Frey C F
Am J Surg. 1979 May;137(5):616-23. doi: 10.1016/0002-9610(79)90034-5.
An experience with 68 patients with hemorrhagic pancreatitis identified at operation or autopsy is reported. Sixteen of the patients were subjected to operation, and 6 survived after celiotomy and peritoneal irrigation. There were no survivors in the unoperated group. Death when the pancreas is hemorrhagic and due to pancreatitis occurs an average of 10 days after the onset of symptoms or within 7 days of hospitalization. In eight patients who presented in coma, the diagnosis was not established before death. Early recognition of patients with hemorrhagic pancreatitis can be facilitated by the routine use of amylase and methemalbumin determinations and peritoneal lavage. Translocation of large volumes of albumin-rich fluid from the intravascular compartment to the retroperitoneum and pleural and abdominal cavities is in part responsible for many of the signs, symptoms, and complications of hemorrhagic pancreatitis. These include hemoconcentration, hypotension, tachycardia, tachypnea, ascites, abdominal distress, respiratory insufficiency, and renal failure. Adequate initial resuscitation and intensive follow-up are probably the most important elements in the management of patients with hemorrhagic pancreatitis. Careful monitoring of fluid and electrolytes and blood gases is required to avoid shock and renal and pulmonary failure. The need for careful monitoring is emphasized by the number of our patients in whom inadequacies of fluid replacement and ventilation were often not appreciated until the patient was in extremis from shock or respiratory or renal failure. Antibiotics are indicated in patients with biliary tract disease and penetrating ulcer in whom the risk of secondary infection is considerable. Associated diseases that initiated pancreatitis and that in themselves may be life-threatening, such as acute cholecystitis or cholangitis, should be promptly treated by operation. Diagnostic and therapeutic lavage are justified in the treatment of hemorrhagic pancreatitis. Resection of the necrotic pancreas should be considered when the patient fails to improve after lavage and nonoperative resuscitation.
本文报告了68例在手术或尸检时确诊为出血性胰腺炎患者的治疗经验。其中16例患者接受了手术治疗，6例在剖腹术和腹腔灌洗术后存活。未接受手术治疗的患者无一存活。出血性胰腺炎导致的死亡平均发生在症状出现后10天或住院后7天内。8例昏迷患者在死亡前未能确诊。常规测定淀粉酶、高铁血红蛋白并进行腹腔灌洗有助于早期识别出血性胰腺炎患者。大量富含白蛋白的液体从血管内间隙转移至腹膜后、胸膜腔和腹腔，这在一定程度上导致了出血性胰腺炎的许多体征、症状和并发症。这些包括血液浓缩、低血压、心动过速、呼吸急促、腹水、腹部不适、呼吸功能不全和肾衰竭。充分的初始复苏和密切随访可能是出血性胰腺炎患者治疗中最重要的环节。需要仔细监测液体、电解质和血气，以避免休克以及肾衰竭和肺衰竭。我们的许多患者直到因休克、呼吸或肾衰竭而处于危急状态时，才发现液体补充和通气不足，这凸显了仔细监测的必要性。对于胆道疾病和穿透性溃疡患者，由于继发感染风险较大，应使用抗生素。引发胰腺炎且本身可能危及生命的相关疾病，如急性胆囊炎或胆管炎，应及时进行手术治疗。诊断性和治疗性灌洗对于出血性胰腺炎的治疗是合理的。如果患者在灌洗和非手术复苏后病情没有改善，应考虑切除坏死的胰腺。
