醫(yī)學保健胰腺疾病

醫(yī)學保健胰腺疾病第1頁/共56頁Anatomy

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

第4頁/共56頁AnatomyBloodsupplyThesuperiorpancreaticoduodenalarteryarisesfromthegastroduedenalartery,runsparalleltotheduodenum,andeventuallymeetstheinferiorpancreaticoduodenalartery,abranchofthesuperiormesentericartery,toformanarcade.Thesplenicarteryprovidestributariesthatsupplythebodyandtailofthepancreas.pancreaticmagnaA第5頁/共56頁superiormesentericarterysplenicarteryarcadesuperiorpancreaticoduodenalarteryinferiorpancreaticoduodenalarterydorsalpancreaticApancreaticmagnaAsuperiormesentericV第6頁/共56頁第7頁/共56頁Physiology

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

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

Acutepancreatitisisoneoffollowingfiveacuteabdomen

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

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

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

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

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

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

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

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

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

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

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

胰腺癌

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