慢性胰腺炎胰周积液的特征及处理策略

Characteristics and management of peripancreatic effusion in chronic pancreatitis

目的探讨慢性胰腺炎各种类型的胰周积液的特征以及处理策略。方法回顾2018年1月—2019年12月在广西医科大学第一附属医院住院治疗的32例慢性胰腺炎、141例急性胰腺炎确诊患者资料。按亚特兰大分类分为4类:急性胰周液体积聚(acute peripancreatic fluid collection,APFC)、急性坏死物积聚(acute necrotic collection,ANC)、胰腺假性囊肿(pancreatic pseudocyst,PPC)、包裹性坏死(walled-off necrosis,WON)。记录各类患者一般情况、临床表现、病史、实验室检查指标、治疗情况等。结果在32例慢性胰腺炎合并胰周积液患者中,占比最多的是PPC[84.4%(27/32)],其次为WON[9.4%(3/32)]和APFC[6.2%(2/32)],未发现慢性胰腺炎合并ANC者。慢性胰腺炎的胰周积液和急性胰腺炎的胰周积液相比,PPC发生率更高[84.4%(27/32)比31.2%(44/141),P<0.01],APFC发生率较低[6.2%(2/32)比24.8%(35/141),P=0.021],ANC发生率亦较低[0.0%(0/32)比36.9%(52/141),P<0.01],WON发生率差异无统计学意义[9.4%(3/32)比7.1%(10/141),P=0.944]。急性胰腺炎胰周积液患者相对于慢性胰腺炎胰周积液患者,临床表现中有发热[19.1%(27/141)比3.1%(1/32)]、恶心[59.6%(84/141)比21.9%(7/32)]、呕吐[56.7%(80/141)比21.9%(7/32)]、压痛[79.4%(112/141)比34.4%(11/32)]、反跳痛[42.6%(60/141)比0.0%(0/32)]、C反应蛋白升高[95.7%(135/141)比40.6%(13/32)]者所占比例更大(P<0.05),且中位住院时间也较长(13 d比11 d,P=0.048)。影像学检查发现急性胰腺炎PPC患者病变直径>5 cm者比例大于慢性胰腺炎PPC患者[70.5%(31/44)比29.6%(8/27),P=0.001],慢性胰腺炎WON均局限在胰腺内[3/3比1/10,P=0.014]。在治疗策略方面,32例慢性胰腺炎胰周积液患者中有25例(78.1%)选择保守治疗;未发现急性胰腺炎和慢性胰腺炎的胰周积液在治疗策略上的差异有统计学意义。结论慢性胰腺炎的胰周积液类型中,PPC较多见。胰周积液以保守治疗为主,未见慢性胰腺炎胰周积液各型在治疗策略上的差异,但相比慢性胰腺炎,急性胰腺炎的胰周积液可能需要更为积极的干预。

Objective To study the characteristics and management of peripancreatic effusion in chronic pancreatitis.Methods Data of 32 patients with chronic pancreatitis and 141 acute pancreatitis admitted to the First Affiliated Hospital of Guangxi Medical University from January 2018 to December 2019 were collected.According to the Atlanta classification,the peripancreatic effusion was divided into four categories:acute peripancreatic fluid collection(APFC),acute necrotic collection(ANC),pancreatic pseudocyst(PPC)and walled-off necrosis(WON).The general information,clinical manifestations,medical history,laboratory examination indicators and treatment of the four types of patients were recorded and analyzed.Results Among the 32 patients with chronic pancreatitis complicated with peripancreatic effusion,27 patients(84.4%)were diagnosed as having PPC,3 patients(9.4%)WON and 2(6.2%)APFC.No chronic pancreatitis with ANC was found.The incidence of PPC was higher in patients with chronic pancreatitis than those with acute pancreatitis[84.4%(27/32)VS 31.2%(44/141),P<0.01],and the APFC was lower[6.2%(2/32)VS 24.8%(35/141),P=0.021].The incidence of ANC was also lower[0.0%(0/32)VS 36.9%(52/141),P<0.01],and there was no significant difference in the incidence of WON[9.4%(3/32)VS 7.1%(10/141),P=0.944].Compared with patients with peripancreatic effusion of chronic pancreatitis,acute pancreatitis showed a higher proportion of clinical manifestations:fever[19.1%(27/141)VS 3.1%(1/32)],nausea[59.6%(84/141)VS 21.9%(7/32)],vomit[56.7%(80/141)VS 21.9%(7/32)],tenderness[79.4%(112/141)VS 34.4%(11/32)],rebounding pain[42.6%(60/141)VS 0.0%(0/32)],increase of C reactive protein[95.7%(135/141)VS 40.6%(13/32)](P<0.05),and the mean hospital stay was longer(13 days VS 11 days,P=0.048).Imaging examination showed that the proportion of lesions>5 cm in diameter in PPC patients with acute pancreatitis was higher than those with chronic pancreatitis[70.5%(31/44)VS 29.6%(8/27),P=0.001].WON in chronic pancreatitis patients was limited to the pancreas[3/3 VS 1/10,P=0.014].In terms of treatment strategies,25 patients(78.1%)received conservative treatment in 32 chronic pancreatitis.There was no significant difference in treatment strategy between patients with acute pancreatitis and those with chronic pancreatitis.Conclusion In the peripancreatic effusion of chronic pancreatitis,PPC is the most common.Peripancreatic effusion is mainly treated conservatively.There is no difference in treatment among different types of peripancreatic effusion in chronic pancreatitis.However,compared with chronic pancreatitis,peripancreatic effusion in acute pancreatitis may need more active intervention.