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单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,ACUTE PANCREATITIS,Xu,San,Rong,Department of Gastroenterology,Huashan,Hospital,Fudan,University,1,General consideration(1),Pancreatitis,acute pancreatitis,（,AP,）,chronic pancreatitis (CP),recurrent pancreatitis,From edematous pancreatitis (MAP) ,pancreatic necrosis (SAP).,2,General consideration(2),Epidemiological Information:,incidence: 4.824/10,6,mean age: 55 year,Mild acute pancreatitis (MAP),severe acute pancreatitis (SAP),3,General consideration(3),Causes of acute pancreatitis,Common causes,gallstones,postoperative,alcohol consumption,drugs,hypertriglyceridemia,ERCP,trauma,sphincter of,Oddi,dysfunction,4,General consideration(4),Uncommon causes,vascular causes and vasculitis:,CTD (,systemic lupus,erythematosus, SLE,),and TTP,cancer of pancreas:,pancreatic,divisum,5,General conideration(5),rare causes,infectious agents : (mumps virus),autoimmune: (SS),causes of recurrent pancreatitis,without an obvious etiology,microlithiasis,idiopathic,6,Etiology and Pathogenesis(1),Etiology,1 Gallstones: 30%60% (54.4%, 1).,2 Alcohol: 5/10,6, (8.0%, 4).,3,Hypertrilyceridemia,: 1.3%3.8% (12.6%,3).,4 ERCP: 5%20%.,5 Drugs: 2%5%.,6 idiopathic: (19.70%, 2).,注：括弧里的数据为,2005,年全国,12,所三甲医院,6223,例病人的资料。,见：中华医学会第,7,次消化病学术会议论文汇编，,2007,：,423425,7,Etiology and Pathogenesis(2),Autodigestion,:,to be activated in the pancreas ?,in the intestinal lumen?,a number of,factors,proenzymes,Enzymes,trypsin,autodigestion,Activate,Other enzymes,8,Etiology and Pathogenesis(2),Three phases of the evolution of AP,initial step:,proenzymes,activation in,acinus,Acinar,cell injury by activated enzymes.,second step:,activation,chemoattraction, and,sequestration of,neutrophils,.,9,Etiology and Pathogenesis(3),third step,injury of the distant organs,Active enzymes,Trypsin,Elastase,Phospholipase,Mediators,Bradykinin,Peptide,Vascular,Substances,histamine,Injury of,the distant organs,10,Etiology and Pathogenesis(4),A cascade,systemic inflammatory response syndrome (SIRS),acute respiratory distress syndrome (ARDS),multiple organ failure (MOF),(multiple organ dysfunction syndrome, MODS),11,Etiology and Pathogenesis(5),gallstones,infection,Bile juice,reflux,trypsin,Kinin,systems,elastase,Trypsin,chymotrypsino,Phospho,-,lipaseA2,lipidase,Free fat,acid,hemorrhage,Sever pain,Serum,calcium,12,Clinical Features (1),Symptoms,Pain,sites,relate to the body pose,Nausea and vomiting,Abdominal distension,Chemical peritonitis,13,Clinical Features (2),Signs,distress and anxiety,low-grade fever, tachycardia, hypotension,jaundice,erythematous,skin nodules,basilar,rales,atelectasis, pleural effusion,abdominal tenderness, muscle rigidity,bowel sounds,abdominal mass,Cullen sign, Turner sign,14,Laboratory Data (1),Serum amylase:,cut off value,:,values threefold or more above,normal, (upper limit of normal value, ULN),should exclude some diseases,no definite correlation (severity and elevated value),total serum amylase, after 4872h of attack,p.,isoamylase,and lipase level, for 714 d,in many other conditions,(,acidemia,),15,Laboratory Data (2),Serum lipase,in parallel with amylase activity,may be used to diagnose the AP,(,nonpancreatic,causes of,hyperamylasemia,),measurement of both enzymes increases the yield,Peritoneal or pleural fluid amylase,1,500,nmol,/L (5,000 U/dl),16,Laboratory Data (3),Leukocytosis,：,15.0*10,9,20.0*10,9,/L,Hemoconcentration,:,hematocrit,value,50%,Hyperglycemia: common in the patients,Hypocalcemia,: 25% of patients,Hyperbilirubinemia,serum,bilirubin,68,umol,/L (4.0 mg/,dL,),17,Laboratory Data (4),Serum alkaline,phosphatase,(ALP),serum,aspartate,aminotransferase,(AST),transiently elevated,in parallel with serum,bilirubin,value,Serum lactic,dehydrogenase,(LDH),levels,8.5umol/L (500U/dL),18,Laboratory Data (5),Decreased Serum albumin: (10%),=30 g/L (3.0,g/dL,),associated with more severe pancreatitis,associated with a higher mortality rate,Hypertriglyceridemia,: (15%20%),serum amylase levels often spurious,normal in this condition,19,Laboratory Data (6),Hypoxemia: (25%), PO2= 60mmHg,herald of ARDS,ECG:,ST-segment, T-wave abnormalities,X-ray examination,chest and abdomen films,Sonography,and radionuclide scanning,gallbladder and,biliary,tree,20,Laboratory Data (7),Computed tomography (CT),confirm the clinic impression,indicate degree of the severity of AP,CT grading system of Balthazar and,ranson,pancreatic manifestations of CT,grade A,normal-appearing pancreas 0,grade B focal or diffuse enlargement of the pancreas 1,grade c gland abnormalities accompanied by mild 2,peripancreatic,inflammatory changes,grade D fluid collection in a single location 3,grade E,2 fluid collections near the pancreas or 4,gas either within the pancreas or within,peripancreatic,inflammation,21,Laboratory Data (8),computed tomography severity index,CT grade score necrosis score,A 0 none 0,B 1 one third 2,C 2 one half 4,D 3 one half 6,E 4,CT grade(0-4) + necrosis(0-6) = total score,22,Diagnosis(1),Diagnosis,Clinical presentations,Laboratory and assistant examination,Not all above findings have to be present,Differential diagnosis,perforated,viscus, acute,cholecystitis, acute,intestinal obstruction, ,23,Diagnosis(2),Ranson,criteria of severity,at admission during initial 48 hours,age 55 years,Hct,drop 10mg/dL,wbc,16*10,9,/L bun rise 5mg/dL,glucose 11.2umol/L calcium 350iu/L PaO2 250u /L base deficit 4,mEq,/L,fluid sequestration 6 L,3 70ys,body mass index (BMI) 30 (kg/m2),hematocrit,(,Hct,) 44%,C-creative protein (admission on 48 hr), 150mg/L,elevated levels of urine,typsinogen,activation peptide (TPA),Cut off value: TAP35nmol/L,26,Course of acute pancreatitis (2),Key factors (2): shock and organ failure,shock: SBP 130,respiratory failure: PO2 177umol/L (2.0mg/dL),gastrointestinal bleeding: 500ml/24h,27,Complications (1),Local Complications,necrosis,pancreatic fluid collections,pancreatic abscess,pancreatic,pseudocyst,28,Complications (2),Systemic Complications,1 major systemic complications,(1) respiratory failure (acute respiratory,distress syndrome, ARDS),(2) acute renal failure,(3) cardiovascular failure,29,Complications (3),(4) gastrointestinal bleeding,(5) septicemia (SIRS),(6) blood system dysfunction,(7) central nervous system,pancreatic,necephalopathy,(8) hyperglycemia,(9) disorder of acid-base and electrolytes,30,Complications (4),most dangerous complication,multiple organ dysfunction syndrome,( MODS),multiple systemic organ failure (MSOF),multiple organ failure (MOF),31,Recurrent Pancreatitis,Incidence : Approximately 25%,Two most causes:,alcohol,cholelithiasis,Obvious causes,microlithiasis,4%7%,hypertriglyceridemia,fasting levels 8.5,mmol,/L high risk,32,Treatment (1),Conventional measures:,1 analgesics for pain,2 maintain normal intravascular volume,3 no oral alimentation (fasting),4,nasogastric,suction,33,Treatment (2),Nutrition for mild to moderate AP,1. Intravenous fluid, fasting,possibly,nasogastric,suction, 24ds,2. a clear liquid diet is started 3rd6,th,3. regular diet by 5th7th,34,Treatment (3),Criteria to retrieve oral intake,1. a decrease in or resolution of,abdominal pain.,2. hungry.,3. organ dysfunction has improved.,4.,unnecessaries,:,decrease in elevated amylase/lipase,no inflammatory changes on CT scan,35,Treatment (4),“,Rest the pancreas” have not changed the,course of AP,anticholinergic,drugs,nasogastric,suction,36,Treatment (5),The use of the antibiotics,no benefit in mild to moderate AP,prophylactic use in necrotizing AP (SAP),reduction in sepsis by 21%,mortality by 12%,recommended antibiotics:,such as,imipenem-cilastatin, 0.5g,tid,* 2 w,secondary infection of necrotic p. tissue,37,Treatment (6),No effective drugs,glucagon,H2 receptor blockers (,cimetidine,),protease inhibitors (,aprotinin,),glucocorticoids,calcitinin,(CT),lexiplafant,(a PAF inhibitor),38,Treatment (7),Have effective drugs,somatostatin,octreotide,reduction of the mortality,no change in complications with,octreotide,gabexate,mesilate,(FOY),reduction of pancreatic damage,no effect on mortality,Early prophylactic use of fungicide .,39,Treatment (8),The patient with unremitting FP,inordinate amount of fluid.,close attention of severe complications.,Infected necrosis,debridement should be undertaken, if,conventional treatments are not effective.,40,Treatment (9),Patients with gallstone pancreatitis,endoscopical,treatment,(1),Endoscopical,duodenal,papilo,-,sphincterotomy,(EST),(2),Endoscopical,balloon dilation (EBD),41,Treatment (10),Treatment for,Hypertrilyceridemia,-associated pancreatitis,ideal weight,a lipid-restricted diet,exercise,alcohol and some drugs,control diabetes mellitus,42,Infected Pancreatic Necrosis,Occurring in the initial 12 w.,Secondarily infected in 40%60% of patients.,Gram-negative bacteria of alimentary origin.,Can be diagnosed by CT-guided needle,aspiration.,Should be treated by debridement, but not,percutaneous,evacuation.,43,Pancreatic abscess,Occurring in the 46 w after the onset.,Occurring in 3%4% of patients,To be less life-threatening and lower rate,of surgical mortality.,Can be treated by surgery or by,percutaneous,drainage.,44,Pancreatic,pseudocyst,Developing over a period of 14 w after onset.,Form in approximately 15% patients.,Pseudocyst,does not have epithelial lining.,Associated with pancreatitis in 90% cases, with,trauma in 10%; approximately 85%, in the body or tail, and 15%, in the head.,Spontaneously resolve in 25%40% of patient,diameter 5cm, persist for 6w, should be,considered for drainage.,45,Pancreatic,Ascites,and,pancreatic pleural effusion,Internal fistula, and leaking,pseudocyst,.,in the,ascites,fluid, the Levels of albumin,30g/L; elevated amylase concentration .,15% of patients with,pseudocysts,have concurrent pancreatic,ascites,.,Treatment:,nasogastric,suction and,parenteral,nutrition;,octreotide,; surgery;,endoscopic measurement (stent).,46,THANK YOU !,47,
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