胆道和胰腺疾病肝胆外科

胆道和胰腺疾病肝胆外科解剖生理概要Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

切开后腹膜，向右牵开十二指肠及胰头部胰十二指肠背面结构Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.★胰液量750ml-1500ml/d★多种消化酶★胰岛B细胞-胰岛素、A细胞-胰高血糖素D细胞-生长抑素等

胰腺的外分泌、内分泌功能Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.胰腺炎*急性胰腺炎慢性胰腺炎Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.（一）急性胰腺炎AcutepancreatitisEvaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.病因★梗阻因素胆石、蛔虫胆汁返流胰液激活★暴饮暴食胰液过量分泌、胰管梗阻★胰腺创伤外伤、ERCP★胰腺缺血

★感染★特发性胰腺炎Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.在正常情况下不产生自身消化的原因：★胰管上皮有粘多糖保护★大部分胰酶以不激活的胰酶原存在★血液和胰液中含有少量胰酶抑制物可中和少量激活的胰酶★胰腺腺泡细胞具有代谢活力阻止胰酶侵入细胞。Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.发病机制胰腺消化酶异常激活后对本器官及其周围脏器产生消化作用“自我消化”作用Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.胰酶激活胆汁返流十二指肠液反流自我消化弹性蛋白酶破坏弹性组织胰腺充血出血磷脂酶A激活细胞膜的磷脂，使卵磷脂转变成溶血卵磷脂，引起胰腺和胰周组织的广泛坏死脂肪酶使脂肪分解坏死，并与钙离子结合形成皂化斑，可使血钙降低Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.酒精刺激作用胰腺大量分泌Oddi括约肌痉挛直接损伤腺泡细胞胰腺损伤胰酶激活欧美发病原因Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.胰腺血液循环障碍胰腺组织坏死

重症胰腺炎又称为全身过度炎症反应综合征与细胞因子、血管活性物质有关后期合并感染多器官功能衰竭Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.病理★急性水肿型胰腺炎（胰体尾多见）局限性或弥漫性水肿、被膜紧张充血、变硬镜下炎性细胞浸润、伴有轻度出血及局灶性坏死Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.★急性出血坏死性胰腺炎

广泛出血坏死、胰腺发黑、变软

血性腹水、有皂化斑、胰腺脓肿Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.临床表现★腹痛

饮酒或高脂餐后中上腹偏左、腰背放射★

恶心,呕吐★

腹胀病情加重表现，肠麻痹胀气、后腹膜炎症★

腹膜炎体征★

其他:Gery-Turner征、发热、黄疸、Cullen征、休克Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.诊断1.临床表现2.实验室检查3.影像学检查Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.实验室检查★胰酶测定:

血淀粉酶-高于100U/L,发病后2小时开始升高,24小时达高峰,持续4-5天.尿淀粉酶-高于460U/L,发作后24小时升高,可持续1-2周.Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.★血常规:白细胞升高★电解质:低钙(病后2-3天)等★血气分析:ARDS表现★诊断性穿刺:腹水淀粉酶水平升高培养药敏涂片Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.诊断:CT检查示正常胰腺Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.急性胰腺炎CTEvaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

增强CT的意义Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.超声检查Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.非手术治疗★禁食,胃肠减压★防止休克★解痉止痛★抑制胰腺分泌—生长抑素★营养支持★抗生素Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.手术治疗手术治疗指征:

★继发性胰腺感染

★

合并胆道病变

★

经治疗后临床症状继续恶化手术方式:灌洗引流、坏死组织清除、规则性胰腺切除、三造瘘

目的：清除胰酶、毒性物质和坏死组织

对胆源性胰腺炎:ERCP/EST取石引流急诊手术解除梗阻Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.（二）慢性胰腺炎

慢性复发性胰腺炎★胰腺内、外分泌功能衰退、丧失★胰腺影像学检查以及胰腺组织学★反复发作上腹痛★检查异常等★病期应在半年以上。Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.病因国外--饮酒国内--胆道疾病营养不良、中毒等

Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.胰腺萎缩、变硬胰管结石胰腺组织不可逆变化：腺泡细胞破坏、纤维增生、导管狭窄病理Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

症状腹痛是最常见的症状，呈反复发作食欲不振、饱胀、嗳气排便次数增多、腹泻、量多；脂肪泻体重减轻及糖尿病等表现Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.诊断

病史、典型临床表现及特殊检查实验室检查

血、尿淀粉酶在急性发作时可增高。镜下观察粪便有多量脂肪滴和未消化的肌纤维。尿糖和糖耐量试验呈阳性改变。

Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

影像检查

B型超声检查：胰腺形态不规整、腺体肿大或缩小，胰石，胰管扩张或呈分段不规则扩张，胰腺囊肿等。内镜逆行胰胆管造影：胰管粗细不规则，胰石或囊肿；胆石或胆总管改变。Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.X线腹部平片胰腺可有结石、钙化CT胰腺肿大或缩小，边缘不清，密度降低，钙化，胰石，胰腺囊肿。胆石和胆总管改变。

Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

非手术疗法

原则控制腹痛、尽力调整胰腺内外分泌功能

镇痛（药物、腹腔神经丛封闭）饮食及胰酶制剂治疗糖尿病者服用降糖药

营养支持Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

手术疗法

目的减轻疼痛保留胰腺功能

壶腹切开胰管引流胰腺切除Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

（三）胰腺肿瘤

男性多见预后差5年存活率1%-3%Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.胰腺癌病理特点常见部位:胰头部分类:胰头,胰体尾,胰腺囊腺癌病理组织:导管腺癌最常见囊腺癌腺泡细胞癌Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.胰头癌，梗阻性黄疸行内、外引流Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.经皮肝穿刺胆管造影（percutaneoustranshepeticcholangiography,PTC）

★方法：右侧腋中线法：此法最常用在B超或X线引导下经腋中线7、8肋间穿入肝内胆管至第一腰椎右侧2CM停止。推注造影剂见“如烟而逝”表明在血管内，即所谓的“冒烟”现象

。若呈云雾状提示造影剂注入肝组织内，只有表现为树枝状时穿刺成功。

胰头癌Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.内镜逆行胆胰管造影ERCP

(endoscopicretrogradecholangiopancreatography)★方法★诊断十二指肠乳头，取材活检取肠液、胰液检查胆道胰腺疾病（胆管癌、肝胆管结石、胰头癌双管征慢性胰腺炎呈现钙化、结石，主胰管不规则慢性胰腺炎Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.发病率呈逐年上升趋势癌症相关死亡的第四大原因预后恶劣（5年生存率1－2％，85％病人在确诊后12个月内死亡）侵袭性生长早期多极化浸润转移毗邻器官较多，无完整包膜，周围淋巴、血管、神经组织丰富，易早期侵犯血管、淋巴管及神经鞘膜，发生胰内及胰外转移Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.侵袭性生长早期多极化浸润转移毗邻器官较多，无完整包膜，周围淋巴、血管、神经组织丰富，易早期侵犯血管、淋巴管及神经鞘膜，发生胰内及胰外转移Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.

胰头癌临床表现Canceroftheheadofthepancreas

上腹痛和上腹饱胀黄疸早晚与胆管距离有关消瘦乏力呕吐Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.诊断

临床表现影像学检查B超、CT、ERCPEvaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.治疗治疗原则早期发现,早期诊断,早期手术手术方法胰十二指肠切除术保留幽门的胰十二指肠切除术姑息性手术

Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.FeaturesofStandardResectionEvaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.（四）壶腹周围癌

Periampullaryadenocarcinoma定义

胆总管末段，壶腹部和十二指肠乳头附近的癌肿包括：壶腹部、十二指肠和胆总管下段三种癌Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.壶腹癌：波动性黄疸十二指肠癌：胆道不全梗阻十二指肠梗阻表现胆总管下段癌：进行性加重黄疸白陶土便临床表现和诊断Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.ERCP检查具有重要价值Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile.Copyright2004-2011AsposePtyLtd.治疗手术方法胰十二指肠切除术保留幽门的胰十二指肠切除术手术切除率高，远期效果良好Evaluationonly.CreatedwithA