急性胆源性胰腺炎诊疗进展：循证更新与临床实践优化

唐 玉强1, 刘林 勋*2
1、青海大学临床医学院
2、青海省人民医院

摘要


急性胆源性胰腺炎（ABP）作为胆石症最严重的并发症，占急性胰腺炎病因的50%-70%，其全球疾病负担因胆石症患病率上升而持续加重。本文聚焦三大核心议题：（1）诊断革新：提出基于内镜超声（EUS）联合MRCP的病因分型策略，显著提升微结石检出率（51% vs. 20%），指导个体化干预；（2）关键争议优化：ERCP指征决策：强调合并胆管炎/梗阻时24小时内行ERCP可降低病死率（OR=0.42），但无梗阻者需规避误吸性肺炎等风险（OR=4.00）；胆囊切除术时机：同次住院手术（IAC）使复发风险降低90%（RR=0.10），延迟手术（>4周）致33.3%患者再入院；重症管理：微创升阶梯策略降低病死率15%，早期肠内营养（24-72小时）及抗生素分层使用规范疗效显著；（3）未来方向：人工智能驱动影像组学提升早期诊断精度，靶向肠道菌群干预及机器人辅助清创术等微创技术将重塑诊疗范式。综述撰写目的在于整合2020-2024年循证证据，破解临床实践差异，构建个体化诊疗框架，最终改善预后并减轻医疗系统负担。

关键词


急性胆源性胰腺炎；内镜逆行胰胆管造影术；胆囊切除术时机；内镜超声；微创治疗；多学科管理

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参考


[1]PATEL H, JEPSEN J. Gallstone Disease: Common Questions and Answers [J]. Am Fam Physician, 2024, 109(6): 518-24.

[2]RESHETNYAK V I. Concept of the pathogenesis and treatment of cholelithiasis [J]. World J Hepatol, 2012, 4(2): 18-34.

[3]ETHERIDGE J C, CASTILLO-ANGELES M, SINYARD R D, et al. Impact of hospital characteristics on best-practice adherence for gallstone pancreatitis: a nationwide analysis [J]. Surg Endosc, 2023, 37(1): 127-33.

[4]WANG G J, GAO C F, WEI D, et al. Acute pancreatitis: etiology and common pathogenesis [J]. World J Gastroenterol, 2009, 15(12): 1427-30.

[5]PRASANTH J, PRASAD M, MAHAPATRA S J, et al. Early Versus Delayed Cholecystectomy for Acute Biliary Pancreatitis: A Systematic Review and Meta-Analysis [J]. World J Surg, 2022, 46(6): 1359-75.

[6]VAN GEENEN E J, VAN DER PEET D L, BHAGIRATH P, et al. Etiology and diagnosis of acute biliary pancreatitis [J]. Nat Rev Gastroenterol Hepatol, 2010, 7(9): 495-502.

[7]WILKINS T, AGABIN E, VARGHESE J, et al. Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia Early Versus Delayed Cholecystectomy for Acute Biliary Pancreatitis: A Systematic Review and Meta-Analysis [J]. Prim Care, 2017, 44(4): 575-97.

[8]BORNMAN P C, BECKINGHAM I J, KRIGE J E, et al. Gallstone pancreatitis--a critical review of current treatment strategies [Acute biliary pancreatitis. Therapeutic trends][J]. S Afr J Surg, 2000, 38(4): 97-9.

[9]ŞURLIN V, SĂFTOIU A, DUMITRESCU D. Imaging tests for accurate diagnosis of acute biliary pancreatitis [J]. World J Gastroenterol, 2014, 20(44): 16544-9.

[10]DILL J E, HILL S, CALLIS J, et al. Combined endoscopic ultrasound and stimulated biliary drainage in cholecystitis and microlithiasis--diagnoses and outcomes [J]. Endoscopy, 1995, 27(6): 424-7.

[11]ŻORNIAK M, SIRTL S, BEYER G, et al. Consensus definition of sludge and microlithiasis as a possible cause of pancreatitis [J]. Gut, 2023, 72(10): 1919-26.

[12]BUXBAUM J L, ABBAS FEHMI S M, SULTAN S, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis [J]. Gastrointest Endosc, 2019, 89(6): 1075-105 e15.

[13]MAITRA I, BENNETT G, MORAIS C, et al. Laparoscopic cholecystectomy for mild acute gallstone pancreatitis-indication itself is a good predictor of (minimal) intraoperative difficulty-a retrospective cohort study [J]. Turk J Surg, 2021, 37(2): 103-8.

[14]ORTEGA A R, GóMEZ-RODRíGUEZ R, ROMERO M, et al. Prospective comparison of endoscopic ultrasonography and magnetic resonance cholangiopancreatography in the etiological diagnosis of “idiopathic” acute pancreatitis [J]. Pancreas, 2011, 40(2): 289-94.

[15]MONTENEGRO A, ANDúJAR X, FERNáNDEZ-BAñARES F, et al. Usefulness of endoscopic ultrasound in patients with minilithiasis and/or biliary sludge as a cause of symptoms of probable biliary origin after cholecystectomy Combined endoscopic ultrasound and stimulated biliary drainage in cholecystitis and microlithiasis--diagnoses and outcomes Idiopathic acute pancreatitis-A myth or reality? Role of endoscopic ultrasonography and magnetic resonance cholangiopancreatography in its diagnosis [J]. Gastroenterol Hepatol, 2022, 45(2): 91-8.

[16]ROSMORDUC O, POUPON R. Low phospholipid associated cholelithiasis: association with mutation in the MDR3/ABCB4 gene [J]. Orphanet J Rare Dis, 2007, 2: 29.

[17]ELTA G H. Sphincter of Oddi dysfunction and bile duct microlithiasis in acute idiopathic pancreatitis [J]. World J Gastroenterol, 2008, 14(7): 1023-6.

[18]MALOOF T, RODRIGUES D, LI T, et al. Early Endoscopic Retrograde Cholangiopancreatography in Gallstone Pancreatitis Is Safe: Results From a Large Single-Center Retrospective Study [J]. Pancreas, 2024, 53(8): e657-e61.

[19]VAN SANTVOORT H C, BESSELINK M G, DE VRIES A C, et al. Early endoscopic retrograde cholangiopancreatography in predicted severe acute biliary pancreatitis: a prospective multicenter study [J]. Ann Surg, 2009, 250(1): 68-75.

[20]HALLENSLEBEN N D, STASSEN P M C, SCHEPERS N J, et al. Patient selection for urgent endoscopic retrograde cholangio-pancreatography by endoscopic ultrasound in predicted severe acute biliary pancreatitis (APEC-2): a multicentre prospective study Timing of Performing Endoscopic Retrograde Cholangiopancreatography and Inpatient Mortality in Acute Cholangitis: A Systematic Review and Meta-Analysis [J]. Gut, 2023, 72(8): 1534-42.

[21]VAN GEENEN E J, MULDER C J, VAN DER PEET D L, et al. Endoscopic treatment of acute biliary pancreatitis: a national survey among Dutch gastroenterologists Early Endoscopic Retrograde Cholangiopancreatography in Gallstone Pancreatitis Is Safe: Results From a Large Single-Center Retrospective Study [J]. Scand J Gastroenterol, 2010, 45(9): 1116-20.

[22]WEISSMAN S, SHARMA S, EHRLICH D, et al. The role and timing of endoscopic retrograde cholangiopancreatography in acute biliary pancreatitis without cholangitis: A nationwide analysis Optimal timing of endoscopic retrograde cholangiopancreatography for acute cholangitis associated with distal malignant biliary obstruction [J]. J Hepatobiliary Pancreat Sci, 2023, 30(6): 767-76.

[23]BUONOCORE M R, GERMANI U, CASTELLANI D, et al. Timing of endoscopic therapy for acute bilio-pancreatic diseases: a practical overview [J]. Ann Gastroenterol, 2021, 34(2): 125-9.

[24]PARIKH M P, WADHWA V, THOTA P N, et al. Outcomes Associated With Timing of ERCP in Acute Cholangitis Secondary to Choledocholithiasis [J]. J Clin Gastroenterol, 2018, 52(10): e97-e102.

[25]PARK N, LEE S H, YOU M S, et al. Optimal timing of endoscopic retrograde cholangiopancreatography for acute cholangitis associated with distal malignant biliary obstruction [J]. BMC Gastroenterol, 2021, 21(1): 175.

[26]TSE F, YUAN Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis [J]. Cochrane Database Syst Rev, 2012, 2012(5): CD009779.

[27]FöLSCH U R, NITSCHE R, LüDTKE R, et al. Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis. The German Study Group on Acute Biliary Pancreatitis Urgent ERCP in all cases of acute biliary pancreatitis? A prospective randomized multicenter study [J]. N Engl J Med, 1997, 336(4): 237-42.

[28]TAN M, SCHAFFALITZKY DE MUCKADELL O B, LAURSEN S B. Association between early ERCP and mortality in patients with acute cholangitis [J]. Gastrointest Endosc, 2018, 87(1): 185-92.

[29]DUPONT B, LOZAC’H J, ALVES A. Etiological treatment of gallstone acute pancreatitis [J]. World J Gastrointest Surg, 2025, 17(5): 105410.

[30]SVATOŇ R, KALA Z, NOVOTNý I, et al. The timing of ERCP in acute biliary pancreatitis [J]. Rozhl Chir, 2019, 98(1): 10-3.

[31]ACKERMANN T G, CASHIN P A, ALWAN M, et al. The Role of Laparoscopic Cholecystectomy After Severe and/or Necrotic Pancreatitis in the Setting of Modern Minimally Invasive Management of Pancreatic Necrosis Effect of surgical timing on outcomes after cholecystectomy for mild gallstone pancreatitis [J]. Pancreas, 2020, 49(7): 935-40.

[32]CHO N Y, CHERVU N L, SAKOWITZ S, et al. Effect of surgical timing on outcomes after cholecystectomy for mild gallstone pancreatitis [J]. Surgery, 2023, 174(3): 660-5.

[33]RIQUELME F, MARINKOVIC B, SALAZAR M, et al. Early laparoscopic cholecystectomy reduces hospital stay in mild gallstone pancreatitis. A randomized controlled trial [J]. HPB (Oxford), 2020, 22(1): 26-33.

[34]BASILE G, VACANTE M, CORSARO A, et al. Treatment of acute pancreatitis Clinical outcomes of early and delayed cholecystectomy for acute gallstone-related disease [J]. Minerva Surg, 2025, 80(3): 236-57.

[35]CAMERON D R, GOODMAN A J. Delayed cholecystectomy for gallstone pancreatitis: re-admissions and outcomes [J]. Ann R Coll Surg Engl, 2004, 86(5): 358-62.

[36]AMIRTHALINGAM V, LOW J K, WOON W, et al. Tokyo Guidelines 2013 may be too restrictive and patients with moderate and severe acute cholecystitis can be managed by early cholecystectomy too [J]. Surg Endosc, 2017, 31(7): 2892-900.

[37]MUECK K M, WEI S, PEDROZA C, et al. Gallstone Pancreatitis: Admission Versus Normal Cholecystectomy-a Randomized Trial (Gallstone PANC Trial) [J]. Ann Surg, 2019, 270(3): 519-27.

[38]LYU Y X, CHENG Y X, JIN H F, et al. Same-admission versus delayed cholecystectomy for mild acute biliary pancreatitis: a systematic review and meta-analysis [J]. BMC Surg, 2018, 18(1): 111.

[39]KWONG W T, VEGE S S, MACES S, et al. Unrecognized necrosis at same admission cholecystectomy for pancreatitis increases organ failure and infected necrosis Cholecystectomy in Mild and Moderate Acute Pancreatitis: A Retrospective Study [J]. Pancreatology, 2017, 17(1): 41-4.

[40]GUADAGNI S, CENGELI I, PALMERI M, et al. Early cholecystectomy for non-severe acute gallstone pancreatitis: easier said than done [J]. Minerva Chir, 2017, 72(2): 91-7.

[41]AKSOY F, DEMIRAL G, EKINCI Ö. Can the timing of laparoscopic cholecystectomy after biliary pancreatitis change the conversion rate to open surgery? [J]. Asian J Surg, 2018, 41(4): 307-12.

[42]GIUFFRIDA P, BIAGIOLA D, CRISTIANO A, et al. Laparoscopic cholecystectomy in acute mild gallstone pancreatitis: how early is safe? Laparoscopic cholecystectomy in acute gallstone pancreatitis in index hospital admission: feasibility and safety [J]. Updates Surg, 2020, 72(1): 129-35.

[43]DEGRATE L, BERNASCONI D P, MERONI P, et al. Mild acute biliary pancreatitis: the timing of cholecystectomy should not exceed index admission [J]. Minerva Chir, 2017, 72(5): 383-90.

[44]ARVANITAKIS M, GKOLFAKIS P, FERNANDEZ Y V M, et al. Nutrition in acute pancreatitis American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis [J]. Curr Opin Clin Nutr Metab Care, 2021, 24(5): 428-32.

[45]VISHNUPRIYA K, CHANMUGAM A, ARVANITAKIS M, et al. Acute Pancreatitis: The Increasing Role of Medical Management of a Traditionally Surgically Managed Disease Nutrition in acute pancreatitis American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis [J]. Am J Med, 2022, 135(2): 167-72.

[46]BARON T H, DIMAIO C J, WANG A Y, et al. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis [J]. Gastroenterology, 2020, 158(1): 67-75 e1.

[47]GOMES C A, DI SAVERIO S, SARTELLI M, et al. Severe acute pancreatitis: eight fundamental steps revised according to the ‘PANCREAS’ acronym [J]. Ann R Coll Surg Engl, 2020, 102(8): 555-9.

[48]TAKADA T, ISAJI S, MAYUMI T, et al. JPN clinical practice guidelines 2021 with easy-to-understand explanations for the management of acute pancreatitis Acute Pancreatitis: The Increasing Role of Medical Management of a Traditionally Surgically Managed Disease Nutrition in acute pancreatitis American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis [J]. J Hepatobiliary Pancreat Sci, 2022, 29(10): 1057-83.

[49]PODDA M, PELLINO G, DI SAVERIO S, et al. Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study [J]. Updates Surg, 2023, 75(3): 493-522.

[50]HERBERS U, TRAUTWEIN C, TACKE F, et al. [Diagnosis and stage-adapted treatment of acute pancreatitis[J]. Med Klin Intensivmed Notfmed, 2018, 113(7): 593-605.

[51]BRUNO M J. Improving the Outcome of Acute Pancreatitis [J]. Dig Dis, 2016, 34(5): 540-5.

[52]LEE P J, PAPACHRISTOU G I. Management of Severe Acute Pancreatitis [J]. Curr Treat Options Gastroenterol, 2020, 18(4): 670-81.

[53]BUSH N, KHASHAB M, AKSHINTALA V S. Current and Emerging Applications of Artificial Intelligence (AI) in the Management of Pancreatobiliary (PB) disorders [J]. Curr Gastroenterol Rep, 2024, 26(11): 304-9.

[54]HU J X, ZHAO C F, WANG S L, et al. Acute pancreatitis: A review of diagnosis, severity prediction and prognosis assessment from imaging technology, scoring system and artificial intelligence [J]. World J Gastroenterol, 2023, 29(37): 5268-91.

[55]LIU Q, RUAN K, AN Z, et al. Updated review of research on the role of the gut microbiota and microbiota-derived metabolites in acute pancreatitis progression and inflammation-targeted therapy [J]. Int J Biol Sci, 2025, 21(3): 1242-58.

[56]ZHANG C, LI G, LU T, et al. The Interaction of Microbiome and Pancreas in Acute Pancreatitis [J]. Biomolecules, 2023, 14(1).

[57]TAKENAKA M, SAITO T, HAMADA T, et al. Disconnected pancreatic duct syndrome: diagnostic and therapeutic challenges and future directions Current and Emerging Applications of Artificial Intelligence (AI) in the Management of Pancreatobiliary (PB) disorders A Modified AUGIS Delphi Process to Establish Future Research Priorities in Benign Upper Gastrointestinal Surgery Acute pancreatitis: management update and future directions of pancreatic imaging [J]. Expert Rev Gastroenterol Hepatol, 2024, 18(10): 631-45.

[58]PODDA M, PISANU A, PELLINO G, et al. Machine learning for the rElapse risk eValuation in acute biliary pancreatitis: The deep learning MINERVA study protocol [J]. World J Emerg Surg, 2025, 20(1): 17.

[59]DI VINCENZO F, NICOLETTI A, NEGRI M, et al. Gut Microbiota and Antibiotic Treatments for the Main Non-Oncologic Hepato-Biliary-Pancreatic Disorders [J]. Antibiotics (Basel), 2023, 12(6).

[60]CRIBARI C, TIERNEY J, LAGRONE L. Managing complicated pancreatitis with more knowledge and a bigger toolbox! [J]. Trauma Surg Acute Care Open, 2025, 10(Suppl 1): e001798.

[61]中华医学会消化病学分会胰腺疾病学组.中国急性胰腺炎诊治指南（草案）[J].中华消化杂志，2004，（03）：62-64.


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