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CRISTINACIJEVSCHI PRELIPCEAN
CTLINAMIHAI
NOIUNI DE
GASTROENTEROLOGIE
I HEPATOLOGIE
PENTRU STUDENI
Editura Gr. T. Popa" , U.M.F. Iai
2013
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Descrierea CIP a Bibliotecii Naionale a
RomnieiCijevschi-Prelipcean, Cristina
Gastroenterologie i hepatologie pentru studeni / Cristina
Cijevschi
Prelipcean, Ctlina Mihai. - Iai : Editura Gr.T. Popa, 2013
Bibliogr.
ISBN 978-606-544-133-0
616.3(075.8)
Refereni tiinifici:
Prof. Univ. Dr. Mircea DICULESCU, Universitatea de Medicin i
Farmacie
Carol Davila Bucureti
Prof. Univ. Dr. Dan DUMITRACU, Universitatea de Medicin i
Farmacie Iuliu
Haieganu Cluj Napoca
Editura Gr. T. PopaUniversitatea de Medicin i Farmacie Iai
Str. Universitii nr. 16
Toate drepturile asupra acestei lucrri aparin autorului i
Editurii Gr.T. Popa" Iai. Nici o
parte din acest volum nu poate fi copiat sau transmis prin nici
un mijloc, electronic sau
mecanic, inclusiv fotocopiere, fr permisiunea scris din partea
autorului sau a editurii.
Tiparul executat la Tipografia Universitii de Medicin i Farmacie
"Gr. T. Popa" Iai
str. Universitii nr. 16, cod. 700115, Tel. 0232 301678
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Prefa
Hipocrate spunea c toate afeciunile au originea n tubul
digestiv.Cartea Noiuni de gastroenterologie i hepatologie pentru
studeni a aprutdin necesitatea de a prezenta ntr-o manier succint
cunotinelede baz din
gastroenterologie i hepatologie, noiunipe care orice medic
trebuie s lecunoasc i aplice n practica clinic curent.
Aa cum sugereaz i titlul, cartea se adreseaz n primul rnd
studenilor Facultii de Medicin dar n acelai timp credem c va fi
uninstrument apreciat de ctre medicii rezideni gastroenterologi i
din alte
specialiti nrudite, doctoranzi i practicieni cu experien care
doresc s iactualizeze cunotinele n domeniu.
Din punct de vedere al coninutului lucrarea este structurat
ntr-omanier clasic, parcurgnd principalele afeciuni digestive, de
laepidemiologie la tratament. ntr-o specialitate n care progresele
se deruleaz
rapid, am ncercat s integrm noiunile clasice cu cele mai noi
achiziiitiinifice, eliminnd elementele perimatei punnd accent pe
noile modalitide diagnostic i tratament, n concordan cu ghidurile i
recomandrileactuale.
Spre deosebire de cursurile clasice, originalitatea este dat de
formatulcrii: pe de o parte prezentarea schematic, succint, a
noiunilor teoretice iar
pe de alt parte spaiile libere alturate care permit cititorului
s fac adnotri,completri, precizri, facilitnd procesul de
cunoatere.
Editarea acestei cri nu a fost o munc uoar.
Mulumimcolaboratoarelor noastre dr. Mihaela Dranga i dr. Iulia
Pintilie pentruajutorul dat n tehnoredactare. Din punctul nostru de
vedere cartea a fost unexerciiu, n care am regsit ceea ce spunea
Seneca: nvei nvnd pe alii.Sperm ca i din punct de vedere al
cititorilor cartea s fie un instrument util n
formarea medical.
Cristina Cijevschi Prelipcean
Ctlina Mihai
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ABREVIERI
5 ASA: 5 aminosalicilic
Ac: anticorpi
ACE: antigen carcinoembrionar
AFP: alfafetoprotein
Ag: antigen
AINS: antiinflamatorii nesteroidiene
ALT: alaninaminotransferaza
ANA: anticorpi antinucleari
ASMA: anticorpi anti fibr muscular
neted
AST: aspartataminotransferaza
AZT: azatioprin
BC: boal Crohn
BII: boal inflamatorie intestinal
BRGE: boal de reflux gastroesofagian
CBIH: ci biliare intrahepatice
CBP: ciroz biliar primitiv
CCR: cancer colorectal
CE: cancer esofagian
CG: cancer gastric
CH: ciroz hepatic
COX: ciclooxigenaz
CP: cancer pancreatic
CRP: protein C reactiv
CT: computer tomografie
DAA: antivirale cu aciune direct
DZ: diabet zaharat
EB: esofag Barrett
EDS: endoscopie digestiv superioar
EEG: electroencefalogram
EHP: encefalopatie hepato-portal
ERCP: colangiopancreatografie retrograd
endoscopic
EUS: ultrasonografie endoscopic
FA: fosfataza alcalin
FAP: polipoza adenomatoas familial
FOBT: hemoragii oculte fecale
FR: factor reumatoid
GGTP: gamaglutamiltranspeptidaza
HAI: hepatit autoimun
HCC: hepatocarcinom
HDS: hemoragie digestiv superioar
HIV: virusul imundeficienei umane
HNPCC: cancer colorectal ereditar
nonpolipozic
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Hp: Helicobacter pylori
HRM: manometrie de nalt rezoluie
HTA: hipertensiune arterial
HTP: hipertensiune portal
IFN: interferon
Il: interleukin
IPP: inhibitori de pomp de protoni
IRC: insuficien renal cronic
IS: intestin subire
LDH: lacticdehidrogenaza
LES: lupus eritematos sistemic
MALT: esut limfatic asociat mucoasei
MRCP: colangiopancreatografie prin
rezonan magnetic
MTS: metastaze
NAFLD: ficat gras nonalcoolic
NASH: steatohepatit nonalcoolic
NO: oxid nitric
PA: pancreatita acut
PAF: factor activator plachetar
PBH: puncie biopsie hepatic
PBS: peritonit bacterian spontan
PC: pancreatit cronic
PCR: reacie de polimerizare n lan
PET: tomografie cu emisie de pozitroni
PMN: polimorfonucleare
PR: poliartrit reumatoid
Ps: prednison
RBV: ribavirin
RCUH: rectocolit ulcero-hemoragic
RM: rezonan magnetic
RVS: rspuns viral susinut
SDE: spasm difuz esofagian
SEI: sfincter esofagian inferior
SES: sfincter esofagian superior
TA: tensiune arterial
TIPS: unt portosistemic intrahepatic
transjugular
Tis: tumor in situ
TNF: factor de necroz tumoral
UD: ulcer duodenal
UG: ulcer gastric
VE: varice esofagiene
VHA: virusul hepatitic A
VHB: virusul hepatitic B
VHC: virusul hepatitic C
VHD: virusul hepatitic D
VIP: peptidul intestinal vasoactiv
VP: vena port
VS: vena splenic
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CUPRINS
METODE DE EXPLORARE A TRACTULUI DIGESTIV
............................ 1
DISPEPSIA
....................................................................................
15
HELICOBACTER PYLORI DUP MASTRICHT IV
................................ 21
BOALA DE REFLUX ESOFAGIAN
..................................................... 29TULBURRI
MOTORII ESOFAGIENE ...............................................
41
CANCERUL ESOFAGIAN
................................................................
49
ULCERUL GASTRIC I DUODENAL
.................................................. 53
CANCERUL GASTRIC
.....................................................................
71
PATOLOGIA INTESTINULUI SUBIRE
.............................................. 85
COLONUL IRITABIL
.......................................................................
97
BOLILE INFLAMATORII INTESTINALE
............................................ 105
CANCERUL COLORECTAL
.............................................................
125
HEPATITA CRONIC VIRAL C
...................................................... 137
HEPATITA CRONIC VIRAL
B...................................................... 145
FICATUL GRAS NONALCOOLIC
..................................................... 155
BOALA HEPATIC ALCOOLIC
......................................................161
HEPATITELE AUTOIMUNE
............................................................
167
CIROZA HEPATIC
.......................................................................
173
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CANCERUL HEPATIC PRIMITIV
..................................................... 207
PATOLOGIA BILIAR
....................................................................
215
PANCREATITA ACUT
..................................................................
229PANCREATITA CRONIC
..............................................................
239
CANCERUL PANCREATIC
..............................................................
249
BIBLIOGRAFIE SELECTIV
............................................................
255
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METODE DE EXPLORARE ATRACTULUI DIGESTIV
Introducere Hipocrate: All the diseases begin in the gut
Afeciunile digestive intereseaz un segment importantdin populaia
general, indiferent de vrst, mai alespersoane de vrst medie
Costuri directe: spitalizare, investigaii, tratamente Costuri
indirecte: absenteism, pensionare, asisten la
domiciliu, moarte prematur Afeciunile funcionale (dispepsie,
reflux gastro-
esofagian, colon iritabil): What matters in chronicdisorders is
the patients suffering, not the disease entity
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ENDOSCO PIA DIGESTIV SUPERIOAR
Primul endoscop optic flexibil a fost realizat de Hirschowitzi
colaboratorii
Este metod diagnostic i terapeutic
ERCP colangiopancreatografie endoscopic retrograd
EUS ultrasonografie endoscopic
n ultimii ani progrese n acurateea diagnosticului
princromoendoscopie, magnificaie, narrow band imaging
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Indicaii: simptomatologie dispeptic la persoane n vrst sau
cu
simptome de alarm (hemoragie gastrointestinal,scdere ponderal,
vrsturi sugernd insuficienevacuatorie gastric, anemie etc. ) sau
rebel latratament
disfagie ingestie de corpi strini, substane caustice hemoragie
digestiv superioar (acut i cronic) durere abdominal cronic boal
inflamatorie intestinal (boal Crohn) suspiciune de neoplazie
confirmare examen radiologic supraveghere leziuni preneoplazice
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Contraindicaii: refuzul pacientului pacient necooperant, agitat
suspiciune de perforaie intestinal pacient n stare de oc (EDS se va
efectua dup
echilibrare volemic) afeciuni severe asociate (infarct de
miocard
recent, accident vascular cerebral)
! Consimmnt informat
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Pregtirea pacientului:
repaus alimentar de cel puin 6 ore n urgen (HDS) splturi
gastrice anterior
explorrii anestezie topic faringian xilin decubit lateral stng
sedare iv midazolam 2-5 mg
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Endoscopia digestiv superioar terapeutic- HDS variceal:
sclerozare endoscopic prin injectare de
substane sclerozante (moruat de sodiu, alcool absolut etc)sau
ligatur variceal cu benzi elastice
HDS non variceal: hemostaz prin injectare deepinefrin sau soluie
salin hiperton, fotocoagulare laser,electrocoagulare,
termocoagulare, clipare
dilatare stenoze: esofagiene, pilorice
extragere corpi strini
proteze
polipectomii
mucosectomie endoscopic
tratament endoscopic n BRGE, acalazia cardiei
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Complicaii: majore la 1/1000 - 1/3000 de endoscopii
perforaii ale esofagului, stomacului hemoragie aspiraie pulmonar
(mai frecvent la EDS cu sedare) aritmii cardiace severe
mortalitatea variaz ntre 1/3000 i 1/16000 de endoscopii
sedarea cu midazolam reacii alergice, hipotensiune,depresie
respiratorie
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Endoscopia digestiv inferioar
Indicaii:
sngerare digestiv (rectoragie sau sngerare ocult)
boal inflamatorie intestinal
suspiciune de polipi, cancer
durere abdominal cu etiologie neprecizat
tulburri de tranzit intestinal
Contraindicaii:
aceleai ca la endoscopie +
boal inflamatorie intestinal fulminant
megacolon toxic
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Pregtire:- Evacuarea colonului (fortrans, picoprep, clisme
evacuatorii)
Posibilitate de efectuare cu sedare
Endoscopia digestiv inferioar terapeutic: polipectomii
mucosectomie tratament hemostatic (injectare de substane
vasoconstrictoare, fotocoagulare, clipuri etc) dilatare stenoze
stenturi
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Complicaii Complicaii majore
Perforaia Hemoragia < 1% din colonoscopii, mai frecvent n
cele terapeutice
(polipectomii) Alte complicaii
Aritmii cardiace Reacii vasovagale Hipotensiune, insuficien
cardiac (pregtire
colonoscopie) Reacii la medicamentele folosite pentru sedare
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Colangiopancreatografia endoscopicretrograd - ERCP
- Vizualizarea cilor biliare i canalului pancreatic
- Invaziv (risc de pancreatit acut!) n scop diagnosticmetoda a
fost nlocuit de tehnici noninvazive (MRCP)
- i pstreaz valoarea i utilitatea ca metod terapeutic:
- sfincterotomie endoscopic extracie de calculi
- stentare endoscopic
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Enteroscopia
Vizualizarea intestinului subire
Rol diagnostic (inclusiv prelevare de biopsie) i
terapeutic(hemostaz, polipectomii)
Eficien diagnostic comparabil cu videocapsula
Tehnici: spiral, dublu balon etc
Metod laborioas, necesit sedare, dotare i endoscopistcu
experien
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CAPSULA ENDOSCOPIC
1966, Fantastic Voyage (Raquel Welch) submarinminiaturizat
aruncat n circulaia sanguin
Ideal o singur capsul pentru explorarea complet atractului
digestiv, de la cavitatea oral la anus
n prezent capsul IS, esofag, colon
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Metod Pacient a jun de cel puin 8 ore
Ingerare capsul cu un pahar cu ap
interzis fumatul modific culoarea mucoaseigastrice
nu se administrez: antiacide ader la mucoas mpiedic
vizualizarea antispastice ncetinesc tranzitul intestinal
sucralfat preparate de fier narcotice
La 2 ore de la ingestie sunt permise lichidele, la 4 oreo
gustare
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Indicaii
- boala Crohn- hemoragia gastrointestinal de cauz obscur
Indicaii relative- boala celiac- suspiciunea unei tumori maligne
de intestin subire- polipoza intestinal ereditar (sindromul
Peutz-
Jeghers, polipoz juvenil familial)- leziunile vasculare
intestinale- enteropatia indus de AINS- diareea cronic- durerea
abdominal (suspiciune de boal
organic)- transplantul de intestin subire (diagnosticul
rejetului de gref)
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Contraindicaii Stenoz, obstrucie, fistul (orice segment al
tractului
gastrointestinal) Intervenii chirurgicale majore anterioare
abdominale/pelvine Tulburri de deglutiie Pseudo-obstrucie
intestinal Pacemaker cardiac sau alt dispozitiv electromedical
implantat Contraindicaii relative: sarcin, diverticul
Zenker,
gastroparez, diverticuloz intestinal (diverticulinumeroi i
voluminoi)
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Complicaii
1. Impactarea capsulei la nivelul unei stenozeintestinale
nediagnosticate anterior2. Aspiraia traheal a capsulei3. Impactarea
capsulei la nivel cricofaringian4. Retenia capsulei n diverticul
Zenker
Ideal n suspiciunea de stenoz sau alte leziuniobstructive se
administraz capsula de paten biodegradabil!
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Concluzii
capsula endoscopic s-a impus ca cea mai performantmetod de
examinare a intestinului subire
reprezint metoda de elecie n diagnosticul bolii Crohni pentru
stabilirea etiologiei hemoragiei digestive de
cauz obscur
este metod sigur, practic lipsit de complicaii dac seface
selecia adecvat a pacienilor
dezavantajele sunt legate de pre, imposibilitatea de apreleva
biopsii i de a efectua manevre terapeutice
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Viitor capsul ideal?
o singur capsul pentru ntreg tractul digestiv examinare inclusiv
ultrasonografic msurarea pH-ului, temperaturii, presiunii
aprecierea eliberrii medicamentelor la diferite nivele determinarea
motilitii prelevare de biopsii detectare: markeri oncologici (ACE,
CA19-9), markeri
serologici ( Ac anti edomisium), citokine etc.
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EXAMENUL RADIOLOGIC
Radiografia abdominal simpl: perforaie, ocluzie,
calcificri Radiografia baritat eso-gastro-duodenal Tranzit
intestin subire
- specificitate, sensibilitate reduse- enteroclisma
Clisma baritat (irigografia) Colecistografia oral sau
intravenoas nlocuite
de tehnici mai performante
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Ecografia abdominal Accesibil Ieftin Neinvaziv Repetabil
Diagnostic pozitiv, diagnostic diferenial, supraveghere,
puncii ecoghidate diagnostice i terapeutice Ficat, colecist,
pancreas, splin, rinichi, pelvis, tubdigestiv, cavitate peritoneal,
vase
Ecografie Doppler vascularizaie, flux vascular Ecografie cu
substan de contrast caracterizarea
vascular a formaiunilor expansive, traumatismelor etc
Ecoendoscopia profunzimea invaziei tumorale a
tubului digestiv, diagnosticul etiologic al icteruluiobstructiv,
permite manevre terapeutice (drenarepseudochisturi pancreas
etc)
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Computer tomografia Rezoluie superioar ecografiei Difereniaz
formaiunile solide de cele chistice Permite puncia cu ac fin
(diagnostic), drenarea chisturilor
suprainfectate, abceselor (terapeutic)
Rezonana magnetic Avantaje (comparativ cu CT): nu utilizeaz
radiaii
ionizante, nu necesit substan de contrast, nlturartefactele
osoase
Explorare hepatic (formaiuni expansive hepatice,suprancrcare cu
fier, tromboz portal)
Colangiografia RMN (MRCP) a nlocuit ERCP-uldiagnostic
Tomografia cu emisie de pozitroni Are avantajul evalurii nu doar
structurale, ci i funcionale;
rol n detectarea recidivelor neoplazice la distan
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Puncia biopsie hepatic
Indicaii:
Evaluarea inflamaiei, steatozei i fibrozei n hepatitele
cronicevirale, cu implicaii terapeutice i prognostice
Formaiuni expansive hepatice (ecoghidat) Diagnosticul bolilor
colestatice, granulomatozelor hepatice Post-transplant hepatic n
cazul rejetului de gref
Contraindicaii: Timp de protrombin crescut, INR > 1.6
Trombocitopenie < 60.000/mmc
Ascit (se prefer calea transjugular) Hemangioame hepatice
Suspiciune de chist hidatic Pacient necooperant
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Complicaii
Durere (pleural, peritoneal, diafragmatic) Hemoragie
(peritoneal, intrahepatic, hemobilie) Peritonit biliar
Bacteriemie, sepsis Pneumotorax, pleurezie, hemotorax Emfizem
subcutanat Complicaii legate de anestezie Biopsierea altor organe
(rinichi, plmn, colon, colecist) Mortalitate (0.0088-0.3%)
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Metode imagistice non-invazive deevaluare a fibrozei
hepatice
tind s nlocuieasc puncia biopsie hepatic (PBH) metodinvaziv n
evaluarea pacienilor cu hepatopatii cronice
au o bun discriminare pentru fibroza joas (F0 F1) ifibroza
avansat (F4); sunt mai puin eficace n evaluareagradelor
intermediare de fibroz
cele mai multe studii au fost efectuate la pacieni cu
hepatitcronic viral C
includ:- elastografia n timp real HiRTE sau ARFI- elastografia
tranzitorie Fibroscan-ul- elastografia prin rezonan magnetic
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Elastografia n timp real
Poate fi efectuat:- aparat Hitachi Hitachi Real Time
TissueElastography (Hi RTE) evalueaz relativ elasticitateahepatic
printr-o scal de culori: cu ct esutul hepaticeste mai dur va
predomina culoarea albastr- aparat Siemens Acoustic Radiation Force
Impulse(ARFI) elasticitatea tisular este cuantificat ntr-o
ariepredefinit fiind exprimat n m/s
Aceste dou metode au avantajul determinrii elasticitiitisulare n
continuarea unei ecografii standard
Necesit n continuare studii pentru validare n practica
clinic curent
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Elastografia tranzitorie (Fibroscan)
este cea mai utilizat i validat modalitate de
evaluarenon-invaziv a fibrozei hepatice
transducerul aparatului transmite vibraii de frecven
iamplitudine joas care vor fi reflectate de esutul hepatic
viteza undelor se coreleaz cu duritatea esutuluihepatic, iar
rezultatele se exprim n kilopascali pentru diagnosticul de ciroz
hepatic (F4) sensibilitatea
i specificitatea Fibroscan-ului se apropie de 90% n cazul
activitii hepatice (transaminaze mult crescute)
rezultatele pot fi mai mari dect valoarea real a fibrozei
limitele metodei: pacienii cu obezitate morbid
(examinare cu sond special), ascit sau cu spaiiintercostale
nguste
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Elastografia RMN
folosete unde mecanice de frecven joas realiznd ohart a
elasticitii i vscozitii hepatice
este o metod promitoare dar limitat nc de costulcrescut i
accesibilitatea redus
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Metode serologice de apreciere afibrozei hepatice
Combin markeri serologici n vederea determinriifibrozei,
activitii necro-inflamatorii i steatozei hepatice
La fel ca metodele imagistice au specificitate crescutpentru
absena fibrozei (F0) i fibroza avansat (F4); auvaloare redus n
discriminarea gradelor intermediare defibroz
Au valoare predictiv pentru evoluia i prognosticul
boliihepatice
APRI (raport AST/trombocite), Fibrotest, FibroMax
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Fibrotest/Actitest
Fibrotest: alfa2macroglobulina, haptoglobina,apolipoproteina A1,
bilirubina total,gamaglutamiltranspeptidaza
Actitest asociaz ALT pentru determinarea activitii bolii
hepatice
Algoritmul ajusteaz rezultatele funcie de vrst i sex
Limite: hepatita acut (cresc valorile ALT), hemoliza acut(scade
valoarea haptoglobinei), stri inflamatorii acute(crete valorea
alfa2-macroglobulinei) sau sindrom Gilbert,colestaza extrahepatica,
hemoliz cronic (crete valoareabilirubinei)
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FibroMax
Combinatie de 5 teste non-invazive diferite: FibroTest,ActiTest,
SteatoTest, NashTest i AshTest
Markeri serici: alfa-2macroglobulina,
haptoglobina,apolipoproteina A1, bilirubina
total,gamaglutamiltranspeptidaza, ALT, AST, glicemia
bazal,colesterolul, trigliceridele, ajustate funcie de vrsta,sexul,
greutatea inlimea pacientului
Limitele metodei: la fel ca pentru fibrotest/actitest
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FibroMaxFibroTest msoara gradul fibrozei (corespunzator
stadiilor
F0-F4 ale scorului METAVIR)
F0 absena fibrozei F1 fibroz portal F2 fibroz n punte cu rare
septuri F3 fibroz n punte cu numeroase septuri F4 ciroz
ActiTest msoara gradul de activitate
necro-inflamatorie(corespunzator gradelor A0-A3 ale scorului
METAVIR)
A0 absena activitii A1 activitate minim A2 activitate
moderat
A3 activitate sever
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FibroMaxSteatoTest evalueaz steatoza hepatic 0 absenta steatozei
S1 steatoz minim (
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Alte explorri
Teste respiratorii: infecia Hp, insuficiena pancreaticexocrin,
malabsorpia
Angiografia- diagnosticul tumorilor abdominale- poate evidenia
sursa sngerrii
- valene terapeutice: vasopresin, chemoembolizare Scintigrafia-
hepato-splenic nlocuit de ecografie, CT
- HIDA (acid dimetilfenilcarbamilmetil iminodiacetic) evaluare
colecist, ci biliare
- hematii marcate evidenierea sngerrii- leucocite marcate
evidenierea abceselor, necrozelor
tisulare
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DISPEPSIA
Definiie
dys e peptein- nu se diger bine Dispepsia - conglomerat de
simptome cu sau fr substrat
organic n care durerea cronic sau recurent, localizat nabdomenul
superior este elementul principal
Durerea poate fi singurul element care caracterizeazdispepsia
sau poate fi asociat cu:saietate precoce,plenitudine postprandial,
grea, vrsturi, eructaii, pirozis
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Epidemiologie
ntre 25-40% din populaia adult din rile industrializate
sufer de dispepsie recurent
Reprezint 5-7% din totalul consultaiilor primare
1% din EDS anuale se efectueaz pentru dispepsie
Prin costuri directe i indirecte, dispepsia depetenmulte ri SUA
- 2 miliarde de dolari anual
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Clasificare i etiologieDispepsia: A. Organic - 40% din
cazuri
B. Funcional - 60% din cazuri
A. Cauzele dispepsiei organice:
I. Afeciuni organice ale tractului gastrointestinal:refluxul
gastroesofagian, gastropareza (diabet,postvagotomie), neoplasmul
gastric sau esofagian,malabsorbia (boala celiac, intolerana la
lactoz), ulcerulpeptic, patologia vascular ischemic, parazitoze
(Giardia,Strongyloides stercoralis)
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II. Medicamente : aspirina, antiinflamatoriinesteroidiene
(AINS), antibiotice (macrolidele,metronidazolul, sulfonamidele) ,
teofilina, digoxinul,diuretice de ans, fierul, suplimentele de
potasiu,inhibitorii enzimei de conversie, estrogenii
III. Afeciunile biliopancreatice: pancreatitacronic, neoplasmul
pancreatic, litiaza biliar,diskineziile sfincterului Oddi
IV. Afeciunile sistemice : diabetul zaharat,afeciunile tiroidei,
ischemia cardiac, insuficienacardiac congestiv, insuficiena renal,
boli decolagen etc
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B. Dispepsia funcional problem de sntate public: prevalen n
cretere
morbiditate ridicatcosturi socioeconomice semnificative
Definiie (Roma III): prezena simptomelor dispeptice (
saietateprecoce, plenitudine postprandial, durere sau arsur
epigastric cutopografie abdominal) n absena leziunilor organice
Se caracterizeaz prin triada :1. simptome persistente sau
recurente (durere sau discomfort n
abdomenul superior)2. absena unei afeciuni organice (inclusiv
prin explorare
endoscopic)3. nu se poate evidenia ameliorarea simptomelor dup
defecaie
sau existena concomitent a modificrilor n numrul sauconsistena
scaunelor
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Roma I i Roma II: dispepsia durere i discomfort nabdomenul
superior
Roma III pstreaz definiia i adaug simptomelecardinale ale
dispepsiei:
durere epigastric arsur epigastric
plenitudine postprandial saietate precoce
Dou sindroame noi majore Roma III
1. Postprandial dystress syndrome saietate precocepostprandial,
plenitudine postprandial
2. Epigastric pain syndrome durere sau arsur
intermitente,localizate n epigastru, cu intensitate variabil
(moderat sever) care apare cel puin o dat pe sptmn
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Fiziopatologie
tulburri de motilitate gastroduodenal
ntrzierea golirii gastrice
alterarea acomodrii gastrice anomalii mioelectrice
hipersensibilitate visceral: fr cauz cunoscut,fr legtur evident
cu tulburrile de motilitate
relaia cu infecia cu Helicobacter pylori:n prezent nupoate fi
explicat prin consens
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Tulburri de motilitate gastroduodenal1) ntrzierea golirii
gastrice
lipsa coordonrii eficiente a sistemului neuromusculargastric fa
de bolul alimentar (40% din cazurile dedispepsie) ar putea explica
saietatea precoce
2) alterarea acomodrii gastrice controlat normal prin vag i
mediat prin eliberare de
oxid nitric i 5-OH triptamin n dispepsia funcional bolul
alimentar este distribuit
direct n stomacul distal determinnd dilataia bruscantral
3) anomaliile mioelectrice hipomotilitate antral postprandial ca
urmare a
distensiei precipitate antrale
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Diagnostic pozitiv ( 1- 4) Anamneza esenial n afirmarea
diagnosticului Important de urmrit urmtoarele etape
1) simptomele de alarm- scderea ponderal necesit imediat
investigaii
- vrsturile incoercibile invazive pentru excluderea:- HDS
(hematemez, melen) - leziunilor organice- sindromul anemic - altor
afeciuni (DZ,
afeciuni tiroidiene, cardiace)- disfagia afectare tiroidian,
afeciune- icterul
+- examen baritat cu
suspiciuni de diagnostic- mas abdominal
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2) explorarea umoral biochimic de rutin- nu aduce date n
susinerea diagnostic
3) endoscopia digestiv superioar ( gold standardul)
- exclude alte leziuni, confirm diagnosticul pozitiv- imposibil
de a efectua EDS la toi pacienii dispeptici
4) n cazuri selecionate pentru excluderea altor afeciuni:- EDS
cu biopsie duodenal (excludere boala celiac)- echografie abdominal,
eventual CT- explorarea endoscopic, radiologic sau prin
videocapsul a intestinului subire- pH-metrie esofagian - 24 ore,
manometrie esofagian- examen psihologic (stress prelungit,
suprasolicitare,
tulburri psihiatrice cu fixaii cenestopate)
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Diagnostic diferenial
1) refluxul gastro- esofagian (arsuri retrosternale,regurgitaii
acide)
important de difereniat ntruct are terapie diferit
2) colonul iritabil- asociaz n 50 % din cazuri
simptomatologie
dispeptic
3) toate afeciunile organice care se nsoesc de
sindromdispeptic
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Principii de tratament
Regimul igienodietetic- prnzuri mici, frecvente cu evitarea
alimentelor care
agraveaz simptomatologia dispeptic
- evitarea grsimilor concentrate (lipidele ajunse nduoden cresc
sensitivitatea mecanic a stomacului)
- se contraindic formal cafeaua, alimentele picanteetc., n
special seara (relaxare SEI)
- scderea n greutate- ntreruperea fumatului
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Tratamentul medicamentos (1 5) eradicarea Hp tratament
antisecretor medicamente cu efecte asupra activitii motorii i
reflexe
medicamente cu efect antinociceptiv terapii alternative
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1. Eradicarea Hp
- eradicarea Hp are, comparativ cu tratamentulantisecretor,
efect benefic mic
- singurul argument (cercettori japonezi ) pentru care seindic
eradicarea Hp este legat de profilaxia ulceruluipeptic i a
cancerului gastric noncardial
2. Medicaia antisecretoare
- este superioar tratamentului de eradicare Hp ndispepsie
- durata tratamentului este de 2-8 sptmni
- aciunea benefic se bazeaz pe diminuarea aciditiii sensibilitii
duodenale
- IPP > inhibitorii H2 > placebo- beneficii > ca prim
linie de tratament n epigastric
pain syndrome comparativ cu postprandial dystresssyndrome
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3. Medicamente cu efect asupra activitii motorii i reflexe
Medicaia prokinetic (stimuleaz musculatura netedgastric)
acioneaz pe receptorii dopaminei (metoclopramida,
domperidonul) accelereaz golirea gastric stimuleaz contracia
musculaturii nedete gastrice
Eritromicina macrolid, agonist al receptorilor motilinici
Tegaserod agonist al receptorului 5 hidroxitriptaminic
administrat 6 mg x 2/zi accelereaz evacuare gastric
pe voluntarii sntoi i la pacienii cu dispepsie
Levosulpiride antagonist dopaminergic cu efecte favorabile n
specialn dispepsia prin dismotilitate
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4. Medicamente cu efect antinociceptiv
Antidepresivele triciclice n doze mici amelioreaz simptomele fr
a
aciona pe senzaia de distensie gastric antidepresivele n doze
mici > placebo
Alte medicamente, cu efect analgezic visceral agonitii opioizi
octreotridul
antagonitii neurokininei5. Terapii alternative
hipnoza, relaxarea interpersonal i alte metodepsihiatrice: pe
loturi mici, efect mai bun comparativ cuplacebo
medicaie naturist : experien favorabil pe loturimici
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Recomandrile Societii Americane de
Gastroenterologien evaluarea dispepsiei:
Au la baz strategia test and treat Primul pas testarea prezenei
infeciei cu Hp
Dac este prezent se trateaz infecia Hp n cazurile Hp negative se
administreaz antisecretorii
sau prokinetice sau ambele Pacienii care rmn simptomatici dup
tratament - EDS
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HELICOBACTER PYLORI DUP MASTRICHT IV
Helicobacter pylori Bacterie dublu spiralat gram negativ
Activitate ureazic
50% din populaia adult infectat
Transmitere: oral- oral, fecal oral
Omul rezervor Hp; apa
Starea socio-economic a societii:
-ri n curs de dezvoltare 80-90% din populaia >20 ani
-ri dezvoltate 20% la persoanele >25 ani
- prevalena crete cu 1%/an 50 60% la 70 ani
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Istoric
1938 Doenges bacili curbiformi n mucoasa gastric
1975 Sterr i Colin Jones - asociere cu gastrita
1983 Warren i Marshall - descriere, rol n gastrit iulcer peptic
- 2005 Premiul Nobel pentru medicin
1987 European Helicobacter pylori Study Group (EHSG)
1996, 2000, 2005, 2012 Maastricht 1, 2, 3, 4
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Testarea Helicobacter pyloriTeste noninvazive:
- confirm primo-infecia
- verific succesul tratamentului
Testul respirator C13sau C14: ureaza Hp hidrolizeaz ureea
n bicarbonat i amoniu i elibereaza CO2 care este absorbiti
eliberat n plmn; specificitate 95%
Ag n scaun
- de prim intenie la persoane < 45 ani, cu sindrom
dispeptic,dar fr semne de alarm sau istoric de cancer familial
- reduce numrul de endoscopii- specificitate 98%
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Serologia
- la pacienii netratai specificitate 90%
- nu poate fi folositn verificarea succesului terapiei saun
reinfecie (Ac rmn la valori crescute > 3 ani)
- nu necesit oprirea IPP cu 2 sptmni anterior testrii
- test diagnostic: ulcer hemoragic, atrofie gastric, limfomMALT,
dac pacientul este sub tratament cu antibioticesau IPP
! Cu excepia serologiei, pentru celelalte teste, se ntrerupIPP
cu minim 2 sptmni naintea testrii.
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Testarea Helicobacter pyloriTeste invazive:
Examenul histopatological materialului prelevat n timpulEDS;
specificitate > 95%
Testul rapid al ureazei: viraj colorimetric la schimbarea de
pH;specificitate 100%
Cultura Hp din biopsia gastric
- metod laborioas- incubare n medii speciale 3-5 zile- indicatn:
- cazurile n care rezistena la antibiotic este peste 15
20% n aria geografic respectiv- dup eecul a 2 cure de
eradicare
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Diagnosticul eficienei tratamentuluiinfeciei Hp
Se face la distan - cel puin 4 sptmni de la
terminareatratamentului
Testul respirator - de elecie
Ag n scaun
Testul serologic nu are valoare n testarea
eficieneitratamentului, scderea titrului Ac Hp necesit timp
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Indicaiile absolute de eradicaren infeciacu Helicobacter pylori
(Maastricht 4)
Indicaii UD/UG (activ sau complicat) Limfom tip MALT Gastrita
atrofic
- pangastrit atrofie i metaplazie intestinaladenocarcinom
- reversibilitatea leziunilor dup eradicare
subiectcontroversat
Gastrita de bont (stomac operat pentru cancer gastric) Pacienii
cu rude de gradul I cu istoric de cancer gastric La cererea
pacientului (consultarea prealabil a medicului
curant)
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Alte indicaii pentru eradicarea infecieicu Helicobacter
pylori
Dispepsia functional
Boala de reflux gastroesofagian (BRGE)
Antiinflamatorii nesteroidiene (AINS)
Pediatrie
Alte afeciuni (trombocitopenie idiopatic, anemia prin deficitde
fier, deficitul de vitamin B12)
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Dispepsia funcional
principalele teste non-invazive ce pot fi utilizate
pentrustrategia test and treat sunt testul respirator i Ag
fecal;sunt acceptatei testele serologice
test and treat este metod de elecie la adultul cudispepsie
funcional i infecie cu Hp, n ariile cuinciden crescut a infeciei Hp
(> 20%)
eradicarea Hp amelioreaza dispepsia pe o perioada lungde
timp
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BRGE
exist asociere negativntre prevalena infeciei Hp,severitatea
BRGE i incidena adenocarcinomului esofagian
prezena Hp nu influeneaza severitatea simptomatologiei,recurena
sau eficiena tratamentului BRGE
eradicarea Hp nu accentueaz BRGE preexistent i nuinflueneaz
eficiena tratamentului cu IPP
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Antiinflamatorii nesteroidiene (AINS)
infecia cu Hpse asociaz cu risc crescut de apariie a
ulcerelor gastricei duodenale la pacienii consumatori deAINS sau
doze mici de aspirin
eradicarea Hp reduce riscul de apariie a ulcerelor laaceti
pacieni
eradicarea Hp se recomand anterior iniierii AINS ieste
obligatorie la pacienii cu istoric de ulcer peptic
simpla eradicare Hp - insuficient pentru prevenireaulcerului
indus de AINS
incidena pe termen lung a HDS secundare ulceruluipeptic este mic
dup eradicare, chiar n absenaproteciei gastrice
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Populaia pediatric Ulcerul peptic
Copiii cu antecedente heredocolaterale de ulcer pepticsau cancer
gastric - testaii tratai
Anemia neexplicat i colica abdominal recurent -testare Hp
Alte afeciuni Trombocitopenia idiopatic(TIP)
- > 50% din cei cu TIP au infecie Hp- eradicarea infeciei Hp
se nsoete de remisiuneaparial sau total a trombocitopeniei
(explicat prinreactivitatea ncruciat ale Ag de suprafa ale
placheteii Hp)
Anemia cronic prin deficit de fier fr cauz ideficitul de
vitamina B12se amelioreaz la eradicareainfeciei Hp
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Infecia Hp i riscul de cancer gastric
Beneficiul major al strategiei de eradicare Hp -
posibilitatea
de prevenire a cancerului gastric!
Pacienii infectai cu Hp au inciden de 20 ori mai mare
de apariie a cancerului gastric comparativ cu populaia
general.
OMS clasific Hp: carcinogen de grup I
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Terapia standard de eradicare pentru Hp
Maastricht IV 10-14 zile
IPP CLARITROMICINA METRONIDAZOL AMOXICILINA
1. IPP 500mg x 2/zi 1000 mg x 2/zi
2. IPP 500mg x 2/zi 500 mg x 2/zi
Qvadrupla terapie: SUBCITRAT DE BISMUT COLOIDAL 140mg x4/zi
+
METRONIDAZOL 125 mg x4/zi+
TETRACICLINA 125 mg x4/zi+
IPP (20mgx2/zi) (pastil unic!)
Omeprazol 20 mg x2/zi sau
Lansoprazol 30 mg x 2/zi sau
Pantoprazol 40 mg x 2 /zi sau
Rabeprazol 20 mg x2 /zi sau
Esomeprazol 20 mg x 2 /zi
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IPP (indiferent de tipul folosit) au eficien > anti H2
Doza trebuie respectat i fracionat - antibiotic, IPP
Eficien: max 70%
Efecte secundare:
- dispepsie, diaree- diareea este de obicei tranzitorie i
autolimitat (cazuri rare cuClostridium difficile); se recomand
folosirea probioticelor- sunt mai frecvente n combinaia
Claritromicin - Amoxicilin(20%) comparativ cu Claritromicina i
Metronidazol, motivpentru care se recomand Metronidazolul n zonele
n carerezistena la acesta este
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Terapia de linia a II-a n eradicarea HP
Rezistena secundar:- metronidazol 60-70%- claritromicin 30 %
Cea de-a doua linie de tratament determin eradicareainfeciei Hp
n 75% din cazuri
n zonele cu rezisten la claritromicin dup eeculqvadruplei
terapii se recomand tripla terapie culevofloxacina
LEVOFLOXACIN + AMOXICILIN + IPP- este eficientn 90% din cazuri-
la 10 zile de tratament eradicarea este 94%- levofloxacina este
sigur i eficient
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A III-a linie de tratament
Dup eecul terapiei de linia a II-a tratamentul trebuieghidat
prin testarea sensibilitii la antibiotic: endoscopiecu prelevare de
biopsie, cultur
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Terapia secvenial
Un modul secvenial de 10 zile a fost recent introdus-5 zile IPP
+ Amoxicilin-5 zile IPP + Tinidazol + Claritromicin 250 mg x 2/zi
eradicare 93%
Claritromicin 500 mg x 2/zi 94%
Fr efecte secundare
Terapia secvenial - eradicare semnificativ mai marecomparativ cu
terapia convenional 10 zile.
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Reinfecia Frecvena reinfeciei dup eradicare:
- n rile dezvoltate: 0,5 2%/an- n rile n curs de dezvoltare
5%/an
Este mai curnd o recrudescen a bolii (pentru reinfeciear trebui
demonstrat aceeai tulpin bacterian)
Vaccinarea pentru Hp s-a dovedit eficient la animal, dar pentru
a putea fi
recomandat la om necesitn continuare cercetri i
studiiaprofundate
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Concluzii tratamentul infeciei Hp este eficient
rezistena la antibiotice trebuie cuantificat
permanentantibiotice alternative
creterea duratei tratamentului 10-14 zile crete eficiena
cvadrupla terapie i terapia secvenial cresc
succesultratamentului
cazurile care nu rspund la tratament necesit
testareasensibilitii microbiene
monoterapia este o realitate ndeprtatn tratamentul
infecieiHp
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BOALA DE REFLUXGASTROESOFAGIAN
Definiie: totalitatea simptomelor i modificrilor
histo-patologice determinate de refluxul coninutului gastric
nesofag
Ali termeni: boala de reflux endoscopic negativ
BRGE noneroziv (simtome caracteristice prezente frmodificri
endoscopice ale mucoasei)
BRGE cu manifestri extradigestive
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Epidemiologie
- extrem de frecvent- n rile dezvoltate
-25% din populaie pirozis - o dat / sptmn-7% pirozis - o dat /
zi
- prevalena n cretere - dublarea n ultimele 2 decade- distribuia
- egal pe sexe
Complicaii : M>F - esofagite (2-3 B/1F)- esofag Barrett
(10B/1F)
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Etiopatogenie
cea mai frecvent cauz - hernia hiatal prin alunecare
poate apare la orice cretere a presiunii abdominale: tuse,
corsete, ascit, tumori abdominale voluminoase, sarcin
vagotomie, gastrectomie, sclerodermie sau neuropatieautonom
diabetic
Atenie! Hp rol protectiv n BRGE (Hp gastrit antrui corpmasa
celular parietal secreia acid, pH-ul gastric)
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Patogenie
I.Incompentena mecanismelor de barier antireflux:1. sfincterul
esofagian inferior(SEI)2. absena sau scurtarea segmentului
intraabdominal
esofagian3. unghiul Hiss lrgit - nu poate preveni refluxul
II.Clearence-ul esofagian prelungit
III. ntrzierea evacurii gastrice (tulburri de motilitate
gastro-duodenale relaxarea tranzitorie SEI)
IV. Coninutul refluxului - agresivitatea depinde de prezena
iconcentraia de HCl
V. Scderea capacitii de aprare a mucoasei esofagiene(bicarbonat
i prostaglandine).
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Tablou clinic
I. Manifestri digestive Pirozis (arsur retrosternal, accentuat
de alcool, alimente
iritante, fierbini, clinostatism)
Regurgitaia (refluarea coninutului gastric n esofag,favorizat de
clinostatism)
Sialoreea (consecina refluxului esofagian salivar declanatde
contactul coninutului gastric refluat cu mucoasa)
Disfagia (determinat de complicaii ale refluxului:
stenozepeptice, adenocarcinom)
Odinofagia (deglutiie dureroas) apare n esofagita sever
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II . Manifestri extradigestive manifestri respiratorii (aspiraia
materialului refluat n cile
aeriene, cu bronhospasm sau reflex vagal): traheobronite,crize
de dispnee expiratorie (bronhospasm), tuse cu caractercronic,
nocturn (diagnostic diferenial cu dispneea paroxisticnocturn din
insuficiena ventricular stng)
manifestri cardiace (durat i volum refluat tulburri de
motilitate esofagiene): dureri precordiale noncardiace -mimeaz
angina pectoral i pot fi explicate parial prinaciditate, durat i
volumul coninutului refluat tulburri demotilitate esofagian
manifestri ORL: arsuri bucale, gingivit, eroziuni
dentare,senzaie de corp strin, laringit (cea mai
frecvent),laringospasm, otit medie, sinuzit
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Explorri paraclinice
I. Endoscopia- indicat la toi pacienii cu simptome de alarm
pentru
BRGE ct i la cei care nu rspund la tratament- specificitate
foarte bun (90-95%), diagnostic etiologic i
al complicaiilor BRGE- exclude afeciuni asociate (ulcere
gastrice, duodenale)- permite tratamentul n unele complicaii ale
BRGE
(stenoze, esofag Barrett)
Simptomele de alarmn BRGE: disfagia, odinofagia,scderea n
greutate, anemia, HDS, istoric de cancer detract digestiv
superior
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Esofagita peptic - 30% din pacieni
Clasificarea Savary Miller (1977):
grad 0 esofag macroscopic normal grad I: eroziuni neconfluente
eritematoase saueritematoexudative pe un singur pliu;
grad II: eroziuni multiple, confluente, necircumfereniale,pe mai
multe pliuri;
grad III: eroziuni confluente, circumfereniale; grad IV: ulcer,
strictur, izolat sau asociat cu II, III; grad V: esofag Barrett
I-III.
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Clasificarea Los Angeles (1994)
Grad A: una sau mai multe pierderi de substan, dar niciuna nu
depete 5mm n lungime;
Grad B: cel puin o eroziune peste 5 mm dar fr leziuniconfluente
ntre 2 pliuri;
Grad C: cel puin o eroziune confluent ntre unul saumai multe
pliuri dar nedepind 75% din circumferin;
Grad D: pierdere de substan (ulcere) > 75% dincircumferina
esofagului.
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II. Examenul radiologic baritat valoare diagnostic redus
evideniaz hernia hiatal, tulburri de motilitate,
complicaii(stenoze, tumori)
III. Monitorizarea pH-ului esofagian metoda cea mai sensibil,
permite nregistrarea episoadelor
de reflux, durata, momentul apariiei
Asociaia American de Gastroenterologie recomand ncazuri
selecionate :
preoperator i postoperator dac simptomatologia persist;
lipsa de rspuns la tratamentul cu IPP cu persistenasimptomelor i
endoscopie normal;
durere toracic non-cardiac sau BRGE cu manifestriORL sau de astm
non-alergic.
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