外科胰腺疾病课件

PANCREAS Thechapterincludes Summaryofanatomy physiologyAcutepancreatitisChronicpancreatitisPancreaticcystPancreaticcancer PeriampullarycarcinomaPancreaticendocrinetumors Location region Anatomy physiology Length 12 20cmWidth 3 4cmWeight 75 125g Bloodsupply Head Gastroduodenala Ant andpost sup pancreaticoduodenala Sup mesenterica Ant andpost inf pancreaticoduodenala Body tail Splenica Dorsalpancreatica Transversepancreatica Venous lymphdrainage Lymphdrainagebymultiplenodegroups mainlyceliacnodes sup mesentericnodes Ducts theductofWirsung mainducttheductofSantorini accessoryduct Physiology exocrinepancreas pancreaticjuice 750 1500ml d bicarbonate digestiveenzymes proenzymesendocrinepancreas 1 7 2 0millionsofislets 4majorcelltypes someminortypesAcells glucagonsBcells insulinDcells somatostatinPPcells pancreaticpolypeptideGcells gastrinD1 vasoactiveintestinalpolypeptide Acutepancraetitis Acommonacuteabdomen includingmild severetypes Whatisit benigndisease malignantprognosis Causes BiliarytractstonesEthanolabuseHyperlipidemiaDietaryfactorsTrauma Surgery ERCP ESTInfectionDrugs thiazidediuretics oralcontraceptivesMetabolicabnormalities Biliarytractstones obstruction Bilerefluxtheory Commonchanneltheory stone Ethanolabuse IncreasingductalpressureIncreasingpancreaticenzymesecretionDirectinjurytopancreaticacinarcells SIRSsystemicinflammatoryresponsesyndromeMODSmultipleorgandysfunctionsyndrome Presentation acuteabdominalpainnausea vomitingabdominaldistension abdominalcompartmentsyndrome ACS fever hyperthermiajaundiceshock MODS Presentation GreyTurnersign flankbluishecchymosesCullensign umbilicalbluishecchymosesARDSacuterespiratorydistresssyndromeSIRSsystemicinflammatoryresponsesyndromeMODSmultipleorgandysfunctionsyndrome LaboratoryFindings SerumamylaseandlipaselevelsSerumcalciumbloodglucosearterialbloodgaswhitebloodcellcount Imagingstudies Chest abdominalradiographsUltrasoundCTMRIMRCP contrastCT AdmissionAge 55yrWBC 16000 mm3Glucose 200mg dLLDH 350IU LAST 250IU L Initial48hrsHctfall 10 BUNelevation 5mg dLCa2 4mmol LFluidsequestration 6L 3or4signsmortality15 7or8signsmortality90 Ranson sPrognosticSigns Differentialdiagnosis acutecholangitis cholecystitisperforatedhollowviscusbowelobstructionmesentericischemia infarctionacutegastroenteritisacutemyocardialinfarction Thestagesofcourse stageofacutereaction within2wstageofsystemicinfection 2w 2mstageofresidualinfection laterthan2 3musuallybutnotalways Localcomplications acutefluidcollectionpancreaticandperipancreaticnecrosispancreaticpseudocystpancreaticabscess TreatmentMedicaltherapy fastingdiet gastricsuctioninhibitionofpancreaticjuicesecreting somatostatin Sandostatin Stilamin Uinastatin paregorics spasmolysisfluid electrolytemanagementAntacids Ranitidine Losec prophylacticantibioticstraditionalChinesemedicine TreatmentMedicaltherapy Nutritionalsupport totalparenteralnutritionInsulinOxygenprovidedThoracentesisDialysis TreatmentSurgicaltherapy Endoscopicsphincterotomy ESTGallbladderremovalPeritonealirrigating nolongerwidelyused CT guidedneedleaspirationDebridement Treatmentofseverepancreatitis stageofacutereaction nonoperative surgicalstageofsystemicinfection antibiotics ultrasoundorCT guided needleaspiration surgicaldrainagestageofresidualinfection nutritionalsupport surgery Treatmentofacutebiliarypancreatitis Thegroupwithoutbileductobstructionorcholangitis nonoperativetherapythencholecystectomyThegroupwithbileductobstructionorcholangitis earlyoperationorEST ENBD ERCPstoneextraction Treatmentoflocalcomplications acutefluidcollection spontaneouslyresolvepancreaticandperipancreaticnecrosis debridementanddrainagepancreaticpseudocyst 6cmwithoutsymptom notreatment theothersorexistingmorethan3 6m surgicaldrainagepancreaticabscess surgicaldrainage ChronicPancreatitisPancreaticCyst PeriampullaryCarcinoma carcinomaofheadofpancreasampullarycarcinomaduodenalpapillarycarcinomacarcinomaofdistalcommonbileductcarcinomaofVater sampulla Symptomsandsignsupperabdominalpain vague severe backpain 70 jaundice painless 80 weightloss75 Trousseau ssyndrome Courvoisier ssignothers nausea vomiting anorexia steatorrhea panceatitis changesofstools diabetesmellitus etcBloodtestbilirubin alkalinephosphatase transaminase CA19 9 CEA PerampullaryCarcinoma Imagingstudies ultrasound initial BMbariummealCTERCPPTCDMRI MRCPangiograp