内科学：急性胰腺炎

1、Acute Pancreatitis,Definition, An acute chemical inflammatory process (pancreatic enzymes autodigest the pancreas) a discrete episode of abdominal pain + serum amylase (淀粉酶) + lipase (脂肪酶) levels at least three times greater than the upper limit of normal characteristic findings of acute pancreatiti

2、s on contrast-enhanced computed tomography (CECT),Clinical Classification （Grades of severity）,Mild AP (No organ failure + No local or systemic complications) 不伴有器官功能衰竭及局部或全身并发症 Moderately severe AP ( transient organ failure: organ failure resolves within 48 h without persistent organ failure; local

3、 complications such as acute peripancreatic fluid collections (APFC) and acute necrotic collections (ANC) 伴有一过性的器官功能衰竭(48 h内可自行恢复)，或伴有局部或全身并发症而不存在持续性的器官功能衰竭(48 h内不能自行恢复) Severe AP (persistent organ failure for more than 48 h. Organ failure involved in three systems (respiratory, cardiovascular, and

4、renal); single or multiple organ failure 须伴有持续的器官功能衰竭(持续48 h以上、不能自行恢复的呼吸系统、心血管或肾脏功能衰竭，可累及一个或多个脏器),Table 1. Revised Atlanta classification,Complications,Local complications acute peripancreatic fluid collections (APFC); acute necrotic collection (ANC)； pancreatic pseudosyst; Walled-off necrosis (WON)

5、 ； infected necrosis Other local complications gastric outlet dysfunction, splenic and portal vein thrombosis, and colonic necrosis Systemic complications,Local Complications Connections Self-Learn, 急性胰腺炎初期，胰腺周围尚未形成完整包膜的渗液，称之为胰周急性胰腺炎,若后期形成完整包膜，则转化为胰腺假性囊肿，这一过程往往需要4周左右。 若早期胰腺周围渗液中含有较多坏死物，则为急性坏死物积聚,后期则

6、转化为包裹性坏死;若以上2种病理过程中出现细菌感染，则转为胰腺脓肿，感染的诊断可依据直接证据，如细针穿刺物细菌或真菌培养阳性，或者感染间接征象（增强CT提示的气泡征）。,Pathologic Classification1.Edematous pancreatitis:*interstitial edema*inflammatory cell infiltration of the parenchyma2.Hemorrhagic or necrotizing pancreatitis* marked tissue / parenchymal necrosis and hemorrhage *

7、fat necrosis, Associated with interstitial edematous pancreatitis with no peripancreatic necrosis. Applies only to areas of peripancreatic fluid seen within the first 4weeks and without the features of a pseudocyst.,1急性胰周液体积聚 (acute peripancreatic fluid collection，APFC),(acute interstitial oedematou

8、s pancreatitis and acute peripancreatic fluid collection (APFC) in the left anterior pararenal space (white arrows showing the borders of the APFC).,The pancreas enhances completely, is thickened, and has a homogeneous appearance due to edema. APFC has fluid density without an encapsulating wall. (B

9、) A few weeks later, a follow up CT shows complete resolution of the APFC with minimal residual peripancreatic fat stranding. .,CECT criteria Occurs in the setting of interstitial edematous pancreatitis (No necrosis) Homogeneous collection with fluid density （entirely liquid） Confined by normal peri

10、pancreatic fascial planes No definable wall encapsulating the collection （ No defined fibrous wall or granulation tissue ）缺乏完整包膜 Adjacent to pancreas (No intrapancreatic extension) Resolving spontaneously;, An encapsulated collection of fluid with a well defined inflammatory wall (lacking a true epi

11、thelial lining ) usually outside the pancreas with minimal or no necrosis. usually occurs more than 4weeks after onset of interstitial edematous pancreatitis to mature. 有完整非上皮性包膜包裹的液体积聚，内含胰腺分泌物、肉芽组织、纤维组织等，多发生于AP起病4周后。,2胰腺假性囊肿 (pancreatic pseudocyst),A 40-year-old man with two pseudocysts in the less

12、er sac （outside the pancreas）6weeks after an episode of acute interstitial pancreatitis on CT (A, B).,Peter A Banks et al. Gut 2013;62:102-111,Note the round to oval, low-attenuated, homogeneous fluid collections with a well defined enhancing rim (white arrows pointing at the borders of the pseudocy

13、sts), but absence of areas of greater attenuation indicative of non-liquid components. White stars denote normal enhancing pancreas.,CECT criteria Well circumscribed, usually round or oval Homogeneous fluid density （ a collection of pancreatic juice ） No non-liquid component （ no solid necrotic mate

14、rial ） Well defined wall; completely encapsulated （enclosed by a wall of fibrous or granulation tissue） Maturation usually requires 4weeks after onset of acute pancreatitis; occurs after interstitial edematous pancreatitis, A collection containing variable amounts of both fluid and necrosis associat

15、ed with necrotizing pancreatitis; the necrosis can involve the pancreatic parenchyma and/or the peripancreatic tissues 发生于病程早期，表现为液体内容物，包含混合的液体和坏死组织，坏死物包括胰腺实质或胰周组织的坏死。,3急性坏死物积聚 acute necrotic collection，(ANC),Three different patients (A, B, C) with acute necrotising pancreatitis and acute necrotic c

16、ollections (ANC) involving the pancreatic parenchyma and the peripancreatic tissues.,Peter A Banks et al. Gut 2013;62:102-111,In all three patients, there is extensive parenchymal necrosis (white stars) of the body and tail of the pancreas. Heterogeneous collections are seen in the pancreatic and pe

17、ripancreatic tissues (white arrows pointing at the borders of the ANC) of the left anterior pararenal space (A, B, C) and in the lesser sac (A, C). These latter collections represent peripancreatic necrosis.,CECT criteria Occurs only in the setting of acute necrotizing pancreatitis Heterogeneous and

18、 non-liquid density of varying degrees in different loculations (some appear homogeneous early in their course) No definable wall encapsulating the collection Location:intrapancreatic and/or extrapancreatic, A mature, encapsulated collection of pancreatic and/or peripancreatic necrosis + a well defi

19、ned inflammatory wall. occurs 4weeks after onset of necrotizing pancreatitis. 是一种成熟的、包含胰腺和(或)胰周坏死组织、具有界限分明炎性包膜的囊实性结构，多发生于AP起病4周后。,4包裹性坏死 (walled-off necrosis，WON),(AC) Three different patients with walled-off necrosis (WON) after an acute attack of necrotising pancreatitis.,Peter A Banks et al. Gut

20、2013;62:102-111,(In all three patients, a heterogeneous, fully encapsulated collection is noted in the pancreatic and peripancreatic area. (A) Non-liquid components of high attenuation (black arrowheads) in the collection are noted. The collection has a thin, well defined, and enhancing wall (thick

21、white arrows). (B, C) A largely liquefied collection in the bed of the pancreas is observed with non-liquid components representing areas of trapped fat (black arrowheads). (D) represents the corresponding T2-weighted MRI to (C), showing the true heterogeneity of the collection. Black arrowheads den

22、ote areas of necrotic debris surrounded by fluid (white on T2-weighted image).,CECT criteria Heterogeneous with liquid and non-liquid density with varying degrees of loculations (some may appear homogeneous) Well defined inflammatory wall， completely encapsulated Location:intrapancreatic and/or extr

23、apancreatic Maturation usually requires 4weeks after onset of acute necrotizing pancreatitis, contains purulent liquid with no solid necrotic material in the pancreatic and/or peripancreatic tissues; can be diagnosed by following the patients clinical course; presence of gas on CT scans Bubbles, cau

24、sed by gas-forming microorganisms, indicate that the pancreatic necrosis is infected. 胰腺内或胰周的脓液积聚，增强CT提示气泡征，细针穿刺物细菌或真菌培养阳性。,5infected necrosis,Pancreatic and peripancreatic collections should be described on the basis of location (pancreatic, peripancreatic) the nature of the content (liquid, solid,

25、 gas) the thickness of any wall (thin, thick) The pattern and extent of impaired pancreatic parenchymal perfusion,Systemic Complications,organ failure: respiratory, cardiovascular, and renal systemic inflammatory response syndrome（SIRS） 全身炎性反应综合征 systemic infection 全身感染 intra-abdominal hypertension

26、(IAH) 腹腔内高压 abdominal compartment syndrome (ACS) 腹腔间隔室综合征 pancreatic encephalopathy (PE) 胰性脑病,Definition of organ failure Self-Learn,Three organ systems should be assessed to define organ failure: respiratory, cardiovascular and renal. Organ failure is defined as a score of 2 or more for one of thes

27、e three organ systems using the modified Marshall scoring.,Organ failure Self-Learn,AP的严重程度主要取决于器官功能衰竭的出现及持续时间(是否超过48 h)，出现2个以上器官功能衰竭称为多器官功能衰竭(multiple organ failure，MOF) 呼吸衰竭：急性呼吸窘迫综合征(acute respiratory distress syndrome，ARDS) 循环衰竭：心动过速、低血压或休克 肾功能衰竭：少尿、无尿和血清肌酐升高,呼吸系统的影响 Self-Learn,十分常见，主要原因为通气降低、通气

28、与血流平衡遭到破坏、补体介导的中性粒细胞在肺泡血管聚集、淤积诱发急性呼吸窘迫综合征（acute respiratory distress syndrome,ARDS），发病初期主要表现出低氧血症，随着病情的恶化会引起肺部并发症类似肺水肿、胸腔积液及ARDS（主要症状表现包括呼吸加快、呼吸困难和紫绀等），呼吸衰竭是重度急性胰腺炎初期导致死亡的重要因素。,心脏的影响 Self-Learn,病情较轻的患者出现如心率增快和心律不齐症状，病情严重的患者则可能出现心肌梗死、心源性休克、心室颤动，甚至引起心包炎或心包积液。,肾脏功能的影响 Self-Learn,在病情较轻的患者表现为肾小管或者肾小球功能异常

29、，表现为一过性少尿，在病情严重的患者则可能出现急性肾功能衰竭。,SIRS,符合以下临床表现中的2项及以上，可以诊断为SIRS心率90次min；体温38；WBC计数12 109L；呼吸频率20次min或PCO232 mmHg)。 SIRS持续存在将会增加器官功能衰竭发生的风险。,全身感染 Self-Learn,SAP患者若合并脓毒症，病死率升高，为5080。主要以革兰阴性杆菌感染为主，也可有真菌感染。,IAH和ACS Self-Learn,SAP时IAH和ACS的发生率分别约为40和10，IAH已作为判定SAP预后的重要指标之一，容易导致多器官功能不全综合征(multiple organ dys

30、function syndrome，MODS)。 膀胱压(urinary bladder pressure，UBP)测定是诊断ACS的重要指标，膀胱压20 mm Hg，伴有少尿、无尿、呼吸困难、吸气压增高、血压降低时应考虑出现ACS。,胰性脑病 Self-Learn,重度急性胰腺炎时因大量活性蛋白水解酶、磷脂酶A等进入脑内，对脑组织与血管产生影响，引起中枢神经系统损害症候群，此症候群称为胰性脑病。 是AP的严重并发症之一，常见的症状为反应迟钝、定向力障碍、谵妄、意识模糊、昏迷、烦躁不安、抑郁、恐惧、妄想、幻觉、语言障碍、共济失调、震颤、反射亢进或消失以及偏瘫等，多发生于AP早期。,Defini

31、tion of types of acute pancreatitis 1. Interstitial edematous pancreatitis mainly diffuse enlargement of the pancreas inflammatory edema On CECT, the pancreatic parenchyma : homogeneous enhancement peripancreatic fat: some inflammatory changes of haziness or mild stranding some peripancreatic fluid

32、symptoms usually resolve within the first week,A 63-year-old man with acute interstitial oedematous pancreatitis.,Peter A Banks et al. Gut 2013;62:102-111,peripancreatic fat stranding (arrows) without an acute peripancreatic fluid collection; the pancreas enhances completely,(A) A 38-year-old woman

33、with acute interstitial oedematous pancreatitis and acute peripancreatic fluid collection (APFC) in the left anterior pararenal space (white arrows showing the borders of the APFC).,Peter A Banks et al. Gut 2013;62:102-111,(A) The pancreas enhances completely, is thickened, and has a heterogeneous a

34、ppearance due to oedema. APFC has fluid density without an encapsulating wall. (B) A few weeks later, a follow up CT shows complete resolution of the APFC with minimal residual peripancreatic fat stranding.,2. Necrotizing pancreatitis About 510% of patients develop necrosis of the pancreatic parench

35、yma, the peripancreatic tissue or both (pancreatic and peripancreatic collections) most necrosis involving both the pancreas and peripancreatic tissues less commonly as necrosis of only peripancreatic tissue rarely of the pancreatic parenchyma alone,Definition of types of acute pancreatitis,(A) Acut

36、e necrotic collections (ANC) in a 44-year-old man with acute necrotising pancreatitis involving only the peripancreatic tissues.,Peter A Banks et al. Gut 2013;62:102-111,(A) acute necrotising pancreatitis involving only the peripancreatic tissues. Note enhancement of the entire pancreatic parenchyma

37、 (white stars) and the heterogeneous, non-liquid peripancreatic components in the retroperitoneum (white arrows pointing at the borders of the ANC). (B) The ANC in the same patient as (A) but imaged a few weeks later demonstrate a heterogeneous collection with areas of fat (black arrowheads) surroun

38、ded by fluid density, and areas which have a slightly greater attenuation (black arrows) than seen in collections without necrosis such as shown in figure 7. This finding is typical for peripancreatic necrosis. White arrows denote border of ANC; white stars denote enhancement of pancreatic parenchym

39、a. The ANC are not yet fully encapsulated.,Three different patients (A, B, C) with acute necrotising pancreatitis and acute necrotic collections (ANC) involving the pancreatic parenchyma and the peripancreatic tissues.,Peter A Banks et al. Gut 2013;62:102-111,In all three patients, there is extensiv

40、e parenchymal necrosis (white stars) of the body and tail of the pancreas. Heterogeneous collections are seen in the pancreatic and peripancreatic tissues (white arrows pointing at the borders of the ANC) of the left anterior pararenal space (A, B, C) and in the lesser sac (A, C). These latter colle

41、ctions represent peripancreatic necrosis.,Acute necrotic collection (ANC) in a 47-year-old woman with acute necrotising pancreatitis involving the pancreatic parenchyma alone.,Peter A Banks et al. Gut 2013;62:102-111,Thin white arrows denote a newly developed, slightly heterogeneous collection in th

42、e region of the neck and body of the pancreas, without extension in the peripancreatic tissues.,Definition of types of acute pancreatitis 3. Infected pancreatic necrosis Pancreatic and peripancreatic necrosis: sterile or infected The diagnosis of infected pancreatic necrosis is important : need for

43、antibiotic treatment + active intervention The presence of infection: when there is extraluminal gas in the pancreatic and/or peripancreatic tissues on CECT or when percutaneous, image-guided, fine-needle aspiration (FNA) is positive for bacteria and/or fungi on Gram stain and culture. There may be

44、a varying amount of suppuration (pus) associated with the infected pancreatic necrosis, and this suppuration tends to increase with time with liquefaction.,A 47-year-old man with acute necrotising pancreatitis complicated by infected pancreatic necrosis.,Peter A Banks et al. Gut 2013;62:102-111,Ther

45、e is a heterogeneous, acute necrotic collection (ANC) in the pancreatic and peripancreatic area (white arrows pointing at the borders of the ANC) with presence of gas bubbles (white arrowheads), usually a pathognomonic sign of infection of the necrosis (infected necrosis).,Early phase Self-Learn sys

46、temic disturbances result from the host response to local pancreatic injury. usually over by the end of the first Cytokine cascades are activated by the pancreatic inflammation which manifest clinically as the systemic inflammatory response syndrome (SIRS). When SIRS is persistent, there is an incre

47、ased risk of developing organ failure. The determinant of the severity of acute pancreatitis during the early phase is primarily the presence and duration of organ failure. transient organ failure : organ failure resolves within 48h persistent organ failure: organ failure persists for 48h. If organ

48、failure affects more than one organ system: multiple organ failure (MOF).,Late phase Self-Learn systemic signs of inflammation or by the presence of local complications, and so by definition the late phase occurs only in patients with moderately severe or severe acute pancreatitis. Local complicatio

49、ns evolve during the late phase. Persistent organ failure remains the main determinant of severity,Etiology In China, biliary diseases account for approximately 50% of patients. In western countries, biliary diseases account for approximately 40% and a history of sustained alcohol abuse accounts for

50、 35% of patients.,Common Causes,Cholelithiasis胆石症 (Biliary microlithiasis 胆道微结石):胆源 性胰腺炎仍是我国AP的主要病因 Hypertriglyceridemia (HTG)高三酰甘油血症:高三酰甘油血症性胰腺炎的发病率呈上升态势【三酰甘油1130 mmolL，极易发生AP；三酰甘油565 mmolL，发生AP的危险性减少】 Ethanol 乙醇,Biliary Tract Diseases,cholelithiasis (gallstones), acute or chronic cholecystitis (胆囊

51、炎), cholangitis (胆管炎), biliary tract ascarid (蛔虫), etc. caused by any biliary tract disease (biliary acute pancreatitis) Gallstone : the most dominant type,Biliary Tract Diseases,Explained by “common channel hypothesis”,Biliary Tract Diseases,In 70%-80% of normal population, pancreatic duct and comm

52、on bile duct form a common channel before entering into descending segment of duodenum. The length of common channel is 2-5 mm.,Gallstones,ascarid,Imbed or impact ampulla of Vater,obstruction of exit of Vater,inflammation,edema,spasm,impediment of excretion of bile,inner pressure in the biliary trac

53、t,inner pressure in the biliary Tract inner pressure in the pancreatic duct,bile flows retrogradely into pancreatic duct,acute pancreatitis,common channel,bile reflux,common bile duct,ampulla of Vater,migratory gallstones,damage,Dysfunction of Oddi sphincter,duodenal Contents flow Retrogradely into

54、pancreatic duct,activating pancreatic enzymes,acute pancreatitis,duodenal reflux,Other Causes of AP,Sphincter of Oddi dysfunction，SOD 壶腹乳头括约肌功能不良 Medicines and toxicants Trauma Hypercalcemia 高钙血症 Vasculitis 血管炎 Congenital (Pancreas divisum 胰腺分裂、Annular pancreas 环形胰腺、 Juxtapapillary duodenal divertic

55、ulum 十二指肠乳头旁憩室) Neoplastic periampullary carcinoma (壶腹周围癌)、 pancreatic carcinoma Infectious (Coxsackie virus 柯萨奇病毒、mumps virus 腮腺炎病毒、Acquired immunodeficiency virus 获得性免疫缺陷病毒、ascariasis 蛔虫症) Autoimmune (systemic lupus erythematosus 系统性红斑狼疮、 sjogren syndrome 干燥综合征) a1 antitrypsin deficiency a1一抗胰蛋白酶缺

56、乏症 Endoscopic retrograde cholangiopancreatography, ERCP 内镜逆行胰胆管造影,Clinical Manifestations,abdominal pain, nausea and vomiting (typical symptoms),Abdominal Pain,develops first and remains constant, without the waxing and waning pattern (intestinal or renal colic). persists for more than 24 h to days

57、without relief steady, dull, or boring located in the epigastrium with radiation to the midback worse in the supine position alleviate in the sitting and leaning forward position,Abdominal Pain,reaches peak intensity within 30 minutes to 1 hour from onset the more abrupt onset of pain with a perfora

58、ted viscus associated with nausea and vomiting rare patients without abdominal pain but with a severe systemic illness ( hypotension, hypoperfusion and depression of mental status) - grave prognosis (present in shock),Clinical Manifestations,Nausea and vomiting (pain not relieved by vomiting; presen

59、t in the majority of patients; occur with or without ileus ) Abdominal Distention a paralytic ileus (麻痹性肠梗阻) retroperitoneal irritation / ascites / a retroperitoneal phlegmon develop during the first few days：extension of the inflammatory process into the small intestine and colonic mesentery(肠系膜),Clinical Manifestations,Fever Low-grade fevers in more than half of patients (SIRS); high-grade fevers may indicate the presence of cholangitis or infected necrosis Hypotension and Shock (SAP),Signs,MAP - mild upper abdominal tendernes