Acute Pancreatitis：急性胰腺炎.ppt

Acute pancreatitis refers to an acute inflammatory process of the pancreas,usually accompanied by abdominal pain and elevations of serum pancreatic enzymes.,Definition of Acute Pancreatitis,Classification(Atlanta 1992),Acutepancreatitis,Mild acute pancreatitis,Severe acute pancreatitis,Examples of drug-induced pancreatitis,Pathogenesis&Pathophysiology,Obstruction of intracellular trafficking of zymogens Systemic toxic injury of the acinar cells Changes in cell and tissue compartmentalization Intracellular activation of intrapancreatic enzyme Inhibition of zymogen release from acinar cell,Synthesis of enzymes as inactive zymogens Storage of zymogen granules Inhibitors of protease activity Serum antiproteases Unimpeded drainage of secretions and lymphBlood perfusion of organs,Defense mechanism,Triggering factor,Pathophysiology(Acinar Cells),Gallstones,Alcohol,Intra-acinar triggeringIntracellular enzymeactivation,Extra-acinar triggeringIncreased intraductalpressure with disruption of the duct barrierInterstitial enzyme activation,InflammationEnzyme activationDisruption of compartmentalizationAutodigestion,Acute Alcohol Effects,Autodigestion,Enzyme Effects,Clinical Manifestation,Severe acute pancreatitis,Mild acute pancreatitis,Symptoms and Sings,SIRS is present if two or more of the four criteria are present.,Systemic inflammatory response syndrome(SIRS),Necrosis Abscess Pseudocyst Paralytic ileus Ascites Pleural effusion Jaundice,Pulmonary failure Renal failure Shock Encephalopathy GI Bleeding Septicemia Hyperglycemia Hypocalcemia Metabolic acidosis,Complications,Systemic,Local,Systemic Complications,One of the followings:Local complications(pancreatic)Necrosis Pseudocyst Abscess Organ failure 3 Ranson criteria 8 APACHE II points,Definition of Severe acute pancreatitis,Ranson Criteria,This system uses 14 routinely measured parameters of physiological activity and biochemical function,and generates a numerical score that depends on the deviation of those parameters from the normal range.,The Acute Physiology and Chronic Health Evaluation(APACHE)II,Grey Turner sign,Acute Biliary Pancreatitis,C-reactive protein(150mg/ml at 48h)Methemalbumin Ribonuclease Procalcitonin Interleukins:IL-6,-8,-10 Complement factors Phospholipase A2 activity Adhesion molecules PMN elastase,Markers of severe acute pancreatitis,Plasma CRP in Acute Pancreatitis,Temporal peaks after onset of disease and validity ratings of the best markers of necrotizing pancreatitis,Amylase Lipase,Laboratory Examination Serum pancreatic enzymes,Causes of Increased Serum Amylase,CRP Leukocytes Hemoglobin(hematocrit)Platelet count Coagulation parameters Creatinine Alkaline phosphatase Bilirubin ALT,AST Glucose Blood gas analysis(pO2,pCO2,BE)Serum electrolytes(K,Na,Ca),Laboratory Examination,Ultrasound imaging of acute pancreatitis,Normal pancreas,Acute pancreatitis:pancreas is enlarged,hypoechoic and hetero-geneous,L:liver;PC:portal confluence,Computerized Tomography:Indications,Diagnosis Prognosis Detect the complications,Computed Tomography Severity Index(CTSI),CTSI=grade points+degree of necrosis,CTSI correlates with mortality in acute pancreatitis,Mild acute pancreatitis,Severe acute pancreatitis,Infected pancreatic necrosis,Pancreatic pseudocyst,Pancreatic Necrosis,Day1 Day 7 Day 28,Diagnosis,Characteristic signs and symptomsThree folds elevation of serum amylase/lipase levelPositive evidence in imaging studies,Complications of peptic ulcer Acute cholecystitis/biliary colic Intestinal obstruction Mesenteric infarction Peritonitis Colonic diverticulitis/perforation Pleurisy/pneumonia Myocardial infarction Renal colic,Differential Diagnosis,Treatment,Hospitalization NPO,Intravenous fluids Monitoring of blood pressure,pulse and temperature Acid suppression Analgesia,Nasogastric intubation Central venous catheter Bladder catheter for urinary monitoring Parenteral/enteral nutrition Antibiotics Urgent ERCP/EST,Basic Therapy,Obligatory,Optional,Activities of Antibiotics(Pharmacokinetic studies on concentrations in the human pancreas),Specific Therapy,Protease inhibitors:Aprotinin Gabexate mesylate Hormones/inhibitors of pancreatic secretion:Glucagon Calcitonin Atropine Somatostatin Octreotide,Clinical effect has not been established,Infected pancreatic necrosis Positive demonstration of pathogens(FNA,with gram stain and culture),or Gas bubbles revealed by CT/MRIPersistent necrotizing pancreatitis 4 weeks of intensive care,no significant clinical improvementFulminant necrotizing pancreatitis Rapidly progressive multi organ failure despite maximum intensive treatment(last resort),Indications for Surgery,With clinically confirmed success Necrosectomy with closed retroperitoneal lavage Necrosectomy with wide peripancreatic drainage Necrosectomy with staged re-exploration,Surgical Procedures,Prognosis,