膽道和胰腺疾病肝膽外科

膽道和胰腺疾病肝膽外科解剖生理概要Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

切開后腹膜，向右牽開十二指腸及胰頭部胰十二指腸背面結(jié)構(gòu)Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.★胰液量750ml-1500ml/d★多種消化酶★胰島B細(xì)胞-胰島素、A細(xì)胞-胰高血糖素D細(xì)胞-生長抑素等

胰腺的外分泌、內(nèi)分泌功能Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.胰腺炎*急性胰腺炎慢性胰腺炎Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.（一）急性胰腺炎AcutepancreatitisEvaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.病因★梗阻因素膽石、蛔蟲膽汁返流胰液激活★暴飲暴食胰液過量分泌、胰管梗阻★胰腺創(chuàng)傷外傷、ERCP★胰腺缺血

★感染★特發(fā)性胰腺炎Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.在正常情況下不產(chǎn)生自身消化的原因：★胰管上皮有粘多糖保護★大部分胰酶以不激活的胰酶原存在★血液和胰液中含有少量胰酶抑制物可中和少量激活的胰酶★胰腺腺泡細(xì)胞具有代謝活力阻止胰酶侵入細(xì)胞。Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.發(fā)病機制胰腺消化酶異常激活后對本器官及其周圍臟器產(chǎn)生消化作用“自我消化”作用Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.胰酶激活膽汁返流十二指腸液反流自我消化彈性蛋白酶破壞彈性組織胰腺充血出血磷脂酶A激活細(xì)胞膜的磷脂，使卵磷脂轉(zhuǎn)變成溶血卵磷脂，引起胰腺和胰周組織的廣泛壞死脂肪酶使脂肪分解壞死，并與鈣離子結(jié)合形成皂化斑，可使血鈣降低Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.酒精刺激作用胰腺大量分泌Oddi括約肌痙攣直接損傷腺泡細(xì)胞胰腺損傷胰酶激活歐美發(fā)病原因Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.胰腺血液循環(huán)障礙胰腺組織壞死

重癥胰腺炎又稱為全身過度炎癥反應(yīng)綜合征與細(xì)胞因子、血管活性物質(zhì)有關(guān)后期合并感染多器官功能衰竭Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.病理★急性水腫型胰腺炎（胰體尾多見）局限性或彌漫性水腫、被膜緊張充血、變硬鏡下炎性細(xì)胞浸潤、伴有輕度出血及局灶性壞死Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.★急性出血壞死性胰腺炎

廣泛出血壞死、胰腺發(fā)黑、變軟

血性腹水、有皂化斑、胰腺膿腫Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.臨床表現(xiàn)★腹痛

飲酒或高脂餐后中上腹偏左、腰背放射★

惡心,嘔吐★

腹脹病情加重表現(xiàn)，腸麻痹脹氣、后腹膜炎癥★

腹膜炎體征★

其他:Gery-Turner征、發(fā)熱、黃疸、Cullen征、休克Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.診斷1.臨床表現(xiàn)2.實驗室檢查3.影像學(xué)檢查Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.實驗室檢查★胰酶測定:

血淀粉酶-高于100U/L,發(fā)病后2小時開始升高,24小時達高峰,持續(xù)4-5天.尿淀粉酶-高于460U/L,發(fā)作后24小時升高,可持續(xù)1-2周.Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.★血常規(guī):白細(xì)胞升高★電解質(zhì):低鈣(病后2-3天)等★血氣分析:ARDS表現(xiàn)★診斷性穿刺:腹水淀粉酶水平升高培養(yǎng)藥敏涂片Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.診斷:CT檢查示正常胰腺Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.急性胰腺炎CTEvaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

增強CT的意義Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.超聲檢查Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.非手術(shù)治療★禁食,胃腸減壓★防止休克★解痙止痛★抑制胰腺分泌—生長抑素★營養(yǎng)支持★抗生素Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.手術(shù)治療手術(shù)治療指征:

★繼發(fā)性胰腺感染

★

合并膽道病變

★

經(jīng)治療后臨床癥狀繼續(xù)惡化手術(shù)方式:灌洗引流、壞死組織清除、規(guī)則性胰腺切除、三造瘺

目的：清除胰酶、毒性物質(zhì)和壞死組織

對膽源性胰腺炎:ERCP/EST取石引流急診手術(shù)解除梗阻Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.（二）慢性胰腺炎

慢性復(fù)發(fā)性胰腺炎★胰腺內(nèi)、外分泌功能衰退、喪失★胰腺影像學(xué)檢查以及胰腺組織學(xué)★反復(fù)發(fā)作上腹痛★檢查異常等★病期應(yīng)在半年以上。Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.病因國外--飲酒國內(nèi)--膽道疾病營養(yǎng)不良、中毒等

Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.胰腺萎縮、變硬胰管結(jié)石胰腺組織不可逆變化：腺泡細(xì)胞破壞、纖維增生、導(dǎo)管狹窄病理Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

癥狀腹痛是最常見的癥狀，呈反復(fù)發(fā)作食欲不振、飽脹、噯氣排便次數(shù)增多、腹瀉、量多；脂肪瀉體重減輕及糖尿病等表現(xiàn)Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.診斷

病史、典型臨床表現(xiàn)及特殊檢查實驗室檢查

血、尿淀粉酶在急性發(fā)作時可增高。鏡下觀察糞便有多量脂肪滴和未消化的肌纖維。尿糖和糖耐量試驗呈陽性改變。

Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

影像檢查

B型超聲檢查：胰腺形態(tài)不規(guī)整、腺體腫大或縮小，胰石，胰管擴張或呈分段不規(guī)則擴張，胰腺囊腫等。內(nèi)鏡逆行胰膽管造影：胰管粗細(xì)不規(guī)則，胰石或囊腫；膽石或膽總管改變。Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.X線腹部平片胰腺可有結(jié)石、鈣化CT胰腺腫大或縮小，邊緣不清，密度降低，鈣化，胰石，胰腺囊腫。膽石和膽總管改變。

Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

非手術(shù)療法

原則控制腹痛、盡力調(diào)整胰腺內(nèi)外分泌功能

鎮(zhèn)痛（藥物、腹腔神經(jīng)叢封閉）飲食及胰酶制劑治療糖尿病者服用降糖藥

營養(yǎng)支持Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

手術(shù)療法

目的減輕疼痛保留胰腺功能

壺腹切開胰管引流胰腺切除Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

（三）胰腺腫瘤

男性多見預(yù)后差5年存活率1%-3%Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.胰腺癌病理特點常見部位:胰頭部分類:胰頭,胰體尾,胰腺囊腺癌病理組織:導(dǎo)管腺癌最常見囊腺癌腺泡細(xì)胞癌Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.胰頭癌，梗阻性黃疸行內(nèi)、外引流Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.經(jīng)皮肝穿刺膽管造影（percutaneoustranshepeticcholangiography,PTC）

★方法：右側(cè)腋中線法：此法最常用在B超或X線引導(dǎo)下經(jīng)腋中線7、8肋間穿入肝內(nèi)膽管至第一腰椎右側(cè)2CM停止。推注造影劑見“如煙而逝”表明在血管內(nèi)，即所謂的“冒煙”現(xiàn)象

。若呈云霧狀提示造影劑注入肝組織內(nèi)，只有表現(xiàn)為樹枝狀時穿刺成功。

胰頭癌Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.內(nèi)鏡逆行膽胰管造影ERCP

(endoscopicretrogradecholangiopancreatography)★方法★診斷十二指腸乳頭，取材活檢取腸液、胰液檢查膽道胰腺疾?。懝馨⒏文懝芙Y(jié)石、胰頭癌雙管征慢性胰腺炎呈現(xiàn)鈣化、結(jié)石，主胰管不規(guī)則慢性胰腺炎Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.發(fā)病率呈逐年上升趨勢癌癥相關(guān)死亡的第四大原因預(yù)后惡劣（5年生存率1－2％，85％病人在確診后12個月內(nèi)死亡）侵襲性生長早期多極化浸潤轉(zhuǎn)移毗鄰器官較多，無完整包膜，周圍淋巴、血管、神經(jīng)組織豐富，易早期侵犯血管、淋巴管及神經(jīng)鞘膜，發(fā)生胰內(nèi)及胰外轉(zhuǎn)移Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.侵襲性生長早期多極化浸潤轉(zhuǎn)移毗鄰器官較多，無完整包膜，周圍淋巴、血管、神經(jīng)組織豐富，易早期侵犯血管、淋巴管及神經(jīng)鞘膜，發(fā)生胰內(nèi)及胰外轉(zhuǎn)移Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

胰頭癌臨床表現(xiàn)Canceroftheheadofthepancreas

上腹痛和上腹飽脹黃疸早晚與膽管距離有關(guān)消瘦乏力嘔吐Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.診斷

臨床表現(xiàn)影像學(xué)檢查B超、CT、ERCPEvaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.治療治療原則早期發(fā)現(xiàn),早期診斷,早期手術(shù)手術(shù)方法胰十二指腸切除術(shù)保留幽門的胰十二指腸切除術(shù)姑息性手術(shù)

Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.FeaturesofStandardResectionEvaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.（四）壺腹周圍癌

Periampullaryadenocarcinoma定義

膽總管末段，壺腹部和十二指腸乳頭附近的癌腫包括：壺腹部、十二指腸和膽總管下段三種癌Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.壺腹癌：波動性黃疸十二指腸癌：膽道不全梗阻十二指腸梗阻表現(xiàn)膽總管下段癌：進行性加重黃疸白陶土便臨床表現(xiàn)和診斷Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.ERCP檢查具有重要價值Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.治療手術(shù)方法胰十二指腸切除術(shù)保留幽門的胰十二指腸切除術(shù)手術(shù)切除率高，遠(yuǎn)期效果良好Evaluationonly.CreatedwithA