胰腺疾病中山大学内科学.ppt

LING YUNBIAO Department of Hepatobiliary Surgery, The 3rd Affiliated Hospital of Sun Yat-sen University 凌云彪 中山大学附属第三医院肝胆外科,PANCREAS,The chapter includes:,Summary of anatomy physiology Acute pancreatitis Chronic pancreatitis Pancreatic cyst Pancreatic cancer / Periampullary carcinoma Pancreatic endocrine tumors,Location region,Anatomy physiology,Length: 12-20cm Width: 3-4cm Weight: 75-125g,Blood supply,Head：Gastroduodenal a. Ant. and post. sup. pancreaticoduodenal a. Sup. mesenteric a. Ant. and post. inf. pancreaticoduodenal a. Body tail: Splenic a.，Dorsal pancreatic a. Transverse pancreatic a.,Venous lymph drainage,Lymph drainage by multiple node groups, mainly celiac nodes sup. mesenteric nodes,Ducts: the duct of Wirsung/ main duct the duct of Santorini/ accessory duct,Physiology,exocrine pancreas: pancreatic juice, 750-1500ml/d - bicarbonate digestive enzymes/proenzymes endocrine pancreas: 1.7-2.0 millions of islets - 4 major cell types some minor types A cells glucagons B cells insulin D cells somatostatin PP cells pancreatic polypeptide G cells gastrin D1 vasoactive intestinal polypeptide,Acute pancraetitis,A common acute abdomen, including mild severe types,What is it?,benign disease, malignant prognosis,Causes,Biliary tract stones Ethanol abuse Hyperlipidemia Dietary factors Trauma, Surgery, ERCP Infection Drugs: thiazide diuretics, oral contraceptives Metabolic abnormalities,Biliary tract stones,Bile reflux theory - Common channel theory,stone,Ethanol abuse,Increasing ductal pressure Increasing pancreatic enzyme secretion Direct injury to pancreatic acinar cells,SIRS systemic inflammatory response syndrome MODS multiple organ dysfunction syndrome,Presentation,acute abdominal pain nausea, vomiting abdominal distension / abdominal compartment syndrome (ACS) fever / hyperthermia jaundice shock, MODS,Presentation,Grey Turner sign flank bluish ecchymoses Cullen sign umbilical bluish ecchymoses ARDS acute respiratory distress syndrome SIRS systemic inflammatory response syndrome MODS multiple organ dysfunction syndrome,Laboratory,Serum amylase and lipase levels Serum calcium blood glucose arterial blood gas white blood cell count,Laboratory Findings,Imaging studies,Chest/abdominal radiographs Ultrasound CT MRI MRCP,contrast CT,Admission Age 55 yr WBC16000/mm3 Glucose 200 mg/dL LDH350 IU/L AST250 IU/L,Initial 48 hrs Hct fall 10% BUN elevation 5mg/dL Ca2+ 4mmol/L Fluid sequestration6L,3 or 4 signs mortality 15%, 7 or 8 signs mortality 90%,Ransons Prognostic Signs,Differential diagnosis,acute cholangitis / cholecystitis perforated hollow viscus bowel obstruction mesenteric ischemia / infarction acute gastroenteritis acute myocardial infarction,The stages of course,stage of acute reaction - within 2w stage of systemic infection - 2w-2m stage of residual infection - later than 2-3m usually but not always,Local complications,acute fluid collection pancreatic and peripancreatic necrosis pancreatic pseudocyst pancreatic abscess,Treatment nonoperative therapy,fasting diet, gastric suction inhibition of pancreatic juice secreting- somatostatin (Sandostatin，Stilamin，Uinastatin) paregoric spasmolysis fluid electrolyte management Antacids (Ranitidine，Losec) prophylactic antibiotics traditional Chinese medicine,Treatment nonoperative therapy,Nutritional support /total parenteral nutrition Insulin Oxygen provided Thoracentesis Dialysis,Treatment Surgical therapy,Endoscopic sphincterotomy Gallbladder removal Peritoneal lavage （no longer widely used） CT-guided needle aspiration Debridement,Treatment of severe pancreatitis,stage of acute reaction - nonoperative surgical stage of systemic infection - antibiotics (ultrasound or CT-guided) needle aspiration surgical drainage stage of residual infection - nutritional support surgery,Treatment of acute biliary pancreatitis,The group without bile duct obstruction or cholangitis - nonoperative therapy then cholecystectomy The group with bile duct obstruction or cholangitis -early operation or EST, ENBD,ERCP stone extraction,Treatment of local complications,acute fluid collection - spontaneously resolve pancreatic and peripancreatic necrosis - debridement and drainage pancreatic pseudocyst - 6cm without symptom, no treatment; the others or more than 3-6m, surgical drainage pancreatic abscess - surgical drainage,Chronic Pancreatitis Pancreatic Cyst,Periampullary Carcinoma,carcinoma of head of pancreas ampullary carcinoma duodenal papillary carcinoma carcinoma of distal common bile duct carcinoma of Vaters ampulla,Symptoms and signs upper abdominal pain (vague severe, back pain) 70 jaundice (painless) 80% weight loss 75 Trousseaus syndrome, Courvoisiers sign others: nausea, vomiting, anorexia, steatorrhea, panceatitis, changes of stools, diabetes mellitus, etc Blood test bilirubin, alkaline phosphatase , transaminase CA19-9,CEA,Periampullary Carcinoma,Imaging studies,ultrasound (initial) BM barium meal CT ERCP PTCD MRI, MRCP angiography EUS endoscopic ultrasonography,Surgical procedur