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

much

more

important

than

knowingwhat

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/AREFROM

DOG(S)

WITH

ACUTEPANCREATITIS?哪份血常规结果是来自急性胰腺炎患犬的？147033

14719890524159796PCVWBCSegsBands28.530,00026,10090028.845,50033,6702,730309,8004,6062,4504011,5009,8900Plat87,000407,000

679,000

470,000Toxicmodmodnonenone147033

14719890524159796PCVWBCSegsBands28.530,00026,10090028.845,50033,6702,730309,8004,6062,4504011,5009,8900Plat87,000407,000

679,000

470,000ToxicmodmodnonenoneClinical

Pathology临床病理学•

An

anorexic,

vomiting

dog

with

fasting

hyperlipidemia

probably

has

acute

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

fastinghyperlipidemia

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

havefasting

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#203505PCV

=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#203505Abd

U/S:

“...

.

enlarged

pancreas

withnodules

...

hepatic

mass

mostconsistent

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#203505Snap

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）2Repeat

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8PANCREATITISversusCLINICALLY

IMPORTANTPANCREATITIS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%

•

Becausecliniciansrarelyrepeatthe

ultrasound

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%

•

Findingscanchangewithinhours...

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Bewillingtorepeatultrasound重复进行超声检查All

things

being

equal,

tryto

avoid

surgery平衡一切，尽量避免手术All

things

being

equal,

tryto

avoid

surgery平衡一切，尽量避免手术Bewillingtorepeatultrasound重复进行超声检查THE

REAL

PROBLEM

IS

THAT

ACUTE

PANCREATITIS

CAN

PRESENT

IN

SO

MANYDIFFERENTWAYS

THAT

YOU

DON’T

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#88267

Sig:

7

yr

M

Sheltie

CC:

Vomiting

HPI:

Began

5

weeks

ago7岁

雄性

喜乐蒂呕吐

五周前开始PE:Partial

anorexia,

vomits

phlegm

or

bile

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#159796

Sig:

9

yr

M(c)

Pug9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

to

fluid

therapy,

but

became

ill

again

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

Dog’s

eyes

turned

yellow

患犬眼部发黄TAMU#159796

PCV

=

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

#152494

Sig:

9

yr

F(s)

Dalmation

CC:

Vomiting/diarrhea

9岁

雌性绝育

大麦町呕吐/腹泻HPI:

Vomiting

food/bile

6-8X

in

2

weeks

2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/minTAMU

#152494PCV

=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)•

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

everyone’s

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

therapy液体疗法Crystalloids

晶体液

Plasma

Colloids

Nutrition•

Analgesics血浆

胶体液

营养

镇痛剂

THERAPY

FOR

PANCREATITIS

胰腺炎的治疗

Only

supportive

and

symptomatic•

Early

Feeding

早期饲喂•

Buprenorphine丁丙诺啡•

FLK

cocktail

(CRI

of

fentanyl,

lidocaine,

ketamine)

FLK

鸡尾酒疗法（恒速输注芬太尼、利多卡因和氯胺酮）–Butorphanol

(more

of

a

seda