Patologias de vias biliares
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Gabriela Caballero Padilla
PATOLOGIAS DE VIAS BILIARES
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ANATOMÍA
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- Forma de Bombilla- 30 a 60 ml- Cuelga del Mesenterio Vólvulos- Drena en el colédoco - Castico: 1 a 5 cm - Válvulas espirales de Heister
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COLEDOCO
Longitud total: 5 – 15cm1) Supraduodenal: 0 – 4 cm2) Retroduodenal 1 – 3,5 cm3) Pancreática 1,5 – 6 cm4) Intramural 0,8 – 2,4 cm
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PRINCIPALES SINTOMAS
T: Cólico BiliarC: Dolor constanteL: Epigastrio o CSDA: PosprandialSigno de Murphy
DOLOR
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Escleras 2,5 mg/dl
Piel 5mg/dl
Colecistitis A. no causa ictericia
Triada de Charcot: Fiebre + Dolor
Pentada de Reynolds: Fiebre + Dolor+ Hipotensión + Estado metal
Quirurgia: Obstrucción
Médica: proceso Hepatocelular
FIEBRE
ICTERICIA
Acceso directo e inmediato al
parénquima hepático ( metabólicam. activo) Secreción de citoquinas
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ENFERMEDAD BILIAR POR CALCULOS
70% colesterol y calcioColesterol <10%Pigmentario: negros y
marronesSupersaturación de bilis
segregada,Concentración de bilis en vesícula biliar, nucleación de cristales, motilidad biliar ayuno prolongado, NPT, posvagotomía, análogos de la somatostatina
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Evolución Natural:
AsintomáticosCólico biliar causado por bloqueo temporal
(posprandial)Solo un 20 a 30% presentará síntomas en 20 añosNo colecistectomíaSi colecistectomíaA. hemolítica, falciformeVesícula biliar de porcelanaCálculos de más de 2,5 cmRápida pérdida de pesoInmonodeprimidos
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Tratamiento no quirúrgico
Litotricia extracorpórea por ondas de choque
Recidiva en el 20%Cálculos de 0,5 a 2 cm
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COLECISTITIS CRONICAAtaques recurrentes de
cólicos biliaresOclusión temporal del
conducto císticoPuede cursar con
inflamación, aparición de tejido cicatricial en el cuello de la vesícula y del conducto cístico
Fibrosis repetición de episodios de inflamación
Dolor posprandial de pocas horas
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Diagnóstico
Ecografía TA
Dilatación de
colédoco
Barro o lodo biliar
Colesterolosis
Pólipos en Vesícula
Antecedentes
Enf. del árbol biliar
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Colecistitis crónica. El examen Doppler power en condiciones basales (a) evidencia una litiasis alojada en el infundíbulo (flechas) de una vesícula de paredes engrosadas (puntas de flecha) en las que no se detectan señales de color ni trayectos vasculares. Tras administración de contraste (b) podemos apreciar señales de color dispersas (puntas de flecha) en la pared vesicular, sin que existan trayectos vasculares definibles
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Tratamiento
COLECISTECTOMÍA PROGRAMADA
Bajo RiesgoComplicaciones: 1- 3%Modificación de dieta y estilo de vidaColecistectomía laparoscópica90% curativa
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COLECISTITIS AGUDA
Impactación de cálculos obstrucción del cond. Cístico
Impactación temporal sin resolver
InflamaciónEdemaHemorragia subserosa
Colecistitis Aguda
IsquemiaNecrosis
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Presentación
Fiebre Dolor en CSD
Sensibilidad dolorosa
ala palpación
Signo de Murphy
FA, Bilirrubina, Transamin
asa, leucocitosi
s
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DiagnósticoEcografía TA: Sensible, económica y fiable. S: 85% E: 95%Líquido pericolecístico, engrosamiento de la
pared de la vesícula biliar.HIDA (ganmagrafía hepático con ác.
iminodiacético)TAC
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TratamientoEstancamiento e Inflamación: Sobreinfección
NPOHidrataciónAntibióticos parenterales ( aerobios gram- más frecuentes)
(anaerobios y aerobios gram +)
Analgesicos: opiáceos
COLECISTECTOMÍA ABIERTA O LAPAROSCÓPICA
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COLEDOCOLITIASISPresencia de cálculo den el colédoco o
conducto biliar.Cálculo Primario: cálculos marrones
(asiáticos) infecciónCálculo Secundario: de la vesícula al conducto
biliarFiebre
Dolor en CSD
Cólico Biliar
Oscurecimiento de
orina
Ictericia
Aclaramiento de heces
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DiagnósticoPerfil HepáticoHemogramaEcografía TA: C.B. dilatado (>8mm)CPRE: muy sensible y específica, también terapéutica.
Indicaciones: Colangitis, pancreatitis biliar, limitada experiencia del cirujano en la exploración del colédoco, pactes con comorbilidades.
Colangiopancreatografía por RM: S: >90% E: casi 100%Laparoscopia exploradora
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Tratamiento
Colangiopancreatografía endoscópica retrógrada
Exploración laparoscópica del colédocoExploración abierta del colédoco
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