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Curs 7.Aparatul Digestiv

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    CURS DE MEDICINA INTERNA

    CONF DR BABES KATALIN

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    Hepatitele croniceInfamatia catli c per!i!tenta proce!li

    infamator cel ptin " lni#

    Etiolo$ie% & 'epatita c (ir! C !i B )mai rar D* & alcooll

    & me+icamente )i,onia,i+a-metil+opa- anticonceptionale-etc*

    & .actori to/ici )c'imici- ciperci*

    & .actori meta0olici )'ipertiroi+i!m-+ia0et*

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    Ta0lol clinicFoarte (ariat % a!imptomatic 1 .orme !e(ereSimptome neuro-psihice% a!tenie- o0o!eala la

    e.ortri mici- in!ta0ilitate (e$etati(a )tran!piratie-

    ta'icar+ie- lipotimie- tl0rare +e +inamica !e/ala*Simptome digestive% 2ena !a +i!com.ort in eta2l

    a0+ominal !perior !i 'ipocon+rl +rept- anore/ie-+iaree- intoleranta la alcool !i $ra!imiSemne generale% !0icter !a icter- !tari

    !0.e0rile- artral$ii- acnee- erptii (a!clare-anemie#Ex. obiectiv% 'epatome$alie- !plenome$alie- icter-

    !telte (a!clare

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    E/aminarile paraclinice)3*Teste functionale hepatice:

    a*In!cienta 'epatica%

    & in!cienta !inte,elor proteice% proteinetotale- al0mina- 0rino$enl !ca,te#

    & !ca+erea (al4 Cole!terolli

    & +eciente in !tocarea $lco,ei !0 .orma +e$lico$en in cat#

    0* Te!te care e/prima pre,enta ni !in+rominfamator%

    & 5SH accelerat

    & cre!terea $amma$lo0linelor

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    E/aminarile paraclinice)6*c* Te!te care e/prima pre,enta +e 'epatocitoli,a% & cre!terea 78T- 7OT- LDH#

    +* Te!te care e/plorea,a !in+roml 0ilioe/cretor

    )cole!tatic*% & cre!te 0ilir0ina +irecta

    & .o!.ata,a alcalina & $amma 7T

    e*Te!te care e/plorea,a !in+roml 'ematolo$ic%

    )e/pre!ia 'iper!pleni!mli 1 cre!te +i!trctiaelementelor $rate ale !an$eli*

    & lecopenie & trom0ocitopenie

    & anemie

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    E/aminarile paraclinice)9*.* Te!te imnolo$ice% & imnelectro.ore,a

    & +eterminarea in !an$e a nor anti$ene (irale

    & +eterminarea in !an$e a nor anticorpi .ata +ecomponentele (irale

    Punctie biopsie hepatica

    & permite +i.erentierea +e 'apatitele acte c

    reca+eri- +e ciro,a 0iliara primiti(a- +e 'epatopatiaalcoolica

    & necro,a 'epatocellara- inltrat cellar infamator

    & 0ro,a a0!enta !a re+!a

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    TratamentlPrognostic.oarte (aria0il% re$re!ie- e(oltie

    lenta !a !pre ciro,a 'epatica

    Tratamentul%

    & intrerperea con!mli +e alcool !a ame+icamentli in ca,a#

    & +ieta ) n .oarte re!tricti(a:*

    & a$enti anti(irali% lami(+ina- $anciclo(ir-

    ri0a(irina# & mo+icatori ai ra!pn!li imnolo$ic%

    inter.eronl- interle;inele

    & imno!timlatoarele

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    Ciro,a 'epaticaDenitie% 0oala 'epatica +i.,a% a!ocierea

    0ro,ei c no+ri +e re$enerare !i necro,e 1alterarea ar'itectrii 'epatice#

    Mo+icarile !nt la ni(ell intre$li cat !i !ntire(er!i0ile

    Etiologie% in.ectii )(ir!rile 'epatice B-C !i D*-to/ine )alcooll*- ra!pn! imn alterat- o0!trctie

    0iliara- tl0rari (a!clarePatogenie% !ta+il nal al nmeroa!elor tipri +ele,ini 'epatice 1 n atat +e mlt +e a$entlca,al- cat +e natra le,inilor !i +e ra!pn!lcatli

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    Ta0lol clinic )3*Ciroa hepatica compensata%

    & a!imptomatici !a

    & !la0icine $enerali,ata- anore/ie- !ca+ere +in$retate- !in+rom +i!peptic ne!pecic#fatlenta- +reri a0+ominale +i.,e- meteori!m#

    & catl mai .erm- c mar$inea a!ctita

    & !plenome$alie

    & pro0ele 0iolo$ice% normale !a mici cre!t

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    Ta0lol clinic )6*Ciroa hepatica decompensata1.Parenchimatos:

    & capacitatea +e e.ort ,ic !i intelectal e!te re+!a

    & +entritia & catl mic- neori nepalpa0il

    & .e0ra ) citoli,a 'epatica- in.ectie !praa+a$ata-carcinom 'epatic*

    & icter

    & 'ipere!tro$eni!m% !telte (a!clare- eritem palmar-plantar- .emini,are ) re+cerea parli p0ian- a/ilar- apilo,itatii .aciale la 0ar0ati- $inecoma!tie

    & .actorii +e coa$lare +ecitari% $in$i(ora$ii- epi!ta/i!-'emora$ie +i$e!ti(a- 'ematoame- ec'imo,e- pete!ii#

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    Ta0lol clinic )9*

    & e/aminarile paraclinice% !an$ine 1

    tran!amina,e cre!cte- .o!.ata,a alcalina-$amma$lo0lone- cole!terol- pancitopenie-etc

    & eco$raa a0+ominala% +imen!inile !i

    !trctra catli !i a !plinei & pnctie 0iop!ie 'epatica

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    Ta0lol clinic )=*2. CH decompensata vascular

    & 'iperten!ine portala

    & !plenome$alie & circlatia colaterala a0+ominala

    & 'emoroi,i

    & (aricele e!o.a$iene !i $a!trice 1 rptra 1

    'emora$ii +i$e!ti(e !perioare% 'emateme,a !imelena

    & a!cita

    & ence.alopatia portala

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    TratamentlPrognostic1 +icil +e e!timat- +i.erite

    etiolo$ii

    Tratamentul de sustinere% & eliminarea a$entilor to/ici

    & +ieta normala- !plimente (itaminice-'epatoprotectoare !a troce 'epatice

    & me+icamente anti0ro,ante )colc'icina*

    & tratamentl complicatiilor

    Transplantul hepatic

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    Litia,a 0iliara

    Denitie% pre,enta calclilor la ni(ell

    (e,iclei 0iliare !i>!a cailor [email protected] pe!te " +e ani pre,inta litia,a 0iliara

    6&9 / mai .rec(enta la .emei

    Alti .actori .a(ori,anti% o0e,itatea- +iate-antece+ente .amiliare- +ia0etl ,a'arat

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    Ta0lol clinicA!imptomaticiSimptome +e +i!pep!ie necaracteri!tica% 0alonari-

    $retri-etc

    O0!trctia tran,itorie a canalli ci!tic 1 +rere colicati(aO0!trctia per!i!tenta% infamatie !i coleci!tita acta

    Colica biliara

    - +pa in$e!tia +e alimente coleci!to;inetice

    & locali,ata in 'ipocon+rl +rept !a epi$a!tr

    & inten!itatea cre!te pro$re!i( !i rapi+- +pa care !ementine con!tant pe toata +rata colicii

    & apare mai ale! noaptea

    & !e pot in!oti +e $retri- (ar!atri 0ilioa!e- .e0ra-tran!piratii- !0icter pa!a$er

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    Dia$no!ticl

    Eco$raa a0+ominala 1 (i,ali,ea,a in mo+

    +irect calcliiE/4 Ra+iolo$ic 1 til pentr calclii ra+iopaci

    E/4 Biolo$ice 1 normale in litia,a necomplicata

    & 5SH accel4 78T- 7OT- amila,e-te!te +e

    cole!ta,a- etc

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    TratamentlCalclii a!imptomatici% [email protected] complicatii>pe an

    Calclii !imptomatici%

    & colica 0iliara 1 +ieta- anti!patice- antial$ice-AB

    & ri!c cre!ct +e complicatii% coleci!tita acta-pancreatita acta- per.oratie c peritonita

    acta- mali$ni,are- etc & coleci!tectomie la rece

    & coleci!tectomie laparo!copica

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    Coleci!tita acta )3*Denitie% infamatia acta a pereteli coleci!tli-

    pro(ocata +e o0icei +e o0!trctia litia,ica a canalli ci!tic)@*

    Simptome si semne%

    & +rere colicati(a locali,ata in 'ipocon+rl +rept cira+iere !0!caplar +r4

    & $reata- (ar!atri

    & aparare m!clara in partea +r4

    & coleci!t palpa0il )[email protected]* & 2n$'i +rero! la in!pir pro.n+

    & !emnl li Mp'

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    Coleci!tita acta )6*Evolutia:& ameliorare in 6&9 ,ile- !e re,ol(a

    in ,ile

    Complicatii% empiem- $an$rena- per.oratie% & !tare $enerala alterata- .e0ra-

    lecocito,a- !emne +e peritonita- ile!- icter

    & amila,ele cre!te 1 pancreatita

    Diagnostic%

    & eco$rae a0+ominala

    & colan$iocoleci!to$rae i,otopica

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    Coleci!tita acta )9*

    Taratamentul% & re'i+ratare parenterala

    & !on+a +e a!piratie na!o$a!trica

    & coleci!tecomie +e r$enta )in ca, +e

    complicatii*

    & coleci!tectomie tar+i(a 1 la " !apt4

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    Coleci!tita cronicaDenitie%

    & in$ro!area !i 0ro,a parietala c retractia(e,icii 0iliare#

    Clinic%& colici recrente

    Patogenie%

    & calcli !a noroi care pot o0!tra canall

    ci!tic & mcoa!a lcerata !i 0ro,ataTratament!

    & c'irr$ical

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    8ancreatita actaDenitie% infamatie acta care !e (in+eca clinic

    !i 'i!tolo$icEtiologie:

    & afectiunile biliare - alcoolul

    & me+icamente & 'iperlipemie- 'ipertri$liceri+emie

    & in.ectii- & inter(entii c'irr$icale

    & anomalii !trctrale ale cailorpancreatice- 0iliare-

    & tramati!me#

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    8ato$enieE+em 1 necro,a 1 'emora$ie

    Acti(area en,imelor pancreatice )trip!ina-.o!.olipa,a*

    8ancreatita e+ematoa!a 1 infamatia limitata la

    pancrea! 1 mortalitatea @

    8ancreatita 'emora$ica 1 necro,a !i 'emora$ie 1mortalitatea G3?&[email protected]

    Hipo(olemie 1 !oc

    En,imele intra in circlatie 1 le,ini or$anice +i.,e

    In.ectie

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