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1、Diseases of pancreas,DAI Chao-Liu2nd clinical college of China Medical University,Acute pancreatitis,AnatomyHead,neck.body,tail,uncinate process,Main pancreatic duct(duct of Wirsung)Dorsal pancreatic duct(duct of Santorini)Pancreatic excretionExocrine(extra secretion)Endocrine（internal secretion):B,
2、A,D,G cell,c,CausesGallstones:60%(3550%in USA)Alcohol:!4%Drug:Azathioprine.6-Mercaptopurine-Pancreas divisum(胰腺分裂;胰分裂)MicrolithiasisMetabolic causeSphincter of Oddi dysfunctionInfectious causesTrauma,ascaris worms,HIV-Miscellaneous,Acute pancreatitis,Pathologyacute edematous pancreatitisacute hemorr
3、hagic necrotizing pancreatitis(acute hemorrhagic pancreatitis,acute necrotizing pancreatitis),Acute pancreatitis,Pathophysiology Hypersecretion and obstruction Self-enzymatic digestiono Lymphatic obstruction Cytokine，infection Decreased arterial perfusionEdematous hemorrhagic necrotizing,Acute pancr
4、eatitis,Clinical findingAbdominal painAbdominal distention Nausea and vomiting Respiratory failure,confusion,or coma.Low-grade to moderate fever Tachycardia and hypotension Mild jaundice,Pleural effusion.Shock,Acute pancreatitis,Acute pancreatitis,Peritoneal irritation sign（Abdominal tenderness，rebo
5、und tenderness and rigidity）Shifting dullnessDecreased bowel sounds Cullen sign:discoloration of periumbilical area Grey Turner sign:discoloration of flanks,Laboratory findingAmylase and lipase(elevations of amylase are more sensitive but less specific than lipase in the diagnosis of acute pancreati
6、tis)5004003002001000 0 1H 24H 48H 5DAY,Acute pancreatitis,Blood amylase,Urine amylase,Acute pancreatitis,Serum calcium Serum glucose Blood gas analysisCRP(C-reactive protein)Imunolipase,trypsinogen,and immuno elastase.ALT and AST(gallstone pancreatitis),Imaging finding X-ray Dilated loop of small bo
7、wel(sentinel loop)Abrupt cessation of gas in the distal transverse colon(colon cutoff sign)Radioopaque densities(biliary calculi)Left-sided pleural effusionB-US:pancreatic edema,ascites-CT:Important,Acute pancreatitis,CT is the best diagnostic test for the diagnosis of acute pancreatitis.Contrast-en
8、hanced CT is excellent for diagnosis of pancreatic necrosis,有力武器,Acute pancreatitis,Assessment of severity of acute pancreatitis Ransons criteria On Admission Within 48 Hours Age 55 years Hematocrit decrease by 10%WBC 16,000 mm Urea nitrogen increase 5 mg/dl LDH 350 IU/L Serum calcium 200 mg/dl Arte
9、rial PO 250 IU/L Base deficit 4 mEq/L Estimated fluid sequestration 6 L,Acute pancreatitis,Glasgow criteriaWithin 48 HoursAge 55WBC 15,000 mmLDH 600 IU/LGlucose 180 mg/dlAlbumin 45 mg/dlArterial PO2 60 mm Hg,Acute pancreatitis,APACHE III criteriaTemperature BUN Mean blood pressure Leukocytes Serum C
10、reatinine HematocritHeart rate Albumin Respiratory rate Bilirubin Oxygenation Arterial pHSerum sodium and potassiumSerum glucose 8 Scores-SAP,Diagnosis and differential DiagnosisAcute edematous pancreatitis and acute hemorrhagic necrotizing pancreatitisOther diseasesAcute appendtitisIleus Perforated
11、 gastroduodenal ulcer Biliary disease Ruptured hepatoma,Acute pancreatitis,Clinical findingAmylaseCT Abdominal paracentesis,Acute pancreatitis,TreatmentAcute edematous pancreatitisinternal medicine(Emergency surgery is not indicated in mild acute pancreatitis)Acute hemorrhagic necrotizing pancreatit
12、isSupportive care Replacement of fluid and electrolytesCorrection of metabolic abnormalitiesNutritional support Other measures:nasogastric suction and antibiotics,Agents to inhibit pancreatic secretionHave not been found to be useful in altering the course in acute pancreatitis Somatostatin(sandosta
13、tin stilamin)Glucagon.Protease inhibitors(trasylol)Surgical therapy Inefficiency by internal medicine Complication(pancreatic or/and peripancreatic Infection and abscess)Combined wit biliary diseases(Gallstone ASP)Diagnosis unclear,Surgical approach Rresection of necrotic tissue and peritoneal lavag
14、e severe,progressive necrotizing pancreatitis or pancreatic abscess.Cholecystectomy recurrent acute pancreatitis and microlithiasis.Surgical sphincteroplasty of the pancreatic sphincter pancreatic sphincter dysfunctionoutcome is the same as for the endoscopic pancreatic sphincterotomy more invasiver
15、equiring laparotomy and duodenotomy,Acute pancreatitis,Endoscopic therapy 1)acute gallstone pancreatitis 2)recurrent pancreatitis due to pancreatic sphincter dysfunction,3)recurrent pancreatitis due to pancreas divisum.The rationale for endoscopic therapy in each area is the relief of obstruction to
16、 flow of pancreatic juice,Chronic pancreatitis,Causes AlcoholPancreas divisumTropical pancreatitisHyperparathyroidismTraumaObstructive pancreatitisIdiopathic chronic pancreatitisCystic fibrosisHereditary chronic pancreatitis,Chronic pancreatitis,ClassificationObstructive chronic pancreatitisCalcifie
17、d chronic pancreatitisInflammatory chronic pancreatitisPathology pancreatic fibrosis-,Chronic pancreatitis,Clinical finding and diagnosisAbdominal pain,distentionDiarrhageDyspepsiaMalnutrtionDiabetes Narcotic addictionJaundice,Biochemical measurementsIsoamylase,lipase trypsin,and elastaseQuantitativ
18、e measurement of fecal fat glucose tolerance testSecretin stimulation testPlasma cholecystokinin(CCK)(may be elevated)Bentiromide(苯酪肽)test,Chronic pancreatitis,Chronic pancreatitis,Imaging findingPlain abdominal filmTransabdominal ultrasound CT MRCP Endoscopic diagnosis procedures(ERCP,EUS),Chronic
19、pancreatitis,Medical therapyAlcohol and cigarette avoidanceAnalgesics Enzyme therapyTreatment of malnutrition Surgical therapyBiliary Obstruction,pancreatic pseudocysts,combined with biliary diseases,intractabe pain,Celiac nerve blockTherapeutic endoscopy,Tumors of Pancreas,Pancreatic carcinomaArise
20、 from acinar or duct cellsEarly diagnosis very difficulty,prognosis poorObstructive jaundice(permanent):main symptomAbdominal pain DiabetesWeakness,emaciation(消瘦)Stools:acholic Gallbladder:DistendedAbdominal mass,Diagnosis of pancreatic carcinomaLaboratory test:AKP,r-GT,LDH;CEA,POA,PCCA,CA19-9:C-K-r
21、as-Imaging findingUS,CT(CTA),MRCPERCP,PTC&PTCDPET(正电子发射断层扫描)Biopsy(FNA)and cytology,Tumors of Pancreas,Treatment of pancreatic carcinomaRadical operation Pancreatoduodenectomy-tumor in pancreatic head Resection of pancreatic body and tail-tumor in pancreatic body or tailPalliative operation:to relie
22、ve jaundice Biotherapy,Tumors of Pancreas,Pancreatic endocrine neoplasm(PEN)InsulinomaArise from B cellSymptoms:whipples triadSpontaneous hypoglycemia accompanied by central nervous system,psychiatric,or vasomotor symptomsRepeated blood sugar levels below 2.8mmol/L(50mg%)Relief of symptoms by oral o
23、r intravenous administration of glucoseDiagnosis:symptom and IRI/G0.3,B-us,CT,MRI,Endo-US,Angiography,PTPC,ASVSTreatment:operation(resection),Tumors of Pancreas,Arise from:Papilla of duodenumVater ampulla Distal CBDSymptom:obstructive jaundiceDiagnosis Treatment:similar to pancreatic carcinoma,Carcinoma of periampulla,Thank you very much,
