【作者】 周晶；

【导师】 李维勤；

【作者基本信息】 南京大学 ， 临床医学， 2013， 硕士

【摘要】 门脉系统血栓是重症急性胰腺炎的一种较为少见的并发症,并可导致胃食管静脉曲张,临床上称为胰源性门静脉高压症。胰腺位于门脉系统的枢纽位置,尤其是脾静脉,在解剖学位置上毗邻胰腺,被胰周纤维结缔组织包裹。因此,多种胰腺疾病可导致脾静脉、肠系膜上静脉和门静脉狭窄、管壁增厚、栓塞、回流受阻,在其引流区域出现侧枝循环开放,最终形成胰腺源性门静脉高压症。研究表明病因以胰腺肿瘤、慢性胰腺炎和胰腺假性囊肿为主,分别占39.0%、32.6%和19.4%。[1-4]随着影像学技术的进步,越来越多的重症急性胰腺炎病人被发现患有门脉系统血栓及胰源性门静脉高压症。但重症胰腺炎合并门脉系统血栓的发病率、临床特点及意义、危险因素均不明确。本研究分析重症急性胰腺炎合并门脉系统血栓的临床特点及危险因素。本文共分两部分：第一部分重症急性胰腺炎合并门脉系统血栓的临床特点目的：目前对血栓的认识主要来自于慢性胰腺炎,探讨重症急性胰腺炎合并门脉系统血栓的临床特点方法：回顾性分析我科2012年1月到2012年12月收治并于入院72h内行增强CT&门静脉成像的164例重症急性胰腺炎患者的影像学及APACHE II评分、Ranson评分、BalthazarCT评分、死亡率、手术(穿刺)率、MODS发生率、胰腺坏死率、血培养阳性率、腹水天数、腹水量、腹腔压力值及肠内营养耐受情况。血栓的诊断标准：增强CT静脉期或门脉成像,血管内光通量出现斑状阴影或血管突然消失。影像学确诊血栓并合并胃底静脉曲张形成则诊断为胰源性门静脉高压症。结果：自发病至血栓发现,平均天数为38.77±33.51天。56例患者(34.1%)被发现有门脉系统血栓：其中仅有PV血栓的11例(6.7%),仅有SV血栓的22例(13.4%),仅有SMV血栓的3例(1.8%)；PV+SV血栓的10例(6.1%),PV+SMV血栓的4例(2.4%),SV+SMV血栓2例(1.2%)；PV+SV+SMV血栓4例(2.4%)。56例胰源性门脉系统血栓患者中,26例患者(46.4%)被诊断为胰源性门静脉系统高压症。PV血栓并合并胃底静脉曲张5例(8.9%),SV血栓合并胃底静脉曲张6例(10.7%),SMV合并胃底静脉曲张0例；PV+SV血栓合并胃底静脉曲张8例(14.3%),PV+SMV血栓合并胃底静脉曲张血栓3例(5.4%),SV+SMV血栓合并胃底静脉曲张1例(1.8%)；PV+SV+SMV血栓合并胃底静脉曲张2例(3.6%),合并胃底食管静脉曲张1例(1.8%)。56例胰源性门脉系统血栓患者中,23例发现腹水。PV血栓并合并腹水5例(8.9%),SV血栓并合并腹水4例(7.1%),SMV血栓并合并腹水0例；PV+SV血栓并合并腹水7例(12.5%),PV+SMV血栓并合并腹水3例(5.4%),SV+SMV血栓并合并腹水2例(3.6%)；PV+SV+SMV血栓并合并腹水4例(7.1%)。重症急性胰腺炎伴门脉系统血栓组与不伴门脉系统血栓患者组相比,APACHEII评分15.4±5.6vs.11.4±3.4；p=0.01。Ranson评分4.7±0.8vs.3.9±0.9；p=0.01。Balthazar CT评分7.8±2.2vs.6.1±1.1；p=0.04。死亡患者例数17vs.8(30.4%vs.7.4%)；p＜0.001。需要手术／穿刺的患者例数46vs.55(82.1%vs.50.9%)；p=0.12。MODS患者例数48vs.36(85.7%vs.33.3%)；p=0.02。胰腺坏死患者例数42vs.35(75%vs.32.4%)；p=0.03。血培养阳性患者例数36vs.24(64.3%vs.22.2%)；p=0.02。住院天数：43.2±35.3vs.21.9±13.8；p<0.001,ICU天数为20.7±14.4vs.10.4±4.1；p<0.001。腹水患者例数23vs.11(41.1%vs.10.2%)；p=0.007。腹水天数为5±2.3vs.2.1±0.9；p=0.004。腹水量为2400±1453vs.700±374；p=0.002。腹腔压力为17.0±4.6vs.14.6±3.2；p=0.05。血栓组4天内肠内营养不耐受组5例。结论：胰源性门脉系统血栓在重症急性胰腺炎病人中发病率高达34.1%。46.4%胰源性门系统血栓患者最终发展成为胰源性门脉高压症。合并血栓患者的Apache Ⅱ评分、Ranson评分、CT评分、患者病死率、脏器衰竭发生率均高于未合并血栓的患者。合并血栓的患者住院时间、ICU时间、腹水量及天数均大于未合并血栓的患者。第二部分重症急性胰腺炎合并门脉系统血栓的危险因素目的胰源性门脉血栓的产生可能与多种因素有关,本文多因素分析重症急性胰腺炎合并门脉系统血栓的危险因素方法回顾性分析我科2012年1月到2012年12月收治并于入院72h内行CT增强&门静脉成像的164例重症急性胰腺炎患者的一般资料、凝血功能指标、胆固醇、甘油三酯、CRP、HCT、ANC例数,使用多因素logistic回归分析胰源性门脉系统发生的危险因素。结果血栓多见于男性,男女比例接近2：1。血栓组年龄略大于非血栓组49±15.73vs.45±12.75,p=0.04。吸烟、饮酒、胆固醇、高脂血症均不是血栓发生危险因素。凝血因素包括：D-D、PT、INR、AT-Ⅲ均没有统计学意义。血栓组Hct小于非血栓组：0.292±0.065vs.0.337±0.083；p=0.001。血栓组与非血栓组相比, ANC例数为48(86%)vs.36(23.7%),p＜0.001。以P=0.1为初筛条件,对性别、年龄、HCT、ANC做多元logistic回归分析,胰源性门脉血栓发生与性别(Odds Ratio(OR):1.255(95%CI：0.081-0.802),p=0.02)、HCT(OR：0(95%CI：0-0.007),p＜0.001)、ANC(OR：2.254(95%CI：0.42-03.774,p=0.04)显著相关。结论凝血功能异常不是胰源性门脉血栓形成的原因。性别、ANC所导致的局部因素可能是血栓形成的危险因素。全文结论：胰源性门脉系统血栓在重症急性胰腺炎病人中发病率高达34.1%。46.4%胰源性门系统血栓患者最终发展成为胰源性门脉高压症。合并血栓患者的Apache Ⅱ评分、Ranson评分、CT评分、患者病死率、脏器衰竭发生率均高于未合并血栓的患者。合并血栓的患者住院时间、ICU时间、腹水量及天数均大于未合并血栓的患者。凝血功能异常不是胰源性门脉血栓形成的原因。性别、ANC所导致的局部因素可能是血栓形成的危险因素。更多还原

【Abstract】 Portal venous system thrombosis (PVST) involving the splenic, mesenteric, and/or portal veins is a rare clinical syndrome of severe acute pancreatitis (SAP) and can lead to gastric and esophageal varices called pancreatic portal hypertension(PPH). Pancreas located in the hub of the portal system. Splenic vein is adjoined to pancreas according to the anatomy and is wrapped by peripancreatic connective tissue. So, varies kinds of pancreatic disease could lead to narrow, thickening and embolism portal veins. This results in venous hypertension in collateral pathways, producing gastric varices. In the past studies, three main cause of PVST is pancreatic tumor (39%), chronic pancreatitis (32.6%), pancreatic pseudocyst(19.4).With the development of recognition and inspection techniques, more and more SAP patients were diagnosed with PVST and/or PPH. However, little is known about incidence, clinical relevance, risk factor and optimal treatment strategy. This study is mainly about the clinical characters, risk factors and prognosis of patients gained SAP accompanied with PVT.PARTI The Clinical relevance of severe acute pancreatitis accompanied with portal venous system thrombosisObjective:The aim of the study was to evaluate the clinical relevance of patients suffered SAP accompanied with PVST.Methods:164patients admitted among January,2012to December,2012were reviewed. Contrast-enhanced CT scan and portal venous system imaging was conducted during their first72h after admitted to the hospital. Clinical and laboratory data were collected in the first3days.Results:The mean days from SAP onset to thrombosis diagnosis is38.77±33.51days.56patients were diagnosed with PPVT:11(6.7%) cases of PV thrombosis,22(13.4) cases of SV thrombosis,3(1.8%) cases of SMV thrombosis.10(6.1%) cases of PV+SV thrombosis.4(2.4%) cases of PV+SMV thrombosis.2(1.2%) cases of SV+SMV thrombosis.4(2.4%) cases of PV+SV+SMV thrombosis.Among56SAP patients with PPVT,26patients diagnosed with PPH:5(8.9%) cases of PVT with gastric varices.6(10.7%) cases of SVT with gastric varices. None case of SMVT with gastric varices.8(14.3%) cases of PVT+SVT with gastric varices.3(5.4%) cases of PVT+SMVT with gastric varices.1(1.8%) case of SVT+SMVT with gastric varices.2(3.6%) case of PVT+SVT+SMVT with gastric varices.1case case of PVT+SVT+SMVT with esophageal and gastric varices.Among56SAP patients with PPVT,23patients diagnosed with ascites:5(8.9%) cases of PVT with ascites.4(7.1%) cases of SVT with ascites. None case of SMVT with ascites.7(12.5%) cases of PVT+SVT with ascites.3(5.4%) cases of PVT+SMVT with ascites.2(3.6%) case of SVT+SMVT with ascites.4(7.1%) case of PVT+SVT+SMVT with ascites.Compare SAP with PPVT group and none-PPVT group, the APACHEII score is15.4±5.6vs.11.4±3.4;p=0.01.The Ranson score is4.7±0.8vs.3.9±0.9;p=0.01.The Balthazar CT score is7.8±2.2vs.6.1±1.1; p=0.04.Death cases is17vs.8(30.4%vs.7.4%); p<0.001.The number of patients need surgery or drainage is46vs.55(82.1%vs.50.9%); p=0.12.The number of patients with MODS is48vs.36(85.7%vs.33.3%); p=0.02。The number of patients with pancreatic necrosis is42vs.35(75%vs.32.4%); p=0.03.The number of patients with positive blood samples is36vs.24(64.3%vs.22.2%); p=0.02。 The mean hospital days is43.2±35.3vs.21.9±13.8;p <0.001,mean ICU days is20.7±14.4vs.10.4±4.1;p<0.001.The number of patients with ascites is23vs.11(41.1%vs.10.2%);p=0.007.Duration of ascites is5±2.3vs.2.1±0.9;p=0.004.The amount of ascites is2400±1453vs.700±374;p=0.002.The intra-abdominal pressure is17.0±4.6vs.14.6±3.2;p=0.05。 Besides,5enteral nutrition intolerance cases happened in first3days.Conclusions:PPVT incidence reaches34.1%in SAP patients.46.4%of the PPVT patients finally developed PPH. Compared with the non-PPVT group, the PPVT group have higher APACHE II score, Ranson score, Balthazar CT score, death rate, hospital stay, ICU stay, ascites amount, ascites duration.PART2Risk factors of severe acute pancreatitis accompanied with pancreatic portal venous thrombosisObjective:The aim of this study is to analyze risk factors of severe acute pancreatitis accompanied with pancreatic portal venous thrombosis by using multivariate logistic regression analysis.Methods:164patients admitted among January,2012to December,2012were reviewed. Contrast-enhanced CT scan and portal venous system imaging was conducted during their first72h after admitted to the hospital. Patients’general characteristics,coagulation parameters, cholesterol level, triglycerides level,CRP level,HCT level, ANC cases data were collected in the first3days. Risk factors were analyzed by using multivariate logistic regression analysis.Results:PPVT was more common in males, and the ratio is nearly2:1.The mean age of PPVT group is49±15.73y while the non-PPVT group is45±12.75y, p=0.04.Smokers, drinkers, high cholesterol, hypertriglyceridemia and coagulability (such as D-D,PT,INR,AT-Ⅲ) are not the risk factors of thrombosis. Compare SAP with PPVT group and none-PPVT group, the HCT is0.292±0.065vs.0.337±0.083; p=0.001.The ANC cases is48(86%)vs.36(23.7%), p<0.001。 Conduct multivariate logistic regression with gender, age, HCT and ANC, PPVT incidence is correlate with Gender (OR:1.255(95%CI:0.081-0.802), p=0.02))、 HCT(OR:0(95%CI:0-0.007), p<0.001) ANC (OR:2.254(95%CI:0.42-03.774,p=0.04)Conclusions:Coagulation disorders are not the risk factor of PPVT. Gender and local factors caused by ANC are the risk factors of thrombosis.更多还原