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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¤»óÈ­µÇ´Âµ¥ 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¤»óÈ­µÈ´Ù.

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