急性胰腺炎的临床处理(美国胃肠病学,2013.5).ppt
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1、华西医院中西医结合科,Clinical Management of Patients With Acute Pancreatitis,GASTROENTEROLOGY MAY 2013;144:12721281,1Center for Pancreatic Care, Southern California Permanente Medical Group, Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California (南加州,凯萨医疗机构) ; an
2、d 2 Center for Pancreatic Disease, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Womens Hospital, Harvard Medical School, Boston, Massachusetts(波士顿,哈佛医学院),Keywords: Clinical Management; Fluid Resuscitation; Necrosis; Quality Improvement.,Abstract,Acute pancreatitis is the leadi
3、ng cause of hospitalization for gastrointestinal disorders in the US, with more than 280,000 hospitalizations each year. The average length of stay at US hospitals in 2010 was estimated to be 5 days, at an aggregate cost of $2.9billion. 高发病率;平均住院时间:5天;治疗费用高昂 Mortality ranges from 3% for patients wit
4、h interstitial (edematous) pancreatitis to 15% for patients who develop necrosis. 死亡率:3%(间质水肿性AP)-15%(坏死性AP) As the rate of hospitalization for acute pancreatitis continues to increase, so does the demand for effective management. This demand has resulted in publication of at least 14 clinical pract
5、ice guidelines in the past decade. An update to the American Pancreas Association and International Association of Pancreatology guidelines is forthcoming. 急性胰腺炎诊治指南需进一步规范,1. Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 20
6、12;143:11791187. 2. Singh VK, Bollen TL, Wu BU, et al. An assessment of the severity of interstitial pancreatitis. Clin Gastroenterol Hepatol 2011;9:10981103. 3. van Santvoort HC, Bakker OJ, Bollen TL, et al. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome
7、. Gastroenterology 2011;141:12541263,Contents,Diagnosis,The diagnosis of acute pancreatitis requires at least 2 of the following: 1.typical upper abdominal pain 典型的上腹部疼痛 2.serum levels of amylase or lipase 3 times the upper limit of normal, 胰腺酶水平3倍正常值的上限 3.conrmatory ndings from crosssectional imagi
8、ng analysis. 影像学支持,A recently completed revision of the Atlanta Classication provides a more detailed system that emphasizes disease severity and includes comprehensive denitions of pancreatic and peripancreatic collections. There are also more complete denitions of local and systemic complications.
9、,Disease Denitions: The Revised Atlanta Classication,The Atlanta Classication system was developed at a consensus conference in 1992 to establish standard denitions for classication of acute pancreatitis.,最新修订版的亚特兰大分类标准提供了一个更加详细的分类标准,它着重于疾病的严重程度,及包括胰腺和胰周液体聚集的综合定义,而有更加完整的局部及系统性并发症的定义。,12. Banks PA, B
10、ollen TL, Dervenis C, et al. Classication of acute pancreatitis2012: revision of the Atlanta classication and denitions by international consensus. Gut 2013;62:102111. 13. Marshall JC, Cook DJ, Christou NV, et al. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome.
11、Crit Care Med 1995;23:16381652.,1,2,3,Denition of Local Complications 局部并发症的定义,Denition of Systemic Complications and Organ Failure 全身并发症及器官衰竭的定义,Denition of Severity 严重程度分类,4,Roles of Advanced Imaging Techniques 影像学的作用,Diagnosis,Denition of Local Complications,急性胰腺炎,急性胰周液体积聚(APFC),胰腺假性囊肿,坏死性胰腺炎,急性坏
12、死物积聚(ANC) 包裹性坏死(WON),A variety of local complications have been delineated. Interstitial pancreatitis involves acute collection of peripancreatic uid(ACPF) and formation of pancreatic pseudocysts. 间质水肿性胰腺炎涉及急性胰周液体积聚和胰腺假性囊肿的形成 APFC develop during the early phase早期 of interstitial pancreatitis. They a
13、re homogeneous in appearance without a well-dened wall, usually remain sterile, and frequently resolve spontaneously (Figure A). 急性胰周液体积聚(APFC)发生胰腺炎病程早期,渗出液均匀地而边界模糊地分布于胰周,通常是无菌的,可以自行吸收 If an acute peripancreatic uid collection does not resolve spontaneously, it could develop into a pseudocyst with a
14、 welldened inammatory wall that contains uid with very little, if any, solid material (Figure B). 如果一旦胰周积液不能自行吸收,它将可能发展为有完整炎症性包膜容纳少量渗出液及极少量坏死组织的假性囊肿(发生AP后4周),间质水肿性胰腺炎,Figure (A) Interstitial pancreatitis with acute peripancreatic uid collection. Peripancreatic uid collection (arrows) is poorly dened
15、 with homogeneous uid density. Figure(B) Resolving interstitial pancreatitis with pseudocyst. A pseudocyst (arrow) is typically a round or oval encapsulated collection with homogeneous uid density.,急性胰周液体积聚(APFC),胰腺假性囊肿,Necrotizing pancreatitis involves acute collection of necrosis and walled-off ne
16、crosis. 坏死性胰腺炎包括急性坏死物积聚(ANC)及包裹性坏死(WON)。 An acute necrotic collection refers to the presence of necrotic tissue involving pancreatic parenchyma and peripancreatic tissues (Figure 2). These collections can be sterile or infected. If infected,they are called infected necrosis. 急性坏死物积聚(ANC)指的是胰腺实质及胰周组织
17、的坏死(如表格2),坏死物的积聚可是无菌性和感染性,其中感染性的又叫感染坏死。 After 4 or more weeks, an acute necrotic collection can become smaller but rarely disappears completely and usually evolves into walled-off necrosis. Walled-off necrosis has a well-dened inammatory wall that contains varying amounts of uid and necrotic debris
18、(Figure 3). 在4周及之后,急性坏死物的积聚逐渐变小,但很少有被完全吸收,通常发展为有炎症性包膜容纳混合大量渗出液及少量坏死物碎片的包裹性坏死(WON)(如表格3)。,Figure 2. Pancreatic and peripancreatic necrosis. This image shows an acute necrotic collection involving both the pancreas (large arrow) and peripancreatic tissue. Figure 3. Walled-off pancreatic necrosis is an
19、 encapsulated collection of necrosis. This type of collection typically forms 4 to 6 weeks after disease onset. This image shows pancreatic and peripancreatic necrosis.,坏死性胰腺炎,急性坏死物积聚(ANC),包裹性坏死(WON),Denition of Systemic Complications and Organ Failure,In the revised Atlanta Classication, systemic c
20、omplications are dened as exacerbations of preexisting comorbidities such as chronic lung disease, chronic liver disease, or congestive heart failure, recognizing the failure of respiratory, cardiovascular, and renal organ systems.,在修订版的亚特兰大分类标准,全身并发症被定义为,先前存在的疾病诸如慢性肺部疾病、慢性肝病、充血性心力衰竭等的突然恶化,这些被认为是呼吸系
21、统、心血管系统、肾脏功能系统的损害加重而衰竭。,Denition of Systemic Complications and Organ Failure,The scoring system that has been chosen to characterize organ failure is the modied Marshall scoring system . The modied Marshall system classies disease severity on a scale from 0 to 4, so that the overall evaluation of or
22、gan dysfunction can be more completely delineated and characterized over time. In this system, organ failure is dened by a score of 2 for one or more of these organ systems.,改良的马歇尔评分系统用于器官衰竭的评分,该评分系统将急性胰腺炎的严重程度分为04级,以至于更能清晰及特征性地对器官功能障碍发展进行综合评价。在该评分系统中,器官衰竭定义为有任何1个及多个器官功能评分 2分。,13. Marshall JC, Cook
23、DJ, Christou NV, et al. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome.Crit Care Med 1995;23:16381652.,Denition of Severity,Most patients with mild acute pancreatitis do not require pancreatic imaging analysis and are usually discharged within 3 to 5 days of on
24、set of illness . 轻型急性胰腺炎患者无需影像学检查,住院时间通常为3-5天,Patients with moderately severe acute pancreatitis frequently require extended hospitalization but have lower mortality rates than patients with severe acute pancreatitis. 中度重症急性胰腺炎需延长住院时间,但病死率低于重症急性胰腺炎,A meta-analysis found patients with severe acute pa
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