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1、Pancreas胰腺疾病胰腺疾病 DepartmentofSurgeryMaQingyongAnatomy Thepancreaslieswithintheretroperitoneumintheupperabdomen,lyinginfrontofthesecondlumbervertebraandendinginthesplenichilum.Theglandcanbedividedintofourportions-head,neck,body,andtail.uncinateprocessAnatomyThemainpancreaticduct(theductofWirsung,23mm
2、indiameter)coursesalongtheglandfromthetailtotheheadandjoinsthecommonbileductjustbeforeenteringtheduodenumattheampullaofVater(85%).Theaccessorypancreaticduct(theductofSantorini)enterstheduodenum22.5cmproximaltotheVater.the duct of WirsungSantoriniampulla of Vateruncinate processAnatomy Blood supplyTh
3、esuperiorpancreaticoduodenalarteryarisesfromthegastroduedenalartery,runsparalleltotheduodenum,andeventuallymeetstheinferiorpancreaticoduodenalartery,abranchofthesuperiormesentericartery,toformanarcade.Thesplenicarteryprovidestributariesthatsupplythebodyandtailofthepancreas.pancreaticmagnaAsuperior m
4、esenteric arterysplenic arteryarcadesuperior pancreaticoduodenal arteryinferior pancreaticoduodenal arterydorsal pancreatic Apancreatic magna Asuperior mesenteric VPhysiology Exocrine FunctionTheexternalsecretionconsistsofaclear,alkaline(pH7.08.3)solutionof7501000ml/dcontainingdigestiveenzymes.Secre
5、tionisstimulatedbythehormonessecretinandcholecystokinin(CCK)andbyparasympatheticvagaldischarge.SecretinandCCKaresynthesized,store,andreleasedfromduodenalmucosalcellsinresponsetospecificstimuli.Acidinthelumenoftheduodenumcausesthereleaseofsecretin,andluminaldigestionproductsoffatandproteincausetherel
6、easeofCCK.PhysiologyExocrine Functionenzymessynthesized,stored(aszymogengranules),andreleasedbytheacinarcellsofthegland,inresponsetoCCKandvagalstinulation.Pancreaticenzymesareproteolytic,lipolytic,andemylolytic.Lipaseandamylasearestoredandsecretedinactiveforms.Theprolyticenzymesaresecretedasinactive
7、precursorsandactivatedbytheduodenalenzymeenterokinase.OtherenzymesincluderibonucleasesandphospholipaseA.PhysiologyEndocrine FunctionInsulin(51aminoacidresidues,formedinthebetacellsviatheprecursorproinsulin)glucagons(29aminoacids,formedinthecells)pancreaticpolypeptideandsomatostatinareproducedbytheis
8、letsofLangerhans.Acute Pancreatitis急性胰腺炎急性胰腺炎AcutepancreatitisisoneoffollowingfiveacuteabdomenAcutepancreatitis,Acuteappendicitis,Intestinalobstruction,PerformedgatroduodenalulcerCholecystitisorcholelithiasis).Etiology Mostcasesofpancreatitisarecausedbygallstonediseaseoralcoholism;afewresultfromhype
9、rcalcemia,trauma,hyperlipidemia,andgeneticpredisposition;andtheremainderareidiopathic.EtiologyBiliary pancreatitis:About4060%ofcasesofpancreatitisareassociatedwithgallstonedisease,which,ifuntreated,usuallygivesrisetoadditionalacuteattacks.Bilerefluxpancreaticductactivateenzymes.Obstructionincreasedd
10、uctpressuredamagepancreaticacinusdistroygland.EtiologyAlcoholic Pancreatitis:AlcoholstimulatesgastricacidsecretionwhichincreasesCCK-PZ(cholecystokinandpancreozymin)excretioninduodenumandthenincreasespancreaticsecretion.MakethesphincterspasmandedemaIncreaseductpressure.DirecttoxictopancreasEtiologyIn
11、fection:e.g.hepatitisvirus,parotitisvirusandtyphoidbacillus. Trauma and operation,endoscopy(iatrogenicPancreatitis):followingcommonbileductexploration,especiallyifsphincterotomywasperformed.1).UseofacommonductTtubewithalongarmpassingthroughofsphincterofOddi,2).Dilationofthesphincterto57mmduringcommo
12、nductexploration.EtiologyHypercalcemia:hyperparahtyroidismandotherdisordersaccompaniedbyhypercalcemiaareoccasionallycomplicatedbyacutepancreatitis,itisthoughtthattheincreasedcalciumconcentrationsinpancreaticjuicethatresultfromhypercalcemiamayprematurelyactivateproteases,theymayalsofacilitateprecipit
13、ationofcalculiintheduct.EtiologyHyperlipidemia:pancreatitisseemstobeadirectconsequenceofthemetabolicabnormality.duringanacuteattackusuallyassociatedwithmormalserumamylaselevels,becausethelipidinterfereswiththechemicaldeterminationforamylase;urinaryoutputofamylasemaystillbehigh.EtiologyDrug-induced p
14、ancreatitis:corticosteroids,estrogen-containingcontraceptives,azathioprine,thiazidediuretics,andtetracyclines.Pancreatitisassociatedwithuseofestrogensisusuallytheresultofdrug-inducedhypertriglyceridemia.EtiologyIdiopathicpancreatitisandmiscellaneouscauses:Inabout15%ofpatientsthereisnoidentifiablecau
15、seofthecondition.PathogenesisEnzymaticdigestion(autodigestion):Trypsinnotonlydestroystissuebutalsoactivatesotherdestructiveenzymessuchaselastaseandlecithinase.Vasoactivesubstancesincludingkinins,kallikrein,andhistamineleadtocardiovasculardysfunctionandcollapse.PathogenesisIschemia,O-,inflammatorymed
16、iatorsMOD(principallyARDS,myocardialdepression,renalinsufficiency,andgastricstressulceration.PathologyEdematouspancreatitis:localordiffusededemawithcongestion,enlargement,hard.Microscopically,acinicandinterstitialedema,infiltratedwithinflammatorycellswithsmallfociofhemorrhageandnecrosis.Hemorrhagica
17、ndnecroticpancreatitis:hemorrhageandnecrosis,ascites,fatnecrosiswithsaponifyingpatchesinlesserandgreateromenta,mesentery,retroperitonealareas.ComplicationsShock:Trypsin,tissuenecrosis,infectivetoxinpromotingreleaseofvasoactivesubstancesLossofbodyfluidDICPyogenic infection:e.g.suppurativeperitonitis,
18、peripancreaticabscess,septicemiaMODS:ARF,ARDS,poisoningencephalopathyPseudocyst or chronic pancreatitisClinical FindingsSymptoms and signs:Abdominalpain:Theacuteattachbeginsfollowingalargemealandconsistofsevereepigastricpainthatradiatesthroughtotheback,persistentwithvomitingandretching.Wholepancreas
19、beltbackHeadrightupperabdomenradiatestorightshoulderBodyepigastric(middleupperabdomen)BodyandtailleftupperleftshoulderClinical FindingsSymptoms and signs:Nausea and vomiting:withoutrelieftoabdominalpainaftervomitingSigns of peritoneal irritation:tenderness,reboundpain,rigidity,guardingDistention:bow
20、elparalysis,decreasedorabsentbowelsounds,silentabdomen,failuretopasseithergasorfeces.Clinical FindingsSymptoms and signs:HighTwithoutchilling,compressCBDjaundice,decreasedBP,andshock;fulminantpancreatitiscancauseasuddenshockBleeding:Gastrointestinalhematemesisandmelena;bluishdiscolorationintheflank(
21、GreyTurnerssign)orperiumbilicalarea(Cullenssign)GreyTuner征Cullen征Clinical FindingsLaboratory findingsSerumamylaseconcentration:risesfrom3-12h,thepeakis24-48hand2-5dnormalUrinerisesfrom12-24h,slowdecreaseElevatedserumlipaseElevatedhematocritduetodehydrationLowhematocritduetobloodlossClinical Findings
22、Laboratory findingsModerateleukocytosisInnecroticpancreatitis:sugar11.1mmol/L,calcium2.0mmol/L,PaO28.0kPa,increasedBUN,acidosisandevenMODSAbdominalpuncture:bloodyascites,increasedamylaseClinical FindingsImaging studyCTandUSshowadiffuseenlargement,necrosis,andascitesX-ray:isolateddilationofasegmentof
23、gut(sentinelloop)consistingofjejunum,transversecolon,orduodenumadjacenttothepancreas.Gasdistendingtherightcolonthatabruptlystopsinthemidorlefttransversecolon(coloncutoffsign)isduetocolonicspasm正常胰腺CT胰腺动态CT时间时间1.312.22.92.172.273.17胆源性胰腺炎patch of saponificationEssentials of DiagnosisAbruptonsetofepig
24、astricpain,frequentlywithbackpainNauseaandvomitingElevatedserumorurinaryamylaseCholelithiasisoralcoholism(manypatients)Differential DiagnosisAcute cholecystitis:biliarycolic,feverandchills,MurphyssignandenlargedgallbladderPeptic ulcer perforationAcute abdominal obstructionRenal colicAcute gastroente
25、ritisCoronary disease TreatmentMedical treatment:thegoalsofmedicaltherapyarereductionofpancreaticsecretorystimuliandcorrectionoffluidandelectrolytederangement.Gastric suction and diet controlOxygen Fluid replacement and nutritionAntibioticsTreatment(2)Medical treatment:Calcium and magnesium replacem
26、entAnti-enzyme drugs: 5-FU(250-500mgin5%glucose500ml),octreotide,sandostatin,aprotinin,andH2receptorblockersSpasmolytic and painkiller atropine,dolantin,pro-BanthineTCMTreatment(3)Surgical treatment(necroticPancreatitiswithcomplication,andbiliaryP)Necrosectomy,debridementremovenecrotictissueThorough
27、drainage(peritoneallavage)OtherproceduresBiliarypancreatitisTtubedrainageGastrostomyfordecompressionJejunostomyfornutritionTPN(totalperenteralnutrition)Chronic Pancreatitis慢性胰腺炎慢性胰腺炎Essentials of DiagnosisPersistentorrecurrentabdominalpain.Pancreaticcalcificationonx-rayin50%.Pancreaticinsufficiencyi
28、n30%;malabsorptionanddiabetesmellitus.Mostoftenduetoalcoholism.Carcinoma of the Pancreas胰腺癌胰腺癌PathologyMostareintheheadofthepancreas(2/3).Ductcellcancerismorethan90%,Therestarefromacinarcells.Metastasisandspreadaremainlyfromlymphaticmetastasisanddirectinvasion.Clinical FindingsSymptoms and signsUppe
29、rabdominalpain(deepseated,andpersistent),distention,discomfortObstructivejaundice:Alimentarysymptoms(poorappetite,anorexia,dyspepsiadiarrheaorconstipation,nauseaandvomitingifinvasiontoduodenumorstomach)Weightloss,faintandcachexiaOthers(fever,mass,ascites)Clinical FindingsLaboratory studyIncreasedamy
30、lase,bloodsugar,positivesugartolerancetest,increasedALP,bilirubin,andtransaminaseifthereishepaticmetastasisorCBDobstructionTumormarkers:CEA,CA19-9,PCAA.thelevelsareelevatedinmostpatientswithpancreaticcancerandalsoinothergastrointestinalcancers.Clinical FindingsImaging studyBUS and CT:CBDandWirsungdu
31、ctdilationwithenlargedgallbladderX-ray:reversed3signifthetumorlocatedintheheadofthepancreasERCPintheabsenceofamass,anERCPisindicated.itisthemostsensitivetest(95%)fordetectingpancreaticcancerTreatmentPancreaticresectionforpancreaticcancerisappropriateonlyifallgrosstumorcanberemovedwithastandardresect
32、ion.Forcurablelesionsofthehead,pancreaticoduodenectomy (Whippleoperation)isrequired.Thisinvolvesresectionofthecommonbileduct,thegallbladder,theduodenum,andthepancreastothemidbody.Thereisanincreasingtendencytopreservetheantrumandpylorus.PancreaticoduodenectomyTreatmentRadiotherapyshouldbecombinedwith
33、chemotherapy(fluorouracil)forpalliation.Radiotherapyalonehasbeenshowntobenobenefit.Carcinoma of the Ampulla of VaterClinical FindingsJaundice:(earlystage)somearefluctuationduetotumornecrosisandexfoliation.EnlargedgallbladderandliverWithinfectionchillsandfeverAbdominalpainOthers(poorappetite,weightlo
34、ss,diarrhea,nauseaandvomitingetc.)ERCPfordiagnosis.TreatmentPancreaticoduodenectomy.1、病毒性肝炎：、病毒性肝炎：由病毒造成的肝炎按照其病毒系列不同分为甲、乙、丙、丁、戊和庚共六种类型病毒性肝炎。能引起肝脏细胞肿胀，是世界上流传广泛，危害很大的传染病之一。 1908 年，才发现病毒也是肝炎的致病因素之一。1947 年，将原来的传染性肝炎（infectious hepatitis）称为甲型肝炎（Hepatitis A, HA）；血清性肝炎（serum hepatitis）称为乙型肝炎（Hepatitis B, H
35、B）。1965 年人类首次检测到乙型肝炎的表面抗原。 我国经济和科学技术日益发展，学术文化领域百家争鸣，（df高血压958心脏病983u6 糖尿病87fr）特别是思想家的革新精神，为中医学理论的创新和突破性进展，提供了有利的文化背景。宋代陈无择著三因极一病证方论一书，（45传染病q566 丙肝964jo乙肝28jgsx甲肝gh）提出三因学说；并产生了最具盛名四大学派，刘完素倡导火热论；张从正力倡“攻邪论”；李杲提出“内伤脾胃，百病由生”的理论；朱震亨创造性地阐明了相火的演变规律。编辑本段明清时期（df肺25s血液f369血小板t5172 红血球gdf55m 白血球fd2）是中医学理论综合汇编、
36、深化发展，临床各科辨证体系丰富、提高阶段。如明代楼英的医学纲目和王肯堂的证治准绳，清代吴谦等编著的医宗金鉴和陈梦雷主编的古今图书集成医部全录等。王清任著医林改错，注重实证研究，（df高血压958心脏病983u6 糖尿病87fr）纠正了古医籍中关于解剖知识的某些错误，肯定了“脑主思维”，发展了瘀血理论。温病学说的形成和发展，标志着中医理论的创新与突破，吴有性著温疫论，叶天士著温热病篇，吴鞠通著温病条辨等，在药物学研究方面，（45传染病q566 丙肝964jo乙肝28jgsx甲肝gh）李时珍著的本草纲目，总结了16世纪以前我国药物学研究的成就。医的诊察疾病能参考现代医学的微观分析，将辨证与辨病相结
37、合，实现宏观与微观的统一，使中医诊断客观化，即把分析与综合相结合的方法引入中医理、法、方、药的研究，使二者有机结合，互相借鉴、补充，避免各自的片面性、局限性，这将有利于中西医学的优势互补，“和而不同”，多元发展。近年来，中医药在防治非典、禽流感和艾滋病方面发挥的独特作用也证实了二者的有机结合，具有肯定的临床疗效。编辑本段东西方医学交融不管是中医学还是西医学，从二者现有的思维方式的发展趋势来看，均是走向现代系统论思维，中医药学理论与现代科学体系之间具有系统同型性，属于本质相同而描述表达方式不同的两种科学形式。可望在现代系统论思维上实现交融或统一，成为中西医在新的发展水平上实现交融或统一的支撑点，
38、希冀籍此能给中医学以至生命科学带来良好的发展机遇，进而对医学理论带来新的革命。编辑本段现代中医史上个世纪末,本世纪初，1996 年,清华学界对中医气本质，经络实质，阴阳，五行，藏象，中医哲学观等都有了新的全面整体创造性的认识和解说。如，邓宇等发现的:气是流动着的信息能量物质的混合统一体；分形分维的经络解剖结构；数理阴阳；中医分形集：分形阴阳集阴阳集的分形分维数，五行分形集五行集的分维数；分形藏象五系统暨心系统、肝系统、脾系统、肺系统、肾系统；中医三个哲学观新提出的第三哲学观：相似观分形论等。 还包括近代针灸经络的发展史,近代中医气的进展简史,中西医结合史,中医中药史等.六种类型的病毒性肝炎遗传
39、因子不同，除乙型肝炎遗传因子是DNA外，其余几型肝炎遗传因子均为RNA。其中甲型肝炎的传播途径是粪口传播，乙型肝炎的传播途径是血液传播、性传播和母婴传播。疫苗。 2、酒精性肝炎：、酒精性肝炎：酒精性肝炎早期可无明显症状，但肝脏已有病理改变，发病前往往有短期内大量饮酒史，有明显体重减轻，食欲不振，恶心，呕吐，全身倦怠乏力，发热，腹痛及腹泻，上消化道出血及精神症状。体征有黄疸，肝肿大和压痛，同时有脾肿大，面色发灰，腹水浮肿及蜘蛛痣，食管静脉曲张。从实验室检查看，有贫血和中性白细胞增多，红细胞容积测定（MCV）大于95FL,血清胆红素增高，可达17.1moL/L 或以上，转氨酶中度升高，常大于2.0，测定线粒体AST（mAST）及其与总AST（tAST）的比值，其升高可达12.5+5.2% 。并有-GT，谷氨酸脱氢酶和碱性磷酸酶活力增高，凝血酶原时间延长。此外，病毒性肝炎还有丙型肝炎、丁型肝炎、戊型肝炎和庚型肝炎。过去被定为己型肝炎病毒的病毒现在被确定为乙型肝炎病毒的一个属型，因此己型肝炎不存在。 在病毒肝炎的疫苗，A型、B型、D型的疫苗已研发成功；C型、E型、F型的目前无编辑本段宋金元时期精品课件文档，欢迎下载，下载后可以复制编辑。更多精品文档，欢迎浏览。
