華西醫(yī)院中西醫(yī)結(jié)合科ClinicalManagementofPatientsWithAcutePancreatitisGASTROENTEROLOGYMAY2013;144:1272–12811CenterforPancreaticCare,SouthernCaliforniaPermanenteMedicalGroup,DepartmentofGastroenterology,KaiserPermanenteLosAngelesMedicalCenter,LosAngeles,California（南加州,凱薩醫(yī)療機(jī)構(gòu)）;

and2CenterforPancreaticDisease,DivisionofGastroenterology,HepatologyandEndoscopy,BrighamandWomen’sHospital,HarvardMedicalSchool,Boston,Massachusetts（波士頓，哈佛醫(yī)學(xué)院)Keywords:ClinicalManagement;FluidResuscitation;Necrosis;QualityImprovement.Abstract

AcutepancreatitisistheleadingcauseofhospitalizationforgastrointestinaldisordersintheUS,withmorethan280,000hospitalizationseachyear.TheaveragelengthofstayatUShospitalsin2010wasestimatedtobe5days,atanaggregatecostof$2.9billion.

高發(fā)病率；平均住院時(shí)間：5天；治療費(fèi)用高昂

Mortalityrangesfrom3%forpatientswithinterstitial(edematous)pancreatitisto15%forpatientswhodevelopnecrosis.

死亡率：3%（間質(zhì)水腫性AP）-15%(壞死性AP)Astherateofhospitalizationforacutepancreatitiscontinuestoincrease,sodoesthedemandforeffectivemanagement.Thisdemandhasresultedinpublicationofatleast14clinicalpracticeguidelinesinthepastdecade.AnupdatetotheAmericanPancreasAssociationandInternationalAssociationofPancreatologyguidelinesisforthcoming.

急性胰腺炎診治指南需進(jìn)一步規(guī)范1.PeeryAF,DellonES,LundJ,etal.BurdenofgastrointestinaldiseaseintheUnitedStates:2012update.Gastroenterology2012;143:1179–1187.2.SinghVK,BollenTL,WuBU,etal.Anassessmentoftheseverityofinterstitialpancreatitis.ClinGastroenterolHepatol2011;9:1098–1103.3.vanSantvoortHC,BakkerOJ,BollenTL,etal.Aconservativeandminimallyinvasiveapproachtonecrotizingpancreatitisimprovesoutcome.Gastroenterology2011;141:1254–1263ContentsDiagnosis1RiskandPrognosticFactors

2Treatment3Prevention4DiagnosisThediagnosisofacutepancreatitisrequiresatleast2ofthefollowing:

1.typicalupperabdominalpain

典型的上腹部疼痛

2.serumlevelsofamylaseorlipase>3timestheupperlimitofnormal,

胰腺酶水平>3倍正常值的上限3.con?rmatory?ndingsfromcrosssectionalimaginganalysis.

影像學(xué)支持ArecentlycompletedrevisionoftheAtlantaClassi?cationprovidesamoredetailedsystemthatemphasizesdiseaseseverityandincludescomprehensivede?nitionsofpancreaticandperipancreaticcollections.Therearealsomorecompletede?nitionsoflocalandsystemiccomplications.DiseaseDe?nitions:TheRevisedAtlantaClassi?cation

TheAtlantaClassi?cationsystemwasdevelopedataconsensusconferencein1992toestablishstandardde?nitionsforclassi?cationofacutepancreatitis.

最新修訂版的亞特蘭大分類標(biāo)準(zhǔn)提供了一個(gè)更加詳細(xì)的分類標(biāo)準(zhǔn)，它著重于疾病的嚴(yán)重程度，及包括胰腺和胰周液體聚集的綜合定義，而有更加完整的局部及系統(tǒng)性并發(fā)癥的定義。12.BanksPA,BollenTL,DervenisC,etal.Classi?cationofacutepancreatitis—2012:revisionoftheAtlantaclassi?cationandde?nitionsbyinternationalconsensus.Gut2013;62:102–111.13.MarshallJC,CookDJ,ChristouNV,etal.Multipleorgandysfunctionscore:areliabledescriptorofacomplexclinicaloutcome.CritCareMed1995;23:1638–1652.123De?nitionofLocalComplications

局部并發(fā)癥的定義

De?nitionofSystemicComplicationsandOrganFailure

全身并發(fā)癥及器官衰竭的定義De?nitionofSeverity嚴(yán)重程度分類4RolesofAdvancedImagingTechniques

影像學(xué)的作用

Diagnosis間質(zhì)水腫性胰腺炎De?nitionofLocalComplications急性胰腺炎急性胰周液體積聚（APFC）胰腺假性囊腫壞死性胰腺炎急性壞死物積聚（ANC）包裹性壞死（WON）

Avarietyoflocalcomplicationshavebeendelineated.Interstitialpancreatitisinvolvesacutecollectionofperipancreatic?uid（ACPF）andformationofpancreaticpseudocysts.

間質(zhì)水腫性胰腺炎涉及急性胰周液體積聚和胰腺假性囊腫的形成

APFCdevelopduringtheearlyphase早期ofinterstitialpancreatitis.Theyarehomogeneous

inappearancewithoutawell-de?nedwall,usuallyremainsterile,andfrequentlyresolve

spontaneously(FigureA).

急性胰周液體積聚（APFC）發(fā)生胰腺炎病程早期，滲出液均勻地而邊界模糊地分布于胰周，通常是無菌的，可以自行吸收Ifanacuteperipancreatic?uidcollectiondoesnotresolvespontaneously,itcoulddevelopintoapseudocystwithawellde?nedin?ammatorywallthatcontains?uidwithverylittle,ifany,solidmaterial(FigureB).

如果一旦胰周積液不能自行吸收，它將可能發(fā)展為有完整炎癥性包膜容納少量滲出液及極少量壞死組織的假性囊腫(發(fā)生AP后4周)間質(zhì)水腫性胰腺炎Figure(A)Interstitialpancreatitiswithacuteperipancreatic?uidcollection.Peripancreatic?uidcollection(arrows)ispoorlyde?nedwithhomogeneous?uiddensity.Figure(B)Resolvinginterstitialpancreatitiswithpseudocyst.Apseudocyst(arrow)istypicallyaroundorovalencapsulatedcollectionwithhomogeneous?uiddensity.急性胰周液體積聚（APFC）胰腺假性囊腫

Necrotizingpancreatitisinvolvesacutecollectionofnecrosisandwalled-offnecrosis.壞死性胰腺炎包括急性壞死物積聚（ANC）及包裹性壞死（WON）。

Anacutenecroticcollectionreferstothepresenceofnecrotictissueinvolvingpancreaticparenchymaandperipancreatictissues

(Figure2).Thesecollectionscanbesterileorinfected.Ifinfected,theyarecalledinfectednecrosis.急性壞死物積聚（ANC）指的是胰腺實(shí)質(zhì)及胰周組織的壞死（如表格2），壞死物的積聚可是無菌性和感染性，其中感染性的又叫感染壞死。After4ormoreweeks,anacutenecroticcollectioncanbecomesmallerbutrarelydisappearscompletelyandusuallyevolvesintowalled-offnecrosis.Walled-offnecrosishasawell-de?nedin?ammatorywallthatcontainsvaryingamountsof?uidandnecroticdebris(Figure3).在4周及之后，急性壞死物的積聚逐漸變小，但很少有被完全吸收，通常發(fā)展為有炎癥性包膜容納混合大量滲出液及少量壞死物碎片的包裹性壞死（WON）（如表格3）。Figure2.Pancreaticandperipancreaticnecrosis.Thisimageshowsanacutenecroticcollectioninvolvingboththepancreas(largearrow)andperipancreatictissue.

Figure3.Walled-offpancreaticnecrosisisanencapsulatedcollectionofnecrosis.Thistypeofcollectiontypicallyforms4to6weeksafterdiseaseonset.Thisimageshowspancreaticandperipancreaticnecrosis.壞死性胰腺炎急性壞死物積聚（ANC）包裹性壞死（WON）De?nitionofSystemicComplicationsandOrganFailureIntherevisedAtlantaClassi?cation,systemiccomplicationsarede?nedasexacerbationsofpreexistingcomorbiditiessuchaschroniclungdisease,chronicliverdisease,orcongestiveheartfailure,recognizingthefailureofrespiratory,cardiovascular,andrenalorgansystems.在修訂版的亞特蘭大分類標(biāo)準(zhǔn)，全身并發(fā)癥被定義為，先前存在的疾病諸如慢性肺部疾病、慢性肝病、充血性心力衰竭等的突然惡化，這些被認(rèn)為是呼吸系統(tǒng)、心血管系統(tǒng)、腎臟功能系統(tǒng)的損害加重而衰竭。De?nitionofSystemicComplicationsandOrganFailure

Thescoringsystemthathasbeenchosentocharacterizeorganfailureisthemodi?edMarshallscoringsystem.Themodi?edMarshallsystemclassi?esdiseaseseverityonascalefrom0to4,sothattheoverallevaluation

oforgandysfunctioncanbemorecompletelydelineatedandcharacterizedovertime.Inthissystem,organfailureisde?nedbyascoreof≥2foroneormoreoftheseorgansystems.改良的馬歇爾評分系統(tǒng)用于器官衰竭的評分，該評分系統(tǒng)將急性胰腺炎的嚴(yán)重程度分為0—4級，以至于更能清晰及特征性地對器官功能障礙發(fā)展進(jìn)行綜合評價(jià)。在該評分系統(tǒng)中，器官衰竭定義為有任何1個(gè)及多個(gè)器官功能評分≥

2分。13.MarshallJC,CookDJ,ChristouNV,etal.Multipleorgandysfunctionscore:areliabledescriptorofacomplexclinicaloutcome.CritCareMed1995;23:1638–1652.De?nitionofSeverityMAPMilddisease

isde?nedasacutepancreatitisnotassociatedwithorganfailure,localorsystemiccomplications.無器官衰竭、無局部或全身并發(fā)癥MSAPpresenceoftransientorganfailure(presentfor<48hours),localorsystemiccomplications.一過性器官衰竭（<48h）伴有局部或全身并發(fā)癥SAPpresenceofpersistentorganfailure(presentfor>48hours).Mostpatientswithpersistentorganfailurehavepancreaticnecrosis.持續(xù)性器官衰竭（>48h）,多伴有胰腺壞死Mostpatientswithmildacutepancreatitisdonotrequirepancreaticimaginganalysisandareusuallydischargedwithin3to5daysofonsetofillness.

輕型急性胰腺炎患者無需影像學(xué)檢查，住院時(shí)間通常為3-5天

Patientswithmoderatelysevereacutepancreatitisfrequentlyrequireextendedhospitalizationbuthavelowermortalityratesthanpatientswithsevereacutepancreatitis.

中度重癥急性胰腺炎需延長住院時(shí)間，但病死率低于重癥急性胰腺炎15.PetrovMS,ShanbhagS,ChakrabortyM,etal.Organfailureandinfectionofpancreaticnecrosisasdeterminantsofmortalityinpatientswithacutepancreatitis.Gastroenterology2010;139:813–820.RolesofAdvancedImagingTechniquesTheroleofCTinassessingpatientswithacutepancreatitishaschangedwithtime.CT的作用是用于評價(jià)急性胰腺炎發(fā)病及治療各階段的變化Acontrast-enhancedCTscanobtainedwithinthe?rstseveraldaysofillnesscannotbeusedtodeterminewhetherapatienthasnecrotizingorsevereinterstitialpancreatitis.Thismightbebecauseintrapancreatic?uidcausesheterogeneousenhancement,whichcanindicatenecrosis.在發(fā)病的前幾天，不能通過CT檢查判斷出胰腺壞死的存在及其范圍，這可能是由于胰腺內(nèi)液體滲出導(dǎo)致了CT的不均勻增強(qiáng)。

Overaperiodofseveraldays,the?uidcanbereabsorbedsuchthatasubsequentCTscanclearlyshowstheabsenceofnecrosis.Assuch,patientsshouldnotbeevaluatedbyCTwithinafewdaysaftertheonsetofdiseasetoestablishthepresenceorextentofpancreaticnecrosis.胰腺積液被重吸收后，后來的CT檢查才能夠區(qū)分液體積聚或胰腺壞死范圍。

Thebestuseofanearly-stageCTscanistocon?rmadiagnosisofacutepancreatitiswhentheclinicalsituation

isunclear.

發(fā)病早期行CT檢查僅能用于診斷不明時(shí)，以確診急性胰腺炎。ThebestuseofaCTscanafterthe?rst5to7daysistoevaluatethepresenceoflocalcomplicationsinpatientswithmoderatelysevereorseverepancreatitistoguideongoingcare.

發(fā)病的第一個(gè)5-7天后行CT檢查最大好處，用以評價(jià)中度重癥急性胰腺炎或重癥急性胰腺炎病人的局部并發(fā)癥，并指導(dǎo)治療。MRCPhasbecomeausefulprocedureforidentifyingretainedcommonbileductstones.

SelectiveuseofMRCPcanreducetheneedforERCPforpatientswithsuspectedgallstonepancreatitis.

MRCP對膽管結(jié)石敏感，能夠減少因懷疑為膽源性胰腺炎而行ERCP檢查。MRI

ishelpfulindistinguishingwalled-offnecrosisfromapseudocyst.Forexample,inwalled-offnecrosis,therearevariableamountsof?uidandsoliddebristhatcanbevisualizedusingT2-weightedimaging.MRI能用于鑒別是包裹性壞死（WON）或是胰腺假性囊腫，因?yàn)門2加權(quán)像能很直觀地看出含有大量滲液體及固體壞死物的包裹性壞死。

Endoscopicultrasonographyisahighlysensitivetestfordetectingcholelithiasisandcholedocholithiasis.19ItcouldbeanalternativetoMRCP,whichhaslimitedaccuracyfordetectingsmallergallstonesorsludge.超聲內(nèi)鏡對膽石病高度敏感，可以代替對細(xì)小結(jié)石或淤泥樣膽汁不敏感的MRCP檢查。123PrognosticFactors預(yù)后因素RiskandPrognosticFactorsClinicalscoringsystems

臨床系統(tǒng)性評分Riskfactors危險(xiǎn)因素Riskfactors

AgeObesity

RiskfactorsAP？ComorbidillnessesAlcohol60yearsofageoroldercancer,heartfailure,andchronickidneyandliverdiseaseBMI>30kg/m2chronicalcoholconsumptionincreasestheriskofseverepancreatitis3-foldandmortality2-foldClinicalscoringsystems

Theinitial12to24hoursofhospitalizationiscriticalduringpatientmanagement,becausethehighestincidenceoforgandysfunctionoccursduringthisperiod.

發(fā)病第12-24h是臨床處理非常重要，器官功能障礙多發(fā)生于這個(gè)時(shí)段。Anumberofclinicalscoringsystemsandbiomarkers

havebeendevelopedtofacilitateriskstrati?cation

duringthisphase.WhereaspreviousscoringsystemssuchastheRansonorImrie–Glasgowscoresrequired48hourstocomplete,2scoringsystemswererecentlydevelopedandinvolveasimpli?edapproachthatcanbeperformedduringthe?rst24hoursofhospitalization——TheBedsideIndexofSeverityinAcutePancreatitis.

Ranson評分系統(tǒng)、Imrie–Glasgow評分系統(tǒng)對疾病的危險(xiǎn)分層評分滯后，最新的AP嚴(yán)重程度床旁指數(shù)（BISAP）可在發(fā)病24h內(nèi)完成。26.HarrisonDA,D’AmicoG,SingerM.Casemix,outcome,andactivityforadmissionstoUKcriticalcareunitswithsevereacutepancreatitis:asecondaryanalysisoftheICNARCCaseMixProgrammeDatabase.CritCare2007;11(Suppl1):S1.27.WuBU,ConwellDL.Updateinacutepancreatitis.CurrGastroenterolRep2010;12:83–90.ClinicalscoringsystemsAP嚴(yán)重程度床旁指數(shù)BUN>25mg/dl(8.9mmol/L)Impairedmentalstatus精神狀態(tài)受損SIRSage60yearsorolderpleuraleffusion胸腔積液Score>2within24hoursisassociatedwitha7-foldincreaseinriskoforganfailureand10-foldincreaseinriskofmortality.發(fā)病24小時(shí)內(nèi)分?jǐn)?shù)>2分，發(fā)生器官衰竭的風(fēng)險(xiǎn)增加7倍，死亡的風(fēng)險(xiǎn)增加10倍。

Anotherscoringsystem,theHarmlessAcutePancreatitisScore,usesadifferentapproachtoriskstrati?cation,identifyingpatientsatthetimeofadmissionwhoareunlikelytoexperiencecomplicationsrelatedtoacutepancreatitis.Speci?cally,patientswithanormalhematocrit

andnormalserumlevelofcreatininewithoutreboundtenderness

orguarding,areunlikelytodevelopseverepancreatitis(positivepredictivevalueof98%).

輕癥急性胰腺炎評分（HAPS）則注重于在入院時(shí)不會發(fā)生與急性胰腺炎相關(guān)并發(fā)癥的病人的評分，特別是Hct、Cre正常，無反跳痛體征的病人，將不再發(fā)展為重癥急性胰腺炎（陽性率高達(dá)98%）。Withrespecttoscoringsystems,themostwidelyvalidatedremainstheAcutePhysiologyandChronicHealthExaminationIIscore.Thesescoringsystemshavecomparablelevelsofoverallaccuracy.

最受到廣泛認(rèn)同的評分系統(tǒng)為急性生理功能和慢性健康狀況評分系統(tǒng)

(APACHEII)，

這些評分系統(tǒng)具有相當(dāng)?shù)乃降恼w精度。PrognosticFactorsAdditionalapproacheshavebeendevelopedtomonitor

diseaseprogression.Parametersthatareeasytodetermineandhavebeenvalidatedfortheirabilitytodeterminediseaseactivity

includethepresenceofSIRS,levelofBUNorCr,andhematocrit.

SIRS、尿素氮水平、肌酐水平、紅細(xì)胞壓積的參數(shù)，用于監(jiān)測疾病的進(jìn)展。

ProspectivestudieshaveshownthatthelevelofBUNatadmissionandduringtheinitial24hoursofhospitalizationisastrongprognosticfactor.Forexample,patientswithalevelofBUNatadmission>20mg/dLthatincreasedduringtheinitial24hourshave9%to20%mortality.Bycontrast,patientswithanincreasedlevelofBUNatadmissionthatdecreasedatleast5mg/dLwithin24hourshave0%to3%mortality.入院時(shí)及入院后24小時(shí)內(nèi)BUN水平的高低是一個(gè)非常重要的預(yù)后因素。例如，入院時(shí)患者BUN>20mg/dL（7.14mmol/L），在發(fā)病最初24小時(shí)內(nèi)可增加9%-20%的病死率，相反，高BUN水平在入院后24小時(shí)內(nèi)至少下降5mg/dL(1.8mmol/L)則有0%-3%病死率。38.WuBU,BakkerOJ,PapachristouGI,etal.Bloodureanitrogenintheearlyassessmentofacutepancreatitis:aninternationalvalidationstudy.ArchInternMed2011;171:669–676.39.WuBU,JohannesRS,SunX,etal.Earlychangesinbloodureanitrogenpredictmortalityinacutepancreatitis.Gastroenterology2009;137:129–135.全身炎癥反應(yīng)綜合征(SIRS)

2ormoreofthefollowingcriteriaT>38.3°C

或<36°C脈搏>90次/分WBC>12×10^9/L或<4×10^9/L不成熟白細(xì)胞比例>10%呼吸>20次/分

AserumlevelofCr>1.8mg/dL（159umol/L）withinthe?rst24hoursofhospitalizationisassociatedwitha35-foldincreasedriskofdevelopmentofpancreaticnecrosis.ApersistentincreaseinHCT>44%hasalsobeenshowntoincreasetheriskofnecrosisandorganfailure.

研究表明，在發(fā)病的最初的24小時(shí)內(nèi)血肌酐>1.8mg/dL，發(fā)展為胰腺壞死的風(fēng)險(xiǎn)增加35倍紅細(xì)胞壓積持續(xù)>44%也同樣增加了胰腺壞死及器官衰竭的風(fēng)險(xiǎn)。33.MuddanaV,WhitcombDC,KhalidA,etal.Elevatedserumcreatinineasamarkerofpancreaticnecrosisinacutepancreatitis.AmJGastroenterol2009;104:164–170.34.BrownA,OravJ,BanksPA.Hemoconcentrationisanearlymarkerfororganfailureandnecrotizingpancreatitis.Pancreas2000;20:367–372.Treatment123InitialResuscitationandManagement早期治療

ManagementofLocalComplications

局部并發(fā)癥的治療ManagementofExtrapancreaticComplications

胰腺外并發(fā)癥的治療

4SpecialConsiderationsBasedonEtiology對因治療

InitialResuscitationandManagement

Aggressivevolumeresuscitationhasbeenacornerstoneoftherapy,basedonstudiesinanimalmodelsandobservationaldatafromclinicalstudies.However,approachesto?uidresuscitationrequireoptimization.

Under-resuscitationduringtheearlyphaseofacutepancreatitishasbeenassociatedwithincreasedriskofnecrosisandmortality.Incontrast,over-resuscitationcanleadtocomplicationssuchaspulmonarysequestration（肺隔離癥）.

積極的容量復(fù)蘇已經(jīng)成為治療的里程碑，疾病早期液體復(fù)蘇的容量不足會增加胰腺壞死及死亡的風(fēng)險(xiǎn)，相反，如過度補(bǔ)液可能導(dǎo)致諸如肺隔離癥的并發(fā)癥，制定最優(yōu)化液體復(fù)蘇方案很重要。44.de-MadariaE,Soler-SalaG,Sanchez-PayaJ,etal.In?uenceof?uidtherapyontheprognosisofacutepancreatitis:aprospectivecohortstudy.AmJGastroenterol2011;106:1843–1850.45.MaoEQ,FeiJ,PengYB,etal.Rapidhemodilutionisassociatedwithincreasedsepsisandmortalityamongpatientswithsevereacutepancreatitis.ChinMedJ2010;123:1639–1644.NO.1InitialResuscitationInitialResuscitationandManagementAprospective,randomized,controlledtrialassessedtheeffectsofbolusinfusionof20mL/kgintheemergencydepartment,followedbycontinuousinfusionof3mL·kg-1·h-1,withintervalassessmentevery6to8hours(comprisingvitalsignmonitoring,pulseoximetry,

andphysicalexamination).RepeatvolumechallengewasadministeredifthelevelofBUNdidnotdecrease.Alternatively,iftheBUNleveldecreased,therateoftheinfusionwasreducedto1.5mL·kg-1·h-1.Thisapproachwasfoundtobesafeandfeasibleinanacutecaresetting.

研究表明，在急診科按20mL/kg進(jìn)行開始補(bǔ)液，隨后按3mL·kg-1·h-1的速度進(jìn)行持續(xù)補(bǔ)液，每間隔6-8小時(shí)進(jìn)行病情評估（包括生命體征、血氧飽和度、身體狀況）：如果BUN水平?jīng)]有下降，需反復(fù)地補(bǔ)液；相反，如果BUN水平下降了，則補(bǔ)液速度減少至1.5mL·kg-1·h-1，最后證明此治療方案在急診治療中是安全可行的。

Ingeneral,patientsundergoingvolumeresuscitationshouldhavetheheadofthebedelevated,undergocontinuouspulseoximetry,andreceivesupplementaloxygen.

患者進(jìn)行液體復(fù)蘇時(shí)，需抬高床頭，持續(xù)的血氧飽和度監(jiān)測及吸氧。

LactatedRinger’ssolutionreducestheincidenceofSIRSby>80%comparedwithsaline.Nevertheless,LR’ssolutionisareasonablechoiceforinitialresuscitation,basedonitspositiveeffectsonacid-basehomeostasis,comparedwithlarge-volumesalineresuscitation.BecauselactatedRinger’ssolutioncontainscalcium,itshouldnotbeadministeredinquantitytopatientswithhypercalcemia.

與用生理鹽水復(fù)蘇相比，乳酸林格氏液能減少80%的SIRS發(fā)生，乳酸林格氏液對維持酸堿平衡有積極的影響，更加適用于早期的液體復(fù)蘇，

高鈣血癥患者慎用。

Volumeexpansionwithcolloidhasnotbeenshowntobemoreeffectivethanwithcrystalloidsincriticallyillpatients.

對于危重病人，使用膠體液擴(kuò)容的益處并不多于使用晶體液。NO.2IndicationsforIntensiveCare

重癥監(jiān)護(hù)的適應(yīng)癥Respiratoryfailureisthemostcommonformoforgandysfunction.Patientswithsignsofrespiratoryfailureorhypotensionthatfailtorespondtoinitialresuscitationshouldbeconsideredfordirectadmissiontoanintensivecareunit（ICU）.

呼吸衰竭是最常見的器官功能障礙，病人因?yàn)闆]有進(jìn)行早期的液體復(fù)蘇，而出現(xiàn)了呼吸衰竭或低血壓的跡象，可以直接送至ICU。Patientswithmultiorgandysfunctionareatthegreatestriskfordeathandshouldbemanagedinacriticalcaresettingwithamultidisciplinarycareteam.存在多器官功能障礙是最重要的死亡因素，必須成立多由學(xué)科治療團(tuán)隊(duì)組成的特別治療組進(jìn)行臨床管理及診治。Inaddition,patientswithpersistentSIRS,increasedlevelsofBUNorcreatinine,increasedhematocrit,orunderlyingcardiacorpulmonaryillnessshouldstronglybeconsideredformanagementinamonitoredsetting.另外，對有持續(xù)性SIRS、BUN水平升高、HCT升高或潛在的心肺疾病的病人，需在有監(jiān)控設(shè)置下進(jìn)行管理及治療。NO.3IndicationsforTransfer轉(zhuǎn)院指征NO.4Analgesia鎮(zhèn)痛Effectiveanalgesiashouldbeapriorityincaringforpatientswithacutepancreatitis.Despiteitsimportance,strategiestomanagepaininpatientswithacutepancreatitisareunderstudied.

急性胰腺炎病人需要優(yōu)先給予有效地鎮(zhèn)痛，

盡管重要，但對急性胰腺炎患者的鎮(zhèn)痛管理策略還在研究中。Werecommendacomprehensivepainmanagementapproachthatincludespatienteducation,collectingpatients’historiesofchronicpain,andusingvalidatedpaininstrumentstoassesspainrelief.

推薦采用綜合的疼痛管理方法，包括病人教育、收集病人慢性疼痛病史、使用有效的鎮(zhèn)痛儀器，以評價(jià)疼痛緩解情況。Patientswhoreceiverepeatedadministrationofnarcoticanalgesicsshouldhaveoxygensaturationmonitored.

反復(fù)使用靜脈麻醉止痛劑時(shí)，必須監(jiān)測病人的血氧飽和度。

InitialResuscitationandManagementNO.5NutritionalSupport營養(yǎng)支持Datafrom2randomizedcontrolledtrials

supportearly-stageintroductionoflow-fatsolidfoodastheinitialmealforpatientswhohavedevelopedmildpancreatitis;choledocholithiasis,durationoffasting,andquicklyplacingpatientsonafulldiethavebeenassociatedwithrecurrenceofpain.

研究數(shù)據(jù)支持發(fā)病早期提供MAP病人低脂固體食物，但有膽總管石病、長期禁食、過早普食可導(dǎo)致再發(fā)腹痛。Forpatientswithmoresevereformsofillnessorpersistentabdominalpainwhorequirefurthernutritionalsupport,enteralnutrition

hasclearadvantagesovertotalparenteralnutrition.

病情更重、持續(xù)性疼痛的患者需要更長久的營養(yǎng)支持，腸內(nèi)營養(yǎng)優(yōu)于腸外營養(yǎng)。ACochranemeta-analysisof8randomizedcontrolledtrialsfoundareductioninmortality,systemicinfection,andmultiorgandysfunctionamongpatientswhoreceivedenteralasopposedtoparenteralnutrition.

數(shù)據(jù)表明，與場外營養(yǎng)相比，腸內(nèi)營養(yǎng)可以減少病死率、全身感染、多器官功能障礙的風(fēng)險(xiǎn)。ManagementofLocalComplications1.ProphylacticAntibiotics預(yù)防性抗感染Twohigh-quality,double-blind,randomized,controlledtrialsdidnotshowthatprophylacticantibioticsbene?ttedpatientswithnecrotizingpancreatitis.Currentpracticeguidelinesandupdatedmeta-analysesdidnot?ndsuf?cientevidencetorecommendroutineuseofprophylacticantibioticsinpatientswithacutenecroticcollections.

有研究表明，對壞死性胰腺炎預(yù)防性抗感染并沒有使病人受益

現(xiàn)行的診療指南也沒有充分證據(jù)推薦對急性壞死物積聚病人使用抗生素。

Overall,therehasbeenadecreaseinincidenceofinfectednecrosisamongpatientsevenintheplaceboarmsoftrials(15%–20%ofcaseswithnecrosis),consistentwithfindingsfromcontemporarycohortstudies.總體來看，即使在安慰劑組，感染性壞死的發(fā)生率也有降低的趨勢。2.Necrosis胰腺壞死Thisstep-upapproachreducedmajorcomplicationsordeathby29%comparedwithtraditionalopennecrosectomy.Themediantimetointerventionwas29to30days.3.Pseudocyst假性囊腫

71.LenhartDK,BalthazarEJ.MDCTofacutemild(nonnecrotizing)pancreatitis:abdominalcomplicationsandfateof?uidcollections.AJRAmJRoentgenol2008;190:643–649.72.VaradarajuluS,ChristeinJD,TamhaneA,etal.ProspectiverandomizedtrialcomparingEUSandEGDforransmuraldrainageofpancreaticpseudocysts(withvideos).GastrointestEndosc2008;68:1102–1111.Aductaldisruptioncanresultinunilateralpleuraleffusion,pancreaticascites,orenlarging?uidcollection.Symptomsincludeshortnessofbreath,abdominalpain,andevenearlysatiety,withvomiting

ifthecollectioncompressesthestomach.

胰管斷裂可以導(dǎo)致并發(fā)胸膜積液、胰源性腹水、液體積聚范圍增大，癥狀表現(xiàn)為氣促、上腹部痛、早飽感、嘔吐等。

NoninvasiveimagingtechniquessuchasMRCPmightbeusedtoidentifyalargedisruptioninductsbutdetectsmalldisruptionswithlowlevelsofsensitivity.

非侵入性的MRCP對較大的胰管破裂敏感，

但對小的斷裂敏感性要低

4.DuctalDisruption胰管斷裂5.PeripancreaticVascularComplications胰周血管并發(fā)癥ManagementofExtrapancreaticComplications

Extrapancreaticinfectionssuchasbloodstreaminfections,pneumonia,andurinarytractinfections

occurinupto20%ofpatientswithacutepancreatitisandincreasemortality2-fold.Ifsepsisissuspectedduringthecourseofpancreatitis,itisreasonabletostartantibiotictherapywhilewaitingforcultureresults.Ifcultureresultsarenegative,thenantibioticsshouldbediscontinuedtoreducetheriskoffungemiaorClostridiumdif?cileinfection.

多達(dá)20%的SAP可發(fā)生胰腺外感染（血行感染、肺炎、尿路感染），病死率可增加2倍如果考慮有敗血癥，在等待藥敏結(jié)果的同時(shí)可以開始經(jīng)驗(yàn)性抗感染治療如果細(xì)菌培養(yǎng)陰性，必須馬上停用，以減少真菌血癥、艱難梭菌感染的機(jī)會。

Comorbiditiescausesigni?cantmortalityamongpatientswithinterstitialornecrotizingpancreatitis.Patientsshouldbemonitoredforexacerbationofunderlyingconditionssuchascongestiveheartfailureorchronicobstructivepulmonarydisease.

并存病（基礎(chǔ)疾病）對病死率有重大影響，所以需對其進(jìn)行密切監(jiān)測，防止出現(xiàn)基礎(chǔ)疾病的惡化（如CHF、COPD）。Inaddition,treatmentshouldbeprovidedforconcurrentillnessessuchasalcoholwithdrawal

ordiabeticketoacidosis.

另外，對諸如酒精戒斷、糖尿病酮性酸中毒的并存病也需進(jìn)行治療。SpecialConsiderationsBasedonEtiology1.TimingofERCPforPatientsWithBiliaryPancreatitis

Serumtriglyceridelevelsgreaterthan1000mg/dL（11.3mmol/L）areconsiderednecessarytoattributeanattackofpancreatitistohypertriglyceridemia.

甘油三酯水平>1000mg/dL（11.3mmol/L）的胰腺炎定義為高甘油三酯血癥胰腺炎。

Current?rst-linetherapyissupportivecare,asforotherformsofacutepancreatitis.Caseseriesstudieshavesuggesteduseofinsulin,combinedwithheparinorapheresis,fortreatment.Administrationof?bratesshouldbeginasearlyaspossibletohelpreducethetriglyceridelevels.

對于所有急性胰腺炎病人，支持治療為一線治療方法，

研究推薦使用胰島素、聯(lián)合使用肝素及血漿置換進(jìn)行治療，

貝特類藥物應(yīng)盡早使用以降低其水平。2.HypertriglyceridemicAcutePancreatitis3.Hypercalcemia高鈣血癥Acutepancreatitiswithincreasedlevelsofcalciumismostfrequentlyobservedinpatientswithhyperparathyroidismor,onoccasion,metastatictumors.Itisimportanttotreattheunderlyingcauseofhypercalcemiatopreventrecurrenceofacutepancreatitisinthesepatients.并存病中的甲狀旁腺功能亢進(jìn)、轉(zhuǎn)移瘤多導(dǎo)致高鈣血癥，有效處理這些患者高鈣血癥的原發(fā)病是關(guān)鍵，以預(yù)防胰腺炎復(fù)發(fā)，4.AutoimmunePancreatitis自身免疫性胰腺炎

Autoimmunityisararecauseofacutepancreatitis.Althoughlymphoplasmacyticsclerosingortype1autoimmunepancreatitisismorecommon,theidiopathicduct-centrictype2formofthediseasehasbeenmorefrequentlyassociatedwithacutepancreatitis(5%vs34%,respectively)

最常見的是1型（淋巴細(xì)胞硬化型）自身免疫性胰腺炎，以導(dǎo)管為中心的特發(fā)性2型自身免疫性胰腺