Severe Acute Pancreatitis - Determinant Factors and Current Therapeutic Conduct

Abstract

RezumatAşa cum a fost considerată de Dieulafoy şi cum a rămas, pe drept cuvânt "marea drama abdominală", pancreatita acută a constituit întotdeauna, rămânând ca atare şi în prezent, o adevărată provocare diagnostică şi terapeutică din cauza variabilităţii sale etiologice, clinice şi biologice, caracterului imprevizibil al evoluţiei şi dificultăţilor de stabilire a tratamentului adecvat fiecărui pacient. În acest context s-au confruntat de-a lungul timpului concepţii diferite, uneori diametral opuse, cu privire la interpretarea cazurilor şi la algoritmul terapeutic adoptat, dovadă stând numărul foarte mare de lucrări consacrate acestui subiect. Înţelegerea mai aprofundată a fiziopatologiei pancreatitei acute odată cu creşterea interesului în clasificarea severităţii pe baza factorilor determinanţi (locali şi generali) reprezintă factori decisivi în preconizarea severităţii şi adoptarea strategiei terapeutice moderne a acestei maladii complexe şi heterogene.Cuvinte cheie: pancreatita acută severă, factori determinanţi, disfuncţie multiplă de organe (MODS), necroză închistată (WONwalled of necrosis), necrozectomie, tehnici chirurgicale hibride Abstract Considered by Dieulafoy as the "great abdominal drama", acute pancreatitis has always been, and still remains, a real diagnostic and therapeutic challenge because of its etiological, clinical and biological variability, the unpredictable evolution and the difficulty of establishing appropriate treatment for each patient. In this context, various, sometimes diametrically opposed, conceptions about the interpretation of the cases and the adopted therapeutic algorithm have been encountered over time, as evidenced by the great number of papers dedicated to this subject. A more thorough understanding of acute pancreatitis pathophysiology, with increasing interest in severity classification based on determinant factors (local and general) are decisive factors in predicting severity and adopting the modern therapeutic strategy of this complex and heterogeneous disease.

Acute Chest Pain in an Acute Complicated Pancreatitis with Severe Hypophosphatemia

“…4 The pathophysiology of acute pancreatitis includes activation of trypsinogen into trypsin within the acinar cells upon increased ductal pressures and adenosine triphosphate depletion resulting in increased intra-acinar calcium concentration which activates zymogens. 5,6 This leads to the destruction of pancreatic parenchyma and the release of Damage Associated Molecular Patterns (DAMPs) that activate neutrophils and trigger the inflammatory cascade responsible for the systemic manifestation of acute pancreatitis. As a result, increased capillary permeability and damage of the endothelium results along with microvascular thrombosis that leads to multiorgan dysfunction syndrome (MODS).…”