生态免疫肠内营养对急性胰腺炎肠道通透性及感染并发症的影响

目的观察生态免疫肠内营养对急性胰腺炎肠通透性及感染并发症的影响。方法76例急性胰腺炎患者在入院48h内随机分为2组,即肠外营养组(PN组)38例和生态免疫肠内营养组(EIN组)36例,EIN组经鼻空肠营养管注入100ml植物乳酸菌(活菌,1×10~8 cfu/ml)持续7d。观察入院时和第8天APACHEⅡ、Balthazar CT评分,统计SIRS,MODS发生率,测定鼻胃管抽吸物细菌含量;入院时、支持后第5天和第8天口服乳果糖和甘露醇(L/M),采用HPLC测定尿中L/M比值;第8天测定血内毒素水平和进行肠道细菌DNA基因指纹分析;营养支持第5天测定营养治疗2h内的促胆囊收缩素和胃泌素含量;第8天统计感染性并发症的发生率和死亡率。结果EIN组获得了良好的治疗效果,感染性并发症明显降低,肠道细菌多样性和通透性得到改善,APACHEⅡ计分和死亡率明显下降,EIN组出现暂时性的CCK分泌增高,但未增加疾病负担。结论EIN能减轻疾病严重程度,改善肠道通透性,降低感染性并发症发生率。     

Possible role of cholecystokinin in the development of acute pancreatitis in rats

The aim of this study was to elucidate whether cholecystokinin (CCK) had a role in the occurrence and/or in the development of experimental acute pancreatitis in rats, and furthermore to find the possibility for the treatment of acute pancreatitis with a CCK antagonist, proglumide. The administration of CCK-8 significantly increased serum levels of amylase, lipase and pancreatic wet weight. The administration of proglumide significantly reduced the blood levels of trypsin, pancreatic wet weight, water content and improved survival rate. These findings were supported by microscopic examination. The results of this study demonstrate that CCK has an important role in the development of acute pancreatitis and that proglumide might have prophylactic and therapeutic effects in acute pancreatitis.     

The important role of the gut in initiating the hyperdynamic response during early sepsis

BACKGROUND: Although the initial response to sepsis includes a hyperdynamic phase and although the increased hepatic perfusion in early sepsis is due solely to the increased portal blood flow, it remains unknown whether the gut plays an important role in producing such a response. MATERIALS AND METHODS: Adult male Sprague-Dawley rats underwent a complete enterectomy (ER) before being subjected to sepsis by cecal ligation and puncture (CLP; the cecum was excised from the removed gut and stitched to the posterior peritoneum in ER groups) or sham operation. At 2 h after CLP (i.e., the early, hyperdynamic phase of sepsis), cardiac output and heart performance (+/-dP/dt(max)), as well as hepatic and renal blood flow, were measured. Systemic and regional oxygen delivery (DO(2)) and oxygen consumption (VO(2)) were also determined. RESULTS: Cardiac output, heart performance, organ blood flow, as well as DO(2) and VO(2), increased significantly 2 h after CLP. ER prior to the onset of sepsis, however, prevented the elevation of those parameters. ER in sham animals did not alter the measured parameters with the exception that portal blood flow decreased by 85% and hepatic arterial blood flow increased by 368%, resulting in no significant reduction in hepatic DO(2) and VO(2). There were no changes in circulating blood volume among groups, indicating that the effect of ER on hemodynamics after CLP was not due to alterations in blood volume. CONCLUSION: Since ER immediately before the onset of sepsis prevents the increase in cardiac output and regional hemodynamics, the gut appears to play an important role in producing the hyperdynamic response during the early stage of polymicrobial sepsis.     

NF-κB在重症急性胰腺炎中作用研究进展

近年来，细胞因子在重症急性胰腺炎(SAP)发生、发展中的作用再次受到重视，其与SAP并发MODS有密切关系。然而，对细胞因子产生机制却知之甚少。笔者综述介绍NF-κB组成成分、激活与抑制机制、NF-κB与炎症介质产生关系，以及在SAP中NF-κB对炎症介质产生的调节作用，企以为临床治疗SAP寻找新的治疗方法。     

Whole gut washout ameliorates the progression of acute experimental pancreatitis

BACKGROUND: Septic complications are mainly responsible for deterioration of a patient with acute pancreatitis. Intestinal tract is accepted as the main source of pancreatic or peripancreatic infection. MATERIAL AND METHODS: Acute pancreatitis was induced in 40 Sprague-Dawley rats by ligation of the main biliopancreatic duct. Animals were divided into two groups. The first group of animals (n = 20) received high volume polyethylene glycol-3500 (GoLYTELY) for 6 hours through a silastic catheter introduced into the proximal part of the jejunum from a puncture gastrostomy during the initial laparotomy. The second group animals (n = 20) did not receive any treatment. Half of the animals from each group were sacrificed 72 hours later and tissue samples were taken from mesenteric lymph nodes, pancreas, spleen, and liver for bacteriologic cultures. Cecum cultures were also prepared. Blood samples at 72 hours were obtained for the measurement of amylase, lactic dehydrogenase (LDH), lactic acid, alanine aminotransferase (ALT), glucose, calcium, arterial pH, base excess, partial oxygen pressure, bicarbonate, leucocyte count, and hematocrit levels. The pancreas was examined histopathologically. The remaining half of the animals from each group were allowed to survive until death. RESULTS: The levels of amylase, LDH, ALT, lactic acid, pH, pO(2), bicarbonate and base excess for the rats in group I were significantly lower when compared with the rats in group II (P<0.05). Positive mesenteric lymph node cultures were detected in 30% of group I animals whereas they were positive in 90% of group II animals (P = 0.0198). Distant organ cultures were positive in 8 animals (liver 5, spleen 2, pancreas 1) in group II, whereas only one positive distant organ culture (liver) was established in group I (P>0.05). Histopathological scoring observed in the pancreas were less severe for the rats in group I when compared with the rats in group II (P = 0.012). The rats in group I survived longer than the rats in group II (median survival 6.8 days versus 17.3 days, P<0.001). CONCLUSIONS: Whole gut washout with high-volume polyethylene glycol in pancreatitis reduced the blood levels of enzymes and increased the survival. Whole gut washout for acute pancreatitis appears effective to ameliorate the prognostic factors in blood and this modality may be a promising treatment method in acute pancreatitis.     

The role of acute pancreatitis in pediatric burn patients

Few publications recognize acute pancreatitis as a complication after large burns, consequently the incidence and outcome acute pancreatitis after burn in children is not well defined. The aim of this study was to determine the incidence, morbidity, and mortality relating to acute pancreatitis in a pediatric burn population and to correlate clinical diagnosis with autopsy findings to determine the incidence of unrecognized pancreatitis. Records of 2699 patients with acute burns were reviewed. Acute pancreatitis was defined as abdominal pain and/or feeding intolerance in addition to a three-fold elevation of amylase and/or lipase. One-hundred twenty-seven burned children served as the control cohort. To assess the presence of autopsy confirmed AP in pediatric burn patients, we evaluated autopsy reports of 78 children who died from burns, looking for reported evidence of pancreatic inflammation, and fat/parenchymal necrosis. Our data show that acute pancreatitis in children has a low incidence after burn. The study included 2699 patients of which 13 were suffering acute pancreatitis (13/2699 = 0.05%). Mortality is significantly higher for the acute pancreatitis group vs. the control group, p < 0.05. Autopsy reports established 11 of 78 patients with evidence of pancreatitis, resulting in an incidence of 0.17% for pancreatitis at autopsy. Although it has low incidence, acute pancreatitis is associated with increased mortality in severely burned pediatric patients, which underlines the importance of increased vigilance in the evaluation and treatment of pancreatitis in burned children.     

细胞凋亡在实验性急性胰腺炎发病中的作用

目的　探讨细胞凋亡在急性胰腺炎发病机制中的作用 ,了解川芎嗪在AP中对细胞凋亡的影响。方法　实验动物随机分为 3组 :( 1)AP组 ;( 2 )对照组 ;( 3 )治疗组。通过病理评分和TUNEL法检测 3组胰腺组织的病理形态和胰腺细胞的凋亡指数。结果　胰腺炎早期以细胞凋亡为主 ,病变程度轻 ;晚期以细胞坏死为主 ,病变程度重 ;诱导细胞凋亡有利于减轻胰腺炎病情。结论　通过诱导细胞凋亡可以减轻胰腺炎的病变程度 ,但具有一定的时间性     

The role of computed tomography in the management of acute pancreatitis

Sixty-three patients with the clinical diagnosis of acute pancreatitis were submitted to contrast enhanced CT examination. As compared to Ranson's objective clinical parameters, CT grading according to Hill et al. as modified by Balthazar et al. was found to reflect accurately the severity of acute pancreatitis. Evaluation of serial CT examination did not reveal any significant progression in classification during the course of acute pancreatitis. The presence of hypodense areas in the pancreas as a single parameter seems to have a distinct prognostic value. In only one out of five pancreatic abscesses was the presence of gas bubbles observed on CT. It is concluded that contrast enhanced CT has a definite place in the management of acute pancreatitis.     

The role of surgery in the management of acute pancreatitis.

Surgical intervention in acute pancreatitis may have varied goals. Early laparotomy may be required for diagnostic purposes. There is, however, no convincing evidence that attempts to reduce the morbidity of severe pancreatitis by early operative pancreatic drainage, early formal pancreatic resection, or early biliary procedures have been effective. In fact, they may be harmful. Peritoneal lavage by catheter induced under local anesthesia may ameliorate early cardiovascular and respiratory complications in some patients. Preliminary experience suggests that early operative debridement of devitalized pancreatic tissue with postoperative lavage may be helpful in selected patients. Patients with infections of devitalized pancreatic or peripancreatic tissue require operative debridement and drainage or packing. Other complications such as colonic necrosis or pseudocysts also require operative treatment. Rarely do patients require operation to relieve protracted pancreatitis. Patients with gallstone-associated pancreatitis should usually undergo surgical correction of their cholelithiasis as soon as their pancreatitis has subsided.     

重症急性胰腺炎时肠屏障破坏的机制及防治

众多因素参与了重症急性胰腺炎时肠屏障破坏的发生、发展,随之而来的菌群移位及内毒素血症又加重了肠屏障破坏,导致严重不良预后。本文综合了肠屏障受损的可能原因,同时针对发病原因提出了相应防治对策。     

生长抑素减轻大鼠急性坏死性胰腺炎的肠屏障损害

目的　观察生长抑素对大鼠急性坏死性胰腺炎 (ANP)肠屏障损害和肠道内毒素移位的影响。方法　采用胰管逆行灌注法复制大鼠ANP模型 ,随机分为正常对照组 (n =6 )、假手术组(n =18)、ANP组 (n =2 0 )和生长抑素治疗组 (n =19)。观察胰腺病理、血淀粉酶、肿瘤坏死因子(TNFα)和白细胞介素 (IL) 1β、肠上皮细胞间紧密连接、肠通透性 (血浆D 乳酸 )、循环内毒素和病死率的变化。结果　生长抑素减轻了ANP早期胰腺病理改变〔8h组织学评分由 (4 2± 0 3)降至 (2 0±0 4) ,P <0 0 1〕 ;72h血淀粉酶由 (6 2 31± 44 6 1)U/L降至 (2 6 48± 1798)U/L ,P <0 0 5 ;72hTNFα由(4 7± 2 4)pg/ml降至 (2 3± 2 1)pg/ml,IL 1β由 (10 3± 40 )pg/ml降至 (5 0± 2 4)pg/ml,P均 <0 0 5 ;肠上皮细胞间紧密连接的破坏减轻 ;2 4h血浆D 乳酸由 (14 7± 4 9) μg/ml降至 (8 0± 4 2 ) μg/ml,P <0 0 1;2 4h血浆内毒素由 (0 6 11± 0 2 10 )EU/ml降至 (0 336± 0 110 )EU/ml,P <0 0 1;ANP大鼠 72h病死率由 5 9%降至 17% ,P <0 0 5。结论　生长抑素可减轻ANP大鼠的肠屏障损害 ,对肠道内毒素移位有抑制作用 ,可降低ANP大鼠的病死率。     

阶段性营养支持在治疗重症急性胰腺炎中的作用

目的　探讨阶段性营养支持在治疗重症急性胰腺炎 (SAP )中的作用。方法　将 4年间收治的 10 0例SAP患者随机分为两组 ,即全胃肠外营养组 (TPN组 ,5 0例 )及阶段性营养支持组 (SN组 ,5 0例 ) ,比较并分析两组的治疗结果。结果　SN组总并发症率、导管并发症、二重感染、肝功能损害、腹腔感染发生率及住院费用均明显低于TPN组 (P <0 .0 5 ) ;SN组恢复经口进食时间及住院时间显著短于TPN组 (P <0 .0 5 )。结论　阶段性营养支持可以改善SAP患者的营养状况 ,且具有并发症少、住院时间短、住院费用少等优点 ,是治疗SAP理想的营养支持方式。     

The role of acetaldehyde in the pathogenesis of acute alcoholic pancreatitis.

Acetaldehyde (AA), the first product of ethanol metabolism, has been suggested as an important mediator in alcoholic pancreatitis, but experimental evidence has not been convincing. Prior work using the isolated perfused canine pancreas preparation has suggested that toxic oxygen metabolites generated by xanthine oxidase (XO) may mediate the early injury in pancreatitis. Xanthine oxidase is capable of oxidizing AA, and during this oxidation free radicals are released. The hypothesis that acute alcoholic pancreatitis may be initiated by AA in the presence of active XO (converted from xanthine dehydrogenase [XD]) was tested in the authors' experimental preparation by converting XD to XO by a period of ischemia, and infusing AA. Control preparations remained normal throughout the 4-hour perfusion (weight gain, 7 +/- 4 g; amylase activity, 1162 +/- 202 U/dL). One hour of ischemia or infusion of AA at 25 mg/hr or at 50 mg/hr without ischemia did not induce changes in the preparation. Acetaldehyde at 250 mg/hr induced minimal edema and weight gain (16 +/- 4 g; p less than 0.05), but not significant hyperamylasemia. Changes also were not observed when 1-hour ischemia was followed by a bolus of ethanol (1.5 g) or sodium acetate (3.0 g), or by infusion of 25 mg/hr of AA. One hour of ischemia followed by infusion of AA at 50 mg/hr or at 250 mg/hr induced edema, hemorrhage, weight gain (22 +/- 7 g [p less than 0.05] and 26 +/- 17 g [p less than 0.05]) and hyperamylasemia (2249 +/- 1034 U/dL [p less than 0.05] and 2602 +/- 1412 U/dL [p less than 0.05]). Moreover infusion of AA at 250 mg/hr after 2 hours of ischemia potentiated the weight gain (62 +/- 20 g versus 30 +/- 14 g [p less than 0.05]), but not the hyperamylasemia (3404 +/- 589 U/dL versus 2862 +/- 1525 U/dL) as compared with 2 hours of ischemia alone. Pancreatitis induced by 1 hour of ischemia followed by AA at 50 mg/hr could be inhibited by pretreatment with the free radical scavengers superoxide dismutase and catalase and ameliorated with the XO inhibitor allopurinol. The authors conclude that AA, in the presence of active XO, can initiate acute pancreatitis in the isolated canine pancreas preparation and may be important in the initiation of acute alcoholic pancreatitis in man. Toxic oxygen metabolites appear to play an important intermediary role.