acute pancreatitis
Introduction
Introduction to acute pancreatitis Acute pancreatitis (AP) is a common acute abdomen, and its incidence accounts for the third to fifth places of acute abdomen. More than 80% of the patients have milder conditions, that is, acute edematous pancreatitis, which can be cured by non-surgery, which is basically a medical disease. About 10% of patients belong to severe pancreatitis, that is, acute hemorrhagic necrotizing pancreatitis. The inflammation of the pancreas is irreversible or self-limiting. It is often treated with surgery and should be regarded as a surgical disease. Due to the deeper understanding of acute pancreatitis, diagnostic techniques and treatment methods have been greatly developed, and it has become a problem of great interest to surgeons. At the same time, the mortality rate is still high, reaching 30% to 60%. And prone to a variety of serious comorbidities, is a serious challenge for doctors. basic knowledge The proportion of sickness: 0.1--0.3% Susceptible people: no specific population Mode of infection: non-infectious Complications: pancreatic abscess pancreatic pseudocyst shock shock hematuria gastrointestinal bleeding diffuse intravascular coagulation disturbance of consciousness coma sepsis chronic pancreatitis
Cause
Cause of acute pancreatitis
Obstruction factor (25%):
Bile reflux occurs due to biliary mites, incomplete ampullary calculi, and narrowing of the duodenal papilla. If the lower end of the bile duct is obviously obstructed, the pressure in the biliary tract is very high, and the high-pressure bile refluxes the pancreatic duct, causing the pancreatic acinus to rupture, and the pancreatic enzyme enters the pancreatic interstitial and pancreatitis occurs.
Alcohol factor (20%):
Long-term drinkers are prone to pancreatitis. On the basis of this, when a large amount of drinking and overeating occurs, the secretion of pancreatic enzyme is promoted, causing the pressure in the pancreas to rise suddenly, causing the pancreatic vesicle to rupture and the pancreatic enzyme to enter between the acinus. The interstitial causes acute pancreatitis. The simultaneous intake of alcohol and high-protein and high-fat foods not only increases the secretion of pancreatic enzymes, but also causes hyperlipoproteinemia. At this time, pancreatic lipase decomposes triglyceride to release free fatty acids and damage the pancreas.
Vascular factors (20%):
Pancreatic small arteries, acute embolism, obstruction, acute pancreatitis caused by pancreatic acute blood circulation disorder; another factor is based on pancreatic duct obstruction, when pancreatic duct obstruction, pancreatic duct hypertension, passive pancreatic enzyme Sexual "infiltration" interstitial. As a result of pancreatic enzyme stimulation, lymphatic vessels, veins, and arterial embolism in the interstitium are caused, followed by ischemic necrosis of the pancreas.
Trauma (15%):
Pancreatic trauma causes pancreatic duct rupture, pancreatic fluid spillover, and insufficient blood supply after trauma, resulting in acute severe pancreatitis.
Infection factor (15%):
Acute pancreatitis can cause various bacterial infections and viral infections. Viruses or bacteria enter the pancreatic tissue through blood or lymph, causing pancreatitis. Under normal circumstances, this infection is simple edematous pancreatitis, and there are fewer patients with hemorrhagic necrotizing pancreatitis.
Prevention
Acute pancreatitis prevention
Acute pancreatitis has a recurrent trend. Preventive measures include removing the cause and avoiding incentives, such as abstinence, overeating, and treatment of hyperlipidemia. Cholelithiasis plays an important role in the pathogenesis of acute pancreatitis, so it is acute. Patients with cholelithiasis with a history of pancreatitis should undergo elective cholecystectomy and common bile duct exploration.
Complication
Acute pancreatitis complications Complications pancreatic abscess pancreatic pseudocyst shock shock hematuria gastrointestinal bleeding diffuse intravascular coagulation disturbance disorder coma sepsis chronic pancreatitis
Mild acute pancreatitis rarely has complications, and severe acute pancreatitis often presents multiple complications.
1, local complications
(1) Pancreatic abscess: refers to the enveloping empyema around the pancreas, which is formed by the infection of pancreatic tissue necrosis and liquefaction. It usually occurs after 2 to 3 weeks of onset. At this time, the patient has high fever with symptoms of poisoning, and abdominal pain is aggravated. In the upper abdominal mass, the white blood cell count was significantly increased, the puncture fluid was purulent, and the bacteria grew in the culture.
(2) pancreatic pseudocyst: the volume of the pancreatic pericarp is not absorbed, and is surrounded by fibrous tissue to form a pseudocyst, which is formed after 3 to 4 weeks of onset. The physical examination often causes a mass in the upper abdomen, and a large cyst can oppress the adjacent area. The organization produces the corresponding symptoms.
2, systemic complications
(1) organ failure: functional failure of one or more organs can occur to varying degrees, and severe cases are characterized by multiple organ failure (MOF), mainly:
1 circulatory failure, manifested as shock.
2 arrhythmia and heart failure.
3 Acute respiratory failure or acute respiratory distress syndrome, manifested as rapid development of dyspnea, cyanosis, conventional oxygen therapy can not be alleviated.
4 acute renal failure, manifested as oliguria, progressive blood urea nitrogen and creatinine.
5 gastrointestinal bleeding, manifested as hematemesis, black feces or bloody stools, fecal occult blood test was positive.
6 diffuse intravascular coagulation.
7 pancreatic encephalopathy, manifested as mental disturbance disorder and even coma.
(2) Infection: The disease can be secondary to infections such as abdominal cavity, respiratory tract, and urinary tract. The spread of infection can cause sepsis. In the later stage, the body's resistance is extremely low, and the use of antibiotics is prone to fungal infection.
(3) A small number can evolve into chronic pancreatitis.
Symptom
Acute pancreatitis symptoms Common symptoms Vomiting fecal vomiting Abdominal tenderness Fading around the umbilicus Peritoneal irritation Signs Cellular enzyme activity Abnormal abdominal pain Quiet abdominal nausea inflammation
1, symptoms
(1) Abdominal pain: Most of the acute pancreatitis is sudden onset, which is characterized by severe upper abdominal pain and more radiation to the shoulders and back. The patient feels a sense of "banding" in the upper abdomen and lower back. The position of abdominal pain is related to the location of the lesion. If the lesion of the head of the pancreas is severe, the abdominal pain is mainly in the right upper abdomen and radiates to the right shoulder. If the lesion is in the tail of the pancreas, the abdominal pain is the upper left abdomen and the left shoulder is radiated. The intensity of the pain is consistent with the degree of the lesion. For edematous pancreatitis, abdominal pain is mostly accompanied by increased paroxysmal ablation. Acupuncture or injection of antispasmodic drugs can relieve abdominal pain; if hemorrhagic pancreatitis, abdominal pain is very severe, often accompanied by shock, generally used The pain relief method is difficult to relieve pain.
(2) nausea and vomiting: it occurs at the beginning of the onset, which is characterized by the inability to relieve abdominal pain after vomiting. The frequency of vomiting is also consistent with the severity of the lesion. In edematous pancreatitis, not only nausea, but also often vomiting 1~ 3 times; in hemorrhagic pancreatitis, vomiting is severe or persistent retching frequently.
(3) systemic symptoms: may have fever, jaundice, etc., the degree of fever and the severity of the lesion is more consistent, edematous pancreatitis, may not have fever or only mild fever; hemorrhagic necrotizing pancreatitis may appear high fever, if fever does not retreat There may be complications, such as pancreatic abscess, etc., the occurrence of jaundice may be caused by complicated biliary tract disease or compression of the common bile duct by the enlarged pancreatic head.
The jaundice caused by these two reasons needs to be identified by combining medical history, laboratory examination, and the like.
A very small number of patients have very rapid onset, and may have no obvious symptoms or symptoms soon, that is, shock or death, called sudden death or fulminant pancreatitis.
2, signs
(1) Full body sign:
1 position: more lying or side, but hi lying.
2 blood pressure, pulse, breathing: in edematous pancreatitis, there is no significant change, but in hemorrhagic necrotizing pancreatitis, blood pressure can drop, pulse and breathing speed up, and even shock, it is worth mentioning that in acute bleeding In patients with necrotic pancreatitis, acute respiratory distress syndrome (ARDS) can occur, which is a very dangerous syndrome that requires early diagnosis and treatment based on medical history, laboratory tests, etc.
3 tongue coating: more reddish tongue, accompanied by red or purple red infection; tongue white or white greasy, severe cases of yellow greasy or yellow dry.
(2) Abdominal signs:
1 visual examination: the abdomen is flat, but hemorrhagic necrotizing pancreatitis can cause abdominal distension due to intestinal paralysis, and when there is a pancreatic cyst or abscess, there may be localized bulging.
2 palpation: tenderness, rebound tenderness and muscle tension may vary depending on the extent and location of the lesion. Under normal circumstances, there are different degrees of tenderness in the upper abdomen, but the tenderness is related to the lesion, and the lesion is in the head of the pancreas. , tenderness in the right upper abdomen; lesions in the tail of the pancreas, tenderness in the left upper abdomen; lesions involving the entire pancreas, all the upper abdomen has tenderness, if hemorrhagic necrotizing pancreatitis, abdominal cavity exudate for a long time, often full abdominal tenderness, rebound Pain and muscle tension.
In acute pancreatitis, a mass is often found in the upper abdomen. The cause of the mass may be: A. swollen gallbladder, located in the right upper abdomen gallbladder area; B. swollen pancreatic head, located in the right upper abdomen, but in a deep position; Pancreatic cysts or abscesses, mostly round cystic masses; D. Inflamed tissues of edema, such as the omentum, intestinal tract or small reticular sac.
3 percussion: When there is flatulence, the percussion is drum sound. If there is exudate in the abdominal cavity, the percussion is voiced and the mobile dullness can be measured.
4 auscultation: the bowel sounds are weakened, when there is intestinal paralysis, it can be "quiet belly."
The diagnosis of acute pancreatitis is mainly based on clinical manifestations. Relevant laboratory examinations and imaging examinations are not only required to diagnose pancreatitis, but also to evaluate the development of the disease, complications and prognosis.
Examine
Examination of acute pancreatitis
[Laboratory Inspection]
1, white blood cell count
In mild pancreatitis, it may not increase or increase slightly, but in severe cases and with infection, it is often significantly increased, and neutrophils are also increased.
2, amylase determination
This is one of the important objective indicators for the diagnosis of acute pancreatitis, but it is not a specific diagnostic method. In the early stage of the disease, when there is embolism of the pancreatic blood vessels and some hemorrhagic necrotizing pancreatitis, it may not increase due to severe destruction of pancreatic tissue. Sometimes shock, acute renal failure, pneumonia, mumps, perforation of ulcer disease, and intestinal and biliary infections, amylase can also be increased, therefore, when there is an increase in amylase, it is also necessary to combine medical history, symptoms and signs, to rule out An increase in amylase caused by non-pancreatic diseases can be diagnosed as acute pancreatitis.
The increase of amylase has a certain relationship with the onset time of pancreatitis. According to clinical observation, there are several performances:
(1) Serum amylase reached the highest peak at 24h after onset, and the highest peak of urinary amylase appeared after 48h;
(2) Urine amylase reaches its peak in the short term after the onset, while serum amylase may not increase or slightly increase;
(3) serum amylase and urinary amylase increased at the same time, but gradually returned to normal;
(4) The elevating curve of amylase is wave-like or long-term, revealing the occurrence of complications.
It is worth mentioning that the degree of amylase increase is not necessarily proportional to the severity of inflammation. For example, in edematous pancreatitis, amylase can reach a higher degree. In some necrotizing pancreatitis, due to the massive destruction of pancreatic tissue, Amylase is not increased.
Regarding the accuracy of serum amylase and urinary amylase, there are differences in the literature. Some people think that the determination of serum amylase is accurate. Some people think that the determination of urinary amylase is accurate, and urine collection is easy, and it can be repeatedly examined. Therefore, the current clinical There are more people who measure urinary amylase.
3, blood chemistry check
In severe pancreatitis, the carbon dioxide binding capacity decreases, and the blood urea nitrogen rises, indicating that the kidney has been damaged. When the islets are damaged, blood sugar may increase, but most of them are transient. In hemorrhagic pancreatitis, blood calcium is often lowered. When it is less than 7 mg%, it often shows a poor prognosis.
4, abdominal puncture
For cases with peritoneal exudation, abdominal puncture can help the diagnosis of this disease. The puncture fluid is mostly bloody. If the amylase is measured, the disease can be diagnosed.
5, amylase isozyme test
There are two types of amylase isoenzymes, pancreatic isoenzymes and salivary isoenzymes (STI). In acute pancreatitis, pancreatic isoenzymes can be significantly increased, and pancreatitis is highly suspected and amylase is normal. Whether the amylase of hyperamylasemia is derived from the pancreas, the determination of isozymes is more valuable. Some people in China use electrophoresis. From the cathode to the anode, PIA has three kinds of P3, P2 and P1, of which P3 is Sensitive and reliable indicators for the diagnosis of acute pancreatitis.
6. Radioimmune trypsin assay (RIA)
Because the amylase assay is not specific for the diagnosis of pancreatitis, with the advancement of immunoassay technology, many scholars are looking for a more accurate diagnostic method, namely pancreatic enzyme radioimmunoassay. Currently, there are roughly the following enzymes. .
(1) Immunologically active trypsin (IRT): In acute pancreatitis, pancreatic acinar damage can release a large amount of trypsin and zymogen, which is a protease only present in the pancreas, so serum trypsin and zymogen are determined. The concentration should have a certain specificity. Clinical application proves that serum IRT has a large increase in duration of severe pancreatitis and lasts for a long time. It is helpful for the early diagnosis and differentiation of acute pancreatitis.
(2) Elastase II: The serum immunological activity of elastase (IRE) can be determined by radioimmunoassay. Since the serum IRE can disappear after total pancreatectomy, the enzyme can be determined specifically.
(3) pancreatic trypsin inhibitor (PSTI): PSTI is secreted by pancreatic acinar and can inhibit the activation of pancreatic protease. Because it is a specific trypsin inhibitor, it is present in pancreatic juice and blood. Determination of its content can not only diagnose acute pancreatitis early, but also identify the severity of the disease, which is conducive to the observation of the disease.
(4) Phospholipase A2 (PLA2): PLA2 is a lipolytic enzyme, which is one of the important factors causing pancreatic necrosis. Acute pancreatitis can be elevated in the early stage and lasts longer than serum amylase. The diagnosis is useful.
Film degree exam
1, X-ray inspection
(1) Abdominal plain film: The following signs may be seen:
1 increased density of the pancreas (due to inflammatory exudation);
2 reflex intestinal stagnation (mainly in the stomach, duodenum, jejunum and transverse colon);
3 diaphragmatic muscle elevation, pleural effusion;
4 a small number of cases can be seen in pancreatic stones or biliary stones;
5 duodenal ring stasis, its inner edge has a straight undershot;
6 supine abdominal plain film, showing "transverse colon truncation" sign, that is, colonic hepatic flexion, spleen flexion, even if the position of the transverse colon is still not inflated, which is caused by acute pancreatitis caused by colonic spasm.
(2) Upper gastrointestinal barium meal imaging: The following signs may be seen:
1 The head of the pancreas is enlarged and the duodenal ring is enlarged;
2 the stomach sinus is under pressure;
3 Duodenum has expansion and deposition;
4 duodenal papillary edema or inverted "3" sign due to swelling of the pancreatic head;
5 pancreatic pseudocysts, visible gastrointestinal compression.
2, ultrasound examination
Ultrasound plays an increasingly important role in the diagnosis of acute pancreatitis, and it is one of the indispensable routine examination methods, but it is susceptible to gastrointestinal gas accumulation. The diagnosis of pancreatitis by ultrasound can be found as follows.
(1) Increased pancreas volume: In edematous pancreatitis, the pancreas increases in volume; in severe pancreatitis, it increases, and the contour of the pancreas is blurred, the surface is not smooth, and the deep surface of the pancreas is separated from the splenic vein. Unclear, sometimes the front and back of the pancreas are difficult to identify.
(2) Enhancement of pancreatic echo: In the edematous pancreatitis, the echo of the pancreas is enhanced, but in the case of severe pancreatitis, the interior of the pancreas is largely uneven, with strong echoes and irregular low echo areas.
(3) peritoneal exudate: rare in edematous pancreatitis, but more in severe pancreatitis, most of which are diffuse effusion, can also be a localized effusion around the pancreas, after treatment can also Pancreatic abscess and pseudocyst were found.
According to the above, combined with clinical features, ultrasound can be used as one of the means to identify edema and severe pancreatitis.
3, CT examination
CT scan can also show various pathological changes of the pancreas and its surrounding tissues from mild edema, hemorrhage to necrosis and suppuration. CT can also find effusion and small omentum around the pancreas, edema around the kidney, which helps early The discovery and follow-up of pancreatic pseudocysts is more advantageous and accurate than ultrasound examination because of the influence of gastrointestinal gas and obesity. However, due to the high cost of examination, it can not be routinely used.
4, fiber endoscopy
(1) Fiberoptic endoscopy has no direct diagnostic value. It may be seen that the edema and hyperemia of the gastric duodenal mucosa may be seen in the posterior wall of the stomach (caused by enlarged pancreas).
(2) In addition to the lesions of the duodenal mucosa, the duodenal mucosa can be observed abnormalities or lesions in the duodenal papilla, especially in the case of pancreatitis caused by ampullary incarceration You can see the raised nipple or stone to find the cause directly.
(3) Endoscopic retrograde cholangiopancreatography (ERCP): It is only suitable for the treatment of biliary tract lesions after acute symptom control. Although it can also make judgments on pancreatic duct obstruction, it may cause pancreatitis to recur. It is a possibility of injecting pancreatitis, so it should not be used routinely.
5, laparoscopy
For acute upper abdominal pain or severe pancreatitis, which is not well understood, laparoscopy can be meaningful. A series of lesions can be seen by laparoscopy and can be divided into accurate signs and relative signs.
(1) Accurate signs: Refer to the microscope to see the diagnosis of pancreatitis, including:
1 focal necrosis: the result of fat necrosis caused by lipase and phospholipase activation. In the early stage of the disease, this necrosis is seen in the small aortic cavity of the upper abdomen. Due to the spread of the lesion, it can be found in the omentum, small Omentum, transverse colon, gastric collateral ligament, perirenal fat sac, paracolon, etc., the extent of grayish white fat necrosis is consistent with the extent of the lesion,
2 exudate: in severe pancreatitis, can be found in 85.5% of cases, the amount of exudate is 10 ~ 600ml, the most pancreatic ascites can reach more than 6L, some people measured the amylase activity of exudate increased, slightly increased The mortality rate was 19%, the amylase was higher than 1024U, and the mortality rate was 59.1%. The color of the exudate was also related to the prognosis.
(2) Relative signs: no independent diagnosis, combined with accurate signs and clinical, in order to make a correct diagnosis,
1 abdominal congestion: often accompanied by abdominal exudate, more found in the upper abdomen,
2 elevation of the stomach position: This is due to the enlarged pancreas, inflammation of the small omentum or cysts caused by the stomach pad, when the fiber wall is used to contact the stomach wall, the hard pancreas can be felt.
6, angiography
In order to diagnose vascular or hemorrhagic complications of acute pancreatitis, selective laparoscopic angiography in some patients is also a new development in recent years. Angiography can show vascular lesions in the pancreas and peri-pancreatic arteries (eg Aneurysms and pseudoaneurysms, which help to develop a treatment plan, such as the implementation of arterial intubation embolization, may avoid open surgery for bleeding control.
7, radionuclide scanning
It is more normal in the early stage of the disease, but in the case of severe pancreatitis, uneven or non-developed or localized radioactive defect areas can be seen. Since this method requires certain equipment, it cannot be used universally.
8, other inspection methods
Electrocardiogram, EEG, etc., have no direct help in the diagnosis of this disease, but there are many changes in severe pancreatitis, which can be used as an auxiliary examination method for diagnosis and treatment.
Diagnosis
Diagnosis and diagnosis of acute pancreatitis
Diagnostic criteria:
1, with typical clinical manifestations, such as abdominal pain or nausea and vomiting, accompanied by upper abdominal tenderness or peritoneal irritation.
2. Serum, urine or abdominal puncture fluid has an increase in trypsin content.
3, image examination (ultrasound, CT) showed pancreatic inflammation or surgical findings or autopsy pathological examination confirmed pancreatitis lesions.
4, can exclude other similar clinical manifestations of the disease.
Differential diagnosis
The correct diagnosis rate of acute pancreatitis has been significantly improved in recent years, but in atypical cases, it is often confused with other acute abdominal diseases, so it should be vigilant at any time. The identification points are as follows.
1, acute cholecystitis, cholelithiasis: acute cholecystitis abdominal pain is lighter than acute pancreatitis, the pain is the upper right abdominal gallbladder area, and to the right chest and right shoulder radiation, blood urease amylase normal or slightly higher; Biliary stones, the degree of abdominal pain is more severe, and often accompanied by chills, high fever and jaundice.
2, biliary ascariasis: sudden onset of biliary ascariasis, mostly for children and young people, began to the right side of the upper abdomen xiphoid, showing severe paroxysmal cramps, patients often say that there is an upward "drilling feeling", pain At the time of onset, uneasiness, sweating, cold hands and feet, as usual after pain, characterized by "severe symptoms, mild signs" (symptoms and signs), blood urease amylase is normal, but in the case of biliary mites with pancreatitis, starch The enzyme can be raised.
3, stomach and duodenal ulcer perforation: perforation of ulcer disease is a sudden onset of severe pain in the upper abdomen, and soon spread to the whole abdomen, the abdominal wall is plate-like tonic, the bowel sound disappears, the liver dullness shrinks or disappears, the abdominal plain film has The presence of pneumoperitoneum is more likely to help confirm the diagnosis.
4, acute renal colic: sometimes should be differentiated from left kidney stones or left ureteral stones, renal colic as paroxysmal colic, intermittent pain may be, with the waist as the weight, and to the groin and testicular Radiation, if there is hematuria, frequent urination, urgency, it is more helpful to identify.
5, coronary heart disease or myocardial infarction: in acute pancreatitis, abdominal pain can be reflected to the precordial area or produce a variety of ECG changes, often confused, however, patients with coronary heart disease may have a history of coronary heart disease, chest The area has oppression, abdominal signs are not obvious, etc., must be carefully identified.
