyst indicates that there is no epithelial lining.
• Two mechanisms of pathogenesis:
Complication of pancreatitis. 2% (one cyst, 85%)
Alcoholics and trauma victims.
SIGNS AND SYMPTOMS
When a person is suspected draw, no signs of recovery after a week, or after a temporary improvement, the symptoms reappear.
And tender palpable mass in the epigastrium, due to the swelling of the pancreas and adjacent viscera (cellulitis).
Common sign: Pain.
50% of the px:feverWeight Loss.hypersensitivity
COMPLICATIONS
Infections:Are rare, high fever, chills, and leukocytosis.It is possible percutaneous drain through a tube.
breakage:occurs in less than 5% of cases.Perforation into the peritoneal cavity, chemical peritonitis (abdominal rigidity board, severe pain).
hemorrhage:into the cavity of the cyst (false aneurysm)anemiaHemorrhagic shock.
Tx open cyst.Flirt glass.Drain cyst.
TREATMENT
• Symptomatic improvement and prevention of complications.Treatment expectation (40% spontaneous resolution)
• Cysts larger than 5 cm active treatment. (Percutaneous drainage or to the stomach).
• Resection:definitive treatment for traumatic cysts in the tail of the pancreas.
• External drainage:best treatment for patients in critical condition, although the incidence of recurrent pseudocyst is four times higher after external drainage into the intestine.
• Drainage Internal:Preferred method.Roux Anasotmosis And at one end of the jejunum (cistoyeyunostomia)the rear wall of the stomach (cystogastrostomy)or the duodenum (cistoduodenostomia).
• Nonsurgical drainage:Percutaneous external drainage tube was permanently eradicated 66% of infected cysts.
FORECAST:
• 10% recurrence
• More frequent relapse after tx with external drainage.
• Pancreatic abscess
PANCREATIC ABSCESS
• Complication of 5% of postoperative pancreatitis.
• Lethal without treatment.
• Secondary to bacterial contamination and exudate hemorrhagic necrotic debris.
CLINICAL MANIFESTATIONS
• Acute pancreatitis does not yield, fever or recurrence of symptoms after a period of recovery.
• Serum albumin concentration is less than 2.5 g / dl
• Alkaline phosphatase
TREATMENT AND PROGNOSIS• Drain the accumulated pus.
Surgical debridement for necrotic debris in the retroperitoneal space that do not pass by the probe.Antibiotics (Escherichia coli, Staphylococcus, Klebsiella, Proteus).
• 20% mortality rate for incomplete drainage and inability to establish Dx.
BIBLIOGRAPHY:
Diagnosis and surgical treatment, Gerard M. Doherty
13th edition, McGrawHill Lange.
P. 495-507
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