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R2CG Carlos Hernández Brito
IMSS
CMN Manuel Ávila Camacho
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• Proceso inflamatorio del páncreas
• El proceso inflamatorio se puede delimitar a páncreas o
extender a otros órganos
• La completa recuperación es la regla
• La mayoría de casos son leves y presentan recuperación
espontánea
Wang, G., Acute pancreatitis: Etiology and common pathogenesis, World J Gastroenterol 2009 March 28; 15(12): 1427-1430
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• Forma más severa es la pancreatitis necrotizante
• Las complicaciones tardías ocurren después de la 2°semana
• No se conoce hasta el día de hoy la manera exacta en la que se desarrolla la pancreatitis
• Todas las causas conocidas en algún punto convergen en su patogenia
Wang, G., Integrity of the pancreatic duct-acinar system in the pathogenesis of acute pancreatitis, Hepatobiliary Pancreat Dis Int, Vol 9,No 3 •
June 15,2010
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• 1era causa de muerte FOM
• 2nda causa sepsis
Wang, G., Acute pancreatitis: Etiology and common pathogenesis, World J Gastroenterol 2009 March 28; 15(12): 1427-1430
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• Cálculos biliares, alcoholismo e hipertrigliceridemia
• Obesidad
• Frecuencia inversa al tamaño del lito
• La incidencia se ha incrementado debido al consumo de
alcohol
• Mortalidad del 9 al 11%
Cruz-Santamaría, D., Update on pathogenesis and clinical management of acute pancreatitis, World J
Gastrointest Pathophysiol 2012 June 15; 3(3): 60-70
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Cruz-Santamaría, D., Update on pathogenesis and clinical management of acute pancreatitis, World J
Gastrointest Pathophysiol 2012 June 15; 3(3): 60-70
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Whitcomb, D., Genetic Risk Factors for Pancreatic Disorders, GASTROENTEROLOGY 2013;144:1292–1302
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Ho Gak Kim, Obesity and Pancreatic Diseases, Korean J Gastroenterol Vol. 59 No. 1, 35-39
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• Reflujo biliar
• Activación de enzimas pancreáticas
• Obstrucción del conducto
• Reflujo duodenal
• Apoptosis de células acinares
Wang, G., Acute pancreatitis: Etiology and common pathogenesis, World J Gastroenterol 2009 March 28; 15(12): 1427-1430
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Wang, G., Acute pancreatitis: Etiology and common pathogenesis, World J Gastroenterol 2009 March 28; 15(12): 1427-1430
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• Activación enzimática temprana
• Autodigestión pancreática
• Confluyen en toxicidad metabólica, mecánica y genética
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1. La pancreatitis inicia en las células acinares
Catepsinas B y L Autofagia celular
2. Los mecanismos mediantes los cuáles se origina la
pancreatitis y el por qué de su variabilidad de
presentación permanecen inciertos
No se desarrolla en todos los pacientes
Sah, R., Molecular mechanisms of pancreatic injury, Curr Opin Gastroenterol. 2011 September ; 27(5): 444–451
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3. Activación enzimática a pesar de los mecanismos de
defensa
Inhibidor del tripsinógeno, proteasa sérica inhibitoria Kazal 1 (SPINK1), mesotripsina, enzima Y, α1antitripsina
y la α2-macroglobulina
4. Autodigestión pancreática
Sah, R., Molecular mechanisms of pancreatic injury, Curr Opin Gastroenterol. 2011 September ; 27(5): 444–451
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5. Activación de múltiples vías por la tripsina
Sistema de complemento
Cascada de la coagulación
Sistema fibrinolítico
Liberación de citocinas
6. Daño multiorgánico
SIRS
FOM
Sah, R., Molecular mechanisms of pancreatic injury, Curr Opin Gastroenterol. 2011 September ; 27(5): 444–451
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7. Susceptibilidad genética
PRSS1
CFTR
Polimorfismo en SPINK1
Receptores de calcio
Sah, R., Molecular mechanisms of pancreatic injury, Curr Opin Gastroenterol. 2011 September ; 27(5): 444–451
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• La respuesta a la lesión pancreática puede ser
suficiente, insuficiente, o excesiva
• Células involucradas: células acinares, células
endoteliales, neutrófilos, linfocitos, monocitos y
macrófagos
Parrilla, P., cirugia AEC, 2° ed, ed panamericana
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Shrivastava, P., Essential role of monocytes and macrophages in the progression of acute pancreatitis, World J
Gastroenterol 2010 August 28; 16(32): 3995-4002
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SIRS• TNF
• IL 1
• IL 2
• IL 6
• IL 8
• ICAM
• MCP 1
• Sustancia P
• C5a
• IL 18
• PAF
• PCR
• NF-κB
CARS
• IL 10
• IL 11
Shrivastava, P., Essential role of monocytes and macrophages in the progression of acute pancreatitis, World J
Gastroenterol 2010 August 28; 16(32): 3995-4002
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Shrivastava, P., Essential role of monocytes and macrophages in the progression of acute pancreatitis, World J
Gastroenterol 2010 August 28; 16(32): 3995-4002
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Thrower, E., Molecular and cellular mechanisms of pancreatic injury, Curr Opin Gastroenterol. 2010 September; 26(5): 484–489
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Brunicardi, C., schwartz principles of surgery, 9° ed, mc graw hill
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Gukovsky, I., Impaired Autophagy and Organellar Dysfunction in Pancreatitis, J Gastroenterol Hepatol. 2012 March ; 27(Suppl 2): 27–32
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Gukovsky, I., Impaired Autophagy and Organellar Dysfunction in Pancreatitis, J Gastroenterol Hepatol. 2012 March ; 27(Suppl 2): 27–32
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Gukovsky, I., Impaired Autophagy and Organellar Dysfunction in Pancreatitis, J Gastroenterol Hepatol. 2012 March ; 27(Suppl 2): 27–32
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Leena Kyl¨anp¨a¨, The Clinical Course of Acute Pancreatitis and the InflammatoryMediators That Drive It, International Journal
of Inflammation Volume 2012, A
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Leena Kyl¨anp¨a¨, The Clinical Course of Acute Pancreatitis and the InflammatoryMediators That Drive It, International Journal
of Inflammation Volume 2012, A
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Markus, M., Models of Acute and Chronic Pancreatitis, GASTROENTEROLOGY 2013;144:1180–1193
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Brunicardi, C., schwartz principles of surgery, 9° ed, mc graw hill
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• La respuesta a la lesión puede ser suficiente, insuficiente
o excesiva
De lesión (temprana)
Progresión de lesión (temprana)
Infección (tardía)
Parrilla, P., cirugia AEC, 2° ed, ed panamericana
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Ledesma-Heyer, J., Pancreatitis aguda, Med Int Mex 2009;25(4):285-94
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Ledesma-Heyer, J., Pancreatitis aguda, Med Int Mex 2009;25(4):285-94
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Ledesma-Heyer, J., Pancreatitis aguda, Med Int Mex 2009;25(4):285-94
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Ledesma-Heyer, J., Pancreatitis aguda, Med Int Mex 2009;25(4):285-94
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Ledesma-Heyer, J., Pancreatitis aguda, Med Int Mex 2009;25(4):285-94
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T. L. Bollen, The Atlanta Classification of acute pancreatitis revisited, British Journal of Surgery 2008; 95: 6–21
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Banks, P., Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus, Gut
2013;62:102–111. doi:10.1136/gutjnl-2012-302779
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• Dolor abdominal
• Elevación de enzimas pancreáticas
• Demostración radiológica
Banks, P., Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus, Gut
2013;62:102–111. doi:10.1136/gutjnl-2012-302779
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• Edematosa
Banks, P., Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus, Gut
2013;62:102–111. doi:10.1136/gutjnl-2012-302779
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• Necrotizante
Banks, P., Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus, Gut
2013;62:102–111. doi:10.1136/gutjnl-2012-302779
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Temprana
• Termina en la 1° semana
• SIRS
• Presencia de falla orgánica
• Pueden presentarse complicaciones locales
Tardía
• Persistencia de signos de inflamación sistémica
• Complicaciones locales
El mayor determinante de severidad es la persistencia de falla orgánica
Banks, P., Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus, Gut
2013;62:102–111. doi:10.1136/gutjnl-2012-302779
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Banks, P., Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus, Gut
2013;62:102–111. doi:10.1136/gutjnl-2012-302779
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Banks, P., Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus, Gut
2013;62:102–111. doi:10.1136/gutjnl-2012-302779
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Banks, P., Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus, Gut
2013;62:102–111. doi:10.1136/gutjnl-2012-302779
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Banks, P., Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus, Gut
2013;62:102–111. doi:10.1136/gutjnl-2012-302779
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Banks, P., Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus, Gut
2013;62:102–111. doi:10.1136/gutjnl-2012-302779
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Banks, P., Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus, Gut
2013;62:102–111. doi:10.1136/gutjnl-2012-302779
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Banks, P., Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus, Gut
2013;62:102–111. doi:10.1136/gutjnl-2012-302779
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Banks, P., Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus, Gut
2013;62:102–111. doi:10.1136/gutjnl-2012-302779
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Banks, P., Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus, Gut
2013;62:102–111. doi:10.1136/gutjnl-2012-302779