Pancreatitis Aguda Grave Necrosis Pancreatica

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Pancreatitis Aguda Grave Necrosis Pancreatica

  1. 1. • Paciente varón de 74 años.• AP: Pancreatitis aguda en Set 06 catalogada como etílica• Ingreso actual por pancreatitis aguda
  2. 2. PANCREATITIS AGUDA GRAVE 07 07 07 07 07 20 20 20 20 20 9/ 9/ 9/ 9/ 0/ /0 /0 /0 /0 /1 04 11 18 25 024039 Augmentine PAAF 3/10 Imipenen38 Temperatura37 Dieta Absoluta Dieta liquida NP36 IR Ileo TAC 18/9 TAC 1/10 TAC 6/9 Empeoramiento Gas35 GE E. Oral: 21/09 1/10 Leu: 18000 Leu: 16000 PCR: 223 PCR: 20
  3. 3. PANCREATITIS AGUDA GRAVE
  4. 4. PANCREATITIS AGUDA GRAVE
  5. 5. PANCREATITIS AGUDA GRAVE• COMENTARIOS – Antecedente de la etiologia – Diagnostico de necrosis pancreática por TAC a veces es díficil ( RNM ) – Profilaxis infección de la necrosis – Nutricion enteral vs parenteral en PAG – Tratamiento de necrosis pancreatica infectada
  6. 6. PANCREATITIS AGUDA GRAVE• Pancreatitis aguda idiopatica: demostar que no es biliar, con 2º prueba de imagen y estudio de bilis
  7. 7. PANCREATITIS AGUDA GRAVEProfilaxis de la infeccion de la necrosis pancreatica
  8. 8. PANCREATITIS AGUDA GRAVE
  9. 9. PANCREATITIS AGUDA GRAVE
  10. 10. PANCREATITIS AGUDA GRAVE
  11. 11. PANCREATITIS AGUDA GRAVE
  12. 12. PANCREATITIS AGUDA GRAVE
  13. 13. PANCREATITIS AGUDA GRAVE• Conclusiones profilaxis de la infeccion de la necrosis pancreatica. – Imipenen previene la infeccion de la necrosis – Reduce la mortalidad
  14. 14. PANCREATITIS AGUDA GRAVENutricion enteral vs parentral en pancreatitis grave
  15. 15. PANCREATITIS AGUDA GRAVE
  16. 16. PANCREATITIS AGUDA GRAVE
  17. 17. PANCREATITIS AGUDA GRAVE
  18. 18. PANCREATITIS AGUDA GRAVE
  19. 19. PANCREATITIS AGUDA GRAVE
  20. 20. PANCREATITIS AGUDA GRAVE
  21. 21. PANCREATITIS AGUDA GRAVE• No hay suficiente evidencia para recomendar una frente a otra, faltando estudios de calidad• Hay una recomendación al uso de n enteral
  22. 22. PANCREATITIS AGUDA GRAVETratamiento de la necrosis infectada• Cirugia• Endoscopia• Drenaje percutaneo• Otros
  23. 23. PANCREATITIS AGUDA GRAVETratamiento de la necrosis infectada
  24. 24. PANCREATITIS AGUDA GRAVE
  25. 25. PANCREATITIS AGUDA GRAVE
  26. 26. PANCREATITIS AGUDA GRAVE TRATAMIENTO ENDOSCOPICO •Transmural approach• ASGE guideline: the role of endoscopy in the diagnosis and management of cystic lesions and inflammatory fluid collections of the pancreas. Jacobson BC; Baron TH; Adler DG et al. Gastrointest Endosc 2005; 61(3):363-70
  27. 27. PANCREATITIS AGUDA GRAVE TRATAMIENTO ENDOSCOPICO• Mithöfer K, Mueller PR, Warshaw AL. Interventional and surgical tratment of pancreatic abscess. World J Surg 1997; 21:162-68
  28. 28. PANCREATITIS AGUDA GRAVE TRATAMIENTO ENDOSCOPICO• Endoscopic Therapy for organized Pancreatic Necrosis. Baron TH, Thaggard WG, Morgan DE; Stanley RJ. Gastroenterology 1996; 111:755-764.
  29. 29. PANCREATITIS AGUDA GRAVE• JPN Guidelines for the management of acute pancreatitis: surgical treatment. Isaji S, TaKada T, Kawarada Y et al. J Hepatobiliary Pancreat Surg 2006; 13:48-55 •CQ1. Which procedure will best result in a definite diagnosis of infected pancreatic necrosis ? •CQ2. What is the indication for surgical intervention in necrotizing pancreatitis ? •CQ3. How should sterile pancreatic necrosis be managed ? •CQ4. What is the optimal timing for surgical intervention ? •CQ5. What is the optimal surgical procedure for infected pancreatic necrosys? •CQ6. What is the optimal drainage procedure after necrosectomy ? •CQ7. How should pancreatic abscess be managed ? •CQ8. What is the indication for surgical drainage in pancreatic abscess? •CQ9. What are the indications for drainage treatment in pancreatic pseudocysts? •CQ10. What is the indication for surgical intervention in pancreatic pseudocysts ?
  30. 30. PANCREATITIS AGUDA GRAVE• How should sterile pancreatic necrosis be managed ? Conservadora salvo complicaciones sistemicas persistentes o deterioro clinico severo a pesar de manejo UCI. RECOMENDACIÓN B
  31. 31. PANCREATITIS AGUDA GRAVE• What is the optimal surgical procedure for infected pancreatic necrosys? Necrosectomia. RECOMENDACIÓN A
  32. 32. PANCREATITIS AGUDA GRAVE• What is the optimal drainage procedure after necrosectomy ?
  33. 33. PANCREATITIS AGUDA GRAVE otros• Percutaneous pancreatic necrosectomy NICE December 2003• Endoscopic transmural necrosectomy
  34. 34. PANCREATITIS AGUDA GRAVE• How should pancreatic abscess be managed ?• What is the indication for surgical drainage in pancreatic abscess?Puede ser manejado tanto quirurgicamente como con drenaje percutaneo RECOMENDACIÓN BSi hay deterioro clínico cirugia RECOMENDACIÓN A
  35. 35. PANCREATITIS AGUDA GRAVE• Conclusiones• En PAG recomendar uso precoz de Nutricion enteral• Imipenen si se demuestra Necrosis• Tratamiento evacuador si de demuestra infeccion de la necrosis, quirurgico, (recomendación grado A) y si el paciente no está septico podria ser valido otras alternativas dada la alta mortalidad de la cirugia

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