Dr. Jorge Alejandro Gracia Pech R2CG
Pancreatitis aguda imagenes diagnostico
Jul 20, 2015
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Dr. Jorge Alejandro Gracia Pech
R2CG
En individuos sanos el pancres produce el 40-45% de la amilasa circulante. (P isoamilasa)
Inicia la elevación a las 6-12 hr
Vida media de 10 hr
25% depurado por riñon
Risk and Markers of Severe Acute Pancreatis. Georgios I. Papachristou, Gastroenterol Clin N Am 36 (2007) 277–296
Se puede detectar 3- 5dias
Sensibilidad de 85%
Se puede encontrar normal en paciente con hipertrigliceridemia o con pancreatitis crónica.
Risk and Markers of Severe Acute Pancreatis. Georgios I. Papachristou, Gastroenterol Clin N Am 36 (2007) 277–296
50% de los pacientes con elevación de amilasa cursar sin pancreatitis
Se debe contar con una elevación de 3 veces por encima del valor normal
Risk and Markers of Severe Acute Pancreatis. Georgios I. Papachristou, Gastroenterol Clin N Am 36 (2007) 277–296
Risk and Markers of Severe Acute Pancreatis. Georgios I. Papachristou, Gastroenterol Clin N Am 36 (2007) 277–296
En las pancreatitis aguda la razón amilasa/creatinina urinarias se eleva del 3% al 10%.
La isoamilasa puede elevarse de 7- 14 días
Risk and Markers of Severe Acute Pancreatis. Georgios I. Papachristou, Gastroenterol Clin N Am 36 (2007) 277–296
La sensibilidad y especificad va del 85-96%
Elevación desde el primer dia
Elevación tres veces por encima
Risk and Markers of Severe Acute Pancreatis. Georgios I. Papachristou, Gastroenterol Clin N Am 36 (2007) 277–296
Elevación del 7-14 días
Risk and Markers of Severe Acute Pancreatis. Georgios I. Papachristou, Gastroenterol Clin N Am 36 (2007) 277–296
ESTUDIOS DE IMAGEN
RADIOGRAFIA
Asa entrecortada
Imagen de asa en C
Derrame pleural
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
Uso limitado
Visualización inadecuada e el 30%
Determinación de origen
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
Imagen hipoecogenica
Determinación de colecciones (espacios pararrenales)
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
Disminuye las complicaciones relacionadas con la CPRE (71%)
Muestra una mayor eficacia en el diagnóstico que la RM (51-20%)
Menor eficacia en pacientes con colecistectomía previa
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
Tienes adecuada correlación con los criterios de Atlanta en los siguientes casos.
1.- edema peripancreático
2.- dilatación da via biliar
3.- ascitis
4.- Edema peripancreático
Mayor utilidad en fases tempranas.
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
La sensibilidad, especifidad y valor predictivopositivo y negatico para pancreatitis severabasado en hallazgos tomográficos fue de 91,100%, 100% y 83 %
Utilidad en :
Diagnostico
etiologia
Estadificacion y pronóstico
La clasificación morfológica se divide en
- P. edematosa intersticial
- P necrotica
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
Se emplea con mayor frecuencia la tomografia contrastada
Vigilancia de pacientes en sospecha de pancreatitis hemorragica
Utilización de tomografía multidetector
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
En la TAC contrastada se puede emplear 900 to 1000 mL de medio de contraste neutrooral of neutral oral contrast (agua)
la sensibilidad:
Necrosis extensa: 100% E 87%
Necrosis escasa: 50% especifidad 100%
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
El pancreas cuenta con densidades de 40-50 UH.
Se espera la elevacion a 100-150 UH
Menor de 30 UH necrosis
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
En las primeras 12 hr solo inflamación difusa
Se debe realiza en las 24-48 hr
Mayor diagnóstico 2-3 dias
22% páncreas normal con colecciones.
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
Parénquima homogéneo
Aumento focalizado o localizado
Realce normal
Sin alteración de lo tejidos peripancreático o retroperitoneales
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
1.- necrosis parénquima y peripancreatica
Necrosis parenquima únicamente
Necrosis peripancreática sin necrosis pancreatica
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
En las primeras 2 semana aprece como zona sin realce
Posterior a las 4 semanas se observa homogeneo con discreta atenuacion
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
Zonas de necrosis menores de 5 cm
Representa el 20%
Resultado de la extensión a partir de la superficie pancreática
Mayor utilidad del USG o de la RM
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
Comparable para visualizar cambios morfológicos
Ideal para paciente que no pueden recibir contraste iodados por alergia o falla renal
Evitar exposicion a radiación
A nivel de T2 en Fast spin echo se visualizan colecciones, psudoquiste y hemorragias
A nivel T1 se visualiza edema pancreatico
Fase arterial (20-40 seg), venosa (40-80 seg) y estabilización 180 seg
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
Consiste en:
Cortes delgado coronales
Cortes gruesos oblicuos-coronales
El segundo obtiene imágenes de anatomia de via biliar y del páncreas.
El primero anatomía de órganos sólidos.
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Balthazar E. Radiology 2002; 223:603–613Imaging of Acute Pancreatitis: Update of the Revised Atlanta Classification Thomas L. Bollen, Radiol Clin N Am 50 (2012) 429–445
Cross-Sectional Imaging in Acute Pancreatitis Anuradha Saokar , Chad B. Rabinowitz, Dushyant V. Sahani. Radiol Clin N Am 45 (2007) 447–46
La sangre obtenida es anticuagulada con citrato
Se disuelve con hydroxyethylstarch al 6%
Se realiza centrifugación
Se agrega Tcexametazina
Eficacia de 25-60%
Technetium-99m-Labeled White Blood Cells. Jens Werner. ANNALS OF SURGERY Vol. 227, No. 1, 86-94
Estudio prospectivo de 84 pacientes
Comparación de resultados con la TAC, y los scores
Resultados :
11 pancreatitis necrótica
Marcaje de leucoticos en 38 pac (45%)
Sensibilidad de 91%
Especifidad de 88%
VPP 53%
VPN 98%
Paciente con grado II.III 71 veces mas probable de pancreatitis necrótica
166 pacientes evaluados
2009 a 2010
C. exclusión
- Embarazo
- Infección
- Obesidad
-
Esteblece una imagen de base en modo B de la región (15-20mm)
Un pulso acústico (100 microsegundo)
Distensibilidad de 1-20 microns
En pacientes con sintomatologia los valorespor encima de 2.2 m/s se asocian a pancreatitis
eSie elastograma
Utiliza compresion gentil y monitoreo continuo de pulsos
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