徐三荣－急性胰腺炎.ppt

1,ACUTEPANCREATITIS,XuSanrongDepartmentofGastroenterologyHuashanHospitalFudanuniversity,2,DEFINITION,Anacuteinflammatoryprocessofthepan-creasusuallyassociatedwithseverpainintheupperabdomeninmostinstances,bloodlevelsofpancrea-ticenzymesareincreasedseveracutepancreatitis:organsfailureand/orlocalcomplications(necrosis,absc-ess,psuedocyst),3,PATHOLOGY(1),Mildacutepancreatitis(MAP)characterizedbyinterstitialedemaassoci-atedwithinflammatorycellwithinparench-yma,andmicroscopicparenchymanecro-siscanbedetectable.,4,PATHOLOGY(2),Severacutepancreatitis(SAP)Severnecrotizingpancreatitis(SNP)macroscopicevidenceofeitherfocalordiffusenecrosisandhemorrhageofthepancreaticparenchyma,5,PATHOGENYANDPATHOGENESIS(1),1commonchannelandrefluxofduodenaljuice,gallstones,infection,Bilejuicereflux,trypsin,Kininsystems,elastase,Trypsinchymotrypsino,Phospho-lipaseA2,Steatolyticenzymes,Severpain,hemorrhage,Freefatacid,Serumcalcium,6,PATHOGENYANDPATHOGENESIS(2),2alcoholicandovereat3obstructofmainpancreaticduct4diseasesroundtheduodenum/ampullaryregion5postoperativepancreatitisandpancreatictrauma,7,PATHOGENYANDPATHOGENESIS(3),6infectiousagents7medications:corticosteroids,estrogens8disordersofendocrinologyandmetabol-ism:hyperparathyroidism,hyperlipidemia9others:,8,PATHOGENYANDPATHOGENESIS(4),6inflammatorymediatheoryInAP,theleukocytesthatappearfirstinareasofinflammationareneutrophils,thenmacrophages,monocytes,lymphocytes,andothercells.Thesecellscansecretealotofinflammatorymedia.(1)plateletactivatingfactor,PAF(2)prostaglandins,PGs,9,PATHOGENYANDPATHOGENESIS(5),(3)leukotriens,LTs(4)kallikreinkininsystems,KKS(5)tumornecrosisfactor-,TNF-(6)nitrogenmonoxide,NO(7)complements(8)others:nuclearfactorB(NF-B),tolllikereceptors(TLRs).,10,DIAGNOSIS(1),Clinicalcharacteristics1abdominalpain2fever3nauseaandvomiting,11,DIAGNOSIS(2),4hypotensionandshock5jaundice6tenderness7peritonealirritationsigntenderness,reboundtenderness,andabdominalmuscletenseness8Grey-turnersign,cullensign9ascites,12,DIAGNOSIS(3),Assistantexamination1bloodexamination(1)bloodroutineexamination(whitebloodcellcount),hematocrit(Hct),packedcellvolume(PCV)(2)blood,urineamylaseSalivary-am,P-amCam/Ccr,13,DIAGNOSIS(4),(3)serumlipase(4)bloodglucose(10mmol/L),serumcalcium(55yearsHctdecreaseof10mg/dLwbc16*109/Lbunincreaseof5mg/dLglucose11.2umol/Lcalcium250u/Lbasedeficit4mEq/Lfluidsequestration6L3onehalf6E4CTgrade(0-4)+necrosis(0-6)=totalscore,20,Complications,Localcomplications1pancreaticnecrosis2pancreaticpseudocyst3pancreaticabscess,21,Complications,Systemiccomplications1majorsystemiccomplications(1)respiratoryfailure(2)renalfailure(3)hypotention2dangerousestcomplicationmultipleorgansfailure(MOF),22,TREATMENT(1),Managementofinternalmedicine1commonmanagement(1)intensivecareunit(2)fluidresuscitation(3)nutritionalsupport,23,TREATMENT(2),2treatmentofinfectionMAPSAP3reliefofpain(1)anisodamine(654-2)(2)bucinnazine,pethidine(3)0.1%procaine(4)*morphine,24,TREATMENT(3),4inhibitionofpancreaticsecretion(1)atropine,anisodamine(654-2)(2)H2-receptorantagonists(H2RAs)protonpumpinhibitors(PPI)(3)somatostatin,anditsanalogoctreotide,25,TREATMENT(4),5inhibitionofactivatedpancreaticenzymes(1)aprotinin(2)gabexatemesilate(FOY)6drugsofanti-inflammatoryfactors7eliminatinginflammatorymediatorsperitoneallavage8traditionalmedicine,26,TREATMENT(5),8endoscopicsphincterotomy9surgeryindications:(1)with3daysafterdiagnosisofgallstonepancreatitis,(2)pancreaticabscessandpsuedocyst,(3)perforatedhollowviscus,necrosisofintestine,27,PROGNOSIS,Mildacutepancreatitisseveracutepancreatitiswithfocalnecrosis(sterile):10%-15%