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1、我们毕业啦其实是答辩的标题地方,Clinical practice guideline: management of acutepancreatitis,Repoeter,Weirui Ren,Graduate student in Heibei Medical University,There has been an increase in the incidence of acute pancreatitis reported worldwide.Despite improvements in access to care, imaging and interventional techn
2、iques, acute pancreatitis continues to be associated with signifcant morbidity and mortality. Despite the availability of clinical practice guidelines for the management of acute pancreatitis,recent studies auditing the clinical management of the condition have shown important areas of noncompliance
3、 with evidence-based recommendations. This underscores the importance of creating understandable and implementable recommendations for the diagnosis and management of acute pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the management of both mild
4、 and severe acute pancreatitis as well as the gall stoneinduced pancreatitis.,Methodology,Diagnosis of acute pancreatitis,AssessMent of severity,Supportive care,CONTANTS,Nutrition,Prophylactic antibiotics,Management of acute gallstone pancreatitis,CONTANTS,Methodology,1,2,3,The guideline was develop
5、ed under the auspices of the Universityof Toronto.,They searched Medline for guidelines published between 2002 and 2014 using the Medical Subject Headings “pancreatitis” and “clinical practice guideline.” This search identifed 14 guidelines published between 2008 and 2014.,Another electronic search
6、of Medline was performed using the Medical Subject Headings “pancreatitis,”“acute necrotizing pancreatitis,” “alcoholic pancreatitis,” and “practice guidelines” to update the systematic review. The results were limited to articles published in English between January 2007 and January 2014. Therefere
7、nces of relevant guidelines were reviewed. Up-todate articles on acute pancreatitis diagnosis and management were also reviewed for their references.,1,Diagnosis of acute pancreatitis (2 of the following) Abdominal pain (acute onset of a persistent, severe, epigastric pain often radiating to the bac
8、k) Serum lipase activity (or amylase) at least 3 times greater than the upper limit of normal Characteristic findings of acute pancreatitis on computed tomography or magnetic resonance imaging,Serum lipase has a slightly higher sensitivity for detection of acute pancreatitis.One study demonstrated t
9、hat at day 01 from onset of symptoms, serum lipase had a sensitivity approaching 100% compared with 95% for serum amylase.13 For days 23 at a sensitivity set to 85%, the specifcity of lipase was 82% compared with 68% for amylase. Serum lipase is therefore especially useful in patients who present la
10、te to hospital.,2,Right upper quadrant ultrasonography is the primary imaging modality forsuspected acute biliary pancreatitis owing to its low cost, availability and lack of associated radiation exposure.Ultrasonography has a sensitivity and specifcity greater than 95% in the detection of gallstone
11、s, although the sensitivity may be slightly lower in the context of ileus with bowel distension, commonly associated with acute pancreatitis.Ultrasonography can also identify gallbladder wall thickening and edema, gallbladder sludge, pericholecystic fluid and a sonographic Murphy sign,consistent wit
12、h acute cholecystitis. When these signs are present, the positive predictive value of ultrasonography in the diagnosis of acute cholecystitis is greater than 90%, and additional studies are rarely needed.,3,Diagnosis of acute pancreatitis,4,Magnetic resonance cholangiopancreatography is useful in id
13、entifying CBD stones and delineating pancreatic and biliary tract anatomy. A systematic review that included a total of 67 studies found that the overall sensitivity and specificity of MRCP to diagnose biliary obstruction were 95% and 97%, respectively. Sensitivity was slightly lower, at 92%, for de
14、tection of biliary stones.,5,In severe disease, CT is useful to distinguish between interstitial acute pancreatitis and necrotizing acute pancreatitis and to rule out local complications. However, in acute pancreatitis these distinctions typically occur more than 34 days from onset of symptoms, whic
15、h makes CT of limited use on admission.,Diagnosis of acute pancreatitis,1,At 48 hours, serum CRP levels above 14286 nmol/L have a sensitivity, specifcity, positive predictive value and negative predictive value of 80%, 76%, 67%, and 86%, respectively, for severe acute pancreatitis. Levels greater th
16、an 17 143 nmol/L within the frst 72 hours of disease onset have been correlated with the presence of necrosis with the sensitivity and specifcity both greater than 80%. Serum CRP generally peaks 3672 hours after disease onset, so the test is not helpful in assessing severity on admission.,A variety
17、of reports have correlated a higher APACHE II Score at admission and during the first 72 hours with a higher mortality ( 4% with an APACHE II Score 8 and 11%18% with an APACHE II Score 8).There are some limitations in the ability of the APACHE II Score to stratify patients for disease severity. For
18、example, studies have shown that it has limited ability to distinguish between interstitial and necrotizing acute pancreatitis, which confer different prognoses.In a recent report, APACHE II Scores generated within the frst 24 hours had a positive predictive value of only 43% and negative predictive
19、 value of 86% for severe acute pancreatitis.,2,The organ failurebased criteria for the prediction of severity in acute pancreatitis are taken, in part, from the modifed Multiple Organ Dysfunction Score presented by Banks and colleagues in their revision of the Atlanta Classifcation. A diagnosis of s
20、evere acute pancreatitis should also be made if a patient exhibits signs of persistent organ failure for more than 48 hours despite adequate intravenous fluid resuscitation.,3,AssessMent of severity,1,In a RCT (n = 40), Wu and colleagues found that after 24 hours of resuscitation there was an 84% re
21、duction in the incidence of SIRS in patients resuscitated with Ringers Lactate (p = 0.035) as well as a significant reduction in CRP from 9905 nmol/L to 5143 nmol/L when Ringers Lactate was selected over normal saline (p = 0.02).,Pain control is an important part of the supportive management of pati
22、ents with acute pancreatitis. Therefore, in the absence of any patient-specifc contraindications, a multimodal analgesic regimen is recommended, including narcotics, nonsteroidal anti-inammatories and acetaminophen.,2,However, a systematic review of 26 observational studies showed that critically il
23、l patients cared for by an intensivist or using an intensivist consultant model in a closead intensive care unit (ICU) had a shorter stay in the ICU and lower mortality than similar patients cared for in units without such staffing patterns.,3,Supportive care,1,In the past, it was accepted practice
24、that bowel rest would limit the inammation associated with this process.Recently, however, a series of RCTs have convincingly shown that early oral/enteral feeding in patients with acute pancreatitis is not associated with adverse effects and may be associated with substantial decreases in pain, opi
25、oid usage and food intolerance.,Eckerwall and colleagues demonstrated that oral feeding on admission for mild acute pancreatitis was associated with a signifcant decrease in length of stay from 6 to 4 days compared with withholding oral food and fluids. The major benefts from early feeding appear to
26、 be effective only if feeding is commenced within the frst 48 hours following admission,60 and the current recommendation based on a 2010 meta-analysis of 32 RCTs is to commence oral feeding at the time of admission if tolerated or within the frst 24 hours.,2,Several meta-analyses have shown similar
27、 results, with signifcant reductions in infectious complications, mortality and multiorgan dysfunction when enteral nutrition is commenced within the frst 48 hours following admission.,3,Nutrition,A meta-analysis65 of 4 prospective studies of patients with predicted severe acute pancreatitis demonst
28、rated no change in intolerance of feeding or in mortality when given enteral feeds by nasogastric feeding tube versus nasojejunal feeding tube. In a more recent meta analysis of 3 RCTs , Chang found no signifcant differences in mortality , tracheal aspiration, diarrhea , exacerbation of pain and mee
29、ting energy balance between patients fed through nasogastric and nasojejunal feeding tubes.,Although semi-elemental, immune-enhanced and probiotic enteral feeds showed initial promise in the management of severe acute pancreatitis, meta-analyses still indicate that there is insuffcient evidence to r
30、ecommend the use of any of these nutritional formulations at this time. Given its promise in the context of other critically ill and septic patients, the use of probiotics in the management of acute pancreatitis may yet prove effective as research continues.,4,5,Nutrition,1,A 2010 meta-analysis of 7
31、 RCTs involving 404 patients comparing prophylactic antibiotics versus placebo in CT proven necrotizing acute pancreatitis concluded that there was no statistically signifcant reduction of mortality with therapy, nor a signifcant reduction in infection rates of pancreatic necrosis,In light of the la
32、ck of demonstrated beneft of prophylactic antibiotics in the treatment of acute pancreatitis, the adverse effects of this practice must be carefully considered. In a prospective, randomized controlled trial , Marav-Poma and colleages76 demonstrated a 3-fold increase in the incidence of local and sys
33、temic fungal infection with Candida albicans (from 7% to 22%) in patients with prolonged treatment with prophylactic antibiotics, a fnding consistent with those of other similar studies.In addition, overuse of antibiotics is associated with the increased risk of antibiotic-associated diarrhea and Cl
34、ostridium difficile colitis80 and with the selection of resistant organisms, all of which suggest that the adverse effects of prophylactic antibiotic coverage outweighs any benefit offered by the practice,2,Prophylactic antibiotics,1,A 2012 Cochrane meta-analysis129 included RCTs comparing early rou
35、tine ERCP versus early conservative management with or without selective use of ERCP in patients with suspected acute gallstone pancreatitis. There were 5 RCTs with a total of 644 patients. Overall, there were no statistically signifcant differences between the 2 treatment strategies in mortality ,
36、local or systemic complications as defined by the Atlanta Classifcation.,In an RCT from China 130 patients with severe acute gallstone pancreatitis were randomized to early treatment (within 72 h of onset) with ERCP or image-guided percutaneous transhepatic gallbladder drainage (PTGD).Success rates
37、were comparable between the ERCP and PTGD , and 4-month mortality, local complications and systemic complications did not differ signifcantly. The author concluded that PTGD is a safe, effective and minimally invasive option that should be considered for all patientswith severe acute gallstone pancr
38、eatitis who are poor candidates for or who are unable to tolerate ERCP.,2,Management of acute gallstone pancreatitis,4,A systematic review131 of 8 cohort studies (n = 948) and1 RCT (n = 50) revealed that while the readmission rate for gallstone disease in patients admitted for acute gallstone pancre
39、atitis and discharged without cholecystectomy was 18% within the frst 58 days after discharge, it was 0%in the cohort that underwent index admission cholecystectomy (p 0.001). These results are supported by several retrospective studies that also cited signifcantly higher recurrence rates of gallsto
40、ne disease (15%32%) in patients who did not undergo index admission cholecystectomy. The majority of these recurrent attacks occurred before the time of interval cholecystectomy.,A systematic review of 8 cohort studies and 1 RCT demonstrated a similar reduction in biliary events from 24% to 10% when
41、 patients not undergoing index admission cholecystectomy underwent ERCP and sphincterotomy before discharge. These data strongly support the consideration of ERCP with sphincterotomy for patients unable to tolerate surgery on the index admission owing to comorbidities or deconditioning.,5,Management of acute gallstone pancreatitis,THANKS,
