重症急性胰腺炎早期合并感染、黄疸、休克、出血、腹腔高压

急性胰腺炎是消化系统常见疾病,其中重症急性胰腺炎(SAP)起病凶险,病死率高。本例患者在外院诊断为SAP,因病情加重转入南昌大学第一附属医院,早期即出现多器官功能障碍综合征、感染、黄疸、休克、腹腔出血、腹腔间隔室综合征等并发症,经3次多学科讨论和积极治疗后痊愈出院。     

腹腔透析灌洗治疗重症急性胰腺炎疗效观察

重症急性胰腺炎是一种发病机制复杂、治疗困难的危重急症,有很高的并发症发生率和死亡率,其死亡率约20%。重症急性胰腺炎早期手术治疗可加重内环境紊乱及胰腺组织的坏死,并增加手术并发症及感染机会,加重对患者的打击。近年来很多学者提出早期积极的非手术治疗能降低重症胰腺炎的死亡率。腹腔透析灌洗治疗作为一种积极有效的治疗方法,作者采用该法治疗26例重症胰腺炎,取得了较满意的治疗效果,介绍如下。     

重症急性胰腺炎42例临床诊治分析

目的 分析重症急性胰腺炎的高危因素、并发症，探讨其治疗方法及预后。方法 收集我院1999年2月～2005年3月42例重症胰腺炎患者资料，进行临床分析。结果 42例中治愈35例，死亡7例，行手术治疗13例，非手术治疗29例，其中非手术死亡6例，术后死亡1例，休克和MOF是死亡的主要原因。结论 重症急性胰腺炎宜行非手术治疗与手术治疗双轨疗法，早期宜行非手术治疗，并注意预防高脂血症、糖尿病、饮酒等高危因素，严格掌握手术适应证。     

腹腔透析灌洗治疗重症急性胰腺炎疗效观察

重症急性胰腺炎是一种发病机制复杂、治疗困难的危重急症,有很高的并发症发生率和死亡率,其死亡率约20%[1].重症急性胰腺炎早期手术治疗可加重内环境紊乱及胰腺组织的坏死,并增加手术并发症及感染机会,加重对患者的打击[2-4].近年来很多学者提出早期积极的非手术治疗能降低重症胰腺炎的死亡率.腹腔透析灌洗治疗作为一种积极有效的治疗方法[5],作者采用该法治疗26例重症胰腺炎,取得了较满意的治疗效果,介绍如下.     

重症急性胰腺炎的治疗方案选择与预后关系

目的：探讨重症急性胰腺炎的治疗方案选择与疗效的关系。方法：分析1996年1月至2000年12月共收治的重症急性胰腺炎271例，分析其病因、治疗方案选择与患者预后间的关系。结果：重症胆源性胰腺炎手术治疗64例，治愈率92．2％，死亡病例平均生存天数29．0d，主要死亡原因是MODS和坏死感染；非手术治疗56例，治愈率85．7％，死亡病例平均生存天数6．2d，主要死亡原因为休克、严重感染、肾功能衰竭、胰性脑病和MODS。重症非胆源性胰腺炎手术治疗76例，治愈率75．0％，死亡病例平均生存天数52．9d，死亡原因有MODS、感染、DIC、消化道瘘和腹腔内出血；重症非胆源性胰腺炎非手术治疗75例，治愈率89．3％，死亡病例平均生存6.4d(1-54d)，早期死亡的病例发病急，迅速出现休克、肾功能衰竭、ARDS和腹内高压，后期死亡的病例有包裹性感染坏死病灶破裂、全身感染 和MODS。结论：胆源性胰腺炎有胆道梗阻者应当行急诊手术或者行EST及ENBD，同时积极抗休克、防治肾功能衰竭，无胆道梗阻者先做积极的抗感染非手术治疗，后期作胆囊切除手术，是否探查胆总管根据病情决定。对来势急，经过积极的非手术治疗仍迅速出现休克、肾功能衰竭、ARDS、胰性脑病，或伴有腹膜炎或腹内高压者应及时手术引流。     

重症急性胰腺炎的治疗方案选择与预后关系

目的探讨重症急性胰腺炎的治疗方案选择与疗效的关系.方法分析1 996年1月至2000年12月共收治的重症急性胰腺炎271例,分析其病因、治疗方案选择与患者预后间的关系.结果重症胆源性胰腺炎手术治疗64例,治愈率92.2%,死亡病例平均生存天数29.0 d,主要死亡原因是MODS和坏死感染;非手术治疗56例,治愈率85.7%,死亡病例平均生存天数6.2 d,主要死亡原因为休克、严重感染、肾功能衰竭、胰性脑病和MODS.重症非胆源性胰腺炎手术治疗76例,治愈率75.0%,死亡病例平均生存天数52.9 d,死亡原因有MODS、感染、DIC、消化道瘘和腹腔内出血;重症非胆源性胰腺炎非手术治疗75例,治愈率89.3%,死亡病例平均生存6.4 d(1～54 d),早期死亡的病例发病急,迅速出现休克、肾功能衰竭、ARDS和腹内高压,后期死亡的病例有包裹性感染坏死病灶破裂、全身感染和MODS.结论胆源性胰腺炎有胆道梗阻者应当行急诊手术或者行EST及ENBD,同时积极抗休克、防治肾功能衰竭,无胆道梗阻者先做积极的抗感染非手术治疗,后期作胆囊切除手术,是否探查胆总管根据病情决定.对来势急,经过积极的非手术治疗仍迅速出现休克、肾功能衰竭、ARDS、胰性脑病,或伴有腹膜炎或腹内高压者应及时手术引流.     

重症急性胰腺炎患者中心静脉置管相关感染的危险因素及预防

目的探讨重症急性胰腺炎患者中心静脉置管(CVC)相关性感染的现状和危险因素,为降低重症急性胰腺炎患者导管感染率提供依据及预防措施。方法选取2017年1月至2018年12月入住我院诊断为重症急性胰腺炎患者126例为研究对象,回顾性分析患者临床资料,记录患者CVC感染率和病原菌类别,并对发生感染患者进行因素分析。结果发生CVC相关感染患者共计23例,细菌检出15株,革兰阳性菌9株,革兰阴性菌6株,真菌检出11株。分析结果显示,合并有基础疾病、并发腹腔感染、长期静脉营养日、置管部位及导管留置时间是重症急性胰腺炎患者发生导管相关性感染的主要危险因素(P0.05)。结论合并有基础疾病、并发腹腔感染、长期静脉营养日、置管部位及导管留置时间为导致重症急性胰腺炎患者导管相关性感染高风险因素,需采取相应的措施以降低导管感染发生率。     

经腹腔镜治疗老年重症急性出血坏死性胰腺炎

经腹腔镜治疗老年重症急性出血坏死性胰腺炎郑兴学魏洪斌老年重症急性出血坏死性胰腺炎是一种高危急腹症，１９９３年１０月至１９９６年１１月我院采用腹腔镜下置管腹腔灌洗治疗９例患者，疗效较好，报告如下。一、资料与方法１．临床资料：男３例，女６例，年龄６０～８...     

重症急性胰腺炎非手术治疗的临床研究

目的探讨重症急性胰腺炎的早期手术与非手术治疗效果。方法符合重症急性胰腺炎诊断标准的64例患者,其中非手术治疗43例,手术治疗21例。非手术治疗以禁食、胃肠减压、改善胰腺微循环,抑制胰酶分泌,抗感染等为主；手术治疗包括清除坏死胰腺、胰床及腹腔引流、胆囊切除切胆道取石等。将手术治疗21例、非手术治疗43例患者的死亡率和并发症等临床资料进行总结并比较分析。结果 (1)死亡率：比较非手术组死亡2例(4．7％),手术治疗组死亡5例(23．8％)。两组间有显著性差异(P<0．001)。(2)非手术组与手术组并发症发生率的比较：ARDS 16．28％vs 23．8％；肾功能不全9．30％vs 28．57％；休克6．98％vs 14．29％；心功能不全4．65％vs 19．05％；胰腺脓肿2．33％vs 9．52％。两组间有显著性差异(P<0．01)。结论重症急性胰腺炎的早期非手术治疗明显优于早期手术治疗。     

重症急性胰腺炎非手术治疗的临床研究

目的探讨重症急性胰腺炎的早期手术与非手术治疗效果.方法符合重症急性胰腺炎诊断标准的64例患者,其中非手术治疗43例,手术治疗21例.非手术治疗以禁食、胃肠减压、改善胰腺微循环,抑制胰酶分泌,抗感染等为主;手术治疗包括清除坏死胰腺、胰床及腹腔引流、胆囊切除切胆道取石等.将手术治疗21例、非手术治疗43例患者的死亡率和并发症等临床资料进行总结并比较分析.结果 (1)死亡率:比较非手术组死亡2例(4.7%),手术治疗组死亡5例(23.8%),两组间有显著性差异(P < 0.001).(2)非手术组与手术组并发症发生率的比较:ARDS 16.28% vs 23.8%;肾功能不全9.30% vs 28.57%;休克6.98% vs 14.29%;心功能不全4.65% vs 19.05%;胰腺脓肿2.33% vs 9.52%.两组间有显著性差异(P < 0.01).结论重症急性胰腺炎的早期非手术治疗明显优于早期手术治疗.     

重症胰腺炎保守治疗20例

目的:探讨重症胰腺炎保守治疗方法.方法:回顾性分析20例重症胰腺炎保守治疗的临床资料.结果:20例重症胰腺炎经中西医结合治疗治愈.20例出现炎性腹水,6例休克,17例出现麻痹性肠梗阻,2例胰周感染,3例出现ARDS及1例肾功能衰竭,无死亡病例.结论:中西医结合治疗重症胰腺炎疗效满意,可阻止其进一步发展,减少并发症的出现,值得推荐.     

早期高容量血液滤过持续时间对重症急性胰腺炎急性肺损伤影响研究

目的 研究早期高容量血液滤过(HVHF)持续时间对重症急性胰腺炎(SAP)急性肺损伤(ALI)的影响.方法 将2006年8月到2009年4月怀化市第三人民医院ICU收治的49例入院时合并ALI急性呼吸窘迫综合征(ARDS)并在72 h内接受HVHF治疗的SAP患者随机分为两组.在常规治疗的基础上分别接受血滤持续时间8 h(Ⅰ组)和72 h(Ⅱ组)治疗.比较两组患者的APACHEⅡ评分、氧合指数、ALI/ARDS的改善率(包括治愈率)、机械通气的例数及时间、急性期并发症、HVHF相关并发症、结局及医疗费用等.结果 ①氧合指数及APACHEⅡ评分:两组入院第3天和第14天均较入院当天有所改善(P＜0.05).但在人院第3天和第14天,两组患者差异无统计学意义.②ALI、ARDS的改善率(包括治愈率):两组入院第3天和第14天较入院当天升高(P＜0.05);但在入院第3天和第14天.两组患者差异无统计学意义.③两组患者急性期机械通气的例数及时间、急性期并发症(多器官功能障碍综合征、急性肾功能衰竭、腹腔室隔综合征、导管相关感染、低血压)差异无统计学意义,但医疗费用差异有统计学意义(P＜0.05).两组患者急性期均无死亡.结论 发病72 h内的SAP早期短时(8 h)持续性HVHF治疗能有效促进合并ALI/ARDS的SAP患者肺功能的恢复,并且节约医疗费用.     

Factors Predicting Mortality in Severe Acute Pancreatitis

Acute pancreatitis (AP) is a common disorder in which ensuing serious complications may lead to a fatal outcome in patients. Background/Aims: To describe a large series of patients with severe AP (SAP) who were admitted to our hospital and to identify factors predicting mortality.Patients and Methods: In a retrospective study, all patients with SAP diagnosed between February 1996 and October 2000 according to the Atlanta criteria were studied.Results: Out of a total of 363 AP patients, 67 developed SAP. The mean age of the patients was 69; the commonest etiology was biliary; 55.2% developed necrosis; the commonest systemic complication was respiratory failure (44.7%), followed by acute renal failure (35.8%) and shock (20.9%). A total of 31.3% of the patients died. Factors significantly related to mortality were age, upper digestive tract bleeding, acute renal failure, respiratory failure and shock by univariate analysis. However, pseudocysts seemed to have a protective effect. By multivariate analysis, independent prognostic factors were age, acute renal failure and respiratory failure.Conclusions: Patients with SAP mainly died due to systemic complications, especially acute renal failure and respiratory failure. Necrosis (in the absence or presence of infection) was not correlated with increased mortality. A pseudocyst was found to be a protective factor, probably because the definition itself led to the selection of patients who had survived multiorgan failure.     

The use of antibiotics for acute pancreatitis: Is there a role?

Infections due to pancreatic necrosis and abscesses are observed in one third of patients with severe acute pancreatitis (SAP). Based on results of double-blind, randomized, placebo-controlled trials, antibiotic prophylaxis in SAP is ineffective for reducing the frequency of infected necrosis and to decrease hospital mortality. Antibiotic treatment using carbapenems and quinolones is indicated on demand in patients with SAP and multiorgan failure at admission and in those with hemodynamic shock. Patients with biliary acute pancreatitis (AP) and clinically acute cholecystitis and/or cholangitis benefit from antibiotic treatment. Patients with AP associated with bacteremia, positive bronchoalveolar lavage, and urinary tract infection should receive antibiotics. In necrotizing pancreatitis, evidence-based data do not support late use of antibiotic prophylaxis after onset. Further high-quality, randomized, controlled trials are needed to evaluate antibiotic prophylaxis in the first 24 to 48 hours after SAP onset.     

Association of polymorphisms of IL and CD14 genes with acute severe pancreatitis and septic shock

IM: To investigate IL-1β+3 594 in the 5th intron, IL-10-1 082 and CD14-159 polymorphisms in patients with acute pancreatitis (AP) and septic shock. METHODS: The study included 215 patients (109 with acute severe pancreatitis (SAP), 106 with acute mild pancreatitis (MAP)) and 116 healthy volunteers. Genomic DNA was prepared from peripheral blood leukocytes. Genotypes and allele frequencies were determined in patients and healthy controls using restriction fragment length polymorphism analysis of PCR products. RESULTS: The frequencies of IL-1β+3 594T, IL-10-1082G and CD14-159T allele were similar in patients with mild or severe pancreatitis and in controls. Within SAP patients, no significant differences were found in the allele distribution examined when etiology was studied again. Patients with septic shock showed a significantly higher prevalence of IL-10-1082G allele than those without shock (X2 = 5.921, P=0.015). CONCLUSION: IL-10-1082G plays an important role in the susceptibility of SAP patients to septic shock. Genetic factors are not important in determination of disease severity or susceptibility to AP.     

预防性应用抗生素在重症急性胰腺炎中的作用

急性胰腺炎是消化系常见急症，可分为轻症急性胰腺炎（MAP）和重症急性胰腺炎（SAP）。SAP症状较重，病死率高，患者主要死于早期毒血症、全身炎症反应综合征（SIRS）、多器官功能衰竭（MODS）等严重并发症和后期继发感染。随着重症监护、影像学、内镜检查和外科技术的发展，多数患者能度过早期SIRS、MODS等并发症，但后期继发感染仍是患者致死的主要危险因素。因此．目前早期应用抗生素能否预防SAP后期继发感染已成为研究热点。本文就预防性应用抗生素在SAP中作用的研究进展作一综述。     

重症急性胰腺炎治疗的几个问题

急性胰腺炎是消化系统常见急症,分为轻症急性胰腺炎(MAP)和重症急性胰腺炎(SAP),其中80%的患者为MAP,病情具有自限性,预后良好,而SAP因常伴有诸多局部和系统性并发症,死亡率高。胰腺或胰腺周围坏死感染是SAP最严重的并发症,其病死率高达30%。虽然抗生素、肠内营养和益生菌都被用来预防胰腺感染,但只有肠内营养的作用被肯定,而其余两者在SAP中的作用还存在较多争议。     

Clinical characteristics and management of patients with early acute severe pancreatitis： Experience from a medical center in China

AIM: To study clinical characteristics and management of patients with early severe acute pancreatitis (ESAP). METHODS: Data of 297 patients with severe acute pancreatitis (SAP) admitted to our hospital within 72 h after onset of symptoms from January 1991 to June 2003 were reviewed for the occurrence and development of early severe acute pancreatitis (ESAP). ESAP was defined as presence of organ dysfunction within 72 h after onset of symptoms. Sixty-nine patients had ESAP, 228 patients without organ dysfunction within 72 h after onset of symptoms had SAP. The clinical characteristics, incidence of organ dysfunction during hospitalization and prognosis between ESAP and SAP were compared. RESULTS: Impairment degree of pancreas (Balthazar CT class) in ESAP was more serious than that in SAP (5.31+/-0.68 vs 3.68+/-0.29, P<0.01). ESAP had a higher mortality than SAP (43.4% vs 2.6%, P<0.01), and a higher incidence of hypoxemia (85.5% vs 25%, P<0.01), pancreas infection (15.9% vs 7.5%, P<0.05), abdominal compartment syndrome (ACS) (78.3% vs 23.2%, P<0.01) and multiple organ dysfunction syndrome (MODS)(78.3% vs 10.1%, P<0.01). In multiple logistic regression analysis, the main predisposing factors to ESAP were higher APACHE II score, Balthazar CT class, MODS and hypoxemia. CONCLUSION: ESAP is characterised by MODS, severe pathological changes of pancreas, early hypoxemia and abdominal compartment syndrome. Given the poor prognosis of ESAP, these patients should be treated in specialized intensive care units with special measures such as close supervision, fluid resuscitation, improvement of hypoxemia, reduction of pancreatic secretion, elimination of inflammatory mediators, prevention and treatment of pancreatic infections.     

Pathogenesis of pancreatic encephalopathy in severe acute pancreatitis

BACKGROUND: Pancreatic encephalopathy (PE) is a serious complication of severe acute pancreatitis (SAP). In recent years, more and more PE cases have been reported worldwide, and the onset PE in the early stage was regarded as a poor prognosis sign of SAP, but the pathogenesis of PE in SAP still has not been clarified in the past decade. The purpose of this review is to elucidate the possible pathogenesis of PE in SAP. DATA SOURCES: The English-language literature concern- ing PE in this review came from the Database of MEDLINE (period of 1991-2005), and the keywords of severe acute pancreatitis and pancreatic encephalopathy were used in the searching. RESULTS: Many factors were involved in the pathogenesis of PE in SAP. Pancreatin activation, excessive release of cytokines and oxygen free radicals, microcirculation abnormalities of hemodynamic disturbance, ET-1/NO ratio, hypoxemia, bacterial infection, water and electrolyte imbalance, and vitamin B1 deficiency participated in the development of PE in SAP. CONCLUSIONS: The pathogenesis of PE in SAP has not yet been fully understood. The development of PE in SAP may be a multi-factor process. To find out the possible inducing factor is essential to the clinical management of PE in SAP.