pancreatitis

1. PANCREATITIS
CRUZ OROZCO AIDEE NAILEA
ALFARO HERNÁNDEZ DANIELA CITLALI
Aguda

2. Embriología
4ta Semana de gestación
Se forma el intestino primitivo
PÁNCREAS
Deriva del intestino primitivo anterior
caudal
● Esbozo pancreatico dorsal
● Esbozo pancreatico ventral
Endodermo

3. 6ta Semana de gestación
Rotación de las yemas en sentido horario
7ta Semana de gestación
Fusión de las yemas pancreáticas

4. 8ta Semana de gestación
Alcanza su posición definitiva.
Formación de conductos pancreáticos
Wirsung
Papila
duodenal
mayor
Santorini
Papila duodenal
menor

5. 8va Semana de gestación
Histodiferenciación del islote
pancreático
9na Semana de gestación
Células α → Glucagón
10ma Semana de gestación
Células β → Insulina
11va Semana de gestación
Células δ → Somatostatina
Los islotes pancreáticos (Langerhans)
se desarrollan a partir de tejido
pancreático parenquimatoso
Genes PAX4 y PAX6 = Células β,
Células δ y γ (polipéptido páncreatico)
Gen PAX6 = Células α

6. Histología
● Exocrino: 98-99%: Tejido pancreático organizado
en acinos pancreáticos
● Endocrino 1-2%: Islotes de Langerhans

7. Situado oblicuamente
en la pared abdominal
posterior, a nivel de los
cuerpos vertebrales de
L1 y L2
Glándula mixta alargada
Rosa grisaceo
12-15cm de longitud
7cm de altura
2-3cm de espesor
65 a 70gr
Anatomía

8. Anterior
Estómago, bolsa omental,
mesocolon transverso, A.
mesentérica sup
Posterior
Aorta, VCI, A. renal der, V.
renal der e izq, vasos
mesentéricos sup, V.
esplénica, V. porta hepática,
riñón izquierdo, glándula
suprarrenal izquierda
Superior A. esplénica
Lateral Bazo
Medial
Duodeno (porción
descendente y porción
horizontal)
Relaciones anatomicas

9. Wirsung
Papila duodenal
mayor
Santorini
Papila duodenal menor

10. Irrigación
Proceso unciforme y la cabeza
A. pancreaticoduodenal superior -
Rama de la gastroduodenal - Hepática
común
A. pancreaticoduodenal inferior -
Rama de la mesentérica superior
Cuerpo y cola
A. pancreáticas - Ramas A. esplénica,
gastroduodenal y mesentérica superior.

11. Drenaje
V. pancreaticoduodenal superior
ant - drena en la V. mesentérica
superior
V. pancreaticoduodenal superior
post- drena en la V. porta hepática.
V.pancreaticoduodenal inferior
anterior y posterior - drenan en la V.
mesentérica superior
V. pancreáticas del cuerpo y la cola -
drenan en la V. esplénica.
INERVACIÓN
Parasimpática - N. vago
Simpática - N. esplácnicos mayor y menor

12. fisiopatologia

13. Etiología

14. Cuadro clínico
Dolor abdominal
(Periumbilical o
epigastrico)
(Súbito, intenso,
transfictivo y constante)
“Irradiación en cinturón”
Tórax y espalda media.
Nauseas
Vómito
Anorexia
Saciedad
Distensión
90%
Después de ingesta de comida grasosa o alcohol.
Harrison: Principios de Medicina Interna, 20ª Edición. McGraw-Hill Interamericana

15. EXPLORACIÓN FÍSICA
Fiebre, hipotensión, oliguria, taquicardia y peristaltismo ausente o
disminuido
● Ictericia
● Nódulos
eritematosos en piel
● Estertores basales,
atelectasia y
derrame pleural
Harrison: Principios de Medicina Interna, 20ª Edición. McGraw-Hill Interamericana

16. Grey Turner
(equimosis en la pared
lateral del abdomen)
Signos
Cullen
(equimosis
periumbilical)
Fox
(Equimosis en la porción
inf. del lig. inguinal)
Suelen observarse 48 a 72 horas después de la presentación de pancreatitis
3% Indican datos de gravedad.
Harrison: Principios de Medicina Interna, 20ª Edición. McGraw-Hill Interamericana

17. Diagnostico
● Cuadro clínico
● Alteraciones bioquímicas
● Estudios de gabinete (US, TC, RM)
ENZIMAS PANCREÁTICAS
Lipasa sérica:
E y S: 90-100%
Se eleva de 4 a 8 hrs, máx 24 hrs y
permanece elevada x 7 a 14 días
>3 veces el rango normal
10-140U/L
Harrison: Principios de Medicina Interna, 20ª Edición. McGraw-Hill Interamericana

18. Amilasa sérica:
S y E: 80-90%
40-45% se produce en páncreas
Se eleva de 6 a 12 hrs y permanece
elevada x 3 a 5 días
>3 veces el rango normal
25-125U/L
Se asocia a obstrucción intestinal, peritonitis,
perforación de ulcera duodenal, insuficiencia renal
Harrison: Principios de Medicina Interna, 20ª Edición. McGraw-Hill Interamericana

19. Proteína C reactiva
Estándar de oro en la valoración del
pronóstico de la gravedad
E y S: 75% al 80%
Determinación a las 24 a 48 horas
1.0 mg/L y 3.0 mg/L
Tripsina/tripsinogeno, carboxipeptidasa A, colipasa, elastasa y
ribonucleasa
GPC. Diagnostico y tratamiento de pancreatitis aguda. IMSS

20. PRUEBAS DE FUNCIÓN HEPÁTICA
Pancreatitis de origen biliar
(Compresión del coledoco distal por el tejido pancreatico inflamado)
● AST (5-35u/l) - Alcoholica
● ALT (30-65 U/l)
● FA (40-150 g/dl)
● GGT (12-64 U/l)
● BT (0.2-1.2mg/dl)
● BD (0-0.5mg/dl)
● BI (0.2-1.2mg/dl)
● DHL (125-220 U/L)
GPC. Diagnostico y tratamiento de pancreatitis aguda. IMSS

21. LEUCOCITOSIS
(15 000- 20 000 leucocitos/uL)
HIPOCALCEMIA
Saponificación intraperitoneal del
Ca por los Ac grasos en zonas de
necrois grasa
HIPERAZOEMIA
BUN >22mg/100ml
HEMATOCRITO >44%
(Hemoconcentración)
Pérdida del plasma hacia el espacio retropancreatico y cavidad peritoneal
HIPERGLUCEMIA
↓insulina, ↑liberación del
glucagón y ↑producción de
catecolaminas y glucocorticoides
suprerrenales.
Harrison: Principios de Medicina Interna, 20ª Edición. McGraw-Hill Interamericana

22. USG
● ↑volumen pancreático con ↓de la
ecogenicidad.
○ ↑ volumen >2.4cm de diámetro
○ Arqueamiento anterior
○ Iirregularidad superficial.
○ ↓ecogenicidad =exudación de
líq. = heterogeneidad del
parénquima.
● Desplazamiento del colon transverso
y/o del estómago por la expansión del
volumen pancreático
Determinar si el origen es por cálculos biliares

24. TC
Hallazgos típicos
● Agrandamiento
parenquimatoso focal o
difuso
● cambios en la densidad
(edema)
● Márgenes pancreáticos
indistintos (inflamación)
● Tejido adiposo
retroperitoneal circundante
Mancilla, C & Sanhueza, A. (2012). Clasificación Baltazar-Ranson. Gastroenterolgía. Latinoamerica. 21 (3). pp. 415-417

25. Mancilla, C & Sanhueza, A. (2012). Clasificación Baltazar-Ranson. Gastroenterolgía. Latinoamerica. 21 (3). pp. 415-417

26. Pancreas normal, sin alteracion del
tejido circundante, contorno bien
definido.
Aumento de tamaño, sin alteracion
del tejido circundante
Mancilla, C & Sanhueza, A. (2012). Clasificación Baltazar-Ranson. Gastroenterolgía. Latinoamerica. 21 (3). pp. 415-417

27. Inflamación del tejido
peripancreatico, aumento de su
densidad sin colecciones liquidas
Colección liquida peripancreatica,
colección liquida * detrás de la cola
pancreatica
Mancilla, C & Sanhueza, A. (2012). Clasificación Baltazar-Ranson. Gastroenterolgía. Latinoamerica. 21 (3). pp. 415-417

28. Dos o más colecciones liquidas
peripancreaticas
Mancilla, C & Sanhueza, A. (2012). Clasificación Baltazar-Ranson. Gastroenterolgía. Latinoamerica. 21 (3). pp. 415-417

29. Grado de necrosis
Un foco de necrosis en el cuerpo del
páncreas
Necrosis de la totalidad de la cola
del páncreas
Mancilla, C & Sanhueza, A. (2012). Clasificación Baltazar-Ranson. Gastroenterolgía. Latinoamerica. 21 (3). pp. 415-417

30. Necrosis de cabeza, cuerpo y parte de la cola del pancreás
Escaso tejido viable en la cola *
Mancilla, C & Sanhueza, A. (2012). Clasificación Baltazar-Ranson. Gastroenterolgía. Latinoamerica. 21 (3). pp. 415-417

31. Clasificación de ATLANTA
Tiempo de evolución
Fase temprana:
(>2 semanas)
Fase tardía:
(>2 semanas)
Grado de severidad
Cede por si sola (3-7d)

36. Role: Taking a taxi and giving directions
Overview: One student should be the ‘taxi driver’ and three o four students should be
the ‘passengers’
● The passengers will tell the taxi driver where they want to go. For example, “Take
me to the park, please.”
● But, there is a big problem! This is the taxi drivers first day on the job and so he/she
does not know how to get to the destination. To get to where they want to go, the
passengers must give directions to the taxi driver
Activity A / Flag down a taxi /

37. Role: Giving Instructions
Overview: In this role, one student will play the ‘instructor’ and one student will play
the student
● The instructor should guide the student on how to complete a task, and the student
should follow the instructions and act out what the instructor is saying
● For example, the instructor could be a artist and could teach the student how to
draw a flowers and plants
Activity B / Giving instructions /

38. “This is a quote, words
full of wisdom that
someone important said
and can make the
reader get inspired.”
—Someone Famous

39. Objectives
Mercury is the closest planet
to the Sun and the smallest
one in the Solar System—it’s
only a bit larger than the Moon
Mercury
Venus has a beautiful name
and is the second planet from
the Sun. It’s hot and has a
poisonous atmosphere
Venus

40. Role: Telephone conversation
Overview: In this role, one student will
speaking to another student about a doctor
job position
● Get the students who are practicing
to sit back to back for a better
interpretation of the roles
Activity C / Telephone conversation /

41. Role: Interviewer and applicant
Overview: In this role play, one student will play the ‘interviewer’ and one student will
play the ‘applicant’
● Ideas about the positions for the interview: a gamer, an actor, an astronaut, an
worldpacker, etc
● A good tip would be to have the interviewer have a list of set questions, and the
students can take it from there
Activity D / Job interview /

42. ● Despite being red, Mars is
actually a cold place. It's full of
iron oxide dust, which gives the
planet its reddish cast
● Earth is the third planet from the
Sun and the only one that harbors
life in the Solar System. This is
where we all live on
● Neptune is the farthest planet
from the Sun
Why role play?

43. Role: Debate
Overview: In this role, play students should act out an argument between two friends
● Students should act out meeting one of their friends in the city
● Some debate topics:
○ Which is a better dessert? Cake or ice cream?
○ Which makes a better pet? Cats or dogs?
○ Summer is better than winter. Agree or disagree?
Activity E / Debate /

44. Role: Doctor and patient
Overview: This is a role play for paired
students. One student plays a ‘doctor’ who
has just graduated and it’s her first day in
the ER, the other student plays "patient"
Activity F / In the emergency room /

45. Constructing a role play
/ 01 /
Venus is the
second planet
from the Sun
Venus
/ 02 /
Earth is the
third planet
from the Sun
Earth
/ 03 /
Despite being
red, Mars is
very cold
Mars
/ 04 /
Jupiter is the
biggest planet
of them all
Jupiter
/ 05/
Saturn was
named after a
Roman god
Saturn

46. Role: Gypsy fortune teller and a customer
Overview: The students work in pairs with one playing the role of a gypsy fortune teller
and the other playing the role of the customer
Activity G / I'll tell you your future /

47. Role: Blood donor and nurse
Overview: One student should be the ‘blood
donor’ and the other student should be the
‘nurse’
Activity H / Blood donation /

48. A picture is worth a thousand words

49. Running a role play
Mercury is the closest planet to the Sun
and the smallest one in the Solar System.
This planet's name has nothing to do with
the liquid metal, since Mercury was
named after the Roman messenger god
Jupiter is a gas giant and the biggest
planet in the Solar System. It's the
fourth-brightest object in the night sky. It
was named after the Roman god of the
skies and lightning

50. Role: Dialogue between a person who wants to go to the cinema and a cinema clerk
Overview: This is a role play for paired students. I used the movies that are on now in
the cinema
● Some questions:
○ Which movies are on
○ Ask genres of each movie
○ At what time the movies are on
○ Ticket price?
Activity I / Cinema /

51. Role: Famous person and the interviewer
Overview: They have to work in pairs, one student will be a ‘famous person’ and the other
one will be the ‘interviewer’
● Some themes:
○ Date and place of birth
○ Profession
○ Relationships
○ Hobbies
○ Family
Activity J / Famous person /

52. Graph
Follow the link in the graph to modify its data and then paste the new one here. For more info, click here
Venus is the second
planet from the Sun
Venus
Despite being red,
Mars is very cold
Mars

53. Role: Travel agent and the tourist
Overview: There's a role play between a travel agent and the tourist. Students can use
their vocabulary by having a conversation about tourism places around their country
or city. Students can also talk about another place they know
Activity K / Travel guide /

54. Role: Flatmate
Overview: Working in pairs, students role play a flatmate wanted interview. One is in the
house, the other is applying for the room. Before the interview both must write four
questions to ask the other. They should try to negotiate terms
● Some questions:
○ How long do you plan to stay?
○ How often do you clean?
○ Do you smoke?
○ Do you have pets?
Activity L / Flatmate wanted /

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