ABSCESOS HEPÁTICOS Amibiano y piógeno.

Presentación del tema: "ABSCESOS HEPÁTICOS Amibiano y piógeno."— Transcripción de la presentación:

1 ABSCESOS HEPÁTICOS Amibiano y piógeno

2 Absceso Hepático Amibiano
Ha disminuído la frecuencia 25% tienen antecedente de diarrea Más frecuente en hombres Más frecuente en LHD Absceso único más frecuente Serameba 1:256 Tratamiento: Metronidazol Drenaje en algunos casos

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4 MECANISMO DE TRANSMISIÓN DE E
MECANISMO DE TRANSMISIÓN DE E. HISTOLYTICA Y FACTORES DE RIESGO ASOCIADOS MECANISMOS ALIMENTOS CONTAMINADOS MANEJADORES DE ALIMENTOS RIESGO CONTAMINADO FERTILIZANTES FECALES INSECTOS (MOSCAS-CUCARACHA) CONTACTO DIRECTO: ANO-MANO-BOCA ANO-BOCA PRINCIPALES FACTORES DE RIESGOS ASOCIADOS HIGIENE INADECUADA DE ALIMENTOS. MAL CONTROL DE MANEJADORES DE ALIMENTOS TÉCNICAS INADECUADAS DE RIEGO Y FERTILIZACIÓN HÁBITOS HIGIÉNICOS POBRES INSUFICIENTE ABASTECIMIENTO DE AGUA HOMOSEXUALIDAD SISTEMA INADECUADO DE ABASTECIMIENTO DE AGUA AGUA CONTAMINADA: RÍOS, POZOS, DEPÓSITOS DE AGUA, RUPTURA DE REDES, ETC.

5 ABSCESO HEPÁTICO AMIBIANO
DATOS CLÍNICOS PRESENTADOS EN EL GRUPO TOTAL DE PACIENTES: # DE PACIENTES DOLOR ABDOMINAL FIEBRE DIARREA ARTRALGIAS MIALGIAS COLURIA CEFALEA DISTENSIÓN ABDOMINAL TOS CONSTIPACIÓN DERRAME PLEURAL ICTERICIA (OBJETIVO) 140 (100%) 34 (24.3%) 13 (9.3%) 8 (6.7%) 25 (17.9%) 13 (9.3%) 12 (8.6%) 2 (1.4%) 11 (7.9%) 19 (13.6%)

6 ABSCESO HEPÁTICO AMIBIANO Localización y Número de Abscesos
Un absceso Dos abscesos Tres ó más abscesos No especificado LOCALIZACIÓN Lóbulo derecho Lóbulo izquierdo Ambos lados # DE PACIENTES 108 19 9 4 110 12 14

7 AMIBIASIS INVASORA Serameba HAI # de pacientes AHA % Negativo 1 0.71
1:32 3 2.12 1:64 4 2.83 1:128 20 14.18 1:256 18 12.76

8 AMIBIASIS INVASORA Serameba HAI # de pacientes AHA % 1:512 21 14.89
Cont.... Serameba HAI # de pacientes AHA % 1:512 21 14.89 1:1024 20 14.18 1:2048 16 11.34 1:4096 15 10:63 > 1:8192 23 16.29 Total 141 MUÑOZ Y COLS. 1990

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12 Efectos Adversos Contraindicaciones
Metronidazol Dosis: 1 a 2 g diario durante 5 a 10 días Efectos Adversos Contraindicaciones Epigastralgia, náuseas, Embarazo durante vómito, leucopenia, ataxia lactancia, consumo de urticaria. alcohol.

13 Abscesos Hepáticos Piógenos
Más frecuentes múltiples Cuadro agudo abdominal como colecistitis, apendicitis, colangitis, postrasplante hepático con sufrimiento de la arteria. Son graves, en ambos lóbulos, deben drenarse Antibióticos: gram positivos , negativos y anaerobios

14 US hepático que demuestra una lesión hipoecóica, heterogénea, en un paciente con fiebre y dolor a la percusión hepática, datos compatibles con un absceso hepático. En (b) se observa la aguja dentro del absceso para obtener muestra y proceder al drenaje percutáneo.

15 ARBOL BILIAR

16 ANATOMIA POR IMAGEN EN LAS VÍAS BILIARES
ESTUDIOS RADIOLÓGICOS CONTRASTADOS

17 ANATOMIA POR IMAGEN EN LAS VÍAS BILIARES
COLANGIOGRAFIA POR RESONANCIA

18 COLANGITIS ESCLEROSANTE
FACTOR INFLAMATORIO COLANGITIS ESCLEROSANTE

19 COLANGITIS ESCLEROSANTE PRIMARIA
Enfermedad colestásica crónica caracterizada por inflamación difusa, obliteración y fibrosis de los conductos biliares intra y extrahepáticos, que eventualmente lleva a desarrollar cirrosis biliar. La etiología es desconocida pero la evidencia indica autoinmunidad

20 COLANGITIS ESCLEROSANTE PRIMARIA
75% padecen colitis ulcerosa crónica inespecífica Prevalencia de colangiocarcinoma 10 a 30% Riesgo de Ca de páncreas aumentado 14x Riesgo de Ca de colon aumentado 10x AutoAc: pANCA +, ANA +

21 Colangitis Esclerosante

22 Colangitis Esclerosante Primaria

23 Trasplante Hepático Sufrimiento de la arteria hepática

24 Hemangioma. Imagen por Resonancia
T1 T2

25 RMN hemangioma hepático en lóbulo hepático derecho, la cual se observa hiperintensa en T1.

26 Malignant Transformation Multistep
Normal liver Liver cirrhosis Hepatitis C Hepatitis B Ethanol NASH Epigenetic alterations Genetic alterations HCC[2] Dysplastic nodules[1] Potential Targets Oxidative stress and inflammation Viral oncogenes Carcinogens Growth factors Telomere shortening Cancer stem cells Loss of cell cycle checkpoints Antiapoptosis Angiogenesis HCC, hepatocellular carcinoma; NASH, nonalcoholic steatohepatitis. Jorge A. Marrero, MD, MS: This slide illustrates the multistep transformation that results in the development of HCC. The process starts with a normal liver that undergoes chronic liver injury, for example, infection with hepatitis C or hepatitis B, leading to fibrosis development and, eventually, cirrhosis. The next phase is dysplasia, which in turn evolves through genetic or epigenetic alterations into HCC. This sequence has been studied in detail and more is being discovered about the exact pathways that underlie malignant transformation as time goes by. 1. Tornillo L, et al. Lab Invest. 2002;82: Verslype C, et al. AASLD Abstract 24. 26 26

27 CHC Diagnóstico temprano
Alfa fetoproteína > 500 ng / mL Estudio de imagen Seguimiento en pacientes con cirrosis hepática cada 6 meses

28 Patients for Whom HCC Surveillance Is Recommended
Asian males HBV carriers older than 40 yrs of age Asian female HBV carriers older than 50 yrs of age HBV carrier with HCC family history African/N American blacks with HBV Cirrhotic HBV carriers Hepatitis C with cirrhosis Stage 4 primary biliary cirrhosis Genetic hemochromatosis and cirrhosis Alpha-1 antitrypsin deficiency and cirrhosis Other cirrhosis 80% of patients with HCC have underlying cirrhosis HBV, hepatitis B virus; HCC, hepatocellular carcinoma. Jorge A. Marrero, MD, MS: This slide shows patients for whom HCC surveillance is recommended. According to guidelines from the American Association for the Study of Liver Disease (AASLD), surveillance is recommended in Asian males or females with hepatitis B who are older than 40 or 50 years of age, respectively; carriers of hepatitis B with a family history of HCC; Africans or North African black persons with hepatitis B; cirrhotic patients with hepatitis B; and patients with hepatitis C cirrhosis or cirrhosis from other causes. Josep M. Llovet, MD: The great majority (approximately 80%) of patients with HCC has underlying cirrhosis whereas only a small proportion of patients with noncirrhotic livers develop HCC. Mostly, these are patients with chronic hepatitis B, but most patients who should be included in surveillance programs are cirrhotic patients. Bruix J, et al. AASLD HCC guidelines. July 2010. Simonetti RS, et al. Dig Dis Sci. 1991;36:

29 TAC gran CHC en fase arterial hipervascularización del tumor
CHC microscopico TAC gran CHC en fase arterial hipervascularización del tumor

30 Carcinoma hepatocelular pronóstico
Status Tumor Numero Tamaño Invasión microvascular Diseminación extrahepaitica Status paciente Comorbilidades Obesidad Diabetes Mellitus Edad Función hepatica Child Pugh MELD BT ALB TP

31 . TAC metástasis en ambos campos pulmonares

32 Signos y sintomatología inicial en 46 pacientes con carcinoma hepatocelular
Ascitis 55 % Dolor abdominal 68 % Ictericia 51% Pérdida de peso 60% Dolor en hipocondrio derecho 31% Distensión abdominal 42% Hematemesis o melena 17%

33 CHC Tratamiento TACE Quimioembolización transarterial. quimioterapia selectiva intra-arterial, doxorrubicina unida a lipiodol TARE. Ytrium 90 Radioembolización transarterial. Trasplante Hepatico Nexavar (Sorafenib) Unico tratamiento aprobado x FDA 400 mg C/12 hs

34 BCLC Staging and Treatment Strategy
HCC PS 0, Child-Pugh A Okuda 1-2, PS 0-2, Child-Pugh A-B Okuda 3, PS > 2, Child-Pugh C Very early stage (0) Early stage (A) Intermediate stage (B) Advanced stage (C) Terminal stage (D) Single < 2 cm Carcinoma in situ Single or 3 nodules Portal invasion, < 3 cm, PS 0 N1, M1, PS 1-2 Multinodular, PS 0 Single 3 nodules ≤ 3 cm Portal pressure/bilirubin BCLC, Barcelona Clinic Liver Cancer; HCC, hepatocellular carcinoma; PEI, percutaneous ethanol injection; PS, performance score; RCT, randomized controlled trial; RFA, radiofrequency ablation; TACE, transarterial chemoembolization. Josep M. Llovet, MD: With appropriate use of resection, transplantation, and local ablation, 5-year survival rates > 50% can be expected, rising to 70% with resection and liver transplantation. However, these treatments are currently considered in approximately 30% of patients in the West and even fewer patients worldwide. For example, in Asia, only 5% to 10% of patients receive potentially curative therapies. Jorge A. Marrero, MD, MS: How does one choose between radiofrequency ablation and resection, given that there are data from a randomized trial showing no difference in overall survival between the 2 strategies? If the tumor is < 2 cm in diameter, radiofrequency ablation can achieve a complete response rate of up to 98%, which is comparable with resection. In tumors of this size, the decision of whether to apply radiofrequency ablation rather than resection may depend on local availability of a hepatobiliary team with experience in resecting tumors or, conversely, access to an interventional radiologist able to perform local ablation with high accuracy. For tumors > 2 cm in diameter, in my experience, local ablation does not achieve a complete response rate of 100%, and as the tumor size increases, the response rate decreases, such that for a tumor of 4-5 cm in diameter, radiofrequency ablation achieves complete response in approximately 50% to 60% of cases. This does not compete well with resection. Therefore, resection remains a first-line treatment option for tumors > 2 cm in diameter. For very small tumors of < 2 cm, there is a question about which approach is optimal, and local expertise should factor in the decision. Increased Associated diseases Normal No Yes Resection Liver transplantation RFA/PEI TACE Sorafenib Symptomatic (20%); survival < 3 mos Curative treatments (30%); 5-yr survival: 40%-70% RCTs (50%); 3-yr survival: 10%-40% Llovet JM, et al. Design and endpoints of clinical trials in hepatocellular carcinoma. Journal of the National Cancer Institute. 2008;100(10): , by permission of Oxford University Press. 34

35 BCLC Staging and Treatment Strategy
HCC PS 0, Child-Pugh A Okuda 1-2, PS 0-2, Child-Pugh A-B Okuda 3, PS > 2, Child-Pugh C Very early stage (0) Early stage (A) Intermediate stage (B) Advanced stage (C) Terminal stage (D) Single < 2 cm Carcinoma in situ Single or 3 nodules Portal invasion, < 3 cm, PS 0 N1, M1, PS 1-2 Multinodular, PS 0 Single 3 nodules ≤ 3 cm Unresectable HCC Portal pressure/bilirubin BCLC, Barcelona Clinic Liver Cancer; HCC, hepatocellular carcinoma; PEI, percutaneous ethanol injection; PS, performance score; RCT, randomized controlled trial; RFA, radiofrequency ablation; TACE, transarterial chemoembolization. Josep M. Llovet, MD: For patients with intermediate-stage B disease who have multinodular tumors without symptoms, no portal invasion, extrahepatic spread, or lymph node involvement, the recommended treatment is transarterial chemoembolization. Surgery is not indicated in patients who have satellite lesions or portal hypertension. Other treatment options include internal radiation with yttrium 90, which is currently in phase III study. Early data are encouraging, but there is insufficient evidence on which to base a recommendation at this point. Increased Associated diseases Normal No Yes Resection Liver transplantation RFA/PEI TACE Sorafenib Symptomatic (20%); survival < 3 mos Curative treatments (30%); 5-yr survival: 40%-70% RCTs (50%); 3-yr survival: 10%-40% Llovet JM, et al. Design and endpoints of clinical trials in hepatocellular carcinoma. Journal of the National Cancer Institute. 2008;100(10): , by permission of Oxford University Press. 35

36 Phase III SHARP Trial: OS (ITT)
1.00 Sorafenib (n = 299) Median: 10.7 mos (95% CI: ) 0.75 Placebo (n = 303) Median: 7.9 mos (95% CI: ) Survival Probability 0.50 0.25 CI, confidence interval. Josep M. Llovet, MD: In the SHARP study, sorafenib significantly improved survival vs placebo, from a median of 7.9 months to 10.7 months in the sorafenib-treated group. For more information, go online to: HR (S/P): 0.69 (95% CI: ; P = ) 8 16 24 32 40 48 56 64 72 80 Wks Pts at Risk, n Sorafenib Placebo 299 303 274 276 241 224 205 179 161 126 108 78 67 47 38 25 12 7 2 Llovet JM, et al. N Engl J Med. 2008;359: Copyright © 2008 Massachusetts Medical Society. All rights reserved.

37 Liver Transplantation for HCC: Milan Criteria (Stage 1 and 2)
Single tumor, not > 5 cm Up to 3 tumors, none > 3 cm + Absence of macroscopic vascular invasion, absence of extrahepatic spread HCC, hepatocellular carcinoma. Josep M. Llovet, MD: For patients with liver dysfunction, such as portal hypertension or abnormal bilirubin or those with Child-Pugh class B disease, the first-line treatment option is liver transplantation. When used appropriately, transplantation has been associated with 5-year survival rates of 70% and a 5-year recurrence rates of < 15%. However, there is a shortage of donors in almost every country worldwide. Were this not the case, liver transplantation could be considered in patients with single tumors not > 5 cm or with up to 3 tumors < 3 cm that are not resectable. 5-yr survival with transplantation: ~ 70% 5-yr recurrent rates: < 15% Mazzaferro V, et al. N Engl J Med. 1996;334: Llovet JM. J Gastroenterol Hepatol. 2002;17(suppl 3):S428-S433.

38 Trasplante hepático CHC
Yao et al Liver Transpl 2002

39 TAC Helicoidal Reconstrucción vascular

40 Candidates for RFA/PEI
Includes individuals who are not candidates for surgery Radiofrequency ablation generally preferred over percutaneous ethanol injection Necrotic effect more predictable across tumor sizes Meta-analyses suggest survival benefit with radiofrequency ablation vs percutaneous ethanol injection PEI, percutaneous ethanol injection; RFA, radiofrequency ablation. Josep M. Llovet, MD: A third option is percutaneous local ablation. This procedure is suitable for patients who are not candidates for surgery or liver transplantation. Radiofrequency ablation is considered the first-line treatment option for these patients based on data from 4 randomized, controlled trials that found this approach to be significantly more effective than percutaneous ethanol injection regarding local control of disease. In addition, meta-analyses suggest there may be an overall survival benefit in favor of radiofrequency ablation. Bruix J, et al. AASLD HCC guidelines. July 2010.

41 Arterial Embolization for HCC Meta-analysis of 6 RCTs (2-Yr Survival)
Random Effects Model, OR (95% CI) Author, Journal Yr Patients, n Lin, Gastroenterology GETCH, NEJM Bruix, Hepatology Pelletier, J Hepatol Lo, Hepatology Llovet, Lancet Overall 503 0.01 0.1 0.5 1 2 10 100 GETCH, Groupe d'Etude de Traitement du Carcinome Hepatocellular; HCC, hepatocellular carcinoma; OR, odds ratio; RCT, randomized controlled trial. Josep M. Llovet, MD: Several randomized, controlled trials have been conducted in this patient population. The results of a meta-analysis published in 2003 found that chemoembolization was significantly more effective than best supportive care or suboptimal therapies, with a median survival of 20 months. Based on these data, both the European Association for the Study of the Liver and AASLD guidelines recommend chemoembolization as the first-line treatment option for this patient group. Z = -2.3 P = .017 Median survival: ~ 20 mos Favors Treatment Favors Control Llovet JM, et al. Hepatology. 2003;37:

42 Molecular Therapies Under Evaluation for HCC in Phase III (2011)
Targeted Population Phase III Comparison Adjuvant Prevent recurrences Sorafenib vs placebo Retinoids vs placebo Intermediate HCC Improve TACE TACE ± sorafenib TACE ± brivanib Advanced HCC First line: Second line: Sorafenib ± erlotinib Sorafenib vs brivanib Sorafenib vs sunitinib Sorafenib vs lifitinib Sorafenib ± Y90 Sorafenib ± doxorubicin Brivanib vs placebo Everolimus vs placebo Ramucirumab vs placebo NEGATIVE: ASCO 2010 HALTED: 2010 ASCO, American Society for Clinical Oncology; HCC, hepatocellular carcinoma; TACE, transarterial chemoembolization. Josep M. Llovet, MD: Trials emerging in this area are exciting. In 2011, at least 12 phase III trials of molecular therapies are ongoing. In first-line therapy, several studies are evaluating the combination of sorafenib with another agent, for example, erlotinib. This tyrosine kinase inhibitor blocks epidermal growth factor receptor 1. In HCC, epidermal growth factor signaling is activated and is a factor in the pathogenesis of the disease. Sorafenib does not target epidermal growth factor signaling, and so the combination of these 2 agents may provide dual activity. Another phase III trial is comparing sorafenib vs brivanib in the first-line setting. Brivanib is another novel tyrosine kinase inhibitor, which blocks several pathways, including vascular endothelial growth factor (VEGF) and FGF receptor. A trial comparing sorafenib with sunitinib was halted in 2010 for futility and toxicity, and sunitinib is no longer under investigation in the setting of advanced HCC. Sunitinib is a potent multikinase inhibitor that blocks several signaling cascades, some of which are also blocked by sorafenib. Gefitinib, another multikinase inhibitor is also under evaluation as first-line therapy, and there are additional trials involving other types of therapies. One is evaluating sorafenib with or without internal radiation with yttrium 90. Another study is investigating first-line use of sorafenib plus or minus doxorubicin. This combination showed some efficacy in a phase II study, although there is concern about potential cardiac toxicity. For patients with progression on sorafenib, there are 3 trials of second-line therapy under way. One compares brivanib with placebo, and another involves everolimus, an mammalian target of rapamycin inhibitor that has shown some efficacy in HCC. Finally, there is the phase III, placebo-controlled study of ramucirumab, a monoclonal antibody against VEGF receptor 2. These phase III trials provide a range of options to the patient. In addition, there are a number of phase II studies ongoing, involving c-Met inhibitors, for instance, monoclonal antibodies against glypican 3 or hedgehog protein 90.

43 Quiste simple

44 US hepático lesión menor a 2 cms
US hepático lesión menor a 2 cms., bien circunscrita, homogéneamente hiperecóica, hemangioma.

45 La lesión que originalmente era hipodensa (no se muestra) se llena de medio de contraste un hemangioma por TAC.

46 Tumoración, captación irregular del medio de contraste, lo que sugiere cierto grado de necrosis, y áreas mas hipodensas en su interior, que representan zonas con infiltración grasa en el tumor, hepatocarcinoma. lesiones satélites,

47 Metástasis

48 Hospital Universitario
Trasplante Hepático

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51 αFP levels Pre-treatment levels Post-treatment levels OLT
1st chemoembolization Feb. 14, 06 631 ng/mL Feb 6, 06 694 ng/mL March 10, 06 Radiofrequency ablation Feb. 17, 06 1297 ng/mL Apr. 3, 06 2nd chemoembolization Apr. 4, 06 1659 ng/mL May 29, 06 2239 ng/mL Aug 1, 06 23 ng/mL Sept. 14, 06 3rd chemoembolization Aug. 4, 06 18 ng/mL Oct 13, 06 2 ng/mL March 27, 06 OLT Oct. 28, 06

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