胰腺疾病(英文).PPT

1、1胰腺疾病胰腺疾病2 解剖生理概要 解剖解剖 頭，頸，體，尾，鉤突。頭，頸，體，尾，鉤突。 主胰管主胰管 (duct of Wirsung) 副胰管副胰管 (duct of Santorini) 胰腺分泌胰腺分泌 外分泌外分泌Exocrine 內分泌內分泌Endocrine B,A,D,D1,G cell34c Causes Gallstones:60%( 3550% in USA) Alcohol:14% %(60% in USA) Duodenal juice countercurrent flow: Sphincter of Oddi dysfunction Trauma Pancrea

2、s circulation disorder Other factors: Drug: Azathioprine(硫唑嘌呤) .6-Mercaptopurine(6-巰基嘌呤), Pancreas divisum(胰分裂), Microlithiasis Metabolic cause Infectious causes, ascaris worms蛔蟲,HIV- Miscellaneous急性胰腺炎急性胰腺炎56 Pathology acute edematous pancreatitis acute hemorrhagic necrotizing pancreatitis (acute h

3、emorrhagic pancreatitis, acute necrotizing pancreatitis)急性胰腺炎急性胰腺炎7 Pathophysiology Hypersecretion and obstruction Self-enzymatic digestion Enhancement of Vessel permibility Cytokine，infection Decreased arterial perfusion Edematous hemorrhagic necrotizing 急性胰腺炎急性胰腺炎8 Clinical finding Abdominal pain

4、Abdominal distention Nausea and vomiting Peritonitis Other: Respiratory failure, confusion, or coma. Low-grade to moderate fever Tachycardia and hypotension and Shock Mild jaundice, Pleural effusion.急性胰腺炎急性胰腺炎9急性胰腺炎急性胰腺炎 Peritoneal irritation sign （Abdominal tenderness， rebound tenderness and rigidi

5、ty） Shifting dullness Decreased bowel sounds Cullen sign: discoloration of periumbilical area Grey Turner sign:discoloration of flanks1011 Laboratory finding Amylase and lipase (elevations of amylase are more sensitive but less specific than lipase in the diagnosis of acute pancreatitis ) 500 400 30

6、0 200 100 0 0 1H 24H 48H 5DAY急性胰腺炎急性胰腺炎Blood amylaseUrine amylase12急性胰腺炎急性胰腺炎 Serum calcium Serum glucose Blood gas analysis Imunolipase ALT and AST (gallstone pancreatitis ) 13 Imaging finding X-ray Dilated loop of small bowel (sentinel loop) Abrupt cessation of gas in the distal transverse colon (

7、colon cutoff sign) Radioopaque densities (biliary calculi) Left-sided pleural effusion B-US: pancreatic edema, ascites- CT: Important急性胰腺炎急性胰腺炎14CT is the best diagnostic test for the diagnosis of acute pancreatitis. Contrast-enhanced CT is excellent for diagnosis of pancreatic necrosis15急性胰腺炎急性胰腺炎

8、Assessment of severity of acute pancreatitis Ransons criteria On Admission Within 48 Hours 16急性胰腺炎急性胰腺炎 Glasgow Criteria Within 48 Hours Age 55 WBC 15,000 /mm LDH 600 IU/L Glucose 180 mg/dl Albumin 3.2 g/dl Calcium 45 mg/dl Arterial PaO2 8 Scores -SAP18 Diagnosis and differential Diagnosis Acute ede

9、matous pancreatitis and acute hemorrhagic necrotizing pancreatitis Other diseases Acute appendtitis Ileus Perforated gastroduodenal ulcer Biliary disease Ruptured hepatoma急性胰腺炎急性胰腺炎Clinical findingAmylaseCT Abdominal paracentesis19急性胰腺炎急性胰腺炎 Treatment Acute edematous pancreatitisinternal medicine (E

10、mergency 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 20 Agents to inhibit pancreatic

11、 secretion Have not been found to be useful in altering the course in acute pancreatitis Somatostatin(sandostatin stilamin) Protease inhibitors (trasylol抑肽酶) Surgical therapy Inefficiency by internal medicine Complication (pancreatic or/and peripancreatic Infection and abscess) Combined with biliary

12、 diseases(Gallstone ASP)21 Surgical approach Resection 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 sphinc

13、ter dysfunctionoutcome is the same as for the endoscopic pancreatic sphincterotomy more invasiverequiring laparotomy and duodenotomy22急性胰腺炎急性胰腺炎 Endoscopic therapy 1) acute gallstone pancreatitis 2) recurrent pancreatitis due to pancreatic sphincter dysfunction, 3) recurrent pancreatitis due to panc

14、reas divisum分裂分裂. The rationale for endoscopic therapy in each area is the relief of obstruction to flow of pancreatic juice 23242526慢性胰腺炎慢性胰腺炎 Causes Alcohol Pancreas divisum Acute pancreatitis Hyperparathyroidism Trauma Obstructive pancreatitis Idiopathic chronic pancreatitis Cystic fibrosis Hered

15、itary chronic pancreatitis27慢性胰腺炎慢性胰腺炎 Classification Obstructive chronic pancreatitis Calcified chronic pancreatitis Inflammatory chronic pancreatitis Pathology pancreatic fibrosis -28慢性胰腺炎慢性胰腺炎 Clinical finding and diagnosis Abdominal pain , distention Diarrhage Dyspepsia Malnutrtion Diabetes Narc

16、otic addiction Jaundice 29 Biochemical measurements Isoamylase,lipase trypsin,and elastase彈性蛋白酶 Quantitative measurement of fecal fat glucose tolerance test Secretin stimulation test Plasma cholecystokinin (CCK)( may be elevated ) Bentiromide (苯酪肽) test（與糜蛋白酶反應）慢性胰腺炎慢性胰腺炎3031慢性胰腺炎慢性胰腺炎 Imaging findi

17、ng Plain abdominal film Transabdominal ultrasound CT MRCP Endoscopic diagnosis procedures(ERCP,EUS)323334慢性胰腺炎慢性胰腺炎 Medical therapy Alcohol and cigarette avoidance Analgesics 鎮(zhèn)痛鎮(zhèn)痛 Enzyme therapy Treatment of malnutrition Surgical therapy Biliary Obstruction, pancreatic pseudocysts, combined with bil

18、iary diseases, intractabe pain, Celiac nerve block （難處理）（難處理） Therapeutic endoscopy35363738394041胰腺腫瘤胰腺腫瘤 Pancreatic carcinoma Arise from acinar腺泡 or duct cells Early diagnosis very difficulty , prognosis poor Obstructive jaundice(permanent):main symptom Abdominal pain Diabetes Weakness, emaciation(

19、消瘦) Stools: acholic無膽汁 Gallbladder:Distended Abdominal mass42 Diagnosis of pancreatic carcinoma Laboratory test: AKP ,r-GT,LDH;CEA ,POA胰胚抗原, PCCA胰癌相關抗原,CA19-9 Imaging finding US,CT( CTA),MRCP ERCP, PTC&PTCD PET(正電子發(fā)射斷層掃描) Biopsy(FNA) and cytology胰腺腫瘤胰腺腫瘤43 Treatment of pancreatic carcinoma Radical operation Pancreatoduodenectomy - tumor in pancreatic head Resection of pancreatic body and tail-tumor in pancreatic body or tail Palliativ