pancreatitis aguda
TRANSCRIPT
![Page 1: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/1.jpg)
PANCREATITIS AGUDA
(ACUTE PANCREATITIS)
Verano MMXV
Nosología Clínica Quirúrgica de
abdomenFacultad de
Medicina
Alumno: Jorge Antonio Mirón
Vleázquez
![Page 2: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/2.jpg)
Definición
Atlanta Symposium: 1992
Feldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
Proceso
InflamatorioDaño
Local
sistémico
Falla orgánica
![Page 3: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/3.jpg)
Síntomas consistentes
Amilasa o lipasa 3x su límite superior
Hallazgos Radiológicos (CT o MRI)
Feldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
Evolución
AgudaCrónica• Exacerbaci
ón
Severidad
LeveGrave• Atlanta• Ranson• APACHE-II
![Page 4: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/4.jpg)
Epidemiología
Mundialmente
5 a 80/ 100,000
Mortalidad:
1/100,000
Brunicardi C. et al. Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014
14°
Piel negra: 20.7
Piel blanca: 5.7US/
100,000Nativos: 4
Piedras biliares Alcohol
![Page 5: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/5.jpg)
Etiología
Piedras biliares Alcohol Iatrogénica
Tumores Hereditarios
Hiperlipidemia
Fármacos Traumáticos Otros
Brunicardi C. et al. Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014
![Page 6: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/6.jpg)
Piedras biliares
Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014/ Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-
Elsevier; 2010
40% PA
Mujeres
H. Del conducto común
H. Reflujo duodenal
H. Hipertensión
ductal
Microlitiasis-Lodo biliar
67-74% PA Idiopática
![Page 7: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/7.jpg)
Citotoxicidad
Hipersecresión inicial
Tapones protéicos Esfinterero-
spásmo
Permeabilidad ductal
Activación enzimática
Alcohol
PA agudas
Recurrencia
Abuso10-20 años
PA Crónica
Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014/ Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-
Elsevier; 2010
30%
PA
![Page 8: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/8.jpg)
Hipertriacilgliceridemia
3ra causa
1000 mg/dL
Citotoxicidad
Feldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
• Alcoholismo• DbM2• Dieta/fármacos
Adquirida
• Deficiencia de lipoproteínas
• Déficit de APO CII
Congénita
5%
PA
![Page 9: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/9.jpg)
Tumores
40 años PA idiopático Recurrente
1 al 2 %
Neoplasia mucinosa
papilar intraductal
Adenocarcinoma
Metástasis
Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014/ Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-
Elsevier; 2010
![Page 10: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/10.jpg)
Fármacos
120 fármacos
Hipersensi-bilidad
MetabolitosInducir hiper TAG
Toxicidad intrínseca
Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014/ Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-
Elsevier; 2010
![Page 11: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/11.jpg)
Hipercalcémia-Hiperparatiroidismo
Infeciones
• Virus: Sarampión, HBV, Coxsackievirus,CMV• Bacterias: Mycoplasma, Salmonella, Brucella, Mycobacterium• Hongos: Aspergillus, Candida• Parásitos: Ascaris, Cryptosporidium, Toxoplasma
Feldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
![Page 12: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/12.jpg)
Iatrogenia
Post Colangiopancreatografía retrograda endoscópica
Biopsias, Exploración de vías biliares y ámpula de Vater
Linfadenectomía retroperitoneal , nefrectomía, esplenectomía
Feldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
![Page 13: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/13.jpg)
Patofisiología
Brunicardi C. et al. Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014
Intracinares
• Autodigestión-Tripsina-Catepsian B-Ca+2
Intrapancreáticos
• Quimiotáxis: Neutrófilos- ROS, Macrófagos-Citocinas proinflamatorias• Permeabilidad, edema, hemorragia, microtrombos• Hipoperfusión-Necrosis
Sistémicos
• Citocias-NFB• Disfunción orgánica: Cardiaco, respiratorio, renal
![Page 14: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/14.jpg)
Manifestaciones clínicas
Dolor Insoportable, continuo y taladrante
Epigástrico Progresivo: rápido (10’-20’) Alivio leve o nulo a cambio
de posición Irradiación en banda o
cinturón
Feldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
![Page 15: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/15.jpg)
Manifestaciones clínicas
Nausea Arcada-Vómito grado
variable (No alivia el dolor)
Ictericia conjuntival Dolor tipo cólico biliar: Preceder
el cuadro
Feldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
![Page 16: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/16.jpg)
Exploración Física
Rigidez muscular ausente
Dolor a la percusión o agitamiento gentil
Ruidos abdominales disminuídos
Signo de Grey Turner Signo de Cullen
1% = mal
pronóstico-
Sangrado
retropancréat
icoFeldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th
Saunders-Elsevier; 2010
![Page 17: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/17.jpg)
Exploración Física
Normotermia o Fiebre Taquipnea, poco
profundas Respiración dolorosa-
exudados subdiafragmáticos
Disnea-Efusión pleural, atelectasia, ARDS, falla cardiaca congestiva
Disminución de campos pulmonares
Feldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
![Page 18: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/18.jpg)
Exploración Física
Hepatomegalia angiomas en
araña Engrosamiento
de las vainas palmares (Dupuytren)
Xantomas/Xantelasma
Feldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
![Page 19: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/19.jpg)
Diagnóstico: Laboratorio de análisis clínicoPancreát
icaSalivar
Suero: 53–123 U/LOrina: 0–375 U/L
Amilasa
X3 valor superior normal
6 – 12h post injuria
3-5 días valores normales in sera
Hiperamilasemia Obstrucción
intestinal Ulcera duodenal
perforada Inflamación
intrabdominal Patología de
glándula salival7 oviductos
Neoplasias ováricas/quístes
CKD>3-5 vecesSchwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014/ Sleisenger and fordtran’s gastrointestinal and liver
disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
Hipertriaciltri
gliceridemia
alterar los
resultados de
la muestra
![Page 20: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/20.jpg)
Lipasa
• Sensibilidad 85-100%• Primeros días, se mantiene
14 días más que amilasa
0–160 U/L
• > x3 + amilasa
Falsos positivos: disfunción de glándulas salivales, tumores ginecológicos, macroamilasemia, CKD (<x2)
Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014/ Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
Diagnóstico: Laboratorio de análisis clínico
![Page 21: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/21.jpg)
WBCVCM(alcoholicos)Hematocrito 44% -Hemoconcentración
Citometría
GlucemiaALT (>150 UI/L Alcohólicos)ASTFosfatasa alcalina>300mg/dL (lito biliar)BilirrubinaTAG
Química sanguínea
Diagnóstico: Laboratorio de análisis clínico
Feldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
![Page 22: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/22.jpg)
Diagnóstico: Placa de abdomen simple
Feldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
Asa centinela
Colon cortado
![Page 23: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/23.jpg)
Elevación de hemidiafragma
Efusión pleural
Infilrados
Atelectasias
Signos de falla Cardiaca congestiva
Feldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
Diagnóstico: Placa de tórax
![Page 24: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/24.jpg)
•24h.- signos de coledocolitiasis•Datos de pancreatitis crónica•hipoecogenicidad•Formación de pseudoquiste
•Pancreatitis idiopática•Búsqueda de tumores•Pancreas divisum •Piedras biliares
Diagnóstico:Ultrasonografía
Feldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
![Page 25: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/25.jpg)
Diagnóstico: Tomografía computada
Indicaciones
Descarta perforación de úlcera pépticaEstadifica severidadEvalúa complicaciones
Más importante
Diagnóstico
Contra-
indicaciones
AlergiaCKD: CrS> 2mg/dL
Feldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
![Page 26: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/26.jpg)
índice de severidad por CT (CTSI)
Estados de Balthazar
A(0) Páncreas Normal, consistente con pancreatitis leve
B(1) Agrandamiento focal o difusa de la glándula, incluye irregularidades del contorno y atenuación heterogenea pero sin infiltración peripancreatica
C(2) Grado B + datos de inflamación peripancreática
D(3) Grado C+ colección simple de fluidos peripancreáticos
E(4) Grado C + dos o más colecciones de fluidos peripancreáticos o gas en páncreas o retropeitoneo
Feldman M. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
Escala de necrosis
0 Ausencia de necrosis
2 Necrosis de al menos 33%
4 Necrosis de 33%-50%
6 Necrosis > 50%
CTSI= Escala de Balthazar + Escala de necrosis
![Page 27: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/27.jpg)
![Page 28: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/28.jpg)
Sistemas de evaluación
Atlanta Ranson
APACHE-II
BISAP
Marshall
Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014/ Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
![Page 29: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/29.jpg)
Atlanta 2013 (ACG)
Tenner et al. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol;2015
![Page 30: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/30.jpg)
Escala de Ranson
Evaluación post 48 horas
< 3 criterios positivos (leve) (Mortalidad 2.5%)
>6 criterios positivos (Mortalidad de 50%)
Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014/ Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
![Page 31: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/31.jpg)
APACHE-II
Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
>8 PA severa
![Page 32: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/32.jpg)
Bedside Index for severity in Acute Pancreatitis (BISAP)
Primeras 24 hr >3 = 7-12x Fallo
orgánico
Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014/ Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
Mortalidad
0 0.2
1 0.6
2 2
3 5-8%
4 13-19%
5 22-27%
![Page 33: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/33.jpg)
Clasificación para la evaluación del fallo orgánico secuencial (Marshal)
Brunicardi C. et al. Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014
![Page 34: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/34.jpg)
Manejo
Fluidos Manejo del dolor Soporte/Vigilancia
Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014/ Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010/ Tenner et al. American College of Gastroenterology Guideline:
Management of Acute Pancreatitis. Am J Gastroenterol;2015
![Page 35: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/35.jpg)
Manejo: Fluidos
“Early aggressive Intravenous hydratation”
250-300 mL/48h
Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014/ Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010/ Tenner et al. American College of Gastroenterology Guideline:
Management of Acute Pancreatitis. Am J Gastroenterol;2015
Ancianos
CHD AKD
ACG.-
250-
500ml/
12-24h
Metas:
¯ Hematocr
ito
Normalizar:
BUN y
Creatinina
![Page 36: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/36.jpg)
Manejo: Dolor
Metamizol
2g/TID
IV Analgesia
Buprenofina
0.3mg/4h
Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014/ Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010/ Tenner et al. American College of Gastroenterology Guideline:
Management of Acute Pancreatitis. Am J Gastroenterol;2015
![Page 37: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/37.jpg)
Manejo: Dieta
Sonda Nasogástrica
• Ileo gástrico/ intestinal• PA Severa-alimentación
Parenteral
• suplementaria
Tenner et al. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol;2015
Enteral
No NPO
24h
Baja estancia
hospitalariaCompli
caciones
infecciones
morbim
or-talidad
líquida Blanda
![Page 38: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/38.jpg)
Iniciar
Carbapanemicos, quinolonas y metronidazol
CT-FNA:Cultivos
Tinción de GramNegativos
Suspender
Manejo: Antibióticos
Sospecha de infacción• Evidencia de colangitis,
infecciones adquiridas por catéteres, bacteriemia, neumonía
Profiláctico
•Proscrito
Tenner et al. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol;2015
¿PA necrótica infectada?
Necrosis pancreática o extrapancreática con deterioro o fallo de recuperación después de 7-10 días
![Page 39: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/39.jpg)
Quirúrgicos
Colangiopancreat
o endosco
pía retrogra
da
24h.-PA Severa complicada con Colangitis agudaReduce las complicaciones en PA de litos biliaresPA post CPRE, sangrado, colangitis y perforación duodenal
Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014/ Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
Prevención PA post CPRE
Stent - 3Frs NSAID-VR, :
Indometacina 50mg -100mg
Diclofenac: 100mg
![Page 40: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/40.jpg)
Quirúrgicos
Colescistectomía
Prevención de recurrencia de PA por lito biliar
Schwartz’s Principles of Surgery. Tenth edition. McGrawHill;2014/ Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
![Page 41: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/41.jpg)
50% reduce el uso de laparotomía
Tenner et al. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol;2015
Drenaje percutáneo/Desbridación endoscópica
![Page 42: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/42.jpg)
Complicaciones Locales
Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen.9th Saunders-Elsevier; 2010
Pseudoquistes
Necrosis estéril
Necrosis infectada
Absceso Sangrado GI Pancreatitis
asociada a daño de la arteria o vena esplénica
Ruptura de Vena porta
Trombosis venosa Sangrado de
várices esofágicas Sangrado post
necrosectomía Hematomas Fistulas Hidronefros
derecho
![Page 43: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/43.jpg)
Complicacines sistémicas
Fallo respiratorio Insuficiencia renal Choque Hiperglucemia Hipocalcemia Coagulación intravascular diseminada Necrosis grasa Retinopatía
![Page 44: Pancreatitis Aguda](https://reader035.vdocument.in/reader035/viewer/2022062406/55c04c22bb61eb1f1e8b45e7/html5/thumbnails/44.jpg)
Bibliografía
Feldman M. et al. Sleisenger and fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/managemen. Nineth edition. Saunders- Elsevier; 2010
Brunicardi C. et al. Schwartz’s Principles of Surgeru. Tenth edition. McGrawHill;2014
Tenner et al. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol;2015