急性胰臟炎的診斷與治療之最新進展

Recent Advances in the Diagnosis and Treatment of Acute Pancreatitis

潘之瑩(Chih-Ying Pan) ； 李嘉龍(Chia-Long Lee) ； 吳啟華(Chi-Hwa Wu)

《內科學誌》 24卷3期 (2013/06) Pp. 162-180

https://doi.org/10.6314/JIMT.2013.24(3).02

摘要

1992亞特蘭大胰臟炎的分類至今已被採用二十年，隨著醫學的進步及對疾病的進一步了解，新的版本在多國專家的共識下已經推出。胰臟炎仍然分成急性間質水腫性及壞死性兩類，嚴重度的評估不再是以危險因素的有無為依據，而是以實際決定因素的存在與否為主。其全身性決定因素為短暫性或是持續性器官衰竭，局部決定因素為胰臟或胰週邊壞死，無菌性或是感染性。嚴重度除了原有的輕度和重度外，兩者間又加上了中重度的三級分類，或是重度中衍生出的危急的四級分類。對於胰及胰週的液體或是壞死積聚，也因影像學檢查的進步而有明確的定義。臨床階段的早期和後期的變化及治療也都有共識，在感染性壞死的清創手術目前建議遞增性的治療，先使用微創手術治療，開腹清創則是最後步驟。

關鍵字

急性間質性水腫性胰臟炎 ； 急性壞死性胰臟炎 ； 亞特蘭大分類 ； 決定因素

並列摘要

Two decades has been passed since the development of Atlanta classification of acute pancreatitis in 1993. The definitions of the severity are based on empiric description of occurrence that are merely associated with severity. With the advance of diagnostic modalities and therapeutic techniques, different outcomes have been noted in different subgroups of patient. The factors associated severity prediction is no longer suitable for clinical practice and the local and systemic determinants seem more realistic to reflect the severity status. Therefore, the new classification has been emerged recently by the consensus from multinational specialists. The new classification categorized the severity into 4 grades, i.e. mild, moderate, severe and critical according to the presence and combination of local and systemic determinants. The former includes peri- or pancreatic necrosis with or without infection and the latter transient or persistent organ failure. The acute pancreatitis is composed of two-stage clinical courses. The first phase is seen within first 1-2 weeks after onset and relates to the systemic inflammatory response syndrome (SIRS) resulted from autodigestion of the pancreatic enzyme. Vigorous fluid supplement is the most important. Prevention of infection from necrosis with antibiotics, probiotics or early enteral nutrition is controversial and need further elucidation. Endoscopic papillary sphincterotomy depends on the existence of severity of the biliary tract infection. Abdominal compartment syndrome (ACS) and bowel ischemia require early intervention. If infection of the peri- or pancreatic necrosis occurred in second phase, invasive treatment is required when supportive treatment fails. The so-called step-up approach is recommended with the following subsequent orders: drainage by percutaneous catheter drainage or endoscopic transluminal drainage, debridement by video-assisted retroperitoneal or endoscopic transluminal debridement, or finally by open debridement. The open method is reserved for the last till sufficient encapsulation and well demarcation of the necrosis. The role of the radiology and endoscopy in the diagnosis and minimal invasive treatment has gained its importance recently. Multidisciplinary treatment of the acute pancreatitis is the mainstay approach in current evidence-based medicine.

並列關鍵字

Acute interstitial and edematous pancreatitis ； Acute necrotizing pancreatitis ； Atlanta classification ； Determinant