急性胰腺炎概述、發(fā)病機制和治療acutepancreatitis

1、急性胰腺炎概述、發(fā)病機制和治療（acute pancreatitis)概 念胰酶在胰腺內(nèi)激活引起胰腺組織自身消化的急性化學性炎癥分 類輕型急性胰腺炎（90%）（Mild acute pancreatitis）重癥急性胰腺炎（ Severe acute pancreatitis）分 類 病理分類：急性水腫型胰腺炎（90%） Acute interstitial pancreatitis急性出血壞死性胰腺炎 Acute necrotizing pancreatitis病因和發(fā)病機制膽管疾?。懺葱约毙砸认傺祝懡Y(jié)石、炎癥、寄生蟲）壺腹部出口梗阻Oddi括約肌功能不全細菌毒素Biliary tra

2、ct obstruction caused by a gallstone in the distal common bile duct. F, 49 Y/O, there is much exudate between the gastric wall and the pancreatic parenchyma.F, 49 Y/O, the echoic foci was found in the CBD with acoustic shadowing大量飲酒和暴飲暴食胰腺分泌乳頭水腫，Oddi括約肌痙攣胰管內(nèi)壓嘔吐腸內(nèi)壓 十二指腸內(nèi)容物反流蛋白栓胰管阻塞結(jié)石寄生蟲炎癥腫瘤胰腺分裂癥（panc

3、reas divisum ）Picture 2. ERCP of pancreas divisum. Injection of contrast following cannulation of the minor ampulla (same patient as Picture 1) demonstrates filling of a separate larger duct of Santorini, which drains the entire pancreatic body and tail. Picture 1. ERCP of pancreas divisum. Contrast

4、 injection following cannulation of the ampulla of Vater demonstrates filling of the common bile duct and a small pancreatic duct of Wirsung, which drains the pancreatic head. Picture 2.Picture 1乳頭部位病變憩室、輸入袢綜合征腸系膜上動脈綜合征手術與創(chuàng)傷內(nèi)分泌與代謝障礙感染藥物發(fā)病機制胰腺分泌胰液排泄障礙 胰腺血循環(huán)紊亂胰酶抑制物 胰酶激活自身消化 卵磷脂 溶血卵磷脂 組織壞死、溶血彈力蛋白酶破壞彈力纖

5、維胰腺出血和血栓激肽原 激肽和緩激肽血管擴張、 通透性休克脂肪酶脂肪壞死、液化磷脂酶A激肽酶炎癥反應全身性炎癥反應綜合征(systemic inflammatory response syndrome SIRS)血小板活化因子腫瘤壞死因子微循環(huán)障礙炎性介質(zhì)血管活性物質(zhì)病 理水腫型：胰腺腫大，間質(zhì)水腫、充血、炎性細胞浸潤，少量腺泡壞死壞死型：腺泡、脂肪壞死。血管出血、壞死臨床表現(xiàn)輕型急性胰腺炎重癥急性胰腺炎輕型急性胰腺炎輕微臟器功能紊亂，臨床恢復順利無明顯腹膜炎體征無嚴重代謝紊亂等臨床表現(xiàn)重癥急性胰腺炎伴有臟器功能障礙或出現(xiàn)壞死、膿腫或假性囊腫等局部并發(fā)癥或兩者兼有臨床表現(xiàn)腹痛：上腹中部，劇烈，

6、向腰背部放射，彎腰抱膝疼痛可減輕惡心、嘔吐和腹脹發(fā)熱休克水電解質(zhì)及酸堿平衡紊亂：脫水、代堿、代酸、低鉀、低鈣、高血糖腹痛的機制刺激胰腺包膜的神經(jīng)末梢刺激腹膜和腹膜后組織腸腔積氣胰管阻塞膽囊炎、膽石癥休克的機制血液和血漿滲出嘔吐緩激肽增加消化道出血體 征輕型：多數(shù)上腹壓痛，無腹肌緊張與反跳痛，可有腹脹和腸鳴音減少重癥：脈率快，血壓，氣促上腹部壓痛顯著，肌衛(wèi)，反跳痛腸鳴音Grey-Turner征，Cullen征腹膜炎，胸膜炎黃疸R.E.Pounder et.al. 1989病 程急性輕型：1周急性重癥：23周并發(fā)癥全身:急性呼吸衰竭（ARDS）心律失常和心力衰竭急性腎衰竭消化道出血胰性腦病凝血異常

7、多器官功能衰竭敗血癥及真菌感染高血糖慢性胰腺炎并發(fā)癥局部：膿腫假性囊腫 實驗室檢查白血球計數(shù)，紅細胞壓積血淀粉酶：大于正常值3倍起病8小時歷時35天尿淀粉酶歷時12周淀粉酶、肌肉酐清除率比值（CAm/CCr%）CAm/CCr%=尿淀粉酶血淀粉酶血清肌酐尿肌酐100血清脂肪酶：晚升高特異性血清正鐵血蛋白：出血壞死性胰腺炎（+）生化檢查血糖膽紅素ALT、LDH，白蛋白血鈣低O2血癥腹部B超常規(guī)初篩檢查，胰腺腫大、胰內(nèi)胰周回聲異常、膿腫、假性囊腫CT檢查評估胰腺炎嚴重程度；增強掃描診斷胰腺壞死；疑感染，CT引導下穿刺；發(fā)現(xiàn)局部并發(fā)癥。診 斷急性上腹痛，上腹壓痛血尿淀粉酶升高B超、CT發(fā)現(xiàn)胰炎 含第一

8、項在內(nèi)的2項以上指標，排除其他急腹癥診斷標準符合下列4個條件之一者可診斷為SAP:有胰腺局部并發(fā)癥（胰腺壞死、假性囊腫、胰腺膿腫等）有器官功能衰竭Ranson評分3APACH評分855歲16109 mmol/L250U/L350U/L下降10%mmol/L2mmol/L4mEq/L6L 入院時年齡血白細胞 血糖ASTLDH入院48hHCTBUN血鈣PaO2BE失液量急性胰腺炎Ranson標準急性生理學和慢性健康評估系統(tǒng)APACH- SCOREAcute Physiology and Chronic Health EvaluationA: 總急性生理參數(shù)Total Acute Physiolog

9、y Score ( APS) B: 年齡分數(shù) Age pointsC: 慢性健康狀況評分Chronic Health pointsTotal APACHE - SCORE: ABC鑒別診斷潰瘍穿孔病史突然發(fā)病劇烈腹痛板樣腹肝濁音界消失膈下游離氣體膽囊炎病史右上腹痛黃疸Murphy征（+）B超征象急性腸梗阻陣發(fā)性絞痛腸鳴音肛門排便、排氣停止X線征象心肌梗塞冠心病史心前壓痛心電圖改變心肌酶譜異常治 療輕型：禁食、補液、對癥治療重癥：監(jiān)護補液、抗休克抑制胰液分泌：禁食、生長抑素止痛抗生素治 療內(nèi)鏡下Oddi括約肌切開術Vedio Needle-knife papillotomy in patient with stone impacted in the papillary orifice. This is the easiest and safest setting in which to perform needle-knife