急性胰腺炎acute pancreatitis（八年制）课件

Acute Pancreatitis Xia, Zhongsheng Department of Gastroenterology The Second Affiliated Hospital Sun Yat-sen University Teaching Objective nTo know the etiology and pathogenesis of acute pancreatitis nTo master the clinical features and key points of diagnosis for different types of acute pancreatitis nTo master the therapy principles of acute pancreatitis Definition nAcute pancreatitis is a inflammation of the pancreas induced by the activation of the pancreatic enzymes derived from various causes. Etiology nBiliary duct diseases: gallstone, acute and chronic cholecystitis, ascariasis accompanied with inflammatory stricture at the level of the papilla. Common channel hypothesis nAlcohol and/ or square meal nhyperlipidemia nPostoperation: post-ERCP, abdominal operation. Etiology nMetabolic diseases: hyperparathyroidism, hypercalcemia, etc. nDrugs: glucocorticords, diuretics, azathioprine, estrogen, etc. nAutoimmune diseases: SLE, RA, vasculitis, etc. nViral infections: mumps, coxsackie virus , HIV, etc nIdiopathic pancreatitis. Pathogenesis ntrypsinogen trypsin ntrypsin pancreatic enzymes, complement system and kinin system nPathophysiological changes: leukocyte chemotaxis, release of active agents, oxygenic stress, microcirculation disorder and bacteria transposal. nTrypsin activates other proenzymes and results in proteolysis, edema and vascular damage nLipase produces extrapancreatic fat necrosis nPhospholipase degrades the lecithin into the lysolecithin which induces pancreatic necrosis and hemorrhage nKallikrein and elastase cause vascular destruction nBradykinin peptidase and vasoactive substance induce vasodilatation, increase vascular permeability and edema nCytokine, oxygen free radicals, platelet activating factor, prostaglandins, blood circulation disturbance, systemic inflammation response syndrome (SIRS) Pathology Mild form (interstitial or edematous pancreatitis) nfocal or diffused edema nslight leukocyte infiltration Severe form (necrotic or hemorrhagic pancreatitis) nmarked acinar destruction with hemorrhage nextensive leukocyte infiltration nnecrosis of parapancreatic fat ngrossly an inflammatory tumor-like mass with diffused hemorrhagic change nsecondary infection induces the formation of abscess or pseudocysts Symptoms nabdominal pain: located in epigastrium and radiates to the back. The lateral kneel-chest position with the neck flexed may relieve the abdominal pain. nNausea, vomiting, abdominal distention: 90% patients nFever: low-grade fever in mild pancreatitis; high fever suggests coexisting infection. nHypotension or shock: often in severe pancreatitis Clinical manifestations Signs nMAP: signs are mild. Abdominal tenderness and diminished bowel sounds are present. nSAP: n peritoneal irritation sign n bowel sounds are diminished or absent n ascites or shifting dullness n Grey-Turner sign n Cullen sign n jaundice n Pancreatic pseudocyst Complications Local complications nPseudocyst: occur 2 weeks after the onset. nAcute fluid collection: occur in the early stage. nPancreatic abscess: after 4 weeks on the basis of pseudocyst nPancreatic necrosis infection: usually after 2 weeks Systemic complications nARDS nacute renal failure nheart failure and cardiac arrhythmia ngastrointestinal bleeding nSepticemia ndisorders of hemostasis: thrombosis, DIC. ndisorders of CNS: pancreatic encephalopathy nHyperglycemia ndisorders of water, electrolytes and acid-base balance Laboratory Studies nblood count: leukocytes count is more than 10,000/mm3 nHematocrit (Hct): is high (over 50%) because of loss of plasma into the retroperitoneal space Amylase nnormal values of the serum amylase: 40 to 180 Somogyi units or 8 to 64 Winslow units nover 500 Somogyi units are strongly suggested acute pancreatitis. nthere is no significant correlation between the severity of the pancreatitis and the levels of the serum amylase nnormal values of urinary amylase: 3 nor APACHE-II 8 nor CT grading: D, E or CTSI 3. Differential diagnosis nPerforated peptic ulcer nAcute calculous cholecystitis nAcute ileus nMesenteric vascular embolism nRupture of the spleen nAcute appendicitis nAngina pectoris nAcute myocardial infarction Therapy-MAP nMonitoring: should be monitored for at least 3 days. nSupportive treatment: volume repletion with crystalloids and colloids to keep balance. nRelieve severe pain: Dolantin is preferred over morphine. ninhibit excrine of the pancreas: n No oral alimentation and continuous nasogastric suction n H2RA or PPI n Somatostatin and its long-acting analogue (Sandostatin) nAntibiotics is required especially in infection of biliary duct. Therapy-SAP nMonitoring nNutritional support: n parenteral nutritionenteral nutrition n maintain balance of water, electrolytes and acid-base. n essential diet nPrevention of infection: n oral antibiotics n intravenous infusion of antibiotics n enteral feeding ninhibit excrine of pancreas and pancreatic enzymes: n No oral alimentation and continuous nasogastric suction n H2RA or PPI n Somatostatin and its long-acting analogue (Sandostatin) n protease inhibitors: gabexate, aprotinin, etc. nPrevention and treatment of enteral failure n oral antibiotics n enteral microecological preparations n glutamine n enteral feeding nTreatment of multiple organs failure nTraditional Chinese medicine: 生大黄、清胰汤 nEndoscopic therapy: ERCP+EST+ENBD nSurgical operation: indications n necrotic pancreatitis with infection n pancreatic abscess n early severe acute pancreatitis (ESAP) n abdominal compartment syndrome (ACS) n pancreatic pseudocyst: 6cm n diagnosis remain unclear and GI perforation is suggested nEmerging drugs: n CCK receptor antagonist: loxiglumide n Prostaglandins: PGE1 n Platelet activating factor (PAF) antagonist n TNF monoclonal antibody: Infliximab prognosis nMAP: good nSAP: poor. 1030% mortality nRisk factors: age, hypotension, hypoalbuminemia, hypoxemia, hypocalcemia, miscellaneous complications. Questions nWhat are the clinical manifestations of acute pancreatitis? nWhat is the diagnostic key points of acute pancreatitis? nWhat is the therapy of acute pancreatitis? necrotic pancreatitis Grey-Turner sign Cullen sign jaundice Pseudocyst of