acute pancreatitis in the elderly
Introduction
Introduction to acute pancreatitis in the elderly Senile acute pancreatitis (senileacutepancreatitis) is an acute inflammatory lesion of the pancreas caused by the digestion of the pancreas in the elderly. It is an important cause of acute abdomen in the elderly, accounting for 5% to 7%. The incidence of acute pancreatitis in the elderly is less than that of young people, but once the disease is often caused by poor stress and complications, the disease develops rapidly, and early shock and multiple organ failure can occur. basic knowledge Sickness ratio: 0.0004% Susceptible people: the elderly Mode of infection: non-infectious Complications: shock, diabetes, arrhythmia, heart failure, gastrointestinal bleeding, acute respiratory distress syndrome
Cause
The cause of acute pancreatitis in the elderly
Biliary disease (30%):
Accounted for 50% to 70%, acute pancreatitis and biliary system diseases are closely related, because the bile duct and pancreatic duct open in Vater's ampulla accounted for 80%, after confluence into the duodenum, the common pipeline length is 2 ~ 5mm If the ampulla is blocked and the pressure in the bile duct shrinks beyond the pancreatic duct pressure, the bile can flow back into the pancreatic duct to activate the trypsin to cause self-digestion. The so-called "common plumbing theory" causes the obstruction of the ampulla: Common incarceration of common bile duct stones, blockage of acute infection secretions, Oddi sphincter spasm and biliary ascariasis.
Idiopathic (15%):
23% to 30% of acute pancreatitis in the elderly is idiopathic, compared with 10% to 15% in the general population. Recent studies have shown that about 74% of patients who are considered to be idiopathic pancreatitis are due to bile deposition. , cholesterol crystal suspension, bilirubin calcium salt particles, or due to abnormal pancreaticobiliary ducts such as duodenal diverticulum around the ampulla, nipple stenosis.
Surgical traumatic (10%):
Acute pancreatitis caused by surgical trauma in the elderly, accounting for about 12.5%, any upper abdominal or retroperitoneal surgery may cause pancreatic injury, intraoperative high-dose calcium supplementation, preoperative renal dysfunction is an important cause of acute pancreatitis Pancreatic ischemia is an important factor in the development of acute pancreatitis. The elderly have poor tolerance to hypoperfusion, and about 50% of patients with severe hypovolemic shock may develop acute pancreatitis.
Pancreatic cancer (10%):
The elderly are high-risk populations of pancreatic cancer, and about 1% of acute pancreatitis is secondary to pancreatic cancer.
Drugs (10%):
As early as the 1980s, drug-induced pancreatitis has attracted people's attention. The drugs that can cause pancreatitis include thiazides, furosemide, sulfonamides, estrogens, steroids, methyldopa, procainamide, and metronidazole. Oxazole, etc., the elderly are prone to multiple organ diseases and often use more drugs, so drugs are a factor that can not be ignored in the elderly to induce pancreatitis.
Endoscopic retrograde cholangiopancreatography (ERCP) (5%):
ERCP can cause a transient increase in blood amylase, causing about 5% of acute pancreatitis, but ERCP causes a higher risk of acute pancreatitis in the elderly.
Pathogenesis
The normal pancreas secretes more than a dozen pancreatic enzymes, including amylase, protease and lipase, as well as phospholipase A, elastin, pancreatic vasopressin and nuclease, etc., in the pancreas, amylase, lipase and Ribonuclease is the active enzyme, and the rest are in the form of zymogen. Because of the inhibitor of enzyme, the pancreas itself can be prevented from digesting. Once the harmful factors exceed the protective factor, trypsin is activated in the pancreas. The pancreas itself undergoes digestion, resulting in edema of the pancreatic tissue, inflammatory cell infiltration, congestion, hemorrhage and necrosis.
Pathologically, acute pancreatitis is classified into acute edema type and acute hemorrhagic necrosis type.
1. Acute edema type (interstitial type) Interstitial edema, hyperemia and inflammatory cell infiltration, parenchymal cells do not change much, may have mild fat necrosis and ascites.
2. Acute necrosis (hemorrhagic necrosis) Acinar and adipose tissue necrosis, vascular necrosis hemorrhage is a characteristic of this type, this change can affect the surrounding tissue, prone to secondary infection, formation of pancreatic pseudocyst after treatment, fibrous tissue Hyperplasia, calcification, etc.
Prevention
Elderly acute pancreatitis prevention
1. Elderly patients with acute pancreatitis need only fasting, rest, rehydration, nutrition, support and proper symptomatic treatment.
2. Critically ill patients should closely observe changes in pulse, respiration, blood pressure, heart rate, etc., and actively prevent complications.
Complication
Elderly acute pancreatitis complications Complications, shock, diabetes, arrhythmia, heart failure, gastrointestinal bleeding, acute respiratory distress syndrome
Domestic reports of complication of senile acute pancreatitis as high as 73%, common are: ARDS, shock, electrolyte acid-base balance disorders, diabetes and heart failure, arrhythmia, renal failure, severe gastrointestinal bleeding.
Symptom
Acute pancreatitis symptoms in the elderly Common symptoms Abdominal pain High fever Abdominal peritonitis Shock Blood pressure drop Intestinal jaundice Peritoneal stimulation Blood stasis Ascites
The elderly have decreased function, autonomic dysfunction, increased pain threshold, low sensitivity and poor resolution, resulting in atypical symptoms and signs, complex clinical manifestations, rapid development of the disease, early shock and multiple organ failure.
1. Abdominal pain: slight abdominal pain or no abdominal pain, abdominal pain is mostly dull pain, located in the upper abdomen, typical upper abdomen less pain, with general antispasmodic drugs are not easy to relieve.
2. Nausea, vomiting, bloating: more than 80% have nausea, vomiting, and bloating.
3. Fever: Most patients have moderate fever, a few of the body temperature is not high, very few can be high fever, fever usually lasts for 3 to 5 days, such as persistent high fever, should be suspected secondary infection (such as pancreatic abscess, peritonitis, etc.).
4. Shock: It can occur gradually or suddenly, or even die very quickly. The patient's skin is pale, cold sweat, weak pulse, and blood pressure drop.
5. Astragalus: A small number of patients have jaundice, which is caused by inflammation of the biliary tract or compression of the common bile duct due to inflammation of the pancreas.
6. Signs: often lack of typical peritoneal irritation, only mild to moderate tenderness, rebound tenderness, weakened bowel sounds, acute necrotic hemorrhagic pancreatitis can often cause ascites, ascites can be bloody, bloody ascites penetrates into the skin, in Subcutaneous hemorrhage may occur on both sides of the abdomen or umbilicus. Ascites may enter the thoracic cavity through the lymphatic plexus and transverse micropores to cause pleural effusion, atelectasis or pneumonia.
Examine
Examination of acute pancreatitis in the elderly
1. White blood cells: White blood cells can be increased to (10 ~ 20) × 109 / L, neutrophils are significantly increased.
2. Blood amylase: 8h after onset begins to rise, peaks at 24h, lasts for 3 to 5 days, and acute pancreatitis >250U% (Somogyi method), such as >500U% can be diagnosed, the level of amylase is not It must be said that the inflammation is light, heavy, and light may be high, and the hemorrhagic necrosis type may be normal.
3. Urine amylase: the increase of urinary amylase generally occurs 12 to 24 hours after onset, which lasts for 1 to 2 weeks. The abnormal rate of urinary amylase in elderly acute pancreatitis is lower than that of blood amylase, which may be related to renal arteriosclerosis in the elderly. The renal clearance function is reduced. The normal value is 64U (Winslow method), >128U is meaningful, and acute pancreatitis is often above 256U.
4. Urinary amylase creatinine clearance rate: normal 3.1%, can increase 3 times in acute pancreatitis.
5. Serum lipase: normal value is 0.2-0.7U%, acute pancreatitis >1.5U%, starting to rise at 72h after onset, and serum amylase has returned to normal, serum lipase has reference value.
6. Serum methemoglobin: In acute hemorrhagic necrotic pancreatitis, due to internal hemorrhage, red blood cell destruction product is too much heme, combined with albumin to form methemoglobin, negative for acute edematous pancreatitis, necrosis Positive, has a reference value for diagnosis and prognosis.
7. Blood calcium: It can be reduced in hemorrhagic necrotic pancreatitis, such as <1.75mmol/L, which is a sign of poor prognosis.
8. Other: The content of amylase in pleural effusion or ascites is higher than that of hematuria.
9. Abdominal flat film can be seen in small intestine flatulence, chest radiograph can be seen in pleural effusion, atelectasis, ECG shows ST segment decline, T wave is low or inverted, normal condition returns to normal, pancreatic B-ultrasound or CT can be seen pancreatic enlargement, necrosis Or bleeding, abscess or cyst formation.
Diagnosis
Diagnosis and diagnosis of acute pancreatitis in the elderly
diagnosis
The symptoms and signs of acute pancreatitis in the elderly are not typical. Therefore, it is difficult to confirm the diagnosis based on symptoms and signs alone. It is necessary to combine blood and urine amylase to reduce the missed diagnosis. For example, the patient has sudden shock, no urine, and the pain is not obvious. Suddenly after upper abdominal surgery Shock, fever; diabetes coma occurs shock; sudden appearance of symptoms similar to myocardial infarction; etc., should promptly think of the disease, timely check pancreatic enzymes, blood calcium, positive iron albumin, etc., such as the onset of 4 to 5 days to come to the hospital, urine Amylase is negative, and it is most appropriate to check lipase at this time.
Differential diagnosis
Acute pancreatitis in the elderly needs to be differentiated from acute ulcer perforation, acute cholecystitis, cholelithiasis, myocardial infarction, acute intestinal obstruction and other diseases. As long as you have a deep understanding of the medical history, carefully check and use X-ray, ECG and B-ultrasound, CT and other examinations. Identification.
