不同病因急性胰腺炎临床特征及其预后相关因素研究

发布时间：2018-07-11 18:52

本文选题：急性胰腺炎 + 高三酰甘油血症性胰腺炎　；参考：《第三军医大学》2017年硕士论文

【摘要】：背景急性胰腺炎(acute pancreatitis,AP)是消化内科常见疾病,胆源性急性胰腺炎(biliary acute pancreatitis,BAP)为其首要病因,近年来高三酰甘油血症性胰腺炎(hypertriglyceridemic pancreatitis,HTGP)发病率逐年上升,病因占比上升至AP第3位(12.6%),是继BAP和酒精源性急性胰腺炎之后常见病因之一。不同病因的急性胰腺炎从临床症状、实验室检验指标、病情严重程度等临床表现均有差异,了解急性胰腺炎临床及流行病学特点,有利于加深对HTGP的认识,为临床鉴别AP病因及治疗提供参考。随HTGP发病率的逐年上升,血脂与AP的相关性及其对预后的影响受到临床的关注。研究证实,高胆固醇血症一般不会诱发AP,高脂血症性胰腺炎应准确称为高甘油三酯(triglyceride,TG)血症性胰腺炎,HTGP的TG水平通常≥11.30mmol/L。有研究结果显示HTGP的预后(尤其器官功能衰竭的发生)较其它病因的急性胰腺炎相对较差,仍有待临床研究进一步证实;甘油三酯是AP发生器官功能衰竭的危险因素已经被临床研究证实,全身炎症反应综合征(systemic inflammatory response syndrome,SIRS)通常是临床重症急性胰腺炎的早期表现,随后随病情加重而逐渐发生器官功能衰竭,研究显示TG可水解为具有细胞毒性的游离脂肪酸,损伤胰腺。可能因患者TG水平差异导致SIRS的发生、临床表现及预后存在明显差异,但相关研究缺乏。因此,我们将以新桥医院2012.01-2015.12年收治的518例急性胰腺炎患者为对象,分析不同病因AP患者临床特征及流行病学特点,并进一步评价患者不同TG水平与SIRS发生相关性、临床表现及预后,为临床诊断治疗不同病因的急性胰腺炎提供参考依据并深入认识HTGP的发生机制及临床特征。目的1.了解不同病因急性胰腺炎临床特征及流行病学特点。2.分析不同血清甘油三酯水平与急性胰腺炎患者的病情严重程度及预后相关性。方法以2012.01-2015.12在新桥医院院按照《中国急性胰腺炎诊治指南(2013,上海)》诊断明确的全部急性胰腺炎患者为研究对象,从病历中提取患者一般资料、临床表现及预后等相关信息,排除欠缺大量临床资料、合并其它严重影响预后的疾病如肿瘤、慢性肝、肾功能衰竭等患者,最终共518例纳入分析。采用SPSS 20.0进行数据管理和分析,按照各类诊断标准对急性胰腺炎患者进行病因分类和病情严重程度等分类,进行不同病因(HTGP、BAP、其它病因AP)的临床和流行病学特点描述、组间比较。根据血清TG值是否高于1.70 mmol/L分为正常组与升高组,升高组再分为轻、中、重组,分析不同TG水平与病情严重程度及预后相关性,采用Logistic回归分析校正相关因素,以P0.05为统计学显著性差异标准。结果1.收集新桥医院消化内科出院诊断的AP患者共计518例,其中女性190例,男性328例,男女比例1.7:1。发病年龄范围16~92岁,平均年龄48.67±14.57岁。HTGP占10.6%(55/518),BAP患者35.9%(186/518),其它病因(包括酒精、免疫、药物、创伤等)AP患者53.5%(277/518)。HTGP构成比有增多的趋势,从2012年7.4%上升至2015年17.7%(P0.05),轻重比例2.7:1,16.2%(84/518)合并糖尿病,24.5%(127/518)合并脂肪肝,14.1%(73/518)合并高血压。AP患者平均住院时间为11.97±12.27天,腹痛缓解时间4.56±3.15天,SAP中56.1%胰腺CT评级为D、E级,AP总病死率4.4%。SAP在各组中HTGP比例最高45.5%(25/55),BAP28.0%(52/186),其它病因AP22.4%(62/277)。不同病因临床生化指标比较:BAP组血淀粉酶水平明显高于HTGP、其它病因AP组,其中HTGP组血淀粉酶水平最低。C-反应蛋白(c-reaction protein,CRP)、血糖、红细胞比容(red blood cell specific volume,HCT)在HTGP组中最高,血钙、白细胞计数、血肌酐、尿素、白蛋白组间未见明显差异。不同病因AP合并症比较:糖尿病比例最高的是HTGP(29.1%),其次其它病因AP(15.9%)。脂肪肝比例最高的是HTGP(41.8%),其次其它病因AP(24.9%)。比较不同病因AP的预后:HTGP更容易发生SIRS,其腹痛缓解时间及平均住院时间HTGP组均长于BAP、其它病因AP。胰腺CT分级(D、E级)虽在HTGP比例最高,但组间未见统计学意义,多器官功能衰竭(multiple organ failure,MOF)、病死率均未见统计学意义。2.479例AP患者于我院检测TG,其中TG升高组276例(57.6%),TG正常组203例(42.4%),TG升高组SIRS、胸腔积液、病情严重程度明显高于正常组(P0.05);组间MOF差异无统计学意义(P0.05);随着TG升高,各组并发SIRS风险越高(P0.001)。Logistic回归分析TG与SIRS独立相关[OR=1.138(95%CI:1.082~1.197);P0.001]。重度TG升高组中使用血液净化(29例)治疗后,TG水平、白细胞计数、急性生理学和慢性健康状况评分(acute physiology and chronic health status score,APACHEⅡ)与治疗前比较明显降低(P0.001)。结论AP多见于男性,近年来HTGP有上升趋势。AP患者较易合并高脂血症、脂肪肝、糖尿病、高血压等代谢疾病。病死率4.4%。HTGP相比于BAP、其它病因AP,病情严重程度更重,临床生化指标血淀粉酶升高不明显,C-反应蛋白、血糖、HCT均显著高于其它两组,更易合并高脂血症、糖尿病、脂肪肝代谢综合症。不同病因AP病死率未见明显差异。相对于TG正常组AP患者,TG升高组AP患者预后更差,血清TG水平越高,AP发生SIRS风险越高,但合并MOF无差异。血液净化能有效缓解TG重度升高组的病情。
[Abstract]:Background acute pancreatitis (acute pancreatitis, AP) is a common disease in the digestive department. Biliary acute pancreatitis (biliary acute pancreatitis, BAP) is the primary cause. In recent years, the incidence of hypertriglyceridemic pancreatitis (hypertriglyceridemic pancreatitis, HTGP) is increasing year by year, the ratio of etiology is up to AP third (12.6%), which is the following BAP It is one of the common causes of acute pancreatitis after alcoholic acute pancreatitis. Acute pancreatitis with different causes has different clinical manifestations, such as clinical symptoms, laboratory test indexes, and the severity of the disease. To understand the clinical and epidemiological characteristics of acute pancreatitis is beneficial to the recognition of HTGP, and to provide reference for the clinical identification of AP etiology and treatment. The incidence of TGP is increasing year by year. The correlation between blood lipid and AP and its effect on the prognosis are concerned. It is confirmed that hypercholesterolemia generally does not induce AP. Hyperlipidemic pancreatitis should be called high triglyceride (triglyceride, TG) pancreatitis, and the TG level of HTGP is usually more than 11.30mmol/L., and the results of the study show HTG. The prognosis of P (especially organ failure) is relatively poor compared with other causes of acute pancreatitis, which remains to be further confirmed by clinical studies. Triglycerides, a risk factor for AP organ failure, have been confirmed by clinical studies, and systemic inflammatory response syndrome (systemic inflammatory response syndrome, SIRS) is usually present. The early manifestation of severe acute pancreatitis in bed is followed by progressive organ failure with the aggravation of the disease. The study shows that TG can be hydrolyzed to a cytotoxic free fatty acid and damage the pancreas. There may be significant differences in the occurrence of SIRS, clinical manifestation and prognosis in patients with the difference of TG level, but the related research is lack. Therefore, we will The clinical features and epidemiological characteristics of 518 patients with acute pancreatitis treated in Xinqiao Hospital 2012.01-2015.12 were analyzed, and the correlation of different TG levels with SIRS, clinical manifestation and prognosis were further evaluated, which provided a reference for the clinical diagnosis and treatment of acute pancreatitis with different causes. To understand the pathogenesis and clinical characteristics of HTGP. Objective 1. to understand the clinical characteristics and epidemiological characteristics of acute pancreatitis with different causes..2. analysis of the correlation between the levels of triglycerides in different serum levels and the severity and prognosis of patients with acute pancreatitis. Methods 2012.01-2015.12 was used in the hospital of Xinqiao Hospital in accordance with the diagnosis and treatment of acute pancreatitis in China. Guidelines (2013, Shanghai) > diagnosis of all patients with acute pancreatitis, from the medical record, the general data, clinical manifestations and prognosis information, the exclusion of a large number of clinical data, combined with other serious prognosis of the disease such as tumors, chronic liver, renal failure and other patients, the final total of 518 cases included in the analysis. SPSS 20 was used for data management and analysis. The clinical and epidemiological characteristics of different etiological factors (HTGP, BAP, other pathogeny AP) were classified according to various diagnostic criteria, and the clinical and epidemiological characteristics of different causes (HTGP, BAP, and other causes) were compared. According to whether the TG value of blood clear was higher than 1.70 mmol/L, the normal group and the elevated group were divided. The elevation group was redivided into light, medium and reorganized, and the correlation between the different TG levels and the severity and prognosis of the disease was analyzed. The correlation factors were corrected by Logistic regression analysis, and P0.05 was a significant difference standard. Results 1. of the AP patients in the digestive department of Xinqiao Hospital were collected, of which 190 cases were female, 328 men were male, and the ratio of men and women was 1. The age of.7:1. was 16~92 years old, the average age of 48.67 + 14.57 years.HTGP accounted for 10.6% (55/518), BAP patients 35.9% (186/518), other causes (including alcohol, immunity, medicine, trauma, etc.) 53.5% (277/518).HTGP constituent ratio of AP patients increased, from 7.4% in 2012 to 17.7% (P0.05) in 2015, 2.7:1,16.2% (84/518) with diabetes mellitus combined with diabetes The average hospitalization time of patients with 24.5% (127/518) with fatty liver, 14.1% (73/518) with hypertension.AP was 11.97 + 12.27 days, abdominal pain remission time was 4.56 + 3.15 days, 56.1% pancreatic CT rating was D, E, and AP total fatality rate 4.4%.SAP was 45.5% (25/55) in each group. Biochemical indexes were compared: the level of blood amylase in group BAP was significantly higher than that of HTGP, other cause AP, of which the lowest level of.C- reaction protein (C-reaction protein, CRP), blood glucose and erythrocyte specific volume (red blood cell specific) were the highest in group HTGP, and the blood calcium, white blood cell count, blood creatinine, urea and albumin were not found in the group. The AP complication of different etiology was compared: the highest proportion of diabetes was HTGP (29.1%), followed by other causes AP (15.9%). The highest proportion of fatty liver was HTGP (41.8%), and the other cause AP (24.9%). The prognosis of AP in different causes was compared: HTGP was more likely to occur SIRS, its abdominal pain relief time and the average length of hospital stay were longer than BAP, other diseases. The CT classification of AP. (D, E) was the highest in HTGP, but there was no statistical significance between the groups. There was no statistical significance in multiple organ failure (multiple organ failure, MOF), and no statistical significance was found in the fatality rate of.2.479 AP patients in our hospital. There were 276 cases (57.6%) in the ascending group and 203 cases (42.4%) in the normal group. The pleural effusion, pleural effusion, and the severity of the disease were serious. The degree of MOF was significantly higher than that of the normal group (P0.05), and there was no significant difference between the groups (P0.05), and with the increase of TG, the higher the risk of SIRS (P0.001).Logistic regression analysis of TG and SIRS independent related [OR=1.138 (95%CI:1.082~1.197), and the level of blood purification (29 cases), the leukocyte count, and the acute physiology. Acute physiology and chronic health status score, APACHE II) was significantly lower than before treatment (P0.001). Conclusion AP is more common in men. In recent years HTGP has a rising trend in.AP patients with hyperlipidemia, fatty liver, diabetes, hypertension and other metabolic diseases. The cause of the disease was AP, the severity of the disease was more serious, the serum amylase of the clinical biochemical indexes was not obvious, the C- reactive protein, blood glucose and HCT were significantly higher than those of the other two groups, which were more likely to be associated with hyperlipidemia, diabetes, and fatty liver metabolism syndrome. The mortality rate of AP was not significantly different in different etiology. For AP patients in normal TG group, the prognosis of AP patients in TG elevated group was worse. The higher the level of TG, the higher the risk of SIRS in AP, but there was no difference in MOF.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R576

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