Early recognition of abdominal compartment syndrome in patients with acute pancreatitis

AIM： To assess the value of widely used clinical scores in the early identification of acute pancreatitis （AP） patients who are likely to suffer from intra-abdominal hypertension （IAH） and abdominal compartment syndrome （ACS）.
METHODS： Patients （η = 44） with AP recruited in this study were divided into two groups （ACS and non-ACS） according to intra-abdominal pressure （IAP） determined by indirect measurement using the transvesical route via Foley bladder catheter. On admission and at regular intervals, the severity of the AP and presence of organ dysfunction were assessed utilizing different multifactorial prognostic systems： Glasgow-Imrie score, Acute Physiology and Chronic Health Evaluation Ⅱ （APACHE-Ⅱ） score, and Multiorgan Dysfunction Score （MODS）. The diagnostic performance of scores predicting ACS development, cut-off values and specificity and sensitivity were established using receiver operating characteristic （ROC） curve analysis.
RESULTS： The incidence of ACS in our study population was 19.35%. IAP at admission in the ACS group was 22.0 （18.5-25.0） mmHg and 9.25 （3.0-12.4） mmHg in the non-ACS group （P 〈 0.01）. Univariate statistical analysis revealed that patients in the ACS group had significantly higher multifactorial clinical scores （APACHE Ⅱ, Glasgow-Imrie and MODS） on admission and higher maximal scores during hospitalization （P 〈 0.01）. ROC curve analysis revealed that APACHE Ⅱ, Glasgow-Imrie, and MODS are valuable tools for early prediction of ACS with high sensitivity and specificity, and that cut-off values are similar to those used for stratification of patients with severe acute pancreatitis （SAP）.
CONCLUSION： IAH and ACS are rare findings in patients with mild AR Based on the results of our study we recommend measuring the IAP in cases when patients present with SAP （APACHE Ⅱ 〉 7; MODS 〉 2 or Glasgow-Imrie score 〉 3）.     

Adjunctive continuous high-volume hemofiltration in acute severe pancreatitis patients: A retrospective study

Abstract

Objective. To evaluate the efficacy of continuous high-volume hemofiltration for the treatment of severe acute pancreatitis patients and the impact of acute physiology and chronic health evaluation (APACHE) II score on the efficacy of high-volume hemofiltration. Material and methods. A total of 63 patients diagnosed with severe acute pancreatitis between January 2005 and July 2007 were retrospectively analyzed: 34 accepted adjunctive continuous high-volume hemofiltration (HVHF group); and 29 only accepted conventional recommended treatments (control group). Results. There were no differences in physiological characteristics between the two groups when entering the intensive care unit. After treatment, the percentages of patients successfully weaned from mechanical ventilation (p = 0.004) and who experienced renal function recovery (p = 0.046) were significantly higher in the HVHF group than in the control group. The 28-day survival rate was 91.2% in the HVHF group, compared with 65.5% in the control group (p = 0.014). For patients with APACHE II scores > 15, survival was significant higher in the HVHF group than in the control group (87.5% vs 50%; p = 0.044). No difference in survival was found in patients with APACHE II scores ≤ 15 between the two groups (94.4% vs 76.5%; p = 0.177). After HVHF therapy, APACHE II score, body temperature, urine volume and laboratory indices, including serum creatinine, base excess and blood calcium, were significantly improved. Conclusions. Adjunctive continuous HVHF was beneficial for the survival of severe acute pancreatitis patients. Survival improvement was significant in patients with APACHE II score > 15.     

强化胰岛素治疗在重症急性胰腺炎中的作用

目的 探讨强化胰岛素治疗在重症急性胰腺炎中的作用.方法 将31例患者分成强化胰岛素治疗组(18例)和对照组(13例).强化胰岛素治疗组在常规综合治疗基础上给予强化胰岛素治疗,使血糖控制在4.4～6.1 mmol/L ;对照组当血糖超过11.9 mmol/L时用胰岛素将血糖控制在10.0～11.7 mmol/L.观察两组患者血和尿淀粉酶、血常规、血生化指标并进行APACHEⅡ评分,分析两组患者的并发症发生率和住院天数.结果 (1)强化胰岛素治疗组APACHEII评分显著下降的时间(1天)较对照组(3天)提前,且强化胰岛素治疗组3天起较对照组显著降低(P＜0.05);(2)强化胰岛素治疗组与对照组比较,患者的住院死亡率和并发症发生率有下降趋势,但无显著性差异;(3)强化胰岛素治疗组患者的住院时间较对照组明显缩短;(4)18例强化胰岛素治疗组患者中有4例发生低血糖血症,而对照组无低血糖血症发生.结论 强化胰岛素治疗可以促使重症急性胰腺炎的恢复,改善病情并减少患者的住院天数.     

Clinical Effects of Pulse High‐Volume Hemofiltration on Severe Acute Pancreatitis Complicated With Multiple Organ Dysfunction Syndrome

To evaluate the effects of pulse high‐volume hemofiltration (PHVHF) on severe acute pancreatitis (SAP) with multiple organ dysfunction syndrome (MODS). Thirty patients were divided into two groups: PHVHF group and continuous venovenous hemofiltration (CVVH) group. They were evaluated in terms of clinical symptoms, acute physiology and chronic health evaluation (APACHE) II score, sequential organ failure assessment (SOFA) score, simplified acute physiology (SAPS) II score and biochemical changes. The levels of IL‐6, IL‐10 and TNF‐α in plasma were assessed by ELISA before and after treatment. The doses of dopamine used in shock patients were also analyzed. In the two groups, symptoms were markedly improved after treatment. Body temperature (BT), breath rate (BR), heart rate (HR), APACHE II score, SOFA score, SAPS II score, serum amylase, white blood cell count and C‐reactive protein were decreased after hemofiltration (P < 0.05). The PHVHF group was superior to the CVVH group, especially in APACHE II score, CRP (P < 0.01), HR, temperature, SOFA score and SAPS II score (P < 0.05). The doses of dopamine for shock patients were also decreased in the two groups (P < 0.05), with more reduction in the PHVHF group than the CVVH group (P < 0.05). The levels of IL‐6, IL‐10 and TNF‐α decreased (P < 0.05) in the PHVHF group more significantly than the CVVH group (P < 0.01). PHVHF appears to be superior to CVVH in the treatment of SAP with MODS.     

Treatment of abdominal compartment syndrome in severe acute pancreatitis patients with traditional Chinese medicine

AIM： To investigate the therapeutic effect of traditional Chinese traditional medicines Da Cheng Qi Decoction （Timely-Purging and Yin-Preserving Decoction） and Glauber＇s salt combined with conservative measures on abdominal compartment syndrome （ACS） in severe acute pancreatitis （SAP） patients.
METHODS： Eighty consecutive SAP patients, admitted for routine non-operative conservative treatment, were randomly divided into study group and control group （40 patients in each group）. Patients in the study group received Da Cheng Qi Decoction enema for 2 h and external use of Glauber＇s salt, once a day for 7 d. Patients in the control group received normal saline （NS） enema. Routine non-operative conservative treatments included non-per os nutrition （NPON）, gastrointestinal decompression, life support, total parenteral nutrition （TPN）, continuous peripancreatic vascular pharmaceutical infusion and drug therapy. Intra-cystic pressure （ICP） of the two groups was measured during treatment. The effectiveness and outcomes of treatment were observed and APACHE Ⅱ scores were applied in analysis.
RESULTS： On days 4 and 5 of treatment, the ICP was lower in the study group than in the control group（P 〈 0.05）. On days 3-5 of treatment, acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ） scores for the study and control groups were significantly different （P 〈 0.05）. Both the effectiveness and outcome of the treatment with Da Cheng Qi Decoction on abdominalgia, burbulence relief time, ascites quantity, cyst formation rate and hospitalization time were quite different between the two groups （P 〈 0.05）. The mortality rate for the two groups had no significant difference.
CONCLUSION： Da Cheng Qi Decoction enema and external use of Glauber＇s salt combined with routine non-operative conservative treatment can decrease the intra-abdominal pressure （IAP） of SAP patients and have preventive and therapeutic effects on abdominal compartment syndrome o     

清下化瘀方对急性胰腺炎胃肠道及免疫功能的保护作用

[目的]：评价清下化瘀方配合常规西药治疗对急性胰腺炎的胃肠道及免疫功能的保护作用.[方法]将65例急性胰腺炎患者分为治疗组32例、对照组33例.其中,对照组给予西药常规治疗,治疗组在西药常规治疗的基础上加服清下化瘀方.2组均治疗7d后,通过观察临床症状积分的缓解程度以及监测血淀粉酶、CRP、补体C3/C4,并给予APACHEⅡ积分评分评价其功能.[结果]治疗后2组患者的中医症状积分较治疗前均有明显下降,2组治疗前后胃肠道症状比较差异有统计学意义（P＜0.05或P＜0.01）.2组比较,血清CRP、血清补体C3、血淀粉酶差异均有统计学意义：治疗前2组血淀粉酶（AMY）明显高于正常值,治疗后2组AMY明显下降,治疗组恢复至正常值.2组治疗后血淀粉酶差值比较有统计学意义;治疗后2组CRP比较差异有统计学意义（P＜0.01）;2组治疗前C3、C4均有所上升,且2组比较差异无统计学意义;治疗后C3、C4恢复至正常水平,其中2组C3比较差异有统计学意义（P＜0.05）.2组治疗前评分值均接近重症急性胰腺炎的评分标准（APACHEⅡ评分≥8分）,经治疗后2组均有明显下降.[结论]清下化瘀方结合西药常规治疗急性胰腺炎,对其胃肠道及免疫功能有良好的保护作用.     

Current concepts of the role of abdominal compartment syndrome in acute pancreatitis – An opportunity or merely an epiphenomenon

The association of acute pancreatitis (AP) with intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) has only recently been recognized. The detrimental effects of raised intra-abdominal pressure in cardiovascular, pulmonary and renal systems have been well established. Although IAH was associated with a higher APACHE II score and multi-organ dysfunction syndrome (MODS) in severe acute pancreatitis, a causal relationship between ACS and MODS in SAP is yet to be established. It is therefore debatable whether IAH is a phenomenon causative of organ failure or an epiphenomenon seen in conjunction with other organ dysfunction. This review systemically examines the pathophysiological basis and clinical relevance of ACS in AP and summarizes all the available evidence in its management.     

早期血液滤过对重症胰腺炎的治疗效果及预后的研究

目的：探讨重症胰腺炎采用早期血液滤过治疗的临床价值。方法：通过前瞻性的随机对照方法的原则,纳入我院2011年9月至2015年11月收治的确诊为重症胰腺炎患者共100例,所有病例均在发病72小时内接受治疗,其中对照组采用的是常规对症内科治疗、胃肠减压、灌肠肠内营养、腹腔穿刺引流等方法;早期血液滤过治疗组则在对照组的基础上进行早期血液滤过治疗。分别观察两组患者1周内的APACHE-II和Balthazar CT评分,同时记录并发症发生率和病死率。结果：入院治疗后从第3天开始,早期血液滤过治疗组的APACHE-II评分低于对照组,两组差异具有统计学意义;入院后第7天行CT检查Balthazar评分早期血液滤过治疗组低于对照组,两组差异具有统计学意义;早期血液滤过治疗组7d后并发症和死亡的发生率低于对照组,差异具有统计学意义。结论：早期血液滤过治疗可以降低重症胰腺炎的并发症及病死率,是治疗重症胰腺炎有效方法之一。     

持续血液滤过治疗高脂血症性急性胰腺炎24例

目的:观察早期连续血液滤过(continuous veno-venous hemofiltration,CVVH)对高脂血症性急性胰腺炎(hyperlipidemic acute pancreatitis,HLP)的治疗效果.方法:49例HLP患者随机分为2组:连续血液滤过组(A组,n=24)和对照组(B组,n=25).在常规治疗的基础上,A组加用连续血液滤过.观察治疗前后两组患者的心率(HR)、呼吸(R)、氧合指数(PO2/FiO2)、血氧饱和度(SaO2)、血清甘油三酯(TG)、白介素-6(IL-6)以及肿瘤坏死因子-α(TNF-α)等指标的变化;并行APACHE~ 动态评分;比较两组治疗前后急性并发症的变化及治愈率.结果:经CVVH治疗后72h,患者临床症状改善明显,HR、R降至正常,APACHE~评分下降明显(10.8±5.1vs15.5±6.9,P<0.05);血清TG、IL-6及TNF-α亦明显下降(6.8±3.7vs18.5±6.3,39.8±16.7vs72.4±25.1,37.5±14.1vs61.2±16.1,P<0.05).治疗7d后,两组休克均获纠正(P<0.05).A组ARDS和急性肾功能障碍控制迅速,发生率下降明显(5.0%vs37.5%,5.0%vs25%,P<0.05).A组治愈22例,死亡2例,死亡率8.3%;B组治愈20例,死亡5例,死亡率20%,治疗效果显著.结论:CVVH治疗HLP有明显的效果,能有效改善患者病情,降低病死率.     

Comparison of integrated Chinese and Western medicine with and without somatostatin supplement in the treatment of severe acute pancreatitis

AIM: To evaluate the therapeutic effect of the combined use of early short-term somatostatin and conventional integrated Chinese and Western medicine in treating severe acute pancreatitis. METHODS: Sixty patients with severe acute pancreatitis were divided at random into a somatostatin group and a basic treatment group. Both groups received integrated traditional Chinese and Western medicine without surgery. For patients in the somatostatin group, somatostatin was infused intravenously 250 μg/h for 72 h; other medications were the same as in the basic treatment group. In both groups, comparisons of therapeutic effectiveness were made in terms of morbidity of organic dysfunction and mortality rate, and severity of the disease according to serum levels of C-reaction protein, scores of acute physiology and chronic health evaluation (APACHE Ⅱ), and scores of Balthazar-CT. RESULTS: The indexes for C-reaction protein levels on the fourth and seventh clays, and APACHE II scores on the seventh day after treatment, were significantly improved in the somatostatin group than in the basic treatment group. The morbidity of organic dysfunction was lower in the somatostatin group than in the basic treatment group, although the difference was not statistically significant. There was no significant difference in mortality between the two groups. CONCLUSION: We conclude that combined traditional Chinese and Western medicines with an early short-term use of somatostatin can improve the condition of patients with severe acute pancreatitis.     

Balthazar computed tomography severity index is superior to Ranson criteria and APACHE II and III scoring systems in predicting acute pancreatitis outcome

BACKGROUND AND GOALS: Acute pancreatitis runs an unpredictable course. We prospectively analyzed the prognostic usefulness of four different scoring systems in separately assessing three variables; acute pancreatitis severity, development of organ failure and pancreatic necrosis. STUDY: 78 patients with acute pancreatitis were studied prospectively. Data pertinent to scoring systems were recorded 24 hours (APACHE II and III scores), 48 hours (Ranson score) and 72 hours (Balthazar computed tomography severity index) after admission. Statistical analysis was performed by using receiver operating characteristic curves and by comparing likelihood ratios of positive test (LRPT) for all three outcome variables. RESULTS: 44 patients were classified as mild and 34 as severe pancreatitis. When we compared LRPT, only that for the Balthazar score (11.2157) was able to generate large and conclusive changes from pretest to post-test probability in acute pancreatitis severity prediction. LRPT were 2.4157 for Ranson, 4.0980 for APACHE II and 3.6670 for APACHE III score. The APACHE II and III scores and Ranson criteria performed slightly better than the Balthazar score in predicting organ failure (LRPT: 4.0667, 3.2892, 3.0362 and 1.7941 respectively), while when predicting pancreatic necrosis the APACHE II and III performed slightly better than the Ranson score (LRPT: 2.0769, 2.7500 and 1.7813 respectively). CONCLUSIONS: In all outcome measures the APACHE scores generate small and of similar extent changes in probability. The Balthazar score is superior to other scoring systems in predicting acute pancreatitis severity and pancreatic necrosis. However the Ranson and APACHE scores perform slightly better with respect to organ failure prediction.     

Formalized therapeutic guideline for hyperlipidemic severe acute pancreatitis

AIM: To investigate a formalized therapeutic guideline for hyperlipidemic severe acute pancreatitis (HL-SAP).METHODS: Thirty-two consecutive patients with severe acute pancreatitis were included in the clinical trial. All of them met the following five criteria for admission to the study, namely the Atlanta classification and stratification system for the clinical diagnosis of SAP, APACHEII score more than 8, time interval for therapeutic intervention less than 72 hours after onset of the disease, serum triglyceride (TG) level 6.8 mmol/l or over, and exdusion of other etiologies.They were divided into severe acute pancreatitis group (SAP,22 patients) and fulminant severe acute pancreatitis group (FSAP, 10 patients). Besides the conventional therapeutic measures, Penta-association therapywas also applied in the two groups, which consisted of blood purification (adsorption of triglyceride and hemofiltration), antihyperlipidemic agents (fluvastatin or lipanthyl), low molecular weight heparin (fragmin), insulin, topical application of Pixiao (a traditional Chinese medicine) over the whole abdomen, serum triglyceride,pro-inflammatory cytokines and anti-inflammatory cytokines were determined before blood purification (PF), at the end of blood purification (AFE) and on the 7th day after onset of the disease (AF7) respectively. Simultaneously, severity of the diseases was assessed by the APACHE Ⅱ system.Prognosis was evaluated by non-operation cure rate,absorption rate of pseudocyst, time interval pseudocyst absorption, hospital stay and survival rate.RESULTS: Serum triglyceride level (mmol/L), TNFα (U/mi) concentration and APACHE Ⅱ score were significantly decreased (P＜0.05) at AFE and AF7, as compared with PF.However, serum IL-10 concentration (pg/ml) was increased significantly (P＜0.001) at AFE, and decreased significantly (P＜0.05) at AF7 when compared with PF. Operations: The First surgical intervention time was 55.8±42.6 days in SAP group (5 patients) and 12.2±6.6 days in FSAP group (7 patients),there was a significant difference between the two groups (P=0.02). The number of operations in the two groups was 1.33±0.5 vs3.5±1.2 (P=0.0037), respectively. Prognosis: Nonoperation cure rate, absorption rate of pseudocyst, hospital stay and survival rate in SAP group and FSAP group were 100 % (22/22) vs11.1% (1/9), 77.3 % (17/22) vs 11.1%(1/9), 54.2±35.9 vs99.1±49.5 days (P=0.008) and 100 %(22/22) vs66.7 % (6/9) (P=0.0044). The time for absorption of pseudocyst was 135.1±137.5 days in SAP group.CONCLUSION: Penta-association therapy is an effective guideline in the treatment of hyperlipidemic severe acute pancreatitis at its early stage (within 72 hours).     

生长抑素联合前列地尔治疗重症急性胰腺炎43例临床观察

目的:评价生长抑素联合前列地尔治疗重症急性胰腺炎(SAP)的临床疗效并探讨其作用机制。方法:将69例SAP患者分为生长抑素联合前列地尔组(联合组)和单用生长抑素组(对照组),观察2组患者血内毒素、TNF-α、IL-6、血浆内血小板颗粒膜蛋白(GMP140)、血栓素B2(TXB2)、血管性假血友病因子相关抗原(vWF:Ag)水平的变化,比较2组患者治疗前和治疗后14dAPACHEⅡ评分及Binder评分,平均ICU住院时间及28d病死率。结果:2组患者入院时血内毒素、TNF-α、IL-6、GMP140、TXB2、vWF:Ag均高于正常,治疗后降低,联合组较对照组下降的趋势更明显(均P<0.05)。治疗后与对照组比较,联合组APACHEⅡ评分及Binder合并症评分降低更为明显(P<0.05);ICU住院时间明显缩短(P<0.05);病死率显著下降(P<0.05)。结论:生长抑素联合前列地尔治疗SAP比单独应用生长抑素更能抑制炎症介质释放,改善胰腺微循环障碍,缩短ICU住院日。     

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.     

Biliary decompression by nasobiliary catheter or biliary stent in acute suppurative cholangitis: a prospective randomized trial

BACKGROUND: Endoscopic drainage has replaced emergent surgery for biliary decompression in patients with acute cholangitis. The aim of this study was to prospectively compare the efficacy of the nasobiliary catheter and indwelling stent as temporary measures for biliary decompression in acute suppurative cholangitis caused by bile duct stones. METHODS: Over a 60-month period, 79 patients with acute cholangitis who required emergent endoscopic drainage were recruited. Indications for urgent drainage included any one of the following: temperature greater than 39 degrees C, septic shock with systolic blood pressure less than 90 mm Hg, increasing abdominal pain, and impaired level of consciousness. Patients who had previously undergone sphincterotomy or had coexisting intrahepatic duct stones were excluded. After successful bile duct cannulation, patients were randomized to receive either a nasobiliary catheter or indwelling stent without sphincterotomy for biliary decompression. Outcome measures included procedure time, complications, clinical response, and patient discomfort (scored with a 10-cm, unscaled visual analog score). RESULTS: Of the 79 patients, 5 were excluded because of previous sphincterotomy and intrahepatic duct stones, 40 were randomized to receive a nasobiliary catheter (NBC group), and 34 to receive indwelling stent (stent group). Demographic data were similar between the groups. All procedures were successful in the NBC group; there was one failure in the stent group. The mean (SD) procedure time was similar (NBC group 14.0 [9.3] minutes vs. stent group 11.4 [7.2] min). There were 2 ERCP-related complications in the NBC group. Four patients pulled out the nasobiliary catheter and one catheter became kinked. One stent occluded. There was a significantly lower mean (SD) patient discomfort score on day 1 after the procedure in the stent group (stent group 1.8 [2.6] vs. NBC group 3.9 [2.7]; p = 0.02 t test). The overall mortality rate was 6.8% (2.5% NBC group vs. 12% stent group). CONCLUSION: Endoscopic biliary decompression by nasobiliary catheter or indwelling stent was equally effective for patients with acute suppurative cholangitis caused by bile duct stones. The indwelling stent was associated with less postprocedure discomfort and avoided the potential problem of inadvertent removal of the nasobiliary catheter.     

连续性血液净化治疗重症急性胰腺炎的临床观察

目的探讨应用连续性床旁血液净化(CBP)治疗重症急性胰腺炎的临床效果,以有效防止并发症的恶化及减少死亡率的发生。方法回顾性分析2007～2009年我院应用床旁连续性静脉-静脉血液滤过(CVVH)净化方法治疗重症急性胰腺炎或暴发性胰腺炎28例的临床资料。结果重症急性胰腺炎28例,其中暴发性胰腺炎21例。所有患者均在综合治疗的基础上进行CVVH净化治疗,病情好转26例,死亡2例。结论应用CBP治疗重症急性胰腺炎或暴发性胰腺炎,可阻断机体的炎症介质的瀑布式炎症反应,明显的改善了各脏器的功能,病死率显著降低,显示出了其独特的功效。     

Evaluation of prognostic score based on the Japanese criteria for the severity of acute pancreatitis. Part II. Prospective study

From July 1994 to October 1995, a prospective study was conducted at the First Department of Surgery, Mie University School of Medicine, to assess the usefulness of a prognosis score based on the Japanese criteria for the severity of acute pancreatitis. Ten patients with severe acute pancreatitis were treated, and all had good outcomes there were no deaths. In selecting early treatment according to the scoring of severity, we suggest that when the prognosis score is 2 or more and the APACHE II score is 8 or more, gallstone pancreatitis should first be treated by biliary drainage, and non-gallstone pancreatitis by peritoneal lavage. When infected pancreatic necrosis is exhibited, surgery is indicated. Conservative therapy should be selected when the prognosis score is less than 2 and the APACHE II score is less than 8. We found that the prognosis score was useful for both determining the severity of acute pancreatitis and in selecting appropriate treatment.     

重症急性胰腺炎新分类再评价的单中心临床研究

目的 探讨新的急性胰腺炎（AP）分类标准的临床应用价值.方法 回顾性分析2005年1月至2012年12月收治的649例重症急性胰腺炎（SAP）患者资料,按新的分类标准将其分为中度AP（MSAP）和重度AP（SAP）,比较两组患者的Ranson、APACHEⅡ、BISAP、MCTSI、Marshall评分,器官衰竭发生率,临床治疗情况,预后及病死率.结果 649例传统分类的SAP患者按照新分类标准分为MSAP559例和SAP 90例.两组患者的性别、年龄、病因差异均无统计学意义.新分类的MSAP患者入院时的Ranson、APACHEⅡ、BISAP、MCTSI、Marshall评分分别为（1.5±1.3）、（7.6±4.8）、（1.6±0.9）、（6.0±1.8）、（0.0±0.4）分,新分类的SAP患者分别为（3.4±1.7）、（16.8±5.7）、（2.7±0.9）、（6.9±2.1）、（4.3±2.0）分,两组差异均有统计学意义（P值均＜0.01）.MSAP患者发生呼吸衰竭1例次,肾脏衰竭1例次,循环衰竭0例次,发生2个脏器衰竭0例,3个脏器衰竭1例,新分类的SAP患者分别为30、23、l例次和20、11例,两组差异具有统计学意义（P值均＜0.01）.新分类的SAP患者需要入住的重症监护病房（ICU）、血液净化、机械通气、介入引流、外科手术等例数的百分比均显著高于MSAP组,且需要时间也长于后者,两组间的差异均有统计学意义（P值均＜0.01）,但两组患者需要肠内营养支持的例数差异无统计学意义.新分类的SAP患者的院内病死率为35.6％（32/90）,显著高于MSAP组的2.0％（11/559）,平均住院时间为（36.3 ±30.2）d,也显著长于MSAP患者的（23.0±18.8）d,两组间的差异均具有统计学意义（P值均＜0.01）.结论 采用新的AP分类方法能更精确地反映病情的严重程度,更准确地判断预后并指导临床治疗.     

Risk Factors and Outcome for Massive Intra-Abdominal Bleeding Among Patients With Infected Necrotizing Pancreatitis

The incidence of acute bleeding is reported to be 13.5% in patients with acute necrotizing pancreatitis. However, of all the bleeding events, intra-abdominal bleeding was less studied in the literature and its risk factors have not been well defined yet. The purpose of the present study was to investigate the risk factors for massive intra-abdominal bleeding among the patients with infected necrotizing pancreatitis and assessed the outcome of these patients.Both univariate and multivariate logistic regression models were applied for evaluating risk factors for intra-abdominal bleeding using 33 indices, including age, sex, etiology of acute pancreatitis (AP), APACHE II score, etc. Outcome assessments such as mortality, hospital and intensive care unit (ICU) durations, and cost were also compared between patients with or without intra-abdominal bleeding.Acute kidney injury (AKI) (odds ratio [OR]: 7.54, 95% confidence interval [CI]: 2.53–22.52, P < 0.001) and number of operation (OR: 8.84, 95% CI: 2.01–38.86, P = 0.004) were 2 predictors for massive intra-abdominal bleeding in the patients with infected necrotizing pancreatitis. In addition, AP patients with intra-abdominal bleeding also showed significantly higher mortality rate, prolonged hospital and ICU durations, more complications and invasive treatments, as well as increased cost.Our study revealed that AKI and multiple operations were 2 critical factors increasing the risk of intra-abdominal bleeding among patients with infected necrotizing pancreatitis. Additionally, massive intra-abdominal bleeding was also associated with poor prognosis.     

Computerized tomographic scan-guided drainage of intra-abdominal abscesses

PURPOSE: Computerized tomographic (CT) scan-guided percutaneous drainage of intra-abdominal abscesses has changed the colon and rectal surgeon's approach to preoperative and postoperative intra-abdominal infections. This study is an effort to prove the efficacy of CT scan-guided percutaneous drainage. METHODS: A retrospective study was performed on 133 patients who underwent CT scan drainage of intra-abdominal abscesses over a 6.3-year period. RESULTS: 67 patients had underlying lower gastrointestinal disease. Twenty-three of these patients (34 percent) had spontaneous abscesses and underwent drainage as a preoperative or final modality, whereas 44 patients (66 percent) were drained postoperatively. In 78 percent of patients, surgery was successfully avoided or delayed. Ten patients had acute diverticulitis associated with a large pelvic abscess. Eight patients underwent successful CT scanguided percutaneous drainage, yielding an 80 percent success rate. Morbidity from the CT scan-guided percutaneous drainage procedure in spontaneous and postoperative groups was 0 percent and 9 percent, respectively. Mortality was 9 percent and 11 percent, respectively, and associated with an elevated Acute Physiology and Chronic Health Evaluation II (APACHE II) score. CONCLUSION: CT scan-guided percutaneous drainage of intra-abdominal abscesses is an important adjunct to colon and rectal surgery because roughly 80 percent of spontaneous and postoperative abscesses were successfully managed.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.