急性胰腺炎PPT课件.ppt

急性胰腺炎急性胰腺炎Teaching ObjectiveTo To know know the the etiology etiology and and pathogenesis pathogenesis of of acute acute pancreatitis pancreatitis To To master master the the clinical clinical features features and and key key points points of of diagnosis diagnosis for for different different types types of of acute acute pancreatitis pancreatitis To To master master the the therapy therapy principles principles of of acute acute pancreatitispancreatitisDefinitionAcute Acute pancreatitis pancreatitis is is a a inflammation inflammation of of the the pancreas pancreas induced induced by by the the activation activation of of the the pancreatic pancreatic enzymes enzymes derived derived from from various various causes.causes.EtiologyBiliary Biliary duct duct diseases:diseases:gallstone,gallstone,acute acute and and chronic chronic cholecystitis,cholecystitis,ascariasis ascariasis accompanied accompanied with with inflammatory inflammatory stricture stricture at at the the level level of of the the papilla.papilla.Common channel hypothesisCommon channel hypothesisAlcohol and/or square meal Alcohol and/or square meal hyperlipidemia hyperlipidemia Postoperation:post-ERCP,abdominal operation.Postoperation:post-ERCP,abdominal operation.EtiologyMetabolic Metabolic diseases:diseases:hyperparathyroidism,hyperparathyroidism,hypercalcemia,etc.hypercalcemia,etc.Drugs:Drugs:glucocorticords,glucocorticords,diuretics,diuretics,azathioprine,azathioprine,estrogen,etc.estrogen,etc.Autoimmune diseases:SLE,RA,vasculitis,etc.Autoimmune diseases:SLE,RA,vasculitis,etc.Viral infections:mumps,coxsackie virus,HIV,etcViral infections:mumps,coxsackie virus,HIV,etcIdiopathic pancreatitis.Idiopathic pancreatitis.Pathogenesistrypsinogen trypsintrypsinogen trypsintrypsin trypsin pancreatic pancreatic enzymes,enzymes,complement complement system and kinin system system and kinin system Pathophysiological Pathophysiological changes:changes:leukocyte leukocyte chemotaxis,chemotaxis,release release of of active active agents,agents,oxygenic oxygenic stress,stress,microcirculation microcirculation disorder disorder and bacteria transposal.and bacteria transposal.Trypsin Trypsin activates activates other other proenzymes proenzymes and and results results in in proteolysis,edema and vascular damageproteolysis,edema and vascular damage Lipase produces extrapancreatic fat necrosisLipase produces extrapancreatic fat necrosis Phospholipase Phospholipase degrades degrades the the lecithin lecithin into into the the lysolecithin lysolecithin which induces pancreatic necrosis and hemorrhage which induces pancreatic necrosis and hemorrhage Kallikrein and elastase cause vascular destructionKallikrein and elastase cause vascular destruction Bradykinin Bradykinin peptidase peptidase and and vasoactive vasoactive substance substance induce induce vasodilatation,increase vascular permeability and edemavasodilatation,increase vascular permeability and edema Cytokine,Cytokine,oxygen oxygen free free radicals,radicals,platelet platelet activating activating factor,factor,prostaglandins,prostaglandins,blood blood circulation circulation disturbance,disturbance,systemic systemic inflammation response syndrome(SIRS)inflammation response syndrome(SIRS)PathologyMild Mild formform (interstitial(interstitial or or edematous edematous pancreatitis)pancreatitis)focal or diffused edemafocal or diffused edemaslight leukocyte infiltrationslight leukocyte infiltrationSevere Severe formform (necrotic necrotic or or hemorrhagic hemorrhagic pancreatitispancreatitis)marked acinar destruction with hemorrhagemarked acinar destruction with hemorrhageextensive leukocyte infiltrationextensive leukocyte infiltrationnecrosis of parapancreatic fatnecrosis of parapancreatic fatgrossly grossly an an inflammatory inflammatory tumor-like tumor-like mass mass with with diffused hemorrhagic changediffused hemorrhagic changesecondary secondary infection infection induces induces the the formation formation of of abscess or pseudocystsabscess or pseudocystsSymptomsSymptoms abdominal abdominal pain:pain:located located in in epigastrium epigastrium and and radiates radiates to to the the back.back.The The lateral lateral kneel-chest kneel-chest position position with with the the neck neck flexedflexed may relieve the abdominal pain.may relieve the abdominal pain.Nausea,vomiting,abdominal distention:90%patientsNausea,vomiting,abdominal distention:90%patients Fever:Fever:low-grade low-grade fever fever in in mild mild pancreatitis;pancreatitis;high high fever fever suggests coexisting infection.suggests coexisting infection.Hypotension or shock:often in severe pancreatitisHypotension or shock:often in severe pancreatitisClinical manifestationsSignsMAP:MAP:signs are mild.Abdominal tenderness and signs are mild.Abdominal tenderness and diminished bowel sounds are present.diminished bowel sounds are present.SAP:SAP:peritoneal irritation sign peritoneal irritation sign bowel sounds are diminished or absent bowel sounds are diminished or absent ascites or shifting dullness ascites or shifting dullness Grey-Turner signGrey-Turner sign Cullen signCullen sign jaundicejaundice Pancreatic pseudocystPancreatic pseudocystComplicationsLocal complicationsLocal complicationsPseudocyst:occur 2 weeks after the onset.Pseudocyst:occur 2 weeks after the onset.Acute fluid collection:occur in the early stage.Acute fluid collection:occur in the early stage.Pancreatic abscess:after 4 weeks on the basis of Pancreatic abscess:after 4 weeks on the basis of pseudocystpseudocystPancreatic necrosis infection:usually after 2 weeksPancreatic necrosis infection:usually after 2 weeksSystemic complicationsARDSARDSacute renal failureacute renal failureheart failure and cardiac arrhythmiaheart failure and cardiac arrhythmiagastrointestinal bleedinggastrointestinal bleedingSepticemiaSepticemiadisorders of hemostasis:thrombosis,DIC.disorders of hemostasis:thrombosis,DIC.disorders of CNS:pancreatic encephalopathydisorders of CNS:pancreatic encephalopathyHyperglycemiaHyperglycemiadisorders of water,electrolytes and acid-base disorders of water,electrolytes and acid-base balancebalanceLaboratory Studiesblood count:leukocytes count is more than blood count:leukocytes count is more than 10,000/mm10,000/mm3 3Hematocrit(Hct):is high(over 50%)because of Hematocrit(Hct):is high(over 50%)because of loss of plasma into the retroperitoneal spaceloss of plasma into the retroperitoneal spaceAmylasenormal values of the serum amylase:normal values of the serum amylase:40 40 to to 180 180 Somogyi Somogyi units units or or 8 8 to to 64 64 Winslow Winslow units units over over 500 500 Somogyi Somogyi units units are are strongly strongly suggested suggested acute pancreatitis.acute pancreatitis.there there is is no no significant significant correlation correlation between between the the severity severity of of the the pancreatitis pancreatitis and and the the levels levels of of the the serum amylaseserum amylasenormal values of urinary amylase:normal values of urinary amylase:256 Winslow units 256 Winslow unitsover over 256 256 Winslow Winslow units units are are suggested suggested acute acute pancreatitispancreatitisFalse False positive positive amylase amylase elevation elevation in in serum serum or or urine urine may may occur occur in in many many conditions conditions other other than than pancreatitis,pancreatitis,such such as as the the other other acute acute abdominal abdominal diseasesdiseases,proximal proximal renal renal tubular tubular malfunction,malfunction,including including thermal thermal burns,burns,diabetic diabetic acidosis acidosis and and postoperative states or macroamylasemia.postoperative states or macroamylasemia.Serum lipaseSerum lipase serum serum lipase lipase levels levels increase increase parallel parallel with with amylase amylase within within 2472 2472 hours hours after after the the onset onset and and still still keep keep in in a a high high levels levels for for 7-10 7-10 days days even even the the serum amylase returns to normal.serum amylase returns to normal.Biochemical testBiochemical test Hypocalcemia Hypocalcemia Hyperglycemia Hyperglycemia Hyperbilirubinemia Hyperbilirubinemia Hypoxemia HypoxemiaImaging examinationX-ray:X-ray:Abdominal X-rayAbdominal X-ray sentinel loopsentinel loop colon cut-offcolon cut-offChest Chest X-ray:X-ray:may may reveal reveal the the complications complications of of lung lung such such as as pleural pleural effusion,effusion,pulmonary pulmonary edema edema and interstitial inflammation.and interstitial inflammation.UltrasonographyUltrasonographyIt It is is a a useful useful method method to to find find an an enlarged enlarged pancreas,pancreas,a a pseudocystpseudocyst,ascites,ascites,biliary biliary stone,stone,dilated dilated common common bile bile duct duct and and other other pancreatic pancreatic massmassCT&MRICT&MRI正常胰腺CT平扫肝右叶胰头肠管肾腹主动脉下腔静脉 胰腺体、尾部胆囊肝右叶脾肠管下腔静脉膈脚腹主动脉Normal pancreasNormal pancreasContrast CT showing pancreatic necrosisDiagnosis-criteriasymptoms:symptoms:acute,acute,severe severe constant constant epigastric epigastric pain.pain.Nausea and vomiting.Nausea and vomiting.Physical Physical examination:examination:epigastric epigastric tenderness tenderness with with or without rebound tenderness.or without rebound tenderness.Laboratory Laboratory studies:studies:elevated elevated serum serum amylase amylase(3(3 times of high limit of normal value)times of high limit of normal value)Imaging Imaging examinations:examinations:morphological morphological changes changes of of pancreas or notpancreas or notExcluding the other acute abdominal diseases.Excluding the other acute abdominal diseases.Clinical manifestationsClinical manifestationsScoring systems:APACHE-II,Scoring systems:APACHE-II,RansonRansonCT gradingCT gradingSerum biomarkers:CRP,IL-6Serum biomarkers:CRP,IL-6Diagnosis-evaluation of patients conditionDiagnosis-classificationMAP(mild acute pancreatitis):MAP(mild acute pancreatitis):Acute pancreatitisAcute pancreatitisNo dysfunction of organ or local complicationsNo dysfunction of organ or local complicationsRansons score 3Ransons score 3or APACHE-II 8or APACHE-II 8or CT grading:A,B,C or CTSI 2or CT grading:A,B,C or CTSI 3or Ransons score 3or APACHE-II 8or APACHE-II 8or CT grading:D,E or CTSI 3.or CT grading:D,E or CTSI 3.Differential diagnosisPerforated peptic ulcerPerforated peptic ulcerAcute calculous cholecystitisAcute calculous cholecystitisAcute ileusAcute ileusMesenteric vascular embolismMesenteric vascular embolismRupture of the spleenRupture of the spleenAcute appendicitisAcute appendicitisAngina pectorisAngina pectorisAcute myocardial infarctionAcute myocardial infarctionTherapy-MAPMAP Monitoring:should be monitored for at least 3 days.Monitoring:should be monitored for at least 3 days.Supportive treatment:volume repletion with crystalloids Supportive treatment:volume repletion with crystalloids and colloids to keep balance.and colloids to keep balance.Relieve severe pain:Dolantin is preferred over morphine.Relieve severe pain:Dolantin is preferred over morphine.inhibit excrine of the pancreas:inhibit excrine of the pancreas:No oral alimentation and continuous nasogastric suction No oral alimentation and continuous nasogastric suction H H2 2RA or PPIRA or PPI Somatostatin and its long-acting analogue(Sandostatin)Somatostatin and its long-acting analogue(Sandostatin)Antibiotics is required especially in infection of biliary Antibiotics is required especially in infection of biliary duct.duct.Therapy-SAPSAPMonitoringMonitoringNutritional support:Nutritional support:parenteral nutritionenteral nutrition parenteral nutritionenteral nutrition maintain balance of water,electrolytes and acid-base.maintain balance of water,electrolytes and acid-base.essential diet essential dietPrevention of infection:Prevention of infection:oral antibiotics oral antibiotics intravenous infusion of antibiotics intravenous infusion of antibiotics enteral feeding enteral feedinginhibit excrine of pancreas and pancreatic enzymes:inhibit excrine of pancreas and pancreatic enzymes:No oral alimentation and continuous nasogastric suction No oral alimentation and continuous nasogastric suction H H2 2RA or PPIRA or PPI Somatostatin and its long-acting analogue(Sandostatin)Somatostatin and its long-acting analogue(Sandostatin)protease inhibitors:gabexate,aprotinin,etc.protease inhibitors:gabexate,aprotinin,etc.Prevention and treatment of enteral failurePrevention and treatment of enteral failure oral antibiotics oral antibiotics enteral microecological preparations enteral microecological preparations glutamine glutamine enteral feeding enteral feedingTreatment of multiple organs failureTreatment of multiple organs failureTraditional Chinese medicine:Traditional Chinese medicine:生大黄、清胰汤生大黄、清胰汤Endoscopic therapy:ERCP+EST+ENBDEndoscopic therapy:ERCP+EST+ENBDSurgical operation:indicationsSurgical operation:indications necrotic pancreatitis with infection necrotic pancreatitis with infection pancreatic abscess pancreatic abscess early severe acute pancreatitis(ESAP)early severe acute pancreatitis(ESAP)abdominal compartment syndrome(ACS)abdominal compartment syndrome(ACS)pancreatic pseudocyst:6cm pancreatic pseudocyst:6cm diagnosis remain unclear and GI perforation is suggested diagnosis remain unclear and GI perforation is suggestedEmerging drugs:Emerging drugs:CCK receptor antagonist:loxiglumide CCK receptor antagonist:loxiglumide Prostaglandins:PGE Prostaglandins:PGE1 1 Platelet activating factor(PAF)antagonist Platelet activating factor(PAF)antagonist TNF monoclonal antibody:Infliximab TNF monoclonal antibody:Infliximab prognosisMAP:goodMAP:goodSAP:poor.1030%mortalitySAP:poor.1030%mortalityRisk Risk factors:factors:age,age,hypotension,hypotension,hypoalbuminemia,hypoalbuminemia,hypoxemia,hypoxemia,hypocalcemia,hypocalcemia,miscellaneous complications.miscellaneous complications.QuestionsWhat What are are the the clinical clinical manifestations manifestations of of acute acute pancreatitis?pancreatitis?What What is is the the diagnostic diagnostic key key points points of of acute acute pancreatitis?pancreatitis?What is the therapy of acute pancreatitis?What is the therapy of acute pancreatitis?necrotic pancreatitisGrey-Turner signCullen signjaundicePseudocyst of pancreasSentinel loopColon cut-off sign.Supine abdominal radiograph obtained in a patient with acute pancreatitis shows an abrupt termination of air in the left side of the transverse colon(arrows).Pseudocyst of pancreasEdematous pancreasOn admission:On admission:Age 55 Age 55 Leukocyte count 16,000/mm Leukocyte count 16,000/mm3 3 Blood glucose 11mmol/L Blood glucose 11mmol/L LDH 350 IU/L LDH 350 IU/L AST 250 AST 250After 48 hours:After 48 hours:Hct decrease 10%Hct decrease 10%BUN rise 5 mmol/L BUN rise 5 mmol/L Serum calcium 2 mmol/L Serum calcium 2 mmol/L PaO PaO2 2 60mmHg 4mmol/L Base deficit 4mmol/L Estimated flui