胰腺疾病英文课件

DepartmentofSurgeryRuijinClinicalMedicalCollegeShanghaiJiaoTongUniversityPancreaticDisease第1页AnatomyofpancreasPancreatitisPancreaticpseudocystPancreaticcancer第2页Anatomy Location:retroperitoneal

第3页headneckbodytailuncinateprocessSMVpancreaticduct

wirsungductaccessorypancreaticductsantoriniduct第4页Arterieshead&neckceliacaxis,superiormesentericarteryGDAsuperior&inferiorpancreaticoduodenalAsuperior&inferiorpancreaticarteriesbody&tailsplenic&leftgastroepiploicarteries第5页Veins Superiormesentericvein Splenicvein Portalvein第6页Lymph&Nervelymph SPD SP splenichilum IPD IP head SMAnodes celiacaxisnodes tail splenicnodesnerve sympathetic¶sympathetic第7页Histoloy&physiologyExocrine acinarcell digestiveenzymes ductalcell bicarbonate secretionofcontrol vagal&CCK第8页Histoloy&physiologyEndocrine isletsofLangerhans

βcell50% insulin αcell20% glucagon δcell5% somatostatinnonβcell vasoactiveintestinalpeptide nonβcell gastrin nonβcell pancreaticpolypeptide（PP）第9页

AcutePancreatitis第10页DefinitionAcutepancreatitis(AP)isanacuteinflammatoryprocessofthepancreas,withvariableinvolvementofotherregionaltissueorremoteorgansystems.Thediseaseincludesabroadspectrumofpancreaticdisease,whichvariesfrommildparenchymaledematoseverehemorrhagicpancreatitisassociatedwithsubsequentgangreneandnecrosis..

第11页TheclinicalpresentationPainofabdomenisdiffuseHypotensionMetabolicderangementsSepsisFluidsequenstrationMultipleorganfailureDeath

第12页EtiologyGallstonesSustainedalcoholOtherInchina:biliarytractdisease

distalcommonbileductstone stenosisofthepapillaofVater ascaridinbiliaryduct第13页PathogenesisAcomplicatedpathophysiologicprocessEnzymeautoactivationandself-digestionTruemechanismremainsunknown第14页Pancreaticself-protectivemechanismMucopolysaccharideonpancreaticductepitheliaProenzymePancreatininhibitorAcinusmetabolismactivityAnti-refluxmechanism:oddi’ssphincter

pancreaticductsphincter第15页Initiationfactorinearlierperiod

⑴BilerefluxBilecommonchannelpancreaticduct

1.hypertensioninpancreaticduct

2.activationofpancreaticenzymes

3.injuretheliningofthepancreaticducts

pancreasedemaornecrosis

MODS

1.Pancreaticenzymeabnormalactivating第16页⑵DuodenalRefulx

duodenalenterokinasepancreaticduct

trypsinogentrypsin

elastasnogenelastase

phospholipasogen

phospholipase

Lecithinlysolecthin

1.Pancreaticenzymeabnormalactivating第17页⑴Stimulatethepancreastosecretepancreatichypertentiontinypancreaticductandacinusrupturepancreaticjuicespillage⑵Spasmoftheoddi’ssphinctor⑶directlyinjurepancreas2.AlcoholToxicity第18页⑴systemichypotension⑵hyperlipidemia:triglycerides

lipase

freeacid

fattyacidsinjurepancreaticmicrocirculation⑶atheroembolism⑷vasculitis3.PancreaticMicrocirculationDisorder第19页Aggravativefactorsinlaterperiod⑴Infection:pancreaticabscess⑵Intestinalbacteriatranslocation⑶Cytokineandsystemicinflammation reactionsyndrome

TNFIL-1IL-6PAFMSOF⑷Freeradicals第20页PathologyEdematouspancreatitis:

interstitialedema

inflammatorycellinfiltrationofthegland

parenchymaHemorrhagicornecrotizingpancreatitisextensivepancreaticandperipancreatic

fatnecrosis

parenchymalnecrosis

saponatusspot第21页Hemorrhagicornecrotizingpancreatitis第22页Clinicalpresentation1.Abdominalpainpredominantclinicalfeature

-midepigastrium,intherightorleftupperquadrants

-apenetratingpain,radiatetotheback-rarepatientswithoutabdominalpainbutwithaseveresystemicillness(hypotension,hypoperfusionanddepressionofmentalstatus)第23页Clinicalpresentation2.Nauseaandvomiting3.AbdominalDistention

resultfromaparalyticileusarisingfromretroperitonealirritationorascitesoraretroperitonealphlegmon4.Janndice

distalcommonbileductobstructionbygallstonescompressionofthedistalCBDbypancreaticheadedemaorbyotheruncommonfindings第24页Clinicalpresentationof

severeacutepancreatitis1.CirculatoryDerangements:

hypotention,hypovolemiahypoperfusion

circulatingmyocardialdepressantfactor

decreasedpreloadtotheheart

reducedsystemicvascularresistance

sepsis-likesyndrome

hyperdynamicstate

elevatedcardiacoutput

loweredsystemicvascularresistance

loweredarteriovenousoxgendifference第25页Clinicalpresentationof

severeacutepancreatitis 2.leftpleuraleffusion

3.pulmonaryfailure

tachypnea,dyspneaandcyanosis

4.cerebralabnormalities

belligerence,confusion,psychosisandcoma

5.TurnersignandCullensign

abluishcolorintheflanksoraroundtheumbilicus,(representblooddissectedtothoseareasfromtheretroperitoneumnearthepancreas)第26页PhysicalExaminationEpigastrictenderness,rigidityandreboundTendernessBowelsoundsdecreasedorabsentPalpablemass

swollenpancreas

pseudocyst

abscess第27页LaboratoryTestSerumAmylaseUrinaryAmylaseSerumLipaseHypocalcemia第28页DisordersAssociatedwithhyperamylasemia

Intra-Abdominal

Extra-Abdominal

Pancreaticdisorders

Salivaryglanddisorders

acutepancreatitismumps

chronicpancreatitisparotitis

traumatrauma

carcinomacalculi

pseudocystirradiationsialoadenitis

pancreaticascitesimpairedamylaseexcretion

abscessrenalfailure

Nonpancreaticdisordersmecroamylasemia

biliarytractdiseaseMiscellaneus

intestinalobstructionpneumonia

mesentericinfarctionpancreaticpleuraleffusion

perforatedpepticulcermediastinalpseudocyst

peritonitiscerebraltrauma

afferenloopsyndromesevereburns

acuteappendicitisdiabeticretoacidosis

eupturedectopicpregnancypregnancy

salpingitisdrugs

rupturedaorticaneurysmbisalbuminemia

第29页OtherlaboratoryTest ElevatedWBC>10000cellspermm3 Hyperglycemia

Mildazotemia:relatedtofluidsequestration

Abnormalitiesofliverfunctiontest第30页Imaging第31页1.ApainAbdominalFilmnotspecific

dilatationofanisolatedloopofintestine

adjacenttothepancreas

calcificationinthepancreas

leftpleuraleffusions

第32页2.UltrasoundexaminationnotraumapancreaticandperipancreaticedemaoffluidcollectionPseudonymsDilationofpancreaticductGBstoneandCBDstone第33页3.CTScansconfirmdiagnosisofpancreatitisconfirmdiagnosisofcomplicationssuchasabscess,pseudocystrevealextensionofinflammationandnecrosisimplyprognosisaneedleaspirationunderCTguide第34页CT第35页Computedtomographicfindingsinacutepancreatitispancreaticchangesnonspecificfindings

parenchymalenlargementboweldistentiondiffuse

pleuraleffusion

focal

mesentericedema

parenchymaledema

necrosis

peripancreaticchanges

blurringoffatplanes

thickeningoffascialplanes

presenceoffluidcollections

第36页4.Diagnosticnotanidealtest

aninvasiveprocedure

complicationslackofcompletespecificityofperitonealfluidenzymeelevationHelpdiagnosis

elevationsinperitonealfluidamylaseandlipase第37页Edematouspancreatitisnercotizingpancreatitis

abdominalpain++++

vomitingandnausea+++

feverlowhigh

jaundice(-)-(+)++-+++

psychiatricsymptomnoyes

signsofperitonitis+++-+++

cullen’ssignnoyes

GreyTurner’ssignnoyes

hemorrhagicascitesnoyes

WBC<16000/mm3>16000/mm3

bloodglucosenormal→↑>11.1mmol/L

serumcalciumnormal>2.0mmol/L

amylase↑↑↑↑or(-)

PaO2normal<8.0kpa

Bun.Crnoyes

ARDSnoyes

DICnoyes

ARFnoyes

mortalitylowhigh

第38页DifferentialDiagnosis1.Intestinalperforation

2.Pepticulcer

3.Cholecystitis

4.acuteintestinalobstruction

5.renalcolic

6.myocardialischemia

7.acutegastroenteritis

第39页Treatment1.Non-operativeManagement

DietaryControl NasogastricSunction Intravenousfluidtherapyandelectrolytereplacement NutritionalSupport Antibiotics Analgesia PancreaticExocrineSecretionSuppression Pancreaticenzymeinhibitor

第40页2.Surgericprecedure

Peritoneallavage:removetoxinsandvariousmetabolites Pancreaticdrainage Debridementofnecrotictissue Biliaryprocedure:

endoscopicsphincterotomy

cholecystectomy

removetheCBDstone第41页3.Operativeindication Secondarypancreaticinfection Correctionofassociatedbiliarytractdisease Progressiveclinicaldeterioration

surgeryiscontraindicatedinuncomplicatedacute pancreatitis第42页ComplicationsSystemiccomplications

ARDS

Renalfailure

Cardiovascularfailure

MOSFLocalcomplications

pancreaticabscess

pancreaticpsuedocysts

pancreaticphlegmon

pancreaticascites

pleuraleffusion

pancreaticfistula

intestinalfistula第43页Pancreaticcancer

第44页CausesSmokingAdvancedageMalesex–

Themale-to-femaleratioofpancreaticcanceris1.3:1

Chronicpancreatitis

-Inflammationofthepancreas,usuallyfromexcessivealcoholintakeorgallstonesDiabetesmellitusFamilyhistoryofpancreaticcancer第45页SymptomsPaini