重新认识胰腺炎ppt课件.pptx

重新认识犬胰腺炎 1 History病史 Signalment临床表现 Diet Vomiting 饮食情况呕吐 Historyofpancreatitis胰腺炎病史 Diarrhea 腹泻 2 History病史 Signalment临床表现 Diet Vomiting 饮食情况呕吐 Historyofpancreatitis胰腺炎病史 Diarrhea 腹泻 3 History病史 Signalment临床表现 Diet Vomiting 饮食情况呕吐 Historyofpancreatitis胰腺炎病史 Diarrhea 腹泻 4 KnowingtheLIMITATIONSofatestorprocedureisoftenmuchmoreimportantthanknowing whataprocedurecando 了解某项检查或操作的局限性比了 解某项操作的作用更为重要 5 PhysicalExamination体格检查 Anteriorabdominalpain前腹部疼痛 Icterus Profuseascites 黄疸大量腹水 FeverSQabscesses 发热皮下脓肿 6 PhysicalExamination体格检查 Anteriorabdominalpain前腹部疼痛 Icterus Profuseascites 黄疸大量腹水 FeverSQabscesses 发热皮下脓肿 7 PhysicalExamination体格检查 Anteriorabdominalpain前腹部疼痛 Icterus Profuseascites 黄疸大量腹水 FeverSQabscesses 发热皮下脓肿 8 WHICHCBC S IS ARE FROMDOG S WITHACUTE PANCREATITIS 哪份血常规结果是来自急性胰腺 炎患犬的 9 147033147198 90524 159796 PCVWBCSegsBands 28 530 00026 100900 28 845 50033 6702 730 309 8004 6062 450 4011 5009 8900 Plat 87 000 407 000679 000470 000 Toxic mod mod none none 10 147033147198 90524 159796 PCVWBCSegsBands 28 530 00026 100900 28 845 50033 6702 730 309 8004 6062 450 4011 5009 8900 Plat 87 000 407 000679 000470 000 Toxic mod mod none none 11 ClinicalPathology 临床病理学 Ananorexic vomitingdogwithfastinghyperlipidemiaprobablyhasacutepancreatitis 患犬厌食 呕吐 突然出现高脂血症 可能患有急性胰腺炎 12 ClinicalPathology 临床病理学 Ananorexic vomitingdogwithfasting hyperlipidemiaprobablyhasacutepancreatitis 患犬厌食 呕吐 突然出现高脂血症可能患有急性胰腺炎 MostdogswithpancreatitisDONOThave fastinghyperlipidemia 大部分胰腺炎患犬并未突然出现高脂血症 13 ClinicalPathology临床病理学 Amylase Lipase Sensitivity 50 Specificity 50 淀粉酶 脂肪酶敏感性 50 特异性 50 TLI 血清胰蛋白酶样免疫反应 Sensitivity 35 特异性 35 14 ClinicalPathology临床病理学 Amylase Lipase Sensitivity 50 Specificity 50 淀粉酶 脂肪酶敏感性 50 特异性 50 TLI 血清胰蛋白酶样免疫反应 Sensitivity 35 特异性 35 15 ClinicalPathology 临床病理学 cPLI Sensitivity 80 85 敏感性 80 85 16 TAMU 203505Sig 14yrM n ShihTzu14岁雄性已去势西施犬 CC Abdominalpain 前腹部疼痛 HPI Pain2daysagoandyesterday两天前和昨天疼痛 Vomited1timePU PDforlastweek 呕吐一次上周多饮多尿 PE Normalappetite bodyweight食欲 体重正常Noabnormalitiestoday今日无异常 17 TAMU 203505 PCV WBC Segs Bands Lymphs 24 35 55 23 300 ul 6 14 000 17 475 ul 4 12 000 0 ul 500 4 660 ul 1 4 000 Platelets 498 000 ul 200 500 000 18 TAMU 203505 肌酐钙钠钾 Creatinine Calcium Sodium Potassium 0 78mg dl 2 0 9 7mg dl 9 3 11 8 153mEq L 138 148 3 8mEq L 3 8 5 1 白蛋白Albumin ALT SAP 胆红素Bilirubin 2 7gm dl 2 5 4 4 8 258IU L 130 2 354IU L 147 0 3mg dl 0 0 8 19 TAMU 203505 AbdU S enlargedpancreaswith nodules hepaticmassmost consistentwithprimarylivertumor 腹部超声检查 胰腺体积增大 可见胰腺结节 肝 脏肿物符合原发性肝肿瘤特征 20 TAMU 203505 SnapPL positivecPL试剂盒检测 阳性 21 Yourbestnextstepis 下一步最好 1Forgetaboutit dogisnowhappy 算了吧 狗狗现在挺开心的 2 RepeatcPLIandultrasoundtomorrow 明日复查cPLI和超声检查3Txforacutepancreatitis IVfluids 治疗急性胰腺炎 静脉补液 4Txwithpancreaticenzymes用胰酶治疗 5Hepaticlobectomy 肝叶切除术 8 22 PANCREATITIS versus CLINICALLYIMPORTANT PANCREATITIS 胰腺炎和临床上需重视的胰腺炎 23 Diagnostics 诊断 cPLI Sensitivity 80 敏感性 80 Abdominalultrasound 腹部超声检查 Sensitivity40 65 敏感性40 65 24 Diagnostics诊断 cPLI Sensitivity 80 敏感性 80 Abdominalultrasound腹部超声检查 Sensitivity40 65 敏感性40 65 Becausecliniciansrarelyrepeattheultrasound因为临床医师很少重复进行超声检查 25 Diagnostics cPLI Sensitivity 80 敏感性 80 Abdominalultrasound腹部超声检查 Sensitivity40 65 敏感性40 65 Findingscanchangewithinhours 检查结果数小时内就可能发生变化 26 27 WHATISTHEBESTWAY TODIAGNOSECANINEACUTEPANCREATITIS 诊断犬急性胰腺炎最好的方法是 28 29 Bewillingtorepeat ultrasound 重复进行超声检查 30 Allthingsbeingequal try toavoidsurgery 平衡一切 尽量避免手术 31 Allthingsbeingequal try toavoidsurgery 平衡一切 尽量避免手术 Bewillingtorepeat ultrasound 重复进行超声检查 32 THEREALPROBLEMISTHATACUTEPANCREATITISCANPRESENTINSOMANYDIFFERENTWAYSTHATYOUDON TEVENSUSPECTITINITIALLY 真正的问题是急性胰腺炎可能有很多种表现 在开始时你也许都不会怀疑是胰腺炎 33 TAMU 88267Sig 7yrMSheltieCC VomitingHPI Began5weeksago 7岁雄性喜乐蒂呕吐五周前开始 PE Partialanorexia vomitsphlegmorbileoncedaily有时厌食 呕吐黏液或胆汁 每日一次Dogotherwiseprettyhealthy其他方面无异常Nosignificantabnormalities未见明显异常 34 TAMU 159796Sig 9yrM c Pug 9岁雄性去势巴哥 犬CC Vomiting yellowscleras呕吐 巩膜发黄HPI Feelingbad12daysago12天前状态不佳Startedvomiting respondedtofluidtherapy butbecameillagainwhenstartedfeedingit开始呕吐后 液体疗法有效 但恢复进食后病情反复Dog seyesturnedyellow患犬眼部发黄 35 TAMU 159796PCV BUN 葡萄糖Glucose 40 35 55 4mg dl 8 29 95mg dl 75 133 钾 Potassium 3 6mEq L 3 8 5 1 胆固醇Cholesterol 白蛋白Albumin ALT SAP 胆红素Bilirubin 597mg dl 120 247 2 9gm dl 2 5 4 4 1 691IU L 130 3 134IU L 147 4 5mg dl 0 0 8 36 TAMU 152494Sig 9yrF s DalmationCC Vomiting diarrhea 9岁雌性绝育大麦町呕吐 腹泻 HPI Vomitingfood bile6 8Xin2weeks2周内呕吐食物 胆汁6 8次Diarrheaconstantfor2weeks持续腹泻2周时间Decreasedappetitefor10days anorexiafor5days食欲减退10天 厌食5天 PE T 39 2C HR 102 min 37 TAMU 152494 PCV WBC Segs 叶状中性粒细胞Bands 35 5 35 55 21 700 ul 6 14 000 15 200 ul 4 12 000 630 ul 500 杆状中性粒细胞Lymphs 1 400 ul 1 4 000 淋巴细胞Platelets 568 000 ul 200 500 000 38 TAMU 152494 钠钾葡萄糖白蛋白肌酐 Sodium Potassium Glucose Albumin ALT SAP Creatinine 152mEq L 138 148 4 1mEq L 3 5 5 0 107mg dl 60 120 2 7gm dl 2 5 4 4 123IU L 110 2 174IU L 130 1 3mg dl 2 0 39 TAMU 152494 Abdominalultrasound Smallamountofanechoiceffusionbetweenliverlobesandaroundurinarybladder 腹部超声 肝叶之间及膀胱周围可见少量无回声液体 40 TAMU 152494Abdominalfluid 腹腔积液 WBC RBC 153 000 ul0 ul Totalprotein 4 6gm dl 总蛋白90 nondegenerateneutrophils非退行性中性粒细胞8 macrophages vaculated巨噬细胞 空泡化 41 Sterilepancreatitis 无菌性胰腺炎 Versus和 Septicperitonitis 败血性腹膜炎 42 Abdominalfluid腹腔积液 147260152494 152485 109612 TPgm dl5 1 4 6 1 3 3 6 WBC ul 15 059153 000700 18 200 RBC ul 91 1120 30 000 83 700 43 Abdominalfluid腹腔积液 147260152494 152485 109612 TPgm dl5 1 4 6 1 3 3 6 WBC ul 15 059153 000700 18 200 RBC ul 91 1120 30 000 83 700 44 PANCREATITISCAN 胰腺炎时可能 a makenoabdominaleffusion 无腹腔积液 b makealittleabdominaleffusion 产生少量腹腔积液 c makeamassiveabdominaleffusion 45 Pancreatitiscanpresentas 胰腺炎可表现为 acutevomitingwithabdominalpain 急性呕吐伴有腹部疼痛 chronic lowgradevomiting anorexia abscess 慢性轻度呕吐 厌食 脓肿 icterus biliarytractobstruction 黄疸 胆道阻塞 ascites minimal littleorlots 腹水 少量 无腹水或大量 acuteabdomen looksjustlikesepticperitonitis 急腹症 症状类似败血性腹膜炎 SIRS lookslikesepticshock SIRS 症状类似败血性休克 46 SYSTEMICINFLAMMATORY RESPONSESYNDROME 全身性炎症反应综合征 usedtobecalled Septicshock 曾被称为 败血性休克 47 SYSTEMICINFLAMMATORY RESPONSESYNDROME 全身性炎症反应综合征 inadequateperfusionofthebodytissues becauseofanexaggeratedinflammatory response 剧烈的炎症反应导致机体组织灌注不良 48 WHATISSUPPOSEDTOHAPPEN认为会发生什么Bacterialtoxin inflammatorycytokines细菌毒素 炎性细胞因子Lymphnodes hepaticmacrophages淋巴结 肝脏巨噬细胞 Systemiccirculation全身循环 49 WHATISSUPPOSEDTOHAPPEN认为会发生什么Bacterialtoxin inflammatorycytokines细菌毒素 炎性细胞因子Lymphnodes hepaticmacrophages淋巴结 肝脏巨噬细胞 Systemiccirculation全身循环 50 Inflammatorycytokines Lymphnodes淋巴结 Systemic circulation 全身循环 WHATCANHAPPEN 会发生什么 炎性细胞因子 51 EARLY SIRSMildunevenvasodilatation轻度部分血管扩张 Highoutput shock高输出性休克 Brightredmucusmembranes黏膜鲜红Fastcapillaryrefilltime毛细血管再充盈时间短 BoundingpulsesTachycardia 脉搏跳跃 洪脉 心动过速 52 LATE SIRSSevereperipheralvasodilatation poorcardiaccontractility严重的外周血管扩张 心收缩力不足 Lowoutput shock低输出性休克 Palemucusmembranes黏膜苍白 Weakpulses 脉搏微弱 Slowrefilltime毛细血管再充盈时间延长 53 THERAPYFORPANCREATITIS 胰腺炎的治疗 Onlysupportiveandsymptomatic 仅用支持疗法和对症治疗 NPO nothingperos vsEarly Feeding NPO 禁食 和早期饲喂 54 EarlyFeeding早期饲喂 Feedsmallamountsofultra lowfatfood evenifvomiting 即使呕吐也饲喂少量超低脂食物 Continuefeedingaslongasthepatient doesnotgetworse 只要动物病情没有恶化 便继续饲喂 THERAPYFORPANCREATITIS 胰腺炎的治疗 Onlysupportiveandsymptomatic 仅用支持疗法和对症治疗 55 Fluidtherapy 液体疗法 Crystalloids晶体液 PlasmaColloids 血浆胶体液 THERAPYFORPANCREATITIS胰腺炎的治疗Onlysupportiveandsymptomatic仅用支持疗法和对症治疗 EarlyFeeding早期饲喂 56 Fluidtherapy 液体疗法 Crystalloids晶体液 PlasmaColloids 血浆胶体液 Hetastarchisnolongereveryone sbestfriend JVetEmergCriticalCare25 20 47 2015 羟乙基淀粉不再是所有人最好的朋友 THERAPYFORPANCREATITIS胰腺炎的治疗Onlysupportiveandsymptomatic EarlyFeeding早期饲喂 57 Fluidtherapy 液体疗法 Crystalloids晶体液 PlasmaColloids 血浆胶体液 Total partialparenteralnutrition 完全 部分肠外营养支持 THERAPYFORPANCREATITIS胰腺炎的治疗Onlysupportiveandsymptomatic EarlyFeeding早期饲喂 58 Fluidtherapy 液体疗法 Crystalloids晶体液 PlasmaColloids 血浆胶体液 Jejunostomyfeeding空肠造口饲喂 PEG J NasalJ regularJ THERAPYFORPANCREATITIS胰腺炎的治疗Onlysupportiveandsymptomatic仅用支持疗法和对症治疗 EarlyFeeding早期饲喂 59 Fluidtherapy 液体疗法