胃十二指肠疾病PPT课件.ppt

胃十二指肠疾病 中南大学湘雅医院普外科裴海平 1 2 解剖和生理概要AnatomyandPhysiology 胃的解剖Theposition腹腔左上方 贲门幽门Theshape与充盈程度和体位有关thefundusthebodyantrum 3 4 胃壁SerosaMuscularisSubmucosaMucosa 5 6 胃的腺体细胞parietalcellsH intrinsicfactorchiefcellspepsinogenmucouscellsmucusendocrinecellsGcellsgastrin 7 血供 腹腔干Celiactrunkcommonhepaticaleftsplenicagastricaproperhepaticagastroduodenalaleftgastroepiloicashortandposteriorgastricarightgastricarightgastroepiloicaveinportalvein 8 9 淋巴回流4lymphaticdrainageareas胃小弯上部胃左A旁淋巴结腹腔淋巴结群胃小弯下部胃右A旁淋巴结幽门上淋巴结群胃大弯右侧胃网膜右A旁幽门下淋巴结群胃大弯上部脾胰淋巴结3stations16groupsNervesSupplysympathetic celiacganglia parasympathetic vagus 10 胃的生理 Motility收缩蠕动SecretionModulatebyneuro endocrine脑相胃相肠相 11 十二指肠的解剖和生理 解剖C型 球部 降部 水平部和升部血供胰十二指肠上A 来自胃十二指肠A 胰十二指肠下A 发自肠系膜上A 生理是胆汁 胰液和食糜汇集处 12 13 胃十二指肠的外科治疗 IntroductionOldadage Noacid noulcerNewadage NoH pylori noacid noulcerEtiologyIncreasedacidsecretionHelicobacterpyloriDecreasedthegastricmucosalbarrierNSAIDs 14 SurgicalTreatmentofDU 诊断要点EpigastricpainrelievedbyfoodorantacidsEpigastrictendernessNormalorincreasedgastricsecretionSignsofulcerdiseaseonuppergastro intestinalx raysorendoscopyEvidenceofHelicobacterpyloriinfection 15 适应症出现严重的并发症 急性穿孔 大出血 瘢痕性幽门梗阻严格内科治疗无效的顽固性溃疡X ray检查球部大龛影 严重变形 穿透性溃疡 球后溃疡 16 SurgicalTreatmentofGU 病理和临床Gastriculcersareduetochronicgastritis inducedforinstancebyH pylori tendingtoformonthelessercurvature 95 ofthestomach Poorerbloodsupply Age40 60EpigastricPainsoonaftereating easyrelapselesscharacterthanwithDU 17 IndicationsIntractablepainorrecurrenceofpainwithfrequentabsencesfromworkandfailureoftheulcertorespondto 8 12W orrecurrenceinmedicaltreatment 6 12M ComplicationsPresenceofamalignantgastriculcerAge 45Largeulcerorhigherposition 18 Themainaimsofthesurgicaltreatment 切除溃疡Excisetheulcer消除症状Relievethesymptoms防止复发PreventrecurrenceDUreducethegastricacidsecretioncorrectorpreventanycomplications 19 GUexcisetheulcerbearingareaandstomachdistaltotheulcerimproveemptyingofthestomachpreventcomplicationsensuremalignantulcersareremoved 20 急性穿孔 DefinitionPerforationindicatesabreachthroughtheentirethicknessofthewallofstomachorduodenum PathologyThecontentsoftheintestinetoentertheperitonealcavitycausingacuteperitonitis 21 溃疡活动 侵蚀穿破浆膜多位于幽门 胃小弯 十二指肠前壁 后壁多为穿透性溃疡多数为单个初始为化学性腹膜炎6 8小时后细菌性腹膜炎 22 临床表现ulcerativehistory 90 sudden sharp severeepigastricorabdominalpainandshock guardingandrigidityandbowelsoundsbecomeweakandtendernessandreboundtenderness 23 airunderthediaphragmTheerectabdominalX rayshowairunderthediaphragm 24 DiagnosisHistoryclinicalInvestigationX ray膈下游离气体 80 DifferentialDiagnosis acutepancreatitisacutecholecystitisacuteappendicitis 25 TreatmentNon surgicaltherapy适应症 一般情况好 空腹穿孔 穿孔 24hr腹膜炎已局限 造影示穿孔已封闭 InsertionofIVlineandadministrationoffluids antacidInsertionofnaso gastrictubetoemptystomachPossibleuseofantibioticsPreparationforlaparotomy 26 SurgicaltherapyThesimplestprocedureissutureoftheperforation 首选 HighlyselectivevagotomyTruncalvagotomyandpyloroplastyTruncalvagotomyandgastro enterostomyifthepyloricregionisgrosslyscarredandstenosed Partialgastrectomy 27 28 Hemorrhage EtiologyandPathology Asanulcereatsintothemusclesofthestomachorduodenalwall bloodvesselsmayalsobedamaged causingbleeding 29 临床表现hematemesisand ormelena hypovolemicshock出血部位胃小弯胃左右A分支球后部胃十二指肠A或胰十二指肠上A 30 诊断Historyclinicalfindingsinvestigation鉴别诊断急诊胃镜stressulcergastriccarcinomableedingfromoesophagealvaricesbilebleeding 31 治疗内科治疗ControlshockGivenaso gastrictubeAcutegastrointestinalendoscopyDrugtherapy外科处理 5 10 partialgastrectomyunderunvesselwithnonabsorbablesutureTruncalvagotomyandpyloroplasty 32 EtiologyandPathologyEdemaMuscularspasmObstructionScarring 疤痕性幽门梗阻 33 临床表现vomitingabdominalpain gastricpatternsandperistalticwavesweightlosselectrolyteimbalance 低氯低钾性碱中毒 诊断Historyclinicalinvestigation 34 鉴别诊断pyloricswellingorspasmofactiveulcergastriccarcinomaobstructionundertheduodenalbulb治疗术前准备partialgastrectomyvagotomyandgastrojejunostomy 35 胃大部分切除术切除胃的2 3 3 4 包括胃体大部 胃窦 幽门以及部分十二指肠 合理性切除胃窦 消除了G细胞分泌胃泌素切除大部分胃体 使分泌胃酸和胃蛋白酶的细胞数量减少切除了溃疡的好发部位切除了溃疡本身 不一定必需 溃疡病外科手术方式 36 Billroth thecutendofthestomachandduodenuminanend to sideanastomasisBillrothIIendoftheduodenumisclosed Thejejunumisbroughtupandsuturedtothecutendofthestomachinanend to sideanastomasis ThisiscalledaBillrothIIreconstruction 37 38 39 迷走神经切断术 Truncalandselectivevagotomyandpyloroplasty 40 highlyselectivevagotomy parietalcellvagotomy 41 外科手术方式的选择 GUGastrectomy Billroth DUGastrectomy Billroth HighselectivevagotomySelectivevagotomypluspyloroplasty 42 术后并发症 胃大部分切除术后并发症Bleeding 术后一般不超过100 300ml TheraptureofthestumpduodenumStomalraptureorfistulaVomitingDelayedgastricemptying 43 ObstructionafferentloopobstructionthestenosisofstomaefferentloopobstructionDumpingsyndromeearly in30minutes nausea distensionassociatedwithsweating faintness palpationDuetodumpingoffoodintojejunum rapidfluiddilutionofthehighosmoticload 44 delayed alsocalledhypoglycemicsyndrome 2 4hoursafterintake BilerefluxgastritisGastricemptyingdisorderNutritionalcomplicationsweightlossAnemiadiarrheaosteopathyStumpcarcinoma benigngastrectomy 5years 45 迷走神经切断术后并发症DysphagiaIschemicnecrosisoflessercurvatureDiarrhea 46 GastricCancer IntroductionItsincidenceinthefareasthigherthanwesternsociety morecommoninolderpeople itisseenmoreinpeoplewithbloodgroupA 47 48 病因 不明 Benignchronicdiseaseofstomachincludegastriculcer polyp atrophygastritisandstumpstomachaftergastrectomyGeneticfactors bloodgroupA somefamilialcancersyndromekindreds LynchTypeII afirstdegreerelativewithgastriccancer andfamilialpolyposis 49 InfectionwithHelicobacterpyloriDietaryandenvironmentalfactors highdietaryintakeofsalt carbohydrates preservativeslikenitratesindrinkingandwaterandsmokedfoodGastricdysplasiafrommildtoseveretocancer与饮食关系密切 有一定的地理分布 寒冷地区发病率比炎热地区高 50 病理部位 胃窦部多见 50 以上 早期胃癌 confinedtothemucosaandsubmucosa IProtrudedIIA Superficial elevatedIIB Superficial flatIIC SuperficialdepressedIII Excavated小胃癌 直径6 10mm微小胃癌 直径 5mm 51 Advanced Borrmanntypes I PolypoidorfungatingII ExcavatingIII UlceratedandinfiltratingIV Infiltrating diffusethickening Linitusplastica 52 组织学分型PapillaryTubularMucinousSignetringcellPoororundifferentiatedSpecifictypesCarcinoidAdenosquamousOthers 53 转移途径directinvasionlymphnodemetastasisbloodmetastasisperitonealspreadKrukenbergTumor 54 临床表现abdominaldiscomfortorpainnausea vomitingweightlossepigastricdilationetc Butlackofspecificsymptomsformostgastriccancer Therefore mostpatientsdonotgetdiagnosisuntilthecancerisfairlyadvanced 55 诊断早期诊断较为困难 普查是发现胃癌的好方法 但费用太高 检出率约1 1000SymptomsandsignsFecaloccultbloodtestBariumswallowEndoscopyandbiopsyUltrasoundEUSMSCT 56 重点对象40岁以上 既往无胃病史而出现消化道症状或有胃病史其性质规律发生改变有萎缩性胃炎 胃溃疡 胃酸低下等应逐年检查手段纤维胃镜为首选气钡双重造影 57 治疗 手术治疗为主 dependso