1、重新認識犬胰腺炎History 病史 Signalment 臨床表現 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 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 Diet Vomiting飲食情況嘔吐 History of pancreatitis胰腺炎病史Diarrhea腹瀉Knowing the LIMITATIONS of atest or p

2、rocedure is often muchmore important than knowingwhat a procedure can do了解某項檢查或操作的局限性比了解某項操作的作用更為重要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 absces

3、ses發熱皮下膿腫147033 14719890524159796PCVWBCSegsBands28.530,00026,10090028.845,50033,6702,730309,8004,6062,4504011,5009,8900Plat87,000407,000 679,000 470,000Toxicmodmodnonenone147033 14719890524159796PCVWBCSegsBands28.530,00026,10090028.845,50033,6702,730309,8004,6062,4504011,5009,8900Plat87,000407,000 6

4、79,000 470,000ToxicmodmodnonenoneClinical Pathology臨床病理學 An anorexic, vomiting dog withfasting hyperlipidemia probably hasacute pancreatitis患犬厭食、嘔吐，突然出現高脂血癥可能患有急性胰腺炎Clinical Pathology臨床病理學 cPLI Sensitivity 80-85%敏感性 80-85%TAMU#203505Sig: 14 yr M(n) Shih Tzu 14歲 雄性已去勢 西施犬CC:Abdominal pain前腹部疼痛HPI: Pa

5、in 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,- 5

6、00,000)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)PANCREATITISversusCLINICALLY IMPORTANTPANCREATITIS胰腺炎和臨床

7、上需重視的胰腺炎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%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% Because clinicians rarely repeat theultrasound因為臨床醫師很少重復進行超聲檢查Diagnostics cPLI Sen

8、sitivity 80%敏感性-80% Abdominal ultrasound 腹部超聲檢查 Sensitivity 40% - 65% 敏感性 40% - 65% Findings can change within hours .檢查結果數小時內就可能發生變化WHAT IS THE BEST WAYTO DIAGNOSE CANINEACUTE PANCREATITIS?診斷犬急性胰腺炎最好的方法是Be willing to repeatultrasound重復進行超聲檢查All things being equal, tryto avoid surgery平衡一切，盡量避免手術TAMU

9、#88267Sig: 7 yr M SheltieCC: VomitingHPI: Began 5 weeks ago7歲 雄性 喜樂蒂嘔吐五周前開始PE:Partial anorexia, vomits phlegm orbile once daily有時厭食，嘔吐黏液或膽汁，每日一次Dog otherwise pretty healthy其他方面無異常No significant abnormalities 未見明顯異常TAMU#159796Sig: 9 yr M(c) Pug9歲 雄性去勢 巴哥犬CC: Vomiting, yellow scleras 嘔吐，鞏膜發黃HPI: Feeli

10、ng bad 12 days ago 12天前狀態不佳Started vomiting, responded tofluid therapy, but became illagain when started feeding it開始嘔吐后，液體療法有效，但恢復進食后病情反復Dogs eyes turned yellow 患犬眼部發黃TAMU#159796PCV =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 Albu

11、min =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 #152494Sig: 9 yr F(s) DalmationCC: Vomiting/diarrhea9歲 雌性絕育 大麥町嘔吐/腹瀉HPI: Vomiting food/bile 6-8X in 2 weeks2周內嘔吐食物/膽汁6-8次Diarrhea constant for 2 weeks持續腹瀉2周時間Decreased appetite

12、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)桿狀中性粒細胞Lymphs = 1,400/ul (1,-4,000)淋巴細胞Platelets =568,000/ul (200,-500,000)TAMU #152494鈉鉀葡萄糖白蛋白肌酐Sodium =Potassium =Glu

13、cose =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回聲液體TA

14、MU #152494Abdominal fluid: 腹腔積液WBC =RBC =153,000/ul0/ulTotal protein =4.6 gm/dl總蛋白90% nondegenerate neutrophils非退行性中性粒細胞8% macrophages, vaculated巨噬細胞，空泡化Sterile pancreatitis無菌性胰腺炎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 70

15、018,200RBC/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:胰腺炎時可能：a) make no abdominal effusion無腹腔積液b) make a little abdominal effusion產生少量腹腔積液c) make a massive abdominal effusionPancreat

16、itis can present as:胰腺炎可表現為： 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 (loo

17、ks like septic shock)SIRS（癥狀類似敗血性休克）SYSTEMIC INFLAMMATORYRESPONSE SYNDROME全身性炎癥反應綜合征 used to be called “Septicshock” 曾被稱為“敗血性休克”SYSTEMIC INFLAMMATORYRESPONSE SYNDROME全身性炎癥反應綜合征 inadequate perfusion of the body tissuesbecause of an exaggerated inflammatoryresponse劇烈的炎癥反應導致機體組織灌注不良WHAT IS SUPPOSED TOH

18、APPEN 認為會發生什么Bacterial toxin, inflammatory cytokines細菌毒素，炎性細胞因子Lymph nodes, hepatic macrophages淋巴結，肝臟巨噬細胞Systemic circulation全身循環WHAT IS SUPPOSED TOHAPPEN 認為會發生什么Bacterial toxin, inflammatory cytokines細菌毒素，炎性細胞因子Lymph nodes, hepatic macrophages淋巴結，肝臟巨噬細胞Systemic circulation全身循環Inflammatory cytokines

19、Lymph nodes 淋巴結Systemiccirculation全身循環WHAT CAN HAPPEN會發生什么炎性細胞因子EARLY SIRSMild uneven vasodilatation 輕度部分血管擴張“High output” shock 高輸出性休克Bright red mucus membranes 黏膜鮮紅Fast capillary refill time 毛細血管再充盈時間短Bounding pulsesTachycardia脈搏跳躍（洪脈）心動過速LATE SIRSSevere peripheral vasodilatation + poorcardiac con

20、tractility嚴重的外周血管擴張+ 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 毛細血管再充盈時間延長THERAPY FOR PANCREATITIS胰腺炎的治療Only supportive and symptomatic僅用支持療法和對癥治療 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 foo

21、deven 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只要動物病情沒有惡化，便繼續飼喂THERAPY FOR PANCREATITIS胰腺炎的治療Only supportive and symptomatic僅用支持療法和對癥治療 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僅用支持療法和對癥

22、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 everyones 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Plasma

23、Colloids血漿膠體液Total/partial parenteral nutrition完全/部分腸外營養支持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僅用支持療法和對癥治療 Early Feeding 早期飼喂 Fluid therapy液體療法Crystalloids 晶體液PlasmaColloidsNutrition Analgesics血漿膠體液營養鎮痛劑THERAPY FOR PANCREATITIS胰腺炎的治療Only supportive and symptomatic Early Fee