内科学课件：8-4急性胰腺炎课件

1、 急性胰腺炎急性胰腺炎(acute pancreatitis) 指胰腺及其周围组织被胰腺分泌的消化酶自身消化所引起的化学性炎症an chemical inflammatory disease of the pancreas, caused by pancreatitis and circum-tissues autodigestion by digestive enzyme secreted by pancreatitis. 病因很多，在我国最为常见的病因是胆道疾病，西方国家大量饮酒亦为主要病因.The list of causative factors of acute pancreatit

2、is arealcoholism(west country) and biliary tract disease(China) are most frequent .l1胆道疾病（胆道疾病（共同通道学说共同通道学说） biliary tract disease (common channel theory）l 约约50%的急性胰腺炎由胆道结石、炎症和蛔的急性胰腺炎由胆道结石、炎症和蛔虫引起，尤其是胆石症最多见虫引起，尤其是胆石症最多见 About 50% of acute pancreatitis caused by biliary calculi/inflammation/lumbricoi

3、des.l gallstones is most frequentpancreatemphraxis胰腺分裂症胰腺分裂症：胰腺发育过程中主、胰腺发育过程中主、副胰管未融合的先副胰管未融合的先天性发育不全，大天性发育不全，大部分胰液通过相对部分胰液通过相对较细的副乳头引流，较细的副乳头引流，引起部分及功能性引起部分及功能性梗阻，导致胰性腹梗阻，导致胰性腹痛和胰腺炎发作。痛和胰腺炎发作。3十二指肠乳头邻近部位病变Disease of adjacent position of duodenal papilla. （二）大量酗酒和暴饮暴食alcohol and overeating（三）手术与创伤（三

4、）手术与创伤operation and injury（四）内分泌和代谢障碍（四）内分泌和代谢障碍 endocritic and metabolic disfunction 1高钙血症 hypercalcinemia2家族性高脂血症 familinal hyperlipidemia3妊娠 pregnancy4糖尿病昏迷 diabetic coma（五）感染（五）感染 infection（六）药物（六）药物 medicine（七）其他（七）其他other（一）急性水肿型胰腺炎（一）急性水肿型胰腺炎 acute interstitial pancreatitis （二）急性坏死型胰腺炎（二）急性坏死

5、型胰腺炎 acute acute hemorrhagic pancreatitis （一）症状（一）症状s symptoms 1 1腹痛腹痛急性腹痛是急性胰腺炎最为常见的首发症状（95%） abdominal pain: pain usually develops first and remains constant. 腹痛腹痛部位部位: 一般位于中上腹，可偏左或偏右 Location: superior belly. may deviation to left or right腹痛腹痛特点特点 1）急性发作 acute episode 2）疼痛性质：钝痛、刀割样、或绞痛 quality: d

6、ull pain; lance-like; 3）持续性疼痛并有阵发性加重 lasted pain and paroxysmal aggravation 4）疼痛可向腰背部放散 the pain frequently is located in the epigastrium with radiation to the midback . 5）进食后疼痛加重，前倾坐位或弯腰抱位可缓解 aggravate after foodintake, relieve when anteverted sitting position or cyrto-lumbar brooding position6）不能为

7、一般解痉剂缓解 cant be relieved by spasmolytic7）水肿型持续35天自限缓解 interstitial pancreatitis Self-relief after 3-5 day 2恶心、呕吐及腹胀恶心、呕吐及腹胀nausea; vomiting; abdominal distention 特点特点 呕吐后腹痛无缓解abdominal pain is not relieved by vomiting 3发热发热 fever腹痛伴发热是本病的特点之一 abdominal pain with fever is one of features of this dise

8、ase 4低血压或休克低血压或休克 仅见于重症 hypotension or shock :only in severe case 5 5水、电解质紊乱水、电解质紊乱 water-electrolyte disturbances脱水、代酸、低钾、低镁、低钙血症等。血钙2mmol/L。 dehydrolysis; metabolic acidosis ;hypopotassaemia; hypomagnesemia; hypocalcemia.blood calcium 2mmol/L.（二）体征（二）体征 sign 1轻型：一般全身情况尚好，体征较少，多.数有上腹压痛，无肌紧张与反跳痛，可有腹

9、胀、肠鸣音减弱，一般无移动性浊音 most have minimal local tenderness, abdominal distension, decreased bowel sounds. 2重症：全身情况：表情，脉搏，血压，呼吸；腹部：压痛明显，腹膜刺激征，Grey-Turner综合征或者Cullen征,肠麻痹，移动性浊音阳性；黄疸；腹水常为血性，淀粉酶明显增高severe case:systemic condition: expression; pulse; blood pressure; respiration; etc.Abdominal: tenderness obvious

10、ly, peritoneal irritation sign; Grey-Turner sign or Cullen sign ; Enteroparalysis; shifting dullness(+); jaundice; amylase increase obviously; GreyGreyTurnerTurner征、征、CullenCullen征征： In severe necrotizing pancreatitis, large ecchymoses occasionally may appear in the flanks (Grey Turners sign;) or th

11、e umbilical area (Cullens sign); these ecchymoses are caused by blood dissecting from the retroperitoneally located pancreas along the fascial planes. （三）病程（三）病程course of disease1轻型 一周左右症状消失 About a week2重症severe case至少23周后始能恢复，病程中多伴有并发症，时刻威胁生命 2-3weeks at least. usually accompany with complication

12、which threaten life.3胰源性猝死: 休克、心跳骤停、昏迷而死亡Pancreatogenic sudden death :shock /cardiac arrest/coma-deathcomplication急性水肿型绝大多数病情经过顺利，一般很少有并发症，出血坏死型几乎都有并发症acute interstitial pancreatitis :seldomacute hemorrhagic pancreatitis: almost（一）（一）局部并发症局部并发症 local complicationlocal complication1 1胰瘘、胰腺假性囊肿胰瘘、胰腺假性

13、囊肿 pancreatic pancreatic fistulefistule、pancreatic pseudocyst2 2胰腺脓肿胰腺脓肿pancreatic abscess3. 3. 左侧门静脉高压左侧门静脉高压 portal vein portal vein hypertentionhypertention（二）全身并发症（二）全身并发症 systemic systemic complication1呼吸系统respiratory system 2泌尿系统 urinary system3心血管系统 cardiovascular system4败血症 septicemia5消化道并发症

14、 gastrointestinal complication: 上消化道出血 upper gastrointestinal hemorrhage6血液凝固异常 abnormality of blood coagulation DIC,出血 DIC hemorrhage 7代谢异常abnormality of metabolism低血钙、高血脂、高血糖 hypocalcemia; hyperlipemia; hyperglycosemia8胰性脑病pancreatic encephalopathy9MOF(多脏器功能衰竭)10慢性胰腺炎chronic pancreatitis（一）白细胞计数 w

15、hite blood count（二）淀粉酶（二）淀粉酶 amylase 1血清淀粉酶测定 超过500U（Somogyi）即可确诊。但需注意（1）时间一般起病后612小时开始升高，48小时开始下降，持续35天 Typically the serum amylase level rises rapidly over the initial 2 to 12 hours of an attack, then slowly declines to its normal values over the next 3 to 5 days. （2）部分重症者可以正常或低于正常 Some severe cas

16、e can normal or below the normal（3）不仅见于胰腺炎 hyperamylasemia is not specific to pancreatitis 2尿淀粉酶 urinary amylase3胰源性腹水或胸水内淀粉酶浓度明显增高， 对诊断很有价值amylase in pancreatogenic ascitcs and pleural fluid4淀粉酶肌酐清除率比值（CAm/CCr）（尿淀粉酶 / 血淀粉酶）（血清肌酐 / 尿肌酐）100 正常值14%（5%）,急性胰腺炎时可增 加3倍，是特异性较好的指标之一lNormal:1-4%,(3-foldl hig

17、h specificity（三）脂肪酶（三）脂肪酶lypase 一般病后2472小时开始上升，持续710天，1.5U（CherryCrandall），是特异性较好的指标之一 increase in 24-72h,last for 7-10 day,1.5U, high specificity.（五）生化检查（五）生化检查 biochemistry 1高血糖hyperglycosemia 2低血钙hypocalcemia 3肝功能Hepatic function 高胆红素血症，血清AST、LDH增高 hyperbilirubinemia;AST/LDH 4低氧血症 hyoxemia 5如血清白蛋

18、白降低，病死率高case fatality rate increase if SAB decrease（六）B超 B-ultrasound（七）CT 增强增强CT是目前诊断胰腺坏死的最好方法. CT: Best method.（八）X线平片检查 X-raydiagnosis and Differential Diagnosis（一）诊断标准一）诊断标准 diagnostic code 1 1急性水肿性胰腺炎急性水肿性胰腺炎 acute interstitial pancreatitis ）急性上腹痛发作伴上腹压痛或腹膜刺激征 acute upper abdominal pain with up

19、per abdominal tenderness or peritoneal irritation sign 2）血、尿及腹水淀粉酶增高 amylase of serum/urine/ascites rise 3）影象学或手术发现胰腺炎症、坏死等直接或间接征象Pancreatic inflammation or necrosis foundby imageology or operation 具备含第1）项加2）或）项并排除其他急腹症者即可诊断1)+2)or3),and deplete other acute abdomen.重症胰腺炎重症胰腺炎sever pancreatitis急性胰腺炎出

20、现坏死、脓肿或假性囊肿等局部并发症或伴有脏器功能衰竭，甚至两者兼有 local complication such as necrosis, abscess or pseudocyst or/and MOF happens in acute pancreatitis （二）鉴别诊断（二）鉴别诊断 Differential Diagnosis 1急腹症如溃疡病穿孔 acute abdomen :perforation of peptic ulcer 2胆囊炎胆石症 cholecystitis cholelithiasis 3肠梗阻 intestinal obstruction 4肠系膜血管缺血和

21、栓塞 ischemia and embolism of mesenteric vessel. 5心肌梗塞 myocardial infarct 6肺炎 pneumoniaTherapy( (一一) )治疗原则治疗原则 therapeutic principle 1减轻和控制胰腺本身炎症Lighten and control the inflammation of pancreas ）控制胰液分泌 control the pancreatic secretion ）止痛 relieve pain ）改善胰腺微循环 improve pancreatic microcirculation 2阻断和防

22、止并发症发生Block up and prevent the complication 3全身支持疗法和治疗并发症Systemic supportive therapy and treat the complication( (二二) )内科治疗内科治疗medical treatment 1一般治疗general treatment 生命体征的监护，积极补充有效血容量，营养支持，抗休克及纠正水电解质平衡Monitor the vital sign , replenish effective blood volume, nutritional support, antishock, retrieve water-electrolyte balance 2 减轻和控制胰腺本身炎症Lighten and control the inflammation of pancreas ）控制胰液分泌: H2受体阻断剂、质子泵抑制剂、生长抑素等 control the pancreatic secretion :R,PPI, somatostatin.2）阻碍和(或)抑