內(nèi)科學(xué)教學(xué)課件：Acute Pancreatitis

1、Acute Pancreatitis 2 3 4 Overview Pancreatitis is an inflammation of the pancreas. Pancreatitis Acute pancreatitis Chronic pancreatitis 5 Acute Pancreatitis Pancreatitis is an inflammatory process in which pancreatic enzymes autodigest the gland 6 Classification: Pathological: nacute edematous pancr

2、eatitis nacute hemorrhagic necrotizing pancreatitis Clinical: nMild acute pancreatitis nSevere acute pancreatitis nMild acute pancreatitis is not associated with organ dysfunction or complications, and recovery is uneventful. nSevere acute pancreatitis is associated with decreased function of the pa

3、ncreas, local and systemic complications, and a complicated recovery. 7 Severe acute pancreatitis nHow to identify SAP from MAP? 2021-7-14 2021-7-14 MAP：no organ dysfunction SAP：at lease one of the following organ dysfunction local complication (necrosis abscess or pseudocyst ) Ranson score 3 or APA

4、CHE 8 Balthazar CT score 2021-7-14 術(shù)語術(shù)語定義定義 急性胰腺炎急性胰腺炎胰腺的急性炎癥胰腺的急性炎癥 輕癥急性胰腺炎輕癥急性胰腺炎無明顯器官功能障礙，對液體治療反應(yīng)良好無明顯器官功能障礙，對液體治療反應(yīng)良好 重癥急性胰腺炎重癥急性胰腺炎具備下列情況之一具備下列情況之一 局部并發(fā)癥（胰腺壞死、假性囊腫、胰腺膿腫）局部并發(fā)癥（胰腺壞死、假性囊腫、胰腺膿腫） 器官衰竭器官衰竭 Ranson評分評分3 APACHE 8 胰腺壞死胰腺壞死增強增強CT發(fā)現(xiàn)失活的胰腺組織發(fā)現(xiàn)失活的胰腺組織 急性液體聚集急性液體聚集胰腺及胰周液體積聚，發(fā)生與病程早期并缺乏完整包膜胰腺及胰周

5、液體積聚，發(fā)生與病程早期并缺乏完整包膜 急性假性囊腫急性假性囊腫有完整包膜的液體積聚，包含有胰腺分泌物有完整包膜的液體積聚，包含有胰腺分泌物 胰腺膿腫胰腺膿腫胰腺及胰周的膿液聚積胰腺及胰周的膿液聚積 11 v假性囊腫假性囊腫 周形成周形成,由胰液和壞由胰液和壞 死組織在胰腺內(nèi)或周圍包裹形成，囊壁死組織在胰腺內(nèi)或周圍包裹形成，囊壁 無上皮，為壞死肉芽和纖維結(jié)締組織無上皮，為壞死肉芽和纖維結(jié)締組織 v治療：治療：6周內(nèi)自行吸收周內(nèi)自行吸收40%，6周后吸收周后吸收 機機 會減少，會減少，13周后均無法吸收。周后均無法吸收。 v 6周內(nèi)密切隨訪周內(nèi)密切隨訪 如出現(xiàn)并發(fā)癥或如出現(xiàn)并發(fā)癥或6周不周不 吸

6、收可考慮內(nèi)吸收可考慮內(nèi)/外引流外引流 v發(fā)生率發(fā)生率10% 2021-7-14 器官功能衰竭器官功能衰竭 Signs of Organ Failure in Acute Pancreatitis 13 14 Etiology and mechanism: 原發(fā)性的原發(fā)性的 15 Etiology and mechanism 16 水水 腫腫 型型 的的 病病 理理 外觀：外觀： 胰腺胰腺腫大、變硬、腫大、變硬、少量周圍組織壞死。少量周圍組織壞死。 顯微鏡下：顯微鏡下： 間質(zhì)間質(zhì)充血、水腫、炎癥充血、水腫、炎癥細胞浸潤，少量腺細胞浸潤，少量腺 泡壞死。泡壞死。 17 出出 血血 壞壞 死死 型型

7、 病病 理理 外觀：外觀： 胰腺胰腺彌漫性腫大彌漫性腫大、大網(wǎng)膜大網(wǎng)膜 和胰腺上大小不等的鈣皂和胰腺上大小不等的鈣皂 顯微鏡下：顯微鏡下： 胰實質(zhì)、脂肪胰實質(zhì)、脂肪壞死壞死； 水腫、水腫、出血出血和血栓形成；和血栓形成； 炎癥炎癥反應(yīng)。反應(yīng)。 19 Acute hemorrhagic pancreatitis. 20 Clinical manifestations nSymptoms n1、 Abdominal pain: nSteady, dull, or boring midepigastric pain associated with nausea and vomiting is the

8、 classic presentation of acute pancreatitis. It radiates straight to the midline of the lower thoracic vertebral region in about 50% of patients and is usually worse in the supine position.) Painless acute pancreatitis is very rare but carries a grave prognosis because the patients frequently presen

9、t in shock. nParalytic ileus(麻痹性腸梗阻麻痹性腸梗阻) with abdominal distention may develop during the first few days, signifying extension of the inflammatory process into the small intestinal and colonic(結(jié)結(jié) 腸的腸的) mesentery(腸系膜腸系膜). nOne to 2 weeks after the onset, large ecchymoses(瘀斑瘀斑) may appear in the fla

10、nks側(cè)側(cè) 腹腹 (Grey Turners sign) or the umbilical area (Cullens sign); 29 Clinical features : MAP (mild AP) Abdominal pain, usually epigastric, constant with radiation to the back Associated nausea and vomiting May also have fever and jaundice 痛痛 嘔嘔 熱熱 30 hypotension or shock exudative pleurisy 滲出性胸膜炎滲出

11、性胸膜炎 Grey-Turner sign Grey-Turner sign Cullen sign Cullen sign 出出 血血 壞壞 死死 型型 臨臨 床床 表表 現(xiàn)現(xiàn) general peritonitis 彌漫性腹膜炎彌漫性腹膜炎 31 Grey-Turner征征 Cullen征征 nInitial physical examination reveals mild fever and tachycardia(心動過心動過 速速); nHypotension is present in 30 to 40% of patients. nTotal serum amylase act

12、ivity is the test most frequently used to diagnose acute pancreatitis. nThe level rises 6 to 12 hours after onset of symptoms and remains elevated for 3 to 5 days in most cases. nValues more than 3 times the upper limit of normal are highly specific for acute pancreatitis but are found in only 80 to

13、 90% of cases. nThe magnitude of the rise in serum amylase does not correlate with the severity of the attack, nor does prolonged hyperamylasemia indicate developing complications. nthe absence of hyperamylasemia cant exclude the diagnosis of acute pancreatitis (extensive pancreatic necrosis) nSerum

14、 triglyceride levels should be obtained in all patients because of their etiologic implications. nUltrasound examination showing two large pancreatic pseudocysts. Both cysts are indicated by the large white arrows. na dynamic CT scan will reveal extension of peripancreatic inflammation, involvement

15、of adjacent organs, venous thrombosis, and fluid collections. nMost importantly, pancreatic necrosis can be identified and quantitated by the lack of contrast medium enhancement after the bolus injection. nThe abdominal CT scan may be normal, however, in about 10% of patients with early, mild pancre

16、atitis. Abdominal Ultrasonography (US) and Computed Tomography (CT) nWhen the clinical diagnosis is made, the CT scan is far superior to US for assessing the extent and local complications of pancreatitis. nComputed tomogram of a patient with pancreatic abscess. The pancreas is diffusely involved, a

17、nd its margins are difficult to define because of the massive peripancreatic inflammation, which is reflected in the streaking seen in this scan. Toward the tail of the pancreas, numerous small and large bubbles are noted (arrows) in the peripancreatic inflammatory mass. Bubbles, caused by gas-formi

18、ng microorganisms, indicate that the pancreatic abscess is infected. 2021-7-14 Case 1A 2021-7-14 Case 1B 13d 2021-7-14 Case 1C 23d 2021-7-14 Case 2A ERCP 后 2021-7-14 2021-7-14 Case 3A 2021-7-14 Case 4A 2021-7-14 Case 4B 2021-7-14 Case 5A 2021-7-14 Case 5A 14d 223223 Nutritional SupportNutritional Support Acute Pancreatitis Acute Pancreatitis Consid