胰腺疾病外科教学课件

Diseases of pancreas,DAI Chao-Liu 2nd clinical college of China Medical University,Acute pancreatitis,Anatomy Head, neck.body, tail, uncinate process, Main pancreatic duct (duct of Wirsung) Dorsal pancreatic duct (duct of Santorini) Pancreatic excretion Exocrine (extra secretion) Endocrine（internal secretion):B,A,D,G cell,c,Causes Gallstones:60%( 3550% in USA) Alcohol:!4% Drug: Azathioprine .6-Mercaptopurine- Pancreas divisum(胰腺分裂;胰分裂) Microlithiasis Metabolic cause Sphincter of Oddi dysfunction Infectious causes Trauma, ascaris worms,HIV- Miscellaneous,Acute pancreatitis,Pathology acute edematous pancreatitis acute hemorrhagic necrotizing pancreatitis (acute hemorrhagic pancreatitis, acute necrotizing pancreatitis),Acute pancreatitis,Pathophysiology Hypersecretion and obstruction Self-enzymatic digestiono Lymphatic obstruction Cytokine，infection Decreased arterial perfusion Edematous hemorrhagic necrotizing,Acute pancreatitis,Clinical finding Abdominal pain Abdominal distention Nausea and vomiting Respiratory failure, confusion, or coma. Low-grade to moderate fever Tachycardia and hypotension Mild jaundice, Pleural effusion. Shock,Acute pancreatitis,Acute pancreatitis,Peritoneal irritation sign （Abdominal tenderness， rebound tenderness and rigidity） Shifting dullness Decreased bowel sounds Cullen sign: discoloration of periumbilical area Grey Turner sign:discoloration of flanks,Laboratory finding Amylase and lipase (elevations of amylase are more sensitive but less specific than lipase in the diagnosis of acute pancreatitis ) 500 400 300 200 100 0 0 1H 24H 48H 5DAY,Acute pancreatitis,Blood amylase,Urine amylase,Acute pancreatitis,Serum calcium Serum glucose Blood gas analysis CRP(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 transverse colon (colon cutoff sign) Radioopaque densities (biliary calculi) Left-sided pleural effusion B-US: pancreatic edema, ascites- CT: Important,Acute pancreatitis,CT is the best diagnostic test for the diagnosis of acute pancreatitis. Contrast-enhanced CT is excellent for diagnosis of pancreatic necrosis,有力武器,Acute pancreatitis,Assessment 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 sequestration 6 L,Acute pancreatitis,Glasgow criteria Within 48 Hours Age 55 WBC 15,000 mm LDH 600 IU/L Glucose 180 mg/dl Albumin 45 mg/dl Arterial PO2 60 mm Hg,Acute pancreatitis,APACHE III criteria Temperature BUN Mean blood pressure Leukocytes Serum Creatinine Hematocrit Heart rate Albumin Respiratory rate Bilirubin Oxygenation Arterial pH Serum sodium and potassium Serum glucose 8 Scores -SAP,Diagnosis and differential Diagnosis Acute edematous pancreatitis and acute hemorrhagic necrotizing pancreatitis Other diseases Acute appendtitis Ileus Perforated gastroduodenal ulcer Biliary disease Ruptured hepatoma,Acute pancreatitis,Clinical finding Amylase CT Abdominal paracentesis,Acute pancreatitis,Treatment Acute edematous pancreatitisinternal medicine (Emergency surgery is not indicated in mild acute pancreatitis) Acute hemorrhagic necrotizing pancreatitis Supportive care Replacement of fluid and electrolytes Correction of metabolic abnormalities Nutritional support Other measures :nasogastric suction and antibiotics,Agents to inhibit pancreatic secretion Have not been found to be useful in altering the course in acute pancreatitis 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 necrotic 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 dysfunction outcome is the same as for the endoscopic pancreatic sphincterotomy more invasive requiring laparotomy and duodenotomy,Acute pancreatitis,Endoscopic 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 each area is the relief of obstruction to flow of pancreatic juice,Chronic pancreatitis,Causes Alcohol Pancreas divisum Tropical pancreatitis Hyperparathyroidism Trauma Obstructive pancreatitis Idiopathic chronic pancreatitis Cystic fibrosis Hereditary chronic pancreatitis,Chronic pancreatitis,Classification Obstructive chronic pancreatitis Calcified chronic pancreatitis Inflammatory chronic pancreatitis Pathology pancreatic fibrosis -,Chronic pancreatitis,Clinical finding and diagnosis Abdominal pain , distention Diarrhage Dyspepsia Malnutrtion Diabetes Narcotic addiction Jaundice,Biochemical measurements Isoamylase,lipase trypsin,and elastase Quantitative measurement of fecal fat glucose tolerance test Secretin stimulation test Plasma cholecystokinin (CCK)( may be elevated ) Bentiromide (苯酪肽) test,Chronic pancreatitis,Chronic pancreatitis,Imaging finding Plain abdominal film Transabdominal ultrasound CT MRCP Endoscopic diagnosis procedures(ERCP,EUS),Chronic pancreatitis,Medical therapy Alcohol and cigarette avoidance Analgesics Enzyme therapy Treatment of malnutrition Surgical therapy Biliary Obstruction, pancreatic pseudocysts, combined with biliary diseases, intractabe pain, Celiac nerve block Therapeutic endoscopy,Tumors of Pancreas,Pancreatic carcinoma Arise from acinar or duct cells Early diagnosis very difficulty , prognosis poor Obstructive jaundice(permanent):main symptom Abdominal pain Diabetes Weakness, emaciation(消瘦) Stools: acholic Gallbladder:Distended Abdominal mass,Diagnosis of pancreatic carcinoma Laboratory test: AKP ,r-GT,LDH;CEA ,POA, PCCA,CA19-9: C-K-ras- Imaging finding US,CT( CTA),MRCP ERCP, PTC&PTCD PET(正电子发射断层扫描) Biopsy(FNA) and cytology,Tumors of Pancreas,Treatment of pancreatic carcinoma Radical operation Pancreatoduodenectomy - tumor in pancreatic head Resection of pancreatic body and tail-tumor i