intestin subtire

8/16/2019 Intestin Subtire

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CURSCURS

GASTROENTEROLOGIEGASTROENTEROLOGIEintestin subtireintestin subtire


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Normal histologyNormal histology

Layers:Layers: - MucosaMucosa- SubmucosaSubmucosa- Muscularis propria (externa)Muscularis propria (externa)- SubserosaSubserosa

Serosa - contains mesothelialSerosa - contains mesotheliallining, loose connective tissuelining, loose connective tissue

Lamina propria:Lamina propria: contains loosecontains looseconnective tissue, lymphocytes,connective tissue, lymphocytes,plasma cells, occasionalplasma cells, occasionaleosinophils, macrophages, masteosinophils, macrophages, mastcells, neutrophilscells, neutrophils


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MucosaMucosacontains villi withcontains villi withcentral bloodcentral bloodvessels, lymphaticsvessels, lymphatics

epitheliumepithelium

lamina proprialamina propriamuscularis mucosamuscularis mucosa


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MucosaMucosa

Villi:Villi: containcontainmicrovilli; containmicrovilli; containprimarily columnarprimarily columnarabsorptive cells andabsorptive cells andgoblet cellsgoblet cellsAbsorptive cells:Absorptive cells: have microvilli onhave microvilli onluminal surfaceluminal surface(brush border) and(brush border) andunderlying mat ofunderlying mat ofmicrofilamentsmicrofilaments(terminal web)(terminal web)


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Crypts of LieberkuhnCrypts of Lieberkuhnlower 2 ! of epithelium,lower 2 ! of epithelium,containcontain undifferentiatedundifferentiated(immature) crypt cells(immature) crypt cells ,,Paneth cellsPaneth cells (have large,(have large,apical eosinophilic granulesapical eosinophilic granulescontaining antimicrobialcontaining antimicrobialproteins),proteins), scatteredscatteredgoblet cellsgoblet cells andandendocrine cellsendocrine cellssecrete ions, water, "g#,secrete ions, water, "g#,antimicrobial peptides intoantimicrobial peptides intolumenlumencrypt cells ta$e %-& days tocrypt cells ta$e %-& days tomigrate to surface;migrate to surface; allowsallowsfor rapid repairfor rapid repair , but also, but alsocauses these cells to becauses these cells to besensitive to radiationsensitive to radiationtherapy and chemotherapytherapy and chemotherapy


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SubmucosaSubmucosa

contains connectivecontains connectivetissue, bloodtissue, bloodvessels, lymphatics,vessels, lymphatics,submucosalsubmucosal(Meissner's) plexus(Meissner's) plexus


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Muscularis propria (externa)Muscularis propria (externa) inner circularinner circularandand outerouter

longitudinallongitudinallayer, withlayer, withmyentericmyenteric(( Auerbach’sAuerbach’s ))plexus betweenplexus betweenthese layers;these layers;plexus alsoplexus also

containscontainsinterstitialinterstitial cellcellof Ca alof Ca al ,,ganglion cellsganglion cells ,,fibroblastsfibroblasts


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Auerbach’s cellsAuerbach’s cells

!nterstitial cell of Ca al!nterstitial cell of Ca al type of interstitial cell foundtype of interstitial cell found

in the gastrointestinal tractin the gastrointestinal tractthat serves as a pacema$erthat serves as a pacema$erwhich creates the basalwhich creates the basalelectrical rhythm leading toelectrical rhythm leading toperistalsisperistalsisganglion cellsganglion cells specialspecialnerve cellsnerve cells in the intestinein the intestinethat ma$e the muscles push;that ma$e the muscles push;congenital aganglionosis-congenital aganglionosis-

irschsprung*s diseaseirschsprung*s diseasefibroblastsfibroblasts produce theproduce theextracellular matrix andextracellular matrix andparticipate in the transport ofparticipate in the transport ofabsorbet metabolites to theabsorbet metabolites to theblood and lymphatic apillariesblood and lymphatic apillaries


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En ocrine cellsEn ocrine cells

similar to cells insimilar to cells inpancreas, biliary tree,pancreas, biliary tree,lung, thyroid, urethralung, thyroid, urethracontain fine eosinophiliccontain fine eosinophilicgranules with secretorygranules with secretoryproteinsproteinsnuclei on luminal side ofnuclei on luminal side ofgranules, not basalgranules, not basal

- "erotonine"erotonine(enterocromafine)(enterocromafine)

- #astrine (#)#astrine (#)- "ecretine (")"ecretine (")- $nteroglucagon ($#)$nteroglucagon ($#)


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DIAREEADIAREEADefintie: tranzit accelerat, >3 scaune zi, scaun nef!r"at > #$$% zi&izi!l!%ie:' in tract %astr!intestinal intra ()*$ l flui+e #l in%estie, restul

secretii-.' Na ) c!)trans/!rt cu Cl si %luc!za in intestin subtire iar in ile!nul

ter"inal cu sarurile biliare. c!)trans/!rt cu 0 ) 0CO3. 1 seabs!arbe la sc2i"b cu 0 sau Ca

' In c!l!n, Na se abs!arbe /rin canalele +in "e"brana a/icala sieste /!"/at afara +e Na)1 )AT4 aza +in "e"brana baz!laterala.

' /arasi"/aticul sti"uleaza /eristaltis"ul si secretia +e electr!liti.si"/aticul in5ers

' siste" ner5!s enteric aut!n!"


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&i%ure 6 * ) 7ater flu8es t2r!u%2 t2e intestine&i%ure 6 * ) 7ater flu8es t2r!u%2 t2e intestine

9C!/ ri%2t Science 4ress Internet Ser5ices


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DIAREEADIAREEADiaree acuta ; # sa/ta"ini' cauze: infecti!ase bacteriene stafil!c!c, sal"!nela-. 5irale Ec2!-

4arazitare %iar+ia, enta"!eba-. aler%ie, t!8ic, "e+ica"ent!asa, stress,secun+are un!r b!li %enerale: "enin%ite, ure"ie, criza 2i/ertir!i+iana-Diaree cr!nica > # sa/ta"ini&alsa +iaree: +u/a c!nsti/atie +e zile, scaun lic2i+ cu fra%"ente"ai +ure /rece+at +e c!lici, e8a"enul scaunului aratin+ ! +i%estie

c!"/leta&alsa +iaree: frec5enta crescuta a +efecatiil!r, +ar cu scaun +ec!nsistenta n!r"alaInc!ntinenta fecala: eli"inare in5!luntara +e "aterii fecale


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DIAREEA CRONICADIAREEA CRONICADIAREE OS


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DIAREEA CRONICADIAREEA CRONICADIAREE IN&LA


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Electr!liElectr!li i, %aura !s"!tici, %aura !s"!ticSupernatantSupernatant+ osmotic subst ne-electrolitice re.in osmotic subst ne-electrolitice re.in

apaapa+ secretorie electroli.ii re.in apa secretorie electroli.ii re.in apa

/aura osmotic 20 -2(1a 3)/aura osmotic 20 -2(1a 3)+ 4526m7sm8$g- osmotica4526m7sm8$g- osmotica+ 96 m7sm8$g- :secretorie96 m7sm8$g- :secretorie


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TA LE 6 ) ? T 4ICAL &EATURES O&TA LE 6 ) ? T 4ICAL &EATURES O&SECRETOR DIARR0EASECRETOR DIARR0EA

!A"LE #$%& !'()CAL *EA!+,ES -* SEC,E!-,' .)A,,/EA

>!lu"in!us, Fater: st!!ls

Little !r n! fecal !s"!tic %a/, st!!l /0 near G3$

Usuall: /ers ists +urin% fastin%

Usuall: n! /us, bl!!+, !r e8cess fat in st!!ls


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MALA"S-, ! -NMALA"S-, ! -N


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=lasificare: >i iopatologie=lasificare: >i io patologie?rocesul complex al digestiei


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": >a a luminal": >a a luminalidroli a deficitar a nutrimentelor (lipide,idroli a deficitar a nutrimentelor (lipide,

proteine, hidra.i de carbon)proteine, hidra.i de carbon) datorat Adatorat A- insuficien.ei pancreatice exocrine- insuficien.ei pancreatice exocrine →→ pancreatita cronic , =a: pancreaspancreatita cronic , =a: pancreas

- sdr: DE, re ec.ie gastric- sdr: DE, re ec.ie gastric hidroli a deficitar a lipidelor alimentarehidroli a deficitar a lipidelor alimentare AA-- maldigestie lipidemaldigestie lipide →→ afec.iuni ce reducafec.iuni ce reducsecre.ia lipa ei, colipa ei pancreaticesecre.ia lipa ei, colipa ei pancreatice--

simptomele datorate lipoli ei insuficienteAsimptomele datorate lipoli ei insuficienteA

steatoree, diaree, deficit vit: liposolubilesteatoree, diaree, deficit vit: liposolubile(tetanie, sdr: hemoragipar)(tetanie, sdr: hemoragipar)


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hidroli a deficitar a proteinelor alimentareAhidroli a deficitar a proteinelor alimentareA- pepsine- pepsine

- protea e pancreatice- protea e pancreatice→→

sc dere ponderal ,sc dere ponderal ,sc derea masei musculare, edemesc derea masei musculare, edeme

hidroli a deficitar a glucidelor alimentarehidroli a deficitar a glucidelor alimentare- expuse bacteriilor colonice de fermenta.ie- expuse bacteriilor colonice de fermenta.ie →→ ac: gra


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eficit de solubili are a lipideloreficit de solubili are a lipidelor deficit de s ruri biliare (sinte , excre.ie)deficit de s ruri biliare (sinte , excre.ie)

clinicA diaree, steatoree, deficit vitamineclinicA diaree, steatoree, deficit vitamineliposolubile (tetanie, sdr: hemoragipar, fracturiliposolubile (tetanie, sdr: hemoragipar, fracturiosoase)osoase)Sc derea absorb.iei nutrimentelorSc derea absorb.iei nutrimentelor ionul ferosionul feros →→ forma de absorb.ie a >eforma de absorb.ie a >e →→ depinde de p -ul acid gastricdepinde de p -ul acid gastric factorul intrinsec gastricfactorul intrinsec gastric →→ secretat de cel:secretat de cel:parietale gastriceparietale gastrice →→ esen.ial pt: abs: vit: F52esen.ial pt: abs: vit: F52(deficit congenital, gastrectomii, #c anti celul(deficit congenital, gastrectomii, #c anti celulparietal )parietal )


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"": >a a mucosal (de absorb.ie)"": >a a mucosal (de absorb.ie)

afec.iuni difu e muco ale sau pierdere extins aafec.iuni difu e muco ale sau pierdere extins amucoasei intestinalemucoasei intestinale re ec.ii extinse de intestinre ec.ii extinse de intestin →→ malabsorb.ie globalmalabsorb.ie global boala celiac , diareea tropical , b: =rohnboala celiac , diareea tropical , b: =rohnanomalii enterocitareanomalii enterocitare hidroli deficitar la nivelul Bmarginii @n periehidroli deficitar la nivelul Bmarginii @n perie C C

- hidrola ehidrola e →→ carbohidra.icarbohidra.i →→ mono aharide enterocitarmono aharide enterocitar- deficit de hidrola edeficit de hidrola e →→ carbohidra.i incomplet digera.icarbohidra.i incomplet digera.i

→→ coloncolon →→ metaboli a.i de bacteriimetaboli a.i de bacterii →→ aci i gra


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transport deficitar la nivelul enterocitelortransport deficitar la nivelul enterocitelor- anomalii genetice ale transportului ##anomalii genetice ale transportului ##- aa HHlipoproteinemielipoproteinemie →→ acumulare intracelularacumulare intracelular

trigliceridetrigliceride →→ diaree, steatoree, malabsorb.ie vit:diaree, steatoree, malabsorb.ie vit:IiposolubileIiposolubile

""":""": >a a de transport limfatic a a de transport limfatic


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!A"LE %$0& CLASS)*)CA!)-N -* .)SEASES !/A! CA+SE)N!ES!)NAL MALA"S-,(!)-N

(remucosal Mucosal (ostmucosal

4ancreaticinsufficienc: Celiac s/rue

C!n%enitall:"/2an%iectasia

0e/at!biliar:+isease Tr!/ical s/rue

Sec!n+ar:l:"/2an%iectasia

Aacterial!5er%r!Ft2 72i//leIs +isease

Ra/i+ intestinaltransit E!sin!/2ilic enteritis

Gastrect!": Arus2 b!r+er enz:"e+eficienc:

L:"/2!"a

S2!rt)b!Fel s:n+r!"e

4r!l!n%e+ "alnutriti!n

Ra+iati!n enteritis

4arasitic infecti!n


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iagnostici agnostic#namne G etiologieA#namne G etiologieA

interven.ii chirurgicale (re ec.ii gastrice,interven.ii chirurgicale (re ec.ii gastrice,

intestinale, intestin scurt, poluareintestinale, intestin scurt, poluarebacterian )bacterian ) sdr: Dollinger-Ellisonsdr: Dollinger-Ellison

diaree cronic , anemie, deficit ponderaldiaree cronic , anemie, deficit ponderal →→enteropatie glutenicenteropatie glutenic consum medicamente (neomicin ,consum medicamente (neomicin ,

laxative) laxative) consum etanolconsum etanol hipertiroidie, Dhipertiroidie, D

< i5 " ll)b!F l ti! i% ifi t< i5 " ll)b!F l ti! i% ifi t


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J Re%ular +iet

*?*)#$$ )

J Re%ular +iet

>#$$ ) !r J Re%ular +iet


Simptome intestinaleSimptome intestinale


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Simptome intestinaleSimptome intestinale iareeaiareea

- %-5 scaune82Kh, decolorate, voluminoas%-5 scaune82Kh, decolorate, voluminoas 44 K -6 gK -6 g- scaunele plutesc (con.in ga , lipide)scaunele plutesc (con.in ga , lipide)- scaun steatoreicscaun steatoreic →→ chitos, mat, aderentchitos, mat, aderent- explo iv , caracter apos, meteorism abdominal,explo iv , caracter apos, meteorism abdominal,

eritem perianaleritem perianal →→ malabsorb.ie carbohidra.imalabsorb.ie carbohidra.i

urerea abdominalurerea abdominaldisconfort difu abdominaldisconfort difu abdominal- caracteristic @nA pancreatita cronic , boala =rohn,caracteristic @nA pancreatita cronic , boala =rohn,

steno e digestive, ischemie me entericsteno e digestive, ischemie me enteric

#lte manifest ri intestinale#lte manifest ri intestinale- meteorism, flatulen. , borborisme (apar la % -0 minmeteorism, flatulen. , borborisme (apar la % -0 min

dup ingestia de carbohidra.i)dup ingestia de carbohidra.i)- diaree apoas (deficit di aharide din Bmarginea @ndiaree apoas (deficit di aharide din Bmarginea @n

perieC enterocite)perieC enterocite)


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Simptome extraintestinaleSimptome extraintestinale sc dere ponderal (sc dere ponderal ( severa casexiesevera casexie ))

- aa norexienorexie (hiprfagie)(hiprfagie)- reducere aport caloricreducere aport caloricmalabsorb.ie protein caloricmalabsorb.ie protein caloric

retard staturo-ponderal, infantilismretard staturo-ponderal, infantilism @ntLr ierea de volt rii sexuale @ntLr ierea de volt rii sexuale hipopla ii dentarehipopla ii dentare

anemie (astenie, fatigabilitate, verti , dispnee,anemie (astenie, fatigabilitate, verti , dispnee, angor) angor) dureri


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Examenul fi icExamenul fi icJegumenteAJegumenteA

- sub.iri, atrofice, f r elasticitatesub.iri, atrofice, f r elasticitate- petee)- dermatit herpetiformdermatit herpetiform →→ boala celiacboala celiac- eritem nodoseritem nodos →→ boala =rohnboala =rohn- hipocratism digitalhipocratism digital →→ malabsorb.ie severmalabsorb.ie sever- leuconichieleuconichie (hipoalbuminemie)(hipoalbuminemie)


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glosit acutglosit acut- limb roe

ulcera.ii aftoide, recidivanteulcera.ii aftoide, recidivante →→ b:=rohn,b:=rohn,b: celiac , b: Fehb: celiac , b: Feh OOetet

macroglositmacroglosit →→

amiloidoamiloidohipoalbuminemie severhipoalbuminemie sever →→ edemeedemeperiferice, rar acuteperiferice, rar acutehipo=a, Mghipo=a, Mg →→ spasm carpopedalspasm carpopedalpareste ii, neuropatie perifericpareste ii, neuropatie periferic →→ vit:F52vit:F52


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Explorare sindromului de malabsorb.ieExplorare sindromului de malabsorb.ie5:5: Jeste sLnge de prim linie (screening)Jeste sLnge de prim linie (screening)

investiga.ii hematologiceinvestiga.ii hematologice- anemie (macrocitar , microcitar )anemie (macrocitar , microcitar )- >e seric>e seric , feritina, feritina

investiga.ii biochimiceinvestiga.ii biochimice- serineserine 99 2,6g8dl2,6g8dl

- =a, Mg, ># (osteoporo )=a, Mg, ># (osteoporo )- "P (vit:3)"P (vit:3)- "g# (sc ute)"g# (sc ute)

f l b b


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22 :: Jeste care confirm malabsorb.iJeste care confirm malabsorb .i aaMalabsorb.ia lipidelorMalabsorb.ia lipidelor

- normal @n scaun se eliminnormal @n scaun se elimin 99 Nglipide82KhNglipide82Kh- test Sudan (metod calitativ )test Sudan (metod calitativ )- test respirator cu =5K G trioleintest respirator cu =5K G triolein

(administrare oral(administrare oral →→ m surare =72 expiratm surare =72 expirattimp de Nh dup adm:)timp de Nh dup adm:) →→ limitatlimitat

Malabsorb.ia carbohidra.ilorMalabsorb.ia carbohidra.ilor- testul de toleran. oral la lactotestul de toleran. oral la lacto

(adm: 6 g lacto(adm: 6 g lacto →→ glicemia dup % -0 min:)glicemia dup % -0 min:)- testul respirator lacto - 2testul respirator lacto - 2- testul la xilo Atestul la xilo A

6 g -xilo adm: per os diminea.a6 g -xilo adm: per os diminea.a →→ urina colectat 6h dup administrareurina colectat 6h dup administrare →→excre.iaexcre.ia 99 5,%g @n urin malabsorb.ie5,%g @n urin malabsorb.ie


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Malabsorb.ia proteinelorMalabsorb.ia proteinelor G dificilG dificil#lte teste#lte teste AA

testul Schillingtestul Schilling →→

vit: F52vit: F52

test pentru abs: aci i biliaritest pentru abs: aci i biliari →→ test respiratortest respiratorcu =5K - glicocoliccu =5K - glicocolictest pentru dg: sdr: de poluare bacteriantest pentru dg: sdr: de poluare bacterian

- culturi tract digestivculturi tract digestiv- test respirator cu =5K xilotest respirator cu =5K xilo

%:%: Exam rad: al intestin sub.ireExam rad: al intestin sub.ire- enteroclisma (diverticuli, steno e, b:=rohn,enteroclisma (diverticuli, steno e, b:=rohn,tbc, limfom) tbc, limfom)


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K: Fiopsii muco aleK: Fiopsii muco ale →→ E SE S →→ cheia decheia dedg:dg:

6: Echo abdominal6: Echo abdominalN: =JN: =JQ: ER=?Q: ER=?

?rincipii terapeutice?rinci pii terapeuticecorec.ia deficitelor nutri.ionalecorec.ia deficitelor nutri.ionaletratamentul afec.iunii cau aletratamentul afec.iunii cau ale


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Jratament medicalJratament medical=holestyramina (agent chelator de=holestyramina (agent chelator des ruri biliare)s ruri biliare) →→ K -& gx%8 i, @nainteK -& gx%8 i, @nainte

de mesede mese(malabsorb.ie de aci i biliari)(malabsorb.ie de aci i biliari)Ioperamida ("modium) KmgIoperamida ("modium) Kmg →→ 2mg2mgpentru fiecare scaun neformatpentru fiecare scaun neformat


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Jratamentul afec.iunii cau aleJratamentul afec .iunii cau ale

insuficien.a pancreatic exocrininsuficien.a pancreatic exocrin →→ en ime pancreaticeen ime pancreaticeentoropatia glutenicentoropatia glutenic →→ dieta f rdieta f rglutenglutensprue tropicalsprue tropical →→ antibioticeantibiotice

sindromul de poluare bacteriansindromul de poluare bacterian →→antibioticeantibioticeFoala =rohnFoala =rohn →→ corticoterapiecorticoterapie


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ENTERO4ATIA GLUTENICKENTERO4ATIA GLUTENICKE>"1" "EE>"1" "Eafec.iune cronic intestinalafec.iune cronic intestinalcaracteri at prin atrofie vilo itar


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p gp g5:5: >actori de mediuA glutenul actori de mediuA glutenul actori geneticiA mar$eri de susceptibilitate>actori geneticiA mar$eri de susceptibilitate

I# actori imunologiciA- boala celiac este determinat de un r spunsboala celiac este determinat de un r spuns

imunologic, mediat celular, anormal la glutenul dinimunologic, mediat celular, anormal la glutenul din

diet , observat numai la persoanele susceptibilediet , observat numai la persoanele susceptibilegeneticgenetic- anomaliile imunologice din E/ interesea atLtanomaliile imunologice din E/ interesea atLt

- r spunsul imun celular (nr: limfocite- r spunsul imun celular (nr: limfociteintraepiteliale crescut) intraepiteliale crescut)

- imunitatea umoral (#c antigliadin de tip- imunitatea umoral (#c antigliadin de tip"g#


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=riterii de diagnostic=riterii de d iagnostic5: #natomopatologicA5: #natomopatologicA

pre en.a atrofiei vilo itare intestinalepre en.a atrofiei vilo itare intestinalesubtotal 8totalsubtotal 8total

Tipuri lezionale înTipuri lezionale înenteropatiaenteropatiaglutenicăglutenică

tip 0tip 0 preinfltrativpreinfltrativ

tip 1tip 1 infltrativinfltrativtip 2tip 2 hiperplastichiperplastictip 3tip 3 plat-destructivplat-destructiv

tip 4tip 4 hipoplastic-atrofchipoplastic-atrofc


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!ala celiac e8 2ist!l!%ic!ala celiac e8 2ist!l!%ic


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!ala celiac ) 2ist!l!%ie!ala celiac ) 2ist!l!%ie


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2: =linic2: =linicSimptome gastrointestinaleSimptome gastrointestinale

diareediareeGG % -Q ! (5-5 scaune82Kh)% -Q ! (5-5 scaune82Kh)- scaune voluminoase- scaune voluminoase 44 K -6 ml82KhK -6 ml82Kh

- semiconsistente, decolorate- semiconsistente, decolorate- aspect chitos, gr sos- aspect chitos, gr sos- con.inut mare de ga e


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Simptome extraintestinaleSimptome extraintestinale

deficit ponderaldeficit ponderal

@ntLr ierea de volt rii staturo-ponderale la @ntLr ierea de volt rii staturo-ponderale lacopilcopil astenie fi ic


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!ala celiac +er"atit 2er/etif!r"!ala celiac +er"atit 2er/etif!r"


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!ala celiac leziuni cutanate!ala celiac leziuni cutanate


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Fiopsia intestinalFiopsia intestinal- E S- E S

Jeste de screeningJeste de screening- #c antigliadin ("g#)#c antigliadin ("g#) →→ Q -5 !Q -5 !

netrata.inetrata.i

- #c antiendomisium#c antiendomisium- #c antitransglutamina tisular#c antitransglutamina tisular

(autoag recunoscut de #c antiendomisium)(autoag recunoscut de #c antiendomisium)

TideocapsulaTideocapsula


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!ala celiac ) en+!sc!/ie!ala celiac ) en+!sc!/ie


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!ala celiac ) 5i+e!ca/sula!ala celiac ) 5i+e!ca/sula


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%: ?araclinic%: ?araclinicJeste biochimice


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iagnosticul diferen.ialia gnosticul diferen.ial#fec.iuni intestinale caracteri ate prin#fec.iuni intestinale caracteri ate prinle iuni anatomopatologice celiac li$ele iuni anatomopatologice celiac li$e(atrofie vilo itar )(atrofie vilo itar ) sdr: imunodeficien. dobLnditsdr: imunodeficien. dobLndit sprue tropicalsprue tropical

limfom intestinallimfom intestinal infestare para itarinfestare para itar#fec.iuni care determin sindrom de#fec.iuni care determin sindrom demalabsorb.iemalabsorb.ie

boala =rohnboala =rohn pancreatita cronicpancreatita cronic sdr: Dollinger-Ellisonsdr: Dollinger-Ellison

sdr: poluare bacterian intestinalsdr: poluare bacterian intestinal

=omplica.ii=om

plica.ii


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omplica.iiom plica.ii limfom intestinal primitiv (6 !)limfom intestinal primitiv (6 !) e unoileita ulcerat nespecific G rar e unoileita ulcerat nespecific G rar

boala celiac refractar (Q-&!)boala celiac refractar (Q-&!)>orme clinice>orme clinice E/ simptomatic (clinic manifest )E/ simptomatic (clinic manifest )- pre en.a atrofiei vilo itare- pre en.a atrofiei vilo itare

- manif: clinice intestinale


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p pp pieta f r glutenieta f r gluten

pe tot parcursul vie.iipe tot parcursul vie.ii restric.ie complet


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Enteropatia complicat sau severEnteropatia complicat sau sever

tratament imunosupresortratament imunosupresor

administrarea de =a, acid folic,administrarea de =a, acid folic,vit:F52, >e, vit: , vit:#vit:F52, >e, vit: , vit:#


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Dieta %luten freeDieta %luten free


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Dieta %luten freeDieta %luten free

4at2!/2 si!l!% !f bacterial !5er%r!Ft24at2!/2 si!l!% !f bacterial !5er%r!Ft2


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4at2!/2 si!l!% !f bacterial !5er%r!Ft2! ! !% ! ! % !


4at2!/2 si!l!% !f lactase +eficienc4at2!/2 si!l!% !f lactase +eficienc


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4at2!/2 si!l!% !f lactase eficienc



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Jumorile maligneAJumorile ma

ligneA


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Jumorile maligneAJumorile ma ligneAEpidemiologieA 6-5 ! din tumorileEpidemiologieA 6-5 ! din tumorile

tubului digestiv tubului digestiv#denocarcinom#denocarcinom>ibrosarcom>ibrosarcom

#ngiosarcom#ngiosarcomIeiomiosarcomIeiomiosarcomIimfomIimfom1eurofibrosarcom1eurofibrosarcom

Eti l giEtiolo

gie AA


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EtiologieEtiolo gie AAfactori alimentarifactori alimentari →→ abu de carne,abu de carne,

gr simi, dieta s rac @n fibregr simi, dieta s rac @n fibrefactori geneticifactori genetici →→ controlate de genacontrolate de genaSS"= 5 de pe cr :KSS"= 5 de pe cr :K

Foli cu poten.ial cancerigenAFoli cu poten.ial cancerigenA- adenoamele se maligni ea @n 6 !adenoamele se maligni ea @n 6 !- sdr: ?eut -Vegherssdr: ?eut -Veghers- sdr: /ardnersdr: /ardner- enteropatia glutenicenteropatia glutenic

i i il li>

i i t il li


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>recven.a mai mic a tumorilor maligne se>recve n.a mai mic a tumorilor maligne seexplic prinex plic prin AA

p crescut @mpiedic transformareap crescut @mpiedic transformareaaci ilor biliari @n substan.e carcinogeneaci ilor biliari @n substan.e carcinogeneflora microbian anaerob redus (rol @nflora microbian anaerob redus (rol @napari.ia produ


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#natomie patologic#natomie patologic AAma oritatea @n e unul proximalma oritatea @n e unul proximal

6 ! se de volt din cel: epit: de6 ! se de volt din cel: epit: desuprafa.suprafa.macroscopicA t: sesile sau pediculatemacroscopicA t: sesile sau pediculatemicroscopicA adenocarcinom (N !),microscopicA adenocarcinom (N !),leiomiosarcom, limfom primar,leiomiosarcom, limfom primar,schawannomschawannom

tumori metastaticetumori metastatice →→ melanommelanommalign (N ! mts digestive),malign (N ! mts digestive),=a:pulmonar, mamar=a:pulmonar, mamar


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=omplica.iiA=om

plica.iiA


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ppsLnger ri digestive masivesLnger ri digestive masive →→ melenmelensLnger ri digestive ocultesLnger ri digestive oculte →→ anemieanemiehipocrom secundar (2 -6 !)hipocrom secundar (2 -6 !)perfora.ia intestinalperfora.ia intestinal →→ peritonit sec:peritonit sec:

isemin ri la distan. Aisemin ri la distan. A- MJS hepatice- MJS hepatice →→ hepatomegaliehepatomegalie- MJS peritoneale- MJS peritoneale →→ ascitascit- icter- icter

Ex:obiectivAEx:obiectivA

t: palpabil , mobil ,t: palpabil , mobil ,meteorism, borborisme, sensibiitatemeteorism, borborisme, sensibiitate

abdominal abdominal

Explor ri paracliniceAE

xplor ri paracliniceA


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Explor ri paracliniceAExplor ri paracliniceA#nali e sLngeA#nali e sLngeA

- anemie hipocrom , microcitar- anemie hipocrom , microcitar- cre#- cre#- I , #g=E, J/7, J/?- I , #g=E, J/7, J/?

Examen radiologic baritatExamen radiologic baritat →→administrarea bariului @n cantit .iadministrarea bariului @n cantit .imici, progresivmici, progresiv →→ relev anserelev anseintestinaleintestinale

T "! i i ) 8 i!l!%iT "! i t ti ) 8 +i!l!%i


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Tu"!r intestin) e8 ra+i!l!%icTu"!r intestin) e8 ra+i!l!%ic


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g: po itiv- tardiv, complica.iig: po itiv- tardiv, complica.ii


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g p , pg p , p

g: diferen.ialAg: diferen.ialA5:5: tbc ileocecaltbc ileocecal2:2: boala =rohnboala =rohn%:%:

tumori benignetumori benigneK:K: tumori colontumori colon

JratamentAJratamentA- chirurgical- chirurgical- chimio


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TU


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Manifest ri clinice tipiceAManifest ri clinice tipiceA


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ppdeterminate de eliberare @n circula.ie adeterminate de eliberare @n circula.ie asubstan.elor vasodilatatoaresubstan.elor vasodilatatoare

a:a: 'lush ul cutanat'lush ul cutanat colora.ia ro


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b:b: iareeaiareeasecundar cre


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dd :: anifest&ri cardiovasculareanifest&ri cardiovascularehipotensiunehipotensiune

tahicardie, extrasistoletahicardie, extrasistoledesc rc ri bradi$inindesc rc ri bradi$inin

e+ *anifest&ri neuropsihicee+ *anifest&ri neuropsihiceanxietate, agita.ieanxietate, agita.ieonstabilitate psihiconstabilitate psihic

f f :: ,epatomegalia,epatomegaliag+ -ronhospasmg+ -ronhospasm .. flushflush

Explor ri paracliniceAExplor ri paracliniceA


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Explor ri paracliniceAExplor ri paracliniceA

cre


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JratamentJratament=hirurgical=hirurgicalMedicalAMedicalA

- cyproheptadin (?erioctine)-- cyproheptadin (?erioctine)-efect antiserotoninic, scade flush efect antiserotoninic, scade flush

- sandostatin 56 mgx28 i,- sandostatin 56 mgx28 i,

Q6-& !Q6-& !- somatulin- somatulin

Jratamentul mtsJratamentul mts- 6 fluorouracil, doxorubicina,- 6 fluorouracil, doxorubicina,- emboli are arter hepatic- emboli are arter hepatic

Evolu.ieEvolu.ie →→ K luniK luni →→ 52-5& luni52-5& luni


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