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Pancreatita acuta (Tratament (internare oblig, uneori ATI"nimic pe…
Pancreatita acuta
Tratament
internare oblig, uneori ATI"nimic pe gura" hidratare iv.
suprimarea durerii: Acetaminofen 50-100mg la 4-6h iv,evitat morfina
pt soc: restabilirea volemia,sol cristaloide, plasma, albumina,sange,sust cardiopulmonar, O2,renal sonda ,ventilatie
suport nutritional
pt infectie :cefalosporine III, metronidazol iv,imipenem 500 mg iv
lavaj peritoneal
Trat endoscopic PA+colangita dator litiaza bil coledocian
necrotomia minim inv ecoendo
chir
Tablou clinice
Durere epigastrica: iradiere in "bara",debut brutal,intens,
greata si varsaturi
ex ob:febra 75% tahicardie 65,hipoTA,stare gen alterata,anxios,disnpnee10%,soc,hematemeza melena 5%(Triada Dieulafoy(
ap resp:dispnee,cianoza,colectie pleurara stg,tahipnee, insuf rest
Ap card: tahicardie ,hipoTA,soc si ap renal Iren acut
Ex loca: abd destins, meteorism,sensibil la palpare in epigastru, mai rar echimoza in flancuri,ascita
Biologic:cresc amilaza si lipaza, amilazemia in primele 2-12 h 3-5 zile,transaminaze cresterea ALT peste 150 PA sec lit biliare. Leucocitoza, hiperglic,hipocacemia,pcr,paracenteza abd, enzime in lich pleural
Etiologie
litiaza biliara 40-65%
alcoolul 25-40%
alte cauze 10-30% idiopatice 10%
factori mecanici: trauma intrapoper, traumatisme abd
Med: azatioprina, izoniazida, estrogeni, 5ASA,corticost, AINS,metronidazol, tetraciclin
Cauze mai rare: CMV,EBV, v hepatice, ascaris, DZ, IRen avansat, malformatii pancreas , boala tes conj cu vasculite, LES,purpura. b.Crohn,UD penetrant,diverticuli Duod., disfunctia sf odii, tumori, carcinoame pancr, sarcoame etc., autoimuna f rara
Anatomie patologica
PA usoara: edem, discret,necroza grasoasa
PA severa: necroza grasoasa extensiva, necroza,hemoragii,pseudochiste,ascita pancr. necroza enzimatica a tes adip, necroza peretilor vasc ,adipocit
Evaluare imagistica
Radiologia abd, semne poz(ileus), neg( lipsa pneumoperitoneu) in torace pleurezie.
Ecografie ,ecoendo, CT, colangiopancreatografia RM,CPRE
Definitie: tablou clinic instalat brusc cu dureri abd cresc enzimelor pancr in sg si urina ,datorita unui proces de autodigestia pancreatica. Epidemio 20-120/100.000 in pop. tendinta crescut a varstei medii si alcool
Patogenie
: activarea enzimelor pancreatice, autodigestia glandei. Loc central: activ tripsinei- sist kalikreina kinina-activ chimotripsinei-elastazei,fosfolipazei A2. Disfunctia inhibit tripsinei. Alterarea microcirc si endot vasc la niv pancr
Evaluarea severitatii criterii Ranson: PA de cauza nebiliara 3/mm fac risc (forma severa),in primele 48, peste 55 de ani, Ht sub 10%, cresc ureei serice PaO peste 60 mmg,leucocitoza peste 200 glicemia,LDH serice peste 350 UI/I, asat peste 250,calcemie sub 8mg%
Evaluare seveeritatii: PA sever: PCR peste 150mg/L, urinare a peptidei de activare a tripsinogenului, cresc conc serice a elastazie , lichid peritoneal steril.
Evolutie:acuta usoara,fara compl,CT fara mod. Acuta severa:suferinta multisist.
Complicatii:
pancreatice:colectii lich, pseudochiste, abces pancr, necroza infectata, fustule, extra/intra. Extrapancreatice sunt:encefalopatia pancr,soc,pericardita, HDS, tromboza VP,IRA(renal), ascita masiva, ruptura splina
Diagnostic diferential
:cu boala digestiva: infarct intestino-mezenteric,UG/UD perforat,ocluzii intestinale mecanie,porfiria, IMA,anevr ,disec de AO, sarcina ectopia