Pancreatic abscess
Introduction
Introduction to pancreatic abscess Pancreatic abscess is caused by necrotic tissue of acute pancreatitis or secondary infection of pseudocyst, which can occur in any part of the pancreas. The main pathogen is enterobacter. Abscess ulceration and corrosion of adjacent organs can cause intestinal cramps or bleeding. The definition of pancreatic abscess has long been inaccurate. Clinically reported pancreatic abscesses and pancreatic infections are confused, and pancreatic abscesses, pancreatic sepsis, pancreatic cellulitis, and infectious pancreatic necrosis are often considered synonymous. basic knowledge The proportion of sickness: 0.004% - 0.009% Susceptible people: no special people Mode of infection: non-infectious Complications: lower gastrointestinal bleeding, blood in the stool, pancreatic fistula, colon fistula, diabetes
Cause
Causes of pancreatic abscess
Pancreatic tissue infection (85%)
Pancreatic abscess is formed by focal necrosis of necrotizing pancreatitis or pancreatic fat, liquefaction, secondary infection, because necrosis is an ideal place for bacterial growth, accumulation of pus in the pancreas or around the pancreas, containing a small amount or It does not contain pancreatic necrotic tissue and is wrapped with fibrous walls.
Pathogenesis
In order to clarify the difference between infection and abscess, Rainer Isenmann et al identified pancreatic abscess and infectious pancreatic necrosis. From 1982 to 1993, 1300 patients with pancreatitis were admitted to the hospital. 31 patients (2.4%) had one or more abscesses and were infectious. 77 cases (5.9%) of pancreatic necrosis.
In addition, according to clinical data, there is a low correlation between alcoholic pancreatitis and abscess, and there is a high risk after surgery or pancreatic injury.
Prevention
Pancreatic abscess prevention
Active treatment of biliary tract diseases, smoking cessation and avoid overeating, antibiotic treatment should be strengthened for infectious diseases. The disease is a complication after acute pancreatitis or pancreatic injury, so the key to the prevention of this disease is early diagnosis of acute pancreatitis or pancreatic injury, and timely correct treatment.
Complication
Pancreatic abscess complications Complications, lower gastrointestinal bleeding, blood, pancreatic fistula, colon, diabetes
1. Transverse colon perforation and lower gastrointestinal bleeding is one of the serious complications of pancreatic abscess. It occurs mostly in the acute phase of the disease. The development process is followed by pancreatic abscess or pseudo-pancreatic cyst secondary infection and blood, which eventually leads to colon necrosis. For perforation, the mortality rate is above 60%, and 85% of perforators occur in the transverse colon or colon spleen. The reasons are:
(1) pancreatic necrosis, infection caused by mesenteric vascular thrombosis.
(2) Trypsin digestion.
(3) The vascular necrosis of the pancreas or abscess wall caused a sudden increase in intracavitary pressure, oppression of the colon wall and inflammation and invasion.
(4) The blood supply to the spleen of the colon is poor, and the colon is adjacent to the onset of the pancreas.
Clinically, the pancreatic abscess first occurs after the colonic internal hemorrhoids and blood is released, blood in the stool. The clinical manifestations are high fever, abdominal pain is aggravated, abdominal mass and blood in the stool. If there is more bleeding, the colostomy should be performed in time, temporarily diverted, drainage abscess. A small colon with no bleeding can be fasted and cured against infection.
2. Intra-abdominal hemorrhage: erosion of blood vessels by abscess, such as splenic artery, left gastric artery or gastroduodenal artery, superior mesenteric vein.
3. Abdominal multiple abscess: As the pancreatic abscess spreads to the sides along the retroperitoneum, it can go up to the armpit, still to the mediastinum, down the paracolic sulcus or the psoas muscle to the groin.
4. Concurrent sputum: duodenal fistula, jejunum sputum, stomach cramps, pancreatic fistula and so on.
5. Others: Delayed gastric emptying; diabetes.
Symptom
Pancreatic abscess symptoms Common symptoms Nausea abdominal pain High fever Lung abscess Abdominal paralysis Septic tachycardia
Signs of infection are common clinical manifestations. Patients with acute pancreatitis should behave like sepsis, but no other reason can be found. It is highly suggestive of pancreatic abscess. Pancreatic abscess can be occult or fulminant. At this time, the patient's original symptoms and signs occur. Change and aggravation, manifested as persistent tachycardia, rapid breathing, intestinal paralysis, increased abdominal pain, with low back pain, elevated peripheral white blood cells, patients with poisoning, rising body temperature, occasionally gastrointestinal symptoms (such as Nausea, vomiting and loss of appetite), a small number of patients have diabetes symptoms.
Physical examination showed tenderness in the upper abdomen or total abdomen, which could reach the mass, but in a few patients, there was no fever, only persistent tachycardia, mild loss of appetite, atelectasis and mild liver dysfunction.
In the course of acute pancreatitis, high fever, peripheral blood leukocytes increased and left shift, abdominal pain increased, abdominal mass and systemic toxicity symptoms, should be suspected of pancreatic abscess, serum amylase in l / 3 ~ 2/3 cases are elevated, which may have liver function damage, which is characterized by elevated serum transaminase and alkaline phosphatase, which is about 40% of survival cases and 60% of cases of death from pancreatic abscess, 40% to 48% of cases Renal dysfunction, serum urease and creatinine may increase, 35% of patients with chest radiographs may show pneumonia, atelectasis, pleural reaction and pleurisy or diaphragmatic elevation, abdominal X-ray film can show localized post-gastric air bubbles , the bubble sign between the stomach and the transverse colon, the gas outside the gastrointestinal tube with the stomach shifting forward, and the gas-liquid level in the small omentum capsule changes.
Examine
Examination of pancreatic abscess
Laboratory inspection
The white blood cell count is significantly increased, often up to (20 ~ 50) × 109 / L, blood culture can have bacterial growth, serum and urine amylase continued to rise, lasting more than 1 week.
Film degree exam
1. CT examination: The accumulation of liquid in the CT film, especially the presence of gas in the accumulated liquid is the pathological feature of abscess formation, and the presence of gas in the abscess is the main marker.
2. B-mode ultrasound: B-mode ultrasound can show the presence, size, number and location of pancreatic abscess, but there are certain restrictions on severe acute pancreatitis.
3. X-ray chest: It can be seen that the left diaphragm is elevated, the left lower lung is atelectasis, and some may have obvious pleural effusion.
4. Abdominal plain film: Most small air bubbles are found in the pancreas area, that is, small air bubbles or gas-liquid cavity (caused by gas-producing bacteria in the abscess). In addition, transverse colonic palsy can be seen, and the gas in the gastrointestinal tract is similar to "soap bubble". A translucent area.
5. Gastrointestinal barium examination: visible signs of enlargement of the pancreatic area, widening of the duodenal ring, according to the different parts and sizes of the abscess, the stomach and transverse colon have different degrees and different directions of displacement.
6. Magnetic resonance imaging (MRI): It can show signs of vascular spasm in the pancreatic enlargement and pancreatic abscess area, but it is expensive.
Diagnosis
Diagnosis and differentiation of pancreatic abscess
diagnosis
B-ultrasound and CT examination are the main means to determine the diagnosis. B-mode ultrasound can show the presence, size, number and location of pancreatic abscess. CT-guided percutaneous aspiration of pancreatic pus can not only confirm the diagnosis, but also aspiration. The pus is stained and cultured by Gram. The infected bacteria are often Gram-negative bacilli, such as Escherichia coli, Pseudomonas, Klebsiella and Proteus, and some positive bacteria may exist, such as Staphylococcus aureus. And some anaerobic bacteria, can also be mixed with several bacteria, the combination of the two can lead to a precise diagnosis, the correct rate of diagnosis is 90% to 95%.
Therefore, there are pus, with little or no pancreatic necrotic tissue, and bacterial or fungal culture positive is the main point of diagnosis of pancreatic abscess, which can be distinguished from infectious pancreatic necrosis.
Differential diagnosis
1. Pancreatic pseudocysts In patients with acute pancreatitis, recurrent pancreatitis or upper abdominal trauma several days to several months, the upper abdomen appears gradually increasing painless or dull pain mass, the mass boundary is clear, no fever There was no sepsis, and there was no change in blood. B-ultrasound and CT examination were clear cystic masses.
2. Chronic pancreatitis mass is a complication of acute pancreatitis or chronic pancreatitis, mild pain and hypothermia in the upper abdomen, no sepsis, upper abdomen can touch the unclear mass, B-ultrasound and CT examination is solid The mass can be cured by conservative treatment.
