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1、医学,1,PANCREAS,2,医学,Anatomy and Physiology,1.Structure:Pancreas is a glanodular structurelocated in the retroperitoneum.Anterioly,the pancreas is covered at thedistal head and neck by the pylorus and thetransverse mesocolon,the neck and body arecovered anteriorly by the posterior gastricwall.The ante
2、rior surface is covered by aperitoneal leaf(lesser sac),3,医学,The pancreas is routinely divided into the head, the neck,the body and the tail.The pancreas is almost enteraly retroperitoneal and has close relationship with numerous surrounding structures,4,医学,5,医学,6,医学,2.Pancreatic ductsThe main pancr
3、eatic duct (Wirsung) run theentire length of the pancreas and joinsthe common duct to empty into duodenumat the ampula of Vater,7,医学,The normal duct is only 2-4 mm in diameter, and contains 20 secondary branches.Pancreatic duct pressureis15 to 30 mmHg. Whereas that in the common bile duct is only 7-
4、17 mmHg. This differential is thought to prevent reflux bile,8,医学,9,医学,3.Common channel Variations in the relation between the intrapancreatic portion of the common bile ductand the main pancreatic duct at the ampula of Vater. A short common channel containflow from both secretary system.,10,医学,11,医
5、学,3.Arterial supplyThe celiac and superior mesenteric arteriessupply blood to the pancreas through theirmajor branches.Some variations of hepatic arteries in relation to the pancreas,12,医学,13,医学,4.Venous drainageThe venous drainage of the pancreasand duodenum follows the arterial supply ,The veins a
6、re usually superficial to the arteries and the frenquency of anomalies is similar,14,医学,15,医学,5.Physiology (1)Exocrine function:Islet peptide products influence the function of the exocrine pancreasBicarbonate secretion:(20 mmol/L,pH7-9)Enzyme secretion:(amylases,lipases,proteases),16,医学,(2)Endocrin
7、e functionInsulin Other: Neuropeptide(VIP,Glucagon galanin, serotonin, Somatastatine amylin )Pancreatic polypeptide,17,医学,Acute pancreatitis,Acute pancretitis is an acuteinflammatory process of thepancreas with variable involvement of other regionaltissue or organs.,18,医学,300000/year in USA hospital
8、ized 4000 deaths. 75% of cases are attributable to either gallstone or alcohol.,19,医学,20% of cases severe, its defined as associated with one or more of thefollowing: necrosis, distant organfailure, local complications( hemorrhage, abscess, pseudocyst),20,医学,The mortality rate(severe)10-20%,with hal
9、f deaths in the first 2 weekas the result of SIRS, inducedmultisystem organ failure,remaningnecrosis/infection,and hemorrhge,21,医学,1.Classification and definition,22,医学,2. Pathophysiology* Mild: interstitial (edematous) pancreatitis* Severe: associated with necrotizingpancreatitis, have undergone ti
10、ssuenecrosis with vascular inflammation and thrombosis being prominent features,23,医学,24,医学,3.Etiology,25,医学,26,医学,27,医学,4. Clinical presentationMost prevalent symptoms:Abdominal pain,nausea,and vomiting Tachycardia and hypotensionLow grade feverJaundice,28,医学,Grey Turners sign:blue discoloration of
11、 the flanks (blood dissects into subcutaneous tissue Cullens sign: umbilicus blue discoloration Foxs sign: Inguinal region blue discoloration,29,医学,Laboratory tests Imaging tests US,CT,MRI,30,医学,Assessment of disease severity (1) Scoring system* Ranson criteriaOn adimssion 1.Age 55 year 2.Wbc 16000
12、3.Glucose 200 mg / dl 4.lactase dehydrogenase 350IU /L 5.Glutamine-oxaloacetic transminase 250 IU / L,31,医学,After 48 hour 1. Hct 5 mg/dl 3. Calcium 4 mEq / L 6. Fluid sequestration 6L,32,医学,* Glascow system,33,医学,(2) CT ScaningIts most important imaging test for AP and is useful in comforming the di
13、agnosis,assessing disease severity, and detecting complications.,34,医学,Serum and urinary markersCRPNeutrophil elastaseIL-6,35,医学,5.Management (1)Goals of management,36,医学,(2)Providing supportive care Fluid resuscitation ICU(CVP,PAWP) Positive pressure ventilation, vasopressin, hemodialysis IV narcot
14、is Nasogastric tube,37,医学,(3)Minimizing progression of pancreatic inflammation and injury Bowel rest (nothing by mouth) Limit stimulation of pancreatic exocrine secretion Severe cases used TPN,38,医学,Inhibit activated pancreatic enzymes(Somatastatin,Octreotide) Platlet activating factor antagonist -
15、Lexiparfant Other adjuncts: glucagons, fresh frozen plasma, anticholinergics, peritoneal lavage,39,医学,(4)Treating the underlying cause Gallstone pancreastitis;ERCP(stone extraction) 6 week later undergo cholecystectomy Endoscopic sphinctrotomy,40,医学,(5) Preventing and treating complicationsInfection
16、 of pancreatic and peripancreaticnecrosis complicates 30-70% of cases ofANP and most commonly becomeestablished during the second to third weeks after onset of disease,41,医学,Infected necrosisFNA(CT guide) for diagnosis(95%)Surgical intervention (debrided anddrainage)Necrosectomy with lavage Prophylactic antibiotics,42,医学,PseudocystsAcute fluid collections,30-50%10% of them fluid collections progress to develop a wall of fibrous tissue, pseudocysts If cysts less than 6 cm in diameter - nonoperation,
