急性胰腺炎

AcutePancreatitisTeachingObjectiveToknowtheetiologyandpathogenesisofacutepancreatitisTomastertheclinicalfeaturesandkeypointsofdiagnosisfordifferenttypesofacutepancreatitisTomasterthetherapyprinciplesofacutepancreatitisDefinitionAcutepancreatitisisainflammationofthepancreasinducedbytheactivationofthepancreaticenzymesderivedfromvariouscauses.EtiologyBiliaryductdiseases:gallstone,acuteandchroniccholecystitis,ascariasisaccompaniedwithinflammatorystrictureatthelevelofthepapilla.CommonchannelhypothesisAlcoholand/orsquaremealhyperlipidemiaPostoperation:post-ERCP,abdominaloperation.EtiologyMetabolicdiseases:hyperparathyroidism,hypercalcemia,etc.Drugs:glucocorticords,diuretics,azathioprine,estrogen,etc.Autoimmunediseases:SLE,RA,vasculitis,etc.Viralinfections:mumps,coxsackievirus,HIV,etcIdiopathicpancreatitis.Pathogenesistrypsinogen→trypsintrypsin→pancreaticenzymes,complementsystemandkininsystemPathophysiologicalchanges:leukocytechemotaxis,releaseofactiveagents,oxygenicstress,microcirculationdisorderandbacteriatransposal.Trypsinactivatesotherproenzymesandresultsinproteolysis,edemaandvasculardamageLipaseproducesextrapancreaticfatnecrosisPhospholipasedegradesthelecithinintothelysolecithinwhichinducespancreaticnecrosisandhemorrhageKallikreinandelastasecausevasculardestructionBradykininpeptidaseandvasoactivesubstanceinducevasodilatation,increasevascularpermeabilityandedemaCytokine,oxygenfreeradicals,plateletactivatingfactor,prostaglandins,bloodcirculationdisturbance,systemicinflammationresponsesyndrome(SIRS)PathologyMildform(interstitialoredematouspancreatitis)focalordiffusededemaslightleukocyteinfiltrationSevereform(necroticorhemorrhagicpancreatitis)markedacinardestructionwithhemorrhageextensiveleukocyteinfiltrationnecrosisofparapancreaticfatgrosslyaninflammatorytumor-likemasswithdiffusedhemorrhagicchangesecondaryinfectioninducestheformationofabscessorpseudocystsSymptomsabdominalpain:locatedinepigastriumandradiatestotheback.Thelateralkneel-chestpositionwiththeneckflexedmayrelievetheabdominalpain.Nausea,vomiting,abdominaldistention:90%patientsFever:low-gradefeverinmildpancreatitis;highfeversuggestscoexistinginfection.Hypotensionorshock:ofteninseverepancreatitisClinicalmanifestationsSignsMAP:signsaremild.Abdominaltendernessanddiminishedbowelsoundsarepresent.SAP:peritonealirritationsignbowelsoundsarediminishedorabsentascitesorshiftingdullnessGrey-TurnersignCullensignjaundicePancreaticpseudocystComplicationsLocalcomplicationsPseudocyst:occur2weeksaftertheonset.Acutefluidcollection:occurintheearlystage.Pancreaticabscess:after4weeksonthebasisofpseudocystPancreaticnecrosisinfection:usuallyafter2weeksSystemiccomplicationsARDSacuterenalfailureheartfailureandcardiacarrhythmiagastrointestinalbleedingSepticemiadisordersofhemostasis:thrombosis,DIC.disordersofCNS:pancreaticencephalopathyHyperglycemiadisordersofwater,electrolytesandacid-basebalanceLaboratoryStudiesbloodcount:leukocytescountismorethan10,000/mm3Hematocrit(Hct):ishigh(over50%)becauseoflossofplasmaintotheretroperitonealspaceAmylasenormalvaluesoftheserumamylase:40to180Somogyiunitsor8to64Winslowunitsover500Somogyiunitsarestronglysuggestedacutepancreatitis.thereisnosignificantcorrelationbetweentheseverityofthepancreatitisandthelevelsoftheserumamylasenormalvaluesofurinaryamylase:<256Winslowunitsover256WinslowunitsaresuggestedacutepancreatitisFalsepositiveamylaseelevationinserumorurinemayoccurinmanyconditionsotherthanpancreatitis,suchastheotheracuteabdominaldiseases,proximalrenaltubularmalfunction,includingthermalburns,diabeticacidosisandpostoperativestatesormacroamylasemia.Serumlipaseserumlipaselevelsincreaseparallelwithamylasewithin24~72hoursaftertheonsetandstillkeepinahighlevelsfor7-10dayseventheserumamylasereturnstonormal.BiochemicaltestHypocalcemiaHyperglycemiaHyperbilirubinemiaHypoxemiaImagingexaminationX-ray:AbdominalX-raysentinelloopcoloncut-offChestX-ray:mayrevealthecomplicationsoflungsuchaspleuraleffusion,pulmonaryedemaandinterstitialinflammation.UltrasonographyItisausefulmethodtofindanenlargedpancreas,apseudocyst,ascites,biliarystone,dilatedcommonbileductandotherpancreaticmassCT&MRI正常胰腺CT平扫肝右叶胰头肠管肾腹主动脉下腔静脉胰腺体、尾部胆囊肝右叶脾肠管下腔静脉膈脚腹主动脉NormalpancreasContrastCTshowingpancreaticnecrosisDiagnosis-criteriasymptoms:acute,severeconstantepigastricpain.Nauseaandvomiting.Physicalexamination:epigastrictendernesswithorwithoutreboundtenderness.Laboratorystudies:elevatedserumamylase(≥3timesofhighlimitofnormalvalue)Imagingexaminations:morphologicalchangesofpancreasornotExcludingtheotheracuteabdominaldiseases.ClinicalmanifestationsScoringsystems:APACHE-II,RansonCTgradingSerumbiomarkers:CRP,IL-6Diagnosis-evaluationofpatients’conditionDiagnosis-classificationMAP(mildacutepancreatitis):AcutepancreatitisNodysfunctionoforganorlocalcomplicationsRanson’sscore<3orAPACHE-II<8orCTgrading:A,B,CorCTSI<2Diagnosis-classificationSAP(severeacutepancreatitis):AcutepancreatitisLocalcomplicationsororganfailureorRanson’sscore>3orAPACHE-II>8orCTgrading:D,EorCTSI>3.DifferentialdiagnosisPerforatedpepticulcerAcutecalculouscholecystitisAcuteileusMesentericvascularembolismRuptureofthespleenAcuteappendicitisAnginapectorisAcutemyocardialinfarctionTherapy-MAPMonitoring:shouldbemonitoredforatleast3days.Supportivetreatment:volumerepletionwithcrystalloidsandcolloidstokeepbalance.Relieveseverepain:Dolantinispreferredovermorphine.inhibitexcrineofthepancreas:NooralalimentationandcontinuousnasogastricsuctionH2RAorPPISomatostatinanditslong-actinganalogue(Sandostatin)Antibioticsisrequiredespeciallyininfectionofbiliaryduct.Therapy-SAPMonitoringNutritionalsupport:parenteralnutrition→enteralnutritionmaintainbalanceofwater,electrolytesandacid-base.essentialdietPreventionofinfection:oralantibioticsintravenousinfusionofantibioticsenteralfeedinginhibitexcrineofpancreasandpancreaticenzymes:NooralalimentationandcontinuousnasogastricsuctionH2RAorPPISomatostatinanditslong-actinganalogue(Sandostatin)proteaseinhibitors:gabexate,aprotinin,etc.PreventionandtreatmentofenteralfailureoralantibioticsenteralmicroecologicalpreparationsglutamineenteralfeedingTreatmentofmultipleorgansfailureTraditionalChinesemedicine:生大黄、清胰汤Endoscopictherapy:ERCP+EST+ENBDSurgicaloperation:indicationsnecroticpancreatitiswithinfectionpancreaticabscessearlysevereacutepancreatitis(ESAP)abdominalcompartmentsyndrome(ACS)pancreaticpseudocyst:>6cmdiagnosisremainunclearandGIperforationissuggestedEmergingdrugs:CCKreceptorantagonist:loxiglumideProstaglandins:PGE1Plateletactivatingfactor(PAF)antagonistTNFmonoclonalantibody:InfliximabprognosisMAP:goodSAP:poor.10~30%mortalityRiskfactors:age,hypotension,hypoalbuminemia,hypoxemia,hypocalcemia,miscellaneouscomplications.QuestionsWhataretheclinicalmanifestationsofacutepancreatitis?Whatisthediagnostickeypointsofacutepancreatitis?Whatisthetherapyofacutepancreatitis?necroticpancreatitisGrey-TurnersignCullensignjaundicePseudocystofpancreasSentinelloopColoncut-offsign.Supineabdominalradiographobtainedinapatientwithacutepancreatitisshowsanabruptterminationofairintheleftsideofthetransversecolon(arrows).PseudocystofpancreasEdematouspancreasOnadmission:Age>55Leukocytecount>16,000/mm3Bloodglucose>11mmol/LLDH>350IU/LAST>250After48hours:Hctdecrease>10%BUNrise>5mmol/LSerumcalcium<2mmol/LPaO2<60mmHgBasedeficit>4mmol/LEstimatedfluidsequestration>6LRanson’sscoringsystemCTgradingGradeA:normalpancreasGradeB:enlargementofpancreasGradeC:GradeB+peripancreatitisGradeD:GradeC+oneareaoffluidcollectionGradeE:multipleregionoffluidcollection