重症急性胰腺炎血行感染患者肠屏障功能障碍的研究

A study of intestinal barrier dysfunction in patients with severe acute pancreatitis and bloodstreaminfection

目的研究重症急性胰腺炎（SAP）患者肠屏障功能障碍与血行感染之间的关系。方法55例SAP患者按双侧上肢静脉血双瓶培养是否阳性分为确诊血行感染组（A组，18例）和可疑血行感染或无血行感染组（B组，37例）。按指南标准的诊治常规采用中西医结合方法系统性治疗SAP，计算人组时两组患者急性生理学与慢性健康状况评分系统Ⅱ（APACHEII）评分。检测人组1、3、7d尿乳果糖／甘露醇（L／M）比值，外周血内毒素（ET）水平；提取粪便总DNA，获得反映肠道菌群组成特征的肠道细菌基因重复一致序列（ERIC）的指纹图谱，计算内生肌酐清除率（CCr）、累及器官数，并统计患者住外科重症监护病房（SICU）时间、住院时间及28d病死率。结果A组住SICU时间（d：11．75±4．83比7．68±3．33）及28d病死率（16．67％比5．40％）均较B组显著增加。两组人组1dL／M比值、ET水平、累及器官数、CCr差异均无统计学意义（均P〉0．05），一周内A组L／M比值、ET水平均显著上升，B组显著降低，且A组各时间点均高于B组（L／M比值3d：3．83±1．67比1．33±0．56，7d：4．37±1．95比0．95±0．30；ET（kEU／L）3d：110．40±50．32比45．19±15．68，7d：212．10±100．46比30．07±10．02，均P〈0．05]；累及器官数（个）A组随时间延长显著增加，B组7d较1d、3d显著下降，且3d,7d均显著低于A组[3d：2．17±1．11比3．12±1．51，7d：1．56±0．61比4．23±1．94，均P〈0．05]。两组CCr比较差异无统计学意义（均P〉0．05）。全部患者各时间点L／M比值与ET呈正相关（r=0．867，P〈0．05）。A组ERIC优势条带数目、结构分布差异较大，B组优势条带数目、结构分布趋于相似。结论血行感染患者1周内肠屏障功能障碍显著加重，血ET水平显著上升，累及多器官，加快多器官衰竭的病程，病死率增加。故有效进行肠屏障功能的监测和保护，将成为在SAP病程中控制发展为血行感染、降低病死率的重要方法和手段。

Objective To investigate the relationship between the bloodstream infection and intestinal barrier dysfunction in patients with severe acute pancreatitis （SAP）. Methods Fifty-five cases of SAP patients were divided into confirmed bloodstream infection group （group A, 18 cases） and suspicious bloodstream infection or without bloodstream infection group （group B, 37 cases） by the positive or negative results of bilateral upper extremity venous double flask culture. According to the guide, the patients were diagnosed and conventional integrated traditional Chinese medicine and western medicine was used to treat them systemically. The acute physiology and chronic health evaluationⅡ （APACHE ]]）scores were calculated on the entrance into the groups. The lactulose/mannitol （L/M）ratio and the level of peripheral blood endotoxin （ET）was detected on the 1st, 3rd, 7th day after entrance into the groups ; the enterobacterial repetitive intergenic consensus （ERIC） fingerprint which reflected the composition of intestinal microflora characteristics from total DNA extraction of feces was obtained. The endogenous creatinine clearance rate （CCr）, the number of involved organs, the length of stay in surgical intensive care unit （SICU） and in the hospital and mortality in 28 days were recorded. Results The length of stay in SICU in group A （days ： 11.75±4.83 vs. 7.68±3.33） and the mortality in 28 days （16.67% vs. 5.40%） were significantly higher than those in group B. The general conditions of two groups had no significant difference on the first day and so did L/M ratio, ET, the number of involved organs, endogenous CCr （all P〉0.05）. Within a week, the L/M ratio and ET levels in group A were significantly increased, while in group B those were decreased obviously, and at each time point, the above indexes in A group were higher than those in group B （L/M ratio on the 3rd day： 3.83±1.67 vs. 1.33±0.56, on the 7th day： 4.37± 1.95 vs. 0.95±0.30 ; ET （kEU/L） on the 3rd day ： 110.40±50.32 vs. 45.19±15.68, on the 7th day ： 212.10±100.46 vs. 30.07± 10.02, all P〈0.05）. Along with the prolongation of time, the number of involved organs in group A was obviously increased, while in group B, on the 7th day, the number was significantly decreased compared with that on the 1st day and 3rd day, and the number of involved organs in group B on the 3rd day and 7th day was lower than that in group B （on the 3rd day ： 2.17±1.11 vs. 3.12±1.51, on the 7th day ： 1.56±0.61 vs. 4.23±1.94, all P〈0.05）. In the comparison between the two groups in the level of CCr, there was no statistical significant difference （all P〉0.05）. At each time point, the L/M ratio was positively correlated with ET in all the patients （r = 0.867, P〈0.05）. In group A, the differences in ERIC advantage band numbers and structure distribution between each other were great, while in group B, similar between each other. Conclusions Within a week, the intestinal barrier dysfunction is significantly aggravated, plasma endotoxin level also elevated obviously, more multiple organs are involved, the course of multiple organ failure is accelerated and the mortality increased in patients with bloodstream infection. Therefore,effective monitoring and protecting the intestinal barrier function becomes an important method to reduce the mortality and control the bloodstream infection in patients with SAP.