Sindrom ocluziv cronic. Caz clinic
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Sdr. ocluziv cronic Sdr. ocluziv cronic complicat cu perforatie complicat cu perforatie
intestinala, MSOF si exitusintestinala, MSOF si exitusPrezentare de cazPrezentare de caz
Andritoiu A, Prof. Dr. Mercut D, Resceanu Aurelia, Silosi C, Robescu F, Demetrian P, Prof. Dr. Stoica Zoia
Spitalul Clinic de Urgenta Militar Craiova - SPAD
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Motivele internarii
• V. F-D, B, 33 ani• Mediu rural
• Marirea de volum a abdomenului
• Scadere ponderala progresiva (casexie) in max 6 sapt.
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Abdomen destins de volum
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Ex. obiectiv
• Casexie (IMC = 15.2 Kg/mp)
• Abdomen in tensiune, usor asimetric, hipersonor
• Ficat/splina nedelimitabile
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Probleme de diagnostic
• Abdomenul destinsAbdomenul destins• Ascita (ciroza
hepatica la un consumator etanolic)?
• Ocluzie intestinala (in absenta varsaturilor, cu tranzit intestinal prezent)?
• Scaun de consistenta moale, ,in creion,,
• CasexiaCasexia• Sdr. Neoplazic• Boli inflamatorii
intestinale• sdr. de mal-absorbtie
intestinala
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Ex. biologice• VSH 30 mm/h -17mm/h• Leuc =10.200-2900/mmc• Hb 12.5 g/dL; Ht 35%• Na 126 mmol/L;K5 mmol/L, • Ca 7.8-6.8 mg/dL; Mg 2.6 mg/dL• Glicemie 132-161 mg/dL• Uree 47-51 mg/dL, creatinina 0.7 mg/dL• Amilaza pancreatica 38 UI/L• TGO 20 UI/L, TGP 22 UI/L, GGT 36 UI/L• BRT 0.9 mg/dL• Proteine totale 4.6 g/dL• Ex. Sumar de urina –relatii normale
CEA 2.07 ng/mL
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Echo abdomen
• Ficat omogen, LD 14 cm, LS 7 cm
• Aerocolie generalizata
• Anse intestinale destinse, stazice, atone
• Lichid de ascita in cantitate minima
• Paracenteza in scop diagnostic (ghidata ecografic)–se extrag 10 mL lichid de ascita usor opalescent
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CT torace si abdomen
• Torace• Pulmon , mediastin si
pleura fara procese evolutive
• Fara adenopatii mediastinale
• Abdomen• Ficat, colecist,
pancreas, splina, RD, RS normale
• Aerocolie generalizata de la cec, la ampula rectala.
• Lama de lichid in peritoneu
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CT abdomen
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RMN abdomen
• Disetensie aerica marcata la niv. Intestinului gros
• Imagini hidro-aerice pe ansele intestinale
• Fluid peri-hepatic, perislenic, bursa omentala si parieto-colic bilateral
• Micro-adenopatii lombo-aortice
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RMN pelvis
• Infiltrare parietala la nivelul sigmoidului
• Diminuarea calibrului• Formatiune tumorala
endoluminala tisulara, slab gadofila, fara semne de extensie parietala
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Lichid de ascita
• Citologie• Frotiu cu celularitate
bogata-celule mezoteliale cu carcatere benigne si limfocite-30%
• FROTIU NEGATIV
• Biochimie• Glucoza 136 mg/dL• Ptroteine 1.8 g/dL• LDH 190 UI/L• CRP 0.3 mg/dL• CEA 0.73 ng/mL• Amilaza 25 Ui/L
Cultura aeroba - negativa
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Tratament
• Ciprofloxacina 500 mg x 2/zi p.o.
• Gentamicina 80 mg x2/zi i.m.
• Sol. Ringer
• Aminoplasmal
• Albumina
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Evolutie nefavorabila Z a 8-a
• Durere abdominala socogena
• Transipratii reci
• Tahicardic
• Prabusire tensionala
• Abdomen destins
• Transfer in ATI
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Tuseu rectal
• Ampula goala
• La varful degetului explorator se palpeaza o formatiune polipoida, friabila, sangeranda.
• Din fragmentele tumorale detasate se preleveaza ptr. ex. H-P
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ATI
• Stare generala critica – MSOF• Masuri terapeutice suportive• Dopamina, Furosemid, Cefort, Albumina,
Aspatofort, Ampicilina, Ringer, Amino-Hepa• Aspiratie gazo-gastrica, tub de gaze• Se practica laparatomie minima de degajare • Se evacuaza materii fecale din cavitatea
peritoneala in cantitate impresionanta!• EXITUS
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Laparatomie minima de degajare(compartiment abdominal)
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Examen H-P
• Fragment cu aspect de mucoasa de intestin gros cu zone cu structuri glandulare cu displazie usoara sau moderata.
• Fragment tumoral cu aspect de ADENOCARCINOM MODERAT ADENOCARCINOM MODERAT DIFERENTIATDIFERENTIAT cu reactie desmoplazica moderata, cu infiltrat inflamator linfocitar intratumoral
Dr. Drighicu CorinaMedic primar Anatomie patologica