• Paciente varón de 74 años.

• AP: Pancreatitis aguda en Set 06 catalogada como etílica

• Ingreso actual por pancreatitis aguda

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35

36

37

38

39

40

04/09/2007

11/09/2007

18/09/2007

25/09/2007

02/10/2007

TemperaturaAugmentine

Dieta liquida

Imipenen PAAF 3/10

NPDieta Absoluta

IRIleoTAC 6/9

TAC 18/9Empeoramiento G E

TAC 1/10GasE. Oral:

21/09Leu: 18000PCR: 223

1/10Leu: 16000PCR: 20

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• COMENTARIOS– Antecedente de la etiologia– Diagnostico de necrosis pancreática por TAC

a veces es díficil ( RNM )

– Profilaxis infección de la necrosis– Nutricion enteral vs parenteral en PAG– Tratamiento de necrosis pancreatica

infectada

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• Pancreatitis aguda idiopatica: demostar que no es biliar, con 2º prueba de imagen y estudio de bilis

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Profilaxis de la infeccion de la necrosis pancreatica

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• Conclusiones profilaxis de la infeccion de la necrosis pancreatica.– Imipenen previene la infeccion de la necrosis

– Reduce la mortalidad

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Nutricion enteral vs parentral en pancreatitis grave

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• No hay suficiente evidencia para recomendar una frente a otra, faltando estudios de calidad

• Hay una recomendación al uso de n enteral

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Tratamiento de la necrosis infectada

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• Cirugia• Endoscopia• Drenaje percutaneo • Otros

Tratamiento de la necrosis infectada

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• ASGE guideline: the role of endoscopy in the diagnosis and management of cystic lesions and inflammatory fluid collections of the pancreas. Jacobson BC; Baron TH; Adler DG et al. Gastrointest Endosc 2005; 61(3):363-70

•Transmural approach

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TRATAMIENTO ENDOSCOPICO

• Mithöfer K, Mueller PR, Warshaw AL. Interventional and surgical tratment of pancreatic abscess. World J Surg 1997; 21:162-68

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TRATAMIENTO ENDOSCOPICO

• Endoscopic Therapy for organized Pancreatic Necrosis. Baron TH, Thaggard WG, Morgan DE; Stanley RJ. Gastroenterology 1996; 111:755-764.

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TRATAMIENTO ENDOSCOPICO

• JPN Guidelines for the management of acute pancreatitis: surgical treatment. Isaji S, TaKada T, Kawarada Y et al. J Hepatobiliary Pancreat Surg 2006; 13:48-55

•CQ1. Which procedure will best result in a definite diagnosis of infected pancreatic necrosis ?

•CQ2. What is the indication for surgical intervention in necrotizing pancreatitis ?

•CQ3. How should sterile pancreatic necrosis be managed ?

•CQ4. What is the optimal timing for surgical intervention ?

•CQ5. What is the optimal surgical procedure for infected pancreatic necrosys?

•CQ6. What is the optimal drainage procedure after necrosectomy ?

•CQ7. How should pancreatic abscess be managed ?

•CQ8. What is the indication for surgical drainage in pancreatic abscess?

•CQ9. What are the indications for drainage treatment in pancreatic pseudocysts?

•CQ10. What is the indication for surgical intervention in pancreatic pseudocysts ?

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• How should sterile pancreatic necrosis be managed ?

Conservadora salvo complicaciones sistemicas persistentes o deterioro clinico severo a pesar de manejo UCI. RECOMENDACIÓN B

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• What is the optimal surgical procedure for infected pancreatic necrosys?

Necrosectomia. RECOMENDACIÓN A

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• What is the optimal drainage procedure after necrosectomy ?

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• Percutaneous pancreatic necrosectomyNICE December 2003

• Endoscopic transmural necrosectomy

otros

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• How should pancreatic abscess be managed ?

• What is the indication for surgical drainage in pancreatic abscess?

Puede ser manejado tanto quirurgicamente como con drenaje percutaneo RECOMENDACIÓN B

Si hay deterioro clínico cirugia RECOMENDACIÓN A

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• Conclusiones• En PAG recomendar uso precoz de Nutricion

enteral• Imipenen si se demuestra Necrosis

• Tratamiento evacuador si de demuestra infeccion de la necrosis, quirurgico, (recomendación grado A) y si el paciente no está septico podria ser valido otras alternativas dada la alta mortalidad de la cirugia

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