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Ultrasonografia in managementul urgentelor digestive (II)

Urgente
Articol pentru sectiunea EMC gastroenterologie, luna aprilie 2007

Mirela Ciocirlan1, Mihai Ciocirlan1, Alexandru Lupu2, Mircea Diculescu1

  1. Centrul de Gastroenterologie si Hepatologie Fundeni, Bucuresti
  2. UMF Carol Davila Bucuresti


| recapituleaza prima parte a articolului | (chestionar de evaluare separat)

Durerea abdominala acuta reprezinta un motiv frecvent de adresare la camera de garda, iar imagistica a revolutionat abordarea diagnostica. Ecografia abdominala joaca un rol central in evaluarea urgentelor medicale si chirurgicale.

In abordarea diagnostica trebuiesc initial precizate: antecedentele pacientului, intensitatea durerii, tipul de debut: brutal sau progresiv, caracterul localizat sau difuz al durerii, asocierea febrei, existenta tranzitului, evaluarea hemodinamica, anomaliile biochimice.

Practicarea ecografiei in urgenta presupune dispunerea de un material minim necesar : sonda sectoriala de 3.5MHz pentru o evaluarea standard a organelor intraabdominale, sonda lineara de 5/7.5MHz pentru evaluarea tubului digestiv, eventual o sonda endovaginala, modul Doppler pentru evaluarea vascularizatiei parietale si splanhnice, eventual armonice. Nu este necesara o preparare speciala, si de multe ori, fiind un context de urgenta, explorarea nu se face neaparat a jeun. Examenul ecografic intampina multiple greutati in aceste conditii fiind vorba deseori de pacienti non cooperanti, a caror mobilizare se face cu dificultate, asociind frecvent ileus.

Se apreciaza ca asocierea ultrasonografiei la examenul clinic adauga aproximativ 20% la acuratetea diagnostica fata de examenul clinic singur (88% versus 69%) [1, 2], insa, in functie de diagnosticul final, se apreciaza ca acest beneficiu poate creste pana la 50% [3, 4].

Printre multiplele avantaje ale ultrasonografieie in diagnosticul urgentelor abdominale amintim timpul scurt, caracterul noniradiant si repetabilitatea acesteia, dar si o foarte buna sensibilitate si specificitate [5, 6].

Vom prezenta in continuare cele mai frecvente urgente abdominale si caracteristicile lor ecografice, grupate in medicale si chirurgicale

Urgente digestive « medicale »

Pancreatita acuta ?

Diagnosticul de pancreatita acuta este in primul rand clinic si biochimic (durere abdominala insotita de cresterea de > 3x valoarea normala a amilazei/lipazei serice). Ecografia abdominala are un rol limitat in pancreatita acuta, conditiile de vizualizare sunt extrem de precare iar un aspect ecografic normal nu exclude diagnosticul de pancreatita acuta.

Utilitatea practica o reprezinta identificarea litiazei veziculare pentru stabilirea etiologiei.

Uneori pot fi puse in evidenta marirea focala/difuza a glandei, de aspect hipoecogen prin edem. Pot fi puse in evidenta semen de gravitate: colectii peripancreatice, epansament lichidian liber in marea cavitate peritoneala.

Figura 7. Pancreatita acuta cu edem la nivel cefaic si corporeal si mici colectii lichidiene intraglandulare

Diagnosticul diferential se face cu afectiuni biliare, patologia cardiovasculara, ulcerul, etc.

Diverticulita acuta?

Ecografia ramane prima o metoda foarte buna de diagnostic in suspiciunea de diverticulita acuta, dar examenul imagistic de referinta este tomografia abdomini-pelvina.. Clinic pacientul prezinta durere localizata cel mai frecvent in cadranul inferior stang (colonul sigmoid). In aceste conditii, un ecografist experimentat poate diagnostica diverticulita acuta in aproximativ 90% din cazuri [34, 35]. In cazurile neclare sau atunci cand exista suspiciunea unei complicatii (abces, perforatie) este indicata realizarea unei tomografii abdominale.

Ecografic, se descrie clasic aspectul « pseudo-renal », respectiv o imagine paracolica saculara hipoecogena cu o zona hiperecogena centrala ; alti autori descriu zone rotunde/ovalare de ecogenitate variabila, iesind din conturul colonului, atat in plan transversal cat si longitudinal. Alte aspecte intalnite pot fi : ingrosari parietale colonice localizate (> 5mm), abcese/colectii pericolice (imagini lichidiene/hidroaerice paracolice, mai mult sau mai putin heterogene) [34, 35, 36, 37, 38, 39, 40].

Tesutul gras pericolic este normal in formele necomplicate, in cele care evolueaza spre abcedare grasimea pericolica este de aspect inflamator, hiperecogen.

Figura 8. Aspect ecografic si respectiv CT de diverticulita acuta necomplicata (colon sigmoid)

Figura 9. Diverticulita acuta – aspect « pseudo-renal »

Diverticulita acuta se preteaza la diagnosticul diferential cu : colite infectioase, boli inflamatorii colonice nespecifice – mai ales boala Crohn-, colite ischemice, iar la femei cu patologia anexiala. Cel mai important diagnostic diferential imagistic este insa cu cancerul colorectal. Pledeaza pentru cancer colorectal : ingrosare parietala majora, neregulata, caracterul obstructiv al leziunii, prezenta de adenopatii supracentrimetrice. In orice suspiciune de cancer colorectal trebuie efectuata intr-un prim timp o tomografie, care va detecta corect aproximativ 90% din diverticulite si circa 84.5% din cancere [41, 42].

Gastroenterita ?

Durerea abdominala insotita de diaree reprezinta prezentarea clinica cea mai frecventa. Ecografia cu sonda superficiala obiectiveaza prezenta de anse intestinale hiperperistaltice, destinse de lichid, cu pereti normali, asociind frecvent multiple adenomegalii mezenterice, fara alte anomalii, in particular fara a evidentia un obstacol in aval [1].

Figura 10. Anse intestinale destinse de lichid in contextul unei gastroenterite



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