Acute pancreatitis
1. °³¿ä
¹Ì±¹¿¡¼ °¡Àå ¸¹Àº ¿øÀÎÀº ¾ËÄÚ¿ÃÀ̸ç À¯·´¿¡¼´Â ´ã¼®ÀÌ´Ù.
*¿øÀÎ Tab 304-1
2. ¿øÀÎ ¹× º´ÀÎ
¿øÀÎÁß ¾à¹°ÀÌ Â÷ÁöÇÏ´Â ºñÁßÀº 2-5%Á¤µµÀ̸ç
±âÀüÀº hypersensitivity reaction or toxic metabolite¿¡ ÀÇÇØ ¹ß»ýÇÏÁö ¾ÊÀ»±î »ý°¢µÈ´Ù..
*Autodigestion theory
proteolytic enzyme(trypsinogen, chymotrypsinogen, proelastase, phospholipase A)˼
ÃéÀå¿¡¼ Ȱ¼ºÈµÇ¸ç ¸¹Àº ÀÎÀÚµéÀÌ À̵é proenzymeÀ» Ȱ¼ºÈ½ÃŰ´Â °ÍÀ¸·Î »ý°¢µÈ´Ù.
Ȱ¼ºÈµÈ ´Ü¹éºÐÇØÈ¿¼Ò(ƯÈ÷ trypsin)´Â
-> pancreatic, peripancreatic, tissue digestion
-> ´Ù¸¥ È¿¼Òµé(elastase, phospholipase µî)À» Ȱ¼ºÈ
-> ¼¼Æ÷¸· ¼Õ»ó
-> ´Ü¹éºÐÇØ, ºÎÁ¾, ÃâÇ÷, Ç÷°ü¼Õ»ó, coagulation necrosis, fat necrosis, ½ÇÁú¼¼Æ÷
±«»ç¸¦ ÀÏÀ¸Å²´Ù
ÀÌ·¸°Ô ¼Õ»óµÈ ¼¼Æ÷´Â Ȱ¼ºÈµÈ È¿¼Ò(bradykinin, vasoactive substance=histamine)¸¦
¹æÃâÇÏ¿© vasodilation -> vascular permeability, edema -> acute necrotizing pancreatitis
¸¦ ÀÏÀ¸Å²´Ù.
ÃÖ±Ù ÃéÀå³» acinar cell¿¡¼ lysosomal hydrolase¿¡ ÀÇÇØ zymogenÀÌ È°¼ºÈµÈ´Ù´Â °¡¼³
ÀÌ ÀÖ´Ù.
3. ÀÓ»óÀû Ư¡
¨ç abd pain , N/V, abd distention
jaundice - µå¹°´Ù.
¨è P/E»ó low-grade fever, tachycardia, hypotension
* shockÀÇ ±âÀü i) hypovolemia
ii) kinin peptideÇü¼º & ºÐºñ
iii) proteolytic & lipolytic enzymeÀÇ systemic effect
* erythematous skin nodules(subcutaneous fat necrosis¶§¹®)
* pul. findings(10-20%): basilar rales, atelectasis, pleural effusion(Lt)
* Bowel sound¡é
* pancreatic pseudocyst - Lt abd palpable
* Cullen's sign, Turner's sign: µå¹°Áö¸¸ severe necrotizing pancreatitis°¡ ÀÖÀ½À»
ÀǹÌÇÑ´Ù.
4. Lab
Áõ»ó + amylase, lipaseÀÇ 3¹èÀÌ»ó »ó½ÂÀÏ ¶§ Áø´ÜÇÒ¼ö ÀÖ´Ù.
Amylase´Â 48-72½Ã°£ÈÄ Á¤»óȵǴµ¥ isoamylase, lipase´Â 7-14ÀϱîÁö Áõ°¡ÇØ ÀÖ´Ù.
¨ç lipase or trypsin : aucte pancreatitis¿¡¼ Áø´ÜÀû °¡Ä¡°¡ Àִµ¥
hyperamylasemiaÀÇ nonpancreatic cause°¡Áø ȯÀÚ¿¡¼ À¯¿ëÇÏ´Ù.
peritoneal or pleural fluid amylase(> 5000U/dL) Áø´Ü¿¡ È®Á¤Àû
¨è leukocytosis : hemoconcentration¶§¹®
¨é Hyperglycemia : insulinºÐºñ¡é, glucagonºÐºñ¡è, adrenal glucocorticoid catecholamine¡è
¨ê Hypocalcemia(25%)
fat necrosisµÈ °÷¿¡ Ca saponification, soap formation
¨ë Hyperbilirubinemia: >4 mg/dl(10%), ±×·¯³ª jaundice´Â ÀϽÃÀûÀ̸ç 4-7Àϳ» Á¤»óȵȴÙ.
ÀϽÃÀûÀÎ AST/ALT»ó½ÂÀÌ µ¿¹ÝµÈ´Ù.
¨ì LDH(> 500U/dL) = poor Px
¨í Alb < 3.0 g/dL(10%) - severe pancreatitis, higher mortality
¨î TG(10-20%)¡è: ÀÌ·± ȯÀڵ鿡°Ô¼ s-amylase´Â ÈçÈ÷ Á¤»óÀÌ´Ù.
Lipid metabolism ÀÌ»ó ¶§¹®¿¡ ¹ß»ýÇÑ´Ù.
¨ï Hypoxemia(PaO2 60 mmHg) ARDS¿¡¼
¨ð EKG : ST segment, T wave abnormality => myocardial ischemia
5. °æ°ú
1) Ranson criteria Tab 304-2
Adm Age, WBC, Glu, LDH, AST
48½Ã°£ ³» Hct fall, fluid deficit, Ca, PaO2, BUN increase, Alb
cf. Ranson criteria: alcoholÀÌ ¿øÀÎÀÏ ¶§
Glasgow scale: ¸ðµç ¿øÀÎÀÇ pancreatitis¿¡¼
2) Obesity
ÃÖ±Ù obesity(BMI > 29)°¡ severe pancreatitisÀÇ major risk factor
: peripancreatic fat deposit
more extensive pancreatic & peripancreatic necrosis
3) APACHE II(Acute physiology and chronic health evaluation) score > 12
³Ê¹« º¹ÀâÇØ¼ Àß »ç¿ë¾ÈÇÑ´Ù.
4) ¿¹Èĸ¦ ¿¹ÃøÇϴµ¥ »ç¿ëµÇ´Â reliable, simple biochemical test(3°¡Áö)
i) CRP
ii) Serum granulocyte elastase
iii) Urinary trypsinogen activation peptide(TAP)
5) severe attackÀÇ key indicators(organ failure)
i) hypotension(<90 mmHg) or tachycardia(>130ȸ/min)
ii) PaO2 < 60 mmHg
iii) oliguria(<50 ml/h) or BUN, Cre¡è
iv) metabolic indicators: Ca < 8.0 mg/dL or s-Alb < 3.2 g/d
ÀÌÁß ÇÑ °³¸¸ À־ ÇÕº´Áõ À§ÇèÀº Áõ°¡Çϸç 2°³ ÀÖÀ» ¶§ÀÇ mortality risk´Â 20-30%
6. ÇÕº´Áõ Tab 304-3
ù 2-3ÁÖ¿¡ inflammatory massÇü¼º(pancreatic necrosis¿¡ ÀÇÇϰųª abscess,
pseudocystÇü¼º)
*pancreatitis¿Í hypertriglyceridemiaÀÇ °ü°è
¿øÀΰú °á°ú »çÀÌÀÇ »ó°ü°ü°è¿¡ ´ëÇØ ¾ÆÁ÷ Àß ¸ð¸£Áö¸¸ ¸î°¡Áö µµÃâµÈ °á·ÐÀº ´ÙÀ½°ú °°´Ù.
i) hypertriglyceridemia°¡ ¼±ÇàÇÒ¼ö ÀÖÀ¸¸ç À̶§ ÃéÀå¿°À» ÀÏÀ¸Å²´Ù.
ii) Acute pancreatitisÀÇ ´ëºÎºÐ(>80%)Àº hypertriglyceridemia¸¦ µ¿¹ÝÇÏÁö ¾Ê´Â´Ù.
iii) µÑ´Ù Á¸ÀçÇϴ ȯÀÚµé ´ëºÎºÐÀº lipoprotein metabolismÀÌ»óÀ» °¡Áø´Ù.
iv) ÃéÀå¿°¿¡¼ ȸº¹µÈÈÄ hypertriglyceridemia°¡ Áö¼ÓÇϴ ȯÀÚµéÀº recurrent pancreatitis
°¡ Àß »ý±ä´Ù.
v) ¾à¹°À̳ª ¾ËÄڿð°Àº °ÍµéÀº °©ÀÛ½º·´°Ô TG»ó½Â(>1000mg/dL)À» ÀÏÀ¸ÄÑ
ÃéÀå¿°À» À¯¹ß½ÃŰ¸ç ½ÉÇÑ ÇÕº´Áõ ¹× ¶§·Î´Â Àü°Ý¼º ÃéÀå¿°À» ÀÏÀ¸Å²´Ù.
- Æó°æ¿©¼º¿¡¼ ÃéÀå¿°À» ¹æÁöÇϱâ À§ÇØ ERT½ÃÇàÀü TGÃøÁ¤ÀÌ ÇÊ¿äÇÏ´Ù.
fasting 300mg/dL : no risk
750mg/dL : high risk
vi) apolipoprotein CII deficiency: pancreatitis riskÁõ°¡
* apoprotein CII : lipoprotein lipaseȰ¼ºÈ => Ç÷Áß¿¡¼ chylomicronÁ¦°Å
* Purtscher's retinopathy : sudden & severe vision loss
aggregated granulocyte¿¡ ÀÇÇØ post retinal a. occlusion
7. Gallstone pancreatitis risk
5mm ¹Ì¸¸ÀÇ ÀÛÀº ´ã¼®ÀÌ Å« ´ã¼®º¸´Ù ÃéÀå¿° À§ÇèÀÌ ´õ ³ô´Ù(4¹è).
¶Ñ·ÇÇÑ ¿øÀξø´Â recurrent pancreatitisȯÀÚÀÇ 2/3°¡ occult gallstone disease
(microlithiasis)¸¦ °®°í ÀÖ´Ù. ÀÌ·± ȯÀڵ鿡°Ô¼ duodenal aspirationÇÏ¿© cholesterol
crystalÀ» Áõ¸íÇÔÀ¸·Î½á È®ÁøÇÒ¼ö ÀÖ´Ù.
8. Pancreatitis in AIDS patient
i) infection risk ( CMV, Cryptosporidium, M. avium complex)
ii) AIDSÄ¡·á¾àÁ¦ ÀÚü°¡ pancreatitis¸¦ Àß ÀÏÀ¸Å²´Ù.
( didanosine, pentamidine, bactrim)
9. Ä¡·á
1) °í½ÄÀû Ä¡·á
¨ç ´ëºÎºÐ(85-90%)°¡ 3-7Àϳ» ÀúÀý·Î ȸº¹µÈ´Ù.
pain control, IV fluid, NPO, NG suction
ÃÖ±Ù NG suctionÀº mild, moderately severe pancreatitisȯÀÚ¿¡¼ µæÀÌ ¾øÀ½ÀÌ ¹àÇôÁ³´Ù.
µû¶ó¼ ¼±ÅÃÀûÀ¸·Î »ç¿ë
anticholinergics´Â ÀûÀÀ¡¿
¨è prophylactic antibiotics
severe acute pancreatitis¿¡¼ prophylactic antibiotics¸¦ »ç¿ëÇÏ¿© ÁÁÀº °á°ú¸¦ ¾ò°í,
°¨¿° ¹× »ç¸Á·üÀ» °¨¼Ò½ÃÄ×´Ù´Â º¸°í°¡ ÀÖ´Ù.
¨é È¿°ú°¡ ¾ø´Â °ÍÀ¸·Î ÆÇ¸íµÈ ¾à
glucagon, H2 blocker, protease inhibitor(aprotinin), glucocorticoid, lexiplafant, PAF
inhibitor
¨ê somatostatin : mortality rate¡é, Cx change(-)
¨ë antiprotease(gabexate methylate) : motality¿¡´Â ¿µÇâ¡¿, pancreatic damage¡é
2) Necrosisµ¿¹ÝµÈ °æ¿ì
infected necrosis : aggressive surgical pancreatic debridement(necrosectomy) &
multiple op ÇÊ¿ä
sterile necrotizing pancreatitis : mortality rate 10%
laparotomy with adequate drainage & necrotic tissue removal
intraabdominal candida infection during acute necrotizing pancreatitis
: mortality rate¡è, bacterial infectionº¸´Ù »ç¸Á·üÀÌ 4¹è ´õ ³ô´Ù.
3) Severe gallstone-induced pancreatitis
36-72½Ã°£³» papillotomyÇϸé dramatic improvement
4) Hypertriglyceridemia-associated pancreatitis Tx
¨ç weight loss
¨è lipid-restricted diet
¨é exercise
¨ê alcohol, TG»ó½Â¾à¹° ÇÇÇÒ °Í : estrogen, vit A, thiazide, ¥â-blocker
¨ë DM control
10..CT(CECT, Contrast-enhanced dynamic CT)
1) ÀÕÁ¡
¨ç severity & Px¿¡ ´ëÇÑ Á¤º¸Á¦°ø
¨è pancreatic necrosisÁ¤µµ¸¦ ¾Ë¼ö ÀÖ´Ù.
2) Severity index
1-2 : Cx - negligible
3-6 : low
7-10 : 92% mortality 17%
* CT»ó necrosis°¡ º¸À̸é mortality´Â 20% ÀÌ»ó, ¾øÀ¸¸é 10% ¹Ì¸¸
3) CECT check indications
¨ç Ranson criteria 3°³ÀÌ»ó
¨è severely ill pt
¨é clinical deterioration