RESUMO
Chronic pancreatitis is characterized by recurrent or persisting pain. As the exocrine pancreatic insufficiency occurs early in the progression of the disease, the endocrine function may persist intact. Imaging procedures and pancreatic function tests are used to make a diagnosis. Therapy consists of pain reduction, which might require endoscopic or surgical intervention. Treatment of exocrine and endocrine pancreatic insufficiency is based on diet and substitution of pancreatic enzymes, minerals and vitamins, as well as insulin.
Assuntos
Pancreatite/diagnóstico , Dor Abdominal/etiologia , Doença Crônica , Diagnóstico Diferencial , Diagnóstico por Imagem , Endoscopia do Sistema Digestório , Insuficiência Pancreática Exócrina/diagnóstico , Insuficiência Pancreática Exócrina/etiologia , Insuficiência Pancreática Exócrina/genética , Insuficiência Pancreática Exócrina/terapia , Humanos , Extratos Pancreáticos/administração & dosagem , Testes de Função Pancreática , Pancreatite/etiologia , Pancreatite/genética , Pancreatite/terapia , Guias de Prática Clínica como Assunto , Prognóstico , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
While interstitial acute pancreatitis usually takes a benign course, necrotizing acute pancreatitis takes a severe course, mainly because of severe local and systemic complications. After a quick diagnosis it is necessary to rapidly assess a degree of severity of the disease and thus the prognosis. The clinical picture and the result of imaging procedures do not always correspond. The management basically includes to treat pain as well as to administer fluid, electrolyte, protein and calories. In addition, systemic treatment of complications such as shock or respiratory and renal insufficiency--if occurring--is necessary. In case of pancreatic necrosis, prophylactic administration of pancreas-penetrable antibiotics is recommended to avoid infection. In the severely ill with infected pancreatic necrosis, surgery is the treatment of choice. In approximately 10% of all patients with alcohol-induced pancreatitis, there is a gradual transition to chronic pancreatitis.
Assuntos
Pancreatite/diagnóstico , APACHE , Doença Aguda , Amilases/sangue , Diagnóstico Diferencial , Diagnóstico por Imagem , Humanos , Lipase/sangue , Pancreatite/complicações , Pancreatite/terapia , Pancreatite Necrosante Aguda/complicações , Pancreatite Necrosante Aguda/diagnóstico , Pancreatite Necrosante Aguda/terapiaRESUMO
OBJECTIVE: A study was designed to reevaluate hemoconcentration as an early marker of severe and/or necrotizing pancreatitis and compare it against contrast-enhanced CT, the gold standard to diagnose acute necrotizing pancreatitis. METHODS: This prospective study covers the years 1988-1999 for 316 patients (202 male, 114 female) with a first attack of acute pancreatitis. The role of the hematocrit as an early marker of severe and/or necrotizing pancreatitis has been retrospectively evaluated against the prospectively obtained data. They all underwent a CT within 72 h after admission. In addition to the CT-controlled diagnosis of interstitial/necrotizing pancreatitis, the following variables were used to assess severity: initial organ failure according to the Atlanta classification; indication for artificial ventilation and/or dialysis; Ranson score adjusted for etiology; Imrie score; Balthazar score; length of stay in intensive care unit (ICU); total hospital stay; development of pancreatic pseudocysts; indication for operation (necrosectomy); and mortality. Hemoconcentration on admission was defined as a hematocrit level >43.0% for male and >39.6% for female patients. Logistic regression was used to assess the correlation between hemoconcentration and the severity of variables. RESULTS: Hematocrit, as a single parameter measured on admission, had the same sensitivity and negative predictive value as the more complicated Ranson and Imrie scores obtained only after 48 h. However, its specificity, positive predictive value, and total accuracy were lower. Hemoconcentration significantly correlated with the Balthazar score (differential diagnosis between interstitial and necrotizing pancreatitis), stay in ICU, and total hospital stay. Sensitivity and specificity of the hematocrit cut-off level of 43.0% for male and 39.6% for female patients to detect necrotizing pancreatitis were 74% and 45%, respectively. The positive predictive value was 24% and the negative predictive value 88%. Receiver operation characteristics (ROC) curve values for several cut-offs did not result in more ideal levels. CONCLUSION: Hemoconcentration does not significantly correlate with important clinical outcome variables of acute pancreatitis including organ failure and mortality rate. Its prognostic value is comparable to the more complicated Ranson and Imrie scores obtained only after 48 h. The major value of this single easily obtainable and cheap parameter on admission lies in its high negative predictive value. In the absence of hemoconcentration, contrast-enhanced CT may be unnecessary on admission unless the patient does not improve.
Assuntos
Hematócrito/métodos , Pancreatite Necrosante Aguda/diagnóstico , Adolescente , Adulto , Idoso , Biomarcadores/análise , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X/métodosAssuntos
Fístula Brônquica/diagnóstico , Fístula Pancreática/diagnóstico , Pancreatite Necrosante Aguda/complicações , Escarro/química , Adulto , Fístula Brônquica/diagnóstico por imagem , Fístula Brônquica/etiologia , Tosse/etiologia , Feminino , Humanos , Odorantes , Fístula Pancreática/etiologia , Pseudocisto Pancreático/complicações , RadiografiaRESUMO
BACKGROUND AND STUDY AIMS: Gastroscopy has been reported to be dangerous for unstable patients with coronary heart disease (CHD). The aims of this study were to find out whether endoscopy is equally liable to cause myocardial ischemia in stable CHD patients, and whether this can be predicted prior to endoscopy, and to find out the frequency of abnormal findings in patients for whom a secondary prophylaxis with acetylsalicylic acid (ASA) is indicated. PATIENTS AND METHODS: Electrocardiograph recording using a Holter monitor was performed during gastroscopy in 71 patients with stable CHD, to check for silent ischemia. To predict potential ischemia during gastroscopy, the Holter monitoring ECG was applied prior to a treadmill test, and withdrawn after gastroscopy 16-22 hours later. RESULTS: During gastroscopy, 30 patients (42%) had silent ischemia, but only 1 patient (1%) became symptomatic. Ischemia was dependent on heart-rate (median heart rate with ischemia 124 beats/min, without 104 beats/min). Abnormal findings on gastroscopy were found in 53 patients (75%). They implied a potential bleeding risk in 30 patients (42%) and prevented the indication for ASA in 6 of them (8%). CONCLUSIONS: Gastroscopy is potentially a harmful procedure for CHD patients, but the incidence of ischemic periods may be reduced by conscious sedation and, if the patient is receiving beta-blocking agent therapy, by applying this medication prior to gastroscopy.
Assuntos
Gastroscopia/efeitos adversos , Isquemia Miocárdica/etiologia , Adulto , Idoso , Aspirina/uso terapêutico , Doença das Coronárias/complicações , Doença das Coronárias/diagnóstico , Doença das Coronárias/fisiopatologia , Eletrocardiografia Ambulatorial , Doenças do Esôfago/diagnóstico , Teste de Esforço , Feminino , Fibrinolíticos/uso terapêutico , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/fisiopatologia , Isquemia Miocárdica/prevenção & controle , Prognóstico , Fatores de Risco , Gastropatias/diagnósticoRESUMO
In a 91-year-old female patient admitted with an ileus, ultrasound and computed tomography demonstrated the obstruction of the upper jejunum by a large gallstone. Due to concurrent diseases the patient was unfit for surgery. An attempt was made to remove the impacted stone endoscopically. After successful mobilization and fragmentation by mechanical lithotripsy the obstruction was cleared away. Since the patient improved considerably after this procedure, the gallbladder and the cholecystoduodenal fistula were left in place.
Assuntos
Colelitíase/complicações , Endoscopia Gastrointestinal , Obstrução Intestinal/etiologia , Doenças do Jejuno/etiologia , Idoso , Idoso de 80 Anos ou mais , Colelitíase/cirurgia , Feminino , Humanos , LitotripsiaRESUMO
Results of the SPT and the ERCP staged for their severity were compared in 202 patients. The correlation between both investigations was significant (p < 0.001); however, ERCP showed significantly more severe changes (p = 0.04). Furthermore, we found that 129 (64%) patients had parallel SPT and ERCP results, matching in all four gradings of severity. Forty-three (21%) patients had abnormal results for both SPT and ERCP, but the severity gradings did not parallel. Finally, 30 (15%) patients showed totally nonparallel results, a normal SPT and abnormal ERCP, or vice versa. Abnormal ERCP but normal SPT results were found in 23 of these 30 patients (group 1), and normal ERCP but abnormal SPT results in the seven remaining cases (group 2). In the first group, more patients had a history of acute pancreatitis compared to the second group (19 vs. one, p < 0.005). Based on medical history, laboratory and functional test results, and other morphological tests, chronic pancreatitis was diagnosed in two of 23 patients in group 1 and in all seven patients in group 2. Follow-up interviews (86 +/- 54 months) were possible in 20 of the remaining 21 patients in group 1 and showed definite chronic pancreatitis in one and probable chronic pancreatitis in another two of them, whereas in the other 17 patients no symptoms of acute pancreatitis or abdominal pain suggestive of chronic pancreatitis had occurred. In conclusion, both SPT and ERCP should be used to complement each other when chronic pancreatitis is suspected. ERCP seems to over-diagnose the disease since duct changes may only reflect scars after severe acute pancreatitis, or old age, and are not necessarily a sign of chronic pancreatitis. SPT seems to diagnose chronic pancreatitis with more reliability.
Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Colecistocinina , Pancreatite/diagnóstico , Secretina , Adulto , Idoso , Doença Crônica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
An alcoholic, 67-year old retired male nurse complained of abdominal pain, loss of appetite and weight loss of 10 kg within one year. Based on elevated serum enzyme levels, ultrasonography and computed tomography examinations, an acute attack of chronic pancreatitis with several pancreatic pseudocysts was diagnosed. Ultrasonographically, an 1.8 cm phi, echo-free, pulsatile, space-occupying lesion, suggestive of a pancreatic pseudoaneurysm, was found at the right lateral margin of an almost echo-free pseudocyst measuring 6.8 x 5.6 x 5.0 cm in the head of the pancreas. Shortly before the planned discharge when the patient felt well, he developed acute abdominal pain. An immediate ultrasound examination showed an inhomogenous and echo-dense pseudocyst, in short, an acute hemorrhage. Rupture of the pseudoaneurysm of the Arteria gastroduodenalis was suspected and later confirmed by angiography and laparotomy. After proximal an distal ligation of the vessel and fibrin sealing of the inner surface of the cyst, the patient recovered and, under alcohol abstinence, has been free of symptoms since one year.
Assuntos
Abdome Agudo/etiologia , Falso Aneurisma/complicações , Aneurisma Roto/complicações , Hemoperitônio/etiologia , Pâncreas/irrigação sanguínea , Pseudocisto Pancreático/complicações , Pancreatite/complicações , Abdome Agudo/cirurgia , Idoso , Falso Aneurisma/diagnóstico , Falso Aneurisma/cirurgia , Aneurisma Roto/diagnóstico , Aneurisma Roto/cirurgia , Doença Crônica , Diagnóstico Diferencial , Diagnóstico por Imagem , Hemoperitônio/diagnóstico , Hemoperitônio/cirurgia , Humanos , Masculino , Pseudocisto Pancreático/diagnóstico , Pseudocisto Pancreático/cirurgia , Pancreatite/diagnóstico , Pancreatite/cirurgia , Ruptura EspontâneaRESUMO
Painful acute pancreatitis masking pancreatic carcinoma and painless acute pancreatitis with shock or coma as leading symptoms have been described before. We report a first case of almost-painless pancreatitis mimicking pancreatic carcinoma with spontaneous normalization of symptoms and biochemical as well as imaging procedure findings.
Assuntos
Dor , Neoplasias Pancreáticas/diagnóstico , Pancreatite/diagnóstico , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Diagnóstico Diferencial , Humanos , Masculino , Pancreatite/diagnóstico por imagem , Tomografia Computadorizada por Raios X , UltrassonografiaRESUMO
A fine punch needle with a new bevelled geometry for easy, single-handed, ultrasound-guided biopsies is presented. The needle requires a significantly lower advancing force compared with the commonly used punch needles of the Menghini type. Since, therefore, our needle penetrates the organs to be investigated easier, it enables the puncture of easily movable (stomach, gut) and/or solid organs (kidney) with the yield of sufficiently long punch cylinders. The first 196 biopsies were well tolerated and histological diagnosis could be made in 94% of the cases.
Assuntos
Biópsia por Agulha/instrumentação , Agulhas , Ultrassonografia/instrumentação , Fenômenos Biomecânicos , Desenho de Equipamento , Humanos , Modelos Anatômicos , Vísceras/patologiaRESUMO
We report a patient with chronic nausea as the leading symptom of a primary carcinoma of the duodenum located at the flexura duodeno-jejunalis. The tumour was not reached at gastroscopy, which was performed twice. Since this area usually cannot be seen upon gastroscopy or upon small bowel enteroclysma according to Sellink, a double-contrast investigation of the upper gastrointestinal tract using a hypotonic agent should be performed when nausea persists although gastroscopy is normal.
Assuntos
Adenocarcinoma/complicações , Neoplasias Duodenais/complicações , Obstrução Duodenal/complicações , Gastroscopia , Náusea/etiologia , Adenocarcinoma/diagnóstico por imagem , Adenocarcinoma/cirurgia , Brometo de Butilescopolamônio , Neoplasias Duodenais/diagnóstico por imagem , Neoplasias Duodenais/cirurgia , Obstrução Duodenal/diagnóstico por imagem , Obstrução Duodenal/cirurgia , Humanos , Pólipos Intestinais/complicações , Pólipos Intestinais/diagnóstico por imagem , Pólipos Intestinais/cirurgia , Masculino , Pessoa de Meia-Idade , Náusea/diagnóstico por imagem , Náusea/cirurgia , Segunda Neoplasia Primária/complicações , Segunda Neoplasia Primária/diagnóstico por imagem , Segunda Neoplasia Primária/cirurgia , RadiografiaAssuntos
Abdome Agudo/diagnóstico , Diagnóstico Diferencial , Feminino , Humanos , Masculino , GravidezRESUMO
Hyperamylasemia has been reported in heroin addicts and ascribed to an increase of salivary isoamylase. Ours is the first report on acute pancreatitis in a heroin user. All prognostic parameters indicating a severe course of the disease were present, and computed tomography showed an edematous pancreatitis, but the acute pancreatitis took a benign clinical course.
Assuntos
Heroína , Pancreatite/etiologia , Transtornos Relacionados ao Uso de Substâncias/complicações , Doença Aguda , Adulto , Amilases/sangue , Humanos , Isoamilase/sangue , Lipase/sangue , Masculino , Pancreatite/diagnóstico , Pancreatite/enzimologiaRESUMO
A case of splenic lesion is reported in a 48-year-old female patient who underwent an uneventful diagnostic laparoscopy. Symptoms suggesting massive intraabdominal bleeding occurred 5 hours later. Intraoperatively, a small posterior splenic lesion was found, which could be repaired using fibrin glue. This protracted complication must have occurred while establishing the pneumoperitoneum; its cause is unclear, but distortion and stretching of small adhesions of the spleen with the abdominal wall may have played a role. Although rare, this complication should be considered when a patient deteriorates after an uneventful laparoscopy.
Assuntos
Emergências , Hemoperitônio/etiologia , Laparoscópios , Baço/lesões , Feminino , Hemoperitônio/cirurgia , Hemostasia Cirúrgica , Humanos , Pessoa de Meia-Idade , Baço/cirurgiaRESUMO
Recently, a high incidence of hepatic hematomas following percutaneous liver biopsy was reported. This induced us to undertake this prospective ultrasound examination before, as well as 2 and 24 h after, percutaneous liver biopsy, using a Menghini needle (O 1.4 mm), in 93 patients for diagnostic purposes. Two hours after biopsy a small subcapsular fluid margin was found in one patient (1.1%) which disappeared within 24 h. We conclude that hepatic hematomas are not frequent following percutaneous liver biopsy and that it remains a safe diagnostic procedure to find out the reason for chronically elevated liver enzymes and evaluate suspected diffuse parenchymal lesions of the liver.