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Rui Moreno
Editor of RPMI
(Fulltext-Introdução.pdf)
Revista Portuguesa de Medicina Intensiva 2000; 9:115
A brief review of
the embryology and anatomy of the pancreas
Nelson José Silva, Francisco Oliveira Martins,
Ana Cristina Alves
Serviço 6, Cirurgia Geral, Hospital
Santo António Capuchos, Lisboa
ABSTRACT
The authors describe the pancreas embryological origin,
showing the presence of the two portions, dorsal and
ventral, and their importance in both pancreatic tissues
and delivery ducts. In the second part, we describe
synthetically the anatomical general and partial
neighboring of pancreas and other structures, and the
organ blood supply, lymphatic drainage and nerve supply.
(Fulltext-embrio.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9:117-118
Epidemiology
Teresa Fevereiro1, Umbelina Caixas2,
Inês Vaz Pinto3
1 Hospital Santo António Capuchos, Serviço 3
Medicina, Lisboa
2 Hospital do Desterro, Serviço de Medicina, Lisboa
3 Hospital Condes Castro Guimarães, Serviço de
Medicina, Cascais
ABSTRACT
Severe acute pancreatitis represents a small percentage
of the ICU admissions. It frequently leads to Multiple
Organ Failure, consuming important human and technical
resources and presenting a high mortality rate.
Based on published data and in a revision of the patients
with acute pancreatitis admitted to two mixed
medical-surgical Portuguese ICU's during a time period of
seven years, we present a characterisation of the
epidemiology of this situation.
(Fulltext-epidemiologia.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9:119-121
Etiopathogeny
Rogério Godinho
Serviço de Gastroenterologia, Hospital de
S. Francisco Xavier, Lisboa
ABSTRACT
Although it has more than a century the Acute
Pancreatitis (AP) to be considered an autodigestive
process, its patho-physiology still remains obscure.
Nowadays it is considered a complex process of crossed
and additives stimulation that involve three phases:
aggression by multiple distinct etiologies;
intrapancreatic activation of trypsinogen and others
zymogens; progression and exportation of the inflammatory
process.
The different etiologies of AP act essentially by
pancreatic outflow obstruction (biliary AP), secratogogue
hyperstimulation (scorpion, organophosphates), ischemia
(cardiac transplant and vasculites), cellular toxicity
(toxic AP, virus), disturbance of the calcium homeostasis
(hipercalcemia) and reduction of the pancreatic defenses
(Hereditary Pancreatitis); the alcohol is the etiology of
AP more disputed and less clarified, being possible to
admit it a mixing, toxic and obstructive mechanism. The
central common phenomena to these different etiologies
seems to be the ectopic activation of zymogens within
pancreatic acini and their secretory block, in a process
depending on disturbances of intracellular free ionised
calcium, acinar cell cytoskeleton disruption and the
co-localisation of pancreatic enzymes. Once ectopic
trypsin activation has occurred that breakdown the
pancreatic defence mechanisms - Pancreatic Secretory
Trypsin Inhibitor, trypsin autodigestion, seric
antiproteases - the interstitial and systemic activation
of trypsin starts an inflammatory cascade, both
local and systemic, with neutrophil chemotaxis, ischemia,
oxidative stress, lipid peroxidation and pro-inflammatory
cytokines activation that leads into a Systemic
Inflammatory Response Syndrome, frequently complicated by
sepsis, which determines the further AP evolution, in
about 20% of cases ending in Multiple Organ Failure.
(Fulltext-etiopatogenia.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9:123-136
Clinics
Armindo Ramos
Unidade de Cuidados Intensivos
Polivalente, Hospital do Desterro, Lisboa
ABSTRACT
Acute pancreatitis is an inflammatory process of the
pancreas with multiple etiologies and a physiopathology
that is still unclear. It has a non specific clinical
presentation, varying from moderate to severe forms,
including the Multiple Organ Disfunction Syndrome (MODS).
The latter is associated with severe acute pancreatitis
and evolves with
high morbility, mortality and costs. A correct clinical
evaluation can identify the patients with higher severity
of ill-ness, influencing both the confirmation with
diagnostic test, and the therapeutic strategy, and
determine the admission to Intensive Care Units (ICU). In
severe acute
pancreatitis it is important to identify the signs and
symptoms that correlate with the severity of illness,
witch are not always evident. The early diagnosis and
assessement of severity are critical, since they can
influence the evolution and the prognosis.
We review the signs and symptoms that accompany this
ill-ness, as well as the multisystemic presentation.
(Fulltext-clinica.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9:137-139
Laboratory
Pedro Póvoa
Unidade de Cuidados Intensivos,
Hospital Garcia de Orta, Almada
ABSTRACT
A review of the literature on the role of laboratory
investigation on acute severe pancreatitis was performed.
Several laboratory studies are very useful in the
diagnosis and prognosis of acute pancreatitis, as well as
in the detection of complications. Although several
limitations serum amylase levels is always requested in
the diagnosis of acute pancreatitis, and in the
differential diagnosis of acute abdomen. C-reactive
protein is a good marker of clinical evolution, with
levels > 120 mg/L being indicative of bad prognosis
(diagnostic efficacy: 85 to 90%). The most feared
complication is pancreatic infection. Both procalcitonin
and C-reactive protein have been studied as markers of
this complication. However, it is necessary more research
to be sure of the role of each of these markers.
(Fulltext-laboratorio.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9:141-144
Diagnostic Radiology
Guida Matos Ferreira, Vasco
Magalhães, Ramalho
Serviço de Radiologia, Hospital Curry Cabral,
Lisboa
ABSTRACT
Objectives: To write a Review
Article about the interest of Diagnostic Radiology in
Acute Pancreatitis, to be published in a monothematic
issue, answering to an invitation coming from the Editor
of Revista Portuguesa de Medicina Intensiva. Information
Sources: Radiology Text Books and published scientific
papers.
Results: Synthesis of radiological semiology and the
prevaling opinion on indications, diagnostic and
interventional relevance of Radiology in Acute
Pancreatitis.
Conclusions: The introduction of tomographic methods
relegated
Conventional Radiology to a secondary role and restricted
the indications of Angiography, allowing higher
diagnostic and interventional capacity, focused on the
Radiologist as a Consultant in the approach of the
clinical problem.
(Fulltext-radiologia.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9: 145-149
Medical support therapy
Paulo Martins
Serviço de Medicina Intensiva, Hospitais
da Universidade de Coimbra
ABSTRACT
Pancreatitis is a disease with a wide spectrum, that
ranges from a mild spontaneously disorder to a severe
disease with high mortality.
The problem is that we have no effective treatment
directed against causative pathophysiological mechanism.
Many patients with severe acute pancreatitis develop
multiple organ failure (MOF) during the first days of
illness and, this accounts for the majority of early
deaths.
At this moment, we are still limited to organ supportive
therapy, hoping that the patient will ride through their
critical illness.
There is growing body of evidence that the early
anti-citokyne therapy with platelet antagonist factor
(PAF) antagonists will minimise the systemic
complications associated with MOF and may be useful as an
adjuvant to good supportive care.
(Fulltext-tmedica.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9: 151-154
Severe acute pancreatitis and
multiple organ failure
Rui Moreno
Hospital Santo António Capuchos,
Unidade de Cuidados Intensivos Polivalente, Lisboa
ABSTRACT
Severe acute pancreatitis is frequently accompanied by
the emergence of a widespread systemic inflammation,
traduced clinically by the appearance of the signs and
symptoms of the systemic inflammatory response syndrome.
This situation can be self-limited or progress to the
progressive dysfunction of several organs and systems,
the so-called multiple organ dysfunction/failure
syndrome. We present some methods for the evaluation and
quantification of this situation, and discuss the
principal determinant of its emergence and its impact on
morbidity and mortality.
(Fulltext-fmo.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9: 155-157
Severity
scores
Ricardo Matos
Hospital Santo António Capuchos,
Unidade de Cuidados Intensivos Polivalente, Lisboa
ABSTRACT
Severity stratification in acute pancreatitis has been a
long subject of debate and the early assessment of
severity is still considered to be a determinant issue in
the approach to this disease. The availability of
specific instruments for this pathologic condition did
not stopped the intensivists, in their efforts to get
better results with more precise prog-nostic models, such
as general severity scores and organ failure scores. We
don't see a satisfactory end for this controversy at the
moment.
In this article we describe all this severity scores,
their use, applicability and results in this group of
patients. We present the results of a study in which we
compared all this specific scores, general severity
scores and organ failure scores on the same cohort, in a
cohort of patients admitted with acute pancreatitis to a
mixed medical-surgical Intensive Care Unit (ICU). In this
cohort of patients, general severity scores and the
Sequential Organ Failure Assessment (SOFA) score
presented a better discriminative capability than
disease-specific scores, and the results support their
use in risk stratification in these patients.
(Fulltext-igravidade.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9: 159-162
Analgesia
Alexandre Carrilho
Hospital do Desterro, Unidade de
Cuidados Intensivos Polivalente, Lisboa
ABSTRACT
An inflammatory process of the pancreas characterizes the
acute pancreatitis.
In severe acute pancreatitis the inflammatory process
expands to peripancreatic and retroperitoneal tissues
with hemorrhage areas and necrosis that cause serious
local and systemic complications.
This process produces and acute and severe pain, which
has a somatic and visceral component, that can last for
days or weeks. Anxiety, sleep privation, and psychiatric
disturbances are adjuvant factors that can increase the
pain and must be corrected, applying the norms and
protocols of the ICU sedation that include analgesic
drugs.
Through a a continuous monitorization of the pain, of the
analgesic effects, and of the acquired secondary effects
and through a continuous intervention, directed and
adjusted to each patient needs, it is possible to obtain
success in the analgesia. In acute pancreatitis the most
used analgesics are the opioids by intravenous route.
Mepridine intravenous, in bolus, has been the most used
opioid, although in our days, its benefits in the
pancreatitis aren't confirmed so it is not recommended
its administration for more than 48 hours. In patients
with spontaneous ventilation, tramadol is a good choice
buts it's analgesic effect is often insufficient.
Morphine stands as a good option, if not the best,
because it allows a proper analgesia in the patient with
severe acute pancreatitis, and is very used in the
critically ill patient for long periods of time. In
patients with renal failure, alfentanil in continuous
infusion is more desirable, comparing to morphine,
because of the absence of cumulative effects.
Regional analgesia via epidural provides an enormous
analgesic effectiveness with less side effects. This
technique requires experience in epidural analgesia and
in it's contraindications. More controlled studies are
needed, with a larger number of patients, so we can draw
conclusions about the importance of epidural block in
patients with severe acute pancreatitis, beyond the
analgesic for besides the analgesic effectiveness.
(Fulltext-analgesia.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9: 163-166
Antibioterapy
José Manuel Pereira, José
Artur Paiva
Serviço de Cuidados Intensivos,
Hospital de S. João, Porto
ABSTRACT
Acute pancreatitis is a reversible inflammatory process
of the pancreas that may also involve peripancreatic
tissues and other organs. In spite of the progresses
obtained in diagnosis and treatment, mortality may reach
35% and the acute necrotizing form ( 15-20% of the cases)
has a mortality rate of 60%. Pancreatic and
peripancreatic necrosis is the fundamental condition for
the developmentof infection, usually occurring late in
the course of pancreatitis. Pancreatic infection causes a
higher length of stay, higher risk of complications and
higher mortality. Gram nega-tive enteric bacilli, namely
E. coli, are the most frequent pathogens. However Gram
positive cocci ( Staphylococcus aureus, Enterococcus spp,
Streptococcus faecalis ) may also be involved. Fungal
infection is rare, but an exagerated use of antibiotics
may increase their prevalence.
Therapeutic use of antibiotics is unquestionable and
their prophylatic use, although not mandatory, is
advocated by several authors. Considering spectrum of
activity, pharmacokinetics and prevalence of the several
pathogens, imipenem and fluoroquinolones seem to be the
most appropriate antibiotics for prophylaxis and therapy
of the pancreatic infection.
(Fulltext-antibioterapia.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9: 167-171
Nutritional support
Fátima Campante
Hospital Nossa Senhora do Rosário,
Barreiro
ABSTRACT
The authors review the etiology and fisiopathology of
acute pancreatitis, with special emphasis on the role of
pancreatic enzymes on the pathogenesis of the
inflammatory process. The importance of nutritional
support on these patients is discussed, specially with
respect to the type of nutrients, with or without lipids
and the route of administration.
We conclude for the need to establish an adequate
nutritional plan for each patient, according to the
clinical situation.
(Fulltext-nutricao.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9: 173-175
New medical therapies
Pedro Duarte
Serviço de Gastroenterologia,
Hospital Santo António Capuchos, Lisboa
ABSTRACT
The medical therapeutics of acute pancreatitis has been,
basically, a supportive therapeutics and the favorable
evolution of the mortality in the last years is, largely,
owed to the improvement of the surveillance conditions
and therapeutics gotten in intensive care units.
Different attempts have been made in the sense of
altering the course of the disease, especially in the
severe form, with the use of several substances in an
early phase of acute pancreatitis. The results were
disappointing. The concept that blocking the systemic
inflammatory response syndrome initiated by the
pancreatitis could avoid the emergence of systemic
complications, namely multiple organ failure, and so
interfere with the course of the disease in its more
severe form, took to clinical trials with lexipafant, an
antagonist of the platelet-activating factor and, for the
first time, to exciting results that suggested the real
possibility of a mortality decrease in severe acute
pancreatitis. Unfortunately the last phase III clinical
trial did not confirm the initial perspectives.
The possibility of an early intervention continues a
potential objective to achieve.
(Fulltext-nmedicas.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9: 177-179
Intervention radiology
Paulo Almeida, Paulo Donato, Fernando
Alves
Serviço de Imagiologia, Hospitais Universidade Coimbra
ABSTRACT
After reviewing the indications to CT-guided drainage of
pancreatic collections, the authors presents their
results with this modality of drainage, performed between
1995 and March 2000 in the Department of Radiology of the
Coimbra´s University Hospital.
CT-guided percutaneous drainage is a secure method for
the treatment of peri-pancreatic collections avoiding
surgery in same cases. When it isn't efficient by it self
it allows the surgeon to postpone the surgery giving the
patient better conditions and reducing the risks.
(Fulltext-radinterv.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9: 181-184
Endoscopic therapy
João Coimbra, Afonso Maldonado,
António Mateus Dias, Rogério Godinho, João Martins,
António Cruz Pinho
Serviço de Gastroenterologia,
Hospital Santo António Capuchos, Lisboa
ABSTRACT
Acute Pancreatitis (AP) was described at the end of XIX
century, nevertheless one hundred years later the
pathogenesis is not totally known and some controversy on
therapeutic is still carried on.
It's a clinical entity that causes great morbility. In
spite medical and technological advances, a great
mortality occur, and in the most serious cases it could
reach 20 %.
The etiological diagnostic and the severity evaluation
are important in the strategy of therapeutic.
Gallstone is the etiological factor most frequent (50% of
the cases). In patients with acute biliary pancreatitis
[ABP] the early elimination of gallstones, can change the
evolution of ABP.
In the last twenty years many studies search the best
method (ERCP/ES or Surgery) and the timing of elimination
the gallstones in the patients with ABP. Randomized
clinical trials have demonstrated the advantage for
ERCP/ES, this reduce the morbility, the mortality and
hospital stay, especially in the patients with severe
attacks and biliary obstruction.
The authors talk about the indications and the timing of
ERCP/ES in patients with ABP, and, show the
internationals results and ours experience.
(Fulltext-endoscopia.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9: 185-192
Surgical therapy
Francisco Oliveira Martins,
Nelson José Silva, Ana Cristina Alves
Serviço 6, Cirurgia Geral, Hospital Santo
António Capuchos, Lisboa
ABSTRACT
Acute pancreatitis presents variable involvement of
regional tissues and remote organ systems. The authors
notice that the initial prediction of the severity is
important and has implications for management. Severity
stratification should be made in all patients and a
variety of criteria (Ranson score, CRP, APACHE II, SAPS,
etc.) are available to stratify the patient, both for
initial assessment and for monitoring of the severe
cases. The surgical management is important in the
multidisciplinary approach and laparotomy may be
necessary.
Surgical management of acute pancreatitis is a complex
but worthwhile procedure. An aggressive operative
strategy is necessary sometimes with multiple
reoperations, because early and late complications are
devastating, associated with a high morbidity and
mortality. The patients with infected necrosis should be
debrided with associated continuous drainage and local
lavage. “Planned” reoperations for more
necrosectomy with open management of the abdomen or
relaparotomy “on demand” should be performed if
necessary. There are various surgical procedures
available. Finally, it is discussed the role of
video-assisted pancreatic necrosectomy.
(Fulltext-cirurgia.pdf)
Revista Portuguesa de Medicina Intensiva
2000; 9: 193-198
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