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我们毕业啦其实是答辩的标题地方Clinicalpracticeguideline:managementofacutepancreatitisRepoeterWeiruiRenGraduatestudentinHeibeiMedicalUniversityTherehasbeenanincreaseintheincidenceofacutepancreatitisreportedworldwide.Despiteimprovementsinaccesstocare,imagingandinterventionaltechniques,acutepancreatitiscontinuestobeassociatedwithsignifcantmorbidityandmortality.Despitetheavailabilityofclinicalpracticeguidelinesforthemanagementofacutepancreatitis,recentstudiesauditingtheclinicalmanagementoftheconditionhaveshownimportantareasofnoncompliancewithevidence-basedrecommendations.Thisunderscorestheimportanceofcreatingunderstandableandimplementablerecommendationsforthediagnosisandmanagementofacutepancreatitis.Thepurposeofthepresentguidelineistoprovideevidence-basedrecommendationsforthemanagementofbothmildandsevereacutepancreatitisaswellasthegallstone–inducedpancreatitis.MethodologyDiagnosisofacutepancreatitisAssessMentofseveritySupportivecareCONTANTSNutritionProphylacticantibioticsManagementofacutegallstonepancreatitisCONTANTSMethodologyItwasthebestoftimes,itwastheworstoftimes;itwastheageofwisdom,itwastheageoffoolishness.Methodology123TheguidelinewasdevelopedundertheauspicesoftheUniversityofToronto.TheysearchedMedlineforguidelinespublishedbetween2002and2014usingtheMedicalSubjectHeadings“pancreatitis”and“clinicalpracticeguideline.”Thissearchidentifed14guidelinespublishedbetween2008and2014.AnotherelectronicsearchofMedlinewasperformedusingtheMedicalSubjectHeadings“pancreatitis,”“acutenecrotizingpancreatitis,”“alcoholicpancreatitis,”and“practiceguidelines”toupdatethesystematicreview.TheresultswerelimitedtoarticlespublishedinEnglishbetweenJanuary2007andJanuary2014.Thereferencesofrelevantguidelineswerereviewed.Up-todatearticlesonacutepancreatitisdiagnosisandmanagementwerealsoreviewedfortheirreferences.DiagnosisofacutepancreatitisItwasthebestoftimes,itwastheworstoftimes;itwastheageofwisdom,itwastheageoffoolishness.1Diagnosisofacutepancreatitis(2ofthefollowing)•Abdominalpain(acuteonsetofapersistent,severe,epigastricpainoftenradiatingtotheback)•Serumlipaseactivity(oramylase)atleast3timesgreaterthantheupperlimitofnormal•CharacteristicfindingsofacutepancreatitisoncomputedtomographyormagneticresonanceimagingSerumlipasehasaslightlyhighersensitivityfordetectionofacutepancreatitis.Onestudydemonstratedthatatday0–1fromonsetofsymptoms,serumlipasehadasensitivityapproaching100%comparedwith95%forserumamylase.13Fordays2–3atasensitivitysetto85%,thespecifcityoflipasewas82%comparedwith68%foramylase.Serumlipaseisthereforeespeciallyusefulinpatientswhopresentlatetohospital.2Rightupperquadrantultrasonographyistheprimaryimagingmodalityforsuspectedacutebiliarypancreatitisowingtoitslowcost,availabilityandlackofassociatedradiationexposure.Ultrasonographyhasasensitivityandspecifcitygreaterthan95%inthedetectionofgallstones,althoughthesensitivitymaybeslightlylowerinthecontextofileuswithboweldistension,commonlyassociatedwithacutepancreatitis.Ultrasonographycanalsoidentifygallbladderwallthickeningandedema,gallbladdersludge,pericholecysticfluidandasonographicMurphysign,consistentwithacutecholecystitis.Whenthesesignsarepresent,thepositivepredictivevalueofultrasonographyinthediagnosisofacutecholecystitisisgreaterthan90%,andadditionalstudiesarerarelyneeded.3Diagnosisofacutepancreatitis4MagneticresonancecholangiopancreatographyisusefulinidentifyingCBDstonesanddelineatingpancreaticandbiliarytractanatomy.Asystematicreviewthatincludedatotalof67studiesfoundthattheoverallsensitivityandspecificityofMRCPtodiagnosebiliaryobstructionwere95%and97%,respectively.Sensitivitywasslightlylower,at92%,fordetectionofbiliarystones.5Inseveredisease,CTisusefultodistinguishbetweeninterstitialacutepancreatitisandnecrotizingacutepancreatitisandtoruleoutlocalcomplications.However,inacutepancreatitisthesedistinctionstypicallyoccurmorethan3–4daysfromonsetofsymptoms,whichmakesCToflimiteduseonadmission.DiagnosisofacutepancreatitisAssessMentofseverityItwasthebestoftimes,itwastheworstoftimes;itwastheageofwisdom,itwastheageoffoolishness.1At48hours,serumCRPlevelsabove14286nmol/Lhaveasensitivity,specifcity,positivepredictivevalueandnegativepredictivevalueof80%,76%,67%,and86%,respectively,forsevereacutepancreatitis.Levelsgreaterthan17143nmol/Lwithinthefrst72hoursofdiseaseonsethavebeencorrelatedwiththepresenceofnecrosiswiththesensitivityandspecifcitybothgreaterthan80%.SerumCRPgenerallypeaks36–72hoursafterdiseaseonset,sothetestisnothelpfulinassessingseverityonadmission.AvarietyofreportshavecorrelatedahigherAPACHEIIScoreatadmissionandduringthefirst72hourswithahighermortality(4%withanAPACHEIIScore8and11%–18%withanAPACHEIIScore≥8).TherearesomelimitationsintheabilityoftheAPACHEIIScoretostratifypatientsfordiseaseseverity.Forexample,studieshaveshownthatithaslimitedabilitytodistinguishbetweeninterstitialandnecrotizingacutepancreatitis,whichconferdifferentprognoses.Inarecentreport,APACHEIIScoresgeneratedwithinthefrst24hourshadapositivepredictivevalueofonly43%andnegativepredictivevalueof86%forsevereacutepancreatitis.2Theo