【作者】 曹立瀛；

【导师】 李勇； 范立侨；

【作者基本信息】 河北医科大学 ， 外科学， 2004， 硕士

【摘要】 目的：急性胰腺炎（Acute Pancreatitis，AP）是外科常见急腹症，约１／５的患者可恶化成为重症急性胰腺炎（Severe Acute Pancreatitis，SAP）。SAP在临床上以发病快、病变多端、病情凶险、死亡率高而为外科所棘手。且易并发肺、肝、肾等多器官功能障碍综合征（Multiple organ dysfunction syndrome， MODS），死亡率极高。在正常生理情况下，机体内部存在着炎症反应和抗炎反应这一平衡机制，两者的动态平衡维持着机体的自稳状态，适度的炎症反应对机体是有利的，如果炎症反应过度，则会打破自稳状态，导致全身炎症反应综合症（System Inflammatory Reaction Syndrome，SIRS），严重者可导致MODS。呼吸功能障碍在75%的SAP患者中发生，临床症状从较轻的低氧血症到急性成人呼吸窘迫综合征（Acute Respiratory Distress Syndrome，ARDS）均可出现。最新的研究表明，SAP早期是一种SIRS，其发病机制十分复杂，与多种因素有关。近年来经大量研究，许多学者对SAP合并肺损伤的发病机制有了较多的认识，其中以细胞因子学说和缩血管物质损伤为最新研究焦点。SAP合并肺损伤的治疗目前主要是通过阻断胰腺炎的进一步发展，防止肺损伤的发生。国内有关中药复合制剂治疗SAP合并肺损伤动物实验的报<WP=4>道很少。本研究通过建立SAP合并肺损伤动物模型，旨在探讨SAP合并肺损伤时IL-6、TNF-α、ET、MDA、SOD、血气分析的变化及胰腺与肺脏的病理变化，观察应用胆胰和胃冲剂治疗后上述各指标的变化情况。为临床应用胆胰和胃冲剂治疗SAP合并肺损伤提供动物实验依据，并通过检测上述数据来判断治疗效果及监测预后。　　　　　　　　方法：选择健康SD大鼠96只，体重330±30g，雌雄不拘，随机分为12组，每组8只，分别为假手术2h组（F2h）、6h组（F6h）、12h组（F12h）、24h组（F24h），重症急性胰腺炎2h组（SAP2h）、6h组（SAP6h）、12h组（SAP12h）、24h组（SAP24h），胆胰和胃冲剂治疗2h组（DY2h）、6h组（DY6h）、12h组（DY12h）、24h组（DY24h），各组动物均在实验前12h禁食不禁水，用2％戊巴比妥钠腹腔麻醉（0.3ml/100g体重）后将大鼠仰卧，剑突下正中切口，进入腹部后确认胆胰管开口，用7号针头穿刺胆胰管开口对侧十二指肠壁，将拉细的硬膜外导管于穿刺口插入，经胆胰管开口导入胆胰管内并缝扎固定，用小血管夹夹闭胆胰管近肝端，注入5%牛磺胆酸钠0.11ml/100g，注射后保持压力3min，观察胰腺出现水肿、充血、出血等改变后，去血管夹、拆线、拔管。无损伤线修补十二指肠穿刺口的浆肌层，十二指肠复位。由胃壁穿刺置入头皮导管入胃内约3cm，无损伤缝合线缝扎穿刺口并固定造瘘管，造瘘管由腹壁另行戳孔引出并固定于皮肤，缝合切口，包扎切口并固定敷料。F组和SAP组于0、6、12、18小时通过胃造瘘管<WP=5>注入生理盐水1ml/100g，夹闭1小时后开放引流，DY组分别于0h、6h、12h及18h给予胆胰和胃冲剂胃造瘘管内注入1ml/100g(100ml生理盐水加25gDY)，夹闭胃造瘘管1小时后开放引流。在制模成功并给药后在规定时间抽血并处死动物后取材。 观察记录各组、各时点病理形态学、胰腺和肺脏系数、胰腺病理组织评分，检测AMY、LIP、TNF-α、IL-6、MDA、ET红细胞SOD及血气分析，对测定结果进行统计学分析。　　结果：（１）、SAP各组与同时点假手术组相比，腹水量亦明显增加（P<0.01），并随时间延长明显增加；血清AMY、LIP水平均明显增高（P<0.01）；胰腺病理评分明显增加（P<0.01），并随时间延长增加更明显（P<0.01），而12h与24h组比较无显著性差异；胰腺系数明显增加（P<0.01），肺脏系数除2h组外明显增加（P<0.01）；镜下见胰腺水肿、出血、炎细胞浸润、点片状坏死；肺脏呈充血、水肿、中性粒细胞浸润、灶性肺不张表现，并随时间的延长病理改变加重。（２）、SAP组与同时点假手术组比较血TNF-α、ET、IL-6、MDA均明显增高（P<0.01），并随时间的延长而增加；（３）、SAP组与同时点假手术组比较红细胞SOD明显下降（P<0.01），并随时间的延长下降更加明显（P<0.01）；（４）、除2h组外，SAP其余各组与同时点假手术组相比动脉血氧分压（PO2）明显下降（P<0.01），二氧化碳分压（PCO2）明显升高（P<0.01）；（５）、DY治疗组与SAP组比较除2h组外，其余各组与同时点SAP相比腹水量、胰腺系数亦明显减少（P<0.01）；除2h、6h组外<WP=6>肺脏系数明显减少（P<0.05）；除2h组外，其余各组与同时点SAP组相比镜下见胰腺水肿、出血、炎细胞浸润、点片状坏死减轻；肺脏充血、水肿、中性粒细胞浸润、灶性肺不张表现较前好转。（６）、DY治疗组与SAP组比较，除2h组ET、PCO2、PO2外，其余各组与同时点SAP组相比血AMY、LIP、MDA、TNF-α、IL-6、ET、PCO2明显下降，（P<0.05或P<0.01）；（７）、DY治疗组与SAP组比较，除2h组PO2外，其余各组与同时点SAP组相比PO2 和红细胞SOD明显升高（P<0.05或P<0.01）。结论：（1）、应用5%牛磺胆酸钠逆行胰胆管内注射，大鼠模型的胰腺及肺脏组织经病理学检查，具有明确的胰腺水肿、出血、坏死及肺脏水肿、充血、炎细胞侵润、灶性肺不张等改变。说明该方法制备SAP合并肺损伤具有方法简便、重复性好的优更多还原

【Abstract】 Objective: Acute pancreatitis is a usually disease of acute abdomen and about one-fifth patients can develop to severe acute pancreatitis　(SAP). SAP is a fatal surgical disease, often be in companion with multiple system organ failure (MSOF) and high morality with lung, heart and adrenal complication. There is a balance-system of inflammatory and anti-inflammatory in usual body. Adequate inflammatory reaction is benefit to body, but hyper-inflammatory reaction can lead to systemic inflammatory reaction syndrome (SIRS), seriously MSOF. Acute lung injury can be caused in 75 percent patients. The most important cause of early death in SAP is acute lung injury and ARDS. Experiment studies have demonstrated that cytokine and vasoactive mediators plays the important role during acute severe pancreatitis in recent years. The therapy of SAP with lung injury presently is mostly to interrupt progress of pancreatitis. The reports that experimental SAP animals with lung injury were treated by traditional Chinese medicine are few. The aim of this study is to investigate the serum lever of AMY, LIP, IL-6, TNF-α, <WP=9>MDA, ET, SOD in the red cells and PO2, PCO2 in arterial blood, to observe the pathologic changes for pancreas, lungs in SAP with lung injury rat model, and to study the influence of DY. This research was done to elucidate the reasonable mechanism of SAP with lung injury and influence of DY. Methods: 96 healthy S-D rats randomly divided into 12 groups: false SAP2h, 6h, 12h, 24h groups; SAP2h, 6h, 12h, 24h groups　(false treated groups); DY2h, 6h, 12h, 24h groups (treated with DY). model of SAP with lung injury was induced by contra- injection of 5% sodium taurocholate to pancreatic duct and gastric- leakage was finished by a conduit which was opened out of body. DY was injected into stomach through the conduit. Animals were killed and animals’ blood was drawn in schedule time. Animals’ lungs and pancreas were selected and adopted. Determining serum level of AMY, LIP, TNF-α, IL-6, ET, MDA, SOD in red-cell and PO2, PCO2 in arterial blood, pancreatic pathologic grades. Weigh pancreas, lungs, count their quotiety and observe their changes after treatment. Data was analyzed by statistics. Results: (1) Compared with F same time groups after operation, serum level of AMY, LIP, the amount of the ascites and pathology scores of pancreas in SAP rat models kept rise continuously. Difference is significantly, the longer the time, the more serious the case. Pancreas was <WP=10>observed edema, hemorrhage, necrosis spots; Lungs were observed edema, hemorrhage, inflammatory cell infiltration under light microscope and pulmonary atelectasis. The longer the time goes, the more serious the damage is. (2) Compared with F same time groups, The serum levels of TNF, IL-6, MDA, ET increased significantly in SAP groups. The longer the time goes, the higher the data is. (3) Compared with F same time groups, SOD in red-cell decreased significantly in SAP groups (except SAP2h). The longer the time goes, the lower the data is. (4) Compared with F same time groups, PO2 in arterial blood decreased significantly and PCO2 in arterial blood increased significantly in SAP groups (except SAP2h). (5) After gastric-leakage conduit injection of DY, the pathology changes of pancreas and lungs get better, the amount of the ascites, quotiety of pancreas and lung decrease significantly.　(6) Compared with SAP same time groups, The serum levels of AMY, LIP, TNF, IL-6, MDA, ET (except DY2h), PCO2 (except DY2h) in arterial blood decreased significantly in DY groups. (7) Compared with SAP same time groups, The levels of PO2 (except DY2h) in arterial blood and SOD in red-cell SOD in red-cell increased significantly in DY groups.Conclusions: (1) The method to contra-injection 5% sodium taurocholate to pancreatic duct to induce SAP with lung injury. Pancreas was observed edema, hemorrhage, <WP=11>necrosis spots; Lungs were observed edema, hemorrhage, inflammatory cell infiltration under light microscope and pulmonary atelectasis. The model i更多还原