PANCREATITIS AGUDA

XIMENA MARN QUINTERO UNIVERSIDAD DEL TOLIMA

Hospital Federico
DIEGO FERNANDO DURN UNIVERSIDAD DEL TOLIMA
Lleras Acosta
Caso Clnico

Paciente masculino de 40 aos

Cuadro clnico de 24 horas de evolucin
Dolor epigstrico de inicio progresivo que lleg
rpidamente a su mxima intensidad,
empeora con la palpacin y se atena al
inclinarse hacia delante
Sin antecedentes de importancia
Al examen fsico: dolor a la palpacin de
cuadrante superior derecho, abdomen
distendido, sin signos de irritacin peritoneal,
signo de murphy negativo
 Diagnstico diferencial dolor epigstrico

Anlisis 05
La pancreatitis puede distinguirse Isquemia mesentrica
Dolor periumbilical,
basndose en la clnica
caracterstica descrita y las
04 desproporcionado al examen fsico.
Pacientes con edad avanzada,
alteraciones en los valores de aterosclerosis, valvulopatas, IAM
reciente. La amilasa y lipasa no estn
laboratorio. Cuando no es claro el
cuadro se recurre a la imaginologa
03 tan elevadas

como la TAC contrastada Obstruccin intestinal

Dolor abdominal, anorexia, emesis biliosa, constipacin y
02 elevacin de amilasa y lipasa. Usualmente hay
antecedente de ciruga abdominal y/o hernias
Colecistitis
01 Dolor en cuadrante superior derecho irradiado a hombro derecho.
Hay signo de Murphy. La amilasa y lipasa no estan elevadas 3
veces lo normal
Coledocolitiasis o Colangitis
Transaminasas, bilirrubina y fosfatasa alcalina
elevadas. Amilasa y lipasa normales
lcera pptica
[3-7] Dolor epigstrico crnico e intermitente. No
irradiado a la espalda. La amilasa y lipasa estn
Enfoque Diagnstico [3-5]
Anamnesis

Antecedentes de colelitiasis, alcoholismo, hipertrigliceridemia,

uso de frmacos como diurticos, cido valprico o
sulfonamidas. Traumas abdominales previos, historia de
enfermedades autoinmunes
Pruebas de Laboratorio

Determinar la amilasa y lipasa sricas, niveles de triglicridos,

niveles de clcio y pruebas de funcin heptica.

Ecografa abdominal

A todo paciente con pancreatitis aguda para evaluar colelitiasis

o coldocolitiasis

Ecografa endoscpica o CPRE

Se realiza Colangiopancreatografa Endoscpica Retrgrada (CPRE) si se documenta colelitiasis o

coledocolitiasis. Ecografa endoscpica para evaluar anormalidades anatmicas, tumores o
Causas Principales

Mecnicas Frmacos Vasculares

[8-10] [21-25] [27]

Metablicas Txicas
[15-20] [26]

Alcohol Infecciones
[11-14] [26]

Trauma Congnita
[28] [29]
Epidemiologa [1,2]

Incidencia anual de 4.9 a 35 por 100.000 habitantes

Principal causa gastrointestinal de hospitalizacin en
USA MORTALIDAD

1 2 3 4
1. Mortalidad generalen paciente hospitalizado
2. Pancreatitis aguda leve 10% 1.5% 3% 30%
3. Pancreatitis intersticial
4. Pancreatitis necrotizante
 Etiologa

Obstruccin mecnica [8-10] Alcohol (30%) [11-14]

Clculos biliares (35-40%) Aumento de sntesis
Barro biliar (20%) enzimtica por clulas
Ascaris lumbricoides acinares pancreticas
Tumores pancreticos Sobresensibilizacin a la
colecistokinina

Toxinas [26] Idioptico (30%) [1,2]

Escorpiones Luego de una

(Centruroides, Tityus) investigacin
Araa reclusa marrn imaginolgica,
Actan por estimulacin serolgica y
colinrgica endoscpica
 Manifestaciones Clnicas [30-39]

Sntomas Clasificacin por

Dolor epigstrico severo y severidad
rpidamente progresivo, atenuado
al inclinarse hacia adelante Predictores de Severidad
Pancreatitis aguda leve-
Alcanza su mxima intensidad en ausencia de falla orgnica y/o Edad > 75a
10-20 minutos y perdura por horas complicaciones locales o Alcoholismo
a das sistmicas Irritacin
En un 50% de los pacientes se
Peritoneal
IMC > 30
irradia a la espalda Pancreatitis aguda moderada Dao Orgnico en las
Se asocia a nuseas y vmito Complicaciones locales o primeras 72h
Examen Fsico
(90%) sistmicas con falla orgnica
Hemoconcentracin
PCR > 150 en
Epigastrio sensible a la palpacin transitoria (<48 horas) 48h BUN > 20
Distensin abdominal
Creatinina
Disminucin de ruidos intestinales
Pancreatitis aguda severa Dao >1.8 Derrame
leo debido a inflamacin
orgnico persistente que Pleural
Escleras ictricas Ictericia
involucra uno o mltiples rganos
obstructiva debido a
coledocolitiasis
 Signos de sangrado retroperitoneal [30-32]

Ocurre con la complicacin de pancreatitis necrotizante

Grey Turner

Cullen

Reproduced from: Masha L, Bernard S. Cullen's sign suggesting retroperitoneal haemorrhage. Reproduced from: Masha L, Bernard S. Grey Turner's sign suggesting retroperitoneal haemorrhage.
Lancet 2014; 383:1920. Illustration used with the permission of Elsevier Inc. All rights reserved. Lancet 2014; 383:1920. Illustration used with the permission of Elsevier Inc. All rights reserved.
Scores de Severidad [30-35]
Hora 0
Edad >55
Criterios de Ranson
Recuento de leucocitos >16,000/mm3
para predecir la
severidad Glucosa sangunea >200 mg/dL
Lactato deshidrogenasa >350 U/L
Aspartato aminotransferasa >250 U/L
48 Horas
Hematocrito Cada 10%
La presencia de 1-3 BUN Aumento 5 mg/dL
criterios predice una Clcio srico < 8 mg/dL
pancreatitis aguda leve; pO2 < 60 mmHg
la mortalidad aumenta
significativamente con 4 Base exceso > 4 MEq/L
o mas Acumulacin de lquidos > 6000 mL
Scores de severidad
[30-35]

APACHE II
Acute Physiology And Chronic Health
Evaluation II
Clasificacin de Baltazar Radiolgica [30-35]

Grado de pancreatitis Necrosis pancretica Puntuacin

A: pncreas normal ninguna 0
Estratificacin
B: Agrandamiento del 1
pncreas Leve (intersticial)
C: Cambios 30% 2 Baltazar B o C sin
inflamatorios del necrosis pancretica o
pncreas y la grasa extrapancretica
peripancretica
Intermedia (pancreatitis
D: Coleccin de fluido 3
exudativa) Baltazar D
peripancretico
o E sin necrosis
simple y definida
pancretica
E: dos o mas 30-50% 4
colecciones Severa (Necrotizante)
peripancreticas Necrosis pancretica
poco definidas
> 50% 6
 Complicaciones locales [40-42]

Coleccin de fluido Pancreatitis Pancreatitis Pseudoquiste

peripancretico Necrotizante necrotizante infectada pancretico

Graphic 88436 Version 1.0

Graphic 88431 Version 2.0 Graphic 88434 Version 1.0 https://gi.jhsps.org/Upload/200802291655_2963_000.jpg

Coleccin necrtica aguda

(< 4 semanas)
Coleccin necrtica
encapsulada (> 4 semanas)
 Complicaciones sistmicas [43]

Segn la clasificacin de Atlanta, una complicacin sistmica es cualquier exacerbacin de una

comorbilidad subyacente (p,ej. Enfermedad coronaria o EPOC)

Falla Orgnica Score de Marshall modificado

Un puntaje de 2 o ms en cualquiera de los 3 sistemas orgnicos define una falla del mismo
Sistema Score
Orgnico
0 1 2 3 4

PaO2/FiO2 >400 301-400 201-300 101-200 101

Creatinina < 1,4 1,4 1,8 1,9 3,6 3,6 4,9 > 4,9
(mg/dL)
Presin arterial > 90 < 90, responde < 90, requiere < 90, pH < 7,3 < 90, pH < 7,2
sistlica mmHg a lquidos vasopresor
Diagnstico [44-49]

TAC abdominal
Clnica Lipasa o Amilasa Ecografa Abdominal
contrastado o
Resonancia magntica
Dolor epigstrico de Pancreas
Pncreas aumentado de tamao
inicio agudo, severo Elevacin 3 veces edematoso y
con hiperdensidades
y persistente mayor a lo normal agrandado, con heterogneas focales o difusas.

usualmente posible presencia de Si no hay hiperdensidad con

colelitiasis o contraste puede ser una
irradiado a la pancreatitis necrotizante
coledocolitiasis
Manejo de la Pancreatitis Aguda [50-56]

Lquidos Analgesia Nutricin Antibiticos

Cristaloides Opioides IV Reposo No profilaxis!

Isotnicos Fentanyl: bolos de Leve: suspender Microorganismos:
20-50 microgramos via oral hasta que E.coli,
5 10 mL/kg/h con intervalos de disminuya dolor. pseudomonas,
10 minutos. Retomar con dieta klebsiella,
Si hay hipotensin Infusin contnua: clara baja en enterococos
y taquicardia: 50-700 mcg/h grasa. Manejo dirigido:
20 mL/kg en 30 Hidromorfona: Moderada y Tincin Gram y
min y continuar a 0,2 1 mg cada 2- severa: Frmula Cultivo de aspirado
3 mL/kg/h por 12 h 3 horas en bolos elemental o semi- guiado por TAC
elemental por Manejo emprico:
sonda nasoyeyunal Carbapenmicos o
Quinolonas +
Metronidazol
Indicaciones de monitoreo en UCI [50-53]

Paciente con 1 o ms de los

siguientes
FC < 40 o > 150 por minuto
Pancreatitis aguda severa PAS < 80 mmHg o PAM < 60 mmHg
FR > 35 por minuto
APACHE II > 8 en las primeras 24 Sodio < 110 mmol/L o > 170 mmol/L
Potasio < 2.0 mmol/L o > 7.0 mmol/L
horas PaO2 < 50 mmHg
pH < 7,1 O > 7,7
Edad > 60 aos Glicemia > 800 mg/dL
Calcio > 15 mg/dL
Anuria
Coma
 Intervenciones quirrgicas [55-60]

Intervenciones
Indicaciones Procedimientos
Pseudoquiste Drenajes
pancretico Endoscpico
Pancreatitis Percutneo con
necrotizante catter guiado por
infectada TAC
Pancreatitis Quirrgico
necrotizante (Cistogastrostoma,
encapsulada (>4 cistoenterostoma,
semanas) reseccin, necrosectoma)
Pancreatitis por CPRE / Colecistectoma
http://img.medscapestatic.com/pi/meds/ckb/25/10625tn.jpg
colelitiasis y
coledocolitiasis Embolizacin +
Pseudoaneurisma
Cuando sospechar un pseudoaneurisma:
reseccin
1. Sangrado gastrointestinal inexplicado
2. Expansin sbita de una coleccin necrtica encapsulada
3. Caida de hematocrito inexplicada
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