薄世宁,张淑文,王宝恩
首都医科大学附属北京友谊医院感染内科,北京100050
摘要:目的:观察大黄对于急性出血坏死性胰腺炎的治疗作用。方法:采用随机、对照研究方法,对37例出血坏死性胰腺炎患者(大黄组20例、对照组17例)进行了腹痛持续时间、住院日、高淀粉酶血症持续时间、内毒素、肿瘤坏死因子-α(TNF-α)水平、并发症的发生率、病死率的检测和分析,以评价中药大黄对于急性出血坏死性胰腺炎的治疗作用。结果:大黄组胃肠衰竭的发生率(35.0%比70.6%,P<0
05)及持续时间<(2.25±1.48)d比(3.91±1.37)d,P<0.05)、腹痛持续时间<(4
85±2.28)d比(6.82±2.
27)d,P<0.05)较对照组明显缩短。平均住院日显著短于对照组<(25.90±15.04)d比(36.71±16.79)d,P<0.05)。呼吸衰竭的发生率2组未见明显差异(35.0%比35.3%,P>0.05),但进一步观察表明,大黄组有助于纠正呼吸功能受损患者的低氧血症,低氧血症持续时间显著低于对照组<(5.88±2.03)d比(9.00±2.92)d,P<0.05)。继发感染的发生率显著低于对照组(10,0%比41.2%,P<0.05)。血内毒素水平大责组低于对照组<(0.16±0.13)kEU/L比(0.47±0.27)kEU/L,P<0.05)。2组患者高淀粉酶血症持续时间、TNF-α水平以及肾脏功能衰竭、循环衰竭、肝脏功能衰竭、中枢神经系统功能衰竭、弥散性血管内凝血、低钙血症、高血糖、胰腺假性囊肿等并发症的发病率无显著性差异。大黄组病死率低于对照组,但无显著性差异(20.0%比29.5%,P>0.05)。结论:在常规西医药脏器功能支持的基础上加用大黄治疗急性出血坏死性胰腺炎,具有较好的效果。
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关键词:胰腺炎;急性;出血坏死;大黄;中医药
自1890年胰腺炎被首次描述至今,临床上仍无确切的降低病死率的治疗措施。尤其是急性出血坏死性胰腺炎(acute
hemorrhagic necrotic
pancreatitis,AHNP),由于其病情笃重,常并发多脏器功能不全/多脏器衰竭,死亡率居高不下。探讨出血坏死性胰腺炎的治疗问题,进一步降低其病死率,一直是近年来急救医学领域研究的重点和难点之一,通腑法是中医治疗法则之一,我科多年来将其用于治疗出血坏死性胰腺炎,以大黄为通腑法的代表药物。通过临床观察得出,其具有缓解腹痛快,退热、解毒、通腑疗效好等特点<1>。为进一步研究大黄在出血坏死性胰腺炎治疗中的作用,进行本临床研究,报告如下。
1 资料与方法
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1.显研究对象:①纳入标准:1998年1月~2000年3月,所有人住我科的急性出血坏死性胰腺炎患者。诊断按文献<2>标准。除外标准:年龄<18岁;妊娠、哺乳期妇女;入院前昏迷者;入院48小时内死亡者;治疗期间自动转院、出院、放弃治疗者。
1.2研究分组:所有人选患者随机分为2组:①大黄组(A组,20例):在西医药治疗基础上加用大黄治疗。用生大黄
30 g,水煎成 200
ml溶液(水煎15分钟),每日分2次口服。行胃肠减压者在服用中药前夹闭胃管,持续1~2小时。②对照组(B组,17例):仅给予常规西医治疗,包括:禁食,补液,静脉营养支持,各组织器官的支持治疗,静脉预防性应用广谱抗生素,纠正水、电解质、酸碱平衡紊乱,抗胰腺外分泌治疗(善得定0.1mg,皮下注射,每日
3次)。2组患者在数量、年龄、性别、病因学诊断和入院 24小时病情严重度评分(采用
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APACHE血评分标准)上无显著性差异,具有可比性。见表1。
1.3观测指标:腹痛持续时间;住院日;并发症的发生率;高淀粉酶血症持续时间;入院后第24小时血内毒素;入院后第24小时血肿瘤坏死因子-α(TNF-α);病死率。
1.4统计学方法:计量资料采用均值±标准差(平均X±S)表示,采用t检验;2组计数资料对比用/检验。采用SPSS9.0软件进行统计学分析。
2结果
2.1
A组腹痛持续时间、肠鸣音减弱或消失时间、平均住院日较西药治疗组明显缩短;血中内毒素水平A组低于B组;2组患者在高淀粉酶血症持续时间、TNF-α浓度(入院后第24
小时A组有7例、B组有5例增高)和病死率(A组为20.0%,B组为29.5%)无显著性差异。见表2。
2.2
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A组胃肠道功能不全或衰竭的发生率显著低于B组。其余指标的发生率2组间比较无显著性差异。进一步观察表明,A组较B组可显著缩短胃肠功能不全或衰竭的持续时间,有助于纠正低氧血症,低氧血症持续时间<(5.88±2.03)d>显著低于单纯西医药治疗B组<(9.00±2.92)d,P<0.05)>。另外,A组败血症、胰腺和胰周脓肿等继发感染的发生率明显低于B组。见表3。
表1 患者一般情况统计表
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B
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">组
| , 百拇医药
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 47.35pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
vAlign=top width=63>
lang=EN-US>17
| , http://www.100md.com
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 47.35pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
vAlign=top width=63>
lang=EN-US>9
| , 百拇医药
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 47.35pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
vAlign=top width=63>
lang=EN-US>8
| , 百拇医药
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 47.35pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
vAlign=top width=63>
51
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">(, http://www.100md.com
lang=EN-US>22~74
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">)
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 47.35pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
, 百拇医药
vAlign=top width=63>
lang=EN-US>11
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 47.35pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
, 百拇医药
vAlign=top width=63>
lang=EN-US>0
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 47.35pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
, http://www.100md.com
vAlign=top width=63>
lang=EN-US>6
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 47.35pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
, 百拇医药
vAlign=top width=63>
lang=EN-US>13.9
表2 2组观测指标比较(x±s)
style="BORDER-BOTTOM: medium none; BORDER-COLLAPSE: collapse; BORDER-LEFT: medium none; BORDER-RIGHT: medium none; BORDER-TOP: medium none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt"
, http://www.100md.com
width="98%"> |
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: windowtext 0.5pt solid; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: windowtext 0.5pt solid; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 57.75pt"
vAlign=top width=77>
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">组别
| , 百拇医药
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: windowtext 0.5pt solid; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 59.25pt; mso-border-left-alt: solid windowtext .5pt"
vAlign=top width=79>
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">腹痛持续时间(, http://www.100md.com
lang=EN-US>d
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">)
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: windowtext 0.5pt solid; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 59.2pt; mso-border-left-alt: solid windowtext .5pt"
, 百拇医药
vAlign=top width=79>
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">平均住院日(
lang=EN-US>d
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">)
|
, http://www.100md.com
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: windowtext 0.5pt solid; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 59.2pt; mso-border-left-alt: solid windowtext .5pt"
vAlign=top width=79>
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">高淀粉酶血症持续时间(, http://www.100md.com
lang=EN-US>d
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">)
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: windowtext 0.5pt solid; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 59.25pt; mso-border-left-alt: solid windowtext .5pt"
, http://www.100md.com
vAlign=top width=79>
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">肠鸣音减弱或消失时间(
lang=EN-US>d
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">)
| , 百拇医药
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: windowtext 0.5pt solid; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 70.05pt; mso-border-left-alt: solid windowtext .5pt"
vAlign=top width=93>
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">内毒素浓度(, 百拇医药
lang=EN-US>Keu/L
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">)
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: windowtext 0.5pt solid; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 61.4pt; mso-border-left-alt: solid windowtext .5pt"
, 百拇医药
vAlign=top width=82>
lang=EN-US>TNF-
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">α浓度(
lang=EN-US>ng/L
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">)
| , 百拇医药
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: windowtext 0.5pt solid; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 57.75pt; mso-border-top-alt: solid windowtext .5pt"
vAlign=top width=77>
A
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">组
| , http://www.100md.com
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 59.25pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
vAlign=top width=79>
lang=EN-US>4.85, 百拇医药
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">±
lang=EN-US>2.28*
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 59.2pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
, 百拇医药
vAlign=top width=79>
lang=EN-US>25.90
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">±
lang=EN-US>15.04*
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 59.2pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
, http://www.100md.com
vAlign=top width=79>
lang=EN-US>2.30
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">±
lang=EN-US>1.21
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 59.25pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
, 百拇医药
vAlign=top width=79>
lang=EN-US>2.25
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">±
lang=EN-US>1.48*
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 70.05pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
, 百拇医药
vAlign=top width=93>
lang=EN-US>0.16
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">±
lang=EN-US>0.13*
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 61.4pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
, http://www.100md.com
vAlign=top width=82>
lang=EN-US>9.50
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">±
lang=EN-US>3.24
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: windowtext 0.5pt solid; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 57.75pt; mso-border-top-alt: solid windowtext .5pt"
, 百拇医药
vAlign=top width=77>
B
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">组
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 59.25pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
, http://www.100md.com
vAlign=top width=79>
lang=EN-US>6.82
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">±
lang=EN-US>2.27
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 59.2pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
, 百拇医药
vAlign=top width=79>
lang=EN-US>36.71
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">±
lang=EN-US>16.79
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 59.2pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
, 百拇医药
vAlign=top width=79>
lang=EN-US>3.00
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">±
lang=EN-US>1.84
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 59.25pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
, http://www.100md.com
vAlign=top width=79>
lang=EN-US>3.91
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">±
lang=EN-US>1.37
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 70.05pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
, 百拇医药
vAlign=top width=93>
lang=EN-US>0.47
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">±
lang=EN-US>0.27
|
style="BORDER-BOTTOM: windowtext 0.5pt solid; BORDER-LEFT: medium none; BORDER-RIGHT: windowtext 0.5pt solid; BORDER-TOP: medium none; PADDING-BOTTOM: 0cm; PADDING-LEFT: 5.4pt; PADDING-RIGHT: 5.4pt; PADDING-TOP: 0cm; WIDTH: 61.4pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt"
, 百拇医药
vAlign=top width=82>
lang=EN-US>8.94
style="FONT-FAMILY: 宋体; mso-ascii-font-family: 'Times New Roman'; mso-hansi-font-family: 'Times New Roman'">±
lang=EN-US>3.17
表3 2组合并症发生率比较
, 百拇医药
width="98%">
style="FONT-FAMILY: 宋体; Times: ">组别
|
style="FONT-FAMILY: 宋体; Times: ">胃肠
style="FONT-FAMILY: 宋体; Times: ">功能衰竭
| , 百拇医药
style="FONT-FAMILY: 宋体; Times: ">呼吸功能衰竭
|
style="FONT-FAMILY: 宋体; Times: ">肾脏功能
style="FONT-FAMILY: 宋体; Times: ">衰竭
| , 百拇医药
style="FONT-FAMILY: 宋体; Times: ">循环衰竭
|
style="FONT-FAMILY: 宋体; Times: ">肝脏功能衰
style="FONT-FAMILY: 宋体; Times: ">竭
| , 百拇医药
style="FONT-FAMILY: 宋体; Times: ">中枢神经系统功能衰竭
|
style="FONT-FAMILY: 宋体; Times: ">弥散性血管内凝血
|
, 百拇医药
style="FONT-FAMILY: 宋体; Times: ">败血症、胰周和胰腺脓肿 |
style="FONT-FAMILY: 宋体; Times: ">低钙血症
|
style="FONT-FAMILY: 宋体; Times: ">高血糖
| , http://www.100md.com
style="FONT-FAMILY: 宋体; Times: ">胰腺假性囊肿
|
lang=EN-US>A
style="FONT-FAMILY: 宋体; Times: ">组
|
, 百拇医药
lang=EN-US>7(35.0)* |
lang=EN-US>7(35.0)
|
lang=EN-US>6(30.0)
|
, 百拇医药
lang=EN-US>5(25.0) |
lang=EN-US>1(5.0)
|
lang=EN-US>1(5.0)
|
, http://www.100md.com
lang=EN-US>4(20.0) |
lang=EN-US>2(10.0)*
|
lang=EN-US>3(15.0)
|
, 百拇医药
lang=EN-US>4(20.0) |
lang=EN-US>9(45.0)
|
lang=EN-US>B
style="FONT-FAMILY: 宋体; Times: ">组
| , 百拇医药
lang=EN-US>12(70.6)
|
lang=EN-US>6(35.3)
|
lang=EN-US>7(41.2)
| , http://www.100md.com
lang=EN-US>3(17.6)
|
lang=EN-US>1(5.9)
|
lang=EN-US>0(0)
| , 百拇医药
lang=EN-US>5(29.4)
|
lang=EN-US>7(41.2)
|
lang=EN-US>4(23.5)
| , http://www.100md.com
lang=EN-US>2(11.8)
|
lang=EN-US>10(58.8)
|
3讨论
出血坏死性胰腺炎时,由于机体大量释放各种炎症因子并形成“瀑布”效应,作用于全身各组织器官,引发多脏器衰竭,这也是出血坏死性胰腺炎病死率居高不下的根本原因之一。本研究表明,在各脏器中,胃肠道最易受损(19/37,51.4%)。其发生与出血坏死性胰腺炎时胃肠道供血减少、缺血一再灌注损伤、细菌移位、胃肠道粘膜细胞屏障功能受损等诸多因素相关。另外,本研究亦发现,出血坏死性胰腺炎患者血内毒素水平升高,而内毒素可作用干胃肠道阿片受体,减弱胃肠道推进蠕动能力。
胃肠衰竭多表现为麻痹性肠梗阻或胃肠道出血。中医证型为“腑气不通”,治则为通腑攻下,大黄为其主药。本研究大黄组患者入院后即用大黄,可明显减少胃肠道衰竭发生率及其持续时间,改善患者腹痛症状,这与我们既往研究相一致<1,3>。其机制可能为:1)大黄可增加胃肠道平滑肌细胞电活动;2)减轻细菌移位的发生;3)明显降低血内毒素水平<4>。
重症急性胰腺炎患者死亡与继发感染密切相关。胰腺脓肿患者,均先存有胰腺或胰周组织的坏死<5>。胰腺脓肿的形成与以下因素有关;1)坏死组织是病原菌理想的培养基;2)胰腺血管内微血栓形成引起血供障碍;3)肠道细菌移位<6>;4)机体患病时免疫力减弱。所有这些均参与了胰腺、胰周脓肿及其它部位感染的发生。因此,近年来提出预防性应用抗生素的观点,应用于临床并取得了一定的疗效。本研究表明大黄的应用可进一步减少胰腺、胰周脓肿、败血症的发生率。其可能机制之一为大黄可明显改善胃肠道功能紊乱,减少了肠道细菌移位的发生。国外报道亦发现胰腺感染的主要病原菌为肠源性<7>,这说明了减轻细菌移位对于出血坏死性胰腺炎患者防治感染具有较重要的作用。 另有研究表明:大黄可提高中性粒细胞吞噬功能和血清总补体水平,提高了机体的免疫力;具有一定程度的抑菌作用及对抗内毒素作用<1,.3>。这些可能亦是大黄降低继发感染发生率的作用机制。
大黄治疗组患者与对照组相比较,呼吸功能受损的发生率无显著差异,但低氧血症持续时间明显短于对照组,其具体作用机制有待进一步探讨。
应用大黄组在高淀粉酶血症持续时间、低血钙、高血糖、胰腺假性囊肿的形成,肾功能衰竭、中枢神经系统功能衰竭、肝功能障碍的发生率等方面同对照组相比未见明显差异。
TNF-α是由巨噬细胞产生的17
, 百拇医药
ku的蛋白质物质。静注TNF-α可引起与革兰氏阴性杆菌相同的中毒综合征。国外有研究表明,TNF-α可在一定程度上反映出血坏死性胰腺炎患者病情严重度和合并症的发生<8>。本研究中约1/3患者在入院24小时可检测到TNF-α明显增高。但未观测到2组具有明显差异。
大黄治疗患者的平均住院日短于对照组,这可能是由于大黄的多种作用,如降低败血症、胰腺脓肿的发生,提高机体免疫力,有助于纠正低氧血症,减少了胃肠衰竭的持续时间等因素的综合作用相关,患者平均住院日减少,无疑可在一定程度上节省住院费用。
尽管2组患者在病死率上无显著性差异,但大黄治疗组病死率确低于对照组。统计学上未见显著意义可能与样本含量相关,还需进一步扩大研究样本数量以期证实。
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