胰腺疾病外科教学课件

1、胰腺疾病外科教学课件 Acute pancreatitisAnatomyHead, neck.body, tail, uncinate process, Main pancreatic duct (duct of Wirsung)Dorsal pancreatic duct (duct of Santorini) Pancreatic excretionExocrine (extra secretion)Endocrine（internal secretion):B,A,D,G cellcCausesGallstones:60%( 3550% in USA)Alcohol:!4%Drug: A

2、zathioprine.6-Mercaptopurine-Pancreas divisum(胰腺分裂;胰分裂)MicrolithiasisMetabolic causeSphincter of Oddi dysfunctionInfectious causesTrauma, ascaris worms,HIV-MiscellaneousAcute pancreatitisPathologyacute edematous pancreatitisacute hemorrhagic necrotizing pancreatitis (acute hemorrhagic pancreatitis,

3、acute necrotizing pancreatitis)Acute pancreatitisPathophysiology Hypersecretion and obstruction Self-enzymatic digestiono Lymphatic obstruction Cytokine，infection Decreased arterial perfusionEdematous hemorrhagic necrotizing Acute pancreatitisClinical findingAbdominal painAbdominal distention Nausea

4、 and vomiting Respiratory failure, confusion, or coma. Low-grade to moderate fever Tachycardia and hypotension Mild jaundice, Pleural effusion.ShockAcute pancreatitisAcute pancreatitisPeritoneal irritation sign （Abdominal tenderness， rebound tenderness and rigidity）Shifting dullnessDecreased bowel s

5、ounds Cullen sign: discoloration of periumbilical area Grey Turner sign:discoloration of flanksLaboratory findingAmylase and lipase (elevations of amylase are more sensitive but less specific than lipase in the diagnosis of acute pancreatitis )5004003002001000 0 1H 24H 48H 5DAYAcute pancreatitisBloo

6、d amylaseUrine amylaseAcute pancreatitisSerum calcium Serum glucose Blood gas analysisCRP(C-reactive protein)Imunolipase, trypsinogen ,and immuno elastase. ALT and AST (gallstone pancreatitis ) Imaging finding X-ray Dilated loop of small bowel (sentinel loop)Abrupt cessation of gas in the distal tra

7、nsverse colon (colon cutoff sign)Radioopaque densities (biliary calculi) Left-sided pleural effusionB-US: pancreatic edema, ascites- CT: ImportantAcute pancreatitisCT is the best diagnostic test for the diagnosis of acute pancreatitis. Contrast-enhanced CT is excellent for diagnosis of pancreatic ne

8、crosis有力武器Acute pancreatitisAssessment of severity of acute pancreatitis Ransons criteria On Admission Within 48 Hours Age 55 years Hematocrit decrease by 10% WBC 16,000 mm Urea nitrogen increase 5 mg/dl LDH 350 IU/L Serum calcium 200 mg/dl Arterial PO 250 IU/L Base deficit 4 mEq/L Estimated fluid s

9、equestration 6 LAcute pancreatitisGlasgow criteriaWithin 48 HoursAge 55WBC 15,000 mmLDH 600 IU/LGlucose 180 mg/dlAlbumin 3.2 g/dl Calcium 45 mg/dlArterial PO2 8 Scores -SAPDiagnosis and differential DiagnosisAcute edematous pancreatitis and acute hemorrhagic necrotizing pancreatitisOther diseasesAcu

10、te appendtitisIleus Perforated gastroduodenal ulcer Biliary disease Ruptured hepatomaAcute pancreatitisClinical findingAmylaseCT Abdominal paracentesisAcute pancreatitisTreatmentAcute edematous pancreatitisinternal medicine (Emergency surgery is not indicated in mild acute pancreatitis)Acute hemorrh

11、agic necrotizing pancreatitisSupportive care Replacement of fluid and electrolytesCorrection of metabolic abnormalitiesNutritional support Other measures :nasogastric suction and antibiotics Agents to inhibit pancreatic secretionHave not been found to be useful in altering the course in acute pancre

12、atitis Somatostatin(sandostatin stilamin)Glucagon. Protease inhibitors (trasylol)Surgical therapy Inefficiency by internal medicine Complication (pancreatic or/and peripancreatic Infection and abscess) Combined wit biliary diseases(Gallstone ASP)Diagnosis unclear Surgical approach Rresection of necr

13、otic tissue and peritoneal lavage severe, progressive necrotizing pancreatitis or pancreatic abscess. Cholecystectomy recurrent acute pancreatitis and microlithiasis. Surgical sphincteroplasty of the pancreatic sphincter pancreatic sphincter dysfunctionoutcome is the same as for the endoscopic pancr

14、eatic sphincterotomy more invasiverequiring laparotomy and duodenotomyAcute pancreatitisEndoscopic therapy 1) acute gallstone pancreatitis 2) recurrent pancreatitis due to pancreatic sphincter dysfunction, 3) recurrent pancreatitis due to pancreas divisum. The rationale for endoscopic therapy in eac

15、h area is the relief of obstruction to flow of pancreatic juice Chronic pancreatitisCauses AlcoholPancreas divisumTropical pancreatitisHyperparathyroidismTraumaObstructive pancreatitisIdiopathic chronic pancreatitisCystic fibrosisHereditary chronic pancreatitisChronic pancreatitisClassificationObstr

16、uctive chronic pancreatitisCalcified chronic pancreatitisInflammatory chronic pancreatitisPathology pancreatic fibrosis -Chronic pancreatitisClinical finding and diagnosisAbdominal pain , distentionDiarrhageDyspepsiaMalnutrtionDiabetes Narcotic addictionJaundice Biochemical measurementsIsoamylase,li

17、pase trypsin,and elastaseQuantitative measurement of fecal fat glucose tolerance testSecretin stimulation testPlasma cholecystokinin (CCK)( may be elevated )Bentiromide (苯酪肽) testChronic pancreatitisChronic pancreatitisImaging findingPlain abdominal filmTransabdominal ultrasound CT MRCP Endoscopic d

18、iagnosis procedures(ERCP,EUS)Chronic pancreatitisMedical therapyAlcohol and cigarette avoidanceAnalgesics Enzyme therapyTreatment of malnutrition Surgical therapyBiliary Obstruction, pancreatic pseudocysts, combined with biliary diseases, intractabe pain,Celiac nerve blockTherapeutic endoscopyTumors

19、 of PancreasPancreatic carcinomaArise from acinar or duct cellsEarly diagnosis very difficulty , prognosis poorObstructive jaundice(permanent):main symptomAbdominal pain DiabetesWeakness, emaciation(消瘦)Stools: acholic Gallbladder:DistendedAbdominal massDiagnosis of pancreatic carcinomaLaboratory tes

20、t: AKP ,r-GT,LDH;CEA ,POA, PCCA,CA19-9: C-K-ras-Imaging findingUS,CT( CTA),MRCPERCP, PTC&PTCDPET(正电子发射断层扫描)Biopsy(FNA) and cytologyTumors of PancreasTreatment of pancreatic carcinomaRadical operation Pancreatoduodenectomy - tumor in pancreatic head Resection of pancreatic body and tail-tumor in pancrea