胰腺疾病 讲解材料.ppt

2003-3 急性胰腺假性囊肿 指急性胰腺炎后形成的有纤维组织或肉芽囊壁包裹的胰液积聚。急性胰腺炎患者的假性囊肿少数可通过触诊发现，多数通过影像学检查确定诊断。常呈圆形或椭圆形，囊壁清晰。 2003-3 胰腺脓肿 发生于急性胰腺炎胰腺周围的包裹性积脓，含少量或不含胰腺坏死组织。感染征象是其最常见的临床表现。它发生于重症胰腺炎的后期，常在发病后4 周或4 周以后。有脓液存在，细菌或真菌培养阳性，含极少或不含胰腺坏死组织，这是区别于感染性坏死的特点。胰腺脓肿多数情况下是由局灶性坏死液化继发感染而形成的。 2003-3 2003-3 2003-3  multiple organ dsysfuction syndrome (MODS) Necrosis infection sepsis 50% death 2003-3 Prediction of severity aim Immediately selecting on admission Simple scoring system Good biochemical marker 2003-3 Classification system General evaluation John Ranson score (1974):5(on admission) +6(48hr) Imrie score:8 (WBC,Ca,sugar,PO2,LF) APACHE II score (1985):12+age＋Chronic health+coma Atlanta classification system(1992) Local evaluation Beger’ criteria (1985) Balthazar CT classification system (1990):I,II,III GRADE MODS evaluation Marshall MODS score system(1995):6 systems/organs involved 2003-3 Inflammatory mediators C-reactive protein(CRP) Upstream cytokines: IL-6,IL-8 Trypsinogen activation markers TAP 2003-3 Clinical classification Mild acute pancreatitis ( MAP ) Severe acute pancreatitis ( SAP ) （p 651） 2003-3 SAP的临床诊断 急性胰腺炎伴有脏器功能障碍，或出现坏死、脓肿或假性囊肿等局部并发症者，或两者兼有 APACHE II 评分 ? 8 Balthazar CT分级系统 ? II级 2003-3 SAP的严重度分级 无脏器功能障碍者为I 级 伴有脏器功能障碍者为II 级 2003-3 SAP的病程分期 急性反应期：自发病至2周左右，常可有休克、呼衰、肾衰、脑病等主要并发症。 全身感染期：2 周到2 个月左右，以全身细菌感染、深部真菌感染（后期）或双重感染为其主要临床表现。 残余感染期：时间为2 ? 3 个月以后，主要临床表现为全身营养不良，存在腹膜后或腹腔内残腔，常常引流不畅，窦道经久不愈，伴有消化道瘘。 2003-3 Treatment 2003-3 Management strategies Largely supportive surgery Optimal timing and indications Limited role Development of novel and more specific therapies are needed 2003-3 Conservative treatment (Non-operative) 2003-3 Acute reaction phase Usually monitoring in ICU Anti-shouk Pancreas rest Antibiotic prophylaxis Adequate analgesia Microcirculation improvement - Chinese traditional medicine Nutritional management 2003-3 General infection phase Sensitive antibiotic General support Serial CT 2003-3 Residual infection phase Prevention and treatment o