胰腺疾病.ppt

DepartmentofSurgeryRuijinClinicalMedicalCollegeShanghaiJiaoTongUniversity,PancreaticDisease,AnatomyofpancreasPancreatitisPancreaticpseudocystPancreaticcancer,Anatomy,Location:retroperitoneal,headneckbodytailuncinateprocessSMVpancreaticduct,wirsungductaccessorypancreaticductsantoriniduct,Arteries,head&neckceliacaxis,superiormesentericarteryGDAsuperior&inferiorpancreaticoduodenalAsuperior&inferiorpancreaticarteriesbody&tailsplenic&leftgastroepiploicarteries,Veins,SuperiormesentericveinSplenicveinPortalvein,Lymph&Nerve,lymphSPDSPsplenichilumIPDIPheadSMAnodesceliacaxisnodestailsplenicnodesnervesympathetic¶sympathetic,Histoloy&physiology,Exocrineacinarcelldigestiveenzymesductalcellbicarbonatesecretionofcontrolvagal&CCK,Histoloy&physiology,EndocrineisletsofLangerhanscell50%insulincell20%glucagoncell5%somatostatinnoncellvasoactiveintestinalpeptidenoncellgastrinnoncellpancreaticpolypeptide（PP）,AcutePancreatitis,Definition,Acutepancreatitis(AP)isanacuteinflammatoryprocessofthepancreas,withvariableinvolvementofotherregionaltissueorremoteorgansystems.Thediseaseincludesabroadspectrumofpancreaticdisease,whichvariesfrommildparenchymaledematoseverehemorrhagicpancreatitisassociatedwithsubsequentgangreneandnecrosis.,Theclinicalpresentation,PainofabdomenisdiffuseHypotensionMetabolicderangementsSepsisFluidsequenstrationMultipleorganfailureDeath,Etiology,GallstonesSustainedalcoholOtherInchina:biliarytractdiseasedistalcommonbileductstonestenosisofthepapillaofVaterascaridinbiliaryduct,Pathogenesis,AcomplicatedpathophysiologicprocessEnzymeautoactivationandself-digestionTruemechanismremainsunknown,Pancreaticself-protectivemechanism,MucopolysaccharideonpancreaticductepitheliaProenzymePancreatininhibitorAcinusmetabolismactivityAnti-refluxmechanism:oddissphincterpancreaticductsphincter,Initiationfactorinearlierperiod,BilerefluxBilecommonchannelpancreaticduct1.hypertensioninpancreaticduct2.activationofpancreaticenzymes3.injuretheliningofthepancreaticductspancreasedemaornecrosisMODS,1.Pancreaticenzymeabnormalactivating,DuodenalRefulxduodenalenterokinasepancreaticducttrypsinogentrypsinelastasnogenelastasephospholipasogenphospholipaseLecithinlysolecthin,1.Pancreaticenzymeabnormalactivating,StimulatethepancreastosecretepancreatichypertentiontinypancreaticductandacinusrupturepancreaticjuicespillageSpasmoftheoddissphinctordirectlyinjurepancreas,2.AlcoholToxicity,systemichypotensionhyperlipidemia:triglycerideslipasefreeacidfattyacidsinjurepancreaticmicrocirculationatheroembolismvasculitis,3.PancreaticMicrocirculationDisorder,Aggravativefactorsinlaterperiod,Infection:pancreaticabscessIntestinalbacteriatranslocationCytokineandsystemicinflammationreactionsyndromeTNFIL-1IL-6PAFMSOFFreeradicals,Pathology,Edematouspancreatitis:interstitialedemainflammatorycellinfiltrationoftheglandparenchymaHemorrhagicornecrotizingpancreatitisextensivepancreaticandperipancreaticfatnecrosisparenchymalnecrosissaponatusspot,Hemorrhagicornecrotizingpancreatitis,Clinicalpresentation,1.Abdominalpainpredominantclinicalfeature-midepigastrium,intherightorleftupperquadrants-apenetratingpain,radiatetotheback-rarepatientswithoutabdominalpainbutwithaseveresystemicillness(hypotension,hypoperfusionanddepressionofmentalstatus),Clinicalpresentation,2.Nauseaandvomiting3.AbdominalDistentionresultfromaparalyticileusarisingfromretroperitonealirritationorascitesoraretroperitonealphlegmon4.JanndicedistalcommonbileductobstructionbygallstonescompressionofthedistalCBDbypancreaticheadedemaorbyotheruncommonfindings,Clinicalpresentationofsevereacutepancreatitis,1.CirculatoryDerangements:hypotention,hypovolemiahypoperfusioncirculatingmyocardialdepressantfactordecreasedpreloadtotheheartreducedsystemicvascularresistancesepsis-likesyndromehyperdynamicstateelevatedcardiacoutputloweredsystemicvascularresistanceloweredarteriovenousoxgendifference,Clinicalpresentationofsevereacutepancreatitis,2.leftpleuraleffusion3.pulmonaryfailuretachypnea,dyspneaandcyanosis4.cerebralabnormalitiesbelligerence,confusion,psychosisandcoma5.TurnersignandCullensignabluishcolorintheflanksoraroundtheumbilicus,(representblooddissectedtothoseareasfromtheretroperitoneumnearthepancreas),PhysicalExamination,Epigastrictenderness,rigidityandreboundTendernessBowelsoundsdecreasedorabsentPalpablemassswollenpancreaspseudocystabscess,LaboratoryTest,SerumAmylaseUrinaryAmylaseSerumLipaseHypocalcemia,DisordersAssociatedwithhyperamylasemiaIntra-AbdominalExtra-AbdominalPancreaticdisordersSalivaryglanddisordersacutepancreatitismumpschronicpancreatitisparotitistraumatraumacarcinomacalculipseudocystirradiationsialoadenitispancreaticascitesimpairedamylaseexcretionabscessrenalfailureNonpancreaticdisordersmecroamylasemiabiliarytractdiseaseMiscellaneusintestinalobstructionpneumoniamesentericinfarctionpancreaticpleuraleffusionperforatedpepticulcermediastinalpseudocystperitonitiscerebraltraumaafferenloopsyndromesevereburnsacuteappendicitisdiabeticretoacidosiseupturedectopicpregnancypregnancysalpingitisdrugsrupturedaorticaneurysmbisalbuminemia,OtherlaboratoryTest,ElevatedWBC10000cellspermm3HyperglycemiaMildazotemia:relatedtofluidsequestrationAbnormalitiesofliverfunctiontest,Imaging,1.ApainAbdominalFilm,notspecificdilatationofanisolatedloopofintestineadjacenttothepancreascalcificationinthepancreasleftpleuraleffusions,2.Ultrasoundexamination,notraumapancreaticandperipancreaticedemaoffluidcollectionPseudonymsDilationofpancreaticductGBstoneandCBDstone,3.CTScans,confirmdiagnosisofpancreatitisconfirmdiagnosisofcomplicationssuchasabscess,pseudocystrevealextensionofinflammationandnecrosisimplyprognosisaneedleaspirationunderCTguide,CT,Computedtomographicfindingsinacutepancreatitis,pancreaticchangesnonspecificfindingsparenchymalenlargementboweldistentiondiffusepleuraleffusionfocalmesentericedemaparenchymaledemanecrosisperipancreaticchangesblurringoffatplanesthickeningoffascialplanespresenceoffluidcollections,4.Diagnostic,notanidealtestaninvasiveprocedurecomplicationslackofcompletespecificityofperitonealfluidenzymeelevationHelpdiagnosiselevationsinperitonealfluidamylaseandlipase,Edematouspancreatitisnercotizingpancreatitisabdominalpain+vomitingandnausea+feverlowhighjaundice(-)-(+)+-+psychiatricsymptomnoyessignsofperitonitis+-+cullenssignnoyesGreyTurnerssignnoyeshemorrhagicascitesnoyesWBC16000/mm3bloodglucosenormal11.1mmol/Lserumcalciumnormal2.0mmol/Lamylaseor(-)PaO2normal8.0kpaBun.CrnoyesARDSnoyesDICnoyesARFnoyesmortalitylowhigh,DifferentialDiagnosis,1.Intestinalperforation2.Pepticulcer3.Cholecystitis4.acuteintestinalobstruction5.renalcolic6.myocardialischemia7.acutegastroenteritis,Treatment,1.Non-operativeManagementDietaryControlNasogastricSunctionIntravenousfluidtherapyandelectrolytereplacementNutritionalSupportAntibioticsAnalgesiaPancreaticExocrineSecretionSuppressionPancreaticenzymeinhibitor,2.SurgericprecedurePeritoneallavage:removetoxinsandvariousmetabolitesPancreaticdrainageDebridementofnecrotictissueBiliaryprocedure:endoscopicsphincterotomycholecystectomyremovetheCBDstone,3.OperativeindicationSecondarypancreaticinfectionCorrectionofassociatedbiliarytractdiseaseProgressiveclinicaldeteriorationsurgeryiscontraindicatedinuncomplicatedacutepancreatitis,Complications,SystemiccomplicationsARDSRenalfailureCardiovascularfailureMOSF,Localcomplicationspancreaticabscesspancreaticpsuedocystspancreaticphlegmonpancreaticascitespleuraleffusionpancreaticfistulaintestinalfistula,Pancreaticcancer,Causes,SmokingAdvancedageMalesexThemale-to-femaleratioofpancreaticcanceris1.3:1Chronicpancreatitis-Inflammationofthepancreas,usuallyfromexcessivealcoholintakeorgallstonesDiabetesmellitusFamilyhistoryofpancreaticcancer,Symptoms,Painintheabdomen,theback,orbothWeightloss,oftenassociatedwiththefollowing:Lossofappetite(anorexia)BloatingDiarrheaorfattybowelmovementsthatfloat