乌司他汀治疗重症急性胰腺炎的疗效分析

<正>急性胰腺炎(Acute pancreatitis,AP)是常见的急腹症,其中约10%～20%是重症急性胰腺炎(SAP),死亡率高达40%,其病情凶险,发展迅速,并发症多,预后差,传统治疗效果欠佳。造成患者死亡的主要原因是胰腺组织坏死感染继发的多器官功能衰竭(MOF)及全身炎性反应综合性(SIRS)。乌司     

急性胰腺炎胰腺感染及抗生素使用

急性胰腺炎（AP）胰腺感染是AP的局部并发症，包括感染性坏死、胰腺脓肿、感染性急性假性囊肿。AP中有8％～10％并发胰腺感染，而重症胰腺炎（SAP）并发胰腺感染高达40％～70％。有报道称，因AP死亡的病例中80％与胰腺感染有关。新近Buchler等报道86例急性坏死性胰腺炎（ANP）中，无菌性坏死的病死率为1．8％，而感染性坏死的病死率为24％。因此，对抗生素在AP治疗中的作用，特别是预防性使用抗生素有许多新认识。现就AP胰腺感染及抗生素使用的有关问题综述如下。     

重症急性胰腺炎胰腺感染及抗生素的合理使用

急性胰腺炎(acute pancreatitis,AP)胰腺感染包括感染性坏死、胰腺脓肿、感染性急性假性囊肿。AP中8%~10%并发胰腺感染,而重症胰腺炎(SAP)并发胰腺感染高达40%~70%。有报告因AP死亡中80%与胰腺感染有关。近年来,对抗生素在AP治疗中的作用,特别是预防性使用抗生素有许多新认识。     

中西医结合治疗急性胰腺炎68例分析

<正>急性胰腺炎(AP)是多种病因导致胰酶在胰腺内被激活,继以胰腺局部炎性反应为主要特征伴有或不伴有其他器官功能改变的疾病,治疗不及时或不当时容易发展成重症胰腺炎(SAP),SAP是病理过程发展迅速、胰腺组织不断持续坏死的疾病。它发病急剧,易引起休克、急性呼吸窘迫综合     

细胞因子及其抑制剂对重症急性胰腺炎的作用研究进展

急性胰腺炎（acute pancreatitis，AP）是临床内、外科常见的急症之一。病理上分为水肿型和出血坏死型，临床上又分为轻型AP和重症急性胰腺炎（severe acute pancretitis，SAP）。后者是指有局部并发症（胰腺出血、坏死、脓肿、假性囊肿等）和（或）伴有脏器官功能衰竭，约占AP15％-20％，其临床表现危重，病情凶险，病死率可高达30％。而目前对AP（尤SAP）的发病机制尚未完全阐明，治疗上亦尚无一个行之有效的方法来遏制SAP的演进过程。现临床上多采用综合治疗，如抑制胰酶分泌、手术等治疗，虽起一定作用，但并不能阻止胰腺的自身消化和并发症的发生，也不能防止术后残余胰腺的继续坏死和后期的继发感染。     

重症急性胰腺炎的非手术治疗现况

急性胰腺炎是一种常见病,近年发病率呈上升趋势。80%的患者病情呈自限性,经过一般治疗可痊愈,很少发生局部及全身性并发症;而另20%则呈暴发性,通常伴多器官功能衰竭(MOF),死亡率高达30%,称为重症急性胰腺炎(SAP)[1]。80年代以来,随着人们对SAP发病机制和临床研究的深入,SAP的治疗观念发生了一场革命,由过去强调的早期手术治疗发展到对胰腺坏死合并感染才行手术治疗的“个体化治疗方案”。非手术治疗使大部分SAP患者获得了满意疗效。现就有关SAP的非手术治疗现况综述如下。一、抗休克微循环障碍是引起胰腺坏死的主要原因。SAP患者早…     

重症急性胰腺炎36例治疗体会

急性胰腺炎（AP）是胰酶在胰腺内被激化后引起胰腺组织自身消化的化学性炎症，是临床上常见的急腹症之一。临床上按疾病的严重程度又分为重症胰腺炎和轻症胰腺炎。重症急性胰腺炎（SAP）大多数伴有广泛胰旁和胰腺内出血，大范围区域脂肪坏死和实质坏死，死亡率高。我院自2003年2月～2006年3月采用综合治疗36例重症急性胰腺炎，取得了较好疗效，报道如下。     

重症急性胰腺炎的营养支持

重症急性胰腺炎（severe acute pancreatitis，SAP）约占所有急性胰腺炎（acute pancreatitis，AP）的15％～20％，是指具有明显腹膜炎体征和（或）伴有器官功能障碍者。胰腺及胰周多有坏死，病死率为20％～60％。SAP的治疗多以非手术治疗为主，重点是脏器功能维护、液体复苏、纠正内稳态失调、抑制胰腺外分泌和预防胰腺坏死合并感染。     

中药清胰汤治疗重症胰腺炎的观察和护理

急性胰腺炎是因胰腺分泌的消化酶引起胰腺组织自身消化的化学性炎症,临床主要表现为急性上腹痛、发热、恶心、呕吐、血和尿淀粉酶增高,白细胞计数上升,重症伴腹膜炎休克等并发症,分为水肿型和出血坏死型,出血坏死型胰腺炎又称重症胰腺炎(SAP),其死亡率高达50%[1],     

重症急性胰腺炎非感染性胰腺坏死治疗体会

目的：分析急症急性胰腺炎合并非感染性胰腺坏死的手术治疗方法。方法：回顾2012年7月～2013年12月就诊我院普外科治疗的19例重症急性胰腺炎合并非感染性胰腺坏死的患者临床资料,总结手术治疗情况。结果：发病在3周内的患者共4例,病灶主要集中在胰腺头、尾部,周围组织有坏死且胰床与周围肠系膜有粘连,但没有感染表现;发病时间在3～4周的患者10例,可见胰腺组织坏死,且表现为灰白色或紫色,病灶与周围组织粘连严重;发病时间超过5周的患者5例,病灶组织已经分离,周围组织坏死病出现液化现象。结论：重症急性胰腺炎非感染性胰腺坏死及时处理度过全身炎症期后,发病3周内病灶与周围组织有粘连,术中要避免出血,发病3～4周患者最宜行手术治疗;发病超过5周,病灶可能合并感染,需严格控制感染。     

Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis

Background Hemoconcentration may be an important factor that determines the progression of severe acute pancreatitis （SAP）. In addition, it has been proposed that biomarkers may be useful in predicting subsequent necrosis in SAP. However, it is still uncertain whether hemodilution in a short term can improve outcome. We aimed to investigate the effect of rapid hemodilution on the outcome of patients with SAP. Methods One hundred and fifteen patients were admitted prospectively according to the criteria within 24 hours of SAP onset. Patients were randomly assigned to either rapid hemodilution （hematocrit （HCT） 〈35%, n=56） or slow hemodilution （HCT 〉35%, n=-59） within 48 hours of onset. Balthazar CT scores were calculated on admission, day 7, and day 14, after onset of the disease. Time interval for sepsis presented, incidence of sepsis within 28 days and in-hospital survival rate were determined. Results The amount of fluid used in rapid hemodilution was significantly more than that used in slow hemodilution （P 〈0.05） on the admission day, the first day, and the second day. There were significant differences between the rapid and slow hemodilution group in terms of hematocrit, oxygenation index, pH values, APACHE II scores and organ dysfunction at different time during the first week. There were significant differences in the time interval to sepsis in rapid hemodilution （（7.4±1.9） days） compared with the slow hemodilution group （（10.2±2.3） days）, and the incidence of sepsis （78.6%） was higher in the rapid group compared to the slow （57.6%） in the first 28 days. The survival rate of the slow hemodilution group （84.7%） was better than the rapid hemodilution （66.1%. P 〈0.05）. Conclusions Rapid hemodilution can increase the incidence of sepsis within 28 days and in-hospital mortality. Hematocrit should be maintained between 30%-40% in the acute response stage.     

重症急性胰腺炎的早期处理

近20年来急性胰腺炎(acute pancreatitis,AP)诊治水平有了很大提高,病死率有所下降。随着循证医学的发展,AP治疗指南的纷纷出现,AP的治疗更加趋于科学化。目前一致认为早期处理是减轻胰腺坏死和缓解器官功能不全的重要步骤和关键时间,对改善其预后有着至关重要的作用。AP的处理首先需要明确AP的病因和预测严重程度,以致早期进行针对病因的治疗和决定是否需要加强治疗。AP的分型依据亚特兰大会议标准。Ranson评分、APACHEⅡ评分、CT、CRP等是AP严重程度评价的主要方法。早期处理主要包括:适量液体复苏、充分氧供、防治感染、镇静、镇痛、营养支持、抑制胰腺外分泌、促进胃肠功能的恢复、早期血滤、小剂量糖皮质激素应用。少数患者可能需要针对病因和局部并发症的手术治疗。     

急性坏死性胰腺炎修复中胶原Ⅰ的表达和胰腺细胞的修复

目的　探讨急性胰腺炎(AP)修复中胶原Ⅰ的表达和胰腺细胞的修复。方法　将NIHswiss小鼠分为2 组:盐水对照组和急性胰腺炎组。急性胰腺炎诱导采用蛙皮素腹腔注射,用常规病理评价胰腺的炎症程度;免疫组织化学方法检测胶原Ⅰ的表达;流式细胞仪检测细胞增生状态。结果　蛙皮素腹腔注射可诱导小鼠急性胰腺炎。急性胰腺炎组小鼠诱导后8 h胰腺组织损伤最严重,至第7天时组织损伤基本恢复正常。AP时胶原Ⅰ的表达增强。AP诱导后细胞增生状态分3个时期:早期的增生活跃期、中期的增生抑制期和后期的高增生状态。结论　AP是一种自限性疾病,机体可自行修复损伤。AP机体修复过程中,纤维化修复占重要地位,胶原Ⅰ表达升高;胰腺细胞增生在修复中也起重要作用。     

Effect of vagotomy on acute pancreatitis in rats

Acute pancreatitis ( AP) is a common surgicalabdomen,which has a high mortality,especiallyhemorrhagic necrotic pancreatitis.Many things areunknown for its pathogen,pathogenesis and clinicaltreatment.Restraining secretion of pancreatin so asto decrease its complication is used now in clinicalpractice[1] .A lot of information indicates that vagushas directdomination on exocrine of pancreas[2 ] .Thepurpose of this study was to investigate whether thevagotomy ( VG) had effect on AP in rats.1　M…     

PAPⅠ基因在实验性急性胰腺炎模型大鼠中的表达

目的 研究胰腺炎相关蛋白Ⅰ(pancreatitis associated proteinⅠ,PAPⅠ)在急性胰腺炎(acute pancreatitis,AP)动物模型胰腺组织中的表达特点及意义.方法 大鼠轻型胰腺炎(mild acute pancreatitis,MAP)和重型胰腺炎(severe acute pancreatitis,SAP)模型由逆行胰胆管注射1.5%及3.0%牛磺胆酸钠制备.采用反转录聚合酶链反应(RT-PCR)法检测胰腺组织PAPⅠ mRNA的表达,同时检测胰腺组织病理改变、湿/干质量比率、腹水量以评价炎症程度.结果 PAPⅠ mRNA在正常对照组无表达, AP造模后6 h即明显升高, 24 h达高峰,48 h迅速下降.SAP组PAPⅠ mRNA表达水平在6、24、48、72 h各时间点均显著高于MAP组(P＜0.05).同时PAPⅠ mRNA表达与胰腺组织病理、胰腺组织湿/干质量比率和腹水量相关.结论 PAPⅠ mRNA的表达变化与AP时胰腺组织损伤程度相关.     

Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis

Background Hemoconcentration may be an important factor that determines the progression of severe acute pancreatitis (SAP). In addition, it has been proposed that biomarkers may be useful in predicting subsequent necrosis in SAP. However, it is still uncertain whether hemodilution in a short term can improve outcome. We aimed to investigate the effect of rapid hemodilution on the outcome of patients with SAP.Methods One hundred and fifteen patients were admitted prospectively according to the criteria within 24 hours of SAP onset. Patients were randomly assigned to either rapid hemodilution (hematocrit (HCT) <35%, n=56) or slow hemodilution (HCT 235%, n=59) within 48 hours of onset. Balthazar CT scores were calculated on admission, day 7, and day 14, after onset of the disease. Time interval for sepsis presented, incidence of sepsis within 28 days and in-hospital survival rate were determined.Results The amount of fluid used in rapid hemodilution was significantly more than that used in slow hemodilution (P <0.05) on the admission day, the first day, and the second day. There were significant differences between the rapid and slow hemodilution group in terms of hematocrit, oxygenation index, pH values, APACHE II scores and organ dysfunction at different time during the first week. There were significant differences in the time interval to sepsis in rapid hemodilution ((7.4 1.9) days) compared with the slow hemodilution group ((10.2 2.3) days), and the incidence of sepsis (78.6%) was higher in the rapid group compared to the slow (57.6%) in the first 28 days. The survival rate of the slow hemodilution group (84.7%) was better than the rapid hemodilution (66.1%. P<0.05).Conclusions Rapid hemodilution can increase the incidence of sepsis within 28 days and in-hospital mortality. Hematocrit should be maintained between 30%-40% in the acute response stage.     

Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis

Background Hemoconcentration may be an important factor that determines the progression of severe acute pancreatitis (SAP). In addition, it has been proposed that biomarkers may be useful in predicting subsequent necrosis in SAP. However, it is still uncertain whether hemodilution in a short term can improve outcome. We aimed to investigate the effect of rapid hemodilution on the outcome of patients with SAP.Methods One hundred and fifteen patients were admitted prospectively according to the criteria within 24 hours of SAP onset. Patients were randomly assigned to either rapid hemodilution (hematocrit (HCT) <35%, n=56) or slow hemodilution (HCT 235%, n=59) within 48 hours of onset. Balthazar CT scores were calculated on admission, day 7, and day 14, after onset of the disease. Time interval for sepsis presented, incidence of sepsis within 28 days and in-hospital survival rate were determined.Results The amount of fluid used in rapid hemodilution was significantly more than that used in slow hemodilution (P <0.05) on the admission day, the first day, and the second day. There were significant differences between the rapid and slow hemodilution group in terms of hematocrit, oxygenation index, pH values, APACHE II scores and organ dysfunction at different time during the first week. There were significant differences in the time interval to sepsis in rapid hemodilution ((7.4 1.9) days) compared with the slow hemodilution group ((10.2 2.3) days), and the incidence of sepsis (78.6%) was higher in the rapid group compared to the slow (57.6%) in the first 28 days. The survival rate of the slow hemodilution group (84.7%) was better than the rapid hemodilution (66.1%. P<0.05).Conclusions Rapid hemodilution can increase the incidence of sepsis within 28 days and in-hospital mortality. Hematocrit should be maintained between 30%-40% in the acute response stage.     

气肿型胰腺炎的分类及其与预后的关系

目的： 气肿型胰腺炎(emphysematous pancreatitis,EP)是感染性胰腺坏死(infected pancreatic necrosis, IPN)的一种亚型,其特点是胰腺坏死组织内部或胰周有气体积聚。本研究探讨EP的分类与预后的关系,以期为临床 诊治IPN提供指导。方法：2010 年1 月至2020 年6 月间中南大学湘雅医院普通外科连续收治228 例IPN患者,将其中 在入院前未行外科干预的120 例IPN 患者纳入本研究,并分为EP组和非EP组,比较2 组的一般临床资料和病原微生 物检查结果。将EP患者根据气泡征出现的时间分为早期EP和后期EP患者;根据气泡征的分布范围分为广泛型EP和 普通型EP患者。比较IPN死亡组与存活组,EP死亡组与存活组的临床特征。结果：120 例IPN患者中有EP患者25 例 (20.8%)和非EP 患者95 例(79.2%)。早期EP 8 例(32.0%),后期EP 17 例(68.0%);普通型EP 15 例(60.0%),广泛型EP 10 例(40.0%)。EP组和非EP组性别、年龄、病因、病死率等的差异均无统计学意义(均P>0.05)。EP组大肠埃希菌的 感染率显著高于非EP 组(52.0% vs 16.5%,P<0.05)。120 例IPN 患者中35 例死亡(IPN 死亡组),85 例存活(IPN 存活 组),IPN 病死率为29.2%。IPN 死亡组和IPN 存活组性别、年龄、病因等的差异无统计学意义(均P>0.05)。IPN 死亡 组重症患者占比明显高于IPN 存活组(97.1% vs 54.1%,P<0.05)。25 例EP 患者中8 例死亡(EP 死亡组),17 例存活(EP 存活组),EP病死率为32.0%。EP死亡组和EP存活组性别、年龄、病因、发现气体至外科干预的时间等的差异无统 计学意义(均P>0.05)。EP 死亡组早期EP、广泛型EP 占比均明显高于EP 存活组,差异有统计学意义(均P<0.05)。早 期EP+广泛型EP 患者病死率高达100%。EP 死亡组100%为重症患者,EP 存活组中58.8%的为中重症患者,差异有 统计学意义(P<0.05)。EP 存活组100%采用升阶梯外科治疗策略。结论：气泡征与IPN 的预后无关。早期EP 和广泛 型EP往往提示预后不良,需积极采取升阶梯外科治疗策略为主的干预。     

重症急性胰腺炎后多器官衰竭

本文分析我院过去16年间连续收治的重症急性胰腺炎70例及其中并发MOF者17例,以探讨影响重症胰腺炎临床治愈率的限制性因素。本组总病死率为20.0％,其中12例死亡与MOF有关,占85.7％;MOF的病死率高达70.6％。于胰腺炎病程不同时期发生的MOF具有不同的临床过程或模式,可分为早期速发单相型和后期迟发双相型。与重症胰腺炎后MOF有关的发病因素包括早期循环休克、胰腺脓毒症及重度胰坏死等,后者可能是MOF发病中的主导因素。重症胰腺炎后MOF的临床过程以显著的全身炎性反应为特征,由局部胰腺毒性病灶始动的失控的全身炎性反应可能是重症胰腺炎导致MOF的共同病理通路。     

腹腔液淀粉酶测定估价急性胰腺炎病变程度及预后的作用

通过主胰管逆行注入不同剂量的胆汁和胰蛋白酶混合液，在２２只猫诱发了程度不同的急性胰腺炎。组织病理学表明：Ａ组动物主胰管注入０．８ｍｌ／ｋｇ混合液，诱发的胰腺炎较轻，病理改变以间质水肿为主；Ｂ组动物注射１．０ｍｌ／ｋｇ混合液，胰腺病变为广泛坏死；Ｃ组动物注射１．２ｍｌ／ｋｇ混合液，胰腺广泛坏死合并肺、肝损害。所有实验动物腹腔液淀粉酶均明显升高，升高幅度与胰腺病变程度呈正比，与实验动物的生存时间呈反比。Ａ组动物腹腔液淀粉酶为４８９０Ｕ／Ｌ，其生存时间在７ｄ以上；胰腺坏死严重的Ｂ组动物，腹腔液淀粉酶为１３９５２Ｕ／Ｌ，生存时间５０．４ｈ；Ｃ组动物腹腔液淀粉酶２３８１０Ｕ／Ｌ，生存时间１０．４ｈ。实验结果表明：腹腔液淀粉酶测定对估价急性胰腺炎病变程度及预后有显著意义，可做为评定急性胰腺炎病变程度及估价预后的重要指标。