Lee Peter J, Papachristou Georgios I
Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA USA.
Division of Gastroenterology and Hepatology, Department of Medicine, Ohio State University Wexner Medical Center, 410 W 10th Street, 2nd floor, Columbus, OH 43210 USA.
Curr Treat Options Gastroenterol. 2020;18(4):670-681. doi: 10.1007/s11938-020-00322-x. Epub 2020 Nov 19.
There have been significant advancements in different aspects of management of severe acute pancreatitis (SAP). Our review of the most recent literature focuses on severity prediction, fluid resuscitation, analgesic administration, nutrition, and endoscopic intervention for SAP and its extra-pancreatic complications.
Recent studies on serum cytokines for the prediction of SAP have shown superior prognostic performance when compared with conventional laboratory tests and clinical scoring systems. In patients with established SAP and vascular leak syndrome, intravenous fluids should be administered with caution to prevent intra-abdominal hypertension and volume overload. Endoscopic retrograde cholangiopancreatography improves outcomes only in AP patients with suspected cholangitis. Early enteral tube-feeding does not appear to be superior to on-demand oral feeding. Abdominal compartment syndrome is a highly lethal complication of SAP that requires percutaneous drainage or decompressive laparotomy. Endoscopic transmural drainage followed by necrosectomy (i.e., "step-up approach") is the treatment strategy of choice in patients with symptomatic or infected walled-off pancreatic necrosis.
SAP is a complex clinical syndrome associated with a high mortality rate. Early prediction of SAP remains challenging due to the limited accuracy of the available prediction tools. Early fluid resuscitation, organ support, enteral nutrition, and prevention of/or prompt recognition of abdominal compartment syndrome remain cornerstones of its management. A step-up, minimally invasive drainage/debridement is the preferred approach for patients with infected pancreatic necrosis.
在重症急性胰腺炎（SAP）的不同管理方面已取得显著进展。我们对最新文献的综述聚焦于SAP及其胰腺外并发症的严重程度预测、液体复苏、镇痛药物使用、营养支持以及内镜干预。
近期关于血清细胞因子预测SAP的研究表明，与传统实验室检查和临床评分系统相比，其预后性能更优。对于已确诊的SAP和血管渗漏综合征患者，应谨慎给予静脉输液，以预防腹腔内高压和容量超负荷。内镜逆行胰胆管造影仅在疑似胆管炎的急性胰腺炎患者中能改善预后。早期肠内管饲似乎并不优于按需口服喂养。腹腔间隔室综合征是SAP的一种高致死性并发症，需要进行经皮引流或剖腹减压术。对于有症状的或感染性包裹性胰腺坏死患者，内镜经壁引流联合坏死组织清除术（即“递进式方法”）是首选的治疗策略。
SAP是一种复杂的临床综合征，死亡率高。由于现有预测工具的准确性有限，早期预测SAP仍然具有挑战性。早期液体复苏、器官支持、肠内营养以及预防和/或及时识别腹腔间隔室综合征仍然是其管理的基石。对于感染性胰腺坏死患者，递进式微创引流/清创是首选方法。
