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1、胰腺疾病,解剖生理概要,解剖 头，颈，体，尾，钩突。 主胰管 (duct of Wirsung) 副胰管 (duct of Santorini) 胰腺分泌 外分泌Exocrine 内分泌Endocrine B,A,D,D1,G cell,c,Causes Gallstones:60%( 3550% in USA) Alcohol:14% %(60% in USA) Duodenal juice countercurrent flow: Sphincter of Oddi dysfunction Trauma Pancreas circulation disorder Other factors
2、: Drug: Azathioprine(硫唑嘌呤).6-Mercaptopurine(6-巯基嘌呤), Pancreas divisum(胰分裂), Microlithiasis Metabolic cause Infectious causes, ascaris worms蛔虫,HIV- Miscellaneous,急性胰腺炎,Pathology acute edematous pancreatitis acute hemorrhagic necrotizing pancreatitis (acute hemorrhagic pancreatitis, acute necrotizing
3、pancreatitis),急性胰腺炎,Pathophysiology Hypersecretion and obstruction Self-enzymatic digestion Enhancement of Vessel permibility Cytokine，infection Decreased arterial perfusion Edematous hemorrhagic necrotizing,急性胰腺炎,Clinical finding Abdominal pain Abdominal distention Nausea and vomiting Peritonitis O
4、ther: Respiratory failure, confusion, or coma. Low-grade to moderate fever Tachycardia and hypotension and Shock Mild jaundice, Pleural effusion.,急性胰腺炎,急性胰腺炎,Peritoneal irritation sign （Abdominal tenderness， rebound tenderness and rigidity） Shifting dullness Decreased bowel sounds Cullen sign: disco
5、loration of periumbilical area Grey Turner sign:discoloration of flanks,Laboratory finding Amylase and lipase (elevations of amylase are more sensitive but less specific than lipase in the diagnosis of acute pancreatitis ) 500 400 300 200 100 0 0 1H 24H 48H 5DAY,急性胰腺炎,Blood amylase,Urine amylase,急性胰
6、腺炎,Serum calcium Serum glucose Blood gas analysis Imunolipase ALT and AST (gallstone pancreatitis ),Imaging finding X-ray Dilated loop of small bowel (sentinel loop) Abrupt cessation of gas in the distal transverse colon (colon cutoff sign) Radioopaque densities (biliary calculi) Left-sided pleural
7、effusion B-US: pancreatic edema, ascites- CT: Important,急性胰腺炎,CT is the best diagnostic test for the diagnosis of acute pancreatitis. Contrast-enhanced CT is excellent for diagnosis of pancreatic necrosis,有力武器,急性胰腺炎,Assessment of severity of acute pancreatitis Ransons criteria On Admission Within 48
8、 Hours Age 55 years Hematocrit decrease by 10% WBC 16,000 /mm Urea nitrogen increase 5 mg/dl LDH 350 IU/L Serum calcium 11.1mmol/l Arterial PO 250 IU/L Base deficit 4 mEq/L Estimated fluid sequestration 6 L,急性胰腺炎,Glasgow Criteria Within 48 Hours Age 55 WBC 15,000 /mm LDH 600 IU/L Glucose 180 mg/dl A
9、lbumin 45 mg/dl Arterial PaO2 60 mm Hg,急性胰腺炎,APACHE III criteria Temperature BUN Mean blood pressure Leukocytes Serum Creatinine Hematocrit Heart rate Albumin Respiratory rate Bilirubin Oxygenation Arterial pH Serum sodium and potassium Serum glucose 8 Scores -SAP,Diagnosis and differential Diagnosi
10、s Acute edematous pancreatitis and acute hemorrhagic necrotizing pancreatitis Other diseases Acute appendtitis Ileus Perforated gastroduodenal ulcer Biliary disease Ruptured hepatoma,急性胰腺炎,Clinical finding Amylase CT Abdominal paracentesis,急性胰腺炎,Treatment Acute edematous pancreatitisinternal medicin
11、e (Emergency surgery is not indicated in mild acute pancreatitis) Acute hemorrhagic necrotizing pancreatitis Supportive care Replacement of fluid and electrolytes Correction of metabolic abnormalities Nutritional support Other measures :nasogastric suction and antibiotics,Agents to inhibit pancreati
12、c secretion Have not been found to be useful in altering the course in acute pancreatitis Somatostatin(sandostatin stilamin) Protease inhibitors (trasylol抑肽酶) Surgical therapy Inefficiency by internal medicine Complication (pancreatic or/and peripancreatic Infection and abscess) Combined with biliar
13、y diseases(Gallstone ASP),Surgical approach Resection of necrotic tissue and peritoneal lavage severe, progressive necrotizing pancreatitis or pancreatic abscess. Cholecystectomy recurrent acute pancreatitis and microlithiasis. Surgical sphincteroplasty of the pancreatic sphincter pancreatic sphinct
14、er dysfunction outcome is the same as for the endoscopic pancreatic sphincterotomy more invasive requiring laparotomy and duodenotomy,急性胰腺炎,Endoscopic therapy 1) acute gallstone pancreatitis 2) recurrent pancreatitis due to pancreatic sphincter dysfunction, 3) recurrent pancreatitis due to pancreas
15、divisum分裂. The rationale for endoscopic therapy in each area is the relief of obstruction to flow of pancreatic juice,慢性胰腺炎,Causes Alcohol Pancreas divisum Acute pancreatitis Hyperparathyroidism Trauma Obstructive pancreatitis Idiopathic chronic pancreatitis Cystic fibrosis Hereditary chronic pancre
16、atitis,慢性胰腺炎,Classification Obstructive chronic pancreatitis Calcified chronic pancreatitis Inflammatory chronic pancreatitis Pathology pancreatic fibrosis -,慢性胰腺炎,Clinical finding and diagnosis Abdominal pain , distention Diarrhage Dyspepsia Malnutrtion Diabetes Narcotic addiction Jaundice,Biochemical measurements Isoamylase,lipase trypsin,and
