Millat B, Gayral F
Service de Chirurgie, Hôpital Lapeyronie, Montpellier.
Presse Med. 1993 Jan 23;22(2):72-6.
The physical characteristics of gallstones and anatomical predisposing factors strongly suggest that acute pancreatitis associated with gallstones is due to a transient blockage of the ampulla of Vater by migrating stones. The diagnosis of acute pancreatitis is based on clinical probabilities and is supported by a threefold elevation in serum amylase. In cases of acute biliary pancreatitis the initial serum amylase value is higher and its decline more rapid than in pancreatitis due to other causes. The diagnostic sensitivity and specificity of serum amylase are higher in cases of acute biliary pancreatitis. The early detection of gallstones in acute pancreatitis by standard imaging techniques may be misleading; ultrasonography fails to identify the gallbladder in almost one-third of patients. The reported accuracy of systems for the clinico-biochemical detection of gallstones in acute pancreatitis is 75 percent. Their lack of specificity prohibits their use as the sole means of detecting gallstones, but they may allow the selection of patients who require further investigations. Ranson's multiple laboratory criteria are generally recognized as providing the best early assessment of severity in acute pancreatitis; a modified scoring system is required for patients known to have pancreatitis due to gallstones. The timing of surgery in gallstone pancreatitis is no longer controversial. In patients with benign pancreatitis the time of surgery appears to have little effect on the outcome, whereas in patients with severe pancreatitis early surgery results in a significant increase in morbidity and mortality rates. Surgery should be performed in the first days following hospital admission, soon after the pancreatitis has subsided. Further investigations are warranted before advocating a widespread use of early endoscopic sphincterotomy in the treatment of severe gallstone acute pancreatitis.
胆结石的物理特性和解剖学易感因素强烈提示，与胆结石相关的急性胰腺炎是由于移动的结石短暂阻塞了 Vater 壶腹所致。急性胰腺炎的诊断基于临床可能性，并得到血清淀粉酶升高三倍的支持。在急性胆源性胰腺炎病例中，初始血清淀粉酶值更高，其下降速度比其他原因引起的胰腺炎更快。血清淀粉酶在急性胆源性胰腺炎病例中的诊断敏感性和特异性更高。通过标准成像技术在急性胰腺炎中早期检测胆结石可能会产生误导；超声检查在几乎三分之一的患者中无法识别胆囊。据报道，急性胰腺炎中临床生化检测胆结石系统的准确率为 75%。它们缺乏特异性，禁止将其用作检测胆结石的唯一手段，但它们可能有助于选择需要进一步检查的患者。Ranson 的多项实验室标准通常被认为是对急性胰腺炎严重程度进行最佳早期评估的标准；对于已知因胆结石引起胰腺炎的患者，需要一种改良的评分系统。胆结石性胰腺炎的手术时机不再有争议。在良性胰腺炎患者中，手术时间似乎对结果影响不大，而在重症胰腺炎患者中，早期手术会导致发病率和死亡率显著增加。手术应在入院后的头几天进行，即在胰腺炎消退后不久。在主张广泛使用早期内镜括约肌切开术治疗重症胆结石急性胰腺炎之前，有必要进行进一步的研究。
