دانلود کتاب تشخیص و درمان پزشکی در حال حاضر

Gallstones small enough to pass through the biliary tree may enter the pancreatic duct and potentially obstruct at the level of the ampulla of Yater. These stones will then cause obstruction of the pancreatic ductal system, resulting in pancreatitis. Gallstones are associated with approximately 45-50% of all cases of pancreatitis in the United States. Patients presenting with pancreatiti.s typically have varying degrees of abdominal pain, usually located in the epigastrium or RUQ. The pain may radiate to the back or shoulders. Nausea and vomiting are common. Laboratory studies will reveal elevation of lipase and (occasionally) amylase. If gallstones remain in the biliary tree, then liver transaminases and bilirubin may also be elevated. Although ultrasound is useful to confirm presence of gallstones, computed tomography (CT) scanning is useful in delineating the severity of pancreatitis. The treatment of gallstone pancreatitis is eventual cholecystectomy. As the gallbladder is the source of the stones, cholecystectomy will prevent subsequent episodes of pancreatiti. s. Cholecystectomy should not be attempted until the resolution of pancreatiti.s. Treatment for pancreatitis involves bowel rest with intravenous hydration. Severe cases of pancreatitis may require intensive care unit admission with cardiovascular and respiratory support. Regardless of the patient’s condition, cholecystectomy should be postponed until after the pancreatiti.s has resolved. It has been suggested that morbidity and mortality are improved if these patients undergo ERCP within 2 days of onset of symptoms. ERCP may be able to remove an impacted stone and thus allow for pancreatic decompression. This approach is generally considered in patients with moderate or severe pancreatitis. The presence or absence of a persistent bile duct stone should be determined prior to proceeding with cholecystectomy. In most circumstances, normalization of serum lipase, amylase, and liver function tests (if originally elevated) occurs rapidly. In these circumstances, no imaging of the biliary tree is required because of the low probability of a persistent bile duct stone. However, patients with persistent abnormalities of their liver functions, amylase, or lipase should be evaluated for the presence of common bile duct stones. Biliary imaging may be obtained by means of intraoperative cholangiography at the time of cholecystectomy, perioperative ERCP, or magnetic resonance cholangiopancreatography (MRCP). MRCP is the least invasive modality but is only diagnostic. ERCP allows for both visualization and extraction of stones of diameter :!> 1.5 cm. ERCP may be used to extract common bile duct stones either antecedent or subsequent to cholecystectomy. Common bile duct stones not amenable to endoscopic removal are removed operatively by performing a common bile duct exploration . The overall long-term outcome of patients is related to the severity of the pancreatitis. Localized morbidity includes pancreatic necrosis, splenic vein thrombosis with gastric varices, hemorrhagic pancreatitis, and pancreatic abscess formation. Systemic morbidity can result in multisystem organ failure or even death.