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Varón con dolor abdominal y bultoma en hipocondrio
 

Varón con dolor abdominal y bultoma en hipocondrio

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  • In the past, open surgery was the only option Some asymptomatic cysts, particularly if heavily, may be able to be monitored without specific therapy Active hydatid liver disease, treatment with albendazole, in combination with either surgery or the PAIR procedure (Percutaneous Aspiration, Introduction of a protoscolicidal agent, and Reaspiration) Removal of large developing and transitional cysts with multiple daughter vesicles Single liver cysts situated superficially that may rupture spontaneously Open surgery should be considered if percutaneous treatment is not available As an alternative to percutaneous therapy for cysts communicating with the biliary tree Management of cysts exerting pressure on adjacent vital organs. Prevention of cystic echinococcosis often can be achieved merely by avoiding close contact with dogs. Careful washing of vegetables and contaminated fresh produce can also reduce infection. Prohibition of home-slaughter of sheep will prevent dogs from consuming infected viscera, thus disrupting the life cycle of the parasite. Elimination of stray dogs and surveillance techniques, involving either diagnostic purging of dogs or coproantigen tests, have helped to reduce infections in some endemic areas [105]. Programs using praziquantel therapy for infected dogs have also been successful. Vaccination is also a prospect for prevention of echinococcosis, since protective immunity does develop in intermediate hosts. A vaccine for E. granulosus, known as the EG95 vaccine, contains a purified recombinant protein of the parasite oncosphere as well as an adjuvant. Two doses of the vaccine are administered initially one month apart, followed by a required annual booster. This vaccine has been studied in animals and appears to afford 95 percent protection to sheep, cattle and goats in preliminary trials [105,107-109]. Similar vaccines may be able to be used in humans in the future.

Varón con dolor abdominal y bultoma en hipocondrio Varón con dolor abdominal y bultoma en hipocondrio Presentation Transcript

  • Sesión Clínica CS Verge del Toro. Maó15-6-2012 Varón con dolor abdominal y bultoma en hipocondrio derecho Dr. Mateu Seguí Diaz UBS Es Castell. Menorca
  • Varón de 37 años Varón de 37 años, sin hábitos tóxicos. Natural de Marruecos Trabaja en la construcción Sobrepeso sin otros FRCV Acude por diversos problemas gástricos
  • Varón de 37 años 05-2011 Acude a Urgencias por dolor abdominal de 3 días de evolución que no responde al tratamiento (IBP). Facies de afectación por dolor. Ictericia de piel y mucosas. Abdomen tenso y defensivo, especialmente en epigastrio, con severo dolor a este nivel y defensa involuntaria. Blumberg (+) débil.
  • Analítica• Analítica : - leucocitosis (20.800), sin desv a la izqda. - eosinofilia (31%) - Bb total = 9, con directa = 5,7 - amilasa = 3.513 - discreta alteración de la coagulación
  • RX simple de abdomenEn Rx simple abdomen : asa centinela y calcificación redondeada, central, a nivel de epigastrio (¿vesícula calcificada?, ¿quiste hidatídico?). No neumoperitoneo
  • Ecografía de abdomen
  • Ecografía de abdomen
  • Ecografía de abdomen
  • Ecografía de abdomen
  • Ecografía de abdomen
  • Ecografía de abdomen
  • Ecografía de abdomen
  • Ecografía de abdomen
  • Ecografía de abdomen
  • Ecografía de abdomen
  • TAC de abdomen TAC  Masa hepática sugestiva de quiste hidatídico.  Discreta cantidad de líquido libre intraabdominal.  Esplenomegalia
  • Varón de 37 años-Control Quiste hidatídico , con clínica de dolor en epigastrio y en HD, con amilasemia probablemente secundaria a suelta de hidátides Se practicó CPRE y papilotomía. Pancreatitis leve post- CPRE.
  • Varón de 37 años-Control• Albendazol• Control de sangre Ac el día (cumplidos los 28 dias)• Se comparan los títulos de AC antes y después del tratamiento, para programar una eventual cirugía
  • TAC de abdomen TAC 10-05-2012  El estudio comparativo con exploraciones previas, la última del 14-04-2011, pone de manifiesto persistencia sin cambios significativos de la masa en segmento IV hepático, heterogénea, con calcificaciones groseras murales y lesiones quísticas intralesionales de predominio periférico.
  • El QuisteHidatídico
  • Quiste hidatídico- E. granulosus Echinococcal disease is caused by infection with the metacestode stage of the tapeworm Echinococcus, which belongs to the family Taeniidae. Four species of Echinococcus produce infection in humans; E. granulosus and E. multilocularis are the most common, causing cystic echinococcosis (CE) and alveolar echinococcosis (AE).2012 UpToDate, |Release: 20.5 - C20.7.
  • Quiste hidatídico-Ciclo  Un huésped definitivo, el que posee, la tenia o gusano en estado adulto, y un intermediario donde se desarrolla la tenia en estado de larva (quiste hidático).  Los huéspedes definitivos son mamíferos carnívoros, mientras que pueden actuar como huéspedes intermediarios varias especies de herbívoros y omnívoros, entre ellos el hombre.2012 UpToDate, |Release: 20.5 - C20.7.
  • Quiste hidatídico-Clínica  The initial phase of primary infection is always asymptomatic.  Latent periods of more than 50 years before symptoms arise have been reported.  While approximately 50 percent of detected cases occur in asymptomatic patients, many more cases remain undiagnosed or are found incidentally at autopsy.2012 UpToDate, |Release: 20.5 - C20.7.
  • Quiste hidatídico- Crecimiento  Cysts typically increase in diameter at a rate of one to five centimeters per year.  The liver is affected in approximately two-thirds of patients, the lungs in approximately 25 percent, and other organs including the brain, muscle, kidney, bone, heart, and pancreas in a small proportion of patients.2012 UpToDate, |Release: 20.5 - C20.7.
  • Q hidatídico- Afectación del hígado  E. granulosus infection of the liver frequently produces no symptoms.  The right lobe is affected in 60 to 85 percent of cases.  Significant symptoms are unusual before the cyst has reached at least 10 cm in diameter.  E. granulosus cysts can rupture into the biliary tree and produce biliary colic, obstructive jaundice, cholangitis, or pancreatitis.2012 UpToDate, |Release: 20.5 - C20.7.
  • Q. hidatídico- Afectación Pulmón  Pulmonary involvement with E. granulosus can lead to a variety of symptoms, including chronic cough (sometimes with accompanying hemoptysis or evacuation of cyst material), chest pain, pleuritis or dyspnea.  Rupture of a cyst into a bronchus may lead to hemoptysis, respiratory distress, and asthma-like symptoms.Kern P, Bardonnet K, Renner E, et al. European echinococcosis registry: human alveolar echinococcosis, Europe, 1982-2000.
  • Q. hidatídico-Ruptura del quiste  Cyst rupture — Fever and acute hypersensitivity reactions including anaphylaxis, may be the principal manifestations of cyst rupture. Hypersensitivity reactions are related to the release of antigenic material and secondary immunologic reactionsMcManus DP, Zhang W, Li J, Bartley PB. Echinococcosis. Lancet 2003; 362:1295
  • Q. hidatídico- Evolución asintomática  33 patients with asymptomatic liver hydatid cysts  . Fifteen percent of patients had undergone surgery 10 to 12 years after the initial diagnosis, while the remaining 85 percent had not.  Seventy-five percent of the patients who did not have an operation remained asymptomatic  57 percent did not show a change in the size of the cyst by imaging.Frider B, Larrieu E, Odriozola M. Long-term outcome of asymptomatic liver hydatidosis. J Hepatol 1999; 30:228.
  • Q, hidatídico-Calcificación  Calcification, which usually requires five to 10 years to develop, occurs most commonly with hepatic cysts but rarely with pulmonary or bone cysts.  Total calcification of the cyst wall suggests that the cyst may be nonviable.2012 UpToDate, |Release: 20.5 - C20.7.
  • Quiste hidatídico-Supervivencia  If left untreated, more than 90 percent of patients will die within 10 years of the onset of clinical symptoms.  Since treatment with albendazole has been introduced, the prognosis has improved considerably.  Of 117 patients from France who underwent long term  follow-up, the actuarial survival rate was 88 percent2012 UpToDate, |Release: 20.5 - C20.7.
  • Q. hidatídico-Laboratorio  Nonspecific leukopenia or thrombocytopenia, mild eosinophilia, and nonspecific liver function abnormalities may be detected, but are not diagnostic.  Fewer than 15 percent of cases have eosinophilia, which generally occurs only if there is leakage of antigenic materialMcManus DP, Zhang W, Li J, Bartley PB. Echinococcosis. Lancet 2003; 362:1295
  • Q. hidatídico- Ecografía  Ultrasound is employed most widely because it is easy to perform and less expensive.  Ultrasound has a sensitivity of approximately 90 to 95 percentWHO Informal Working Group. International classification of ultrasound images in cystic echinococcosis for application in clinical
  • Q. hidatídico-TAC, RMN  However, both CT and MRI may provide more detail and greater specificity  CT has a higher overall sensitivity than ultrasound, with sensitivity rates of 95 to 100 percent2012 UpToDate, |Release: 20.5 - C20.7.
  • Q. hidatídico-Serología • Immunodiagnosis is useful for primary diagnosis and for follow-up after treatment . • Detection of circulating E. granulosus antigens in serum is less sensitive than antibody detection, which remains the method of choice. • Serologic testing produces both many false positive and false negative results.2012 UpToDate, |Release: 20.5 - C20.7.
  • Quiste hidatídico-Serología • Indirect hemagglutination (IHA) • Indirect immunofluorescence • Latex agglutination • Double diffusion immunoelectrophoresis • Counter-current immunoelectrophoresis (CIEP) • Radioimmunoassay (RIA) • Enzyme-linked immunosorbent assay (ELISA) • Enzyme-linked immunoelectrotransfer blots (EITB) • Enzyme-linked immunoelectrodiffusion assay (ELIEDA) • Time-resolved fluoroimmunoassay (TR-FLA) • Immunoblot2012 UpToDate, |Release: 20.5 - C20.7.
  • Q. hidatídico-Aspiración y biopsia  Percutaneous aspiration or biopsy may be required to confirm the diagnosis  This method of diagnosis is reserved for situations when other diagnostic methods are inconclusive  Potential anaphylaxis and secondary spread of the infection2012 UpToDate, |Release: 20.5 - C20.7.
  • Q. hidatídico-Tratamiento médico (1)  In the past, open surgery was the only option  Some asymptomatic cysts, particularly if heavily, may be able to be monitored without specific therapy  Active hydatid liver disease, treatment with albendazole, in combination with either surgery or the PAIR procedure (Percutaneous Aspiration, Introduction of a protoscolicidal agent, and Reaspiration)2012 UpToDate, |Release: 20.5 - C20.7.
  • Q. hidatídico-Tratamiento médico (2)  Albendazole generally is given at a dosage of 10 to 15 mg/kg per day in two divided doses.  Absorption is improved by taking albendazole with a fatty meal.  It comes in 400 mg tablets, and the usual dose is 800 mg daily.  Therapy most often is indicated for a minimum of three to six months2012 UpToDate, |Release: 20.5 - C20.7.
  • Q. hidatídico-Tratamiento Quirúrgico  Single liver cysts situated superficially that may rupture spontaneously  Open surgery should be considered if percutaneous treatment is not available  As an alternative to percutaneous therapy for cysts communicating with the biliary tree  Management of cysts exerting pressure on adjacent vital organs.2012 UpToDate, |Release: 20.5 - C20.7WHO informal working group panel.
  • Quiste hidatídico-Prevención  Avoiding close contact with dogs.  Careful washing of vegetables and contaminated fresh produce can also reduce infection.  Prohibition of home-slaughter of sheep will prevent dogs from consuming infected viscera, thus disrupting the life cycle of the parasite.  Vaccination is also a prospect for prevention of echinococcosis2012 UpToDate, |Release: 20.5 - C20.7.
  • Quiste hidatídico-Ideas clave (1)  La infección por E granulosis es generalmente asintomática durante muchos años  Las complicaciones dependen del sitio donde se asiente el gusano y del tamaño del quiste  2/3 de los quiste se asientan en el hígado y un 1/3 en los pulmones  Los síntomas con hepatomegalia, ictericia y pérdida de peso  Con síntomas y sin tratamiento la mortalidad es del 100%  El diagnóstico es generalmente por ecografía  Confirmado por serología ELISA  La aspiración-biopsia solo se utiliza cuando los otros test no son concluyentes2012 UpToDate, |Release: 20.5 - C20.7.
  • Quiste hidatídico-Ideas clave (2)  En individuos asintomáticos monitorizar la evolución  Calcificación es sinónimo de no viable  Albendazol + PAIR (Percutaneous Aspiration, Introduction of a protoscolicidal agent, and Reaspiration)  Tratamiento quirúrgico en grandes quistes con múltiples vesiculas, superficiales y si pueden romperse con facilidad  Y sin el tratamiento percutáneo no es posible o ejerce presión sobre organos vitales.  Evitar el contacto con perros, y no alimentar a estos con visceras contaminadas  Lavar las verduras2012 UpToDate, |Release: 20.5 - C20.7.