内科学教学课件：Acute Pancreatitis

1、Acute Pancreatitis 2 3 4 Overview Pancreatitis is an inflammation of the pancreas. Pancreatitis Acute pancreatitis Chronic pancreatitis 5 Acute Pancreatitis Pancreatitis is an inflammatory process in which pancreatic enzymes autodigest the gland 6 Classification: Pathological: nacute edematous pancr

2、eatitis nacute hemorrhagic necrotizing pancreatitis Clinical: nMild acute pancreatitis nSevere acute pancreatitis nMild acute pancreatitis is not associated with organ dysfunction or complications, and recovery is uneventful. nSevere acute pancreatitis is associated with decreased function of the pa

3、ncreas, local and systemic complications, and a complicated recovery. 7 Severe acute pancreatitis nHow to identify SAP from MAP? 2021-7-15 2021-7-15 MAP：no organ dysfunction SAP：at lease one of the following organ dysfunction local complication (necrosis abscess or pseudocyst ) Ranson score 3 or APA

4、CHE 8 Balthazar CT score 2021-7-15 术语术语定义定义 急性胰腺炎急性胰腺炎胰腺的急性炎症胰腺的急性炎症 轻症急性胰腺炎轻症急性胰腺炎无明显器官功能障碍，对液体治疗反应良好无明显器官功能障碍，对液体治疗反应良好 重症急性胰腺炎重症急性胰腺炎具备下列情况之一具备下列情况之一 局部并发症（胰腺坏死、假性囊肿、胰腺脓肿）局部并发症（胰腺坏死、假性囊肿、胰腺脓肿） 器官衰竭器官衰竭 Ranson评分评分3 APACHE 8 胰腺坏死胰腺坏死增强增强CT发现失活的胰腺组织发现失活的胰腺组织 急性液体聚集急性液体聚集胰腺及胰周液体积聚，发生与病程早期并缺乏完整包膜胰腺及胰周

5、液体积聚，发生与病程早期并缺乏完整包膜 急性假性囊肿急性假性囊肿有完整包膜的液体积聚，包含有胰腺分泌物有完整包膜的液体积聚，包含有胰腺分泌物 胰腺脓肿胰腺脓肿胰腺及胰周的脓液聚积胰腺及胰周的脓液聚积 11 v假性囊肿假性囊肿 周形成周形成,由胰液和坏由胰液和坏 死组织在胰腺内或周围包裹形成，囊壁死组织在胰腺内或周围包裹形成，囊壁 无上皮，为坏死肉芽和纤维结缔组织无上皮，为坏死肉芽和纤维结缔组织 v治疗：治疗：6周内自行吸收周内自行吸收40%，6周后吸收周后吸收 机机 会减少，会减少，13周后均无法吸收。周后均无法吸收。 v 6周内密切随访周内密切随访 如出现并发症或如出现并发症或6周不周不 吸

6、收可考虑内吸收可考虑内/外引流外引流 v发生率发生率10% 2021-7-15 器官功能衰竭器官功能衰竭 Signs of Organ Failure in Acute Pancreatitis 13 14 Etiology and mechanism: 原发性的原发性的 15 Etiology and mechanism 16 水水 肿肿 型型 的的 病病 理理 外观：外观： 胰腺胰腺肿大、变硬、肿大、变硬、少量周围组织坏死。少量周围组织坏死。 显微镜下：显微镜下： 间质间质充血、水肿、炎症充血、水肿、炎症细胞浸润，少量腺细胞浸润，少量腺 泡坏死。泡坏死。 17 出出 血血 坏坏 死死 型型

7、 病病 理理 外观：外观： 胰腺胰腺弥漫性肿大弥漫性肿大、大网膜大网膜 和胰腺上大小不等的钙皂和胰腺上大小不等的钙皂 显微镜下：显微镜下： 胰实质、脂肪胰实质、脂肪坏死坏死； 水肿、水肿、出血出血和血栓形成；和血栓形成； 炎症炎症反应。反应。 19 Acute hemorrhagic pancreatitis. 20 Clinical manifestations nSymptoms n1、 Abdominal pain: nSteady, dull, or boring midepigastric pain associated with nausea and vomiting is the

8、 classic presentation of acute pancreatitis. It radiates straight to the midline of the lower thoracic vertebral region in about 50% of patients and is usually worse in the supine position.) Painless acute pancreatitis is very rare but carries a grave prognosis because the patients frequently presen

9、t in shock. nParalytic ileus(麻痹性肠梗阻麻痹性肠梗阻) with abdominal distention may develop during the first few days, signifying extension of the inflammatory process into the small intestinal and colonic(结结 肠的肠的) mesentery(肠系膜肠系膜). nOne to 2 weeks after the onset, large ecchymoses(瘀斑瘀斑) may appear in the fla

10、nks侧侧 腹腹 (Grey Turners sign) or the umbilical area (Cullens sign); 29 Clinical features : MAP (mild AP) Abdominal pain, usually epigastric, constant with radiation to the back Associated nausea and vomiting May also have fever and jaundice 痛痛 呕呕 热热 30 hypotension or shock exudative pleurisy 渗出性胸膜炎渗出

11、性胸膜炎 Grey-Turner sign Grey-Turner sign Cullen sign Cullen sign 出出 血血 坏坏 死死 型型 临临 床床 表表 现现 general peritonitis 弥漫性腹膜炎弥漫性腹膜炎 31 Grey-Turner征征 Cullen征征 nInitial physical examination reveals mild fever and tachycardia(心动过心动过 速速); nHypotension is present in 30 to 40% of patients. nTotal serum amylase act

12、ivity is the test most frequently used to diagnose acute pancreatitis. nThe level rises 6 to 12 hours after onset of symptoms and remains elevated for 3 to 5 days in most cases. nValues more than 3 times the upper limit of normal are highly specific for acute pancreatitis but are found in only 80 to

13、 90% of cases. nThe magnitude of the rise in serum amylase does not correlate with the severity of the attack, nor does prolonged hyperamylasemia indicate developing complications. nthe absence of hyperamylasemia cant exclude the diagnosis of acute pancreatitis (extensive pancreatic necrosis) nSerum

14、 triglyceride levels should be obtained in all patients because of their etiologic implications. nUltrasound examination showing two large pancreatic pseudocysts. Both cysts are indicated by the large white arrows. na dynamic CT scan will reveal extension of peripancreatic inflammation, involvement

15、of adjacent organs, venous thrombosis, and fluid collections. nMost importantly, pancreatic necrosis can be identified and quantitated by the lack of contrast medium enhancement after the bolus injection. nThe abdominal CT scan may be normal, however, in about 10% of patients with early, mild pancre

16、atitis. Abdominal Ultrasonography (US) and Computed Tomography (CT) nWhen the clinical diagnosis is made, the CT scan is far superior to US for assessing the extent and local complications of pancreatitis. nComputed tomogram of a patient with pancreatic abscess. The pancreas is diffusely involved, a

17、nd its margins are difficult to define because of the massive peripancreatic inflammation, which is reflected in the streaking seen in this scan. Toward the tail of the pancreas, numerous small and large bubbles are noted (arrows) in the peripancreatic inflammatory mass. Bubbles, caused by gas-formi

18、ng microorganisms, indicate that the pancreatic abscess is infected. 2021-7-15 Case 1A 2021-7-15 Case 1B 13d 2021-7-15 Case 1C 23d 2021-7-15 Case 2A ERCP 后 2021-7-15 2021-7-15 Case 3A 2021-7-15 Case 4A 2021-7-15 Case 4B 2021-7-15 Case 5A 2021-7-15 Case 5A 14d 223223 Nutritional SupportNutritional Support Acute Pancreatitis Acute Pancreatitis Consid