儿童及青少年糖尿病酮症酸中毒合并急性胰腺炎患者临床特点分析

Clinical characteristics of diabetic ketoacidosis complicated with acute pancreatitis in children and adolescents

目的了解儿童糖尿病酮症酸中毒(DKA)合并胰酶升高患者的临床特点、治疗经验及转归,为避免过度诊断急性胰腺炎(AP)和过度的长期禁食治疗提供证据。方法回顾性调查首都医科大学附属北京儿童医院内分泌遗传代谢中心2015年1月至2019年1月收治的年龄小于18岁的DKA合并胰酶升高的患儿,分析其临床症状、血淀粉酶、脂肪酶、血脂、胰腺影像学资料、治疗及临床转归等,总结治疗经验。数据采用中位数(上下四分位数)表示。结果4年共收治330例DKA患儿,38例(11.5%)合并胰酶升高,升高3倍以上的有22例(6.7%)。16例(4.8%)无胰腺影像学改变为疑诊AP,其中14例无腹痛症状,未经AP相关治疗,预后良好;1例有腹痛症状,常规进行DKA治疗,第2天腹痛症状缓解;另外1例合并腹痛症状的患者按照AP治疗12 d,在第14天开始尝试经口喂养,虽有胰酶复升高,但继续按原计划进行营养治疗病情无反复。6例(1.8%)合并胰酶升高患儿有影像学改变为确诊AP,4例有腹痛,6例均按照AP常规治疗,腹痛症状2~19 d缓解,胰酶2~15 d降至3倍以下,禁食时间3~60 d,随访5~32个月均无AP复发。结论DKA患儿胰酶增高并不少见,但AP发生率低,且预后好,是一个相对良性的过程,尚需更多数据证明。

Objective To provide new evidence to avoid overdiagnosis of acute pancreatitis(AP)and unnecessary long-term fasting treatment in diabetic ketoacidosis(DKA)pediatric patients.Methods Children under the age of 18 suffered from DKA combined with elevated trypsin were enrolled in the Department of Endocrinology,Genetics and Metabolism of Beijing Children′s Hospitalfrom January 2015 to January 2019.Clinical data,including symptoms,serum amylase,lipase,lipid levels,pancreatic imaging,treatment options and clinical outcomes were analyzedretrospectively.The data were represented with median(upper and lower quartile).Results Among 330 DKA children admitted in 4 years,there were 38(11.5%)DKA patients combined with elevated trypsin,22(6.7%)children whose trypsin were elevated more than 3 times.Sixteen(4.8%)patients with negative pancreatic imaging were defined as suspected AP,among which 14 patients in the absent of abdominal pain prognosed well without AP treatment.1 out of 16 patients developed abdominal pain,which was relieved the next day after routine DKA treatment.Another patient presented abdominal pain received 12 days of AP treatment and despite having blood trypsin level increased when oral feeding began at the 14th day,she continued oral enteral nutrition withoutrelapse of AP symptoms.Six patients(1.8%)with positive imaging changes were defined as confirmed AP,among which 4 patients having abdominal pain received regular AP treatment and recovered from abdominal pain in 2-19 days respectively and their blood trypsin levels went below less than 3 times in 2-15 days.All of 6 patients had no recurrence of AP in the 5-32 months of follow-up.Conclusion Increased trypsin is common in children with DKA and it is usually associated with low incidence of AP and good prognosis.