急性胰腺炎初期全身炎症反应综合征持续时间与感染性胰腺坏死的关系

目的探究急性胰腺炎(AP)患者早期炎症反应与晚期感染性胰腺坏死(IPN)的潜在关系。方法回顾性纳入西南医科大学附属医院2019年6月—2020年6月收治的中度重症急性胰腺炎(MSAP)患者219例,重症急性胰腺炎(SAP)患者53例,根据起病初期是否合并全身炎症反应综合征(SIRS),分为SIRS组160例,非SRIS组112例。纳入基线资料、血清学指标、并发症及病死率。计量资料两组间比较采用t检验或Mann-Whitney U检验;计数资料组间比较采用χ2检验,多组间进一步两两比较采用Bonferroni法。logistic回归分析筛选有价值的变量,受试者工作特征曲线(ROC曲线)用于比较变量的诊断价值,ROC曲线下面积(AUC)的两两比较采用Z检验。结果SIRS组患者的WBC、CRP、降钙素原更高(P值均<0.05),SIRS组合并急性胰周坏死物聚集(ANC)、IPN、胰腺坏死(PN)、器官功能障碍(OF)、多器官功能障碍(MODS)、重症急性胰腺炎(SAP)、危重症急性胰腺炎(CAP)、死亡、BISAP评分>2、CTSI评分>2、RANSON评分>2的比例均高于非SIRS组(P值均<0.05)。单因素分析显示,SIRS持续时间、肥胖、CRP、WBC、血尿素氮、PN、ANC、SAP、MODS、RANSON评分、BISAP评分、CTSI评分均是AP患者发生IPN的影响因素(P值均<0.05);多因素分析显示,SIRS持续时间(OR=1.307,95%CI:1.081~1.580,P=0.006)、ANC(OR=42.247,95%CI:10.829~164.818,P<0.001)是IPN的危险因素,排除ANC时,SIRS持续时间(OR=1.430,95%CI:1.207~1.694,P<0.001)、PN(OR=5.296,95%CI:1.845~15.203,P=0.002)是IPN的危险因素。预测IPN的ROC曲线显示:SIRS持续时间(AUC=0.772,约登指数:0.521)、RANSON评分(AUC=0.701,约登指数:0.319)、BISAP评分(AUC=0.741,约登指数:0.377)、CTSI评分(AUC=0.765,约登指数:0.414)的AUC两两比较差异均无统计学意义(P值均>0.05)。超长时间SIRS组(>4 d)患者发生PN、ANC、IPN、SAP、CAP的比例均显著高于无SIRS组(0)、短暂性SIRS组(1~2 d)和持续性SIRS组(3~4 d)(P值均<0.05),持续性SIRS组患者发生SAP的比例高于无SIRS组(P<0.05)。结论AP患者早期合并SIRS时更容易发生器官功能衰竭及局部并发症,当SIRS持续时间>4.5 d时,患者发生IPN的风险显著增加。

Association of the duration of systemic inflammatory response syndrome with infectious pancreatic necrosis at the initial stage of acute pancreatitis

Objective To investigate the potential association between early-stage inflammatory response and late-stage infectious pancreatic necrosis(IPN)in patients with acute pancreatitis(AP).Methods A retrospective analysis was performed for the clinical data of 219 patients with moderate-severe acute pancreatitis(MSAP)and 53 patients with severe acute pancreatitis(SAP)who were admitted to The Affiliated Hospital of Southwest Medical University from June 2019 to June 2020,and according to the presence or absence of systemic inflammatory response syndrome(SIRS)at the initial stage of the disease,they were divided into SIRS group with 160 patients and non-SRIS group with 112 patients.Baseline data,serological markers,complications,and mortality rate were included for analysis.The t-test or the Mann-Whitney U test was used for comparison of continuous data between two groups;the chi-square test was used for comparison of categorical data between multiple groups,and the Bonferroni method was used for further comparison between two groups.A logistic regression analysis was used to screen out valuable variables;the receiver operating characteristic(ROC)curve was used to compare the diagnostic value of variables,and the Z-test was used for pairwise comparison of area under the ROC curve(AUC).Results Compared with the non-SIRS group,the SIRS group had significantly higher white blood cell count(WBC),C-reactive protein(CRP),and procalcitonin(all P<0.05)and a significantly higher proportion of patients with acute peripancreatic necrosis(ANC),IPN,pancreatic necrosis(PN),organ dysfunction,multiple organ dysfunction syndrome(MODS),SAP,critically-ill acute pancreatitis(CAP),death,BISAP score>2,CTSI score>2,or RANSON score>2(all P<0.05).The univariate analysis showed that SIRS duration,obesity,CRP,WBC,blood urea nitrogen,PN,ANC,SAP,MODS,RANSON score,BISAP score,and CTSI score were risk factors for IPN in patients with AP(all P<0.05),and the multivariate analysis showed that SIRS duration(odds ratioOR]=1.307,95%confidence intervalCI]:1.081-1.580,P=0.006)and ANC(OR=42.247,95%CI:10.829-164.818,P<0.001)were risk factors for IPN;when ANC was excluded,SIRS duration(OR=1.430,95%CI:1.207-1.694,P<0.001)and PN(OR=5.296,95%CI:1.845-15.203,P=0.002)were risk factors for IPN.The ROC curve showed that SIRS duration(AUC=0.772,Youden index=0.521),RANSON score(AUC=0.701,Youden index=0.319),BISAP score(AUC=0.741,Youden index=0.377),and CTSI score(AUC=0.765,Youden Index=0.414)had a certain value in predicting IPN,and there was no significant difference in AUC between any two indices.The long-duration SIRS group(>4 d)had a significantly higher proportion of patients with PN,ANC,IPN,SAP,or CAP than the non-SIRS group(0 d),the transient SIRS group(1~2 d),and the persistent SIRS group(3~4 d)(all P<0.05),and the persistent SIRS group had a significantly higher proportion of patients with SAP than the non-SIRS group(P<0.05).Conclusion AP patients with SIRS in the early stage are likely to develop organ failure and local complications,and there is a significant increase in the risk of IPN when SIRS duration is>4.5 days.