急性胰腺炎的外科治疗

急性胰腺炎是临床比较常见的急腹症之一,近年来发病率比较高,其主要临床症状为恶心、呕吐、急性上腹痛、发热以及血胰酶增高等,若是处理不及时,可能导致慢性胰腺炎、脏器功能衰竭、胰腺脓肿、感染等并发症。通常实施早期的治疗,能够有效改善预后,降低病死率。现阶段,我国在治疗急性胰腺炎方面获得较大进展,尤其是随着临床外科对急性胰腺炎的认识不断深入,诊断技术和治疗方法有了新突破。本文主要对急性胰腺炎外科治疗方面进行综述。     

急性胰腺炎患者胰腺及肝脏的CT影像学分析

采用CT观察急性胰腺炎患者胰腺及肝脏的影像学变化。结果显示急性胰腺炎时CT表现胰腺增大，密度减低或不均匀，周围有液性渗出．吉氏筋膜增厚，胰腺增强不均匀；同时均伴有肝脏密度明显减低的脂肪肝表现。认为急性胰腺炎时胰腺细胞和间质水肿、脂肪组织坏死及出血、血清淀粉酶和甘油三酯增高是脂肪肝形成的基础。对于症状不典型的急性胰腺炎患者，如果发现有脂肪肝表现则可以帮助诊断。     

急性胰腺炎血管并发症的诊断和治疗

重症急性胰腺炎是消化科凶险的急腹症之一,起病急、病情重,可有一系列并发症,其中随着对其认识的提高及诊断方法的进步,血管并发症发病率逐渐升高。血管并发症可分为静脉性和动脉性,需根据临床表现、实验室及影像学检查进行诊断及治疗,目前临床上诊治强调个体化。综述了急性胰腺炎血管并发症的种类,临床表现,实验室、影像学检查及诊断、治疗方面的最新进展,以期对临床工作及相关研究有所帮助。     

急性胰腺炎临床病程与影像学变化相关性研究进展

影像学检查是诊断急性胰腺炎较有价值的指标。急性胰腺炎的病程发展与炎症因子的相关性研究,与辅助检查的相关性研究,如与血、尿淀粉酶的相关性,都存在一定的规律,而急性胰腺炎的病理变化、影像表现与病程变化的相关性尚未有定论。此文综述了影像学检查对急性胰腺炎病程变化的相关研究进展。     

GP-2在急性胰腺炎诊断中的临床价值

目的对血清GP-2(glycoprotein2)浓度在急性胰腺炎中的诊断价值进行研究。方法通过临床症状、血清酶学、影像学和病理学诊断的48例急性胰腺炎患者分为重症急性胰腺炎(n=28)和轻症急性胰腺炎(n=20)两组,另选择20例非胰腺炎腹痛患者作为对照组,测定他们血清中的GP-2浓度,并和他们的血清酶学结果进行比较。结果GP-2诊断急性胰腺炎的特异性为100%,高于淀粉酶(83.3%)和脂肪酶(89.6%);淀粉酶和脂肪酶水平分别在入院后的第3及第4天降至正常值上限的3倍以下,而在观察的第6天,GP-2水平仍然维持在诊断标准的5倍以上;同时在轻症急性胰腺炎和重症急性胰腺炎患者,GP-2平均水平分别为4.71U和11.30U,后者明显高于前者(P<0.05)。结论GP-2对急性胰腺炎的早期诊断特异性高,持续时间长,同时对病情的判断有一定的帮助,因此有相当的I临床应用价值。     

GP-2在急性胰腺炎诊断中的临床价值

目的对血清GP-2(glycoprotein 2)浓度在急性胰腺炎中的诊断价值进行研究.方法通过临床症状、血清酶学、影像学和病理学诊断的48例急性胰腺炎患者分为重症急性胰腺炎(n ＝ 28)和轻症急性胰腺炎(n ＝ 20)两组,另选择20例非胰腺炎腹痛患者作为对照组,测定他们血清中的GP-2浓度,并和他们的血清酶学结果进行比较.结果 GP-2诊断急性胰腺炎的特异性为100%,高于淀粉酶(83.3%)和脂肪酶(89.6%);淀粉酶和脂肪酶水平分别在入院后的第3及第4天降至正常值上限的3倍以下,而在观察的第6天,GP-2水平仍然维持在诊断标准的5倍以上;同时在轻症急性胰腺炎和重症急性胰腺炎患者,GP-2平均水平分别为4.71U和11.30U,后者明显高于前者(P＜ 0.05).结论 GP-2对急性胰腺炎的早期诊断特异性高,持续时间长,同时对病情的判断有一定的帮助,因此有相当的临床应用价值.     

急性胰腺炎首发72h的处理

急性胰腺炎是消化系统常见疾病之一,起病急,如治疗不及时,可在短时间内重症化,重度急性胰腺炎死亡率仍较高。因此,急性胰腺炎早期,特别是首发72 h的处理显得尤为重要。本文阐述了急性胰腺炎的诊断标准、严重程度分级、预后影响因素以及病因治疗、液体复苏、营养支持、抗菌药物的使用、器官功能维护等早期处理措施,有助于规范临床医师对急性胰腺炎的早期处理。     

慢性胰腺炎研究进展

慢性胰腺炎以胰腺慢性纤维化、钙化、胰管慢性炎症和胰管结石为主要病理改变,其发病率在国内外有逐年升高的趋势.虽然内镜治疗技术的飞速发展、胰酶替代药物的广泛应用、影像学和实验室技术的发展使慢性胰腺炎的内科诊断和治疗措施有了较大的进展。但确切的病因和发病机制尚不清楚,其诊断和治疗也尚未达成共识.因此,迫切需要开展慢性胰腺炎的流行病学、病因学、诊断学和治疗学等相关基础与,临床研究,为慢性胰腺炎的诊治提供理论和实践依据,并尽快制定出科学、客观的慢性胰腺炎诊治规范,指导其诊断和治疗.     

重症急性胰腺炎的诊疗现状和思考

急性胰腺炎的诊治指南是临床医师救治急性胰腺炎尤其是重症急性胰腺炎(SAP)的重要依据,但是我国目前存在很多环节在认识和实施上不统一的现状,直接影响到SAP的救治效果和成功率。从SAP的诊断标准和治疗措施两方面,就其中临床关心的焦点问题作一阐述,希望能引起关于SAP临床诊治的思考和讨论。     

老年急性胰腺炎的临床特点

随着老龄化社会的到来,急性胰腺炎在老年人群体中的发病率有着逐渐上升的趋势,现阶段及未来都应得到重视。本文通过相关文献综述,阐述了老年急性胰腺炎患者的病因、病理生理特征、临床表现与并发症、诊断方法、治疗和预后,以期为该病的诊断和治疗提供参考。     

Autoimmune chronic pancreatitis

In recent years a peculiar type of chronic pancreatitis with underlying autoimmunity has been described. Lymphoplasmacytic infiltration and fibrosis on histology and elevated IgG levels or detected autoantibodies on laboratory data support the concept of autoimmune chronic pancreatitis (AIP). Pancreatic imaging reveals a rare association of diffuse enlargement of the pancreas and irregular narrowing of the main pancreatic duct, which is unique and specific to AIP. Although AIP is not a common disease, it is increasingly being recognized as knowledge of this entity builds up. Clinically it is very important to be aware of this disease because AIP can clinically disguise as pancreaticobiliary malignancies, ordinary chronic, or acute pancreatitis. Above all, AIP is a very attractive disease to clinicians in terms of its dramatic response to oral steroid therapy in contrast to ordinary chronic pancreatitis. This review discusses the clinical, laboratory, histologic, and imaging findings that are seen in patients with AIP, especially focusing on the diagnosis.     

自发性食管破裂的诊断和治疗

自发性食管破裂,又称Boerhaave综合征,是临床上一种严重的胸科急症,因临床少见且易与其他疾病,如急性心肌梗死、消化性溃疡穿孔、急性胰腺炎等混淆,临床诊断较困难,死亡率高。本病的治疗各家纷说不一,早期诊断对其预后有重要意义。随着新技术的不断发展,内镜治疗起重要作用。目前对本病的报道多以一个或多个病例为主,对该病系统的归纳和总结较少见。本文对自发性食管破裂的诊断和治疗作一综述,旨在提高其临床诊治水平。     

Magnetic resonance imaging for local complications of acute pancreatitis: A pictorial review

Acute pancreatitis is a common disease characterized by sudden upper abdominal pain and vomiting. Alcoholism and choledocholithiasis are the most common factors for this disease. The choice of treatment for acute pancreatitis might be affected by local complications, such as local hemorrhage in or around the pancreas, and peripancreatic infection or pseudoaneurysm. Diagnostic imaging modalities for acute pancreatitis have a significant role in confirming the diagnosis of the disease, helping detect the exte...     

JPN Guidelines for the management of acute pancreatitis: diagnostic criteria for acute pancreatitis

The currently used diagnostic criteria for acute pancreatitis in Japan are presentation with at least two of the following three manifestations: (1) acute abdominal pain and tenderness in the upper abdomen; (2) elevated levels of pancreatic enzyme in the blood, urine, or ascitic fluid; and (3) abnormal imaging findings in the pancreas associated with acute pancreatitis. When a diagnosis is made on this basis, other pancreatic diseases and acute abdomen can be ruled out. The purpose of this article is to review the conventional criteria and, in particular, the various methods of diagnosis based on pancreatic enzyme values, with the aim of improving the quality of diagnosis of acute pancreatitis and formulating common internationally agreed criteria. The review considers the following recommendations:

• — Better even than the total blood amylase level, the blood lipase level is the best pancreatic enzyme for the diagnosis of acute pancreatitis and its differentiation from other diseases.
• — A pivotal factor in the diagnosis of acute pancreatitis is identifying an increase in pancreatic enzymes in the blood.
• — Ultrasonography (US) is also one of the procedures that should be performed in all patients with suspected acute pancreatitis.
• — Magnetic resonance imaging (MRI) is one of the most important imaging procedures for diagnosing acute pancreatitis and its intraperitoneal complications.
• — Computed tomography (CT) is also one of the most important imaging procedures for diagnosing acute pancreatitis and its intraabdominal complications. CT should be performed when a diagnosis of acute pancreatitis cannot be established on the basis of the clinical findings, results of blood and urine tests, or US, or when the etiology of the pancreatitis is unknown.
• — When acute pancreatitis is suspected, chest and abdominal X‐ray examinations should be performed to determine whether any abnormal findings caused by acute pancreatitis are present.
• — Because the etiology of acute pancreatitis can have a crucial influence on both the treatment policy and severity assessment, it should be evaluated promptly and accurately. It is particularly important to differentiate between gallstone‐induced acute pancreatitis, which requires treatment of the biliary system, and alcohol‐induced acute pancreatitis, which requires a different form of treatment.

     

EPC/HPSG evidence-based guidelines for the management of pediatric pancreatitis

Background

Pediatric pancreatitis is an underdiagnosed disease with variable etiology. In the past 10–15 years the incidence of pediatric pancreatitis has increased, it is now 3.6–13.3 cases per 100,000 children. Up-to-date evidence based management guidelines are lacking for the pediatric pancreatitis. The European Pancreatic Club, in collaboration with the Hungarian Pancreatic Study Group organized a consensus guideline meeting on the diagnosis and management of pancreatitis in the pediatric population.

Diagnosis and treatment of acute pancreatitis

In patients with abdominal pain, an acute pancreatitis is likely when lipase is elevated more than 3-fold above normal. The diagnosis should be confirmed by an imaging technique (either sonography or CT). The determination of the severity is difficult as all methods (laboratory values, imaging systems, scores) exhibit a significant uncertainty. The regular clinical investigation of the patients is still needed. In contrast to a severe course, in mild or moderate disease the treatment of the patient in an intensive care unit is not obligatory. In biliary pancreatitis the extraction of biliary stones after papillotomy is indicated and in severe disease the procedure should be done without delay. Meanwhile enteral nutrition is standard treatment although the data are not completely convincing. Further measures are administration of pain killers, volume substitution and treatment of pulmonary and renal failure. Although data are not completely clear the prophylactic administration of antibiotics in necrotizing pancreatitis is routine. Puncture of the necrosis may be used to detect the responsible microorganisms. In patients with infected necrosis who deteriorate during conservative treatment, necrosectomy may be an option. There is a tendency to postpone the operation until the necrosis can be clearly separated from non-necrotic tissue. Although a specific pharmacological agent for the treatment of pancreatitis is still not available, the above procedure has led to a significant reduction of mortality in patients with severe acute pancreatitis.     

Fluid collections in and around the pancreas in acute pancreatitis

The advent of computed tomographic scan with its wide use in the evaluation of acute pancreatitis has opened up a new topic in pancreatology i.e. fluid collections. Fluid collections in and around the pancreas occur often in acute pancreatitis and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992. Two decades since the Atlanta Conference additional experience has brought to light the inadequacy and poor understanding of the terms used by different specialists involved in the care of patients with acute pancreatitis when interpreting imaging modalities and the need for a uniformly used classification system. The deficiencies of the Atlanta definitions and advances in medicine have led to a proposed revision of the Atlanta classification promulgated by the Acute Pancreatitis Classification Working Group. The newly used terms "acute peripancreatic fluid collections," "pancreatic pseudocyst," "postnecrotic pancreatic/peripancreatic fluid collections," and "walled-off pancreatic necrosis" are to be clearly understood in the interpretation of imaging studies. The current treatment methods for fluid collections are diverse and depend on accurate interpretations of radiologic tests. Management options include conservative treatment, percutaneous catheter drainage, open and laparoscopic surgery, and endoscopic drainage. The choice of treatment depends on a correct diagnosis of the type of fluid collection. In this study we have attempted to clarify the management and clinical features of different types of fluid collections as they have been initially defined under the 1992 Atlanta Classification and revised by the Working Group's proposed categorization.     

Modern diagnostics of chronic pancreatitis

Chronic pancreatitis is a well-defined disease on histopathological grounds, but for clinical purposes diagnosis is generally not based on histological specimens. Imaging procedures, non-invasive or with different degrees of invasiveness, and pancreatic function tests are therefore the diagnostic mainstay in patients with suggestive clinical history. The correct diagnosis of chronic pancreatitis is easy in late stages but difficult in an early stage of the disease. A particular challenge is the differentiation between acute or recurrent acute and early chronic pancreatitis. Earlier classifications (Cambridge and Marseille) did not consider the complex interrelationship between (especially alcoholic) acute and chronic pancreatitis. A possible solution is to separate the entities into probable and definite alcoholic chronic pancreatitis, with the assignment into the latter category achieved by follow-up investigations. Up to now the best diagnostic accuracy at an early stage is achieved by the detection of abnormalities of the ductal system in endoscopic retrograde pancreatography or by assessing exocrine function with the secretin-ceruletide test. The endoscopic ultrasound may substitute the endoscopic retrograde pancreatography as superior imaging modality that detects both parenchymal and ductal changes of chronic pancreatitis at an early stage. Magnetic resonance pancreatography is a further promising diagnostic tool without the risk of pancreatitis after endoscopic retrograde pancreatography, but imaging of the side branches, which is crucial for detection of early chronic pancreatitis, is not yet sufficient. Faecal elastase is a progress in non-invasive testing of exocrine pancreatic function, but its value for the diagnosis of chronic pancreatitis under conditions of clinical practice is limited. Several (13)C breath tests have been developed, but their availability and their diagnostic accuracy in chronic pancreatitis is still limited. Light to moderate exocrine pancreatic insufficiency is not detectable with adequate accuracy by tubeless function tests. A specific serum marker of pancreatic fibrosis which would reliably indicate the presence of chronic pancreatitis or its progression to is not available.     

New diagnostic criteria of acute pancreatitis

Practical guidelines for the diagnosis of acute pancreatitis are presented so that a rapid and adequate diagnosis can be made. When acute pancreatitis is suspected in patients with acute onset of abdominal pain and tenderness mainly in the upper abdomen, the diagnosis of acute pancreatitis is made on the basis of elevated levels of pancreatic enzymes in the blood and/or urine. Furthermore, other acute abdominal diseases are ruled out if local findings associated with pancreatitis are confirmed by diagnostic imaging. According to the diagnostic criteria established in Japan, patients who present with two of the following three manifestations are diagnosed as having acute pancreatitis: characteristic upper abdominal pain, elevated levels of pancreatic enzymes, and findings of ultrasonography (US), CT or MRI suggesting acute pancreatitis. Detection of elevated levels of blood pancreatic enzymes is crucial in the diagnosis of acute pancreatitis. Measurement of blood lipase is recommended, because it is reported to be superior to all other pancreatic enzymes in terms of sensitivity and specificity. For measurements of the blood amylase level widely used in Japan, it should be cautioned that, because of its low specificity, abnormal high values are also often obtained in diseases other than pancreatitis. The cut-off level of blood pancreatic enzymes for the diagnosis of acute pancreatitis is not able to be set because of lack of sufficient evidence and consensus to date. CT study is the most appropriate procedure to confirm image findings of acute pancreatitis. Elucidation of the etiology of acute pancreatitis should be continued after a diagnosis of acute pancreatitis. In the process of the etiologic elucidation of acute pancreatitis, judgment whether it is gallstone-induced or not is most urgent and crucial for deciding treatment policy including the assessment of whether endoscopic papillary treatment should be conducted or not. The diagnosis of gallstone-induced acute pancreatitis can be made by combining detection of elevated levels of bilirubin, transamylase (ALT, AST) and ALP detected by hematological examination and the visualization of gallstones by US.