Acute Pancreatitis234OverviewPancreatitis is an inflammation of the pancreas.PancreatitisAcute pancreatitisChronic pancreatitis5Acute PancreatitisPancreatitisisaninflammatoryprocessinwhichpancreaticenzymesautodigestthegland6Classification:Pathological:nacuteedematouspancreatitisnacutehemorrhagicnecrotizingpancreatitisClinical:nMildacutepancreatitisnSevereacutepancreatitisnMild acute pancreatitis is not associated with organ dysfunction or complications, and recovery is uneventful. nSevere acute pancreatitis is associated with decreased function of the pancreas, local and systemic complications, and a complicated recovery. 7Severe acute pancreatitis nHowtoidentifySAPfromMAP?2024/8/192024/8/19MAP：no organ dysfunction SAP：at lease one of the following organ dysfunction local complication (necrosis abscess or pseudocyst ) Ranson score 3 or APACHE 8 Balthazar CT score 2024/8/19术语定定义急性胰腺炎急性胰腺炎胰腺的急性炎症胰腺的急性炎症轻症急性胰腺炎症急性胰腺炎无明无明显器官功能障碍，器官功能障碍，对液体治液体治疗反反应良好良好重症急性胰腺炎重症急性胰腺炎具具备下列情况之一下列情况之一 局部并局部并发症（胰腺坏死、假性囊症（胰腺坏死、假性囊肿、胰腺、胰腺脓肿） 器官衰竭器官衰竭 Ranson评分分3 APACHE 8胰腺坏死胰腺坏死增增强强CT发现失活的胰腺失活的胰腺组织急性液体聚集急性液体聚集胰腺及胰周液体胰腺及胰周液体积聚，聚，发生与病程早期并缺乏完整包膜生与病程早期并缺乏完整包膜急性假性囊急性假性囊肿有完整包膜的液体有完整包膜的液体积聚，包含有胰腺分泌物聚，包含有胰腺分泌物胰腺胰腺脓肿胰腺及胰周的胰腺及胰周的脓液聚液聚积11v假性囊肿假性囊肿 周形成周形成,由胰液和坏由胰液和坏死组织在胰腺内或周围包裹形成，囊壁死组织在胰腺内或周围包裹形成，囊壁无上皮，为坏死肉芽和纤维结缔组织无上皮，为坏死肉芽和纤维结缔组织v治疗：治疗：6周内自行吸收周内自行吸收40%，6周后吸收周后吸收 机机会减少，会减少，13周后均无法吸收。周后均无法吸收。 v 6周内密切随访周内密切随访 如出现并发症或如出现并发症或6周不吸周不吸收可考虑内收可考虑内/外引流外引流v发生率发生率10% 2024/8/19器官功能衰竭器官功能衰竭Signs of Organ Failure in Acute Pancreatitis1314Etiology and mechanism:原发性的原发性的 15Etiology and mechanismn n70-80% of patients either have gallstones or a history of sustained alcohol abuse. 16水水 肿肿 型型 的的 病病 理理 外观：外观： 胰腺胰腺肿大、变硬、肿大、变硬、少量周围组织坏死。少量周围组织坏死。 显微镜下：显微镜下： 间质间质充血、水肿、炎症充血、水肿、炎症细胞浸润，少量腺细胞浸润，少量腺泡坏死。泡坏死。17出出 血血 坏坏 死死 型型 病病 理理 外观：外观： 胰腺胰腺弥漫性肿大弥漫性肿大、大网膜大网膜 和胰腺上大小不等的钙皂和胰腺上大小不等的钙皂 显微镜下：显微镜下： 胰实质、脂肪胰实质、脂肪坏死坏死； 水肿、水肿、出血出血和血栓形成；和血栓形成； 炎症炎症反应。反应。 Pathology1.Edematous pancreatitis:*interstitial edema*inflammatory cell infiltration of the gland parenchyma2.Hemorrhagic or necrotizing pancreatitis*extensive pancreatic and peripancreatic fat necrosis *parenchymal necrosis19Acute hemorrhagic pancreatitis.20Clinical manifestationsnSymptomsn1、 Abdominalpain:predominant clinical predominant clinical featurefeatureClinical PresentationnSteady, dull, or boring midepigastric pain associated with nausea and vomiting is the classic presentation of acute pancreatitis.Abdominal pain n na penetrating pain, radiating to the back (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.)Abdominal painn nrarepatientswithoutabdominalpainbutwithaseveresystemicillness(hypotension,hypoperfusionanddepressionofmentalstatus)-Painless acute pancreatitis is very rare but carries a grave prognosis because the patients frequently present in shock.Clinical Presentationn nNauseaandvomitingn nAbdominalDistentionresultingfromaparalyticileusarisingfromresultingfromaparalyticileusarisingfromretroperitonealirritationorascitesoraretroperitonealirritationorascitesoraretroperitonealphlegmonretroperitonealphlegmonn nJaundicedistalcommonbileductobstructionbydistalcommonbileductobstructionbygallstonescompressionofthedistalCBDbygallstonescompressionofthedistalCBDbypancreaticheadedemaorbyotherpancreaticheadedemaorbyotheruncommonfindingsuncommonfindingsAbdominal DistentionnParalytic ileus(麻痹性肠梗阻麻痹性肠梗阻) with abdominal distention may develop during the first few days, signifying extension of the inflammatory process into the small intestinal and colonic(结结肠的肠的) mesentery(肠系膜肠系膜).Clinical Presentation of Sever Pancreatitisn nCirculatory Derangements: hypotention, Circulatory Derangements: hypotention, hypovolemia, hypoeffusionhypovolemia, hypoeffusioncirculating myocardial depressant factorcirculating myocardial depressant factor decreased preload to the heartdecreased preload to the heartreduced systemic vascular resistancereduced systemic vascular resistancesepsis-like syndromesepsis-like syndromeClinical Presentation of Sever Pancreatitisn npleuraleffusionpleuraleffusionn npulmonaryfailurepulmonaryfailuretachypnea,dyspneaandcyanosistachypnea,dyspneaandcyanosisn ncerebralabnormalitiescerebralabnormalitiesbelligerence,confusion,psychosisandbelligerence,confusion,psychosisandcomacoman nGreyTurnersignandCullensignGreyTurnersignandCullensignabluishcolorintheflanksoraroundtheabluishcolorintheflanksoraroundtheumbilicus,(representingblooddissectingtoumbilicus,(representingblooddissectingtothoseareasfromtheretroperitoneumnearthoseareasfromtheretroperitoneumnearthepancreasalongfascialplanes)thepancreasalongfascialplanes)nOne to 2 weeks after the onset, large ecchymoses(瘀斑瘀斑) may appear in the flanks侧侧腹腹 (Grey Turners sign) or the umbilical area (Cullens sign);29Clinical features :MAP (mild AP) Abdominalpain,usuallyepigastric,constantwithradiationtothebackAssociatednauseaandvomitingMayalsohavefeverandjaundice 痛痛呕呕热热30 hypotensionorshock exudativepleurisy渗出性胸膜炎渗出性胸膜炎Grey-Turner sign Grey-Turner sign Cullen sign Cullen sign出出 血血 坏坏 死死 型型 临临 床床 表表 现现generalperitonitis弥漫性腹膜炎弥漫性腹膜炎31Grey-Turner征征Cullen征征Physical ExaminationnInitial physical examination reveals mild fever and tachycardia(心动过速心动过速); nHypotension is present in 30 to 40% of patients.Physical Examinationn nepigastriatenderness,rigidityandreboundepigastriatenderness,rigidityandreboundtendernesstendernessn nbowelsoundsdecreasedorabsentbowelsoundsdecreasedorabsentn npalpablemasspalpablemassswollenpancreasswollenpancreasPseudocystPseudocystabscessabscessLaboratory TestSerum AmylasenTotal serum amylase activity 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. Serum AmylasenValues more than 3 times the upper limit of normal are highly specific for acute pancreatitis but are found in only 80 to 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)Disorders Associated with hyperamylasemiaIntra-AbdominalExtra-AbdominalIntra-AbdominalExtra-AbdominalPancreaticdisordersPancreaticdisordersSalivarySalivaryglanddisordersglanddisordersacutepancreatitismumpsacutepancreatitismumpschronicpancreatitisparotitischronicpancreatitisparotitistraumatraumatraumatraumacarcinomacalculicarcinomacalculipseudocystirradiationsialoadenitispseudocystirradiationsialoadenitispancreaticascitesimpairedamylasepancreaticascitesimpairedamylaseexcretionexcretionabscessrenalfailureabscessrenalfailureNonpancreaticdisordersNonpancreaticdisordersmecroamylasemiamecroamylasemiabiliarytractdiseaseMiscellaneusbiliarytractdiseaseMiscellaneusintestinalobstructionpneumoniaintestinalobstructionpneumoniamesentericinfarctionpancreaticpleuraleffusionmesentericinfarctionpancreaticpleuraleffusionperforatedpepticulcermediastinalpseudocystperforatedpepticulcermediastinalpseudocystperitonitiscerebraltraumaperitonitiscerebraltraumarupturedaorticaneurysmbisalbuminemiarupturedaorticaneurysmbisalbuminemia Urinary Amylasen nasensitiveindexofthepancreatitisn nelevationspersistforalongerperiodthanserumamylasen nsomeotherdiseasesalsomanifesthyperamylasurian nanormalurinaryamylasecantprecludethepancreatitisSerum Lipasen namoreaccurateindicatorofacutepancreatitisamoreaccurateindicatorofacutepancreatitisn nlipaseissolelyofpancreaticoriginlipaseissolelyofpancreaticoriginn nTheserumlipaselevelstendtoremainelevatedTheserumlipaselevelstendtoremainelevatedlongerthantheamylaselevelsduringthehealinglongerthantheamylaselevelsduringthehealingphaseofpancreatitis.phaseofpancreatitis.n nsomeotherdiseasesalsomanifestelevatedserumsomeotherdiseasesalsomanifestelevatedserumlipaselipaseperforatedpepticulcerperforatedpepticulceracutecholecystitisacutecholecystitisintestinalischemiaintestinalischemian nThecombinationofserumamylaseandlipaseThecombinationofserumamylaseandlipasedeterminationsismoreaccuratethaneithertestdeterminationsismoreaccuratethaneithertestalone).alone).Hypocalcemian ntheconsequenceofdilutionalhypoalbuminemiatheconsequenceofdilutionalhypoalbuminemian ncalciumdespositioninareasoffatnecrosiscalciumdespositioninareasoffatnecrosisn nTheionizedcalciumconcentrationremainsTheionizedcalciumconcentrationremainsnormal,andsymptomsoftetany(normal,andsymptomsoftetany(手足抽搐手足抽搐)are)areextremelyrare.extremelyrare. Other laboratory TestElevatedwhitecellcount10000cellspermmElevatedwhitecellcount10000cellspermm33Leukocytosis(Leukocytosis(白细胞增多白细胞增多) ) HyperglycemiaHyperglycemia MildazotemiaMildazotemia氮质血症氮质血症:relatedtofluidsequestration:relatedtofluidsequestration AbnormalitiesofliverfunctiontestAbnormalitiesofliverfunctiontestnSerum triglyceride levels should be obtained in all patients because of their etiologic implications. Imaging Tests1. A plain Abdominal Film 1. A plain Abdominal Film *notspecific*notspecific*dilatationofanisolatedloopofintestine*dilatationofanisolatedloopofintestineadjacenttothepancreasadjacenttothepancreas*calcificationinthepancreas*calcificationinthepancreas*leftpleuraleffusions*leftpleuraleffusionsPlain films should be obtained routinely to rule out Plain films should be obtained routinely to rule out the presence of free air caused by perforation of a the presence of free air caused by perforation of a viscus.viscus. 2. Ultrasound Examination* notrauma*pancreaticandperipancreaticedemaoffluidcollection*pseudosyst*dilationofpancreaticduct*GBstoneandCBDstonenUltrasoundexaminationshowingtwolargepancreaticpseudocysts.Bothcystsareindicatedbythelargewhitearrows.3. CT Scans*confirmdiagnosisofpancreatitis*confirmdiagnosisofcomplicationssuchasabscessorpseudocyst*revealextensionofinflammationandnecrosis*implyprognosis*aneedleaspirationunderCTguidena dynamic CT scan will reveal extension of peripancreatic inflammation, involvement 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 pancreatitis.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, and 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-forming microorganisms, indicate that the pancreatic abscess is infected.2024/8/19Case1A2024/8/19Case1B13d2024/8/19Case1C23d2024/8/19Case2AERCP后2024/8/19Case 3A2024/8/19Case3A2024/8/19Case 4A2024/8/19Case 4B2024/8/19Case 5A2024/8/19Case 5A 14d4. Diagnostic Paracentesis穿刺术穿刺术1.notanidealtest*aninvasiveprocedure*complications*lackofcompletespecificityofperitonealfluidenzymeelevations2.Helpdiagnosis*elevationsinperitonealfluidamylaseandlipaseDifferential Diagnosis1.Intestinalperforation2.Pepticulcer3.Cholecystitis4.acuteintestinalobstruction5.myocardialischemia6.acutegastroenteritisTreatmentNonoperative Management1. Dietary Control Oralintakeisinitiallyprohibited;Oralintakecanberesumedduringthefirstweekoftreatmentwhenabdominalpainandtendernesshaveimproved,ileushasresolvedandhyperamylasemiaisnormalizing.2. Nasogastric Suction reducevomitingandabdominaldistensionreducepancreaticexocrinesecretionbyreducingsecretionrelease3. Intravenous fluid therapy and electrolyte replacement* hypokalemia,hypochoremia,hypocalcaemiaandhypomagnesemiashouldbecorrected*Causesofhypovolemia:Generousfluidresuscitationisveryimportant*mildhyperglycemia:insulintreatment4. Nutritional Support* fastingforalongtime*enteralalimentationisbetterthanthatthroughtheparenteralroute 5. Antibiotics* prophylaxis*preventintestinalbacteriatranslocation*Treatsuppurative化脓性的complication 6. Analgesia *Meperidine(哌替啶,度冷丁)isthepreferreddrug;*Morphine(吗啡)shouldbeavoided:causingspasmofthesphincterofoddi7.Pancreatic Exocrine Secretion Pancreatic Exocrine Secretion SuppressionSuppression1.nasogastricsuction1.nasogastricsuction2.histamine(H2)-receptorantagonists2.histamine(H2)-receptorantagonists3.antacids3.antacids4.anticholinergics4.anticholinergics5.glucagon5.glucagon6.somatostatin,octreotideandsandostatin6.somatostatin,octreotideandsandostatin生长抑素生长抑素施他宁施他宁(250(250 gg静推，静推，30003000 gg静滴静滴24h)24h)善宁善宁(0.1mg(0.1mg静推静推,0.6mg,0.6mg静滴静滴24h)24h)7.proglumide(cck-receptorantagonists7.proglumide(cck-receptorantagonists)8. Pancreatic enzyme inhibitor* aprotinin*gabexate*camostatSurgical Treatment Operative indication1.secondarypancreaticinfection2.correctionofassociatedbiliarytractdisease3.progressiveclinicaldeteriorationSurgery is contraindicated in uncomplicated acute pancreatitis. Surgical Procedure1.peritoneallavage:removetoxinsandvariousmetabolites2.pancreaticdrainage3.debridementofnecrotictissue4.biliaryprocedure: endoscopic sphincterotomy cholecystectomy remove the CBD stone74Thank you!Thank you!