内科学课件：Acute Pancreatitis

Acute Pancreatitis234OverviewPancreatitis is an inflammation of the pancreas.PancreatitisAcute pancreatitisChronic pancreatitis5Acute PancreatitisPancreatitisisaninflammatoryprocessinwhichpancreaticenzymesautodigesttheglandAcutepancreatitisnPathophys-insultleadstoleakageofpancreaticenzymesintopancreaticandperipancreatictissueleadingtoacuteinflammatoryreaction7Classification:Pathological:nacuteedematouspancreatitisnacutehemorrhagicnecrotizingpancreatitisClinical:nMildacutepancreatitis(MAP)nSevereacutepancreatitis(SAP)8Etiology and mechanism:原发性的 9Etiology and mechanismn n70-80% of patients either have 70-80% of patients either have gallstones or a history of sustained gallstones or a history of sustained alcohol abuse. alcohol abuse. nMild acute pancreatitis is not associated with organ dysfunction or complications, and recovery is uneventful. nSevere acute pancreatitis is associated with decreased function of the pancreas, local and systemic complications, and a complicated recovery. 1011水 肿 型 的 病 理 外观： 胰腺肿大、变硬、少量周围组织坏死。 显微镜下： 间质充血、水肿、炎症细胞浸润，少量腺泡坏死。12出 血 坏 死 型 病 理 外观： 胰腺弥漫性肿大、大网膜 和胰腺上大小不等的钙皂 显微镜下： 胰实质、脂肪坏死； 水肿、出血和血栓形成； 炎症反应。 PathologyPathology1.Edematous pancreatitis:1.Edematous pancreatitis:*interstitial edema*interstitial edema*inflammatory cell infiltration of the gland *inflammatory cell infiltration of the gland parenchyma parenchyma2.Hemorrhagic or necrotizing pancreatitis2.Hemorrhagic or necrotizing pancreatitis*extensive pancreatic and peripancreatic *extensive pancreatic and peripancreatic fat necrosis fat necrosis *parenchymal necrosis*parenchymal necrosis14Acute hemorrhagic pancreatitis.15Clinical manifestationsnSymptomsn1、 Abdominalpain:predominant clinical predominant clinical featurefeature16Clinical manifestations Abdominalpain,usuallyepigastric,constantwithradiationtotheback Clinical PresentationClinical PresentationnSteady, dull, or boring midepigastric pain associated with nausea and vomiting is the classic presentation of acute pancreatitis.Abdominal pain Abdominal pain n na penetrating pain, radiating to the back a penetrating pain, radiating to the back ( (It radiates straight to the midline of the lower thoracic vertebral region in about 50% of patients and is usually worse in the supine position.)Abdominal painAbdominal painn nrarepatientswithoutabdominalpainbutrarepatientswithoutabdominalpainbutwithaseveresystemicillness(withaseveresystemicillness(hypotension,hypoperfusionandhypotension,hypoperfusionanddepressionofmentalstatus)-depressionofmentalstatus)-Painless acute pancreatitis is very rare carries a grave prognosis because the patients frequently present in shock.Clinical PresentationClinical Presentationn nNauseaandvomitingNauseaandvomitingn nAbdominalDistentionAbdominalDistentionresultingfromaparalyticileusarisingfromresultingfromaparalyticileusarisingfromretroperitonealirritationorascitesoraretroperitonealirritationorascitesoraretroperitonealphlegmonretroperitonealphlegmonn nJaundiceJaundicedistalcommonbileductobstructionbydistalcommonbileductobstructionbygallstonescompressionofthedistalCBDbygallstonescompressionofthedistalCBDbypancreaticheadedemaorbyotherpancreaticheadedemaorbyotheruncommonfindingsuncommonfindingsAbdominal DistentionAbdominal DistentionnParalytic ileus(麻痹性肠梗阻) with abdominal distention may develop during the first few days, signifying extension of the inflammatory process into the small intestinal and colonic mesentery.Clinical Presentation of Clinical Presentation of SAPSAPn nCirculatory Derangements: hypotention, Circulatory Derangements: hypotention, hypovolemia, hypoeffusionhypovolemia, hypoeffusioncirculating myocardial depressant factorcirculating myocardial depressant factor decreased preload to the heartdecreased preload to the heartreduced systemic vascular resistancereduced systemic vascular resistancesepsis-like syndromesepsis-like syndromeClinical Presentation of Clinical Presentation of SAPSAPn npleuraleffusionpleuraleffusionn npulmonaryfailurepulmonaryfailuretachypnea,dyspneaandcyanosistachypnea,dyspneaandcyanosisn ncerebralabnormalitiescerebralabnormalitiesbelligerence,confusion,psychosisandbelligerence,confusion,psychosisandcomacoman nGreyTurnersignandCullensignGreyTurnersignandCullensignabluishcolorintheflanksoraroundtheabluishcolorintheflanksoraroundtheumbilicus,(representingblooddissectingtoumbilicus,(representingblooddissectingtothoseareasfromtheretroperitoneumnearthoseareasfromtheretroperitoneumnearthepancreasalongfascialplanes)thepancreasalongfascialplanes)nOne to 2 weeks after the onset, large ecchymoses(瘀斑) may appear in the flanks侧腹 (Grey Turners sign) or the umbilical area (Cullens sign);25Grey-Turner征Cullen征Severe acute pancreatitis nHowtoidentifySAPfromMAP?*MAP：no organ dysfunction SAP：at lease one of the following organ dysfunction local complication (necrosis abscess or pseudocyst ) Ranson score 3 or APACHE 8 Balthazar CT score *术语定义急性胰腺炎胰腺的急性炎症轻症急性胰腺炎无明显器官功能障碍，对液体治疗反应良好重症急性胰腺炎具备下列情况之一 局部并发症（胰腺坏死、假性囊肿、胰腺脓肿） 器官衰竭 Ranson评分3 APACHE