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1、PANCREAS,Anatomy and Physiology,1.Structure:Pancreas is a glanodular structure located in the retroperitoneum.Anterioly,the pancreas is covered at the distal head and neck by the pylorus and the transverse mesocolon,the neck and body are covered anteriorly by the posterior gastric wall.The anterior
2、surface is covered by a peritoneal leaf(lesser sac),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,2.Pancreatic ducts The main pancreatic duct(Wirsung)run t
3、he entire length of the pancreas and joins the common duct to empty into duodenum at the ampula of Vater,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 7-17 mmHg.This differential is t
4、hought to prevent reflux bile,3.Common channel Variations in the relation between the intra pancreatic portion of the common bile duct and the main pancreatic duct at the ampula of Vater.A short common channel contain flow from both secretary system.,3.Arterial supply The celiac and superior mesente
5、ric arteries supply blood to the pancreas through their major branches.Some variations of hepatic arteries in relation to the pancreas,4.Venous drainage The venous drainage of the pancreas and duodenum follows the arterial supply,The veins are usually superficial to the arteries and the frenquency o
6、f anomalies is similar,5.Physiology(1)Exocrine function:Islet peptide products influence the function of the exocrine pancreas Bicarbonate secretion:(20 mmol/L,pH7-9)Enzyme secretion:(amylases,lipases,proteases),(2)Endocrine function Insulin Other:Neuropeptide(VIP,Glucagon galanin,serotonin,Somatast
7、atine amylin)Pancreatic polypeptide,Acute pancreatitis,Acute pancretitis is an acute inflammatory process of the pancreas with variable involvement of other regional tissue or organs.,300000/year in USA hospitalized4000 deaths.75%of cases are attributable to eithergallstone or alcohol.,20%of cases s
8、evere,its defined as associated with one or more of the following:necrosis,distant organ failure,local complications(hemorrhage,abscess,pseudocyst),The mortality rate(severe)10-20%,with half deaths in the first 2 week as the result of SIRS,induced multisystem organ failure,remaning necrosis/infectio
9、n,and hemorrhge,1.Classification and definition,2.Pathophysiology*Mild:interstitial(edematous)pancreatitis*Severe:associated with necrotizing pancreatitis,have undergone tissue necrosis with vascular inflammation and thrombosis being prominent features,3.Etiology,4.Clinical presentation Most prevale
10、nt symptoms:Abdominal pain,nausea,and vomiting Tachycardia and hypotension Low grade fever Jaundice,Grey Turners sign:blue discoloration of the flanks(blood dissects into subcutaneous tissueCullens sign:umbilicus blue discolorationFoxs sign:Inguinal region blue discoloration,Laboratory testsImaging
11、tests US,CT,MRI,Assessment of disease severity(1)Scoring system*Ranson criteria On adimssion1.Age 55 year2.Wbc 160003.Glucose 200 mg/dl4.lactase dehydrogenase 350IU/L5.Glutamine-oxaloacetic transminase 250 IU/L,After 48 hour1.Hct 5 mg/dl3.Calcium 4 mEq/L6.Fluid sequestration 6L,*Glascow system,(2)CT
12、 Scaning Its most important imaging test for AP and is useful in comforming the diagnosis,assessing disease severity,and detecting complications.,Serum and urinary markers CRP Neutrophil elastase IL-6,5.Management(1)Goals of management,(2)Providing supportive careFluid resuscitationICU(CVP,PAWP)Posi
13、tive pressure ventilation,vasopressin,hemodialysisIV narcotisNasogastric tube,(3)Minimizing progression of pancreatic inflammation and injuryBowel rest(nothing by mouth)Limit stimulation of pancreatic exocrine secretionSevere cases used TPN,Inhibit activated pancreatic enzymes(Somatastatin,Octreotid
14、e)Platlet activating factor antagonist-LexiparfantOther adjuncts:glucagons,fresh frozen plasma,anticholinergics,peritoneal lavage,(4)Treating the underlying causeGallstone pancreastitis;ERCP(stone extraction)6 week later undergo cholecystectomyEndoscopic sphinctrotomy,(5)Preventing and treating comp
15、lications Infection of pancreatic and peripancreatic necrosis complicates 30-70%of cases of ANP and most commonly become established during the second to third weeks after onset of disease,Infected necrosis FNA(CT guide)for diagnosis(95%)Surgical intervention(debrided and drainage)Necrosectomy with
16、lavage Prophylactic antibiotics,Pseudocysts Acute 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,NEOPLASMS OF EXOCRINE PANCREAS,PANCREAS CANCER,1.Epidemiology11/100000/year incidence rate
17、relative stableIn China,during last two decade increased two fold,2.Risk factorsDemographic factors:elder,male,BlackraceHost factors:Colorectal cancer,Familial breast cancer,Peutz-Jeghers Syndrome,melanoma,pancreatitis.,3.Molecular geneticsOncogenes:K-rasTumor suppressor:p16,p53,DPCA,BRCA2,4.Patholo
18、gyClassification(1)Duct cell origin(89%)Duct cell adenocarcinoma Giant cell carcinoma Adenosaquamous carcinoma Microcarcinoma Mucinous cyst adenocarcinoma,(2)Acinar cell origin(1%)Acinar cell carcinoma Cystadenoma(3)Uncertain histogenesis Pancreatic blastoma Papillary and cystic neoplasm Mixed-Ducta
19、 and islet cells,5.Clinicopathologic staging and 5 years survivalIA T1 N0 M0 5 years 20-30%IB T2 N0 M0 survival 20-30%IIA T3 N0 M0 10-25%IIB T123 N1 M0 10-15%III T4 anyN M0 0-5%IV anyT anyN M1-,6.DiagnosisSymptom(%)Head cancer Weight loss 92 Jaundice 82 Pain 72 Anorexia 64 Dark urine 63 Light stools
20、 62 Nausa 37,Symptom(%)Body and tail cancer Weight loss 100 Pain 87 Weakness 43 Nausa 43 Vomiting 37 Constipation 27 Melena,jaundice,fever,diarrhea,Sign(%)Head cancer Jaundice 87 Palpable liver 83 Palpable gallbladder 29 Tenderness 26 Ascites 14 Abdominal mass 13,Sign(%)Body and tail cancerPalpable
21、liver 33Tenderness 27Abdominal mass 23Jaundice 13Diarrhea 3,7.Resection of pancreatic carcinoma,Carcinoma of the head,neck,and Uncinate process1912,Kaush first success resection1935,Whipple described technique of redical resection Performe two stages:Stage 1,decompress the obstruction Stage 2,en blo
22、c resection,Extent of resection,Carcinoma of the body and tailMuch more limited than that of the head and neckMost patients are unable to undergo resectionIf tumor cant resected,tissue biopsy chemical splanchnicectomy,gastrojejunostomy,Complications after pancreaticoduodenectomyCommon:Delay gastric
23、emptying,pancreatic fistula,intraabdominal abscess,hemorrhage,wound infection,diabetes,pancreatic exocrine insufficiency,Uncommon:Fistula(biliary,duodenal,gastric)Organ failure(Pancreatic,hepatic Pulmonary,renal)Pancrestitis,marginal ulcer,Long-term survival,Adjuvant and neoajuvant therapy,Palliatio
24、n treatment(1)Jaundice Choledochojejunstomy Cholecystojejunostomy(2)Duodenal obstruction Prophylactive gastric bypass(3)Pain,NEOPLASMS OF THE ENDOCRINE PANCREAS,1.ClassificatnInsulinoma Hypoglycemia 10%malignancyGastrinoma Peptic ulcer 50%malignancyVIPoma Watery diarrhea Most HypocalcemiaGlucagonoma
25、 Hyperglycemia Most DermatitisSomtostatinoma Hyperglycemia Most Steatorrhea Gallstone,2.Insulinoma Whipples triad:(1)Symptoms of hypoglycemia(fasting)(2)Documentation of hypoglycemia,with a Serum glucose level below 50mg/dl(3)Relief of hypoglycemisa symptoms,following administration of exocrine gluc
26、ose,In the most common neoplasm of the endocrine pancreas,autonomous insulin secretion leads to spontaneous hypoglycemia Symtoms can be classifiedm into 2 groups:(1)Neuroglycopenic symptoms,includeConfusion,seizura,obtundation,Personality change,coma,(2)Hypoglycemia induced symptoms,Related to catec
27、holamine levels,include palpitations,trembling,diaphoresis,and tachycardia Most cases consume carbohydrate rich meals and snacks to relieve or prevent these symptoms,Diagnosis（1）Monitored fast:Blood glucose and insulin every 4-6 hours,when glucose 50 mg/dl,the symptoms occure（2）Insulin to-glucose ra
28、tio:0.3（3）Beta-cell products synthesized in（4）Excess:C peptide,proinsulin,10%of insulinoma are malignant Presenting with lymph node or liver metastasesResection of the primary tumor should be considered can help reducing hypoglycemia symptomsIn unresectable cases,Diazoxide and octretide can be used
29、to reduce insulin secretion,Selective transhepatic portal venous hormone sampling may help in locatzing the occult neoplasm overall accuracy of this test rangs 70%-95%,Treatment Before operation,localization and staging At operation,can also by US Resecte tumor,3.Gastrinoma(Zollinger-Ellison syndrom
30、e)1955,Z an E report two cases with peptic ulcer disease and pancreatic endocrine tumor 1/1000 in duodenal ulcer,2/100 in resected duodenal ulcer 75%spontaneous,25%associated MEN-1 Majority were found to be malignant,Symptoms:Peptic ulcer disease Diarrhea EsophagitisDiagnosis:Gastrin measurement Gas
31、tric acid analysis(PH)Secrection stimulation testAnatomic localization:Duodenum and heat of pancreas(Gastrinoma triangle),4.VIPoma Watery diarrhea,hypocalemia,most in body and tail5.Glucagonoma Dermatitis,hyperglycemia,hypoprotienemia,most in body and tail6.Somatostatinoma Stearorrhea,hypoglycemia,hypochlorhydria,Gallstone,most in head and neck,
