Ko te Pancreatitis Acute, Ko te Wehenga o te Gallbladder, me te Whakataetae Cholangitis Ake¶

Ko te mamae o runga o te puku e toro ana ki te tuara, ki te mata pakihiwi matau ranei, ka uru ki te momo ora-mate-mate ranei o nga mate ohorere hepatobiliary me te pancreatic. Ko te mea ka timata mai i te ahua noa "whakaeke gallbladder" (biliary colic) i muri i te kai ngako ka tere te piki ki te ** cholecystitis whakapeka** (he ngongo ngongo kua arai, kua pangia ka pakaru te gangrenous), cholangitis piki (he kowhatu kawa e tarai ana i te takere nui o te taiapa ki roto i te ate ki raro i te pehanga o te toto ki roto i te ate. ohorere i roto i nga haora), he acute necrotizing pancreatitis (i te mea na te kowhatu kawa, te inu waipiro nui ranei e whakaohooho ana i te pancreas ki te tuku i nga whākōkī kūnatu e whakamomori ana i te pancreas me nga whekau retroperitoneal huri noa).

Ko o kawenga tonu ina kua whakapaehia he kohungahunga whakapeka, he awa papa, he whawhati tata pancreatic ranei, ko te tirotiro mo nga haki whero whakamate o Charcot Triad (te kirikaa nui me te wiri, he kowhai kowhai i roto i nga kanohi/kiri, me te mamae o te puku o runga matau) me Reynolds Pentad (Charcot Triad) me te mohio ki te pehanga toto iti me te toru o nga tau Ko te mamae o te epigastric e hoha tika ana ki waenganui o muri ka pai ake i te wa e anga whakamua ana i roto i te mate pancreatic nui, waea atu ki nga ratonga hauora ohorere mena kei te kirikaa, te jaundice, te ruaki tonu, te whanoke ranei, kaore he kai ma te waha (kaore he kai, he wai, he antacids ranei), me te tuu i te manawanui ki te okioki paku ki mua, ki tana taha ranei e kawe ana ki te tari whawhati tata.

Mahia tenei inaianei¶

1. Waea atu ki nga ratonga hauora whawhati tata ki te mea kei reira nga haki whero o te biliary sepsis me nga haki whero nui o te pancreatitis: Waea atu ki to nama whawhati tata (911 i te United States me Canada, 112 puta noa i te Kotahitanga o Europi, 999 i te United Kingdom, 000 i Ahitereiria) tirohia to maatau raarangi ingoa tau ohorere Mena ka tupu te tangata e mamae ana te puku o runga, taha matau ranei ka kirikaa, ka wiri ranei (he kaha), ka kowhai nga ma o nga kanohi, kiri ranei (jaundice) he mimi parauri pouri ranei te tae tea, te mamae nui ka puta tika i waenganui o te puku ki te tuara, ka ruaki tonu, ka pohehe te manawa, raruketanga o te manawa, rareketanga o te manawa, **
2. Haere ki te tari whawhati tata mena ka roa ake te "whakaekea o te gallbladder" neke atu i te 4 ki te 6 haora: Ko te kowhatu biliary ngawari (he kowhatu kawa e pehia ana te kaki o te gallbladder) tata tonu ka mama i roto i te 1 ki te 4 haora ka taka te kohatu ki muri. Mena kei te haere tonu te mamae o te puku matau o runga ** 4 ki te 6 haora** ka puta ranei he koi ka mau ki te manawa i te pehi i raro i nga rara matau (Poitive Murphy Sign), ka kaha te mumura o te gallbladder (acute cholecystitis) me te tiaki wawe i te hohipera.
3. Kaore e hoatu he mea ma te waha (NPO: kore kai, kore wai, kore wai-a-waha): Ko te kai me te inu noa i te iti o te wai e whakaihiihi ana i te duodenum ki te tuku i te homoni cholecystokinin (CCK) me te secretin, e kaha ana te mumura o te gallbladder ki te pa atu ki te kowhatu kua marara ki te paopao i te kowhatu e pupuhi ana i te kopu.
4. Awhina i te manawanui ki te noho tika me te anga whakamua (he korikori ranei ki tana taha me nga turi kua toia ki runga): I roto i te panctitis acute, ko te takoto papatahi ki muri ka pehi tika atu nga whekau puku ki raro ki runga i te pancreatic retroperitoneal tetere, ka mamae te mamae. Tukua te tūroro ki te noho ki runga ka anga whakamua ki runga i te urunga i runga i o ratou uma, ka takoto kopikopiko ranei tona taha i roto i te turanga fetal me nga turi e kumea ana ki te uma.
5. Tirotirohia nga kiri ma o nga kanohi i raro i te marama ma kanapa ka tirohia te tae mimi: Kumea ata te kamo o raro i raro i te awatea maori ranei he rama waea ma ki te rapu mo te kowhai kowhai moata o te sclera (scleral icterus), ka patai mena kua huri te mimi ki te amipere-parauri (penei i te cola me te tii kaha) kua huri ranei te kuemu ki te paraka o te kowhatu koma ** he kowhatu paraka te kowhatu.
6. Kaua rawa e hoatu he aspirini, ibuprofen (NSAIDs), he pire mamae narcotic ranei i te kainga i mua i te whakamatautauranga o te hohipera: Ka kino te NSAID i nga whatukuhu e matekai ana mo te wai mo te pancreatitis whakapeka (kei te 4 ki te 6 rita o te plasma ka rere ki roto i te retroperitoneum), me te tango i nga toenga opioids i te kainga ka taea te mokowhiti i te Sphincter of Oddi i raro o te awaawa.

flowchart TD
    Start["Te mamae nui o te Puawai Matau o runga (RUQ) ranei te mamae o te puku o runga o runga (Epigastric)"] --> CheckCholangitis{"1. Tirohia Charcot Triad / Reynolds Pentad: Kei te Kirika/Rigors, Ko nga Kanohi Kowhai ranei/Pouri Mimi, Ko te Hurorirori kau/Kei te Rua?"}
    CheckCholangitis -->|Yes| CallEMS["Waea atu ki nga Ratonga Ohotata (911 / 112 / 999) Inamata: Te whakapae kei te piki haere te cholangitis, te pancreatitis necrotizing ranei"]
    CheckCholangitis -->|No| CheckPancreas{"2. Ka pa te mamae ki waenganui o muri, he kino ake te takoto papa, me te ruaki kore?"}
    CheckPancreas -->|Yes| CallEMS
    CheckPancreas -->|No / Right Rib Pain| CheckDuration{"3. He mamae te Puke Matau o Runga > 4 ki te 6 haora, ka mau ranei te manawa o te manawanui i te pehi i raro i nga riu matau (tohu Murphy)?"}
    CheckDuration -->|Yes| UrgentED["Kawea atu ki te Tari Ohotata o te Hohipera mo te Iratuki, Toto Lipase/Paewhiri ate, me nga Paturopi IV"]
    CheckDuration -->|Under 4 Hours,Subsiding| UrgentEval["Kia mau ki te NPO (Kaore he mea ma te waha) ka whakarite wawe i te Aromātai Hauora me te Ultrasound Biliary"]
    CallEMS --> Position["4. Te Turanga Noho Runga Whakamua Ki runga i te Urunga (Ka Kopikopiko Taha Ki te Ruaki); Tino Kore Kai, Wai ranei"]
    UrgentED --> Position

Ko te 4-waahanga hepatobiliary me te pancreatic spectrum: Me pehea te kowhatu kawa e puta ai nga momo ohorere e wha¶

Kia mohio ai koe he aha te mate o te kowhatu kawa mai i te 2-haora i muri i te kai i te kai ki te 24-haora te whawhai mo te oranga, ka awhina i te kimi i te paipa tika o te rakau biliary:

Ka mahia tonutia te pire e te ate, ka rere ki raro i roto i nga ngongo ate, ka rongoa ki roto i te gallbladder te ahua o te pea ma te peka-taha whaiti e kiia nei ko te cystic duct. Ka kai koe i te ngako, i te pūmua ranei, ka pehia e te gallbladder te taipa ki waho o te duct cystic ki te huarahi matua, te common bile duct (CBD), e hono ana ki te nui pancreatic duct tika tonu ki te pukoro uaua (ampulla of Vater / Sphincter of Oddi) ka uru ki te wahanga tuatahi o te whekau iti (duoden). I runga i te mimita tika i te wa e mau ai te kowhatu kawa, e wha nga mate rereke ka puta:

Ko te cholangitis piki: Te mohio ki a Charcot Triad me Reynolds Pentad i mua i te tiango septic¶

Ko te cholangitis piki whakapeka tetahi o nga mate ohorere tino tere haere i roto i nga rongoa o roto me te pokanga. Ko te tikanga, ka rere whakararo te ate mai i te ate ki roto i te whekau i te iti o te pehanga huna o 10 ki te 15 henemita o te wai, me te uaua Sphincter of Oddi ka pupuri i nga huakita whekau kia kaua e kauhoe whakarunga.

I te wa e puruhia ana e te kowhatu kawa (he puku, he whakatiki ranei i te ngongo ngongo) te ngongo ngongo noa, ka piki ake te pehanga o roto i te 20 ki te 25 henemita te wai. I taua paepae pehanga nui, ka pupuhi nga rohe moroiti i waenga i te bile canaliculi me nga sinusoids toto o te ate (cholangiovenous reflux), ka pupuhi i te purulent, huakita-a-whare tika ki roto i nga uaua ate me te taha matau o te ngakau.

1. Charcot Triad (Tauwhiu takitoru tātaritanga o te cholangitis piki)¶

I whakaahua tuatahitia e te tohunga neurologist Jean-Martin Charcot i te tau 1877, Charcot Triad neke atu i te 90 paiheneti te motuhake mo te cholangitis piki whakapeka (ahakoa ka puta tahi nga tohu e toru i te wa kotahi i roto i te 50 ki te 70 paiheneti noa o nga turoro, na te mea ka tae mai nga tokorua e hiahia ana ki te mahi i nga hohipera ohorere):

1. Te kirika me te wiri (Rigor) (Kei roto i te 90 paiheneti o nga turoro): Ka piki ohorere te pāmahana ki te 38.5 ki te 40.0 nga nekehanga Celsius (101.3 ki te 104.0 nga nekehanga Fahrenheit) ka haere tahi me te ngau o nga niho kare e taea te whakahaere na te kuhu mai o te karama kino ki te toto.
2. Nga Tohu Arai Iwi / Biliary (Kei te 60 ki te 70 paiheneti o nga turoro): Te kowhai kowhai o nga ma o nga kanohi (scleral icterus, ka kitea ina neke ake te bilirubin toto i te 2.5 ki te 3.0 mg/dL) me te kiri, me te uru tahi me te ma te mimi me te mimi kua marara ki te cola-parauri ** tea-parauri, te tii-parauri ranei. he tae putty, he paru paru ranei (kaore he puranga o te repa e tae ana ki te whekau).
3. Right Upper Quadrant (RUQ) or Epigastric Abdominal Pain (Kei roto i te 70 ki te 80 paiheneti o nga turoro): Te mamae hohonu, te mamae koi ranei i raro i te ribcage matau (Tuhipoka: I nga pakeke pakeke ake i te 70, ka ngaro pea te mamae o te puku, me te cholangitis he ahua noa iho ** te kirikaa, te rangiruatanga **).

2. Reynolds Pentad (Fulminant Suppurative Cholangitis / Tokyo Guidelines Grade III Severe)¶

Ki te kore e rongoahia te cholangitis kakea mo etahi haora, ka whakakiia te ngongo o te ate ki te pana paraka matotoru i raro i te pehanga teitei (acute suppurative cholangitis), ka whanake te manawanui i te Reynolds Pentad (he nui ake te 50 ōrau o te mate ki te kore e mahia tonutia te whakahekenga o te endoscopic endoscopic or percutaneous bile channel):

• 1. Te kirika me te uaua
• 2. Jaundice
• 3. Te mamae o te puku o te taha matau o runga
• 4. Te whakaheke me te Te Huri Huri: Ka heke iho te pehanga toto Systolic i raro i te 90 mmHg, ka eke te reiti o te ngakau ki runga ake i te 110 ki te 130 pao i ia meneti, ka huri kopa, ka marumaru ranei nga pito, ka mutu te whakaputa mimi.
• 5. Kua Hurihia te Turanga Hinengaro (CNS Depression): Hou raruraru, whakararuraru, whakararuraru, irirangi, koma ranei na te endotoxemia me te hypoperfusion roro.

Ko te cholecystitis me te puwha o te gallbladder: Me pehea te tirotiro i te Waitohu Murphy me te Waitohu Boas¶

Ki te noho he kowhatu taiwhanga ki roto i te ngongo kiri mo te neke atu i te 4 ki te 6 haora, ka tahuna matū e nga tote taipa e mau ana te ara o roto o te gallbladder (lysolecithin chemical mumura), ka piri nga poihau o te gallbladder (hydrops of the gallbladder), me te mate huakita tuarua kei roto (**acutecyolecalculiculture).

1. Me pehea e tirohia ai e nga kairorohiko te Sonographic me te Moenga "Waitohu Murphy"¶

• Me takoto te manawanui ki runga i tona tuara me nga turi he paku piko.
• Whakanohoia o maihao ki raro noa iho i te tawhiu utu matau (te tapa o raro o te ribcage matau) ki te raina waenga-clavicular (tika iho mai i te waenganui o te iwi matau), kei reira te pito (fundus) o te gallbladder e noho ana.
• Tonoa te tūroro ki te he puhoi, he manawa hohonu ki roto i tona waha.
• Waitohu Murphy Pai: I te turakitanga o te diaphragm i te ate me te gallbladder mumura ki raro i te wa e whakahiatotia ana, ka pa atu te gallbladder ngawari ki o maihao tirotiro, ka ** hoha te manawanui ka mutu ohorere te hongi i te manawa-waenganui ("ka mau i te manawa")** na te mate ohorere o te mamae. (Ki te rite te mamae me te kore e mutu te manawa i nga taha e rua, he kino te whakamatautau).

2. Te mamae o te pakihiwi matau me te "Waitohu Boas"¶

• He aha te take i mamae ai to matau pakihiwi matau (scapula) ma te puku o te puku katau ranei? Ka whakapouritia e te gallbladder me te kapene ate te taha matau o raro o te diaphragm, e whakarotohia ana e te te nerve phrenic matau (cervical nerve roots C3, C4, me C5). Na te mea ko te C3 ki te C5 ka tuku kiri ki runga i te pakihiwi matau me te rohe subscapular (supraclavicular nerves), ka kite te roro i te mumura o te gallbladder he mamae hohonu i raro i te mata o te pokohiwi matau.
• Waitohu Boas: Ko te kaha ake o te kiri kiri, te mamae ranei ki te pa ngawari (hyperesthesia) i runga i te tuara matau i raro noa iho i te ** scapula matau (T7 ki te T11 dermatomes)** he tohu motuhake mo te cholecystitis acute.

3. Nga haki whero mo te cholecystitis gangrenous, te cholecystitis emphysematous, me te pakaru o te gallbladder¶

I roto i nga pakeke tawhito, tane neke atu i te 60, me turoro kei te mate huka, ko te tuku toto ki te gallbladder (te arai cystic, he arai mutunga kotahi karekau he oko whakaraerae) ka tere kato, ka puta ki:

• Gangrenous Cholecystitis and Gallbladder Perforation (Rupture): He mea whakamihi, ina mate te pakitara o te gallbladder i te gangrene, ka mate ano ona uaua mamae, no reira ka iti haere te mamae o te taha matau o runga i te taha matau mo etahi haora** i mua tonu i te pakarutanga o te gallbladder mate ka maringi te taiapa paitini ki roto i te puku (**0 patene ki roto i te kopu mate (**0%). reiti).
• Emphysematous Cholecystitis (Huawahotata mate huka): Ko nga huakita hanga hau (Clostridium perfringens, E. coli) ka uru ki te pakitara gallbladder ischemic i roto i nga turoro mate huka, ka whakakiia te pakitara gallbladder ki nga mirumiru hau (e hua ana te crepitus me te gangrene tere i roto i te 24 haora).
• Colecystitis Acalculous: Necrosis ngongo ngongongo e whakararu ana i te ora kare he kowhatu taiwhanga, ka puta i roto i te whara kino ICU, i te wera, i nga turoro sepsis ranei na te ischemia o te gallbladder me te mate o te ate.

Pankreatitis Acute: He aha te autodigestion ka nui te wiri mokowhiti tuatoru me te korenga o te huhu¶

Ka whakaputahia e te pancreas nga whaakōnae kūnatu kaha (trypsin, lipase, amylase, elastase, me te phospholipase A2) i hangaia kia noho haumaru hei pro-enzymes (zymogens) kia tae ra ano ki te whekau iti. I roto i te pancreatitis whakapeka (i puta i roto i te 70 ki te 80 paiheneti o nga keehi na te kowhatu kowhatu, te inu waipiro nui ranei, a, i nga keehi e toe ana na ** hypertriglyceridemia tino nui ake i te 1,000 mg/dL**, Nga tikanga ERCP, hypercalcemia, tukino puku penei i te paihikara paihikara i pa ki te tamaiti, 1, 1, thioppromedical, LP. nga agonists, thiazide diuretics ranei), ka whakahohehia e aua enzyme i roto i te pancreas ake ano, te keri i te kiko pancreatic me te ngako retroperitoneal (saponification).

1. Whakaaturanga haumanu matarohia o te pancreatitis whakapeka¶

• Te mamae ohorere, he rite ki te maripi te mamae epigastric ka hoha tika ki muri: Kaore i te ahua o te biliary colic (ka tupu i muri i te kai ka memeha i roto i te 3 haora), ka tae te mamae o te pancreatitis ki te tino kaha i roto i 10 ki te 30 meneti, ka puta totika ki roto i te puku o runga ki te T10 ki te L2 waenganui-muri ano he aho wera ki te tuara, karekau he rino i roto i te 90 **50 ōrau o te hunga tūroro karekau he rino wera i roto i te 9000 ōrau.
• Whakaora i te turanga (Te Pancreatic Tripod / Knee-Chest Posture): Ma te takoto papa ki muri ka toro te peritoneum o muri ki runga ake i te pancreatic tetere ka kaha ake te mamae. Ko nga turoro ka noho tika ki te anga whakamua, ka kopikopiko ranei ki o ratou taha me o ratou turi e piri ana ki o ratou uma.
• Ko te ruaki kare, kare e whakaora (Gastric and Duodenal Ileus): Ko te mumura i muri tonu o te puku me te duodenum ka pararutiki nga uaua o te uaua, ka mau tonu te pupuhi maroke me te ruaki bilious e kaore e whakaora i te mamae o te puku.

2. He aha te mate pancreatic kino i te 48 haora tuatahi: Retroperitoneal tuatoru mokowā, ARDS, me te hypocalcemia¶

I te wa e rere ana nga enzyme pancreatic (ina koa elastase me phospholipase A2) me nga cytokine mumura ki roto i te retroperitoneum me te rere toto, e toru nga raru o te punaha whakararu i te ora (**Whakahouhia te Whakar

1. Massive Retroperitoneal Fluid Sequestration ("Internal Burn" Hypovolemic Shock): Ko te retroperitoneum mumura ka rite ki te wera nui-toru o roto, ka ngotea 4 ki te 8 rita (1 ki te 2 karani) o te plasma ki waho i te toto i roto i te 24 ki te 48 haora tuatahi. Ma tenei ka waiho te toto o te manawanui kia matotoru me te noho (hemoconcentration me te piki haere o te hematocrit me te hauota urea toto), ka matekai nga whatukuhu e rua (te mate whatukuhu whakapeka) me te pancreas tonu (ka huri te pancreatic interstitial ngawari hei pancreatitis necrotizing acute).
2. Acute Respiratory Distress Syndrome (ARDS) me te Left Pleural Effusion: Ko te pancreatic phospholipase A2 e haere ana i roto i te awa toto ki te pūkahukahu me te whakangaro ** pulmonary surfactant** i roto i nga pukoro hau (alveoli), i te wa e kuhu ana te inflammatory exudate puta noa i te diaphragm maui ki te whakaki i te kohao o te uma maui ki te wai () Ko nga turoro pancreatic ka tupu ** te manawa tere (> 24 manawa/meneti), te poto o te manawa, te heke o te hau o te hāora kei te pakaru mai i te pulmonary capillary me te hiahia kia tere te tautoko i te manawa ICU.
3. Severe Acute Hypocalcemia ("Fat Saponification"): Pancreatic lipase keri ngako retroperitoneal ki nga waikawa ngako kore utu, ka herea te toto tohanga konupora ki te hanga hopi konupūmā ma (saponification ngako). Ko tenei heke ohorere i roto i te konupūmā toto ka paheke te uaua, te ngongo i te waha me nga maihao, nga tohu pai o Chvostek/Trousseau, me te arrhythmias ngakau.
4. Nga Tohu Kiri Hemorrhagic Retroperitoneal (Waitohu Cullen, Tohu Huri Kerei, me te Tohu Fox): I roto i nga hemorrhagic or necrotizing pancreatitis nui (ka puta i roto i te 1 ki te 3 paiheneti o nga keehi, ka puta mai i te 24 ki te 72 haora i muri mai i te tiimatanga me te pa ana ki te mate nui), te rere o te wai pancreatic kua pangia e te toto ma te rere o te kiri o te kiri ki te totone.
5. Waitohu Cullen: He maru puru-papura huri noa i te ** umbilicus (te puku)** (te whai toto i te taha o te whalciform ligament).
6. Waitohu Huri Kerei: He marumaru-papura, parauri ranei te maru i te taha maui me te taha matau i waenga i nga riu o raro me te koiwi hope.
7. Waitohu Pokiha: E maru ana te huha o runga o waho i raro iho o te inguinal ligament.

Ko te awhina tuatahi i mua i te hohipera me nga mea hei tumanako i roto i te tari ohorere¶

Te tiaki i mua i te hohipera i te wa e tatari ana ki te kawe¶

1. Whakamanahia te NPO tino (Kore kai, kore wai, kore wai o te waha): Ahakoa ka tono te turoro mo te wai i muri i te ruaki, kaua e tukua kia inu. Whakamahia he tauera hauhautanga, makuku hei muru i o ratou kanohi me o ratou ngutu, me horoi ranei o ratou waha ki te wai ka tuwha katoa.
2. ** Tautokohia te noho pai me te tiaki i te huarahi rererangi i te wa e ruaki ana:**
3. Mēnā kei te mataara te tūroro me te mamae nui o te pancreatic, waiho ** kia noho tika ki te anga whakamua** ma te awhi i te urunga ki runga i te puku, ka takoto ranei ki te taha maui me nga turi kua toia ki runga.
4. Kia mau ki te peeke emesis, peeke kirihou ranei i nga wa katoa kia kore ai e tu ki runga, e werohia ranei ina ruaki.
5. Mena kei roto te manawanui i te septic or hypovolemic shock (he koma, he werawera makariri, he mangere, he BP systolic i raro i te 90 mmHg, he rangirua ranei i Reynolds Pentad), whakatakotohia ki tona taha (turanga whakaora) kaua ki te noho tika kia mau te rere o te toto ki te roro i te tiaki i te huarahi rererangi mai i te ruaki.
6. ** Wewetehia nga kakahu kikii huri noa i te hope me te uma:** Wewetehia te patene tarau, wetewete i nga whitiki, me te wetewete i nga awhi piri e piri ana ki te epigastrium tetere me te aukati i te manawa diaphragmatic.
7. Whakaritea he whakarāpopototanga hauora 30-hekona mo nga rata ohorere: Kia rite ki te korero ki te roopu whakamatautau:
8. Mēnā he hītori o te tūroro e mōhiotia ana ** kōwhatu kawa**, tōmua biliary colic, ahakoa ** kei te mau tonu to ratou gallbladder** (whakatupato: ahakoa ko nga tangata kua tangohia o ratou gallbladder i nga tau ki muri ma te cholecystectomy ka taea tonu te whakawhanake ** kohatu ngongo ngongo noa tuatahi ranei me te cholangitis piki**).
9. Te inu waipiro tika i roto i nga haora 72 kua hipa, te hitori o te nui o te triglycerides, me te rarangi katoa o nga rongoa o ia ra.
10. Ahakoa e tango ana ratou i nga mahi whakaheke toto (anticoagulants penei i te apixaban, rivaroxaban, warfarin, clopidogrel ranei), me mohio nga taote i mua i te mahi i nga tikanga whawhati tata endoscopic bile duct (ERCP) me te whakaheke i te gallbladder percutaneous.

Me pehea nga tari ohorere ki te tirotiro me te rongoa i nga mate ohorere pancreaticobiliary¶

• Rapid Diagnostic Workup (Te "Atlanta Paearu" mo te Pancreatitis):
• Ka whakatauhia e nga taakuta panctitis acute ka tutuki i te iti rawa 2 o te 3 Paearu o Atlanta: (1) Ko te mamae o te epigastric e toro ana ki te tuara, (2) Serum lipase (amylase ranei) kua piki ake ki te 3 neke atu i te tepe o runga noa, me/ranei (3) Nga kitenga o te mumura pancreatic i runga i te CT, MRI, ultrasound ranei.
• Ka whakawhiwhia ano e ia turoro he Right Upper Quadrant Ultrasound (te whakamatautau tuatahi pai rawa atu ki te kite i nga kowhatu kowhatu, te matotoru o te pakitara gallbladder> 3 mm, te wai pericholecystic, te tohu Murphy sonographic, me te whakawhanuitanga o te whare nui noa> 6 ki te 8 mm), me te tatau toto katoa, te pae ate (bilirubin, AST, ALT, alkaline toto), hauota toto. (BUN), creatinine, konupūmā, me te triglycerides.
• Ko te Whakaora Whakaora Whakaora i roto i te Waa (Lactated Ringer Solution):
• I roto i te pancreatitis whakapeka, ko te whakamakuku i roto wawe me te Lactated Ringer solution (e whakaatuhia ana e nga whakamatautau haumanu he whakaiti ake i te mumura o te punaha me te waikawa hyperchloremic pai ake i te saline noa) ka whakahoki i te microcirculation pancreatic me te aukati i te necrosis pancreatic. Whai muri i te tohu tohu whakamatautau WATERFALL, ka whakamahia e nga aratohu hou te whakaora i te wai i roto i te toto, te whai whaainga (10 mL/kg bolus mena he hypovolemic, whai muri mai i te 1.5 mL/kg/haora kua tata ki te whakaputanga mimi>0.5 mL/kg/haora, ka hinga te BUN, me te hematocrit, me te karo i te taumahatanga o te wai ki te pumanawa).
• Ko te Paheketanga Pire Ohotata (ERCP) me te Cholecystectomy:
• Mo te Acute Ascending Cholangitis: Nga rongoa paturopi whaanui-a-whanui tonu (pēnei i te piperacillin-tazobactam, cefepime me te metronidazole, meropenem ranei) i roto i te 1 haora, ka whai muri mai i te **Endoscopic Retrograde Cholangiopancreatography (ERCP) me te endoscopic sphincterotomy me te tangohanga o te kowhatu tukunga o te kowhatu me te tangohanga o te kowhatu o te kowhatu. pana pehanga.
• Mo te Cholecystitis Acute: Nga patu paturopi uru me te te cholecystectomy laparoscopic moata (te tango pokanga o te gallbladder, he pai i te wa o te whakaurunga ki te hohipera kotahi i roto i te 24 ki te 72 haora, me te whakaheke i te ngongo cholecystostomy percutaneous ki te kore e tino pumau te manawanui mo te mate whaanui).
• Mo te Gallstone Pancreatitis: I te wa e tau ana te pancreatitis ngawari-ki-moderate i runga i te 48 ki te 72 haora, ka mahia e nga taote taakuhi te mahi laparoscopic cholecystectomy kotahi ano te whakaurutanga i mua i te hokinga atu o te manawanui ki te kainga, na te mea ka tukuna he turoro ma te kore e tango i te gallbladder ka pa he **25 ki te 30 paiheneti o te mate o te mate pancreatic i roto i nga wiki e 6 pea o te mate pukupuku o te rua o nga wiki.

He pehea te tere o nga hohipera: Aratohu Tokyo (TG18) me te Score BISAP¶

Ka tae koe ki te tari whawhati tata, ka whakamahia e nga taakuta nga punaha tohu haumanu e rua kua whakamanahia e te ao ki te whakatau mena ka hiahia koe ki te whakauru wawe ki te waahanga tiaki mate me te whakahekenga ohotata endoscopic/haparapara i roto i nga haora:

1. Tokyo Guidelines (TG18) te karaehe kino mo te Acute Ascending Cholangitis¶

2. Te Taurangi Taha Moenga mo te taumahatanga o te Pancreatitis Acute (Taka BISAP)¶

I nga haora 24 tuatahi o te whakaurunga ki te hōhipera mo te panctitis acute, ka tatauhia e nga taote ohorere te 5-ira BISAP Score (1 ira mo ia BUN>25 mg/dL, Iraruraru te mana hinengaro/poauau, Systemic Inflammatory Response Syndrome [SIRS], Age >60 tau, me te **P-raruraru i runga i te ultrasound). Ko nga turoro he BISAP 0 ki te 1 he iti iho i te 1 paiheneti te mate mate, engari ko te BISAP score o 3, 4, 5 ranei e tohu ana i nga turoro he nui te mate mo te rare tonu o te okana, pancreatic necrosis, me te mate nui atu i te 15 ki te 20 paiheneti, e whakaohooho ana i te hekenga tere ki tetahi waeine aroturuki.

Pātai auau¶

Kua tirohia nga puna¶

• Tokyo Guidelines (TG18): Tokyo Guidelines for the Management of Acute Cholangitis and Acute Cholecystitis (Acute Grading, Charcot Triad, me nga Paearu Whakaheke Kore Ake).
• American College of Gastroenterology (ACG, United States): ACG Clinical Guideline: Whakahaere o Acute Pancreatitis (2024 Update) me ASGE Guideline on the Role of Endoscopy in Choledocholithiasis and Cholangitis.
• World Society of Emergency Surgery (WSES): 2020 WSES Guidelines for the Detection and Management of Acute Calculous Cholecystitis me WES Guidelines for the Management of Severe Acute Pancreatitis.
• National Institute for Health and Care Excellence (NICE, United Kingdom): Gallstone Disease: Diagnosis and Management (CG188) and Pacreatitis (NG104).
• de-Madaria E, Buxbaum JL, et al. (WaTERFALL Trial Investigators, New England Journal of Medicine, 2022): Te Whakaoranga Wai Kaitariri, Tikanga Mo Te Pancreatitis Acute.

Nga kaiarahi e pa ana¶

• Te whakamohiotanga o te sepsis me te ru septic me te awhina tuatahi ohorere
• Ruhia te awhina tuatahi me te tuunga whakaheke toto
• Ko te mate ngakau me te mamae o te epigastric atypical
• Nga momo rerekee o te esophageal, cirrhosis, me nga mate ohorere
• Appendicitis whakapeka, apiti pakaru, me te haki whero peritonitis
• Ko nga nama ohorere ma te whenua