PANCREATITIS. UNIVERSIDAD DE GUADALAJARA CENTRO UNIVERSITARIO DE CIENCIAS DE LA SALUD Surgical Clinics.Dr. Benjamín Robles MariscalProfesor: Dr. Héctor VirgenAyala Luis Gerardo Caballero Romero. EPG MCPA
• 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 corticosteroids steroidal contraceptives azathioprine thiazide diuretics tetracyclines• 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
ACUTE PANCREATITIS• Sudden epigastric pain• Nausea, vomiting• High concentrations of amylase• Edematous condition Similar disease processes• Bleeding form 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 gravity deep dehydration tachycardia 1 to 2% Grey Turners sign (bluish hipertencion postural discoloration flanc) Decreased myocardial function Cullens 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 HrsEDAD > 55 DISMINUCION DEL > 10% HEMATOCRITOCUENTA DE > 16,000 AUMENTO DEL BUN >8 mg/dlLEUCOSITOSGLUCOSA 200 mg/dl Ca EN SUERO < 8mg/dlLDH EN SUERO >350 IU/L Po2 ARTERIAL < 60 mmHgAST (GOT) > 250 IU/dl DEFICIT BASAL >4mg/L CALCULO DE >600 mL LIQUIDOSAST ---ASPARTATO TRASNAMINASA
• 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.
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 system is 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.
• 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 SYMPTOMSWhen a person is suspected draw, no signs of recovery after a week, or after atemporary improvement, the symptoms reappear.And tender palpable mass in the epigastrium, due to the swelling of thepancreas and adjacent viscera (cellulitis).Common sign: Pain.50% of the px:feverWeight Loss.hypersensitivity
COMPLICATIONSInfections: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, severepain).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• 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. Doherty13th edition, McGrawHill Lange.P. 495-507
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