胰腺疾病-外科教学课件

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1、Diseases of pancreas DAI Chao-Liu2nd clinical college of China Medical University Acute pancreatitis Anatomy Head, neck.body, tail, uncinate process, Main pancreatic duct (duct of Wirsung) Dorsal pancreatic duct (duct of Santorini) Pancreatic excretion Exocrine (extra secretion) Endocrineinternal se

2、cretion):B,A,D,G cellc Causes Gallstones:60%( 3550% in USA) Alcohol:!4% Drug: Azathioprine .6-Mercaptopurine- Pancreas divisum(胰腺分裂;胰分裂) Microlithiasis Metabolic cause Sphincter of Oddi dysfunction Infectious causes Trauma, ascaris worms,HIV- MiscellaneousAcute pancreatitis Pathology acute edematous

3、 pancreatitis acute hemorrhagic necrotizing pancreatitis (acute hemorrhagic pancreatitis, acute necrotizing pancreatitis)Acute pancreatitis Pathophysiology Hypersecretion and obstruction Self-enzymatic digestiono Lymphatic obstruction Cytokine，infection Decreased arterial perfusionEdematous hemorrha

4、gic necrotizing Acute pancreatitis Clinical finding Abdominal pain Abdominal distention Nausea and vomiting Respiratory failure, confusion, or coma. Low-grade to moderate fever Tachycardia and hypotension Mild jaundice, Pleural effusion. ShockAcute pancreatitisAcute pancreatitis Peritoneal irritatio

5、n sign Abdominal tenderness， rebound tenderness and rigidity Shifting dullness Decreased bowel sounds Cullen sign: discoloration of periumbilical area Grey Turner sign:discoloration of flanks Laboratory finding Amylase and lipase (elevations of amylase are more sensitive but less specific than lipas

6、e in the diagnosis of acute pancreatitis ) 500 400 300 200 100 0 0 1H 24H 48H 5DAYAcute pancreatitisBlood amylaseUrine amylaseAcute pancreatitis Serum calcium Serum glucose Blood gas analysis CRP(C-reactive protein) Imunolipase, trypsinogen ,and immuno elastase. ALT and AST (gallstone pancreatitis )

7、 Imaging finding X-ray Dilated loop of small bowel (sentinel loop) Abrupt cessation of gas in the distal transverse colon (colon cutoff sign) Radioopaque densities (biliary calculi) Left-sided pleural effusion B-US: pancreatic edema, ascites- CT: ImportantAcute pancreatitisCT is the best diagnostic

8、test for the diagnosis of acute pancreatitis. Contrast-enhanced CT is excellent for diagnosis of pancreatic necrosisAcute pancreatitis Assessment of severity of acute pancreatitis Ransons criteria On Admission Within 48 Hours Acute pancreatitis Glasgow criteria Within 48 Hours Age 55 WBC 15,000 mm L

9、DH 600 IU/L Glucose 180 mg/dl Albumin 3.2 g/dl Calcium 45 mg/dl Arterial PO2 8 Scores -SAP Diagnosis and differential Diagnosis Acute edematous pancreatitis and acute hemorrhagic necrotizing pancreatitis Other diseases Acute appendtitis Ileus Perforated gastroduodenal ulcer Biliary disease Ruptured

10、hepatomaAcute pancreatitisClinical findingAmylaseCT Abdominal paracentesisAcute pancreatitis Treatment Acute edematous pancreatitisinternal medicine (Emergency surgery is not indicated in mild acute pancreatitis) Acute hemorrhagic necrotizing pancreatitis Supportive care Replacement of fluid and ele

11、ctrolytes Correction of metabolic abnormalities Nutritional support Other measures :nasogastric suction and antibiotics Agents to inhibit pancreatic secretion Have not been found to be useful in altering the course in acute pancreatitis Somatostatin(sandostatin stilamin) Glucagon. Protease inhibitor

12、s (trasylol) Surgical therapy Inefficiency by internal medicine Complication (pancreatic or/and peripancreatic Infection and abscess) Combined wit biliary diseases(Gallstone ASP) Diagnosis unclear Surgical approach Rresection of necrotic tissue and peritoneal lavage severe, progressive necrotizing p

13、ancreatitis or pancreatic abscess. Cholecystectomy recurrent acute pancreatitis and microlithiasis. Surgical sphincteroplasty of the pancreatic sphincter pancreatic sphincter dysfunctionoutcome is the same as for the endoscopic pancreatic sphincterotomy more invasiverequiring laparotomy and duodenot

14、omyAcute pancreatitis Endoscopic therapy 1) acute gallstone pancreatitis 2) recurrent pancreatitis due to pancreatic sphincter dysfunction, 3) recurrent pancreatitis due to pancreas divisum. The rationale for endoscopic therapy in each area is the relief of obstruction to flow of pancreatic juice Ch

15、ronic pancreatitis Causes Alcohol Pancreas divisum Tropical pancreatitis Hyperparathyroidism Trauma Obstructive pancreatitis Idiopathic chronic pancreatitis Cystic fibrosis Hereditary chronic pancreatitisChronic pancreatitis Classification Obstructive chronic pancreatitis Calcified chronic pancreati

16、tis Inflammatory chronic pancreatitis Pathology pancreatic fibrosis -Chronic pancreatitis Clinical finding and diagnosis Abdominal pain , distention Diarrhage Dyspepsia Malnutrtion Diabetes Narcotic addiction Jaundice Biochemical measurements Isoamylase,lipase trypsin,and elastase Quantitative measu

17、rement of fecal fat glucose tolerance test Secretin stimulation test Plasma cholecystokinin (CCK)( may be elevated ) Bentiromide (苯酪肽) testChronic pancreatitisChronic pancreatitis Imaging finding Plain abdominal film Transabdominal ultrasound CT MRCP Endoscopic diagnosis procedures(ERCP,EUS)Chronic

18、pancreatitis Medical therapy Alcohol and cigarette avoidance Analgesics Enzyme therapy Treatment of malnutrition Surgical therapy Biliary Obstruction, pancreatic pseudocysts, combined with biliary diseases, intractabe pain, Celiac nerve block Therapeutic endoscopyTumors of Pancreas Pancreatic carcin

19、oma Arise from acinar or duct cells Early diagnosis very difficulty , prognosis poor Obstructive jaundice(permanent):main symptom Abdominal pain Diabetes Weakness, emaciation(消瘦) Stools: acholic Gallbladder:Distended Abdominal mass Diagnosis of pancreatic carcinoma Laboratory test: AKP ,r-GT,LDH;CEA

20、 ,POA, PCCA,CA19-9: C-K-ras- Imaging finding US,CT( CTA),MRCP ERCP, PTC&PTCD PET(正电子发射断层扫描) Biopsy(FNA) and cytologyTumors of Pancreas Treatment of pancreatic carcinoma Radical operation Pancreatoduodenectomy - tumor in pancreatic head Resection of pancreatic body and tail-tumor in pancreatic bo

21、dy or tail Palliative operation: to relieve jaundice BiotherapyTumors of Pancreas Pancreatic endocrine neoplasm(PEN) Insulinoma Arise from B cell Symptoms: whipples triad Spontaneous hypoglycemia accompanied by central nervous system, psychiatric,or vasomotor symptoms Repeated blood sugar levels bel

22、ow 2.8mmol/L(50mg%) Relief of symptoms by oral or intravenous administration of glucose Diagnosis: symptom and IRI/G0.3,B-us,CT,MRI, Endo-US,Angiography,PTPC,ASVS Treatment:operation(resection)Tumors of Pancreas Arise from: Papilla of duodenum Vater ampulla Distal CBD Symptom: obstructive jaundice Diagnosis Treatment :similar to pancreatic carcinomaCarcinoma of periampulla