curs 7.aparatul digestiv
TRANSCRIPT
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CURS DE MEDICINA INTERNA
CONF DR BABES KATALIN
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Hepatitele croniceInfamatia catli c per!i!tenta proce!li
infamator cel ptin " lni#
Etiolo$ie% & 'epatita c (ir! C !i B )mai rar D* & alcooll
& me+icamente )i,onia,i+a-metil+opa- anticonceptionale-etc*
& .actori to/ici )c'imici- ciperci*
& .actori meta0olici )'ipertiroi+i!m-+ia0et*
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Ta0lol clinicFoarte (ariat % a!imptomatic 1 .orme !e(ereSimptome neuro-psihice% a!tenie- o0o!eala la
e.ortri mici- in!ta0ilitate (e$etati(a )tran!piratie-
ta'icar+ie- lipotimie- tl0rare +e +inamica !e/ala*Simptome digestive% 2ena !a +i!com.ort in eta2l
a0+ominal !perior !i 'ipocon+rl +rept- anore/ie-+iaree- intoleranta la alcool !i $ra!imiSemne generale% !0icter !a icter- !tari
!0.e0rile- artral$ii- acnee- erptii (a!clare-anemie#Ex. obiectiv% 'epatome$alie- !plenome$alie- icter-
!telte (a!clare
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E/aminarile paraclinice)3*Teste functionale hepatice:
a*In!cienta 'epatica%
& in!cienta !inte,elor proteice% proteinetotale- al0mina- 0rino$enl !ca,te#
& !ca+erea (al4 Cole!terolli
& +eciente in !tocarea $lco,ei !0 .orma +e$lico$en in cat#
0* Te!te care e/prima pre,enta ni !in+rominfamator%
& 5SH accelerat
& cre!terea $amma$lo0linelor
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E/aminarile paraclinice)6*c* Te!te care e/prima pre,enta +e 'epatocitoli,a% & cre!terea 78T- 7OT- LDH#
+* Te!te care e/plorea,a !in+roml 0ilioe/cretor
)cole!tatic*% & cre!te 0ilir0ina +irecta
& .o!.ata,a alcalina & $amma 7T
e*Te!te care e/plorea,a !in+roml 'ematolo$ic%
)e/pre!ia 'iper!pleni!mli 1 cre!te +i!trctiaelementelor $rate ale !an$eli*
& lecopenie & trom0ocitopenie
& anemie
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E/aminarile paraclinice)9*.* Te!te imnolo$ice% & imnelectro.ore,a
& +eterminarea in !an$e a nor anti$ene (irale
& +eterminarea in !an$e a nor anticorpi .ata +ecomponentele (irale
Punctie biopsie hepatica
& permite +i.erentierea +e 'apatitele acte c
reca+eri- +e ciro,a 0iliara primiti(a- +e 'epatopatiaalcoolica
& necro,a 'epatocellara- inltrat cellar infamator
& 0ro,a a0!enta !a re+!a
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TratamentlPrognostic.oarte (aria0il% re$re!ie- e(oltie
lenta !a !pre ciro,a 'epatica
Tratamentul%
& intrerperea con!mli +e alcool !a ame+icamentli in ca,a#
& +ieta ) n .oarte re!tricti(a:*
& a$enti anti(irali% lami(+ina- $anciclo(ir-
ri0a(irina# & mo+icatori ai ra!pn!li imnolo$ic%
inter.eronl- interle;inele
& imno!timlatoarele
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Ciro,a 'epaticaDenitie% 0oala 'epatica +i.,a% a!ocierea
0ro,ei c no+ri +e re$enerare !i necro,e 1alterarea ar'itectrii 'epatice#
Mo+icarile !nt la ni(ell intre$li cat !i !ntire(er!i0ile
Etiologie% in.ectii )(ir!rile 'epatice B-C !i D*-to/ine )alcooll*- ra!pn! imn alterat- o0!trctie
0iliara- tl0rari (a!clarePatogenie% !ta+il nal al nmeroa!elor tipri +ele,ini 'epatice 1 n atat +e mlt +e a$entlca,al- cat +e natra le,inilor !i +e ra!pn!lcatli
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Ta0lol clinic )3*Ciroa hepatica compensata%
& a!imptomatici !a
& !la0icine $enerali,ata- anore/ie- !ca+ere +in$retate- !in+rom +i!peptic ne!pecic#fatlenta- +reri a0+ominale +i.,e- meteori!m#
& catl mai .erm- c mar$inea a!ctita
& !plenome$alie
& pro0ele 0iolo$ice% normale !a mici cre!t
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Ta0lol clinic )6*Ciroa hepatica decompensata1.Parenchimatos:
& capacitatea +e e.ort ,ic !i intelectal e!te re+!a
& +entritia & catl mic- neori nepalpa0il
& .e0ra ) citoli,a 'epatica- in.ectie !praa+a$ata-carcinom 'epatic*
& icter
& 'ipere!tro$eni!m% !telte (a!clare- eritem palmar-plantar- .emini,are ) re+cerea parli p0ian- a/ilar- apilo,itatii .aciale la 0ar0ati- $inecoma!tie
& .actorii +e coa$lare +ecitari% $in$i(ora$ii- epi!ta/i!-'emora$ie +i$e!ti(a- 'ematoame- ec'imo,e- pete!ii#
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Ta0lol clinic )9*
& e/aminarile paraclinice% !an$ine 1
tran!amina,e cre!cte- .o!.ata,a alcalina-$amma$lo0lone- cole!terol- pancitopenie-etc
& eco$raa a0+ominala% +imen!inile !i
!trctra catli !i a !plinei & pnctie 0iop!ie 'epatica
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Ta0lol clinic )=*2. CH decompensata vascular
& 'iperten!ine portala
& !plenome$alie & circlatia colaterala a0+ominala
& 'emoroi,i
& (aricele e!o.a$iene !i $a!trice 1 rptra 1
'emora$ii +i$e!ti(e !perioare% 'emateme,a !imelena
& a!cita
& ence.alopatia portala
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TratamentlPrognostic1 +icil +e e!timat- +i.erite
etiolo$ii
Tratamentul de sustinere% & eliminarea a$entilor to/ici
& +ieta normala- !plimente (itaminice-'epatoprotectoare !a troce 'epatice
& me+icamente anti0ro,ante )colc'icina*
& tratamentl complicatiilor
Transplantul hepatic
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Litia,a 0iliara
Denitie% pre,enta calclilor la ni(ell
(e,iclei 0iliare !i>!a cailor 0iliare6?@ pe!te " +e ani pre,inta litia,a 0iliara
6&9 / mai .rec(enta la .emei
Alti .actori .a(ori,anti% o0e,itatea- +iate-antece+ente .amiliare- +ia0etl ,a'arat
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Ta0lol clinicA!imptomaticiSimptome +e +i!pep!ie necaracteri!tica% 0alonari-
$retri-etc
O0!trctia tran,itorie a canalli ci!tic 1 +rere colicati(aO0!trctia per!i!tenta% infamatie !i coleci!tita acta
Colica biliara
- +pa in$e!tia +e alimente coleci!to;inetice
& locali,ata in 'ipocon+rl +rept !a epi$a!tr
& inten!itatea cre!te pro$re!i( !i rapi+- +pa care !ementine con!tant pe toata +rata colicii
& apare mai ale! noaptea
& !e pot in!oti +e $retri- (ar!atri 0ilioa!e- .e0ra-tran!piratii- !0icter pa!a$er
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Dia$no!ticl
Eco$raa a0+ominala 1 (i,ali,ea,a in mo+
+irect calcliiE/4 Ra+iolo$ic 1 til pentr calclii ra+iopaci
E/4 Biolo$ice 1 normale in litia,a necomplicata
& 5SH accel4 78T- 7OT- amila,e-te!te +e
cole!ta,a- etc
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TratamentlCalclii a!imptomatici% 6@ complicatii>pe an
Calclii !imptomatici%
& colica 0iliara 1 +ieta- anti!patice- antial$ice-AB
& ri!c cre!ct +e complicatii% coleci!tita acta-pancreatita acta- per.oratie c peritonita
acta- mali$ni,are- etc & coleci!tectomie la rece
& coleci!tectomie laparo!copica
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Coleci!tita acta )3*Denitie% infamatia acta a pereteli coleci!tli-
pro(ocata +e o0icei +e o0!trctia litia,ica a canalli ci!tic)@*
Simptome si semne%
& +rere colicati(a locali,ata in 'ipocon+rl +rept cira+iere !0!caplar +r4
& $reata- (ar!atri
& aparare m!clara in partea +r4
& coleci!t palpa0il )?@* & 2n$'i +rero! la in!pir pro.n+
& !emnl li Mp'
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Coleci!tita acta )6*Evolutia:& ameliorare in 6&9 ,ile- !e re,ol(a
in ,ile
Complicatii% empiem- $an$rena- per.oratie% & !tare $enerala alterata- .e0ra-
lecocito,a- !emne +e peritonita- ile!- icter
& amila,ele cre!te 1 pancreatita
Diagnostic%
& eco$rae a0+ominala
& colan$iocoleci!to$rae i,otopica
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Coleci!tita acta )9*
Taratamentul% & re'i+ratare parenterala
& !on+a +e a!piratie na!o$a!trica
& coleci!tecomie +e r$enta )in ca, +e
complicatii*
& coleci!tectomie tar+i(a 1 la " !apt4
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Coleci!tita cronicaDenitie%
& in$ro!area !i 0ro,a parietala c retractia(e,icii 0iliare#
Clinic%& colici recrente
Patogenie%
& calcli !a noroi care pot o0!tra canall
ci!tic & mcoa!a lcerata !i 0ro,ataTratament!
& c'irr$ical
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8ancreatita actaDenitie% infamatie acta care !e (in+eca clinic
!i 'i!tolo$icEtiologie:
& afectiunile biliare - alcoolul
& me+icamente & 'iperlipemie- 'ipertri$liceri+emie
& in.ectii- & inter(entii c'irr$icale
& anomalii !trctrale ale cailorpancreatice- 0iliare-
& tramati!me#
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8ato$enieE+em 1 necro,a 1 'emora$ie
Acti(area en,imelor pancreatice )trip!ina-.o!.olipa,a*
8ancreatita e+ematoa!a 1 infamatia limitata la
pancrea! 1 mortalitatea @
8ancreatita 'emora$ica 1 necro,a !i 'emora$ie 1mortalitatea G3?&?@
Hipo(olemie 1 !oc
En,imele intra in circlatie 1 le,ini or$anice +i.,e
In.ectie
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Ta0lol clinicDreri a0+ominale !e(ere c ira+iere in !pate-
tenace- per!i!ta ore !a ,ile
7reata- (ar!atriTran!piratii- ta'icar+ie
Re!piratia !perciala
Fe0ra
Alterarea con!tientei 1 precoma
Di!tenia a0+ominala- iritatie peritoneala a0+omen +e lemn
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E(oltie- complicatiiDece! prin !oc !i in!cienta renala !a prin
in!cienta re!piratorieIn.ectia pancreatica a te!trilor
retroperitoneale c $ram ne$ati(i
8!e+oc'i!t pancreatic 1 colectie +e lic'i+
pancreatic 0o$at in en,ime !i retri ti!lareinantrl ,onei +e necro,a 1 in.ectie-'emora$ie !a rptra
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Dia$no!ticCre!terea amilaei si lipaei serice"adiograa abdominala pe gol% calcli- ile!
+inamic#
Ecograa% calcli 0iliari- +ilatatia cailor 0iliaree+empancreaticTC% (i,ali,area pancrea!li- e+em- e/tra(a,are +e
lic'i+e- necro,a pancreatica## criterii prognostice ale lui "$%S&%% (ar!ta
G +e ani- $licemia G 6?? m$>+l- LDH G 9? UI-78T G 6? U- lecocito,a G 3"???>mlLa = +e ore !ca+erea Ht c G3?@- cre!terea reeei
G m$>+l- Ca !eric m$>+l- 8aO6 "? mmH$-+ecit +e 0a,e G =mE>l- !ec'e!trare lic'i+iana G "l
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TratamentSon+a na!o&$a!trica- per.,ii i(- a!piratia
lic'i+li $a!tric !i a $a,elor
Internare intr&o !ectie +e ATICompen!area pier+erilor 'i+rice
Tratamentl +rerii
Tratamentl in!cientei car+iace- renale
Anti0iotice
Alimentatia i(- re(ine pe!te 6&9 !aptamani-
Inter(entie c'irr$icala
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8ancreatita cronicaEtiopatogenie% alcooli!m !i i+iopatice-
microlitia,a- ocl,ia canalli pancreatic principalprin !teno,a- litia,a !a cancer
Simptome si semne% +rere epi$a!trica- !tetoreec !cane $ra!e- intoleranta la $lco,a
Diagnostic% & e/4 Ra+iolo$ic- e/4 Eco$rac !i TC
)normale in primii ani +e 0oala*
Tratament% & alcooll inter,i!- tratarea ni p!eact- ma!ri +ietetice- tratament c'irr$ical