1、胰腺疾病英文 解剖生理概要 解剖解剖 头，颈，体，尾，钩突。头，颈，体，尾，钩突。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 内分泌内分泌Endocrine B,A,D,D1,G cellc Causes Gallstones:60%(3550%in USA)Alcohol:14%(60%in USA)Duodenal juice countercurrent flow:Sphincter of Oddi dysfunction Trauma Pancreas circulation disor
2、der Other factors:Drug:Azathioprine(硫唑嘌硫唑嘌呤呤).6Mercaptopurine(6巯基嘌呤巯基嘌呤),Pancreas divisum(胰分裂胰分裂),Microlithiasis Metabolic cause Infectious causes,ascaris worms蛔虫蛔虫,HIV Miscellaneous急性胰腺炎急性胰腺炎 Pathology acute edematous pancreatitis acute hemorrhagic necrotizing pancreatitis (acute hemorrhagic pancre
3、atitis,acute necrotizing pancreatitis)急性胰腺炎急性胰腺炎 Pathophysiology Hypersecretion and obstruction Selfenzymatic digestion Enhancement of Vessel permibility Cytokine，infection Decreased arterial perfusion Edematous hemorrhagic necrotizing 急性胰腺炎急性胰腺炎 Clinical finding Abdominal pain Abdominal distention
4、Nausea and vomiting Peritonitis Other:Respiratory failure,confusion,or coma.Lowgrade to moderate fever Tachycardia and hypotension and Shock Mild jaundice,Pleural effusion.急性胰腺炎急性胰腺炎急性胰腺炎急性胰腺炎 Peritoneal irritation sign（Abdominal tenderness，rebound tenderness and rigidity）Shifting dullness Decreased
5、 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急性胰腺炎急性胰腺炎
6、Blood amylaseUrine amylase急性胰腺炎急性胰腺炎 Serum calcium Serum glucose Blood gas analysis Imunolipase ALT and AST(gallstone pancreatitis)Imaging finding Xray Dilated loop of small bowel(sentinel loop)Abrupt cessation of gas in the distal transverse colon(colon cutoff sign)Radioopaque densities(biliary cal
7、culi)Leftsided pleural effusion BUS:pancreatic edema,ascites CT:Important急性胰腺炎急性胰腺炎CT is the best diagnostic test for the diagnosis of acute pancreatitis.Contrast-enhanced CT is excellent for diagnosis of pancreatic necrosis急性胰腺炎急性胰腺炎 Assessment of severity of acute pancreatitis Ransons criteria On
8、Admission Within 48 Hours Resection of pancreatic body and tailtumor in pancreatic body or tailBiliary Obstruction,pancreatic pseudocysts,combined with biliary diseases,intractabe pain,Inflammatory chronic pancreatitisUS,CT(CTA),MRCP8mmol/L(50mg%)Resection of necrotic tissue and peritoneal lavage se
9、vere,progressive necrotizing pancreatitis or pancreatic abscess.Vater ampullaCalcified chronic pancreatitisacute edematous pancreatitisOther diseasesTransabdominal ultrasoundSurgical sphincteroplasty of the pancreatic sphincterLDH 600 IU/L1)acute gallstone pancreatitisPlain abdominal filmacute hemor
10、rhagic necrotizing pancreatitisAlbumin 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 SAP Diagnosis and differential Diagnosis Acute edematous pancreatitis and acute hemorrhagic necrotizing pancreatitis Other diseases Acute appendtitis Ileus
11、Perforated gastroduodenal ulcer Biliary disease Ruptured hepatoma急性胰腺炎急性胰腺炎Clinical findingAmylaseCT Abdominal paracentesis急性胰腺炎急性胰腺炎 Treatment Acute edematous pancreatitisinternal medicine(Emergency surgery is not indicated in mild acute pancreatitis)Acute hemorrhagic necrotizing pancreatitis Suppo
12、rtive 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
13、stilamin)Protease inhibitors(trasylol抑肽酶)Surgical therapy Inefficiency by internal medicine Complication(pancreatic or/and peripancreatic Infection and abscess)Combined with biliary diseases(Gallstone ASP)Surgical approach Resection of necrotic tissue and peritoneal lavage severe,progressive necroti
14、zing pancreatitis or pancreatic abscess.Cholecystectomy recurrent acute pancreatitis and microlithiasis.Surgical sphincteroplasty of the pancreatic sphincter pancreatic sphincter dysfunctionoutcome is the same as for the endoscopic pancreatic sphincterotomy more invasiverequiring laparotomy and duod
15、enotomy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 pancreas divisum分裂分裂.The rationale for endoscopic therapy in each area is the relief of obstruction to flow of pancreatic juice 慢性胰腺炎慢性
16、胰腺炎 Causes Alcohol Pancreas divisum Acute pancreatitis Hyperparathyroidism Trauma Obstructive pancreatitis Idiopathic chronic pancreatitis Cystic fibrosis Hereditary chronic pancreatitis慢性胰腺炎慢性胰腺炎 Classification Obstructive chronic pancreatitis Calcified chronic pancreatitis Inflammatory chronic pan
17、creatitis Pathology pancreatic fibrosis 慢性胰腺炎慢性胰腺炎 Clinical finding and diagnosis Abdominal pain,distention Diarrhage Dyspepsia Malnutrtion Diabetes Narcotic addiction Jaundice Serum Creatinine HematocritAge 55 years Hematocrit decrease by 10%Nausea and vomitingClinical finding and diagnosisObstruct
18、ive pancreatitisAST 250 IU/L Base deficit 4 mEq/LNausea and vomitingLDH 600 IU/LArterial pHEndoscopic therapyNutritional supportPleural effusion.Tachycardia and hypotension and ShockResection of necrotic tissue and peritoneal lavage severe,progressive necrotizing pancreatitis or pancreatic abscess.S
19、erum sodium and potassiumLowgrade to moderate feverComplication(pancreatic or/and peripancreatic Infection and abscess)Arterial pHTemperature BUNHypersecretion and obstruction头，颈，体，尾，钩突。Biochemical measurements Isoamylase,lipase trypsin,and elastase弹性蛋白酶 Quantitative measurement of fecal fat glucose
20、 tolerance test Secretin stimulation test Plasma cholecystokinin(CCK)(may be elevated)Bentiromide(苯酪肽)test（与糜蛋白酶反应）慢性胰腺炎慢性胰腺炎慢性胰腺炎慢性胰腺炎 Imaging finding Plain abdominal film Transabdominal ultrasound CT MRCP Endoscopic diagnosis procedures(ERCP,EUS)慢性胰腺炎慢性胰腺炎 Medical therapy Alcohol and cigarette avo
21、idance Analgesics 镇痛镇痛 Enzyme therapy Treatment of malnutrition Surgical therapy Biliary Obstruction,pancreatic pseudocysts,combined with biliary diseases,intractabe pain,Celiac nerve block （难处理）（难处理）Therapeutic endoscopySecretin stimulation testWBC 15,000/mmWithin 48 HoursClinical finding and diagn
22、osisVater ampullaSymptom:obstructive jaundiceVater ampullaSurgical approachMean blood pressure LeukocytesSelfenzymatic digestionCT:ImportantCholecystectomyrequiring laparotomy and duodenotomyAbdominal painNutritional supportResection of pancreatic body and tailtumor in pancreatic body or tailGrey Tu
23、rner sign:discoloration of flanksTreatment of pancreatic carcinoma胰腺肿瘤胰腺肿瘤 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(消瘦)Stools:acholic无胆汁 Gallbladder:D
24、istended Abdominal mass Diagnosis of pancreatic carcinoma Laboratory test:AKP,rGT,LDH;CEA,POA胰胚抗原,PCCA胰癌相关抗原,CA199 Imaging finding US,CT(CTA),MRCP ERCP,PTC&PTCD PET(正电子发射断层扫描)Biopsy(FNA)and cytology胰腺肿瘤胰腺肿瘤 Treatment of pancreatic carcinoma Radical operation Pancreatoduodenectomy tumor in pancreatic
25、 head Resection of pancreatic body and tailtumor in pancreatic body or tail Palliative operation:to relieve jaundice Biotherapy胰腺肿瘤胰腺肿瘤SPN胰腺密度胰腺肿瘤密度低于胰腺密度 Pancreatic endocrine neoplasm(PEN)Insulinoma Arise from B cell Symptoms:whipples triad 1 Spontaneous hypoglycemia accompanied by central nervous
26、system,psychiatric,or vasomotor symptoms 2 Repeated blood sugar levels below 2.8mmol/L(50mg%)3 Relief of symptoms by oral or intravenous administration of glucose Diagnosis:symptom and IRI/G0.3,Bus,CT,MRI,EndoUS,Angiography,PTPS Treatment:operation(resection)胰腺肿瘤胰腺肿瘤 Arise from:Papilla of duodenum Vater ampulla Distal CBD Symptom:obstructive jaundice Diagnosis Treatment:similar to pancreatic carcinoma壶腹周围癌
