重新認(rèn)識(shí)胰腺炎課件

重新認(rèn)識(shí)犬胰腺炎

History

病史?

Signalment

臨床表現(xiàn)?

Diet?

Vomiting飲食情況

嘔吐?

History

of

pancreatitis

胰腺炎病史?Diarrhea腹瀉

History

病史?

Signalment

臨床表現(xiàn)?

Diet?

Vomiting飲食情況

嘔吐?

History

of

pancreatitis

胰腺炎病史?Diarrhea腹瀉

Physical

Examination

體格檢查?Anterior

abdominal

pain

前腹部疼痛?

Icterus?

Profuse

ascites

黃疸大量腹水??FeverSQ

abscesses發(fā)熱皮下膿腫

Physical

Examination

體格檢查?Anterior

abdominal

pain

前腹部疼痛?

Icterus?

Profuse

ascites

黃疸大量腹水??FeverSQ

abscesses發(fā)熱皮下膿腫

Physical

Examination

體格檢查?Anterior

abdominal

pain

前腹部疼痛?

Icterus?

Profuse

ascites

黃疸大量腹水??FeverSQ

abscesses發(fā)熱皮下膿腫WHICH

CBC(S)

IS/AREFROM

DOG(S)

WITH

ACUTEPANCREATITIS?哪份血常規(guī)結(jié)果是來(lái)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

470,000ToxicmodmodnonenoneClinical

Pathology臨床病理學(xué)?

An

anorexic,

vomiting

dog

with

fasting

hyperlipidemia

probably

has

acute

pancreatitis患犬厭食、嘔吐，突然出現(xiàn)高脂血癥可能患有急性胰腺炎Clinical

Pathology臨床病理學(xué)?

An

anorexic,

vomiting

dog

with

fastinghyperlipidemia

probably

has

acutepancreatitis患犬厭食、嘔吐，突然出現(xiàn)高脂血癥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現(xiàn)高脂血癥Clinical

Pathology

臨床病理學(xué)?

Amylase/Lipase

–

Sensitivity

~

50%

–

Specificity

~

50%淀粉酶/脂肪酶

敏感性-50%

特異性-50%?

TLI血清胰蛋白酶樣免疫反應(yīng)–

Sensitivity

~

35%特異性-35%Clinical

Pathology

臨床病理學(xué)?

Amylase/Lipase

–

Sensitivity

~

50%

–

Specificity

~

50%淀粉酶/脂肪酶

敏感性-50%

特異性-50%?

TLI血清胰蛋白酶樣免疫反應(yīng)–

Sensitivity

~

35%特異性-35%

TAMU#203505Sig:

14

yr

M(n)

Shih

Tzu

14歲

雄性已去勢(shì)

西施犬CC:Abdominal

pain前腹部疼痛HPI:

Pain

2

days

ago

and

yesterday

兩天前和昨天疼痛Vomited

1

timePU-PD

for

last

week嘔吐一次

上周多飲多尿PE:Normal

appetite/body

weight食欲/體重正常No

abnormalities

today

今日無(wú)異常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肌酐鈣鈉鉀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

=膽紅素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”腹部超聲檢查：胰腺體積增大，可見胰腺結(jié)節(jié)…肝臟腫物符合原發(fā)性肝腫瘤特征TAMU#203505Snap

PL:

positivecPL試劑盒檢測(cè)：

陽(yáng)性

Your

best

next

step

is:

下一步最好：1

Forget

about

it

(dog

is

now

happy)

算了吧（狗狗現(xiàn)在挺開心的）2Repeat

cPLI

and

ultrasound

tomorrow

明日復(fù)查cPLI和超聲檢查3

Tx

for

acute

pancreatitis

(IV

fluids)

治療急性胰腺炎（靜脈補(bǔ)液）

4

Tx

with

pancreatic

enzymes

用胰酶治療5

Hepatic

lobectomy肝葉切除術(shù)8Diagnostics診斷?

cPLI–

Sensitivity

~

80%

敏感性-80%?

Abdominal

ultrasound腹部超聲檢查–

Sensitivity

40%

-

65%敏感性

40%

-

65%Diagnostics

診斷?

cPLI

–

Sensitivity

~

80%敏感性-80%?

Abdominal

ultrasound

腹部超聲檢查

–

Sensitivity

40%

-

65%

敏感性

40%

-

65%

?

Becausecliniciansrarelyrepeatthe

ultrasound

因?yàn)榕R床醫(yī)師很少重復(fù)進(jìn)行超聲檢查WHAT

IS

THE

BEST

WAY

TO

DIAGNOSE

CANINEACUTE

PANCREATITIS?診斷犬急性胰腺炎最好的方法是Bewillingtorepeatultrasound重復(fù)進(jìn)行超聲檢查All

things

being

equal,

tryto

avoid

surgery平衡一切，盡量避免手術(shù)Bewillingtorepeatultrasound重復(fù)進(jìn)行超聲檢查THE

REAL

PROBLEM

IS

THAT

ACUTE

PANCREATITIS

CAN

PRESENT

IN

SO

MANYDIFFERENTWAYS

THAT

YOU

DON’T

EVEN

SUSPECT

IT

INITIALLY

真正的問(wèn)題是急性胰腺炎可能有很多種表現(xiàn)，在開始時(shí)你也許都不會(huì)懷疑是胰腺炎？TAMU#88267

Sig:

7

yr

M

Sheltie

CC:

Vomiting

HPI:

Began

5

weeks

ago7歲

雄性

喜樂蒂嘔吐

五周前開始PE:Partial

anorexia,

vomits

phlegm

or

bile

once

daily有時(shí)厭食，嘔吐黏液或膽汁，每日一次Dog

otherwise

pretty

healthy

其他方面無(wú)異常No

significant

abnormalities

未見明顯異常TAMU#159796

Sig:

9

yr

M(c)

Pug9歲

雄性去勢(shì)

巴哥

犬CC:

Vomiting,

yellow

scleras

嘔吐，鞏膜發(fā)黃HPI:

Feeling

bad

12

days

ago

12天前狀態(tài)不佳

Started

vomiting,

responded

to

fluid

therapy,

but

became

ill

again

when

started

feeding

it

開始嘔吐后，液體療法有效，

但恢復(fù)進(jìn)食后病情反復(fù)

Dog’s

eyes

turned

yellow

患犬眼部發(fā)黃TAMU#159796

PCV

=

BUN

=

葡萄糖

Glucose

=40%

(35-55)4

mg/dl

(8-29)95

mg/dl

(75-133)鉀Potassium

=3.6

mEq/L

(3.8-5.1)膽固醇

Cholesterol

=白蛋白

Albumin

=

ALT

=

SAP

=膽紅素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歲

雌性絕育

大麥町嘔吐/腹瀉HPI:

Vomiting

food/bile

6-8X

in

2

weeks

2周內(nèi)嘔吐食物/膽汁6-8次

Diarrhea

constant

for

2

weeks

持續(xù)腹瀉2周時(shí)間

Decreased

appetite

for

10

days,

anorexia

for

5

days

食欲減退10天，厭食5天PE:T

=

39.2

C,

HR

=

102/minTAMU

#152494PCV

=WBC

=Segs

=葉狀中性粒細(xì)胞Bands

=35.5%

(35-55)21,700/ul

(6,-14,000)15,200/ul

(4,-12,000)630/ul

(<

500)桿狀中性粒細(xì)胞Lymphs

=

1,400/ul

(1,-4,000)淋巴細(xì)胞Platelets

=568,000/ul

(200,-500,000)TAMU

#152494鈉鉀葡萄糖白蛋白肌酐

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)TAMU

#152494Abdominal

ultrasound:“…

Small

amount

of

anechoic

effusionbetween

liver

lobes

and

around

urinarybladder.”腹部超聲：肝葉之間及膀胱周圍可見少量無(wú)回聲液體TAMU

#152494

Abdominal

fluid:

腹腔積液WBC

=RBC

=153,000/ul

0/ulTotal

protein

=4.6

gm/dl總蛋白

90%

nondegenerate

neutrophils

非退行性中性粒細(xì)胞

8%

macrophages,

vaculated

巨噬細(xì)胞，空泡化Sterile

pancreatitis無(wú)菌性胰腺炎Versus

和Septic

peritonitis敗血性腹膜炎Abdominal

fluid

腹腔積液147260

152494152485109612TP

gm/dl

5.14.61.33.6WBC/ul15,059

153,000

70018,200RBC/ul91,112

030,00083,700Abdominal

fluid

腹腔積液147260

152494152485109612TP

gm/dl

5.14.61.33.6WBC/ul15,059

153,000

70018,200RBC/ul91,112

030,00083,700PANCREATITIS

CAN:胰腺炎時(shí)可能：a)

make

no

abdominal

effusion無(wú)腹腔積液b)

make

a

little

abdominal

effusion產(chǎn)生少量腹腔積液c)

make

a

massive

abdominal

effusionPancreatitis

can

present

as:胰腺炎可表現(xiàn)為：?

acute

vomiting

with

abdominal

pain急性嘔吐伴有腹部疼痛?

chronic,

low

grade

vomiting/anorexia

(abscess)慢性輕度嘔吐/厭食（膿腫）?

icterus

(biliary

tract

obstruction)黃疸（膽道阻塞）?

ascites

(minimal,

little

or

lots)腹水（少量、無(wú)腹水或大量）?

acute

abdomen

(looks

just

like

septic

peritonitis)急腹癥（癥狀類似敗血性腹膜炎）?

SIRS

(looks

like

septic

shock)SIRS（癥狀類似敗血性休克）SYSTEMIC

INFLAMMATORYRESPONSE

SYNDROME全身性炎癥反應(yīng)綜合征–

used

to

be

called

“Septic

shock”

曾被稱為“敗血性休克”SYSTEMIC

INFLAMMATORYRESPONSE

SYNDROME全身性炎癥反應(yīng)綜合征–

inadequate

perfusion

of

the

body

tissuesbecause

of

an

exaggeratedinflammatoryresponse劇烈的炎癥反應(yīng)導(dǎo)致機(jī)體組織灌注不良

WHAT

IS

SUPPOSED

TO

HAPPEN

認(rèn)為會(huì)發(fā)生什么Bacterial

toxin,

inflammatory

cytokines細(xì)菌毒素，炎性細(xì)胞因子

Lymph

nodes,

hepatic

macrophages

淋巴結(jié)，肝臟巨噬細(xì)胞Systemic

circulation全身循環(huán)

WHAT

IS

SUPPOSED

TO

HAPPEN

認(rèn)為會(huì)發(fā)生什么Bacterial

toxin,

inflammatory

cytokines細(xì)菌毒素，炎性細(xì)胞因子

Lymph

nodes,

hepatic

macrophages

淋巴結(jié)，肝臟巨噬細(xì)胞Systemic

circulation全身循環(huán)Inflammatory

cytokinesLymph

nodes

淋巴結(jié)Systemiccirculation全身循環(huán)WHAT

CAN

HAPPEN會(huì)發(fā)生什么炎性細(xì)胞因子

EARLY

–

SIRSMild

uneven

vasodilatation

輕度部分血管擴(kuò)張“High

output”

shock

高輸出性休克Bright

red

mucus

membranes

黏膜鮮紅Fast

capillary

refill

time

毛細(xì)血管再充盈時(shí)間短Bounding

pulsesTachycardia

脈搏跳躍（洪脈）心動(dòng)過(guò)速

LATE

–

SIRSSevere

peripheral

vasodilatation

+

poorcardiac

contractility嚴(yán)重的外周血管擴(kuò)張+

心收縮力不足

“Low

output”

shock

低輸出性休克Pale

mucus

membranes

黏膜蒼白Weak

pulses脈搏微弱Slow

refill

time

毛細(xì)血管再充盈時(shí)間延長(zhǎng)THERAPY

FOR

PANCREATITIS胰腺炎的治療Only

supportive

and

symptomatic僅用支持療法和對(duì)癥治療?

NPO

(nothing

per

os)

vs

EarlyFeedingNPO（禁食）和早期飼喂?

Early

Feeding

早期飼喂–

Feed

small

amounts

of

ultra-low

fat

foodeven

if

vomiting即使嘔吐也飼喂少量超低脂食物–

Continue

feeding

as

long

as

the

patientdoes

not

get

worse只要?jiǎng)游锊∏闆]有惡化，便繼續(xù)飼喂THERAPY

FOR

PANCREATITIS胰腺炎的治療Only

supportive

and

symptomatic僅用支持療法和對(duì)癥治療?

Fluid

therapy液體療法Crystalloids

晶體液PlasmaColloids

血漿膠體液

THERAPY

FOR

PANCREATITIS

胰腺炎的治療

Only

supportive

and

symptomatic

僅用支持療法和對(duì)癥治療?

Early

Feeding

早期飼喂?

Fluid

therapy液體療法Crystalloids

晶體液PlasmaColloids血漿

膠體液

Hetastarch

is

no

longer

everyone’s

bestfriend

...

(J

Vet

Emerg

Critical

Care

25:

20-47,

2015)

羥乙基淀粉不再是所有人最好的朋友…

THERAPY

FOR

PANCREATITIS

胰腺炎的治療

Only

supportive

and

symptomatic?

Early

Feeding

早期飼喂?

Fluid

therapy液體療法Crystalloids

晶體液PlasmaColloids血漿

膠體液Total/partial

parenteral

nutrition完全/部分腸外營(yíng)養(yǎng)支持

THERAPY

FOR

PANCREATITIS

胰腺炎的治療

Only

supportive

and

symptomatic?

Early

Feeding

早期飼喂?

Fluid

therapy液體療法Crystalloids

晶體液PlasmaColloids血漿

膠體液Jejunostomy

feeding

空腸造口飼喂

(PEG-J,

Nasal

J,

regular

J)

THERAPY

FOR

PANCREATITIS

胰腺炎的治療

Only

supportive

and

symptomatic

僅用支持療法和對(duì)癥治療?

Early

Feeding

早期飼喂?

Fluid

therapy液體療法Crystalloids

晶體液

Plasma

Colloids

Nutrition?

Analgesics血漿

膠體液

營(yíng)養(yǎng)

鎮(zhèn)痛劑

THERAPY

FOR

PANCREATITIS

胰腺炎的治療

Only

supportive