ERCP治疗急性胆源性胰腺炎

急性胆源性胰腺炎(ABP)是消化内科常见急腹症之一,是急性胰腺炎中最常见的类型,占急性胰腺炎每年发病人数的40%-60%,病死率较高,常规药物治疗不能从根本上解除病因,易导致复发,手术治疗风险较大,创伤较大,费用较高,住院时间较长,易引起其术后并发症,不利于患者恢复。而经内镜逆行胰胆管造影(ERCP)作为一种内镜与放射技术相结合的诊断治疗方法,对胆管内结石并发急性胰腺炎的诊断率是最高的,诊断结石的敏感性大于95%。在20世纪70年代被认为是急性胆源性胰腺炎的禁忌症,近年来随着ERCP技术的不断发展和广泛应用,ERCP已成为治疗胆胰疾病的一种安全有效的技术。ERCP可清除胆管结石,从而达到通畅胆道,减少胆汁向胰管反流,迅速改善患者病情,阻断病情进展的目的,并有效缩短住院时间,减轻患者痛苦,减少复发和改善总体预后,为广大ABP患者带来了福音,此外,还能减少患者住院费用,节省医疗资源,对于个人及社会均具有积极意义,值得推广。     

急性胆源性胰腺炎行腹腔镜胆囊切除的体会

目的:探讨应用腹腔镜技术治疗急性胆源性胰腺炎的可行性、有效性和手术方法。方法:回顾分析我院腹腔镜胆囊切除术在急性胆源性胰腺炎治疗中的病人资料,将其按发病后的手术时间分为三组,统计各组病人的手术耗时、术后住院天数、住院花费以及并发症的有无。结果:经过随访有34位患者术后恢复良好,有1位复发,三组之间的手术耗时、术后住院天数、住院花费以及并发症无统计学差异(P>0.05)。结论:急性胆源性胰腺炎患者采用腹腔镜手术治疗效果明显、安全,手术时机的选择无严格的限定。     

急性胰腺炎患者腹腔镜胆囊切除术的时机研究

目的:探讨急性胰腺炎胆囊切除术的有效性及时机。方法:分别对患有急性胰腺炎而进行腹腔镜胆囊切除的38例患者的临床信息进行了研究。结果:首先对38例病人进行了3~15天非手术的保守治疗,当临床症状和表征基本消失,血、尿中的淀粉酶接近正常水平时,进行胆囊切除。手术时间为30分钟到90分钟(平均时间60分钟),手术中无转化和严重并发症症状发生。对这38例病人随访6到56周后无复发现象发生。结论:当临床症状和表征基本消失,血、尿中的淀粉酶接近正常水平时,急性胰腺炎胆囊切除术是有效且可行的。在中国患有急性胰腺炎的患者中,进行腹腔镜胆囊切除的占50%~70%[1]。胆结石治疗取决于患者胰腺炎的严重性,及患者是否患有梗阻性黄疸。对于非梗阻性胰腺炎的患者,早期是否要进行明确的手术治疗尚无定论。我院患有急性胰腺炎的38例患者进行腹腔镜胆囊切除术(2004年2月到2009年4月之间)后取得了满意的效果。详情如下。     

急性胰腺炎患者腹腔镜胆囊切除术的时机研究

目的：探讨急性胰腺炎胆囊切除术的有效性及时机。方法：分别对患有急性胰腺炎而进行腹腔镜胆囊切除的38例患者的临床信息进行了研究。结果：首先对38例病人进行了3-15天非手术的保守治疗,当临床症状和表征基本消失,血、尿中的淀粉酶接近正常水平时,进行胆囊切除。手术时间为30分钟到90分钟（平均时间60分钟）,手术中无转化和严重并发症症状发生。对这38例病人随访6到56周后无复发现象发生。结论：当临床症状和表征基本消失,血、尿中的淀粉酶接近正常水平时,急性胰腺炎胆囊切除术是有效且可行的。在中国患有急性胰腺炎的患者中,进行腹腔镜胆囊切除的占50％～70％。胆结石治疗取决于患者胰腺炎的严重性,及患者是否患有梗阻性黄疸。对于非梗阻性胰腺炎的患者,早期是否要进行明确的手术治疗尚无定论。我院患有急性胰腺炎的38例患者进行腹腔镜胆囊切除术（2004年2月到2009年4月之间）后取得了满意的效果。详情如下。     

Retrocrural Space Involvement on Computed Tomography as a Predictor of Mortality and Disease Severity in Acute Pancreatitis

Background

Because computed tomography (CT) has advantages for visualizing the manifestation of necrosis and local complications, a series of scoring systems based on CT manifestations have been developed for assessing the clinical outcomes of acute pancreatitis (AP), including the CT severity index (CTSI), modified CTSI, etc. Despite the internationally accepted CTSI having been successfully used to predict the overall mortality and disease severity of AP, recent literature has revealed the limitations of the CTSI. Using the Delphi method, we establish a new scoring system based on retrocrural space involvement (RCSI), and compared its effectiveness at evaluating the mortality and severity of AP with that of the CTSI.

Methods

We reviewed CT images of 257 patients with AP taken within 3–5 days of admission in 2012. The RCSI scoring system, which includes assessment of infectious conditions involving the retrocrural space and the adjacent pleural cavity, was established using the Delphi method. Two radiologists independently assessed the RCSI and CTSI scores. The predictive points of the RCSI and CTSI scoring systems in evaluating the mortality and severity of AP were estimated using receiver operating characteristic (ROC) curves.

Principal Findings

The RCSI score can accurately predict the mortality and disease severity. The area under the ROC curve for the RCSI versus CTSI score was 0.962±0.011 versus 0.900±0.021 for predicting the mortality, and 0.888±0.025 versus 0.904±0.020 for predicting the severity of AP. Applying ROC analysis to our data showed that a RCSI score of 4 was the best cutoff value, above which mortality could be identified.

Conclusion

The Delphi method was innovatively adopted to establish a scoring system to predict the clinical outcome of AP. The RCSI scoring system can predict the mortality of AP better than the CTSI system, and the severity of AP equally as well.     

Protective Effects of Hydrogen Gas on Experimental Acute Pancreatitis

Acute pancreatitis (AP) is an inflammatory disease mediated by damage to acinar cells and pancreatic inflammation. In patients with AP, subsequent systemic inflammatory responses and multiple organs dysfunction commonly occur. Interactions between cytokines and oxidative stress greatly contribute to the amplification of uncontrolled inflammatory responses. Molecular hydrogen (H₂) is a potent free radical scavenger that not only ameliorates oxidative stress but also lowers cytokine levels. The aim of the present study was to investigate the protective effects of H₂ gas on AP both in vitro and in vivo. For the in vitro assessment, AR42J cells were treated with cerulein and then incubated in H₂-rich or normal medium for 24 h, and for the in vivo experiment, AP was induced through a retrograde infusion of 5% sodium taurocholate into the pancreatobiliary duct (0.1 mL/100 g body weight). Wistar rats were treated with inhaled air or 2% H₂ gas and sacrificed 12 h following the induction of pancreatitis. Specimens were collected and processed to measure the amylase and lipase activity levels; the myeloperoxidase activity and production levels; the cytokine mRNA expression levels; the 8-hydroxydeoxyguanosine, malondialdehyde, and glutathione levels; and the cell survival rate. Histological examinations and immunohistochemical analyses were then conducted. The results revealed significant reductions in inflammation and oxidative stress both in vitro and in vivo. Furthermore, the beneficial effects of H₂ gas were associated with reductions in AR42J cell and pancreatic tissue damage. In conclusion, our results suggest that H₂ gas is capable of ameliorating damage to the pancreas and AR42J cells and that H₂ exerts protective effects both in vitro and in vivo on subjects with AP. Thus, the results obtained indicate that this gas may represent a novel therapy agent in the management of AP.     

Effects of Soluble Epoxide Hydrolase Deficiency on Acute Pancreatitis in Mice

Background

Acute pancreatitis (AP) is a frequent gastrointestinal disorder that causes significant morbidity, and its incidence has been progressively increasing. AP starts as a local inflammation in the pancreas that often leads to systemic inflammatory response and complications. Soluble epoxide hydrolase (sEH) is a cytosolic enzyme whose inhibition in murine models has beneficial effects in inflammatory diseases, but its significance in AP remains unexplored.

Methodology/Principal Findings

To investigate whether sEH may have a causal role in AP we utilized Ephx2 knockout (KO) mice to determine the effects of sEH deficiency on cerulein- and arginine-induced AP. sEH expression increased at the protein and messenger RNA levels, as well as enzymatic activity in the early phase of cerulein- and arginine-induced AP in mice. In addition, amylase and lipase levels were lower in cerulein-treated Ephx2 KO mice compared with controls. Moreover, pancreatic mRNA and serum concentrations of the inflammatory cytokines IL-1B and IL-6 were lower in cerulein-treated Ephx2 KO mice compared with controls. Further, Ephx2 KO mice exhibited decreased cerulein- and arginine-induced NF-κB inflammatory response, MAPKs activation and decreased cell death. Conclusions -These findings demonstrate a novel role for sEH in the progression of cerulein- and arginine-induced AP.     

空肠营养对重症急性胰腺炎的疗效观察

目的:探讨早期空肠营养对重症急性胰腺炎(SAP)的疗效。方法:118名重症急性胰腺炎患者随机分为EN组和TPN组,比较两组SAP病人住院时间、费用、感染率、并发症及死亡率等。结果:TPN组住院时间长,费用高,感染率、并发症及病死率高,差异具有显著性。结论:早期空肠营养支持可明显改善SAP病情,提高治疗效果。     

空肠营养对重症急性胰腺炎的疗效观察

目的：探讨早期空肠营养对重症急性胰腺炎（SAP）的疗效。方法：118名重症急性胰腺炎患者随机分为EN组和TPN组．比较两组SAP病人住院时间、费用、感染率、并发症及死亡率等。结果：TPN组住院时间长,费用高,感染率、并发症及病死率高。差异具有显著性。结论：早期空肠营养支持可明显改善SAP病情,提高治疗效果。     

双氯灭痛胶浆对重症急性胰腺炎大鼠的治疗作用机制

目的:研究双氯灭痛胶浆对大鼠重症急性胰腺炎(SAP)的治疗作用及机制探讨.方法:将大鼠随机分成双氯灭痛胶浆治疗组(Ds)、重症急性胰腺炎组(SAP)和正常对照组(N),术后分别于12、24和36h处死,观察血清淀粉酶、SOD、CAT、NO、丙二醛(MDA)、核因子κB(NF-κB)、及胰腺大体病理及光镜下病理变化.结果:治疗组的淀粉酶、NF-κB、NO、MDA、胰腺组织的Hughes评分均明显降低、SOD、CAT、明显升高(P＜0.05).结论:双氯灭痛胶浆对大鼠SAP有治疗作用,其作用机制可能与抑制NF-κB等前致炎物质的释放,清除自由基和抗脂质过氧化反应,抑制胰腺组织中的中性粒细胞的浸润及其活化程度有关.     

Serum YKL-40 Levels Correlate with Infarct Volume,Stroke Severity,and Functional Outcome in Acute Ischemic Stroke Patients

Background and Purpose

YKL-40 is associated with various neurological disorders. However, circulatory YKL-40 levels early after onset of acute ischemic stroke (AIS) have not been systematically assessed. We aimed to identify the temporal changes and clinical usefulness of measuring serum YKL-40 immediately following AIS.

Methods

Serum YKL-40 and C-reactive protein (CRP) levels were monitored over time in AIS patients (n = 105) and compared with those of stroke-free controls (n = 34). Infarct volume and stroke severity (National Institutes of Health Stroke Scale; NIHSS) were measured within 48 hours of symptom onset, and functional outcome (modified Rankin Scale; mRS) was measured 3 months after AIS.

Results

Within 12 hours of symptom onset, levels of YKL-40 (251 vs. 41 ng/mL) and CRP (1.50 vs. 0.96 µg/mL) were elevated in AIS patients compared to controls. The power of YKL-40 for discriminating AIS patients from controls was superior to that of CRP (area under the curve 0.84 vs. 0.64) and YKL-40 (r = 0.26, P<0.001) but not CRP levels were correlated with mRS. On day 2 of admission (D2), YKL-40 levels correlated with infarct volume and NIHSS. High YKL-40 levels predicted poor functional outcome (odds ratio 5.73, P = 0.03). YKL-40 levels peaked on D2 and declined on D3, whereas CRP levels were highest on D3.

Conclusions

Our results demonstrate serial changes in serum YKL-40 levels immediately following AIS and provide the first evidence that it is a valid indicator of AIS extent and an early predictor of functional outcome.     

ERCP联合胆道微结石检测在特发性急性胰腺炎病因诊断中的临床意义

目的:探讨内镜下逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)联合胆道微结石检测对特发性急性胰腺炎(idiopathic acute pancreatitis,IAP)病因诊断的意义;方法:选择我院普外科收治的急性胰腺炎患者178例,其中69例以常规方法检查(对照组),其余109例除行常规检查项目外,对不能明确病因者即IAP行ERCP+胆道微结石(biliarymicrolithiasis,BML)检测寻找病因,比较两种方法对IAP病因学诊断的临床意义。结果:对照组有39例明确病因,占56.52%。研究组常规检查后有65例明确病因,占59.63%。未知病因的患者行ERCP+BML检测,其中35例明确病因,8例ERCP无异常,IAP的总病因诊断率为79.55%(35/44)。对照组通过常规方法检测明确IAP病因12例,占40.00%(12/30),显著低于研究组(x2=12.038,P<0.001)。(P<0.05)。结论:BML是IAP的重要病因之一,ERCP检查联合BML检测可显著提高IAP的病因诊断率。     

参芪扶正注射液对大鼠重症急性胰腺炎的治疗作用

目的:研究参芪扶正注射液对重症急性胰腺炎(SAP)的治疗作用。方法:66只Wistar大鼠随机分为:SAP假手术组(SO组),SAP模型组(SAP组)和参芪扶正注射液治疗组(SQ组),胆胰管逆行注射50g.l~(-1)牛磺胆酸钠复制大鼠SAP模型。造模成功后2、4、8、12、24 h检测血清中TNF-α、IL-6和ALT水平,观察肝脏组织病理改变。结果:与SO组相比,SAP组及SQ组血清中TNF-α、IL-6和ALT水平明显升高(P<0.05)。与SAP组相比,从8 h开始SQ组血清中TNF-α、IL-6和ALT水平开始下降(P<0.05),两组的肝脏病理改变无统计学意义。结论:参芪扶正注射液可以降低SAP时血清中ALT、TNF-α和IL-6水平,但不能改善肝脏组织的病理损伤程度,对SAP的发生、发展可能有一定的预防作用。     

Age-Dependent Effects of UCP2 Deficiency on Experimental Acute Pancreatitis in Mice

Reactive oxygen species (ROS) have been implicated in the pathogenesis of acute pancreatitis (AP) for many years but experimental evidence is still limited. Uncoupling protein 2 (UCP2)-deficient mice are an accepted model of age-related oxidative stress. Here, we have analysed how UCP2 deficiency affects the severity of experimental AP in young and older mice (3 and 12 months old, respectively) triggered by up to 7 injections of the secretagogue cerulein (50 μg/kg body weight) at hourly intervals. Disease severity was assessed at time points from 3 hours to 7 days based on pancreatic histopathology, serum levels of alpha-amylase, intrapancreatic trypsin activation and levels of myeloperoxidase (MPO) in lung and pancreatic tissue. Furthermore, in vitro studies with pancreatic acini were performed. At an age of 3 months, UCP2^-/- mice and wild-type (WT) C57BL/6 mice were virtually indistinguishable with respect to disease severity. In contrast, 12 months old UCP2^-/- mice developed a more severe pancreatic damage than WT mice at late time points after the induction of AP (24 h and 7 days, respectively), suggesting retarded regeneration. Furthermore, a higher peak level of alpha-amylase activity and gradually increased MPO levels in pancreatic and lung tissue were observed in UCP2^-/- mice. Interestingly, intrapancreatic trypsin activities (in vivo studies) and intraacinar trypsin and elastase activation in response to cerulein treatment (in vitro studies) were not enhanced but even diminished in the knockout strain. Finally, UCP2^-/- mice displayed a diminished ratio of reduced and oxidized glutathione in serum but no increased ROS levels in pancreatic acini. Together, our data indicate an aggravating effect of UCP2 deficiency on the severity of experimental AP in older but not in young mice. We suggest that increased severity of AP in 12 months old UCP2^-/- is caused by an imbalanced inflammatory response but is unrelated to acinar cell functions.     

丹参和甘遂在重症急性胰腺炎治疗中的联合应用

目的:探讨丹参和甘遂联合应用对重症急性胰腺炎(SAP)的治疗价值。方法:我院收治的SAP患者62例随机分为常规治疗组和联合治疗组(常规治疗加丹参和甘遂联合治疗)两组。比较两组间腹痛缓解时间、肠鸣音恢复时间、体温恢复时间、血淀粉酶恢复正常时间;局部并发症;ARDS、休克、肾功能衰竭、胰性脑病等全身并发症;平均住院时间、ICU住院时间、中转手术数和死亡例数。结果:与常规治疗组比较,联合治疗组中腹痛缓解时间、肠鸣音恢复时间、局部和全身并发症发生率、平均住院时间、ICU住院时间、死亡率显著减少(P<0.05),但体温恢复时间、血淀粉酶恢复正常时间和中转手术数无明显变化(P>0.05)。结论:在常规治疗基础上,联合应用丹参和甘遂对SAP具有缓解病情,降低平均住院时间和死亡率的作用。     

降钙素原与APACHEⅡ评分对急性胰腺炎病情严重程度及预后的评估价值

目的:探讨血清降钙素原(PCT)与急性生理学与慢性健康状况评分(APACHE Ⅱ)对急性胰腺炎(AP)患者病情严重程度及预后的评估价值。方法:选取本院2012年5月-2015年5月收治的急性胰腺炎患者280例为研究对象。根据急性胰腺炎患者病情严重程度将其分为低危组(83例)、中危组(102例)和高危组(95例);按患者临床结局将其分为存活组(248例)及死亡组(32例),采用酶联免疫吸附法(ELISA)检测各组血清PCT水平同时记录APACHE Ⅱ评分情况,分别比较PCT水平的差异以及与APACHE Ⅱ评分的相关性,评价血清PCT及APACHEⅡ评分对急性胰腺炎患者病情严重程度及预后的评估价值。结果:低危组、中危组及高危组间血清PCT水平和APACHE Ⅱ评分的差异具有统计学意义(P0.05)。其中,高危组血清PCT水平和APACHE Ⅱ评分最高,中危组次之,低危组最低(P0.05);死亡组PCT水平及APACHE Ⅱ评分显著高于存活组(P0.05)。相关性分析显示血清PCT水平与APACHE Ⅱ评分呈正相关(r=0.64,P0.01)。以PCT2.13 ng/m L为评估急性胰腺炎患者预后不佳界限时,其敏感性和特异性分别79.2%和91.3%;以APACHE Ⅱ评分18.1分为评估急性胰腺炎患者预后不佳界限时,其敏感性和特异性分别为82.7%和90.1%;两者指标串联评估敏感性及特异性分别为86.1%和92.9%,ROC曲线下面积为0.921(95%CI 0.824~0.938)。结论:急性胰腺炎患者血清PCT水平和APACHE Ⅱ评分具有较好的相关性,血清PCT水平越高,APACHEⅡ评分越高,患者病情越严重及预后也越差,二者联合可作为预测急性胰腺炎患者病情严重程度及预后的敏感指标,具有较好的临床应用价值。     

奥曲肽辅助十二指肠镜治疗急性水肿型胆源性胰腺炎疗效及对炎症反应的影响

目的:探讨奥曲肽辅助十二指肠镜治疗急性水肿型胆源性胰腺炎疗效及对炎症反应的影响。方法:选择急性水肿型胆源性胰腺炎患者100例,随机分为研究组与对照组各50例,两组患者均给予禁食、抗感染、营养支持、酶抑制剂治疗,对照组同期给予十二指肠镜治疗,研究组同期给予奥曲肽辅助十二指肠镜治疗,比较两组腹痛缓解时间,白细胞(WBC)、体温恢复正常时间,治疗前(T0)、治疗3d(T1)、治疗7d(T2)血、尿淀粉酶水平与炎症因子CRP、IL-6、TNF-α水平的变化。结果:(1)研究组腹痛缓解时间、WBC、体温恢复正常时间均较对照组明显缩短(P0.05);(2)两组患者T1、T2血、尿淀粉酶水平均较T0明显降低,且T2血、尿淀粉酶水平低于T1(P0.05),研究组T1、T2血、尿淀粉酶水平均低于对照组(P0.05);(3)两组T1、T2血清CRP、IL-6、TNF-α水平均较T0明显降低,且T2低于T1(P0.05),研究组T1、T2时血清CRP、IL-6、TNF-α水平均低于对照组(P0.05)。结论:奥曲肽辅助十二指肠镜治疗急性水肿型胆源性胰腺炎可提高早期治疗效果,减轻炎症反应。