胰腺疾病(英文)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%)3Reliefofsymptomsby