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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! ("/$
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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
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