急性胰腺炎胸腔积液与病情严重程度关系分析

2009-11-27 02:14卢秀英刘俊丁震侯晓华
中华胰腺病杂志 2009年5期
关键词:淀粉酶天数胸腔

卢秀英 刘俊 丁震 侯晓华

·论著·

急性胰腺炎胸腔积液与病情严重程度关系分析

卢秀英 刘俊 丁震 侯晓华

目的分析急性胰腺炎(AP)患者胸腔积液的发生率,探讨胸腔积液与病情严重程度的关系。方法回顾性分析766例AP患者胸腔积液的发生率及其与发病年龄、性别、Ranson评分、CT分级(CTSI)、血淀粉酶水平、白蛋白含量以及住院天数之间的关系。结果766例AP患者中,129例(16.8%)发生胸腔积液。171例重症急性胰腺炎(SAP)中38例(22.2%)发生胸腔积液,595例轻症急性胰腺炎(MAP)中91例(15.3%)出现胸腔积液,SAP患者的胸腔积液发生率显著高于MAP患者(Plt;0.05)。发生胸腔积液患者的血淀粉酶水平、白蛋白含量、Ranson评分、CTSI及住院天数分别为(795±1013)U/L、(36±7)g/L、1.12±1.15、4.02±1.16和(23.4±23.4)d;无胸腔积液者分别为(592±856)U/L、(38±6)g/L、0.85±0.98、3.15±16.60和(17.3±16.6)d。胸腔积液患者的Ranson评分、血淀粉酶水平、CTSI均显著高于无胸腔积液者(Plt;0.05或lt;0.01);血清白蛋白含量显著低于无胸腔积液者(Plt;0.01);住院天数明显长于无胸腔积液者(Plt;0.01)。 双侧胸腔积液92例,右侧胸腔积液11例,左侧胸腔积液26例,胸腔积液部位与病情无关,但左侧胸腔积液者住院天数较长(Plt;0.05)。结论AP患者发生胸腔积液者病情较重,胸腔积液可能是个较好的评估SAP的指标。

胰腺炎; 胸腔积液; 回顾性研究

急性胰腺炎(AP)可分为重症急性胰腺炎(SAP)与轻症急性胰腺炎(MAP),两者的临床发展过程与预后完全不同。SAP的早期诊断与早期治疗对缩短患者病程、降低患者病死率极为重要。胸腔积液是AP的一个常见并发症,其发生部位可为左侧、右侧或者双侧胸腔。目前对胸腔积液在AP发病过程中的意义仅有散在报道,且对不同部位的胸腔积液是否具有预测疾病的价值未见相关分析。本文回顾性分析我院10余年来所收治的766例AP患者的临床资料,分析胸腔积液的发生率及发生部位与病情严重程度的关系,以期对SAP的早期判断提供新的思路。

资料与方法

一、临床资料

收集1998年至2008年间武汉协和医院所有住院的AP患者共766例,男473例,女293例;SAP 171例,MAP 595例。胸腔积液的诊断主要依靠48 h之内CT影像获得。同时记录患者入院48 h内的血淀粉酶、白蛋白水平以及Ranson评分、CTSI、住院天数,分析胸腔积液与这些指标的相关关系。

二、诊断标准

根据美国AP诊治指南规定,具有下列三项之二的即可诊断为AP[1]:(1)有腹痛、恶心、呕吐等症状,腹部有压痛、反跳痛、移动性浊音等体征;(2)血、尿淀粉酶升高超过正常值上限3倍;(3)CT影像学检查示胰腺有形态学改变。

SAP的诊断根据2002年世界胰腺疾病会议的诊断标准,具有以下四项之一可诊断SAP:(1)Ranson评分≥3;(2)有局部并发症;(3)有器官功能障碍;(4)APACHEⅡ评分≥8分。

胸腔积液的诊断:CT显示胸腔有积液,除外原有胸、肺器质性疾病和肿瘤等所致胸腔积液。

三、统计学处理

结 果

766例AP患者中,129例发生胸腔积液,发生率为16.8%。SAP中38例发生胸腔积液,占22.2%;MAP中91例出现胸腔积液,占15.3%,SAP患者的胸腔积液发生率显著高于MAP患者(Plt;0.05)。

129例并发胸腔积液患者中,男85例,女44例,发生胸腔积液在性别上无明显差异;并发胸腔积液者年龄为(48±14)岁,无胸腔积液者为(44±15)岁,虽然并发胸腔积液者年龄大于无胸腔积液者,但无统计学意义。

发生胸腔积液者的血淀粉酶、白蛋白水平以及Ranson评分、CTSI、住院天数分别为(795±1 013)U/L、(36±7)g/L、1.12±1.15、4.02±1.16和(23.4±23.4)d;无胸腔积液者分别为(592±856)U/L、(38±6)g/L、0.85±0.98、3.15±16.60和(17.3±16.6)d。发生胸腔积液患者的Ranson评分、血淀粉酶水平均显著高于无胸腔积液者(Plt;0.05或lt;0.01);血清白蛋白水平显著低于无胸腔积液者(Plt;0.01);住院天数明显长于无胸腔积液者(Plt;0.01)。

129例发生胸腔积液的AP患者中,双侧胸腔积液者92例,右侧胸腔积液11例,左侧胸腔积液26例,不同部位胸腔积液患者的Ranson评分、血淀粉酶水平、CTSI无明显差异,但左侧胸腔积液者住院天数明显长于右侧胸腔积液者或双侧胸腔积液者(表1)。

讨 论

AP是消化科常见疾病,临床表现复杂多样,特别是SAP起病快,发展迅猛,病情凶险严重,病死率高。目前SAP判断标准较多,如Ranson评分、APACHE评分及C反应蛋白(CRP)等生化检查,但至今仍缺乏特异性强、敏感性高的指标。目现,国内外有散在报道指出胸腔积液与病情严重程度相关。

表1 不同部位胸腔积液与病情的关系

注:与其他两组比较,aPlt;0.05

近年来国内学者刘子君等[2]指出,胸腔积液可作为SAP的一项早期判别指标。张利等[3]认为,胸腔积液可作为评估SAP的一项独立指标。美国《临床指南》指出胸腔积液是SAP危险因子。国外文献报道,胸腔积液的发生与以往的Ranson评分、APACHE评分相比,更能准确地反映疾病的严重程度[4-5];通过对AP患者胸片检查有助于对SAP进行早期判别诊断[6-8];胸腔积液的发生强烈提示SAP的可能[9-10]。还有学者检测胸水淀粉酶,并联合HCT等指标对AP 评估,获得相同的结果[8,11]。这些结果均提示胸腔积液可早期预测SAP。

本结果显示,AP胸腔积液的发生与性别、年龄相关性不大,但与Ranson评分、CISI、血清白蛋白和血淀粉酶水平等均有关,且SAP较MAP患者更易出现胸腔积液,提示胸腔积液的发生与病情严重程度相关。胸腔积液为入院48 h内CT检查发现,可早期反映病情,提示其可能是个较好的确定SAP的参考因素之一。在临床工作中,若发现胸腔积液,表明胰腺炎已累及胰腺外系统[12-13],应积极防止其他并发症的发生,特别是呼吸衰竭。

国内学者刘子君等[2]认为,胸腔积液的发生部位与病情无关,多发生在左侧及双侧。本组胸腔积液的部位亦与病情无关,大多发生在双侧。提示AP患者出现胸腔积液可能不仅仅是因为横膈周围的淋巴丛与纵隔及胸膜下间隔相关[14],可能还有全身炎症反应及低白蛋白血症的参与。本组胸腔积液患者的住院时间延长,以左侧胸腔积液者的住院时间最长,其原因需进一步的探讨。

[1] 廖家智.美国急性胰腺炎临床指南(诊断部分).临床内科杂志,2007,24:136-139.

[2] 刘子君,井清源.急性胰腺炎并发胸腔积液对病情评估的意义.南通医学院学报,2001,21:434.

[3] 张利,朱海杭,徐永居,等.胸腔积液对重症急性胰腺炎评估的临床价值.医学临床研究,2007,24:2120-2121.

[4] Ocampo C,Silva W,Zandalazini H,et al.Pleural effusion is superior to multiple factor scoring system in predicting acute pancreatitis outcome.Acta Gastroenterol Latinoam,2008,38:34-42.

[5] Uchikov AP,Shipkov HD,Markova DI.Pleural effusions in acute pancreatitis.Folia Med(plovdiv),2000,42:34-36.

[6] Pezzillik R.The use of peripheral leukocyte count and chest x-rays in early assessment of the severity of acute pancreatitis in comparison whith the Ranson score system.Panminerva Med,1999,41:39-42.

[7] Lankish PG,Mahldke R,Blum T,et al.Hemoconcentration:an early marker of severe and/or necrotizing pancreatitis.A critical appraisou.Am J Gastroenterol,2001,96:2081-2085.

[8] Brown A,James-Stevenson T,Dyson T,et al.The panc 3 score: a rapid and accurate test for predicting severity on presentation in acute pancreatitis.J Clin Gastroenterol,2007,41:855-858.

[9] Gumate V,Singh V,Dave P.Significance of pleural effusion in patients with acute pancreatitis.Am J Gastroenterol,1992,87:871-874.

[10] Lankisch PG,Dröge M,Becher R.Pleural effusions:a new negative prognostic parameter for acute pancreatitis.Am J Gastroenterol,1994,89:1849-1851.

[11] Gupta D,Chakraborty KL,Gomber S,et al.Massive pancreatico-pleural effusion-an often unrecognised entity.Indian J Pediatr.2001,68:883-885.

[12] De Waele JJ,Delrue L,Hoste EA,et al.Extrapancreatic inflammation on abdominal computed tomography as an early predictor of disease severity in acute pancreatitis:evaluation of a new scoring system.Pancreas,2007,34:185-190.

[13] Maringhini A,Ciambra M,Patti R,et al.Ascites, pleural, and pericardial effusions in acute pancreatitis.A prospective study of incidence,natural history,and prognostic role.Dig Dis Sci,1996,41:848-852.

[14] 刘春萍,陆慰.消化系统疾病的肺部表现.临床内科杂志,2003,20:340-343.

2008-11-05)

(本文编辑:屠振兴)

Relationbetweenpleuraleffusionandseverityofacutepancreatitis

LU Xiu-ying,LIU Jun,DING Zhen,HOU Xiao-hua.

Department of Gastroenterology,Union Hospital,Tongji Medical College,Huazhong University of Science and Techonology,Wuhan 430022,China

LIUJun,Emailliujun_99@126.com

Pancreatitis; Pleural effusion; Retrospective studies

AbstrastObjctiveTo investigate the incidence of pleural effusion in acute pancreatitis (AP) and the relation between pleural effusion and severity of AP.MethodsThe medical records of 766 patients with AP were analyzed retrospectively. The incidence of pleural effusion was documented and its relationship with age of onset, sex, Ranson score, CTSI, serum albumin and hospital day was analyzed.ResultsIn the 766 AP patients, there were 129 (16.8%) patients had pleural effusion. In 171 SAP patients, there were 91(15.3%) patients had pleural effusion. In the 595 MAP patients, there were 129 (16.8%) patients had pleural effusion. The difference in the incidence of pleural effusion between MAP and SAP patients was statistically significant (Plt;0.05). The serum amylase, albumin, Ranson score, CTSI, and hospital day in patients with pleural effusion were (795±1 013) U/L, (36±7) g/L, 1.12±1.15, 4.02±1.16 and (23.4±23.4)d, respectively; while the corresponding values in patients without pleural effusion were (592±856) U/L, (38±6)g/L, 0.85±0.98, 3.15±16.60 and (17.3±16.6)d, respectively. The difference in Ranson score, serum amylase, CTSI between the two groups was statistically significantly (Plt;0.05 or lt;0.01), the serum level of albumin in patients with pleural effusion was significantly lower than that in patients without pleural effusion (P lt;0.01), the hospital day in patients with pleural effusion was significantly longer than that in patients without pleural effusion (Plt;0.01). Pleural effusion of both sides was present in 92 patients, while pleural effusion of right side was present in 11 patients, pleural effusion of left side was present in 26 patients; the site of pleural effusion was not associated with the severity of AP, however, patients with pleural effusion of left side tended to have longer hospital day (Plt;0.05).ConclusionsPatients with pleural effusion during AP were more likely to be complicated with severe conditions, and the presence of pleural effusion may be a good marker for severity evaluation.

10.3760/cma.j.issn.1674-1935.2009.05.007

430022 武汉,华中科技大学同济医学院附属协和医院消化科(卢秀英,现在湖北钟祥市人民医院工作)

刘俊,Email,liujun_99@126.com

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