急性胰腺炎初期全身炎症反应综合征持续时间与感染性胰腺坏死的关系

严永峰; 蒋鑫; 钟瑞; 徐欢; 彭燕; 汤小伟

doi:10.3969/j.issn.1001-5256.2021.03.029

急性胰腺炎初期全身炎症反应综合征持续时间与感染性胰腺坏死的关系

DOI: 10.3969/j.issn.1001-5256.2021.03.029

西南医科大学附属医院消化内科，四川泸州 646000

基金项目:

西南医科大学附属医院博士科研启动基金资助项目 (16229);

泸州市人民政府西南医科大学科技战略合作项目 (2019LZXNYDJ24)

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突，特此声明。

作者贡献声明：汤小伟负责课题设计；蒋鑫、钟瑞、徐欢参与收集数据和资料分析；严永峰负责拟定写作思路及撰写论文；彭燕、汤小伟指导撰写文章并最后定稿。

详细信息

作者简介:
严永峰(1994—)，男，主要从事胰腺疾病的基础和临床研究

通信作者:
汤小伟，583437126@qq.com

中图分类号: R576
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出版历程
- 收稿日期: 2020-08-27
- 录用日期: 2020-10-20
- 出版日期: 2021-03-20

Association of the duration of systemic inflammatory response syndrome with infectious pancreatic necrosis at the initial stage of acute pancreatitis

Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China

摘要

摘要: 目的探究急性胰腺炎 (AP) 患者早期炎症反应与晚期感染性胰腺坏死(IPN)的潜在关系。方法回顾性纳入西南医科大学附属医院2019年6月—2020年6月收治的中度重症急性胰腺炎(MSAP)患者219例，重症急性胰腺炎(SAP)患者53例，根据起病初期是否合并全身炎症反应综合征(SIRS)，分为SIRS组160例，非SRIS组112例。纳入基线资料、血清学指标、并发症及病死率。计量资料两组间比较采用t检验或Mann-Whitney U检验；计数资料组间比较采用χ²检验，多组间进一步两两比较采用Bonferroni法。logistic回归分析筛选有价值的变量，受试者工作特征曲线(ROC曲线)用于比较变量的诊断价值，ROC曲线下面积(AUC)的两两比较采用Z检验。结果 SIRS组患者的WBC、CRP、降钙素原更高(P值均＜0.05)，SIRS组合并急性胰周坏死物聚集(ANC)、IPN、胰腺坏死(PN)、器官功能障碍(OF)、多器官功能障碍(MODS)、重症急性胰腺炎(SAP)、危重症急性胰腺炎(CAP)、死亡、BISAP评分＞2、CTSI评分＞2、RANSON评分＞2的比例均高于非SIRS组(P值均＜0.05)。单因素分析显示，SIRS持续时间、肥胖、CRP、WBC、血尿素氮、PN、ANC、SAP、MODS、RANSON评分、BISAP评分、CTSI评分均是AP患者发生IPN的影响因素(P值均＜0.05)；多因素分析显示，SIRS持续时间(OR=1.307，95%CI：1.081~1.580，P=0.006)、ANC(OR=42.247，95%CI：10.829~164.818，P＜0.001)是IPN的危险因素，排除ANC时，SIRS持续时间(OR=1.430，95%CI：1.207~1.694，P＜0.001)、PN(OR=5.296，95%CI：1.845~15.203，P=0.002)是IPN的危险因素。预测IPN的ROC曲线显示：SIRS持续时间(AUC=0.772，约登指数：0.521)、RANSON评分(AUC=0.701，约登指数：0.319)、BISAP评分(AUC=0.741，约登指数：0.377)、CTSI评分(AUC=0.765，约登指数：0.414)的AUC两两比较差异均无统计学意义(P值均＞0.05)。超长时间SIRS组(＞4 d)患者发生PN、ANC、IPN、SAP、CAP的比例均显著高于无SIRS组(0)、短暂性SIRS组(1~2 d)和持续性SIRS组(3~4 d)(P值均＜0.05)，持续性SIRS组患者发生SAP的比例高于无SIRS组(P＜0.05)。结论 AP患者早期合并SIRS时更容易发生器官功能衰竭及局部并发症，当SIRS持续时间＞4.5 d时，患者发生IPN的风险显著增加。
- 急性胰腺炎 /
- 全身炎症反应综合征 /
- 感染性胰腺坏死
Abstract: Objective To investigate the potential association between early-stage inflammatory response and late-stage infectious pancreatic necrosis (IPN) in patients with acute pancreatitis (AP). Methods A retrospective analysis was performed for the clinical data of 219 patients with moderate-severe acute pancreatitis (MSAP) and 53 patients with severe acute pancreatitis (SAP) who were admitted to The Affiliated Hospital of Southwest Medical University from June 2019 to June 2020, and according to the presence or absence of systemic inflammatory response syndrome (SIRS) at the initial stage of the disease, they were divided into SIRS group with 160 patients and non-SRIS group with 112 patients. Baseline data, serological markers, complications, and mortality rate were included for analysis. The t-test or the Mann-Whitney U test was used for comparison of continuous data between two groups; the chi-square test was used for comparison of categorical data between multiple groups, and the Bonferroni method was used for further comparison between two groups. A logistic regression analysis was used to screen out valuable variables; the receiver operating characteristic (ROC) curve was used to compare the diagnostic value of variables, and the Z-test was used for pairwise comparison of area under the ROC curve (AUC). Results Compared with the non-SIRS group, the SIRS group had significantly higher white blood cell count (WBC), C-reactive protein (CRP), and procalcitonin (all P < 0.05) and a significantly higher proportion of patients with acute peripancreatic necrosis (ANC), IPN, pancreatic necrosis (PN), organ dysfunction, multiple organ dysfunction syndrome (MODS), SAP, critically-ill acute pancreatitis (CAP), death, BISAP score > 2, CTSI score > 2, or RANSON score > 2 (all P < 0.05). The univariate analysis showed that SIRS duration, obesity, CRP, WBC, blood urea nitrogen, PN, ANC, SAP, MODS, RANSON score, BISAP score, and CTSI score were risk factors for IPN in patients with AP (all P < 0.05), and the multivariate analysis showed that SIRS duration (odds ratio [OR]=1.307, 95% confidence interval [CI]: 1.081-1.580, P=0.006) and ANC (OR=42.247, 95% CI: 10.829-164.818, P < 0.001) were risk factors for IPN; when ANC was excluded, SIRS duration (OR=1.430, 95% CI: 1.207-1.694, P < 0.001) and PN (OR=5.296, 95% CI: 1.845-15.203, P=0.002) were risk factors for IPN. The ROC curve showed that SIRS duration (AUC=0.772, Youden index=0.521), RANSON score (AUC=0.701, Youden index=0.319), BISAP score (AUC=0.741, Youden index=0.377), and CTSI score (AUC=0.765, Youden Index=0.414) had a certain value in predicting IPN, and there was no significant difference in AUC between any two indices. The long-duration SIRS group (> 4 d) had a significantly higher proportion of patients with PN, ANC, IPN, SAP, or CAP than the non-SIRS group (0 d), the transient SIRS group (1~2 d), and the persistent SIRS group (3~4 d) (all P < 0.05), and the persistent SIRS group had a significantly higher proportion of patients with SAP than the non-SIRS group (P < 0.05). Conclusion AP patients with SIRS in the early stage are likely to develop organ failure and local complications, and there is a significant increase in the risk of IPN when SIRS duration is > 4.5 days.
- Acute Pancreatitis /
- Systemic Inflammatory Response Syndrome /
- Infective Pancreatic Necrosis

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图 1 SIRS持续时间与AP病情评分预测IPN的ROC曲线

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表 1 两组AP患者基线资料比较

项目	SIRS组(n=160)	非SIRS组(n=112)	统计值	P值
年龄(岁)	48(42~57)	48(42~54)	Z=-0.343	0.731
男性[例(%)]	105(65.6)	67(59.8)	χ²=0.954	0.329
病因[例(%)]			χ²=1.067	0.785
胆源性	65(40.6)	51(45.5)
高脂血症性	64(40.0)	38(33.9)
酒精性	15(9.4)	11(9.8)
其他	16(10.0)	12(10.7)
肥胖[例(%)]	75(46.9)	45(40.2)	χ²=1.198	0.274
吸烟史[例(%)]	64(40.0)	42(37.5)	χ²=0.173	0.677
2型糖尿病[例(%)]	32(20.0)	21(18.8)	χ²=0.066	0.798
高血压[例(%)]	51(31.9)	25(22.3)	χ²=2.987	0.084

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表 2 两组AP患者临床资料比较

项目	SIRS组(n=160)	非SIRS组(n=112)	统计值	P值
血清学指标
WBC(10⁹/L)	14.88(12.25~18.68)	11.65(9.66~16.37)	Z=-4.315	＜0.001
CRP (mg/L)	99.68(36.02~173.00)	47.21(7.62~104.64)	Z=-3.973	＜0.001
PCT (ng/L)	0.35(0.13~1.46)	0.13(0.05~0.40)	Z=-4.447	＜0.001
BUN(mmol/L)	5.17(3.81~7.24)	5.16(3.88~6.49)	Z=-0.570	0.569
并发症[例(%)]
APFC	141(88.1)	105(93.8)	χ²=2.411	0.120
ANC	48(30.0)	20(17.9)	χ²=5.181	0.023
IPN	35(21.9)	9(8.0)	χ²=9.306	0.002
PN	50(31.3)	12(10.7)	χ²=18.788	＜0.001
OF	45(28.1)	8(7.1)	χ²=18.488	＜0.001
MODS	39(24.4)	4(3.6)	χ²=21.423	＜0.001
疾病严重程度[例(%)]
SAP	45(28.1)	8(7.1)	χ²=10.210	0.001
CAP	19(11.9)	1(0.9)	χ²=11.664	0.001
死亡	10(6.3)	1(0.9)	χ²=4.872	0.027
AP相关评分[例(%)]
BISAP评分＞2	40(25.0)	1(0.9)	χ²=29.909	＜0.001
CTSI评分＞2	140(87.5)	80(71.4)	χ²=11.005	0.001
RANSON评分＞2	75(46.9)	13(11.6)	χ²=37.422	＜0.001

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表 3 IPN的单因素回归分析

项目	B值	SE	Wald	P值	OR	95%CI
SIRS持续时间	0.429	0.067	40.674	＜0.001	1.535	1.346~1.751
胆源性AP(是=1，否=0)	0.573	0.331	2.990	0.084	1.774	0.926~3.397
肥胖(是=1，否=0)	0.950	0.341	7.759	0.005	2.587	1.325~5.409
PCT	0.013	0.007	3.121	0.077	1.013	0.999~1.207
CRP	0.005	0.002	4.437	0.035	1.005	1.000~1.009
WBC	0.152	0.034	20.589	＜0.001	1.164	1.090~1.244
BUN	0.083	0.040	4.411	0.036	1.087	1.006~1.174
SAP(是=1，否=0)	1.594	0.357	19.995	＜0.001	4.924	2.448~9.904
APFC(是=1，否=0)	1.667	1.034	2.601	0.107	5.296	0.699~40.147
PN(是=1，否=0)	2.436	0.370	43.438	＜0.001	11.424	5.537~23.572
ANC(是=1，否=0)	4.622	0.632	53.452	＜0.001	101.741	29.466~351.289
MODS(是=1，否=0)	1.866	0.373	25.004	＜0.001	6.460	3.109~13.422
BISAP评分	0.828	0.163	25.831	＜0.001	2.288	1.663~3.149
CTSI评分	0.510	0.098	27.365	＜0.001	1.665	1.376~2.016
RANSON评分	0.402	0.087	21.418	＜0.001	1.494	1.261~1.772

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表 4 IPN的多因素回归分析

项目	B值	SE	Wald	P值	OR	95%CI
回归方程1
SIRS持续时间	0.267	0.097	7.613	0.006	1.307	1.081~1.580
ANC(是=1，否=0)	3.744	0.695	29.050	＜0.001	42.247	10.829~164.818
回归方程2
SIRS持续时间	0.358	0.086	17.135	＜0.001	1.430	1.207~1.694
WBC	0.023	0.013	3.238	0.072	1.024	0.998~1.050
PN(是=1，否=0)	1.667	0.538	9.600	0.002	5.296	1.845~15.203

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表 5 预测IPN的ROC曲线结果

项目	AUC	P值	敏感度(%)	特异度(%)	约登指数	95%CI	cut-off值
SIRS持续时间	0.772	＜0.001	59.09	92.98	0.521	0.718~0.821	4.5
BISAP评分	0.741	＜0.001	75.00	62.72	0.377	0.685~0.792	1.5
RANSON评分	0.701	＜0.001	59.09	72.81	0.319	0.643~0.755	2.5
CTSI评分	0.765	＜0.001	54.55	86.84	0.414	0.710~0.810	7.0

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表 6 根据SIRS持续时间分组比较

项目	无SIRS组(n=112)	短暂性SIRS组(n=54)	持续性SIRS组(n=64)	超长时间SIRS组(n=42)	χ²值	P值
PN[例(%)]	12(10.7)¹⁾	6(11.1)¹⁾	13(20.3)¹⁾	31(73.8)	75.811	＜0.001
ANC[例(%)]	20(17.9)¹⁾	4(7.4)¹⁾	11(17.2)¹⁾	33(78.6)	78.330	＜0.001
IPN[例(%)]	9(8.0)¹⁾	3(5.6)¹⁾	6(9.4)¹⁾	26(61.9)	76.919	＜0.001
SAP[例(%)]	8(7.1)¹⁾²⁾	6(11.1)¹⁾	15(23.4)¹⁾	24(57.1)	51.890	＜0.001
CAP[例(%)]	1(0.9)¹⁾	1(1.9)¹⁾	2(3.1)¹⁾	16(38.1)	69.207	＜0.001
注：与超长时间SIRS组比较，1)P＜0.05；与持续性SIRS组比较，2)P＜0.05。

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