重新认识胰腺炎课件

重新认识犬胰腺炎

History

病史•

Signalment

临床表现•

Diet•

Vomiting饮食情况

呕吐•

History

of

pancreatitis

胰腺炎病史•Diarrhea腹泻

History

病史•

Signalment

临床表现•

Diet•

Vomiting饮食情况

呕吐•

History

of

pancreatitis

胰腺炎病史•Diarrhea腹泻

History

病史•

Signalment

临床表现•

Diet•

Vomiting饮食情况

呕吐•

History

of

pancreatitis

胰腺炎病史•Diarrhea腹泻

Knowing

the

LIMITATIONS

of

atest

or

procedure

is

often

much

more

important

than

knowingwhat

a

procedure

can

do了解某项检查或操作的局限性比了解某项操作的作用更为重要

Physical

Examination

体格检查•Anterior

abdominal

pain

前腹部疼痛•

Icterus•

Profuse

ascites

黄疸大量腹水••FeverSQ

abscesses发热皮下脓肿

Physical

Examination

体格检查•Anterior

abdominal

pain

前腹部疼痛•

Icterus•

Profuse

ascites

黄疸大量腹水••FeverSQ

abscesses发热皮下脓肿

Physical

Examination

体格检查•Anterior

abdominal

pain

前腹部疼痛•

Icterus•

Profuse

ascites

黄疸大量腹水••FeverSQ

abscesses发热皮下脓肿WHICH

CBC(S)

IS/AREFROM

DOG(S)

WITH

ACUTEPANCREATITIS?哪份血常规结果是来自急性胰腺炎患犬的？147033

14719890524159796PCVWBCSegsBands28.530,00026,10090028.845,50033,6702,730309,8004,6062,4504011,5009,8900Plat87,000407,000

679,000

470,000Toxicmodmodnonenone147033

14719890524159796PCVWBCSegsBands28.530,00026,10090028.845,50033,6702,730309,8004,6062,4504011,5009,8900Plat87,000407,000

679,000

470,000ToxicmodmodnonenoneClinical

Pathology临床病理学•

An

anorexic,

vomiting

dog

with

fasting

hyperlipidemia

probably

has

acute

pancreatitis患犬厌食、呕吐，突然出现高脂血症可能患有急性胰腺炎Clinical

Pathology临床病理学•

An

anorexic,

vomiting

dog

with

fastinghyperlipidemia

probably

has

acutepancreatitis患犬厌食、呕吐，突然出现高脂血症可能患有急性胰腺炎•

Most

dogs

with

pancreatitis

DO

NOT

havefasting

hyperlipidemia大局部胰腺炎患犬并未突然出现高脂血症Clinical

Pathology

临床病理学•

Amylase/Lipase

–

Sensitivity

~

50%

–

Specificity

~

50%淀粉酶/脂肪酶

敏感性-50%

特异性-50%•

TLI血清胰蛋白酶样免疫反响–

Sensitivity

~

35%特异性-35%Clinical

Pathology

临床病理学•

Amylase/Lipase

–

Sensitivity

~

50%

–

Specificity

~

50%淀粉酶/脂肪酶

敏感性-50%

特异性-50%•

TLI血清胰蛋白酶样免疫反响–

Sensitivity

~

35%特异性-35%Clinical

Pathology临床病理学•

cPLI–

Sensitivity

~

80-85%敏感性~

80-85%

TAMU#203505Sig:

14

yr

M(n)

Shih

Tzu

14岁

雄性已去势

西施犬CC:Abdominal

pain前腹部疼痛HPI:

Pain

2

days

ago

and

yesterday

两天前和昨天疼痛Vomited

1

timePU-PD

for

last

week呕吐一次

上周多饮多尿PE:Normal

appetite/body

weight食欲/体重正常No

abnormalities

today

今日无异常TAMU#203505PCV

=WBC

=Segs

=Bands

=Lymphs

=24%

(35-55)23,300/ul

(6,-14,000)17,475/ul

(4,-12,000)

0/ul

(<

500)4,660/ul

(1,-

4,000)Platelets

=

498,000/ul

(200,-

500,000)TAMU#203505肌酐钙钠钾Creatinine

=

Calcium

=

Sodium

=

Potassium

=0.78

mg/dl

(<

2.0)9.7

mg/dl

(9.3-11.8)153

mEq/L

(138-148)3.8

mEq/L

(3.8-5.1)白蛋白Albumin

=

ALT

=

SAP

=胆红素Bilirubin

=

2.7

gm/dl

(2.5-4.4)8,258

IU/L

(<

130)2,354

IU/L

(<

147)0.3

mg/dl

(0-0.8)TAMU#203505Abd

U/S:

“...

.

enlarged

pancreas

withnodules

...

hepatic

mass

mostconsistentwithprimarylivertumor〞腹部超声检查：胰腺体积增大，可见胰腺结节…肝脏肿物符合原发性肝肿瘤特征TAMU#203505Snap

PL:

positivecPL试剂盒检测：

阳性 Yourbestnextstepis: 下一步最好：1Forgetaboutit(dogisnowhappy) 算了吧〔狗狗现在挺开心的〕2Repeat

cPLI

and

ultrasound

tomorrow 明日复查cPLI和超声检查3Txforacutepancreatitis(IVfluids) 治疗急性胰腺炎〔静脉补液〕 4Txwithpancreaticenzymes 用胰酶治疗5

Hepatic

lobectomy肝叶切除术8PANCREATITISversusCLINICALLY

IMPORTANTPANCREATITIS胰腺炎和临床上需重视的胰腺炎Diagnostics诊断•

cPLI–

Sensitivity

~

80%

敏感性-80%•

Abdominal

ultrasound腹部超声检查–

Sensitivity

40%

-

65%敏感性

40%

-

65%Diagnostics

诊断•

cPLI

–

Sensitivity

~

80%敏感性-80%•

Abdominal

ultrasound

腹部超声检查

–

Sensitivity

40%

-

65%

敏感性

40%

-

65%

•

Becausecliniciansrarelyrepeatthe

ultrasound

因为临床医师很少重复进行超声检查Diagnostics•

cPLI

–

Sensitivity

~

80%敏感性-80%•

Abdominal

ultrasound

腹部超声检查

–

Sensitivity

40%

-

65%

敏感性

40%

-

65%

•

Findingscanchangewithinhours...

检查结果数小时内就可能发生变化…WHAT

IS

THE

BEST

WAY

TO

DIAGNOSE

CANINEACUTE

PANCREATITIS?诊断犬急性胰腺炎最好的方法是Bewillingtorepeatultrasound重复进行超声检查All

things

being

equal,

tryto

avoid

surgery平衡一切，尽量防止手术All

things

being

equal,

tryto

avoid

surgery平衡一切，尽量防止手术Bewillingtorepeatultrasound重复进行超声检查THE

REAL

PROBLEM

IS

THAT

ACUTE

PANCREATITIS

CAN

PRESENT

IN

SO

MANYDIFFERENTWAYS

THAT

YOU

DON’T

EVEN

SUSPECT

IT

INITIALLY 真正的问题是急性胰腺炎可能有很多种表现，在开始时你也许都不会疑心是胰腺炎？TAMU#88267

Sig:

7

yr

M

Sheltie

CC:

Vomiting

HPI:

Began

5

weeks

ago7岁

雄性

喜乐蒂呕吐

五周前开始PE:Partial

anorexia,

vomits

phlegm

or

bile

once

daily有时厌食，呕吐黏液或胆汁，每日一次Dog

otherwise

pretty

healthy

其他方面无异常No

significant

abnormalities

未见明显异常TAMU#159796

Sig:

9

yr

M(c)

Pug9岁

雄性去势

巴哥

犬CC:

Vomiting,

yellow

scleras

呕吐，巩膜发黄HPI:

Feeling

bad

12

days

ago

12天前状态不佳

Started

vomiting,

responded

to

fluid

therapy,

but

became

ill

again

when

started

feeding

it

开始呕吐后，液体疗法有效，

但恢复进食后病情反复

Dog’s

eyes

turned

yellow

患犬眼部发黄TAMU#159796

PCV

=

BUN

=

葡萄糖

Glucose

=40%

(35-55)4

mg/dl

(8-29)95

mg/dl

(75-133)钾Potassium

=3.6

mEq/L

(3.8-5.1)胆固醇

Cholesterol

=白蛋白

Albumin

=

ALT

=

SAP

=胆红素Bilirubin

=597

mg/dl

(120-247)2.9

gm/dl

(2.5-4.4)1,691

IU/L

(<

130)3,134

IU/L

(<

147)4.5

mg/dl

(0-0.8)TAMU

#152494

Sig:

9

yr

F(s)

Dalmation

CC:

Vomiting/diarrhea

9岁

雌性绝育

大麦町呕吐/腹泻HPI:

Vomiting

food/bile

6-8X

in

2

weeks

2周内呕吐食物/胆汁6-8次

Diarrhea

constant

for

2

weeks

持续腹泻2周时间

Decreased

appetite

for

10

days,

anorexia

for

5

days

食欲减退10天，厌食5天PE:T

=

39.2

C,

HR

=

102/minTAMU

#152494PCV

=WBC

=Segs

=叶状中性粒细胞Bands

=35.5%

(35-55)21,700/ul

(6,-14,000)15,200/ul

(4,-12,000)630/ul

(<

500)杆状中性粒细胞Lymphs

=

1,400/ul

(1,-4,000)淋巴细胞Platelets

=568,000/ul

(200,-500,000)TAMU

#152494钠钾葡萄糖白蛋白肌酐

Sodium

=

Potassium

=

Glucose

=

Albumin

=

ALT

=

SAP

=Creatinine

=152

mEq/L

(138-148)4.1

mEq/L

(3.5-5.0)107

mg/dl

(60-120)2.7

gm/dl

(2.5-4.4)123

IU/L

(<

110)2,174

IU/L

(<

130)1.3

mg/dl

(<

2.0)TAMU

#152494Abdominal

ultrasound:“…Smallamountofanechoiceffusionbetweenliverlobesandaroundurinarybladder.〞腹部超声：肝叶之间及膀胱周围可见少量无回声液体TAMU

#152494

Abdominal

fluid:

腹腔积液WBC

=RBC

=153,000/ul

0/ulTotal

protein

=4.6

gm/dl总蛋白

90%

nondegenerate

neutrophils

非退行性中性粒细胞

8%

macrophages,

vaculated

巨噬细胞，空泡化Sterile

pancreatitis无菌性胰腺炎Versus

和Septic

peritonitis败血性腹膜炎Abdominal

fluid

腹腔积液147260

152494152485109612TP

gm/dl

5.14.61.33.6WBC/ul15,059

153,000

70018,200RBC/ul91,112

030,00083,700Abdominal

fluid

腹腔积液147260

152494152485109612TP

gm/dl

5.14.61.33.6WBC/ul15,059

153,000

70018,200RBC/ul91,112

030,00083,700PANCREATITIS

CAN:胰腺炎时可能：a)

make

no

abdominal

effusion无腹腔积液b)

make

a

little

abdominal

effusion产生少量腹腔积液c)

make

a

massive

abdominal

effusionPancreatitis

can

present

as:胰腺炎可表现为：•

acute

vomiting

with

abdominal

pain急性呕吐伴有腹部疼痛•

chronic,

low

grade

vomiting/anorexia

(abscess)慢性轻度呕吐/厌食〔脓肿〕•

icterus

(biliary

tract

obstruction)黄疸〔胆道阻塞〕•

ascites

(minimal,

little

or

lots)腹水〔少量、无腹水或大量〕•

acute

abdomen

(looks

just

like

septic

peritonitis)急腹症〔病症类似败血性腹膜炎〕•

SIRS

(looks

like

septic

shock)SIRS〔病症类似败血性休克〕SYSTEMIC

INFLAMMATORYRESPONSE

SYNDROME全身性炎症反响综合征–usedtobecalled“Septic shock〞曾被称为“败血性休克〞SYSTEMIC

INFLAMMATORYRESPONSE

SYNDROME全身性炎症反响综合征–

inadequate

perfusion

of

the

body

tissuesbecause

of

an

exaggeratedinflammatoryresponse剧烈的炎症反响导致机体组织灌注不良

WHAT

IS

SUPPOSED

TO

HAPPEN

认为会发生什么Bacterial

toxin,

inflammatory

cytokines细菌毒素，炎性细胞因子

Lymph

nodes,

hepatic

macrophages

淋巴结，肝脏巨噬细胞Systemic

circulation全身循环

WHAT

IS

SUPPOSED

TO

HAPPEN

认为会发生什么Bacterial

toxin,

inflammatory

cytokines细菌毒素，炎性细胞因子

Lymph

nodes,

hepatic

macrophages

淋巴结，肝脏巨噬细胞Systemic

circulation全身循环Inflammatory

cytokinesLymph

nodes

淋巴结Systemiccirculation全身循环WHAT

CAN

HAPPEN会发生什么炎性细胞因子 EARLY–SIRSMildunevenvasodilatation轻度局部血管扩张“Highoutput〞shock高输出性休克Bright

red

mucus

membranes

黏膜鲜红Fast

capillary

refill

time

毛细血管再充盈时间短Bounding

pulsesTachycardia 脉搏跳跃〔洪脉〕心动过速 LATE–SIRSSevereperipheralvasodilatation+poorcardiaccontractility严重的外周血管扩张+心收缩力缺乏 “Lowoutput〞shock低输出性休克Pale

mucus

membranes

黏膜苍白Weak

pulses脉搏微弱Slow

refill

time

毛细血管再充盈时间延长THERAPY

FOR

PANCREATITIS胰腺炎的治疗Only

supportive

and

symptomatic仅用支持疗法和对症治疗•

NPO

(nothing

per

os)

vs

EarlyFeedingNPO〔禁食〕和早期饲喂•

Early

Feeding

早期饲喂–

Feed

small

amounts

of

ultra-low

fat

foodeven

if

vomiting即使呕吐也饲喂少量超低脂食物–

Continue

feeding

as

long

as

the

patientdoes

not

get

worse只要动物病情没有恶化，便继续饲喂THERAPY

FOR

PANCREATITIS胰腺炎的治疗Only

supportive

and

symptomatic仅用支持疗法和对症治疗•

Fluid

therapy液体疗法Crystalloids

晶体液PlasmaColloids

血浆胶体液

THERAPY

FOR

PANCREATITIS

胰腺炎的治疗

Only

supportive

and

symptomatic

仅用支持疗法和对症治疗•

Early

Feeding

早期饲喂•

Fluid

therapy液体疗法Crystalloids

晶体液PlasmaColloids血浆

胶体液 Hetastarchisnolongereveryone’sbestfriend...(JVetEmergCriticalCare25:20-47,2021) 羟乙基淀粉不再是所有人最好的朋友…

THERAPY

FOR

PANCREATITIS

胰腺炎的治疗

Only

supportive

and

symptomatic•

Early

Feeding

早期饲喂•

Fluid

therapy液体疗法Crystalloids

晶体液PlasmaColloids血浆

胶体液Total/partial

parenteral

nutrition完全/局部肠外营养支持

THERAPY

FOR

PANCREATITIS

胰腺炎的治疗

Only

supportive

and

symptomatic•

Early

Feeding

早期饲喂•

Fluid

therapy液体疗法Crystalloids

晶体液PlasmaColloids血浆

胶体液Jejunostomy

feeding

空肠造口饲喂

(PEG-J,

Nasal

J,

regular

J)

THERAPY

FOR

PANCREATITIS

胰腺炎的治疗

Only

supportive

and

symptomatic

仅用支持疗法和对症治疗•

Early

Feeding

早期饲喂•

Fluid

therapy液体疗法Crys