胰腺疾病(英文)課件課件現(xiàn)在是1頁\一共有47頁\編輯于星期日

解剖生理概要解剖頭，頸，體，尾，鉤突。

主胰管

(ductofWirsung)副胰管

(ductofSantorini)

胰腺分泌外分泌Exocrine內(nèi)分泌EndocrineB,A,D,D1,Gcell現(xiàn)在是2頁\一共有47頁\編輯于星期日現(xiàn)在是3頁\一共有47頁\編輯于星期日cCausesGallstones:60%(35–50%inUSA)Alcohol:14%%(60%inUSA)Duodenaljuicecountercurrentflow:SphincterofOddidysfunctionTraumaPancreascirculationdisorderOtherfactors:Drug:Azathioprine(硫唑嘌呤)

.6-Mercaptopurine(6-巰基嘌呤),Pancreasdivisum(胰分裂),MicrolithiasisMetaboliccauseInfectiouscauses,ascarisworms蛔蟲,HIV-----Miscellaneous急性胰腺炎現(xiàn)在是4頁\一共有47頁\編輯于星期日現(xiàn)在是5頁\一共有47頁\編輯于星期日Pathologyacuteedematouspancreatitisacutehemorrhagicnecrotizingpancreatitis(acutehemorrhagicpancreatitis,acutenecrotizingpancreatitis)急性胰腺炎現(xiàn)在是6頁\一共有47頁\編輯于星期日PathophysiologyHypersecretionandobstruction

Self-enzymaticdigestion

EnhancementofVesselpermibilityCytokine，infection

DecreasedarterialperfusionEdematoushemorrhagicnecrotizing急性胰腺炎現(xiàn)在是7頁\一共有47頁\編輯于星期日ClinicalfindingAbdominalpainAbdominaldistentionNauseaandvomitingPeritonitisOther:Respiratoryfailure,confusion,orcoma.Low-gradetomoderatefeverTachycardiaandhypotensionandShockMildjaundice,Pleuraleffusion.急性胰腺炎現(xiàn)在是8頁\一共有47頁\編輯于星期日急性胰腺炎Peritonealirritationsign（Abdominaltenderness，reboundtendernessandrigidity）ShiftingdullnessDecreasedbowelsoundsCullen’sign:discolorationofperiumbilicalareaGreyTurner’sign:discolorationofflanks現(xiàn)在是9頁\一共有47頁\編輯于星期日現(xiàn)在是10頁\一共有47頁\編輯于星期日LaboratoryfindingAmylaseandlipase(elevationsofamylasearemoresensitivebutlessspecificthanlipaseinthediagnosisofacutepancreatitis)500400300200100001H24H48H5DAY急性胰腺炎BloodamylaseUrineamylase現(xiàn)在是11頁\一共有47頁\編輯于星期日急性胰腺炎Serumcalcium

Serumglucose

BloodgasanalysisImunolipaseALTandAST(gallstonepancreatitis)現(xiàn)在是12頁\一共有47頁\編輯于星期日ImagingfindingX-ray

Dilatedloopofsmallbowel(sentinelloop)Abruptcessationofgasinthedistaltransversecolon(coloncutoffsign)Radioopaquedensities(biliarycalculi)

Left-sidedpleuraleffusionB-US:pancreaticedema,ascites----CT:Important急性胰腺炎現(xiàn)在是13頁\一共有47頁\編輯于星期日?CTisthebestdiagnostictestforthediagnosisofacutepancreatitis.?Contrast-enhancedCTisexcellentfordiagnosisofpancreaticnecrosis有力武器現(xiàn)在是14頁\一共有47頁\編輯于星期日急性胰腺炎Assessmentofseverityofacutepancreatitis

Ranson'scriteria

OnAdmissionWithin48Hours

Age>55yearsHematocritdecreaseby>10%WBC>16,000/mm3Ureanitrogenincrease>5mg/dlLDH>350IU/LSerumcalcium<1.87mmol/lGlucose>11.1mmol/lArterialPO2<8KPa(60mmHg)AST>250IU/LBasedeficit>4mEq/L

Estimatedfluidsequestration>6L現(xiàn)在是15頁\一共有47頁\編輯于星期日急性胰腺炎GlasgowCriteriaWithin48HoursAge>55WBC>15,000/mm3LDH>600IU/LGlucose>180mg/dlAlbumin<3.2g/dlCalcium<8mg/dlUrea>45mg/dlArterialPaO2<60mmHg現(xiàn)在是16頁\一共有47頁\編輯于星期日急性胰腺炎APACHEIIIcriteriaTemperature?BUNMeanbloodpressure?LeukocytesSerumCreatinine?HematocritHeartrate?AlbuminRespiratoryrate?BilirubinOxygenationArterialpHSerumsodiumandpotassiumSerumglucose>8Scores----SAP現(xiàn)在是17頁\一共有47頁\編輯于星期日DiagnosisanddifferentialDiagnosisAcuteedematouspancreatitisandacutehemorrhagicnecrotizingpancreatitisOtherdiseasesAcuteappendtitisIleusPerforatedgastroduodenalulcerBiliarydiseaseRupturedhepatoma急性胰腺炎ClinicalfindingAmylaseCTAbdominalparacentesis現(xiàn)在是18頁\一共有47頁\編輯于星期日急性胰腺炎TreatmentAcuteedematouspancreatitis—internalmedicine(Emergencysurgeryisnotindicatedinmildacutepancreatitis)AcutehemorrhagicnecrotizingpancreatitisSupportivecareReplacementoffluidandelectrolytesCorrectionofmetabolicabnormalitiesNutritionalsupportOthermeasures:nasogastricsuctionandantibiotics現(xiàn)在是19頁\一共有47頁\編輯于星期日AgentstoinhibitpancreaticsecretionHavenotbeenfoundtobeusefulinalteringthecourseinacutepancreatitis

Somatostatin(sandostatinstilamin)Proteaseinhibitors(trasylol抑肽酶)SurgicaltherapyInefficiencybyinternalmedicineComplication(pancreaticor/andperipancreaticInfectionandabscess)Combinedwithbiliarydiseases(GallstoneASP)現(xiàn)在是20頁\一共有47頁\編輯于星期日SurgicalapproachResectionofnecrotictissueandperitoneallavage

severe,progressivenecrotizingpancreatitisorpancreaticabscess.

Cholecystectomy

recurrentacutepancreatitisandmicrolithiasis.

Surgicalsphincteroplastyofthepancreaticsphincter

pancreaticsphincterdysfunctionoutcomeisthesameasfortheendoscopicpancreaticsphincterotomymoreinvasiverequiringlaparotomyandduodenotomy現(xiàn)在是21頁\一共有47頁\編輯于星期日急性胰腺炎Endoscopictherapy

1)acutegallstonepancreatitis2)recurrentpancreatitisduetopancreaticsphincterdysfunction,3)recurrentpancreatitisduetopancreasdivisum分裂.Therationaleforendoscopictherapyineachareaisthereliefofobstructiontoflowofpancreaticjuice現(xiàn)在是22頁\一共有47頁\編輯于星期日現(xiàn)在是23頁\一共有47頁\編輯于星期日現(xiàn)在是24頁\一共有47頁\編輯于星期日現(xiàn)在是25頁\一共有47頁\編輯于星期日慢性胰腺炎Causes

AlcoholPancreasdivisumAcutepancreatitisHyperparathyroidismTraumaObstructivepancreatitisIdiopathicchronicpancreatitisCysticfibrosisHereditarychronicpancreatitis現(xiàn)在是26頁\一共有47頁\編輯于星期日慢性胰腺炎ClassificationObstructivechronicpancreatitisCalcifiedchronicpancreatitisInflammatorychronicpancreatitisPathologypancreaticfibrosis----現(xiàn)在是27頁\一共有47頁\編輯于星期日慢性胰腺炎ClinicalfindinganddiagnosisAbdominalpain,distentionDiarrhageDyspepsiaMalnutrtionDiabetesNarcoticaddictionJaundice現(xiàn)在是28頁\一共有47頁\編輯于星期日BiochemicalmeasurementsIsoamylase,lipasetrypsin,andelastase彈性蛋白酶QuantitativemeasurementoffecalfatglucosetolerancetestSecretinstimulationtestPlasmacholecystokinin(CCK)(maybeelevated)Bentiromide(苯酪肽)test（與糜蛋白酶反應(yīng)）慢性胰腺炎現(xiàn)在是29頁\一共有47頁\編輯于星期日現(xiàn)在是30頁\一共有47頁\編輯于星期日慢性胰腺炎ImagingfindingPlainabdominalfilmTransabdominalultrasoundCTMRCPEndoscopicdiagnosisprocedures(ERCP,EUS)現(xiàn)在是31頁\一共有47頁\編輯于星期日現(xiàn)在是32頁\一共有47頁\編輯于星期日現(xiàn)在是33頁\一共有47頁\編輯于星期日慢性胰腺炎MedicaltherapyAlcoholandcigaretteavoidanceAnalgesics鎮(zhèn)痛EnzymetherapyTreatmentofmalnutrition

SurgicaltherapyBiliaryObstruction,pancreaticpseudocysts,combinedwithbiliarydiseases,intractabepain,Celiacnerveblock（難處理）Therapeuticendoscopy現(xiàn)在是34頁\一共有47頁\編輯于星期日現(xiàn)在是35頁\一共有47頁\編輯于星期日現(xiàn)在是36頁\一共有47頁\編輯于星期日現(xiàn)在是37頁\一共有47頁\編輯于星期日現(xiàn)在是38頁\一共有47頁\編輯于星期日現(xiàn)在是39頁\一共有47頁\編輯于星期日現(xiàn)在是40頁\一共有47頁\編輯于星期日胰腺腫瘤PancreaticcarcinomaArisefromacinar腺泡orductcellsEarlydiagnosisverydifficulty,prognosispoorObstructivejaundice(permanent):mainsymptomAbdominalpainDiabetesWeakness,emaciation(消瘦)Stools:acholic無膽汁

Gallbladder:DistendedAbdominalmass現(xiàn)在是41頁\一共有47頁\編輯于星期日DiagnosisofpancreaticcarcinomaLaboratorytest:AKP,r-GT,LDH;CEA,POA胰胚抗原,PCCA胰癌相關(guān)抗原,CA19-9ImagingfindingUS,CT(CTA),MRCPERCP,PTC&PTCDPET(正電子發(fā)射斷層掃描)Biopsy(FNA)andcytology胰腺腫瘤現(xiàn)在是42頁\一共有47頁\編輯于星期日TreatmentofpancreaticcarcinomaRadicaloperationPancreatoduodenectomy----tumor