急性胰腺炎評(píng)分系統(tǒng)的應(yīng)用及研究進(jìn)展

張映媛，黃 華

昆明醫(yī)科大學(xué)第二附屬醫(yī)院消化內(nèi)科，云南 昆明 650000

急性胰腺炎評(píng)分系統(tǒng)的應(yīng)用及研究進(jìn)展

張映媛，黃 華

昆明醫(yī)科大學(xué)第二附屬醫(yī)院消化內(nèi)科，云南 昆明 650000

急性胰腺炎(acute pancreatitis， AP)是常見消化系統(tǒng)急重癥之一。20%～30%會(huì)發(fā)展為急性重癥胰腺炎(severe acute pancreatitis，SAP)，其病情兇險(xiǎn)、并發(fā)癥多、預(yù)后差。早期進(jìn)行評(píng)估及合理治療，能大大降低并發(fā)癥及病死率，節(jié)約醫(yī)療資源，減少住院費(fèi)用，對(duì)AP患者診治及預(yù)后有重要意義。目前國(guó)內(nèi)外常用的Ranson、APACHEⅡ、CTSI評(píng)分系統(tǒng)，及近年有學(xué)者提出的PANC-3、JSS、HAPS、POP等評(píng)分系統(tǒng)，各有利弊。本文對(duì)現(xiàn)有的AP評(píng)分系統(tǒng)及近年來(lái)的研究進(jìn)展作一概述。

急性胰腺炎；評(píng)分系統(tǒng)；嚴(yán)重程度；預(yù)后

急性胰腺炎(acute pancreatitis，AP)是指多種病因引起的胰酶激活，以胰腺局部炎癥反應(yīng)為主要特征，伴或不伴其他臟器功能障礙或代謝紊亂的疾病，是常見消化系統(tǒng)急重癥之一。根據(jù)2012年亞特蘭大國(guó)際共識(shí)修訂分類，臨床上分為輕度AP(mild acute pancreatitis，MAP)、中度AP(moderately severe acute pancreatitis，MSAP)和重度AP(severe acute pancreatitis，SAP)[1-2]。MAP一般病情較輕，多呈自限性，通常在1～2周內(nèi)恢復(fù)。SAP占AP的20%～30%，常伴器官功能衰竭和(或)胰腺局部并發(fā)癥，病情兇險(xiǎn)、預(yù)后差，病死率為36%～50%[3]。隨著研究不斷深入，目前國(guó)內(nèi)外常用評(píng)分和近年來(lái)有學(xué)者新提出新型評(píng)分系統(tǒng)在SAP診治方面取得巨大進(jìn)展。

1 國(guó)內(nèi)外常用臨床評(píng)分系統(tǒng)

1.1 Ranson評(píng)分 Ranson評(píng)分于1974年由Ranson等[4]提出，包括入院時(shí)5項(xiàng)指標(biāo)和48 h 6項(xiàng)指標(biāo)，能反映AP局部病變、全身炎性反應(yīng)及第三間隙丟失情況，評(píng)分≥3分提示SAP。Valverde-Lpez等[5]發(fā)現(xiàn)Ranson評(píng)分對(duì)判斷SAP病死率的敏感度約82%，在預(yù)測(cè)持續(xù)器官功能衰竭和病死率方面具有較高的準(zhǔn)確性。但該評(píng)分也有其缺點(diǎn)：所含指標(biāo)過多，操作繁瑣，需進(jìn)行二次評(píng)估，缺乏動(dòng)態(tài)性和連續(xù)性，不能在急診科發(fā)揮時(shí)效性[6]。盡管如此，Ranson評(píng)分仍是國(guó)內(nèi)外和大多數(shù)指南推薦的常用評(píng)分標(biāo)準(zhǔn)?；谠撛u(píng)分系統(tǒng)，也衍生出如APACHEⅡ、Balthazar CT、Glasgow等其他評(píng)分。

1.2 APACHE Ⅱ評(píng)分 急性生理和慢性健康狀況評(píng)分(acute physiology and chronic health evaluation Ⅱ，APACHE Ⅱ)由Knaus等[7]于1981年提出，經(jīng)修改，目前有APACHEⅡ、APACHE Ⅲ及APACHE O評(píng)分，但仍以APACHEⅡ應(yīng)用最多，由急性生理指數(shù)、年齡指數(shù)和慢性健康指數(shù)三部分構(gòu)成，評(píng)分≥8分提示SAP。評(píng)分>15分，高度懷疑AP合并深部真菌感染；評(píng)分≥12分時(shí)，院內(nèi)病死率極高[8]。Yang等[9]發(fā)現(xiàn)該評(píng)分能準(zhǔn)確判斷高脂血癥性胰腺炎(hyperlipidemic pancreatitis，HLAP)。在一項(xiàng)低血壓聯(lián)合APACHE Ⅱ評(píng)分診斷SAP的研究中發(fā)現(xiàn)，APACHE Ⅱ預(yù)測(cè)胰腺壞死的對(duì)比值高達(dá)4.77[10]。APACHEⅡ評(píng)分客觀全面，不受時(shí)間限制，可動(dòng)態(tài)監(jiān)測(cè)SAP多器官受累情況。該評(píng)分側(cè)重于全身并發(fā)癥的演變，對(duì)局部并發(fā)癥預(yù)測(cè)能力較弱；且指標(biāo)較為繁瑣，無(wú)法及時(shí)提供所需內(nèi)容，容易造成誤差。

1.3 CTSI評(píng)分 CT嚴(yán)重程度指數(shù)評(píng)分(computed tomography severity index，CTSI)由Balthazar等[11]在1985年首先提出Balthazar CT分級(jí)，為提高對(duì)SAP預(yù)測(cè)，1990年將Balthazar CT分級(jí)與胰腺自身壞死聯(lián)系起來(lái)，提出CTSI評(píng)分，當(dāng)評(píng)分≥4分提示SAP。2004年Mortele等對(duì)該評(píng)分進(jìn)行修改、形成了簡(jiǎn)化CTSI評(píng)分(modified computed tomography severity index，MCTSI)，其更能反映胰腺外并發(fā)癥(胸腔積液、腹水、胃腸道侵犯等)，MCTSI>8分提示SAP。Karag?z等[12]發(fā)現(xiàn)，增強(qiáng)CT聯(lián)合MCTSI評(píng)分能更加準(zhǔn)確地診斷需要入住ICU的AP患者。但使用造影劑檢查可能加重病情，造影劑過敏或合并腎功能不全者為禁忌證；胰周壞死和假性囊腫形成多數(shù)不在AP發(fā)病初期，評(píng)估需要在入院后2～3 d，不利于SAP的早期判斷[13]。但作為國(guó)際常用評(píng)分，CTSI評(píng)分對(duì)AP局部并發(fā)癥發(fā)生率及病死率的預(yù)測(cè)仍有不可替代的價(jià)值。

1.4 Glasgow(Imrie)評(píng)分 Glasgow評(píng)分于1978年由Imrie等[14]提出，經(jīng)過兩次修改，也稱Imrie標(biāo)準(zhǔn)。包括年齡、白細(xì)胞計(jì)數(shù)、血糖、血尿素氮(BUN)、動(dòng)脈氧分壓、血鈣、白蛋白、乳酸脫氫酶8項(xiàng)參數(shù)構(gòu)成，入院48 h評(píng)分>3分是判斷SAP的有效閾值，多用于酒精或膽石所致AP的評(píng)估。Glasgow評(píng)分較Ranson評(píng)分有較高特異度和陽(yáng)性預(yù)測(cè)值[15]，它繼承了Ranson評(píng)分的優(yōu)點(diǎn)，同時(shí)評(píng)估所需指標(biāo)減少，增強(qiáng)了可行性；缺點(diǎn)是仍需入院48 h進(jìn)行評(píng)估，具有一定滯后性。

1.5 BISAP評(píng)分 嚴(yán)重程度床邊指數(shù)(bedside index for severity in acute pancreatitis，BISAP)由Wu等[16]于2008年提出，包括BUN、精神神經(jīng)狀態(tài)異常、全身炎癥反應(yīng)綜合征、年齡和胸腔積液5項(xiàng)指標(biāo)，評(píng)分≥3分提示SAP及病死率風(fēng)險(xiǎn)明顯升高。Yang等[17]在一項(xiàng)Meta分析中發(fā)現(xiàn)，BISAP評(píng)分靈敏度較低，但用于評(píng)估SAP嚴(yán)重程度其特異度則高達(dá)83.62%。BISAP評(píng)分是一種簡(jiǎn)易、及時(shí)、全面的評(píng)分[18]，無(wú)論在準(zhǔn)確性、時(shí)效性，還是在早期識(shí)別院內(nèi)病死率風(fēng)險(xiǎn)性方面優(yōu)勢(shì)都尤為突出。

2 其他評(píng)分系統(tǒng)

2.1 PANC-3評(píng)分 PANC-3評(píng)分是2007年由Brown等[19]提出。評(píng)分包括3個(gè)SAP危險(xiǎn)因子：(1)血清紅細(xì)胞比積(HCT)>44 mg/dl；(2)體質(zhì)量指數(shù)(BMI)>30 mg/kg；(3)胸片提示胸腔積液。SAP早期胰酶和炎性介質(zhì)使毛細(xì)血管通透性增加，出現(xiàn)全身毛細(xì)血管滲漏綜合征(CLS)，血漿外滲透至第三間隙，HCT能及時(shí)反映微循環(huán)障礙及血液濃縮。有研究表明，入院24 h內(nèi)HCT≥44%對(duì)預(yù)測(cè)持續(xù)性器官衰竭和胰腺壞死的AUC值分別為0.67和0.66，明顯優(yōu)于其他實(shí)驗(yàn)室指標(biāo)和APACHE Ⅱ評(píng)分；HCT<44者，能肯定無(wú)胰腺壞死，且48 h后其預(yù)測(cè)價(jià)值無(wú)明顯差異[20]。在炎性介質(zhì)介導(dǎo)下，將富含胰酶的液體輸送至縱隔淋巴叢及胸膜下間隙，加重膈肌炎癥并形成滲出性積液[21]，作為SAP的獨(dú)立危險(xiǎn)因子，胸腔積液也同樣被納入BISAP、MCTSI、PANC-3、EPIC評(píng)分中。隨著肥胖人群逐年增加，BMI對(duì)AP的預(yù)測(cè)價(jià)值日益受到關(guān)注。AP合并肥胖者，大量炎癥介質(zhì)和游離脂肪酸，損傷胰腺微循環(huán)造成胰腺出血壞死，BMI超標(biāo)者發(fā)展成為SAP的速度快且預(yù)后差。Kumaravel等[22]利用淀粉酶結(jié)合BMI，提出了新的計(jì)算比值比公式模型以確定AP損傷壞死。

一項(xiàng)對(duì)65例患者的前瞻性研究發(fā)現(xiàn)，PANC-3評(píng)分對(duì)評(píng)估SAP的靈敏度31.25%，特異度100%，陽(yáng)性預(yù)測(cè)值100%，陰性預(yù)測(cè)值81.66%，準(zhǔn)確度83.07%，且與Ranson評(píng)分有較好的相關(guān)性[23]。Beduschi等[24]在最新研究中指出，PANC-3評(píng)分中變量胸腔積液為最重要的預(yù)測(cè)因子，這不同于最初的研究(紅細(xì)胞比積是一個(gè)更強(qiáng)的預(yù)測(cè)，胸腔積液和BMI只是表示一種病情演變趨勢(shì))，該研究強(qiáng)化了先前描述的事實(shí)，還提出該評(píng)分與住院時(shí)間也有一定相關(guān)性。總之，PANC-3評(píng)分系統(tǒng)能迅速評(píng)估并分流疑似有發(fā)展為SAP危險(xiǎn)因素的患者，將其轉(zhuǎn)至重癥監(jiān)護(hù)病房，有利于在72 h范圍內(nèi)的干預(yù)和管理，是一種極為簡(jiǎn)單又能夠準(zhǔn)確評(píng)估SAP嚴(yán)重程度及預(yù)后的新型評(píng)分。

2.2 JSS評(píng)分 日本嚴(yán)重度評(píng)分(Japanese severe score，JSS)由5項(xiàng)臨床征象(休克、呼吸衰竭、神志錯(cuò)亂、嚴(yán)重感染、出血體質(zhì))、10項(xiàng)血試驗(yàn)(BE、Ht、BUN、血鈣、血糖、PaO2、LDH、總蛋白、凝血酶原時(shí)間、血小板計(jì)數(shù))、CT分級(jí)Ⅳ或Ⅴ、SIRS評(píng)分≥3和年齡(≥70歲)作為評(píng)分指標(biāo)[25]。AP在入院第1個(gè)48 h內(nèi)持續(xù)發(fā)生SIRS的病死率明顯高于短暫發(fā)生SIRS者或未發(fā)生SIRS者；故JSS評(píng)分納入了SIRS標(biāo)準(zhǔn)，全面綜合考慮了器官衰竭及CT影像學(xué)改變。當(dāng)JSS評(píng)分≥4分，給予腸內(nèi)營(yíng)養(yǎng)可顯著減少AP的病死率[26]。在對(duì)17 091例患者研究發(fā)現(xiàn)，該評(píng)分中9大預(yù)后因子對(duì)AP的多器官衰竭發(fā)生率及院內(nèi)病死率方面準(zhǔn)確性高達(dá)0.798[27]。但JSS評(píng)分項(xiàng)目多，操作復(fù)雜，故臨床使用受到限制。

2.3 HAPS評(píng)分 無(wú)害性急性胰腺炎評(píng)分(harmless acute pancreatitis score，HAPS)是由Lankisch等[28]于2009年提出的一種簡(jiǎn)單、快速、可行性強(qiáng)的新型評(píng)分。它包括：(1)無(wú)反跳痛和肌緊張；(2)血細(xì)胞比積正常(異常：男性>43 mg/dl，女性>39.6 mg/dl)；(3)血肌酐正常(異常：>177 mmol/L)。若3項(xiàng)均無(wú)異常視為無(wú)害，即為MAP，用于快速鑒別MAP與SAP。該評(píng)分對(duì)評(píng)估入住重癥監(jiān)護(hù)病房、住院時(shí)間、并發(fā)癥、醫(yī)院感染、住院病死率上有一定優(yōu)勢(shì)[29-30]。與其他評(píng)分最大的區(qū)別在于：它能準(zhǔn)確預(yù)測(cè)出不會(huì)發(fā)展為SAP的患者，及時(shí)分類干預(yù)治療，對(duì)AP的簡(jiǎn)易評(píng)估和急診出院的硬性指標(biāo)有一定臨床意義。

2.4 POP評(píng)分 胰腺炎結(jié)局預(yù)測(cè)評(píng)分系統(tǒng)(pancreatitis outcome prediction，POP)是2007年由Harrison等[31]提出，包含血pH值、年齡、BUN、平均動(dòng)脈壓、氧和指數(shù)和血清鈣6項(xiàng)參數(shù)，評(píng)分>10提示SAP。當(dāng)評(píng)分≥14分時(shí)對(duì)病死率的敏感度為90%，特異度為92%，明顯優(yōu)于其他評(píng)分[32]。其中BUN作為蛋白質(zhì)的代謝產(chǎn)物，SAP發(fā)生時(shí)，組織液進(jìn)入第3間隙，導(dǎo)致腎灌注不足，BUN可反映體內(nèi)低血容量和高分解狀態(tài)。入院時(shí)BUN升高(>20 mg/dl)或24 h內(nèi)仍有上升趨勢(shì)，可直接作為評(píng)估SAP的最優(yōu)預(yù)測(cè)因子[33]。在Glasgow、Ranson、BISAP、JSS、POP、SPS評(píng)分的參數(shù)中都有BUN，可見其在SAP的評(píng)估中占有重要地位。

2.5 MEWS評(píng)分 改良早期預(yù)警評(píng)分(modified early warning score，MEWS)最早由Morgan等提出，后經(jīng)Subbe等[34]修改，形成新的MEWS評(píng)分，從心率、收縮壓、呼吸頻率、體溫和意識(shí)5個(gè)方面評(píng)估，入院72 h內(nèi)評(píng)分>3分，提示SAP死亡風(fēng)險(xiǎn)高。MEWS評(píng)分方便、及時(shí)、可行性強(qiáng)、可靠性高，是一種簡(jiǎn)單的床邊生理評(píng)分，對(duì)器官衰竭預(yù)測(cè)敏感性及特異性較強(qiáng)，特別是發(fā)病后第2、3天[35]。但目前針對(duì)該評(píng)分的相關(guān)研究較少，在對(duì)SAP的判斷上還有待進(jìn)一步證實(shí)。

2.6 EPIC評(píng)分 Kaya等[36]認(rèn)為，某些AP患者在發(fā)生胰腺壞死以前就已出現(xiàn)全身并發(fā)癥，其嚴(yán)重程度超過了影像學(xué)的判斷，CTSI評(píng)分與胰腺外并發(fā)癥無(wú)明顯相關(guān)性；且入院后48 h不宜再行增強(qiáng)CT檢查?；谏鲜鯟TSI評(píng)分不足之處，2007年De Waele等[37]提出了胰腺外炎癥CT評(píng)分(extra pancreatic inflammation on CT score，EPIC)，通過觀察胸水、腹水、腹膜后炎癥及腸系膜炎癥的腹部CT表現(xiàn)，更好預(yù)測(cè)胰腺外并發(fā)癥，當(dāng)EPIC≥4分時(shí)，診斷SAP的敏感度及特異度為100%和70.8%。該評(píng)分在預(yù)測(cè)SAP病死率及合并急性腎衰竭、感染性休克方面較先前的影像學(xué)評(píng)分更有價(jià)值[38]。其最大優(yōu)點(diǎn)在于不需行增強(qiáng)CT，避免了使用造影劑所造成的腎毒性，加重SAP病情。

2.7 SPS評(píng)分 簡(jiǎn)易評(píng)分系統(tǒng)(simple prognostic score，SPS)由Ueda等[39]于2007年提出，評(píng)分包括BUN≥25 mg/dl，乳酸脫氫酶≥900 IU/L，CT提示胰腺壞死3個(gè)指標(biāo)。入院時(shí)這3個(gè)因素以0～3分來(lái)記分，通過比較SPS、Ranson、APACHEⅡ及Glasgow評(píng)分在ROC曲線下面積(AUC)分別為0.83、0.83、0.81及0.75，認(rèn)為SAP患者使用SPS評(píng)分保持較高陽(yáng)性分值，達(dá)2～6 d，是預(yù)測(cè)AP 嚴(yán)重程度較為方便、簡(jiǎn)單的評(píng)分系統(tǒng)，目前同JSS評(píng)分一樣已在日本臨床中得到廣泛運(yùn)用[40]。

AP病情變化復(fù)雜，進(jìn)展迅速，既有局部病變又涉及全身多個(gè)系統(tǒng)。隨著研究不斷深入，將生理指標(biāo)、血液生化、影像學(xué)檢查相結(jié)合，新型評(píng)分系統(tǒng)的建立在SAP診治上都取得巨大進(jìn)展。最理想的評(píng)分系統(tǒng)應(yīng)具有指標(biāo)構(gòu)成簡(jiǎn)單、操作性強(qiáng)、能節(jié)約醫(yī)療資源，減少住院費(fèi)用，可被大多數(shù)醫(yī)院推廣實(shí)施等特點(diǎn)。但目前尚無(wú)任何單一評(píng)分系統(tǒng)能夠覆蓋AP診治的全過程，對(duì)其作出準(zhǔn)確的判斷[41-42]。因此，我們只有將各個(gè)評(píng)分系統(tǒng)聯(lián)合起來(lái)，及時(shí)準(zhǔn)確地評(píng)估病情，指導(dǎo)臨床采取合理治療措施，才能提高AP治愈率、降低病死率、改善預(yù)后。

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(責(zé)任編輯：李 健)

Application and research progress of scoring systems of acute pancreatitis

ZHANG Yingyuan, HUANG Hua

Department of Gastroenterology, the Second Affiliated Hospital of Kunming Medical University, Kunming 650000, China

Acute pancreatitis (AP) is one of the acute diseases in digestive system. About 20%～30% of all AP cases will transform into severe acute pancreatitis (SAP) with its dangerous condition, more complications and poor prognosis. Early assessment and providing reasonable treatment, can greatly reduce the complications and mortality, save the medical resources, reduce the cost of hospitalization and may have a great significance to the diagnosis, treatment and prognosis of AP patients. At present, the commonly used at home and abroad Ranson, APACHEⅡ, CTSI scoring systems, as well as PANC-3, JSS, HAPS, POP and other scoring systems in recent years, each has its pros and cons. This article will introduce the existing AP scoring systems and discuss recent research progress in review.

Acute pancreatitis; Scoring systems; Severity; Prognosis

10.3969/j.issn.1006-5709.2017.05.031

張映媛，碩士研究生在讀，研究方向：消化系統(tǒng)疾病。E-mail：zhangyingyuan5202@163.com

黃華，碩士，主任醫(yī)師，碩士研究生導(dǎo)師，研究方向：消化系統(tǒng)疾病的臨床診治和教學(xué)。E-mail：hhtrq@163.com

R576

A

1006-5709(2017)05-0594-04

2016-07-25