Colecistita cronica litiazica – tabloul clinic
Colecistita cronica litiazica – tabloul clinic
Colecistita cronica litiazica – tabloul clinic
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<strong>Colecistita</strong> <strong>cronica</strong> <strong>litiazica</strong> <strong>–</strong> <strong>tabloul</strong> <strong>clinic</strong><br />
Examenul obiectiv:<br />
- poate fi neinformativ<br />
Å durere la palpare in hipocondrul drept,<br />
in special in punctul cistic<br />
<strong>Colecistita</strong> <strong>cronica</strong> <strong>litiazica</strong><br />
Å hidrops vezicular<br />
Diagnosticul de certitudine:<br />
ecografie <strong>–</strong> imagine ecogena cu<br />
con de umbra posterior<br />
<strong>Colecistita</strong> <strong>cronica</strong> <strong>litiazica</strong><br />
<strong>Colecistita</strong> <strong>cronica</strong> <strong>litiazica</strong><br />
Hidrops. Calcul<br />
infundibular<br />
Diagnosticulde certitudine:<br />
ecografie<strong>–</strong> imagine ecogenacu<br />
con de umbra posterior
<strong>Colecistita</strong> <strong>cronica</strong> <strong>litiazica</strong><br />
Colecist scleroatrofic<br />
(mulat pe calculi)<br />
<strong>Colecistita</strong> <strong>cronica</strong> <strong>litiazica</strong><br />
Colangiografia orala<br />
-lacune de umplere<br />
-utila pentru afectiunile neliatiazice ale colecistului<br />
(de ex. b. colului vezicular)<br />
<strong>Colecistita</strong> <strong>cronica</strong> <strong>litiazica</strong><br />
Vezicula de portelan<br />
<strong>Colecistita</strong> <strong>cronica</strong> <strong>litiazica</strong><br />
Diagnosticulpozitiv:<br />
-sindromuldispepticbiliar<br />
-sindromuldureros<br />
-aspectulecografic<br />
Radiografia<br />
abdominala simpla<br />
-calculi radiopaci<br />
(rar)
Dg. ≠<br />
<strong>Colecistita</strong> <strong>cronica</strong> <strong>litiazica</strong><br />
Tratamentul chirurgical: colecistectomia<br />
<strong>Colecistita</strong><br />
<strong>cronica</strong><br />
<strong>litiazica</strong><br />
-retrograda<br />
-anterograda<br />
-bipolara<br />
<strong>Colecistita</strong> <strong>cronica</strong> <strong>litiazica</strong><br />
Tratament:<br />
Colicabiliara→ antispastice<br />
Prevenireacolicii→ regim alimentar<br />
Tratamentde dizolvarea calculilor<br />
-eficientaredusa<br />
-numaiin cazulcalculilorde colesterolpur<br />
<strong>Colecistita</strong> <strong>cronica</strong> <strong>litiazica</strong><br />
Tratamentulchirurgical: colecistectomialaparoscopica
<strong>Colecistita</strong> <strong>cronica</strong> <strong>litiazica</strong><br />
Tratamentul chirurgical: colecistectomia laparoscopica<br />
<strong>Colecistita</strong> acuta <strong>litiazica</strong><br />
congestie, edem<br />
<strong>Colecistita</strong> acuta <strong>litiazica</strong><br />
= o complicatie a litiazei veziculare<br />
-exista si colecistite acute nelitiazice, dar f. rar<br />
d.p.d.v. anatomo-patologic:<br />
-forma congestiva<br />
-forma flegmonoasa (purulenta)<br />
empiem vezicular<br />
-forma gangrenpoasa<br />
<strong>Colecistita</strong> acuta <strong>litiazica</strong><br />
necroza, hemoragie
<strong>Colecistita</strong> acuta <strong>litiazica</strong><br />
gangrena<br />
<strong>Colecistita</strong> acuta <strong>litiazica</strong><br />
Tabloul <strong>clinic</strong> este determinat de manifestarile generale si<br />
locale ale inflamatiei:<br />
Durerea<br />
-debuteaza ca o colica biliara<br />
-nu se amelioreaza la antispastice<br />
-persista timp indelungat (zile)<br />
Greata, varsaturi<br />
Febra<br />
-insotesc durerea<br />
- de obicei peste 38ÜC<br />
<strong>Colecistita</strong> acuta <strong>litiazica</strong> cu bloc subhepatic<br />
Blocul (plastronul) pericolecistic (subhepatic):<br />
= o forma a colecistitei acute<br />
-viscerele adiacente (duoden, colon si mezocolon transvers,<br />
epiploon) blocheaza procesul inflamator<br />
- aderente de fibrina la colecistul inflamat<br />
-subhepatic apare o “tumora” imprecis delimitata, ferma,<br />
solidara cu ficatul, dureroasa, cu semne locale de iritatie<br />
peritoneala<br />
<strong>Colecistita</strong> acuta <strong>litiazica</strong><br />
La palpare:<br />
-durere provocata la palpare (sensibilitate) <strong>–</strong> subhepatic<br />
-aparare musculara in hipocondrul drept<br />
-semnul Blumberg in hipocondrul drept<br />
-semnul Murphy<br />
-hidrops vezicular
<strong>Colecistita</strong> acuta <strong>litiazica</strong> <strong>–</strong> tablou <strong>clinic</strong><br />
Anamneza:<br />
- tipic: pacient cu istoric indelungat de litiaza biliara (sindrom<br />
dispeptic si sindrom dureros) la care simptomatologia se<br />
agraveaza printr-o colica ce nu se mai remite<br />
Ex. Obiectiv:<br />
-semne generale de infectie (febra)<br />
-semne locale (in hipocondrul drept):<br />
iritatie<br />
peritoneala<br />
Å hidrops<br />
<strong>Colecistita</strong> acuta <strong>litiazica</strong><br />
Ex de laborator:<br />
bloc<br />
subhepatic<br />
-sindrom inflamator: leucocitoza, accelerarea VSH<br />
Ecografia abdominala:<br />
-cresterea volumului colecistului<br />
-ingrosarea peretelui vezicular (> 3mm)<br />
-hipoecogenitati (focale / liniare) in grosimea peretelui<br />
-dublu contur<br />
-neregularitati ale peretelui<br />
-membrane intraluminale flotante<br />
-microbule ecogene de gaz<br />
<strong>Colecistita</strong> acuta <strong>litiazica</strong><br />
Ex de laborator:<br />
-sindrominflamator: leucocitoza, accelerareaVSH<br />
+/-crestereabilirubinemiei(< 4 mg/dl)<br />
+/-crestreafosfatazeialcaline<br />
+/-crestereatransaminazelor<br />
+/-crestereaamilazemiei<br />
<strong>Colecistita</strong> acuta <strong>litiazica</strong><br />
Peretevezicularángroşat cu dublucontur. Litiazăbiliară<br />
vezicularămultiplă. Calculinclavatán infundibul.
<strong>Colecistita</strong> acuta <strong>litiazica</strong><br />
<strong>Colecistita</strong> acuta cu abces pericolecistic<br />
<strong>Colecistita</strong> acuta <strong>litiazica</strong><br />
Diagnosticul pozitiv:<br />
-durere persistenta, nu cedeaza la antispastice<br />
-febra<br />
-semne locale de iritatie peritoneala<br />
-sindrom inflamator<br />
-aspectul ecografic<br />
<strong>Colecistita</strong> acuta <strong>litiazica</strong><br />
Ingroşarea pereteluivezicular. Imaginitranssonicefine<br />
grosimeapereteluivezicularcu semnificaţie de abcese<br />
intramurale.<br />
<strong>Colecistita</strong> acuta <strong>litiazica</strong><br />
Tratamentul: colecistectomia<br />
Momentuloperator: 2 atitudini<br />
-operatieimediata<br />
-operatie“la rece”<br />
- reechilibrarehidro-electroliticăşi metabolicăgenerală<br />
- tratamentanalgetic, antiinflamator<br />
- tratamentantibiotic<br />
-in colecistitacu bloc subhepatic: tratamentconservator si<br />
operatiela rece
Litiaza coledociana<br />
Dintre pacienţii cu litiază biliară 15% au calculi şi án CBP.<br />
migrati din<br />
colecist<br />
Calculii coledocieni<br />
Calculi coledocieni<br />
“autohtoni”<br />
= obstacol in calea evacuarii bilei<br />
ã colestaza - icter mecanic<br />
ã pancreatita<br />
Litiaza coledociana <strong>–</strong> forme <strong>clinic</strong>e<br />
- angiocolita<br />
icter (obstructiv) mecanic<br />
colica biliara<br />
colangita<br />
pancreatita<br />
acuta<br />
asimptomatica<br />
Litiaza coledociana<br />
Litiaza coledociana<br />
Ecografia:<br />
-dilatareaCBP<br />
-calcul coledocian<br />
TriadaCharcot:<br />
DURERE - FEBRA - ICTER<br />
Obs: coledocul este dificil de examinat<br />
ecografic datorita suprapunerii<br />
duodenului.
Litiaza coledociana<br />
ERCP:<br />
-dilatarea CBP<br />
-stopul substantei de<br />
contrast<br />
Litiaza coledociana<br />
Tratament:<br />
-endoscopic<br />
sau<br />
chirurgical<br />
Sfincterotomie<br />
endoscopica<br />
+<br />
colecistectomie<br />
laparoscopica<br />
La cazul mentionat anterior:<br />
-coledocul revine rapid la<br />
dimensiunea normala<br />
-fistula de bont cistic inchisa in<br />
cateva zile<br />
Litiaza coledociana<br />
ERCP:<br />
-dilatareaCBP<br />
-defect de umplere<br />
(calcul inclavatin<br />
portiuneaterminalala<br />
un pacientcu Litiaza<br />
coledocianareziduala<br />
dupacolecistectomiesi<br />
fistula de bont cistic)<br />
Litiaza coledociana<br />
coledocotomia<br />
(coledocolitotomia)<br />
Tratamentulchirurgical:<br />
Extragereacalculilor<br />
(sondacu balonas)
Litiaza coledociana<br />
Extragerea calculilor<br />
(sonda Dormia)<br />
Tratamentul chirurgical:<br />
Extragerea calculilor<br />
(pensa de calculi)<br />
Litiaza coledociana<br />
Drenaj Kehr<br />
Tratamentul chirurgical:
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