处理急性胰腺炎的近代观点

Current viewpoint of management for acute pancreatitis

关键词:  急性胰腺炎  重症型急性胰腺炎  胰腺坏死组织切除术

Key words:  acute pancreatitis  severe acute pancreatitis  necrosectomy

摘要:

急性胰腺炎(AP)是一种胰腺的可逆性炎性过程，其中80%为轻型，死亡率仅<1%；而重症型急性胰腺炎（SAP）虽占20%，其死亡率却高达10%~30%。AP的主要病因和危险因素有食物和药物导致的甘油三酯血症、饮酒、胆石症、感染、损伤和各种手术和检查操作后等。SAP的临床病程可分为两期，第一期是在发病2周以内，其特点是出现全身炎症反应综合征和胰腺坏死，可从发病后第4日开始；第二期从发病后2~3周开始，可发生胰腺坏死细菌感染，这是主要的致死性并发症，死亡率高达20%~50%。对SAP的非手术治疗包括早期液体复苏，营养支持，预防性抗生素的应用，止痛措施，胃肠减压等。对于有胆道梗阻的患者，可进行急症内镜括约肌切开术等，会有所裨益。在外科治疗方面，不推荐发病14 d内手术，这是因为可增高手术死亡率；而延迟手术（发病后3~4周时），则显示可降低手术死亡率。手术方法主要是坏死组织切除术，主要针对感染性胰腺组织坏死；而胰腺脓肿的手术方法为手术或经皮置管引流术。

Abstract:

Acute pancreatitis (AP) is a reversible inflammatory processes of the pancreas, most of them (around 80%) are mild, have 1% or less mortality， but severe AP (ASP) develops in 20% of cases, will a mortality rate of 10%-30%. The most common risk factors for AP are food and drug induced hypertriglyceridemia, alcohol consumption, gallstones, infections and traumatic or post procedure. SAP are classified into two stages, first stage within 2 weeks after onset, is characterized by the SIRS and pancreatic necrosis, it develops within the first 4 days. The second stage begins 2 or 3 weeks after onset with the development of infectious pancreatic necrosis, it is the main life-threatening complication with a mortality rate of 20%-50%. Early fluids resuscitation, nutrition support, prophylactic antibiotics, pain control, nasogastric suction are essential treatment. An emergency endoscopic approach is beneficial in patients with bile duct obstruction. Surgery earlier than 14 days after onset is not recommended, because it is associated with increased mortality. Necrosectomy is the optimal surgical procedure for infected pancreatic necrosis, surgery or percutaneous catheter drainage should be performed for pancreatic abscess.