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Abbreviation (ISO4): Acta Academiae Medicinae Sinicae      Editor in chief: Xuetao CAO

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Acta Academiae Medicinae Sinicae >

2020 , Vol. 42 >Issue 1: 47 - 54

DOI: https://doi.org/10.3881/j.issn.1000-503X.11240

Original Article

Evaluation and Early Diagnosis of Gastrointestinal Failure in Acute Pancreatitis

  • JIN Meng ,
  • ZHANG Huimin ,
  • CHEN Xuanfu ,
  • WU Meixu ,
  • WANG Zheng ,
  • GUO Mingyue ,
  • BAI Xiaoyin ,
  • YANG Hong ,
  • QIAN Jiaming
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  • Department of Gastroenterology,PUMC Hospital,CAMS and PUMC,Beijing 100730,China
QIAN Jiaming Tel:010-69155019,E-mail:

Received date: 2019-02-14

  Online published: 2020-03-05

Supported by

Supported by the Chinese Academy of Medical Sciences Medicine and Health Technology Innovation Project(2016-12M-3-001)

the Health Research & Special Projects Grant of China(201002020)

the Foundation of the Ministry of Education of China for Outstanding Young Teachers in University(20101106120059)

Copyright

Copyright reserved © 2020. Office of Acta Agronomica Sinica All articles published represent the opinions of the authors, and do not reflect the official policy of the Chinese Medical Association or the Editorial Board, unless this is clearly specified.
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Abstract

Objective To investigate the application of Acute Gastrointestinal Injury(AGI) grading in evaluating gastrointestinal failure in patients with acute pancreatitis(AP). Methods In this retrospective observational study,patients presented with moderate severe AP and severe AP in our hospital from October 2013 to October 2016 were consecutively enrolled.Logistic regression analysis and receiver operating characteristic curve were used to explore and evaluate potential predictors of gastrointestinal failure. Results A total of 202 patients were included in this study,with 90 cases(44.6%) identified as gastrointestinal failure.Survival curve showed significantly increased risk of death in patients with gastrointestinal failure(P < 0.05).Logistic regression analysis showed age(OR=1.06,95%CI:1.03-1.09,P<0.001),complaint of stopping flatus and defecation(OR=7.02,95%CI:2.08-23.66,P=0.002),increased counts of white blood cells in peripheral blood(OR=1.09,95%CI:1.02-1.17,P=0.015),decreased level of serum albumin(OR=0.93,95%CI:0.86-1.00,P=0.048),and increased level of serum creatinine at admission(OR=1.02,95%CI:1.01-1.04,P=0.001) were the independent risk factors of gastrointestinal failure.The area under curves of Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) and Beside Index for Severity in Acute Pancreatitis (BISAP) scores in diagnosing gastrointestinal failure were 0.999 and 0.782,respectively. Conclusions Gastrointestinal failure can remarkably increase the risk of death in patients with AP.Both APACHE Ⅱ and BISAP scores at admission are useful in diagnosing gastrointestinal failure in patients with AP.

Key words： acute pancreatitis; gastrointestinal failure; Acute Gastrointestinal Injury grade

Cite this article

JIN Meng , ZHANG Huimin , CHEN Xuanfu , WU Meixu , WANG Zheng , GUO Mingyue , BAI Xiaoyin , YANG Hong , QIAN Jiaming . Evaluation and Early Diagnosis of Gastrointestinal Failure in Acute Pancreatitis[J]. Acta Academiae Medicinae Sinicae, 2020 , 42(1) : 47 -54 . DOI: 10.3881/j.issn.1000-503X.11240

急性胰腺炎(acute pancreatitis,AP)是临床常见急危重症,重症患者病死率高达30%。2012年美国统计数据显示,AP为消化病住院率第3位,医疗费用第4位[1]。胃肠道是本病最常受累的器官之一,文献报道AP患者合并肠黏膜屏障功能障碍的比例约54%~88%[2]。肠道屏障受损后大量细菌移位引起胰腺和胰外感染,形成AP第2个死亡高峰,显著影响预后[3]。故在中重度AP患者中早期识别胃肠道衰竭至关重要。2012年欧洲重症医学会提出了急性胃肠道损伤(Acute Gastrointestinal Injury,AGI)分级系统,其中AGI分级≥Ⅲ级定义为胃肠道衰竭[4]。此后一系列文献报道了该评分在ICU病房重症患者中预测死亡、指导肠内营养治疗的有效性[5]。AP作为临床常见急危重症,尤其是合并局部和/或全身并发症的中重度AP,也在该评分应用范围之内。但目前缺乏数据评价AGI分级在中重度AP中的应用效果和早期诊断指标。本研究将通过回顾性收集中重度AP患者资料,分析中重度AP合并胃肠道衰竭患者的临床特点和危险因素,并进一步评价不同临床评分对胃肠道衰竭的诊断能力,以期加深对AP合并胃肠道衰竭的认识,指导临床早期诊断、早期干预。

资料和方法

资料来源 本研究为回顾性观察性研究。连续性纳入2013年10月至2016年10月北京协和医院就诊的中重度AP患者。AP诊断标准为满足以下3条特征中的2条:(1)腹痛;(2)血清淀粉酶和/或脂肪酶≥3倍正常值上限;(3)B超、CT 或磁共振显示胰腺炎特征性表现。病情严重程度按照2012年修订的亚特兰大分型[6]。排除标准:(1)就诊时发病超过7 d者;(2)非首次发病者;(3)不能表达主观不适症状者;(4)恶性肿瘤患者;(5)合并严重心肺疾病患者。本研究经北京协和医院伦理委员会批准,所有患者均豁免知情同意。
急性胃肠道损伤分级 胃肠道功能评价依据2012年欧洲重症医学协会颁布的AGI分级进行,依据患者的胃肠道症状、食物耐受能力和肠内营养恢复能力等综合判断,分为Ⅰ~Ⅳ级:(1)Ⅰ级:一过性、自限性胃肠道功能受损,除液体支持外无需特殊干预;(2)Ⅱ级:胃肠道功能障碍,经口进食或肠内营养无法在3 d内达到20 kcal/(kg·d)[83.68 kJ/(kg·d)],需要治疗性干预,但不影响整体病情;(3)Ⅲ级:胃肠道功能衰竭,持续食物/肠内营养不耐受,积极治疗后无改善,整体病情加重;(4)Ⅳ级:胃肠道功能衰竭且影响其他脏器功能,引起或加重多器官功能衰竭综合征(multiple organ dysfunction syndroms,MODS),甚至导致死亡[4]。所有纳入研究的患者于入院后1周内每天进行AGI分级评估,选取患者入院后1周内最严重的分级,如AGI分级≥Ⅲ级则为胃肠道衰竭。
数据收集 收集入选患者的性别、年龄、病因、体质量指数(body mass index,BMI),记录入院即刻腹部症状、腹部体征、急性生理与慢性健康评分Ⅱ(Acute Physiology and Chronic Health Evaluation Ⅱ,APACHE Ⅱ)[7],急性胰腺炎床旁严重程度指数(Bedside Index for Severity in Acute Pancreatitis,BISAP)评分[8]和CT严重程度指数(Computed Tomography Severity Index,CTSI)评分[9],实验室、影像学资料和预后。所有数据及临床评分由两名消化科医生独立评估筛选。
统计学处理 采用SPSS 23.0统计软件,计数资料用百分比表示,组间比较行χ2检验;符合正态分布的计量资料以均数±标准差表示,组间比较采用t检验;不符合正态分布的计量资料以M(Q1,Q3)表示,组间比较采用Mann-Whitney U非参数检验;采用 Spearman相关分析评价临床评分与AGI分级相关性,生存曲线分析用于比较两组患者预后的差异,Logsitic回归分析用于胃肠道衰竭的独立危险因素分析,受试者工作特征(receiver operating characteristic,ROC)曲线用于临床评分对胃肠道衰竭的诊断价值,以胃肠道衰竭作为结局变量绘制各指标ROC曲线,金标准为AGI分级(如AGI分级≥Ⅲ级则为胃肠道衰竭);选择Youden指数最大切点为最佳界点;计算曲线下面积(area under curve,AUC),0.5 < AUC<0.7代表较低诊断价值,0.7<AUC<0.9代表有较好诊断价值,AUC大于0.9代表有较高诊断价值;P<0.05为差异有统计学意义。

结 果

患者基线资料 共202例中重度AP患者纳入研究,其中,男121例(59.9%),女81例(40.1%),平均年龄(49.3±16.7)岁(15~97岁);中度AP患者110例(54.5%),重度AP患者92例(45.5%)。202例患者中,AGI分级Ⅰ级0例,Ⅱ级112例(55.4%),Ⅲ级46例(22.8%),Ⅳ级患者44例(21.8%)。将AGI分级Ⅰ、Ⅱ级患者分为非胃肠道衰竭组(112例,55.4%),Ⅲ、Ⅳ级患者分为胃肠道衰竭组(90例,44.6%);两组患者在年龄、性别及病因分布方面差异均没有统计学意义(P均>0.05)(表1)。
表1 胃肠道衰竭组和非胃肠道衰竭组基线资料比较

Table 1 Comparison of baseline characteristics between gastrointestinal failure group ans non-gastrointestinal failure group

分组
Group		 男Male[n(%)] 年龄(x̅±s,岁)
Age(x̅±s,years)		 病因Etiology[n(%)]
胆
Gallstone		 高三酰甘油血症
Hypertriglyceridemia		 酒精
Alcohol
胃肠道衰竭
Gastrointestinal failure(n=90)		 51(56.7) 52.0±17.7 24(26.7) 22(24.4) 7(7.8)
非胃肠道衰竭
Non-gastrointestinal failure(n=112)		 70(62.5) 48.0±18.1 33(29.5) 36(32.1) 17(15.2)
χ2/t 0.707 5.192 0.193 1.445 2.611
P 0.470 0.082 0.753 0.274 0.128
AP合并胃肠道衰竭患者的临床特点
症状及辅助检查:胃肠道衰竭组患者的入院主诉排气排便停止比例(χ2=6.868,P= 0.015)、血白细胞(t=16.531,P<0.001)、血肌酐(t=47.832,P<0.001)和血糖水平(t=7.604,P=0.006)明显高于非胃肠道衰竭组,血白蛋白水平(t=13.997,P<0.001)和血总钙水平(t=8.443,P=0.004)明显低于非胃肠道衰竭组(表2)。
表2 胃肠道衰竭组和非胃肠道衰竭组临床特点比较

Table 2 Comparison of clinical features between gastrointestinal failure group ans non-gastrointestinal failure group

分组
Group		 入院即刻腹部症状及体征Symptoms and physical signs at hospital admission[n(%)]
腹痛
Abdominal pain		 腹胀
Abdominal distension		 排气排便停止
Flatus and
defecation stop		 腹膜刺激征
Signs of peritoneal
irritation		 肠鸣音减弱
Hypoactive bowel sounds
所有患者 All patients
胃肠道衰竭(n=90)
Gastrointestinal failure		 89(98.8) 85(94.4) 26(28.9) 48(53.3) 86(95.6)
非胃肠道衰竭(n=112)
Non-gastrointestinal failure		 110(98.2) 98(87.5) 14(12.5) 57(50.9) 107(95.5)
χ2 0.010 2.045 6.868 0.037 5.078
P 0.921 0.173 0.015 0.873 0.024
重度胰腺炎患者 Severe acute pancreatitis patients
胃肠道衰竭组(n=62)
Gastrointestinal failure		 61(98.4) 58(93.6) 18(29.0) 40(64.5) 58(93.5)
非胃肠道衰竭组(n=30)
Non-gastrointestinal failure		 29(96.2) 26(86.6) 8(26.7) 18(60.0) 30(100.0)
χ2 0.257 0.813 0.032 0.111 2.023
P 0.612 0.367 0.859 0.739 0.155
分组
Group		 入院即刻辅助检查 Lab tests at hospital admission(x̅±s)
血白细胞
(109/L)
White blood cell		 血红蛋白
(g/L)
Hemoglobin		 血细胞比容
(%)
Hematocrit		 血白蛋白
(g/L)
Serum albumin		 血总钙
(mmol/L)
Serum calcium		 血肌酐
(mmol/L)
Serum creatinine		 血糖
(mmol/L)
Blood glucose
所有患者 All patients
胃肠道衰竭(n=90)
Gastrointestinal failure		 18.0±7.4 138.3±37.9 40.0±9.6 33.6±6.7 1.9±0.3 178.7±155.3 13.1±10.3
非胃肠道衰竭(n=112)
Non-gastrointestinal failure		 14.3±5.6 142.9±28.4 41.2±6.4 37.1±6.6 2.1±0.3 74.4±27.4 10.1±4.4
t 16.531 0.792 1.223 13.997 8.443 47.832 7.604
P <0.001 0.375 0.270 <0.001 0.004 <0.001 0.006
重度胰腺炎患者 Severe acute pancreatitis patients
胃肠道衰竭组(n=62)
Gastrointestinal failure		 18.0±7.4 141.1±41.1 40.9±10.7 33.2±6.9 1.9±0.3 219.4±168.2 13.9±11.7
非胃肠道衰竭组(n=30)
Non-gastrointestinal failure		 14.6±5.6 151.0±26.1 42.0±6.9 34.4±6.2 1.9±0.3 84.2±40.3 11.4±5.3
t 4.870 1/263 0.221 0.733 0.758 18.778 1.267
P 0.037 0.265 0.639 0.394 0.759 <0.001 0.263
分组
Group		 入院24小时临床评分
Clinical score within 24 hours after
hospital admission[M(Q1,Q3)]		 入院营养评估
Nutrition evaluation
at admission		 MODS
[n(%)]		 坏死物积聚
[n(%)]
Necrotic
collection		 肠内营养
[n(%)]
Enteral
nutrition
APACHEⅡ BISAP CTSI BMI
(x̅±s,kg/m2)		 NRS
[M(Q1,Q3)]
所有患者 All patients
胃肠道衰竭(n=90)
Gastrointestinal failure		 16.0(13.8,20.3) 3(2,3) 4(4,8) 25.5±4.3 4(4.0,6.0) 43(47.8) 40(44.4) 45(50.0)
非胃肠道衰竭(n=112)
Non-gastrointestinal failure		 6.0( 4.0, 9.0) 2(1,2) 4(4,6) 25.2±3.6 5(4.0,6.5) 0(0) 50(44.6) 62(55.4)
Z/t/χ2 12.182 6.517 0.589 0.371 0.121 67.983 a 0.001 a 0.575 a
P <0.001 <0.001 0.556 0.686 0.732 <0.001 1.000 0.480
分组
Group		 入院24小时临床评分
Clinical score within 24 hours after
hospital admission[M(Q1,Q3)]		 入院营养评估
Nutrition evaluation
at admission		 MODS
[n(%)]		 坏死物积聚
[n(%)]
Necrotic
collection		 肠内营养
[n(%)]
Enteral
nutrition
APACHEⅡ BISAP CTSI BMI
(x̅±s,kg/m2)		 NRS
[M(Q1,Q3)]
重度胰腺炎患者
Severe acute pancreatitis patients
胃肠道衰竭组(n=62)
Gastrointestinal failure		 18.0(14.8,23.3) 3(3,4) 6(4,8) 25.5±4.2 5(4,8) 41(66.1) 35(56.5) 36(58.1)
非胃肠道衰竭组(n=30)
Non-gastrointestinal failure		 9.0(9.0,10.0) 2(2,3) 6(4,6.5) 24.6±3.9 6(4,7) 0(0.0) 15(50.0) 24(80.0)
Z/t/χ2 7.659 2.906 0.981 0.454 0.057 35.787 0.339 4.288 a
P <0.001 0.024 0.341 0.504 0.821 <0.001 0.657 0.038

APACHE Ⅱ:acute physiology and chronic health evaluation Ⅱ;BISAP:bedside index for severity in acute pancreatitis;CTSI:computed tomography severity index;BMI:body mass index;NRS:nutrition risk screening;MODS:multiple organ dysfunction syndrome

APACHE Ⅱ:急性生理与慢性健康评分 Ⅱ;BISAP:急性胰腺炎床旁严重程度指数评分;CTSI:CT严重程度指数评分;BMI:体质量指数;NRS:营养风险筛查;MODS:多器官功能障碍综合征

临床评分:胃肠道衰竭组患者的APACHE Ⅱ评分(Z=12.182,P<0.001)、BISAP评分(Z= 6.517,P<0.001)和合并MODS的比例(χ2=67.983,P<0.001)均显著高于非胃肠道衰竭组,CTSI评分与非胃肠道衰竭组相比差异无统计学意义(Z=0.589,P=0.556)(表1)。
营养方面:胃肠道衰竭组患者的基线BMI(t=0.371,P=0.686)、入院营养风险筛查(Nutric risk screening,NRS)评分(Z=0.121,P=0.732)与非胃肠道衰竭组差异无统计学意义,两组患者接受肠内营养治疗比例差异也无统计学意义(χ2=0.575,P=0.480)。
亚组分析:重度AP患者中,合并胃肠道衰竭患者的血白细胞水平(t=4.870,P=0.037)、血肌酐水平(t=18.778,P<0.001)、MODS比例(χ2=35.787,P<0.001)、APACHEⅡ评分(Z=7.659,P<0.001)、BISAP评分(Z=2.906,P=0.024)和肠内营养比例(χ2=4.288,P=0.038)均显著高于非肠道衰竭患者;两组患者在入院BMI(t=0.454,P=0.504)和NRS评分(Z=0.057,P=0.821)方面差异均无统计学意义(表2)。
胃肠道衰竭对AP患者临床预后的影响 202例患者中,死亡9例(4.5%),胃肠道衰竭组患者的住院死亡率(10.0% 比0;χ2=11.722,P=0.001)、继发感染比例(24.4%比8.0%;χ2=33.075,P=0.002)和收住ICU比例(62.2%比22.3%;χ2=10.342,P<0.001)均显著高于非胃肠道衰竭组(表3)。生存分析结果显示,胃肠道衰竭组患者预后显著下降(P<0.05)(图1)。
图1 中重度急性胰腺炎中非胃肠道衰竭组与胃肠道衰竭组患者生存分析比较

Fig 1 Survival curve analysis of moderate to severe acute pancreatitis patients with and without gastrointestinal failure

表3 胃肠道衰竭组和非胃肠道衰竭组患者预后比较[n(%)]

Table 3 Comparison of prognosis between gastrointestinal failure group and non-gastrointestinal failure group[n(%)]

分组Group 死亡Death 继发感染Secondary infection 重症监护室Intesive care unit
所有患者 All patients
胃肠道衰竭 Gastrointestinal failure(n=90) 9(10.0) 22(24.4) 56(62.2)
非胃肠道衰竭 Non-gastrointestinal failure(n=112) 0( 0 ) 9( 8.0) 25(22.3)
χ2 11.722 33.075 10.342
P 0.001 0.002 <0.001
重度胰腺炎患者 Severe acute pancreatitis patients
胃肠道衰竭组 Gastrointestinal failure(n=62) 9(14.5) 21(33.9) 49(79.0)
非胃肠道衰竭组 Non-Gastrointestinal failure(n=30) 0(0) 4(13.3) 15(50.0)
χ2 4.827 8.049 4.309
P 0.028 0.005 0.038
在重度AP患者亚组分析中,胃肠道衰竭组患者的住院死亡率(14.5% 比0;χ2=4.827,P=0.028)、继发感染比例(33.9%比13.3%;χ2=8.049,P=0.005)和收住ICU比例(79.0%比50.0%;χ2=4.309,P=0.038)均显著高于非胃肠道衰竭组。亚组中生存分析结果显示,重度AP合并胃肠道衰竭患者的预后显著下降(P<0.05)(图2)。
图2 重度急性胰腺炎患者中非胃肠道衰竭组与胃肠道衰竭组患者生存分析比较

Fig 2 Survival curve analysis of severe acute pancreatitis patients with and without gastrointestinal failure

肠道衰竭的危险因素 以胃肠道衰竭(AGI分级≥Ⅲ级)为自变量,以年龄、性别,入院24 h影像学提示坏死物积聚,入院即刻血白细胞升高、血白蛋白降低、血总钙降低、血肌酐水平升高(按检查结果是否异常转换为分类变量,结果异常者赋值为1,正常者赋值为0),入院即刻查体出现腹膜炎体征、排气排便停止为因变量,Logistic回归分析结果显示,年龄(OR=1.06,95%CI:1.03~1.09,P<0.001)、入院主诉排气排便停止(OR=7.02,95%CI:2.08~23.66,P=0.002)、血白细胞水平升高(OR=1.09,95%CI:1.02~1.17,P=0.015)、血白蛋白水平降低(OR=0.93,95%CI:0.86~1.00,P=0.048)、血肌酐水平升高(OR=1.02,95%CI:1.01~1.04,P=0.001)是胃肠道衰竭的独立危险因素(表4)。
表4 中重度急性胰腺炎患者胃肠道衰竭的独立危险因素

Table 4 Independent risk facors for gastrointestinal failure in paitents with moderate to severe acutea pancreatitis

项目Item B SE Wald χ2 P OR(95% CI)
性别Gender 0.87 0.52 2.81 0.094 2.39(0.86-6.59)
年龄Age 0.06 0.02 14.21 <0.001 1.06(1.03-1.09)
坏死物积聚Necrotic collection -0.07 0.48 0.02 0.890 0.94(0.37-2.39)
血白细胞White blood cell 0.09 0.04 5.95 0.015 1.09(1.02-1.17)
血白蛋白Serum albumin -0.08 0.04 5.73 0.048 0.93(0.86-1.00)
血总钙Serum calcium -0.38 1.08 0.12 0.726 0.69(0.08-5.64)
血肌酐Serum creatinine 0.02 0.01 11.22 0.001 1.02(1.01-1.04)
腹膜炎体征Signs of peritoneal irritation -0.64 0.51 1.57 0.210 0.53(0.19-1.44)
排气排便停止Flatus and defecation stop 1.95 0.62 9.88 0.002 7.02(2.08-23.66)
常量Constant -4.21 2.71 2.41 0.120 0.02
采用ROC曲线分析血白细胞、血白蛋白和血肌酐水平诊断胃肠道衰竭的能力,结果显示3者诊断的曲线下面积分别为0.655、0.729和0.651(图3)。其中,当血白细胞> 15.4×109时,诊断胃肠道衰竭的敏感性为62.2%,特异性为60.9%;血肌酐>106.0 μmol/L时,诊断胃肠道衰竭的敏感性为56.7%,特异性为93.6%;血白蛋 <35.5 g/L时,诊断胃肠道衰竭的敏感性为63.3%,特异性为60.0%。
图3 血白细胞、血肌酐、血白蛋白水平对中重度急性胰腺炎患者合并胃肠道衰竭的诊断能力分析

Fig 3 Values of white blood cell,serum creatinine,and serum albumin in predicting gastrointestinal failure in patients with moderate to severe acute pancreatitis

临床评分诊断胃肠道衰竭的能力 Spearman相关系数评价结果显示,APACHE Ⅱ 评分(r=0.848,P<0.001)和BISAP评分(r=0.568,P<0.001)与AGI分级均存在显著正相关,CTSI评分与AGI分级无显著相关关系(P=0.091)。
ROC曲线分析结果显示,入院即刻APACHE Ⅱ 的曲线下面积为0.999,BISAP评分曲线下面积为0.782(图4)。当APACHE Ⅱ 评分>12分时,诊断胃肠道衰竭的敏感性为98.7%,特异性为100%;当BISAP评分>3分时,诊断胃肠道衰竭的敏感性为61.8%,特异性为81.8%。
图4 各临床评分对中重度急性胰腺炎患者合并胃肠道衰竭的诊断能力分析

APACHEⅡ:急性生理与慢性健康评分Ⅱ;BISAP:急性胰腺炎床旁严重程度指数

Fig 4 Values of various clinical scorings systems in predicting gastrointestinal failure in patients with moderate to severe acute pancreatitis

APACHEⅡ:Acute Physiology and Chronic Health Evaluation Ⅱ;BISAP:Beside Index for Severity in Acute Pancreatitis

讨 论

众多研究提示肠道屏障受损后会导致中重度AP继发感染等问题,因此中重度AP患者中早期识别胃肠道衰竭至关重要。然而目前尚缺乏理想的早期识别指标,因此本研究目的是探索急性胃肠道损伤分级在AP相关胃肠道衰竭中的应用及其早期诊断指标。结果发现,在中重度AP患者中AGI分级系统与预后密切相关,依据该分级系统分类为胃肠道衰竭患者的死亡风险显著增加。同时,考虑到该分级系统评价时间相对滞后(入院1周),本研究首次探索了现有临床评分系统(APACHE Ⅱ评分、BISAP评分等)和实验室指标对胃肠道衰竭的诊断价值,期望能够早期诊断、早期干预。结果显示,入院即刻APACHE Ⅱ评分和BISAP评分与AGI分级相关性较好,且对胃肠道衰竭均有较好的诊断价值(APACHE Ⅱ评分> 12分、BISAP评分> 3分)。此外,外周血白细胞、白蛋白和肌酐水平也有助于诊断AP合并胃肠道衰竭。
2012年欧洲重症医学协会提出AGI分级系统,该分级系统依据胃肠道症状、食物耐受能力和肠内营养恢复能力将胃肠道功能分为Ⅰ级至Ⅳ级,其中分级≥Ⅲ级定义为胃肠道衰竭。在此基础上,又有研究提出,通过入院后1周的动态评价,选取最严重的分级程度作为评价标准,优于单次、随机评价,对预后有更好的指导意义[5]。AP作为消化道的危急重症,也在本分级系统的应用范围之内。Sun等[10]曾提出AGI分级可用于评价重症AP患者胃肠道功能,且对预后有重要影响,但该研究样本量较小(52 例患者),并未纳入轻中度患者,且未能提出有效早期诊断胃肠道衰竭的指标以改善临床实践,故指导意义有限。
本中心此前一项研究通过AGI系统评价AP患者早期应用肠内营养的效果,结果提示AGI系统和APACHEⅡ评分等具有良好的相关性,且早期肠内营养能够改善AP患者的胃肠道功能[11]。本研究通过希望进一步扩大样本量,并重点分析AGI分级系统对临床预后的诊断价值。由于轻度AP患者病情较轻,住院时间常小于1周,不合并全身并发症,故本研究仅纳入中重度AP患者。结果显示,AGI系统与临床预后密切相关,表现为AGI分级≥Ⅲ级患者的死亡比例、继发感染比例和ICU比例均显著升高,生存分析显示AGI分级系统定义的胃肠道衰竭显著增加AP患者的死亡风险。同时,为了避免病情严重程度带来的偏移,本研究进一步在重度AP患者亚组中评价胃肠道衰竭对预后影响。结果显示,重度AP合并胃肠道衰竭的患者病情严重程度进一步加重,表现为临床评分升高、MODS比例升高,且生存分析显示临床预后显著下降。
本研究存在以下局限性:(1)AGI分级系统虽然定义简洁、易于推广,但其指标较为主观,且未将胃肠道屏障功能相关的客观指标纳入,故可能存在偏移。(2)本研究为单中心、回顾性研究,且样本量有限,研究结果有待多中心、前瞻性、大样本研究验证。
综上,本研究结果发现,AGI分级系统定义的胃肠道衰竭是AP患者死亡的独立危险因素,可显著增加AP患者死亡风险,入院即刻APACHE Ⅱ评分、BISAP评分和CTSI评分对胃肠道衰竭具有较好的诊断价值。

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