胰腺疾病(英文)精PPT课件

.,胰腺疾病,.,解剖生理概要,解剖头，颈，体，尾，钩突。主胰管(ductofWirsung)副胰管(ductofSantorini)胰腺分泌外分泌Exocrine内分泌EndocrineB,A,D,D1,Gcell,.,.,c,CausesGallstones:60%(3550%inUSA)Alcohol:14%(60%inUSA)Duodenaljuicecountercurrentflow:SphincterofOddidysfunctionTraumaPancreascirculationdisorderOtherfactors:Drug:Azathioprine(硫唑嘌呤).6-Mercaptopurine(6-巯基嘌呤),Pancreasdivisum(胰分裂),MicrolithiasisMetaboliccauseInfectiouscauses,ascarisworms蛔虫,HIV-Miscellaneous,急性胰腺炎,.,.,Pathologyacuteedematouspancreatitisacutehemorrhagicnecrotizingpancreatitis(acutehemorrhagicpancreatitis,acutenecrotizingpancreatitis),急性胰腺炎,.,PathophysiologyHypersecretionandobstructionSelf-enzymaticdigestionEnhancementofVesselpermibilityCytokine，infectionDecreasedarterialperfusionEdematoushemorrhagicnecrotizing,急性胰腺炎,.,ClinicalfindingAbdominalpainAbdominaldistentionNauseaandvomitingPeritonitisOther:Respiratoryfailure,confusion,orcoma.Low-gradetomoderatefeverTachycardiaandhypotensionandShockMildjaundice,Pleuraleffusion.,急性胰腺炎,.,急性胰腺炎,Peritonealirritationsign（Abdominaltenderness，reboundtendernessandrigidity）ShiftingdullnessDecreasedbowelsoundsCullensign:discolorationofperiumbilicalareaGreyTurnersign:discolorationofflanks,.,.,LaboratoryfindingAmylaseandlipase(elevationsofamylasearemoresensitivebutlessspecificthanlipaseinthediagnosisofacutepancreatitis)500400300200100001H24H48H5DAY,急性胰腺炎,Bloodamylase,Urineamylase,.,急性胰腺炎,SerumcalciumSerumglucoseBloodgasanalysisImunolipaseALTandAST(gallstonepancreatitis),.,ImagingfindingX-rayDilatedloopofsmallbowel(sentinelloop)Abruptcessationofgasinthedistaltransversecolon(coloncutoffsign)Radioopaquedensities(biliarycalculi)Left-sidedpleuraleffusionB-US:pancreaticedema,ascites-CT:Important,急性胰腺炎,.,CTisthebestdiagnostictestforthediagnosisofacutepancreatitis.Contrast-enhancedCTisexcellentfordiagnosisofpancreaticnecrosis,有力武器,.,急性胰腺炎,AssessmentofseverityofacutepancreatitisRansonscriteriaOnAdmissionWithin48HoursAge55yearsHematocritdecreaseby10%WBC16,000/mmUreanitrogenincrease5mg/dlLDH350IU/LSerumcalcium11.1mmol/lArterialPO250IU/LBasedeficit4mEq/LEstimatedfluidsequestration6L,.,急性胰腺炎,GlasgowCriteriaWithin48HoursAge55WBC15,000/mmLDH600IU/LGlucose180mg/dlAlbumin45mg/dlArterialPaO28Scores-SAP,.,DiagnosisanddifferentialDiagnosisAcuteedematouspancreatitisandacutehemorrhagicnecrotizingpancreatitisOtherdiseasesAcuteappendtitisIleusPerforatedgastroduodenalulcerBiliarydiseaseRupturedhepatoma,急性胰腺炎,ClinicalfindingAmylaseCTAbdominalparacentesis,.,急性胰腺炎,TreatmentAcuteedematouspancreatitisinternalmedicine(Emergencysurgeryisnotindicatedinmildacutepancreatitis)AcutehemorrhagicnecrotizingpancreatitisSupportivecareReplacementoffluidandelectrolytesCorrectionofmetabolicabnormalitiesNutritionalsupportOthermeasures:nasogastricsuctionandantibiotics,.,AgentstoinhibitpancreaticsecretionHavenotbeenfoundtobeusefulinalteringthecourseinacutepancreatitisSomatostatin(sandostatinstilamin)Proteaseinhibitors(trasylol抑肽酶)SurgicaltherapyInefficiencybyinternalmedicineComplication(pancreaticor/andperipancreaticInfectionandabscess)Combinedwithbiliarydiseases(GallstoneASP),.,SurgicalapproachResectionofnecrotictissueandperitoneallavagesevere,progressivenecrotizingpancreatitisorpancreaticabscess.Cholecystectomyrecurrentacutepancreatitisandmicrolithiasis.Surgicalsphincteroplastyofthepancreaticsphincterpancreaticsphincterdysfunctionoutcomeisthesameasfortheendoscopicpancreaticsphincterotomymoreinvasiverequiringlaparotomyandduodenotomy,.,急性胰腺炎,Endoscopictherapy1)acutegallstonepancreatitis2)recurrentpancreatitisduetopancreaticsphincterdysfunction,3)recurrentpancreatitisduetopancreasdivisum分裂.Therationaleforendoscopictherapyineachareaisthereliefofobstructiontoflowofpancreaticjuice,.,.,.,.,慢性胰腺炎,CausesAlcoholPancreasdivisumAcutepancreatitisHyperparathyroidismTraumaObstructivepancreatitisIdiopathicchronicpancreatitisCysticfibrosisHereditarychronicpancreatitis,.,慢性胰腺炎,ClassificationObstructivechronicpancreatitisCalcifiedchronicpancreatitisInflammatorychronicpancreatitisPathologypancreaticfibrosis-,.,慢性胰腺炎,ClinicalfindinganddiagnosisAbdominalpain,distentionDiarrhageDyspepsiaMalnutrtionDiabetesNarcoticaddictionJaundice,.,BiochemicalmeasurementsIsoamylase,lipasetrypsin,andelastase弹性蛋白酶QuantitativemeasurementoffecalfatglucosetolerancetestSecretinstimulationtestPlasmacholecystokinin(CCK)(maybeelevated)Bentiromide(苯酪肽)test（与糜蛋白酶反应）,慢性胰腺炎,.,.,慢性胰腺炎,ImagingfindingPlainabdominalfilmTransabdominalultrasoundCTMRCPEndoscopicdiagnosisprocedures(ERCP,EUS),.,.,.,慢性胰腺炎,MedicaltherapyAlcoholandcigaretteavoidanceAnalgesics镇痛EnzymetherapyTreatmentofmalnutritionSurgicaltherapyBiliaryObstruction,pancreaticpseudocysts,combinedwithbiliarydiseases,intractabepain,Celiacnerveblock（难处理）Therapeuticendoscopy,.,.,.,.,.,.,.,胰腺肿瘤,PancreaticcarcinomaArisefromacinar腺泡orductcellsEarlydiagnosisverydifficulty,prognosispoorObstructivejaundice(permanent):mainsymptomAbdominalpainDiabetesWeakness,emaciation(消瘦)Stools:acholic无胆汁Gallbladder:DistendedAbdominalmass,.,DiagnosisofpancreaticcarcinomaLaboratorytest:AKP,r-GT,LDH;CEA,POA胰胚抗原,PCCA胰癌相关抗原,CA19-9ImagingfindingUS,CT(CTA),MRCPERCP,PTC&PTCDPET(正电子发射断层扫描)Biopsy(FNA)andcytology,胰腺肿瘤,.,TreatmentofpancreaticcarcinomaRadicaloperationPancreatoduodenectomy-tumorinpancreaticheadResectionofpancreaticbodyandtail-tumorinpancreaticbodyortailPalliativeoperation:torelievejaundiceBiotherapy,胰腺肿瘤,.,SPN,.,胰腺密度,胰腺肿瘤密度低于胰腺密度,.,Pancreaticendocrineneoplasm(PEN)InsulinomaArisefromBcellSymptoms:whipplestriad1Spontaneoushypoglycemiaaccompaniedbycentralnervoussystem,psychiatric,orvasomotorsymptoms2Repeatedbloodsugarlevelsbelow2.8mmol/L(50mg%)3Reliefofsymptomsbyo