[ecografie curs 2003]
DESCRIPTION
Ecografie Curs 2003]TRANSCRIPT
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CRITERII DE DIAGNOSTIC
ECOGRAFIC IN GASTROENTEROLOGIE
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PRINCIPII GENERALE
Metoda imagistica morfo-functionala ce utilizeaza capacitatea ultrasunetelor (US) - vibratii mecanice cu o frecventa de 2-10 MHz ce au ca suport oscilatiile particulelor componente ale materiei - de a strabate mediile biologice si de a fi absorbite si reflectate de catre acestea sub forma de ecouri.
Ecourile iau nastere prin reflectarea US la interfata dintre doua medii cu impedanta acustica diferita (produsul dintre viteza de propagare a US in mediu respectiv si densitatea mediului) sau in interiorul unei structuri neomogene.
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Tra
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DIAGRAMA UNEI UNITATI US
Front-end beam former
Signal pre-processing
Scan converter
Signal post-
processing
Monitor
Transmitter
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AVANTAJE - ATRIBUTE
informatii morfo-functionale exacte, repreductibile
informatii dinamice (in timp real) - utilitate in explorari functionale, ghidarea unor proceduri diagnostice si terapeutice
expeditiva, durata scurta (este rapid informativa)
non-invaziva, non-radianta
repetabila
poate fi aplicata in conditii variate, inclusiv la pacienti in stare critica, necooperanti, comatosi
larg accesibila
cost redus (ieftina) comparativ cu alte explorari imagistice
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DEZAVANTAJE - LIMITE
operator-dependenta (cunostinte, integrare, abilitati tehnice, cunoasterea echipamentului)
pacient-dependenta (pregatire, tip constitutional)
dependenta de rezolutia si buna functionare a echipamentului
dependenta de alegerea corecta a indicatiei
dependenta de timpul alocat examinarii
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PREGATIREA PACIENTULUI
Examinarea US electiva
6-12 h de post (overnight fasting)
regim sarac in hidrocarbonate si fibre in ziua/zilele precedente
utilizarea “ferestrelor acustice”
pacient constient, cooperant
Examinarea US in urgenta
nu este necesara pregatirea, mobilizarea, cooperarea pacientului
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BULETINUL ECOGRAFIC
Examinarea US trebuie sa fie atenta, corecta si completa (integrala), soldata cu un buletin ecografic
caracter DESCRIPTIV !
Nu se formuleaza diagnostice ecografic !
Nu se descriu ca normale structuri incomplet/incorect examinate
Se descriu in detaliu leziunile ecografice interceptate (localizare, forma, structura, dimensiuni, raporturi, complicatii etc)
Recomandari (necesitatea urmaririi sau aportului altor tehnici)
Precizarea unor conditii artefactogene
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TERMINOLOGIE ECOGRAFICA
Ecostructura: totalitatea ecourilor (punctelor luminoase) asamblate intr-o imagine complexa, integrata, coerenta, in scala alb-negru
Ecogen (reflectogen, hiperecoic): US sunt reflectate de mediul biologic strabatut; imaginea rezultata pe monitor va fi alba, luminoasa
Transonic (anecoic, anecogen, sonolucent): US strabat mediul biologic fara a se reflecta; imaginea rezultata este neagra, fara punte luminoase.
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SEMIOLOGIE ECOGRAFICA
Imaginea de tip solid (parenchimatos) Este o imagine ecogena, omogena, datorata texturii (structurii) ordonate a parenchimului si tesutului mezenchimal de sustinere
Organe solide: ficat, splina, pancreas, rinichi etc
Notiunile hipo-, izo- si hiperecogene sunt relative la o structura considerata normala
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SEMIOLOGIE ECOGRAFICA Imaginea hiperecogena cu umbra (con)
acustic Alba, stralucitoare, liniara sau arciforma
Posterior de aceste structuri US sunt absente - rezultand o imagine conica/trapezoidala neagra (“con de umbra” sau “con acustic”
Este datorata structurilor dense, impregnate cu calciu, impenetrabile/slab penetrabile la US, ce reflecta cvasitotal fasciculul US: calculi, calcificari, os, cicatrici fibro-calcare, clipsuri, cleme, calcificari vasculare
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SEMIOLOGIE ECOGRAFICA Imaginea hiperecogena cu umbra (con)
acustic
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SEMIOLOGIE ECOGRAFICA
Imaginea hiperecogena cu “con” acustic & reverberatii posterioare
Prezenta gazului in interiorul sau vecinatatea unei structuri realizeaza interfete cu maxima diferenta de impedanta
Reflectarea US: imagine alba, stralucitoare, dar mobila si anti-decliva
“con acustic” cu reverberatii acustice (“dirty shadow”)
tub digestiv, pulmon, abces cu anaerobi, pneumoperitoneu, pneumobilie
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SEMIOLOGIE ECOGRAFICA
Imaginea transonicaImagine transonica, fara ecouri (“neagra”)
De regula omogena si net conturata
Fenomenul de amplificare acustica posterioara (“acoustic enhancement”) - datorat diferentei de viteza la interfata unor medii cu densitate foarte diferita plus lipsa de reflectare a US in mediul lichidian
ascita, bila, urina, chiste, lichid amniotic, colectii, hematom recent
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SEMIOLOGIE ECOGRAFICA Imaginea tip lichidian “impur”
Corespunde unor structuri lichidiene “impure”, vascoase, cu densitate crescuta, in care se afla numeroase particule in suspensie, mici fragmente tisulare etc
Imaginea este transonica, cu numeroase ecouri fine, punctiforme, flotante sau aspecte de sedimentare
In general sunt structuri complexe, neomogene, stratificate (lichid/semisolid)
Ex: bila in colestaza cronica, abcese, hematom & ascita infectata
Sludge biliar
Ascita
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Pseudochist - abces pancreatic
SEMIOLOGIE ECOGRAFICA Imaginea tip lichidian “impur”
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SEMIOLOGIE ECOGRAFICA Imaginea tip lichidian tubular
Structura sub forma de banda transonica delimitata de pereti liniari, de regula fin ecogeni, regulati, paraleli
Ex: vase, ducte biliare, urinare
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SEMIOLOGIE ECOGRAFICA Imaginea localizata solida nodulara
Semnificatie patologica, localizata si circumscrisa in interiorul unui organ recunoscut ca atare, acre nu o contine in mod normal
Omogena/neomogena, B vs M, hipo-, izo-, hiper-cogena, localizare si dimensiuni variate
imaginea de “cocarda”
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metoda ideala de explorare imagistica a parenchimului hepatic datorita atributelor organului si proprietatilor metodei US
examinare in timp real transducer 3-5 MHz inspir profund blocat sectiuni t, l, o sub apendicele xifoid, rebordul
costal drept, intercostal nu necesita pregatirea speciala a pacientului
EXAMINAREA ECOGRAFICA A FICATULUI
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SEMIOLOGIA ECOGRAFICA A FICATULUI
ecostructura solida omogena; moderat ecogenic (gri)
ecopattern normal: ecouri mici, paralele, de mica si egala amplitudine, echidistante (aspect omogen)
isosonic sau usor mai hiperecogen decat cortexul renal la aceeasi profunzime
margine anterioara rotunjita, neteda
suprafata regulata
inconjurat de o capsula fibroasa - fina, ecogena, neteda
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traversat de 2 sisteme canaliculare: port si hepatic aprecierea dimensiunilor este profund subiectiva
t <13.5 cmprerenal <15 cmlob caudat <45 mm
SEMIOLOGIA ECOGRAFICA A FICATULUI
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SEMIOLOGIA ECOGRAFICA A FICATULUI
2 lobi anatomici, drept si stang, separati prin ligamentum teres si fisura aferenta, si lobul caudat
2 lobi functionali: “hemi-ficat dr si stg” delimitate de linia “Cantlie” ce trece prin foseta VB si VCI (de-a lungul venei hepatice medii)
sectorializarea functionala=portala a ficatului, propusa de Couinaud
4 sectoare portale, alimentate de ramuri portale distincte
8 segmente hepatice
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ANOMALII ECOGRAFICE HEPATICE:
difuze ficatul gras (steatoza, steatohepatita) hepatita cronica ciroza hepatica
focale chiste biliare simple chiste parazitare hemangiomul tumori hepatice benigne - adenom, HFN tumori hepatice maligne - primitive, secundare
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AFECTIUNI HEPATICE DIFUZE
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STEATOZA HEPATICA
infiltrarea grasa a ficatului (cresterea continutului de lipide >5%)
criterii ecografice semnificative la > 10% si o acuratete dg ~ 90%
criterii dg:
- cresterea difuza a ecogenicitatii (ficat alb, stralucitor)
- atenuare posterioara
- stergerea desenului vascular
- stergerea delimitarii posterioare
- hepatomegalie (75%)
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Principalele cauze ale steatozei hepaticeAlcoolicaNon-alcoolica diabet zaharat dislipidemie obezitate sarcina medicamente (corticoterapie) toxice erori innascute de metabolism malnutritie/denutritie hiperalimentatie (TPN)
STEATOZA HEPATICA
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ARII FOCALE DE STEATOZA
cresterea focala a ecogenitatii lobara/segmentara/sub-segmentara relativ bine delimitata
margini angulate, geometriceabsenta efectului de masavase normale, vizibile in aria de steatoza
asociata frecvent cu corticoterapia, etilism cronic, malnutritie
dg dif cu procesele localizate nu este niciodata cert (CT, examen histopatologic-PBH)
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HEPATITA CRONICA
Criteriile ecografice de diagnostic sunt sarace si nespecifice
aspectul poate parcurge un amplu spectru, de la normal la nodular
in general, prezenta infiltratului inflamator cronic ± fibrozei determina un aspect hiperecogen & neomogen
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Contrar, in ciroza hepatica se descrie o pletora de anomalii US a caror mixtura permite adeseori ultrasonografistului sa emita suspiciunea de diagnostic, in afara oricaror date clinico-biologice
CIROZA HEPATICA
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CIROZA HEPATICA ecogenitatea crescuta difuz si neomogen ecostructura remaniata, in plaje/nodular (micro-/macro-nodular) suprafata, margine anterioara remanierea desenului vascular: rr. mari dilatate, rr mici gracile/disparute, rigide, manson hiperecogen periportal (fibroza) hipertrofia lobului stang si caudat (segment I) si atrofia lobului drept t lob caudat>45 mm
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CIROZA HEPATICA
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Modificari asociate - HTPo: dilatarea axului splenoport - splenomegalie omogena, dilatatii
vasculare in hil - circulatie colaterala - dublu contur vezicular - ascita
CIROZA HEPATICA
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CIROZA HEPATICA
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AFECTIUNI HEPATICE FOCALE
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Leziunile focale cele mai frecvent intalnite la examinarea US a ficatului
Numai in situatii exceptionale (infectie, hemoragie, dimensiuni gigante) sunt simptomatice: durereHD, semne hemoragie, febra, hepatomegalie
Mai frecvente la femei Mai frecvente la varstnici Reprezinta anomalii de dezvoltare ale ductelor biliare AP: spatii pline cu fluid, bine delimitate de un epiteliu
cubic Acuratetea US in detectia lor: ~100%
CHISTE HEPATICE ESENTIALE
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CHISTE HEPATICE ESENTIALE
leziuni transonice (anecoice)
bine delimitate de un perete fin ecogen, neted, regulat sau imperceptibil
amplificare acustica post. unice/multiple ± septuri dimensiuni variabile
(<3cm) localizate LD 2xLS DD: chist parazitar,
abces, chistadenom, chist coledocal, meta necrozate
US permite aspiratia decompresiva/alcoolizarea chistelor simptomatice
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Afectiune congentala AD 1:500 Mai frecventa la femei Expresia fenotipica creste cu varsta 1/3 din cazuri au afectare hepatica Manifestarea clinica: hepatomegalie DD: dilatatia CBIH, boala Caroli
BOALA POLICHISTICA HEPATICA (HEPATO-RENALA)
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Se descriu 5 pattern-uri US:
1. Chist solitar (ass. chistului esential)2. Separarea membranei (“US water lily
sign”)3. Aspectul de “vezicule fiice”
(“honeycomb”)4. chiste multiple5. solid pattern
CHISTUL HIDATIC
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CHISTUL HIDATIC
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Cea mai frecventa tumora benigna hepatica
detectata frecvent incidental 8-13%
asimptomatica mai frecventa la sexul feminin si
varsta adulta rotund-ovalare sau polilobate hiperecogene relativ omogene hemangioamele mari sunt
neomogene/hipoecogene central (necroze, hemoragii, degenerare chistica centrala)
Doppler: absenta semnalului Doppler
HEMANGIOMUL HEPATIC
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localizare preferentiala LD unice/multiple (10-25%) in medie, 1-3 cm pattern-ul US este datorat structurii
intrinseci: retea de spatii vasculare pline cu sange (amplificare posterioara: imagine in oglinda) delimitate de endoteliu, plicaturate/angulate intr-o masa fibroasa (numeroase interfete acustice)
la examinarea Doppler: absenta semnalului (circulatie lenta, haotica/divergenta)
nu degenereaza malign, rareori cresc in dimensiuni
nu necesita tratament
HEMANGIOMUL HEPATIC
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2 variante histologice: carcinom hepatocelular si colangiocarcinom (40:1)
US si AFP reprezinta tandemul de screening pentru HCC in populatiile cu risc crescut (cirotici, infectii cu VHB, VHC, expunere masiva la hepatocarcinogeni)
Acuratete de detectie mare: S=90%, Sf=93% Din punct de vedere US nu exista criterii de
departajare intre cele 2 variante histologice
TUMORI PRIMITIVE HEPATICE
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TUMORI PRIMITIVE HEPATICE
Unice/multiple iso/hiper/
hipoecogene relativ la parenchimul hepatic
neomogene imprecis delimitate
dar, cel mai frecvent, cu halo hipoecogen periferic
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TUMORI PRIMITIVE HEPATICE
Pattern US amplu variabil in raport cu dimensiunea si structura intrinseca a neoplasmului
nodular masiv difuz infiltrativ
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TUMORI PRIMITIVE HEPATICE
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TUMORI PRIMITIVE HEPATICE
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Rolul US
detectie diagnostic invaziv: histologic (PBH ghidata
ecografic) stabilirea morfologiei tesutului hepatic non-
tumoral rol terapeutic: injectarea percutanata de
etanol monitorizarea tratamentelor
TUMORI PRIMITIVE HEPATICE
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METASTAZE HEPATICE
Cea mai frecventa interesare neoplazica a ficatului Frecvent, de la neoplasme ale tractului
gastrointestinal, pancreas, pulmon, san
Rolul US: detectie corelatii echopattern-origine?? diagnostic invaziv: histologic (PBH ghidata
ecografic) monitorizarea leziunii sub tratament
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Pattern US amplu variabil in raport cu dimensiunea si structura intrinseca a neoplasmului
neomogene (heterogene)
slab demarcate multiple dimensiuni variate efect de masa efect de halo
periferic (“cocarda”) necroze (arii
anecoice) centrale
METASTAZE HEPATICE
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dilatarea axului spleno-port, VMS (13+/-1.5 mm) (IC ~56%)
absenta variatiilor respiratorii in calibrul VS, VMS (>2 mm) (IC ~80-88%)
detectia colateralelor (IC ~95-99%)- repermeabilizarea v. ombilicale (>3 mm)- dilatarea v. gastrice stangi > 5 mm- colaterale venoase retroperitoneale
(peripancreatice)- vene splenice scurte dilatate in hilul splenic sunt spleno-renal spontan- colaterale venoase in patul colecistic
HIPERTENSIUNEA PORTALA
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HIPERTENSIUNEA PORTALA
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raportata cu incidenta variabila: 1-11% ciroza hepatica reprezinta cauza cea mai frecventa 25% dintre pacientii cu carcinom hepatocelular alte cauze: pancreatita acuta, colecistita acuta,
infarct mezenteric, tumori gastrice/pancreatice, afectiuni hematologice
la copil: tratamente parenterale utilizand vena ombilicala, infectii intestinale
TROMBOZA V. PORTE
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material/banda hiperecogena in lumenul port, non-mobila
ecogenitatea materialului intraluminal creste cu timpul, pe masura organizarii trombului, pana cand peretii devin indistinctibili
repermeabilizarea partiala repermeabilizarea
cavernomatoasa (cand ocluzia este completa): structura ecogena elongata in porta hepatis, strabatuta de canale subtiri, tortuoase (retea)
TROMBOZA V. PORTE
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VEZICULA BILIARA SISTEMUL BILIAR
EXAMINAREA ECOGRAFICA A SISTEMULUI BILIAR
pacient a jeun de minimum 6-8 ore (distensie adecvata)
examinarea in minimum doua pozitii: decubit dorsal si lateral stang (vizualizarea completa a lumenului, mobilitatea gravitationala)
sunt examinate: marimea, forma, continutul/pattern luminal, modificarile parietale si aria pericolecistica
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LITIAZA BILIARA
Criterii bune de diagnostic pentru LB si complicatiile acesteia
Variate aspecte US (variatii de marime, numar, forma, compozitie, efecte asupra VB)
1. clasic (100%): - imagine hipereflectogena intraluminala
- mobila gravitational - umbra acustica
(“clean and sharp”)
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VB contractata (sclero-atrofica sau non-vizibila) (88-96%): con acustic din fosa biliara
“Vezicula de portelan”: 10-20% asociere cu carcinomul vezicular
semnul “dublu arc” (WES: wall-echo-shadow) (99%)
LITIAZA BILIARA
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LITIAZA BILIARA
Complicatii: hidrops vezicular
VB > 8.5/4 cm perete subtire, ecogen
colecistita acuta perete >5 mm dublu contur sludge / calculi colectii pericolecistice
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SLUDGE BILIAR
material echogen cu amplitudine acustica redusa
fara con acustic mobil gravitational (se
dispune lent in noua pozitie gravitationala la mobilizarea pacientului)
coexista cu litiaza biliara la pacientii cu staza biliara cronica
mase focale rotunde/neregulate (“bulgari”) (sludge ball sau lumping sludge)
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Criterii US : anomalii parietale: ingrosarea
neregulata, focala/difuza, a peretelui vezicular
masa solida ecogena, neomogena - ce ocupa in proportie variabila patul colecistic
- lumenul este, adeseori, absent- masa poate contine calculi in interior (“semnul sechestrarii calculilor”
masa polipoida intraluminala neregulata
tumora cu inalta malignitate (sv<5% la 5 ani)
asociere: LB (80-90%); vezicula de portelan (25%)
de 4x mai frecvent la femei, frecventa creste cu varsta
TUMORI BILIARE
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ANOMALII CAI BILIARE
Structuri tubulare dilatate (pattern stelat) in vecinatatea portei hepatis (doppler necesar pentru diferentiere)
“too many tubes” intrahepatic
Semnul “dublului” canal (teava de pusca dubla)
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COLANGITA SCLEROZANTA PRIMITIVA
sexul masculin (70%), varsta medie la diagnostic decada a 4a de viata
pANCA+ 70%
aspect caracteristic al colangiogramei
inflamatia si fibroza difuza a intregului arbore biliar
evolutie progresiva catre fibroza, ciroza si insuficienta hepatica
considerate in stadiile finale indicatii pentru transplant hepatic
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PANCREATITA CRONICA
anomalii ale calibrului DPP calcificarile
ductale/parenchimatoase pancreatice
prezenta de cavitati (chiste si microchiste)
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Pseudochistul de pancreas - colectie de suc pancreatic localizata in afara sistemului ductal normal, delimitata de un perete alcatuit din tesut fibros sau de granulatie.
Ia nastere ca o consecinta a pancreatitei acute, cronice si traumatismelor pancreatice.
PSEUDOCHISTUL DE PANCREAS
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reprezinta o colectie circumscrisa de puroi situata in proximitatea pancreasului, aparuta dupa un episod de pancreatita acuta sau traumatism pancreatic
masa hipoecogena/mixta cu pereti netezi sau, mai frecvent, neregulati si ecouri interne neomogene si, posibil, cu o grupare ecogena cu reverberaaii acustice/con acustic sugerând prezenta gazului
ABCESUL PANCREATIC
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TUMORI PANCREATICE
masa hipoecogena (in > 95% din cazuri)
modifica conturul glandei
ecotextura neomogena, atenuata
margini imprecise si neregulate (policiclice)
DPP este dilatat, terminandu-se brusc in proximitatea masei tumorale
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TUMORI PANCREATICE
Termenul de “cancer de pancreas” se refera la adenocarcinomul ductal ce reprezinta > 95% din tumorile maligne pancreatice
60-70% se localizeaza cefalic (datorita pozitiei “strategice” se manifesta clinic precoce), 20% se localizeaza corporeal si numai ~5% se localizeaza la nivelul cozii
Ultimele doua evolueaza silentios pana la dimensiuni mari (5-7 cm)