重新认识胰腺炎

重新认识犬胰腺炎,History 病史 Signalment 临床表现, Diet Vomiting,饮食情况呕吐, History of pancreatitis胰腺炎病史,Diarrhea,腹泻,History 病史 Signalment 临床表现, Diet Vomiting,饮食情况呕吐, History of pancreatitis胰腺炎病史,Diarrhea,腹泻,History 病史 Signalment 临床表现, Diet Vomiting,饮食情况呕吐, History of pancreatitis胰腺炎病史,Diarrhea,腹泻,Knowing the LIMITATIONS of atest or procedure is often muchmore important than knowing,what a procedure can do,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,Physical Examination体格检查Anterior abdominal pain前腹部疼痛, Icterus Profuse ascites,黄疸大量腹水,FeverSQ abscesses,发热皮下脓肿,Physical Examination体格检查Anterior abdominal pain前腹部疼痛, Icterus Profuse ascites,黄疸大量腹水,FeverSQ abscesses,发热皮下脓肿,Physical Examination体格检查Anterior abdominal pain前腹部疼痛, Icterus Profuse ascites,黄疸大量腹水,FeverSQ abscesses,发热皮下脓肿,WHICH CBC(S) IS/ARE,FROM DOG(S) WITH ACUTE,PANCREATITIS?,哪份血常规结果是来自急性胰腺,炎患犬的？,147033 147198,90524,159796,PCVWBCSegsBands,28.530,00026,100900,28.845,50033,6702,730,309,8004,6062,450,4011,5009,8900,Plat,87,000,407,000 679,000 470,000,Toxic,mod,mod,none,none,147033 147198,90524,159796,PCVWBCSegsBands,28.530,00026,100900,28.845,50033,6702,730,309,8004,6062,450,4011,5009,8900,Plat,87,000,407,000 679,000 470,000,Toxic,mod,mod,none,none,Clinical Pathology,临床病理学, An anorexic, vomiting dog withfasting hyperlipidemia probably hasacute pancreatitis,患犬厌食、呕吐，突然出现高脂血症,可能患有急性胰腺炎,Clinical Pathology,临床病理学, An anorexic, vomiting dog with fasting,hyperlipidemia probably has acutepancreatitis,患犬厌食、呕吐，突然出现高脂血症可能患有急性胰腺炎, Most dogs with pancreatitis DO NOT have,fasting hyperlipidemia,大部分胰腺炎患犬并未突然出现高脂血症,Clinical Pathology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%,Clinical Pathology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%,Clinical Pathology,临床病理学, cPLI, Sensitivity 80-85%,敏感性 80-85%,TAMU#203505Sig: 14 yr M(n) Shih Tzu 14岁 雄性已去势 西施犬,CC:,Abdominal pain,前腹部疼痛,HPI: Pain 2 days ago and yesterday两天前和昨天疼痛,Vomited 1 timePU-PD for last week,呕吐一次上周多饮多尿,PE:,Normal appetite/body weight食欲/体重正常No abnormalities today 今日无异常,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),TAMU#203505,肌酐钙钠钾,Creatinine =Calcium =Sodium =Potassium =,0.78 mg/dl ( 2.0)9.7 mg/dl (9.3-11.8)153 mEq/L (138-148)3.8 mEq/L (3.8-5.1),白蛋白Albumin =ALT =SAP =胆红素Bilirubin =,2.7 gm/dl (2.5-4.4)8,258 IU/L ( 130)2,354 IU/L ( 147)0.3 mg/dl (0-0.8),TAMU#203505,Abd U/S: “. . enlarged pancreas with,nodules . hepatic mass most,consistent with primary liver tumor”,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,TAMU#203505,Snap PL: positivecPL试剂盒检测： 阳性,Your best next step is:下一步最好：1 Forget about it (dog is now happy)算了吧（狗狗现在挺开心的）,2,Repeat cPLI and ultrasound tomorrow,明日复查cPLI和超声检查3 Tx for acute pancreatitis (IV fluids)治疗急性胰腺炎（静脉补液）4 Tx with pancreatic enzymes用胰酶治疗,5 Hepatic lobectomy,肝叶切除术,8,PANCREATITIS,versus,CLINICALLY IMPORTANT,PANCREATITIS,胰腺炎和临床上需重视的胰腺炎,Diagnostics,诊断, cPLI, Sensitivity 80% 敏感性-80%, Abdominal ultrasound,腹部超声检查, Sensitivity 40% - 65%,敏感性 40% - 65%,Diagnostics诊断, cPLI Sensitivity 80%,敏感性-80%, Abdominal ultrasound 腹部超声检查 Sensitivity 40% - 65% 敏感性 40% - 65% Because clinicians rarely repeat theultrasound因为临床医师很少重复进行超声检查,Diagnostics, cPLI Sensitivity 80%,敏感性-80%, Abdominal ultrasound 腹部超声检查 Sensitivity 40% - 65% 敏感性 40% - 65% Findings can change within hours .检查结果数小时内就可能发生变化,WHAT IS THE BEST WAY,TO DIAGNOSE CANINEACUTE PANCREATITIS?,诊断犬急性胰腺炎最好的方法是,Be willing to repeat,ultrasound,重复进行超声检查,All things being equal, try,to avoid surgery,平衡一切，尽量避免手术,All things being equal, try,to avoid surgery,平衡一切，尽量避免手术,Be willing to repeat,ultrasound,重复进行超声检查,THE REAL PROBLEM IS THAT ACUTEPANCREATITIS CAN PRESENT IN SOMANY DIFFERENT WAYS THAT YOUDONT EVEN SUSPECT IT INITIALLY,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？,TAMU#88267Sig: 7 yr M SheltieCC: VomitingHPI: Began 5 weeks ago,7岁 雄性 喜乐蒂呕吐五周前开始,PE:,Partial anorexia, vomits phlegm orbile once daily有时厌食，呕吐黏液或胆汁，每日一次Dog otherwise pretty healthy其他方面无异常No significant abnormalities 未见明显异常,TAMU#159796Sig: 9 yr M(c) Pug,9岁 雄性去势 巴哥,犬CC: Vomiting, yellow scleras 呕吐，巩膜发黄HPI: Feeling bad 12 days ago 12天前状态不佳Started vomiting, responded tofluid therapy, but became illagain when started feeding it开始呕吐后，液体疗法有效，但恢复进食后病情反复Dogs eyes turned yellow 患犬眼部发黄,TAMU#159796PCV =BUN =葡萄糖 Glucose =,40% (35-55)4 mg/dl (8-29)95 mg/dl (75-133),钾,Potassium =,3.6 mEq/L (3.8-5.1),胆固醇 Cholesterol =白蛋白 Albumin =ALT =SAP =胆红素Bilirubin =,597 mg/dl (120-247)2.9 gm/dl (2.5-4.4)1,691 IU/L ( 130)3,134 IU/L ( 147)4.5 mg/dl (0-0.8),TAMU #152494Sig: 9 yr F(s) DalmationCC: Vomiting/diarrhea,9岁 雌性绝育 大麦町呕吐/腹泻,HPI: Vomiting food/bile 6-8X in 2 weeks2周内呕吐食物/胆汁6-8次Diarrhea constant for 2 weeks持续腹泻2周时间Decreased appetite for 10 days, anorexia for 5 days食欲减退10天，厌食5天,PE:,T = 39.2 C, HR = 102/min,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),TAMU #152494,钠钾葡萄糖白蛋白肌酐,Sodium =Potassium =Glucose =Albumin =ALT =SAP =Creatinine =,152 mEq/L (138-148)4.1 mEq/L (3.5-5.0)107 mg/dl (60-120)2.7 gm/dl (2.5-4.4)123 IU/L ( 110)2,174 IU/L ( 130)1.3 mg/dl ( 2.0),TAMU #152494,Abdominal ultrasound:,“ Small amount of anechoic effusionbetween liver lobes and around urinarybladder.”,腹部超声：肝叶之间及膀胱周围可见少量无回声液体,TAMU #152494Abdominal fluid: 腹腔积液,WBC =RBC =,153,000/ul0/ul,Total protein =,4.6 gm/dl,总蛋白90% nondegenerate neutrophils非退行性中性粒细胞8% macrophages, vaculated巨噬细胞，空泡化,Sterile pancreatitis,无菌性胰腺炎,Versus 和,Septic peritonitis,败血性腹膜炎,Abdominal fluid 腹腔积液,147260 152494,152485,109612,TP gm/dl 5.1,4.6,1.3,3.6,WBC/ul,15,059 153,000 700,18,200,RBC/ul,91,112 0,30,000,83,700,Abdominal fluid 腹腔积液,147260 152494,152485,109612,TP gm/dl 5.1,4.6,1.3,3.6,WBC/ul,15,059 153,000 700,18,200,RBC/ul,91,112 0,30,000,83,700,PANCREATITIS CAN:,胰腺炎时可能：,a) make no abdominal effusion,无腹腔积液,b) make a little abdominal effusion,产生少量腹腔积液,c) make a massive abdominal effusion,Pancreatitis can present as:,胰腺炎可表现为：, acute vomiting with abdominal pain,急性呕吐伴有腹部疼痛, chronic, low grade vomiting/anorexia (abscess),慢性轻度呕吐/厌食（脓肿）, icterus (biliary tract obstruction),黄疸（胆道阻塞）, ascites (minimal, little or lots),腹水（少量、无腹水或大量）, acute abdomen (looks just like septic peritonitis),急腹症（症状类似败血性腹膜炎）, SIRS (looks like septic shock),SIRS（症状类似败血性休克）,SYSTEMIC INFLAMMATORY,RESPONSE SYNDROME,全身性炎症反应综合征, used to be called “Septicshock” 曾被称为“败血性休克”,SYSTEMIC INFLAMMATORY,RESPONSE SYNDROME,全身性炎症反应综合征, inadequate perfusion of the body tissues,because of an exaggerated inflammatory,response,剧烈的炎症反应导致机体组织灌注不良,WHAT IS SUPPOSED TOHAPPEN 认为会发生什么Bacterial toxin, inflammatory cytokines细菌毒素，炎性细胞因子Lymph nodes, hepatic macrophages淋巴结，肝脏巨噬细胞,Systemic circulation全身循环,WHAT IS SUPPOSED TOHAPPEN 认为会发生什么Bacterial toxin, inflammatory cytokines细菌毒素，炎性细胞因子Lymph nodes, hepatic macrophages淋巴结，肝脏巨噬细胞,Systemic circulation全身循环,Inflammatory cytokines,Lymph nodes 淋巴结,Systemic,circulation,全身循环,WHAT CAN HAPPEN,会发生什么,炎性细胞因子,EARLY SIRSMild uneven vasodilatation 轻度部分血管扩张,“High output” shock 高输出性休克,Bright red mucus membranes 黏膜鲜红Fast capillary refill time 毛细血管再充盈时间短,Bounding pulsesTachycardia,脉搏跳跃（洪脉）心动过速,LATE SIRSSevere peripheral vasodilatation + poorcardiac contractility严重的外周血管扩张+ 心收缩力不足“Low output” shock 低输出性休克,Pale mucus membranes 黏膜苍白,Weak pulses,脉搏微弱,Slow refill time 毛细血管再充盈时间延长,THERAPY FOR PANCREATITIS,胰腺炎的治疗,Only supportive and symptomatic,仅用支持疗法和对症治疗, NPO (nothing per os) vs Early,Feeding,NPO（禁食）和早期饲喂, Early Feeding 早期饲喂, Feed small amounts of ultra-low fat food,even if vomiting,即使呕吐也饲喂少量超低脂食物, Continue feeding as long as the patient,does not get worse,只要动物病情没有恶化，便继续饲喂,THERAPY FOR PANCREATITIS,胰腺炎的治疗,Only supportive and symptomatic,仅用支持疗法和对症治疗, Fluid therapy,液体疗法,Crystalloids 晶体液,PlasmaColloids,血浆胶体液,THERAPY FOR PANCREATITIS胰腺炎的治疗Only supportive and symptomatic仅用支持疗法和对症治疗 Early Feeding 早期饲喂, Fluid therapy,液体疗法,Crystalloids 晶体液,PlasmaColloids,血浆胶体液,Hetastarch is no longer everyones bestfriend . (J Vet Emerg Critical Care 25: 20-47, 2015)羟乙基淀粉不再是所有人最好的朋友,THERAPY FOR PANCREATITIS胰腺炎的治疗Only supportive and symptomatic Early Feeding 早期饲喂, Fluid therapy,液体疗法,Crystalloids 晶体液,PlasmaColloids,血浆胶体液,Total/partial parenteral nutrition,完全/部分肠外营养支持,THERAPY FOR PANCREATITIS胰腺炎的治疗Only supportive and symptomatic Early Feeding 早期饲喂, Fluid therapy,液体疗法,Crystalloids 晶体液,PlasmaColloids,血浆胶体液,Jejunostomy feeding 空肠造口饲喂(PEG-J, Nasal J, regular J),THERAPY FOR PANCREATITIS胰腺炎的治疗Only supportive and symptomatic仅用支持疗法和对症治疗 Early Feeding 早期饲喂, Fluid th