急性胆源性胰腺炎快速康复治疗探讨—附62例病例分析

发布时间：2018-05-19 23:17

本文选题：急性胰腺炎 + 胆源性　；参考：《吉林大学》2013年硕士论文

【摘要】：急性胰腺炎(acute pancreatitis AP)是普外科常见急腹症，多见于青壮年，虽然发病机理至今仍不能完全解释清楚，但近些年的研究资料表明，，其主要病因是各种因素导致胰管阻塞、胰管内压力骤然增高、胰腺血液淋巴循环障碍等一系列病理生理改变引起胰腺消化酶对其自身消化的一种急性炎症，而胆道梗阻、酒精、胰腺血运循环障碍、创伤、感染等均是高危因素。虽然随着医学技术的发展和人们健康意识提高，使AP的发病率有所下降，但是仍然有20%—30%进一步发展为急性重症胰腺炎(severeacute pancreatitis SAP)，而使AP的总的死亡率仍达到5%—10%。而在AP的的类型中，急性胆源性胰腺炎(acute biliary pancreatitis，ABP)占所有胰腺炎患者的55%左右，病死率更是达20％，伴有并发症的患者者甚至高达50％。对于ABP的发生机理以“共同通道学说”和“胆石通过学说”最为著名且最受认同。在ABP的病因中，我国以胆道结石最为常见，目前认为ABP的发生主要是因为结石引发胆道梗阻，胆汁反流进入胰管，导致胰管内压力增高。所以解除梗阻和降低胰管压力是缓解和治疗急性胰腺炎的主要措施，但对于手术解除梗阻的时机仍无统一定论。临床观察显示，在部分ABP患者的影像学检查、术中探查、术后病理以及粪便中并未发现结石，手术时机的选择上也明显不同。本文通过对搜集的临床病例资料的观察，探讨ABP发生的病理过程以及对比不同手术时机在临床观测指标及预后康复上的差异，以在ABP的治疗上获得最优质的临床疗效。观察不同手术时机的ABP患者的临床资料，监测两种治疗方式（早期手术和延迟手术）术前、术后ABP敏感指标的变化，通过表格数据和直方图直观的进行评估，从而使ABP患者得到更快速有效的治疗，减轻患者的痛苦和经济负担。早期手术选择30例，急诊行腹腔镜胆囊切除手术（Laparoscopic cholecystectomy LC），无中转开腹，术后患者各项指标在短时间内降至正常（血淀粉酶降到正常平均3.70±0.95天，典型症状缓解平均3.53±1.01天），且无其他并发症发生，患者早期康复效果较好，短时间内迅速痊愈出院。延期手术选择32例，入院后保守治疗，胰腺炎症状好转后再行LC，但由于炎症未得到根本解决，血淀粉酶下降缓慢（平均6.50±1.19天），典型症状缓解时间延长（平均4.56±1.24天），手术中胆囊壁水肿渗出较重，增加手术难度和胆道损伤的风险，住院时间延长的同时（平均20.19±2.72天），也相应加重了患者的经济负担。两者的临床资料进行统计学分析，差异具有统计学意义（P=0.010.05）。通过对62例临床资料的观察对比分析发现，胆囊炎急性发作时（伴或不伴胆囊结石）的炎症本身就可引起急性胰腺炎的发生。对于ABP患者的早期治疗，在诊断明确、排除其他胰腺炎病因以及胆道结石的情况下，及早进行LC，完全能够达到快速康复的治疗效果。
[Abstract]:Acute pancreatitis APP (acute pancreatitis) is a common acute abdomen in general surgery. Although the pathogenesis of acute pancreatitis can not be fully explained until now, the main cause of pancreatic duct obstruction is caused by various factors. A series of pathophysiological changes, such as sudden increase of intraductal pressure, disturbance of pancreatic hemolymph circulation, etc., cause an acute inflammation of pancreatic digestive enzyme to its own digestion, while biliary obstruction, alcohol, pancreatic blood circulation disorder, trauma, etc. Infection is a high risk factor. Although the incidence of AP decreased with the development of medical technology and the improvement of people's health awareness, 20% -30% further developed into severe acute pancreatitis SAP, and the total mortality rate of AP still reached 5-10%. Among the types of AP, acute biliary pancreatitis (AP) accounted for about 55% of all patients with acute biliary pancreatitis, the mortality was 20%, and the number of patients with complications was as high as 50%. The common channel theory and gallstone passage theory are the most famous and accepted mechanism of ABP. Cholelithiasis is the most common cause of ABP in China. At present, it is believed that the occurrence of ABP is mainly due to bile duct obstruction caused by stones, bile regurgitation into the pancreatic duct, leading to increased pressure in the pancreatic duct. Therefore, relieving obstruction and reducing pancreatic duct pressure are the main measures to relieve and treat acute pancreatitis. Clinical observation showed that no stones were found in some ABP patients, such as imaging examination, intraoperative exploration, postoperative pathology and stool, and the timing of operation was obviously different. By observing the data of clinical cases collected, we discussed the pathological process of ABP and compared the difference of clinical observation index and prognosis rehabilitation in different operation time, in order to obtain the best clinical curative effect in the treatment of ABP. To observe the clinical data of ABP patients with different operation time, to monitor the changes of ABP sensitive indexes before and after operation of two treatment methods (early operation and delayed operation), and to evaluate them intuitively by tabular data and histogram. Thus, ABP patients can be treated more quickly and effectively, and the pain and economic burden of patients can be alleviated. Early operation was performed in 30 cases. Laparoscopic cholecystectomy was performed in emergency department without conversion to laparotomy. The indexes of postoperative patients were reduced to normal in a short period of time (average of 3.70 卤0.95 days). The average remission of typical symptoms was 3.53 卤1.01 days, and no other complications occurred. The early recovery of the patients was better, and the patients recovered and discharged quickly in a short time. Delayed surgery was performed in 32 cases, conservative treatment after admission, and LC after the improvement of the symptoms of pancreatitis, but the inflammation was not fundamentally resolved. The decrease of serum amylase was slow (mean 6.50 卤1.19 days), and the remission time of typical symptoms was prolonged (average 4.56 卤1.24 days). The gallbladder wall edema and exudation were more serious during the operation, which increased the difficulty of operation and the risk of biliary tract injury. The hospitalization time was prolonged at the same time (average 20.19 卤2.72 days), which increased the economic burden of the patients. The clinical data of the two groups were statistically analyzed and the difference was statistically significant (P < 0. 010.05). Through the observation and comparison of 62 cases of clinical data, it is found that the inflammation of cholecystitis (with or without gallstone) can cause acute pancreatitis in itself during the acute attack of cholecystitis. For the early treatment of ABP patients, under the condition of definite diagnosis, excluding other causes of pancreatitis and cholelithiasis, the treatment effect of rapid recovery can be achieved completely.
【学位授予单位】：吉林大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R657.51

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