Gastro - Sx Icterico

8/18/2019 Gastro - Sx Icterico

1/48

!"#$%&'( *+,-%*+&

!"# %&'()*& +&"",- ./**)*&0&-

.%&/(0&% 1*,234% $( 5*%26"4 7 4$82#,& $( 9. (# 640,%&(#,(%&3&6"4 :#*;(%0*$4$

.4#4'(%*+4#4<

=(>4%,4'(#,& $( 5*%26"4< ?#0@,2,& A4+*+ $( 5*(#+*40 B-$*+40 7 A2,%*+*C#<

53"#*+4 $( D#/(%'($4$(0 =*6(0@;40 7 EF(0*$4$< B-$*+4 !2%


2/48

?+,(%*+*4

• B4%+4$&% +3"#*+& $( 2# $(/(+,& (# (3

'(,4F&3*0'& 7G& (H+%(+*C# $( 34 F*3*%%2F*#4


3/48

.4,&I0*&3&6"4

• 5&3&%4+*C# 4'4%*33(#,4 $( 34 (0+3(%4J 34 >*(3 7

340 '2+&040 $(F*$& 43 $(>&0*,& $( >*6'(#,&0

F*3*4%(0

•

53"#*+4'(#,( 0( $(,(+,4 +24#$& 34 F*3*%%2F*#4

(0 '47&% 4 KLK


4/48

Ictericia escleral


5/48

Q*3*%%2F*#4

• !( &%*6*#4 +&'& >%&$2+,& $( $(6%4$4+*C# $(

34 R6F $( (%*,%&+*,&0 $4S4$&0 & &,%40

>%&,("#40 T2( +@(#(# (3 6%2>& U('(

•

.%&$2+*$4 >&% (3 0*0,('4 %(V+23&L(#$&,(3*43

• !( 3*F(%4 43 >340'4 7 0( 2#( 4 34 43F2'*#4


6/48


7/48

Q*3*%%2F*#4

hígado, bazomedula

Hemoglobina

Globina

Aminoacidos

Heme Bilirrubina

Fe2+

Excreción

Fagocitosis y lisis

Hígado


8/48

Q*3*%%2F*#4


9/48

B(,4F&3*0'&

$( 34F*3*%%2F*#4

•

Sangre

• Conjugada

• orina – Urobilinogeno

•

heces –

estercobilinogeno


10/48

542040 $( (3(;4+*C# $( F*3*%%2F*#4

• .%(U(>W@+40

– !&F%( >%&$2++*C# >&% (3 0*0,('4 %(V+23&L

(#$&,(3*43

•

R(>W@+40

– 94334 (# 34 +4>,4+*C# >&% (3 U(>4,&+*,&

– 94334 (# 34 +⁈+*C# & 34 (H+%(+*C#

• .&0,U(>W@+40

– EF0,%2++*C# $( 34 (H+%(+*C# F*3*4% U4+*4 (3

*#,(0@#&


11/48

5⁈$4 ;0< #& +⁈$4

•

!" $"%&'()*)

• X2'(#,& (# 34

>%&$2++*C# (H+($( 34

+4>4+*$4$ $(+⁈+*C#

• D8('>3&0Y 4#('*40U('&3"@+40J

U('&63&F*#&>4V40J(%%&%(0 *##4,&0 $(3'(,4F&3*0'&J %(4++*C#4 ,%40/20*C#

• +"%&'()*)

• !( >%&$2+( >(%& #& 0(

>2($( (H+%(,4%

•

542040

– =(/(+,& (# (3

'(,4F&3*0'&

– EF0,%2++*C# *#,%4 & (H,%4U(>W@+4

– B4040


12/48

Q*3*%%2F*#4

Properties Unconjugated Conjugated

Normal serum fraction 90% 10%

Water solubility (polarity) 0 (non polar) + (polar)

Affinity to lipids (Kernicterus) +++ ±

Renal excretion Nil +

Temporary Albumin Binding +++ 0Irreversible Delta Bilirubin 0 ++


13/48

Z43&%(0 #&%'43(0 $( .9R

Features Healthy Normal

Total Bilirubin Less than 1.00 mg

Conjugated Bilirubin Less than 0.15 mg

AST (SGOT) Less than 31 i.u/L

ALT (SGPT) Less than 35 i.u/L

Alkaline phosphatase Less than 112 i.u /L

GGT and 5

Nucleosidase, CDT Significantly ! in ALDUrine Bilirubin Absent

Urine Urobilinogen In trace quantity

Urine Bile Salts Absent


14/48

542040 +&'2#(0 $( *+,(%*+*4

• .%(U(>W@+4 OX+&32%*+4P L R('&3"@+4 – A& +⁈$4GQ*3*%%2F*#4 *#$*%(+,4J &%*#4 +34%4

•

R(>W@+4 [ Z*%43J 43+&U&3J ,&H*#40J $%&640 (,+< –

=4S& U(>W@+& [ #& +⁈$4

– EF0,%2++*C# $( +4#43"+23&0 L 5⁈$4

•

.&0,U(>W@+4 OEF0,%2+@;4P [ 5W3+23&0J,2'&%(0 –

5⁈$4GQ*3 =*%(+,4J &%*#4 &F0+2%4


15/48


16/48


17/48


18/48

=4,&0 +3"#*+&0

• R*0,&%*4 +3"#*+4 7 (H>3&%4+*C# \0*+4 +&'>3(,4

• R*0,&%*4 /4'*3*4% O!H< =( ]*3F(%,J ^&,&%J 5%*63(%L

A4884%J =2F*#L_&U0J 4#('*4 $( +-32340

/43+*/&%'(0P

• D3 >%*'(% 3264% $$( 0( (;*$(#+*4 (0 *,-)&"

*, .) .,%(')

• =(0>2-0 (# 34 (0+3(%4


19/48

=4,&0 +3"#*+&0

• D# *#$*;*$2&0 $( >*(3 &0+2%4 0( ;( '(8&% (# 34

(0+3(%4

• D# *+,(%*+*4 $( 34%64 (;&32+*C# 34 >*(3 >2($(

,&'4% 2# +&3&% ;(%$&0& O34 F*3*%%2F*#4 0(

'(,4F&3*`4 4 F*3*;(%$*#4P

• N&0 QL+4%&,(#&0 7 34 U('&+%&'4,&0*0 >2($(#

>%&$2+*% 2#4 +&3&%4+*C# 4'4%*33&L#4%4#84 $( 34

>*(3 >(%& %" /%0".'$1) .) ,2$.,1)


20/48

=4,&0 +3"#*+&0

!

=2%4+*C# $( 34 *+,(%*+*4 [ X62$4 G 5%C#*+4

! 5 $&3&% & 0*# $&3&%

! 9*(F%( [ Z*%43 G F4+,(%*4#4 G0(>0*0

! 5&3&% $( 340 (;4+24+*(0 [4'4%*33& +34%& *+,(%*+*4

&F0,%2+@;4


21/48


22/48

=4,&0 +3"#*+&0

•

D3 $4S& U(>4,&+(3234% >2($( 0(% $(F*$& 4Y – .4%4+(,4'&3

– R43&,4#&

– B(@3$&>4J ?0*4+*$4

–

9(#*,&*#4 – 1(,%4+3&%2%& $( +4%F&

• 5*%%&0*0 43+&UC3*+4Y

– X0+*@0

–

=(F*3*$4$ – .(%$*$4 '20+234%

– R('4#6*&'40 (# 4%4S4

– .%2%*,&


23/48

=4,&0 +3"#*+&0

•

.(#04% (# +&34#6*@0 +24#$& U47Y

– =&3&% (# +24$%4#,( 02>(%*&% $(%(+U&

– ZC'*,&

–

9*(F%( – ?+,(%*+*4

– !(+2#$4%*4 4 +&3($&+&3*@40*0

– N4 +&3(+*0@@0 >&% 0* '*0'4 #& +4204 *+,(%*+*4

–

1%*4$4 $( 5U4%+&,

• ?+,(%*+*4 #& 40&+*4$4 4 $&3&% (# 2# >4+*(#,(4#+*4#& >(#04% (# +W#+(%


24/48

DHW'(#(0 $( 34F&%4,&%*&

•

Q*3*%%2F*#4 – 1&,43 7 $*%(+,4

–

X'*#&,%40/(%4040

– 9X

–

DH4'(# 6(#(%43 $( &%*#4•

Q*3*%%2F*#4

•

:%&F*3*#&6(#&

• QR

•

1.• .4#(3 $( U(>4@@0 ;*%43

•

:! $( ;(0"+234 ( U"64$&


25/48

DHW'(#(0 $( 34F&%4,&%*&

•

R*>(%F*3*%%2F*#('*4 #& +⁈$4

– :#*$4 /2(%,('(#,( 4 43F2'*#4J #& 4>4%(+( (# 34

&%*#4

–

D3 %(0,& $( 340 .9R 0 #&%'43(0

– N4 QR 7 (3 /%&@0 $( 04#6%( '2(0,%4# 4#('*4 7

U('&3*0*0

–

D3 !H< $( ]*3F(%, (0 34 +4204 '40 +&'a#•

N4 U*>(%F*3*%%2F*#('*4 0( 40&+*4 4 (0,%-0 OI(F%(J

46&,4'*(#,&J 472#&J +*%26"4J 7 43+&U&3*0'& 0(;(%&P


26/48

DHW'(#(0 $( 34F&%4,&%*&

•

R*>(%F*3*%%2F*#('*4 +⁈$4

– D0 0&32F3( (# 4624 >&% 3& T2( 0( ;( (# 34 &%*#4 (#

+4#@$4$(0 >(T2(S40

–

D3 2%&F*3*#&6(#& (0,4 420(#,( (# 34 &%*#4 (# +40&

$( +&3(0,40*0

– R47 4#&%'43*$4$(0 (# &,%40 .9R

•

D3(;4+*C# $( 9X 7 ]]1 026*(%(# &F0,%2++*C# *#,%4 &(H,%4 U(>W@+4


27/48

D;4324+*C# $( *+,(%*+*4

3.,0)$/4% *, -/./11'-/%) %" $"%&'()*)5

6$7,1/$/) 8"1 9,:"./2/2

3.,0)$/4% *, -/./11'-/%) $"%&'()*)

6$7,1/$/) *, "1/(,% 9,8)7"$,.'.)1

6$7,1/$/) "-271'$;0)


28/48

Elevación de bilirrubina no

conjugada

Kb

6$7,1/$/) 8"1 9,:"./2/2< 8"$" $":=%

>? @1)27"1%"2 9,:".A;$"2 B C%,:/)

@1)27"1%"2 9,1,*/7)1/"2 D ,2E,1"2/7"2/2 ,7$

F? ,1/71"8"G,2/2 /%,E,$;0) DH>FI J,I J

K? L1"()2 D M/E):8/$/%)I 81"-,%,$/*

N? O,1,%$/) D+1/(.,1 !)&&)1I P/.-,17


29/48


30/48

6$7,1/$/) %,"%)7).

•

Muy común

• 50% de los infantes sanos

• Kernicterus: complicación

•

En el útero la bilirrubina es metabolizada por elhígado de la madre

• Al nacimiento el hígado esta inmaduro

•

Tratamiento: fototerapia (se producenfotoisómeros que son eliminados por la orina)


31/48

c(%#*+,(%20


32/48

?+,(%*+*4 &F0,%2+@;4

•

=&3&%&04 ;0 #& $&3&%&04• N4 &F0,%2++*C# >2($( 0(%

– N2'*#43 O+W3+23&0P

– D0,(#&0*0 OF(#*6#4 ;0 '43*6#4P

– DH,%4 32'*#43Y +4 $( >W#+%(40

•

=*46#&0@+& 7 ,%4,4'*(#,&

– ^4$*&3&6"4 O:!J 51J B^5.P

–

5.^D

–

5*%26"4


33/48

D#/(%'($4$ U(>W@+4 +%C#*+4

!

Alcoholismo

! Hepatitis viral crónica

" Hepatitis B

"

Hepatitis C! Afección autoinmune:

" Hepatitis autoinmune

" Anti musculo liso

"

Cirrosis biliar primaria

!

Padecimientos heredados

" Hemocromatosis

" Enfermedad de Wilson

"

Deficiencia de Alpha1-Antitrypsina

! Esteatohepatitis no

alcohólica

!

Síndrome de Budd-Chiari! Criptogenica


34/48

=%&640 U(>4,&,&H*+40

Medicamentos Sustancias naturales

Paracetamol Hipervitaminosis A

Amiodarona, Diclofenaco Hongos, cocaina

Fuconazol Aflatoxinas

Isoniacida Senecio

Nitrofurantoina

Troglitazona


35/48

D#/(%'($4$ $( d*30

Anillo de Kayser - Fleischer


36/48

542040 $( *+,(%*+*4 +&3(0,40*+4

Intrahepática Extrahepática

Daño hepático agudo, hepatitis viral Coledocolitiasis

Hepatitis alcohólica, drogas Estenosis biliar

Daño hepático crónico Colangiocarcinoma

Colangitis autoinmune Ca de páncreas

TPN PancreatitisInfecciones sistémicas Quistes de colédoco

Linfoma


37/48

Frecuencia de causas de ictericia


38/48

542040 +&'2#(0 $( *+,(%*+*4


39/48

!H< $( ]*3F(%,


40/48

5&'>3*+4+*(0 $( U(>4,&>4@4

+%C#*+4•

Hipertensión portal

– Varices

– Ascitis

–

Hiperesplenismo• Problema de síntesis

– Coagulopatia

– Encefalopatía

•

Inmunodeficiencia

• Desnutrición

• Carcinoma hepatocelular


41/48

5&34#6*& %(0#+*4

Cálculos en la vía biliar


42/48

+".,*"$"./;)2/2

B^5. D^5.


43/48

5.^D


44/48

Colangitis esclerosante

5.^D


45/48

Dilatación de la vía biliar

5.^D


46/48

5*%%&0*0 U(>W@+4 >&% 43+&U&3

Múltiples nódulos pequeños y fibrosis


47/48


48/48

5+320*(0

•

La ictericia y el daño hepático son comunes• Historia clínica y exploración física la base del Dx

• Causas

– Alteración hepato celular aguda con ictericia

–

Alteración hepatocelular crónica

–

Colestasis por obstrucción

• Diagnostico

–

PFH

– US, colangioresonancia, CPRE

– Biopsia hepática

Gastro - Sx Icterico

Documents

Transcript of Gastro - Sx Icterico