AP(内科).ppt

1、Acute Pancreatitis,协 和 医 院 消 化 内 科 刘 诗,Acute pancreatitis,Autodigestion of the pancreas,Activation of the inflammatory processes,Etiology,Obstructive Toxins/drugs Metabolic Infection Vascular Trauma Idiopathic,Obstructive Causes,Gallstones Ampullary/pancreatic cancer Worms in pancreatic duct-ascaris

2、 Choledochocele Periampullary duodenal diverticula Foreign body obstructing duct Hypertensive sphincter of Oddi,胰腺炎梗阻因素,假性囊肿，胰结石，纤维化，组织变性,括约肌痉挛，纤维水肿，结石，肿瘤，囊肿,胆道微结石是指:直径 20 mm1%并发AP 可见微结石在AP中的作用不容忽视,刘枫,李兆申.胃肠病学2002,7(4):236-238.,Toxins,Ethyl alcohol Methyl alcohol Scorpion toxin Organophosphorus inse

3、cticides,Drugs,Immunosuppresive medications Sulfonamide Oral 5-aminosalicylic acid Antibiotics（metronidazole，tetracycline） Valproic acid Corticosteroids Furosemide,Metabolic Causes,Hypercalcemia Hypertrigliceridemia,Infections Causes,Viruses Mumps，Herpes，Hepatitis Bacteria Mycobacteria，Leptospirosis

4、 Fungi Cryptococcus Parasites Ascaris，Clonorchis,Vascular/hypotension,Atherosclerotic emboli Ischemia-hypoperfusion Vasculitis-systemic lupus erythematosus,Traumatic Causes,Blunt trauma Penetrating trauma Postoperative Endoscopic retrograde cholangiopancreatography Sphincter of Oddi manometry,Pathog

5、enesisInitiating Event,Intra-acinar activation of trypsinase，which in tern activates chymotrypsin，elastase，and phospholipase A2, carboxypeptidase Accumulation of lipase in interstitium，which leads to peripancreatic fat necrosis,Pathology,Interstitial pancreatitis Necrotizing pancreatitis,Clinical Pr

6、esentation,Symptoms abdominal pain nausea and vomiting fever,Clinical Presentation,Physical Examination abdominal sign: tenderness guarding, rarely rigid Grey Turner Sign Gullen Sign subcutaneous fat necrosis jaundice systemic sign,Grey Turner Sign ecchymosis in one or both flanks Gullen Sign ecchym

7、osis in the periumbilical region,Laboratory examination,Standard blood tests Amylase Lipase Tests that reflect severity of pancreatitis： CRP, serum glucose，serum calcium level blood urea nitrogen，serum aspartate transaminase，low oxygen situation,Laboratory examination,Amylase Serum amylase：612h 48 3

8、5 days， 3 times Urinary amylase：1214h 12 week，,Laboratory examination,Amylase Other conditions causing higher serum amylase： Intra-abdominal disease（cholecystitis， gallstone，peptic ulcer） Disease of salivary glands（mumps） Tumors（lung cancer） Renal insufficiency Miscellaneous（drugs，endoscopy）,Laborat

9、ory examination,The amylase/creatinine clearance ratio amylase（u）creatinine（s） ACR= amylase（s）creatinine（u） 3 times,Laboratory examination,Lipase Serum lipase：2472 h 710 days more sensitive and specific,Abdominal ultrasonography Computed tomography,Diagnosis,Severe Acute Pancreatitis Organ failure:

10、shock: systolic blood pressure2mg/dl gastrointestinal bleeding: 500ml/24h Local complications: necrosis ,abscess,pseudocyst Unfavorable early prognostic signs: 3 Ransons signs 8 APACHE- points,Ransons Criteria of Severity On admission Age 55 years WBC 16,000/mm3 Blood glucose 200mg/dl Serum LDH 350I

11、U/L Serum AST 250U/L,Ransons Criteria of Severity During initial 48 hr Hematocrit decrease of 10mg/dl BUN increase of 5mg/dl Serum calcium 4 mEg/L Fluid sequestration 6 L,Differential Diagnosis,Biliary colic Perforation of ulcer Mesenteric ischemia Myocardial infarction,Treatment,Intensive care: mon

12、itoring Intravascular volume: fluid resuscitation 56 L/day nutritional support Relief of pain,Treatment,Measures to decrease pancreatic secretion: nasogastric section and fasting H2-receptor blocking agents proton pump inhibitor somatostatin ( octreotide ),Treatment,Medications of inhibit active pancreatic enzymes aprotinin, Foy Treatment of infection ciprofloxacin, ofloxacin, imipenem, metronidazole,Treatment,Peritoneal dialysis Treatment of complications Surgery debride necrosis drain abscess/pseudocyst early severe acute pancreatitis