Read the diagnosis and treatment of acute severe pancreatitis

The patient, a 25-year-old woman, was admitted to hospital on July 27 for "bloating, abdominal pain and vomiting for 3 days".
patients on July 25 no obvious trigger for the on-abdominal persistent sharp pain, radiation to the lower back, after eating the pain intensified, bloating is obvious, accompanied by nausea and nausea leaves, non-injection, about I0 times, for stomach content The total amount of about 500ml, bloating after vomiting slightly reduced, fearless cold fever, in the local health hospital rehydration treatment after 3 days (specific measures are not known), symptoms are not alleviated, and the symptoms of exacerbation, so transferred to our hospital for further treatment.
disease since no yellowing, no anus to stop exhaust detocation, no diarrhea, blood or black stool, especially dizziness, palpitations, shortness of breath, sweating, etc. , urinating normal, 1000-1500ml/d.
history, personal history, family history and menstrual history are not special.
physical examination: T37.5 degrees C, P 105 times/min, R22 times/min, BP 15/10kPa, clear-eyed, passive lying, painful face, skin, sclea without yellowing, shallow lymph nodes No swelling, no deformities in the skull, no swelling of the thyroid gland, centered trachea, HR 105 times / minute, heart rhythm neat, strong heart tone, no murmurs in each valve stethoscope area, double lung breathing sound, unheard and sonic.
surgery on the abdomen.
no abnormalities in the limbs of the spine, no deformities in the anus and external genitalia, physiological reflexes exist, and pathological neurorefractions are not cited.
Surgical conditions: abdominal puffing, no gastrointestinal peristaltic wave and intestinal shape, abdominal wall veins without curvature, Cullen sign (-), Grey-Tumer sign (-), full abdominal muscle tension, pressure, back-jumping pain obviously, liver spleen ribs are not reached, Murphy sign (-), did not touch the block, liver turbidity on the right side of the 5th ribs, hepatic and kidney area distritis (-)
finger test: smooth into the anus, wood touched the swelling, finger set no blood stain.
: Blood routine: WBC 20.7x 109/L, neutral granulocytes 0.82, RBC 4.58 x 1012/L, HGB 108g/L, PLT 215x109/L.
: Na-138mmol/L, K-3.6mmol/L, Cl-102mno/L, BUN 8.9mmo/L, Cr102-mol/L, Ca2-1.8 mmol/L.
blood amylase 239U/L, urinary amylase 1700U/L.
abdominal flat: no abnormalities.
the teacher: Which classmate summarized the characteristics of the case? Intern A: (1) This case is a young female patient with acute illness, and (2) the main clinical symptom is bloating. Persistent upper abdominal pain; (3) physical examination found that the whole abs are tense, pressure pain, anti-jumping pain is obvious, suggesting acute diffuse perititis; (4) laboratory examination found that blood, urinary amylase significantly increased, so should be considered as "acute pancreatitis."
Intern B: Patients are mainly manifested in bloating, abdominal pain and vomiting, bloating after vomiting relief, physical examination found that the whole abs tension, pressure pain, back-jumping pain is obvious, intestinal chirping disappeared, pay attention to the "twisted intestinal obstruction" may be, and in the case of severe perititis, amyloid can also be raised.
intern C: but the patient did not stop exhaust detocation, and the abdominal half did not see abnormal, so basically can exclude the "intestinal obstruction" diagnosis.
blood, urine amylase significantly increased, should be diagnosed as "acute pancreatitis."
: Good analysis! This case is a young female patient, acute illness, mainly manifested as diffuse perititis, laboratory examination found that blood, urine amylase significantly increased, more than 2 times the normal value, although other surgical acute abdominal amylase can also be raised, but its elevation is only mild, generally will not exceed 2 times the normal value.
, the diagnosis of "acute pancreatitis" in this case should be established.
generally speaking, the diagnosis of pancreatitis by blood and urine amylase is rather specific.
1-2h in acute pancreatitis.
Serum amylase began to rise, 24h after the peak, sustainable 72 to 96h, urinary amylase rise is relatively slow, after the disease 12 to 24h began to rise, and slow decline, in the serum amylase decline in the next few days still sustainable increase.
important to note is that the level of amylase does not indicate the severity of the disease.
We know that acute pancreatitis can be divided into two types: light (i.e. edema) and severe (i.e. hemorrhagic necrosis), in this case, which type does it belong to? Intern D: Patients have been suffering from changes in mental and mental state since the oncology, and blood pressure and other vital signs are stable, with a high probability of acute light pancreatitis.
intern E: Teacher, did the patient do a B-super examination? Teacher: Not yet done, you proposed to do B super-check, what is the purpose? Intern E: I'd like to know if the pancreas is necrotic.
: You're right, but before we have imaging data, can we find evidence from the current clinical literature to support your clinic or support your diagnosis? Intern F: Although the patient did not experience shock, mental and mental state changes, but peritonitis is serious, mobile turbid tone can be out, indicating that there is abdominal water, and Grey-Tumer signs (±), may be severe pancreatitis.
teacher: Yes.
We know that patients with severe pancreatitis, in addition to abdominal pain, bloating, vomiting and other symptoms, can also appear shock, jaundice, mental and mental state, but it must be clear that shock, mental and mental state changes are not necessary to diagnose severe pancreatitis, in the early stages of the disease, can not appear.
From the clinical material of the disease, there are 3 points worthy of our high suspicion of severe pancreatitis: (1) bloating is obvious, generally speaking, light pancreatitis patients do not appear bloating, pancreatitis bloating is mainly due to Large oozing in the abdominal cavity, resulting in paralysis intestinal obstruction; (2) severe periaryitis, with abdominal water, while light pancreatitis rarely oozes in large quantities causing abdominal water; and (3) Grey-Tumer is suspected to be positive.
Grey-Tumer or Cullen signs only appear in severe pancreatitis, but not in every case, when in fact these two signs are clinically rare, but once they do, they have great diagnostic value for severe pancreatitis.
Back to this case of patients, I add the hospital after the medical history, the patient in the hospital 5 hours after the beginning of depression, indifference, blood pressure drop, fever T38.5 degrees C, bloating intensified, abdominal puncture out of blood abdominal water, check amylase for 950U/L, after active rehydration, blood pressure stability, that is, to do B super and CT examination.
B ultra-examination showed abnormal liver and bile, which interfered with the examination of the pancreas due to obvious intestinal bloating, and failed to detect lesions;
A: Oh, now the diagnosis of "acute severe pancreatitis" is clear.
Teacher: Acute pancreatitis is one of the common acute abdominal diseases in surgery, its diagnosis should not be difficult, but the accurate judgment of its condition, is light or severe, in the corresponding laboratory examination and imaging examination has not been carried out before, detailed inquiries about medical history, careful physical examination and close dynamic observation of the disease is very important.
example is a good example.
for clinically highly suspected or diagnosed severe pancreatitis, when the condition is stable, the relevant imaging examination should be done, the former is to further clarify the diagnosis, the latter is to solve the extent of pancreatic necrosis.
commonly used imaging checks are B-super and CT.
ultrasound is less accurate than CT due to the influence of the intestines.
CT can be more than 90% correct in the diagnosis of severe pancreatitis, CT is considered to be the preferred method for diagnosing pancreatic lesions.
diagnosis of severe pancreatitis, treatment will be carried out, we talk about what treatment measures? Intern A: Should perform urgent surgery to investigate, remove necrotic pancreatic tissue, and do adequate draination.
B: In this case, the patient's blood pressure is unstable, should fully supplement the blood volume, wait for the blood pressure to stabilize, and then surgery to investigate.
Intern C: can be conservative treatment, measures include: gastrointestinal decompression, inhibit gastric acid secretion, inhibit pancreatic secretion, anti-infection treatment, adequate rehydration and nutritional support treatment, while closely observing vital signs and changes in the condition, after the condition is stable, can be surgically probed to remove necrotic tissue.
Intern D: I think it's surgery or conservative treatment, and think about the cause of pancreatitis.
is due to gallbladder obstruction such as gallbladder stones caused by severe pancreatitis, emergency surgery treatment.
can be treated conservatively if it is caused by alcoholism or overeating or unexplained reasons.
patients in this case can be treated conservatively because the cause is not clear.
intern F: Teacher, this case of patients admitted to the hospital is the use of conservative treatment is surgical investigation? Teacher: We have different views on the treatment of acute severe pancreatitis, there is a right side, there is a lack of side, I take this case of patients as an example, to tell you about the current treatment of acute severe pancreatitis.
treatment of acute pancreatitis, light and severe measures are different.
in the current strong inhibition of pancreatic secretion of drugs such as: staine application, light pancreatitis generally after 1 week of conservative treatment, can be cured.
treatment of acute severe pancreatitis, in the past advocated early surgical treatment, the way is to remove necrosis of tissue, pancreas around the placement of multiple draining tube drains, but also do bile trachea drain, gastrointestinal fistula and so on.
but early surgery has not been found to reduce mortality from severe pancreatitis, sometimes even speeding up patient deaths.
, through extensive basic research and clinical observation, the view of early surgery has changed and is now largely replaced by an "individualized programme".
so-called "individualized program" that is, different patients to take different treatment options, there are surgical signers, surgical treatment;
Currently believe that acute severe pancreatitis surgical investigation signs are as follows: (1) clearly caused by biliary lesions such as stone obstruction caused by severe pancreatitis;
non-surgically identified persons should be strengthened in SICU support treatment, including vital signs monitoring, continuous gastrointestinal decompression, acid production, inhibition of pancreatic secretion, active anti-infection and TPN support therapy.
The pathophysiological basis of acute severe pancreatitis is that the pancreas digests the pancreas and surrounding organs and tissues, produces a large amount of seepage and toxins, which can easily lead to low-volume circulatory disorders and multi-organ dysfunction, and the appearance of multi-organ failure, the mortality rate is very high.
closely observe the changes in the course of treatment, pay attention to the detection of liver, kidney, lung and circulatory function, to prevent the occurrence of multi-organ functional decline scorpion.
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