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Clinical Features of Acute Pancreatitis with Acute Necrotic Collection and Walled-off Pancreatic Necrosis
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摘要:
目的 探讨急性胰腺炎的局部并发症急性坏死物积聚(acute necrotic collection, ANC)和坏死物包裹(walled-off pancreatic necrosis, WOPN)的临床特点及预测指标。 方法 收集2013年10月至2015年10月北京协和医院收治的164例中、重度急性胰腺炎患者的临床资料。对有无并发ANC及WOPN患者的临床和实验室指标进行比较。 结果 急性胰腺炎患者中, ANC患者合并全身并发症及感染的比例较无坏死者明显升高(呼吸衰竭47.1%比30.2%, 循环衰竭14.7%比5.2%, 肾脏衰竭38.2%比15.6%, 感染19.1%比6.3%, P均 < 0.05);入院48 h内心率、超敏C反应蛋白、血糖、血肌酐、尿素较无坏死者显著升高, PaO2明显低于无坏死者(P均 < 0.05)。ANC患者中, WOPN患者继发感染及需要介入、手术干预的比例较坏死物吸收者显著升高(感染40.7%比4.9%, P < 0.001;介入29.6%比7.3%, P=0.020;手术22.2%比0, P=0.003), 住院时间延长[29.0(15.0, 56.0)d比13.0(4.5, 26.3)d, P=0.005]、费用升高[72 818.3(27 805.1, 168 932.9)元比28 155.2(6057.6, 51 259.1)元, P=0.015];与坏死物吸收者相比, WOPN患者在发病1~2周后体温、心率、呼吸、白细胞、中性粒细胞、血钙持续异常。 结论 合并ANC和WOPN的急性胰腺炎患者病情更重, 感染风险增加, 需要介入和手术干预的比例更高, 治疗时间和费用显著增加。实验室指标的检测有助于急性胰腺炎局部并发症的预测和监测。 Abstract:Objective To evaluate the clinical features and explore the prognostic factors of acute necrotic collection (ANC) and walled-off pancreatic necrosis (WOPN) following acute pancreatitis. Methods A retrospective study was conducted to analyze the clinical data of 164 patients with moderate to severe acute pancreatitis treated in Peking Union Medical College Hospital from October 2013 to October 2015. Clinical and laboratory indexes were compared between ANC and non-ANC, WOPN and non-WOPN patients. Results The proportions of systemic complications and infection were significantly higher in patients with ANC following acute pancreatitis (respiratory failure 47.1% vs. 30.2%, cardiovascular failure 14.7% vs. 5.2%, renal failure 38.2% vs. 15.6%, infection 19.1% vs. 6.3%, all P < 0.05). Within 48 hours of admission, higher levels of heart rate, high-sensitive C-reactive protein, glucose, serum creatinine, urea, and lower level of PaO2 were observed in patients with ANC compared with patients without ANC (all P < 0.05). Among ANC patients, higher proportions of infection, intervention therapy and surgery were found in patients with WOPN (infection 40.7% vs. 4.9%, P < 0.001; intervention 29.6% vs. 7.3%, P=0.020; surgery 22.2% vs. 0, P=0.003); these patients also had longer hospital stay[29.0(15.0, 56.0)d vs. 13.0(4.5, 26.3)d, P=0.005] and higher total costs[72 818.3(27 805.1, 168 932.9)RMB vs. 28 155.2(6057.6, 51 259.1)RMB, P=0.015]. Within the first 1-2 weeks after onset, a higher temperature, heart rate, breathe rate, counts of white blood cells, counts of neutrophils, and a lower level of blood calcium were shown in patients with WOPN compared with patients whose necrotic materials were absorbed. Conclusions ANC and WOPN are associated with more severe clinical manifestations, higher risk of infection, higher proportion of intervention therapy and surgery, longer hospital stay and increased cost. Laboratory tests are useful in the prediction and monitoring of local complications in acute pancreatitis. -
表 1 急性胰腺炎患者是否合并坏死物积聚的临床特点和实验室指标比较
项目 合并坏死物积聚(n=68) 未合并坏死物积聚(n=96) P值 性别[例(%)] 0.223 男 44(64.7) 53(55.2) 女 24(35.3) 43(44.8) 年龄(x±s, 岁) 45.1±15.2 50.0±18.5 0.075 病因[例(%)] 胆源性 17(25.0) 30(31.3) 0.383 脂源性 19(27.9) 24(25.0) 0.673 酒精 9(13.2) 11(11.5) 0.732 BMI(x±s, kg/m2) 25.7±4.1 25.1±3.8 0.509 临床分型[例(%)] 0.002 MSAP 35(51.5) 72(75.0) SAP 33(48.5) 24(25.0) 全身并发症[例(%)] 呼吸衰竭 36(47.1) 29(30.2) 0.003 循环衰竭 10(14.7) 5(5.2) 0.036 肾脏衰竭 26(38.2) 15(15.6) 0.001 结局[例(%)] 感染 13(19.1) 6(6.3) 0.011 死亡 6(8.8) 5(5.2) 0.273 干预措施[例(%)] 介入 11(16.2) 8(8.3) 0.122 手术 6(8.8) 1(1.0) 0.021 住院时间[M(Q1，Q3)，d] 18.5(6.0，33.5) 14.5(3.5，24.0) 0.048 住院费用[M(Q1，Q3)，元] 32 118.2(9940.2，103 450.9) 25 105.6(7232.9，46 574.1) 0.023 临床指标(入院48 h内)(x±s) 心率(次/min) 105.5±19.8 94.9±24.4 0.018 hs-CRP(ng/ml) 222.3±94.0 154.0±115.3 0.041 血糖(mmol/L) 12.9±10.8 10.0± 5.0 0.027 血肌酐(μmol/L) 146.6±153.8 109.8±99.0 0.040 尿素(mmol/L) 9.3± 8.0 7.2± 6.9 0.040 PaO2(mm Hg) 77.7±21.1 88.2±23.4 0.024 BMI：体重指数；MSAP：中度急性胰腺炎；SAP：重度急性胰腺炎；hs-CRP：超敏C反应蛋白；1 mm Hg=0.133 kPa 
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表 2 急性胰腺炎并发急性坏死物积聚患者中坏死物包裹与吸收的临床特点比较
项目 坏死物包裹(n=27) 坏死物吸收(n=41) P值 性别[例(%)] 0.807 男 17(63.0) 27(65.9) 女 10(37.0) 14(34.1) 年龄(x±s, 岁) 45.89±13.87 44.00±15.94 0.388 病因[例(%)] 胆源性 7(25.9) 10(24.4) 0.886 脂源性 8(29.6) 11(26.8) 0.801 酒精 5(18.5) 4(9.8) 0.466 BMI(x±s, kg/m2) 24.93±2.76 26.27±5.01 0.518 临床分型[例(%)] 0.959 MSAP 14(51.9) 21(51.2) SAP 14(48.1) 20(48.8) 全身并发症[例(%)] 呼吸衰竭 15(55.6) 21(51.2) 0.726 循环衰竭 6(22.2) 8(19.5) 0.787 肾脏衰竭 11(40.7) 15(36.6) 0.730 结局[例(%)] 感染 11(40.7) 2(4.9) ＜0.001 死亡 2(7.4) 4(9.8) 0.738 干预措施[例(%)] 介入 8(29.6) 3(7.3) 0.020 手术 6(22.2) 0(0) 0.003 住院时间[M(Q1，Q3)，d] 29.0(15.0，56.0) 13.0(4.5，26.3) 0.005 住院费用[M(Q1，Q3)，元] 72 818.3(27 805.1，168 932.9) 28 155.2(6057.6，51 259.1) 0.015 BMI、MSAP、SAP：同表 1
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