pancreatitis aguda · revision of classification and definitions by international consensus. gut...
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PANCREATITIS AGUDA:DIAGNÒSTIC, GRAVETAT I INFORME D’ ALTAAntoni Codina BarrerasServei de Cirurgia Hospital Trueta GironaUnitat HPB
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Definicions:
Què hem de fer constar a l’alta?
Diagnòstic pancreatitisTerminologiaGravetat pancreatitis
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Definicions
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Reforma estructural de la sanitat…
Externalizació de serveis sanitaris…
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Reforma estructural de la sanitat…Retallades en sanitat
Externalizació de serveis sanitaris…Privatitizació
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Definicions
Per entendren’s
Per comparar grups homogenis
Per aplicar el tractament adequat
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Definicions
Per entendren’s
Per comparar grups homogenis
Per aplicar el tractament adequat
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Definicions
Reunions de Marsella 1963 i 1985
Reunió d’Atlanta 1992
PANCREA 20121
Actualització Atlanta 20132
1Determinant-Based Classification of Acute Pancreatitis ... Ann Surg 2012;256: 875–8802Revision of classification and definitions by international consensus. Gut 2013; 62:102-11
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Diagnòstic pancreatitis aguda
- Dolor abdominal
- Amilases/Lipases x 3
- TC característic
Ens calen 2 de 3 condicions:
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Terminologia- Dia 1: dia d’inici del dolor
- Tipus anatomopatològic:PA edematosa intersticialPA necrotitzant -> (peri)pancreàtica
- Necrosi infectada -> (peri)pancreàticaGas (TC)Cultiu + : Drenatge. Cirurgia. PAF
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Terminologia- Fallida orgànica:
- CardiovascularTA < 90mmHg (no respon a líquids) o inotrópics
- Renal Creatinina ≥ 1,9mg/dL
- RespiratoriaPaO2 / FiO2 ≤ 300
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Terminologia
- Fallida orgànica:
Transitoria ≤ 48h ; Persistent › 48h
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Terminologia
- Fallida orgànica:
Transitoria ≤ 48h ; Persistent › 48h
La fallida orgànica persistent defineix com a greu una PA
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Definicions: Gravetat pancreatitis
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Nivells de gravetat Lleu Moderadament
GreuGreu
Fallida Orgànica
No
i
No
Transitoria< 48h
i/o
Si
Persistent> 48h
No/SiComplicacions
Locals
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Complicacions locals< 4 setmanes > 4 setmanes
sense NECROSI :PA Edematosa
Intersticial
Col·lecció líquida aguda Pseudoquist
amb NECROSI :PA Necrotitzant
Col·lecció necrótica aguda
Necrosiencapsulada
(WON)
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Complicacions locals< 4 setmanes > 4 setmanes
sense NECROSI :PA Edematosa
Intersticial
Col·lecció líquida aguda Pseudoquist
amb NECROSI :PA Necrotitzant
Col·lecció necrótica aguda
Necrosiencapsulada
(WON)
Formació de paret
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Complicacions locals< 4 setmanes > 4 setmanes
sense NECROSI :PA Edematosa
Intersticial
Col·lecció líquida aguda Pseudoquist
amb NECROSI :PA Necrotitzant
Col·lecció necrótica aguda
Necrosiencapsulada
(WON)
Afectació per proximitat: paresia gàstrica, necrosi del colon i trombosi venosa portal i/o esplénica
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Què hem de fer constar a l’alta?
- Dia d’inici del dolor (dia 1)
- Diagnòstic: Amilases, TC
- Etiologia PA:
- Biliar: Cal ecografia
- Enólica: També ecografia
- Altres: Ca++ i TG
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Què hem de fer constar a l’alta? - Nivell de gravetat: En cas de PA greu explicitar els
organs fallits. Ingrés UVI
- Tipus PA: Edematosa intersticial Necrotitzant (TC)
- Complicacions locals: coleccions líquides o necrótiques, PSQ, WON, Sdr Wirsung desconectat
- Infecció de la necrosi i gèrmen
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Què hem de fer constar a l’alta? - Recomanacions a domicili:
- Fístula pancreàtica (maneig ambulatori)- Vigilar: febre, dolor, intolerancia alimentaria - Necessitat d’enzims o anticoagulants
- Cita pel cirurgià en les PA d’origen bilar
- Descartar neoplasia abans de derivar el malalt per estudi de PA idiopàtica
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- Què fem amb les idiopàtiques (30%) una
vegada estudiades i descartades altres causes?:
Què hem de fer constar a l’alta?
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Què fem amb les idiopàtiques?
Ann Surg 2015;262:736–741
8 Hospitals Finlandia154 pacients previstos
Avaluats90
Randomitzats85
Cole lap.39
Observació46
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Què fem amb les idiopàtiques?
Ann Surg 2015;262:736–741
Avaluats90
Randomitzats85
Cole lap.39
Observació46
8 Hospitals Finlandia154 pacients previstos
4 / 39
14 / 46
p = 0.016
Recidiva PA
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Per emportar-vos...
1. PA idiopàtica -> Colecistectomia laparoscòpica
2. PA greu < - > Fallida orgànica persistent
3. Lectura molt recomanada: Gut 2013; 62:102–111
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Gràcies !!!
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DANYS COLATERALS
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Definicions: Diagnòstic pancreatitis
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Definicions: Terminologia
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Què hem de fer constar a l’alta?
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