急性胰腺炎英文版ppt课件.pptx

我们毕业啦其实是答辩的标题地方 Clinicalpracticeguideline managementofacutepancreatitis Repoeter WeiruiRen GraduatestudentinHeibeiMedicalUniversity 1 Therehasbeenanincreaseintheincidenceofacutepancreatitisreportedworldwide Despiteimprovementsinaccesstocare imagingandinterventionaltechniques acutepancreatitiscontinuestobeassociatedwithsignifcantmorbidityandmortality Despitetheavailabilityofclinicalpracticeguidelinesforthemanagementofacutepancreatitis recentstudiesauditingtheclinicalmanagementoftheconditionhaveshownimportantareasofnoncompliancewithevidence basedrecommendations Thisunderscorestheimportanceofcreatingunderstandableandimplementablerecommendationsforthediagnosisandmanagementofacutepancreatitis Thepurposeofthepresentguidelineistoprovideevidence basedrecommendationsforthemanagementofbothmildandsevereacutepancreatitisaswellasthegallstone inducedpancreatitis 2 Methodology Diagnosisofacutepancreatitis AssessMentofseverity Supportivecare CONTANTS 3 Nutrition Prophylacticantibiotics Managementofacutegallstonepancreatitis CONTANTS 4 5 Methodology 1 2 3 TheguidelinewasdevelopedundertheauspicesoftheUniversityofToronto TheysearchedMedlineforguidelinespublishedbetween2002and2014usingtheMedicalSubjectHeadings pancreatitis and clinicalpracticeguideline Thissearchidentifed14guidelinespublishedbetween2008and2014 AnotherelectronicsearchofMedlinewasperformedusingtheMedicalSubjectHeadings pancreatitis acutenecrotizingpancreatitis alcoholicpancreatitis and practiceguidelines toupdatethesystematicreview TheresultswerelimitedtoarticlespublishedinEnglishbetweenJanuary2007andJanuary2014 Thereferencesofrelevantguidelineswerereviewed Up todatearticlesonacutepancreatitisdiagnosisandmanagementwerealsoreviewedfortheirreferences 6 7 1 Diagnosisofacutepancreatitis 2ofthefollowing Abdominalpain acuteonsetofapersistent severe epigastricpainoftenradiatingtotheback Serumlipaseactivity oramylase atleast3timesgreaterthantheupperlimitofnormal Characteristicfindingsofacutepancreatitisoncomputedtomographyormagneticresonanceimaging Serumlipasehasaslightlyhighersensitivityfordetectionofacutepancreatitis Onestudydemonstratedthatatday0 1fromonsetofsymptoms serumlipasehadasensitivityapproaching100 comparedwith95 forserumamylase 13Fordays2 3atasensitivitysetto85 thespecifcityoflipasewas82 comparedwith68 foramylase Serumlipaseisthereforeespeciallyusefulinpatientswhopresentlatetohospital 2 Rightupperquadrantultrasonographyistheprimaryimagingmodalityforsuspectedacutebiliarypancreatitisowingtoitslowcost availabilityandlackofassociatedradiationexposure Ultrasonographyhasasensitivityandspecifcitygreaterthan95 inthedetectionofgallstones althoughthesensitivitymaybeslightlylowerinthecontextofileuswithboweldistension commonlyassociatedwithacutepancreatitis Ultrasonographycanalsoidentifygallbladderwallthickeningandedema gallbladdersludge pericholecysticfluidandasonographicMurphysign consistentwithacutecholecystitis Whenthesesignsarepresent thepositivepredictivevalueofultrasonographyinthediagnosisofacutecholecystitisisgreaterthan90 andadditionalstudiesarerarelyneeded 3 Diagnosisofacutepancreatitis 8 4 MagneticresonancecholangiopancreatographyisusefulinidentifyingCBDstonesanddelineatingpancreaticandbiliarytractanatomy Asystematicreviewthatincludedatotalof67studiesfoundthattheoverallsensitivityandspecificityofMRCPtodiagnosebiliaryobstructionwere95 and97 respectively Sensitivitywasslightlylower at92 fordetectionofbiliarystones 5 Inseveredisease CTisusefultodistinguishbetweeninterstitialacutepancreatitisandnecrotizingacutepancreatitisandtoruleoutlocalcomplications However inacutepancreatitisthesedistinctionstypicallyoccurmorethan3 4daysfromonsetofsymptoms whichmakesCToflimiteduseonadmission Diagnosisofacutepancreatitis 9 10 1 At48hours serumCRPlevelsabove14286nmol Lhaveasensitivity specifcity positivepredictivevalueandnegativepredictivevalueof80 76 67 and86 respectively forsevereacutepancreatitis Levelsgreaterthan17143nmol Lwithinthefrst72hoursofdiseaseonsethavebeencorrelatedwiththepresenceofnecrosiswiththesensitivityandspecifcitybothgreaterthan80 SerumCRPgenerallypeaks36 72hoursafterdiseaseonset sothetestisnothelpfulinassessingseverityonadmission AvarietyofreportshavecorrelatedahigherAPACHEIIScoreatadmissionandduringthefirst72hourswithahighermortality 4 withanAPACHEIIScore 8and11 18 withanAPACHEIIScore 8 TherearesomelimitationsintheabilityoftheAPACHEIIScoretostratifypatientsfordiseaseseverity Forexample studieshaveshownthatithaslimitedabilitytodistinguishbetweeninterstitialandnecrotizingacutepancreatitis whichconferdifferentprognoses Inarecentreport APACHEIIScoresgeneratedwithinthefrst24hourshadapositivepredictivevalueofonly43 andnegativepredictivevalueof86 forsevereacutepancreatitis 2 Theorganfailure basedcriteriaforthepredictionofseverityinacutepancreatitisaretaken inpart fromthemodifedMultipleOrganDysfunctionScorepresentedbyBanksandcolleaguesintheirrevisionoftheAtlantaClassifcation Adiagnosisofsevereacutepancreatitisshouldalsobemadeifapatientexhibitssignsofpersistentorganfailureformorethan48hoursdespiteadequateintravenousfluidresuscitation 3 AssessMentofseverity 11 12 1 InaRCT n 40 Wuandcolleaguesfoundthatafter24hoursofresuscitationtherewasan84 reductionintheincidenceofSIRSinpatientsresuscitatedwithRinger sLactate p 0 035 aswellasasignificantreductioninCRPfrom9905nmol Lto5143nmol LwhenRinger sLactatewasselectedovernormalsaline p 0 02 Paincontrolisanimportantpartofthesupportivemanagementofpatientswithacutepancreatitis Therefore intheabsenceofanypatient specifccontraindications amultimodalanalgesicregimenisrecommended includingnarcotics nonsteroidalanti in ammatoriesandacetaminophen 2 However asystematicreviewof26observationalstudiesshowedthatcriticallyillpatientscaredforbyanintensivistorusinganintensivistconsultantmodelinacloseadintensivecareunit ICU hadashorterstayintheICUandlowermortalitythansimilarpatientscaredforinunitswithoutsuchstaffingpatterns 3 Supportivecare 13 14 1 Inthepast itwasacceptedpracticethatbowelrestwouldlimitthein ammationassociatedwiththisprocess Recently however aseriesofRCTshaveconvincinglyshownthatearlyoral enteralfeedinginpatientswithacutepancreatitisisnotassociatedwithadverseeffectsandmaybeassociatedwithsubstantialdecreasesinpain opioidusageandfoodintolerance Eckerwallandcolleaguesdemonstratedthatoralfeedingonadmissionformildacutepancreatitiswasassociatedwithasignifcantdecreaseinlengthofstayfrom6to4dayscomparedwithwithholdingoralfoodandfluids Themajorbeneftsfromearlyfeedingappeartobeeffectiveonlyiffeedingiscommencedwithinthefrst48hoursfollowingadmission 60andthecurrentrecommendationbasedona2010meta analysisof32RCTsistocommenceoralfeedingatthetimeofadmissioniftoleratedorwithinthefrst24hours 2 Severalmeta analyseshaveshownsimilarresults withsignifcantreductionsininfectiouscomplications mortalityandmultiorgandysfunctionwhenenteralnutritioniscommencedwithinthefrst48hoursfollowingadmission 3 Nutrition 15 Ameta analysis65of4prospectivestudiesofpatientswithpredictedsevereacutepancreatitisdemonstratednochangeinintoleranceoffeedingorinmortalitywhengivenenteralfeedsbynasogastricfeedingtubeversusnasojejunalfeedingtube Inamorerecentmetaanalysisof3RCTs Changfoundnosignifcantdifferencesinmortality trachealaspiration diarrhea exacerbationofpainandmeetingenergybalancebetweenpatientsfedthroughnasogastricandnasojejunalfeedingtubes Althoughsemi elemental immune enhancedandprobioticenteralfeedsshowedinitialpromiseinthemanagementofsevereacutepancreatitis meta analysesstillindicatethatthereisinsuffcientevidencetorecommendtheuseofanyofthesenutritionalformulationsatthistime Givenitspromiseinthecontextofothercriticallyillandsepticpatients theuseofprobioticsinthemanagementofacutepancreatitismayyetproveeffectiveasresearchcontinues 4 5 Nutrition 16 17 1 A2010meta analysisof7RCTsinvolving404patientscomparingprophylacticantibioticsversusplaceboinCTprovennecrotizingacutepancreatitisconcludedthattherewasnostatisticallysignifcantreductionofmortalitywiththerapy norasignifcantreductionininfectionratesofpancreaticnecrosis Inlightofthelackofdemonstratedbeneftofprophylacticantibioticsinthetreatmentofacutepancreatitis theadverseeffectsofthispracticemustbecarefullyconsidered Inaprospective randomizedcontrolledtrial Marav Pomaandcolleages76demonstrateda3 foldincreaseintheincidenceoflocalandsystemicfungalinfectionwithCandidaalbicans from7 to22 inpatientswithprolongedtreatmentwithprophylacticantibiotics afndingconsistentwiththoseofothersimilarstudies Inaddition overuseofantibioticsisassociatedwiththeincreasedriskofantibiotic associateddiarrheaandClostridiumdifficilecolitis80andwiththeselectionofresistantorganisms allofwhichsuggestthattheadverseeffectsofprophylacticantibioticcoverageoutweighsanybenefitofferedbythepractice 2 Prophylacticantibiotics 18 19 1 A2012Cochranemeta analysis129includedRCTscomparingearlyroutineERCPversusearlyconservativemanagementwithorwithoutselectiveuseofERCPinpatientswithsuspectedacutegallstonepancreatitis Therewere5RCTswithatotalof644patients Overall therewerenostatisticallysignifcantdifferencesbetweenthe2treatmentstrategiesinmortality localorsystemiccomplicationsasdefinedbytheAtlantaClassifcation InanRCTfromChina130patientswithsevereacutegallstonepancreatitiswererandomizedtoearlytreatment within72hofonset withERCPorimage guidedpercutaneoustranshepaticgallbladderdrainage PTGD SuccessrateswerecomparablebetweentheERCPandPTGD and4 monthmortality localcomplicationsandsystemiccomplicationsdidnotdiffersignifcantly TheauthorconcludedthatPTGDisasafe effectiveandminimallyinvasiveoptionthatshouldbeconsideredforallpatientswithsevereacutegallstonepancreatitiswhoarepoorcandidatesfororwhoa