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pankreatitis akut
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Pankreatitis akutDiskusi Topik Divisi GastroenterologiIPD - FKUIdr. Fransiska
DefinisiProses inflamasi pankreas reversibel Klinis : nyeri perut enzim pankreas darahRingan (80%) berat mengancam nyawa (20%)
Practice Guidelines in Acute Pancreatitis, Am J Gastroenterol 2006;101:2379-400
EpidemiologiMortalitas:ringan < 1% berat 10-30%evaluasi dini stratifikasi risiko
MortalitasPractice Guidelines in Acute Pancreatitis, Am J Gastroenterol 2006;101:2379-400
Etiologi38%36%Hiperamilasea 35-70%
PatofisiologiFase 1: Aktivasi prematur tripsin dalam sel asiner pankreas enzim digesti pankreasFase 2: Inflamasi intrapankreas melalui berbagai mekanisme dan jalurFase 3:Inflamasi ekstrapankreas ARDS Practice Guidelines in Acute Pancreatitis, Am J Gastroenterol 2006;101:2379-400
Patogenesisbile-pancreatic duct common pathway theorypancreatic autodigestion theorygallstone migration theoryenzyme activation theorykinin and complement system activation theorymicrocirculation disturbance theoryleukocyte excessive activation theorypancreatic acinar cell apoptosis and necrosis theoryKONTROVERSIAL
Manifestasi klinisNyeri abdomen : akut Mencapai intensitas max dlm 30 menit, persisten > 24 jam tanpa perbaikanmual dan muntahepigastrium dan periumbilikal.menjalar ke punggung, dada, pinggang, bagian bawah abdomenknee-chest position kurangi nyeri
Manifestasi klinisPF:DemamHipotensiNT abdomendistres pernapasandistensi abdomensyok dan ikterus nodul kulit eritematosa 10-20% kasus ronkhi di basal, atelektasis, dan efusi pleura kiri
Manifestasi klinisPankreatitis nekrosis :Cullens signpucat kebiruan di umbilikus hemoperitoneum
Turners sign warna biru merah keunguan / hijau kecoklatan daerah pinggang katabolisme hemoglobin
Laboratoriumenzim amilase enzim lipase 85-100%DPL, diff countblood urea nitrogen (BUN)KreatininGlukosaKalsiumTrigliseridaUL # severity
RadiologiAbdomen 3 posisi obstruksi 2ndUSG abdomen batu empedu (etiologi)CT ScanPembesaran pankreas dgn edema difusParenkim pankreas heterogenPeripancreatic stranding & fluid collectionERCP/MRCP superior u anatomi duktus dan koledokolitiasisEUS
DiagnosisGuidelines American College of Gastroenterology : 2 dari 3:nyeri abdomen yang khas pankreatitis akutpeningkatan serum amilase dan lipase 3 kali normaltemuan khas pankreatitis akut pada CT scan
Practice Guidelines in Acute Pancreatitis, Am J Gastroenterol 2006;101:2379-400
Diagnosis diferensialIskemia/infark mesenterikaPerforasi ulkus gaster/duodenumKolik bilierAneurisma aorta disektaObstruksi ususInfark miokard akut inferior
Stratifikasi RisikoApache IIRansonCT severity indexImrie scoring system
Guidelines American College of Gastroenterology, 2006DiagnosticLook for risk factors of severity at admissionDetermination of severity by laboratory test at admission or 48 hDetermination of severity during hospitalizationImaging studiesOrgan failure
Guidelines American College of Gastroenterology, 2006TreatmentSupportive carePrevent hypoxemiaFluid resuscitationTransfer to an ICUNutritional supportUse of prophylactic antibiotics in necrotizing pancreatitisTreatment of infected necrosisTreatment of sterile necrosisRole of ERCP and billiary sphincterotomy in gallstone pancreatitis
Terapi medisPuasa NGT, TPNKoreksi cairan dan elektrolit 2000-3000Koreksi metabolikAnti nyeriAntibiotik (+/-)OksigenOctreotide, PPIEndoscopic sphincterotomy (ERCP)
AntibiotikImipenem 3 x 500 mg IVCiprofloxacin 2x400 mg IV + Metronidazol 3x500 mg IVSefalosporin generasi III
Antibiotics and Severe Acute Pancreatitis: ProsSharma VK, Howden CW. Pancreas 2001; 22:28-31. [42]Antibiotic prophylaxis significantly reduced sepsis by 21.1% and mortality by 12.3% compared with no prophylaxisThere was also a non-significant trend toward a decrease in local pancreatic infectionsAntibiotic prophylaxis decreases sepsis and mortality in patients with acute necrotizing pancreatitisAll patients with acute necrotizing pancreatitis should receive prophylaxis with an antibiotic of proven efficacy
The median penetration ratio of CIP:137.5% (11196%) in infected omental bursa fluid59.6% (3214%) in pancreatic necroses 67.1% (1250%) in peripancreatic necrosesChemotherapeutical ratios of CIP as a marker for antimicrobial potency were high against most relevant pathogens in necrotizing pancreatitis.
Conclusion: Due to its antimicrobial spectrum and the good penetration into the relevant compartments, CIP may be useful in preventing local infection in necrotizing pancreatitis.
Options for Nutrition Support in the Individual PatientENStandard Rx (Do nothing)PN Options in acutepancreatitis based on: Disease severity Timing Tolerance
Nutrisi parenteralProTidak ada efek skresi pankreasAman, efektif komplikasi lokal dan mortalitas (vs tanpa nutrisi pada penyakit berat)KontraMahalRisiko infeksiMonitoring ketat elektrolit, trigliseridaKebutuhan insulin
Algoritma
Terima Kasih
The authors concluded that all patients with acute necrotizing pancreatitis should receive early antibiotic treatment [42].However, not all researchers agree that severe acute pancreatitis should be treated with early antibiotic administration [43]. This is the suggested caloric intake for the refeeding of acute pancreatitis patients [46].