重症急性胰腺炎并发假性动脉瘤大出血的处理

The management of bleeding pseudoaneurysms in patients with severe acute pancreatitis

目的探讨重症急性胰腺炎(severe acute pancreatitis,SAP)并发假性动脉瘤大出血的诊断和处理。方法回顾性分析1990年10月至2006年10月收治的12例 SAP 合并假性动脉瘤出血患者的临床资料。病因:胆源性胰腺炎6例,高脂血症3例,甲状旁腺功能亢进危象1例,原因不明2例。结果 CT 诊断假性动脉瘤出血6例(6/9),血管造影均诊断正确(12/12)。受累血管主要为胰腺周围血管。8例"一点法"(出血血管近端)栓塞后成功止血,2例"两点法"(动脉瘤出血血管的近端和远端)血管栓塞后成功止血。2例急诊手术缝扎止血。"一点法"栓塞止血患者中有4例4～7 d后再出血,2例急诊手术止血,2例改用"两点法"成功栓塞。3例死于感染和多器官功能不全综合征,总病死率为25%。结论血管造影是 SAP 并发假性动脉瘤大出血的主要诊断方法,"两点法"血管栓塞止血和急诊手术是有效的治疗手段。

Objective To report the experience in diagnosis and management of bleeding pseudoaneurysms associated with severe acute panereatitis （SAP）. Methods The medical records of 12 patients with bleeding pseudoaneurysms associated with SAP treated between October 1990 and October 2006 were retrospectively reviewed. The etiologies of the 12 patients were gallstones in 6 patients, hyperlipidemia in 3 patients, hyperparathyroidism in 1 patient and the other 2 patients had no definitive causes. Results Abdominal computed tomography revealed bleeding pseudoaneurysms in 6 of 9 patients. Angiography determined correct diagnosis in 12 patients （12/12）. The most involved vessels were peripanereatie arteries. Eight patients were managed by trans-eatheter arterial embolization （TAE） as ＂one point＂ （a proximal point of the pseudo-aneurysm）. Two patients were treated by TAE as ＂two points＂ （both distal and proximal to the pseudo-aneurysm）. The last two cases were treated by surgery as suture and ligation. Four of the ＂one point＂ TAE patients were re-bleeding 4 to 7 days later, and 2 of them were treated with surgery, the other 2 patients were controlled with ＂two points＂ TAE. Three patients were died of infection and multiple organ dysfunction syndromes. Overall mortality rate was 25% （3/12）. Conclusions Angiography is the main diagnostic methods for bleeding pseudoaneurysms in SAP patients. ＂Two points＂ embolization and emergency surgery are an effective treatment options in these patients.