慢性胰腺炎(1)PPT课件.ppt

1 CHRONICPANCREATITIS 2 A49 year oldmanwasadmittedwithanine monthhistoryofintermittentattacksofepigastricpain jaundiceandfever Theseattacksusuallylastuptoseveraldaysassociatedwithnauseaandvomiting Hewaswellinbetweenattacksandhadnolossofweight 3 Whatisyournextstep 4 LabResults AP 1017GGT 269AST 103ALT 186TB 2 DB 1 1 Alb 3 2Lipase 33 upto244duringattacks Amylase 44 Hb 12WBC 5 7Plts 223Na 141K 4 2Ur 15Cr 0 9Ca 8 9FBS 178 5 Whatarearrows 6 Pancreaticcalcification 7 TransabdominalUS NogallstonesormassinheadofpancreasCTscan Theextrahepaticbileductwasmildlydilatedand generouspancreas wasnotedbuttherewasnomass 8 EndoscopicUltrasoundDiffusehypoechoicenlargementofpancreas Fineneedleaspirateofthepancreaswasnegativefortumor 9 ERCPTherewasalongsegmentofextrahepaticbiliarystricture Thepancreaticductwasnormalinsizebutirregular Brushings biopsiesandbileaspiratewerenegativefortumor 10 11 ThepatientunderwentWhipple soperationHistologyofthepancreasshowedchronicpancreatitis nomalignancy 12 Twopresentation EpisodesofacuteinflammationinapreviouslyinjuredpancreasChronicdamagewithpersistentpainormalabsorptionEtiology sameasacutepancreatitis pancreatitisassociatedwithgallstonespredaminantlyacuteorrelapsing acute Moreidiopathictypes 13 Mostcommoncause Inadults alcoholintakeInchildren cysticfibrosisIdiopathicchronicpancreatitisistheleadingcauseofnonalcoholicchronicpancreatitis 14 PATHOPHYSIOLOGY TheeventsthatinitiateaninflamatoryprocessarestillnotwellunderstoodInthealcohol induced suggestedthattheprimarydefectmaybetheprecipitationofprotein inspissatedenzyme Infact shownthatalcoholhasdirecttoxiceffectonthepancreas 15 Clinicalfeatures abdominalpain maybecontinuous intermittentorabsentPatternisoftenatypicalRUQorLUQofthebackDiffusethroughoutupperabdomenMaybereferredtotheanteriorchestorflankTypicalform Persistent deep seated UnresponsivetoantacidsWorsenedbyalcoholintakeoraheavymeal especiallyfattyfoods Oftenneednarcotics 16 PancreaticinsufficiencyWeightlossFatmalabsorption Steatorrhea 15 ofpatientspresentwithsteatorrheaandnopainPancreaticdiabetes LikeDM1needsinsulin butriskofhypoglycemiaismorethanit becausealfacellsisalsoaffectedFat solublevitamindeficiency rare 17 Labdata Amylaseandlipase usuallynormalCBC electrolytes andliverfunctiontestsaretypicallynormalBilrubinandALPmaybeincreasedImpairedglucoseintoleranceandelevatedfastingbloodglucoseSudanstainingoffecesorquantitativetestforsteatorrheafecalelastase Amongpancreaticfunctiontests fecalelastasemeasurementisthemostsensitiveandspecific especiallyintheearlyphasesofpancreaticinsufficiency 18 Cont Classictriad pancreaticcalcification steatorrhea anddiabetesmellitus usuallyestablisheschronicpancreatitisClassictriad foundinfewerthanone thirdItisoftennecessarytoperformsecretinstimulationtest abnormalwhen60 ormoreofpancreaticexocrinefunctionhasbeenlost Adecreasedserumtrypsinogen 20ng ml orafecalelastaselevelof 100ug mgofstoolstronglysuggestsseverepancreaticinsufficiency 19 Imagingstudies Plainfilms Pancreaticcalcifications 30mostcommonwithalcoholicpancreatitis butisalsoseeninthehereditaryandtropicalformsofthedisorder itisrareinidiopathicpancreatitis 20 21 22 CT MRI US calcificationsductaldilatationenlargementofthepancreasfluidcollections eg pseudocysts 23 24 25 ERCP Choicewhencalcificationsarenotpresentandthereisnoevidenceofsteatorrhea anormalstudyshouldnotruleoutthediagnosisofchronicpancreatitis 26 ERCP MayprovideusefulinformationonthestatusofthepancreaticductalsystemAbnormalitiesinclude 1 luminalnarowing2 irregularitisintheductalsystemwithstenosis dilation saculation andectasia3 blockageoftheductbycalciumdeposits 27 28 Endoscopicultrasonography ThemostpredictiveendosonographicfeatureisthepresenceofstoneOthersuggestivefeaturesinclude visiblesidebranchescystslobularityirregularmainpancreaticduct hyperechoicfociandstrandsdilationofthemainpancreaticducthyperechoicmarginsofthemainpancreaticduct 29 30 Complications pseudocystformationbileductorduodenalobstructionpancreaticascitesorpleuraleffusionsplenicveinthrombosisPseudoaneurysmspancreaticcanceracuteattacksofpancreatitis particularlyalcoholicswhocontinuedrinking 31 DIFFERENTIALDIAGNOSIS Pancreaticcancer mostimportant olderageabsenceofahistoryofalcoholuseweightlossaprotractedflareofsymptomsonsetofsignificantconstitutionalsymptomspancreaticductstricturegreaterthan10mminlengthonERCPMarkerssuchasCA19 9andCEApepticulcerdiseasegallstonesirritablebowelsyndromeAcutepancreatitis 32 TREATMENT 33 PAINMANAGEMENT stepwiseapproach generalrecommendationspancreaticenzymesupplementationAnalgesicsinvasiveoptions 34 Generalrecommendations EstablishasecurediagnosisCessationofalcoholintakeSmallmeals 35 Pancreaticenzymesupplements notveryeffectiveresponsemaybebetterinyoungwomenwithsmallductdisease MECHANISM suppressionoffeedbackloopsintheduodenumthatregulatethereleaseofcholecystokinin CCK thehormonethatstimulatesdigestiveenzymesecretionfromtheexocrinepancreassixtabletsofViokase whichcontains 16 000unitsoflipase30 000unitsofprotease30 000unitsofamylase 36 Patientsshouldalsobetreatedwithacidsuppression eitherwithanH2receptorblockeroraprotonpumpinhibitor toreduceinactivationoftheenzymesfromgastricacid 37 Analgesics ifpancreaticenzymetherapyfailstocontrolpain shortcourseofnarcoticscoupledwithlowdoseamitriptylineandanonsteroidalantiinflammatorySimultaneousshort termhospitalization withthepatientkeptNPOtominimizepancreaticstimulation mayalsobeofbenefitinbreakingthepaincycle Chronicnarcoticanalgesiamayberequiredinpatientswithpersistentsignificantpain Long actingagentssuchasMSContinorFentanylpatchesaregenerallymoreeffectivethanshortactingmedications whichlastonlythreeorfourhours 38 Othermedicalthera