内科学-胰腺疾病(英文)--课件

,*,单击此处编辑母版标题样式,ppt课件,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,PANCREAS,1,ppt课件,PANCREAS1ppt课件,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 surface is covered by a,peritoneal leaf(lesser sac),2,ppt课件,Anatomy and Physiology 1.Stru,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,3,ppt课件,The pancreas is routinely div,4,ppt课件,4ppt课件,5,ppt课件,5ppt课件,2.Pancreatic ducts,The main pancreatic duct (Wirsung) run the,entire length of the pancreas and joins,the common duct to empty into duodenum,at the ampula of Vater,6,ppt课件,2.Pancreatic ducts6ppt课件,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 thought to prevent reflux bile,7,ppt课件,The normal duct is only 2-4,8,ppt课件,8ppt课件,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.,9,ppt课件,3.Common channel 9ppt课件,10,ppt课件,10ppt课件,3.Arterial supply,The celiac and superior mesenteric arteries,supply blood to the pancreas through their,major branches.Some variations of hepatic,arteries in relation to the pancreas,11,ppt课件,3.Arterial supply11ppt课件,12,ppt课件,12ppt课件,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 of anomalies is similar,13,ppt课件,4.Venous drainage13ppt课件,14,ppt课件,14ppt课件,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),15,ppt课件,5.Physiology15ppt课件,(2)Endocrine function,Insulin Other: Neuropeptide(VIP,Glucagon galanin, serotonin,Somatastatine amylin ),Pancreatic polypeptide,16,ppt课件,(2)Endocrine function16ppt课件,Acute pancreatitis,Acute pancretitis is an acute,inflammatory process of the,pancreas with variable,involvement of other regional,tissue or organs,.,17,ppt课件,Acute pancreatitis Acute pancr,300000/year in USA hospitalized,4000 deaths.,75% of cases are attributable to either,gallstone or alcohol.,18,ppt课件,300000/year in USA hospitalize,20% of cases severe, its defined as,associated with one or more of the,following: necrosis, distant organ,failure, local complications,( hemorrhage, abscess, pseudocyst),19,ppt课件,20% of cases severe, its def,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/infection,and hemorrhge,20,ppt课件,The mortality rate(severe)10-,1.Classification and definition,21,ppt课件,1.Classification and definitio,2. Pathophysiology,* Mild: interstitial (edematous) pancreatitis,* Severe: associated with necrotizing,pancreatitis, have undergone tissue,necrosis with vascular inflammation and thrombosis being prominent features,22,ppt课件,2. Pathophysiology22ppt课件,23,ppt课件,23ppt课件,3.Etiology,24,ppt课件,24ppt课件,25,ppt课件,25ppt课件,26,ppt课件,26ppt课件,4. Clinical presentation,Most prevalent symptoms:,Abdominal pain,nausea,and vomiting,Tachycardia and hypotension,Low grade fever,Jaundice,27,ppt课件,4. Clinical presentation27ppt课,Grey Turners sign:blue discoloration of the flanks (blood dissects into subcutaneous tissue,Cullens sign: umbilicus blue discoloration,Foxs sign: Inguinal region blue discoloration,28,ppt课件,Grey Turners sign:blue discol,Laboratory tests,Imaging tests US,CT,MRI,29,ppt课件,Laboratory tests29ppt课件,Assessment of disease severity,(1) Scoring system,* Ranson criteria,On adimssion,1.Age 55 year,2.Wbc 16000,3.Glucose 200 mg / dl,4.lactase dehydrogenase 350IU /L,5.Glutamine-oxaloacetic transminase ,250 IU / L,30,ppt课件,Assessment of disease severity,After 48 hour,1. Hct 5 mg/dl,3. Calcium 8mg / dl,4. PaCO,2, 4 mEq / L,6. Fluid sequestration 6L,31,ppt课件,After 48 hour31ppt课件,* Glascow system,32,ppt课件,* Glascow system32ppt课件,(2) CT Scaning,Its most important imaging test for AP and is useful in comforming the diagnosis,assessing disease severity, and detecting complications.,33,ppt课件,(2) CT Scaning33ppt课件,Serum and urinary markers,CRP,Neutrophil elastase,IL-6,34,ppt课件,Serum and urinary markers34,5.Management,(1)Goals of management,35,ppt课件,5.Management35ppt课件,(2)Providing supportive care,Fluid resuscitation,ICU(CVP,PAWP),Positive pressure ventilation, vasopressin, hemodialysis,IV narcotis,Nasogastric tube,36,ppt课件,(2)Providing supportive care36,(3)Minimizing progression,of pancreatic inflammation and injury,Bowel rest (nothing by mouth),Limit stimulation of pancreatic exocrine secretion,Severe cases used TPN,37,ppt课件,(3)Minimizing progression of p,Inhibit activated pancreatic enzymes,(Somatastatin,Octreotide),Platlet activating factor antagonist - Lexiparfant,Other adjuncts: glucagons, fresh frozen plasma, anticholinergics, peritoneal lavage,38,ppt课件,Inhibit activated pancreatic e,(4)Treating the underlying cause,Gallstone pancreastitis;ERCP(stone extraction),6 week later undergo cholecystectomy,Endoscopic sphinctrotomy,39,ppt课件,(4)Treating the underlying cau,(5) Preventing and treating complications,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,40,ppt课件,(5) Preventing and treating co,Infected necrosis,FNA(CT guide) for diagnosis(95%),Surgical intervention (debrided and,drainage),Necrosectomy with lavage Prophylactic antibiotics,41,ppt课件,Infected necrosis41ppt课件,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,42,ppt课件,Pseudocysts42ppt课件,NEOPLASMS OF EXOCRINE PANCREAS,43,ppt课件,NEOPLASMS OF EXOCRINE PANCREAS,PANCREAS CANCER,1. Epidemiology,11/100000/year incidence rate relative stable,In China, during last two decade increased two fold,44,ppt课件,PANCREAS CANCER1. Epidemiolo,2. Risk factors,Demographic factors: elder, male, Blackrace,Host factors: Colorectal cancer, Familial breast cancer, Peutz-Jeghers Syndrome, melanoma, pancreatitis.,45,ppt课件,2. Risk factors45ppt课件,3. Molecular genetics,Oncogenes: K-ras,Tumor suppressor:p16,p53,DPCA,BRCA2,46,ppt课件,3. Molecular genetics46ppt课件,4. Pathology,Classification,(1)Duct cell origin(89%),Duct cell adenocarcinoma,Giant cell carcinoma,Adenosaquamous carcinoma,Microcarcinoma,Mucinous cyst adenocarcinoma,47,ppt课件,4. Pathology47ppt课件,(2) Acinar cell origin(1%),Acinar cell carcinoma,Cystadenoma,(3) Uncertain histogenesis,Pancreatic blastoma,Papillary and cystic neoplasm,Mixed-Ducta and islet cells,48,ppt课件,(2) Acinar cell origin(1%)48p,5.Clinicopathologic staging and 5 years survival,IA 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 -,49,ppt课件,5.Clinicopathologic staging an,6.Diagnosis,Symptom(%) Head cancer,Weight loss 92,Jaundice 82,Pain 72,Anorexia 64,Dark urine 63,Light stools 62,Nausa 37,50,ppt课件,6.Diagnosis50ppt课件,Symptom(%) Body and tail cancer,Weight loss 100,Pain 87,Weakness 43,Nausa 43,Vomiting 37,Constipation 27,Melena, jaundice, fever, diarrhea,51,ppt课件,Symptom(%) Body and tail c,Sign(%) Head cancer,Jaundice 87,Palpable liver 83,Palpable gallbladder 29,Tenderness 26,Ascites 14,Abdominal mass 13,52,ppt课件,Sign(%) Head cancer52ppt课件,Sign(%) Body and tail cancer,Palpable liver 33,Tenderness 27,Abdominal mass 23,Jaundice 13,Diarrhea 3,53,ppt课件,Sign(%) Body and tail cancer,54,ppt课件,54ppt课件,55,ppt课件,55ppt课件,7.Resection of pancreatic carcinoma,56,ppt课件,7.Resection of pancreatic c,Carcinoma of the head , neck, and Uncinate process,1912,Kaush first success resection,1935,Whipple described technique of redical resection,Performe two stages:,Stage 1, decompress the obstruction,Stage 2, en bloc resection,57,ppt课件,Carcinoma of the head , nec,Extent of resection,58,ppt课件,Extent of resection58ppt课件,59,ppt课件,59ppt课件,Carcinoma of the body and tail,Much more limited than that of the head and neck,Most patients are unable to undergo resection,If tumor cant resected,tissue biopsy chemical splanchnicectomy, gastrojejunostomy,60,ppt课件,Carcinoma of the body and tail,Complications after pancreaticoduodenectomy,Common:,Delay gastric emptying, pancreatic fistula, intraabdominal abscess,hemorrhage,wound infection, diabetes,pancreatic exocrine insufficiency,61,ppt课件,Complications after pancreatic,Uncommon:,Fistula (biliary, duodenal, gastric),Organ failure (Pancreatic, hepatic Pulmonary, renal),Pancrestitis, marginal ulcer,62,ppt课件,Uncommon:62ppt课件,Long-term survival,63,ppt课件,Long-term survival63ppt,Adjuvant and neoajuvant therapy,64,ppt课件,Adjuvant and neoajuvant therap,Palliation treatment,(1)Jaundice,Choledochojejunstomy,Cholecystojejunostomy,(2)Duodenal obstruction,Prophylactive gastric bypass,(3)Pain,65,ppt课件,Palliation treatment65ppt课件,NEOPLASMS OF THE ENDOCRINE PANCREAS,66,ppt课件,NEOPLASMS OF THE ENDOCRINE PAN,1.Classificatn,Insulinoma Hypoglycemia 10% malignancy,Gastrinoma Peptic ulcer 50% malignancy,VIPoma Watery diarrhea Most,Hypocalcemia,Glucagonoma Hyperglycemia Most,Dermatitis,Somtostatinoma Hyperglycemia Most,Steatorrhea,Gallstone,67,ppt课件,1.Classificatn67ppt课件,68,ppt课件,68ppt课件,69,ppt课件,69ppt课件,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,glucose,70,ppt课件,2. Insulinoma 70ppt课件,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,include,Confusion,seizura,obtundation,Personality change,coma,71,ppt课件,In the most common neoplasm of,(2)Hypoglycemia induced symptoms,Related to catecholamine levels,include palpitations,trembling,diaphoresis, and tachycardia,Most cases consume carbohydrate rich,meals and snacks to relieve or,prevent these symptoms,72,ppt课件,(2)Hypoglycemia induced sympto,Diagnosis,（1）Monitored fast: Blood glucose and,insulin every 4-6 hours, when glucose,50 mg/dl, the symptoms occure,（2）Insulin to-glucose ratio:0.3,（3）Beta-cell products synthesized in,（4）Excess: C peptide, proinsulin,73,ppt课件,Diagnosis73ppt课件,10% of insulinoma are malignant,Presenting with lymph node or liver metastases,Resection of the primary tumor should be considered can help reducing hypoglycemia symptoms,In unresectable cases,Diazoxide and octretide can be used to reduce insulin secretion,74,ppt课件,10% of insulinoma are malignan,Selective transhepatic portal venous hormone sampling may help in locatzing the occult neoplasm overall accuracy of this test rangs 70%-95%,75,ppt课件,Selective transhepatic portal,76,ppt课件,76ppt课件,Treatment,Before operation,localization and staging,At operation ,can also by US,Resecte tumor,77,ppt课件,Treatment77ppt课件,78,ppt课件,78ppt课件,3.Gastrinoma,(Zollinger-Ellison syndrome),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,79,ppt课件,3.Gastrinoma (Zollinger-Elliso,Symptoms: Peptic ulcer disease,Diarrhea,Esophagitis,Diagnosis: Gastrin measurement,Gastric acid analysis(PH),Secrection stimulation test,Anatomic localization: Duodenum and,heat of pancreas(Gastrinoma triangle),80,ppt课件,Symptoms: Peptic ulcer disease,81,ppt课件,81ppt课件,4. VIPoma,Watery diarrhea, hypocalemia, most in body and tail,5. Glucagonoma,Dermatitis, hyperglycemia, hypoprotienemia,most in body and tail,6. Somatostatinoma,Stearorrhea, hypoglycemia, hypochlorhydria,Gallstone, most in head and neck,82,ppt课件,4. VIPoma82ppt课件,