Cel mal frecvent cancer gastro-intestinal, a trelea cancer ca frecventa (al dollea la femei, al relea la barbatl). Implicarea statusului socio-economic scazut (reste riscul de cc colon dr (30%), factor mai putin implica in cc rec). Factori de mediu | Factori genetici as ‘Consum crescut de grasimi,scazut de legume sifructe PAF (polipara adenomatoasa familial) ‘Sr. HNPCC (ee Fumat, alcool | " nonpolipezc erecitar) Preparate hormonale (anticonceptionale, estrogen, a tamoxifen) Infect virle (HPV) Colecstectomie leadiere Boll inflarator intestinal (coli uleeratia) | mutatiagenel APC (AP cll) ce codifica cilia Mutat ale genelor cu ral | Dfe-myccu olin activitatea oncogenelorce in repararea ADN (MSH, promoveaza cresterea celulara MLH2, PMS2) * mutatia genei RAS ~polipi mari | | - deletia bratului cromozomului 18q ~ rise crescut de recurenta postoperatorie Debut insidios, rar descoperire print complicate (25-25% cazuri sunt dlagnosticate secundar ocluzie) In stadlu incipient, semmnele si simptomele sunt vagi scadere ponderala,subfebrilitate, inapetenta, sdr anemic ~ cu hipotensiune arterala,tahicardie, paloare, astene). Simptomatologia datorata complicatilor local a Colon drept (Colon transvers Colonstang Re Caracteristice ~ compresie ureter Fistula gastro- " Constipatie ‘Seaune mucurs + | Sangerarirectale {ureterohidronefroza) _—colica/duodene- 5O ai si persoane cu rise mediu/crescut (cu AHC/APP de CCR sau alte forme de cancer/RCUH/Boala Crohn/polipaza familial) In vederea conduiteiterapeutice, primul obiectvin diagnosticul une! neoplazl in Portiunea distala# intestinului gros este stabilirea ocalizari (colon sau rect In cazul localizaril pe colon -> interventiechirurgicals urmata de tratament adjuvant In cazul neoplasmull rectal subperitoneal - tratament neoadjuvant (radio-chimioterapie) urmata de interventie chirurgcala (interventiachicurgcala fara tratament neoadjuvant, are o recidiva a 40%),“T= fara evidentierea tumor rimare ‘Tiss ~intraepitliala (cel ec in en ‘membrana bazala/intramucos ot (intereseaza lamina propria) : TANI (a: metastazain 1 gel b:23 oon ‘g),€: nodull sate) in subseroasa oe su in tesuturle neperitonizate pericolice/perirectale) ‘T3IN2 (a: metastazain 4-6 gel bs metastaze > 7 gl) Ta -invadeaza direct alte org/structuri/sau peritoneul visceral (a: afectarea peritoneulu viscera, b: ate organe/structui Stadiul I de boala ~desirezectia chirurgeaa fara ttt adjuvant este standardul actual, evista rise de recidiva si chiar deces in 20% ain cazur! Factor de prognostic negatv in acest sta: ~invanalimfatica,venoasa, neurala gradul de raspuns la tratamentul necad]want -gradul de ciferentiere tumoraia (bine diferentiate:structura slandulara, seretie conservata, stroma in cant echilibrata cu ” b_prolferarea epitelisa; moderat diferentiate:tuburiglandulare Iregulate, mitozefrecvente; slab diferentiage:strcturtubulare rare) ‘Octuzia Perforatia Hemoragia Ces maifrecventa- Indoi tpl [abcese efractonate incaitates perioneala). __Hemoraga severa~ rar; Hemoragi repetate cu caura de cutie. Abeeslintrabdominal fbr, durereabdominala la palpae: canta mi de songe sunt freevente nx de colon ‘Mai freeventa la persoanelein ccentuare (asem star septice) _ contur impreci, + semne de fuctuenta, Semne generale foarte ‘dep s determina anemie feiprva In cancerul de rect e elimina rosu, proaspat, amestecat cu scaunul ‘aula sfrsitulscaunului (sau poate fio emisie numai ddesange eu cheagur, care apare dupa seneatafalsa de scaun). Cand tumora prezinta segmente necrotice = eliminarea acestora produce o hemoragie semnificatva cantitati eae se exterorizeaza co rectorage cu sange rosu,proaspat. varsta [Abcesul retroperitoneal: perforatia nel tumori ce evolueara Semne de | pen segment fic colorectal stare septica + fenomene de sravitate: calulita parietala si emfizem cutanat. aparare + ladistanta(alastatical cel mai frecventintalnta la nivelul rmusculara ‘eculu, cand valva ileo-cecala ramane competenta.Perfoatile sfebre Juxtatumorale sunt specie ce dele rvelul colonull er, iar duvere cele dlastatice sunt specifica ce dela nivel colonulu st. In stad incipient: rezecti radicala cu margini de siguranta de S cm sup int de tumora + rezecte ganglionora + exile completa de ‘mezocolonaferent. Pt evita diseminares: ligaturavaselor la origine + prinepil no touch (evtarea mobiizai tumor Intase exploreatacavperioneala (carcinomatora? mmetastaze?) Pentru tumorile de colon drept: ¢ hhemicolectomie dreapta cu anastomoz ‘ieocolca manvala sau mecanica Pentru tumorile de colon stang lan unghiul splenic colectomie segmentarainalta + igatura rsa ala colice mediisia a. coie stg + anastomoza colo-olca Pentns tumorie de colon descendent: hemicoletomi t+ igatura AMI la eiginea din aorta + anastomoracoloretaa termino terminals (colonul transverse trace peste ultima ana lela sau prin merenteul Pentru tumor situate pe sigmoid colectomie segmentara st, jas, cu igatura AMI su acl de emergenta ala colic st + anastomozacole-rectala (a nivelul vertebre 2), ‘Chimioterapiein staiul N+ (stadt sau daca sunt prezente alte semne de prognostic negativ(invaie vascuara/perineuala, grad de dliferentireseazut) Cancerul de rect, iz excite totala de mezorect (Heald, 1982) ~recidiva < 8%. In momentul iagnosticului~ 10-20% dintre tumarile rectal sunt considerate Inoperabile sub aspectul radicalitaii oncologce,datortainvazlel in fascia mezorectului/organe vecine, RT/CAT preoperatore scade invazia, favorizand rezectiachirurgicaa (down stage, down siz) favorizeaza prezervarea sincterul, eradiearea micrometastazelor.Indcat de ragioterapie preop: neoplasm rectal subpertoneal (poll inferior al tumori < 10 em de marginea anala), 73-4 si/sau NO sau Nv. Se asociaza CCRT. Prezenta leiunilor secundare reprezinta o contraindicati pt tratamentul neoadjuvant! ‘Tratament chirurgical: limits dstala de rezectle= Lom, larlimita marginlrcircumfererentale - Imm: exerexo rectului» mezorectulu structurlinvadate + 9gl loco- regional +ligaturainalto a nedicullor vascular Interventile cu vza radical cu prezervare de sfincter anal SAU formarea une! stome (excizieabdomino- perineala de rect) Abord minim invaziv Inparoscopic, asstat robotic permite posiblitates tune sect foarte joase si prezervareasfincterulu ‘ratament paleativ daca rezectia rectului nu este posiblla. Daca riscul operator este acceptabils textensia boli metastatice minima ~ se recomanda rezectia tumor primare (cestecalitatea viet si previne obstuctia, durerea,sangerarea) ict‘CANCERULGASTRIC ologle. 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Oca recs ete | eminlaprovorestloerenconimutat dupe? 3) Uneor ae pate ee colertomi subatas crePANCREATITA ACUTA Incidenta: 17-80/100 000 locuitori Pancreatita acuta (PA) este o inflamatie pancreatica datorita activarli premature a tripsinei in celulele acinare, extinsa uneori la tesuturile peripancreatice sau la distanta. Pancreatite acute recurente—evolueaza prin fbroza si pierderea tesutulul glandular ~>pancreatita cronica Forme usoare (85% din cazuri = PA edematoasa interstitial; insuficientele de organ sunt absente (sau tranzitoril in 10%, cu ‘mortalitate tY, - 3%) sivascularizatia pancreatica este pastrata, Forma moderat severa sau severa (15% din cazuri, pancreatite necrotice’™* "ive serumrescerarcccterhemens)_afectares vasculara cu neroze si insuficiente de organ tranzitori sau prelungite si complicati locale sau la distant In PA necrotica in 50% din cazuri sunt prezente insuficiente de organ, cuo mortaltate de ‘tama +17%.infectarea necrozelor (33%) = factor agravant, cu mortaltatet 30% Sites Diagnostic: tone 1. Durere acuta, severa, persistenta,epigastrca cu iradiere in spate sau in bara iro 2.activitatiilipazei serice (sau amilazelor) x3 N oer 3. aspect de PA la CT cu contrast Iv (CTCI), IRM, ecografie. ovoapeens/ypecsesense Daca 1+2 sunt prezente, CT si IRM nu sunt necesare, Ecografiaajutalaidentificareaetiologiel.Daca_ then lipazele/amilazele nu sunt>x3N, PA trebuie confirmata prin CTIC sau IRM. me Etiologie consumul de alcool + ltiza biliara sunt raspunzatoare de 80% cazurile de PA Este in TPA prin afectare vasculara pancreatica instar de Soc, IC, pacieti cu inteventi chrurgcale majore, dar si PA idiopatica Factorietiologici in PA Metabolici Mecanicl infectiosi Vasculari/imuni ~ alcool =litiaza biliara Parotidita endemica | Hipoperfuzie tisuiara/ -HiperCalcemia | -tumori periampulare/tumori pancreatice | Cocksakie DCL /s00 -Hiperlipemie | - pancreas divsum/disfuncti sfincter Oddi | HIV Postoperator (anevrism de -Medicamente | -diverticul duodenal perambular/al CBP Mycoplasme aorta, transplant cardiac®) (diuretice, - Traumatisme pancreatice Ascaridoza sialte | Panerterita nodoasa (PAN) antibiotice, = Intervent chirurgicale/ERCP parazitoze Sindrom Sjogren citostatice) + obstructii duodenale/obstructia ansei Les, aferente Panereatita autoimuna = ulcer duodenal postbulbar Deficit de at aT Patogeneza i ne 1. Actvarea prematura at rs - alterarea mecanismelor de semmnalizare prin Cae in eelueleacinare = + scindarea tripsinogenului > tripsina (hidrolaza lizizomala catepsin 8) — a) ~activtati inhiitorullintracellar pancreatic al tripsinel —— ac | 2. Agresiunea ensimatica > inflamatie intrapancreatica -Stimularea Macrofagelor*, Lmfocitelor*; elberare de factor chemotactic-> ‘mobilzareacelulelorinflamatorice aderara la endoteliu 3. Extinderea extrapancreatica a procesululinflamator, ce devine sistemic {imbalanta factor inflamatoriantinfiam?); SIRS, MODS determina exacerbarea afectiunilor preexistente. 4. Afectarea microciculatiel ->tomboze, hemoragi, necroze Peripancreatic,utlerior la lanur fascaleretroperitoneale la dstanta: mezenter, ‘mezocolon, fascia perrenala, Se constitule colecti pancreatice si peripancreatice acute. Ruperea ductulul pancreatic prin necroza determina fstule pancreatice; Poate fi prezenta ascita pancreatica 5. Afectarea vaselor mari din retroperitoneu~> trombora de vena splenica, a. splenic, Vena porta (Hipertensiune Portala), anevrisme arterale, rupturi vasculare cu hemoragii 6. Stomac, duoden, Intestin sau colon transvers: Procesulinflamator din retroperitoneu extins in mezouri determina tulburarlfunctionale, ledem, ischemi, hemoragi, necroze, stenoze,fstule pancreatco-enterale, Obstructie bilara ~ de cauzalitazica sau produsa prin edem pancreatic, necroze si colecti, 7. Supraintectarea tonelor de necroza: supuratie->sepsis->s0c septic Forme anatomo-clinice forma uroars cu remisie completa prima © forma grava, cu necrone ale pancreas "Prezenta zonelor de supuratie (puro) arin saptamana ras peripancreatic; ischemia pancreatica primele 2 sap; clagnostc: CTC -aerinafara ‘edem inflamator pancreatic ‘evolueazaprogresivin 3” sapt tubul intestinal a nvelul necrozelor ‘generalzat/localizat determina hiperrofla _-zone de coptare reduse a contrastululla CTC), pancreatice/peripancreatice; dubli? >FNAC cu Pancreasulu cu coptorerelotivomogeno a _ devin progresiv net marcate siconfluente > ex bactriologl, cultura s antbiagrama ‘contrastuli la CTCL dupa 1 saptamana aparnecrore cuevolutie bees pancreatic (al rarl= ,colecti locaizate -procesul de extinde sla grasimes imprevisbita(raman solide/ se ichefaza/ de material purulent fara o necroza peripancreatica, uneoricucolectilig, dar fara persista se remit se infecteaza) pancreaticasemnficatva", nu se foloseste in necrave! ‘terminologia curenta‘Complicatii generale Aesratar te >20repionnn or ACO, <32 me ces > 12,00 or 4.00 mn 10% pup Secrpte cere Seis Presence o SRS + cond contrition Se hpoperte Sore saps Sepu rele ori tlre, ypotanion adic tase movant Sep seck Sap with hpotansan dpe dug reuscain with th prunes fey moos sles Sepsis=raspunsul sstemic al organismulul la o injure infectioasa cu asocierea uneldisfunctl de organ. - Disfunctia pulmonara: grecoce in SIRS, plamanul find un fitru pt mediator inflamatielintorsl in circulatasistemica. ARDS este caracterizat prin hipoxemie refractara la administrarea de O;, anomalil de ventlate/perfuze (V/C], edem interstitial sl alveolar, CRF (capacitatea ‘eziduala functionala) sia compliantei pulmonare si infitratcifuz a radiologie, - Disfunctia miocardica¥ in soc: mai grava la cei cu afectiuni preexistente, TNF — depresie miocardica®? Lezlunirenale: prin ischemie si inflamatie;redstributi in soc in specials nivelul cortexulu superficial (unde apar leziuile precace, Resuscitarea agresiva poate limita necroza tubulara acuta (NTA). La pacienti uremici cu tub hidro-slectrolitice dializal - Leziuni Gastro-intestinal: ulcerati acute gastrice, cluziefunctionala,clecisttaaitianca. Ruperea barlereintestinale ~ransiocare bbacteriana sia toxinelor in crculatia portala, cu intetinerea procesulutinflamator sl infect bacterien. = Disfunctia metabolica side sinteza hepatica precoce: blrubina, uree,lactat serie. Celulele Kupfer au un rol critic in eliberares de elated Maa cng ten an ean ‘mediator al inflamatiel si v Intretinerea MODS, oe ote ' . 2 , ‘ “Afectarea SNC: afectarea stari de constienta pana la coma omer ne me 2 evaluates graviat stuatilor ee sw hemwene eth mew ‘m-12 Care evoluearacu SIRS s soc 58 a face prin scorurl de severtate = » (Apache sau cel mai : 3 frecvent utlzat-seorul ° ‘Marshall parametri respirator, : hemodinamic funetie rena) we pcm wp ny ea ect tr chan ee hs et restate taht aman Colectiile pancreatice si peripancreatice ‘Atlanta 2012: colecti strict lichidiene SAU cu continut solid/solid cu zone lichidiene (provenind din necroze) 1. Colectillichidiene peripancreatice acute: in fazaintiala de evolutc a PA 1usoare; Ia CTC! colecta unica/multpla este omogena, fara peret prop, delimitata de planurilefasciale normale din retroperitoneu. Sterile, se remit sponton =u necesita ment specific. nu ceprezinto factor de gravitate in evolutio boli, Cond persia > 4s s2.de2voltaIntr-un pseudochist pancreatic, 2. Pseudochistul pancreatic (rar:coletie strict lichidiana (cu enzime’?) peripancreatic (rar partial/n totalitate intrapancreatica),delimitata de un perete bine definit. Este urmarea rupturi ductului pancreatic principal sau aramunioracestula, in absenta necrozeievidemtabileimagistc, cu plerderea de lichid pancreatic si persistenta colectiei peripancreatice > 4 saptamani, Diagnstic: CTC, IRM, Ecoarofie, ecoarafe endoscopica (mai specifice in documentarea ‘absentei unor zone solide in continutul pseudchistul). sitatie poticulara: sar de deconectorea ductala surveit la soptamani ‘dupa necrezectomia chirurgicale. Necroza de istm/corp pancreatic zoleaza o portiune inca viabila de glando, a care secretie se ‘acurmuleaza in spatiu restant dupa necrezectomie. 3. Colecti necrotice acute: continand tesut necrotic i icidan; in primele 4s de boaa a nivelul pancreasulu si peripancreasulu. Pot fi ‘multiple, uneori mutilocuate. Apar ca urmare 8 rupturi ductului pancreatic principal sau al ramurilor acestora in zonele de nacroza 5132 pot infecta;diagnosticuleiferental este dificil intre coeletiielichidiene peripancreatice acute si colectile nacrotice acute in prima sapt de boala(continut fui la CTC!) dupa fazainala-la CTCL: zone de necroze; IRM, Ecografie,eco-endoscopie au sb mal mare in evidentiarea zonelor solide 4 Colectia necroticaincapsulata (,walled off necrosis" /sechestru pancreatic/pseudochist+necroza/necroza pancreatica organizata) in evolutia coletilor necrotice acute, cand lads apar zone de colecti necrotice sunt izolate de un pereteinflamator. Colecti unice/ultipl/la nivel lojei pancreatice/ladistanta s se pot infecta. DDx se face cu pseudochistul: IRM, Eco, Eco endoscople —rone necrotice solide in interior clectel Evidentierea unei comunicar eu sstemul ductal pancreatic are importanta in tratament. 5. Colecti nacrotice acute infectate si colectile necrotice incapsulateinfectate:alterarea star generale; ar in colecte in afara lumenului intestinal la CTC. Dubil? Diagnosticul de certitucine cu FNAC si examen bacteriologic.‘Tablou clinic Examen fizic debut brusc, dupa o masa -deshidratare: turgor cutanat diminuat, bogata in alcool si alimente ‘tegumente uscate, ochi infundati in orbite colecistokinetice; Durere creste __-uneor' subicter scleral; progresiv 7timp de 30min, pana Abdomen: distensie difuza, Durere in etajul devine insuportabila; continua, superior, uneori aparare musculara. Iradiaza in spate ,in bara"; >24h; _Echimoza periombilicala (semn Cullen) si in Durerea poate linsilaceiin soc flancuri (Gray-Turner) sunt rar evidentiate. sau cu senzoriu Ausculator plamani: MV.Lla baze (colecti alterat/postoperator trataticu _lichidiene pleurale, mai ales pe partea sta) antialgice Forme severe: aspect toxic, sor, Insuficeinta * Greata sivarsaturile,oprirea _renala, respiratorie, sangerare gastro-intestinala, tranzitului pt materi si gaze ~asociate constant tulburari de coagulare si metabolice severe *anamneza“etiologielinclusiv semne de cancer, AHC de PA) (hipocalcemia) Paraclinic Cauze de -Amilaze silipaze’™ (lipazele | Diagnostic diferential PA Amitazemie?: raman‘Pmai mult timp, si -infarct -macroamilazemie | sunt mai putin influentabile , , enteromezenteric -parotidita ‘comparativcu amilazele) -ulcer Gastric/duodenal -pancreatita cronica | ALT, bilirubina >x3N=> perforat -ocluzilintestinale | etiologie biliara -colicabiliara carcinoame PCR > 150 mg/l la <36h => -disectia anevrism de -tumori ovariene__| sugereaza o forma severa ; aorta sau prezenta necrozelor; uti = -Ocluze intestinala in urmarirea evolutiei procesululinflamator -IMA inferior Ecografie: 1" pt evidentierea litaze; sb pt Litaza de CBP dilatarea CBP nu e diagnostical).Pancreasul are volum*, hipoecogen (edem), + ascita,pleurezie; CCTCI- de electie cand exista dubit, Pvolumului pancreatic prin edem, captare inomogena, desen ,in suvite” a tesutul peripancreatic si colectilichidiene peripancreatic. Etiologle:caleificari pancreatice (PC alcoolica),dilatarea ductului pancreatic prinipal sau dilatatea chistic (neoplasm mucinos paplir intraductal, neoplasm cistic); index CT de severitate in dinamica ~ volute si complica nu se foloseste substanta de contrast la Cr> 1.5mg/dl sau alergie las. IRM, colangio-RM, eco- endoscopie —ofera detali/zone solide la nivel colectilor/ confirmarea Iitiazel. Nusefacin urgental Forme clinice. Scoruri severitate (Ranson si Imre). A forma usoara = absenta insuficentelor de organ sau a —_Faza initial Faza tardlva complicatilor locale PA edematoasa interstiiala).CTCY/IRM _(primele 25) Persistenta SIRS > 2 ect ern ru sunt necesare de abice, pacienti/sunt externatlin 1” sapt; SIRSenecroza sapt sau aparitia a are loc normalizarea functie pancreaticein 5-7 zle, prognostic pancreatca complication _—_— favorabil Factorul locale la pacientii ‘eokomononsh Forma maderat severa:insuficlente de organ ranzitori determinant al cu forme moderat ~ -<4Bh/ compliati locales sistemice. Exemplu:pacientiicu _evolutiel: MODS. severe de PA. Chiar Semrasnan amr necroze pancreatice sterile, fara insuficiente de organ dar cu Insuficienta de daca persstenta “ease 8 ‘rratamant in cazul necroze extensive cutoleranta,laalim _persistenta da gravitatl in aceasta 2 wecois lorala/ exacerbarea afectiunilor preexistente. dureaza > 48h axa, complicatile 3 Gu>00 Forma severa: nsuficiente de organ persistente >48h (736%), Nuexista 0 locale ausiele un 4 asto250 SIRS prezent si persistent de la inceputul boli anunta forme corespondenta intre _impactimportant nee! severe > de prefaficonsigerata si tratata cao forma severa, SIRS, MODS si asupra peashrs out ‘vand evolutie imprevziial ‘modificarile locale prognosticulul Lice GalvETOH. Lapacientiacare —=>apreciere prin 2. HeT‘al> 10% MODS sunt prezente CTCL, IRM, 5. poxee0 BenivetGn) din primele ale Ecografie “Thin Swi’ martialitatea tajunge Incronet BUN ig 50%, Complicatih roe Ioeale frevente, S. Base defict> Amég/t 6. Sequestration of fis» 6L ‘Ht masurat la 12h apreciara vol de liq sechestrat in spl patolagie. Scorul Ranson: ictiva mai mare pt scoruri mici (<2, forme usoare), sau mari (>6, forme severe). E preferat scorului Marshall,‘Tratament 1 ppacienti trebuie internati pentru evaluarea gravitatil Pacienticu risc inalt sunt directionati catre terapie intensiva: 30, cu insuficiente de organ, colecti sau infiltrati pulmonare sau comorbiditati importante. Evaluarea gravitati in primele 48h: APACHE Il, Marshall, SOFA; >48h: Ranson; PA forma usoara -eechilibrare volemica 3.4L NaCl 0.9% izotona/Ringer Lactat/2i = sub control Hematocrit, PVC, TA, Debit urinar (30mi/); -mentinerea valorilor ‘normale ale glicemie (la pacienti fara diabet, glicemia se normalizeaza dupa 24-36h de la debut); -$atO;>95%; in prezenta Insuficentel respiratorii ccautam ARDS la Rx! -tratamentul dureri pew analgetice, ‘morfina, petidina, dllaudid (hidromorfina), fentanyl -asplratie nazoveastica pentru ameliorarea Leretei sivarsaturilor, a ddureri la pacienticu ileus gastric, Dupa 24-36h> AINS -Alimentatiap.o. se rela progresiv “investigatii pentru etiologie: metabolic, Ecografie. itiaza bi = colecistectomie laparoscopica cu colangiografia Intraoperatorie (in ‘aceeasiinternare, la 3-5 2 dela debut) Faza initiala ~ primele 2 sapt - Principalele obiective terapeutice: functi vitae, Insuficiente de organ; “IOT, suport cardiocirculator cu inotrope, resusctare agresiva (sechestrare cantitati mari‘? de lichid) cu $-10 L/2i sub controlul PVC sia celorllti parametri Pentru formele severe cu raspuns insuficent la rmasurile de resusctare sau ERCP cu sfincterectomle si extractia calculi) = In pancreatita acuta, forma sever de etiologie biliara, colecistectomia se face dupa rezolutiaprocesululinflamator pancreatic s restabilrea stari clinice a pacientilor. Sfincterectomia endoscopica este o alternative la ceicu rise operator‘? pt preventia pancreatitelbliare recurente (chiar daca exista, cel putin teoretc, risculinfectari unor necroze pancreatice sterile)Ditferentit : agnosis ‘Assessment itor Severe pancretinat aut/eronia a serasepritonele aut de get nets chim, aura sb rath In rata, petontacinfciinragertonal ct: Cea ma recent Patogenia dupes cx mo frcvent ste prota secunéara 95%), mratatea mn scdee, pnd de etalope(peront eal 50% erento pene (1/3 talttes prtontelr uu CMHOW-= 1 29) tu TOP caso csloreti [3 aol pends (31), po groan 19) cy Shgrtaes pasts aculigto- “pofrate/cese lane este loaner tare: VD cease caer dspreprionat apart dude ee 3 er ‘nesta ra (lect prorated penta se ceca ae, ovine arenas stomata Se an denture ints ere cle, els rth Inectsineperteneale; —_petonta Sahac renner orgne phir: poor, espe, prorat tere SGutsespetaneatsete Samant mp ne Rematogena: menor ‘sheen oa colt purer: Nea pla ih pancreas ‘tes sucaurtde sim poten ‘sreumocnes ston, reptnccea “postrawnsts: penetrate, purse vcr surance hemoperone gemenisubpatgen; sree ec Tinie vrsdagati dela *estopeto: dehacenteonaometc seo hereon Sirseneenteerner bated Trnomuras ono Falimerebieettdeauns otters easy) Sacwodestrape Sunes {Fea geren’ at trosent) (raw) Sacer ab ptogence initeocigteton nonce Sito ae conn Mctin, ee Maniestar clinics Debut atl in lina stare de senate; posts aparacz pina manfestre Desut neato pertont ie, nero ilo recor atarent inspect Mes caacterste pm otomen mab act feyorterats siperla (ap prod np Faces paca, pe pl oe infandatinobtenas Gust castauamneaneae alta ‘ev ts le pont ra, barb prowminet, coo ‘uate nian pour veno | araparrawin | SUSU cae, tact rf 5 ae mamas | Palas trvanl inden oval apical spare mera Peete ‘Secteay— (pessain ome strat) te RRS tse rn con ‘Siwowes) forme aston cand est iacua ge asters su informe pert, ranpeunlnd_ rot cies php ee ‘ier pmcmernare | sede maoen mate sa onrara poste“Opera anal t materisigae (itl us ani edie apace mecno- wat cu deposaves ambi de cea pate intanatae) ices ncaa bons ‘Seema a cop) = res de itt Dough reser: urbe tat pci nd rect ‘aot recente a amen inl eal acess delat hio- —inenracMe Lato mate) tlectroce severe ft xp n cal expt (meuopate de apae oncom arate Duet ere = sen opotu (Mandl: mata delasbla cet. crt, daa mata hepatic in aettone on gar inallesin Sieh prise eis Sense ects opae/revene:sonds Url ae pain ceo (ae sate) de aspate est) ‘tnt fre arate pull ond ns dsc emerags det ala deb materia hestochae au mela gata ge ——_Tnuractapral fut este deo fun eae Sefer gs ct) i ca tba (deb ibe Rperlenerar-in prone pest bert a iporeatin ara, pltraumatiai 1 Fon (marca acer cant pestent eu micas wate in estar seer) especie Rachograia abdominal: penurcpertane vex inapne pxornomene penn ermolecourams de bie uactort 12 00/20% forme perfor imap howerce (nso) lature msargle peer (hucopena et un sn do Ecogrl ave ugerand incerta meora secre rerloritesiralefobe/pneamen echatalevoetlr infos nets! (temoconcentredatorta peolena) care ningun net interven cine YonogramaPROFUND moafeate hpoK NpoC Moke enéentara: oe potest cu casa bine deta ble de ga oxtail = ‘scundae deshdatrvsturc/prdrhn spi anda, ACES") suetanta de conrat Wate sensing eptre oe pac, ptt (stort lererior gerbe st retrt egal sire pn ‘Npworetotdima sein). ‘heamis or rest enim tote tle spe) Marker fart nepeci VSH', PCRS RaigratePulmonar: exer serio ce oracle Fame enle:“tree/r (eA) pulmonar ca as cotesctra aan (Sagrose ferential) Finca host usr‘ transaminase FA, GGT, Bebina I Sb Cr, neces (onpuore aerate instead UGparscple: port agro itrtament S86: 100% ‘Ae ies: 1G nar date de deze cire halal rb efe cat ip OD) Puncapetoneaaimpasu puncte unc de etapa evolve trans! ce evar sie > xa niamstrleucocte ol gre pot extra es, ls Sener O punctpetva blot agnostic, dr ana neta ini SognDlagnonticpontv Dingoes enc et ta pt ce ge ‘EPS adil: com epic 20m at acd eptoc beta emote de pneumoni. 2S copuls rou nse pi ak: Se eons, Sveptoco bet hemitefpneumocse lone tegumentarstaphylococous ‘olde ear Stapmyonaec ‘Cretan: debut op ge feb stb anna note, Shentn'fn wet “spect de prot rug don in stat compete! Diagnose aferential TP apenas ina urs; meals propnpaTpeToate 2P-pom perforate strona 3 dou cura in a eer /, cance gas, ‘esta saa fegmonoase 5. ara cect aut as punt pate, taumateFeaJCB 30 rn {TP pn prorat nesta sangre once perforate eric eck, ons erat mite mezerton, prorat ea, Boas Cro, Hea neta Sinpertorate clonca pertonta terrain ara ete celal rave forme! ‘uta cntnut peste al eur woe Rpesentia/itenca {bavans tart: dere, colts Schema, veh ener ep sa SAY ‘dose scundre ual obstruct stale (6 el peopae) neh cen {orn ental: gereatiatacaeata gehen: prpagarea ue tft ental facia pons ain 17 ps par camden probe ern tapers dehocrto nor patente diesbefeaes aent ‘CaP smuleres tutu Key, vera peritoneal made recent rele Sere car stra stort tale spel tarda, apne, ogo anne ‘Pps waumatce ov epsie, Aten Ae prea | Sbdomnals enone ature, | LF sept ei perstent atic hmea/esmatics Fangeaectiara | (etme pnceae, ia sue ste ae. se fertera co perforate Imantativa | Utara Dare unstad ade spinel | inti opie Datogentates | infra pertonal ca emer ce | eid de reac ASEMNC corgi | tees crones idebat MODS. | 3Pmedamentssa rata de Bet ca penton asi at neon sects metre | tne Pear | Iter hemes eoxer ‘stuns, | pleeona | “nedabetee | ere ete tebe inoresoienc, “perpen | Prevmonibate | Menge me plea seemed ertssans | spies, rodons | msenees Spates | ng "Ratemen act | Grpacu antes "Scdincien etal alee ‘senile Durraty—ao “tonne Toit amenre Deron agatinres eatComplicati-starea general se arava progrsv in prinele pea dpe 20h apra seme soc pertonecu MODS? nevatat- dest i236 Simplomatloie etonpat a tatran/snanadepina/ omar severe wee cae, Seaton pope) wean set ke, eipwme|=see ees setae Srentprenantcore ‘Someta sre Hewes 2mm aon Sorrento creat wemene Sy eae) Tratnen ietne deecetste seten tone ‘eat cnensuegets YROT pak eat ptomezae ‘ern ene mena use i toe tromotomecrerseveneforpti mentee 2 ohare att nascent feroor mania treme hp . or repo dienes amet ariel eres Se seer an as Worle my 10 soe e300 30 ml clin 3m, otesne cose ee > BRD Fer rn sng plasma: mje couse Mb Bt ‘tse lca de sos Ovgentepetpat re ato arene > lorfvertoie rons, pon mead Enomgll anim a setae mona minut actels Italeri ape igs tape Immpes bel semi ————— Seon beeen cps mela cnr eta Pao pnt 2 Spares coamine thos tacoaa an |. teroores sent ules ow mane su oc. pended pen vert ck. teenie sou pth coun aha) SA tment ect ure ee asc crs rn ease gunms) cel tune pa tn eri ae pode core ornafpe to Wotan astra pas oneness ar) ‘sea rgreat acta ptt etree, 3 er tage ep prataes op B brea onde port abdoina antenna cnn sat ta aap aa pan ls destin 9 abonen ‘eluents pram m pel eee etree prc fail etl ies ton stot us a ha (paren ‘ana eampleter pete, Dee potopertat ras ute msi tae ‘emanates sei eterno de ac ae 3 hu ct Ss povueptone‘lasifcare. Fuopatogenie “onto abn eat neti) z Tae Iecaom e otuare: Preteen] ala (a A cere cade Neen prone pre 8 “etisalat recent teste spna ii est, enone ser se csr voces) ‘hu vier hier emt rp empeten compet tos ropa emer ‘Stanton np mio opr osha ni re Diagnostic - zB tance aaa {ort mugen nents enue Pes "Pag sbi raumstnme desc) | one dae arson breenorsn peer xo emorapsirer pert et pee dea puta gt paar pin inhemorp tern sveratprnel bwin, resin ‘eprchemtnanir fours np) sure etaaes xr porte apr agony apo ene cle ee CT ‘Sewer tre ca pertonta Seana Senailnaepteescteerama WU laprtoma apr Gr puna prs poste eta te eee at _micetsanenorngs ‘Presta reopens prefer col FC, maser ras ee ‘oceitscconrocahensagspte | ciausiapcefpresatstanetoaMsloat Goch pr saamaes| mee tah ae ‘tmponao coco 6 orem | modem sei oro toSroopa ccc Freesereete SSrtcktenpearaitemongsavn aera onpormerltc yw apn cotati | eee urge Som Ingres ae sen nent, | sae goes onamaotten ‘at aon Hes rune pti | plese = imines | Pesta egata fora pont | Ete umoren den tes, | "desir rece = ‘cena prac Conese owe een ests | tena prcans | hepato mre SS ettperea | emnensor ator. Veomploectecas, | earners uch ‘oun oa | Indiseeacs ua pres canplo | bcs pnt reco Rotate) mew. | openness See \ itn ponngeentesesscs nosy, | Frowicese | mnusareaposnas | meri ese it Smowctectems tesserae | | Sm arte: taney eo ee toe neste prt STncor ie | featnersaeanenS Sopa exirsome co pon Set naar sear | é‘Talat, aT ape Tian aor cae sma etn cot, ‘cea pnhnatenson Ini tee CO ats intone pe sean foun Into let ie pre am dso eftne ahs re Sener Sepa ncomance ‘cup onhemostte ee, mp se ‘tote penecome anne aserepan et eget pn ee mio ‘caramel tan sresucecetemenin tae ‘Serta ping or oh Beatin mee ac ei = ‘asian wma ror tremor necmnons) Mcp nncaca Suc pce che IEEE | pms noretnwe ea Speeders | Sterns | Fl bet 20 ees Netra | Dimon eter | Rese mscmefstcmg ‘ocnasemnderime “cine ‘Satay eae saben oa som repertennle oom Saeco 9p cnaweeereee Seeensicenteeaaame ment sri cS ietnreesntommeareias Se ie aeatne see eee mae ene peter re cases | eemcceaatte Seelam (eiicmsicnireetacwiae | Semen, etc eis tees eae eomerapemiile — —S— mma Samatseeine own [Eni eeu tet deepens cree nirmrmpleiine(aie de sera cacao ps “eal ooasans vest VAs (is ace aBu | res fifo sau absent + vene ces State hemosnani acre exe posta veratecu on sngurpomaneiee => |snunUia QA ee {sven pero ea eset | ‘ont Nepraciinabrtaanuldapostecerlapacientinstaecrtea |evenupat Wg ‘on coc ce ‘ort celspocne generat ge 2th Sanne pane inal tater ho “peumotrr nan, drsnie-iatutaicaeseficevendne | sseannein, ‘aumatamee ore neanes neaitcensrepenoasnendiesiancitenstomn |soctoret | \ Soros 14 Insp Ve bias miloce Jou | Pcl perl spat nreorl trans arate Imots apecncsoes |Leaun pumenare en erie ‘eepratore suse homarage xem pgs aa ato. ‘iprs ronhr/enlr urenar tbe aaa pnd cnsonts ge umnare specs surt stutter le profes raat pn trom ‘apr get peter nto, eon su prurettae, Informe gave deseclor ¥/cFeptsl mort unt, hipoxomes percap, AROS tert nent arn pri i ont Ke ce sun spain aparece incl m mte stsh "Sreonas cards una nc cons, grants vensr case hepatoma ‘Sorte alerted researc, Instat ae Ri CF, mT, eee ‘neconent lore et pn sor sigan dace piensa Nee | crn se nea porarocrters rst eospl enti pin se nt a se ct ih ee grat VO ‘ete vate ort dem ces ap dae ma mea “enter n et: marten entlr m= a rer . Fan es upon dot adc: 2 244 cn alee Eo Stanaaeyetere, timate de perorat pewle | Stem staat cae Tetra agra primar ‘Ptambour antic, ‘rer mein Imoresonantorsc, menor peau ro, Fomoptnes ebarc pcr resins > premotor foarte 2s ete Foote sae hema Seneca in FTGnt ‘ng/imentte preter {orcetamie cut arate ‘terete reals sare cut ip Sinirares Santana Sidon | cena a aor rr rosa de | Eergenta rnc | Rupr complet- ees _srewisme [a comprese/romborae/ ‘rot perier/rpere ca hemerabe masa tees 9) | deprmaetcte trtamenl nue deci co I _ Lentunile esofaguil __Letiunile traheo-bronsice Lezlunile ductula __Letiunile aortice: anglo-CT, ETE. Letiunile diafragrnalu 1 —_ ee eee | rtm gr sec 2 fase [ioc Lf scene Tana = twonnce ate tem ‘mets apt pera NY ‘reat decelerat ‘dey molror sore! eee | fSnerporot— cera = 7 stots oct ten | fester, | inane: aeaeae | ec |Pbotatommtigceece’ | Moment ones Ss sfeceaaheniisragnal tang Inerecara ma recent ipl ar perform setae ‘toc pst traumatis gov, ‘rapt mic -progreseara inn su "oh asvcecate testinal (de proerat sbor trace inert chewrpeatsapaoscopica —_]