醫(yī)學(xué)保健胰腺疾病

醫(yī)學(xué)保健胰腺疾病第1頁(yè)/共56頁(yè)Anatomy

Thepancreaslieswithintheretroperitoneumintheupperabdomen,lyinginfrontofthesecondlumbervertebraandendinginthesplenichilum.Theglandcanbedividedintofourportions-head,neck,body,andtail.uncinateprocess第2頁(yè)/共56頁(yè)AnatomyThemainpancreaticduct(theductofWirsung,2~3mmindiameter)coursesalongtheglandfromthetailtotheheadandjoinsthecommonbileductjustbeforeenteringtheduodenumattheampullaofVater(85%).Theaccessorypancreaticduct(theductofSantorini)enterstheduodenum2~2.5cmproximaltotheVater.第3頁(yè)/共56頁(yè)theductofWirsungSantoriniampullaofVateruncinateprocess

第4頁(yè)/共56頁(yè)AnatomyBloodsupplyThesuperiorpancreaticoduodenalarteryarisesfromthegastroduedenalartery,runsparalleltotheduodenum,andeventuallymeetstheinferiorpancreaticoduodenalartery,abranchofthesuperiormesentericartery,toformanarcade.Thesplenicarteryprovidestributariesthatsupplythebodyandtailofthepancreas.pancreaticmagnaA第5頁(yè)/共56頁(yè)superiormesentericarterysplenicarteryarcadesuperiorpancreaticoduodenalarteryinferiorpancreaticoduodenalarterydorsalpancreaticApancreaticmagnaAsuperiormesentericV第6頁(yè)/共56頁(yè)第7頁(yè)/共56頁(yè)P(yáng)hysiology

ExocrineFunctionTheexternalsecretionconsistsofaclear,alkaline(pH7.0~8.3)solutionof750~1000ml/dcontainingdigestiveenzymes.Secretionisstimulatedbythehormonessecretinandcholecystokinin(CCK)andbyparasympatheticvagaldischarge.SecretinandCCKaresynthesized,store,andreleasedfromduodenalmucosalcellsinresponsetospecificstimuli.Acidinthelumenoftheduodenumcausesthereleaseofsecretin,andluminaldigestionproductsoffatandproteincausethereleaseofCCK.第8頁(yè)/共56頁(yè)P(yáng)hysiologyExocrineFunction

enzymessynthesized,stored(aszymogengranules),andreleasedbytheacinarcellsofthegland,inresponsetoCCKandvagalstinulation.Pancreaticenzymesareproteolytic,lipolytic,andemylolytic.Lipaseandamylasearestoredandsecretedinactiveforms.Theprolyticenzymesaresecretedasinactiveprecursorsandactivatedbytheduodenalenzymeenterokinase.OtherenzymesincluderibonucleasesandphospholipaseA.第9頁(yè)/共56頁(yè)P(yáng)hysiologyEndocrineFunctionInsulin(51aminoacidresidues,formedinthebetacellsviatheprecursorproinsulin)glucagons(29aminoacids,formedinthecells)pancreaticpolypeptideandsomatostatinareproducedbytheisletsofLangerhans.第10頁(yè)/共56頁(yè)AcutePancreatitis急性胰腺炎

Acutepancreatitisisoneoffollowingfiveacuteabdomen

Acutepancreatitis,Acuteappendicitis,Intestinalobstruction,PerformedgatroduodenalulcerCholecystitisorcholelithiasis).第11頁(yè)/共56頁(yè)Etiology

Mostcasesofpancreatitisarecausedbygallstonediseaseoralcoholism;afewresultfromhypercalcemia,trauma,hyperlipidemia,andgeneticpredisposition;andtheremainderareidiopathic.第12頁(yè)/共56頁(yè)EtiologyBiliarypancreatitis:About40~60%ofcasesofpancreatitisareassociatedwithgallstonedisease,which,ifuntreated,usuallygivesrisetoadditionalacuteattacks.Bilerefluxpancreaticductactivateenzymes.Obstructionincreasedductpressuredamagepancreaticacinusdistroygland.第13頁(yè)/共56頁(yè)EtiologyAlcoholicPancreatitis:

AlcoholstimulatesgastricacidsecretionwhichincreasesCCK-PZ(cholecystokinandpancreozymin)excretioninduodenumandthenincreasespancreaticsecretion.MakethesphincterspasmandedemaIncreaseductpressure.Directtoxictopancreas第14頁(yè)/共56頁(yè)EtiologyInfection:e.g.hepatitisvirus,parotitisvirusandtyphoidbacillus.Traumaandoperation,endoscopy(iatrogenicPancreatitis):followingcommonbileductexploration,especiallyifsphincterotomywasperformed.1).UseofacommonductTtubewithalongarmpassingthroughofsphincterofOddi,2).Dilationofthesphincterto5~7mmduringcommonductexploration.第15頁(yè)/共56頁(yè)EtiologyHypercalcemia:hyperparahtyroidismandotherdisordersaccompaniedbyhypercalcemiaareoccasionallycomplicatedbyacutepancreatitis,itisthoughtthattheincreasedcalciumconcentrationsinpancreaticjuicethatresultfromhypercalcemiamayprematurelyactivateproteases,theymayalsofacilitateprecipitationofcalculiintheduct.第16頁(yè)/共56頁(yè)EtiologyHyperlipidemia:

pancreatitisseemstobeadirectconsequenceofthemetabolicabnormality.duringanacuteattackusuallyassociatedwithmormalserumamylaselevels,becausethelipidinterfereswiththechemicaldeterminationforamylase;urinaryoutputofamylasemaystillbehigh.第17頁(yè)/共56頁(yè)EtiologyDrug-inducedpancreatitis:corticosteroids,estrogen-containingcontraceptives,azathioprine,thiazidediuretics,andtetracyclines.Pancreatitisassociatedwithuseofestrogensisusuallytheresultofdrug-inducedhypertriglyceridemia.第18頁(yè)/共56頁(yè)EtiologyIdiopathicpancreatitisandmiscellaneouscauses:Inabout15%ofpatientsthereisnoidentifiablecauseofthecondition.第19頁(yè)/共56頁(yè)P(yáng)athogenesisEnzymaticdigestion(autodigestion):Trypsinnotonlydestroystissuebutalsoactivatesotherdestructiveenzymessuchaselastaseandlecithinase.Vasoactivesubstancesincludingkinins,kallikrein,andhistamineleadtocardiovasculardysfunctionandcollapse.第20頁(yè)/共56頁(yè)P(yáng)athogenesisIschemia,O-,inflammatorymediatorsMOD(principallyARDS,myocardialdepression,renalinsufficiency,andgastricstressulceration.第21頁(yè)/共56頁(yè)P(yáng)athologyEdematouspancreatitis:localordiffusededemawithcongestion,enlargement,hard.Microscopically,acinicandinterstitialedema,infiltratedwithinflammatorycellswithsmallfociofhemorrhageandnecrosis.Hemorrhagicandnecroticpancreatitis:hemorrhageandnecrosis,ascites,fatnecrosiswithsaponifyingpatchesinlesserandgreateromenta,mesentery,retroperitonealareas.第22頁(yè)/共56頁(yè)ComplicationsShock:

Trypsin,tissuenecrosis,infectivetoxinpromotingreleaseofvasoactivesubstancesLossofbodyfluidDICPyogenicinfection:e.g.suppurativeperitonitis,peripancreaticabscess,septicemiaMODS:ARF,ARDS,poisoningencephalopathyPseudocystorchronicpancreatitis第23頁(yè)/共56頁(yè)ClinicalFindingsSymptomsandsigns:Abdominalpain:Theacuteattachbeginsfollowingalargemealandconsistofsevereepigastricpainthatradiatesthroughtotheback,persistentwithvomitingandretching.WholepancreasbeltbackHeadrightupperabdomenradiatestorightshoulderBodyepigastric(middleupperabdomen)Bodyandtailleftupperleftshoulder第24頁(yè)/共56頁(yè)ClinicalFindingsSymptomsandsigns:

Nauseaandvomiting:withoutrelieftoabdominalpainaftervomitingSignsofperitonealirritation:tenderness,reboundpain,rigidity,guardingDistention:bowelparalysis,decreasedorabsentbowelsounds,silentabdomen,failuretopasseithergasorfeces.第25頁(yè)/共56頁(yè)ClinicalFindingsSymptomsandsigns:

HighTwithoutchilling,compressCBDjaundice,decreasedBP,andshock;fulminantpancreatitiscancauseasuddenshockBleeding:Gastrointestinalhematemesisandmelena;bluishdiscolorationintheflank(GreyTurner’ssign)orperiumbilicalarea(Cullen’ssign)第26頁(yè)/共56頁(yè)GreyTuner征第27頁(yè)/共56頁(yè)Cullen征第28頁(yè)/共56頁(yè)ClinicalFindingsLaboratoryfindingsSerumamylaseconcentration:risesfrom3-12h,thepeakis24-48hand2-5dnormalUrinerisesfrom12-24h,slowdecreaseElevatedserumlipaseElevatedhematocritduetodehydrationLowhematocritduetobloodloss第29頁(yè)/共56頁(yè)ClinicalFindingsLaboratoryfindings

ModerateleukocytosisInnecroticpancreatitis:sugar>11.1mmol/L,calcium<2.0mmol/L,PaO2<8.0kPa,increasedBUN,acidosisandevenMODSAbdominalpuncture:bloodyascites,increasedamylase第30頁(yè)/共56頁(yè)ClinicalFindingsImagingstudyCTandUSshowadiffuseenlargement,necrosis,andascitesX-ray:isolateddilationofasegmentofgut(sentinelloop)consistingofjejunum,transversecolon,orduodenumadjacenttothepancreas.Gasdistendingtherightcolonthatabruptlystopsinthemidorlefttransversecolon(coloncutoffsign)isduetocolonicspasm第31頁(yè)/共56頁(yè)正常胰腺CT第32頁(yè)/共56頁(yè)胰腺動(dòng)態(tài)CT時(shí)間1.312.22.92.172.273.17第33頁(yè)/共56頁(yè)膽源性胰腺炎第34頁(yè)/共56頁(yè)第35頁(yè)/共56頁(yè)

patchofsaponification第36頁(yè)/共56頁(yè)EssentialsofDiagnosisAbruptonsetofepigastricpain,frequentlywithbackpainNauseaandvomitingElevatedserumorurinaryamylaseCholelithiasisoralcoholism(manypatients)第37頁(yè)/共56頁(yè)DifferentialDiagnosisAcutecholecystitis:biliarycolic,feverandchills,Murphy’ssignandenlargedgallbladderPepticulcerperforationAcuteabdominalobstructionRenalcolicAcutegastroenteritisCoronarydisease第38頁(yè)/共56頁(yè)TreatmentMedicaltreatment:thegoalsofmedicaltherapyarereductionofpancreaticsecretorystimuliandcorrectionoffluidandelectrolytederangement.GastricsuctionanddietcontrolOxygenFluidreplacementandnutritionAntibiotics第39頁(yè)/共56頁(yè)Treatment(2)Medicaltreatment:CalciumandmagnesiumreplacementAnti-enzymedrugs:

5-FU(250-500mgin5%glucose500ml),octreotide,sandostatin,aprotinin,andH2receptorblockersSpasmolyticandpainkiller–atropine,dolantin,pro-BanthineTCM第40頁(yè)/共56頁(yè)Treatment(3)Surgicaltreatment(necroticPancreatitiswithcomplication,andbiliaryP)Necrosectomy,debridement–removenecrotictissueThoroughdrainage(peritoneallavage)OtherproceduresBiliarypancreatitis–TtubedrainageGastrostomyfordecompressionJejunostomyfornutritionTPN(totalperenteralnutrition)第41頁(yè)/共56頁(yè)ChronicPancreatitis

慢性胰腺炎第42頁(yè)/共56頁(yè)EssentialsofDiagnosisPersistentorrecurrentabdominalpain.Pancreaticcalcificationonx-rayin50%.Pancreaticinsufficiencyin30%;malabsorptionanddiabetesmellitus.Mostoftenduetoalcoholism.第43頁(yè)/共56頁(yè)CarcinomaofthePancreas

胰腺癌

第44頁(yè)/共56頁(yè)P(yáng)athologyMostareintheheadofthepancreas(2/3).Ductcellcancerismorethan90%,Therestarefromacinarcells.Metastasisandspreadaremainlyfromlymphaticmetastasisanddirectinvasion.第45頁(yè)/共56頁(yè)ClinicalFindingsSymptomsandsignsUpperabdominalpain(deepseated,andpersistent),distention,discomfortObstructivejaundice:Alimentarysymptoms(poorappetite,anorexia,dyspepsiadiarrheaorconstipation,nauseaandvomitingifinvasiontoduodenumorstomach)Weightloss,faintandcachexiaOthers(fever,mass,ascites)第46頁(yè)/共56頁(yè)ClinicalFindingsLaboratorystudyIncreasedamylase,bloodsugar,positivesugartolerancetest,increasedALP,bilirubin,andtransaminaseifthereishepaticmetastasisorCBDobstructionTumormarkers:CEA,CA19-9,PCAA.thelevelsareelevatedinmostpatientswithpancreaticcancerandalsoinothergastrointestinalcancers.第47頁(yè)/共56頁(yè)ClinicalFindingsImagingstudyBUSandCT:CBDandWirsungductdilationwithenlargedgallbladderX-ray:reversed–3signifthetumorlocatedintheheadofthepancreasERCPintheabsenceofamass,anERCPisindicated.itisthemostsensitivetest(95%)fordetectingpancreaticcancer第48頁(yè)/共56頁(yè)TreatmentPancreaticresectionforpancreaticcancerisappropriateonlyifallgrosstumorcanberemovedwithastandardresection.Forcurablelesionsofthehead,pancreaticoduodenectomy(Whippleoperation)isrequired.Thisinvolvesresectionofthecommonbileduct,thegallbladder,theduodenum,andthepancreastothemidbody.Thereisanincreasingtendencytopreservetheantrumandpylorus.第49頁(yè)/共56頁(yè)P(yáng)ancreaticoduodenectomy第50頁(yè)/共56頁(yè)TreatmentRadiotherapyshouldbecombinedwithchemotherapy(fluorouracil)forpalliation.Radiotherapyalonehasbeenshowntobenobenefit.第51頁(yè)/共56頁(yè)CarcinomaoftheAmpullaofVater第52頁(yè)/共56頁(yè)ClinicalFindingsJaundice:(earlystage)somearefluctuationduetotumornecrosisandexfoliation.EnlargedgallbladderandliverWithinfection–chillsandfeverAbdominalpainOthers(poorappetite,weightloss,diarrhe