DR. Dr. JUWITA SEMBIRING, SEMBIRING, SpPDSpPD-KGEH
DIVISI GASTROENTEROGASTROENTERO-HEPATOLOGI DEPARTEMEN ILMU PENYAKIT DALAM FK. USU / RSUP. H. ADAM MALIK MEDAN
DEFENISI : Radang Pankreas Dengan Simtom Sakit Pada Ulu Hati Menjalar Ke Punggung (95% 95%) Dan Gangguan Exocrin Pankreas, Mual, Muntah (85% 85%) Terdiri dari : akut dan kronik Akut : morfologi/struktur dan fungsi pankreas sebelumnya normal Kronik :
sebelumnya ada kerusakan struktur dan fungsi pankreas
Figure 1. Normal pancreatohepatobiliary system
ETIOLOGI :
Gall Stone (Batu Empedu) & Alkohol (Terbanyak) -
Mekanikal :
Gall Stone, tone, Mikro Litiasis / 80 % Ca. Pankreas Infeksi : Mumps Flaxsechi, Ascaris -Lumbricoedes, Chlonorchies Sineusis ObatObat-obatan : Steroid, Thiazide, Aza Azathioprin Metabolik : Hyperlipidemia, Hypericelsen Trauma : Post Operasi Miscellane Miscellaneus : Gigitan Scorpio Perforasi Tukak Duodeni
GAMBARAN KLINIK : Sakit perut tipical, daerah epigastrium epigastrium, gastrium, lower lower upper quadrant menjalar ke punggung, sakit seperti disayatdisayat-sayat, sakit berkurang bila membungkuk kedepan / duduk Cemas, Cemas, kelihatan sakit berat, takikardi, demam (60%) dan hipotensi (40%), mual, muntah, ikterus, peristaltik ↓. Perdarahan retrosternal : echymose -periumbilikal = Cullen’s Sign, panggul / paha. Grey Tunner’s Sign Diagnosa : Klinik, Lab Amilase, Lipase Pemeriksaan Penunjang : USG CT SCAN ERCP
Lab. : Le Leu ukositosis, kadar gula darah & crp ( > 100 insufisiensi pankreas) albumin ↓, creatinin ↑ (dehidrasi), amylase serum ↑, lipase ↑ Radiologi :
sentinal loop dari usus halus calsifikasi calsifikasi pankreas + sakit
USG : oedematous pankreas, peri pankreatitis, fluid / pseudo kiste ERCP : banyak gas lebih baik dengan CT SCAN “ gold standard “ diagnosa terapi
KEPARAHAN/SEVERITY : Kriteria – Ranson (48 jam) 11 points Glagow ( segera ) 8 points APACHE system Ranson Criteria
Glosgow criteria
(1 points for each criteria)
(1 points for each criteria)
oedematous hemoragic nekrosis Organ failure: hipotensi BP <90 hipoxiensi PaO2 < 8kPa (60 mmHg) Renal failure, creatinin > 200 µmol/l (2mg/dl) GI bleeding > 500 ml / 24 jam Creactive protein > 100 mg/l
severe pankreatitis prognostik jelek “ sensitive parameter “
Severity Of Pancreatitis Ranson criteria (1 point for each factor )
Glosgow criteria (1 point for each factor )
On Admission
On Admission
Age > 55 years WBC count > 16,000 / mm3 Glucose > 200 mg/dl Serum LDH >350 IU/L Serum ast >250 U/dl
Age > 55 years WBC count > 16,000 / mm3 Glucose > 200 mg/dl LDH > 600 IU/L BUN > 45 mg /l PO2 < 60 mmHg Albumin < 3.2 gr / dl Calcium < 8 mg / dl
First 48 hours Serum calcium < 8 mg/dl Base deficit > 4 mEq/L Fluid sequestration > 6 L Arterial PO2 <60 mm Hg BUN rises > 5 mg / dl Haematocrit decreases > 10 %
TERAPI / PENATALAKSANAAN : Ringan : decompresi ( mencegah exocrin ) puasa IVFD NGT (aspirasi cairan lambung) Pain killer – pethidin tramal syringe pump Berat :
ICU
Nutritional support – TPN Mild lapar beri makan PPI / ARH2 – mencegah tukak stres
Figure . Treatment Algorithm for acute pancreatitis Acute Pancreatitis Mild Pancreatitis Ranson less than 3 at 48 h Glasgow less than 3
Severe Pancreatitis Ranson more than 3 at 48 h Glasgow more than 3
Establish Severity
Expected complete recovery in 3-5 days
Admit to ICU Invasive monitoring NPO Analgesia Fluid resuscitation Consider antibiotics Treat metabolic complications Nutrional support
NPO Analgesia IV Hydration Patient Worsens Real Time Ultrasonography
Contrast Echanced CT
No Improvement after 48-72 h
Choledocholithiasis
Pancreatic Necrosis
Peripancreatic fluid collection
Endoscopic papillotomy
CT Guided percutaneous aspiration
CT Guided percutaneous aspiration Infected
Infected
Yes
Yes Technical Failure
Surgery
Failed
Purcutaneous Drainage
Antibiotik : Broad spectrum – cephalosporin - Imipenem 3x500, - Sulperazone IV / 12 jam Indikasi severe pankreatitis necrotizing pankreatitis (dinamik, CT ), cholangitis Somatostatin : 3 mg / 12 jam drip Sandostatin : 12 amp / 24 jam Komplikasi : Sistemik
Lokal
- Paru - GI bleeding - Obtruksi - Pancreatiuc necrosis - Pseudo kiste – spleen - Fistula
Complication of Acute Pancreatitis Local
Systemic
Pancreatic
Cardiovascular Hypotension and shock Pericardial effusion and tamponade Electrocardiogram Changes
Pseudocyst/fluid collection Phlegmon/sterile necrosis Infected pancreatic necrosis Pancreatic abscess
Nonpancreatic Pancreatic ascites Sympathetic effusion Gastrointestinal perforations Mesenteric, splenic, portal vein thrombosis
Resporatory Hypoxaemia Pleural effusion Atelectasis Pulmonary infiltration Adult respiratory distress syndrome Respiratory failure Metabolic Hypocalcaemia Hyperglyceridaemia Metabolic acidosis Renal Oliguria Acute tubular necrosis Renal artery or vein thrombosis Haematological Vascular thrombosis Disseminated intravascular coagulation (DIC) Gastrointestinal bleeding
Complication Of Chronic Pancreatitis
Abdominal Pain Melabsorption Diabetes Pseudocysts Pancreatic Calculi Biliary Obstruction Duodenal Obstruction Splanchnic and mesenteric venous obstruction
PANKREATITIS KRONIK : Defenisi : -
peradangan pankreas yg berlanjut menimbulkan kerusakan struktur dan fungsi yang irreversible.
-
timbul fibrosis dan atrofi kelenjar pankreas, dilatasi saluran.
-
Keparahan:
-
Rasa sakit :
-
- keparahan sakit - insufiasiensi pankreas (fat>20gr/hr)
tanda prognosis pankreatitis kronis, radiasi ke punggung,hyperamykase CT Scan : pseudo kiste Stop alkohol, pain killer : pethidin, NSAID, Opiad, enzym pankreas 3x11 antara makan, ARH2/PPI ERCP drainage : Mengurangi sakit kurangi :
- lemak+ ARH2 / PPI - MCT
TUMOR PANKREAS : Jinak & Ganas ( Carcinoma ) Carcinoma : terlambat diagnosis radical operasi Keluhan :
tergantung bagian yang terkena kaput painless joundice Obesy & tail – sakit + BB ↓ Papilla Vateri – prognosa baik Ikterus – operasi pankreato duonectomysurvival 3 thn 50% kaput 10 %
GAMBARAN KLINIK : Jaundice, bekas garukan, convoisier sign pulpable GB Diagnosa : klinis – ikterus, sakit, BB ↓ USG, CT Scan / MRI biopsi aspirasi ERCP – diagnostik + terapi sitologi / PA Terapi :
- Operasi - Radiasi 16 minggu survival - Chemoterapi 5 FU Chemo + radiasi 40 minggu survival
KOMPLIKASI : Lokal :
nekrosis pankreatik (20%) infeksi Cephalosporin / imipenem ↑ tenderness,demam tinggi,lekositosis,bakteremia sepsis Aspirasi biopsi, CT guided gram stein / kultur GR (-)
Terapi :
infected necrosis surgical emergency “ debridemant” mortilitas 10 %-15 % Steril nekrosis konservatif 10 % sistemic komplikasi agresif medical atau surgical debri demant
Pseudokiste : fluid collection (30-50%) dgn pankreatitis berat. Fluid collection : > 4 minggu 10 % Uncomplicated pseudokiste >6 cm/ > 6 minggu terapi. Asimtomatik psk < 6 cm resolve spontaneus
Terapi PSK : - ERCP
insertion stent pankreatitis Cept gastrostomy, cept duodenectomy
- percutaneus drainage - Operasi: cept gastrostomy cept jejenectomy, cept duodenectomy
Fistula : - asites, pleura efusi cutaneus, bowel, - amylase / protein - drainage of fluid collection by thoracosentesis atau parasentesis. ERCP :
stent pancreatic infeksi dengan somatostain 600 µgr/hari Pankreatic reseksi
Sistemik : Pulmonary :
- drainage pleura efusi - pankreatic - ARDS – respiratory support with positif end expirety
GI hemorahagic angiografi and emboli Obstruksi spasme & odem + reseksi
BATU EMPEDU = KOLELITIASIS Sering dijumpai pada Praktek sehari-hari Banyak pasien batu empedu = asimtomatik Manifestasi klinik :- nyeri episodik - Kolesistitis akut - Ikterus obstruktif, Kolangitis, Pankreatitis bila batu migrasi ke duktus koledokus. Banyak ditemukan pada wanita, makin bertambah dgn meningkatnya usia.
FAKTOR RESIKO UNTUK BATU EMPEDU : - Bertambahnya usia - Gender wanita - Kehamilan - Estrogen - Obesitas - Etnik (penduduk Asli Amerika) - Sirosis - Anemia hemolitik - Nutrisi Parenteral Total
Manifestasi Klinik Batu Empedu tergantung Lokasi di sal. Empedu : 1. Batu empedu asimtomatik 2. Kolik bilier / kolesistitis akut 3. Sindroma Mirizzi : - nyeri - ggn tes fungsi hati (Bil, FA/GGT , SGOT/PT , USG sal empedu melebar) 4. Kolangitis 5. Pankreatitis akut bilier : 6. Batu Intra hepatik
amilase / lipase , fungsi hati
