急性胰腺炎的诊断和治疗.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,.,*,急性胰腺炎的诊断和治疗,09,级 刘国涛,.,一、概 述,急性胰腺炎,(Acute Pancreatitis,AP),是常见急腹症之一，大多由于胰酶不正常被激活而导致胰腺本体出现自身消化、水肿、出血甚至坏死的炎症反应。临床上以急性上腹痛、恶心、呕吐、发热和血胰酶增高为特点。,病情急，病程短，临床表现多变，预后复杂，误诊率病死率高。本病好发年龄为,20-50,岁，女性较男性多见。,胆道疾病：,胆石症最常见，其次为胆道感染，胆道蛔虫。,过量饮酒和暴饮暴食：,酒精能刺激胰液分泌，刺激,Oddi,括约肌痉挛和十二指肠水肿，胰液排出受阻，胰管内压增加甚至破裂。,创伤因素：,胰腺组织或胰腺血供直接或间接受损,胰管梗塞：,因蛔虫、结石、水肿、肿瘤和痉挛等原因可导致胰管梗阻，胰液排泄受阻。,十二指肠液反流，,胰腺血液循环障碍等,二、致病危险因素,三、,临床表现,1,、腹痛：,主要表现和首发症状，多位于左上腹部，向腰背部呈带状放射，严重时可有全腹痛、压痛、反跳痛，疼痛呈持续性，可有阵发性加剧。,2,、腹胀：,肠鸣音减弱，可有麻痹性肠梗阻。,3,、恶心、呕吐：,早发，频繁，剧烈，呕吐后疼痛不减轻。,4,、发热、黄疸,：,合并胆道感染时常伴发寒战、高热。胰腺坏死时，持续高热为主要症状之一。若结石嵌顿或胰头水肿压迫胆总管时可伴发黄疸。,5,、水，电解质及酸碱平衡紊乱,四、急性胰腺炎的诊断,1,、实验室检查,胰酶测定：,血清淀粉酶,500U/dl,（正常值的三倍以上）发病后,2,12h,后开始升高,3,3d,后回复正常,尿淀粉酶 血清淀粉酶升高,2h,后尿中排泄增加,血清脂肪酶 发病后,24-48h,开始上升，,4d,达高峰,2,、影像学诊断,腹部,B,超：胰腺水肿时显示均匀低回声，出现粗大的强回声提示出血、坏死可能。,B,超可见：胰腺增大，周围液性暗区,急性水肿性胰腺炎时，胰腺弥漫性增大、密度不均匀，边界模糊，胰腺包膜凸起，胰周渗液。出血坏死性胰腺炎时，在肿大的胰腺内出现皂泡状的密度减低区，在增强时更为明显。目前,CT,检查已成为诊断急性胰腺炎及判断其程度的重要手段。,增强,CT,扫描：鉴别水肿性和出血坏死性的重要依据,急性水肿性胰腺炎,胰腺体积不同程度的弥漫性肿大,胰腺密度正常或轻度下降，密度均匀或不均匀，后者胰腺间质水肿所致,胰腺轮廓清楚或模糊，渗出明显的，除胰腺轮廓模糊外，可有胰周积液,增强扫描胰腺均匀强化，无坏死区域,男性,46,岁 上腹部疼痛一天，血、尿淀粉酶升高,急性水肿型胰腺炎,急性出血坏死性胰腺炎,胰腺体积弥漫性肿大,胰腺水肿时密度降低，坏死区域密度更低，出血区域密度增高，高于正常胰腺，增强扫描坏死区域无强化。,胰腺周围的脂肪间隙消失,出血坏死性胰腺炎的胰周改变常常明显，表现为脂肪坏死，胰周、胰腺外积液,坏死性胰腺炎,男性,36,岁 上中腹剧痛,3,天 压痛明显,急性坏死性胰腺炎在治疗过程中，仍需,CT,检查评价治疗效果,。,CT,分级,评分,A,级,正常胰腺,0,B,级,胰腺局灶性或弥漫性增大,1,C,级,胰腺腺体异常伴轻度的胰周炎症改变,2,D,级,单个胰周积液，通常局限于肾前间隙,3,E,级,有两个或多发的积液，胰腺内或胰周有气体,4,坏死区域,评分,无,0,1/3,2,1/2,4,1/2,6,CT,严重程度指数（,CTSI,）,=CT,分级评分,+,坏死评分（,010,分）,急性胰腺炎的,CT,分级和,CT,严重指数,严重度分为三级：,I,级，,0-3,分II,级，,4-6,分；,III,级，,7-10,分，,II,级以上为重症,中上腹痛，压痛,血清淀粉酶测定,3,倍正常值上限,正常,动态监测升高,初步诊断成立,血生化，,B,超,病因诊断,评分系统评估、增强,CT,严重程度评估,重症急性胰腺炎,轻症急性胰腺炎,急性胰腺炎诊断流程图,临床类型,急性胰腺炎（,AP):,急性，持续性腹痛，血清淀粉酶增高,3,倍或以上，影像提示胰腺有形态改变,轻症急性胰腺炎（,MAP),：,除,AP,的临床表现和生化改变，无器官功能障碍，,CT,分级为,A,、,B,、,C,。,重症急性胰腺炎（,SAP,）：,除,AP,的临床表现和生化改变伴局部并发症或器官衰竭，,CT,分级为,D,、,E,。,五、急性胰腺炎的治疗,非手术治疗,禁食，胃肠减压,补液，防止休克,镇痛解痉,抑制胰腺分泌,营养支持,抗生素的应用,手术治疗,手术适应症,手术方式,不能排除其他急腹症时,胰腺和胰周坏死组织继发感染,经非手术治疗，病情继续恶化者,暴发性胰腺炎伴多器官功能障碍,伴胆管下端梗阻或胆道感染,合并肠穿孔、大出血和胰腺假性囊肿,最常用的是坏死组织清除加引流术,胆原性胰腺炎的处理：,取出结石，解除梗阻，畅通引流，清除坏死组 织并作广泛引流。,内镜下,Oddi,括约肌切开术（,EST,）,传统开腹清洗引流术,六、预后,1,、水肿性：一周内恢复，不遗留后遗症。,2,、出血坏死性：病情重而凶险，预后差。病死率,30-70,存活者多遗留不同程度的胰腺功能不全，少数演变为慢性胰腺炎。,七、预防,1,、积极治疗胆道疾病,2,、戒酒，避免暴饮暴食,谢谢！,谢谢！,T,he diagnosis,and Treatment strategy for acute pancreatitis,.,Summary Background Data,With acute pancreatitis(AP)is the most common,because not normal pancreatic enzyme caused by activating the pancreas appeared on its own body,Illness,of short duration,manifestations and prognosis is complex,the misdiagnosis rate high mortality,Disease risk factors:biliary disorders,excessive drinking,duodenal reflux,trauma,pancreas,blood circulation barrier etc,The diagnosis of acute pancreatitis,Clinical manifestations,Abdominal pain,Abdominal distension,Nausea,vomiting,Peritonitis signs,other,Laboratory tests,Pancreatic enzyme determination,Serum amylase 500U/dl after ictus 12h 2 3 h after beginning to rise,after the 3d normal,Hematuria elevated serum amylase amylase after urine discharge increase 2h,Serum lipase incidence after 24-48h begins to rise,4d reach peak,Edema pancreatitis,Acutely edematous pancreatitis,pancreas,diffuse enlargement,density,uneven,fuzzy boundaries,enlarged peripancreatic pancreas coated drainage.Hemorrhage,necrotizing pancreatitis enlargement of bubbly soap pancreas appeared in reducing area,enhance density.Currently CT has become the diagnosis of acute pancreatitis and judgment has an important means of degree.,CT grading of severity of acute pancreatitis,Grading system Score,CT grade(Balthazar score),(A)Normal pancreas 0,(B)Oedematous pancreatitis 1,(C)B+mild extrapancreatic changes 2,(D)Severe extrapancreatic changes including one fluid,Collection 3,(E)Multiple or extensive extrapancreatic changes 4,Necrosis,None 0,One-third 2,One-third,one-half 4,Half 6,CT severity index=CT grade+necrosis score,Severe pancreatitis is defined as a Balthazar score of D or E and/or detection ofnecrosis and/or a total severity index of 3.,Treatment,Non-operative therapy,Fast gastrointestinal decompression,Rehydration,prevent shock,Stop pain and spasm,Nutritional support,Antibiotic treatment,Operative therapy,The most commonly used is to remove necrotic tissue and drainage,Thank you!,