【正文】 suggests that in patients with pseudocysts smaller than 6 cm, if there is a mature pseudocyst wall on radiographic imaging that does not resemble a cystic neoplasm, minimal symptoms, and no evidence of active alcohol abuse, the risk of plications is extremely small ( 10%). These patients may be safely observed with little risk of serious plication ? Computed tomogram of a patient with pancreatic abscess. The pancreas is diffusely involved, and its margins are difficult to define because of the massive peripancreatic inflammation, which is reflected in the streaking seen in this scan. Toward the tail of the pancreas, numerous small and large bubbles are noted (arrows) in the peripancreatic inflammatory mass. Bubbles, caused by gasforming microanisms, indicate that the pancreatic abscess is infected. 4. Diagnostic Paracentesis穿刺術(shù) 1. not an ideal test * an invasive procedure * plications * lack of plete specificity of peritoneal fluid enzyme elevations 2. Help diagnosis * elevations in peritoneal fluid amylase and lipase Edematous pancreatitis nercotizing pancreatitis abdominal pain + +++ vomiting and nausea + ++ fever low high jaundice ()(+) ++ +++ psychiatric symptom no yes signs of peritonitis + ++ +++ cullen’s sign no yes Grey Turner’s sign no yes hemorrhagic ascites no yes WBC 16000/mm3 16000/mm3 blood glucose normal→ ↑ normal mmol/L amylase ↑ ↑ ↑ ↑ or () PaO2 normal kpa no yes ARDS no yes DIC no yes ARF no yes mortality low high Differential Diagnosis perforation ulcer intestinal obstruction colic ischemia gastroenteritis Treatment Nonoperative Management 1. Dietary Control √ Oral intake is initially prohibited。 √ Oral intake can be resumed during the first week of treatment when abdominal pain and tenderness have improved, ileus has resolved and hyperamylasemia is normalizing. 2. Nasogastric Suction √ reduce vomiting and abdominal distension √ reduce pancreatic exocrine secretion by reducing secretion release 3. Intravenous fluid therapy and electrolyte replacement * hypokalemia, hypochoremia, hypocalcaemia and hypomagnesemia should be corrected * Causes of hypovolemia: ⑴ paralytic ileus ⑵ vomiting ⑶ extensive exudation in abdominal cavity and peripancreatic region Generous fluid resuscitation is very important * mild hyperglycemia: insulin treatment 4. Nutritional Support * fasting for a long time * persistent pain, ileus or the occurrence of a plication such as pseudocyst, phlegmon or abscess * enteral alimentation is better than that through the parenteral route 營(yíng)養(yǎng)支持 ? 非重癥急性胰腺炎患者不需要空腸營(yíng)養(yǎng)或靜脈營(yíng)養(yǎng)，一般在病程的 4天內(nèi)即能進(jìn)食。 ? 重癥 急性胰腺炎病人應(yīng)給予全胃腸外營(yíng)養(yǎng)或腸內(nèi)營(yíng)養(yǎng)。 給予早期腸內(nèi)營(yíng)養(yǎng)。病程的第 3或 4天，經(jīng)內(nèi)鏡或在 X線引導(dǎo)下給病人置入鼻空腸管，并給予半量要素飲食。濃度大致為 J/ml，如能耐受，逐漸增量至全能營(yíng)養(yǎng)配方。 5. Antibiotics * prophylaxis * prevent intestinal bacteria translocation * Treat suppurative化膿性的 plication 預(yù)防性使用抗生素 ? 并發(fā)感染仍然是重癥急性胰腺炎死亡的重要原因，因此，有胰腺壞死存在就應(yīng)考慮預(yù)防感染。 ? 抗生素的選擇應(yīng)考慮其抗菌譜與感染病原菌的配對(duì)并能有效穿透至胰腺實(shí)質(zhì)中。 ? 環(huán)丙沙星 能透入胰腺壞死組織， 甲硝唑 雖分子量小、通透性高，但只透入壞死液體，因此 兩者合用為宜 胰腺壞死者 。 ? 對(duì)于確有 推薦使用 亞胺培南（泰能） 500 mg， 3/日，共 2周。 ? 其余抗生素均不能進(jìn)入胰腺壞死組織，故而無(wú)效。 6. Analgesia * Meperidine (哌替啶 , 度冷丁 ) is the preferred drug。 * Morphine (嗎啡 ) should be avoided: causing spasm of the sphincter of oddi 7. Pancreatic Exocrine Secretion Suppression suction (H2)receptor antagonists , octreotide and sandostatin 生長(zhǎng)抑素 施他寧 (250?g 靜推， 3000 ?g 靜滴 24h) 善寧 ( 靜推 , 靜滴 24h) (cckreceptor antagonists) 8. Pancreatic enzyme inhibitor * aprotinin * gabexate * camostat Surgical Treatment Operative indication 1. secondary pancreatic infection 2. correction of associated biliary tract disease 3. progressive clinical deterioration Surgery is contraindicated in unplicated acute pancreatitis. Surgical Procedure 1. peritoneal lavage: remove toxins and various metabolites 2. pancreatic drainage 3. debridement of necrotic tissue 4. biliary procedure: endoscopic sphincterotomy cholecystectomy remove the CBD stone Complications Systemic plications ARDS Renal failure Cardiovascular failure MOSF Local plications pancreatic abscess pancreatic psuedocysts pancreatic phlegmon pancreatic ascites pleural effusion pancreatic fistula intestinal fistula Thanks for Your Attentio