seminario patologia biliar

7/25/2019 seminario patologia biliar

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UNIVERSIDAD DE CARABOBOFACULTAD DE CIENCIAS DE LA SALUD

ESCUELA DE MEDICINA

DEPARTAMENTO CLINICO DEL NORTE- HUALCLINICA QUIRUGICA III

PATOLOGA BILIAR

BACHILLERES:MARIANGEL ORTEGAALEJANDRA OVIEDOINDHIRA PACHANO

ROXANNA PANIAGUA

AGOSTO, 2.01


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C!"#$%&! '()*&+%! +$+(#!C!"#$%&! '()*&+%! #((%'!

C!"#$%&! '()*&+%! %!/"

C!"#$%&! %&+%!

V(%$34 B+3+4

C!"#$%&!)4"%(*&+%!

)+"%+)43P4)+34 D$!#("43

/45!

RECORDEMOS

C!36#!%!


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RECORDEMOS

Bilis: 3+$+#! #( %!3! 4/4+33!-7(#!!, 8!/4#4 )! 3! 3!9$3+33!'()*&+%! 5 43/4%("4#4 (" 34 7(%$34 9+3+4. C!/)$(&4:

%+#! 9+3+4( L(%+&+"4 C!3(&(!3 "! (&(+;%4#! B+3+$9+"4 %!"


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LITIASIS BILIAR

P(("%+4 #( %*3%$3! (" 34 749+3+4( )+"%+)43( ! 4%%(!+4.

3+&'!: )+(#4 5 4+: ("8(/(#4#


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AFECCIN LITIASICA BILIAR

D4&! (&4#&+%! A8(%%+@" /4 %!/" #(3 &$9! #+=(&+7!. S(=" +"8!/( #( "(%!)+4 /$(&4" $"4

)(743("%+4 #( 11

S%'K4&. P+"%+)+! #( C+$=+4. E#+&!+43 M% G4K H++33. 74 E#. P4= 2

E#4#

G("(!: /45! ("/$


6/51

C!"&4")+"%+)43/("&( #(

9+3+$9+"4&! #( %43%+!,%!3(&(!3 5 )$(#("

(:

N(=! P4#!: %!"(%$("%+4

TIPOS DE CLCULOS

M+&!P

+=/("&!

C!3(&(!3

80%

20%

C!"&+("(" /4 #(30 #(/!"!'+#4&! #(%!3(&(!3, 43(

9+3+4(, )+=/("&!9+3+4(, )!&("4

5 *%+#! =4!


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FORMACIN DE CLCULOS DE COLESTEROL

S!9(4&$4%+@"#( 9+3+ %!"

%!3(&(!3, )!4$/("&! #( 344%&+7+#4# #(HMG-C!A.

N$%3(4%+!" #(3! %+&43( #(

%!3(&(!3/!"!'+#4&4#!

H+)!/!&+3+#4##( 34 7(%$34

9+3+4,(&44"#! $74%+4/+("&!.


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CLCULOS DE PIGMENTOS

CLCULOS DE PIGMENTO NEGRO CALCULOS DE PIGMENTO PARDO

C!/)$(&! )!9+3+$9+"4 #( %43%+! 5=3$%!)!&(+"4 #(/$%+"4.

F(%$("&( (" +"#+7+#$!%!" (&4#! '(/!3+&+%!%!"+%!, %+!+'()4&+%4, +"#!/( #(G+39(& ("&( !&4.

C!/)$(&! )! 43(#( %43%+!, 9+3+$9+"4 "!%!"


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BARRO BILIAR

M4&(+43 /$%!!, ()(! C!"&+("(: %+&43( #( 3(%+&+"4-%!3(&(!3,

%+&43( #( /!"!'+#4&! #( %!3(&(!3,

9+3+$9+"4&! #( %43%+! 5 '(94 #( /$%+"4. L4 )(("%+4 #( B4! 9+3+4 ( +"#+%4&+7! #(:

T4&!"! #(3 ($+3+9+! "!/43 ("&( 34 (%(%+@"7(+%$34 #( /$%+"4 5 $ (3+/+"4%+@"

N$%3(4%+!" #( 3! !3$&! 9+3+4(.

E3 94! 9+3+4 (" /$%'! %4! ( )(%$! #( 343+&+4+4 9+3+4.


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PRESENTACION CLINICA

ASINTOMATICO

SINTOMTICO

L4 /45!4 #( 3!)4%+("&(#+4="!&+%4#! %!"%!3(3+&+4+ !"'4334=! %4$43(.

S( !+=+"4" 43 )!#$%+(+"4/4%+@" $ !9&$%%+@" $"4

7( $( $" %43%$3! /+=( 43%&+%! ! %!36#!%!.

C@3+%! 7(+%$34 ! 9+3+4:4)4+%+@" ()("&+"4, #( 8$(&(+"&("+#4#, 3!%43+4#! ("

()+=4&+! ( '+)!%!"#+!#((%'!, %!" +4#+4%+@" 4(=+@" +"&((%4)$34,(%4)$34 #((%'4 $ '!/9!,)$(#( #$4 #( 0/+" 4'!4.

A%!/)44#! ! "! #( "4$(4! 7@/+&!.

L4 )(("%+4 #( ;(9( !

(%43!8! $=+(( !&4%!/)3+%4%+!"(.


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MTODOS DIAGNSTICOS


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TRATAMIENTO

MEDICO

M4"&("( (" !9(74%+@" D+(&4 49!3$&4 H+#4&4%+@" )4("&(43,

!3$%+@" 0. EV P!8("+# 100/= EV STAT

I&!)4" 10 /= EV STAT E%!=484 49#!/+"43 R +/)3( #( 49#!/(" L49!4&!+!: H(/4&!3!=4,

TGO, TGP, B+3+$9+"4 &!&43 5

84%%+!"4#4, 8!84&44 43%43+"4,4/+344, 3+)44. C!"&!3 #( +="! 7+&43(

QUIRUGICO

C!3(%+&(%&!/4 P(("%+4 #( "&!/4 $(

+"&(;(4" %!" 34 4%&+7+#4##+4+4 #(3 )4%+("&(

C!/)3+%4%+!"( %!/!%!3(%+&+&+ 4=$#4,)4"%(4&+&+, ;&$34 9+3+4,!&4

P4%+("&( %!" %*3%$3!

/45!( 4 %/


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COLECISTITIS

!"D


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COLECISTITIS !"D

Inflamacin aguda de la mucosa vesicular

producida por la obstruccin del conducto

cstico por un clculo

Obstruccin Contraccin

intensa de vescula

Edema

Inflamacin

severa

Distensin

de vescula

Irrigacin y

drenaje linftico


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COLECISTITIS !"D

#ecrosis

$!angrenaesicular&

'er(oraci)nesicular En*se+atosa

EVOLUCION DE LA ENFERMEDAD

P(+&!"+&+

A9%(! 3!%43

F&$34%!3(%+&!("&6+%

4


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COLECISTITIS !"D

DOLOR enE,ig-strico e.i,ocondrio

derec/oEl ,aciente seencuentra FEBRIL

$81C&

SI!#O DE M"'.'OSITI3O

#auseas 4)+itos

M-56 intensidada las 78 /oras

COLICO BILIR6

C

LI#IC


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Colecistitis guda C!3(%+&+&+ C@"+%4 C@3+%! B+3+4

D!3! (" E)+=*&+%! (H+)!%!"#+! #((%'!$( "! %(#( %!"4"43=6+%!.F+(9( (" CN4$(4 5 7@/+&!

P$(#( ( 4%43%$3!4I"+%+! #( #!3! ("'!4 >-2'?

M!8!3!=4: 7(%$34&$/(84%&4, (#(/4&!4,

%!" (!4 '+)(6/+%45 '(/!*=+%4. L4/$%!4 '(/!*=+%4 !%!" *(4 #( "(%!+ 5)($#!/(/94"4

C3"+%4 ( 7$(37( 4()(&+ )(!:S+" ;(9(

A&4$( 43 (&4#!=("(43D!3! %(#( %!" 34+"=(&4 #( 4"43=6+%!! (" 8!/4 ()!"&*"(4.E&4 4!%+4#4 4

)(("%+4 #( 3+&+4+.

Mor(olog9a: L47(%$34 )$(#( ( #(&4/4! "!/43,#+/+"$+#! !

4$/("&4#!. L4 /$%!44)34"4#4, 4$"$( 47(%( )$(#( &("(*(4 =4"$3!4,=("(43/("&( (" (394%+"(&(. 34 )4(#

=("(43/("&( (&*("=!4#4 5 ;9!4

S@3! !9&$%%+@"()("&+"4 #(3 %!"#$%&!%&+%! ! %!36#!%! )!$" %*3%$3! 9+3+4.D!3! ()+@#+%! ("E)+=4&+! ( '+)!"#+!#((%'! +4#+4#! 4(=+@" (%4)$34#((%'4.I"+%+! (" /+"$&!

>1/+"?N! '45 ;(9(


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COLECISTITIS !"D

A"&(%(#("&( (%+("&( #($" %@3+%! 9+3+4 %!" ;(9()(+&("&( #( +"&("+#4#/!#(4#4.

A"&(%(#("&(#+)6)&+%!:

I"&!3(4"%+4 4 34 %!/+#4%!" =44, 434, 3!

=4"!, %'!%!34&(D!3! 49#!/+"43)!&)4"#+43 (%$("&( ("'+)!%!"#+! #((%'!E)+!#+! #+4(+%!8(%$("&(. D+4="@&+%! 4"&(+! #(

L+&+4+ 7(+%$34.

D(8("4 /$%$34+"7!3$"&4+4 I%&(+%+4 >!3! (3 10 34

)(("&4? L(+!"( (" )+(3 )!

P$+&! P43)4%+@" #( /44 ("

(=+@" 7(+%$34.

D!3! ()!"&*"(! 5 4 34)43)4%+@" (" H+)!%!"#+!#((%'! >7(%$34+"4/4#4 5 #+&("#+#4 ?

M4"+!94 #( M$)'5P!+&+74.

L($%!%+&!+ #( 12.000-1.000 E3(74%+@" #( 34

9+3+$9+"4 4 "+7(3( #(3!#(" #( 2- /=#3

E3(74%+@" 3(7( #( 348!84&44 43%43+"4

E" 43=$"! %4!,

(3(74%+@" #( 34 4/+3446+%4 4 "+7(3( #(1.000 U#L.

ANTECEDENTESEXAMEN FISICO

LABORATORIO

DI!#STICO


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COLECISTITIS !"D

DIAGNSTICOIMAGENOLGICO

N! (7(34(7+#("%+4 #(%!3(%+&+&+

4=$#4

S!3! (7434 34)(/(49+3+#4# #(3

%!"#$%&! %&+%!

"! 7+$43+4%+@" #( 347(%$34 %!" (%(%+@"

%!"(74#4 '4%+4 (3

%!36#!%! ! (3 +"&(&+"!#(3=4#!

D+4="@&+%!#+8(("%+43


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COLECISTITIS !"D

1) C*lculo en el cuello vesicular o en elcstico (difcil de reconocer).

2) Edema de pared vesicular, expresado poraumento de su espesor ( > mm) ! por la

presencia de banda intermedia, continua o

focal, "iperecog6nica (es m*s especfico siaparece en la cara anterior).

) #as intramural en forma de *reas mu!

reflex@genas con sombra posterior.!) $olor selectivo a la presi@n sobre lavescula ( signo de %urp"! ecogr*fico).

1) &resencia de c*lculos en la vescula.2) Engrosamiento de la pared vesicular

(> 'mm).

) uido perivesicular, en ausencia deascitis.

!) Ecos intravesiculares sin sombra por

pus, fibrina o mucosa desprendida.

") $ilataci@n vesicular (> * cm).#) +orma esf6rica.

MAORES

MENORES

C+&(+!

E%!=*;%!


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COLECISTITIS !"D

WE3 )4%+("&( (Q$+=+%! @ #(@3! T4&4/+("&!

/6#+%!S+" +(=! A3&! +(=!


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COLECISTITIS !"D

T4&4/+("&! M6#+%!

;& .os,itali


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COLECISTITIS !"D

T4&4/+("&! Q$+=+%!

Colecistecto+9a


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COLECISTITIS !"D

T4&4/+("&! Q$+=+%!

Clnicos y analticos:

a) Evidencia de peritonitis generaliada o de empiema

b) estado t@xicoc) aumento del dolor

d) fiebre superior a -Ce) leucocitosis de /00001ml o ma!or

f) aparici@n de masa abdominalg) tensi@n sist@lica menor de 0 mm2g") obstrucci@n intestinali) ictericia.

Ecogrficos:

a) luido perivesicularb) gas en pared o lu vesicular

c) edema de pared vesicular

d) liuido libre abdominal.

;6 Colecistecto+9a de "rgencia


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COLECISTITIS !"D

T4&4/+("&! Q$+=+%!

26 Colecistecto+9a,reco


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ICTERICI

OBSTR"CTI3


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ICTERICI

a ictericia es la coloracin amarillenta de la piel

! mucosas debido al aumento de la bilirrubina

s3rica.

45 de 67 0,-89mg1dl

:e evidencia con valores> -mg1dl.

6ilirrubina es un

pigmento ue se +orma de

la degradacion de la

"emoglobina.


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METBOLISMO DE LBIIRR"BI#


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PREHEPATICA HEPATICA EXTRAHEPATICA

H+)(9+3+$9+"(/+4

N! %!"Y

7(%(?

Z 3! "!/43

T44/+"44 - Z 3! "!/43 Y 3! "!/43

INR &4 7+& [ - N! ( %!+=( S( %!+=(

ICTERICI


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ICTERICI

OBSTR"CTI3S"#!/( %44%&(+4#! )! '+)(9+3+$9+"(/+4 conGugada$(( &4#$%( %3"+%4/("&( )! $"4 %!3!4%+@" 4/4+334 #( 34 )+(3 5/$%!4, coluria5 acolia, %4$4#4 )! )!%(! )4&!3@=+%!!9&$%&+7! #( 34 74 9+3+4(.

BE#I!#O MLI!#O

C!3(#!%!3+&+4+P!& !)(4&!+! #((&$%&$4 9+3+4C!34"=+&+ (%3(!4"&(

)+/4+4P4"%(4&+&+ A=$#4P44+&!+ >A%4+?S #( M+++M438!/4%+!"(C!"=6"+&4

C4%+"!/4 #( 347(%$34 9+3+4C4%+"!/4 #( %49(4#( )*"%(4C4%+"!/4 #( 34 )4)+34#( 74&(C!34"=+!%4%+"!/4 #(3! %!"#$%&! 9+3+4(


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COLEDOCOLITISIS

:e define como la presencia de clculos en la

va biliar principal o coledoco, produciendo

obstruccin parcial o total del mismo.

O$I%E& Coledocolitiasis

'rimaria

(e forman en

la va biliar

Coledocolitiasis

(ecundaria

igracion desde

la vesicula biliar


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COLEDOCOLITISIS

'RIMRIOS SEC"#DRIOS

INCIDENCIA

CONFORMACION B+3+$9+"4&! #(%4

C!3(&(!3

COLOR C48( A/4+33!

TAMA\O Y2%/ Z2%/

FACTORES QUE

FAVORECENAPARICION

E&("!+ #( 34

VBM44 (" 34 VB !

4/)!334 #(74&(

C!3(3+&+4+

C+&+%! 4/)3+!L+&! )($(!


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COLEDOCOLITISIS

DOLOR

ICTERICI

COL"RI>COLI

SI!#O DE M"R'.#!TI3O

SI#TOMTICO 0%

CLI#IC


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COLEDOCOLITISIS

ntecedentereciente decolelitiasis

ntecedentesdis,H,ticos:

Intolerancia a lasco+idas con grasas

salsas los granosc/ocolate Dolor a=do+inal

,ost,randialrecurrente en

/i,ocondrio derec/o

Dolor Ictericia

Coluria>acolia

#auseas>3o+itos

Manio=ra deMur,/4 'ositia6

.i,er=ilirru=ine+iaa e5,ensas de laconGugada6

u+ento de la(os(atasa alcalina6

Transas+inasasnor+ales oligera+enteeleadas

E5a+en de orinacon ,resencia de

uro=ilinoge;no6

ANTECEDENTESEXAMEN FISICO

LABORATORIO

DI!#STICO


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COLEDOCOLITISIS

DIAGNSTICO IMAGENOLGICO

ECOGRAFIA

E (3 )!%(#+/+("&! $( ((43+4 #( )+/(4I"&4"%+4 5 ( #( =4" $&+3+#4#54 $( "! )(/+&(

E&4#! #( 34 7(+%$34E+&("%+4 #( 3+&+4+D+34&4%+!" #( 34 7+4 9+3+4(P(("%+4 #( )4"%(4&+&+A)(%&! #(3 '+=4#!

E+&(" 2 )+"%+)43( +"#+%4#!(D( 3+&+4+ #( 34 7+4 9+3+4:D+34&4%+!" #(3 %!3(#!%! Z]//S!/94 4%$&+%4 (" 34 7+4 9+3+4

E" %4! #( ("%!"&4 3+&+4+ ("V(+%$347+4 9+3+4 ! "! ( )$(#("A)(%+4 4"!/43+4 (" (3 ECO, ($&3+4 (3 CPRE.


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V4 9+3+4 (&4'()*&+%4 +="+;%4&+74/("&( #+34&4#4, E3 %!36#!%! /+#(4)!+#4/("&( 2, %/ 5 ( ("%$("&4 #+34&4#! '4&4 $ &(%+! #+&43,

#!"#( ( 7+$43+4 )(("%+4 #( /4&(+43 '+)((%!=6"+%! 5 )!+93( 3+&+4+.

COLEDOCOLITISIS


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COLEDOCOLITISIS

TRATAMIENTO

1. H!)+&43+42. D+(&4 3+$+#4 4 &!3(4"%+4

. H+#4&4%+!" )4("&(43 %!" !3. 0.. O/()4!3 0/= OD ! 4"+&+#+"4 0/=%'. I&!)4" 10/=%' ! 7@/+&!. P!8("+# 100/= %' ! #!3!]. CPRE %!" (;"&(&!/4 #( O##+ 5 (&4%%+@"

#( %*3%$3!. C!"&!3 #( +="! 7+&43(

COLEDOCOLITISIS


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COLEDOCOLITISISC'RE

A- C!3(#!%!3+&+4+ "!!9&$%&+74 >34 !9&$%%+@"

( +"&(/+&("&(?.

COLEDOCOLITISIS


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COLEDOCOLITISISC'RE

B- C!3(#!%!3+&+4+ !9&$%&+7)! %43%$3! ("%3474#! >(%'4

COLEDOCOLITISIS


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COLEDOCOLITISISC'RE

C- P4"3+&+4+ #( 34 749+3+4.

S( )!#$%( !9&$%%+@")4%+43.


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COLANGITIS AGUDA

Causas:

I"8(%%+@" B4%&(+4"4 )!O9&$%%+@" #(3 C!"#$%&! )!%43%$3! 9+3+4

T$/! >C!34"=+!%4%+"!/4?

I"8(%%+@" #( 34 74 9+3+4 $( %!/)3+%4 34 !9&$%%+@"(+&("&( (%$"#4+4 4 $"4 +"8(%%+@" 94%&(+4"4.

'atogenos :

E. %!3+ [3(9+(334 )"($/!"+4( E"&(!94%&( E"&(!%!%! B4%&(+!#( 5 C3!&+#+$/


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COLANGITIS AGUDA

FCTORES DERIES!O

A"&(%(#("&( #( )4&!3!=4 9+3+4>%!3(3+&+4+, )!&(+ 9+3+4, %!34"=+&+

,(&%.? 0-0 4! S+" )(#+3(%%+@" )! (3 (!


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COLANGITIS AGUDA

'uedeirradiarseala

es,aldao de=aGodela

esc-,uladerec/a

En/i,ocondrioderec/o o en

e,igastrio

gudo ti,oc)lico o sordo

Inter+itente

DOLORBDOMI#

L

Triada deC/arcotF+(9(

I%&(+%+4D!3! A9#!/+"43

'entada deRe4noldS'!%_

A3&(4%+!"( #(3("!+!

E%43!8! A%!3+4

C!3$+4N*$(4

57@/+&!

CO G S G


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COLANGITIS AGUDA

!rado I: %!34"=+&+ 4=$#4leeC!34"=+&+ 4=$#4 +" +="! #( #+8$"%+@" !=*"+%4R()$(&4 43&4&4/+("&! 4"&+9+@&+%! +"+%+43!rado II: %!34"=+&+ 4=$#4 +oderada

C!34"=+&+ 4=$#4 +" +="! #( #+8$"%+@" !=*"+%4, $( "! ()!"#(43 &4&4/+("&! 4"&+9+@&+%! +"+%+43!rado III: %!34"=+&+ 4=$#4 graeC!34"=+&+ 4=$#4 %!" +="! #( #+8$"%+@" !=*"+%4, #(;"+#4 )! 34)(("%+4#( $"! #( 3! +=$+("&( %+&(+!:C4#+!74%$34: '+)!&("+@"S+&(/4 "(7+!!: 43&(4%+@" #(3 "+7(3 #( %!"%+("%+4R("43: %(4&+"+"4 Z 2/=#3H(/4&!3@=+%!: &!/9!)("+4 Y 100.000 `3

C34+;%4%+@" #( 34 =47(#4# #( 34 %!34"=+&+ 4=$#4T!_+! G$+#(3+"(

COLANGITIS AGUDA


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COLANGITIS AGUDA

La=oratoriosL($%!%+&!+H+)(9+3+$9+"(/+4 4 ()("4 #( 34#+(%&4E3(74%+@" #( F!84&44 43%43+"4E3(74%+@" #( T4"4/+"44

E3(74%+@" #(=4//4=3$&4+3&4")()&+#44 GGTE3(74%+@" #(3 PCR 5 VSGA3&(4%+!"( )$(94 #( %!4=$34%+@"I+agen

E%!=484 49#!/+"43.

C!34"=+!)4"%(4&!=484 (&@=4#4("#!%@)+%4 >CPRE?.

C!34"=+!)4"%(4&!=484 %!"R(!"4"%+4 M4="6&+%4 N$%3(4>R.M.N.C.P?


46/51

COLANGITIS AGUDA

M4"(

A/)+%+3+"4S$394%&4/2= %-'P+)(4%+3+"4T4!94%&4/= %'C(8!)(4!"4>S$3)(4!"(? =%'M(&!"+#4!300/= %'!4


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PATOLOGA MALIGNA>NEOPLASIA?

L4 )4&!3!=4 /43+="4 #( 34 VB $(#4 %+%$"%+&4 4 =4"#(("&+#4#(:C4%+"!/4 #( 7(%$34

C!34"=+!%4%+"!/4A/)$3!/4.

Carcino+a de es9cula =iliarP(("&4 +"&!/4 5 +="! /$5 +"()(%+;%!./!3(&+4 (" '+)!%!"#+! #((%'!

N4$(4, 7!/+&!I"&!3(4"%+4 4 34 =44S+"&!/4 =("(43( "(!)34+%! >4&("+4, 4"!(+4, )(#+#4 #()(!?

S@3! (" 34 (&4)4 ;"43( #( 34 ("8(/(#4#( #(4!334 +%&(+%+4

)! 48(%&4%+@" #( 34 VB.


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Colangiocarcino+aS( )(("&4 %!" +%&(+%+4 +"#!3!4, #( %4*%&()!=(+7!B+3+$9+"4 /$5 $)(+!( 4 1 /=#3.S( 4%!/)44 #( )$+&!,

S"&!/4 =("(43( "(!)3*+%!.

Signo de Couroisier $( (" (3 %!"&(&! %3"+%!#( $"4 +%&(+%+4 +"#!3!4 ( )*%&+%4/("&(#+4="@&+%4 #( +%&(+%+4 /43+="4.

0 P!%+@" D+&43P!%+!" P!+/4320 H+3+! H()*&+%!

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