胰腺疾病

null胰 腺 疾 病胰 腺 疾 病浙江大学医学院 附属第一医院肝胆胰外科 胰腺外科发展简史胰腺外科发展简史Pancreas------Pan(全)+Kreas(肉) Wirsung-------1642年发现主胰管 Vater-----------1720年描述十二指肠壶腹 Santorini------1742年命名副胰管 Jacques Aubert-----1856年首次报告急性胰腺炎胰腺的解剖胰腺的解剖胰腺长15-20cm，宽3-4cm，厚1.5-2.5cm 分头、颈、体、尾四部 null横卧于1-2腰椎前方，胰头右侧被十二指肠包绕胰尾与脾门相邻 前面有胃、胃结肠韧带和横结肠及其系膜胰腺的毗邻胰腺的血流供应胰腺的血流供应胰头：胃十二指肠动脉的胰十二指肠上动脉和肠系膜上动脉的胰十二指肠下动脉 胰体尾：脾动脉发出的胰大动脉、胰尾动脉以及胰背动脉及其分支胰横动脉 静脉：汇入脾静脉、肠系膜上静脉和门静脉null胰腺的淋巴引流胰腺的淋巴引流胰头注入胰十二指肠上、下淋巴结 胰体注入胰上淋巴结和胰下淋巴结 胰尾注入脾门淋巴结 最后注入腹腔淋巴结和肠系膜上淋巴结null共同通道胰腺生理概要胰腺生理概要外分泌：胰液。由腺泡细胞和导管细胞产生，主要成分为碳酸氢盐和消化酶 内分泌：胰岛素，主要由胰岛B细胞产生；A细胞产生胰高血糖素胰腺的神经胰腺的神经交感神经节后纤维主要终于血管，影响胰腺的外分泌 副交感神经节后纤维终于胰腺腺泡及胰岛细胞，可控制胰腺的内外分泌null 急性胰腺炎 慢性胰腺炎  胰腺癌  壶腹周围癌 胰腺内分泌肿瘤Acute PancreatitisAcute PancreatitisXu Xiao Department of Hepatobiliary & pancreatic Surgery The first Affiliated Hospital Zhejiang University School of Medicine Hangzhou, China 中华医学会外科学分会 胰腺外科学组中华医学会外科学分会 胰腺外科学组《急性胰腺炎诊断及分级初稿》1991年 《重症急性胰腺炎诊治规范初稿》 1998年 《重症急性胰腺炎诊治原则草案》 2001年 中华外科杂志2001 年12 月第39卷第12期Acute pancreatitisAcute pancreatitisLife-threatening inflammatory disorder of the pancreas Abrupt onset and unpredictable course Variable severity and duration Self-limited but remarkable morbidity and mortalityAetiologyAetiologyElusive but sometimes attributable to a specific cause Obstructive Excessive drinking Deranged Diet Hyperlipidemia hypercalcinemia Traumatic Hemodynamic：ischmicPathogenesisPathogenesisBile reflux Self-digestion Trypsinogen activation Inflammatory mediators: IL, TNF Microcirculation and acinar injury Cytokine cascade Two-hit hypothesis of the cytokine-induced systemic inflammatory response syndrome(SIRS) MODS , MOF DIC , ARDS（p 649）Classification Classification Non-obstructive : alcoholic Obstructive : biliary Acute edematous pancreatitis Acute hemorrhgic and necrotic pancreatitis （p 650）Clinical manifestationClinical manifestationAbdominal pain Vomiting Abdominal distention Peritonitis Fever, jaundice, Gray-Turner sign,Cullen sign（p 650）Laboratory findingsLaboratory findingsBlood and urine amylase detection Lipase, WBC, LF, Blood Sugar, Blood gas, hypocalcinemia Fluid from abdominal paracentesisImaging modalities for diagnosisImaging modalities for diagnosisConventional abdominal ultrasonography Serial enhanced computed tomography (CE-CT) ERCP MRCP Endoscopic ultrasonography Others: X-raynull****nullstone nullnullComplicationsComplicationsEarly (2-3d) Systemic Cardiovascular，pulmonary，renal，metabolic Intermediate (2-5w) Septic Abdominl，pancreatic，retroperitoneal Pancreatic / peripancreatic fat necrosis Pseudocysts Late (Months) Vascular /hemorrhagicComplicationsComplicationsSpecific treatment optionsEarly detection and objective evaluationimagingclinical局部并发症局部并发症急性液体积聚急性液体积聚发生于胰腺炎病程的早期，位于胰腺内或胰周，无囊壁包裹的液体积聚。通常靠影像学检查发现。影像学上为无明显囊壁包裹的急性液体积聚。急性液体积聚多会自行吸收，少数可发展为急性假性囊肿或胰腺脓肿。胰腺及胰周组织坏死胰腺及胰周组织坏死胰腺实质的弥漫性或局灶性坏死，伴有胰周脂肪坏死。胰腺坏死根据感染与否又分为感染性胰腺坏死和无菌性胰腺坏死。增强CT 是目前诊断胰腺坏死的最佳方法。在静脉注射增强剂后，坏死区的增强密度不超过50Hu (正常区的增强为50150Hu）null急性胰腺假性囊肿急性胰腺假性囊肿指急性胰腺炎后形成的有纤维组织或肉芽囊壁包裹的胰液积聚。急性胰腺炎患者的假性囊肿少数可通过触诊发现，多数通过影像学检查确定诊断。常呈圆形或椭圆形，囊壁清晰。胰腺脓肿胰腺脓肿发生于急性胰腺炎胰腺周围的包裹性积脓，含少量或不含胰腺坏死组织。感染征象是其最常见的临床现。它发生于重症胰腺炎的后期，常在发病后4 周或4 周以后。有脓液存在，细菌或真菌培养阳性，含极少或不含胰腺坏死组织，这是区别于感染性坏死的特点。胰腺脓肿多数情况下是由局灶性坏死液化继发感染而形成的。 nullnull multiple organ dsysfuction syndrome (MODS) multiple organ dsysfuction syndrome (MODS)Necrosisinfectionsepsis50% deathPrediction of severityPrediction of severityaim Immediately selecting on admission Simple scoring system Good biochemical markerClassification systemClassification systemGeneral evaluation John Ranson score (1974):5(on admission) +6(48hr) Imrie score:8 (WBC,Ca,sugar,PO2,LF) APACHE II score (1985):12+age＋Chronic health+coma Atlanta classification system(1992) Local evaluation Beger’ criteria (1985) Balthazar CT classification system (1990):I,II,III GRADE MODS evaluation Marshall MODS score system(1995):6 systems/organs involved nullInflammatory mediators C-reactive protein(CRP) Upstream cytokines: IL-6,IL-8 Trypsinogen activation markers TAPClinical classification Clinical classification Mild acute pancreatitis ( MAP ) Severe acute pancreatitis ( SAP )（p 651）SAP的临床诊断SAP的临床诊断急性胰腺炎伴有脏器功能障碍，或出现坏死、脓肿或假性囊肿等局部并发症者，或两者兼有 APACHE II 评分  8 Balthazar CT分级系统  II级SAP的严重度分级SAP的严重度分级无脏器功能障碍者为I 级 伴有脏器功能障碍者为II 级SAP的病程分期SAP的病程分期急性反应期：自发病至2周左右，常可有休克、呼衰、肾衰、脑病等主要并发症。 全身感染期：2 周到2 个月左右，以全身细菌感染、深部真菌感染（后期）或双重感染为其主要临床表现。 残余感染期：时间为2  3 个月以后，主要临床表现为全身营养不良，存在腹膜后或腹腔内残腔，常常引流不畅，窦道经久不愈，伴有消化道瘘。TreatmentTreatmentManagement strategiesManagement strategiesLargely supportive surgery Optimal timing and indications Limited role Development of novel and more specific therapies are neededConservative treatment (Non-operative)Conservative treatment (Non-operative)Acute reaction phaseAcute reaction phaseUsually monitoring in ICU Anti-shouk Pancreas rest Antibiotic prophylaxis Adequate analgesia Microcirculation improvement - Chinese traditional medicine Nutritional managementGeneral infection phaseGeneral infection phaseSensitive antibiotic General support Serial CTResidual infection phaseResidual infection phasePrevention and treatment of late complications Enhanced enteral nutrition and supportNutritional managementNutritional managementMild-moderate No specialized nutritional support severe Early aggressive nutritional support Parenteral nutrition(PN) -- ? TPN Enteral nutrition(EN) – enteral feeding via jejunum infusion nullII. Surgical treatmentSurgical intervention indicationSurgical intervention indicationInfected necrosis or deteriorating multi-organ failure despite maximal ICU treatment Specific surgical complications（p 652）nullIII. Biliary pancreatitis null Obstuctive jaundice or cholangitis Urgent Urgent ERCP /EST/NBD Without biliary complications Non-beneficial for urgent intervention Suspected retained stones Electively interventionMainly depending on biliary symptoms急性胰腺炎治疗原则急性胰腺炎治疗原则 急性水肿性急性坏死性急性胆源性急性非胆源性梗阻型非梗阻型已感染未感染内科治疗急诊手术内科治愈后 胆道手术择期手术内科治疗nullnullnullChronic Pancreatitisnull慢性胰腺炎的治疗慢性胰腺炎的治疗减轻病人痛苦（腹痛、脂肪泻） 促使胰液引流通畅 防治急性发作 改善营养 调整胰腺功能 分非手术治疗和手术治疗nullnullnullnullThanks !