探讨儿童重症急性胰腺炎（SAP）的诊断及治疗方式。

回顾性分析2023年2月兰州大学第二医院收治的1例儿童SAP患者临床资料。患儿男，10岁，因“进食油腻食物后持续性上腹痛伴间断呕吐2 d”于2023年2月2日入院。体检：体温36.8℃，心率167次/分，呼吸45次/分，血压92/52 mmHg（1 mmHg=0.133 kPa）。神志不清，意识模糊、谵妄，面色苍白，全身皮肤湿冷，口唇发绀，瞳孔对光反射欠灵敏；全腹腹肌紧张，查体不配合，压痛反跳痛未引出，吸气性三凹征弱阳性、心音低钝。实验室检查：Scr 224.3 μmol/L，血淀粉酶 1 252 U/L，血清脂肪酶>2 000 U/L，乳酸脱氢酶521 U/L，B型利钠肽 2 934 pg/ml；WBC 36.3×10⁹/L，Hb 157 g/L，Plt 347×10⁹/L，血钾7.83 mmol/L，血钠 120 mmol/L，血氯87.9 mmol/L。腹部超声：脂肪肝，胆囊积液，胰腺肿大并胰周积液。结合患儿临床表现及检验检查结果，诊断为小儿SAP伴多器官功能衰竭，弥漫性腹膜炎，感染性休克。

患儿入院后立即给予复苏囊正压通气，气管插管有创呼吸机辅助通气，白蛋白扩容、去甲肾上腺素升压、肾上腺素强心等对症治疗。经全科讨论后给予连续性肾脏替代治疗（CRRT）。并予以亚胺培南抗感染、丙泊酚镇静，其余治疗予以营养心肌、抑酸、抑制胰酶分泌、中药灌肠等对症治疗。2周后患儿情况有所好转，撤离呼吸机，停止CRRT。放置空肠营养管行肠内营养治疗。5 d后患儿胃肠减压管引出暗红色液体，排暗红色血便，行胃镜检查示胃底及胃体大弯侧多发曲张静脉，迂曲走行，胃底为著，局部呈结节状，最大直径约1 cm，红色征阳性。经普外科会诊后于2023年2月24日急诊行开腹胰周坏死脓肿切除术及脾切除术。术后1月患儿经内科规律抗感染治疗后出院。术后随访1年，患儿已恢复正常学习生活。

对于儿童SAP，应及时诊断和干预，防止出现进一步并发症。在儿童SAP管理中，及时实现内外科治疗转换有重要意义，急需开展前瞻性多中心研究，以制定循证指南，优化儿童SAP的治疗和管理。

To investigate the diagnosis and treatment of severe acute pancreatitis (SAP) in a child.

Clinical data of a child with SAP admitted to Lanzhou University Second Hospital in February 2023 were retrospectively analyzed. On February 2, 2023, a 10-year-old boy was hospitalized due to "persistent epigastric pain with intermittent vomiting for 2 d after eating greasy food". Physical examination: body temperature of 36.8℃, heart rate of 167 beats/min, respiratory rate of 45/min, blood pressure of 92/52 mmHg (1 mmHg=0.133 kPa). He was unconscious and delirious, manifested with pale face, wet and cold skin all over the body, cyanosis of mouth and lips, and insensitive pupil light reflex. The abdominal muscles of the whole abdomen were tense. He was unable to cooperate with physical examination. No tenderness or rebound pain was observed. The patient showed weakly-positive inspiratory three-concave sign, and low and dull heart sound. Laboratory examination: Scr level of 224.3 μmol/L, amylase level of 1 252 U/L, serum lipase level of >2 000 U/L, lactate dehydrogenase level of 521 U/L, B-type natriuretic peptide of 2 934 pg/mL, WBC of 36.3×10⁹/L, Hb of 157 g/L, Plt of 347×10⁹/L, blood potassium level of 7.83 mmol/L, blood sodium level of 120 mmol/L and blood chlorine level of 87.9 mmol/L, respectively. Abdominal ultrasound demonstrated fatty liver, gallbladder effusion, pancreatic enlargement complicated with peripancreatic effusion. Based on clinical manifestations and detection results, the child was diagnosed with SAP complicated with multiple organ failure, diffuse peritonitis and septic shock.

Upon admission, the child was given with positive pressure ventilation using resuscitation bag, invasive ventilator-assisted ventilation by tracheal intubation, albumin expansion, norepinephrine for increasing blood pressure and epinephrine for strengthening heart function. Continuous renal replacement therapy (CRRT) was delivered after general consultation. Imipenem was given for anti-infection and propofol for sedation. Symptomatic treatment, such as nourishing myocardium, inhibiting acid, inhibiting the secretion of pancreatic enzyme and enema with traditional Chinese medicine, was also delivered. After 2 weeks, the child was given with ventilator weaning after proper improvement, and CRRT was terminated. Enteral nutrition therapy was performed by placing jejunal tube. After 5 d, dark red fluid and bloody stool were discharged via gastrointestinal decompression tube. Gastroscopy showed multiple varicose veins at the gastric fundus and gastric greater curvature, manifested with tortuosity especially at the gastric fundus, and local nodules with a maximum diameter of approximately 1 cm. He was positive for red color sign. After Department of General Surgery consultation, emergent open peripancreatic necrotic abscess resection and splenectomy were performed on February 24, 2023. At postoperative 1 month, the child was discharged after regular anti-infection treatment. After 1-year follow-up, the child resumed normal study and life.

For pediatric SAP, prompt diagnosis and interventions should be delivered to prevent subsequent complications. It's of importance to timely conversion of medical and surgical treatment in the management of pediatric SAP. Prospective multi-center trials are required to formulate evidence-based guidelines and optimize the treatment and management of pediatric SAP.