【作者】 刘双；

【导师】 刘军；

【作者基本信息】 山东大学 ， 普外科， 2009， 硕士

【摘要】 目的经内镜逆行胰胆管造影术(Endoscopic retrogradecholangiopancreatograph,ERCP)在我国已经开展近30年,成功率不断提高,已成为胰胆疾病的重要诊断方法之一。但其带来的一系列并发症同样受到关注,尤其是ERCP术后急性胰腺炎和高淀粉酶血症,是ERCP术后最常见的并发症,急性胰腺炎更是最严重的并发症,甚至危及生命。近年来,药物预防ERCP术后急性胰腺炎和高淀粉酶血症的临床研究已取得一定进展,生长抑素、加贝酯等有一定临床疗效,但许多药物临床效果并不令人满意。本研究旨在探讨舌下含化硝酸甘油对ERCP术后血清淀粉酶和C反应蛋白变化的影响,以及对ERCP术后急性胰腺炎和高淀粉酶血症的预防作用。临床资料和方法选择2008年1月～12月在山东省交通医院肝胆外科住院治疗、经CT或MRI证实为胆总管结石。排除病人全身情况极差,不能耐受内镜检查者,包括心、脑、肝、肾、肺功能严重衰竭等;食管、幽门或十二指肠球部狭窄,十二指肠镜无法通过者;患有严重凝血机制障碍及出血性疾病;患者有胰腺炎、糖尿病病史;术前已有高淀粉酶血症和胰腺炎样疼痛;急性胆系感染;既往有括约肌切开术史;胆总管十二指肠吻合术后;胰腺功能不全;胰腺肿瘤;头孢类药物过敏者。拟实施ERCP、内镜下乳头括约肌切开术(Endoscopicsphincteroto-papillotomy,EST)及经内镜取石的患者100例,按照随机的原则分为硝酸甘油组(n=50例)与对照组(n=50例),由同一位内镜医生对上述患者进行ERCP、EST、内镜取石及放置鼻胆管等操作。硝酸甘油组患者于ERCP术前5～10分钟舌下含化硝酸甘油0.5mg,对照组不予硝酸甘油,两组患者其他处理因素相同。检测两组患者术前、术后3小时、24小时血清淀粉酶水平,术前、术后24小时C反应蛋白(C-reactive protein,CRP)以及术后急性胰腺炎和高淀粉酶血症的发生情况。结果术前血清淀粉酶:硝酸甘油组(59.04±26.23)U/L,对照组(54.92±20.83)U/L,两组患者术前血清淀粉酶水平的差异无统计学意义(P＞0.05)。术后3小时血清淀粉酶:硝酸甘油组(108.88±152.07)U/L,对照组(196.30±244.41)U/L,硝酸甘油组低于对照组,两组差异有统计学意义(P＜0.05)。术后24小时血清淀粉酶:硝酸甘油组(97.02±113.38)U/L,对照组(234.22±406.05)U/L,硝酸甘油组低于对照组,两组差异有统计学意义(P＜0.05)。术前CRP:硝酸甘油组(13.134±19.81)mg/L,对照组(10.23±15.54)mg/L,两组患者术前CRP水平的差异无统计学意义(P＞0.05)。术后CRP:硝酸甘油组术后24小时CRP(14.46±20.48)mg/L低于对照组(28.36±39.49)mg/L,差异有统计学意义(P＜0.05)。硝酸甘油组ERCP术后高淀粉酶血症6例(6/50;12.0%),急性胰腺炎1例(1/50;2.0%)对照组ERCP术后高淀粉酶血症15例(15/50;30.0%),急性胰腺炎7例(7/50;14.0%);硝酸甘油组高淀粉酶血症及急性胰腺炎的发生率均低于对照组,差异有统计学意义(P＜0.05)。结论舌下含化硝酸甘油可降低ERCP术后血清淀粉酶及CRP水平,减少ERCP术后急性胰腺炎和高淀粉酶血症的发病率,提高ERCP技术的安全性。更多还原

【Abstract】 Objective To investigate the effect of nitroglycerin on the impact of serum amylase and C-reactive protein(CRP) after Endoscopic retrograde cholangiopancreatograph (ERCP) and on preventing the acute pancreatitis and hyperamylasemia after ERCP.Methods One hundred patients diagnosed as common bile duct stones by CT and MRI and planned to undergo ERCP, EST and stones removal under endoscope were selected from January to December in 2008 in Shandong Jiaotong Hospital. These patients were randomly divided into two groups: nitroglycerin group (n=50), in which 0.5mg nitroglycerin was given sublingually in 5-10 minutes before ERCP; Control group (n=50), in which no nitroglycerin was given. The levels of serum amylase of all the patients before ERCP and 3 hours, 24 hours after ERCP and the levels of CRP before and after ERCP were detected. the incidence of hyperamylasemia or the acute pancreatitis after ERCP was also observed too.Results There was no significantly difference in the level of serum amylase and CRP between the two groups before ERCP(P>0.05). The level of serum amylase in nitroglycerin group was lower than that in control group at 3 hours or 24 hours after ERCP (P<0.05). The levels of CRP in nitroglycerin group were lower than that in control group at 24 hours after ERCP(P<0.05).The incidence of hyperamylasemia (6/50; 12.0%) and the acute pancreatitis after ERCP (1/50; 2.0%) in nitroglycerin group was significantly lower than that in control group (hyperamylasemia: 15/50; 30.0%) (the acute pancreatitis: 7/50; 14.0%) (P<0.05).Conclusion Sublingual nitroglycerin can decrease the level of serum amylase and CRP, and reduce the attack rate of acute pancreatitis and hyperamylasemia after ERCP. We can prevent acute pancreatitis and hyperamylasemia after ERCP by sublingual nitroglycerin.更多还原