Download - 32583470 Pancreatite Cronice
![Page 1: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/1.jpg)
PANCREATITE CRONICE
Prof.Dr.Radu VoiosuUniversitatea de Medicină şi Farmacie Carol Davila Bucureşti
![Page 2: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/2.jpg)
![Page 3: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/3.jpg)
DIAGNOSTICUL
E uşor la cei suferinzi de mult timp Paradigma actuală plasează acut şi
cronic la extremităţile aceluiaşi spectru Ce înseamnă precoce = Se poate reveni/încetini dezvoltarea
P.C ?
![Page 4: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/4.jpg)
PLANUL DISCUŢIEI
1.Datele normale structură şi funcţie 2.Conceptul de pancreatită cronică 3.Imagistica pancreatitei cronice 4.Clasificarea etiologică a pancreatitei 5.Tratamente specifice 6.Tratamente comune
![Page 5: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/5.jpg)
… nothing short of a surgical exploration
will unearth
the thick spongy worm
buried deep in the viscera
silent behind the curtain
of peritoneum
with a head, a body and a tail.
![Page 6: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/6.jpg)
Ecce viermele…
![Page 7: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/7.jpg)
![Page 8: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/8.jpg)
ANATOMIA
Formă paralelipipedică 6/4/3 cm Procesul uncinat Canalul principal 4,3,2 mm Canalul accesoriu cranial de ampula
Vater Vase din hepatica, splenică, AMS Raporturi strânse cu v.portă
![Page 9: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/9.jpg)
Structura acinară
![Page 10: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/10.jpg)
Membrana conţine receptori
CCK Bombesină Neuromedina B Secretină VIP
![Page 11: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/11.jpg)
SECREŢIA ESTE DEPENDENTĂ DE METABOLISM
Activare : faza cefalică
faza gastricăfaza intestinală
Inhibare : stimuli adrenergicisomatostatinaPP
secreţia intestinală de peptidaze
![Page 12: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/12.jpg)
![Page 13: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/13.jpg)
Reglarea secreţiei
![Page 14: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/14.jpg)
![Page 15: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/15.jpg)
ENZIME
Proteolitice - tripsinogen
- chemotripsinogen
- elastaza
- carboxipeptidaza A,B
- kallikreina
![Page 16: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/16.jpg)
ENZIME
Lipolitice - colipaza
- lipaza
- carboxihidrolaza
Glicolitice – amilaza 1,4α
![Page 17: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/17.jpg)
Celulele acinare
Produc
Stocheză
Eliberează enzimele
![Page 18: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/18.jpg)
AUTOLIZA E PREVENITĂ :
Sinteza de precursori inactivi
Enzimeanvelopate în organele
Antiproteaze intracelulare
![Page 19: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/19.jpg)
ANTIPROTEAZE CONTROLATE GENETIC
PRSS1 menţine enzimele inactive
SPINK1menţine integritatea inhibitorilor
CFTR reglează secreţia de bicarbonat
![Page 20: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/20.jpg)
Etiologie Mutaţie genetică
Alcoolică SPINK 1
CFTR
Tropicală PRSS 1
SPINK 1
CFTR
Idiopatică SPINK 1
CFTR
![Page 21: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/21.jpg)
ROLUL FIZIOLOGIC
Bernard HENDERSON 1856
![Page 22: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/22.jpg)
Definiţie:
Inflamaţie cronică caracterizată
prin alterări morfologice ireversibile,
ducând la: a)dureri abdominale
b)alterarea permanentă a funcţiilor pancreasului
![Page 23: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/23.jpg)
EVOLUŢIA CONCEPTELOR
1. SARLES , MARSEILLE 1963 Definiţie anatomo-patologică bazată pe 5
anomalii şi anume : Fibroză Celule inflamatorii Pierderea parenchimului Dilataţii canaliculare Litiaza căii principale
![Page 24: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/24.jpg)
EVOLUŢIA CONCEPTELOR
GEORGE ORWELL
1984
![Page 25: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/25.jpg)
EVOLUŢIA CONCEPTELOR
2. Conceptului anatomo patologic i se adaugă :
Obstrucţia Funcţia Clinica , durerea ca simptom princeps
![Page 26: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/26.jpg)
EVOLUŢIA CONCEPTELOR
3. Clasificarea Cambridge incorporează :
Date echografice Date tomografice Date E.R.C.P
![Page 27: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/27.jpg)
EVOLUŢIA CONCEPTELOR
Apare clasificarea japoneză etiologică
cunoscută azi sub numele
TIGAR-O
![Page 28: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/28.jpg)
![Page 29: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/29.jpg)
Modificări morfologice
Distrugerea parenchimului exocrin Focală Segmentară Difuză
prin: anomalii ductale infiltrat inflamator fibroza
![Page 30: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/30.jpg)
Macroscopie
![Page 31: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/31.jpg)
Microscopie
![Page 32: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/32.jpg)
![Page 33: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/33.jpg)
INSUFICIENŢELE MORFOLOGIEI
1.Eşantioane obţinute chirurgical, deci faze avansate.
2.Nu are cuantificare 3.Nu are ierarhizare
![Page 34: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/34.jpg)
Puţină istorie
1856 – Claude Bernard face modelul animal al PA
1878 – Fridreich incriminează alcoolul 1896 – Chiari postulează autodigestia 1946 – Comfort elaborează teoria
necroză/fibroză 1970 – Sarles – ipoteza dopurilor proteice 1996 – Whitcomb defineşte leziunea
cromozomială C 7 q 35
![Page 35: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/35.jpg)
The molecular basis of pancreatic disease arose from the pioneering work of Claude, DeDuve, Palade and Porter, who used the molecular biologic techniques to study the process of cellular protein synthesis.
![Page 36: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/36.jpg)
![Page 37: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/37.jpg)
CLASIFICARE ETIOLOGICĂ
T (toxica-metabolică) I (idiopatică) G (genetică) A (autoimună) R (recidivantă,acută) O (obstructivă)
![Page 38: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/38.jpg)
I. Pancreatite toxic- metabolice
1. alcoolice
2. tabagism
3. hipercalcemie / hiperparatiroidie
4. hiperlipemie
5. medicamentoase – fenacetina
![Page 39: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/39.jpg)
II. Idiopatice
1. debut precoce
2. debut tardiv
3. tropicale
![Page 40: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/40.jpg)
III. Genetice
1.Transmisie autozomal dominantă- gena tripsinogenului cationic (codon 29,122)
2. Transmisie autozomal recesivă - gena SPINK 1 cromozom 5q
- gena CFTR
- gena tripsinogenului cationic (6,22,23)
- deficit α1 AT
![Page 41: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/41.jpg)
ROLUL GENEI SPINK 1 (PSTI)
Situată pe C5 Inhibă 20% din tripsina Substituţia asp/ser (N43S) e mutaţia
cea mai frecventă (1-2 %) E factor de susceptibilitate !
![Page 42: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/42.jpg)
ROLUL GENEI CFTR
Codeză proteina canalelor de clor Sunt cunoscute > 1200 mutaţii 4% din populaţie e heterozigotă 6 clase de mutaţii 1: neexprimată
2+3 nefuncţională
4 canal alterat
5+6 proteină instabilă
![Page 43: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/43.jpg)
IV. Autoimune
1. Izolate
2. Asociate : - S.Gougerot –Sjogren
- B.I.I.
- C.B.P
![Page 44: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/44.jpg)
V. Pancreatite acute severe recidivante
Pancreatita acută necrotică
Pancreatita acută recidivantă
Pancreatita acută ischemică
Pancreatita acută dupa iradiere
![Page 45: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/45.jpg)
VI. Obstructive
1. obstructţe canaliculară
2. stenoza canaliculară cicatrizantă
3. pancreas divisum
4. diskinezie sfincter Oddi
![Page 46: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/46.jpg)
![Page 47: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/47.jpg)
Pancreatita cu eosinofile
![Page 48: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/48.jpg)
Formă rară
Se asociază GEC cu eozinofile
Sindrom hipereozinofilic
![Page 49: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/49.jpg)
Experienţă
Sunt cunoscute 16 cazuri certe
Alergie la 50% din cazuri
Ig E crescut la 80% din cazuri
![Page 50: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/50.jpg)
Pancreatite Autoimune
![Page 51: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/51.jpg)
Sarles 1961 a făcut primele observaţii
Yashida 1995 a mai descris 11 cazuri
2% pancreatite
![Page 52: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/52.jpg)
Caractere
1. Cresterea γglobulinelor (IgG)
2. Prezenta de auto-anticorpi
3. Absenţa calcificărilor şi pseudochistelor
4. Asocierea cu alte afecţiuni
5. Infiltrat limfocitar
6. Răspuns la corticoterapie
![Page 53: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/53.jpg)
Criterii de diagnostic
1. Creşterea IgG 4 (6,6 g/L fata de 0,51 g/L N)2. Anticorpi antinucleari 75%3. Anticorpi antilactoferina 75%4. Anticorpi antianhidraza carbonica II 60%5. Factor reumatoid 30%6. Anticorpi antifibra netedă 20%
![Page 54: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/54.jpg)
Mecanisme propuse
![Page 55: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/55.jpg)
Imunitate umorală
Coexistenţa atingerii pancreatice cu: S Gougerot – Sjogren CSP CBP LES
a generat ideea “dry gland syndrome” / “autoimmune epithelitis”
![Page 56: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/56.jpg)
Imunitate umorală
Antigene ţintă:
1. Anhidraza carbonică II
2. Lactoferina
3. Anhidraza carbonică IV
Nashimori Gut 2005
![Page 57: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/57.jpg)
Imunitate celulară
Limfocite citotoxice CD 8
Intervenţia IL2, TNF α, IFN γ
(profil Th1)
![Page 58: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/58.jpg)
Pancreatite asociate B.I.I.
Diferenţiată de 1. Pancreatita medicamentoasă
1. Sigura 5 ASA2. Probabilă la prednison şi metronidazol3. Improbabilă la tacrolimus şi ciclosporină
2. Pancreatita litiazică 1. Atingere ileala2. Nutriţie parenterală
![Page 59: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/59.jpg)
Prevalenţă 1,2 – 1,5 %
C.U. 56% (42% pancolită)
BC 33%
![Page 60: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/60.jpg)
Manifestări
a) PA 24%
b) Icter 14%
c) Insuficienţa pancreatică 20-80%
![Page 61: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/61.jpg)
Cadru Nosologic
Este de discutat în cadrul etiologiei
- Alcoolice- Medicamentoase
relaţia pancreatită acută -> cronică
![Page 62: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/62.jpg)
Problema care se pune
1. Pancreatita acută survine pe fond cronic (subînţeles : până atunci latentă! )
2. Pancreatita acută este o entitate
3. Pancreatita acută recurentă produce leziunea cronica
![Page 63: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/63.jpg)
Teoria SAPE
![Page 64: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/64.jpg)
Fenomene celulare în cursul Pancreatitei acute
Stress( taurocolat, ceruleina)
Inhibarea genelor care codează enzime
Supraexpresia proteinelor de stress
Diminuarea acestora concomitent cu
Creşterea expresiei genelor de regenerare
![Page 65: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/65.jpg)
Histologie
Creşterea Apoptozei = Necroza
imposibilitatea declanşează
întoarcerii la homeostazie inflamaţia
![Page 66: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/66.jpg)
În Pancreatita cronică :
1. Agresiune mai slabă ca în PA
2. Răspunsul acinar
→ reducerea funcţiei exocrine → inducerea genelor de
supravieţuire
3. Continuarea agresiunii → apoptoza
![Page 67: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/67.jpg)
Derivă
1.Agresiune nonfatală
→ întoarcerea la program de homeostazie
→ regenerare
→ restitutio ad integrum
![Page 68: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/68.jpg)
REZULTĂ CĂ TREBUIE GĂSITĂ EXPLICAŢIA DIFERENŢEI DE PREDISPOZIŢIE => GENE ?
![Page 69: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/69.jpg)
Au fost demonstrate :
Asocierile cu SPINK 1
Anomalii ale raportului tripsinogen / inhibitorul tripsinei
![Page 70: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/70.jpg)
Diferenţa PA – PC este fără obiect căci mecanismele puse în joc sunt IDENTICE.
![Page 71: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/71.jpg)
Se poate afirma că PC = PA benignă prelungită.
![Page 72: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/72.jpg)
![Page 73: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/73.jpg)
![Page 74: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/74.jpg)
• Greu de diferenţiat de PA
• Timp de certitudine 5 ani
Pancreatita Cronică Alcoolică:
![Page 75: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/75.jpg)
Criterii
DEFINITĂ:
Calculi pancreatici
Leziuni la ERCP
Steatoree > 7g / zi (in absenţa altor cauze)
Piesa operatorie
![Page 76: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/76.jpg)
PROBABILĂ:
Leziuni minime ERCP
Chiste persistente, recurente
Test patologic la secretină
Insuficienţa pancreatică endocrina
![Page 77: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/77.jpg)
Opinia curenta
Alcoolul este responsabil de atingerea
CRONICĂ
dar descoperirea clinică poate fi :
ACUTĂ, ZGOMOTOASĂ, PRECOCE
sau, dimpotrivă:
DISCRETĂ ŞI TARDIVĂ !
![Page 78: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/78.jpg)
Pancreatita alcoolică
Relaţia abuz alcool-pancreatită este STABILITĂ.
Dar:
1.Majoritatea pacienţilor sunt alcoolici
2.Majoritatea alcoolicilor nu au pancreatită
![Page 79: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/79.jpg)
Barach’s Rule :
An alcoholic is a person who drinks more than his own physician.
![Page 80: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/80.jpg)
5-10 % din alcoolicii “heavy” dezvoltă boala.
Aceasta subliniază încă o dată relaţia
factori exogeni- factori genetici .
![Page 81: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/81.jpg)
Patogenia pancreatitei alcoolice
![Page 82: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/82.jpg)
1. Mecanisme celulare
Creşterea enzimelor (lipaza, amilaza, proteaze)
Scăderea inhibitorilor
Interferenţa cu transportul intracelular
![Page 83: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/83.jpg)
2. Mecanisme canaliculare
Hipervâscozitate prin hexozamine
Hipoproducţie litostatina
Anomalii ale proteinei GP 2
![Page 84: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/84.jpg)
Intervenţia UDPG transferazei
Risc crescut de 2,2 ori la cei care au gena UGTI A7
![Page 85: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/85.jpg)
Alte teorii patogenetice
a) Teoria permeabilizării ductale
b) Teoria metaboliţilor toxici
c) Teoria ischemică
d) Teoria leziunii mitocondriale
e) Teoria activării celulelor stelate
![Page 86: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/86.jpg)
Pancreatite Genetice
1. Pancreatite cronice ereditare
2. Deficitul α1 AT
3. Fibroza chistica a pancreasului
![Page 87: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/87.jpg)
Pepsinogenul cationic (PRSS I = serine proteinase 1) :
se autoactivează mai usor
e rezistent la autocataliză
![Page 88: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/88.jpg)
Patogenie
1. Creşterea activării intrapancreatice a tripsinogenului depăşind capacitatea PSTI (pancreas secreted tripsine inhibitor)
2. Stabilizarea tripsinei –mecansim accesoriu
![Page 89: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/89.jpg)
![Page 90: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/90.jpg)
Teoria refluxului
![Page 91: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/91.jpg)
Teoria obstructiva
![Page 92: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/92.jpg)
Litogeneza
![Page 93: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/93.jpg)
ASPECTE CLINICE
Durere abdominală :tip A, B
Maldigestie
Diabet zaharat
![Page 94: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/94.jpg)
MECANISMELE DURERII ÎN PANCREATITA CRONICĂ
I. Durerea extrapancreatică
a) stenoza căii biliare principale
b) stenoza duodenului (groove pancreatitis )
Explică durerea postprandială(20%)
![Page 95: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/95.jpg)
II. Durerea pancreatică
A. Teoria creşterii presiunii intraductale
- decompresia influenţează durerea
- suplimentele enzimatice scad CCK
- insuficienţa e indoloră !
![Page 96: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/96.jpg)
Contraargumente
- Durerea există şi la insuficienţii pancreatici
- Octreoctidul e ineficient- Persistă la decomprimaţii chirurgical în
30% cazuri
![Page 97: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/97.jpg)
B. Teoria ischemică
Hipertensiunea ductală şi parenchimalî comprimă vasele producând ischemie
![Page 98: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/98.jpg)
C. Teoria fibrozei
Creşte presiunea intraductală.
Nu există corelaţie fibroză-durere
![Page 99: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/99.jpg)
D.Teoria inflamaţiei neurogene
Substanţa P se leagă de receptorii de neurokinină (NK-R1) generând inflamaţie.
![Page 100: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/100.jpg)
![Page 101: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/101.jpg)
![Page 102: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/102.jpg)
DIAGNOSTICUL IMPUNE ASOCIEREA CU
TESTE IMAGISTICE
TESTE FUNCŢIONALE
![Page 103: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/103.jpg)
IMAGISTICA
Radiografie simplă Echografie Tomografie computerizată Colangiopancreatografia RM+secretină Echoendoscopia Colangiopancreatografia retrogradă per
endoscopică Elastografia per endoscopică
![Page 104: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/104.jpg)
![Page 105: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/105.jpg)
![Page 106: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/106.jpg)
![Page 107: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/107.jpg)
![Page 108: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/108.jpg)
Valoarea diagnostică a echografiei de suprafaţă
Echografie abdominală
Sensibilitate 50-95%
Specificitate 75-95%
1.Atrofia glandei
2.Contur neregulat
3.Căi dilatate
4.Calcificări
![Page 109: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/109.jpg)
Pancreatita cronică - CT
![Page 110: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/110.jpg)
Pancreatita cronică calcificantă
![Page 111: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/111.jpg)
Pseudochist pancreatic - CT
![Page 112: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/112.jpg)
Condiţii de efectuare
Ct Spiral Substanţă de contrast
Grosimea cupelor 5 mm
![Page 113: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/113.jpg)
Valoarea diagnostică a T.C.
Tomografie computerizată
Sensibilitate 55-95%
Specificitate 85-100%
1. Atrofie
2.Contur neregulat
3.Ducte dilatate
4.Calcificări
![Page 114: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/114.jpg)
Pancreatita cronica - ERCP
![Page 115: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/115.jpg)
COLANGIO-RMN
Colangio RMN Sensibilitate 90%
Specificitate 92-98%
1.Atrofie
2.Mărire localizată
3.Contur neregulat
4.Dilataţii
5.Modificări de semnal
![Page 116: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/116.jpg)
Pancreatita obstructivă -ERCP
![Page 117: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/117.jpg)
CRITERIILE CAMBRIDGE
Clasa I < 3 ramuri afectate
Clasa II >3 ramuri sau DUCTUL PRINCIPAL
Defecte de umplere, stenoze/dilataţii.calcificări
![Page 118: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/118.jpg)
Pancreatita autoimună – CT, ERCP
![Page 119: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/119.jpg)
TESTE BIOCHIMICE STATICE
ENZIME SERICE
SEMNE DE COLESTAZĂ
STEATOREEA
![Page 120: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/120.jpg)
ECHOENDOSCOPIA
Avantaje .
poate preleva eşantioane cito/histo
poate TRATA
![Page 121: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/121.jpg)
ECHOENDOSCOPIA
DEZAVANTAJE
E invazivă
Impune pregătire specifică
Necesită echoendoscop linear
![Page 122: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/122.jpg)
CLASIFICAREA ROSEMONT
ANOMALII PARENCHIMATOASE
ANOMALII DUCTALE
![Page 123: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/123.jpg)
ANOMALII PARENCHIMALECaracter Descriere Criteriu major Criteriu minor Grad Histologie
Zone hiperecho cu con de umbră
Structuri echogene>2mm A 1 Calcificări
Lobularitate Structuri>5mm cu inel hiperechoic
2 N/A
A Aspecte de fagure
>3lobuli BB fără aspect de fagure
Lubuli necontigui Da
Zone hiperechogene fără con umbră
> 2mm Da 3 N/A
Chist Da 4 Pseudochist
Stranding Da 5 N/A
![Page 124: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/124.jpg)
ASPECTE DUCTALE
Caracter Definiţie Criteriu major Criteriu minor Grad Histologie
Calculi duct principal
Structuri echogene
A 1 litiază
Contur neregulat
Calibru neregulat
Da 2 N/A
Dilataţii colaterale
>3anormale Da 3 Ectazii
Dilataţii cale principală
>3,5mm Da 4 Dilataţii
Cale principală hiperechogenă
Pereţi echogeni Da 5 Fibroză ductală
![Page 125: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/125.jpg)
DIAGNOSTIC CONSISTENT
1. Un criteriu major A +> 3 minore
2.Un criteriu major A + major B
3. 2 criterii majore A
![Page 126: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/126.jpg)
ASPECT NORMAL AL ELASTOGRAFIEI PANCREAS
![Page 127: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/127.jpg)
![Page 128: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/128.jpg)
ENZIME
Tripsina serică
Chemotripsina fecală
INSENSIBILE!
![Page 129: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/129.jpg)
STEATOREE - Sudan
![Page 130: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/130.jpg)
TESTE DINAMICE-caracteristici:
Sensibile Specifice Uşor de realizat Neinvazive Ieftine
![Page 131: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/131.jpg)
TESTUL CCK-SECRETINĂ
Standardul de aur Complex Consumă timp Neplăcut Greu de suportat Centre terţiare Nestandardizat Recent înlocuite cu dozarea Zn
![Page 132: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/132.jpg)
![Page 133: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/133.jpg)
TESTE DE DIGESTIE
Prânzul Lundh
PABA(specificitate 90% în prezenţa steatoreei, 65 % I.E.P. Moderată)
Lauratfloresceină
![Page 134: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/134.jpg)
TESTE ELISA
SENSIBILITATE LIMITATĂ
Elastază <100µg/g
![Page 135: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/135.jpg)
Teste respiratorii
Colesteroloctanoatul (+ D-xiloză)
Trigliceride
Utilizează C13
![Page 136: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/136.jpg)
Şi atunci de ce teste de funcţie?
Atât Grupul ZURICH cât şi MAYO consideră că pancreatita cronică= I.P.E., indiferent de etiologia pancreatitei !
Steatoreea este apanajul extremei insuficienţe!
![Page 137: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/137.jpg)
EXCEPŢII :
Deficitul izolat de lipază/colipază produse de leziuni C10/C8
Deficitul de enterokinază
![Page 138: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/138.jpg)
![Page 139: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/139.jpg)
Arbore decizional
![Page 140: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/140.jpg)
TRATAMENT
Dietă 2000-3000 cal/zi
Acizi graşi cu catenă medie
Antioxidanţi
Somatostatină 50-200µg/zi
![Page 141: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/141.jpg)
TRATAMENT ENDOSCOPIC
Sfincterotomia +/- stentare Complicaţii : pancreatită acută 2-7%
sângerări 3%
perforaţii < 3%
stenoze < 1%
![Page 142: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/142.jpg)
DILATAŢIE, STENTARE
Fir ghid Dilatare : cateter /balon Stentare 3-10 F
![Page 143: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/143.jpg)
Necunoscute
Durata stentării
Diametrul stentului
Gradul de dilatare cu balonul
![Page 144: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/144.jpg)
Complicaţii
Migrarea stentului 10%
Ocluzia stentului 20%
![Page 145: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/145.jpg)
LITOTRIPSIE
Extracţie cu balon/coşuleţ
ESWL
![Page 146: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/146.jpg)
ALTELE
OBSTRUCŢIA BILIARĂ
PANCREAS DIVIZUM
BLOCAREA ŞI NEUROLIZA CELIACĂ
DRENAJUL PSEUDOCHISTELOR
![Page 147: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/147.jpg)
PREPARATE ENZIMATICE
Capsule acidorezistente
Conţinut variabil în lipază
Când trebuie începută administrarea lor ?
![Page 148: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/148.jpg)
Combaterea durerii
Trepte progresive
Neuroliza
Decompresia
Pancreactectomia
![Page 149: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/149.jpg)
![Page 150: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/150.jpg)
METODE ENDOSCOPICE
Decompresia
Stentarea
Extragerea litiazei
Drenajul pseudochistelor
![Page 151: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/151.jpg)
![Page 152: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/152.jpg)
![Page 153: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/153.jpg)
![Page 154: 32583470 Pancreatite Cronice](https://reader035.vdocuments.pub/reader035/viewer/2022081501/55cf9da0550346d033ae758d/html5/thumbnails/154.jpg)