左旋门冬酰胺酶诱发儿童急性胰腺炎19例分析

Nineteen children suffering from acute pancreatitis induced by L-asparaginase

目的 分析左旋门冬酰胺酶 (L ASP)诱发急性胰腺炎的临床特点 ,以利早期诊断和治疗。方法 对 1996～ 2 0 0 1年应用L ASP进行化疗方案治疗的 675例次中发生急性胰腺炎的 19例的临床特点、血液学和影象学检查及治疗预后作了总结分析。结果 L ASP诱发急性胰腺炎的发生率为 2 8%。临床表现中有腹痛 17例 ,伴恶心 17例、呕吐 16例 ;发烧 13例、腹胀 13例、休克 11例。首发症状中主要为腹痛 ,其次为休克。血液检查 19例中血淀粉酶升高 16例、高血糖 11例、低血钠 11/18例、低血钙 9/18例、低蛋白血症 8/16例、酸中毒 7/18例及肾功不良 3例 ,凝血功能异常 10 /16例。合并症中有肝损害或脂肪肝、腹膜炎、感染。B超或CT检查 :16/18例 (89% )有异常。抢救休克和抑制胰酶分泌是最重要的非手术治疗措施 ;出血坏死性胰腺炎及早手术。 19例胰腺炎中 12例治愈 ,其中 10例水肿型均痊愈 ;9例出血坏死型中 7例死于休克。结论 结合L ASP的用药史 ,监测病人腹痛或休克表现 ,检测血淀粉酶及腹部B超可以使早期诊断成为可能。抢救休克。

Objective Acute pancreatitis in children with acute lymphoblastic leukemia (ALL) and Ⅲ/Ⅳ T cell Non-Hodgkins lymphoma (NHL) was thought to be associated with L-asparaginase (L-ASP) chemotherapy. In the present study, the clinical features of 19 cases were studied. Methods The investigators summarized and analyzed the clinical features of 19 cases of L-Asp-induced acute pancreatitis. They were among the 675 children who accepted L-Asp during the last 5 years (Feb. 1996--Feb. 2001). The symptoms, hematological laboratory findings, imaging results from B-ultrasound and CT examinations, therapeutic options and the prognosis of patients were analyzed. Results The incidence of L-ASP-induced acute pancreatitis was 2.81%, which often occurred during L-Asp induction. The clinical manifestations among the 19 cases were gastralgia (17 cases ) accompanied by nausea(17 cases) and vomiting (16 cases), fever (13 cases) , bloated (13 cases ) and shock (11 cases). The initial symptoms were gastralgia and shock. The abnormal laboratory findings included elevation of serum amylase level in 16 cases, hyperglycemia in 12 out of 19 cases, hyponatremia in 11 out of 18 cases, hypocalcemia in 9 out of 18 cases, hypoproteinemia in 8 out of 16 cases, acidosis in 7 out of 18 cases, renal feature in 3 cases and abnormalities of three coagulation items, i.e. prothrombin time (PT), fibrinogen (Fib) and partial thromboplastin time in 10 out of 16 cases. The complications consisted of liver damage, fatty liver, peritonitis, and infection. Eighteen cases accepted the examinations of B-ultrasound and CT scan and 16 cases (88.9%) had abnormal finding in such examinations. It seemed that the positive rate of B-ultrasound (73%) was higher than CT scan (42%). Twelve out of 19 cases of acute pancreatitis were fully recovered. In the 19 cases of pancreatitis, 10 were of edema type and they were fully recovered. But another 9 patients had necrotizing hemorrhagic pancreatitis, 7 of whom died of shock. Conclusions The L-ASP-induced acute pancreatitis is not very common, but very severe, with high mortality, especially those with necrotizing hemorrhagic pancreatitis which is likely to worsen quickly. Early diagnosis of L-ASP-induced acute pancreatitis depends upon the history of L-ASP administration, symptoms such as gastralgia and/or shock and abnormalities of serum amylase and imaging examinations. Rescuing shock, restraining pancreatitic enzyme secretion and operation are the most important options for treating L-ASP-induced acute pancreatitis.