發(fā)布時間：2018-07-11 18:52

  本文選題：急性胰腺炎 + 高三酰甘油血癥性胰腺炎��； 參考：《第三軍醫(yī)大學(xué)》2017年碩士論文

【摘要】：背景急性胰腺炎(acute pancreatitis,AP)是消化內(nèi)科常見疾病,膽源性急性胰腺炎(biliary acute pancreatitis,BAP)為其首要病因,近年來高三酰甘油血癥性胰腺炎(hypertriglyceridemic pancreatitis,HTGP)發(fā)病率逐年上升,病因占比上升至AP第3位(12.6%),是繼BAP和酒精源性急性胰腺炎之后常見病因之一。不同病因的急性胰腺炎從臨床癥狀、實驗室檢驗指標、病情嚴重程度等臨床表現(xiàn)均有差異,了解急性胰腺炎臨床及流行病學(xué)特點,有利于加深對HTGP的認識,為臨床鑒別AP病因及治療提供參考。隨HTGP發(fā)病率的逐年上升,血脂與AP的相關(guān)性及其對預(yù)后的影響受到臨床的關(guān)注。研究證實,高膽固醇血癥一般不會誘發(fā)AP,高脂血癥性胰腺炎應(yīng)準確稱為高甘油三酯(triglyceride,TG)血癥性胰腺炎,HTGP的TG水平通�！�11.30mmol/L。有研究結(jié)果顯示HTGP的預(yù)后(尤其器官功能衰竭的發(fā)生)較其它病因的急性胰腺炎相對較差,仍有待臨床研究進一步證實;甘油三酯是AP發(fā)生器官功能衰竭的危險因素已經(jīng)被臨床研究證實,全身炎癥反應(yīng)綜合征(systemic inflammatory response syndrome,SIRS)通常是臨床重癥急性胰腺炎的早期表現(xiàn),隨后隨病情加重而逐漸發(fā)生器官功能衰竭,研究顯示TG可水解為具有細胞毒性的游離脂肪酸,損傷胰腺�？赡芤蚧颊逿G水平差異導(dǎo)致SIRS的發(fā)生、臨床表現(xiàn)及預(yù)后存在明顯差異,但相關(guān)研究缺乏。因此,我們將以新橋醫(yī)院2012.01-2015.12年收治的518例急性胰腺炎患者為對象,分析不同病因AP患者臨床特征及流行病學(xué)特點,并進一步評價患者不同TG水平與SIRS發(fā)生相關(guān)性、臨床表現(xiàn)及預(yù)后,為臨床診斷治療不同病因的急性胰腺炎提供參考依據(jù)并深入認識HTGP的發(fā)生機制及臨床特征。目的1.了解不同病因急性胰腺炎臨床特征及流行病學(xué)特點。2.分析不同血清甘油三酯水平與急性胰腺炎患者的病情嚴重程度及預(yù)后相關(guān)性。方法以2012.01-2015.12在新橋醫(yī)院院按照《中國急性胰腺炎診治指南(2013,上海)》診斷明確的全部急性胰腺炎患者為研究對象,從病歷中提取患者一般資料、臨床表現(xiàn)及預(yù)后等相關(guān)信息,排除欠缺大量臨床資料、合并其它嚴重影響預(yù)后的疾病如腫瘤、慢性肝、腎功能衰竭等患者,最終共518例納入分析。采用SPSS 20.0進行數(shù)據(jù)管理和分析,按照各類診斷標準對急性胰腺炎患者進行病因分類和病情嚴重程度等分類,進行不同病因(HTGP、BAP、其它病因AP)的臨床和流行病學(xué)特點描述、組間比較。根據(jù)血清TG值是否高于1.70 mmol/L分為正常組與升高組,升高組再分為輕、中、重組,分析不同TG水平與病情嚴重程度及預(yù)后相關(guān)性,采用Logistic回歸分析校正相關(guān)因素,以P0.05為統(tǒng)計學(xué)顯著性差異標準。結(jié)果1.收集新橋醫(yī)院消化內(nèi)科出院診斷的AP患者共計518例,其中女性190例,男性328例,男女比例1.7:1。發(fā)病年齡范圍16~92歲,平均年齡48.67±14.57歲。HTGP占10.6%(55/518),BAP患者35.9%(186/518),其它病因(包括酒精、免疫、藥物、創(chuàng)傷等)AP患者53.5%(277/518)。HTGP構(gòu)成比有增多的趨勢,從2012年7.4%上升至2015年17.7%(P0.05),輕重比例2.7:1,16.2%(84/518)合并糖尿病,24.5%(127/518)合并脂肪肝,14.1%(73/518)合并高血壓。AP患者平均住院時間為11.97±12.27天,腹痛緩解時間4.56±3.15天,SAP中56.1%胰腺CT評級為D、E級,AP總病死率4.4%。SAP在各組中HTGP比例最高45.5%(25/55),BAP28.0%(52/186),其它病因AP22.4%(62/277)。不同病因臨床生化指標比較:BAP組血淀粉酶水平明顯高于HTGP、其它病因AP組,其中HTGP組血淀粉酶水平最低。C-反應(yīng)蛋白(c-reaction protein,CRP)、血糖、紅細胞比容(red blood cell specific volume,HCT)在HTGP組中最高,血鈣、白細胞計數(shù)、血肌酐、尿素、白蛋白組間未見明顯差異。不同病因AP合并癥比較:糖尿病比例最高的是HTGP(29.1%),其次其它病因AP(15.9%)。脂肪肝比例最高的是HTGP(41.8%),其次其它病因AP(24.9%)。比較不同病因AP的預(yù)后:HTGP更容易發(fā)生SIRS,其腹痛緩解時間及平均住院時間HTGP組均長于BAP、其它病因AP。胰腺CT分級(D、E級)雖在HTGP比例最高,但組間未見統(tǒng)計學(xué)意義,多器官功能衰竭(multiple organ failure,MOF)、病死率均未見統(tǒng)計學(xué)意義。2.479例AP患者于我院檢測TG,其中TG升高組276例(57.6%),TG正常組203例(42.4%),TG升高組SIRS、胸腔積液、病情嚴重程度明顯高于正常組(P0.05);組間MOF差異無統(tǒng)計學(xué)意義(P0.05);隨著TG升高,各組并發(fā)SIRS風(fēng)險越高(P0.001)。Logistic回歸分析TG與SIRS獨立相關(guān)[OR=1.138(95%CI:1.082~1.197);P0.001]。重度TG升高組中使用血液凈化(29例)治療后,TG水平、白細胞計數(shù)、急性生理學(xué)和慢性健康狀況評分(acute physiology and chronic health status score,APACHEⅡ)與治療前比較明顯降低(P0.001)。結(jié)論AP多見于男性,近年來HTGP有上升趨勢。AP患者較易合并高脂血癥、脂肪肝、糖尿病、高血壓等代謝疾病。病死率4.4%。HTGP相比于BAP、其它病因AP,病情嚴重程度更重,臨床生化指標血淀粉酶升高不明顯,C-反應(yīng)蛋白、血糖、HCT均顯著高于其它兩組,更易合并高脂血癥、糖尿病、脂肪肝代謝綜合癥。不同病因AP病死率未見明顯差異。相對于TG正常組AP患者,TG升高組AP患者預(yù)后更差,血清TG水平越高,AP發(fā)生SIRS風(fēng)險越高,但合并MOF無差異。血液凈化能有效緩解TG重度升高組的病情。
[Abstract]:Background acute pancreatitis (acute pancreatitis, AP) is a common disease in the digestive department. Biliary acute pancreatitis (biliary acute pancreatitis, BAP) is the primary cause. In recent years, the incidence of hypertriglyceridemic pancreatitis (hypertriglyceridemic pancreatitis, HTGP) is increasing year by year, the ratio of etiology is up to AP third (12.6%), which is the following BAP It is one of the common causes of acute pancreatitis after alcoholic acute pancreatitis. Acute pancreatitis with different causes has different clinical manifestations, such as clinical symptoms, laboratory test indexes, and the severity of the disease. To understand the clinical and epidemiological characteristics of acute pancreatitis is beneficial to the recognition of HTGP, and to provide reference for the clinical identification of AP etiology and treatment. The incidence of TGP is increasing year by year. The correlation between blood lipid and AP and its effect on the prognosis are concerned. It is confirmed that hypercholesterolemia generally does not induce AP. Hyperlipidemic pancreatitis should be called high triglyceride (triglyceride, TG) pancreatitis, and the TG level of HTGP is usually more than 11.30mmol/L., and the results of the study show HTG. The prognosis of P (especially organ failure) is relatively poor compared with other causes of acute pancreatitis, which remains to be further confirmed by clinical studies. Triglycerides, a risk factor for AP organ failure, have been confirmed by clinical studies, and systemic inflammatory response syndrome (systemic inflammatory response syndrome, SIRS) is usually present. The early manifestation of severe acute pancreatitis in bed is followed by progressive organ failure with the aggravation of the disease. The study shows that TG can be hydrolyzed to a cytotoxic free fatty acid and damage the pancreas. There may be significant differences in the occurrence of SIRS, clinical manifestation and prognosis in patients with the difference of TG level, but the related research is lack. Therefore, we will The clinical features and epidemiological characteristics of 518 patients with acute pancreatitis treated in Xinqiao Hospital 2012.01-2015.12 were analyzed, and the correlation of different TG levels with SIRS, clinical manifestation and prognosis were further evaluated, which provided a reference for the clinical diagnosis and treatment of acute pancreatitis with different causes. To understand the pathogenesis and clinical characteristics of HTGP. Objective 1. to understand the clinical characteristics and epidemiological characteristics of acute pancreatitis with different causes..2. analysis of the correlation between the levels of triglycerides in different serum levels and the severity and prognosis of patients with acute pancreatitis. Methods 2012.01-2015.12 was used in the hospital of Xinqiao Hospital in accordance with the diagnosis and treatment of acute pancreatitis in China. Guidelines (2013, Shanghai) > diagnosis of all patients with acute pancreatitis, from the medical record, the general data, clinical manifestations and prognosis information, the exclusion of a large number of clinical data, combined with other serious prognosis of the disease such as tumors, chronic liver, renal failure and other patients, the final total of 518 cases included in the analysis. SPSS 20 was used for data management and analysis. The clinical and epidemiological characteristics of different etiological factors (HTGP, BAP, other pathogeny AP) were classified according to various diagnostic criteria, and the clinical and epidemiological characteristics of different causes (HTGP, BAP, and other causes) were compared. According to whether the TG value of blood clear was higher than 1.70 mmol/L, the normal group and the elevated group were divided. The elevation group was redivided into light, medium and reorganized, and the correlation between the different TG levels and the severity and prognosis of the disease was analyzed. The correlation factors were corrected by Logistic regression analysis, and P0.05 was a significant difference standard. Results 1. of the AP patients in the digestive department of Xinqiao Hospital were collected, of which 190 cases were female, 328 men were male, and the ratio of men and women was 1. The age of.7:1. was 16~92 years old, the average age of 48.67 + 14.57 years.HTGP accounted for 10.6% (55/518), BAP patients 35.9% (186/518), other causes (including alcohol, immunity, medicine, trauma, etc.) 53.5% (277/518).HTGP constituent ratio of AP patients increased, from 7.4% in 2012 to 17.7% (P0.05) in 2015, 2.7:1,16.2% (84/518) with diabetes mellitus combined with diabetes The average hospitalization time of patients with 24.5% (127/518) with fatty liver, 14.1% (73/518) with hypertension.AP was 11.97 + 12.27 days, abdominal pain remission time was 4.56 + 3.15 days, 56.1% pancreatic CT rating was D, E, and AP total fatality rate 4.4%.SAP was 45.5% (25/55) in each group. Biochemical indexes were compared: the level of blood amylase in group BAP was significantly higher than that of HTGP, other cause AP, of which the lowest level of.C- reaction protein (C-reaction protein, CRP), blood glucose and erythrocyte specific volume (red blood cell specific) were the highest in group HTGP, and the blood calcium, white blood cell count, blood creatinine, urea and albumin were not found in the group. The AP complication of different etiology was compared: the highest proportion of diabetes was HTGP (29.1%), followed by other causes AP (15.9%). The highest proportion of fatty liver was HTGP (41.8%), and the other cause AP (24.9%). The prognosis of AP in different causes was compared: HTGP was more likely to occur SIRS, its abdominal pain relief time and the average length of hospital stay were longer than BAP, other diseases. The CT classification of AP. (D, E) was the highest in HTGP, but there was no statistical significance between the groups. There was no statistical significance in multiple organ failure (multiple organ failure, MOF), and no statistical significance was found in the fatality rate of.2.479 AP patients in our hospital. There were 276 cases (57.6%) in the ascending group and 203 cases (42.4%) in the normal group. The pleural effusion, pleural effusion, and the severity of the disease were serious. The degree of MOF was significantly higher than that of the normal group (P0.05), and there was no significant difference between the groups (P0.05), and with the increase of TG, the higher the risk of SIRS (P0.001).Logistic regression analysis of TG and SIRS independent related [OR=1.138 (95%CI:1.082~1.197), and the level of blood purification (29 cases), the leukocyte count, and the acute physiology. Acute physiology and chronic health status score, APACHE II) was significantly lower than before treatment (P0.001). Conclusion AP is more common in men. In recent years HTGP has a rising trend in.AP patients with hyperlipidemia, fatty liver, diabetes, hypertension and other metabolic diseases. The cause of the disease was AP, the severity of the disease was more serious, the serum amylase of the clinical biochemical indexes was not obvious, the C- reactive protein, blood glucose and HCT were significantly higher than those of the other two groups, which were more likely to be associated with hyperlipidemia, diabetes, and fatty liver metabolism syndrome. The mortality rate of AP was not significantly different in different etiology. For AP patients in normal TG group, the prognosis of AP patients in TG elevated group was worse. The higher the level of TG, the higher the risk of SIRS in AP, but there was no difference in MOF.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R576

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