Gebelikte Akut Pankreatite Yaklaşım

Gürhan Şişman; M. Aytaç Yüksel; Hakan Şentürk

Approach To Acute Pancreatitis In Pregnancy

Yıl 2012, Sayı: 4, 218 - 222, 01.12.2012

Gürhan Şişman M. Aytaç Yüksel Hakan Şentürk

Öz

Acute pancreatitis AP is a dangerous disease in pregnancy but seen as rare. AP is associated with increased maternal and fetal mortality. Metabolic changes that occur in pregnancy can easily cause misdiagnosis of pancreatic pathophysiology. Differential diagnosis of the AP should be considered in pregnant women who have upper abdominal pain with or without nausea and vomitting. Main etiological factors are gallstones, hypertriglyceridemia HTG and alcohol. Non-biliary originated AP has better prognosis that the biliary AP. The main laboratory feature for diagnosis is the amylase level of the patient rises three times higher than upper limit of normal serum amylase level. To support the diagnosis, ultrasound US should be performed, and serum triglyceride TG , and ionized calcium levels should be measured. Cases with elevated TG levels serum amylase levels can be normal so in order to correct the diagnosis we should measure serum lipase and urinary amilase levels. Gadolinium magnetic resonance cholangiopancreatography MRCP cen be performed in cases of insufficient ultrasonographic findings. For avoiding the radiation exposure in pregnant women computed tomography CT and endoscopic retrograde cholangiopancreotography ERCP should not be used.Gastrointestinal decompression and hunger are basic principle of the treatment. In gallstone-induced AP laparoscopic cholecystectomy should be planned because when it is performed as soon as possibly the complication rates decreases. Second trimestre of the pregnancy is the most appropriate time for laparoscopic cholecystectomy because the uterus won’t restrict the surgical area and the fetal organogenesis is completed. Therapeutic ERCP can be performed in selected cases. In AP with HTG poor fat diet , omega -3 fatty acids and plasma exchange can be applied as treatment

Anahtar Kelimeler

pancreatitis, pregnancy

Kaynakça

1. Eddy JJ, Gideonsen MD, Song JY, GrobmanWA, O’Halloran P. Pancreatitis in pregnancy. Obstet Gynecol.2008;112:1075–81.
2. Ramin KD, Ramin SM, Richey SD, Cunningham FG. Acute pancreatitis in pregnancy. Am J Obstet Gynecol. 1995;173:187–91.
3. Wang GJ, Gao CF, Wei D, Wang C, Ding SQ. Acute pancreatitis: etiology and common pathogenesis. World J Gastroenterol 2009; 15:1427–1430.
4. Hernandez A, Petrov MS, Brooks DC, Banks PA, Ashley SW, Tavakkolizadeh A. Acute pancreatitis in pregnancy: a 10-year single center experience.J Gastrointest Surg 2007; 11:1623–1627.
5. Gabryelewicz A. Etiology and pathogenesis of acute pancreatitis: current view. Rocz Akad Med Bialymst 1995; 40:218–226.
6. Everson GT, McKinley C, Lawson M, Johnson M, Kern Jr F. Gallbladder function in the human female: effect of the ovulatory cycle, pregnancy, and contraceptive steroids. Gastroenterology 1982;82:711–19.
7. Braverman DZ, Johnson ML, Kern Jr F. Effects of pregnancy and contraceptive steroids on gallbladder function. N Engl J Med 1980;302:362–64.
8. Van Thiel DH, Gavaler JS. Pregnancy-associated sex steroids and their effects on the liver. Semin Liver Dis 1987;7:1–7.
9. Vonlaufen A, Wilson JS, Apte MV. Molecular mechanisms of pancreatitis: current opinion. J Gastroenterol Hepatol 2008;23:1339–348.
10. Sun L, Li W, Geng Y, Shen B, Li J. Acute pancreatitis in pregnancy. ACTA Obstetricia et Gynecologica 2011;90:671-76.
11. Gosnell FE, O’Neill BB, Harris HW. Necrotizing pancreatitis during pregnancy: a rare cause and review of the literature. J Gastrointest Surg. 2001;5:371–76.
12. Wilkinson EJ. Acute pancreatitis in pregnancy: a review of 98 cases and a report of 8 new cases. Obstet Gynecol Surv 1973; 28:281–303.
13. Nies BM, Dreiss RJ. Hyperlipidemic pancreatitis in pregnancy: a case report and review of the literature. Am J Perinatol 1990; 7:166–169.
14. Toskes PP. Hyperlipidemic pancreatitis. Gastroenterol Clin North Am 1990; 19:783–791.
15. Tsuang W, Navaneethan U, Ruiz L, Palascak JB, Gelrud A. Hypertriglyceridemic pancreatitis: presentation and management. Am J Gastroenterol 2009; 104:984–991.
16. Date RS, Kaushal M, Ramesh A. A review of the management of gallstone disease and its complications in pregnancy. Am J Surg 2008; 196: 599–608.
17. Schnatz PF, Curry SL. Primary hyperparathyroidism in pregnancy: evidence based management. Obstet Gynecol Surv 2002; 57:365–376.
18. Angelini DJ. Gallbladder and pancreatic disease during pregnancy. J Perinat Neonatal Nurs 2002;15:1–12.
19. Kennedy A. Assessment of acute abdominal pain in the pregnant patient. Semin Ultrasound CT MR 2000;21:64–77.
20. Kayatas SE, Eser M, Cam C, Cogendez E, Guzin K. Acute pancreatitis associated with hypertriglyceridemia: a life-threatening complication. Arch Gynecol Obstet 2010;281:427–29.
21. Geng Y, Li W, Sun L, Tong Z, Li N, Li J. Severe Acute Pancreatitis During Pregnancy: Eleven Years Experience from a Surgical Intensive Care Unit. Dig Dis Sci (2011) 56:3672–3677.
22. Augustin G, Majerovic M. Non-obstetrical acute abdomen during pregnancy. Eur J Obstet Gynecol 2007; 131:4–12.
23. Garcia-Bournissen F, Shrim A, Koren G. Safety of gadolinium during pregnancy. Can Fam Phys 2006;52:309–10.
24. Masselli G, Brunelli R, Casciani E, Polettini E, Bertini L, Laghi F et al. Acute abdominal and pelvic pain in pregnancy: MR imaging as a valuable adjunct to ultrasound? Abdom Imaging 2011;36(5):596-603.
25. Roumieu F, Ponchon T, Audra P, Gaucherand P. Acute pancreatitis in pregnancy: place of the different explorations (magnetic resonance cholangiopancreatography, endoscopic ultrasonography) and their therapeutic consequences. Eur J Obstet Gynecol Reprod Biol 2008;140:141–42.
26. Pitchumoni CS, Yegneswaran B. Acute pancreatitis in pregnancy. World J Gastroenterol 2009; 15:5641–5646.
27. Petrov MS, Whelan K. Comparison of complications attributable to enteral and parenteral nutrition in predicted severe acute pancreatitis: a systematic review and meta-analysis. Br J Nutr 2010;103:1287–95.
28. Al Samaraee A, McCallum IJ, Coyne PE, Seymour K. Nutritional strategies in severe acute pancreatitis: a systematic review of the evidence. Surgeon 2010;8:105–10.
29. Russo-Stieglitz KE, Levine AB, Wagner BA, Armenti VT. Pregnancy outcome in patients requiring parenteral nutrition. J Matern Fetal Med 1999;8:164–67.
30. Pezzilli R, Zerbi A, Di Carlo V, Bassi C, Delle Fave GF. Practical guidelines for acute pancreatitis. Pancreatology 2010; 10: 523-535.
31. Burtin P, Taddio A, Ariburnu O, Einarson TR, Koren G. Safety of metronidazole in pregnancy: a meta-analysis. Am J Obstet Gynecol 1995; 172: 525-529.
32. Caro-Paton T, Carvajal A, Martin de Diego I, Martin-Arias LH, Alvarez Requejo A, Rodriguez Pinilla E. Is metronidazole teratogenic? A meta-analysis. Br J Clin Pharmacol 1997; 44: 179-182.
33. Dinsmoor MJ. Imipenem-cilastatin. Obstet Gynecol Clin North Am 1992; 19: 475-482.
34. Banks PA, Freeman ML. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006; 101: 2379-2400.
35. Mayer AD, McMahon MJ, Benson EA, Axon AT. Operations upon the biliary tract in patients with acute pancreatitis: aims, indications and timing. Ann R Coll Surg Engl 1984; 66:179-183.
36. Paloyan D, Simonowitz D, Skinner DB. The timing of biliary tract operations in patients with pancreatitis associated with gallstones. Surg Gynecol Obstet 1975; 141: 737-739.
37. Swisher SG, Hunt KK, Schmit PJ, Hiyama DT, Bennion RS, Thompson JE. Management of pancreatitis complicating pregnancy. Am Surg 1994; 60: 759-762.
38. Jackson H, Granger S, Price R, Rollins M, Earle D, Richardson W et al. Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review. Surg Endosc 2008;22:1917–27.
39. Gouldman JW, Sticca RP, Rippon MB, McAlhany JC Jr. Laparoscopic cholecystectomy in pregnancy. Am Surg 1998;64: 93-97.
40. Chong VH, Jalihal A. Endoscopic management of biliary disorders during pregnancy. Hepatobiliary Pancreat Dis Int 2010;9:180–85.
41. Akcakaya A, Ozkan OV, Okan I, Kocaman O, Sahin M. Endoscopic retrograde cholangiopancreatography during pregnancy without radiation. World J Gastroenterol 2009;15:3649–52.
42. Baillie J, Cairns SR, Putman WS, Cotton PB. Endoscopic management of choledocholithiasis during pregnancy. Surg Gynecol Obstet 1990; 171: 1-4.
43. Cappell MS. Colon cancer during pregnancy. Gastroenterol Clin North Am 2003; 32: 341 383.
44. Baillie J. ERCP during pregnancy. Am J Gastroenterol 2003; 98: 237-238.
45. Tenner S, Dubner H, Steinberg W. Predicting gallstone pancreatitis with laboratory parameters: a meta-analysis. Am J Gastroenterol 1994; 89: 1863-1866.
46. May GR, Shaffer EH. Should elective endoscopic sphincterotomy replace cholecystectomy for the treatment of high-risk patients with gallstone pancreatitis? J Clin Gastroenterol 1991; 13: 125-128.
47. Farca A, Aguilar ME, Rodriguez G, de la Mora G, Arango L. Biliary stents as temporary treatment for choledocholithiasis in pregnant patients. Gastrointest Endosc 1997; 46: 99-101.
48. Takaishi K, Miyoshi J, Matsumura T, Honda R, Ohba T, Katabuchi H. Hypertriglyceridemic acute pancreatitis during pregnancy: prevention with diet therapy and omega-3 fatty acids in the following pregnancy. Nutrition 2009;25:1094–97.
49. Glueck CJ, Streicher P, Wang P, Sprecher D, Falko JM. Treatment of severe familial hypertriglyceridemia during pregnancy with verylow-fat diet and n-3 fatty acids. Nutrition 1996;12:202–5.
50. Nelson-Piercy C, Crook MA. Severe hypertriglyceridemia complicating pregnancy, management by dietary intervention and omega-3 fatty acid supplementation. Nutrition 2009;25:1098–99.
51. Hosokawa A, Bar-Oz B, Ito S. Use of lipid-lowering agents (statins) during pregnancy. Can Fam Physician 2003;49:747–49.
52. Choy CM, Tam WH, Leung TN. Gestational hyperlipidaemic pancreatitis. BJOG. 2002;109:847–848.
53. Sivakumaran P, Tabak SW, Gregory K, Pepkowitz SH, Klapper EB. Management of familial hypertriglyceridemia during pregnancy with plasma exchange. J Clin Apher 2009;24:42–46.
54. Turhan AN, Gonenc M, Kapan S, Islim F, Oner OZ, Tulubas E, Aygun E. Acute biliary pancreatitis related with pregnancy: a 5-year single center experience. Turkis Journal of Travma 2010;16(2):160-64.
55. Hua-ping L, Ya-juan H, Xuan C. Acute pancreatitis in pregnancy: a 6-year single center clinical experience. Chinese Med Journal 20011;124 (17):2771-2775.

Gebelikte Akut Pankreatite Yaklaşım

Yıl 2012, Sayı: 4, 218 - 222, 01.12.2012

Gürhan Şişman M. Aytaç Yüksel Hakan Şentürk

Öz

Gebelikte akut pankreatit AP nadir gözüken tehlikeli bir hastalıktır. Artmış maternal ve fetal mortalite insidansı ile birliktelik gösterir. Gebelikte ortaya çıkan metabolik değişikliklerle pankreatik patofizyolojinin etkileşmesi sonucu tanı kolaylıkla gözden kaçabilir. Bulantı ve kusma eşlik etsin ya da etmesin üst karın ağrısı ile başvuran gebelerde ayırıcı tanıda mutlaka düşünülmelidir. Etiyolojide öne çıkan faktörler; safra taşları, hipertrigliseridemi HTG ve alkoldür. Biliyer kaynaklı AP’de prognoz non-biliyer kaynaklı AP’ye göre daha iyidir. Tanıda en temel laboratuar bulgusu serum amilaz seviyesinin normalin üst sınırının 3 katından fazla yükselmesidir. Tanıyı desteklemek için ultrason US yapılmalı, serum trigliserid TG ve iyonize kalsiyum seviyesine bakılmalıdır. TG yüksekliği olan durumlarda serum amilaz seviyesi normal olabileceği için bu durumda serum lipazı ve idrar amilazına bakmak tanıda daha faydalı olacaktır. US’nin yetersiz kaldığı vakalarda gadoliniumlu manyetik rezonans kolanjiopankreatografi MRCP yapılabilir. Radyasyon maruziyeti dolayısıyla bilgisayarlı tomografi BT ve tanısal endoskopik retrograd kolanjio pankreotografi ERCP kullanılmamalıdır. Gastrointestinal dekompresyon ve açlık tedavinin temelini oluşturmaktadır. Safra taşı nedenli AP’de erken dönemde düşük komplikasyon oranı olduğu için laparoskopik kolesistektomi planlanmalıdır. Laporoskopik kolesistektomi için en uygun zaman, uterusun cerrahi alanı kısıtlamadığı ve fetusun organogenezisinin tamamlandığı 2. trimestır olmalıdır. Seçilmiş vakalarda teröpatik ERCP’de yapılabilir. HTG’li AP’de ise yağdan fakir diyet, omega-3 yağ asitleri ve plazma değişimi tedavileri uygulanabilir

Anahtar Kelimeler

pankreatit, gebelik

Kaynakça

1. Eddy JJ, Gideonsen MD, Song JY, GrobmanWA, O’Halloran P. Pancreatitis in pregnancy. Obstet Gynecol.2008;112:1075–81.
2. Ramin KD, Ramin SM, Richey SD, Cunningham FG. Acute pancreatitis in pregnancy. Am J Obstet Gynecol. 1995;173:187–91.
3. Wang GJ, Gao CF, Wei D, Wang C, Ding SQ. Acute pancreatitis: etiology and common pathogenesis. World J Gastroenterol 2009; 15:1427–1430.
4. Hernandez A, Petrov MS, Brooks DC, Banks PA, Ashley SW, Tavakkolizadeh A. Acute pancreatitis in pregnancy: a 10-year single center experience.J Gastrointest Surg 2007; 11:1623–1627.
5. Gabryelewicz A. Etiology and pathogenesis of acute pancreatitis: current view. Rocz Akad Med Bialymst 1995; 40:218–226.
6. Everson GT, McKinley C, Lawson M, Johnson M, Kern Jr F. Gallbladder function in the human female: effect of the ovulatory cycle, pregnancy, and contraceptive steroids. Gastroenterology 1982;82:711–19.
7. Braverman DZ, Johnson ML, Kern Jr F. Effects of pregnancy and contraceptive steroids on gallbladder function. N Engl J Med 1980;302:362–64.
8. Van Thiel DH, Gavaler JS. Pregnancy-associated sex steroids and their effects on the liver. Semin Liver Dis 1987;7:1–7.
9. Vonlaufen A, Wilson JS, Apte MV. Molecular mechanisms of pancreatitis: current opinion. J Gastroenterol Hepatol 2008;23:1339–348.
10. Sun L, Li W, Geng Y, Shen B, Li J. Acute pancreatitis in pregnancy. ACTA Obstetricia et Gynecologica 2011;90:671-76.
11. Gosnell FE, O’Neill BB, Harris HW. Necrotizing pancreatitis during pregnancy: a rare cause and review of the literature. J Gastrointest Surg. 2001;5:371–76.
12. Wilkinson EJ. Acute pancreatitis in pregnancy: a review of 98 cases and a report of 8 new cases. Obstet Gynecol Surv 1973; 28:281–303.
13. Nies BM, Dreiss RJ. Hyperlipidemic pancreatitis in pregnancy: a case report and review of the literature. Am J Perinatol 1990; 7:166–169.
14. Toskes PP. Hyperlipidemic pancreatitis. Gastroenterol Clin North Am 1990; 19:783–791.
15. Tsuang W, Navaneethan U, Ruiz L, Palascak JB, Gelrud A. Hypertriglyceridemic pancreatitis: presentation and management. Am J Gastroenterol 2009; 104:984–991.
16. Date RS, Kaushal M, Ramesh A. A review of the management of gallstone disease and its complications in pregnancy. Am J Surg 2008; 196: 599–608.
17. Schnatz PF, Curry SL. Primary hyperparathyroidism in pregnancy: evidence based management. Obstet Gynecol Surv 2002; 57:365–376.
18. Angelini DJ. Gallbladder and pancreatic disease during pregnancy. J Perinat Neonatal Nurs 2002;15:1–12.
19. Kennedy A. Assessment of acute abdominal pain in the pregnant patient. Semin Ultrasound CT MR 2000;21:64–77.
20. Kayatas SE, Eser M, Cam C, Cogendez E, Guzin K. Acute pancreatitis associated with hypertriglyceridemia: a life-threatening complication. Arch Gynecol Obstet 2010;281:427–29.
21. Geng Y, Li W, Sun L, Tong Z, Li N, Li J. Severe Acute Pancreatitis During Pregnancy: Eleven Years Experience from a Surgical Intensive Care Unit. Dig Dis Sci (2011) 56:3672–3677.
22. Augustin G, Majerovic M. Non-obstetrical acute abdomen during pregnancy. Eur J Obstet Gynecol 2007; 131:4–12.
23. Garcia-Bournissen F, Shrim A, Koren G. Safety of gadolinium during pregnancy. Can Fam Phys 2006;52:309–10.
24. Masselli G, Brunelli R, Casciani E, Polettini E, Bertini L, Laghi F et al. Acute abdominal and pelvic pain in pregnancy: MR imaging as a valuable adjunct to ultrasound? Abdom Imaging 2011;36(5):596-603.
25. Roumieu F, Ponchon T, Audra P, Gaucherand P. Acute pancreatitis in pregnancy: place of the different explorations (magnetic resonance cholangiopancreatography, endoscopic ultrasonography) and their therapeutic consequences. Eur J Obstet Gynecol Reprod Biol 2008;140:141–42.
26. Pitchumoni CS, Yegneswaran B. Acute pancreatitis in pregnancy. World J Gastroenterol 2009; 15:5641–5646.
27. Petrov MS, Whelan K. Comparison of complications attributable to enteral and parenteral nutrition in predicted severe acute pancreatitis: a systematic review and meta-analysis. Br J Nutr 2010;103:1287–95.
28. Al Samaraee A, McCallum IJ, Coyne PE, Seymour K. Nutritional strategies in severe acute pancreatitis: a systematic review of the evidence. Surgeon 2010;8:105–10.
29. Russo-Stieglitz KE, Levine AB, Wagner BA, Armenti VT. Pregnancy outcome in patients requiring parenteral nutrition. J Matern Fetal Med 1999;8:164–67.
30. Pezzilli R, Zerbi A, Di Carlo V, Bassi C, Delle Fave GF. Practical guidelines for acute pancreatitis. Pancreatology 2010; 10: 523-535.
31. Burtin P, Taddio A, Ariburnu O, Einarson TR, Koren G. Safety of metronidazole in pregnancy: a meta-analysis. Am J Obstet Gynecol 1995; 172: 525-529.
32. Caro-Paton T, Carvajal A, Martin de Diego I, Martin-Arias LH, Alvarez Requejo A, Rodriguez Pinilla E. Is metronidazole teratogenic? A meta-analysis. Br J Clin Pharmacol 1997; 44: 179-182.
33. Dinsmoor MJ. Imipenem-cilastatin. Obstet Gynecol Clin North Am 1992; 19: 475-482.
34. Banks PA, Freeman ML. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006; 101: 2379-2400.
35. Mayer AD, McMahon MJ, Benson EA, Axon AT. Operations upon the biliary tract in patients with acute pancreatitis: aims, indications and timing. Ann R Coll Surg Engl 1984; 66:179-183.
36. Paloyan D, Simonowitz D, Skinner DB. The timing of biliary tract operations in patients with pancreatitis associated with gallstones. Surg Gynecol Obstet 1975; 141: 737-739.
37. Swisher SG, Hunt KK, Schmit PJ, Hiyama DT, Bennion RS, Thompson JE. Management of pancreatitis complicating pregnancy. Am Surg 1994; 60: 759-762.
38. Jackson H, Granger S, Price R, Rollins M, Earle D, Richardson W et al. Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review. Surg Endosc 2008;22:1917–27.
39. Gouldman JW, Sticca RP, Rippon MB, McAlhany JC Jr. Laparoscopic cholecystectomy in pregnancy. Am Surg 1998;64: 93-97.
40. Chong VH, Jalihal A. Endoscopic management of biliary disorders during pregnancy. Hepatobiliary Pancreat Dis Int 2010;9:180–85.
41. Akcakaya A, Ozkan OV, Okan I, Kocaman O, Sahin M. Endoscopic retrograde cholangiopancreatography during pregnancy without radiation. World J Gastroenterol 2009;15:3649–52.
42. Baillie J, Cairns SR, Putman WS, Cotton PB. Endoscopic management of choledocholithiasis during pregnancy. Surg Gynecol Obstet 1990; 171: 1-4.
43. Cappell MS. Colon cancer during pregnancy. Gastroenterol Clin North Am 2003; 32: 341 383.
44. Baillie J. ERCP during pregnancy. Am J Gastroenterol 2003; 98: 237-238.
45. Tenner S, Dubner H, Steinberg W. Predicting gallstone pancreatitis with laboratory parameters: a meta-analysis. Am J Gastroenterol 1994; 89: 1863-1866.
46. May GR, Shaffer EH. Should elective endoscopic sphincterotomy replace cholecystectomy for the treatment of high-risk patients with gallstone pancreatitis? J Clin Gastroenterol 1991; 13: 125-128.
47. Farca A, Aguilar ME, Rodriguez G, de la Mora G, Arango L. Biliary stents as temporary treatment for choledocholithiasis in pregnant patients. Gastrointest Endosc 1997; 46: 99-101.
48. Takaishi K, Miyoshi J, Matsumura T, Honda R, Ohba T, Katabuchi H. Hypertriglyceridemic acute pancreatitis during pregnancy: prevention with diet therapy and omega-3 fatty acids in the following pregnancy. Nutrition 2009;25:1094–97.
49. Glueck CJ, Streicher P, Wang P, Sprecher D, Falko JM. Treatment of severe familial hypertriglyceridemia during pregnancy with verylow-fat diet and n-3 fatty acids. Nutrition 1996;12:202–5.
50. Nelson-Piercy C, Crook MA. Severe hypertriglyceridemia complicating pregnancy, management by dietary intervention and omega-3 fatty acid supplementation. Nutrition 2009;25:1098–99.
51. Hosokawa A, Bar-Oz B, Ito S. Use of lipid-lowering agents (statins) during pregnancy. Can Fam Physician 2003;49:747–49.
52. Choy CM, Tam WH, Leung TN. Gestational hyperlipidaemic pancreatitis. BJOG. 2002;109:847–848.
53. Sivakumaran P, Tabak SW, Gregory K, Pepkowitz SH, Klapper EB. Management of familial hypertriglyceridemia during pregnancy with plasma exchange. J Clin Apher 2009;24:42–46.
54. Turhan AN, Gonenc M, Kapan S, Islim F, Oner OZ, Tulubas E, Aygun E. Acute biliary pancreatitis related with pregnancy: a 5-year single center experience. Turkis Journal of Travma 2010;16(2):160-64.
55. Hua-ping L, Ya-juan H, Xuan C. Acute pancreatitis in pregnancy: a 6-year single center clinical experience. Chinese Med Journal 20011;124 (17):2771-2775.

Toplam 55 adet kaynakça vardır.

Ayrıntılar

Birincil Dil	Türkçe
Bölüm	Collection
Yazarlar	Gürhan Şişman M. Aytaç Yüksel Hakan Şentürk
Yayımlanma Tarihi	1 Aralık 2012
Yayımlandığı Sayı	Yıl 2012Sayı: 4

Kaynak Göster

EndNote	Şişman G, Yüksel MA, Şentürk H (01 Aralık 2012) Gebelikte Akut Pankreatite Yaklaşım. Acıbadem Üniversitesi Sağlık Bilimleri Dergisi 4 218–222.

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