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Pancreatitis aguda: complicaciones

y manejo quirrgico
Roberto Oleas Narea
Universidad Espritu Santo

Objetivos

Identificar la Pancreatitis aguda (PA) mediante un caso.


Discutir el manejo en el caso presentado.
Revisar conceptos bsicos en pancreatitis.
Identificar las complicaciones de la PA y su manejo
quirrgico.

CC: Masculino 23 aos acude a ER con cc. de dolor abdominal 8 horas de


evolucin. Dolor tipo transfictivo (10/10) en epigastrio, irradiado a
hipocondrio izquierdo. No alivia con cambio postural. No alivia con
analgesia convencional. Refiere consumo excesivo de alcohol en los dos
ltimos das.
PMH: HIV (+),
Social: labora como DJ, alcoholismo (20 L cerveza/semana) desde hace tres
aos, tabaquismo, niega uso drogas ilcitas.

Despus de analtica es ingresado a hospital A con el diagnstico presuntivo


de pancreatitis aguda de origen alcohlico, se instaura tratamiento de
soporte con va perifrica y NPO. Al quinto da pide alta a peticin.

Hospital B:
Paciente disneico con distencin abdominal.
Abdomen tenso a la palpacin, tumefacto a nivel de
flanco, fosa iliaca y regin lumbar izquierda.
Signo de Grey Turner.
Ingreso UCI.

HR

110 lpm

RR

28 rpm

38,3

BP

120/70

mmHg

Masha L, Bernard S. Grey Turner's sign suggesting retroperitoneal haemorrhage. Lancet 2014; 383:1920.

Dx: pancreatitis necrotizante hemorrgica.


K85.2
Pancreatitis aguda inducida por
alcohol.
SIRS
Cuerpo y cola pancretico + mltiples abscesos.
Cx. Nueves ocasiones por sangrado + compromiso
hemodinmico.
Necrosectoma y dejado en bolsa de Bogot.
Drenaje de abscesos: 1000 ml purulento + 200
seroso. E. coli BLEE.

CBC

WBC 15,170
80 % PMN
HB 6,2 HTO 20
TP 12 TTP 30
INR 1,26

AB
G

pH 7,41
PCO2 35
HCO3 22,41
SAT O 97
PAFI 365

AN
ALIS
IS

Glicemia 103
CR 0,8
BUN 30
Na 139
K 3,96
Cl 100
P 3,1
Ca 8,1
Lactato 1,6
AMILASA 274 ( 3-110)
LIPASA 1610 (23-300)
HDL 45 LDL 120
COLESTSICAS NEGATIVAS. GOT GPT FA GGT

Tercer da Postopoeratorio: hemorragia cavidad


abdominal + 8 unidades de sangre + FFP.
Ileostoma trmino-terminal con bolsa recolectora.
Dcimo da: abdomen se encuentra cerrado, retira
la bolsa, sin dolor y se inicia alimentacin enteral
por sonda nasoyeyunal.
14 da: NAVM
20 da: colostoma por perforacin ngulo
esplnico.
35 da: Alta.

Pancreatitis aguda

Kumar, V., Abbas, A., Fausto, N., & Aster, J. (2010). Patologa estructural y
funcional: Robbins y Cotran. Barcelona: ELSEVIER.

Kumar, V., Abbas, A., Fausto, N., & Aster, J. (2010). Patologa estructural y funcional: Robbins y Cotran. Barcelona: ELSEVIER.

FISIOPATOLOGA

CT scan of acute
interstitial
edematous
pancreatitis

1. Interstitial edematous pancreatitis


Acute inflammation of the pancreatic parenchyma and peripancreatic tissues, but without recognizable tissue necrosis
Contrast-enhanced computed tomography criteria:Pancreatic parenchyma enhancement by intravenous contrast agent
No findings of peripancreatic necrosis

CT scan of acute necrotic collection

2. Necrotizing pancreatitis

Inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis


Contrast-enhanced computed tomography criteria: Lack of pancreatic parenchymal enhancement by intravenous contrast agent,
and/or
Presence of findings of peripancreatic necrosis (see belowacute peripancreatic fluid collection and walled off necrosis)

CT scan of acute interstitial


pancreatitis with acute
peripancreatic fluid
collections

3. Acute peripancreatic fluid collection (APFC)


Peripancreatic fluid associated with interstitial edematous pancreatitis with no associated peripancreatic necrosis. This term
applies only to areas of peripancreatic fluid seen within the first four weeks after onset of interstitial edematous pancreatitis and
without the features of a pseudocyst.
Contrast-enhanced computed tomography criteria:Occurs in the setting of interstitial edematous pancreatitis
Homogeneous collection with fluid density
Confined by normal peripancreatic fascial planes
No definable wall encapsulating the collection
Adjacent to pancreas (no intrapancreatic extension)

Pancreatic pseudocyst

4. Pancreatic pseudocyst
An encapsulated collection of fluid with a well defined inflammatory wall usually outside the pancreas with minimal or no
necrosis. This entity usually occurs more than four weeks after onset of interstitial edematous pancreatitis to mature.
Contrast-enhanced computed tomography criteria:Well circumscribed, usually round or oval
Homogeneous fluid density
No non-liquid component
Well defined wall (ie, completely encapsulated)
Maturation usually requires >4 weeks after onset of acute pancreatitis; occurs after interstitial edematous pancreatitis

Pancreatic pseudocyst
A well-circumscribed fluid collection that is usually round or oval
The fluid collection is typically extra-pancreatic
Homogenous fluid density
No non-liquid components within the fluid
A well-defined wall that completely encapsulates the fluid collection.

Walled-off pancreatic necrosis


Heterogenous fluid collection with liquid and non-liquid density, with
varying degrees of loculation
A well-defined wall that completely encapsulates the fluid collection
Intra-pancreatic and/or extra-pancreatic location

Walled-off pancreatic fluid collections can produce a wide range of clinical problems
depending on the location and extent of the fluid collection and whether the fluid
collection is infected.
Expansion of the fluid collection can produce abdominal pain, duodenal or
biliary obstruction, vascular occlusion, or fistula formation into adjacent
viscera, the pleural space, or pericardium
Spontaneous infection can develop
Digestion of an adjacent vessel can result in a pseudoaneurysm, which can
produce a sudden, painful expansion of the cyst or gastrointestinal bleeding due
to bleeding into the pancreatic duct (hemosuccus pancreaticus)
Pancreatic ascites or pleural effusion can result from disruption of the
pancreatic duct with fistulization to the abdomen or chest, respectively

Pancreatic
abscess
CT scan in a patient with abdominal
pain, fever, and jaundice shows air
(thin arrow) in the central pancreas,
which is necrotic and largely
replaced by an acute fluid collection
(thick arrows), leaving only a small
residual pancreatic head (P).

CT
scan
of
acute
necrotizing pancreatitis
complicated by infected
pancreatic necrosis

The
presence
of gas bubbles is a
pathognomonic
sign of infection of
the necrosis.

Valoracin y pronstico

AGA
Predictor de severidad: APACHE II mayor a 8,
ingreso a UCI.
Apache II 8 + falla orgnica en 78 horas:
tomografa computada con contraste para valorar
grado de necrosis.
Prueba de laboratorio: PCR 150 mg/dL en 48
horas.
APACHE II + Criterio clnico + PCR

Manejo

Tratamiento de soporte:
- Hidratacin:
- Liquidos IV especialmente en las primeras 24 horas con correcin de
electrolitos.

- Control de dolor: opiodes *


- Monitorizacin de signos vitales y estadificacin.
- Soporte nutricional:
-

NPO en cinco das, hasta una semana.


A la semana colocar tubo nasoyeyunal.
Alimentacin oral segn tolerancia.
Parenteral 25 Kcal/Kg de peso ideal.

Tenner S, Baillie J, Dewitt J, Vege SS. American College of Gastroenterology guideline: Management of acute
pancreatitis. Am J Gastroenterol 2013

AP:
Moderada: recuperan en 3- 7 das.
Tratamiento de soporte:
- Dolor ( morfina fenatil) bomba de analgesia.
- Fluidos intravenosos 24 horas primordialmente + control electrolitos.
- Dieta de poco residuio, baja en grasa, blanda cuando no hay ileo, nausea, vomito, dolor e inflamacion ha bajado
Severa:
Monitoreo invasivo en busca de falla orgnica transitoria ( < 48 horas) o persistente ( > 48 horas) y complicaciones.
Nutricin enteral por medio de sonsa nasoyeyunal colocada por endoscopia en vez de nutricion parenteral. (GRADO
IB)

Acute peripancreatic fluid collections and acute necrotic collections (ANC) may develop
less than four weeks after the onset of pancreatitis,
pancreatic pseudocyst and walled-off necrosis usually occur more than four weeks
after the onset of acute pancreatitis.

Both ANC and WON are initially sterile but may become infected. The occurrence of
pancreatic infection is a leading cause of morbidity and mortality in acute necrotizing
pancreatitis. Infected necrosis should be suspected in patients with pancreatic or
extrapancreatic necrosis who deteriorate
(clinical instability or sepsis physiology, increasing white blood cell count, fevers) or fail
to improve after 7 to 10 days of hospitalization.
In patients with suspected infected necrosis, we suggest empiric antibiotics rather than
CT-guided fine needle aspiration (Grade 2C)

In patients with infected necrosis who fail to respond to antibiotics or who are clinically
unstable, we recommend pancreatic debridement rather than continued conservative
management (Grade 2B). Where possible we attempt to delay intervention until four
weeks after initial presentation to allow the infected necrosis to become walled off.
We perform necrosectomy with minimally invasive methods and reserve open surgical
debridement for patients who are clinically unstable or if minimally invasive debridement
is not possible or fails.
In patients with gallstone pancreatitis, we recommend urgent (<24 hours)
endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy for
patients with cholangitis (Grade 1B). CHOLECYSTECTOMY SHOULD BE PERFORMED AFTER
RECOVERY in all operable patients with gallstone pancreatitis.

MANEJO QUIRRGICO
Treatment options for walled-off pancreatic fluid collections include surgical drainage,
endoscopic transmural drainage, transpapillary stent placement (for pseudocysts), and
percutaneous drainage.
Transmural puncture through the gastric or duodenal wall into the cyst can be performed
in patients who have a large, symptomatic walled-off pancreatic fluid collection that is
compressing the stomach or duodenum when there is close apposition of the fluid
collection to the bowel lumen.

Endoscopic transmural drainage (with or without necrosectomy) is the primary method


used for endoscopic management of walled-off pancreatic fluid collections. If necrotic
material is present within the fluid collection, endoscopic necrosectomy can be
performed.

Endoscopic management of walled-off pancreatic fluid collections is over 90 percent


technically successful with a 10 to 15 percent morbidity rate, a 70 to 80 percent resolution
rate, and a 10 to 15 percent recurrence rate.
Success rates are lower if pancreatic necrosis is present because of higher rates of
infectious complications and because solid debris is much more difficult to remove.
Recurrence rates exceeding 30 percent have been observed in this setting.
Endoscopic ultrasound (EUS) provides visualization of the walled-off pancreatic fluid
collection and facilitates drainage. Studies have reported technical success rates for EUSguided fluid collection drainage of 84 to 94 percent, with fluid collection recurrence rates
of 3 to 18 percent.
Infection is a common complication following endoscopic drainage of fluid collections. Periand post-procedural antibiotics are typically given to help reduce the risk of secondary
infection of a sterile fluid collection. Infection can often be managed with antibiotics and
endoscopic drainage. The most common cause of bleeding during endoscopic drainage is the
inadvertent puncture of intervening blood vessels.

The management of a walled-off pancreatic fluid collection depends on the patient's symptoms,
characteristics and location of the fluid collection, and whether complications such as a
pseudoaneurysm have developed:
In patients with a walled-off pancreatic fluid collection with minimal or no symptoms and no
pseudoaneurysm, we suggest expectant management rather than a drainage procedure (Grade 2C).
Limited natural history data suggest that up to 40 percent of walled-off pancreatic fluid collections
resolve without intervention.
If a pseudoaneurysm is present but the patient has minimal or no symptoms, we recommend
embolization of the aneurysm followed by expectant management.

For patients who are symptomatic, we suggest a drainage procedure rather than expectant
management (Grade 2C). The choice of drainage procedure is largely determined based on local
expertise and the location of the fluid collection. In centers with the appropriate expertise, pancreatic
fluid collections that abut the stomach or duodenum are often approached via an endoscopic approach,
reserving surgical drainage procedures for endoscopic failures, for recurrence following successful
endoscopic drainage, or for those not meeting criteria for endoscopic or percutaneous drainage.

Open surgical debridement is the gold standard for management of pancreatic

necrosis. Laparoscopic debridement is primarily limited to patients with walled-off


pancreatic necrosis.

Pancreatic debridement is indicated for patients with pancreatic necrosis and


progressive clinical sepsis as a complication of severe acute pancreatitis.
Infected pancreatic necrosis and symptomatic sterile necrosis are both accepted
indications for debridement. The goal of pancreatic debridement is to excise all dead
and devitalized pancreatic and peripancreatic tissue, while preserving viable
functioning pancreas, controlling resultant pancreatic fistulas, and limiting
extraneous organ damage
The optimal timing for pancreatic debridement is three to four weeks following the
onset of acute pancreatitis. Delayed debridement allows clinical stabilization of the
patient, resolution of early organ failure, and a decrease in the intense inflammatory
reaction in the retroperitoneum.

RESUMEN Y RECOMENDACIONES

24 horas una PA severa puede ser predecida


mediante la clnica, laboratorio, imgenes y los scores como SIRS,
En las primeras

APACHE II, BISAP y el ndice de severidad tomogrfico. La AGA sugiere el uso de la


SIRS por ser simple, econmica y disponible.

Se recomienda realizar una TC con contraste en pacientes con PA


severa valorado por clnica y APACHE II para detectar tejido necrtico.
La TC no se requiere en el primer da, se requieren das para la aparicin de tejido
necrtico, siendo normal en las primeras 48. Siendo indicado este procedimiento a
las 72 horas segn la AGA en pacientes con PAS predicha o con evidencia de falla
orgnica. TC temprana relacionada con PAS??? Medio de contraste???...

La AGA sugiere el empleo de la cuantificacin de Proteina C-reactiva, siendo


un valor mayor a 150 mg/L a las 48 horas como prueba idonea para discriminar a
pacientes severos.

The dry formal lecture never, or at any rate rarely, touches the
heart, but it is in [the] conversational method of the seminar, or
in the quiet evening at home, with a select group and a few good
editions of a favorite author, that the enthusiasm of the teacher
becomes contagious.
Sir. William Osler