胰腺炎营养治疗国际共识指南-guo-2012.6
重症胰腺炎的营养治疗
3、SAP的特点是大量蛋白质分解代谢且增加 能量需求（Ａ级）
4、静脉输注氨基酸，不影响胰腺分泌及其功能 （Ａ级 ）
5、输入肠外营养，应该考虑补充谷氨酰胺（Ｂ 级）
6、糖是首选碳水化合物能量来源，它会抵消糖 异生，同时应避免高血糖（Ａ级）
7、使用外源性胰岛素以维持血糖接近正常范围 （Ｂ级）
8、静脉输入碳水化合物不影响胰腺的分泌和功 能（Ａ级）
9、血脂可以提供高效的热量，如果没有出现 高甘油三酯血症，静脉输入脂肪乳对胰腺炎患 者是安全的（Ｃ级）；
10、让甘油三酯值低于12 mmol / L，血脂应保 持在正常范围（Ｃ级）；
11、脂肪乳剂适宜的输注率（每天介于到）， 如果持续性72小时出现高甘油三酯血症（12 mmol / L），要停止输注（Ｃ级）
禁食状态下基础相水平低
SPA的能量、底物代谢及营养状况的变化
———营养治疗
（5）一旦幽门梗阻缓解，疼痛不再复发，并发症得到控制，就应积极尝试经口正常进食和（或）进食营养补充物．经口进食改善后，
可逐步减少管饲营养（C级）；
（2）胃肠道并发症：腹泻、腹胀、恶心、呕吐；
肠麻痹解除，肠道有功能时（通常是患病72h后）。
（基础相、头相、胃相、肠相）
12、每天输入多种维生素和微量元素，SAP患者在维生素和微量元素水平上有明显的缺陷，没有足够的数据支持输入超正常剂量的维
生素和微量元素（Ｃ级）
80%的SPA处于高能
脂肪乳剂的使用：只有高甘油三酯血症的胰腺炎，需要PN时，才有必要避免使用脂肪乳剂
（2）长期使用TPN可导致肠黏膜萎缩；
80%的SPA处于高能 量消耗、高蛋白质
胰腺炎营养支持指南CSPEN
第六节胰腺炎一、背景胰腺炎包括急性和慢性两类，随着胆道结石发病率上升和人群中嗜酒者的增多，急性胰腺炎发病率有上升趋势。
大多数急性胰腺炎病程是轻度/自限性的，仅需要一般的糖电解质输液支持。
这些患者不易出现营养不良，病程5d~7 d后已可进食。
重症胰腺炎约占急性胰腺炎的20％～30％。
二、证据轻-中度急性胰腺炎患者接受肠外或肠内营养与不给营养支持相比较能否改善临床结局，目前RCT证据较少。
最近McClanve和Heyland等的Meta分析发现，轻-中度急性胰腺炎患者，早期PN导致并发症增加。
轻症患者一般7 天左右就可开始经口饮食，不需要营养支持[1-3]。
2005年英国胃肠病学会、英国外科医师协会、英国胰腺病学会和英国上消化道外科医师协会联合工作组发表最新版《急性胰腺炎诊疗指南》，其中强调轻症胰腺炎患者不需要任何营养支持。
该急性胰腺炎诊疗指南认为轻症患者亦不需要特别禁食[6]。
这与2002年ESPEN急性胰腺炎营养指南有关轻症急性胰腺炎患者早期需要禁食的推荐意见有所不同[5]。
检索发现，目前缺乏比较轻症胰腺炎患者在发病早期禁食和不禁食两种疗法对临床结局的影响的RCT文献。
生理条件下，摄入混合固体餐后很快引起胰酶分泌的高峰。
鉴于胰腺炎发病中胰酶的作用，在发病初期禁食仍然可能是较安全的策略。
因此，推荐在轻症急性胰腺炎发病的最初2d~5d给予禁食处理。
此时，应对患者进行营养评定，若患者无营养不良，只需要给予糖电解质输液治疗以维持水-电解质平衡。
已有关于需特殊营养支持的重症胰腺炎患者的单个随机对照研究结果显示，与PN相比，EN支持有减少并发症趋势，但差异没有统计学意义；两种支持方式对死亡率无影响。
最近发表的系统评价结果表明，对急性胰腺炎患者，EN可能有利于保护肠道完整性，维持肠道屏障与免疫功能；故感染性并发症的发生率较低，总治疗费用也较低。
如果消化道有部分功能，能够耐受EN，应首选EN支持[4, 5]。
但如果患者无法耐受EN支持，出现腹痛加剧，造瘘口引流量增多等临床表现时，应停用EN，改为PN 。
急性胰腺炎营养支持指南课件
脂肪：选择不饱和脂 肪酸，如橄榄油、鱼
油等，占总热量的 20%-30%
水分：保证充足的水 分摄入，每天至少喝
2000毫升的水
碳水化合物：选择低 升糖指数食物，如燕 麦、全麦面包等，占
总热量的50%-60%
膳食纤维：选择富含膳 食纤维的食物，如全麦 面包、燕麦等，占总热
持
营养支持的方 式：可以通过 口服、鼻饲、 静脉等方式进
行营养支持
营养支持的原 则：根据患者 的病情和营养 状况，制定个 性化的营养支
持方案
营养支持的目 标：提高患者 的营养状况， 促进疾病恢复， 降低并发症的
发生率
营养支持的目标和监测
01
02 目标：维持患者营养状况，促进康复
监测指标：体重、血红蛋白、白蛋白、
低热
血淀粉酶升高： 急性胰腺炎的 诊断依据，表 现为血淀粉酶 水平明显升高
腹部CT：急 性胰腺炎的 诊断方法， 表现为胰腺 水肿、渗出、 坏死等改变
治疗原则和预后
01
治疗原则：早期诊断、早期治疗、
早期营养支持
02
预后：预后与病情严重程度、治
疗时机、营养支持等因素有关
03
治疗方法：药物治疗、手术治疗、
02
营养支持可以减轻患者 的疼痛和疲劳感，提高 生活质量
03
营养支持可以降低患者 的感染风险，减少并发 症的发生
04
营养支持可以缩短患者 的住院时间，降低医疗 费用
谢谢
03
临床表现：腹痛、腹胀、 恶心、呕吐、发热等
04
诊断：血淀粉酶、脂肪 酶、CT等
05
治疗：禁食、补液、抗感 染、抑制胰酶分泌等
临床表现和诊断
慢性胰腺炎营养治疗指南 - 河南省人民医院
慢性胰腺炎营养治疗指南
营养治疗目的
减少胰腺的负担，利于胰腺组织修复，恢复胰腺功能，防止营养不良。
营养治疗原则
限制强烈刺激胰液、胆汁分泌物，供给碳水化合物和维生素丰富的食物，以保护胰腺功能。
营养膳食原则
1、能量以满足人体生理需要，能量主要源于碳水化合物。
2、脂肪每日供给30-40克，病情好转增至40-50克，采用含中链脂肪多的油类和奶油、椰子油等，此类脂肪无需脂肪酶即可吸收。
禁用含脂肪多和易引起胀气的食物，如油炸食品、萝卜、黄豆、鸡汤、肉汤、鱼汤及油腻的、易引起胀气并增加胰腺负担的食品。
3、蛋白质每日供给50-70克。
选用脂肪少、高生物价蛋白食品，如蛋清、鸡肉、虾、鱼、脱脂奶、豆腐、瘦牛肉等。
4、碳水化合物每日供给300克以上，占总能70%以上。
采用藕粉、米、面、燕麦、蔗糖、蜂蜜等。
5、胆固醇限制胆固醇的摄入量，每天300毫克以下，禁用高胆固醇食物，如动物内脏、猪脚、蛋黄、奶油等。
6、维生素多摄入富含B族维生素、维生素A、C的食物，维生素C每日供给300毫克以上，多食用新鲜蔬菜和水果，蔬菜水果中含有丰富的维生素C。
7、限制味精用量，禁酒。
8、饮食方式少量多餐，每日4-5次，避免过饱和暴饮暴食。
胰腺炎治疗指南解读
全身炎症反应综合征
毛细血管渗漏综合征
第21页/共43页
抑制胰腺外分泌
• 生长抑素、奥曲肽 • 强烈抑制胰腺内、外分泌, 尤其降低胰蛋白酶的释放 • 抑制胃液、小肠液、胆汁的分泌 • 抑制胆囊收缩 • 降低门脉压
第22页/共43页
抑制胰腺外分泌
• 质子泵抑制剂（PPI） • H2-R拮抗剂 作用： • 抑制胃酸分泌而间接抑制胰腺分泌 • 预防应激性溃疡 • 主张短期用
小剂量肝素、胰岛素持续静脉输注 血脂吸附、血浆置换 快速降脂
第18页/共43页
发病初期常规治疗
❖目 纠正水、电解质紊乱
❖ 支持治疗
的
❖
防止局部及全身并发症
评
血常规
尿常规
监
粪隐血 肾功能
血压 心电监护 胸片
APACHE-Ⅱ评分
估
严
Ranson评分
重
护
肝功能 血糖
点
血清电解质
（尤其血钙）
中心静脉压 24h尿量 24h出入量
第30页/共43页
感染性坏死
• 临床：出现脓毒血症 • CT ：出现气泡征 • 细针穿刺抽吸物：涂片或培养找到细菌或真菌者 治疗原则：
• 立即针对性抗生素治疗，严密观察抗感染的疗效，稳定 者可延缓手术。
• B 超或CT引导下经皮穿刺引流（PCD）脓液，缓解中毒 症状，可作术前过渡治疗。
• 早发期病手后术3显-著4周增是加坏手死术次组数织、清术除后术并的发最症佳发时生机率及病死
第13页/共43页
全身并发症
• 器官功能衰竭：呼吸、循环、肾功能衰竭 • 全身炎症反应综合症（SIＲS） • 全身感染：GNB、真菌 • 腹腔内高压(IAH)：判定SAP 预后 • 腹腔间隔室综合征(ACS)：膀胱压UBP≥20 mmHg，伴少尿、无尿、呼吸困难、吸气压增高、血压降低 • 胰性脑病(PE）：耳鸣、复视、谵妄、语言障碍、肢体僵硬，昏迷等早期多见
急性胰腺炎国际共识—2012年亚特兰大修订版
急性胰腺炎国际共识—2012年亚特兰大修订版急性胰腺炎国际共识—2012年亚特兰大修订版急性胰腺炎分类和定义的国际共识—2012年亚特兰大修订版急性胰腺炎的亚特兰大分类使相关研究得以标准化，有助于临床医生之间的相互交流。
但为了弥补先前的分类对该病认识的不足，有必要对其进行修订。
一、急性胰腺炎形态学特征的定义修订1、间质水肿性胰腺炎（如图1，图2）胰腺实质和胰周组织的急性炎症，并无组织坏死，CT增强扫描的诊断标准：①静脉使用对比剂后，胰腺实质强化②没有胰周坏死图1、63岁，男患，急性间质水肿性胰腺炎。
箭头所示为胰周脂肪毛糙，无急性胰周液体积聚；胰腺完全强化，但由于水肿导致强化不均匀。
图2、A、38岁，女患，急性间质水肿性胰腺炎，白箭头所示左肾周前间隙急性胰周液体积聚。
胰腺完全强化，增大，但由于水肿导致强化不均匀。
急性胰周液体积聚呈液体密度，无囊壁包裹。
B、几周后，随访CT发现急性胰周液体积聚完全吸收，残留极少胰周脂肪毛糙影。
2、坏死性胰腺炎如图（3、4、5、8)胰腺实质坏死和/或胰周坏死导致的炎症，CT增强扫描的诊断标准：①静脉使用对比剂后，胰腺实质无强化②和/或有胰周的坏死(急性坏死性积聚和包裹性坏死)3、急性胰周液体积聚（如图2）间质水肿性胰腺炎导致的胰周液体积聚，与胰周坏死无关。
这一术语仅用于描述间质水肿性胰腺炎发作4周内导致的胰腺周围的液体，并无假性囊肿的特征。
CT增强扫描的诊断标准：①患者有间质水肿性胰腺炎②积液密度均匀③局限在正常的胰周筋膜内④没有明显的包裹⑤邻近胰腺，但没延伸到胰腺内4、胰腺假性囊肿（如图7）胰腺外经常形成界限清楚的炎性囊壁包裹积聚的液体，没有或者仅有极少的坏死。
常见于间质水肿性胰腺炎发作4周后。
急性胰腺炎形成假性囊肿极为罕见，因此在急性胰腺炎中胰腺假性囊肿这一术语可能会被淘汰。
CT增强扫描的诊断标准：①界限清楚，常为圆形或椭圆形②液体密度均匀③没有非流体成份④有完全包裹的囊壁⑤见于间质水肿性胰腺炎发作后，囊壁的成熟需要大于4周的时间。
急性胰腺炎分类-2012：亚特兰大分类和定义修订的国际共识
急性胰腺炎分类－2012：亚特兰大分类和定义修订的国际共识冷芳1，常志刚2 译，杨尹默3 审校（1 江西省景德镇市第三人民医院消化内科，江西景德镇，333000；2 卫生部北京医院外科，北京100730；3 北京大学第一医院普外科，北京100034）关键词：中图分类号：文献标志码：Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensusLENG Fang，CHANG Zhigang，Y ANG Yinmo.（Department of Gastroenterology, the Third People’s Hospital, Jingdezhen, Jiangxi 333000, China）摘要背景和目的急性胰腺炎的亚特兰大分类使相关研究得以标准化，有助于临床医生之间的相互交流。
但由于此分类存在不足及对该病认识的深入，有必要对其进行修订。
方法在2007年进行了基于网络的商讨，以确保胰腺病学家的广泛参与。
首次会议之后，工作组向11 个国家和国际性的胰腺学会函寄了修订草案，该草案被转发给所有相关成员，根据反馈意见再次做出修订，历经3次以网络为基础的讨论，以有文献支持的证据为基础，最后形成此共识。
结果修订后的急性胰腺炎分类明确了疾病的两个阶段：早期和后期，严重程度分为轻症，中重症及重症，轻症胰腺炎是最常见的类型，无器官衰竭、局部或全身并发症，通常能在发病1周内恢复。
中重症急性胰腺炎定义为存在短暂的器官功能衰竭、局部并发症或共存疾病的加重。
重症急性胰腺炎定义为存在持续性器官功能衰竭，即器官功能衰竭> 48 h。
局部并发症包括胰周液体积聚，胰腺及胰周组织坏死（无菌性或感染性），假性囊肿及包裹性坏死（无菌性或感染性）。
急性胰腺炎专家共识
急性胰腺炎专家共识前言急性胰腺炎是一种严重的疾病，其病程凶险，治疗难度大。
为了更好地探讨急性胰腺炎的诊治和研究方向，我们邀请了国内知名专家，共同制定了本次专家共识，希望能对广大临床医生的实际工作有所帮助。
定义急性胰腺炎是指急性胰腺组织内突发性炎症反应，以腹痛、恶心、呕吐、发热等症状为主要表现。
严重时有可能发生多器官功能衰竭，是一种危及生命的疾病。
诊断临床表现急性胰腺炎的临床表现比较明显，常见症状有：•腹痛：剧烈、持续、难以缓解。
•恶心、呕吐：多见于进食后或在夜间恶化。
•上腹胀痛、腹泻、便秘等消化道症状。
•身体不适、乏力等全身症状。
实验室检查急性胰腺炎的实验室检查主要有以下几项：•血常规：白细胞计数升高。
•电解质、肝酶等生化指标：可呈现轻度异常。
•彩超、CT、MRI等影像学检查：可以发现胰腺、炎症和胰腺坏死等情况。
诊断标准根据2012年国际急性胰腺炎共识指南，急性胰腺炎的诊断标准包括：•急性上腹痛，符合胰腺疼痛的特点。
•血清淀粉酶水平≥3倍正常上限。
•彩超或CT/MRI等影像学检查证实胰腺炎症特点。
治疗急性期治疗急性胰腺炎入院后首先要进行急性期治疗。
胰腺炎的治疗主要包括以下几个方面：•饮食管理：急性胰腺炎发作时，患者不应进食任何食物或饮料。
在病情得到缓解后，应注意低脂饮食。
•药物治疗：疼痛控制是急性期治疗的重要环节，常用的止痛剂有阿片类、丙吡胺等。
•补液：急性胰腺炎患者常因持续呕吐导致脱水，需要进行补液治疗。
•抗感染治疗：严重急性胰腺炎可导致细菌感染，应根据患者感染症状及其病原体的敏感性制定相应的抗生素方案。
中晚期治疗中晚期治疗的主要目的是预防和治疗可能出现的胰腺坏死、脓肿、胆囊感染、胆系统并发症等，并进行病因治疗，以避免复发。
预防由于急性胰腺炎病情严重，治疗难度大，因此需要采取有效措施进行预防，减少患病率。
有以下几个方面：•注意饮食，控制脂肪的摄入量。
•控制饮酒，酗酒是引发急性胰腺炎的重要原因。
胰腺炎营养治疗的国际共识指南
胰腺炎营养治疗国际共识指南International Consensus Guidelines for Nutrition Therapy in PancreatitisIndication for Nutrition Therapy营养治疗的适应症1.Pancreatitis patients are at nutrition risk and should be screened. (Grade B: Gold)1.胰腺炎患者进行营养治疗的风险应进行评估筛选。
（B级：黄金）2. For mild to moderate disease, analgesics, intravenous(IV) fluids, and nil per os (NPO) with a gradual advancement to diet (usually within 3–4 days) are recommended. (Grade C: Silver) 2.轻度至中度AP，建议给予止痛药，静脉输液，禁食并逐步进食（通常在3-4天内完成过度）. （C级：银）The need for nutrition therapy (NT) by the enteral or parenteral route should be based on the extent of disease and nutrition status of the patient.肠内或肠外途径营养治疗（NT）需要根据病人疾病和营养状况的程度决定。
3. NT is not generally needed for mild to moderate disease unless complications ensue. (Grade A: Platinum)3.轻度至中度的AP一般不需要NT，除非发生并发症. （A级：白金）4. NT should be considered in any patient regardless of disease severity if the anticipated duration of being NPO is >5–7 days. (Grade B: Gold)4.任何患者如果预期禁食时间大于5-7天，不论病情严重程度都应考虑NT（B级：黄金）5. NT is needed in mild to moderate disease when the patient has been NPO for 5–7 days. (Grade B: Gold)5.轻度到中度AP患者禁食5-7天需要NT（B级：黄金）6. Early NT is indicated for severe pancreatitis. (Grade A: Platinum)6.重症胰腺炎需早期NT （A级：白金）7. NT is useful in the management of patients who develop complications of surgery. (Grade B: Gold)7.有手术并发症的病人NT非常有用. （B级：黄金）Use of Enteral Nutrition肠内营养的使用8. Enteral nutrition (EN) is generally preferred over parenteral nutrition (PN), or at least EN should, if feasible, be initiated first. (Grade A: Platinum)8.肠内营养（EN）一般优于肠外营养（PN），如果EN可行应作为首选. （A级：白金）9. EN may be used in the presence of pancreatic complications such as fistulas, ascites, and pseudocysts.(Grade C: Silver)9. EN也可用于发生胰腺并发症者如瘘，腹水，假性胰腺囊肿（C级：银）10. Continuous EN infusion is preferred over cyclic or bolus administration. (Grade B: Gold)10. EN采用连续性输入方法优于周期性定时输入或推注的给予方法. （B级：黄金）11. Nasogastric tubes may be used for administration of EN. Postpyloric placement is not necessarily required. (Grade B: Gold)11.鼻胃管也可用于EN的输入，不一定要越过幽门后放置鼻空肠管（B级：黄金）12. For EN, consider a small peptide-based mediumchain triglyceride (MCT) oil formula to improve tolerance. (Grade B: Gold)12.对于EN，考虑以小肽为基础的含中链脂肪酸（MCT）的配方以提高耐受性. （B级：黄金）Use of Parenteral Nutrition肠外营养的使用13. Use PN if NT is indicated, when EN is contraindicated or not well tolerated. (Grade A: Platinum)13.如果需要NT，当禁忌行EN或不耐受时使用PN. （A级：白金）14. IV fat emulsions are generally safe and well tolerated as long as baseline triglycerides are below 400mg/dL (4.4 mmol/L) and there is no previous history of hyperlipidemia. (Grade B: Gold)14.只要甘油三酯低于400毫克/分升（4.4毫摩尔/升）和既往无高脂血症历史的患者静注脂肪乳剂通常是安全的（B级：黄金）15. Glucose is the preferred carbohydrate source with metabolic control of glucose as close to normal as possible. (Grade C: Silver)15.葡萄糖是的首选碳水化合物来源，糖代谢尽可能控制接近正常. （C级：银）16. Consider use of glutamine (0.30 g/kg Ala-Gln dipeptide).(Grade C: Silver)16.谷氨酰胺可以考虑使用（ALA-谷氨酰胺肽0.30克/公斤）.（C级：银）17. No specific complications of PN are unique to patients with pancreatitis. In general, avoid overfeeding.(Grade C: Silver)17.胰腺炎患者行PN没有特殊并发症，一般情况下避免过度营养（C级：银）.Both Enteral and Parenteral Nutrition肠内和肠外营养18. Meet macronutrient requirements with NT. (Grade B: Gold)a. Calories: 25–35 kcal/kg/db. Protein: 1.2–1.5 g/kg/d18. NT营养素要求满足（B级：黄金）：a.卡路里:25-35千卡/公斤/天；b.蛋白质：1.2-1.5克/公斤/天胰腺炎营养治疗的国际共识指南营养治疗的适应症1.胰腺炎患者进行营养治疗的风险应进行评估筛选。
2024版《急性胰腺炎诊治最新指南》正式发布
2024版《急性胰腺炎诊治最新指南》正式发布前言急性胰腺炎（Acute Pancreatitis, AP）是一种常见的消化系统疾病，其病因复杂，临床表现多变，病程进展迅速，严重者可能导致胰腺坏死、感染、多器官功能障碍甚至死亡。
为了提高我国急性胰腺炎的诊治水平，规范临床实践，我国消化病学分会组织专家编写了《急性胰腺炎诊治最新指南》（以下简称《指南》）。
本《指南》的发布旨在为临床医生提供最新的诊断和治疗建议，以提高急性胰腺炎的诊疗质量，改善患者预后。
主要更新内容诊断1. 提高了对急性胰腺炎的病因识别和分类准确性，强调了遗传性胰腺炎、慢性胰腺炎急性发作等特殊类型的识别。
2. 推荐采用淀粉酶、脂肪酶等生物标志物联合影像学检查进行诊断，提高了早期诊断的准确性。
3. 强调了血清脂肪酶测定在急性胰腺炎诊断中的重要性，特别是在病后48-72小时内的诊断价值。
治疗1. 推荐采用个体化治疗策略，根据患者的病情严重程度、病因及并发症风险制定治疗方案。
2. 强调了早期液体复苏和营养支持的重要性，以改善患者的预后。
3. 更新了抗生素的使用指征，推荐在疑似感染性胰腺坏死患者中使用抗生素。
4. 推荐对有高危因素的患者进行手术治疗，如胰腺坏死、胰腺脓肿、胆道梗阻等。
5. 提出了急性胰腺炎患者心血管事件风险的管理策略，以降低心血管并发症的发生。
并发症的防治1. 强调了重症急性胰腺炎患者床旁超声、CT等影像学检查的重要性，以早期发现并干预并发症。
2. 推荐对胰腺坏死、胰腺脓肿等并发症进行早期识别和积极处理，以降低病死率。
3. 提出了急性胰腺炎患者胰腺假性囊肿的处理策略，包括内镜下介入和外科手术治疗。
随访与评估1. 推荐对急性胰腺炎患者进行长期随访，以评估疾病复发和慢性胰腺炎的风险。
2. 强调了生活方式的调整，如戒烟、限制饮酒、保持健康饮食等，以降低急性胰腺炎的复发风险。
结语2024版《急性胰腺炎诊治最新指南》的发布，将为我国急性胰腺炎的诊断和治疗带来新的理念和实践指导。
急性胰腺炎分类_2012_亚特兰大分类和定义修订的国际共识_.
Ⅵ冷——2012 ：亚特兰大分类和定义修订的国际共识芳，等．急性胰腺炎分类— 7 急性胰腺炎严重程度的演变入院时无器官功能衰竭可确定为轻症胰腺炎。
在发病第无需干预常可自行消退。
当局部 APFC 持续可保持无菌状态，超过 4 周，则有发展为胰腺假性囊肿的可能（见下文），但在急性胰腺炎中较为罕见。
消退或无症状的 APFCs 不需要治疗，其本身也非重症急性胰腺炎的构成因素。
8． 2 胰腺假性囊肿胰腺假性囊肿是指位于胰周的液体积聚（偶尔可部分或全部在胰腺实质内）。
胰腺假性囊肿有囊壁包其内不含实性成分（图 7 ）。
通常可基于上述形态学标准进裹，行诊断。
如抽取囊内容物检测，淀粉酶活性常有显著升高。
胰腺假性囊肿是由主胰管或分支胰管的破裂所致，而无任何胰腺由此渗漏的胰液大约在 4 周以后形成持续而局限实质的坏死，的液体积聚。
当充满液体的腔内存在明显的实性坏死组织时，则不应使用假性囊肿这一定义。
急性胰腺炎形成假性囊肿极为罕见，因此在急性胰腺炎中胰腺假性囊肿这一术语可能会被淘汰。
在本分类中，假性囊肿并非由 ANC 所致（定义见下文）。
CECT 最常用于描述假性囊肿的影像学特征，但也常需 MRI 或超声检查以确认其内不含实性成分。
1 个 24 h 出现的器官功能衰竭（急性胰腺炎第 1 周出现的器官功能衰竭往往在入院当时就存在），由于难以确定其是否将会可能难以确定最终的严重程是短暂性或持续性器官功能衰竭，度分级；但此类患者不是轻症胰腺炎，开始就应被视作潜在的重症急性胰腺炎进行治疗。
如器官功能衰竭在 48 h 内恢复（表明仅为短暂性器官功能衰竭），患者应归类为中重症急性胰腺炎。
如患者出现持续器官功能衰竭，则应归类为重症急性胰腺炎。
在早期阶段，当胰腺炎仍在不断发展，可每天重新评估其 48 h 和 7 d。
严重程度。
重新评估的恰当时间点是入院后 24 h，虽然早期即可出现局部并发症，但第 1 周内多无需通过影像学检查加以明确。
我国自身免疫性胰腺炎共识意见(草案+2012,上海)
生堡照监痘苤查！Ｑ！！生！！旦笠！！鲞笠！塑鱼生！』旦！坚堡型！！：里里！塑！：：！！：塑！：！我国自身免疫性胰腺炎共识意见（草案２０１２，上海）《中华胰腺病杂志》编委会本共识意见（草案）依据我国自身免疫性胰腺炎的最近研究，并参考国际相关指南和研究进展，由《中华胰腺病杂志》编委会组织消化、内镜、影像、风湿免疫、病理、检验、内分泌、外科等多学科专家集体讨论形成。
希望同道们参考并提出宝贵意见，以期提高我国自身免疫性胰腺炎的诊治水平。
自身免疫性胰腺炎（ａｕｔｏｉｍｍｕｎｅｐａｎｃｒｅａｔｉｔｉｓ，ＡＩＰ）是一种以梗阻性黄疸、腹部不适等为主要临床表现的特殊类型的胰腺炎。
ＡＩＰ由自身免疫介导，以胰腺淋巴细胞及浆细胞浸润并发生纤维化、影像学表现胰腺肿大和胰管不规则狭窄、血清ＩｇＧ４水平升高、类固醇激素疗效显著为特征。
ＡＩＰ是ＩｇＧ４相关性疾病（ＩｇＧ４一ｒｅｌａｔｅｄｄｉｓｅａｓｅ，ＩｇＧ４一ＲＤ）在胰腺的局部表现，除胰腺受累外，还可累及胆管、泪腺、涎腺、腹膜后、肾、肺等，受累器官也可见大量淋巴细胞、浆细胞浸润及ＩｇＧ４阳性细胞。
由于ＡＩＰ易被误诊为胰腺癌而导致不必要的手术，近年来逐渐引起重视。
此外，与ＩｇＧ４无关的ＡＩＰ亚型也渐得到公认，据此将ＡＩＰ分为１型和２型。
因我国２型ＡＩＰ少见，本文如无特别说明，所述ＡＩＰ均指ｌ型ＡｌＰ。
一、概述历经几十年研究，对ＡＩＰ的认识逐渐清晰。
１９６１年Ｓａｒｌｅｓ等首次报道慢性胰腺炎（ｃｈｒｏｎｉｃｐａｎｃｒｅａｔｉｔｉｓ，ＣＰ）患者合并高１一球蛋白血症，认为这种胰腺炎与自身免疫相关，并将其称为原发性硬化性胰腺炎；上世纪７０年代有研究者报道干燥综合征（Ｓｊ｛ｓｇｒｅｎ’Ｓｓｙｎｄｒｏｍｅ，ｓｉｓ）合并的胰腺炎及胰腺肿块经类固醇激素治疗后好转；１９９２年Ｔｏｋｉ等报道４例ＣＰ患者主胰管弥漫性不规则狭窄，与一般的ＣＰ胰管扩张不同；１９９５年Ｙｏｓｈｉｄａ等正式提出ＡＩＰ的命名，至今已被广泛接受。
急性胰腺炎新分类国际共识
诊断难题
新分类标准在临床实践中可能存在一些诊断难题，如某些病例的 早期诊断和鉴别诊断。
治疗难题
新分类标准可能对治疗方案的选择和调整带来一定的挑战，需要医 生根据具体情况进行判断和决策。
患者教育
新分类标准可能对患者的认知和理解带来一定的困扰，需要医生对 患者进行必要的解释和教育。
未来研究方向与展望
研究重点
对临床医生的指导意义
诊断准确性提高
新分类提供了更为明确和具体的诊断标准，帮助医生更准确地诊 断急性胰腺炎。
治疗方案优化
根据新分类，医生可以更针对性地制定治疗方案，提高治疗效果 。
预后评估准确
新分类对急性胰腺炎的预后评估提供了更为科学的依据，有助于 医生准确判断患者恢复情况。
对患者预后的改善作用
降低并发症发生率
01
未来研究应重点关注新分类标准在临床实践中的应用效果和改
进方向，以及与其他相关疾病的关联研究。
技术创新
02
借助现代科技手段，如人工智能、大数据等，对新分类标准进
行优化和完善，提高其科学性和实用性。
国际合作
03
加强国际间的学术交流与合作，共同推进急性胰腺炎分类标准
的进步和发展。
06
急性胰腺炎新分类国际共识的意义与价 值
促进国际合作
新分类的国际共识有助于各国研究者之间的合作 ，推动急性胰腺炎的研究进展。
3
加速科研成果转化
新分类有助于加速科研成果在实际临床中的应用 和转化。
THANKS
感谢观看
治疗和管理。
05
新分类的争议与展望
分类标准的适用性
争议
新分类标准是否适用于所有类型的急性胰腺炎， 是否存在特殊情况或例外情况。
急性胰腺炎国际共识重症评估标准(完整版)
急性胰腺炎国际共识重症评估标准（完整版）急性胰腺炎国际共识评估重症急性胰腺炎的标准是以脏器功能障碍及持续时间作为基础，具体如下：一、病程特点急性胰腺炎通常病程的前两周为急性反应期，此阶段病因、血容量丢失、休克和全身炎症反应综合征（SIRS）等因素可导致病情持续加重，至发病后72h 达到疾病的高峰，继而出现缺血再灌注损伤和多脏器功能障碍（MODS）。
二、临床表现及检查指标腹痛等症状：患者多以腹痛等症状就诊，需详尽了解病史、体检及辅助检查确定诊断及评估病情。
诊断指标：腹痛症状：符合胰腺炎的腹痛症状。
血淀粉酶数值：受到很多因素影响。
CT 检查：特异性更好，从胸腔至耻骨联合的平扫CT 检查除可作为诊断急性胰腺炎的必需条件外，还有助于评估病情及指导治疗，考虑到胸腔积液为评估急性胰腺炎患者的严重程度指标，积液量是否影响呼吸及是否需要穿刺引流，同时可间接提示腹腔渗出及感染部位。
腹腔压力监测：对于已经符合诊断的重症患者，腹腔压力需要常规规范监测，毫无疑问腹腔间隔室综合征（ACS）患者需要收治于ICU。
关键诊疗措施相关指标：病因处理：病因的持续存在导致急性胰腺炎持续加重。
如胆源性胰腺炎，明确胆道状态，针对完全梗阻型需及时解除梗阻，非完全梗阻型可能继发无菌性胆囊炎甚至胆囊坏疽和胆囊穿孔，早期行经皮经肝胆囊穿刺置管引流术（PTGBD）可避免后期并发症；高脂血症胰腺炎，主动去除血脂可从根本上降低脂肪酸的产生，从而缓解SIRS，保护脏器，改善预后。
液体复苏：SAP 患者存在氧输送下降和代谢需求增加产生氧债，采用“限制性液体复苏”策略，根据临床容易获得的5 项指标（心率≥120 次/min、平均动脉压≥85mmHg 或≤60mmHg、动脉血乳酸≥4mmol/L、尿量≤0.5mL/（kg・h）、红细胞压积≥44%，发病72h 内同时满足3 项或以上即为重度血容量缺乏）启动液体复苏，复苏目标为心率＜120 次/min、平均动脉压为65～85mmHg、尿量≥0.5～1.0mL/（kg・h）、血细胞比容为35%～44%，满足2 项或以上即为扩容达标，实施过程中掌握“三个控制”（控制液体输注的速率为5～10mL/（kg・h）、控制发病当日至发病3d 内的输注总量、控制体液潴留量），以SIRS 消失作为液体复苏的终点（氧债消除的间接指标）。
急性胰腺炎的营养支持治疗
谢 谢！
标志，无肠鸣音不意味着肠道没有功能。
TPN的并发症
主要有以下方面： 1.空气栓塞 2导管阻塞、导管脱位和导管感染 3.相关性肝损害 4. 静脉血栓形成 5.代谢异常如血糖异常、高渗性非酮症昏迷等 6.胃肠、肾脏、骨骼系统的损伤等（屏障、感染、电解质 、微量等）
EN常见并发症
EN常见并发症主要有： 1.误吸（年老体弱、昏迷、胃潴留、呃逆，体位和速度预防，必要时改PN） 2.腹泻、腹胀
PN与EN的相互联系
ESPEN、ASPEN 和我国对AP患者的营养支持 准则中均建议： 1）对AP患者的营养支持方式以EN 为首选 2）最终取决于耐受程度,不能耐受EN 者则选用 PN 3）由于AP,尤其重症患者在疾病早期多伴有明 显腹胀或不耐受EN 而应用PN
PN与EN的相互联系
4) 较理想方式是在疾病早期以PN 联合EN ,在 病情和治疗等允许的情况下尽早转为EN 5) 两者并不矛盾, 据病情先后有序、灵活运用 6）TPN 结合EN 的综合支持治疗可能更有益
AP 的内科治疗原则
AP 起病初期治疗原则: 1.严格监护生命体征、心肺功能 2. 维持水电解质平衡 3.解痉止痛 4. 胰腺休息疗法 5.营养( 能量) 支持 6.防治局部及全身并发症
营养支持的作用
AP 普遍呈高分解代谢、高动力状态过程 合理营养支持对于疾病康复起重要作用 营养支持对AP的作用： 1.补偿高代谢的需要 2.减少胰腺的持续分泌和防止胰腺自溶 3.调节炎症介质反应和改善免疫功能
急性胰腺炎的营养支持治疗
研究生：余佳 导 师：王卫星 教授
急性胰腺炎新分类国际共识
夏忠胜 中山大学孙逸仙纪念医院消化内科
1
急性胰腺炎指南
美国亚特兰大指南（1992年）
世界胃肠病大会指南（2002，曼谷） 中国急性胰腺炎指南 2004（内科） 中国重症急性胰腺炎指南 2007（外科）
中国多年未更新
国际急性胰腺炎分类共识（修订）2012，内科 国际坏死性胰腺炎共识（2012，外科）
14
*Based on the Atlanta classification 新AP分类指南 Gut 2012, 30:2779
器官衰竭是预后判断的主要指标
重症预后指标 器官功能衰竭 呼吸功能衰竭 肾功能衰竭 例数 88 75 29 死亡（例）病死率 住院时间 （%） （中位数，d） 28 31.8 19.5 25 18 33.3 62.1 19.0 14.0
①轻症 AP （ MAP ）：无器官功能衰竭 / 局部并发症。
② 中 症 AP （ MSAP, moderately severe acute pancreatitis ） : 有局部并发症或短暂（ ≤ 48h ）器官 功能衰竭。 ③重症 AP(SAP) ：持续性（ >48h ）器官功能衰竭或
多器官功能衰竭，有或没有局部并发症。
10年后更新部分内容
2
Reference
Banks PA, et al. Classification of acute pancreatitis— 2012: revision of the Atlanta classification and definitions by international consensus. Gut, 2012; 30: 2779
病死率：无器官衰竭2%，有器官衰竭38.5% Vege SS, Am J Gastroenterol 2009;104:710
2012+胰腺炎营养治疗国际共识指南
/NutritionJournal of Parenteral and Enteral/content/36/3/284The online version of this article can be found at:DOI: 10.1177/01486071124408232012 36: 284 originally published online 28 March 2012JPEN J Parenter Enteral Nutr International Consensus Guideline Committee Pancreatitis Task ForceJay M. Mirtallo, Alastair Forbes, Stephen A. McClave, Gordon L. Jensen, Dan L. Waitzberg, Andrew R. Davies and for theInternational Consensus Guidelines for Nutrition Therapy in PancreatitisPublished by: On behalf of:The American Society for Parenteral & Enteral Nutrition can be found at:Journal of Parenteral and Enteral Nutrition Additional services and information for/cgi/alerts Email Alerts:/subscriptions Subscriptions:/journalsReprints.nav Reprints:/journalsPermissions.nav Permissions:What is This?- Mar 28, 2012OnlineFirst Version of Record- Apr 24, 2012Version of Record >>医脉通 w w w .m e d l i v e .c nJournal of Parenteral and Enteral NutritionV olume 36 Number 3May 2012 284-291© 2012 American Societyfor Parenteral and Enteral Nutrition DOI: 10.1177/0148607112440823 hosted atClinical GuidelinesClinical guidelines are statements that are systematically developed and contain recommendations for diagnosis and management of patients. Based on rigorous systematic review and evaluation of published literature, guidelines assist the cli-nician with decisions about appropriate care. Each guideline group develops its own individual methodologies with regard to review of the literature, scoring of the evidence, and proce-dure for obtaining consensus of committee members. As a result, guidelines from different societal groups concerning the same topic may provide conflicting recommendations. Guide-lines that are variable or contradictory between societal reports may cause clinicians to misinterpret, ignore, or apply recom-mendations according to their own individual bias.The International Consensus Guideline Committee (ICGC) was formed to adopt current high-quality guidelines from vari-ous societal reports and encourage the development of a novel system for combining or converging guidelines that would have international applicability. Membership of the committee was by secondment from the world’s most influential clinical nutri-tion societies following a scene-setting, open meeting in Prague in 2008. These societies proposed one or more of their senior members who had a formal responsibility for guidelines, clinical practice, and/or education. The committee has met twice-yearly since then, with extensive electronic communication and, inevitably, with some evolution of membership over time. Thecommittee maintains a regular dialogue with each of the pri-mary societies. The authors of this article have expertise in guidelines, nutrition, and/or pancreatitis and have had the most to do with this specific project among the various endeavors with which the committee has concerned itself. They therefore satisfy the normal criteria for authorship of a scientific paper but acknowledge with great appreciation the contributions of the other members of the committee (listed below*), as well as440823From 1Ohio State University, College of Pharmacy, Columbus, Ohio; 2University College Hospital, London, UK; 3University of Louisville, Louisville, Kentucky; 4Penn State University, University Park, Pennsylvania; 5University of São Paulo Medical School, São Paulo, Brazil; 6Alfred Hospital, Melbourne, Australia.*Rupinder Dhaliwal, Rafael Figueredo Grijalba, Gil Hardy, Jens Kondrup, Demetre Labadarios, Alessandro Laviano, Ainsley Malone, Remy Meier, Ibolya Nyulasi, Juan Carlos Castillo Pineda, Vince V anek, and Theo Wong.Financial disclosure: This article is endorsed by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and the Brazilian Society of Parenteral and Enteral Nutrition.Received for publication January 31, 2012; accepted for publication February 1, 2012.Corresponding Author: Jay M. Mirtallo, MS, RPh, Ohio State University, College of Pharmacy, 500 W 12th Ave, Columbus, OH 43210-1291; e-mail: mirtallo.1@.International Consensus Guidelines for Nutrition Therapy in PancreatitisJay M. Mirtallo, MS, RPh 1; Alastair Forbes, MD 2; Stephen A. McClave, MD 3; Gordon L. Jensen, MD, PhD 4; Dan L. Waitzberg, MD, PhD 5; and Andrew R. Davies, MD 6 for the International Consensus Guideline Committee Pancreatitis Task Force AbstractG uidelines for nutrition support in pancreatitis have been inconsistently adapted to clinical practice. The International Consensus Guideline Committee (ICGC) established a pancreatitis task force to review published guidelines for pancreatitis in nutrition support. A PubMed search using the terms pancreatitis, acute pancreatitis, chronic pancreatitis, nutrition support, parenteral nutrition, enteral nutrition , and guidelines was conducted for the period from January 1999 to May 2011. Eleven guidelines were identified for review. The ICG C used the following process to develop unified guideline statements: summarize the strength of evidence (grading) of the guidelines; establish level of evidence for ICGC statements as high, intermediate, and low; assign published guideline levels of evidence; and define an ICGC grading system. International Pancreatitis Guideline Grades were established as follows: platinum—high level of evidence and consistent agreement among the guidelines; gold—acceptable level of evidence and no conflicting statements in guidelines; and silver—single existing guideline statement with no conflict in other guidelines. Eighteen ICGC statements were derived from the 11 published pancreatitis guidelines. Uniform agreement from widely disparate groups (United States, Europe, Japan, and China) resulted in 4 platinum-level guideline statements for nutrition in pancreatitis: nutrition support therapy (NST) is generally not needed for mild to moderate disease, NST is needed for severe disease, enteral nutrition (EN) is preferred over parenteral nutrition (PN), and use PN when EN is contraindicated or not feasible. This methodology provides a template for future ICGC nutrition guideline development. (JPEN J Parenter Enteral Nutr. 2012;36:284-291)Keywordspancreatitis; guideline; nutrition support; enteral nutrition; parenteral nutrition医脉通 w w w .m e d l i v e .c nNutrition Support in Pancreatitis / Mirtallo et al285the many constructive comments received from guidelines committees and key individuals in the primary societies who have reviewed various drafts of this report. The focus of the ICGC was to review a variety of international guidelines and to evaluate the developmental process for their derivation. The committee was also charged with evaluating the degree of con-sensus for guideline statements across multiple societal reports. Attention was paid as to whether guidelines were developed under rigorous processes, whether high-quality evidence sup-ported each of the recommendations, and whether different societal committees derived similar recommendations on the same topic.The ICGC selected nutrition therapy in acute pancreatitis as the first set of guidelines for the group to evaluate. Nutrition therapy in acute pancreatitis is a topic where guidelines have been inconsistently adapted to clinical practice. This article describes the methodology used to compare and contrast guidelines published on this subject, as well as the process by which the ICGC could derive consensus recommendations for the nutrition management of this patient population.MethodsLiterature ReviewPublications that contained guidelines for nutrition therapy in pancreatitis were identified using the methodologies listed below. PubMed was used as the search engine for the literature review. Search terms included pancreatitis, acute pancreatitis, chronic pancreatitis, nutrition support, parenteral nutrition, enteral nutrition , and guidelines . The search was for the period from January 1999 through May 2011 and included both English and non-English publications. Title and content were searched for using the selected terms. References were selected for review if there was a sponsoring organization (society) and a methodology that described a process for guideline development. For general guidelines on the topic of acute or chronic pancreatitis, only those sections dealing with nutrition therapy were included for review by the committee.Guideline AssessmentGuidelines selected by the ICGC for review had to meet the following criteria:1. The guideline was developed by practitioners with expertise on the topic. The guideline committee used a transparent process for data collection, review, and analysis.2. The guideline was clear, pragmatic, and supported by a national or international society.3. The guideline was founded on evidence specific to pancreatitis.Specific information, abstracted by the ICG C members from the various guidelines, included the following:1. Sponsoring organization, strength of the evidence (grading), and guideline development process2. Guideline recommendations for nutrition therapy in pancreatitis, with references cited from the support-ive literature Once the societal guideline reports were identified, a table was constructed (see the appendix online at http://jpen.sagepub .com/supplemental) to list the comments and specific recom-mendations from each group. Some of the comments included in the table were more of a discussion format, whereas others were specific recommendations. For these latter statements, where appropriate, the individual grade of the recommenda-tion assigned by that societal group was included.Next, the ICGC focused on the 2 major issues: strength of evidence from the literature and consensus between reports. A table was constructed to demonstrate the grading system for level of evidence used by each societal group (Table 1). Because committee members’ strategy, methodology, and bias might vary, successive publications by the same society from different years were regarded as separate and unique societal reports.Another table was constructed to delineate a simplified 3-tier comparative grading scale for level of evidence of sup-portive literature for recommendations published across mul-tiple societal reports (Table 2). Despite wide variation in methodology between societal reports, it was easy to divide overall strength of the literature into 3 levels: a high level of evidence included only prospective randomized control trials of any size, an intermediate level of evidence included any studies in which there was a nonrandomized control group (prospective cohort or historical controls), and a low level of evidence included reports that represented observational stud-ies, case series, or expert opinion. Based on this scheme of hierarchy, the individual methodology from each societal group could be organized into 3 grades of evidence (Table 2).The issue of consensus across multiple societal reports was evaluated by the ICGC by evaluating uniformity and agreement on specific recommendations for nutrition therapy between groups. Table 3 was constructed to show degree of consensus between reports for each specific recommendation. The desig-nation of “yes” in this table indicated positive affirmation of that recommendation, whereas a designation of “no” meant a nega-tive response or disagreement. A blank space reflected the fact that no comment or statement was made on that specific recom-mendation by that individual report. Consensus was defined by uniformity between reports, whereas lack of consensus was defined when a recommendation by one or more societal groups was in conflict or disagreement with that from the rest of the reports.医脉通 w w w .m e d l i v e .c n286 Journal of Parenteral and Enteral Nutrition 36(3)Table 1. Grading System for Level of Evidence Used in Each Societal Report 1-11Organization/CitationLevels of Evidence/GradingA.S.P.E.N./JPEN J Parenter Enteral Nutr . 2002;26(1):Suppl (Jan-Feb)A: There is good research-based evidence to support the guideline (prospective, randomized trials).B: There is fair research-based evidence to support the guideline (well-designed trials without randomization).C: The guideline is based on expert opinion and editorial consensus.ESPEN/Clin Nutr . 2002;21(2):173-183British Society of Gastroenterology/Gut . 2005;54(suppl 3):iii1-iii9Ia: Evidence obtained from meta-analysis of randomized controlled trials Ib: Evidence obtained from at least 1 randomized controlled trialIIa:E vidence obtained from at least 1 well-designed controlled study without randomization IIb: E vidence obtained from at least 1 other type of well-designed quasi-experimentalstudy III: E vidence obtained from well-designed nonexperimental descriptive studies such ascomparative studies, correlation studies, and case studies IV: E vidence obtained from expert committee reports or opinions or clinicalexperiences of respected authorities Recommendation GradeA: Requires at least 1 randomized controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendations (evidence categories Ia, Ib)B: Requires the availability of clinical studies without randomization on the topic of recommendation (evidence categories IIa, IIb, III)C: Requires evidence from expert committee reports or opinions or clinical experience of respected authorities, in the absence of directly applicable clinical studies of good quality (evidence category IV)American College ofGastroenterology/Am J Gastroenterol . 2006;101:2379-2400I: Strong evidence from at least 1 published systematic review of multiple well-designed randomized controlled trials II: S trong evidence from at least 1 published properly designed randomized controlled trial of appropriate size and in an appropriate clinical setting III: E vidence from published well-designed trials without randomization, single grouppre-post, cohort, time series, or matched case-controlled studies IV: E vidence from well-designed nonexperimental studies from more than 1 centeror research group or opinion of respected authorities, based on clinical evidence, descriptive studies, or reports of expert consensus committees Japan (JSEAM)/Hepatobiliary Pancreat Surg . 2006;13:42-47A: Good evidence to support a recommendation for use B: Moderate evidence to support a recommendation for use C: Poor evidence to support a recommendationD: Moderate evidence to support a recommendation against use E: Good evidence to support a recommendation against use ESPEN—enteral nutrition:pancreas/Clin Nutr . 2006;25:275-284A 1a: Meta-analysis of randomized controlled trials A 1b: At least 1 randomized controlled trialB 11a: At least 1 well-designed controlled trial without randomization B 11b: At least 1 other type of well-designed, quasi-experimental studyB III: Well-designed nonexperimental descriptive studies such as comparative studies, correlation studies, and case control studiesC IV: Expert opinions and/or clinical experience of respected authorities AGA/Gastroenterology . 2007;132:2022-2044Not statedA.S.P.E.N. and SCCM/JPEN J Parenter Enteral Nutr . 2009;33(3):277-316Grade of recommendationA: Supported by at least 2 level I investigations B: Supported by 1 level I investigation C: Supported by level II investigations only(continued)医脉通 w w w .m e d l i v e .c nNutrition Support in Pancreatitis / Mirtallo et al287Combining the issues of level of evidence from the litera-ture (Table 2) with that of consensus of opinion (Table 3) facilitated the convergence of societal reports and the derivation of a final set of International Consensus Guide-line Recommendations. Three separate grades of recom-mendations (Table 4) were developed by this schema as follows: •Platinum (A): guideline statement meeting the crite-ria for high grade of evidence with uniform consen-sus across multiple societal reports•Gold (B): guideline statement that meets criteria for low/intermediate grade of evidence or where there is lack of consensus across societal reports (at least 1 societal report is in disagreement)Organization/CitationLevels of Evidence/GradingD: Supported by at least 2 level III investigations E: Supported by level IV or level V evidence Level of evidence I: L arge, randomized trials with clear-cut results; low risk of false-positive (α) error or false-negative (β) errorII: Small, randomized trials with uncertain results; moderate to high risk of false-positive (α) and/or false-negative (β) error III: Nonrandomized, contemporaneous controls IV: Nonrandomized, historical controlsV: Case series, uncontrolled studies, and expert opinionChinese Societies/Chin J Dig Dis . 2005;6(1):47-51Based on the grading and categorization of acute pancreatitis (AP) established at the International Symposium of Acute Pancreatitis (Atlanta, GA, 1992) and the guidelines for management of AP at the World Conference on Gastroenterology (Bangkok, Thailand, 2002), combined with the situation in China, the following terminology and definition of AP have been formulated for the guidance of Chinese clinicians and researchers.Bangkok World Congress of Gastroenterology 2002/J Gastroenterol Hepatol . 2002;17(suppl):S15-S39Level 1: Evidence obtained from systematic reviews of all relevant randomized controlled trialsLevel 2: Evidence derived from at least 1 properly designed randomized controlled trial Level 3: Evidence from a well-designed control trial without randomization or from well-designed cohort or case control analytical studies, preferably from more than 1 center or research group or from multiple time series with or without intervention Level 4: Opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees. This level signifies the need for further research.AGA, American Gastroenterological Association; A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; Chinese Societies, Chinese Society of Gastroenterology, Chinese Medical Association–Pancreatitis Disease Group; ESPEN, European Society for Clinical Nutrition and Metabolism; JSEAM, Japanese Society of Emergency Abdominal Medicine; SCCM, Society for Critical Care Medicine.Table 2. Comparative 3-Tier Grading Scale for Level of Evidence of Recommendations Published Across Societal Reports International Guidelines Recommendations—Comparative ScaleGuideline Source: Organization/YearLevel of Evidence Type of StudiesWorld Congress of Gastroenterology/ 2002 A.S.P.E.N./ 2002British Society of Gastroenterology/ 2005American College of Gastroenterology/ 2006ESPEN/ 2006 and 2009SCCM-A.S.P.E.N./ 2009HighAny prospectiverandomized controlled trials1, 2A A (Ia,b)I, II A (Ia,b)A–C (I–III)Intermediate Controlled nonrandomized 3B B (IIa,b, III)III B (IIa,b, III)D (IV)Low Descriptive case seriesExpert opinion4CC (IV)IVC (IV)E (V)A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; ESPEN, European Society for Clinical Nutrition and Metabolism; SCCM, Society for Critical Care Medicine.Table 1. (continued)医脉通 w w w .m e d l i v e .c n288 Journal of Parenteral and Enteral Nutrition 36(3)Table 3. Consensus Across International Societal Reports and Guideline StatementsA.S.P.E.N. 20021ESPEN 20022Bangkok World Congress of Gastroenterology 200210Chinese Societies 20059British Society of Gastroenterology 20053American College ofGastroenterology 20064Japan 20065ESPEN 20066AGA 20077A.S.P .E.N. 20098ESPEN 2009111. Pancreatitis patients atnutrition risk should be screenedYesYes———Yes———Yes—2. For mild to moderatedisease, analgesics, IV fluids, NPO, advance diet —Yes ——Yes Yes —————Need for NS3. Not needed for mild tomoderate diseaseYes Yes —Yes —Yes —Yes Yes Yes Yes 4. Needed only if anticipatedNPO >5–7 dYes ————Yes ——Yes —Yes 5. Needed in mild tomoderate disease when NPO 5–7 d———————Yes—Yes—6. Needed only for severepancreatitis—Yes Yes Yes ———Yes Yes Yes — 7. Needed for complicationsor for surgery —Yes—————Yes—Yes—Use of EN8. EN preferred over PN orstart with ENYes YesYes —Yes Yes Yes Yes Yes Yes Yes 9. EN may be used in faceof complications (fistula, ascites, pseudocyst)—Yes—————Yes———10. Use continuous-infusion EN —Yes —————Yes —Yes —11. Nasogastric tube may beused——Yes—Yes Yes Yes Yes Yes Yes —12. Use small peptide (MCToil formula to improve tolerance)—YesYes————YesYesYes—Use of PN13. Use if NS indicated but nottolerant to EN (goal not reached)YesYes———YesYesYes Yes Yes Yes14. PN lipids are safe (keeptriglycerides <400 mg/dL)Yes Yes —Yes ——————Yes 15. Glucose is the preferredcarbohydrate source (control blood glucose close to the normal range)——————————Yes16. Consider use of glutamine(0.30 g/kg Ala-Gln dipeptide)——————————Yes17. No specific complicationsof PN unique to pancreatitis; avoid overfeeding——————————Yes18. Meet requirements withEN or PN: 25–35 kcal/kg/d, 1.2–1.5 g protein/kg/d—Yes————————YesAGA, American Gastroenterological Association; A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; Chinese Societies, Chinese Society of Gastroenterology, Chinese Medical Association–Pancreatitis Disease Group; EN, enteral nutrition; ESPEN, European Society for Clinical Nutrition and Metabolism; IV , intravenous; MCT, medium-chain triglyceride; NPO, nil per os; NS, nutrition support; PN, parenteral nutrition.医脉通 w w w .m e d l i v e .c nNutrition Support in Pancreatitis / Mirtallo et al 289•Silver (C): guideline statement meeting the crite-ria for high grade of evidence, published only in a single societal report (consensus not applicable in this case)ResultsOf the 11 societal reports identified, 8 reported a well-defined guideline development process using acceptable methodolo-gies from reputable sources.1,3-6,8,10,11 Three of the reports were developed by nationally recognized groups/organizations but did not have a well-defined process of guideline development or used methodology that resulted in practice recommenda-tions in a review format rather than guideline statements.2,7,9 These latter reports were excluded from this analysis.Using this unique methodology involving evaluation of both level of evidence and consensus of opinion, the ICG C was able to derive the following:International Consensus Guidelines for Nutrition Therapy in PancreatitisIndication for Nutrition Therapy1. Pancreatitis patients are at nutrition risk and should be screened. (Grade B: Gold)2. For mild to moderate disease, analgesics, intrave-nous (IV) fluids, and nil per os (NPO) with a gradual advancement to diet (usually within 3–4 days) are recommended. (Grade C: Silver)The need for nutrition therapy (NT) by the enteral or paren-teral route should be based on the extent of disease and nutri-tion status of the patient.3. NT is not generally needed for mild to moderate dis-ease unless complications ensue. (Grade A: Platinum)4. NT should be considered in any patient regardless of disease severity if the anticipated duration of being NPO is >5–7 days. (Grade B: Gold)5. NT is needed in mild to moderate disease when the patient has been NPO for 5–7 days. (Grade B: Gold)6. Early NT is indicated for severe pancreatitis. (Grade A: Platinum)7. NT is useful in the management of patients who develop complications of surgery. (Grade B: Gold)Use of Enteral Nutrition8. Enteral nutrition (EN) is generally preferred overparenteral nutrition (PN), or at least EN should, if feasible, be initiated first. (Grade A: Platinum)9. EN may be used in the presence of pancreatic com-plications such as fistulas, ascites, and pseudocysts. (Grade C: Silver)10. Continuous EN infusion is preferred over cyclic orbolus administration. (Grade B: Gold)11. Nasogastric tubes may be used for administrationof EN. Postpyloric placement is not necessarily required. (Grade B: Gold)12. For EN, consider a small peptide-based medium-chain triglyceride (MCT) oil formula to improve tolerance. (Grade B: Gold)Use of Parenteral Nutrition13. Use PN if NT is indicated, when EN is contraindi-cated or not well tolerated. (Grade A: Platinum)14. IV fat emulsions are generally safe and well toler-ated as long as baseline triglycerides are below 400 mg/dL (4.4 mmol/L) and there is no previous history of hyperlipidemia. (Grade B: Gold)15. G lucose is the preferred carbohydrate source withmetabolic control of glucose as close to normal as possible. (Grade C: Silver)16. Consider use of glutamine (0.30 g/kg Ala-Gln dipep-tide). (Grade C: Silver)17. No specific complications of PN are unique topatients with pancreatitis. In general, avoid over-feeding. (Grade C: Silver)Table 4. Final Grade of Recommendation for International Consensus Guidelines International Guidelines Recommendations—Grade Categorization Grade of Recommendation Number of Societies Strength of EvidenceConsensus Agreement A (platinum)Multiple societies High level of evidenceConsensusB (gold)Multiple societies Intermediate to low level of evidence Lack of consensusC (silver)Single societyHigh level of evidenceNANA, not applicable.医脉通 w w w .m e d l i v e .c n290 Journal of Parenteral and Enteral Nutrition 36(3)Both Enteral and Parenteral Nutrition18. M eet macronutrient requirements with NT. (GradeB: Gold)a. Calories: 25–35 kcal/kg/db. Protein: 1.2–1.5 g/kg/dDiscussionThe unique contribution of this project and article is a process by which a variety of recommendations on a specific topic from international societies around the world can be used to construct a single set of “global guidelines” based on level of evidence from the literature and consensus of opinion between groups. A similar approach was used for living kidney donors using the AGREE (Appraisal of Guidelines for Research and Evaluation) methodology to assess methodological quality of the guidelines.12 The ICGC approach to pancreatitis guidelines was from the perspective of identifying guideline consistency from reliable methodology for the purposes of identifying consensus among the guidelines rather than critiquing the guidelines themselves. The ICG C committee findings from this process are consistent with that found for kidney donors: there is variation in guideline methodology among the groups but similarities that result in unnecessary duplicative efforts. Therefore, there is a need for international collaboration and coordination of future guidelines to ensure consistency and comprehensiveness.Eighteen ICG C statements were derived from 11 pub-lished guidelines that addressed nutrition therapy in pancre-atitis. The guideline methodologies used by each sponsoring society were unique to that organization, but most were consistent with acceptable principles of guideline development at the time of publication. The challenge was negotiating the wide range of methodology found in these publications, especially because guideline methodology was evolving over this time period. The level of evidence (grading) deter-mined by each societal group was also a challenge for the ICGC, but this issue was easily resolved within the framework of a more global ranking of evidence as high, intermediate, and low.Minor problems arising from comparison of the societal reports were easily resolved by the ICGC members. For exam-ple, the grade A platinum guideline statements tended to be present in several societal reports, but the grades in the pub-lished manuscripts ranged from intermediate to high. These differences may have been due to variances in the perspective of the sponsoring organization. Grade B gold statements also varied in grade from low to high among the published societal reports, but many may have been affected by the fact that nutri-tion therapy was only part of a broader overall guideline topic such as general management of acute pancreatitis. These latter guidelines by nature did not provide as much detail aboutnutrition therapy as the guidelines that focused specifically on nutrition in pancreatitis. Most grade C silver guidelines were PN-specific recommendations.11 These provided much more specific statements for PN than those reports that covered a broader more comprehensive subject of management of acute pancreatitis. Even with these limitations, there was surpris-ingly uniform agreement from widely disparate groups (United States, Europe, Japan, and China). Some of this uniformity may reflect the similarity of the literature reviewed and used by these groups.Anecdotes from clinical experience were evident through-out the societal reports reviewed by the committee. The ICGC noted that the caloric requirements used in the guideline refer-ences for PN and EN ranged from 25–35 kcal/kg/d or 1.5–1.8 times the basal energy expenditure.13-20 When evaluating pro-spective trials comparing PN with EN in patients with pancre-atitis, it was noted that PN was generally better able to achieve caloric goals than EN. The higher calorie prescriptions were associated with a greater frequency of hyperglycemia. As expected, the incidence of hyperglycemia was also higher for patients receiving PN compared with EN. Energy expenditure was measured in patients with pancreatitis using indirect calo-rimetry, even though the number of evaluated patients was small. Dickerson et al 21 found energy expenditure to be about 25 kcal/kg/d, with this value being similar regardless of whether the patient had acute, chronic, or acute/chronic pan-creatitis with sepsis. These observations suggest a need to reconsider the volume or dose of feeding being provided to patients with pancreatitis, to investigate whether outcomes would be improved from delivery of fewer calories (while optimizing glucose control).The ICGC statements for pancreatitis send a clear message to clinicians, providing action statements to help patient man-agement. With the degree of consensus and consistency seen across the varied societal reports, one would question why there is such variation in the practice of nutrition therapy for patients with pancreatitis. At the very least, practitioners should focus on patients with severe disease, favoring EN over PN and only using PN when EN is contraindicated or not feasible.ConclusionCurrent guidelines for nutrition therapy in pancreatitis were assessed for common guideline statements that could be uni-versally applicable. Irrespective of the guideline methodology used by separate groups, a process that combines level of evidence from the literature with consensus of opinion across multiple societal reports provides a unique single set of “global guidelines” to help direct clinicians in the nutrition therapy of the patient with acute pancreatitis. This article pro-vides a template for the future by which to derive International Consensus Guidelines on a wide variety of topics.医脉通 w w w .m e d l i v e .c n。
急性胰腺炎与肠内营养-国际营养
急性胰腺炎与肠内营养急性胰腺炎（AP）是一种由多种病因引起的胰酶激活，继而以胰腺局部炎性反应为主要特征，伴或不伴有其他器官功能改变的疾病。
AP患者，尤其是重症急性胰腺炎（SAP）患者，机体处于负氮平衡状态，蛋白质分解、糖原异生和脂肪动员增加，导致机体内环境紊乱，免疫功能低下和营养不良。
通过营养支持治疗，机体的总蛋白、总水分、总脂肪可以得到较好的保留，在部分患者中甚至含量有所增加，因此营养支持已成为治疗AP的重要措施之一。
不同地区关于AP 营养支持的指南差异较大。
2012年国际指南协会（ICGC）基于11个地区的诊治指南总结发布了《急性胰腺炎营养治疗的国际共识指南》，2013年国际胰腺病协会/美国胰腺协会（IAP/APA）发布了最新的AP 诊治指南，中国也于2013年修订了新的诊治指南。
三个指南在营养支持的适应证方面达成了共识，在其他方面则分歧较多（具体见表１）。
主要的争论点在于：（1）肠内营养（EN）与肠外营养（PN）的选择；（2）EN时机的选择；（3）鼻胃管（NG）与鼻空肠管（NJ）的选择。
营养支持的适应证近年来发布的指南在营养支持的适应证方面已基本达成共识，即对于MAP（中症急性胰腺炎）患者只需短期禁食后便可恢复经口进食，而对SAP患者则强烈推荐实施营养支持。
美国胃肠病学会（AGA）推荐，若患者无恶心呕吐症状，腹痛缓解后即可经口进食少渣、低脂软食，无需从流食过渡。
然而一项包括35例轻、中度AP患者的随机对照研究表明，给予NG营养可以减轻腹痛，缩短腹痛持续时间，进而减少阿片类止痛药的使用，并且可以降低经口进食的不耐受风险。
但因其为小样本试验，确切疗效有待大型临床试验进一步验证。
近期也有研究尝试在SAP 患者入院72h内即予低流量（248～330kcal/d）经口进食，发现其也可促进肠道功能的早期恢复，为AP的营养支持提供了新的方式。
EN与PN的选择过去认为，PN期间胰腺的外分泌功能是“减少和静止”的，能达到“胰腺休息”的目的。
- 1、下载文档前请自行甄别文档内容的完整性，平台不提供额外的编辑、内容补充、找答案等附加服务。
- 2、"仅部分预览"的文档,不可在线预览部分如存在完整性等问题,可反馈申请退款(可完整预览的文档不适用该条件!)。
- 3、如文档侵犯您的权益，请联系客服反馈,我们会尽快为您处理(人工客服工作时间：9:00-18:30)。
International Consensus Guidelines for Nutrition Therapyin Pancreatitis胰腺炎营养治疗国际共识指南Apr 24, 2012 Version of RecordMar 28, 2012 Online First Version of Record •Platinum (A): guideline statement meeting the criteria for high grade of evidence with uniform consensus across multiple societal reports白金（A）：指南建议符合如下标准，具有高水平证据支持并且多个协会指南意见相一致•Gold (B): guideline statement that meets criteria for low/intermediate grade of evidence or where there is lack of consensus across societal reports (at least 1 societal report is in disagreement)黄金（B）：指南建议符合如下标准，中低水平证据支持，或者协会指南之间缺乏共识（至少一个协会指南建议不一致）•Silver (C): guideline statement meeting the criteria for high grade of evidence, published only in a single societal report (consensus not applicable in this case)白银（C）：指南建议符合如下标准，仅有一个协会发布的具有高水平证据支持的建议（共识不适用于此等情况）Indication for Nutrition Therapy营养治疗指征1. Pancreatitis patients are at nutrition risk and should be screened. (Grade B: Gold)1. 胰腺炎患者存在营养风险，应当进行营养筛查。
(Grade B: Gold)2. For mild to moderate disease, analgesics, intravenous (IV) fluids, and nil per os (NPO) with a gradual advancement to diet (usually within 3–4 days) are recommended. (Grade C: Silver)2. 对于轻中度患者，推荐镇痛剂、静脉补液、从开始禁食（NPO）逐渐过渡到日常饮食（一般3-4天）。
(Grade C: Silver)The need for nutrition therapy (NT) by the enteral or parenteral route should be based on the extent of disease and nutrition status of the patient.根据疾病严重程度和患者营养状态判断是否需要肠内或肠外营养治疗（NT）。
3. NT is not generally needed for mild to moderate disease unless complications ensue. (Grade A: Platinum)3. 轻中度胰腺炎一般无需NT，除非并发症出现。
(Grade A: Platinum)4. NT should be considered in any patient regardless of disease severity ifthe anticipated duration of being NPO is >5–7 days. (Grade B: Gold)4. 预期禁食时间超过5-7天应当考虑NT，无需考虑疾病严重程度。
(Grade A: Platinum)5. NT is needed in mild to moderate disease when the patient has been NPO for 5–7 days. (Grade B: Gold)5. 已经禁食5-7天的轻中度胰腺炎患者应当开始NT。
(Grade B: Gold)6. Early NT is indicated for severe pancreatitis. (Grade A: Platinum)6. 重症胰腺炎是早期NT的指征。
(Grade A: Platinum)7. NT is useful in the management of patients who develop complications of surgery. (Grade B: Gold)7. NT有益于出现外科并发症的胰腺炎患者的治疗。
(Grade B: Gold)Use of Enteral Nutrition适用于肠内营养8. Enteral nutrition (EN) is generally preferred over parenteral nutrition (PN), or at least EN should, if feasible, be initiated first. (Grade A: Platinum)8. EN通常优于PN，或者说，只要可能就要先从EN开始。
(Grade A: Platinum)9. EN may be used in the presence of pancreatic complications such as fistulas, ascites, and pseudocysts. (Grade C: Silver)9. 当出现诸如肠瘘、腹水、假性囊肿等胰腺并发症应当开始EN。
(Grade C: Silver)10. Continuous EN infusion is preferred over cyclic or bolus administration. (Grade B: Gold)10. EN持续输注优于间断输注或推注。
(Grade B: Gold)11. Nasogastric tubes may be used for administration of EN. Postpyloric placement is not necessarily required. (Grade B: Gold)11. 实施EN可以使用鼻胃管。
并非必须幽门下置管。
(Grade B: Gold)12. For EN, consider a small peptide-based medium-chain triglyceride (MCT) oil formula to improve tolerance. (Grade B: Gold)12. 对于EN，考虑中长链脂肪乳的短肽制剂改善EN耐受性。
(Grade B: Gold)Use of Parenteral Nutrition适用于肠外营养13. Use PN if NT is indicated, when EN is contraindicated or not well tolerated. (Grade A: Platinum)13. 具有NT指征当EN禁忌或不能耐受时使用PN。
(Grade A: Platinum)14. IV fat emulsions are generally safe and well tolerated as long as baseline triglycerides are below 400 mg/dL (4.4 mmol/L) and there is no previous history of hyperlipidemia. (Grade B: Gold)14. 只要基础甘油三酯低于400 mg/dL (4.4 mmol/L)并且之前没有高脂血症病史，通常静注脂肪乳是安全的并且能够耐受。
(Grade B: Gold) 15. Glucose is the preferred carbohydrate source with metabolic control of glucose as close to normal as possible. (Grade C: Silver)15. 葡萄糖是最主要的碳水化合物来源，血糖控制尽可能接近正常。
(Grade C: Silver)16. Consider use of glutamine (0.30 g/kg Ala-Gln dipeptide). (Grade C: Silver)16. 考虑应用谷氨酰胺（0.30 g/kg丙氨酰-谷氨酰胺二肽）(Grade C: Silver)17. No specific complications of PN are unique to patients with pancreatitis. In general, avoid over-feeding. (Grade C: Silver)17. 没有胰腺炎患者特定的PN并发症。
通常应当避免过度喂养。
(Grade C: Silver)Both Enteral and Parenteral Nutrition肠内肠外营养都适用18. Meet macronutrient requirements with NT. (Grade B: Gold)a. Calories: 25–35 kcal/kg/db. Protein: 1.2–1.5 g/kg/d18. 达到NT最大需要量(Grade B: Gold)a. 热卡: 25–35 kcal/kg/db. 蛋白: 1.2–1.5 g/kg/dA.S.P.E.N./JPEN J Parenter Enteral Nutr. 2002;26(1):Suppl (Jan-Feb) ESPEN/Clin Nutr. 2002;21(2):173-183British Society of Gastroenterology/Gut.2005;54(suppl 3):iii1-iii9 American College of Gastroenterology/Am J Gastroenterol.2006;101:2379-2400Japan (JSEAM)/Hepatobiliary Pancreat Surg. 2006;13:42-47 ESPEN—enteral nutrition:pancreas/Clin Nutr. 2006;25:275-284AGA/Gastroenterology. 2007;132:2022-2044A.S.P.E.N. and SCCM/JPEN J Parenter Enteral Nutr. 2009;33(3):277-316 Chinese Societies/Chin J Dig Dis.2005;6(1):47-51Bangkok World Congress of Gastroenterology 2002/J Gastroenterol Hepatol.2002;17(suppl):S15-S39AGA, American Gastroenterological Association; A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; Chinese Societies, Chinese Society of Gastroenterology, Chinese Medical Association–Pancreatitis Disease Group; ESPEN, European Society for Clinical Nutrition and Metabolism; JSEAM, Japanese Society of Emergency Abdominal Medicine; SCCM, Society for Critical Care Medicine.百普素通用名称：短肽型肠内营养剂英文名称：Short Peptide Enteral Nutrition Powder【成份】本品为复方制剂，其主要成份为：麦芽糊精、水解乳清蛋白、植物油、中链甘油三酯（MCT）、乳化剂、矿物质、维生素和微量元素等。