重症急性胰腺炎中西医结合诊疗指南

中华中医药学会《重症急性胰腺炎中西医结合诊疗指南》起草组

doi:10.12449/JCH240608

重症急性胰腺炎中西医结合诊疗指南

DOI: 10.12449/JCH240608

中华中医药学会《重症急性胰腺炎中西医结合诊疗指南》起草组

基金项目:

天津市中医药重点领域科技项目 (2022005);

天津市自然科学基金重点项目 (21JCZDJC00550);

天津市卫生健康委员会中医中西医结合课题重点项目 (2021006);

天津市131创新型人才团队项目 (201938)

利益冲突声明：本指南由中华中医药学会立项，参与项目制定的所有成员均签署了“利益冲突声明书”，本诊疗指南制定过程中无利益冲突，为此不会成为本诊疗指南制定的偏倚来源，无需进一步处理，已在正式工作开始前公开了利益声明和评价结果，即所有参与本诊疗指南制定的成员均和药品生产企业没有任何经济利益往来。

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出版历程
- 收稿日期: 2024-04-08
- 录用日期: 2024-04-23
- 出版日期: 2024-06-25

Guidelines for integrated traditional Chinese and Western medicine diagnosis and treatment of severe acute pancreatitis

Drafting Group of Guidelines for Integrated Traditional Chinese and Western Medicine Diagnosis and Treatment of Severe Acute Pancreatitis， Chinese Association of Traditional Chinese Medicine

Research funding:

Tianjin Science and Technology Project in Key Areas of Traditional Chinese Medicine (2022005);

Tianjin Natural Science Foundation Key Project (21JCZDJC00550);

Tianjin Municipal Health Commission Key Project of Combined Traditional Chinese and Western Medicine Subjects (2021006);

Tianjin 131 Innovative Talent Team Project (201938)

摘要

摘要: 重症急性胰腺炎起病急、进展快，临床病理变化复杂，病死率高达20%～30%。长期的临床实践与基础研究发现，单纯依赖西医治疗重症急性胰腺炎并不尽如人意，中西医结合治疗能够展现出更为确切的疗效，具有显著的优势。本指南以循证医学证据为基础，结合国内外指南及临床实践，广泛征求专家建议与意见，最终凝练了28个临床问题。具体阐释了重症急性胰腺炎的病因病机与诊断标准，以及中西医结合分型、病程分期、治疗与治疗的关键点，以期对重症急性胰腺炎的中西医结合诊断标准和治疗原则进行规范。该指南经中华中医药学会发布，标准编号：T/CACM 1518—2023。
- 重症急性胰腺炎 /
- 中西医结合 /
- 诊疗准则
Abstract: Severe acute pancreatitis （SAP） is characterized by rapid onset and progression， complex clinicopathological changes， and a mortality rate of as high as 20%‍ ‍—‍ ‍30%. Long-term clinical practice and basic research have shown that relying solely on Western medicine for the treatment of SAP may not achieve satisfactory outcomes， and integrated traditional Chinese and Western medicine therapy has a marked clinical effect and significant advantages. Based on evidence-based medicine and with reference to related guidelines and clinical practice in China and globally， these guidelines summarize 28 clinical questions after widely soliciting opinions and suggestions from experts. This document specifically elaborates on the etiology， pathogenesis， and diagnostic criteria of SAP， as well as the key points of integrated traditional Chinese and Western medicine typing， disease staging， treatment methods， and therapies， so as to standardize the integrated traditional Chinese and Western medicine diagnostic criteria and treatment principles of SAP.
- Severe Acute Pancreatitis /
- Integrated Traditional Chinese Medicine & Western Medicine /
- Practice Guideline

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【据Hepatology international 2021年1月报道】题：低剂量利福昔明可预防肝硬化失代偿期患者的并发症并提高生存率(作者Zeng X等)

利福昔明已被推荐作为肝性脑病(HE)和自发性细菌性腹膜炎(SBP)的预防药物。该研究旨在探讨低剂量利福昔明是否能预防肝硬化患者的整体并发症和延长生存期。

在这项多中心随机开放标签的前瞻性研究中，200例失代偿期肝硬化患者按1∶1的比例随机分配。利福昔明组患者给予利福昔明400 mg，每日2次，疗程6个月，其余治疗策略在两组患者中尽量保持不变。主要疗效终点是总并发症发生率和无肝移植生存率。次要终点是各种主要肝硬化相关并发症的发生率，以及Child-Pugh评分和分级。

除HE外，两组主要的基线特征相似。利福昔明组总并发症的累积发生率明显低于对照组(P＜0.001)。虽然两组间无肝移植生存率无显著差异，但亚组分析显示，利福昔明显著延长Child-Pugh评分≥9的患者无肝移植生存率(P=0.007)。此外，利福昔明显著减少腹水加重(P＜0.001)、HE (P＜0.001)和胃静脉曲张出血(P=0.031)的发生。两组不良事件发生率相似。

在该研究中，低剂量利福昔明显著降低了总体并发症的发生，延长了晚期肝硬化患者的生存期。低剂量利福昔明与正常剂量(1200 mg/d)利福昔明在预防肝硬化相关并发症方面的效果有待进一步研究。

摘译自ZENG X, SHENG X, WANG PQ, et al. Low-dose rifaximin prevents complications and improves survival in patients with decompensated liver cirrhosis[J]. Hepatol Int, 2021, 15(1): 155-165.

(吉林大学第一医院感染病中心肝病科朱玉凡牛俊奇报道)

表 1 AP分类诊断系统

Table 1. Diagnostic system for classification of acute pancreatitis

分级系统	轻症	中度重症	重症	危重症
RAC分级^1）	无器官功能障碍和局部并发症	出现一过性（≤48 h）器官功能障碍和/或局部并发症	出现持续性（>48 h）器官功能障碍	无
DBC分级^2）	无器官功能障碍和胰腺（胰周）坏死	出现一过性（≤48 h）器官功能障碍和/或无菌性坏死	出现持续性（>48 h）器官功能障碍或感染性坏死	出现持续性（>48 h）器官功能障碍和感染性坏死
注：1）RAC分级，即修订版Atlanta分级，依据改良Marshall评分进行器官功能障碍诊断；2）DBC分级，即决定因素的分级，依据序贯器官衰竭评分系统进行器官功能障碍诊断。

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表 2 改良CT严重指数评分^1）标准

Table 2. Scoring criteria for the modified CT severity index

特征	评分（分）
胰腺炎性反应
正常胰腺	0
胰腺和/或胰周炎性改变	2
单发或多个积液区或胰周脂肪坏死	4
胰腺坏死
无胰腺坏死	0
坏死范围≤30%	2
坏死范围>30%	4
胰外并发症^2）	2
注：1）改良CT严重指数评分为炎性反应、坏死与胰外并发症评分之和；2）胰外并发症包括胸腔积液、腹腔积液、血管或胃肠道受累等。

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表 3 BISAP评分

Table 3. BISAP scores

符合以下每项标准评1分	评分（分）
血尿素氨>8.9 mmol/L	1
精神异常	1
存在SIRS	1
年龄>60岁	1
影像检查提示胸腔积液	1

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表 4 SAP中医辨证分期的论治

Table 4. Treatment of severe acute pancreatitis with Chinese medicine identification and staging

病程分期	病理改变	临床表现	中医辨证	治则	代表方剂
第一期	无菌性胰腺胰周坏死、无菌性炎性阶段	急性坏死物积聚、ACS、SIRS、MODS、急性胃肠功能损伤	正盛邪实、少阳阳明合证、阳明腑实证、结胸里实证	通里攻下、活血化瘀	大承气汤、清胰陷胸汤
第二期	感染性胰腺胰周坏死、感染性炎症阶段	脓毒症、代偿性抗炎反应综合征、重症监护后综合征、MODS、包裹性坏死、感染性胰腺坏死	热结腑实、毒热炽盛	清热解毒、活血化瘀、通里攻下	清胰汤、清胰承气汤
第三期	残余感染性胰腺胰周坏死、局部并发症、内分泌功能损伤、外分泌功能损伤	营养不良、局部并发症	正虚邪去、正虚邪恋、正虚邪陷	补气养血、健脾和胃	辨证方剂

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施引文献

期刊类型引用(2)

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2.	赵雷，娄静，王菲，侯留法. 健脾活血利水方联合异甘草酸镁治疗失代偿期肝硬化临床研究. 河南中医. 2024(07): 1105-1109 . 百度学术