Acute Pancreatitis Management Update：急性胰腺炎的更新管理.ppt

Acute Pancreatitis:Management UpdateOverview of Acute Pancreatitisl85%of patients have interstitial pancreatitis;15(range 4 47%)have necrotizing pancreatitislAmong patients with necrotizing pancreatitis,33%(range 16-47%)have infected necrosis lApproximately 10%of patients with interstitial pancreatitis experience organ failure,but in the majority it is transientlMortality in acute pancreatitis overall,is approximately 5%:3%in interstitial pancreatitis,17%in necrotizing pancreatitislIn necrotizing pancreatitis,mortality 3-fold infected vs.sterile necrosislMortality increases with development of organ failure 3%(0-8%)and with multi-system organ failure 47%(range 28-69)ACG Practice Guidelines in Acute Pancreatitis Am J Gastroenterol 2006;101:2379-2400Acute Pancreatitis:Concepts 20091)Volume replacement is the foundation of therapy2)Establish severityUtilize initial laboratory datastandardized modalities i.e.Ranson criteria require 48 hrsCT abnormalities correlate with severity No need for early CT to establish severity3)Establish etiologyImportance is to prevent recurrence4)Biliary Pancreatitis Utilize laboratory markers for diagnosis of retained CBD ERCP is only for treating patients with cholangitis 5)Do not use prophylactic antibiotics6)CT guided aspiration is the diagnostic test for pancreatic infection&allows directed antibiotic therapyAcute Pancreatitis:Concepts 2009Acute Pancreatitis:Concepts 2009(Cont)7)Surgical intervention in patients with infected pancreatic necrosis but rarely in sterile necrosis8)Early enteral feeding is safe,prevents leaky gut and is associated with less complications than TPNDefinition of Severe Acute Pancreatitis(SAP)l SAP is acute pancreatitis with local and/or systemic complicationslLocal complications are:l necrotizing pancreatitislInfected necrosislPancreatic abscesslPeripancreatic fluid collection and pseudocystic lesionslSystemic complications are:lPulmonary and renal failurelShocklCardio-circulatory dysfunctions lsystemic sepsis lcoagulation disorderBradley EL,III.Arch Surg 1993;128:585-590Acute Pancreatitis:Mechanisms of Intra and-Extrapancreatic InflammationlMediated by cytokines and other inflammatory mediators:lActivation of inflammatory cellslChemo-attraction of activated inflammatory cells to the microcirculationlActivation of adhesion molecules allowing the binding of inflammatory cells to the endotheliumlMigration of activated inflammatory cells into areas of inflammationACG Practice Guidelines in Acute Pancreatitis.Am J Gastroenterol 2006;101:2379-2400Acute PancreatitisMechanism of organ dysfunctionVolume depletionVisceral hypofusion Capillary permeability bowel permeability(TNF,IL6,angioprotin adipokines)Bacterial translocationSIRSDavid Whitcomb,M.D.Causes of mortalityAcute PancreatitisDEATHEarly(one week)Multiorgan failure Pancreatic infections/sepsisSystemic Inflammatory Response Syndrome(SIRS)Defined by two or more of the following criteria:Pulse 90 beats/minRespiratory rate 20/min or PCO2 32 mmHgRectal temperature 38CWhite blood count 12,000/mm3ACG Practice Guidelines in Acute Pancreatitis Am J Gastroenterol 2006;101:2379-2400Acute PancreatitisPrognosis Bedside AssessmentUnderestimates severe disease Scoring SystemsRanson,Glasgow,Apache,Rabenek Serum MarkersTrypsinogen activation peptide(TAP)C-reactive protein(CRP)Cytokines Imaging criteriaFluid collections,necrosisPrognosis in Acute PancreatitisAcute PancreatitisEarly Indicators of Severity Tachycardia,hypotension Tachypnea,hypoxemia Hemoconcentration Oliguria EncephalopathyEarly Diagnostic Indicators in Acute PancreatitisAcute PancreatitisNo deteriorating dysfunctionDeteriorating dysfunction25100507501020304050607080900No organ dysfunctionOrgan dysfunction10 2030 4050 60 70 8090251005075Time(days)%Survival rateTime(days)Organ Dysfunction Affects Prognosis in Acute PancreatitisOrgan Dysfunction Affects PrognosisA Buter et al.,Brit.J.Surgery 2002;89:298J Martinez et al.,Pancreas 1999;19:15Effect may be greatest with a high waist/hip fat ratioPossible Mechanisms Free fatty acids Cytokines(TNFa a IL-6)Reduced diaphragmatic excursionBody Mass Index(kg/m2)%Patients020406029Severe PancreatitisSystemic complicationsObesity Worsens PrognosisAutoimmune PancreatitisObesity Worsens the Prognosis in Acute PancreatitisDiagnostic Guideline I:Look for Risk Factors of Severity at AdmissionlOlder age(55 yrs)lObesity BMI 30lOrgan failure at admissionlPleural effusion and/or infiltrateslWhen organ failure is corrected within 48 hours,mortality is close to 0lWhen organ failure persists for more than 48 h,mortality is 36%Level of Evidence IIIACG Practice Guidelines in Acute Pancreatitis Am J Gastroenterol 2006;101:2379-2400APACHE II score=(acute physiology score)1.Rectal temperature(C)2.Mean arterial pressure(mmHg)3.Heart rate(bpm)4.Respiratory rate(bpm)5.Oxygen delivery(mL/min)6.PO2 mmHg)7.Arterial pH8.Serum sodium(mmol/L9.Serum potassium(mmol/L)10.Serum creatinine(mg/dL)11.Hematocrit(%)12.White cell count(103/mL)13.History o