Download - Pankreatitis akut ppt by skl
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PANKREATITIS AKUT
Suryanti K.Lase
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Pankreatitis : inflamasi akut pankreas yang disertaigangguan organ jauh jantung, paru, dan
ginjal. (atlanta, 1992)
Secara patologi, pankreatitis terbagi 4 yaitu :
1. udematosa
2. infiltrate
3. haemorrhagica
4. necroticans.
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Patogenesis :
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Etiologi :
50%
20%
20%
10%
gallstones
alcohol
idiopathic
dll
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Tityus Trinitatis
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Pankreatitis akut dibagi dalam 2 tipe :
Interstitial Oedematous
pancreatitis
(mild acute pancreatitis)
Necrotizing pancreatitis
(severe acute pancreatitis)
pembesaran pancreas yang difus,
penyangatan homogen dari
parenkim pancreas
(CECT), inflamasi peripancreas
fat, dapat dijumpai peripancreatic
fluid, gejala klinis hilang dalam
satu minggu
terjadi nekrosis pada parenkim
dan jaringan peripancreatik,
CECT setelah satu minggu pada
parenkim pancreas tampak
gambaran area tanpa
penyangatan menunjukkan
nekrosis
80 % 20 %
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There is peripancreatic fat
stranding (arrows) without an
acute peripancreatic fluid
collection; the pancreas enhances
completely but has a
heterogeneous appearance due
to oedem
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Acute interstitial oedematous
pancreatitis and acute
peripancreatic fluid collection
(APFC) in the left anterior
pararenal space (white arrows
showing the borders of the
APFC). The pancreas enhances
completely, is thickened, and has
a heterogeneous appearance
due to oedema. APFC has fluid
density without an encapsulating
wall.
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Acute necrotising pancreatitis
involving only the peripancreatic
tissues. Note enhancement of
the entire pancreatic
parenchyma (white stars) and
the heterogeneous, non-liquid
peripancreatic components in
the retroperitoneum (white
arrows pointing at the borders of
the ANC).
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Necrotic pankreatitis
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Manifestasi klinis
diagnosa dari pankreatitis akut ditetapkan jika dijumpai duaatau lebih kriteria berikut :
1. nyeri perut yang berat, terjadi secara tiba-tiba danmenyebar ke punggung belakang
2. peningkatan kadar serum amylase atau lipase lebihdari 3x normal
3. dijumpai contrast enhanced computed tomography
(CECT).
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Gejala klinis lainnya yang dapat dijumpai, al :
- mual dan muntah
- anoreksia
- demam
- tachicardia
- leukositosis
- tanda Gray Turner
- tanda Cullen
- tanda Fox.
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Grey turner’s sign Cullen’s sign
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Pankreatitis akut terjadi dalam dua fase yaitu :
1. Fase I, ditandai dengan terjadinya SIRS selama2 minggu (early phase).
2. Fase II, ditandai dengan adanya keadaanimunosupressi CARS (late phase).
◦ Laboratorium yang diperiksa :
serum amilase/lipase, liver associated enzymes, BUN/creatinine/elektrolit, blood glucose, serum cholesterol/
triglyceride, CBC/Ht, CRP, arterial blood gas value, LDH/bicarbonate, IgG4.
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Radiodiagnostik Imaging yang dapat dilakukan al :
1. Foto polos abdomen
2. Ultrasonography
3. CT Scan
4. ERCP
5. MRI.
◦ Komplikasi yang dapat terjadi : syok dan kegagalan fungsiginjal, kegagalan fungsi paru, nekrosis, infeksisekunder, perdarahan, pseudokista pankreas.
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Sentinel loop. A segment of air-filled small intestine
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Colon cut-off sign. Supine abdominal
radiograph obtained in a patient with acute
pancreatitis shows an abrupt termination of air
in the left side of the transverse colon (arrows).
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Pseudocyst of pancreasEdematous pancreas
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Ct scan Pankreatitis akut:
menunjukkan swelling dan
inflamasi dari pankreas.
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Ranson’s criteria :
1. kriteria awal saat masuk rumeh sakit degree ofinflammation process
- usia > 55 tahun
- leukosit > 16000/ml
- kadar gula darah > 200 mg/dl
- SGOT > 250 IU/dl
- LDH > 350 IU/dl.
2. kriteria dalam 48 jam pertama systemic effect ofactivated enzymes to target organ
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- Ht ↓ > 10 %
- BUN > 5 mg/dl
- Kalsium < 8 mg/dl
- PaO2 < 60 mmhg
- BE > -4 meq/l
- squestrasi cairan > 600 ml.
Angka kematian untuk kriteria yang dijumpai sbb :
0-2 = 2%, 3-4 = 15%, 5-6 = 40%, 7-8 = 100%.
Jika score yang dijumpai : <3 mild acute pancreatitis,
≥3 severe acute pancreatitis.
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Atlanta criteria (1993) Atlanta revision (2013)
Mild acute pancreatitis Mild acute pancreatitis
Absence of organ failure Absence of organ failure
Absence of local complications Absence of local complications
Severe acute pancreatitis Moderately severe acute pancreatitis
1. local complications and/or2. organ failure
1. local complications and/or2. transient organ failure (<48 h)
GI bleeding (>500 cc/24 h) Severe acute pancreatitis
Shock-SBP ≤90 mmhg Persistent organ failure >49 h
PaO2 ≤ 60 %
Creatinine ≥ 2 mg/dl
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Terapi : 80% bergejala ringan dan sembuh sendiridalam 3-5 hari. Ada 2 tujuan terapi padapenanganan awal pankreatitis akut, yaitu:
1. terapi supportif dan terapi spesifik padakomplikasi yang muncul
2. membatasi perkembangan memberatnya responinflamasi dan nekrosis dengan spesifik memutusrantai patogenesisnya.
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Oksigenasi : saturasi O2 arteri > 95%.
Resusitasi cairan dengan mempertahankan produksi urine
> 0,5 ml/kgBB .
Pemasangan CVP, NGT
Pemberian obat-obat antiproteasi, anti secretory agent, anti inflammatoryagent.
Terapi nyeri, meperidin.
Pemberian nutrisi enteral.
Antibiotik prophylactic: imipenem, atau ciprofloksacin + metronidazole.
Terapi endoskopi dengan ERCP.
Terapi invasive: radiological drainage, surgical necrosectomy.
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Indikasi intervensi bedah pada pankreatitis akut nekrotikan:
1. infeksi jaringan nekrosis pancreas
2. pada jaringan nekrosis yang steril, bila: pancreatitisnekrotikan persistent, pancreatitis akut fulminant
3. munculnya komplikasi pancreatitis acute, sepertiperforasi usus dan perdarahan.
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The role of surgery in acute pancreatitis :
1. pasien dengan mild acute pancreatitis,diperlukan pencarian gallstones di gall bladderterlebih dahulu sehingga cholecystectomy harusdilakukan
2. pasien dengan necrotizing biliary acutepancreatitis, untuk mencegah infeksi,cholecystectomy ditunda sampai keadaaninflamasi aktif dan fluid collection stabil
3. pada kasus asymptomatic pseudocysts danpancreatic/extra pancreatic necrosis, intervensi
bedah tidak ada jaminan nya
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4. pasien dengan necrosis terinfeksi yang stabil,
perlakuan surgical/radiologic/drainase
endoscopic
harus ditunda > 4 minggu untuk terjadinya
liquefication dari cairan dan dinding fibrous yang
terbentuk disekitar necrosis
5. pada pasien symptomatic dengan necrosis
terinfeksi, metode minimally invasive necrosectomy
lebih disukai daripada open necrosectomy.
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Nutrisi pada kasus pankreatitis akut :
1. Pada kasus mild acute pancreatitis, oral feedingdapat dimulai segera dimana pemberiannyajika sudah tidak ada nausea, vomiting, danabominal pain. Initial pemberian diet dimulaidengan diet solid rendah lemak dan clearliquid.
2. Pada kasus severe akut pankreatitis, pemberiannutrisi enteral direkomendasikan untukmencegah komplikasi infeksi.
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Parenteral nutrisi harus dihindari, kecuali ruteenteral tidak tersedia, tidak dapat ditoleransi,atau tidak mencukupinya jumlah kalori yangdibutuhkan. Pemasangan nasogastric dan
nasojejunal untuk enteral feeding tampaknyasebanding dalam efficacy dan safety.
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Pemberian antibiotik pada pasien pankreatitis akut :
- antibiotik harus diberikan pada infeksi ekstrapankreatik, seperti cholangitis, infeksi karenapemasangan kateter, bacteremia, infeksi traktusurinarius, pneumonie.
- necrotik terinfeksi harus dipertimbangkan padapasien dengan pancreatic atau ekstrapancreaticnecrosis yang mengalami pemburukan denganbertambahnya hospitalisasi 7-10 hari.
- regimen antibiotik empiris diberi sebagaiprofilaktik untuk pancreatic yang
terinfeksi, sementara menunggu hasil kultur.
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There is a heterogeneous, acute necrotic collection (ANC) in the pancreatic andperipancreatic area (white arrows pointing at the borders of the ANC) with presence ofgas bubbles(white arrowheads), usually a pathognomonic sign of infection of thenecrosis (infected necrosis).
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Rekurensi :
- angka rekurensi relatif tinggi
- alkoholik pankreatitis : 46% rekuren, 80%
rekurensi terjadi dalam 4 tahun
- gallstone pankreatitis : rekurensi 32-61%
bila tidak dilakukan terapi
terhadap gallstone
- idiopatik pankreatitis : rekurensi 3% dalam
3 tahun.
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Daftar pustaka :
1. Acute Necrotizing Pancreatitis, Todd H Baron, MD andDesiree E Morgan, MD. The New England Journal ofMedicine May 6, 1999.
2. Acute Pancreatitis, Timothy B Gardner, MD.www.medscape.com September 3, 2013.
3. Classification of Acute Pancreatitis-2012: Revision of TheAtlanta Classification and Definitions by InternationalConsensus. Peter A Banks et all. http//gut.bmj.com/February 2, 2013.
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4. American College of Gastroenterology Guideline:
Management of Acute Pancreatitis. Scott Tenner, MD et
all. Am J Gastroenterol advance online publication, July
30, 2013.
5. Acute Pancreatitis. Luis Rodrigo. www.intechopen.com
Croatia, December 2011.
6. Shackelford’s Surgery of The Alimentary Tract, seventh
edition, volume 2. Charles J Yeo, MD et all. Elsevier
Saunders, Philadelphia 2013. Pages 1123-1131.
7. Buku Ajar Ilmu Bedah, R.Sjamsuhidajat, Wim de Jong.
EGC Jakarta 1998, hal 804-821.
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terima
kasih