A PANCREAS BELGYÓGYÁSZATI BETEGSÉGEI Irodalomfigyelő

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1 A PANCREAS BELGYÓGYÁSZATI BETEGSÉGEI Irodalomfigyelő - 2005
Dr. Takács Tamás Szegedi Tudományegyetem, I. sz. Belgyógyászati Klinika Szeged, 2006

2 Diagnosztikus és terápiás algoritmus
ACUT PANCREATITIS Diagnosztikus és terápiás algoritmus US / CT amiláz Pancreas ödéma Pancreas necrosis/ folyadékgyülem UH/CT-vezérelt vékonytű aspiráció, bakteriális tenyésztés epehólyag- és/vagy epeúti kő, tágult epeutak (PCT) Steril necrosis Fertőzött necrosis <72h Konzervatív kezelés ERCP, EST köextractio Konzervatív kezelés (ET, antibiotikum?) Sebészet

3 etiológia Diagnosztikus és terápiás algoritmus ACUT PANCREATITIS
US / CT amiláz Pancreas ödéma Pancreas necrosis/ folyadékgyülem UH/CT-vezérelt vékonytű aspiráció, bakteriális tenyésztés epehólyag- és/vagy epeúti kő, tágult epeutak (PCT) Steril necrosis Fertőzött necrosis <72h Konzervatív kezelés ERCP, EST köextractio Konzervatív kezelés (ET, antibiotikum?) Sebészet

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7 diagnózis Diagnosztikus és terápiás algoritmus (PCT) ACUT PANCREATITIS
US / CT amiláz Pancreas ödéma Pancreas necrosis/ folyadékgyülem diagnózis UH/CT-vezérelt vékonytű aspiráció, bakteriális tenyésztés epehólyag- és/vagy epeúti kő, tágult epeutak (PCT) Steril necrosis Fertőzött necrosis <72h Konzervatív kezelés ERCP, EST köextractio Konzervatív kezelés (ET, antibiotikum?) Sebészet

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10 terápia Diagnosztikus és terápiás algoritmus ACUT PANCREATITIS US / CT
amiláz Pancreas ödéma Pancreas necrosis/ folyadékgyülem UH/CT-vezérelt vékonytű aspiráció, bakteriális tenyésztés epehólyag- és/vagy epeúti kő, tágult epeutak (PCT) Steril necrosis Fertőzött necrosis terápia <72h Konzervatív kezelés ERCP, EST köextractio Konzervatív kezelés (ET, antibiotikum?) Sebészet

11 A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis. Eatock FC, Chong P, Menezes N, Murray L, McKay CJ, Carter CR, Imrie CW. Lister Department of Surgery and Department of Nutrition and Dietetics, Glasgow Royal Infirmary, Alexandra Parade, Glasgow G31 2ER, Scotland. BACKGROUND: After 50 yr in which nasoenteric feeding was considered contraindicated in acute pancreatitis (AP), several clinical studies have shown that early nasojejunal (NJ) feeding can be achieved in most patients. A pilot study of early nasogastric (NG) feeding in patients with objectively graded severe AP proved that this approach was also feasible. A randomized study comparing NG versus NJ feeding has been performed. METHODS: A total of 50 consecutive patients with objectively graded severe AP were randomized to receive either NG or NJ feeding via a fine bore feeding tube. The end points were markers of the acute phase response APACHE II scores and C-reactive protein (CRP) measurements, and pain patterns by visual analogue score (VAS) and analgesic requirements. Complications were monitored and comparisons made of both total hospital and intensive-care stays. RESULTS: A total of 27 patients were randomized to NG feeding and 23 to NJ. One of those in the NJ group had a false diagnosis, thereby reducing the number to 22. Demographics were similar between the groups and no significant differences were found between the groups in APACHE II score, CRP measurement, VAS, or analgesic requirement. Clinical differences between the two groups were not significant. Overall mortality was 24.5% with five deaths in the NG group and seven in the NJ group. CONCLUSIONS: The simpler, cheaper, and more easily used NG feeding is as good as NJ feeding in patients with objectively graded severe AP. This appears to be a useful and practical therapeutic approach to enteral feeding in the early management of patients with severe AP. AM J GASTROENTEROL 2005; 100:

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13 Combination of early nasojejunal feeding with modern synbiotic therapy in the treatment of severe acute pancreatitis (prospective, randomized, double-blind study)] [Article in Hungarian] Olah A, Belagyi T, Issekutz A, Olgyai G. Petz Aladar Megyei Oktato Korhaz, Gyor, Sebeszeti Osztaly. BACKGROUND: We showed previously that probiotics containing lactobacilli significantly improve the outcome of acute pancreatitis. "Synbiotic 2000", a new synbiotic composition with high colony forming unit (CFU) comprises four different types of pre- and probiotics. In this prospective, randomized, double-blind study we evaluated the role of "Synbiotic 2000" in the treatment of severe acute pancreatitis. METHODS: Patients with severe acute pancreatitis were randomized into two groups. Nasojejunal feeding was commenced within 24 hours after admission in both groups and continued for at least seven days. The first group of patients received four different lactobacilli preparations with 10(10) CFU, respectively, and prebiotics containing four bioactive fibres (inulin, beta-glucan, resistant starch and pectin) in addition. Patients in the second (control) group received only prebiotics. RESULTS: 62 patients with severe acute pancreatitis completed the study. Altogether 8 patients died. We detected lower incidence of multiorgan failure (MOF), septic complications and mortality in the first group compared to the control, but the differences were statistically not significant. The total incidence of systemic inflammatory response syndrome (SIRS) and MOF were significantly different between the two groups (8 vs. 14; p < 0.05). Furthermore, the number patients recovering with complications were significantly less in the first group receiving modern synbiotic therapy compared to the control (p < 0.05). Finally, we found lower rate of late (over 48 hours) organ failure in the first versus the control group (3.0% vs. 17.2%). CONCLUSION: Our results suggest that early nasojejunal feeding with synbiotic may prevent organ dysfunctions in the late phase of severe acute pancreatitis. In addition, our data also indicate that the infection of pancreatic necrosis may be associated with early phase organ failure. MAGYAR SEB 2005;58:

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17 Chronicus pancreatitis
Diagnosztikus és terápiás algoritmus Klinikai tünetek fájdalom fogyás steatorrhoea (diab. mellitus) UH / CT Norm. / nem meszes pancreas Pancreas meszesedés (CCP) Szűrővizsgálatok (FE/L/ATT) ERCP + Lundh t. (S-MRCP) neg. poz. Belgyógyászati kez. - diéta/abstinencia - fájdalom - szubsztitúció Követés Egyéb vizsgálatok Endoscopos kez. - cysta - köextractio - epeúti stent Sebészet -reszekció -dekompr. -marsupial.

18 Chronicus pancreatitis etiológia
Diagnosztikus és terápiás algoritmus etiológia Klinikai tünetek fájdalom fogyás steatorrhoea (diab. mellitus) UH / CT Norm. / nem meszes pancreas Pancreas meszesedés (CCP) Szűrővizsgálatok (FE/L/ATT) ERCP + Lundh t. (S-MRCP) neg. poz. Belgyógyászati kez. - diéta/abstinencia - fájdalom - szubsztitúció Követés Egyéb vizsgálatok Endoscopos kez. - cysta - köextractio - epeúti stent Sebészet -reszekció -dekompr. -marsupial.

19 Cigarette smoking accelerates progression of alcoholic chronic pancreatitis P. Maisonneuve, A.B. Lowenfels, B. Mullhaupt, G. Cavallini, P.G. Lankisch, J.R. Andersen, E.P. DiMagno, A. Andren-Sandberg, L. Domellof, L. Frulloni, R.W. Ammann Gut 2005;54:   Background: Smoking is a recognised risk factor for pancreatic cancer and has been associated with chronic pancreatitis and also with type II diabetes. Aims: The aim of this study was to investigate the effect of tobacco on the age of diagnosis of pancreatitis and progression of disease, as measured by the appearance of calcification and diabetes. Patients: We used data from a retrospective cohort of 934 patients with chronic alcoholic pancreatitis where information on smoking was available, who were diagnosed and followed in clinical centres in five countries. Methods: We compared age at diagnosis of pancreatitis in smokers versus non-smokers, and used the Cox proportional hazards model to evaluate the effects of tobacco on the development of calcification and diabetes, after adjustment for age, sex, centre, and alcohol consumption. Results: The diagnosis of pancreatitis was made, on average, 4.7 years earlier in smokers than in non-smokers (p = 0.001). Tobacco smoking increased significantly the risk of pancreatic calcifications (hazard ratio (HR) 4.9 (95% confidence interval (CI) 2.3–10.5) for smokers v non-smokers) and to a lesser extent the risk of diabetes (HR 2.3 (95% CI 1.2–4.2)) during the course of pancreatitis. Conclusions: In this study, tobacco smoking was associated with earlier diagnosis of chronic alcoholic pancreatitis and with the appearance of calcifications and diabetes, independent of alcohol consumption.

20 Chronicus pancreatitis
Diagnosztikus és terápiás algoritmus Klinikai tünetek fájdalom fogyás steatorrhoea (diab. mellitus) diagnózis UH / CT Norm. / nem meszes pancreas Pancreas meszesedés (CCP) Szűrővizsgálatok (FE/L/ATT) ERCP + Lundh t. (S-MRCP) neg. poz. Belgyógyászati kez. - diéta/abstinencia - fájdalom - szubsztitúció Követés Egyéb vizsgálatok Endoscopos kez. - cysta - köextractio - epeúti stent Sebészet -reszekció -dekompr. -marsupial.

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23 Chronicus pancreatitis
Diagnosztikus és terápiás algoritmus Klinikai tünetek fájdalom fogyás steatorrhoea (diab. mellitus) UH / CT Norm. / nem meszes pancreas Pancreas meszesedés (CCP) Szűrővizsgálatok (FE/L/ATT) ERCP + Lundh t. (S-MRCP) neg. poz. Belgyógyászati kez. - diéta/abstinencia - fájdalom - szubsztitúció Követés Egyéb vizsgálatok Endoscopos kez. - cysta - köextractio - epeúti stent Sebészet -reszekció -dekompr. -marsupial. terápia

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27 EUROPEAN PANCREATIC CLUB SZEGED - 2009