修回日期: 2011-03-30
接受日期: 2011-04-11
在线出版日期: 2011-04-28
目的: 探讨妊娠期急性胰腺炎(acute pancreatitis in pregnancy, APIP)临床特征及治疗经验.
方法: 回顾性分析武汉大学人民医院于2004-04/ 2011-01收治20例APIP患者的临床资料.
结果: 20例APIP患者中, 2例发病于孕中期, 17例发病于孕晚期, 1例发病于分娩后. 3例(15%)行急诊剖宫术加坏死胰腺清除、胰腺引流. 11例(55%, 孕期均>33 wk)行剖宫产分娩. 5例(25%)病情稳定后出院. 孕妇治愈19例(95%), 死亡1例(5%), 死因为多器官功能障碍综合征. 终止妊娠14例, 继续妊娠5例, 胎儿死亡共2例(10%), 均为入院时胎死宫内; 新生儿无死亡, 未见畸形.
结论: 妊娠中晚期容易诱发急性胰腺炎. 治疗上以积极非手术治疗为主, 遵循个体化治疗原则, 适时终止妊娠(剖宫术为首选)有利于母婴的安全.
引文著录: 赵连武, 于红刚, 沈磊. 妊娠期急性胰腺炎20例. 世界华人消化杂志 2011; 19(12): 1311-1313
Revised: March 30, 2011
Accepted: April 11, 2011
Published online: April 28, 2011
AIM: To explore the clinical features and management of acute pancreatitis in pregnancy (APIP).
METHODS: The clinical data for 20 patients with APIP who were treated at the People's Hospital of Wuhan University from April 2004 to January 2011 were retrospectively reviewed.
RESULTS: Of 20 patients with APIP, 2 were diagnosed in the second trimester, 17 in the third trimester, and 1 in the postpartum period; 3 (15%) received emergency operation, in which clearance of necrotic tissue in the pancreas and abdominal cavity drainage were performed after uterine-incision delivery; 11 (55%, all >33 weeks of pregnancy) received uterine-incision delivery; 5 (25%) were discharged in a stable condition; 19 (95%) recovered, and 1 (5%) died of multiple organ dysfunction syndrome (MODS); 14 (70%) terminated pregnancy, and 5 (25%) continued the pregnancy; 2 had pre-admission fetal death in utero.
CONCLUSION: APIP often occurs in the middle and late pregnancy. Conservative medical therapy is usually recommended first for APIP. Individualized therapy and termination of pregnancy may be beneficial to maternal and neonatal safety in some cases.
- Citation: Zhao LW, Yu HG, Shen L. Acute pancreatitis in pregnancy: an analysis of 20 cases. Shijie Huaren Xiaohua Zazhi 2011; 19(12): 1311-1313
- URL: https://www.wjgnet.com/1009-3079/full/v19/i12/1311.htm
- DOI: https://dx.doi.org/10.11569/wcjd.v19.i12.1311
妊娠期急性胰腺炎(acute pancreatitis in pregnancy, APIP)是一种严重的妊娠合并症, 临床较少见, 其发病率约为1/1 000-1/5 000[1], 且有逐年增加的趋势. 该病较为特殊, 如果诊治不及时, 可威胁母婴的生命. 因此研究其临床特点及诊治具有重要的意义.
2004-04/2011-01武汉大学人民医院共收治APIP患者20例. 年龄(26.8±5.34)岁. 初产妇7例, 经产妇13例, 均为单胎妊娠. 孕中期(孕周均为28 wk)2例, 孕晚期17例(孕周35.5 wk±2.2 wk), 分娩后1例. 根据美国亚特兰大标准[2], 其中轻症急性胰腺炎13例, 重症急性胰腺炎7例. 胆源性11例, 高脂血症性7例, 不明原因2例. APACHEⅡ评分≥8分7例(11.4分±2.6分). 5例发病前进食油腻食物. 3例肾功能不全. 3例孕期发现胆囊结石, 其中2例孕期有胆囊结石诱发胆囊炎病史. 1例于前次妊娠有急性轻症胆源性胰腺炎病史. 20例患者中20例急性起病, 19例持续上腹痛, 8例疼痛向腰背部放射, 14例伴有恶心、呕吐, 3例伴有胸闷、呼吸困难, 5例伴有少尿, 4例发热, 1例体温下降(35.0 ℃), 20例上腹压痛, 2例有下腹压痛, 8例上腹反跳痛, 3例巩膜黄染.
1.2.1 实验室检查: 20例血淀粉酶升高(1 270.5 U/L±973.9 U/L). 16例血白细胞升高(14.6±5.7)×109/L, 其中3例>20×109/L. 9例总胆红素升高(45.2 mmol/L±46.4 mmol/L), 其中4例>34.2 mmol/L; 11例肝酶升高, 其中谷丙转氨酶为110.5 U/L±76.1 U/L, 谷草转氨酶为89.3 U/L±59.0 U/L. 10例血三酰甘油(9.72 mmol/L±5.89 mmol/L)、胆固醇(10.74 mmol/L±4.47 mmol/L)升高. 10例血钙降低(1.97 mmol/L±0.16 mmol/L). 6例血糖升高(11.3 mmol/L±4.4 mmol/L); 1例血糖降低(2.9 mmol/L), 病情好转后血糖均恢复正常.
1.2.2 影像学检查: 入院后均行腹部B超检查, 发现17例胰腺体积增大, 其中7例胰腺边缘模糊、周围有积液. 1例胰腺假性囊肿形成. 4例胆囊结石, 其中1例合并胆总管结石. 5例胆囊增大. 5例胆汁淤积. 5例腹腔积液, 其中2例合并胸腔积液. 2例脂肪肝. 5例行腹部CT平扫, 均征求患者同意, 5例胰腺均增大, 其中2例胰腺周围渗出较多, 1例胰腺假性囊肿.
1.2.3 治疗: 20例患者均给予禁食、抗感染、抑酸、补液纠正水电解质紊乱. 对于呕吐剧烈的6例患者均给予胃肠减压; 对于病程较长病情较重的2例患者予鼻空肠管肠内营养. 7例重症APIP中, 1例积极内科抢救; 3例行急诊剖宫术加胰腺坏死组织清除并切开引流; 3例择期行剖宫术终止妊娠. 13轻症APIP中, 剖宫术终止妊娠7例. 7例高脂血症患者均低脂摄入, 1例急诊手术, 5例终止妊娠, 3例予肝素、胰岛素(增加脂蛋白活性)治疗. 11例胆源性APIP中, 1例急诊术后7 d, 行ERCP胆总管取石.
7例重症APIP中, 1例并发多器官功能障碍综合征抢救无效当天死亡, 2例胎死宫内. 13例轻症APIP中, 无孕妇死亡, 胎儿均成活(3例经新生儿病房监护), 5例(含2例病因未明患者)未在住院期间分娩, 病情稳定后出院, 出院前B超提示胎儿一般情况良好. 7例高脂血症APIP中, 4例于终止妊娠后血脂下降较快. 11例胆源性APIP中, 1例急诊手术后较快恢复, 3例明确为胆囊结石患者均于分娩后择期行腹腔镜胆囊切除术.
APIP可发生于妊娠的各期及产褥期, 但多见于妊娠中晚期[3], 本组孕中期2例(10%), 孕晚期17例(85%), 分娩后1例(5%). 病因以胆源性(11例55%)和高脂血症(7例35%)为主. APIP较急性胰腺炎有其独特的因素: (1)血中孕酮增加可使胆管的张力减低, 胆囊收缩力减弱; (2)胆汁酸、胆固醇分泌亦增多; (3)中晚期, 增大的子宫压迫胆道系统, 胆管及胰管阻力随之增加, 胆汁淤积, 小的结石易形成. 有报道指出, 胆泥和胆石形成与反复多次怀孕有密切关系[3]; (4)为保证胎儿营养, 往往摄入过多的高脂、高蛋白食物, 且孕期雌激素、孕激素、胎盘催乳素等可使胆固醇、三酰甘油升高2-3倍[4], 而高的三酰甘油血症可引起胰腺细胞的急性脂肪浸润, 同时胰腺的微循环障碍也可使脂肪栓塞形成而损伤胰腺[5]. 因此如合并有胆石症或平时血脂较高, 则出现胰腺炎的几率将更高.
APIP的临床表现不典型, 且X线、CT等的运用很慎重, 易误诊, 本组就有2例患者入院时因下腹压痛误诊为急性阑尾炎. B超、MRI、MRCP对于胆管的结石的诊断具有较高的敏感性, 且对胎儿无致畸作用. 若B超或肝酶、胆红素等生化指标异常疑有胆管结石时, 超声内镜(endoscopic ultrasonography, EUS)可作为一种半侵入性的精确诊断手段[6]. Lee等[7]也认为EUS对于胆总管结石的预测性接近100%, 但EUS需静脉镇静, 可能影响胎儿. 本组以临床表现, 血淀粉酶、脂肪酶, B超等为主要诊断手段, 对于2例重症及3例不能明确诊断APIP的患者, 在患者允许下行CT检查以进一步明确病情.
APIP应遵循"个体化治疗"原则[8], 根据病因、病期及母婴的一般情况制定治疗方案. APIP的保守治疗主要有禁食、补液、抑酸、抑酶、纠正水电解质紊乱、胃肠减压、器官功能维持等. 对于24 h积极的非手术治疗病情缓解不明显、高热伴弥漫性腹膜炎白细胞较高(>20×109/L)、部分器官功能不全的患者可考虑行急诊手术[9], 本组3例急诊手术患者, 无孕妇死亡, 娩出2例新生儿经新生儿病房监护后均成活. 适时剖宫产终止妊娠对于母婴安全具有一定的意义: (1)APIP产生炎症因子等可通过胎盘屏障影响胎儿生长, 引起早产、宫内窘迫、胎死宫内等; (2)药物以及一些操作选择性更大; (3)去除胎儿对胆胰管的压迫, 减轻孕妇的负担, 有报道显示, 终止妊娠后, 胆囊及胆管的一些泥沙及细小的结石可能消失[10,11]; (4)充分暴露胰腺视野, 可根据胰腺、胆道所见情况给予相应的外科处理; (5)较自然分娩产程短, 孕妇消耗小. 本组行剖宫产终止妊娠具有如下特点: 孕周均≥33 wk(除1例胎死宫内伴肾功能不全为31 wk外); 胎儿宫内窘迫或胎死宫内; 胎儿足月; 存在胰腺假性囊肿等并发症. 本组适时剖宫终止妊娠后, 母婴预后均良好. 另外, Iskandar等[12]主张用血液透析联合血浆置换治疗重症高脂血症APIP; 对于胆总管结石、胆管炎等诱发的APIP, 行ERCP治疗存在争议, 但有报道称, 在超声内镜或少量X线下行ERCP胆管引流及取石, 或胆管支架植入, 待分娩后再取出支架, 对于母婴是安全的[13-15].
总之, 对于有胆道系统疾病及高脂血症病史的妇女, 应于治愈或明显好转后妊娠, 减少APIP的发生. 掌握APIP的临床特点, 早期诊断, 明确病因. 治疗上以保证孕妇安全为首, 同时兼顾胎儿, 非手术治疗为主, 适时(剖宫术为首选)终止妊娠. 对病情较重患者, 果断行手术治疗.
妊娠期急性胰腺炎(APIP)是一种发病率较少的疾病, 如果存在胆道系统疾病及高三酰甘油血症可以增加其发病的几率. 由于妊娠时孕妇解剖和生理改变, 加上胎儿因素的存在, 增加了诊疗的困难. 并且未见明确的诊疗指南, 在临床中, 常因经验欠缺, 致母婴死亡.
周国雄, 主任医师, 南通大学附属医院消化内科
本文主要根据病例诊疗特点, 提出作者的观点, 根据母婴的一般情况当机立断行急诊手术治疗, 适时终止妊娠, 对于减少母婴死亡率有一定的意义.
本文对临床妊娠期急性胰腺炎的诊断与治疗有一定指导价值.
编辑:李薇 电编:何基才
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