VIÊM TUỴ CẤP

TRẺ EM
Ths.Bs Nguyễn Hồng Vân Khánh
Phó khoa Gan Mật Tuỵ - Ghép gan
Bệnh viện Nhi Đồng 2
 Pretest

Câu 1:
Các xét nghiệm cận lâm sàng trong VTC
A. Amylase độ nhạy và đặc hiệu hơn lipase trong VTC
B. Amylase và Lypase tăng tương ứng với độ nặng của viêm tuỵ
C. Amylase về bình thường nhanh hơn Lipase
D. Amylase và lipase chỉ cùng tăng trong viêm tuỵ cấp
 Pretest

Câu 2:
Chọn câu đúng nhất trong chẩn đoán VTC
A. VTC được chẩn đoán khi men tuỵ Amylase hoặc Lipase tăng gấp 3 giới hạn trên
B. Chẩn đoán VTC phải có hình ảnh ghi nhận tuỵ viêm
C. Lâm sàng là quan trọng nhất trong chẩn đoán VTC
D. Bệnh nhân đến trễ, Amylase và Lipase có thể không tăng
 Pretest

Câu 3:
Dấu hiệu đau bụng trong VTC
A. ?Trẻ thường đau thượng vị lan ra sau lưng
B. 50% trẻ có biểu hiện đau bụng
C. Trẻ nhỏ có triệu chứng đau mơ hồ
D. Vị trí đau thượng vị ít gặp ở trẻ em
 Pretest

Câu 4:
Chẩn đoán hình ảnh trong VTC, chọn câu sai
A. Siêu âm là phương tiện đầu tay trong khảo sát tuỵ và biến chứng tại chỗ
B. CT nên thực hiện khi bệnh nhân diễn tiến xấu và khi chẩn đoán chưa rõ ràng
C. MRCP nên thực hiện ở giai đoạn đầu để kịp thời phát hiện nguyên nhân do bất thường cấu trúc
ống dẫn mật, tuỵ
D. CT nên thực hiện sau khi khởi phát triện chứng 72 đến 96 giờ
 Pretest

Câu 5:
Điều trị đau trong VTC, chọn câu đúng
A. Không nên dùng Morphin vì gây co thắt cơ vòng Oddi
B. Paracetamol và NSAID là thuốc đầu tay trong điều trị
C. Bệnh nhân không nên dùng giảm đau mạnh vì giảm triệu chứng khó theo dõi
D. Bệnh nhân càng đau tiên lượng bệnh diễn tiến nặng
 Pretest

Câu 5:
Dinh dưỡng trong VTC, chọn câu đúng
A. Việc ăn không liên quan đến tăng đau trong VTC
B. Tất cả bệnh nhân nên nhịn ăn trong giai đoạn đầu để tuỵ nghỉ ngơi
C. Nếu bệnh nhân không ăn bằng đường miệng thì nuôi ăn tĩnh mạch
D. Khi Amylase và Lipase tăng ngừng ăn lại
 Pretest

Câu 5:
Truyền dich trong VTC
A. Nên chọn dung dịch cao phân tử đầu tay trong các trường hợp VTC thể nặng
B. Không cần hiệu chỉnh cân nặng lý tưởng khi truyền dịch đối với bệnh nhân dư cân
C. Dịch nên duy trì kéo dài đến khi bệnh nhân phục hồi hoàn toàn
D. Lượng dịch ban đầu nên 1,5 - 2 lần nhu cầu cơ bản
 Mục tiêu

1 3 5
Nắm được chẩn
2 4 Biết một số biến
Hiểu đuơc giá trị
đoán VTC chứng và theo dõi
các xét nghiệm Nắm được các điều
Biết được nguyên
CLS và CDHA trị cơ bản trong
nhân gây VTC
VTC
Phân loại

Acute Pancreatitis - Severe Acute Pancreatitis

Recurrent Acute Pancreatitis
Chronic Pancreatitis
 INSPPIRE
Phân loại (INternational Study
Group of Pediatric
Acute Pancreatitis Phục hồi Pancreatitis: In
Abdominal pain suggestive of AP search for a cuRE)
Amylase and/or lipase levels at least 3 times
Imaging findings consistent with AP

Acute Recurrent Pancreatitis

>=2 acute attacks/a year, interval resolution of pain and enzyme
levels, or
More than 3 lifetime episodes without evidence of CP
Không
Chronic Pancreatitis hồi phục
Irreversible pancreatic duct strictures, exocrine pancreatic
insufficiency, insulin-dependent diabetes mellitus
 Dịch tễ
United Kingdom: 0.78/100,000/year pediatric cases
United Statesper 13.2/100,000/year pediatric cases
Mean age: 9.2 ± 2.4 (SD) years (1 week–21 years)
Frequently in girls than in boys

Ricardo Restrepo1 Heidi E. Hagerott2 Sakil Kulkarni2 Mona Yasrebi3 Edward Y. Lee4 (2018) Acute Pancreatitis in
Pediatric Patients: Demographics, Etiology, and Diagnostic Imaging
Chức năng
Chức năng
 Sinh lý bệnh

Pancreatic acinar cell. The diagram shows the initial insult, which leads to an inappropriate rise in intracellular calcium that
triggers the activation of trypsin and other digestive proenzymes, which in turn stimulate inflammatory cytokines, leading to
systemic inflammatory response syndrome (SIRS) and pancreatitis. Protective mechanisms include the inhibitory factors,
including pancreatic secretory trypsin inhibitor (PSTI), alpha-1 antitrypsin (a1AT), a2-macroglobulin (a2M), and
compensatory anti-inflammatory response syndrome (CARS). IL=interleukin, TNF=tumor necrosis factor.
BILIARY DISORDERS INFECTION
Viruses: mumps, measles, coxsackievirus, echovirus, influenza, hepatitis A,
Gallstones, microlithiasis, choledochal cyst, sludge, and pancreaticobiliary
EBV, CMV, HSV, VZV.
anomalies
Bacterial etiologies for pancreatitis include Mycoplasma pneumoniae,
Common etiologies, 3% to 30% of cases.
Salmonella, and gram-negative bacteria.

METABOLIC DISEASES

Nguyên nhân
SYSTEMIC CONDITIONS
Sepsis, shock, HUS, SLE, juvenile idiopathic arthritis, celiac disease, and
IBD, especially with PSC , cystic fibrosis sclerosing, polyarteritis
nodosum, Henoch-Schonlein purpura, and Kawasaki
MEDICATIONS
Immunologic reactions (eg, 6-mercaptopurine, amino salicylates)
Accumulation of toxic metabolites, ischemia (eg, diuretics),
Intravascular thrombosis (eg, estrogen), and increased viscosity of a
pancreatic juice (eg, glucocorticoids)
Diabetic ketoacidosis, hyperlipidemia, organic acidemias such as
methylmalonic academia, hypercalcemia, and alpha-1 anti- trypsin
deficiency.
Prolonged TPN may not only predispose children to AP but also trigger
acute episodes in patients with CP.
GENETIC DISORDERS
Genes involved in premature intrapancreatic activation of trypsin (CFTR,
PRSS1, PRSS2, SPINK1, CTRC, CTSB, KRT8, CASR) Calcium signaling
and zymogen exocytosis , in pancreatic secretion and ion homeostasis , and
in the autophagy pathway.

TRAUMA AUTOIMMUNE PANCREATITIS

Blunt injury, child abuse
Instrumentation of the pancreaticobiliary junction and pancreatic ducts via
endoscopic retrograde cholangiopancreatography (ERCP)
ANATOMICAL
Pancreaticobiliary junction malunion:poor flow of the pancreatic fluids
Annular pancreas: congenital anomaly increase the risk of pancreatitis.
Pancreas divisum and sphincter of Oddi dysfunction can result in inadequate
pancreatic secretion drainage
Thanh Huong L. Nguyen, MD,* Karla Au Yeung, MD,† Brian Pugmire, MD,‡ Roberto Gugig, MD (2020) Pancreatitis, AAP
Type 1 is associated with elevated immunoglobulin G4 levels, diffuse
narrowing of the main pancreatic duct, seg- mental enlargement of the
pancreas, and/or strictures of the lower bile ductType 2 is more common in
children and is associated with inflammatory bowel disease and other
autoimmune processes
IDIOPATHIC.
13% to 34%
decrease as genetic data for previously diagnosed idiopathic cases
emerge
 Nguyên nhân
Top 6 etiology: Idiopathic/other 24%,
trauma 17%, systemic illness 15%,
structural abnormalities 14%, drugs
10%, and infections 8%.

Urszula Grzybowska-Chlebowczyk1, Martyna Jasielska2, (2018)Acute pancreatitis in children, Gastroenterology Rev 2018; 13 (1): 69–75 DOI
https://doi.org/10.5114/pg.2017.70470
 Trẻ em vs người lớn

Anell Meyera, Michael J. Coffeyd,e, Mark R. Olivera,b,c, Chee Y. Ooid,e,*(2013) Contrasts and comparisons between childhood and adult onset
acute pancreatitis, Pancreatology
 Chẩn đoán
ABDOMINAL PAIN
68% - 95% of patients abdominal pain
62% - 89%: epigastric region
1.6% to 5.6% radiating back pain
followed by epigastric tenderness, nausea, and vomiting
Infants and toddlers: commonly with irritability and vomiting.

􏰏Maisam Abu-El-Haija, ySoma Kumar, zJose Antonio Quiros, §Keshawadhana Balakrishnan, jjBradley Barth, ôSamuel Bitton, #John F. Eisses (2018)
Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology
and Nutrition Pancreas Committee, JPGN 􏰐 Volume 66, Number 1
Thanh Huong L. Nguyen, MD,* Karla Au Yeung, MD,† Brian Pugmire, MD,‡ Roberto Gugig, MD (2020) Pancreatitis, AAP
 Chẩn đoán
BIOCHEMICAL
CRITERIA
Amylase elevated in 50% to 85%
Lipase elevated in 77% to 100%
Lipase is a more sensitive and specific marker of AP (87% – 100% and 95% – 100%, respectively)
Correlation of serum lipase or amylase levels and severity of disease is poor

􏰏Maisam Abu-El-Haija, ySoma Kumar, zJose Antonio Quiros, §Keshawadhana Balakrishnan, jjBradley Barth, ôSamuel Bitton, #John F. Eisses (2018) Management of
Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas
Committee, JPGN 􏰐 Volume 66, Number 1
Thanh Huong L. Nguyen, MD,* Karla Au Yeung, MD,† Brian Pugmire, MD,‡ Roberto Gugig, MD (2020) Pancreatitis, AAP
Chẩn đoán
BIOCHEMICAL
CRITERIA
Chẩn đoán
BIOCHEMICAL
CRITERIA
Chẩn đoán
BIOCHEMICAL
CRITERIA
 Chẩn đoán
BIOCHEMICAL
CRITERIA
Other laboratory tests for monitoring.
• Serum electrolytes, BUN, creatinine and a complete blood cell count: monitor hydration status and renal
function.
• A hepatic enzyme panel: seek biliary or gallstone etiology and to assess for organ involvement.
• Calcium and triglyceride levels should be considered baseline investigations
• Monitoring respiratory status can alert the clinician to the progression from mild to moderately severe or
severe AP.
• Blood gas, lactate: in severe AP
 Chẩn đoán
IMAGING

Transabdominal ultrasonography
• Initial imaging for suspected AP
• Effectiveness rate of 56% to 84% in pediatric patients with AP.
• Advantage: lacks ionizing radiation, is effective for the identification of gallstones and
pancreatic fluid collections, and comparatively costs less than other modalities
• Disadvantage: bowel gas, thick abdominal wall, obesity, The pancreas is not seen on
ultrasound in approximately 6–14% of children
 Chẩn đoán
IMAGING

Contrast-enhanced abdominal computed tomography

• Not firstline imaging due to radiation exposure
• Best for situations of diagnostic uncertainty and clinical deterioration, such as necrosis and
bleeding in clinically severe AP.
• More sensitive in detecting AP, complication and grading severity than ultrasound
• The optimal timing for detecting inflammatory changes surrounding the pancreas is at least
72 to 96 hours after initial AP presentation.
Chẩn đoán
IMAGING - Balthazar score

sensitivity, specificity, positive

predictive value, and negative
predictive value of 81%, 76%,
62%, and 90%,

􏰏Maisam Abu-El-Haija, ySoma Kumar, zJose

Antonio Quiros, §Keshawadhana Balakrishnan,
jjBradley Barth, ôSamuel Bitton, #John F. Eisses
(2018) Management of Acute Pancreatitis in the
Pediatric Population: A Clinical Report From the
North American Society for Pediatric
Gastroenterology, Hepatology and Nutrition
Pancreas Committee, JPGN 􏰐 Volume 66,
Number 1
 Chẩn đoán
IMAGING

MRCP
• Evaluation of the pancreaticobiliary system when TUS is suggestive of AIP or in pediatric
ARP and CP
• Less risk than ERCP and is highly sensitive in detecting congenital ductal abnormalities,
choledocholithiasis, strictures, pancreas divisum, and pancreatic and biliary tumors.
• Performed after an attack of AP has resolved as acute edema may obscure the visualization
of the ducts
 Chẩn đoán
IMAGING

ERCP
• Used only for therapeutic purposes due to the risks, such as bleeding, perforation, and
pancreatitis.
• he risk of pancreatitis after ERCP was reported to be 9.7%
 Phân độ nặng

Maisam Abu-El-Haija, ySoma Kumar, zFlora Szabo, §Steven Werlin, jjDarwin Conwell, ôPeter Banks, and #Veronique D. Morinville (2017) Classification of Acute Pancreatitis in the
Pediatric Population: Clinical Report From the NASPGHAN Pancreas Committee, JPGN 􏰐 Volume 64, Number 6,
 Phân độ nặng

Maisam Abu-El-Haija, ySoma Kumar, zFlora Szabo, §Steven Werlin, jjDarwin Conwell, ôPeter Banks, and #Veronique D. Morinville (2017) Classification of Acute Pancreatitis in the
Pediatric Population: Clinical Report From the NASPGHAN Pancreas Committee, JPGN 􏰐 Volume 64, Number 6,
 Phân độ nặng

Maisam Abu-El-Haija, ySoma Kumar, zFlora Szabo, §Steven Werlin, jjDarwin Conwell, ôPeter Banks, and #Veronique D. Morinville (2017) Classification of Acute Pancreatitis in the
Pediatric Population: Clinical Report From the NASPGHAN Pancreas Committee, JPGN 􏰐 Volume 64, Number 6,
 Biến chứng tại chỗ
• Local complications: peripancreatic fluid collections, necrotic fluid collections, pancreatic and
peripancreatic necrosis (sterile or infected), and development of pseudocysts and walled-off necrosis

• A pseudocyst, a mature fluid collection usually form in >4 weeks.

• Other less common complications: gastric outlet, duodenal obstruction, splenic and portal vein thromboses.
• Some of these complications may not/do not develop within the first few days of the onset of pancreatic
injury, but may manifest later.
• Recurrence of abdominal pain, development of fever, and new and progressive increase in serum pancreatic
enzyme levels could be signs indicating the development of complications.
 Biến chứng toàn thân
Systemic complications in pediatric AP would similarly include symptoms of exacerbation of underlying
previously diagnosed chronic illness such as of chronic lung disease, heart disease, or renal disease.

Maisam Abu-El-Haija, ySoma Kumar, zFlora Szabo, §Steven Werlin, jjDarwin Conwell, ôPeter Banks, and #Veronique D. Morinville (2017) Classification of Acute Pancreatitis in the
Pediatric Population: Clinical Report From the NASPGHAN Pancreas Committee, JPGN 􏰐 Volume 64, Number 6,
 Điều trị

Thanh Huong L. Nguyen, MD,* Karla Au Yeung, MD,† Brian Pugmire, MD,‡ Roberto Gugig, MD (2020) Pancreatitis, AAP
 Điều trị
FLUID RESUSCITATION
• Aggressive fluidresuscitation: mainstay in the acute management
• Current recommendations: initiation of therapy with dextrose-containing crystalloids or LR at 1.5 to 2
times maintenance within 24 hours
• Pediatric studies have demonstrated an association between aggressive fluid administration and fewer ICU
admissions, shortened hospital stays, and higher rates of clinical recovery

Thanh Huong L. Nguyen, MD,* Karla Au Yeung, MD,† Brian Pugmire, MD,‡ Roberto Gugig, MD (2020) Pancreatitis, AAP
 Điều trị
PAIN
• Acetaminophen and ibuprofen are the first-line agents for mild pain, and opioids are indicated for severe pain
• Cochrane review assessing the efficacy and safety of opioid use found that it is appropriate in the treatment of
pain related to AP and that its use may decrease the need for supplementary analgesia.

• Procaine, a local anesthetic that is administered system- ically, has been considered for basic analgesia for AP.

• Epidural anesthesia, used as a sympathetic nerve block that redistributes blood flow to nonperfused
pancreatic regions, has shown improved pancreatic perfusion, decreased AP pain, and the need for
necrosectomy.

Thanh Huong L. Nguyen, MD,* Karla Au Yeung, MD,† Brian Pugmire, MD,‡ Roberto Gugig, MD (2020) Pancreatitis, AAP
 Điều trị
NUTRITION.

• Pancreatic enzyme secretion is significantly reduced in AP, secretion was inversely related to the severity of
pancreatitis
• Early EN resulted in significant exacerbation of symptoms in only 4%
• Injured acinar cells cannot fully respond to physiologic stimuli --> enteral feeding is safe and does not worsen
autodigestion during an attack of pancreatitis
• Safety and benefits of enteral nutrients in terms of mortality, multiorgan failure, infection, complications, and
surgical intervention.
• Administration of EN to stimulate and maintain gut function
• Enteral nutrients help maintain gut integrity, gut-associated lymphoid tissue, and gut microbiota composition.
This strategy reduces bacterial, endotoxin, and pancreatic enzyme translocation, which may attenuate systemic
inflammation, multiorgan failure, infection, and disease severity in AP.

Lakananurak N, Gramlich L. Nutrition management in acute pancreatitis: Clinical practice consideration. World J Clin Cases. 2020 May 6;8(9):1561-1573. doi: 10.12998/wjcc.v8.i9.156
PMID: 32432134; PMCID: PMC7211526
 Điều trị
NUTRITION.

• Feeding within 24 to 48 hours of pancreatitis onset is recommended.

• Multiple studies support early feeding with a regular diet in mild AP because early feeding can reduce
the length of stay. Remaining nil per os or on a clear liquid diet does not improve abdominal pain.
• If a patient cannot tolerate an oral diet, nasogastric or nasojejunal enteral formula.
• Initiation of feedings is not dependent on the severity of pancreatitis, and studies have not demonstrated a
difference between nasogastric and nasojejunal feedings.

• Polymeric formula is appropriate first-line nutrition.

• TPN: enteral nutrition cannot be tolerated, such as pancreatic fistulae, perforated pancreatic duct, ileus,
or abdominal compartment syndrome. The risks of central line infections secondary to bacterial
translocation increase with TPN in the setting of AP.
Điều trị
ANTIBIOTICS
• Prophylactic antibiotics are not recommended in AP even in severe AP or existing necrosis, because
most are sterile.
• Indications for antibiotics include systemic infectious complications, cholangitis, and suspected
infected pancreatic necrosis.
• In the setting of persistent systemic inflammatory response beyond the first week of symptom onset,
ultrasonography guided fine needle aspiration could differentiate infected and sterile pancreatic
necroses.
• Imipenem, meropenem, fluoroquinolones, and metronidazole exhibit effective tissue penetration and
bactericidal properties for infected pancreatic necrosis and prevention of septic complications.
• Antibiotics ideally are used in conjunction with surgical or percutaneous drainage.
Điều trị
PHẪU THUẬT

• Chỉ định can thiệp ngoại khoa: Chấn thương tụy khi bệnh nhân không ổn định và tìm các tổn thương
cơ quan khác.
• Phẫu thuật cắt túi mật an toàn và nên thực hiện trong tình huống VTC do mật nhẹ không biến chứng.
• Trong VTC hoại tử, nên tránh can thiệp ngoại sớm và trì hoãn thậm chí khi có nhiễm trùng hoại tử,
kết quả tốt hơn rõ khi trì hoãn hơn 4 tuần.
• Khi cần dẫn lưu hoặc cắt lọc mô hoại tử, nên chọn các phương pháp ít xâm lấn như nội soi (siêu âm
qua nội soi, ERCP hỗ trợ) hoặc can thiệp qua da hạn chế phẫu thuật mở bụng lấy mô hoại tử hoặc dẫn
lưu nang.
 Tiên lượng
• 10% to 35% chance of AP recurrence after the initial episode
• 15% to 34% of pediatric patients develop severe disease
• Mortality rate 4 - 10%
• Risk factors play a major role in the development of ARP and CP include genetic mutations,
obstructions, toxic/metabolic disorders, and autoimmune processes
• Pancreatic fluid collection and pseudocysts are common complications of AP, occurring in
approximately 58% and 38% of children with AP

Ricardo Restrepo1 Heidi E. Hagerott2 Sakil Kulkarni2 Mona Yasrebi3 Edward Y. Lee4 (2018) Acute Pancreatitis in Pediatric Patients: Demographics,
Etiology, and Diagnostic Imaging
Thanh Huong L. Nguyen, MD,* Karla Au Yeung, MD,† Brian Pugmire, MD,‡ Roberto Gugig, MD (2020) Pancreatitis, AAP
Maisam Abu-El-Haija, ySoma Kumar, zFlora Szabo, §Steven Werlin, jjDarwin Conwell, ôPeter Banks, and #Veronique D. Morinville (2017) Classification of Acute Pancreatitis in the
Pediatric Population: Clinical Report From the NASPGHAN Pancreas Committee, JPGN 􏰐 Volume 64, Number 6,
Kết luận
• Nghĩ đến VTC trên trẻ có đau bụng
• Amylase Lipase tăng trong nhiều nguyên nhân --> phân tích trong bệnh cảnh chung
• Siêu âm là phương tiện CDHA đầu tay
• CT thực hiện khi chẩn đoán ko rõ ràng, diễn tiến xấu, ksat biến chứng, 72 - 96h
• MRI thực hiện sau viêm cấp phát hiện bất thường giải phẫu ống dẫn mật tuỵ
• Morphin an toàn trong giảm đau bệnh nhân VTC
• Dịch truyền 1,5 - 2 lần nhu cầu
• Cho ăn sớm, không phụ thuộc đau bụng và men tuỵ tăng
• Không cho KS dự phòng và không có bằng chứng nhiễm trùng
• Hạn chế can thiệp xâm lấn trên bệnh nhân VTC