成人胰胆管合流异常病人血清淀粉酶同工酶谱的临床观察

胰胆管合流异常（pancreaticobiliary maljunction，PBM)因其与人类肝胆胰系统多种疾病的发病机制及治疗措施密切相关，日益受到外科医师关注。国外文献报道，人群中PBM发生率为2％～3％m，如何准确诊断PBM是我们面临的难题。本文报道成人PBM病人血清淀粉酶同工酶谱检测的结果。     

胰管结石伴先天性胆管扩张症一例

胰管结石较少见．在正常人群发病率不超过1％。胆管扩张症是较常见的先天性胆道畸形，文献报道该病几乎全部伴有胰胆管合流异常（pancrealicobiliary maljunction．PBM），不伴PBM的胆管扩张症少见。近来我院收治了一例胰管结石不伴PBM的先天性胆管扩张症病人．在治疗过程中我们有一些体会．现报告如下。     

儿童先天性胆管扩张症的诊断与治疗

目的:探讨儿童先天性胆管扩张症(CBD)的临床、病理、影像特点及治疗.方法:回顾性分析58例经影像学检查、手术和病理证实CBD患儿的临床资料.结果:58例均出现临床症状,主要表现为腹痛、黄疸、腹部肿块,部分患者合并发热、呕吐症状.CT(45例)、超声(40例)、MRCP(17例)检查均显示胆管扩张;11例MRCP诊断为胰胆管合流异常(PBM).57例成功进行术中胆道造影,影像和手术分型:Ⅰ型43例,其中囊状35例,8例表现为梭型或柱形;Ⅱ型2例;Ⅳ型13例;未发现Ⅲ型患者.58例患儿术后病理显示CBD囊壁纤维组织增生,囊肿壁内衬上皮部分或全部脱落,40例囊壁伴有炎症,39例慢性胆囊炎.53例行一次性囊肿切除肝管空肠Roux-en-Y吻合术,5例先行胆道外引流后二次肝管空肠Roux-en-Y吻合术,术后短期均无严重并发症发生.随访1～9年,患儿无胆道梗阻、胆管炎、肠梗阻和胆道肿瘤发生.结论:超声检查、术中造影、CT和MRCP均对儿童CBD诊断有一定价值;MRCP为CBD合并PBM首选诊断方法;儿童CBD的治疗应早期采用肝管空肠Roux-en-Y吻合术.     

MRCP诊断先天性胆管扩张症的临床评价

目的 评价MRCP诊断先天性胆管扩张症的应用价值。方法 26例先天性胆管扩张症患儿术前行MRCP检查,并均接受扩张胆管切除,肝总管空肠Roux-Y吻合手术,术中再进行胆道穿刺造影,将两者所显示的胆管扩张程度,形态和胆胰管合流异常的结果进行对比分析。结果 MRCP显示胆总管囊性扩张17例,其余9例为梭形扩张,肝内、外胆管显像与术中胆道造影一致,7例显示出胰胆管合流异常,显示率26.9%,术中造影24例显示胰胆管合流异常,显示率92.3%,结论 MRCP可作为诊断先天性胆管扩张症优先选择方法。     

小儿先天性胆管扩张症的诊治：附44例报告

背景与目的:先天性胆管扩张症(CBD)是小儿较常见的胆道畸形,可发生于肝内和肝外胆管的任何部位。随着时间的推移,患者易并发胆道结石、胰腺炎、胆管癌、复发性胆管炎、门静脉高压症、自发性囊肿破裂等严重并发症。CBD常伴有胰胆管合流异常(PBM),且临床症状不典型,部分急性发作患者腹腔粘连严重,手术难度大且术后并发症多,因此其诊断与治疗对小儿外科医生带来了巨大挑战。本研究总结分析小儿CBD的诊治经验,以期为临床工作提供参考。方法:回顾性分析中南大学湘雅医院2010年6月-2017年8月间收治的44例CBD患儿的临床资料。结果:44例患儿中女38例,男6例,男女比1:6.3;发病年龄为2~161个月,中位发病年龄为63个月。主要临床症状为腹痛30例(68.1%)、皮肤巩膜黄染20例(45.5%)、恶心呕吐7例(15.9%)。37例行彩超检查,30例(81.1%)考虑为CBD;32例行CT检查,29例(90.6%)考虑诊断为CBD;20例行磁共振胰胆管成像(MRCP)检查,20例(100.0%)均考虑诊断为CBD,其中18例(90.0%)伴有PBM。按Todani分型:I型34例(77.3%),IVA型10例(32.7%);按董氏分型:C1型26例(59.1%),C2型8例(18.2%),D1型8例(18.2%),D2型2例(4.5%)。一期行胆囊切除+胆总管囊肿切除+肝总管空肠Roux-en-Y吻合术的29例患儿术中出血(80.0±25.0)mL,无并发症发生,术后住院(8.0±1.6)d;行胆囊切除+胆总管囊肿切除+左半肝切除+右肝管空肠Roux-en-Y吻合术的1例术中出血150.0 mL,术后住院10 d;一期行胆总管囊肿切开T管引流术,3个月后行二期胆总管囊肿切除+肝总管空肠Roux-en-Y吻合术的6例患儿术中出血(500.0±125.0)mL,术后住院(11.0±4.2)d;1例行胆总管空肠端侧吻合术患儿术中出血200.0 mL,术后出现吻合口瘘,术后住院24 d,6个月后行二期手术,术中失血200.0 mL,术后住院7 d;7例未行手术治疗,其中4例为IVA型。40例获随访20~110个月(中位随访时间60个月),其中35例行手术治疗患儿均恢复良好,5例未行手术治疗患儿中3例(60.0%)症状反复发作,1例因反复发作胆管炎死亡。结论:MRCP诊断CBD的准确率高,且能显示有无PBM及PBM类型,术中可根据MRCP显示的胰胆管汇合部位而避免损伤胰管并完全切除病变胆管,可作为诊断CBD的首选方法;董氏分型有助于手术方式的选择,为部分IVA型患者提供合理的手术方式。     

ERCP术后胰腺炎的防治

目的　探讨内窥镜逆行胰胆管造影 (ERCP)术后胰腺炎乌司他丁 (Ulinastatin,UTI)的防治作用。方法　对1 998年 1月～ 2 0 0 3年 3月我院住院行 ERCP术 1 6 4例病人作回顾性分析总结。结果　 1 6 4例行 ERCP术病人随机分为三组 :对照组 6 2例 ,乌司他丁组 6 8例 ,生长抑素组 34例。1 34例插管成功 ,成功率 82 .0 % ,其中胆管、胰管均显影 6 6例 ,胆管显影 4 6例 ,胰管显影 5 2例 ,在胆管显影的 1 1 2例中 ,70例总胆管有扩张 ,直径≥ 1 0 m m,4 2例总胆直径正常 <1 0 m m。预防用药组 ER-CP术后 2 h血清淀粉酶 (乌司他丁 2 2 6 .5± 2 6 2 .9U/ L,生长抑素 2 6 4 .0± 2 0 4 .5 U/ L)、2 4 h血清淀粉酶 (乌司他丁 2 92 .4±31 9.6 U/ L,生长抑素 2 82 .7± 2 93.8U/ L)明显低于对照组组 (5 2 2 .2± 4 96 .2 U/ L,5 0 6 .1± 5 5 9.8U/ L,P<0 .0 1 ) ;乌司他丁组、生长抑素组 ERCP术后 2 h、2 4 h血清淀粉酶水平亦明显高于术前水平 (P<0 .0 5 )。结论　乌司他丁通过减少胰液的分泌量和降低胰酶的浓度 ,能够有效防治 ERCP术后胰腺炎的发生     

胰胆管合流异常与先天性胆总管囊肿

目的:探讨胰胆管合流异常(PBM)致先天性胆总管囊肿(CCC)的可能机制。方法:将21例经B超诊断为胆总管囊肿患者行ERCP检查，检查时经选择性胆管插管抽取胆汁检测其中淀粉酶(AMS)及C反应蛋白(CRP)浓度。结果: 21例PBM均合并CCC，其中13例为胆管合流型(C-P型)，8例为胰管合流型(P-C型) PBM。21例胆汁中AMS及CRP浓度均较对照组显著升高(P<0.01)，C-P型较P-C型升高更明显(P<0.05)。 结论:PBM可能是CCC形成的解剖学基础，胰液返流至胆管，被激活的高浓度胰酶破坏胆管壁，则可能是CCC形成的促发因素。     

胰胆管合流异常与胆管囊肿的关系及诊治进展

胰胆管合流异常( pancreaticobiliary maljunction,PBM)是指胰管和胆管在十二指肠壁外合流,通常明显伴有一个长的共同通道.由于胰胆汇合部失去Oddi括约肌的控制,胰液和胆汁的逆流持续发生,导致胆道和胰腺的各种病理变化.PBM和胆管囊肿(choledochal cyst,CC)的关系密切,但两者之间的病因学关系仍然不清楚.另外,PBM被认为是导致胆道肿瘤的高危因素.虽然共同管长度和胆汁淀粉酶是诊断PBM的重要依据,并且完全胆囊、囊肿切除,肝管空肠Roux-Y吻合术这一术式已被广泛采用,但仍存有争议.现就PBM与CC的关系研究进展作一综述.     

术中造影在胆道手术中的应用分析

目的比较术中胆道造影与术前影像检查的差异,分析其对胆道疾病的诊断及术式选择的指导价值。方法 118例胆囊结石和胆道疾病患者,术前24例行B超检查,发现正常胆管22例,胆总管结石1例,胆管扩张1例;69例行CT检查,发现正常胆管49例,泥沙样胆管结石16例,胆管扩张4例;25例行MRCP检查,发现正常胆管17例,胆总管结石6例,胆管扩张2例。术中行胆道造影,根据造影结果确定相应术式。结果术前行B超检查的24例中造影发现正常胆管15例,胆总管结石6例,胆管癌1例,胆囊管变异1例,Caroli氏病1例;术前行CT检查的69例术中造影发现正常胆管51例,胆总管结石10例,胆管癌1例,胆囊扩张2例,胆囊管变异1例,Mirizzi综合征2例,胆管损伤2例;术前行MRCP检查的25例,术中造影发现正常胆管14例,结石5例,胆管扩张4例,胆囊管变异1例,M irizzi综合征1例。术中胆道造影对正常胆管的识别能力优于术前B超(P0.05)。结论术中胆道造影具有操作简单、创伤小、结果可靠等优点,对胆道早期肿瘤、解剖畸形、术中胆道损伤的诊断及术式选择具有指导意义。     

儿童胆道扩张症与胰胆管合流异常的相关性

目的 通过回顾性分析先天性胆道扩张症（CBD）临床病例资料,比较合并胰胆管合流异常（PBM）与无合流异常病例的临床特征之间的差异,探讨PBM以及共同管长度与CBD的发病、临床症状、相关实验室检查结果的相关性,为CBD的发病机理和诊断治疗提供新的理论依据。方法 回顾性总结2017年1月至2019年12月首都医科大学附属北京儿童医院普外科收治的胆道扩张症病例临床资料,83例胆道扩张症患儿纳入研究,以MRCP中胰胆管共同管长度为分组标准,分为合流异常组（共同管长度≥5 mm,n=47）与非合流异常组（共同管长度＜5 mm,n=36）,研究指标包括发病年龄、性别、临床症状、相关实验室检查、共同管长度、胆道结石以及胆总管囊肿大小,研究结果采用非参数检验和χ2 检验。结果 在临床症状中,发热、黄疸、白色大便及胆道结石两组间无统计学差异（P＞0.05）,腹痛症状合流异常组多于无合流组（P＜0.05）;实验室检查结果AST、ALT、TBIL、DBIL及IBIL两组间无统计学差异（P＞0.05）,血清淀粉酶检测合流异常组高于无合流异常组（P＜0.05）;合流异常组胆总管呈囊肿型32例（38.6%）,梭型15例（18.1%）,无合流异常组胆总管呈囊肿型26例（31.3%）,梭型10例（12.0%）,两组间无统计学差异（P＞0.05）,但胆总管囊肿体积合流异常组小于无合流异常组（P=0.02）。结论 先天性胆道扩张症合并胰胆管合流异常的患儿出现腹痛症状较早、较严重,同时血清淀粉酶较高,合并胰腺炎较常见,故易于做出早期诊断,可能也是本组胆总管囊肿体积较小的原因。本研究胰胆管共同管长短与先天性胆道扩张症的临床症状、肝功能、胆红素及血清淀粉酶等水平无明确相关性,故不能单纯以胰胆管共同管长度判断病情轻重。     

Potential diagnostic value of pancreatic isoamylases for pancreaticobiliary maljunction with mild biliary dilatation in patients and a porcine model

Purpose

The aim of this study was to evaluate the diagnostic value of serum pancreatic isoamylases for pancreaticobiliary maljunction (PBM) with mild biliary dilatation.

Methods

Serum and bile from 8 children with PBM and mild biliary dilatation (6 to 11 mm in diameter) and 4 young pigs with an anastomosis constructed between an isolated pancreas-duodenal segment and the gallbladder were studied for pancreatic isoamylases. Using an electrophoretic technique, the assay of pancreatic isoamylases was expressed by peak appearance rate (PAR). Serum from 20 healthy children served as normal controls.

Results

In the serum of the patients, preoperatively there were 5 pancreatic peaks with PAR as follows: P1, 100%; P2, 100%; P3, 100%; P4, 100%; and P5, 66.7%. These abnormal pancreatic isoamylases disappeared 2 weeks after operative treatment. In normal controls, there were only P1 (PAR, 40%) and P2 (PAR, 100%). Mild cylindrical dilatation (6 to 8 mm in diameter) of the common bile duct developed in the porcine PBM model. There were P1 (PAR, 100%) and P2 (PAR, 100%) in the porcine serum preoperatively. Thirty days and 60 days after establishing the model, there appeared in the serum 6 pancreatic peaks with PAR as follows: P1, 100%; P2, 100%; P3, 75%; P4, 100%; P5, 100%, and P6; 75%. The bile patterns of pancreatic isoenzymes in the patients and pigs were similar to those in serum.

Conclusions

Abnormal pancreatic isoamylases are characteristically present in the serum from both children and a porcine model of PBM and mild biliary dilatation. Assay for these abnormalities is promising to recognize this subset of patients in whom diagnosis remains a challenge.     

SHOULD SERUM PANCREATIC LIPASE REPLACE SERUM AMYLASE AS A BIOMARKER OF ACUTE PANCREATITIS?

BACKGROUND: Serum pancreatic lipase may improve the diagnosis of pancreatitis compared to serum amylase. Both enzymes have been measured simultaneously at our hospital allowing for a comparison of their diagnostic accuracy. METHODS: Seventeen thousand five hundred and thirty-one measurements of either serum amylase and or serum pancreatic lipase were made on 10 931 patients treated at a metropolitan teaching hospital between January 2001 and May 2003. Of these, 8937 were initially treated in the Emergency Department. These results were collected in a database, which was linked by the patients' medical record number to the radiology and medical records. Patients with either an elevated lipase value or a discharge diagnosis of acute pancreatitis had their radiological diagnosis reviewed along with their biochemistry and histology record. The diagnosis of acute pancreatitis was made if there was radiological evidence of peripancreatic inflammation. RESULTS: One thousand eight hundred and twenty-five patients had either elevated serum amylase and or serum pancreatic lipase. The medical records coded for pancreatitis in a further 55 whose enzymes were not elevated. Three hundred and twenty of these had radiological evidence of acute pancreatitis. Receiver operator characteristic analysis of the initial sample from patients received in the Emergency Department showed improved diagnostic accuracy for serum pancreatic lipase (area under the curve (AUC) 0.948) compared with serum amylase (AUC, 0.906, P < 0.05). A clinically useful cut-off point would be at the diagnostic threshold; 208 U/L (normal <190 U/L) for serum pancreatic lipase and 114 U/L (normal 27-100 U/L) for serum amylase where the sensitivity was 90.3 cf., 76.8% and the specificity was 93 cf., 92.6%. 18.8% of the acute pancreatitis patients did not have elevated serum amylase while only 2.9% did not have elevated serum pancreatic lipase on the first emergency department measurement. CONCLUSION: It is concluded that serum pancreatic lipase is a more accurate biomarker of acute pancreatitis than serum amylase.     

Alcohol-induced salivary hyperamylasemia

The effects of alcohol intoxication on serum amylase levels were tested in both normal subjects and chronic alcoholics. Paired samples of ethanol levels and isoamylase levels in the normal subjects (n = 11) showed a rise in both total serum amylase (P less than 0.01) and nonpancreatic isoamylase (P less than 0.05) after drinking. Unpaired cohort groups of sober chronic alcoholics at a rehabilitation facility (n = 46) and intoxicated chronic alcoholics in an emergency room (n = 58) were also compared. Average blood alcohol levels in the intoxicated controls were 93 mg% compared to a level of 301 mg% in the intoxicated chronic alcoholic. Intoxication superimposed on chronic alcoholism caused a moderate rise in the total serum amylase (NS) and a significant elevation of the nonpancreatic isoamylase (P less than 0.01). Sober chronic alcoholics had a significantly greater average total serum amylase (P less than 0.001) and nonpancreatic isoamylase (P less than 0.01) than the normal controls. No difference in the average pancreatic isoamylase levels was seen in any group. These data suggest a biphasic response to alcohol on the serum amylase level. Acute and chronic changes appear to operate independently. The cause for these effects is speculative. Isoamylase analysis is needed in the alcoholic population to sort out the meaning of hyperamylasemia.     

Diagnostic value of serum elastase 1 in pancreatic disease

We studied serum elastase 1 concentrations in patients with pancreatic disease to assess its diagnostic value and compare its sensitivity and specificity with that of amylase and pancreatic isoamylase. Markedly raised concentrations of elastase 1 were found in all twenty-nine patients with acute pancreatitis (amylase was elevated in all but three and pancreatic isoamylase in all but one). Serial measurements of the three enzymes in acute pancreatitis showed that elastase remained elevated longer than amylase and pancreatic isoamylase. The majority of chronic pancreatitis patients studied during a painful relapse (16 out of 21, 76 per cent) had elastase concentrations above the upper normal limit. Amylase and pancreatic isoamylase were elevated in 11 (52 per cent) and in 13 (62 per cent), respectively. Most patients with chronic pancreatitis studied during clinical remission (39 out of 43) had serum elastase levels either within (n = 24) or below (n = 15) the control range. The latter had severe exocrine pancreatic insufficiency and steatorrhoea. In carcinoma of the pancrease, 20 out of 32 (63 per cent) had abnormal serum elastase concentrations; 16 were higher and 4 lower than the control range. Amylase was abnormal in 10 (31 per cent) (8 high, 2 low), and pancreatic isoamylase was abnormal in 16 (50 per cent) (11 high, 5 low). In 46 control patients with non-pancreatic abdominal pain, serum elastase concentrations were not significantly different from those in healthy controls. Elastase was slightly raised in two, whereas amylase and pancreatic isoamylase were elevated in seven and eight, respectively. We conclude that serum elastase 1 is a highly sensitive and specific indicator of pancreatic disease.     

钩突完全切除对胰十二指肠切除术后胰瘘发生率的影响

目的 分析胰十二指肠切除术后胰瘘发生的可能因素,探讨钩突完全切除对降低胰瘘发生率的影响.方法 回顾性分析2004年1月至2009年6月单一手术小组收治并行胰十二指肠切除的68例壶腹周围疾病患者的临床资料.以术后腹腔引流液淀粉酶水平诊断胰瘘并行临床资料分析,对可能造成腹腔引流液淀粉酶异常升高的相关因素:钩突是否完全切除、胰肠吻合方式、胰腺纤维化等进行统计学分析.结果 本组胰瘘发生率为33.8%;单因素分析显示:钩突是否完全切除(P=0.000)及血糖水平(P=0.045)与胰瘘关系密切;多因素分析显示本组病例胰瘘发生的独立危险因素为钩突是否完伞切除(P=0.000,OR=7.771),而胰腺纤维化、吻合方式、疾病类型等均不构成胰瘘发生的独立危险因素.结论 完全切除胰腺钩突能够防止"残留钩突型胰瘘"的发生,进而降低胰十二指肠切除术后胰瘘发生率.     

Application of a new collagen-based sealant for the treatment of pancreatic injury

Pancreatic injury is the most frequent serious morbidity that can occur following laparoscopic splenectomy. The presumed mechanism of injury is direct trauma to the pancreatic tail during hilar dissection or transection with endovascular staplers. It was our aim to study the direct application of topical sealants to a pancreatic injury to prevent a pancreatic leak. A porcine model of pancreatic injury in a normal pancreas was developed. Fourteen animals underwent midline laparotomy and subtotal (8 cm) distal pancreatectomy. The pancreas was sharply divided and minimal cauterization used. A (1/4)-inch round Jackson Pratt drain was secured to the pancreatic stump in all animals. The control group (n = 7) underwent no further treatment. Two groups underwent treatment with a sealant. Group 1 (n = 3) had a hydrogel applied to the pancreatic remnant. Group 2 (n = 4) had a biodegradable sealant of PEG (polyethylene glycol)-collagen formulation applied to the pancreatic stump by aerosol. During the postoperative period, animals were fed 2.2 lb/d of a high fat (10% lard) diet to stimulate pancreatic exocrine function. Total daily drain outputs were recorded, and drain amylase content and serum amylase concentration were measured on postoperative days 3, 7, and 10. A significant pancreatic leak was defined as a drain to serum amylase content of greater than 3:1. Animals were killed on day 10 and explored for undrained fluid collections. The pancreas was removed for histologic evaluation. Control and treatment groups were compared using repeated measures ANOVA of log-transformed data. All animals survived until elective necropsy. In group 1, average total drain outputs were not significantly less than the controls (125 mL versus 269; P = .66). The mean drain/serum amylase concentration on days 3, 7, and 10 were not significantly different between group 1 and the control group. Group 2 had significantly less overall average drainage output than controls (40 mL versus 269 mL; P = .0006). Furthermore, group 2 had a significant reduction in pancreatic leaks on days 3, 7, and 10 as measured by mean drain/serum amylase concentration. No undrained fluid collections were identified at autopsy. Based on our experimental porcine model, a novel collagen-based, biodegradable hydrogel can prevent a ductal leak following pancreatic injury. These encouraging data have fostered application by aerosol treatment to the hilar bed at laparoscopic splenectomy to diminish capsular disruption from mechanical injury.     

Puzzling persistent hyperamylasemia, probably neither pancreatic nor pathologic

Increased serum amylase levels most commonly signify pancreatic disease. One hundred seventeen consecutive patients were studied because their serum amylase levels were abnormally high for periods ranging from 3 to 48 weeks. In each case, extensive clinical and radiologic evaluation had failed to reveal a reason for the abnormality. The amylase isoenzymes of their sera were separated by polyacrylamide gel electrophoresis, and the fractions were measured by a saccharogenic assay. The findings in the 117 patients showed that 79 percent had non-pancreatic causes for their hyperamylasemia. The biggest single group (64 percent) had a normal distribution of isoamylases, albeit at unusually high concentrations. This phenomenon, which has not been defined previously, is probably a variant of normal in which the homeostatic balance between production and metabolism is set at a high level. Macroamylasemia accounted for 6 percent of the cases and salivary hyperamylasemia for only 9 percent. Three patients had the characteristic isoamylase pattern ("old amylase") associated with pancreatic pseudocysts. Isoamylase fractionation is a cheap, efficient, and effective means of ruling out a pancreatic cause for hyperamylasemia. It is probable that in the majority of cases of persistent hyperamylasemia without obvious clinical cause there will be no disease at all.     

闭合性胰腺损伤延误手术分析

目的 分析闭合性胰腺损伤延误手术的原因。方法 回顾性分析了下年来闭合性胰腺损伤延误手术治疗９例患者诊治过程。结果 胰腺闭合性损伤延误手术占胰腺闭合笥损伤手术６４％临床上均有不同程度上腹疼痛、呕吐、腹膜刺激征,伴休克２例。术前血淀粉权衡利弊检查６例,５例阳性;尿淀粉酶４例２例阳性,腹水淀粉酶检查３例,均为阳性。腹穿８例均阳性。Ｂ超共６例,确诊３例,ＣＴ检查３例,确诊１例。并发症发生率８０％。死亡１     

Evaluation of amylase and lipase in the diagnosis of acute pancreatitis

Background : The diagnosis of acute pancreatitis relies heavily on a raised amylase. Methods : In the present study patients were prospectively categorized, without knowledge of pancreatic enzyme levels, into acute pancreatitis (AP; n = 51), disease controls (n = 35), indeterminate as to pancreatitis (n = 189) or exclusions (non‐pancreatitis diseases where amylase may be elevated; n = 53). Results : Enzyme levels were analysed by receiver operator characteristics (ROC) curves, with specificity > 80%. Day 1 serum lipase gave the greatest diagnostic accuracy (area under ROC curve = 0.128; P = 0.041 vs serum amylase). At the calculated diagnostic threshold of 208 U/L, lipase gave a sensitivity of 67% and a specificity of 97%. Other diagnostic thresholds (day 1) were: serum total amylase, 176 U/L (ROC 0.104, sensitivity 45%, specificity 97%), urinary total amylase, 550 U/L (ROC 0.108, sensitivity 62%, specificity 97%) and serum pancreatic isoamylase, 41 U/L (ROC 0.107, sensitivity 63%, specificity 85%). At delayed diagnosis (3 days) no enzyme was superior to lipase. The combination of lipase and amylase did not increase diagnostic accuracy. Conclusion : Serum lipase is recommended for diagnosis of AP, both early and late in the disease. Although highly specific when elevated, all pancreatic enzymes have low sensitivity for diagnosis.     

体外循环后胰腺功能的变化

目的观察体外循环下行心脏瓣膜替换术患者胰腺内、外分泌功能的变化,研究其对围手术期治疗的意义。方法采集１６例心脏瓣膜病患者８个时相点全血,测定血糖、乳酸、胰岛素、Ｃ肽、淀粉酶及脂肪酶,分析其变化规律。结果术后围手术期显现出高糖血症和高乳酸血症,二者呈现显著正相关（Ｐ＝０００５）,其峰值于术日１９点,至术后第３日缓慢降到基线水平。胰岛素水平于８个观测时相点测定平均数值基本处于正常水平,仅第３日晨显示轻度升高。血中Ｃ肽水平一直处在稍高于正常范围,在术日１９点达高峰,接近正常倍值。血中淀粉酶与脂肪酶的统计平均数基本处于正常值范围,仅术后第４日脂肪酶稍高出正常值。本组淀粉酶正常１２例,异常４例（２５％）：单纯高淀粉酶血症２例,淀粉酶与脂肪酶均升高者２例（１６％）。高脂肪酶血症８例（５０％）。结论体外循环对围手术期胰腺功能产生病理生理学影响,表现出内、外分泌功能均有一定的改变