| Background and aimsAcute pancreatitis is one of the common critical diseases in clinical practice,which is mainly characterized by abnormal activation of pancreatic enzymes due to various etiologies,followed by local inflammatory response of the pancreas with or without functional changes or even dysfunction of other organs.The annual global incidence is 13～45 per 100,000 people per year.Acute pancreatitis is often clinically classified into three types:MAP,MSAP,SAP,MAP is mild,often self-limiting,with a good prognosis and a very low mortality rate,MSAP and MAP progress rapidly and often combine complications,which may be life-threatening and have a high mortality rate if there is no timely therapeutic intervention The mortality rate is high.Therefore,how to determine the condition and treatment of AP at an early stage is still a key concern in the medical community.The pathogenesis of AP has not yet been elucidated fully,and the pancreatic auto-digestion theory still dominates.The core view is that inactive trypsinogen is prematurely activated into active trypsin in the alveolar cells for various reasons,which leads to the activation of a series of enzymes and eventually causes the pancreatic tissue to self-digest and leads to inflammation.The pathogenic factors of AP are numerous and complex.Because of the differences of geographical,ethnic and living habits,the etiology of AP in different countries or regions are very variable.The most common etiology in China is biliary,followed by hyperlipidemic and alcoholic,while in Western countries,excessive alcohol consumption is the most important etiology of AP,followed by biliary and hyperlipidemic.Other etiologies include:sphincter of Oddi dysfunction,hereditary,pancreatic or jugular abdominal tumors,drugs and toxins,infectious,pancreatic trauma,pancreatic splitting,common bile duct cyst,para-duodenal papillary diverticulum,autoimmune,traumatic,hypercalcemia,vasculitis,α1-antitrypsin deficiency,etc.The etiology of some patients is not yet clear.During the progression of AP,pancreatic enzymes are activated abnormally,pancreatic tissue is damaged,and a large number of inflammatory mediators are released,leading to a chain reaction of inflammation and causing local and systemic complications associated with AP,with common complications including:acute peripancreatic fluid collection(APFC),pancreatic pseudocyst(PPC),acute necrotic collection(ANC),walled-off necrosis(WON),infected pancreatic necrosis(IPN),disconnected pancreatic duct syndrome(DPDS),systemic inflammatory response syndrome(SIRS),multi-organ failure(MOF),acute renal failure(ARF),acute respiratory distress syndrome(ARDS),intra-abdominal hypertension(IAH),abdominal compartment syndrome(ACS),sepsis,pancreatic encephalopathy(PE),disseminated intravascular coagulation(DIC)and hyperglycemia.The BISAP,Ranson,APACHE-Ⅱ,SOFA score and modified Marshall score are often used to assess the criticality of AP patients.In addition,tests such as leukocyte,neutrophil-lymphocyte ratio,C-reactive protein,Procalcitonin,hemoconcetration,interleukin-6,red blood cell distribution width,and calcium can also be used to determine the severity and prognosis of AP at an early stage.Once acute pancreatitis is diagnosed,early treatment should be given,mainly including monitoring changes in vital signs,gastrointestinal decompression,fasting,maintenance and support of organ functions,inhibition of pancreatic exocrine secretion and inhibition of pancreatic enzyme activity,improvement of pancreatic microcirculation,nutritional support,rational use of antibiotics to prevent infection,analgesia,endoscopic treatment,application of traditional Chinese medicine,management of local and systemic complications,and etiologic targeting treatment.In recent years,the widespread use of multidisciplinary individualized and comprehensive treatment model has further improved the treatment effect of acute pancreatitis,effectively increasing the overall cure rate and reducing the mortality rate.There are many causes of AP,the pathogenesis is complex and not completely elucidated,and the incidence is increasing year by year,especially SAP,with many complications,rapid progression,critical condition and high mortality.It is significant for patients with acute pancreatitis to make accurate and rapid judgment on the severity and prognosis of acute pancreatitis in the early stage of the disease,and to give effective and targeted treatment in time.In this study,we retrospectively analyzed the clinical data of 1173 inpatients with AP admitted to the Department of Gastroenterology of Nanfang Hospital of Southern Medical University from June 2011 to June 2021,summarized the pathogenesis,clinical characteristics,treatment plan and prognosis of the transition of acute pancreatitis,and analyzed the relevant clinical test indexes that can be used in clinical efficacy evaluation and prognosis judgment.In order to have a new understanding of the epidemiological characteristics,clinical features and treatment of AP in recent years,and to provide reference for the prevention and diagnosis and treatment of AP.Clinical data and examination methods1.Clinical Data:1173 hospitalized patients who were diagnosed AP in Department of Gastroenterology in Nanfang Hospital from June 2011 to June 2021.All cases are in line with the diagnostic criteria of Chinese acute pancreatitis treatment guidelines(2019,Shenyang).All patients diagnosed with chronic pancreatitis or acute exacerbation of chronic pancreatitis by clinical or imaging examinations such as CT and MRI,and pregnant patients have been excluded.We used a retrospective clinical case analysis case report form to make a complete entry of all patients’ case information,including gender,age,vital signs,clinical signs and symptoms,onset to consultation time,previous underlying diseases,etiology and causative factors,laboratory tests and imaging,diagnosis,assessment results of each scoring system,occurrence of local or systemic complications and organ failure,treatment and duration,prognosis,days of hospitalization,and hospital costs.2.Research Methods:Microsoft Office Excel software was used to import and integrate the clinical data of the included cases.The pathogenesis,clinical characteristics,treatment options and prognosis of regression were analyzed,and the relationship between the relevant clinical tests and the severity of the disease was analyzed.The statistical software SPSS version 25.0 was used for analysis,and the measurement data were expressed as mean ± standard deviation(x±s),and the t-test was used for comparison between two groups,and one-way ANOVA was used for comparison between multiple groups.The Brown-Foreythe test was used for data not satisfying chi-square,and the SNK test was used for comparisons between multiple groups,and the Dunnett T3 test was used for those not satisfying chi-square.Count data were described as number of cases and percentages using X2 test.The risk factors were analyzed by logistic regression analysis,and receiver operating characteristic(ROC)curves were plotted and analyzed,and correlation analysis was performed by Pearson and Spearman methods.p<0.05 was statistically significant.Results1.The General Situation:Of the 1173 patients,764 were male,accounting for 65.1%of all cases;409 were female,accounting for 34.9%of all cases,with a male-to-female ratio of 1.87:1.The age range was 13 to 89 years.The age range for males was 13 to 89 years with a mean age of onset of(49.02±15.22)years,and for females was 12 to 88 years with a mean age of onset of(50.79±14.58)years.There were 455 cases in the youth group(≤44 years old),accounting for 38.8%of all cases,442 cases in the middle-aged group(45-59 years old),accounting for 37.7%of all cases,and 276 cases in the elderly group(≥60 years old),accounting for 23.5%of all cases,with a high prevalence of AP predominantly in young and middle-aged people.2.Causes of Disease:There were 489 cases(41.7%)of biliary pancreatitis,287 cases(24.5%)of hyperlipidemic pancreatitis,68 cases(5.8%)of alcoholic pancreatitis,32 cases(2.7%)of neoplastic factors(including pancreatic tumors,jugular abdominal tumors,etc.),29 cases(2.5%)of medical factors(including ERCP,small bowel microscopy,surgery,etc.),and idiopathic pancreatitis in 268 cases(22.8%).Alcoholic pancreatitis was significantly more prevalent in men compared to biliary pancreatitis and hyperlipidemic pancreatitis(P<0.05).Among the different age groups,biliary pancreatitis mainly occurred in the middle-aged and elderly patient groups,while hyperlipidemic pancreatitis and alcoholic pancreatitis occurred in the young and middle-aged patient groups(P<0.05).3.Clinical Symptoms:Most patients had abdominal pain as the first symptom(99.32%),mostly in the middle and upper abdomen,with sudden onset and persistent pain that could be relieved by curling or leaning forward in position.It may be accompanied by abdominal distension(77.58%),nausea(64.62%),vomiting(52.43%),fever(26.51%),jaundice(7.50%),and anal cessation of defecation(39.13%).There were 5 cases(0.04%)of elderly patients who presented with only mild epigastric discomfort on admission,without abdominal pain sensation and symptoms such as nausea,vomiting and fever.4.Abdominal Signs:Localized pressure pain in the middle and upper abdomen was the most common on physical examination(86.02%).Other signs included abdominal muscle tension(24.04%),peritoneal irritation sign(29.16%),diminished or absent bowel sounds(56.18%),Grey-Turner sign(0.04%),Cullen sign(0.03%),and some patients did not have any positive signs(8.70%).5.Vital Signs:Heart rate,body temperature,and respiratory rate were higher in patients with SAP than in patients with MAP and MSAP(P<0.05);while systolic blood pressure was not significantly different in patients with MAP,MSAP,and SAP.6.Clinical Test Indexes:Blood white blood cells(WBC),neutrophils(N),C-reactive protein(CRP),red blood cell distribution width(RDW),neutrophil-lymphocyte ratio(NLR),and blood glucose were higher in SAP patients than in MSAP and MAP patients,while lymphocytes(L),blood calcium,and blood albumin(ALB)were lower than in MSAP and MAP patients(P<0.05).Logistic regression analysis showed NLR,CRP,leukocytes,and neutrophils as risk factors for SAP(P<0.05).The results of the ROC curve showed that the AUC of NLR was significantly higher than that of CRP,leukocytes and neutrophils,which was 0.903,and its optimal critical value was 11.23,corresponding to a sensitivity and specificity of 0.850 and 0.794,respectively.7.Imaging:All patients completed abdominal ultrasound and abdominal CT examination.There were 1164 cases of abdominal CT suggesting abnormal pancreatic manifestations,with a positive rate of 99.23%,and 996 cases of abdominal ultrasound suggesting abnormal pancreatic manifestations,with a positive rate of 84.91%,and the positive rate of abdominal CT was significantly higher than that of abdominal ultrasound(P<0.05).8.Severity Assessment:There were 422 patients(40.0%)with MAP,402 patients(34.3%)with MSAP,and 349 patients(29.8%)with SAP.In descending order of age:MSAP[(51.49±16.33)years]>MAP[(50.01±17.54)years]>SAP[(44.31±15.10)years](P<0.05);SAP was more prevalent in the young population(P<0.05).Compared to MAP and MSAP,SAP was more frequent in the male population(P<0.05).Hyperlipidemic acute pancreatitis and alcoholic acute pancreatitis were more likely to develop into SAP than biliary acute pancreatitis(P<0.05).9.Complications:Complications occurred in a total of 1004 cases(85.59%).There were 37 cases(3.2%)of ARDS,21 cases(1.8%)of MODS,424 cases(36.1%)of pulmonary infections,343 cases(29.2%)of pleural effusion,123 cases(10.5%)of APFC and PPC,24 cases(2.0%)of IPN,608 cases(51.8%)of abnormal liver function,138 cases of abnormal renal function(11.8%),intestinal paralysis in 751 cases(64.0%),sepsis in 425 cases(36.2%),and pancreatic encephalopathy in 9 cases(0.7%).The number of local or systemic complications was significantly higher in SAP patients than in MAP and MSAP patients(P<0.05).10.Treatments:All patients were treated non-surgically and the mean time to return to diet was(6.45±4.91)days.The main feeding method was trans-oral diet or intra-gastric tube injection(1147 cases,97.78%).Some patients(26 cases,2.21%)were treated with enteral nutrition via jejunal nutrition tube.The average time to resolution of abdominal pain and distension was(4.91±3.21)days,the average time to resolution of abdominal signs was(6.32±3.95)days,the average length of hospital stay was(12.40±8.94)days,and the average hospital cost was(￥37,665.32±31,491.61)yuans.11.Use of Growth Inhibitors:Growth inhibitors or their analogues were given in 1149 cases,accounting for 97.95%of all cases,of which 891 cases were given octreotide and 258 cases were given growth inhibitors.There was no statistical difference between the two groups in terms of time to relief of clinical symptoms and signs,time to resume diet,length of hospitalization,hospitalization cost,complication rate,and overall efficiency(P>0.05).12.Application of peritoneal puncture and drainage:Peritoneal fluid was present in 402 patients(34.5%of all cases),of which 297 patients were treated with peritoneal puncture and drainage.Among them,11 patients with MAP,51 patients with MSAP,and 235 patients with SAP.significantly more patients with SAP presented with peritoneal effusion and required puncture and drainage than patients with MAP and MSAP(P<0.05).13.Chinese Medicine:751 patients presented with intestinal paralysis.In the Chinese medicine group,339 cases(45.14%)had a mean recovery time of(4.55±1.23)days for intestinal paralysis and a mean recovery time of(4.93±2.05)days for diet.In the enema group,170 cases(22.64%)had a mean recovery time of(5.37±1.45)days for intestinal paralysis and a mean recovery time of(5.98±2.61)days for diet.In the Chinese medicine combined with enema group,81 cases(10.79%)had a mean recovery time of(4.32±1.69)days for intestinal paralysis and a mean recovery time of(4.64±1.97)days for diet.In the control group,161 cases(21.44%)had a mean recovery time of(6.87±1.14)days for intestinal paralysis and a mean recovery time of(7.75±2.48)days for diet.The recovery time of intestinal paralysis and the recovery time of diet were significantly shorter in the Chinese medicine combined with enema group than in the other groups(P<0.05).14.Time to start fluid resuscitation:The early group(<24 hours)was better than the intermediate group(24-48 hours)and the late group(>48 hours)in terms of time to relief of abdominal symptoms,time to relief of abdominal signs,time to resume diet,and complication rate(P<0.05).In contrast,there was no statistical difference between the three groups in terms of length of stay,hospital costs,and overall efficiency(P>0.05).15.Prognosis and Regression:729 cases(62.15%)were cured,223 cases(19.01%)were recovered,191 cases(16.28%)were improved,23 cases(1.96%)were void,and 7 cases(0.59%)were dead.The total cure rate were 97.87%,mortality rate was 0.33%.Conclusion1.The incidence of acute pancreatitis is increasing year by year,mainly in young and middle-aged men,and the age of onset tends to be younger.Biliary factors are the most important cause,and the onset of each cause is predominantly male.Compared with biliary acute pancreatitis and hyperlipidemic acute pancreatitis,alcoholic acute pancreatitis is significantly more prevalent in men.Biliary factors are the most common cause of morbidity in middle-aged and elderly patients,while hyperlipidemic acute pancreatitis and alcoholic acute pancreatitis are predominant in young and middle-aged patients.2.Hyperlipidemic acute pancreatitis and alcoholic acute pancreatitis are more likely to progress to SAP.SAP often combined with a variety of complications,poor prognosis,high mortality rate,common complications of AP are intestinal paralysis,abnormal liver function,fluid in the abdominal cavity,lung infection,sepsis,etc.3.NLR,CRP,leukocytes,and neutrophils are risk factors for SAP.It can be used in clinical practice to assess the condition and prognosis of acute pancreatitis,and the test is rapid,simple,low cost,and has high sensitivity and specificity.4.Treatment emphasizes individualized multidisciplinary participation in comprehensive overall treatment,and the severity of the disease affects the treatment effect and prognosis.Growth inhibitors and their analogues,Chinese medicine can effectively relieve patients’ symptoms and signs,shorten the course of the disease and improve the prognosis,which is worth promoting the application. |
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