內科學-胰腺疾病(英文)課件

PANCREASPANCREAS1AnatomyandPhysiology

1.Structure:Pancreasisaglanodularstructurelocatedintheretroperitoneum.Anterioly,thepancreasiscoveredatthedistalheadandneckbythepylorusandthetransversemesocolon,theneckandbodyarecoveredanteriorlybytheposteriorgastricwall.Theanteriorsurfaceiscoveredbyaperitonealleaf(lessersac)AnatomyandPhysiology

1.Stru2

Thepancreasisroutinelydividedintothehead,theneck,thebodyandthetail.ThepancreasisalmostenteralyretroperitonealandhascloserelationshipwithnumeroussurroundingstructuresThepancreasisroutinelydiv3內科學_胰腺疾病(英文)課件4內科學_胰腺疾病(英文)課件52.PancreaticductsThemainpancreaticduct(Wirsung)runtheentirelengthofthepancreasandjoinsthecommonducttoemptyintoduodenumattheampulaofVater

2.Pancreaticducts6

Thenormalductisonly2-4mmindiameter,andcontains20secondarybranches.Pancreaticductpressureis15to30mmHg.Whereasthatinthecommonbileductisonly7-17mmHg.ThisdifferentialisthoughttopreventrefluxbileThenormalductisonly2-47內科學_胰腺疾病(英文)課件83.CommonchannelVariationsintherelationbetweentheintrapancreaticportionofthecommonbileductandthemainpancreaticductattheampulaofVater.Ashortcommonchannelcontainflowfrombothsecretarysystem.3.Commonchannel9內科學_胰腺疾病(英文)課件103.ArterialsupplyTheceliacandsuperiormesentericarteriessupplybloodtothepancreasthroughtheirmajorbranches.Somevariationsofhepaticarteriesinrelationtothepancreas3.Arterialsupply11內科學_胰腺疾病(英文)課件124.VenousdrainageThevenousdrainageofthepancreasandduodenumfollowsthearterialsupply,Theveinsareusuallysuperficialtothearteriesandthefrenquencyofanomaliesissimilar4.Venousdrainage13內科學_胰腺疾病(英文)課件145.Physiology(1)Exocrinefunction:IsletpeptideproductsinfluencethefunctionoftheexocrinepancreasBicarbonatesecretion:(20mmol/L,pH7-9)Enzymesecretion:(amylases,lipases,proteases)5.Physiology15(2)EndocrinefunctionInsulinOther:Neuropeptide(VIP,Glucagongalanin,serotonin,Somatastatineamylin)Pancreaticpolypeptide(2)Endocrinefunction16Acutepancreatitis

Acutepancretitisisanacuteinflammatoryprocessofthepancreaswithvariableinvolvementofotherregionaltissueororgans.AcutepancreatitisAcutepancr17300000/yearinUSAhospitalized4000deaths.75%ofcasesareattributabletoeithergallstoneoralcohol.300000/yearinUSAhospitalize18

20%ofcasessevere,it’sdefinedasassociatedwithoneormoreofthefollowing:necrosis,distantorganfailure,localcomplications(hemorrhage,abscess,pseudocyst)20%ofcasessevere,it’sdef19

Themortalityrate(severe)10-20%,withhalfdeathsinthefirst2weekastheresultofSIRS,inducedmultisystemorganfailure,remaningnecrosis/infection,andhemorrhge

Themortalityrate(severe)10-201.Classificationanddefinition1.Classificationanddefinitio212.Pathophysiology*Mild:interstitial(edematous)pancreatitis*Severe:associatedwithnecrotizingpancreatitis,haveundergonetissuenecrosiswithvascularinflammationandthrombosisbeingprominentfeatures2.Pathophysiology22內科學_胰腺疾病(英文)課件233.Etiology內科學_胰腺疾病(英文)課件24內科學_胰腺疾病(英文)課件25內科學_胰腺疾病(英文)課件264.ClinicalpresentationMostprevalentsymptoms:Abdominalpain,nausea,andvomitingTachycardiaandhypotensionLowgradefeverJaundice4.Clinicalpresentation27GreyTurner’ssign:bluediscolorationoftheflanks(blooddissectsintosubcutaneoustissueCullen’ssign:umbilicusbluediscolorationFox’ssign:InguinalregionbluediscolorationGreyTurner’ssign:bluediscol28LaboratorytestsImagingtestsUS,CT,MRILaboratorytests29Assessmentofdiseaseseverity(1)Scoringsystem*RansoncriteriaOnadimssion1.Age>55year2.Wbc>160003.Glucose>200mg/dl4.lactasedehydrogenase>350IU/L5.Glutamine-oxaloacetictransminase>250IU/LAssessmentofdiseaseseverity30After48hour1.Hct<10%2.Bloodureanitrogen>5mg/dl3.Calcium<8mg/dl4.PaCO2<60mmHg5.Basedeficit>4mEq/L6.Fluidsequestration>6LAfter48hour31*Glascowsystem*Glascowsystem32(2)CTScaningIt’smostimportantimagingtestforAPandisusefulincomformingthediagnosis,assessingdiseaseseverity,anddetectingcomplications.(2)CTScaning33

SerumandurinarymarkersCRPNeutrophilelastaseIL-6Serumandurinarymarkers345.Management(1)Goalsofmanagement5.Management35(2)ProvidingsupportivecareFluidresuscitationICU(CVP,PAWP)Positivepressureventilation,vasopressin,hemodialysisIVnarcotisNasogastrictube(2)Providingsupportivecare36(3)Minimizingprogression

ofpancreaticinflammationandinjuryBowelrest(nothingbymouth)LimitstimulationofpancreaticexocrinesecretionSeverecasesusedTPN(3)Minimizingprogressionofp37Inhibitactivatedpancreaticenzymes(Somatastatin,Octreotide)Platletactivatingfactorantagonist--LexiparfantOtheradjuncts:glucagons,freshfrozenplasma,anticholinergics,peritoneallavageInhibitactivatedpancreatice38(4)TreatingtheunderlyingcauseGallstonepancreastitis;ERCP(stoneextraction)6weeklaterundergocholecystectomyEndoscopicsphinctrotomy(4)Treatingtheunderlyingcau39(5)Preventingandtreatingcomplications

Infectionofpancreaticandperipancreaticnecrosiscomplicates30-70%ofcasesofANPandmostcommonlybecomeestablishedduringthesecondtothirdweeksafteronsetofdisease(5)Preventingandtreatingco40

InfectednecrosisFNA(CTguide)fordiagnosis(95%)Surgicalintervention(debridedanddrainage)NecrosectomywithlavageProphylacticantibioticsInfectednecrosis41

PseudocystsAcutefluidcollections,30-50%10%ofthemfluidcollectionsprogresstodevelopawalloffibroustissue,pseudocystsIfcystslessthan6cmindiameter-nonoperationPseudocysts42NEOPLASMSOFEXOCRINEPANCREASNEOPLASMSOFEXOCRINEPANCREAS43PANCREASCANCER1.Epidemiology11/100000/yearincidenceraterelativestableInChina,duringlasttwodecadeincreasedtwofoldPANCREASCANCER1.Epidemiolo442.RiskfactorsDemographicfactors:elder,male,BlackraceHostfactors:Colorectalcancer,Familialbreastcancer,Peutz-JeghersSyndrome,melanoma,pancreatitis.2.Riskfactors453.MoleculargeneticsOncogenes:K-rasTumorsuppressor:p16,p53,DPCA,BRCA23.Moleculargenetics464.PathologyClassification(1)Ductcellorigin(89%)DuctcelladenocarcinomaGiantcellcarcinomaAdenosaquamouscarcinomaMicrocarcinomaMucinouscystadenocarcinoma4.Pathology47(2)Acinarcellorigin(1%)AcinarcellcarcinomaCystadenoma(3)UncertainhistogenesisPancreaticblastomaPapillaryandcysticneoplasmMixed-Ductaandisletcells(2)Acinarcellorigin(1%)485.Clinicopathologicstagingand5yearssurvivalIAT1N0M05years20-30%IBT2N0M0survival20-30%IIAT3N0M010-25%IIBT123N1M010-15%IIIT4anyNM00-5%IVanyTanyNM1--5.Clinicopathologicstagingan496.DiagnosisSymptom(%)Headcancer

Weightloss92Jaundice82Pain72Anorexia64Darkurine63Lightstools62Nausa37

6.Diagnosis50

Symptom(%)BodyandtailcancerWeightloss100Pain87Weakness43Nausa43Vomiting37Constipation27Melena,jaundice,fever,diarrheaSymptom(%)Bodyandtailc51

Sign(%)HeadcancerJaundice87Palpableliver83Palpablegallbladder29Tenderness26Ascites14Abdominalmass13Sign(%)Headcancer52Sign(%)BodyandtailcancerPalpableliver33Tenderness27Abdominalmass23Jaundice13Diarrhea3Sign(%)Bodyandtailcancer53內科學_胰腺疾病(英文)課件54內科學_胰腺疾病(英文)課件55

7.Resectionofpancreaticcarcinoma7.Resectionofpancreaticc56

Carcinomaofthehead,neck,andUncinateprocess1912,Kaushfirstsuccessresection1935,WhippledescribedtechniqueofredicalresectionPerformetwostages:Stage1,decompresstheobstructionStage2,enblocresectionCarcinomaofthehead,nec57

ExtentofresectionExtentofresection58內科學_胰腺疾病(英文)課件59CarcinomaofthebodyandtailMuchmorelimitedthanthatoftheheadandneckMostpatientsareunabletoundergoresectionIftumorcan’tresected,tissuebiopsychemicalsplanchnicectomy,gastrojejunostomyCarcinomaofthebodyandtail60ComplicationsafterpancreaticoduodenectomyCommon:Delaygastricemptying,pancreaticfistula,intraabdominalabscess,hemorrhage,woundinfection,diabetes,pancreaticexocrineinsufficiency

Complicationsafterpancreatic61Uncommon:Fistula(biliary,duodenal,gastric)Organfailure(Pancreatic,hepaticPulmonary,renal)Pancrestitis,marginalulcerUncommon:62Long-termsurvivalLong-termsurvival63AdjuvantandneoajuvanttherapyAdjuvantandneoajuvanttherap64Palliationtreatment(1)JaundiceCholedochojejunstomyCholecystojejunostomy(2)DuodenalobstructionProphylactivegastricbypass(3)PainPalliationtreatment65NEOPLASMSOFTHEENDOCRINEPANCREASNEOPLASMSOFTHEENDOCRINEPAN66

1.ClassificatnInsulinomaHypoglycemia10%malignancyGastrinomaPepticulcer50%malignancyVIPomaWaterydiarrheaMostHypocalcemiaGlucagonomaHyperglycemiaMostDermatitisSomtostatinomaHyperglycemiaMostSteatorrheaGallstone1.Classificatn67

68內科學_胰腺疾病(英文)課件692.Insulinoma

Whipple’striad:(1)Symptomsofhypoglycemia(fasting)(2)Documentationofhypoglycemia,withaSerumglucoselevelbelow50mg/dl(3)Reliefofhypoglycemisasymptoms,followingadministrationofexocrineglucose2.Insulinoma70Inthemostcommonneoplasmoftheendocrinepancreas,autonomousinsulinsecretionleadstospontaneoushypoglycemiaSymtomscanbeclassifiedminto2groups:(1)Neuroglycopenicsymptoms,includeConfusion,seizura,obtundation,Personalitychange,comaInthemostcommonneoplasmof71(2)Hypoglycemiainducedsymptoms,Relatedtocatecholaminelevels,includepalpitations,trembling,diaphoresis,andtachycardiaMostcasesconsumecarbohydraterichmealsandsnackstorelieveorpreventthesesymptoms(2)Hypoglycemiainducedsympto72Diagnosis（1）Monitoredfast:Bloodglucoseandinsulinevery4-6hours,whenglucose50mg/dl,thesymptomsoccure（2）Insulin–to-glucoseratio:<0.3（3）Beta-cellproductssynthesizedin（4）Excess:Cpeptide,proinsulinDiagnosis7310%ofinsulinomaaremalignantPresentingwithlymphnodeorlivermetastasesResectionoftheprimarytumorshouldbeconsideredcanhelpreducinghypoglycemiasymptomsInunresectablecases,Diazoxideandoctretidecan