胆道胰腺疾病介绍课件

1、胆胰恶性肿瘤与黄疸 山东大学齐鲁医院胆胰恶性疾病key point树立壶腹周围癌的概念症状: 典型的梗阻性黄疸 (皮肤黄染白陶土样便全身瘙痒)影像学特征：复杂性，往往没有明显的占位性改变,诊断依靠间接征象。对造成胰腺癌症状和低切除率的解剖学因素加以了解关于胆胰恶性疾病胆胰恶性疾病的诊断思路胆胰恶性肿瘤与梗阻性黄疸胆胰恶性疾病的特殊影像学表现胆胰恶性肿瘤的有关解剖胆胰恶性肿瘤的鉴别诊断胆胰恶性肿瘤的治疗胆胰恶性疾病的诊断思路胆胰恶性疾病的诊断思路化验：直接胆红素升 高为主的胆红素升高 GGT与ALP的升高 CA199、CA242升高 影像学表现 SpleenBone MarrowSenescen

2、t Red Cells8085%Ineffective Erythropoiesis1520%Hemoglobin Heme GlobinReticulo-endothelialsystem Unconjugated BilirubinALB-boundbilirubinPlasma Unconjugated BilHepaticHemoproteinsConjugated BilirubinLiverUDPGTBilirubin:4mg/kg/dUptakeConjugationExcretionTransportationProductionBilirubin Metabolism* Un

3、conjugated BilUnconjugated Bilirubin KidneyUrineSmall intestineBile duct Stool80-85% UrobilirubinStercobilinPortal vein Urobilirubin15-20%UrineUrobilirubin 2% Bilirubin product Unconjugated bilirubinConjugated bilirybinUrobilirubin,stercobilin Enterohepatic Circulation of Bilirubin ColonBacteria Unc

4、onjugated Bilirubin10% Urobilirubin*Liver3. Decreased conjugation: due to defect or absence of UDP-glucuronyl transferase or other causes Neonatal jaundice Hepatocellular disease: e.g.,post-hepatitic hyperbilirubinemia Drugs: chloramphenicol, etc. Crigller-Najjar syndrome, Gilbert syndrome Predomina

5、nt Unconjugated Hyperbilirubinemia1. Intrahepatic cholestasis Cholestatic hepatitis: viral, alcoholic, auto- immune hepatitis Drug-induced: androgens, estrogens, cyclo- sporins, thiouracils, phenothiazines,captopril Pregnancy Sepsis with Gram negative organisms Primary biliary cirrhosis (PBC) Inheri

6、tary: Dubin-Johnson,Rotor syndromesPredominant Conjugated Hyperbilirubinemia2. Extrahepatic biliary obstruction Gallstones Tumors: pancreatic, bile duct, ampula of Vater Bile duct compression: chronic pancreatitis, lymph nodes Post-operative biliary stricture Primary sclerosing cholangitis (PSC) Con

7、genital biliary atresia Predominant Conjugated HyperbilirubinemiaDistinguish between hepatocellular and cholestatic jaundiceHepatocellular Dis. Cholestasis Bilirubin CB/TB 0.2-0.5 0.5ALT,AST ALP,GGT 3Bilirubinuria + or +Pale stool not present presentLaboratory Differentiation of JaundiceDistinction

8、between intracellular and extrahepatic cholestasis Intrahepatic ExtrahepaticUS,CT, Extra- & intra- Extra- & intrahepatic hepatic bile bile ducts dilated, ducts normal ERCP: stones, ERCP normal tumors, stricturesALP,GGT Auto-Abs AMA,M2 +-+ Inspecific auto-Abs for PBC for PSCSite of Hepatocytes and Ex

9、trahepatic bile lesions canaliculi/ductules ductsLaboratory Differentiation of Jaundice History, Physical ExaminationHb, Blood cells, Bil, ALT, Alb, ALP/GGT, PT+A, HBsAg, Urine, StoolPredominant unconj. bil. MixedPredominant conj. bil. Markers for viral hepatitisImmunological tests Microbial examina

10、tionSystemic diseasesLiver biopsy if necessaryUltrasonographyExtrahepaticbile ductsnot dilatedExtrahepaticbile ductsdilatedCT ERCPMRCPPTCTests for hemolysisBone marrowLiver biopsy if necessarySummary:Approachesto Diagnosisof Jaundice*胆胰恶性肿瘤的影像学表现重要疾病四：恶性疾病-胆囊癌胆囊癌: 与胆囊结石的密切关系Nevin分级转移与侵袭能力较强 胆管癌-间接征象

11、胰腺癌-模糊的占位效应胰腺癌-诊断的复杂性胆胰恶性肿瘤的有关解剖胆胰疾病解剖的密切联系：opie共同通道学说（1901） 肝胆相照“肝胆胰相照 ”胆道解剖-肝外胆管分部胆总管分部胆总管与胰管vater氏壶腹，oddi氏括约肌胆道的生理胆道系统：分泌、贮存、浓缩、输送胆汁胆囊：储存与浓缩胆汁的生理功能：脂肪与脂溶性维生素横结肠空肠下腔静脉 胆总管右膈脚降结肠胰头右肾胰颈肠系膜上静脉肠系膜上动脉腹主动脉左肾 胰 头、胰 颈、肠 系 膜 上 静 脉 断 层胰头下腔静脉十二指肠降部钩突肾窦胆囊肾门腹主动脉肠系膜上动脉肠系膜上静脉空肠胰 头、肠 系 膜 上 静 脉 断 层胆胰恶性肿瘤的鉴别诊断胆胰系统重

12、要疾病-共性疾病炎症：急慢性胆囊炎，胆管炎，急慢性胰腺炎肿瘤：胆管癌，胆囊癌，胰腺癌，壶腹癌先天性疾病：胆总管囊肿，胰腺囊肿胆胰系统重要疾病-特殊疾病结石疾病：胆囊结石与胆、胰管结石胰腺内分泌肿瘤：功能性与无功能胰腺内分泌肿瘤胆囊息肉、胆囊结石与胆囊癌胆囊结石的成因：脂质代谢异常造成的胆固醇 过饱和 症状与其造成的多种并发症有关胆囊结石与胆囊癌 胆囊炎、胆管炎、梗阻性黄疸、胆源性胰腺炎、胆囊十二指肠瘘胆囊疾病与胆囊息肉样病变定义分类：手术适应症独特的胆固醇性息肉炎性息肉腺瘤性息肉腺肌症恶性息肉胆囊疾病与腹腔镜胆囊切除术：微创外科与胰腺胆道手术1987年问世外科技术的重大革命胰腺肿瘤的局部切除是

13、最佳的适应症（eneucleation）胰体尾手术成为常规重建仍然是弱项重要疾病一：胆囊疾病与胆石症胆囊的分部：Hartmann袋，螺旋瓣Calot三角：是由胆囊管、肝总管、肝脏下缘所构成的三角区。其内有胆囊动脉、肝右动脉、副右肝管通过。胆石症：胆固醇、胆色素与混合结石 认识一下慢性胰腺炎酒精、胆道疾病为主要病因胰腺内外分泌功能的丧失胰腺内分泌肿瘤重要疾病五：胰腺内分泌肿瘤胰腺独有的肿瘤如何与外分泌肿瘤鉴别胰岛素瘤和无功能胰岛细胞瘤发病率较高Whipple三联症：与血糖关系密切胆胰恶性疾病的治疗恶性疾病的胰十二指肠切除术壶腹周围癌的经典手术方式复杂的切除与重建工作：涉及胆、胰、胃等脏器的切除与

14、重建梗阻性黄疸造成的凝血机制障碍、全身营养不良加重了手术难度，术后易发生肾功能衰竭、低氧血症治疗（掌握） 肿瘤侵及门静脉、肠系膜上静脉者可将其一段血管连同肿瘤切除，再行血管移植吻合行全胰切除术。对不能切除的胰腺癌，为了解除黄疸，有条件者首先争取作内瘘。胆胰恶性疾病的辅助治疗疼痛：疼痛的阶梯治疗 第一阶段 轻度疼痛，非阿片类镇痛药（阿司匹林、布洛芬、对乙酰氨基酚）第二阶梯 在轻、中度疼痛时，弱阿片药物（可待因、强痛定等） 第三阶梯 选用强阿片类药，代表药物是吗啡、杜冷丁等。其选用应根据疼痛的强度 ( 如中、重剧痛者 ) 而不是根据癌症的预后或生命的时限。常用缓释或控释剂型Case Discuss

15、ion(1)A 30 y.o. female patient was admitted because of anorexia, fatigue, and pain over right costal area for 2 weeks. Her mother was diagnosed as acute hepatitis B six weeks ago. P.E. revealed jaundice over sclerae and a tender liver 2 cm below the right costal margin.What is the most likely diagnosis?What laboratory abnormalities do you expect?ALTAST ALP DBil/TBil 0.80.5 0.2Urine Bilirubin + Case Discussion(1)Case Discussion(2)A female patient of 35 y.o. was admitted because of fever, yellowish skin, pruritus,