胰腺疾病中山大学 内科学课件

LINGYUNBIAODepartmentofHepatobiliarySurgery The3rdAffiliatedHospitalofSunYat senUniversity凌云彪中山大学附属第三医院肝胆外科 PANCREAS Thechapterincludes Summaryofanatomy physiologyAcutepancreatitisChronicpancreatitisPancreaticcystPancreaticcancer PeriampullarycarcinomaPancreaticendocrinetumors Location region Anatomy physiology Length 12 20cmWidth 3 4cmWeight 75 125g Bloodsupply Head Gastroduodenala Ant andpost sup pancreaticoduodenala Sup mesenterica Ant andpost inf pancreaticoduodenala Body tail Splenica Dorsalpancreatica Transversepancreatica Venous lymphdrainage Lymphdrainagebymultiplenodegroups mainlyceliacnodes sup mesentericnodes Ducts theductofWirsung mainducttheductofSantorini accessoryduct Physiology exocrinepancreas pancreaticjuice 750 1500ml d bicarbonate digestiveenzymes proenzymesendocrinepancreas 1 7 2 0millionsofislets 4majorcelltypes someminortypesAcells glucagonsBcells insulinDcells somatostatinPPcells pancreaticpolypeptideGcells gastrinD1 vasoactiveintestinalpolypeptide Acutepancraetitis Acommonacuteabdomen includingmild severetypes Whatisit benigndisease malignantprognosis Causes BiliarytractstonesEthanolabuseHyperlipidemiaDietaryfactorsTrauma Surgery ERCPInfectionDrugs thiazidediuretics oralcontraceptivesMetabolicabnormalities Biliarytractstones Bilerefluxtheory Commonchanneltheory stone Ethanolabuse IncreasingductalpressureIncreasingpancreaticenzymesecretionDirectinjurytopancreaticacinarcells SIRSsystemicinflammatoryresponsesyndromeMODSmultipleorgandysfunctionsyndrome Presentation acuteabdominalpainnausea vomitingabdominaldistension abdominalcompartmentsyndrome ACS fever hyperthermiajaundiceshock MODS Presentation GreyTurnersign flankbluishecchymosesCullensign umbilicalbluishecchymosesARDSacuterespiratorydistresssyndromeSIRSsystemicinflammatoryresponsesyndromeMODSmultipleorgandysfunctionsyndrome Laboratory SerumamylaseandlipaselevelsSerumcalciumbloodglucosearterialbloodgaswhitebloodcellcount LaboratoryFindings Imagingstudies Chest abdominalradiographsUltrasoundCTMRIMRCP contrastCT AdmissionAge 55yrWBC 16000 mm3Glucose 200mg dLLDH 350IU LAST 250IU L Initial48hrsHctfall 10 BUNelevation 5mg dLCa2 4mmol LFluidsequestration 6L 3or4signsmortality15 7or8signsmortality90 Ranson sPrognosticSigns Differentialdiagnosis acutecholangitis cholecystitisperforatedhollowviscusbowelobstructionmesentericischemia infarctionacutegastroenteritisacutemyocardialinfarction Thestagesofcourse stageofacutereaction within2wstageofsystemicinfection 2w 2mstageofresidualinfection laterthan2 3musuallybutnotalways Localcomplications acutefluidcollectionpancreaticandperipancreaticnecrosispancreaticpseudocystpancreaticabscess Treatmentnonoperativetherapy fastingdiet gastricsuctioninhibitionofpancreaticjuicesecreting somatostatin Sandostatin Stilamin Uinastatin paregoric spasmolysisfluid electrolytemanagementAntacids Ranitidine Losec prophylacticantibioticstraditionalChinesemedicine Treatmentnonoperativetherapy Nutritionalsupport totalparenteralnutritionInsulinOxygenprovidedThoracentesisDialysis TreatmentSurgicaltherapy EndoscopicsphincterotomyGallbladderremovalPeritoneallavage nolongerwidelyused CT guidedneedleaspirationDebridement Treatmentofseverepancreatitis stageofacutereaction nonoperative surgicalstageofsystemicinfection antibiotics ultrasoundorCT guided needleaspiration surgicaldrainagestageofresidualinfection nutritionalsupport surgery Treatmentofacutebiliarypancreatitis Thegroupwithoutbileductobstructionorcholangitis nonoperativetherapythencholecystectomyThegroupwithbileductobstructionorcholangitis earlyoperationorEST ENBD ERCPstoneextraction Treatmentoflocalcomplications acutefluidcollection spontaneouslyresolvepancreaticandperipancreaticnecrosis debridementanddrainagepancreaticpseudocyst 6cmwithoutsymptom notreatment theothersormorethan3 6m surgicaldrainagepancreaticabscess surgicaldrainage ChronicPancreatitisPancreaticCyst PeriampullaryCarcinoma carcinomaofheadofpancreasampullarycarcinomaduodenalpapillarycarcinomacarcinomaofdistalcommonbileductcarcinomaofVater sampulla Symptomsandsignsupperabdominalpain vague severe backpain 70 jaundice painless 80 weightloss75 Trousseau ssyndrome Courvoisier ssignothers nausea vomiting anorexia steatorrhea panceatitis changesofstools diabetesmellitus etcBloodtestbilirubin alkalinephosphatase transaminase CA19 9 CEA PeriampullaryCarcinoma Imagingstudies ultrasound initial BMbariummealCTERCPPTCDMRI MRCPangiographyEUSendoscopicultrasonography Surgicalprocedures Whipplep