Cập nhật Chẩn đoán, Tiên lượng và Điều trị Viêm tụy cấp 2019

1. Pancreatitis – Updates on Diagnosis, Prognosis & Treatment
HUỲNH TẤN TÀI, MD, MSc
bshttai@gmail.com
TP.HCM, 09/2019
Nguyen Tri Phuong Hospital, HCMC

2. 
 AGA 2018 (American Gastroenterological
Association)
 WSES 2019 (World Society of Emergency Surgery)
GUIDELINES

3. 
AGA 2018
WSES 2019

4. 
Ít nhất 2 trong 3 tiêu chuẩn:
 Đau bụng điển hình;
 Men tụy (amylase/lipase) tăng trên 3 lần ULN;
 Hình ảnh học gợi ý viêm tụy cấp.
CHẨN ĐOÁN
(Diagnosis)
WSES 2019

5. 
1. Which are the criteria to establish the diagnosis of
Severe Acute Pancreatitis?
QUESTIONWSES 2019

6. 
PHÂN LOẠI
(Classification)WSES 2019
2012

7. VIÊM TỤY NẶNG (Severe Acute Pancreatitis: SAP)
 Là viêm tụy cấp (thường là hoại tử) có liên quan đến
tổn thương dai dẳng (>48h) ở ít nhất 1 hệ cơ quan
khác.
 Tổn thương hệ cơ quan khác ngoài tụy: phổi
(ARDS), thận (AKI), tuần hoàn (tụt huyết áp, sốc
tuần hoàn).
CHẨN ĐOÁN
(Diagnosis)
Source: Marinos’ The Little ICU Book 2nd ed.

8. 
What is the appropriate imaging work-up in case of
suspected SAP?
QUESTIONWSES 2019

9. 
Diagnostic Laboratory Parameters
WSES 2019

10.  RANSON criteria (1974)
 Glasgow-Imrie Score (1978)
 APACHE II (Acute Physiology and Chronic Health Evaluation II)
 SOFA (Sequential Organ Failure Assessment)
 CTSI (CT Severity Index)
 BISAP (Bedside Index of Severity in Acute Pancreatitis-2008)
 Japanese Severity Score
TIÊN LƯỢNG
(Prognosis)
Source: World Journal of Emergency Surgery 2019

11. Wu BU et al (2008): 161 BN; so sánh giá trị tiên lượng sớm của
các thang điểm khác nhau trong viêm tụy cấp. Cut-off dự đoán
VTC nặng:
 Ranson ≥3
 BISAP ≥2
 APACHE II ≥8
 CTSI ≥3
 CRP at 24h ≥210 mg/L
TIÊN LƯỢNG
(Prognosis)
Source: Wu BU (2008) et al. Gut;57:1698-703
Different scoring systems
showed similar predictive
accuracy for severity of AP, but
that APACHE-II demonstrated the
highest accuracy for the
prediction of SAP

12. 
TIÊN LƯỢNG
(Prognosis)

13.  Ranson ≥3
 Glasgow Score
 APACHE II ≥8
 CTSI ≥3
TIÊN LƯỢNG
(Prognosis)
1. Wu BU et al. Gut.2008;57:1698-703
2. Harrison DA et al. Crit Care Med.2007;35:1703-8
A cohort study in the UK: 2,462
pts in 159 ICUs => 75% pts
needed intensive care were
transferred to the ICU within the
first 72h, median time-to-transfer:
24h after admission [2]
Can only be assessed
after 48h => not enable
RISK stratification on
admission [1]
BISAP

14.  Data from 17,992 patients in the US.
 Has similar accuracy to the APACHE-II for
predicting death, applied in earliest phases.
 Park JY et al (2013): BISAP predicts severity, death,
organ failure in AP as well as APACHE-II, better than
Ranson, CTSI, CRP, Hematocrit, and BMI.
BISAP
(Bedside Index of Severity of AP)
1. Wu BU et al. Gut.2008;57:1698-703
2. Park JY et al. Hepatobiliary Pancreat Dis Int.2013;12:645-50

15. 
RISK SCORES
WSES 2019

16. 
BISAP
(Bedside Index of Severity of Acute Pancreatitis)

17. 
ĐIỀU TRỊ
(Treatment)
WSES 2019
AGA 2018

18. 
ĐIỀU TRỊ
(Treatment)AGA 2018
Prophylactic antibiotics has NO IMPACT on the rates important
outcomes: persistent single organ failure, multiple organ failure or
multiple organ dysfunction of unclear duration, single organ failure of
unclear duration, and hospital length of stay.

19. 
ĐIỀU TRỊ
(Treatment)WSES 2019

20. 
ĐIỀU TRỊ
(Treatment)WSES 2019

21. 
ĐIỀU TRỊ
(Treatment)WSES 2019
Aminoglycosides: fail to
penetrate into the
pancreas.
Acylureidopenicillins and
3rd-generation Cephalos:
intermediate penetration.
Quinolones (Cipfro &
Moxiflo): good
penetration.
Carbapenems: good
penetration => broad
spectrum, anaerobes.
Metronidazole: good
penetration => anaerobes.

22. 
ĐIỀU TRỊ
(Treatment)
WSES 2019

23. 
ĐIỀU TRỊ
(Treatment)
AGA 2018

24. 
XIN CHÂN THÀNH CẢM ƠN
SỰ LẮNG NGHE CỦA QUÝ
ĐỒNG NGHIỆP!