急性胰腺炎新分类的再评价的多中心临床研究

发布时间：2018-03-18 13:33

本文选题：急性胰腺炎　切入点：亚特兰大分类　出处：《第二军医大学》2014年硕士论文　论文类型：学位论文

【摘要】：前言：急性胰腺炎是一种临床过程及结果比较多变的疾病，约20%的急性胰腺炎患者临床经过严重。而且重症急性胰腺炎患者病死率达到10-30%。目前，在美国，每年有超过22万的急性胰腺炎患者被收住入院，且急性胰腺炎已居胃肠疾病相关住院的首位。而且发病率也在不断增长，尤其是重症急性胰腺炎。尽管急性胰腺炎在治疗上有了很大的进展，但病死率仍然较高。然而，有研究者认为特异有效的治疗方法至少部分依赖于精确的分类。急性胰腺炎严重程度的精确分类对于临床工作及研究都是很重要的。在临床工作中，精准的分类对于确定疾病严重程度，密切关注疾病临床过程及临床决策都是很有价值的。在临床研究中，对于纳入临床试验研究对象的准确性具有重大意义。急性胰腺炎按照传统的1992年Atlanta严重程度分类分成轻症急性胰腺炎及重症急性胰腺炎。2012年分类学家对Atlanta严重程度分类进行了修正，分为3类：轻症急性胰腺炎，，中度急性胰腺炎和重症急性胰腺炎。研究目的：本研究的目的就是应用上述两种亚特兰大分类系统进行回顾性研究。对急性胰腺炎的1992年亚特兰大分类和2012年亚特兰大分类的临床结果进行比较，进一步评价这两种分类系统。因轻症急性胰腺炎分类标准未发生改变，故本研究只对重症急性胰腺炎做比较。另外，我们还建议将胰腺坏死感染和持续性器官衰竭同时作为2012年亚特兰大分类的重症急性胰腺炎（Severe acute pancreatitis，SAP）的评定标准。方法：上海长海医院、南昌大学第一附属医院是国内最大的，以内科治疗为主的2个重症急性胰腺炎诊疗中心。收集上述2个中心收治的重症急性胰腺炎患者资料（2005年1月至2012年12月），共2154例。将收集到的重症胰腺炎患者（1992年Atlanta分类）按照2012年Atlanta分类重新分类成中度重症急性胰腺炎（Moderate severe acute pancreatitis，MSAP）及SAP。比较各组间的一般状况，病因，严重程度评分，器官衰竭，治疗情况，住院时间，院内死亡率等指标。结果：急性胰腺炎的病因仍以胆源性为最常见，约占60.4%。2012年亚特兰大分类标准的SAP组与MSAP组比较，Ranson评分，APACHEII评分，BISAP评分和Marshall评分均显著增高，且P值0.00，病情明显较重，差异均有统计学意义。重症急性胰腺炎（2012年亚特兰大分类）器官功能衰竭发生率明显增高，均为持续性器官衰竭（48小时）。中度重症急性胰腺炎的总体器官衰竭发生率为33.5%，均为一过性器官衰竭（48小时）。1992年的亚特兰大分类的重症急性胰腺炎器官衰竭的发生率为50.2%。它的发生率较2012亚特兰大分类的重症急性胰腺炎组明显减少，较中度重症急性胰腺炎发生率增高。三组间均是呼吸衰竭发生率最高。2012年亚特兰大分类的重症急性胰腺炎患者的重症监护病房监护需要率，血液净化需要率，机械通气需要率，空肠营养需要率，介入引流需要率，均明显高于中度重症急性胰腺炎患者。且前者周期比后者长。重症急性胰腺炎患者的住院时间也长于中度重症急性胰腺炎，前者院内死亡率（23.2%）明显高于后者（4.8%）。合并感染的重症急性胰腺炎（2012年修正的Atlanta分类）组患者病死率达到41.1%，显著高于中度重症急性胰腺炎（2012年修正的Atlanta分类）组的5.9%。胰腺相关感染，器官功能衰竭及全身炎症反应综合征是院内死亡率的危险因素。总结：2012年亚特兰大分类能够更好的反应病情严重程度，但是未将胰腺感染因素具体纳入胰腺炎分类中。我们建议将2012年修正的Atlanta分类中重症急性胰腺炎的诊断应将胰腺感染同时纳入诊断标准；而不仅仅将持续的器官衰竭作为主要的判别标准。或许能够更好，更精确的反应病情严重程度和临床过程，为临床工作和研究工作带来更大益处。然而此建议还需要大量的前瞻性研究来证实。
[Abstract]:Objective: acute pancreatitis is a clinical process and results of variable disease, about 20% of the patients after serious acute pancreatitis. And the mortality of patients with severe acute pancreatitis at a rate of 10-30%. at present, in the United States, there are more than 220 thousand of the patients with acute pancreatitis were admitted to the hospital each year, and acute pancreatitis has been ranked first in hospital related gastrointestinal diseases. And the incidence rate is also growing, especially in severe acute pancreatitis. Although acute pancreatitis has made great progress in treatment, but the mortality rate is still high. However, some researchers believe that the treatment of specific effect is at least partly dependent on the accurate classification. The accurate classification of the severity of acute pancreatitis is very important in clinical work and research. In clinical work, accurate classification to determine the severity of the disease, pay close attention to clinical disease and clinical decision-making process This is very valuable. In clinical studies, has great significance for clinical research object into the accuracy. The severity of acute pancreatitis according to the 1992 Atlanta classification of traditional divided into mild acute pancreatitis and severe acute pancreatitis.2012 taxonomists modify Atlanta severity classification, divided into 3 categories: mild acute pancreatitis, acute pancreatitis and severe acute pancreatitis with moderate.
Objective: the purpose of this study is to apply the two Atlanta classification system were retrospectively analyzed. Compare the clinical results of acute pancreatitis in 1992 Atlanta and 2012 Atlanta classification classification, further evaluation of the two classification systems. Because of mild acute pancreatitis classification standard is not changed, so the study on severe acute pancreatitis do comparison. In addition, we also suggested that the infection of pancreatic necrosis and persistent organ failure at the same time as the 2012 Atlanta classification of severe acute pancreatitis (Severe acute, pancreatitis, SAP) of the evaluation standard.
Methods: the Changhai Hospital of Shanghai, the First Affiliated Hospital of Nanchang University is the largest, with the medical treatment of 2 severe acute pancreatitis patients. Treatment center. The data collection of the 2 center of severe acute pancreatitis (January 2005 to December 2012), a total of 2154 cases were collected. The patients with severe acute pancreatitis (1992 Atlanta classification) according to the 2012 Atlanta classification re classified as moderately severe acute pancreatitis (Moderate severe acute pancreatitis, MSAP) cause the general situation, and SAP. were compared between groups, severity score, organ failure, treatment, hospitalization time, hospital mortality and other indicators.
Results: the etiology of acute pancreatitis with biliary is the most common, accounting for about 60.4%.2012 years, SAP group and MSAP group of the Atlanta classification standard of Ranson score, APACHEII score, BISAP score and Marshall score were significantly increased, and the P value is 0, the disease was heavier, the differences were statistically significant. (severe acute pancreatitis in 2012 the Atlanta classification) significantly increased the incidence of organ failure, are persistent organ failure (48 hours). The overall organ failure in moderately severe acute pancreatitis occurred in 33.5% were transient organ failure (48 hours) the incidence of severe acute pancreatitis group was 2012 Atlanta classification 50.2%. the decreased organ failure of Atlanta.1992 classification of severe acute pancreatitis, with moderate to severe acute pancreatitis incidence rate increased. Among the three groups are the highest incidence of respiratory failure.2012 The Atlanta classification of patients with severe acute pancreatitis in ICU care need rate, blood purification rate need, the need for mechanical ventilation rate, rate of jejunal nutritional needs, need interventional drainage rate, were significantly higher in patients with moderate to severe acute pancreatitis. And the cycle is longer than that of the latter. The hospitalization time of patients with severe acute pancreatitis is longer than that of moderately severe acute pancreatitis, the former hospital mortality (23.2%) was significantly higher than that of the latter (4.8%). Infection of severe acute pancreatitis (Atlanta's revised 2012) group the mortality rate reached 41.1%, significantly higher than that of moderate to severe acute pancreatitis (Atlanta 2012 Amendment) 5.9%. pancreatic infection group, organ failure and systemic inflammatory response syndrome syndrome is a risk factor for hospital mortality.
Summary: the reaction condition of the 2012 Atlanta classification can be better but not the severity of pancreatic infection factors into specific pancreatitis classification. We suggest the diagnosis of Atlanta in the 2012 amendment to the classification of severe acute pancreatitis should be included in the diagnosis of pancreatic infection and standard; not only will continue organ failure as the main criterion may be. Better, more accurate response to disease severity and clinical course, bring greater benefits for clinical work and research work. However, this suggested that larger prospective studies are needed to confirm.

【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R576

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