【摘要】：[目的]急性胰腺炎(Acute pancreatitis, AP)是臨床常見急腹癥之一。大部分急性胰腺炎為一種輕度的自限性疾病,通常不伴有并發(fā)癥。但是,仍有10%到20%的患者發(fā)展為重癥急性胰腺炎,由于劇烈的炎癥反應,造成了多臟器損傷,延長了住院時間,并出現(xiàn)較高的死亡率[1]。所以判斷急性胰腺炎的嚴重程度對治療及預后的判斷有重要意義,目前臨床對急性胰腺炎嚴重程度的判斷,在臨床癥狀及影像學表現(xiàn)的基礎上,主要依據的指標包括:PCT(procalcitonin)、CRP(C-reactive protein)、IL-6(Interleukin-6)等炎癥因子及相關評分標準。為了提高臨床對急性胰腺炎嚴重程度判斷的準確性、高效性,可以考慮監(jiān)測PCT的同時監(jiān)測IL-6、CRP等傳統(tǒng)炎癥指標,并對比Ranson評分。另一方面,針對急性胰腺炎患者,我們應該選擇有針對性的個體化抗生素治療(個性化抗生素管理”,Individual,Patient-adapted Antibiotic Therapy: “Antibiotic Stewardship”),以強化抗生素的合理應用,減少二重感染發(fā)生。本研究將探討監(jiān)測PCT在急性胰腺炎嚴重程度評估中運用的指導意義,并對比hs-CRP、IL-6以及常規(guī)白細胞計數(shù)、中性粒細胞比值等常用炎癥指標,最后評估PCT聯(lián)合hs-CRP、IL-6、Ranson評分,探索聯(lián)合監(jiān)測在急性胰腺炎嚴重程度診斷方面的意義,同時將探索動態(tài)監(jiān)測PCT對急性胰腺炎抗生素應用的指導意義。[方法]本研究采用回顧性分析方法,所有收集資料來自于昆明醫(yī)科大學第二附屬醫(yī)院的2013年7月至2016年8月診斷為急性胰腺炎的住院患者154例(女49例,男105例,年齡16-75歲)。患者納入標準:符合急性胰腺炎診治指南[2](2014年)診斷標準。排除標準:對未診斷為急性胰腺炎,臨床資料不完整者均排除在本研究之外。入院患者收集記錄患者性別、年齡、病因等一般資料。104例AP患者根據急性胰腺炎診治指南[2](2014年)嚴重程度分級標準,記錄相關數(shù)據,測算Marshall評分并結合臨床證據,分為輕癥急性胰腺炎(54例)、中重癥急性胰腺炎(28例)和重癥急性胰腺炎(22例)即A、B、C三組。分別于入院24小時內采用電化學發(fā)光法法測定PCT、hs-CRP、IL-6含量,同時收集48小時內的相關數(shù)據,測算Ranson評分。再將100例中重癥及重癥急性胰腺炎患者分為:D組,動態(tài)監(jiān)測PCT并應用抗生素,后根據PCT數(shù)值變化判斷是否停用抗生素,中重癥急性胰腺炎和重癥急性胰腺炎患者(50例);E組,已應用抗生素者并未動態(tài)監(jiān)測PCT數(shù)值,經一般常用炎癥指標及傳統(tǒng)臨床證據(包括白細胞計數(shù)、中性粒細胞比值、體溫、心率等)指導判斷是否停用抗生素,中重癥急性胰腺炎和重癥急性胰腺炎患者(50例)。應用spss19.0軟件對數(shù)據進行統(tǒng)計分析:1.PCT、hs-CRP、IL-6、Ranson評分與急性胰腺炎嚴重程度判斷的關系;2.其對于急性胰腺炎分級診斷的價值;3.PCT、hs-CRP、IL-6、Ranson評分與急性胰腺炎嚴重程度的相關性。4.D、E兩組間抗生素使用時長、住院時長、抗生素單一使用或聯(lián)合使用的區(qū)別的。[結果]1.共納入患者104例,中重癥及重癥急性胰腺炎所占比例約為48%。三組急性胰腺炎患者的 PCT (中位數(shù))為{0.14(0.07,0.34) , 0.92(0.50,1.42),6.69(4.82,11.57)ng/ml}; hs-CRP 為(中位數(shù)){70.94±76.22,157.94±88.96,202.75±104.05}; IL-6 為(中位數(shù)){37.20(8.45,71.38),97.80(53.94,178.36),161.40(78.76,274.13)}; Ranson評分為(中位數(shù)){1.00(1.00,2.00), 5.00(4.00,5.00),8.00(6.75,8.00)};三組 PCT、hs-CRP、IL-6、Ranson 評分經 Kruskal-Wallis H 檢驗,三組總體差異均有明顯統(tǒng)計學意義(P 0.001)。進一步運用LSD法對三組hs-CRP進行組間兩兩比較結果顯示,輕癥急性胰腺炎hs-CRP明顯低于中重癥急性胰腺和重癥急性胰腺炎組,差異均有統(tǒng)計學意義(P 0.05);但中重癥急性胰腺和重癥急性胰腺炎組hs-CRP差異無統(tǒng)計學意義(P 0.05)。運用Mann-whitney U檢驗對三組PCT、IL-6、Ranson評分分別進行組間比較結果顯示,重癥急性胰腺炎組PCT明顯高于輕癥急性胰腺炎和中重癥急性胰腺組,同時中重癥急性胰腺組也明顯高于輕癥急性胰腺炎組,差異均有統(tǒng)計學意義(P 0.05)。IL-6結果與hs-CRP 一致。Ranson 評分結果與 PCT 一致。三組 CT 分級經 Kruskal-Wallis H檢驗,差異有統(tǒng)計學意義(P 0.05)。三組一般資料,包括年齡、心率經統(tǒng)計學分析,三組總體差異有統(tǒng)計學意義(P 0.05);平均動脈壓經、性別差異無統(tǒng)計學意義(P 0.05)。對三組患者血液學相關指標,包括中性粒細胞比值(N%)、血鈣、白細胞(WBC)、血糖、LIPASE分別進行統(tǒng)計學分析,三組總體差異有統(tǒng)計學意義(P 0.05),AMY三組總體差異無統(tǒng)計學意義(P 0.05)。2.共納入患者104例,中重癥及重癥急性胰腺炎所占比例約為48%。為了獲得PCT、hs-CRP、IL-6、Ranson評分四者對于診斷中重癥及重癥急性胰腺炎的精確性及臨閾值,采用受試者特征曲線(Receiver Operating Characteristic Curve,ROC)分析,結果提示四者的曲線下面積分別為:PCT (0.948±0.020)、hs-CRP (0.802±0.045)、IL-6 (0.801±0.043)、Ranson (0.980±0.014),對于中重癥及重癥急性胰腺炎的診斷閾值分別為PCT ( 0.4825ng/ml)、hs-CRP(91.69mg/l)、IL-6 (74.25pg/ml)、Ranson 評分(3.5 分),敏感性(Sensitivity,SE)(%)及特異性(Specificity,SP)(%)四者分別為:PCT(88%,88.9%)、hs-CRP(86%,70.4%)、IL-6 (72%, 77.8%)、Ranson (92%,100%)。應用 PCT 聯(lián)合 hs-CRP兩個閾值聯(lián)合測定分析,曲線下面積為:(0.945±0.021),敏感性及特異性為:(80%,96.3%)。應用PCT聯(lián)合Ranson評分兩個閾值聯(lián)合測定分析,曲線下面積為:(0.997±0.003),敏感性及特異性為:(100%,96.3%)。3.共納入患者104例,中重癥及重癥急性胰腺炎所占比例約為48%。PCT、hs-CRP、IL-6、Ranson評分四者與急性胰腺炎嚴重程度呈正相關,結果分別為PCT (r=0.839, P 0.001 )、hs-CRP (r=0.531,P 0.001 )、IL-6 (r=0.541,P 0.001 )、Ranson 評分(r=0.879, P 0.001)。PCT、hs-CRP、IL-6、Ranson 評分四者兩兩間分析,均呈正相關。4.共納入患者100例,兩組患者年齡、性別、Ranson評分沒有統(tǒng)計學差別。D組抗生素使用時長、住院時長結果(均數(shù))分別為:(13.58±8.42, 15.52±6.25),E組抗生素使用時長、住院時長結果(均數(shù))分別為:(17.34±4.95, 22.68±6.14,天);D組、E組抗生素使用時長、住院時長經兩獨立樣本t檢驗,P 0.05。兩組抗生素單一使用或聯(lián)合使用的情況經x2檢驗,P 0.05。[結論]1.PCT、Ranson評分、CT分級可作為判斷急性胰腺炎嚴重程度分級的參考標準,三者數(shù)值或分級越高提示急性胰腺炎程度越重;IL-6、hs-CRP可作評估輕型胰腺炎的參考指標。2.對于中重癥及重癥急性胰腺炎的診斷閾值分別為PCT (0.4825ng/ml)、hs-CRP(91.69mg/l)、IL-6 (74.25pg/ml)、Ranson 評分(3.5 分);對于急性胰腺炎嚴重的診斷價值:PCT聯(lián)合Ranson評分 Ranson評分 PCT PCT聯(lián)合hs-CRP hs-CRP IL-6,說明PCT聯(lián)合Ranson評分對中重癥急性胰腺炎和重癥急性胰腺炎的的診斷效果最好,說明二者聯(lián)合診斷要優(yōu)于其各自診斷價值。PCT聯(lián)合hs-CRP二者聯(lián)合診斷要優(yōu)于hs-CRP診斷,次于PCT診斷。3.PCT、hs-CRP、IL-6、Ranson評分四者與急性胰腺炎嚴重程度呈正相關,四者間兩兩相分析亦為正相關。4.動態(tài)監(jiān)測PCT數(shù)值可作為指導中重癥和重癥急性胰腺炎抗生素治療的有效參考指標。
[Abstract]:[Objective] Acute pancreatitis (AP) is one of the most common acute abdominal diseases. Most acute pancreatitis is a mild self limiting disease, usually without complications. However, 10% to 20% of the patients are still developing into severe acute pancreatitis. The severe inflammatory reaction caused multiple organ damage and prolonged hospitalization. And there is a high mortality rate of [1]., so it is important to judge the severity of acute pancreatitis to judge the treatment and prognosis. On the basis of clinical symptoms and imaging manifestations, the main criteria include: PCT (procalcitonin), CRP (C-reactive protein), IL-6 (Interleuk), and IL-6 (Interleuk). In-6) and other inflammatory factors and related scoring criteria. In order to improve the accuracy and efficiency of the clinical assessment of the severity of acute pancreatitis, we can consider monitoring PCT and monitoring traditional inflammatory markers such as IL-6, CRP, and compared the Ranson score. On the other hand, we should choose targeted individualized antibiotics for patients with acute pancreatitis. Treatment (individualized antibiotic management, Individual, Patient-adapted Antibiotic Therapy: "Antibiotic Stewardship") to strengthen the rational use of antibiotics and reduce the occurrence of double infection. This study will explore the guiding significance of monitoring the use of PCT in the assessment of the severity of acute pancreatitis, and compare hs-CRP, IL-6, and conventional whiteness. Cell count, neutrophils ratio and other commonly used inflammatory markers, and finally to evaluate PCT combined with hs-CRP, IL-6, Ranson score, explore the significance of joint monitoring in the diagnosis of acute pancreatitis, and explore the guiding significance of dynamic monitoring of PCT for the application of acute pancreatitis. [Methods] this study adopted a retrospective analysis, all The data were collected from 154 hospitalized patients (49 women, 105 men, 16-75 years old) diagnosed as acute pancreatitis from July 2013 to August 2016 at the Second Affiliated Hospital of Kunming Medical University. The patients were included in the criteria: guidelines for diagnosis and treatment of acute pancreatitis [2] (2014). Exclusion criteria: undiagnosed as acute pancreatitis, clinical data The patients who were incomplete were excluded from this study. The hospitalized patients collected and recorded the patient's sex, age, and etiology,.104 cases AP patients were divided into mild acute pancreatitis (54 cases) with severe acute pancreatitis (54 cases) according to the severity grading standard of acute pancreatitis, according to the severity grading standard of acute pancreatitis diagnosis and treatment guidelines (2014). 28 cases of pancreatitis (28 cases) and severe acute pancreatitis (22 cases), namely, A, B, and C three groups. The PCT, hs-CRP, IL-6 content were measured by Electrochemiluminescence Method within 24 hours of admission, and the relevant data of 48 hours were collected, and the Ranson score was measured. Then 100 cases of severe and severe acute pancreatitis were divided into D group. After the PCT numerical changes were used to determine whether to discontinue antibiotics, severe acute pancreatitis and severe acute pancreatitis (50 cases). In group E, those who had used antibiotics did not dynamically monitor the PCT values, and were guided by commonly used inflammatory markers and traditional clinical evidence (including leukocyte count, neutrophils ratio, body temperature, heart rate, etc.) No use of antibiotics, severe acute pancreatitis and severe acute pancreatitis (50 cases). The data were statistically analyzed by spss19.0 software: the relationship between 1.PCT, hs-CRP, IL-6, Ranson score and the severity of acute pancreatitis; 2. the value for the classification of acute pancreatitis; 3.PCT, hs-CRP, IL-6, Ranson score and acute pancreas The correlation of inflammatory severity was.4.D, the antibiotics used in the E two groups were long, long hospitalized, single use of antibiotics or combined use of antibiotics. [result]1. was included in 104 cases, and the proportion of severe and severe acute pancreatitis in 48%. three groups of acute pancreatitis was {0.14 (0.07,0.34), 0.92 (0.50,1.42), 6.). 69 (4.82,11.57) ng/ml}; hs-CRP is (median) {70.94 + 76.22157.94 + 88.96202.75 + 104.05}; IL-6 is (median) {37.20 (8.45,71.38), 97.80 (53.94178.36), 161.40 (78.76274.13)}; the score is (median), 5 (median), 8 (8)}; three groups S H test, the total difference between the three groups had significant statistical significance (P 0.001). Further use of LSD method to compare 22 groups of three groups of hs-CRP showed that the hs-CRP of mild acute pancreatitis was significantly lower than that of severe acute pancreatitis and severe acute pancreatitis (P 0.05), but severe acute pancreas and severe acute pancreatitis were in severe acute pancreatitis. There was no significant difference in hs-CRP in the group of sexual pancreatitis (P 0.05). The results of three groups of PCT, IL-6 and Ranson scores by Mann-whitney U test showed that PCT in severe acute pancreatitis group was significantly higher than that of mild acute pancreatitis and medium severe acute pancreas group, and the severe acute pancreas group was also significantly higher than that of mild acute pancreas. The difference was statistically significant (P 0.05).IL-6 results and hs-CRP consistent.Ranson score coincide with PCT. The three group CT grading by Kruskal-Wallis H test, the difference was statistically significant (P 0.05). The three groups of general data, including age, heart rate by statistical analysis, the three groups were statistically significant (P 0.05); mean arterial pressure The gender differences were not statistically significant (P 0.05). The hematology related indexes in the three groups, including neutrophils ratio (N%), blood calcium, leukocyte (WBC), blood glucose and LIPASE were statistically analyzed, the total difference between the three groups was statistically significant (P 0.05), and the total difference of AMY three groups was not statistically significant (P 0.05).2. was included in 104 patients. The proportion of severe and severe acute pancreatitis was about 48%. in order to obtain the accuracy and threshold value of PCT, hs-CRP, IL-6, Ranson score in the diagnosis of severe acute pancreatitis and severe acute pancreatitis (Receiver Operating Characteristic Curve, ROC). The results showed that the area under the curve of the four were: PCT (0). .948 + 0.020), hs-CRP (0.802 + 0.045), IL-6 (0.801 + 0.043), Ranson (0.980 + 0.014). The diagnostic thresholds for severe and severe acute pancreatitis were PCT (0.4825ng/ml), hs-CRP (91.69mg/l), IL-6 (74.25pg/ml), Ranson score (3.5), sensitivity (Sensitivity,%) and four (88) four (88) %, 88.9%), hs-CRP (86%, 70.4%), IL-6 (72%, 77.8%), Ranson (92%, 100%). Using PCT combined hs-CRP two thresholds combined determination analysis, the area under the curve is (0.945 + 0.021), the sensitivity and specificity are: (80%, 96.3%). The application of PCT combined with Ranson score and two threshold determination analysis, the area under the curve is: (0.997), sensitivity and specificity (100%, 96.3%).3. were included in 104 patients. The proportion of severe and severe acute pancreatitis was about 48%.PCT, hs-CRP, IL-6, and Ranson scores were positively correlated with the severity of acute pancreatitis. The results were PCT (r=0.839, P 0.001), hs-CRP (r= 0.531, P 0.001), IL-6 (0.001, 0.001). .PCT, hs-CRP, IL-6, Ranson scores were analyzed in four cases, all of which were positively correlated with 100 patients. There was no statistical difference in age, sex, and Ranson scores in the two groups. The length of antibiotics used in the.D group was long, and the length of hospitalization was (13.58 + 8.42, 15.52 + 6.25). The length of the antibiotics used in the E group and the length of the length of hospitalization (all the mean number) were respectively. (17.34 + 4.95, 22.68 + 6.14, day); group D, group E antibiotics used long, long through two independent samples t test, P 0.05. two antibiotics single use or combined use of x2 test, P 0.05.[conclusion]1.PCT, Ranson score, CT classification can be used as a criterion for judging the severity of acute pancreatitis, three values or scores. The higher the level of acute pancreatitis, the higher the severity of acute pancreatitis; IL-6, hs-CRP can be used as a reference index for the assessment of mild pancreatitis,.2. for severe and severe acute pancreatitis, the diagnostic threshold is PCT (0.4825ng/ml), hs-CRP (91.69mg/l), IL-6 (74.25pg/ml), Ranson score (3.5), and the diagnostic value for acute pancreatitis: PCT combined Ranson The score of Ranson score PCT PCT combined with hs-CRP hs-CRP IL-6, indicating that the combination of PCT and Ranson score is the best for the diagnosis of severe acute pancreatitis and severe acute pancreatitis. It shows that the combined diagnosis of the two cases is better than the diagnostic value of.PCT combined with hs-CRP two. 6, the Ranson score four was positively correlated with the severity of acute pancreatitis, and the 22 phase analysis between the four was also a positive correlation.4. dynamic monitoring PCT value as an effective reference index for the guidance of severe and severe acute pancreatitis in the treatment of antibiotics.
【學位授予單位】：昆明醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R576

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