暴发性急性胰腺炎的诊断与治疗

经过国内、外学者近40年的不懈努力,重症急性胰腺炎(severe acute pancreatitis,SAP)患者的生存率大幅度提高,达86%.但SAP中的暴发性急性胰腺炎(fulminant acute pancreatitis,FAP),因其病情发展迅速,即使在起病72 h内经充分的液体复苏,仍可能出现器官功能衰竭[1].     

暴发性胰腺炎的微创治疗

暴发性胰腺炎(ful minant acute pancreatitis,FAP)是指急性胰腺炎在发病72 h内,虽经充分的液体复苏,仍然迅速出现进行性器官功能障碍者。FAP是重症急性胰腺炎(severe acute pancreatitis,SAP)的一种特殊亚型,起病急骤,病程凶险,并发症多,预后较差。对SAP的治疗,争议从来     

重症急性胰腺炎急性肾功能衰竭临床危险因素及其预防

目的研究重症急性胰腺炎(severe acute pancreatitis，SAP)病人急性肾功能衰竭(acute renal failure，ARF)发生的易患因素，估价ARF与SAP病人预后的相关性，探讨预防ARF发生的措施。方法回顾性分析我院1990年以来收治的SAP病人246例，对病人年龄、性别、病因、Ranson评分、APACHEⅡ评分、低氧血症、腹腔室隔综合征、感染、血淀粉酶水平、尿淀粉酶水平、急诊手术、禁食天数、是否应用生长抑素等因素，进行多因素Logistic回归分析。结果246例SAP病人31例发生ARF，ARF的发病率为12．6％。ARF组APACHEⅡ评分明显高于无ARF组，两组比较有显著性差异。腹腔室隔综合征、低氧血症和急诊手术在两组之间比较有显著性差异。结论在SAP发病过程中，APACHEⅡ评分增高、低氧血症和腹腔室隔综合征可能是导致ARF发生的危险因素。维持病人全身状态稳定、防止肾脏低灌注损害、预防低氧血症的发生以及手术引流腹腔减压可能有预防ARF发生的作用。     

重症急性胰腺炎器官功能维护重要性及实施方案

<正>急性胰腺炎(acute pancreatitis, AP)按照临床病情可分为轻症急性胰腺炎(mild acute pancreatitis, MAP),中重症急性胰腺炎(moderately severe pancreatitis, MSAP)和重症急性胰腺炎(severe acute pancreatitis,SAP)。SAP的特点即为持续性(48 h)的器官功能衰竭(单个或多个器官)。在SAP早期,难以控制的全身性瀑布式炎症反应不     

���������������ιؼ�̽��

目的　探讨暴发性胰腺炎 (FAP)发生、发展的特点及治疗方法。方法　回顾性分析出现症状 72h内住院的重症急性胰腺炎 (SAP) 2 0 9例。所有病人均在ICU行监护及最大限度地加强治疗。FAP为出现症状 72h内发生器官功能障碍的SAP ,比较 5 6例FAP(FAP组 )与 15 3例 72h内未发生器官功能障碍的重症急性胰腺炎 (SAP组 )的临床特点。结果　FAP组胰腺病变程度 (CT分级 )较SAP组严重 (5 19± 0 68vs 3 72± 0 2 5 ) ;FAP组病死率及低氧血症、胰腺感染和多器官功能障碍综合征 (MODS)发生率明显高于SAP组 (5 3 6%vs 2 6%、85 71%vs2 2 88%、17 86%vs 6 5 4%和 78 6%vs 9 15 % )。FAP组中与病死率相关的高危因素为低氧血症、高APACHE Ⅱ分值、器官功能障碍数目以及胰腺病变严重程度。结论　FAP的特征包括MODS发生率高、胰腺病变程度严重、早期发生低氧血症、腹腔室隔综合征 (ACS)、高APACHE Ⅱ评分和高病死率。监护重要脏器功能、适当补充血容量、早期预防性应用抗生素、积极纠正低氧血症、缓解ACS(包括经腹腔镜腹腔冲洗及早期促进胃肠蠕动 )等处理可能对FAP的治疗有益     

暴发性胰腺炎、6例治疗体会

暴发性胰腺炎（fulminant acute pancreatitis，FAP）指重症急性胰腺炎（severe acute pancreatitis，SAP）在发病72h内出现难以控制的器官功能障碍综合征（organ dysfunction syndrome，ODS），根据亚特兰大会议的SAP的诊断标准，FAP的诊断为：SAP在发病后72h内出现以下1项者：（1）肾功能衰竭（血清肌酐〉176．8μmol／L）：（2）呼吸衰竭（PaO2≤8kPa）：（3）APACHEⅡ评分≥20分：（4）腹腔渗液超过3000ml和后腹膜严：重积液：（5）Glasgow〈8分，该病病情极为严重，发展迅速，死亡率很高，近年我科收治6例FAP患者，现报告如下。     

血液滤过持续时间对重症急性胰腺炎治疗的作用

目的探讨血液滤过在重症胰腺炎(severe acute pancreatitis,SAP)急性反应期的治疗模式。方法选取1997年4月至2006年4月间104例急性胰腺炎在发病72 h内接受血液滤过者作为研究对象。分为重症胰腺炎(SAP,66例)和暴发性胰腺炎(fulminant acute pancreatitis,FAP,38例)两组,观察两组患者在接受不同血滤持续时间≤8 h(Ⅰ组)、9～24 h(Ⅱ组)和>24 h(Ⅲ组)后对生存率的影响。SAP和FAP的Ⅰ,Ⅱ,Ⅲ组之间,其入院APACHEⅡ和血滤开始时间均无差异(P>0.05)。SAP患者Ⅰ组、Ⅱ组的存活率显著高于Ⅲ组,其P值分别为0.007,0.01;Ⅰ组和Ⅱ组的存活率无差异。FAP患者,Ⅰ组和Ⅱ组的存活率无差异;Ⅰ组、Ⅱ组的存活率较Ⅲ组显著降低,其P值分别为0.002,0.024。结论SAP和FAP发病72 h内,血液滤过的模式宜分别采用短时(<24 h)和持续血液滤过(>24 h)。     

暴发性胰腺炎的临床特点及治疗

暴发性胰腺炎(fulminant acute pancreatitis,FAP)来势凶猛,并发症多及死亡率高,近年倍受关注.过去虽然有文章在重症急性胰腺炎(severe acute pancreatitis,SAP)中提及FAP,但很少专门对其进行研究,FAP的概念及诊断标准也未达成完全一致.目前多数学者认为FAP实际上是一在尚未出现胰腺感染的SAP早期(发病48 h或72 h内)病情即急剧恶化的特重型SAP,约占SAP的 25%,表现为生命体征不平稳及难以控制的多器官功能障碍综合征(multiple organ dysfunction syndrome,MODS),临床上缺乏有效治疗手段,住院时间长,治疗费用高,死亡率高达30%～60%.     

暴发性胰腺炎16例诊治体会

暴发性急性胰腺炎(ful minatant acute pancreatitis,FAP)由于在病程早期即出现难以控制的器官功能障碍而仍有很高的病死率,我科自2000年1月至2004年12月收治急性胰腺炎312例,其中重症胰腺炎(severe acute pancreatitis,SAP)63例,属于FAP 16例。报告如下。临床资料1.一般资料:2000年1月至2004年12月我科共收治发病72 h内入院的SAP 63例,其中FAP 16例。63例SAP中男29例,女34例,年龄19~87岁,平均51.4岁;16例FAP中男9例,女7例,年龄21~63岁,平均42.3岁。本组在诊断FAP前有6例出现了多脏器功能衰竭,发生腹腔室隔综合征(abdominal compa…     

中度急性胰腺炎临床特征分析

目的探讨中度急性胰腺炎的临床特征。方法回顾性分析2013年1月至12月,青海省交通医院普通外科收治的103例急性胰腺炎（acute pancreatitis,AP）患者临床资料,根据国际AP专题研讨会最新修订的诊断和分类标准（2012年,美国亚特兰大）诊断为轻度急性胰腺炎（mildacutepancreatitis,MAP）61例、中度急性胰腺炎（moderately severe acute pancreatitis,MSAP）25例、重度急性胰腺炎（severe acute pancreatitis,SAP）17例,对比三组患者一般资料、局部并发症发生此例、器官功能衰竭发生比例、入住ICU比例和天数、干预措施、住院天数、病死率。结果三组患者性别、年龄和病因学情况差异均无统计学意义,但MSAP组APACHEⅡ评分显著高于MAP组,同时低于SAP组（均P〈0．05）。MAP、MSAP和SAP三组出现局部并发症的比例分别为0、92．0％（23125）和76．5％（13／17）（P〈0．05）。MAP组无器官功能表竭发生,MSAP组5例出现一过性（〈48h）器官功能表竭,SAP组均出观特续性（〉48h）器官功能衰竭,SAP组器官功能衰竭比例显著高于MSAP组（P〈0．05）。MAP组无入住ICU病例,均无需介入、内镜或外科干预,无死亡病例。MSAP组入住ICU此例、ICU时间、住院时间和病死率显著低于SAP组（P〈0．05）。结论中度急性胰腺炎为有别于轻度和重度急性胰腺炎的独立类型,伴有局部并发症或一过性（48h内）器官功能表竭,但病死率较低,预后明显好于重度急性胰腺炎。     

腹内高压与急性胰腺炎严重程度的相关性分析

目的：探讨腹内高压（IAH）与急性胰腺炎（AP）病情严重程度的相关性。 方法： 选取2014年2月—2015年2月收治的AP患者80例,根据入院APACHE II评分,其中轻症胰腺炎（MAP）49例（MAP组）,重症胰腺炎（SAP）31例（SAP组）。采用经膀胱间接测量法监测腹内压（IAP）,4 h/次,连续5 d,连续2次IAP值≥12 mmHg诊断为IAH。比较两组IAH发生率,分析IAP值与APACHE II评分的相关性;比较SAP患者中发生IAH与未发生IAH患者不良临床事件的发生率,采用ROC曲线（AUC）评价APACHE II评分和IAP值预测SAP患者不良临床事件的价值。 结果：SAP组IAH发生率明显高于MAP组（45.2% vs. 0%,P<0.05）;Pearson相关分析结果显示,IAP值与APACHE II评分呈正相关（r=0.752,P<0.05）;SAP患者中,发生IAH者各项不良临床事件发生率均明显高于未发生IAH者（P<0.05）;IAP值预测SAP患者不良临床事件的AUC明显大于APACHE II评分（0.892 vs. 0.610,P<0.05）。 结论：IAH与AP病情严重程度密切相关,并影响AP患者的临床结局。IAP在预测SAP患者不良临床事件发生风险的方面具有重要的临床价值。     

Treatment of Acute Pancreatic Pseudocysts After Severe Acute Pancreatitis

Treatment of acute pancreatic pseudocysts (APP) after an episode of severe acute pancreatitis (SAP) remains controversial. Both population heterogeneity and limited numbers of patients in most series prevent a proper analysis of therapeutic results. The study design is a case series of a large, tertiary referral hospital in the surgical treatment of patients with APP after SAP. An institutional treatment algorithm was used to triage patients with complicated APP and organ failure based on Sequential Organ Failure Assessment scores to temporizing percutaneous or endoscopic drainage to control sepsis and improve their clinical condition before definitive surgical management. Over a 10-year period of study (December 1995 to 2005), 73 patients with APP after an episode of SAP were treated, 43 patients (59%) developed complications (infection 74.4%, perforation 21%, and bleeding 4.6%) and qualified for our treatment algorithm. Percutaneous/endoscopic drainage was successful in controlling sepsis in 11 of 13 patients (85%) with severe organ failure and allowed all patients to undergo definitive surgical management. The morbidity (7 vs 44.1%, P = 0.005) and mortality rates (0 vs 19%, P = 0.04) were significantly higher in complicated vs uncomplicated APP. Acute pancreatic pseudocysts after SAP are unpredictable and have a high incidence of complications. Once complications develop, there is a significantly higher morbidity and mortality rate. In complicated APP with severe organ failure, percutaneous/endoscopic drainage is useful in controlling sepsis and allowing definitive surgical management.     

Improved prediction of outcome in patients with severe acute pancreatitis by the APACHE II score at 48 hours after hospital admission compared with the APACHE II score at admission. Acute Physiology and Chronic Health Evaluation

HYPOTHESIS: The 48-hour APACHE (Acute Physiology and Chronic Health Evaluation) II score is a better predictor of pancreatic necrosis, organ failure, and mortality in patients with severe acute pancreatitis than the score at hospital admission. DESIGN: A retrospective analysis of 125 patients with acute pancreatitis. SETTING: A tertiary public teaching hospital. PATIENTS: Patients with severe acute pancreatitis as defined by 3 or more Ranson criteria or a hospital stay of longer than 6 days. MAIN OUTCOME MEASURES: Pancreatic necrosis, organ failure, and mortality. RESULTS: A significant association was found between the 48-hour score and the presence of pancreatic necrosis (P<.001), organ failure (P =.001), and death (P<.001). By contrast, the APACHE II score at admission was significantly associated only with the presence of organ failure (P =.007). Deteriorating APACHE II scores over 48 hours were significantly associated with a fatal outcome (P =.03). The combined APACHE II score (defined as the sum of the admission and 48-hour scores) was significantly higher among nonsurvivors than survivors (P<.001), and was strongly associated with the presence of pancreatic necrosis (P =.001) and organ failure (P<.001). The 48-hour and combined scores accurately predicted outcome in 93% of the patients compared with 75% by the admission score. CONCLUSIONS: The 48-hour APACHE II score has improved predictive value compared with the admission score for identifying patients with severe acute pancreatitis who have a poor outcome. A deteriorating APACHE II score at 48 hours after admission may identify patients at risk for an adverse outcome.     

急性胰腺炎患者血清ACE与ACE2的动态变化及其临床意义

目的 探讨急性胰腺炎（acute pancreatitis,AP）病程一周内血清血管紧张素转化酶（ACE）、血管紧张素转化酶2（ACE2）水平的动态变化及其临床意义。方法 选取2015年9月至2018年11月杭州师范大学附属医院AP住院患者60例,按《中国急性胰腺炎诊治指南》分为轻度急性胰腺炎组（MAP,45例）和 中重度急性胰腺炎组[（M）SAP,15例],进行规范化治疗,并与同期健康体检的志愿者进行比较（对照组,10例）。采用酶联免疫吸附法测定各组第1、3、7天的血清ACE、ACE2水平,并将ACE、ACE2、ACE2/ACE分别与急性生理与慢性评分II（APACHE II）作相关性分析。结果 随着病情发展,MAP组和（M）SAP组患者APACHE II评分呈下降趋势,但（M）SAP组患者评分始终高于MAP组（P＜0.05）。MAP组患者随APACHE II评分下降,ACE、ACE2、ACE2/ACE逐渐升高,但差异无统计学意义（P＞0.05）。(M)SAP组患者随APACHEII评分下降,ACE逐渐下降（P=0.006）;ACE2无明显变化（P=0.750）;ACE2/ACE逐渐升高（P＜0.001）。相关性分析表明,ACE与APACHE II评分呈线性正相关（r=0.543,P＜0.01）,ACE2/ACE与APACHE II评分呈线性负相关（r=-0.297,P＜0.05）。ACE、ACE2、ACE2/ACE用于判断病情严重程度的敏感性分别为51.1%、33.3%、84.4%,特异性分别为70.0%、86.7%、63.7%。结论 血清ACE、ACE2均参与了AP疾病的发生、发展,以ACE为代表的经典轴会促进胰腺炎发展;以ACE2为代表的新轴来拮抗经典轴,具有抗炎症作用。ACE2/ACE是判断病情严重程度敏感性的较高指标。     

老年人重症急性胰腺炎的临床特点

目的：总结老年重症急性胰腺炎的临床特点及治疗经验。方法：回顾性分析26例老年重症急性胰腺炎的临床资料,并与同期收治的56例非老年重症急性胰腺炎患者作比较。结果：胆源性和特发性胰腺炎是老年患者最常见病因;老年患者住院时间长,APACHEⅡ评分以及合并症和并发症的发生率均高于非老年患者,老年患者更易出现器官衰竭。结论：老年重症急性胰腺炎患者早期症状不典型,合并症比较多,病情复杂,宜早期积极预防和治疗并发症。     

Surgical Treatment for Severe Acute Pancreatitis: Extent and Surgical Control of Necrosis Determine Outcome

In patients operated on for severe acute pancreatitis (SAP), the factors determining outcome remain unclear. From 1986 to 1998 a total of 340 patients with a diagnosis of SAP and in need of operative treatment were admitted to the intensive care unit (ICU) of a university hospital and a secondary care hospital. The mean APACHE II score on the day of admission was 16.1 (range 8–35). All patients required operative therapy. Among the 340 patients, 270 (79.4%) had to be reoperated: 196 patients (72.6%) underwent operative revisions on demand, and 74 (27.4%) patients had preplanned reoperation. The overall mortality was 39.1% (133 patients). Septic organ failure in 126 patients (37.1%) and myocardial infarction or pulmonary embolism in 7 patients (2%) were the causes of death. The patient’s age (p <0.0002), APACHE II scores at admission (p <0.0001), presence or development of (single or multiple) organ failure (p <0.002), infection (p <0.02) and extent (p <0.04) of pancreatic necrosis, and surgical control of local necrosis (p <0.0001) significantly determined survival. SAP that requires surgical treatment is associated with high in-hospital mortality. Surgical control of local necrosis is the precondition for survival. Advanced age of the patient, high APACHE II score at admission, development of organ failure, and the extent and infection of pancreatic necrosis influence the outcome.     

探讨重症急性胰腺炎与器官功能衰竭之间的关系

目的：研究重症急性胰腺炎患者器官功能衰竭的发病率以及器官功能衰竭与胰腺坏死和感染坏死程度之间的关系。方法：将2003年3月-2011年6月被明确诊断为重症急性胰腺炎的患者纳入本研究。器官功能衰竭的诊断依据是Atlanta标准。感染坏死的诊断是基于标本培养阳性。依据CT扫描情况,胰腺坏死程度被分为〈30％,30～50％和〉50％。对持续器官功能衰竭患者的资料进行分析,探讨胰腺坏死和感染的程度与持续器官功能衰竭之间的关系。结果．128例重症急性胰稼炎患者,男99例,女29例,平均年龄（42．6±16．1）岁,522％（67／128）的患者有器官功能衰竭。在器官功能衰竭患者中,49—3％有1个器官功能衰竭,32．8％有2个器官功能衰竭和17.9％有多器官功能衰竭。肺衰竭是最常见的器官功能障碍（761％）。患者年龄的增加和越高的APACHEII评分是器官功能衰竭进展的重要危险因素（P〈0.05）。CT扫描显示：1个、2个和3个器官衰竭患者的胰8泉坏死超过50％的比例分别为48.5％、59-1％和83．3％,然而,在没有器官功能衰竭的患者中,只有27．9％的患者的胰腺坏死程度超过50％（P〈O.001）。没有发现感染坏死与器官功能衰竭之间存在相关性。总体死亡率为47．7％,衰竭的器官越多,死亡率越高（P〈0．os）。结论：52．2％的重症急性胰腺炎患者出现器官功能衰竭。器官功能衰竭的发生与年龄的增加、较高的APACHEII评分和胰腺坏死的程度显著相关,与感染坏死之间无显著相关性。     

Identification of severe acute pancreatitis using an artificial neural network

BACKGROUND: The aim of this study was to construct and validate an artificial neural network (ANN) model to identify severe acute pancreatitis (AP) and predict fatal outcome. METHODS: All patients who presented with AP from January 2000 to September 2004 were reviewed. Presentation data on admission and at 48 hours were collected. Acute Physiology and Chronic Health Evaluation (APACHE) II and Glasgow severity (GS) score were calculated. A feed-forward ANN was created and trained to predict development of severe AP and mortality from AP; 25% of the data set was withheld from training and was used to evaluate the accuracy of the ANN. Accuracy of the ANN in predicting severity of AP was compared with APACHE II and GS scores. RESULTS: A total of 664 patients with AP were identified of whom 181 (27.3%) fulfilled the clinical and radiologic criteria for severe pancreatitis and 42 patients died (6.3%). Median APACHE II score at 48 hours was 4 (range, 0 to 23). ANN was more accurate than APACHE II or GS scoring systems at predicting progression to a severe course (P < .05 and P < .01, respectively), predicting development of multiorgan dysfunction syndrome (P < .05 and P < .01) and at predicting death from AP (P < .05). CONCLUSIONS: An ANN was able to predict progression to severe disease, development of organ failure and mortality from acute pancreatitis with considerable accuracy and outperformed other clinical risk scoring systems. Further studies are required to assess its utility in aiding management decisions in patients with AP.