改善微循环和防止细胞钙超载在阻止急性胰腺炎重症化治疗中的作用

目的 探讨改善胰腺缺血和防止钙超载在阻止急性胰腺炎理症化治疗中的作用。方法 报道278例急性胰腺炎（AP）的治疗及体会。第一阶段（1990年1月至1994年12月）采取常规非手术治疗，第二阶段（1995年1月至1999年12月）采取改善微循环和防止细胞钙超负荷的措施。结果 后阶段的治疗方案可明显降低轻型胰腺炎向重症胰腺炎的转化率，减少全身并发症发生率，降低死亡率，缩短治愈时间。结论 重点改善胰腺缺血和防止细胞钙超负荷的治疗有助于阻止AP由轻型向重型的发展，限制胰腺坏死，改善AP预后。     

胆胰和胃冲剂预防急性胰腺炎重型化

目的：观察胆胰和胃冲剂在预防急性胰腺炎重型化过程中的作用。方法：将58例轻型急性胰腺炎患者随机分为2组,A组在常规治疗的基础上加用胆胰和胃冲剂,B组仅行常规治疗。结果：胆胰和胃冲剂治疗组（A组）在恢复排气、排便的时间,症状、体征消失时间,住院天数,总疗效及APACHEⅡ评分等评价中显著优于常规治疗组（B组）,P〈0.05。A组有1例患者发展为重症急性胰腺炎,较B组的7例明显减少。结论：胆胰和胃冲剂可使急性胰腺炎的急性生理过程在早期就保持稳定,使其转化为重症急性胰腺炎的风险显著降低。     

阻止急性胰腺炎由轻型向重症发展的非手术治疗172例报告

目的 探讨阻止急性胰腺炎（ＡＰ）由轻型向重症发展的非手术治疗方法。方法 总结分析了１９９４～１９９６年和１９９６～１９９８年两个阶段共收治的１７２例ＡＰ患者的治疗效果。第１阶段采取常规保守治疗,第２阶段采取改善微循环和防止细胞钙超负荷的措施。结果 第１阶段共收治的ＡＰ患者７８例,轻型ＡＰ７６例,其中有转化为重症ＡＰ８例;重症ＡＰ１０例,出现全身性并发症９例,局部并发症７例,死亡３例。第２阶段共收治     

胰激肽原酶对重症急性胰腺炎大鼠胰腺微循环的影响

胰腺微循环障碍是急性胰腺炎发病和加重机制之一及重要的病生理表现,它可能是始动因素,并作为一种持续损伤机制贯穿于急性胰腺炎发展的整个过程.胰激肽原酶有扩张微血管,改善微循环的作用,临床已应用于微循环障碍性疾病的治疗,但在急性胰腺炎中尚未见报道.该文即探讨胰激肽原酶对重症急性胰腺炎大鼠胰腺微循环的影响.     

细胞因子在胰腺炎发生发展中的作用

急性胰腺炎（AP）是胰酶消化胰腺及其周围组织所引起的急性炎症,是一种以炎性细胞浸润、胰腺水肿、出血及坏死为特征的胰腺炎性疾病．AP形成机制主要包括：胰酶自身消化学说、微循环障碍学说、炎症介质释放学说、细胞凋亡学说、钙超载、免疫紊乱学说等。近年来,随着研究的深入,细胞因子和炎症反应失衡理论的重要性已得到公认,细胞因子水平可用于判断AP的病情及预后。     

中西医结合治疗重症急性胰腺炎疗效分析

目的观察中西医结合治疗重症急性胰腺炎的疗效。方法选择我院2002年1月~2005年6月非手术治疗的41例重症急性胰腺炎病人随机分为治疗组和对照组。治疗组21例行西医常规治疗,同时给予中药清胰汤100ml,每12h胃管内注入,加闭管1h。对照组20例仅给予西医常规治疗。比较两组病人腹痛、腹胀缓解,恢复排气、通便,血淀粉酶降至正常时间及平均住院时间,死亡率。结果治疗组腹痛、腹胀缓解,恢复排气、通便及血淀粉酶降至正常时间和平均住院时间均短于对照组。结论中西医结合治疗重症急性胰腺炎有较明显的协同作用,其疗效优于单纯西医常规治疗。     

急性胰腺炎微循环障碍与治疗

急性胰腺炎(Acute pancreatits．AP)的病理生理一直被认为是由于胰酶激活以后所致胰腺及其周围组织的损伤。在治疗上则有针对性地用蛋白酶抑制剂，抑制胰腺分泌。但是大量实验和临床研究并未发现其有想象的效果。近年来人们开始注意到微循环障碍在AP中的作用。在轻症胰腺炎向重症急性胰腺炎(Severe acute pancreatitis,SAP)演进过程中，微循环障碍具有十分重要的作用。改善微循环，将可能提高AP的治疗效果。     

78例急性胰腺炎患者的护理体会

<正>急性胰腺炎是临床外科常见急腹症,多由胰酶对胰腺组织的"消化"作用引起。可分为水肿性胰腺炎和出血坏死性胰腺炎。出血坏死性胰腺炎病情进展迅速,易引起严重的腹膜炎及多脏器功能损害,病死率高。2011-8-2013-8间,我科收治急性胰腺炎患者78例,4例重症患者采取紧急手术治疗,清除胰腺和胰周坏死组织,腹腔灌洗引流。其余74例均采取非手术治疗,给予控制饮食和胃肠减压、静脉补充水分电解质和热能、减少胰酶分泌、抑制胰酶作用、消炎止痛等治疗及护理措施,均痊愈出院,现将护理体会总结如下。     

重症急性胰腺炎营养治疗的策略与效果

一、重症急性胰腺炎(SAP)营养治疗的意义 急性胰腺炎主要的病理基础是胰酶对胰腺和胰周组织的自身消化,导致胰腺实质或胰周组织坏死及局部并发症(假性囊肿、胰腺脓肿等).     

清胰汤治疗重症急性胰腺炎46例

目的:探讨清胰汤治疗重症急性胰腺炎的临床疗效。方法:将98例患者随机分成2组,治疗组采用清胰汤中西结合治疗,对照组采用常规治疗,观察比较两组的疗效。结果:治疗组10d的总体临床效果明显优于对照组,而且并发多脏器功能衰竭、中转手术治疗及死亡率均低于对照组。结论:中西医结合治疗重症急性胰腺炎可提高治愈率,减少并发症及降低死亡率。     

Disturbances of the microcirculation in acute pancreatitis

BACKGROUND: Severe acute pancreatitis is characterized by pancreatic necrosis, resulting in local and systemic inflammation. Pancreatitis affects both the systemic and pancreatic vasculature. This review focuses on the underlying processes involved in the changes of microvascular anatomy following acute pancreatitis. METHODS: A Medline/PubMed search (January 1966 to December 2005) with manual cross-referencing was conducted. All relevant articles investigating the pancreatic microcirculatory anatomy and the effect of pancreatitis on the microcirculation were included. RESULTS: The pancreas is susceptible to ischaemic insult, which can exacerbate acute pancreatitis. There is also increasing evidence of pancreatic and systemic microvascular disturbances in the pathogenesis of pancreatitis, including vasoconstriction, shunting, inadequate perfusion, and increased blood viscosity and coagulation. These processes may be caused or exacerbated by ischaemia-reperfusion injury and the development of oxygen-derived free radicals. CONCLUSION: Acute pancreatitis impairs the pancreatic and systemic microcirculation, which is a key pathological process in the development of severe necrotizing disease.     

Effects of heparin in experimental models of acute pancreatitis and post-ERCP pancreatitis

BACKGROUND: Acute pancreatitis (AP) is a complication of diagnostic or therapeutic endoscopic retrograde cholangiopancreatography (ERCP). In a recent clinical trial, a decreased rate of post-ERCP pancreatitis was shown after prophylactic heparin treatment. The aim of this study was to evaluate the effects of prophylactic heparin application in various experimental models of AP and pancreatic duct obstruction and to assess the underlying mechanisms. METHODS: In various experimental models, pancreatic injury of graded severity was induced in Wistar rats: (1) mild pancreatitis by IV cerulein infusion over 6 hours; (2) severe pancreatitis by infusion of glycodeoxycholic acid into the pancreatic duct plus IV cerulein application over 6 hours. The clinical ERCP situation was imitated in groups (3) obstruction of the pancreatic duct and (4) infusion of contrast medium into the pancreatic duct plus obstruction. In every group the animals received either no heparin (n=six per group) or continuous IV heparin (n=six per group) starting before pancreatic injury. Histologic changes, amylase, and lipase in plasma were evaluated 12 hours after induction of pancreatic injury. Additional animals were treated to investigate pancreatic microcirculation by intravital microscopy (n=six per group). RESULTS: In groups 1, 3, and 4 (mild AP/duct obstruction/duct obstruction plus contrast medium), IV heparin-treated animals showed reduced edema, inflammation, and peak amylase values compared with the corresponding non-heparin-treated animals (P<.05). Moreover, mean erythrocyte velocity was significantly higher and leukocyte-endothelium interaction was reduced in these groups after prophylactic administration of heparin. In contrast, group 2 (severe AP) did not show any difference between control animals and animals that received heparin as assessed by histology and intravital microscopy. CONCLUSIONS: Prophylactic systemic application of heparin provides a protective effect in mild AP and in experimental post-ERCP pancreatitis. The mechanism of the protective effects of heparin seems to be the reduction of leukocyte-endothelium interaction and the normalization of pancreatic microcirculation.     

Pancreatic tissue perfusion in experimental acute pancreatitis.

OBJECTIVE: To investigate pancreatic tissue perfusion and oxygenation in severe and mild experimental acute pancreatitis in pigs. DESIGN: Randomised controlled experiment. SETTING: Animal laboratory, Finland. ANIMALS: 24 domestic pigs weighing 21-27 kg. INTERVENTIONS: 24 pigs were randomised into severe acute pancreatitis, mild acute pancreatitis and control groups (n = 8 in each). The pancreatic duct of eight anaesthetised and mechanically ventilated pigs was cannulated and taurocholic acid was infused into the pancreatic duct to induce severe acute pancreatitis. Eight animals received intraductally infused saline and developed mild acute pancreatitis. Eight pigs had their ducts cannulated alone, and served as controls. MAIN OUTCOME MEASURES: Pancreatic tissue oxygenation, laser Doppler red cell flux, central haemodynamics. RESULTS: Intraductally infused taurocholic acid rapidly induced macroscopically and histologically proven severe necrotising acute pancreatitis. Histological changes characterising mild acute pancreatitis were seen in animals after intraductal saline infusion. Pancreatic tissue oxygen tension decreased in the severe group and increased in the mild group during the six-hour study period. Laser Doppler red cell flux decreased in the severe group. Central haemodynamics, arterial blood gases, and acid base balances were stable throughout the study period in all groups. CONCLUSION: The present model of severe acute pancreatitis significantly impairs pancreatic oxygenation in the early phase. In mild acute pancreatitis, pancreatic oxygenation increases.     

Efficacy of somatostatin and its analogues in the treatment of acute pancreatitis: clinical retrospective study

Acute pancreatitis is an acute inflammatory disease of the pancreas, with variable involvement of other regional tissues or remote organ systems. Acute pancreatitis is mild in 80% of cases; virtually all patients with this form of disease will survive, because it's associated with minimal organ dysfunction and uneventful recovery; the severe pancreatitis develops in 20% of cases and is associated with higher morbidity and mortality. It's most important to identify the severity of disease at the moment of hospital admission; many scoring systems have been developed to serve as early prognostic signs: Ranson's criteria, Imrie's criteria, Apache II score, Balthazar's TC score. Recently, new drugs have been proposed in the treatment of acute pancreatitis, as, for example, calcitonine, glucagon, systemic antioxidants, antagonists of the receptors of interleukines, antiproteases (aprotinin and gabexate-mesilate) and the inhibitors of pancreatic secretions (somatostatin and its analogues). However, many controversies still exist concerning the real efficacy of these drugs in the treatment of acute pancreatitis, particularly regarding the inhibitors of pancreatic secretions: recently, some studies showed that somatostatin is able to actually reduce the local complication of the disease and the development of severe forms of acute pancreatitis; on the other hand, other studies failed to show real advantages of somatostatin reducing morbidity and mortality for pancreatitis. The aim of present study is a retrospective analysis of patients affected by acute pancreatitis in order to evaluate efficacy of somatostatin and its analogues. All patients subdivided in two groups: group A, patients treated with conventional therapy plus somatostatin and/or octreotide (SS/LS), and group B, patients treated only with conventional therapy. Results seem to show that somatostatin does not positively affect morbidity and mortality in patients with acute pancreatitis. The Authors conclude that, at present; somatostatin cannot be considered surely effective in preventing complications and mortality in acute pancreatitis. Further studies are still necessary to verify the effectiveness of somatostatin and its analogues in the therapy of acute pancreatitis.     

Renal microcirculation in experimental acute pancreatitis of dogs--the effect of pancreatic protease inhibitor and dopamine

To understand the renal microcirculation in acute pancreatitis is important to know the pathophysiology of renal insufficiency frequently observed as one of multiple organ failures in severe acute pancreatitis. In mongrel dogs acute pancreatitis was experimentally introduced by autologous bile added trypsin injection into the pancreatic duct. The effect of new synthesized pancreatic protease inhibitor (PATM) and dopamine in a dose of 3mg/kg/hr and 10 micrograms/kg/min were investigated, respectively. In acute pancreatitis dogs, renal arterial blood flow and renal tissue blood flow immediately fell and gradually decreased in time course of experiment and renal vascular resistance increased from 2 hours after onset of pancreatitis. When pancreatic protease inhibitor (PATM) was infused in acute pancreatitis dogs, blood pressure and pulse pressure relatively preserved during the experiment. Renal blood flow and renal tissue blood flow were maintained during the first 1 hour and thereafter slightly decreased, however which was less than that of no PATM treated dogs. When dopamine was infused in acute pancreatitis dogs, blood pressure was maintained during the first 90 minutes thereafter remarkably decreased. Renal blood flow was maintained within 60 minutes, however it remarkably decreased at the end of the experiment. This study suggested that renal microcirculation was disturbed from early period of acute pancreatitis in dogs and pancreatic protease inhibitor (PATM) had a beneficial effect of maintain the renal microcirculation.     

急性胰腺炎患者血液中细胞因子的变化

为探讨急性胰腺炎患者血液中细胞因子变化与病情严重度及多器官功能障碍（ＭＯＤ）之间的关系，对１９９４年至１９９６年入院的３６例急性胰腺炎患者依据ＲＡＮＳＯＮ评分和ＣＴ评分将其分为轻型组（１２例）和重型胰腺炎组（２４例），又将重型胰腺炎组中发生ＭＯＤＳ的９例定名为障碍组。在入院第０、４、８天测定血清ＴＮＦ、ＩＬ６、ＣＲＰ值。结果显示胰腺炎早期患者血液中细胞因子在轻型组、重型组和障碍组之间依次升高，并有显著性差异（Ｐ＜０．０５）。由此表明急性胰腺炎细胞因子升高与疾病严重度和并发症发生有关，极度升高者可能发生多器官衰竭，动态检测上述细胞因子有助于判断患者的预后     

Controlled clinical trial of selective decontamination for the treatment of severe acute pancreatitis.

OBJECTIVE: A randomized, controlled, multicenter trial was undertaken in 102 patients with objective evidence of severe acute pancreatitis to evaluate whether selective decontamination reduces mortality. SUMMARY BACKGROUND DATA: Secondary pancreatic infection is the major cause of death in patients with acute necrotizing pancreatitis. Controlled clinical trials to study the effect of selective decontamination in such patients are not available. METHODS: Between April 22, 1990 and April 19, 1993, 102 patients with severe acute pancreatitis were admitted to 16 participating hospitals. Patients were entered into the study if severe acute pancreatitis was indicated, on admission, by multiple laboratory criteria (Imrie score > or = 3) and/or computed tomography criteria (Balthazar grade D or E). Patients were randomly assigned to receive standard treatment (control group) or standard treatment plus selective decontamination (norfloxacin, colistin, amphotericin; selective decontamination group). All patients received full supportive treatment, and surveillance cultures were taken in both groups. RESULTS: Fifty patients were assigned to the selective decontamination group and 52 were assigned to the control group. There were 18 deaths in the control group (35%), compared with 11 deaths (22%) in the selective decontamination group (adjusted for Imrie score and Balthazar grade: p = 0.048). This difference was mainly caused by a reduction of late mortality (> 2 weeks) due to significant reduction of gram-negative pancreatic infection (p = 0.003). The average number of laparotomies per patient was reduced in patients treated with selective decontamination (p < 0.05). Failure of selective decontamination to prevent secondary gram-negative pancreatic infection with subsequent death was seen in only three patients (6%) and transient gram-negative pancreatic infection was seen in one (2%). In both groups of patients, all gram-negative aerobic pancreatic infection was preceded by colonization of the digestive tract by the same bacteria. CONCLUSION: Reduction of gram-negative colonization of the digestive tract, preventing subsequent pancreatic infection by means of selective decontamination, significantly reduces morbidity and mortality in patients with severe acute necrotizing pancreatitis.     

Safety and efficacy of conservative management in acute severe pancreatitis

Acute severe pancreatitis represents a disease with multiple complications and a high mortality rate. The clinical evolution is related to the acute systemic inflammatory response syndrome, due mainly to inflammatory mediators and pancreatic enzymes and to the infectious complications representing a peak in the incidence of death. This study aims to retrospectively analyse the outcome of patients diagnosed with acute severe pancreatitis, conservatively treated versus those surgically managed. This study includes 151 patients, each having been diagnosed with acute severe pancreatitis (CT using Balthazar's) distributed in term of age, sex and severity parameters. The conservative treatment has included antibiotics, and anti-inflammatory drugs. The imaging and biological parameters were further statistically analysed. The clinical-biological evolution has been paralleled by the CT severity index. The conservatively treated group had a better clinical-biological outcome (p<0.05), when compared with the surgically treated group. Morbidity was significantly higher in the group exposed to surgical treatment. Conservative treatment should be the first option in acute severe pancreatitis management.     

Therapeutic effect of isovolemic hemodilution with dextran 60 on the impairment of pancreatic microcirculation in acute biliary pancreatitis.

Dextran of different molecular weight (Dx 40, Dx 60/70) has often been evaluated as adjunct treatment of experimental acute pancreatitis. A beneficial effect has been documented by a decrease in its lethality. However, the mechanism of action is poorly understood. A specific effect on the pancreatic microcirculation generally has not been documented and differentiation from unspecific improvement of pancreatic blood flow due to volume expansion has been difficult. This investigation was designed to quantify the effect of dextran on the impairment of pancreatic microcirculation during acute biliary pancreatitis by means of intravital microscopy. Dextran 60 (Dx 60, molecular weight 60,000) was chosen in light of the increase in vascular permeability in the early stage of pancreatitis as demonstrated previously in the same model. Isovolemic hemodilution, i.e., exchange of whole blood for Dx 60 was used as a mode of administration to achieve instantaneous onset of therapy without changes in intravascular volume. In the control group a progressive reduction of pancreatic capillary perfusion commenced 30 minutes after induction of acute pancreatitis, resulting in cessation of nutritive tissue perfusion after 3 hours. In the animals subjected to hemodilution, stabilization of the pancreatic microcirculation was accomplished throughout the observation period of 6 hours. Because volume-related effects could be excluded by the protocol and by monitoring central venous pressure and hematocrit, a specific effect of hemodilution with DX 60 on the pancreatic microcirculation is indicated by our results.