PANCREATITA CRONICA

Definitie: Inflamatia cronica a pancrea

-sului cu distrugerea tesutului exocrin prin
fibroza urmata de pierderea functiei en-
docrine
 ETIOLOGIE
Pancreatita cronica obstructiva :
tumori, stenoze, pseudochist, ano-
malii congenitale

Pancreatita cronica calcifianta

(95%): alcool(60-70%);hiperparatiroidism;
 ETIOLOGIE

• Deficit de α1 antitripsina, hemocromatoza ;

• Rare: fibroza chistica, hipercalcemie;

• Autoimuna (ciroza biliara primara, BII);
• Congenitala (autosomal dominant);
• Tropicala (toxice, malnutritie proteica);
• Idiopatica
 FIZIOPATOLOGIE
Procesul care initiaza inflamatia pancre-
asului nu este complet cunoscut
Alcool precipitarea proteinelor in ducte

Obstructie ductala
Toxic direct
PSP- S 2-5, Citrat, pH
< 50g/zi
Calcificari intraductale
(calculi)
 MORFOPATOLOGIE
Leziunile sunt distribuite parcelar, lobular
Precipitate proteice, calcificari, stricturi
ductale
Pierderea MB si atrofia epiteliului ductal
Inflamatia, fibroza si atrofia tes pancreatic
distal de ductul stenozat
Chistul pancreatic (chist de retentie)
Pseudochist de retentie
 MANIFESTARI CLINICE
• Durere
- epigastru, CSS, CSD, iradiaza posterior
- inflamatia n. intrapancreatici, ↑pres. intraductale;
- accentuata postprandial, flexia trunchiului;
- Exacerbari pe un fond dureros cronic;
- Dispare in timp prin fibroza pancreasului.
• Malabsorbtie :
- steatoree, vit. liposolubile (A,D,E,K);
-↓ponderala, Vitamina B12;
• Diabet
- ↓insulina , glucagon
 TRIADA CLASICA

Calcificari pancreatice;
Steatoree
Diabet zaharat

! < 1/3 din pancreatitele cronice

 EXAMEN FIZIC

• Durere : epigastru;

• Masa palpabila (pseudochist, carcinom);

• Malnutritie ;

• Icter colestatic (20%)± ciroza (10%);

• Hipertensiune portala: tromboza venei

splenice sau porte.
 PROBE BIOLOGICE

• Amilaza serica
↑ atac acut, devin N tardiv, prin
• Lipaza serica fibroza pancreasului
• Bilirubina, fosfataza alcalina ↑ (20%);
• Teste hepatice;
• Hipoalbuminemia;
• Hipocalcemia, Fa ↑(vit.D);
Malabsorbtie
• Tulburari de coagulare (vit K);
• Anemie macrocitara (B12);
• Glicemie ↑
 TESTE IMAGISTICE

• Rx abdominala - calcificari ductale (30%);

• Rx. cu bariu - ↑ spatiu retrogastric;

• Ecografia abdominala/ CT : dilatatii ductale, calcificari,

pseudochist, tumori ;
• Echoendoscopia;

• ERCP : stenoze ductale, calculi, dilatatii, chist; duct

principal >1cm cu stenoze intermitente (“sir lacuri”);
Ductele secundare, dilatatii si obstructii - pierderea
“acinalizarii”.
 TESTE ALE FUNCTIEI PANCREATICE
• Teste directe:
- test Lundh/secretina i.v. volumul <2 ml/kg, conc
bicarbonat < 90 mEq/l, prot↓;
• Teste indirecte:
- ex. microscopic fecale (grasime);
- dozare cantitativa lipide fecale ; 70g lipide /zi ;
scaun / 72h; >5g/zi, >5 - 8% din lipidele ingerate;
- test oral cu trigliceride radiomarcate;
- test bentiromida : PABA urina (<60%/ 6h) ;
- elastaza (fecala)<100µg/mg, tripsinogen seric
 TRATAMENT

• Controlul durerii :
▪ abstinenta de alcool, mese fara grasimi;
▪ paracetamol, dyhidrocodeina, AINS;
▪ Feedback : enzime pancreatice (tripsina)
▪ opioide : pethidina – dependenta;
▪ plex celiac: percutan (alcool) :ameliorari tempo-
rare 6 luni)
▪ Chirurgie: drenaj, pancreaticojejunostomie
longitudinala sau caudala, sfincteroplastie, rezectie
pancreatica
• Malabsorbtia:
▪ dieta : restrictie de lipide
▪ enzime pancreatice - lipaza 30000 U/ masa - 10
tb/ masa: Cotazim (6cp), VioKase (8cp) Creon
(3cp), Zymase (3cp). pH gastric >4 -1h post-
prandial : H2 blocant, PPI (p.conventionale). Preparate
enterosolubile (pH >6)
▪ Suport nutritiv : mese mici (proteine), TG lant
mediu (vena porta)

• Proliferarea bacteriana: Tetraciclina 500mg/4/zi,

Metronidazol 500mg/3/zi -7-14 zile

• Diabet : doze mici de insulina

 COMPLICATII
Malabsorbtia B12 (40%) – enz. pancreatice
Retinopatia nondiabetica (vit.A)
Fistule (pleura, peritoneu, pericard)
Sangerare gastrointestinala: pseudochist
ce erodeaza duodenul, varice esofagiene
(gastrice)
Obstructie cronica :icter, colangita, ciroza
biliara
Necroze subcutanate (noduli, artrite)
 COMPLICATII

• Pseudochist - 10 % P. cr, corp/coada, asimptomatice;

- complicatii: ruptura, hemoragie, infectie;
- drenaj extern (ch/perc) intern (ch/end);
• Stricturi - dilatare endoscopica (balon);
• Calculi - litotripsie extracorporeala/ERCP;
• Ascita - octreotide, paracenteza;
- stent (ERCP),
• Fistule - pacreaticopleurala toracenteza;
• Obstructie coledoc : stent (end)/ bypass chirurgical;
• HT portala - tromboza sau compresie vs/vp decomp.ch.
 PROGNOSTIC

• Mortalitate:
- 25 ani 50%;
- 20% exacerbari acute
- alte cauze sinucideri
ciroza
malnutritie
dependenta droguri
infectii
 CANCERUL DE PANCREAS

• Incidenta s-a triplat in ultimii 40 ani;

• barbati, > 60 ani;

• supravietuire 1-2% dupa 5 ani; medie < 6 luni;
• anatomie patologica ADK ductale 90%
T. endocrine 5%
Alte: acinar, epidermoid
• localizare:
- cap (70%)
- corp (20 %)/coada (10%)
 FACTORI DE RISC

• Dieta : carne rosie si lipide ↑;

• Fumatul de tigarete;
• Gastrectomie partiala, colecistectomie;
• Cancer colorectal ereditar nepolipozic, cancer
mamar familial, Sd.Peutz- Jeger
• Pancreatita cronica (ereditara si tropicala);
• Pancreatita acuta recurenta - genetica.
• Expunere: naftylamina, benzidina, metale (praf).
 MANIFESTARI CLINICE

• Initial nespecifice, : anorexie, ↓in G, greata, diaree,

tulburari psihice (depresie);
• Durere epigastrica :75%, irad post, invad n splanh.;
• Cap / corp, coada
- icter colest. progresiv/ tardiv - meta hepatice;
- obstructie duodenala /- ;
- hematemeza (stomac)/ - ;
- colangita, pancreatita acuta recurenta/ - ;
 MANIFESTARI CLINICE

• Diabet recent / intoleranta la glucoza.

• Tromboflebita migratorie (Trousseau)
• Poliartrita, noduli cutanati (necroza grasa)
 SEMNE FIZICE

• Tumora palpabila (epigastru) ¼ pacienti;

• Ascita - invazie peritoneu, HT portala;
• Semn Courvoisier;
• Semn Troissier (gg. scv stg);
• Icter
• S. Paraneoplazice: TF migratorie, endocardita
marantica, S. Cushing
• Necroza grasa metastatica (EN - like, artrite).
 INVESTIGATII
• Markeri tumorali: CEA (50%), CA 19-9 (80%) ;
• Ecografia abd. - masa in P, dilat CBI si CBE;
• CT (spirala), RMN;
• Biopsie percutanata (aspirat citologic);
• ERCP - sensibilitate >90%, lavaj, periaj;
• Ecoendoscopia: stadializare preoperatorie;
• Angiografie: A.celiaca, AMS
• Laparoscopia - biopsie diagnostica,meta (ficat,
peritoneu, epiplon)
 DIAGNOSTIC DIFERENTIAL

• Carcinom ampular - 10 × mai rar, Adk;

- coledoc, pancreas, duoden, ampula;
- icter intermitent initial, apoi progresiv;
- colangita, pancreatita, sangerari digestive;
- ecografia: dilatatie CBI/CBE, obstruc. distala;
- ERCP - dublu duct : dilat. CBE si duct pancreas;
• Colangiocarcinom - icter rapid agravat, nedureros,
colangita;
• Pancreatita cronica.
 STADIALIZARE
Stadiul I: numai pancreasul
Stadiul II: intereseaza P si structurile
vecine
Stadiul III: gg. regionali
Stadiul IV : metastaze

Stadiile I,II si (uneori) III – Tratament

chirurgical
 TRATAMENT
• Radical: chirurgical - <10%;
- Pancr.duod.ectomie (Whipple)/ P ectomie totala;
- tumori <3 cm, fara extesie locala si fara meta.
- mortalitatea op. 16%, suprav. >5ani 4 - 15%;
• Paleativ:
- Icter- nechirurgical (stent) chirurgical
ERCP PTC (perc) ambele C/J anast G/J anast
- Durere - opioide sulfat de morfina 20mg /2×zi,
radioterapie externa, blocarea perc. pl.celiac.
- Chimioterapie ± radioterap., Gematabine, 5FU;
 TUMORI ENDOCRINE PANCREATICE

MEN - neoplazia endocrina multipla : paratiroida,

hipofiza, tiroida, suprarenala, pancreas

Tumori functionale - secretie excesiva hormonala

sindroame clinice variate;

Tumori nefunctionale : obstructii locale - cai

biliare, duoden, hemoragie digestiva, mase abd.

(cromogranina A si B, hCG)
 Tumora Hormoni Localizare Simptome si semne

ACTHom ACTH Pancreas S. Cushing

Gastrinom Gastrina Pancreas(60%) Dureri abd, ulcer,
Duoden (30%) diaree
Alte(10%)
Glucagonom Glucagon Pancreas Intoleranta la
glucoza, anemie, ↓G
GRFom Factor de Plaman (54%), Acromegalie
eliberare Pancreas (30%),
a STH
jejun (7%) alte (13%)
Insulinom Insulina Pancreas Hipoglicemie (post)

Somatostatinom Somato- Pancreas (56%), Intoleranta la gluco-

statina duoden/jejun (44%) za, diaree, calculi VB
Vipom VIP Pancreas (90%) Diaree apoasa
alte (10%) severa, flush, ↓K,
acidoza
 Diagnostic

CT, RMN;
Scintigrafie cu somatostatina
Angiografie selectiva
Ecoendoscopie
 INSULINOM

Secretie ↑de insulina 80% unice, 10%

maligne;
Hipoglicemia
Dg: Glucoza si Insulina/ bazale (<40mg/dl,
>6µU/ml; I ser/G ser>0,3);
Ecoendoscopie
Chirurgie
Multiple: Diazoxid, Ca blocanti, β- blocanti
Streptozocin + 5-fluorouracil.
 SINDROM ZOLLINGER-ELLISON

Tumori ce produc gastrina: (cistic, coledoc,

duoden,gg limfatici, pancreas –”▲gastrinomului”
Hipersecretie acida gastrica, ulcer peptic sever,
localizat atipic ;
50% maligne;
Diaree (25 – 40%);
Gastrina serica > 1000 pg/ml, HCL >15m Eq/h;
Testul la secretina : ↑ gastrina serica;
CT, scintigrafia cu somatostatina,
echoendoscopie;
PPI: esomeprazol 40 mg/bid;
Octreotid 100 -500 µg sc/bid, 20 - 30 mg
im/lunar;
Chirurgie;
Streptozocin + 5 - FU sau doxorubicina
 VIPOAME
Tumori ale celulelor insulare nonβ pancre-
atice;
Secretia substantelor vasoactive intesti-
nale;
50-75% maligne;
Diaree apoasa 1000 -3000ml/zi;
Hipopotasemie, acidoza, deshidratare,
aclorhidrie;
20% flush asociat episoadelor de diaree.
Ecoendoscopie, scintigrafie cu
somatostatina.
Inlocuire hidrica si electrolitica;
Octreotid :20/30 mg/lunar
Tratament chirurgical;
Streptozocin + doxorubicina