急性胰腺炎2012指南

急性胰腺炎新指南新進(jìn)展Classificationofacutepancreatitis—2012:revisionoftheAtlantaclassificationanddefinitionsbyinternationalconsensusDefinitionofdiagnosisThediagnosisofacutepancreatitisrequirestwoofthefollowingthreefeatures:(1)abdominalpainconsistentwithacutepancreatitis(acuteonsetofapersistent,severe,epigastricpainoftenradi-atingtotheback);(2)serumlipaseactivity(oramylaseactivity)atleastthreetimesgreaterthantheupperlimitofnormal;(3)characteristicfindingsofacutepancreatitisoncontrastenhancedcomputedtomography(CECT)andlesscommonlymagneticresonanceimaging(MRI)ortransabdominalultrasonography.Definition

Onsetofacutepancreatitis:

thetimeofonsetofabdominalpain(notthetimeofadmissiontothehospital).Typesofacutepancreatitistwotypes:interstitialoedematouspancreatitisnecrotisingpancreatitis.

Interstitialoedematous

pancreatitis

Diffuse(oroccasionallylocalised)enlargementofthepancreasduetoinflammatoryoedema.

CECT:pancreaticparenchyma:relativelyhomogeneousenhancement,peripancreaticfat:someinflammatorychangesofhazinessormildstranding.

A63-year-oldmanwithacuteinterstitialoedematouspancreatitis.BanksPAetal.Gut2013;62:102-111Copyright?BMJPublishingGroupLtd&BritishSocietyofGastroenterology.Allrightsreserved.Necrotisingpancreatitis5–10%.necrosisinvolvingboththepancreasandperipancreatictissueslesscommonly:theperipancreatictissue,rarely:thepancreaticparenchymaalone.

GradesofseverityMildacutepancreatitisNoorganfailureNolocalorsystemiccomplicationsModeratelysevereacutepancreatitisOrganfailurethatresolveswithin48?h(transientorganfailure)and/orLocalorsystemiccomplicationswithoutpersistentorganfailureSevereacutepancreatitisPersistentorganfailure(>48?h)–Singleorganfailure–Multipleorganfailure

Transientorganfailure:organfailure<48?h.Persistentorganfailure:organfailure>48?h.PancreaticandperipancreaticcollectionsAcuteperipancreaticfluidcollectionPancreaticpseudocystAcutenecroticcollectionWalled-offnecrosisInfectednecrosisAPFC

(acuteperipancreaticfluidcollection)areasofperipancreaticfluidseenwithinthefirst4?weeksafteronsetofinterstitialoedematouspancreatitiswithoutthefeaturesofapseudocyst.APFC

(acuteperipancreaticfluidcollection)areasofperipancreaticfluidseenwithinthefirst4?weeksafteronsetofinterstitialoedematouspancreatitiswithoutthefeaturesofapseudocyst.APFC

(acuteperipancreaticfluidcollection)CECTcriteriaOccursinthesettingofinterstitialoedematouspancreatitisHomogeneouscollectionwithfluiddensityConfinedbynormalperipancreaticfascialplanesNodefinablewallencapsulatingthecollectionAdjacenttopancreas(nointrapancreaticextension)(A)A38-year-oldwomanwithacuteinterstitialoedematouspancreatitisandacuteperipancreaticfluidcollection(APFC)intheleftanteriorpararenalspace(whitearrowsshowingthebordersoftheAPFC).BanksPAetal.Gut2013;62:102-111Copyright?BMJPublishingGroupLtd&BritishSocietyofGastroenterology.Allrightsreserved.Pancreaticpseudocyst

Anencapsulatedcollectionoffluidwithawelldefinedinflammatorywallusuallyoutsidethepancreaswithminimalornonecrosis.Thisentityusuallyoccursmorethan4?weeksafteronsetofinterstitialoedematouspancreatitistomature.

Pancreaticpseudocyst

CECTcriteriaWellcircumscribed,usuallyroundorovalHomogeneousfluiddensityNonon-liquidcomponentWelldefinedwall;thatis,completelyencapsulatedMaturationusuallyrequires>4?weeksafteronsetofacutepancreatitis;occursafterinterstitialoedematouspancreatitisA40-year-oldmanwithtwopseudocystsinthelessersac6?weeksafteranepisodeofacuteinterstitialpancreatitisonCT(A,B).BanksPAetal.Gut2013;62:102-111Copyright?BMJPublishingGroupLtd&BritishSocietyofGastroenterology.Allrightsreserved.ANC

(acutenecroticcollection)Acollectioncontainingvariableamountsofbothfluidandnecrosisassociatedwithnecrotisingpancreatitis;thenecrosiscaninvolvethepancreaticparenchymaand/ortheperipancreatictissuesANC

(acutenecroticcollection)CECTcriteriaOccursonlyinthesettingofacutenecrotisingpancreatitisHeterogeneousandnon-liquiddensityofvaryingdegreesindifferentlocations(someappearhomogeneousearlyintheircourse)NodefinablewallencapsulatingthecollectionLocation—intrapancreaticand/orextrapancreatic(A)Acutenecroticcollections(ANC)ina44-year-oldmanwithacutenecrotisingpancreatitisinvolvingonlytheperipancreatictissues.BanksPAetal.Gut2013;62:102-111Copyright?BMJPublishingGroupLtd&BritishSocietyofGastroenterology.Allrightsreserved.Threedifferentpatients(A,B,C)withacutenecrotisingpancreatitisandacutenecroticcollections(ANC)involvingthepancreaticparenchymaandtheperipancreatictissues.BanksPAetal.Gut2013;62:102-111Copyright?BMJPublishingGroupLtd&BritishSocietyofGastroenterology.Allrightsreserved.Acutenecroticcollection(ANC)ina47-year-oldwomanwithacutenecrotisingpancreatitisinvolvingthepancreaticparenchymaalone.BanksPAetal.Gut2013;62:102-111Copyright?BMJPublishingGroupLtd&BritishSocietyofGastroenterology.Allrightsreserved.WON(walled-offnecrosis)Amature,encapsulatedcollectionofpancreaticand/orperipancreaticnecrosisthathasdevelopedawelldefinedinflammatorywall.WONusuallyoccurs>4?weeksafteronsetofnecrotisingpancreatitis.

WON(walled-offnecrosis)CECTcriteriaHeterogeneouswithliquidandnon-liquiddensitywithvaryingdegreesofloculations(somemayappearhomogeneous)Welldefinedwall,thatis,completelyencapsulatedLocation—intrapancreaticand/orextrapancreaticMaturationusuallyrequires4?weeksafteronsetofacutenecrotisingpancreatitis(A–C)Threedifferentpatientswithwalled-offnecrosis(WON)afteranacuteattackofnecrotisingpancreatitis.BanksPAetal.Gut2013;62:102-111Copyright?BMJPublishingGroupLtd&BritishSocietyofGastroenterology.Allrightsreserved.Infectedpancreaticnecrosis

canbepresumed:whenthereisextraluminalgasinthepancreaticand/orperipancreatictissuesonCECTORwhenpercutaneous,image-guided,fine-needleaspiration(FNA)ispositiveforbacteriaand/orfungionGramstainandculture.n