重症急性胰腺炎胃肠动力障碍的检测与评估

重症急性胰腺炎(severe acute pancreatitis SAP)起病急、进展快、病情复杂,常迅速引起全身多脏器功能损害.SAP常合并胃肠功能紊乱,导致胃肠动力障碍,甚至引起胃肠功能衰竭[1].胃肠动力障碍时,胃肠蠕动减弱使肠道内细菌过度生长繁殖,引起菌群失调,加重胃肠道屏障功能损害,导致使肠道内细菌移位和肠源性感染[2],诱发和加重SIRS及MODS.同时SAP胃肠动力障碍是临床治疗的难点,然而,目前SAP胃肠动力障碍的检测和评估尚缺乏统一的标准,给临床治疗带来困惑.     

肠道细菌移位的研究进展

危重病人肠道内细菌移位可以引发肠源性感染和多器官功能障碍.该文作者简要介绍近年来关于肠道细菌移位发生情况的争议和共识,深入阐述细菌移位发生和转归的机制,旨在为全面认识胃肠道和保护好肠道功能提供新的思路.     

重症急性胰腺炎时细胞因子与肠源性细菌和内毒素移位的实验研究

目的 探讨重症急性胰腺炎(SAP)时血浆细胞因子与肠道屏障损害后肠源性细笛和内毒素移位的关系。方法 将SD大鼠(清洁级)72只随机分为假手术组(n=36)和SAP组(n=36)。采用胰管内逆行注射4％牛磺胆酸钠溶液的方法制作SAP模型。观察胰腺和回肠的病理改变，动态测定血浆TNF-a、IL-6、IL-10和DAO活性、LPS水平以及腹腔脏器细菌移位率。结果 制模后血浆TNF-a、IL-6水平明显升高，48h达到高峰，IL-106h后才明显升高；血浆DAO活性早期升高，24h后明显降低；LPS水平早期即有明显升高，48h达到高峰；SAP24h脏器细笛移位率明显升高，72h达到58．3％。结论 SAP早期即有细胞因子水平的升高和肠道屏障的损害，细胞因子通过损害肠遗屏障，引起肠源性细菌和内毒素移位；同时，肠源性细菌和内毒素移位又促进细胞因子的大量释放。加重肠黏膜屏障本身的损害，遣成恶性循环，引起SIPS和MODS的发生，两者关系密切。     

中药膳食对烫伤大鼠肠源性感染防治作用

目的了解中药膳食对严重烫伤大鼠肠源性感染防治效果,探索临床防治烧伤后肠源性感染的新方法。方法健康Wistar大鼠100只,随机分为药膳组、肉汤组、常规组(n=30)和对照组(n=10);药膳、肉汤、常规组于伤后第1、3、7 d各取10只,无菌条件下取材检测肠粘膜病理形态学、血浆内毒素含量、细菌移位率、盲肠膜菌群、肠黏液中分泌型免疫球蛋白A(sIgA)含量。结果与对照组比较,伤后药膳、肉汤、常规组细菌移位率、内毒素水平升高、酵母菌及大肠杆菌数量明显增多,肠道slgA水平由(59.31±8.66)μg/mL降至(38.12±4.49)μg/mL、双歧杆菌数量由(7.6±0.6)log CFU/g降至(6.3±0.5)log CFU/g(P<0.05);与肉汤、常规组比较,药膳组细菌移位率、内毒素水平降低、酵母菌及大肠杆菌明显减少,肠道slgA水平升高至(53.06±5.23)μg/mL,双歧杆菌数量明显增多(P<0.05)。结论严重烫伤破坏了肠道粘膜屏障功能,引起细菌、内毒素移位,应用中药膳食干预,能有效预防肠源性感染。     

血小板活化因子在烧伤后肠源性感染发病机制中的作用

血小板活化因子（ＰＡＦ）在机体许多病理生理过程中发挥重要作用，为探讨其对烧伤后肠源性感染的影响，本研究在３０％体表Ⅲ度烫伤大鼠模型上，观察ＰＡＦ水平变化与肠道内细菌移位的关系。结果显示：烫伤后肠系膜淋巴结、肝脏和肺脏组织细菌检出数和检出率均显著增高，与肠组织ＰＡＦ水平升高呈显著正相关；ＰＡＦ拮抗剂治疗能明显抑制肠道内细菌移位；健康大鼠静脉注射外源性ＰＡＦ后，肠道内荧光标记菌的移位率也显著增高，且与剂量呈显著依赖关系。实验结果提示ＰＡＦ是导致烧伤后肠源性感染发生的重要因素之一。     

重症病人营养治疗个体化的思考

自1968年Dudrick与 Wilmore 倡用静脉内营养(intravenous hyperalimentation)至今已历时40年.临床营养代谢、营养制剂和输注的理论研究与临床实践都有了很大的进展.它在治疗学中所起的作用已远远超过营养供给的范畴,对危重症与营养不良病人的治疗,起着补充、治疗以及药物性的作用.它不再是为病人提供能量和蛋白质等营养物质,以保持体质与氮平衡,而是朝着维护细胞、组织器官功能、促进病人康复的方向发展.20世纪 80年代后,对肠道功能有了再认识,重视了肠道屏障功能,发现肠道屏障功能障碍后,将出现细菌易位(bacterial translocation),由此而引起代谢紊乱,发生全身炎症反应综合征(SIRS)、多器官功能障碍综合征(MODS),甚至脓毒症(sepsis),是很多危重病人出现继发性MODS、脓毒症等肠源性感染的源头.而肠黏膜的修复、增长需有食糜与肠黏膜直接接触,对肠内营养的需要性有了进一步提高.概括起来,营养支持除供给营养外,还具有免疫调控、减轻氧化应激、维护胃肠功能与结构、降低炎症反应和改善病人生存率等的作用.     

肝硬化细菌移位引起肠道中性粒细胞明胶酶相关脂质运载蛋白表达增强研究

目的观察肝硬化模型中细菌移位与肠道中性粒细胞明胶酶相关脂质运载蛋白(NGAL)表达之间的关系,为临床治疗提供参考依据。方法选取60只SD雄性大鼠,其中5只SD雄性大鼠作为空白对照,55只SD雄性大鼠持续服用四氯化碳诱导形成肝硬化腹水模型,细菌培养及细菌DNA测序法,检测其肠系膜淋巴结细菌移位及移位后细菌的种类,PCR法检测细菌DNA移位情况,免疫组化法及Western blot法测定NGAL在肠道黏膜的表达。结果免疫组化检测提示肠道黏膜在细菌移位时有NGAL表达,且在MLN细菌移位组表达明显强于细菌DNA移位组及无移位组或对照组(P0.05);NGAL在细菌DNA移位组表达又较无细菌移位组或对照组强(P0.05)。结论细菌移位时肠道黏膜表达NGAL增强可能通过抑制肠道细菌铁吸收并促进肠道黏膜的修复进而抑制细菌移位;这可能是机体参与抑制细菌移位的机制之一。     

益生菌在肠内营养中的应用及研究进展

防治肠源性感染的关键在于防止肠内细菌和(或)内毒素的移位,纠正肠内菌群平衡的紊乱和失调,改善肠黏膜屏障功能以及提高肠道局部的免疫功能。而益生菌是具有维持肠内菌群平衡、防止肠黏膜屏障的破坏、增强局部免疫功能、促进和改善消化道蠕动以及吸收等作用的非致病性微生物,可治疗和预防肠源性感染。以下综述益生菌在肠内营养的作用及研究进展。     

合理营养预防颅脑损伤患者肠衰竭的效果

肠道的功能在危重患病的治疗中占有越来越重要的地位,肠道不仅消化吸收营养物质,还具有免疫功能,它还能维持肠道菌群稳定,防止肠道内细菌及内毒素移位,避免由此引发和加重全身炎症应答综合征(SIRS),继而引发多器官功能障碍综合征(MODS)甚至多系统器官衰竭(MOF)。作者综述了颅脑损伤致胃肠功能改变的发生机制和肠衰竭的发病机制及合理营养对肠衰竭的预防作用。     

谷氨酰胺对创伤后肠粘膜通透性的影响

在创伤的情况下,肠道通透性将发生改变,继而引起细菌移位和内毒素血症。谷氨酰胺可以通过降低肠粘膜通透性来减少细菌移位、减轻内毒素血症。     

The gut: the 'motor' of multiple organ dysfunction syndrome?

Abnormal colonization, gut-origin infections, and bacterial translocation are all signs of gut dysfunction that may be implicated in the pathogenesis of multiple organ dysfunction syndrome (MODS). This review summarizes and updates relevant experimental and clinical data that have attempted to correlate these phenomena with the development of MODS and to answer whether or not the gut is the 'motor' of MODS. The presented data suggest that, in some patients, gut dysfunction may precede the development of MODS. However, in most patients, this relationship is less obvious. The gut may still be one of the motors of MODS; however, it does not appear that this motor is fueled by the systemic spread of bacteria. Bacteria may play a role on a local gut-associated level in initiating and perpetuating the production of local inflammatory mediators that may produce distant organ injury.     

Postoperative enteral stimulation by gut feeding improves outcomes in severe acute pancreatitis

OBJECTIVE: We assessed the clinical effectiveness of postoperative enteral stimulation by gut feeding in patients with severe acute pancreatitis (SAP). METHODS: Medical records of 63 patients who were operated on within the past 4 y due to deterioration of SAP were included in this retrospective study. Patients were stratified in gut feeding (GF; n = 33) and standard therapy (ST; n = 30) groups according to the postoperative therapy provided. The GF group received postoperative standard therapy and enteral stimulation by gut feeding, and the ST group received standard therapy only. The Acute Physiology and Chronic Health Evaluation II score, incidence of the systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), daily calories supply, complication rate, and outcomes were analyzed. RESULTS: Patient characteristics did not differ between groups when considering age and severity of the disease. All patients underwent similar surgical interventions. SIRS and MODS were observed initially with the same frequency in both groups. Regression of MODS and a lower postoperative complication rate was observed more often in the GF group. Development of early pulmonary complications was observed in 12.1% to 13.3% in both groups, irrespective of the time of surgery. Subsequently, pulmonary complications developed in 15.2% of GF patients compared with 43.3% of ST patients (P <0.05). Acute renal insufficiency developed similarly in 33.3% of the GF patients and in 26.7% of the ST patients within 3 d after admission. Acute renal insufficiency developed later on only in the ST group (26.7%, P <0.05). Wound- and catheter-related septic complications were considerably more frequent in the ST group (30.0%) than in the GF group (9.1%, P <0.05). Intensive care and hospital stays did not differ. Postoperative gut feeding was associated with 6.1% mortality in the GF compared with 26.7% in the ST (P <0.05). CONCLUSIONS: Enteral stimulation by gut feeding is an effective supplement in the postoperative therapy of patients with SAP.     

Latest results of intensive care of sepsis, septic shock and multiple organ injuries]

Author is first discussing sepsis and its new categories (SIRS, MODS), its pathogenesis and symptoms. One axis of the events is the release of inflammatory and anti-inflammatory cytokines from the monocytes and macrophages, due to the precipitating injury. The other one is the activation of the polymorphonuclear leucocytes and the endothelial cells and their interaction. The basically non infectious SIRS is often maintained and worsened to MODS by the "translocation" of bacteria and endotoxins from the gut into the circulation. It is a new development the use of the serum procalcitonin level for the diagnosis, differential-diagnosis and for the evaluation of the success of the therapy. The causal therapy of the sepsis is still the surgical management of the septic focus, which should be supported by antibiotics and non-specific treatment (fluid-load, ventilation, inotropic, vasoactive and immunogenic drugs). It is new knowledge the effect of antibiotics on the immuno-system. For the treatment of SIRS, it has been tried many anti-cytokine and immunomodulating therapy; author explains the presumable causes of the failure of their majority.     

Usefulness of plasma procalcitonin (PCT) estimation to diagnose patients in departments of infectious diseases

PCT is a new highly sensitive and specific marker of bacterial and fungi infection--to be used in differential diagnosis at Infectious Diseases Departments. Author in this paper presents structure and mechanism of stimulation of PCT as a factor of "early infection's fase" for many infectious agents: bacteria, fungi, viruses and parasites. PCT may be found useful in diagnosing diseases; for ex.: sepsis, meningitis, inflammation of respiratory system, spontaneous bacterial peritonitis (SPB) and other local inflammatory foci (otitis media, endocarditis). PCT level is low in systemic inflammatory response syndrome (SIRS) and multiorgan dysfunction syndrome (MODS) of non-infectious origin (< 0.5 ng/ml), medium in case of localized infections (1.0-2.0 ng/ml) and in severe cases of disseminated infections (sepsis-->SIRS-->MODS) high (approximately 20 ng/ml).     

重型SARS合并MODS的临床救治初探

目的 探讨重型严重急性呼吸综合征(SARS)合并多器官功能障碍综合征(MODS)病例的发病特点、机制和治疗方法。方法 回顾性分析某院收治的54例重型SARS病例临床资料。结果 54例重型SARS患者均出现全身炎症反应综合征(SIRS)；29例(53．70％)并发MODS，死亡12例(41．38％)；器官损害以肺脏和心脏损害最常见，其次是脑、血液系统、肾、肝脏。结论 重型SARS患者出现MODS的主要原因是机体严重缺氧，故对其的救治应强调及时纠正缺氧状态；并需重视对多器官功能障碍的早期检查、诊断和治疗。     

重急性症胰腺炎合并多脏器损伤34例临床分析

目的探讨急性重症胰腺炎合并多脏器损伤的临床治疗。方法回顾分析34例急性重症胰腺炎合并多脏器损伤患者临床资料,结合文献,就诊疗过程加以总结。结果 34例患者有30例(88.24%)痊愈出院,4例死亡(11.76%)。手术治疗5例,死亡2例;非手术治疗25例,死亡2例;并发症及死亡以多脏器衰竭为主。结论治疗急性重症胰腺炎并发多脏器功能衰竭应采取个体化综合治疗,妥善选择手术时机,能够起到良好治疗效果,提高患者生存率。     

显微镜观察药物敏感度检测技术在结核病早期诊断中的应用

目的 利用显微镜观察药物敏感度检测技术(MODS)直接检测痰标本中结核分枝杆菌(MTU),评价其在结核病快速诊断中的应用价值.方法 收集264份肺结核临床疑似患者的痰标本和20份非结核病患者痰标本,分别采用抗酸染色法、罗氏培养基(L-J)培养法和MODS技术进行MTU检测,观察3种方法对痰标本中MTU的检出情况;对抗酸染色法和L-J培养法检测均为阴性的肺结核临床疑似患者进行为期90 d的临床随访,由专科医师在此基础上作出临床诊断,再以临床诊断为标准,对比分析3种方法的检测性能,评价MODS技术的临床应用价值.结果 3种方法检测20份非结核病患者痰标本结果均阴性;在264份肺结核临床疑似患者的痰标本中,抗酸染色法、L-J培养法和MODS技术的阳性检出率分别为28.8％、36.0％、42.8％,其中在102份抗酸染色和(或)L-J培养阳性的痰标本中,MODS检出97份(95.1％),在162份抗酸染色和L-J培养均为阴性的标本中,MODS阳性16份;若以临床诊断为标准,MODS、L-J培养法及抗酸染色法的敏感度和特异度分别为63.4％和97.8％、54.3％和100.0％、43.3％和100.0％,三者敏感性差异有统计学意义(P＜0.01);MODS的阳性检出中位时间为10d,明显短于L-J培养的25 d.结论 MODS技术与传统病原学检测方法相比,具有敏感性好、检出时间短的优势,适用于结核病的临床快速诊断.     

评价显微镜观察药物敏感性技术(MODS)快速检测肺泡灌洗液中结核分枝杆菌对菌阴肺结核的临床诊断价值

目的:探讨肺泡灌洗液中结核分枝杆菌对菌阴肺结核临床诊断过程中显微镜观察药物敏感性技术(MODS)的应用价值。方法:整理2017年3月~2019年3月本院100份肺泡灌洗液标本,对其分别实施MODS、罗氏培养法检测,回顾分析检测结果。结果:与罗氏培养法相比,MODS对结核分枝杆菌的阳性检出时间明显缩短(P<0.05);MODS对结核分枝杆菌的阳性检出率高于罗氏培养法对应的阳性检出率(P<0.05)。结论:肺泡灌洗液中结核分枝杆菌对菌阴肺结核临床诊断期间通过应用MODS技术,可缩短诊断时间,提高阳性检出,保证菌阴性肺结核的诊断准确率。     

ICU重症患者TNFα和CRP测定应用的探讨

目的通过定量测定ICU危重患者肿瘤坏死因子-α（TNF—α）和C-反应蛋白（CRP）的浓度,探讨两者的临床意义。方法将100例危重患者,根据APACHEⅡ评分系统分为A组（〈15分）25例,B组（15～25分）55例,C组（〉25分）20例,按病情分为MODS组38例,非MODS组62例。正常对照组为体检健康者50例。采集每组患者血标本,采用酶联免疫吸附法（ELISA）检测标本TNF—α、cTnI和CRP浓度。结果危重患者的TNF—α和CRP浓度均高于健康体检组（P〈0．01）;不同APACHEⅡ评分组之间TNF-α和CRP差异有统计学意义（P〈0．05或0．01）;MODS组患者的TNF-α和CRP值明显高于非MODS组（P〈0．01）。结论危重患者TNF-α、CRP和A—PACHEⅡ评分有较好的相关性,病情越重,两者的值越高。因此,可用于评价危重患者病情严重程度,对于预测预后有一定的临床意义。     

多器官功能障碍综合征患者血清心肌酶变化及临床意义

目的探讨多器官功能障碍综合征(MODS)患者血清心肌酶的变化及其临床意义。方法采用酶法测定MODS患者和30例健康人(对照组)的血清心肌酶。结果MODS患者血清心肌酶水平与对照组比较有显著性差异(p<0·01)。结论检测MODS患者血清酶水平,可作为反映病情程度和评估预后的相关参考指标。