急性胰腺炎的诊疗.doc
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参见附件(198KB)。
Evidence-based clinical practice guidelines for acute pancreatitis: proposals.
Mayumi T, Ura H, Arata S, Kitamura N, Kiriyama I, Shibuya K, Sekimoto M, Nago N, Hirota M, Yoshida M, Ito Y, Hirata K, Takada T; Working Group for the Practical Guidelines for Acute Pancreatitis. Japanese Society of Emergency Abdominal Medicine.
Department of Emergency Medicine and Intensive Care, Nagoya University School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8560, Japan.
BACKGROUND/PURPOSE: To provide a framework for clinicians to manage acute pancreatitis, evidence-based guidelines have been developed by the Japanese Society of Abdominal Emergency Medicine. METHODS: Evidence was collected by a systematic search of MEDLINE and Japana Centra Revuo Medicina. A total of 1348 papers were reviewed and levels of evidence were assessed. Practical recommendations were also graded. RESULTS: The present guidelines consist of introductions, a summary of recommendations, practice algorithms, definitions, epidemiology, diagnosis, severity assessment, and therapy. The main points of recommendation in these guidelines are: (1) measuring lipase for the diagnosis of acute pancreatitis (recommendation grade [RG], A). (2) The Severity of acute pancreatitis should be assessed using a scoring system, such as that of the Japanese Ministry of Health and Welfare or Acute Physiology and Chronic Health Evaluation (APACHE) II (RG, A). (3) Enhanced computed tomography (CT) should be used for assessment of degree of pancreatic necrosis and inflammation (RG, . (4) Prophylactic antibiotic administration should be used for severe pancreatitis (RG, A), but not for mild to moderate pancreatitis (RG, D). (5) Gabexate mesilate should be used for severe pancreatitis (RG, . Enteral feeding should be used for all pancreatitis (RG, . (7) Continuous hemodiafiltration and continuous arterial infusion of proteinase inhibitor and antibiotics may be of benefit (RG, C). Fine-needle aspiration should be done for the diagnosis of infectious pancreatic necrosis, and if positive, necrosectomy is indicated (RG, A). CONCLUSIONS: These guidelines provide useful information for physicians to manage this troublesome disease。
急性胰腺炎的循证医学临床实践指南2002
背景：近年关于急性胰腺炎的诊疗方法反复较多，因而很多方法存在地区差异性和时间差异性。有多个GUIDELINE发表，很多研究中心提出的干预措施也存在差距。为了给临床医生提供一个相对合理及易操作的诊疗策略，也同时更客观的向病人及家属提供疾病的信息。推出这个基于循证医学的《急性胰腺炎的循证医学临床实践指南2002》。由日本急腹症医学会组织，名古屋医科大学等12所大学的急诊、危重症、外科等医学中心共同完成的系统回顾。MEDLINE (1960-2000)共14821篇关于人类胰腺炎的文章及日本本国医学期刊1475篇共16296篇文献。系统回顾证据分级依据"the levels of evidence and grades of recommendations of the Oxford Centre for Evidence-Based Medicine"及"Guide to development of practice guidelines"。
关于急性胰腺炎的主要观点
说明：A+：有极好证据支持应用
B+：有中等度证据支持应用
C：有较少证据支持应用
A-：有极好证据支持不应用
B-：有极好证据支持不应用
关于急性胰腺炎的主要观点：A级
1对胰腺炎的诊断，血脂肪酶价值优于淀粉酶
2疑诊急性胰腺炎的病人必须拍胸片及腹部平片
3疑诊急性胰腺炎的病人入院时必须行腹部超声检查
4ERCP用于检查反复发作胰腺炎及疑诊胆石性胰腺炎
5严重度分级是急性胰腺炎管理所必须的。
6血清CRP(48小时内)对于急性胰腺炎严重度评估有效
7除非通过临床表现、实验室检查及超声确诊急性胰腺炎，否则必须行腹部CT检查
8APACHE2(24小时内)、RANSON及GCS评分(24～48小时内)对于急性胰腺炎的严重度评估有效
9在重症胰腺炎或怀疑重症胰腺炎中，广谱抗生素应预防性使用
10疑诊坏死组织感染需要在影像学引导下做细针穿刺
11确诊坏死组织感染需要行坏死组织清除术
12假囊有引起临床症状、并发症或不断增大需治疗干预
13除非急性胰腺炎的病原学已明确或胆石性胰腺炎，ERCP对于AP的诊断并非必需 A-
关于急性胰腺炎的主要观点 ：B级
1全球急性胰腺炎有75～80%可明确病因，25%为特发性
2蛋白酶抑制剂在急性胰腺炎行ERCP后推荐使用
3严重程度评估时除临床症状外，需结合其他数据
4增强腹部CT在评估胰腺坏死及炎症扩大程度时是必须的
5所有急性重症胰腺炎病人必须在特殊医疗单元的全面监护下进行管理，同时还需影像学、内镜、手术支持
6即使肠内营养目前尚未证明可提高生存率，它可以减少并发症，如有可能，建议通过空肠营养管早期给肠内营养
7迁延的伴黄疸的胆管阻塞、胆管炎及重症胰腺炎是急症ERCP/ES的适应症
8多数无感染的胰腺坏死可以恢复，如有渐进性的器官功能衰竭或感染不能排除，或病情迁延，则手术是相对适应症
9坏死组织清除是坏死性胰腺炎的标准术式
10无并发症的轻症急性胰腺炎，推荐LC
11经皮引流 6周以上病情无改善，应手术介入
12临床症状不能作为严重度评估的依据
13轻中急性胰腺炎，鼻胃管多数情况下不需要
14轻中急性胰腺炎，抗生素预防不需要
15H2受体阻滞剂的作用尚未明确
16急性胰腺炎的腹腔灌洗疗效尚未明确
117坏死组织清除术后常规放置引流管并不推荐
18生长抑素(奥曲肽)已经被证实对重症胰腺炎的死亡率和发病率没有效果
急性胰腺炎的外科干预
1如急性重症胰腺炎病人临床表现的恶化(如突发高热、腹痛加剧、)、实验室指标变化(如外周血幼稚细胞，CRP升高)、APACHE2升高、血培养阳性、内毒素血症应在影像学引导下做细针穿刺。A
2假如穿刺为阳性结果，则坏死组织清除必须进行，是坏死性胰腺炎的标准术式 。A
3胰腺假囊有引起临床症状、并发症或不断增大是治疗干预的绝对适应症。A
4多数无感染的胰腺坏死可以恢复，如有渐进性的器官功能衰竭或感染不能排除，或病情迁延，则手术是相对适应症。B
5坏死组织清除术后常规放置引流管并不推荐.B
6经皮引流 6周以上病情无改善，应手术介入
7胰腺假囊直径>=6cm是治疗干预的相对适应症。C
急性胰腺炎的管理的总步骤
诊断及初始管理
严重度分级
严重度分级
重症胰腺炎的管理
急性胆石性胰腺炎
感染并发症的管理
急性胰腺炎的抗生素预防性用药问题
In the past decade, three randomised studies comparing
antibiotics with no antibiotics in acute necrotising
pancreatitis have been done. Pederzoli and colleagues64
randomly allocated 74 patients with necrotising pancreatitis
from six centres in Italy either imipenem 0·5 g every 8 h for
2 weeks or no antibiotic. Oral antibiotics were used after the
2-week period if recovery was prolonged. In the imipenem
group, a significant reduction in pancreatic and nonpancreatic
sepsis was noted, but not in surgical intervention,multiorgan dysfunction, or death. In a Finnish study,65
60 patients with acute necrotising pancreatitis were randomly
allocated cefuroxime 4·5 g daily or no antibiotic. A
significant reduction in septic complications and death was
seen in the antibiotic group. However, two patients in the
no antibiotic group died very early in the course of their
illness, and 76% of patients in the no antibiotic group
received an antibiotic at some point during their admission,factors that could have skewed results. In the smallest of the
three studies, Delcenserie and colleagues66 randomly
allocated 23 consecutive patients ceftazidime, amikacin,and metronidazole, or no antibiotic. The incidence of
sepsis-but not mortality-was reduced in the antibiotic
group. Results of a meta-analysis of these trials confirmed a
reduction in mortality in patients with severe acute
pancreatitis treated with antibiotics.67
Buchler and colleagues68 reported that of ten different
antibiotics tested, only imipenem, ofloxacin, and
ciprofloxacin showed adequate tissue penetration and......（后略) ......
Evidence-based clinical practice guidelines for acute pancreatitis: proposals.
Mayumi T, Ura H, Arata S, Kitamura N, Kiriyama I, Shibuya K, Sekimoto M, Nago N, Hirota M, Yoshida M, Ito Y, Hirata K, Takada T; Working Group for the Practical Guidelines for Acute Pancreatitis. Japanese Society of Emergency Abdominal Medicine.
Department of Emergency Medicine and Intensive Care, Nagoya University School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8560, Japan.
BACKGROUND/PURPOSE: To provide a framework for clinicians to manage acute pancreatitis, evidence-based guidelines have been developed by the Japanese Society of Abdominal Emergency Medicine. METHODS: Evidence was collected by a systematic search of MEDLINE and Japana Centra Revuo Medicina. A total of 1348 papers were reviewed and levels of evidence were assessed. Practical recommendations were also graded. RESULTS: The present guidelines consist of introductions, a summary of recommendations, practice algorithms, definitions, epidemiology, diagnosis, severity assessment, and therapy. The main points of recommendation in these guidelines are: (1) measuring lipase for the diagnosis of acute pancreatitis (recommendation grade [RG], A). (2) The Severity of acute pancreatitis should be assessed using a scoring system, such as that of the Japanese Ministry of Health and Welfare or Acute Physiology and Chronic Health Evaluation (APACHE) II (RG, A). (3) Enhanced computed tomography (CT) should be used for assessment of degree of pancreatic necrosis and inflammation (RG, . (4) Prophylactic antibiotic administration should be used for severe pancreatitis (RG, A), but not for mild to moderate pancreatitis (RG, D). (5) Gabexate mesilate should be used for severe pancreatitis (RG, . Enteral feeding should be used for all pancreatitis (RG, . (7) Continuous hemodiafiltration and continuous arterial infusion of proteinase inhibitor and antibiotics may be of benefit (RG, C). Fine-needle aspiration should be done for the diagnosis of infectious pancreatic necrosis, and if positive, necrosectomy is indicated (RG, A). CONCLUSIONS: These guidelines provide useful information for physicians to manage this troublesome disease。
急性胰腺炎的循证医学临床实践指南2002
背景：近年关于急性胰腺炎的诊疗方法反复较多，因而很多方法存在地区差异性和时间差异性。有多个GUIDELINE发表，很多研究中心提出的干预措施也存在差距。为了给临床医生提供一个相对合理及易操作的诊疗策略，也同时更客观的向病人及家属提供疾病的信息。推出这个基于循证医学的《急性胰腺炎的循证医学临床实践指南2002》。由日本急腹症医学会组织，名古屋医科大学等12所大学的急诊、危重症、外科等医学中心共同完成的系统回顾。MEDLINE (1960-2000)共14821篇关于人类胰腺炎的文章及日本本国医学期刊1475篇共16296篇文献。系统回顾证据分级依据"the levels of evidence and grades of recommendations of the Oxford Centre for Evidence-Based Medicine"及"Guide to development of practice guidelines"。
关于急性胰腺炎的主要观点
说明：A+：有极好证据支持应用
B+：有中等度证据支持应用
C：有较少证据支持应用
A-：有极好证据支持不应用
B-：有极好证据支持不应用
关于急性胰腺炎的主要观点：A级
1对胰腺炎的诊断，血脂肪酶价值优于淀粉酶
2疑诊急性胰腺炎的病人必须拍胸片及腹部平片
3疑诊急性胰腺炎的病人入院时必须行腹部超声检查
4ERCP用于检查反复发作胰腺炎及疑诊胆石性胰腺炎
5严重度分级是急性胰腺炎管理所必须的。
6血清CRP(48小时内)对于急性胰腺炎严重度评估有效
7除非通过临床表现、实验室检查及超声确诊急性胰腺炎，否则必须行腹部CT检查
8APACHE2(24小时内)、RANSON及GCS评分(24～48小时内)对于急性胰腺炎的严重度评估有效
9在重症胰腺炎或怀疑重症胰腺炎中，广谱抗生素应预防性使用
10疑诊坏死组织感染需要在影像学引导下做细针穿刺
11确诊坏死组织感染需要行坏死组织清除术
12假囊有引起临床症状、并发症或不断增大需治疗干预
13除非急性胰腺炎的病原学已明确或胆石性胰腺炎，ERCP对于AP的诊断并非必需 A-
关于急性胰腺炎的主要观点 ：B级
1全球急性胰腺炎有75～80%可明确病因，25%为特发性
2蛋白酶抑制剂在急性胰腺炎行ERCP后推荐使用
3严重程度评估时除临床症状外，需结合其他数据
4增强腹部CT在评估胰腺坏死及炎症扩大程度时是必须的
5所有急性重症胰腺炎病人必须在特殊医疗单元的全面监护下进行管理，同时还需影像学、内镜、手术支持
6即使肠内营养目前尚未证明可提高生存率，它可以减少并发症，如有可能，建议通过空肠营养管早期给肠内营养
7迁延的伴黄疸的胆管阻塞、胆管炎及重症胰腺炎是急症ERCP/ES的适应症
8多数无感染的胰腺坏死可以恢复，如有渐进性的器官功能衰竭或感染不能排除，或病情迁延，则手术是相对适应症
9坏死组织清除是坏死性胰腺炎的标准术式
10无并发症的轻症急性胰腺炎，推荐LC
11经皮引流 6周以上病情无改善，应手术介入
12临床症状不能作为严重度评估的依据
13轻中急性胰腺炎，鼻胃管多数情况下不需要
14轻中急性胰腺炎，抗生素预防不需要
15H2受体阻滞剂的作用尚未明确
16急性胰腺炎的腹腔灌洗疗效尚未明确
117坏死组织清除术后常规放置引流管并不推荐
18生长抑素(奥曲肽)已经被证实对重症胰腺炎的死亡率和发病率没有效果
急性胰腺炎的外科干预
1如急性重症胰腺炎病人临床表现的恶化(如突发高热、腹痛加剧、)、实验室指标变化(如外周血幼稚细胞，CRP升高)、APACHE2升高、血培养阳性、内毒素血症应在影像学引导下做细针穿刺。A
2假如穿刺为阳性结果，则坏死组织清除必须进行，是坏死性胰腺炎的标准术式 。A
3胰腺假囊有引起临床症状、并发症或不断增大是治疗干预的绝对适应症。A
4多数无感染的胰腺坏死可以恢复，如有渐进性的器官功能衰竭或感染不能排除，或病情迁延，则手术是相对适应症。B
5坏死组织清除术后常规放置引流管并不推荐.B
6经皮引流 6周以上病情无改善，应手术介入
7胰腺假囊直径>=6cm是治疗干预的相对适应症。C
急性胰腺炎的管理的总步骤
诊断及初始管理
严重度分级
严重度分级
重症胰腺炎的管理
急性胆石性胰腺炎
感染并发症的管理
急性胰腺炎的抗生素预防性用药问题
In the past decade, three randomised studies comparing
antibiotics with no antibiotics in acute necrotising
pancreatitis have been done. Pederzoli and colleagues64
randomly allocated 74 patients with necrotising pancreatitis
from six centres in Italy either imipenem 0·5 g every 8 h for
2 weeks or no antibiotic. Oral antibiotics were used after the
2-week period if recovery was prolonged. In the imipenem
group, a significant reduction in pancreatic and nonpancreatic
sepsis was noted, but not in surgical intervention,multiorgan dysfunction, or death. In a Finnish study,65
60 patients with acute necrotising pancreatitis were randomly
allocated cefuroxime 4·5 g daily or no antibiotic. A
significant reduction in septic complications and death was
seen in the antibiotic group. However, two patients in the
no antibiotic group died very early in the course of their
illness, and 76% of patients in the no antibiotic group
received an antibiotic at some point during their admission,factors that could have skewed results. In the smallest of the
three studies, Delcenserie and colleagues66 randomly
allocated 23 consecutive patients ceftazidime, amikacin,and metronidazole, or no antibiotic. The incidence of
sepsis-but not mortality-was reduced in the antibiotic
group. Results of a meta-analysis of these trials confirmed a
reduction in mortality in patients with severe acute
pancreatitis treated with antibiotics.67
Buchler and colleagues68 reported that of ten different
antibiotics tested, only imipenem, ofloxacin, and
ciprofloxacin showed adequate tissue penetration and......（后略) ......
附件资料：
相关资料1：
- 急性胰腺炎诊治指南(二).pdf
- 重症急性胰腺炎诊治草案（2000年杭州会议）-胰腺病学.pdf
- 重症急性胰腺炎中西医结合诊治常规（草案）.pdf
- 重症急性胰腺炎诊治指南[1].pdf
- 重症急性胰腺炎的早期处理.pdf
- 美国急性胰腺炎临床指南_治疗部分_.pdf
- 急性胰腺炎诊治指南(一).pdf
- 重症急性胰腺炎防治决策的科学基础.pdf
- 2007-重症急性胰腺炎中西医结合诊治常规.pdf
- 2007-重症急性胰腺炎诊治指南.pdf
- 国际胰腺病学会〈急性胰腺炎外科处理指南〉介绍及相关讨论.pdf
- 肠内营养对急性胰腺炎病人血谷氨酰胺水平的影响.pdf
- 实用临床诊疗规范——消化系统疾病(四)：第十一节 急性胰腺炎.pdf
- 急性胰腺炎外科处理指南 .pdf
- 重症急性胰腺炎的内科治疗进展.pdf