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急性重症胰腺炎是临床较为常见的一种急腹症,是由于病人的胰腺组织出血坏死严重,进而诱导继发性的感染,临床表现为急性腹膜炎、感染性休克等[1-2]。急性重症胰腺炎的发病特点是起病急、发展迅速、病情凶险,治疗后常伴有严重并发症,需要及时有效治疗,以防止恶性进展而影响病人的生命安全[3-4]。目前,对于急性重症胰腺炎的治疗以保守治疗为主。研究[5-7]表明,随着急性重症胰腺炎病情的恶化,病人的营养消耗加重,进行针对性营养支持是目前急性重症胰腺炎最重要的疗法之一。笔者比较全胃肠外营养和早期肠内营养治疗急性重症胰腺炎的疗效和预后。现作报道。
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治疗后观察组病人的血淀粉酶恢复时间、尿淀粉酶恢复时间和住院时间均明显少于对照组(P < 0.01)(见表 1)。
分组 n 血淀粉酶恢复时间 尿淀粉酶恢复时间 住院时间 观察组 40 5.25±0.95 12.51±1.65 19.91±3.25 对照组 40 8.27±1.32 19.20±1.42 30.56±5.71 t — 11.74* 19.44 10.25* P — < 0.01 < 0.01 < 0.01 *示t′值 表 1 2组病人血、尿淀粉酶恢复时间和住院时间比较(x±s;d)
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治疗后观察组病人的TP、ALB、BUN水平和Lymph%均明显高于对照组(P < 0.01)(见表 2)。
分组 n TP/(g/L) ALB/(g/L) BUN/(mmol/L) Lymph% 观察组 40 18.75±3.92 16.71±4.35 8.61±2.76 19.71±5.85 对照组 40 12.57±5.12 12.13±3.52 5.56±2.51 13.78±4.20 t — 6.06 5.18 5.17 5.21* P — < 0.01 < 0.01 < 0.01 < 0.01 *示t′值 表 2 2组病人治疗后TP、ALB、BUN和Lymph%比较(x±s)
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2组病人治疗前TNF-α、IL-1β、IL-6、IL-8和内毒素水平差异均无统计学意义(P>0.05)。2组治疗后TNF-α、IL-1β、IL-6、IL-8和内毒素水平均较治疗前降低(P < 0.05~P < 0.01);且治疗后观察组TNF-α、IL-1β、IL-6、IL-8和内毒素水平均低于对照组(P < 0.05~P < 0.01)(见表 3)。
分组 n TNF-α/ (ng/mL) IL-1β/ (ng/mL) IL-6/ (ng/mL) IL-8/ (ng/mL) 内毒素/ (IU/mL) 治疗前 观察组 40 527.21±104.75 10.71±3.71 36.85±13.26 368.75±83.96 0.55±0.16 对照组 40 517.63±115.41 11.21±3.42 35.91±16.17 372.32±94.76 0.53±0.14 t — 0.39 0.63 0.28 0.18 0.60 P — >0.05 >0.05 >0.05 >0.05 >0.05 治疗后 观察组 40 245.27±43.54## 5.17±2.05## 20.78±10.23## 230.21±61.56## 0.32±0.06## 对照组 40 376.98±43.97## 6.74±1.93## 27.44±13.51# 286.85±67.97## 0.42±0.09## t — 13.46 3.53 2.49 3.91 5.85* P — < 0.01 < 0.01 < 0.05 < 0.01 < 0.01 *示t′值;组内配对t检验:#P < 0.05,##P < 0.01 表 3 2组病人治疗前后炎性因子和内毒素水平比较(x±s)
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2组病人治疗前细胞免疫功能指标差异均无统计学意义(P>0.05)。治疗后2组CD3+、CD4+和CD4+/CD8+均较治疗前明显提高(P < 0.01),CD8+均明显降低(P < 0.01);且治疗后观察组CD3+、CD4+和CD4+/CD8+均高于对照组(P < 0.05~P < 0.01),而CD8+明显低于对照组(P < 0.01)(见表 4)。
分组 n CD3+/% CD4+/% CD8+/% CD4+/CD8+ 治疗前 观察组 40 55.29±7.85 42.61±9.41 32.88±6.76 1.27±0.09 对照组 40 54.93±7.21 41.81±8.42 33.21±6.57 1.24±0.06 t — 0.21 0.40 0.22 1.75* P — >0.05 >0.05 >0.05 >0.05 治疗后 观察组 40 64.57±5.51## 49.37±8.05## 23.98±5.53## 1.68±0.16## 对照组 40 59.28±4.93## 45.89±6.46## 27.49±5.59## 1.45±0.17## t — 4.53 2.13 2.82 6.23 P — < 0.01 < 0.05 < 0.01 < 0.01 *示t′值;组内配对t检验:##P < 0.01 表 4 2组病人治疗前后细胞免疫功能比较(x±s)
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治疗前2组病人APACHEⅡ评分差异无统计学意义(P>0.05),治疗后24、48、72 h,观察组病人APACHEⅡ评分均低于对照组(P < 0.05~P < 0.01)。观察组各时点APACHEⅡ评分间差异有统计学意义(P < 0.01),其中治疗后24、48、72 h均明显低于治疗前(P < 0.01),治疗后48、72 h亦均低于治疗后24 h(P < 0.05和P < 0.01);而对照组各时点APACHEⅡ评分间差异无统计学意义(P>0.05)(见表 5)。
分组 n 治疗前 治疗后24 h 治疗后48 h 治疗后72 h F P MS组内 观察组 40 12.25±3.87 10.21±3.45** 8.49±3.26**△ 7.11±2.98**△△ 17.01 < 0.01 11.597 对照组 40 12.17±4.12 12.01±3.42 11.76±3.54 10.89±3.28 1.00 >0.05 12.990 t — 0.09 2.34 4.30 5.39 — — — P — >0.05 < 0.05 < 0.01 < 0.01 — — — q检验:与治疗前比较**P < 0.01;与治疗后24 h比较△P < 0.05,△△P < 0.01 表 5 2组病人治疗前后APACHEⅡ评分比较(x±s;分)
早期肠内营养和全胃肠外营养治疗急性重症胰腺炎的疗效及预后比较
Comparison of the clinical efficacy and prognosis between early enteral nutrition and total parenteral nutrition in the treatment of severe pancreatitis
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摘要:
目的比较早期肠内营养与全胃肠外营养治疗重症胰腺炎的临床疗效及预后。 方法选取重症胰腺炎病人80例,随机分为对照组和观察组,各40例。对照组病人给予全胃肠外营养治疗,观察组病人给予早期肠内营养治疗。比较2组病人的血淀粉酶恢复时间、尿淀粉酶恢复时间、住院时间和血清总蛋白、白蛋白、尿素氮水平及血淋巴细胞百分比、相关炎性因子水平、内毒素水平、细胞免疫功能、APACHEⅡ评分。 结果观察组血、尿淀粉酶恢复时间及住院时间均明显少于对照组(P < 0.01)。治疗后观察组病人的血清总蛋白、白蛋白、尿素氮水平及血淋巴细胞百分比均明显高于对照组(P < 0.01)。治疗后2组病人肿瘤坏死因子-α、白细胞介素(IL)-1β、IL-6、IL-8和内毒素水平均较治疗前降低(P < 0.05~P < 0.01);且治疗后观察组病人的肿瘤坏死因子-α、IL-1β、IL-6、IL-8和内毒素水平均低于对照组(P < 0.05~P < 0.01)。治疗后2组病人的CD3+、CD4+和CD4+/CD8+均较治疗前明显提高(P < 0.01),而CD8+水平较治疗前降低(P < 0.05);治疗后观察组病人的CD3+、CD4+和CD4+/CD8+均高于对照组(P < 0.05~P < 0.01),而CD8+水平则明显低于对照组(P < 0.01)。治疗后24、48、72 h,观察组APACHEⅡ评分均明显低于治疗前(P < 0.01),治疗后48、72 h均低于治疗后24 h(P < 0.05和P < 0.01),且观察组各时点APACHEⅡ评分均低于对照组(P < 0.05~P < 0.01)。 结论早期肠内营养治疗可明显降低重症胰腺炎病人的炎性因子水平,提高免疫功能,改善病人预后。 Abstract:ObjectiveTo compare the clinical efficacy and prognosis between early enteral nutrition and total parenteral nutrition in the treatment of severe acute pancreatitis. MethodsEighty patients with severe pancreatitis were randomly divided into the control group and observation group(40 cases each group).The control group was treated with total parenteral nutrition, and the observation group was treated with early enteral nutrition.The recovery time of hemodiastase and urine amylase levels, hospital stay, levels of total serum protein, albumin and urea nitrogen, percentage of blood lymphocyte, inflammatory factor level, cellular immune function and APACHEⅡ score between two groups were compared. ResultsThe recovery time of hemodiastase, recovery time of urine amylase and hospital stay in observation group after treatment were significantly shorter than those in control group(P < 0.01).The levels of total serum protein, albumin, urea nitrogen and percentage of blood lymphocyte in observation group after treatment were significantly higher than those in control group(P < 0.01).After treatment, the levels of TNF-α, IL-1β, IL-6, IL-8 and endotoxin in two groups significantly decreased compared with before treatment(P < 0.05 to P < 0.01), and the levels of TNF-α, IL-1β, IL-6, IL-8 and endotoxin in observation group were significantly lower than those in control group(P < 0.01).Compared with before treatment, the levels of CD3+, CD4+ and CD4+/CD8+ significantly increased(P < 0.01), and the level of CD8+ significantly decreased in two groups after treatment(P < 0.05).After treatment, the levels of CD3+, CD4+ and CD4+/CD8+ in observation group were significantly higher than those in control group(P < 0.01), and the level of CD8+ in observation group was significantly lower than that in control group(P < 0.01).The APACHEⅡ score in observation group after 24h, 48h and 72h of treatment was significantly lower than that before treatment(P < 0.01), the APACHEⅡ score in observation group after 48 h and 72h of treatment was significantly lower than that after 24h of treatment(P < 0.05 and P < 0.01), and the APACHEⅡ score in observation group at each time-point was significantly lower than that in control group(P < 0.05 to P < 0.01). ConclusionsEarly enteral nutrition in the treatment of severe pancreatitis can effectively reduce the inflammatory factor level, enhance cellular immune function, and improve prognosis of patients. -
表 1 2组病人血、尿淀粉酶恢复时间和住院时间比较(x±s;d)
分组 n 血淀粉酶恢复时间 尿淀粉酶恢复时间 住院时间 观察组 40 5.25±0.95 12.51±1.65 19.91±3.25 对照组 40 8.27±1.32 19.20±1.42 30.56±5.71 t — 11.74* 19.44 10.25* P — < 0.01 < 0.01 < 0.01 *示t′值 表 2 2组病人治疗后TP、ALB、BUN和Lymph%比较(x±s)
分组 n TP/(g/L) ALB/(g/L) BUN/(mmol/L) Lymph% 观察组 40 18.75±3.92 16.71±4.35 8.61±2.76 19.71±5.85 对照组 40 12.57±5.12 12.13±3.52 5.56±2.51 13.78±4.20 t — 6.06 5.18 5.17 5.21* P — < 0.01 < 0.01 < 0.01 < 0.01 *示t′值 表 3 2组病人治疗前后炎性因子和内毒素水平比较(x±s)
分组 n TNF-α/ (ng/mL) IL-1β/ (ng/mL) IL-6/ (ng/mL) IL-8/ (ng/mL) 内毒素/ (IU/mL) 治疗前 观察组 40 527.21±104.75 10.71±3.71 36.85±13.26 368.75±83.96 0.55±0.16 对照组 40 517.63±115.41 11.21±3.42 35.91±16.17 372.32±94.76 0.53±0.14 t — 0.39 0.63 0.28 0.18 0.60 P — >0.05 >0.05 >0.05 >0.05 >0.05 治疗后 观察组 40 245.27±43.54## 5.17±2.05## 20.78±10.23## 230.21±61.56## 0.32±0.06## 对照组 40 376.98±43.97## 6.74±1.93## 27.44±13.51# 286.85±67.97## 0.42±0.09## t — 13.46 3.53 2.49 3.91 5.85* P — < 0.01 < 0.01 < 0.05 < 0.01 < 0.01 *示t′值;组内配对t检验:#P < 0.05,##P < 0.01 表 4 2组病人治疗前后细胞免疫功能比较(x±s)
分组 n CD3+/% CD4+/% CD8+/% CD4+/CD8+ 治疗前 观察组 40 55.29±7.85 42.61±9.41 32.88±6.76 1.27±0.09 对照组 40 54.93±7.21 41.81±8.42 33.21±6.57 1.24±0.06 t — 0.21 0.40 0.22 1.75* P — >0.05 >0.05 >0.05 >0.05 治疗后 观察组 40 64.57±5.51## 49.37±8.05## 23.98±5.53## 1.68±0.16## 对照组 40 59.28±4.93## 45.89±6.46## 27.49±5.59## 1.45±0.17## t — 4.53 2.13 2.82 6.23 P — < 0.01 < 0.05 < 0.01 < 0.01 *示t′值;组内配对t检验:##P < 0.01 表 5 2组病人治疗前后APACHEⅡ评分比较(x±s;分)
分组 n 治疗前 治疗后24 h 治疗后48 h 治疗后72 h F P MS组内 观察组 40 12.25±3.87 10.21±3.45** 8.49±3.26**△ 7.11±2.98**△△ 17.01 < 0.01 11.597 对照组 40 12.17±4.12 12.01±3.42 11.76±3.54 10.89±3.28 1.00 >0.05 12.990 t — 0.09 2.34 4.30 5.39 — — — P — >0.05 < 0.05 < 0.01 < 0.01 — — — q检验:与治疗前比较**P < 0.01;与治疗后24 h比较△P < 0.05,△△P < 0.01 -
[1] 钱家鸣, 赖雅敏.急性胰腺炎分型与病情评估的研究进展[J].临床肝胆病杂志, 2013, 29(7):481. doi: 10.3969/j.issn.1001-5256.2013.07.001 [2] 朱敏丽, 沈志坤.重症胰腺炎病人肠内营养并发症的预防及护理[J].全科护理, 2014, 12(34):3176. [3] MENTULA P, LEPPNIEMI A.Position paper:timely interventions in severe acute pancreatitis are crucial for survival[J].World J Emerg Surg, 2014, 9(1):15. doi: 10.1186/1749-7922-9-15 [4] VAN BAAL MC, KOHOUT P, BESSELINK MG, et al.Probiotic treatment with Probioflora in patients with predicted severe acute pancreatitis without organ failure[J].Pancreatology, 2012, 12(5):458. doi: 10.1016/j.pan.2012.08.004 [5] 杨国祥, 张万里, 杜寒松, 等.谷氨酞胺联合早期肠内营养对急性重症胰腺炎全身炎症的影响[J].中国生化药物杂志, 2014, 34(2):125. [6] 余锋尤, 杨普云, 吴全忠.肠内与肠外营养对急性重症胰腺炎促炎因子及肠屏障功能的影响[J].现代临床医学, 2016, 42(2):131. doi: 10.3760/cma.j.issn.1674-1927.2016.02.009 [7] 韩娟.早期经三腔喂养管进行肠内营养支持在重症胰腺炎病人中的应用[J].全科护理, 2015, 13(31):3122. doi: 10.3969/j.issn.1674-4748.2015.31.010 [8] MANSFIELD CS, JAMES FE, STEINER JM, et al.A pilot study to assess tolerability of early enteral nutrition via esophagostomy tube feeding in dogs with severe acute pancreatitis[J].J Vet Intern Med, 2011, 25(3):419. doi: 10.1111/jvim.2011.25.issue-3 [9] OLÁH A, ROMICS L.Evidence-based use of enteral nutrition in acute pancreatitis[J].Langenbecks Arch Surg, 2010, 395(4):309. doi: 10.1007/s00423-010-0631-4 [10] 温怡洪, 李国伟, 方海星.早期肠内营养治疗对急性重症胰腺炎所致SIRS转归的影响[J].中国普通外科杂志, 2015, 24(3):446. [11] 黄凯涛, 黄潮添, 郑镇.早期和延迟肠内营养治疗急性重症胰腺炎的疗效比较[J].广东医学院学报, 2016, 34(2):175. doi: 10.3969/j.issn.1005-4057.2016.02.019 [12] 陈健, 王磊, 李炳庆, 等.肠内营养支持治疗对急性重症胰腺炎肠黏膜屏障功能及细菌移位的影响[J].中国老年学杂志, 2014, 34(12):3325. doi: 10.3969/j.issn.1005-9202.2014.12.052 [13] TYBERG A, KARIA K, GABR M, et al.Management of pancreatic fluid collections:A comprehensive review of the literature[J].World J Gastroenterol, 2016, 22(7):2256. doi: 10.3748/wjg.v22.i7.2256 [14] VAN BAAL MC, VAN RENS MJ, GEVEN CB, et al.Association between probiotics and enteral nutrition in an experimental acute pancreatitis model in rats[J].Pancreatology, 2014, 14(6):470. doi: 10.1016/j.pan.2014.10.002 [15] 孔庆元, 贺德, 邓俊雄.早期肠内营养辅助治疗重症胰腺炎的临床疗效观察[J].中国医学工程, 2015, 23(2):184. [16] 刘杰锋, 何志国, 陈澍, 等.早期肠内营养辅助治疗重症胰腺炎的临床疗效分析[J].现代生物医学进展, 2013, 13(27):5279. [17] 李诗阳, 王日兴, 吕有凯, 等.早期肠内营养治疗对急性重症胰腺炎病人炎性因子水平的影响及临床意义[J].中国老年学杂志, 2016, 36(10):2429. doi: 10.3969/j.issn.1005-9202.2016.10.054