慢性胰腺炎时的胰酶替代治疗

慢性胰腺炎时常需胰酶治疗．其目的有二：纠正胰源性吸收不良和缓解疼痛。     

慢性胰腺炎的胰酶治疗

慢性胰腺炎时，采用胰酶制剂治疗的目的有二：改善胰腺外分泌功能不全和缓解胰源性疼痛。     

慢性胰腺炎的诊断和胰酶治疗

由于酗酒的原因,欧美国家慢性胰腺炎较多见,而在我国由胆系疾病引起的慢性胰腺炎也并不少见。由于缺乏敏感而简便的胰腺检查方法和有效的治疗方法,慢性胰腺炎的早期诊断和治疗仍然是临床上的难题。慢性胰腺炎的诊断慢性胰腺炎的病理改变包括水肿、炎症、坏死、纤维化、腺体丧失以及胰管狭窄、扩张、管腔内形成蛋白栓及钙化等。而其临床表现则包括因胰胆管梗阻而引起的疼痛和黄疽以及胰内、外分泌功能下降而引起的吸收不良、脂肪泻和糖尿病等。因此,慢性胰腺炎的诊断可根据以下３项指标：（１）有胰腺外分泌功能不全的证据;（２）影像学…     

胰酶替代治疗的临床实践

胰腺外分泌功能是指胰腺分泌胰酶和胰液.胰酶主要包括脂肪酶、蛋白酶(糜蛋白酶、胰蛋白酶)及淀粉酶.一般而言,慢性胰腺炎迁延近10 a才会出现脂肪酶分泌减少,而蛋白酶的变化则在15 a左右.当胰酶分泌量低于正常的10%时,临床上出现脂肪痢、粪中氮质增加、腹痛,淀粉吸收不良,其中以脂肪痢较突出[1].长期的吸收障碍将导致体重减轻、营养不良及 VitA,D,E,K缺乏.胰酶替代治疗的意义就在于其补偿缺乏的胰酶以改善症状、提高生活质量.然而,口服胰酶制剂受到胃酸、十二指肠酸度、胃排空和胰酶之间相互作用的影响,不同的剂型有其各自的优缺点.     

胰酶替代疗法在慢性胰腺炎中的应用

随着慢性胰腺炎的发病率逐年上升,越来越多的慢性胰腺炎患者出现胰腺内、外分泌功能不全,而胰腺外分泌 功能不全常表现为腹泻、脂肪泻、腹部不适、体重减轻、甚至营养不良等,严重影响了患者的生活质量。胰腺外分泌 功能不全主要保守治疗方式是胰酶替代疗法。近期研究证实,胰酶替代疗法可改善慢性胰腺炎患者的脂肪吸收率、 氮吸收率、粪便脂肪排泄、粪便氮排泄,以及腹痛和腹胀等症状,无明显不良事件发生。     

全胰切除术治疗慢性胰腺炎

1985年11月英国和爱尔兰胰腺协会在Bristol大学举行有关全胰切除术(TP)治疗慢性胰腺炎的专题研讨会。约有50名对此有经验的外科医师与会。本文即代表参加会议的6个主要医疗中心最近10年来的经验总结,英联邦在此期间的大部分病例已汇集其中。资料和方法:从1977年开始的10年中,Bristol Royal Infirmary(12例),Manchester Royal lnfirmary(8例),Dundee Ninewells Hospital(11例),Glasgow Royal Infirmary(16例),伦敦Hammersmith Hospital(4例);及伦敦Middlesex Hospital(32例)等6个单位的外科因慢性胰腺炎作TP83例。男57人,女26人,平均年令38岁(19～61岁)。近年来,此类病例有逐渐增加趋势。对所有病例均详询以下     

胰泌素治疗慢性复发性胰腺炎

作者进行随机双盲对照试验,用胰泌素治疗20例慢性复发性胰腺炎。方法治疗组10例,每日早晚给予胰泌素800CU皮下注射,连续7天;安慰剂组10例,只给赋形剂。治疗前后经内窥镜抽取胰腺分泌物,测定粘滞度、乳     

胰十二指肠切除治疗胰头部慢性局限性胰腺炎的护理

胰头部慢性局限性胰腺炎是慢性胰腺炎的一种特殊类型。多呈隐匿发病，因炎症持续存在，可形成胰头部节段性炎性肿大，致胆总管、胰管或十二指肠梗阻，治疗时选择术式困难。近几年，我们对48例病人中的26例进行了胰十二指肠切除术，收到满意的效果。在护理上我们对胰管引流、T型管引流及腹腔各种引流管进行了重点观察和护理，使26例手术病人，未发生任何并发症，全部治愈出院。     

非胰酶抑制剂治疗急性胰腺炎实验研究进展

非胰酶抑制剂治疗急性胰腺炎实验研究进展吕孝东刘根寿苏州医学院附属二院普外科２１５００４主题词胰腺炎／治疗血小板活化因子肿瘤坏死因子自由基Ｓｕｂｊｅｃｔｈｅａｄｉｎｇｓｐａｎｃｒｅａｔｉｔｉｓ／ｔｈｅｒａｐｙｆｒｅｅｒａｄｉｃａｌｓｔｕｍｏｒｎｅｃ...     

胰酶与急性胰腺炎的预后

胰酶与急性胰腺炎的预后张朋彬综述徐纬中审校（第三军医大学新桥医院消化内科重庆６７００３７）急性胰腺炎是临床上常见的急腹症之一，分为单纯水肿型和出血坏死型两型，后者常伴有严重并发症，引起多脏器损害，甚至衰竭，预后很差，死亡率高达４０～７０％［１］。因此...     

Quality of life assessment after pancreatic enzyme replacement therapy in chronic pancreatitis.

GOALS: To evaluate the quality of life (QoL) of patients with chronic pancreatitis before and after pancreatic enzyme replacement therapy in a prospective, multicentre, follow-up study. STUDY: Two groups of patients were evaluated. Group 1 consisted of 31 patients with newly diagnosed chronic pancreatitis who had never been treated with pancreatic enzyme preparations. Group 2 consisted of 39 patients whose disease was diagnosed on average 3.4 years before the start of the study. The latter group of patients had undergone pancreatic enzyme replacement therapy, but during follow-up this treatment proved to be insufficient. The dose of pancreatic enzyme replacement therapy was tailored in accordance with the degree of pancreatic exocrine insufficiency measured by means of exocrine pancreatic function tests. A modified European Organizaton for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) was used to assess QoL. RESULTS: The social functioning and financial strain were significantly better, while the levels of hope and confidence were significantly reduced in group 1 compared with group 2. A significant gain in body weight and a significantly reduced defecation rate were found in both groups one month after the beginning of the pancreatic enzyme replacement therapy when compared with the pretreatment values. The prevalence of general and disease-specific symptoms and the intensity of pain were reduced in both groups after one month of enzyme substitution therapy. The working ability, the financial strain and the overall QoL scores were improved significantly in both groups, while the cognitive functioning score was found to be significantly improved during the follow-up only in group 1. The overall increase in the QoL score correlated significantly with the increase in body weight and the decrease in defecation number in both groups. CONCLUSIONS: Pancreatic enzyme replacement therapy in patients with chronic pancreatitis not only reduced the extent of steatorrhea and pain, but also significantly improved a variety of other symptoms and the patient's QoL. Individually tailored enzyme replacement therapy improved the QoL not only in the untreated chronic pancreatitis patients, but also in the inadequately treated group. This study demonstrated that the EORTC QLQ-C30 questionnaire, with the addition of two further questions about steatorrhea, is a useful tool for the evaluation of QoL in patients with chronic pancreatitis.     

慢性胰腺炎的内镜治疗

慢性胰腺炎治疗目的为解除胰管梗阻、缓解疼痛、防止复发，并争取改善胰腺外分泌功能。过去传统的治疗方法主要有内科长期药物维持治疗及外科减压手术等，但疗效均欠佳。目前内镜治疗在一定程度上可替代手术治疗，成为治疗慢性胰腺炎的首选方案。     

慢性胰腺炎外科治疗

慢性胰腺炎(chronic pancreatitis,CP)的基本病理改变是胰腺组织纤维化,胰腺逐渐变硬变细或呈不规则的结节样硬化,可有大小不等的假性囊肿,胰管扩张和胰管钙化或结石形成.近年来随着医疗科技的迅速发展,对传统治疗手段的改进,使CP的治疗得到了很大的进展.     

Malnutrition after pancreatic enzyme replacement therapy in chronic pancreatitis: Risk factors in real world practice

BackgroundRCTs that have shown improvement in coefficient of fat absorption with pancreatic enzyme replacement therapy (PERT) have seldom evaluated the impact on overall nutritional status.ObjectiveIn this study we evaluated factors responsible for persistence of malnutrition after PERT.MethodsIn this cross-sectional observational study, patients were enrolled based on predefined enrolment criteria. Patients were divided into those taking PERT regularly (Group A), irregularly (Group B) and not taking (Group C) for at least 3 months. Comprehensive evaluation of anthropometric measurements, nutritional assessment and dietary intake was performed. Malnutrition was measured using the Subjective Global Assessment (SGA) tool. Relationship between PERT status, dietary intake and nutritional status were evaluated using standard statistical methods. Logistic regression was performed to identify factors associated with persistence of malnutrition after PERT.Results377 patients with CP and 50 controls were included. 95 (25.2%) patients with CP were in Group A, 106 (28.1%) in Group B and 176 (46.7%) in Group C. 130 (34.5%) patients were malnourished, of which 76 (58.5%) were continuing PERT. There were no differences in clinical and biochemical nutritional markers between Groups A, B, and C. Calorie deficit and daily intake of calorie, protein, carbohydrates and fats were not different between those with and without PERT, but was significantly less in those with malnutrition. Logistic regression demonstrated inadequate dietary intake as independent risk factor for persistence of malnutrition.ConclusionEven though PERT is effective in PEI, comprehensive nutritional assessment, personalized nutritional counselling and therapy along with PERT is mandatory.     

Endoscopic therapy of chronic pancreatitis

We present an overview of endoscopic therapies for chronic pancreatitis (CP) and its associated conditions. It is evident that endoscopy can be a definite therapy for pancreatic pseudocysts, pancreatic ascites and pancreatic duct (PD) disruption. Endoscopic therapy has also been useful in the short-term and medium therapy of common bile duct strictures due to CP, the best results being obtained if there are no calcifications in the head of the pancreas. Although most experts agree that obstruction to the outflow of pancreatic juice and the resulting increased pressure within the main PD is one of the major factors contributing to pain and that endoscopic therapy has been proven effective to remove stones as well as to dilate PD strictures and place stents across the PD, there is no convincing evidence from randomized trials that the patient's dominant symptom of CP, i.e. pain, is resolved in an appropriate and long-term fashion. We believe that there are other factors which are important in the etiology of chronic pain such as pancreatic inflammation and peripancreatic fibrosis with resulting nerve entrapment around the gland. The reader is reminded that endoscopic therapy is associated with significant and important complications, therefore appropriate patient selection and patient information are of paramount importance. Nevertheless, it is important to consider that one advantage of endoscopic management of CP is that it is less invasive as compared with surgery, often effective for years, does not hinder further surgery, and can be repeated. Finally we want to emphasize that there are many valid surgical, radiological and endoscopic techniques to treat the complications of CP. Therefore, the approach to CP and its complications should be by a multidisciplinary team of gastroenterologists, surgeons, radiologists, endoscopists and pain specialists.     

Conservative therapy of chronic pancreatitis

Conservative therapy is applied to various extent in all subjects with chronic pancreatitis. It includes removal of the provoking agent (most frequently alcohol abuse and biliary disease), dietary regimen, treatment of pain, maldigestion, and diabetes. Removal of the provoking agent prevents progression of the disease and relieves intensity of the main symptoms, particularly of pain. Diet in remission should include approximately 1g of protein/kg body mass. Fat intake should be encouraged within limits of individual tolerance. With low caloric intake carbohydrates should be enriched up to 65 - 70% of total energy intake. Abdominal pain may be due to a complication or to the underlying disease itself. For this reason one approach cannot be effective in all subjects. Conservative methods represent the first line of pain therapy. They include alcohol withdrawal, analgesics, narcotics and negative trypsin-induced feedback control of pancreatic secretion. Pancreatin medication is the cornerstone of maldigestion therapy. This is indicated with weight loss and/or symptoms associated with steatorrhea or with 15 - 20 g stool fat/day without additional symptoms. The effect may be evaluated by increase of body mass, decrease of loose stools and by markers of the nutritional status. Adequate replacement therapy with pancreatic enzymes influences also elaboration and secretion of some gastrointestinal hormones. The appearance of secondary diabetes makes abstinence from alcohol again mandatory. Food intake should be divided into 5 - 6 daily doses and adequate enzyme replacement should be applied. Peroral antidiabetics may be considered at the early stage, but many of these patients ultimately require insulin therapy. Its dosage should be adjusted to glucose urinary losses rather than to adhere to tight normoglycemia because of the increased risk of hypoglycemia. The therapeutic options in chronic pancreatitis may stabilize the disease and prevent its progression. The patients may be at the best asymptomatic, but not cured.