重症急性胰腺炎并发胰性脑病诊治的探讨(附11例报告)

目的探讨重症急性胰腺炎并发胰性脑病的临床特点和诊断治疗方法.方法回顾分析11例SAP并发PE患者的临床资料.结果本组共11例,占同期SAP的13.8%(11/80);男性5例,女性6例;手术8例,非手术保守治疗3例;急性期PE 7例,迟发性PE 4例;死亡4例,存活7例,其中治愈3例,好转4例.结论本病主要依据临床症状及排除性诊断.治疗除手术、抑制胰酶分泌、抗感染、支持疗法外,辅以强有力的脱水剂、中枢神经营养药、激素冲击治疗至关重要.     

急性胰腺炎并发胰性脑病和韦尼克脑病

目的探讨急性胰腺炎（AP）并发胰性脑病（PE）和韦尼克脑病（WE）的临床特征和治疗方法。方法回顾性分析8年来收治AP病人394例的临床资料。结果AP中重症急性胰腺炎（SAP）78例，发生脑病8例，其中PE5例，WE3例。死亡3例。PE2例，WE1例，2例WE经注射维生束B1而治愈。结论PE多发生在SAP的早期或病情反复时；WE发生于SAP或AP的恢复期。禁食时间长、反复呕吐及全胃肠外营养中未补充维生素B1是导致急性胰腺炎者维生素B1缺乏，从而发生WE的重要原因。     

胰腺炎并发胰性脑病37例临床分析

目的 探讨胰腺炎并发胰性脑病（PE）的临床表现、诊断、鉴别诊断及可能诱因。方法 回顾性分析5年来上海6所医院急性胰腺炎并发PE37例患者的临床资料。结果37例PE中男性24例，女性13例，平均年龄53岁（25～80岁）。按Ranson诊断标准33例为重症急性胰腺炎（SAP），4例为轻症急性胰腺炎（MAP），其中迟发性PE（DPE）6例，15例发病前有胰腺手术史。PE死亡率56．8％，DPE为66．7％。临床表现和诊断无特异性，血淀粉酶水平与PE严重程度无相关性。PE出现时常伴发低氧血症和急性呼吸窘迫综合征、水电解质紊乱、氮质血症、消化道出血等并发症。结论 PE是胰腺炎发病过程中的严重并发症，死亡率高，多在重症胰腺炎中伴发。在PE的发病过程中，有些因素也可引起胰腺炎患者的精神症状，如低氧血症、Wernicke脑病等，临床上较易混淆，为确诊带来困难。     

急性重症胰腺炎的心脑肺损伤的诊治

目的 为了解急性重症胰腺炎(SAP)的心脑肺损伤的情况与SAP病死率的关系.方法通过对18年我院肝胆外科收治的96例SAP回顾调查,了解SAP并发休克、ARDS和胰性脑病的发生及治疗情况和SAP死亡的主要因素.结果1982-10/2000-08我科共收治SAP 96例,手术治疗69例(72%),非手术治疗27例(28%),治愈77例(80%),死亡19例(20%),发生各种并发症68例(71%).SAP合并心脑肺损伤33例(34%),死亡16例(17%),SAP无心脑肺损伤63例(66%),死亡3例(3%),两者差异有统计学意义(P＜0.05).SAP伴ARDS 14例(15%),8例ARDS治愈(57%),6例ARDS死亡(43%).SAP伴休克13例(14%),5例休克治愈(38%),8例休克病人死亡(62%).SAP伴胰性脑病13例(14%),6例胰性脑病死亡(46%),7例治愈(54%).7例(7%)同时有两种心脑肺损伤,其中4例SAP同时有休克和ARDS,2例SAP病人有胰性脑病和ARDS,2例SAP合并休克和胰性脑病,死亡5例.结论SAP心肺脑损伤治疗困难,其病死率明显高于无心脑肺损伤的SAP,ARDS、休克和胰性脑病是导致SAP死亡的主要并发症和主要致命因素.     

胰腺炎并发胰性脑病 37 例临床分析

目的 探讨胰腺炎并发胰性脑病(PE)的临床表现、诊断、鉴别诊断及可能诱因.方法 回顾性分析5年来上海6所医院急性胰腺炎并发PE 37例患者的临床资料.结果 37例PE中男性24例,女性13例,平均年龄53岁(25 ～ 80岁).按Ranson诊断标准33例为重症急性胰腺炎(SAP),4例为轻症急性胰腺炎(MAP),其中迟发性PE(DPE)6例,15例发病前有胰腺手术史.PE死亡率56.8%,DPE为66.7%.临床表现和诊断无特异性,血淀粉酶水平与PE严重程度无相关性.PE出现时常伴发低氧血症和急性呼吸窘迫综合征、水电解质紊乱、氮质血症、消化道出血等并发症.结论 PE是胰腺炎发病过程中的严重并发症,死亡率高,多在重症胰腺炎中伴发.在PE的发病过程中,有些因素也可引起胰腺炎患者的精神症状,如低氧血症、Wernicke脑病等,临床上较易混淆,为确诊带来困难.     

舒血宁联合奥曲肽对急性坏死性胰腺炎大鼠脑损伤的保护作用

重症急性胰腺炎（SAP）并发脑损伤,又称胰性脑病（pancreatic encephalopathy,PE）,是SAP常见的并发症之一,主要表现为定向力障碍、意识模糊、幻觉等精神状态异常。临床SAP并发PE约占同期患者的18．2％,病死率达67．0％。     

水溶性维生素缺乏致迟发性胰性脑病的诊治

胰性脑病(pancreatic encephalopathy,PE)的病因复杂多样,尤其胰腺炎后期并发胰性脑病疗效较差。本文总结自1998年10月至2001年12月收治的6例急性重症胰腺炎(SAP)后期并发胰性脑病的诊治体会。     

胰十二指肠切除术后胰肠吻合口瘘临床分析

目的：回顾分析胰十二指肠切除术后发生胰肠吻合口瘘病例以减少手术并发症。方法：对1986年1月－2001年6月62例胰十二指肠切除术病例资料行回顾性分析。结果：62例中，发生胰肠吻合口瘘9例，发生率14．5％，其中1986年1月－1991年12月发生胰肠吻合口瘘5例，发生率62．5％（5／8）；1992年1月－2001年6月发生胰肠吻合口瘘4例，发生率7．4％（4／54）。围手术期死亡2例，死亡率3．2％，占胰瘘的22．2％。死因为胰瘘致全身衰竭。结论：要降低胰肠吻合口瘘的发生率，重点在于手术技巧及方式的改进。手术前后的支持治疗、应用生长抑制、控制感染、有效的胃肠减压是必须的。一旦发生胰瘘，若早期诊断，及时采取综合治疗，可以使绝大部分的胰肠吻合口瘘得到治愈。     

水溶性维生素缺乏致迟发性胰性脑病的诊治

胰性脑病 (pancreatic encephalopathy,PE)的病因复杂多样,尤其胰腺炎后期并发胰性脑病疗效较差.本文总结自1998年10月至2001年12月收治的6例急性重症胰腺炎(SAP)后期并发胰性脑病的诊治体会.     

重症急性胰腺炎合并乳糜腹四例临床分析

重症急性胰腺炎(SAP)起病急骤,病情危重而复杂,病死率高.SAP并发症包括器官功能衰竭、全身炎症反应综合征(SIRS)、全身感染、腹腔间室隔综合征(ACS)、胰性脑病(PE)等.有关SAP合并乳糜腹水在国内外报道较少,但该并发症一旦出现,治疗较困难,因此需要引起医护人员的高度重视.本文报道4例SAP合并乳糜腹水的病例,并进行文献复习,以供临床参考.     

Pancreatic encephalopathy and Wernicke encephalopathy in association with acute pancreatitis： A clinical study

AIM: To investigate clinical characteristics and therapy of pancreatic encephalopathy (PE) and Wernicke encephalopathy (WE). METHODS: In a retrospective study of 596 patients with acute pancreatitis (AP), patients with PE were compared to those with WE in regards to history, clinical manifestation, diagnosis, treatment and outcome. RESULTS: There were 93 patients with severe acute pancreatitis (SAP). Encephalopathies were discovered in 10 patients (1.7%). Six patients with PE all developed in SAP (6.5%), and three of them died (3% of SAP, 50% of PE). Four patients with WE developed in AP (0.7%), and two of them died (0.3% of AP, 50% of WE). Two patients with WE were treated with parenteral thiamine and survived. Global confusions were seen in all patients with encephalopathy. Ocular abnormalities were found. Conjugate gaze palsies were seen in 1 of 6 (16.7%) patients with PE. Of 4 patients with WE, one (25%) had conjugate gaze palsies, two (50%) had horizontal nystagmus, three (75%) had diplopia, and one (25%) had myosis. Ataxia was not seen in all patients. None of patients with WE presented with the classic clinical triad. CSF examinations for 2 patients with WE showed lightly-increased proteins and glucose. CT and MRI of the brain had no evidence of characteristic abnormalities. CONCLUSION: PE occurs in early or reiteration stage of SAP, and WE in restoration stage of SAP/AP. Ocular abnormalities are the hallmarks of WE, and horizontal nystagmus is common. It is difficult to diagnose earlier an encephalopathy as PE or WE, as well as differentiate one from the other. Long fasting, hyperemesis and total parenteral nutrition (TPN) without thiamine are main causes of thiamine deficiency in the course of pancreatitis.     

急性胰腺炎994例病因与治疗分析

目的 探讨急性胰腺炎(AP)的病因及其治疗方法 的选择.方法 回顾性分析2003年1月至2007年1月瑞金医院胰腺普外科收治的994例AP患者资料,根据病因及治疗方式进行分类统计.结果 994例AP患者中,胆源性AP 825例(83.0%),酒精性AP 24例(2.41%),高脂血症性AP29例(2.92%),妊娠性AP16例(1.61%),特发性AP 71例(7.14%),外伤性4例(0.40%),两种病因以上的混合性AP 25例(2.52%).轻症急性胰腺炎(MAP)767例(77.2%),重症急性胰腺炎(SAP)227例(22.8%).总的治愈好转率91.2%,病亡87例,病死率8.8%,其中酒精性AP的病死率达37.5%,显著高于胆源性AP.对胆源性AP患者分别采用非手术治疗、内镜逆行胰胆管造影+乳头括约肌切开(ERCP+EST)、胆囊切除术+胆总管探查或ERCP术后腹腔镜下胆囊切除术及清创引流术.采用清创引流术的患者均为SAP患者,术后病死率高达25.0%,显著高于其他治疗方法 者(P＜0.01).其他3种治疗方法 间的SAP病例比及病死率均无显著差异.结论胆道因素仍是AP的首要病因.酒精性AP病情较危重,预后较差.对胆源性AP,多种治疗方法 的疗效无显著差异.     

急性呼吸窘迫综合征在重症急性胰腺炎治疗过程中的临床意义

目的 探讨急性呼吸窘迫综合征（ARDS）在重症急性胰腺炎（SAP）治疗过程中的临床意义.方法 回顾性分析2003年7月至2006年7月收治的76例SAP患者的临床特点、病程演变趋势和治疗效果,其中29例合并ARDS,经有效呼吸支持,病人情况不稳定,脏器功能无好转.及时行外科手术干预治疗.结果 76例SAP存活64例,死亡12例,存活率84.21%;SAP病程中合并ARDS 29例,存活21例,死亡8例,存活率72.41%,其中手术干预15例,存活10例,死亡5例,存活率66.67%.结论 正确认识和处理SAP病程中并发ARDS,合理选择外科干预方式,对于决定SAP预后至关重要.     

Saddle pulmonary embolism diagnosed by CT angiography: frequency, clinical features and outcome

OBJECTIVE: To assess the frequency, clinical presentation and outcome associated with saddle pulmonary embolism (PE) diagnosed by computed tomographic angiography (CTA). PATIENTS: Retrospective review of 546 consecutive patients diagnosed to have acute PE by CTA from 1 September 2002 to 31 December 2003. RESULTS: Fourteen of 546 patients (2.6%) had saddle PE; 10 were men (71%). None of these patients had pre-existing cardiopulmonary disease. Most common presenting symptoms included dyspnea (72%) and syncope (43%). Hypotension was documented in 2 patients (14%). The most common risk factor for PE was obesity (64%). CTA revealed saddle PE and additional filling defects in the main pulmonary arteries in all patients. Echocardiography was performed within 48 h of the PE diagnosis in 10 patients and revealed right ventricular dysfunction in 8 (80%). All patients were initially managed in the hospital, median length of stay of 4 days (range, 1-45 days). Standard anticoagulant therapy with heparin and warfarin was administered to all patients. Five patients (36%) received additional therapy; thrombolytic therapy was administered to 1 patient (7%) and 4 patients (29%) received an inferior vena cava filter. None of the patients died during their hospitalization. Four patients (29%) died following their hospitalization after intervals of 1, 5, 6, and 12 months, respectively. Causes of death were known in 3 patients, all of whom died from progressive malignancy. CONCLUSION: Saddle PE in patients without pre-existing cardiopulmonary disease is associated with a relatively low in-hospital mortality rate and may not necessitate aggressive medical management.     

Percutaneous rheolytic thrombectomy for large pulmonary embolism: a promising treatment option.

BACKGROUND: Pulmonary embolism (PE) is a common cardiovascular disease with significant mortality. Some patients with large PE are not eligible for current treatment options such as thrombolysis or surgical embolectomy. We report our experience of percutaneous rheolytic thrombectomy (PRT) using the AngioJet system combined with adjunctive local thrombolytic therapy and inferior vena cava (IVC) filter placement to treat massive or submassive PE in patients ineligible for current treatment options. METHODS AND RESULTS: Of the 14 consecutive patients ineligible for thrombolysis or embolectomy treated with PRT, 10 patients had massive PE (6 patients were hypotensive and 4 patients had intractable hypoxemia) and 4 patients had submassive PE. Adjunctive local thrombolysis was performed in 5 patients. An IVC filter was placed in 11 patients. Angiographic success based on Miller score was achieved in 13 patients (92.9%). Procedure success was obtained in 12 patients (85.7%). Procedural mortality occurred in one patient who presented in cardiogenic shock (7.1%) and non-fatal hemoptysis occurred in 1 patient (7.1%). Total in-hospital mortality occurred in 3 patients (21.4%). On a mean follow-up of 9 months, all 11 survivors had noted significant improvement in symptoms without recurrence. CONCLUSIONS: Percutaneous rheolytic thrombectomy using the AngioJet may be a treatment option for patients with massive or submassive PE who may not be eligible for thrombolytic therapy or surgical embolectomy.     

Efficacy of rivaroxaban for the treatment of Chinese patients with acute pulmonary embolism: A retrospective study

Pulmonary embolism (PE) is a life-threatening disease, which accounts for the major type of venous thromboembolism. Currently, there is limited understanding and management for PE. Rivaroxaban is reported to treat patients with PE. However, there is still insufficient evidence on rivaroxaban for the treatment of Chinese patients with acute PE. Thus, this retrospective study investigated the benefits and safety of rivaroxaban for Chinese patients with acute PE.A total of 72 Chinese patient cases with acute PE were analyzed in this study. Of these, 36 cases who received rivaroxaban mono-therapy were assigned to the treatment group, while the remaining 36 cases who received standard therapy were assigned to the control group. The benefits were assessed by the duration of hospital stay, treatment satisfaction, and safety.After treatment, rivaroxaban mono-therapy showed better benefits in decreasing the duration of hospital stay (P < .01), increasing treatment satisfaction (P < .01), and reducing mild bleeding (P = .02) in Chinese patients with acute PE, than standard therapy.The results of this study indicated that rivaroxaban may provide more benefits than the standard therapy for Chinese patients with acute PE. Future studies are still needed to warrant the current results.     

Diagnosis and treatment of gallbladder perforation

INTRODUCTION Gallbladder perforation (GBP) is a rare but life threatening complication of acute cholecystitis. Sometimes GBP may not be different from uncomplicated acute cholecystitis with high morbidity and mortality rates because of delay in diagnosis[…     

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。     

老年上消化道穿孔83例临床分析

目的　探讨老年人上消化道穿孔的临床特点 ,提高其诊断与治疗水平。　 方法 　回顾性分析收治的83例老年上消化道穿孔的临床资料。　 结果　 3 9例 ( 46 % )患者临床症状不典型。发病至手术时间在 12h之内死亡及并发症发生率分别为 2 5 %及 3 6 7% ;超过 12h为 11 5 %及 5 3 8%。 6 7例行急症手术治疗 ,行穿孔修补术 5 6例 ,死亡 3例 ,行胃大部切除术 11例 ,死亡 1例 ,手术死亡率为 6 %。保守治疗 16例 ,死亡 4例 ,死亡率为 2 5 %。　结论　老年人上消化道穿孔症状往往较隐匿 ,应尽早诊断 ,及时手术治疗并警惕胃癌穿孔的可能性。手术方法以穿孔修补术较为安全。