徐三榮－急性胰腺炎.ppt

1 ACUTEPANCREATITIS XuSanrongDepartmentofGastroenterologyHuashanHospitalFudanuniversity 2 DEFINITION Anacuteinflammatoryprocessofthepan creasusuallyassociatedwithseverpainintheupperabdomeninmostinstances bloodlevelsofpancrea ticenzymesareincreasedseveracutepancreatitis organsfailureand orlocalcomplications necrosis absc ess psuedocyst 3 PATHOLOGY 1 Mildacutepancreatitis MAP characterizedbyinterstitialedemaassoci atedwithinflammatorycellwithinparench yma andmicroscopicparenchymanecro siscanbedetectable 4 PATHOLOGY 2 Severacutepancreatitis SAP Severnecrotizingpancreatitis SNP macroscopicevidenceofeitherfocalordiffusenecrosisandhemorrhageofthepancreaticparenchyma 5 PATHOGENYANDPATHOGENESIS 1 1commonchannelandrefluxofduodenaljuice gallstones infection Bilejuicereflux trypsin Kininsystems elastase Trypsinchymotrypsino Phospho lipaseA2 Steatolyticenzymes Severpain hemorrhage Freefatacid Serumcalcium 6 PATHOGENYANDPATHOGENESIS 2 2alcoholicandovereat3obstructofmainpancreaticduct4diseasesroundtheduodenum ampullaryregion5postoperativepancreatitisandpancreatictrauma 7 PATHOGENYANDPATHOGENESIS 3 6infectiousagents7medications corticosteroids estrogens8disordersofendocrinologyandmetabol ism hyperparathyroidism hyperlipidemia9others 8 PATHOGENYANDPATHOGENESIS 4 6inflammatorymediatheoryInAP theleukocytesthatappearfirstinareasofinflammationareneutrophils thenmacrophages monocytes lymphocytes andothercells Thesecellscansecretealotofinflammatorymedia 1 plateletactivatingfactor PAF 2 prostaglandins PGs 9 PATHOGENYANDPATHOGENESIS 5 3 leukotriens LTs 4 kallikreinkininsystems KKS 5 tumornecrosisfactor TNF 6 nitrogenmonoxide NO 7 complements 8 others nuclearfactor B NF B tolllikereceptors TLRs 10 DIAGNOSIS 1 Clinicalcharacteristics1abdominalpain2fever3nauseaandvomiting 11 DIAGNOSIS 2 4hypotensionandshock5jaundice6tenderness7peritonealirritationsigntenderness reboundtenderness andabdominalmuscletenseness8Grey turnersign cullensign9ascites 12 DIAGNOSIS 3 Assistantexamination1bloodexamination 1 bloodroutineexamination whitebloodcellcount hematocrit Hct packedcellvolume PCV 2 blood urineamylaseSalivary am P amCam Ccr 13 DIAGNOSIS 4 3 serumlipase 4 bloodglucose 10mmol L serumcalcium 2 0mmol L 5 plasmamethemalbumin2abdominalB ultrasonography 14 DIAGNOSIS 5 3X rayexamination 1 planefilmoftheabdomen 2 chestradiography 3 abdominalcomputedtomography4magneticresonanceimagingMRcholangiopancreatography MRCP 15 DIAGNOSIS 6 Diagnosisclinicalcharacteristics elevatedvalueofserumandurineamylaseultrasonographyandCT MR 16 DIFFRENTIALDIGNOSIS 1perforatedhollowviscus2biliarycolicgallstoneacutecholangitis acutecholecystitis3acuteintestinalobstruction4mesentericischemia5anginapectorisacutemyocardialinfarction AMI 6others 17 PREDICTORSOFSEVERITY 1 1Ranson scriteriaofseverityatadmissionduringinitial48hoursage 55yearsHctdecreaseof10mg dLwbc 16 109 Lbunincreaseof 5mg dLglucose 11 2umol Lcalcium250u Lbasedeficit 4mEq Lfluidsequestration 6L3 mild 3medial 5poorprognosis 18 PREDICTORSOFSEVERITY 2 2CTgradingsystemofBalthazarandransonpancreaticmanifestationsofCTgradeAnormal appearingpancreas0gradeBfocalordiffuseenlargementofthepancreas1gradecglandabnormalitiesaccompaniedbymild2peripancreaticinflammatorychangesgradeDfluidcollectioninasinglelocation3gradeE 2fluidcollectionsnearthepancreasor4gaseitherwithinthepancreasorwithinperipancreaticinflammation 19 PREDICTORSOFSEVERITY 3 computedtomographyseverityindexCTgradescorenecrosisscoreA0none0B1onethird2C2onehalf4D3 onehalf6E4CTgrade 0 4 necrosis 0 6 totalscore 20 Complications Localcomplications1pancreaticnecrosis2pancreaticpseudocyst3pancreaticabscess 21 Complications Systemiccomplications1majorsystemiccomplications 1 respiratoryfailure 2 renalfailure 3 hypotention2dangerousestcomplicationmultipleorgansfailure MOF 22 TREATMENT 1 Managementofinternalmedicine1commonmanagement 1 intensivecareunit 2 fluidresuscitation 3 nutritionalsupport 23 TREATMENT 2 2treatmentofinfectionMAPSAP3reliefofpain 1 anisodamine 654 2 2 bucinnazine pethidine 3 0 1 procaine 4 morphine 24 TREATMENT 3 4inhibitionofpancreaticsecretion 1 atropine anisodamine 654 2 2 H2 receptorantagonists H2RAs protonpumpinhibitors PPI 3 somatostatin anditsanalogoctreotide 25 TREATMENT 4 5inhibitionofactivatedpancreaticenzymes 1 aprotinin 2 gabexatemesilate FOY 6drugsofanti inflammatoryfactors7eliminatinginflammatorymediatorsperitoneallavage8traditionalmedicine 26 TREATMENT 5 8endoscopicsphincterotomy9surgeryindications 1 with3daysafterdiagnosisofgallstonepancreatitis 2 pancreaticabscessandpsuedocyst 3 perforatedhollowviscus necrosisofintestine 27 PROGNOSIS Mildacutepancre