1、急性胰腺炎和结核性腹膜炎急性胰腺炎和结核性腹膜炎概概 念念分分 类类（Mild acute pancreatitis）（Severe acute pancreatitis）分分 类类 病理分类：病理分类：急性水肿型胰腺炎（急性水肿型胰腺炎（90%）Acute interstitial pancreatitis急性出血坏死性胰腺炎急性出血坏死性胰腺炎 Acute necrotizing pancreatitis病因和发病机制病因和发病机制胆管疾病胆管疾病（胆源性急性胰腺炎）（胆源性急性胰腺炎）Biliary tract obstruction caused by a gallstone in t
2、he distal common bile duct.F,49 Y/O,there is much exudate between the gastric wall and the pancreatic parenchyma.F,49 Y/O,the echoic foci was found in the CBD with acoustic shadowing大量饮酒和暴饮暴食大量饮酒和暴饮暴食Picture 2.ERCP of pancreas divisum.Injection of contrast following cannulation of the minor ampulla(
3、same patient as Picture 1)demonstrates filling of a separate larger duct of Santorini,which drains the entire pancreatic body and tail.Picture 1.ERCP of pancreas divisum.Contrast injection following cannulation of the ampulla of Vater demonstrates filling of the common bile duct and a small pancreat
4、ic duct of Wirsung,which drains the pancreatic head.Picture 2.Picture 1手术与创伤手术与创伤内分泌与代谢障碍内分泌与代谢障碍感染感染药物药物炎症反应炎症反应微循环障碍微循环障碍病病 理理临床表现临床表现轻型急性胰腺炎轻型急性胰腺炎重症急性胰腺炎重症急性胰腺炎临床表现临床表现腹痛的机制腹痛的机制休克的机制休克的机制体体 征征重症：重症：R.E.Pounder et.al.1989病病 程程并发症并发症全身全身:急性呼吸衰竭（急性呼吸衰竭（ARDSARDS）心律失常和心力衰竭心律失常和心力衰竭急性肾衰竭急性肾衰竭消化道出血消化道
5、出血胰性脑病胰性脑病凝血异常凝血异常多器官功能衰竭多器官功能衰竭败血症及真菌感染败血症及真菌感染高血糖高血糖慢性胰腺炎慢性胰腺炎并发症并发症实验室检查实验室检查淀粉酶、肌肉酐清除率比值淀粉酶、肌肉酐清除率比值（CAm/CCr%）血清肌酐血清肌酐尿肌酐尿肌酐100100生化检查生化检查血钙血钙低低O2血症血症腹部腹部B B超超常规初筛检查，常规初筛检查，胰腺肿大、胰内胰周回声异胰腺肿大、胰内胰周回声异常、脓肿、假性囊肿常、脓肿、假性囊肿CTCT检查检查评估胰腺炎严重程度；评估胰腺炎严重程度；增强扫描诊断胰腺坏死；增强扫描诊断胰腺坏死；疑感染，疑感染，CT引导下穿刺；引导下穿刺；发现局部并发症。发
6、现局部并发症。诊诊 断断诊断标准诊断标准符合下列符合下列4 4个条件之一者可诊断为个条件之一者可诊断为SAP:SAP:有胰腺局部并发症（胰腺坏死、假性囊肿、有胰腺局部并发症（胰腺坏死、假性囊肿、胰腺脓肿等）胰腺脓肿等）有器官功能衰竭有器官功能衰竭RansonRanson评分评分33APACHAPACH评分评分8855岁岁16109 11.1mmol/L250U/L350U/L下降下降10%上升上升1.8mmol/L2mmol/L4mEq/L6LRansonRanson标准标准急性生理学和慢性健康急性生理学和慢性健康评估系统评估系统APACH-SCOREAcute Physiology and
7、Chronic Health Evaluation A:总急性生理参数总急性生理参数Total Acute Physiology Score(APS)B:年龄分数年龄分数 Age points C:慢性健康状况评分慢性健康状况评分Chronic Health points SCORE:ABC鉴别诊断鉴别诊断溃疡穿孔溃疡穿孔胆囊炎胆囊炎急性肠梗阻急性肠梗阻心肌梗塞心肌梗塞治治 疗疗治治 疗疗Vedio Needle-knife papillotomy in patient with stone impacted in the papillary orifice.This is the easiest and safest setting in which to perform needle-knife precut.The stone delivers itself and biliary drainage is readily achieved.Freeman et.al GIE 2005 手手 术术 治治 疗疗谢谢！
