【医学】胰腺疾病浙江大学附属医院.ppt

胰胰 腺腺 疾疾 病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n nPancreas-Pan(Pancreas-Pan(全全全全)+)+KreasKreas(肉肉肉肉)n nWirsung-1642Wirsung-1642年年年年发现主胰管发现主胰管发现主胰管发现主胰管n nVater-1720Vater-1720年年年年描述十二指肠壶腹描述十二指肠壶腹描述十二指肠壶腹描述十二指肠壶腹n nSantorini-1742Santorini-1742年年年年命名副胰管命名副胰管命名副胰管命名副胰管n nJacques Jacques Aubert-1856Aubert-1856年首次报告急性胰腺炎年首次报告急性胰腺炎年首次报告急性胰腺炎年首次报告急性胰腺炎2003-3胰腺的解剖胰腺的解剖n n胰腺长胰腺长15-20cm，宽宽3-4cm，厚厚1.5-2.5cmn n分头、颈、体、尾四部分头、颈、体、尾四部2003-3n n横卧于横卧于横卧于横卧于1-21-2腰椎腰椎腰椎腰椎前方，胰头右侧前方，胰头右侧前方，胰头右侧前方，胰头右侧被十二指肠包绕被十二指肠包绕被十二指肠包绕被十二指肠包绕胰尾与脾门相邻胰尾与脾门相邻胰尾与脾门相邻胰尾与脾门相邻n n前面有胃、胃结前面有胃、胃结前面有胃、胃结前面有胃、胃结肠韧带和横结肠肠韧带和横结肠肠韧带和横结肠肠韧带和横结肠及其系膜及其系膜及其系膜及其系膜胰腺的毗邻胰腺的毗邻2003-3胰腺的血流供应胰腺的血流供应n n胰头：胃十二指肠动脉的胰十二指肠上动脉胰头：胃十二指肠动脉的胰十二指肠上动脉胰头：胃十二指肠动脉的胰十二指肠上动脉胰头：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和肠系膜上动脉的胰十二指肠下动脉和肠系膜上动脉的胰十二指肠下动脉和肠系膜上动脉的胰十二指肠下动脉n n胰体尾：脾动脉发出的胰大动脉、胰尾动脉胰体尾：脾动脉发出的胰大动脉、胰尾动脉胰体尾：脾动脉发出的胰大动脉、胰尾动脉胰体尾：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以及胰背动脉及其分支胰横动脉以及胰背动脉及其分支胰横动脉以及胰背动脉及其分支胰横动脉n n静脉：汇入脾静脉、肠系膜上静脉和门静脉静脉：汇入脾静脉、肠系膜上静脉和门静脉静脉：汇入脾静脉、肠系膜上静脉和门静脉静脉：汇入脾静脉、肠系膜上静脉和门静脉2003-32003-3胰腺的淋巴引流胰腺的淋巴引流n n胰头注入胰十二指肠上、下淋巴结胰头注入胰十二指肠上、下淋巴结胰头注入胰十二指肠上、下淋巴结胰头注入胰十二指肠上、下淋巴结n n胰体注入胰上淋巴结和胰下淋巴结胰体注入胰上淋巴结和胰下淋巴结胰体注入胰上淋巴结和胰下淋巴结胰体注入胰上淋巴结和胰下淋巴结n n胰尾注入脾门淋巴结胰尾注入脾门淋巴结胰尾注入脾门淋巴结胰尾注入脾门淋巴结n n最后注入腹腔淋巴结和肠系膜上淋巴结最后注入腹腔淋巴结和肠系膜上淋巴结最后注入腹腔淋巴结和肠系膜上淋巴结最后注入腹腔淋巴结和肠系膜上淋巴结2003-3n n共同通道共同通道2003-3胰腺生理概要胰腺生理概要n n外分泌：胰液。由腺泡细胞和导管细胞外分泌：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产生，主要成分为碳酸氢盐和消化酶n n内分泌：胰岛素，主要由胰岛内分泌：胰岛素，主要由胰岛B细胞产细胞产生；生；A细胞产生胰高血糖素细胞产生胰高血糖素2003-3胰腺的神经胰腺的神经n n交感神经节后纤维主要终于血管，影响交感神经节后纤维主要终于血管，影响胰腺的外分泌胰腺的外分泌n n副交感神经节后纤维终于胰腺腺泡及胰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岛细胞，可控制胰腺的内外分泌2003-3 急性胰腺炎急性胰腺炎 慢性胰腺炎慢性胰腺炎 胰腺癌胰腺癌 壶腹周围癌壶腹周围癌 胰腺内分泌肿瘤胰腺内分泌肿瘤2003-3Acute PancreatitisXu Xiao Xu Xiao Department of Department of HepatobiliaryHepatobiliary&pancreatic Surgery&pancreatic SurgeryThe first Affiliated HospitalThe first Affiliated HospitalZhejiangZhejiang University School of Medicine University School of Medicine HangzhouHangzhou,China,China 中华医学会外科学分会胰腺外科学组n n急性胰急性胰腺炎诊断及分级标准初稿腺炎诊断及分级标准初稿1991年年 n n重症急性胰腺炎诊治规范初重症急性胰腺炎诊治规范初稿稿 1998年年 n n重症急性胰腺炎诊治原则草案重症急性胰腺炎诊治原则草案 2001年年 中华外科杂志中华外科杂志20012001 年年1212 月第月第3939卷第卷第1212期期2003-3Acute pancreatitisn nLife-threatening inflammatory disorder of the Life-threatening inflammatory disorder of the pancreaspancreasn nAbrupt onset and unpredictable courseAbrupt onset and unpredictable coursen nVariable severity and durationVariable severity and durationn nSelf-limited but remarkable morbidity and Self-limited but remarkable morbidity and mortalitymortality2003-3Aetiologyn nElusive but sometimes attributable to a specific causeElusive but sometimes attributable to a specific causen nObstructive Obstructive n nExcessive drinking Excessive drinking n nDeranged Diet Deranged Diet n nHyperlipidemiaHyperlipidemian nhypercalcinemiahypercalcinemian nTraumaticTraumaticn nHemodynamicHemodynamic：ischmicischmic2003-3Pathogenesisn nBile refluxBile refluxn nSelf-digestion Self-digestion TrypsinogenTrypsinogen activation activation n nInflammatory mediators:IL,TNF Inflammatory mediators:IL,TNF n nMicrocirculation and Microcirculation and acinaracinar injury injuryn nCytokine cascadeCytokine cascaden nTwo-hit hypothesis of the cytokine-induced systemic Two-hit hypothesis of the cytokine-induced systemic inflammatory response syndrome(SIRS)inflammatory response syndrome(SIRS)n nMODS,MOF MODS,MOF n nDIC,ARDSDIC,ARDS（p 649）2003-3Classification n nNon-obstructive:alcoholicNon-obstructive:alcoholicn nObstructive:Obstructive:biliarybiliaryn nAcute edematous Acute edematous pancreatitispancreatitisn nAcute Acute hemorrhgichemorrhgic and necrotic and necrotic pancreatitispancreatitis （p 650）2003-3Clinical manifestationn nAbdominal painn nVomitingnAbdominal distentionn nPeritonitisn nFever,jaundice,Gray-Turner sign,Cullen sign（p 650）2003-3Laboratory findingsn nBlood and urine amylase detectionn nLipase,WBC,LF,Blood Sugar,Blood gas,hypocalcinemian nFluid from abdominal paracentesis2003-3Imaging modalities for diagnosisn nConventional abdominal Conventional abdominal ultrasonographyultrasonographyn nSerial enhanced computed tomography(CE-Serial enhanced computed tomography(CE-CT)CT)n nERCPERCPn nMRCPMRCPn nEndoscopicEndoscopic ultrasonographyultrasonographyn nOthers:X-rayOthers:X-ray2003-3*2003-3stone 2003-32003-32003-3n nEarly Early (2-3d)(2-3d)n nSystemicSystemicn nCardiovascularCardiovascular，pulmonarypulmonary，renalrenal，metabolic metabolic n nIntermediate Intermediate (2-5w)(2-5w)n nSepticSepticn nAbdominlAbdominl，pancreaticpancreatic，retroperitoneal retroperitoneal n nPancreatic/Pancreatic/peripancreaticperipancreatic fat necrosis fat necrosis n nPseudocystsPseudocystsn nLate Late (Months)(Months)n nVascular/hemorrhagicVascular/hemorrhagicComplications2003-3ComplicationsSpecific treatment optionsSpecific treatment optionsEarly detection and objective evaluationEarly detection and objective evaluationimagingimagingclinicalclinical2003-3局部并发症局部并发症2003-3急性液体积聚急性液体积聚n n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。2003-3胰腺及胰周组织坏死胰腺及胰周组织坏死n n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50150Hu）2003-32003-3急性胰腺假性囊肿急性胰腺假性囊肿n n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。2003-3胰腺脓肿胰腺脓肿n n发生于急性胰腺炎胰腺周围的包裹性积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表现。它发生于征象是其最常见的临床表现。它发生于重症胰腺炎的后期，常在发病重症胰腺炎的后期，常在发病后后4 4 周或周或4 4 周以后。有脓液存在，细菌或真菌培养周以后。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多数情况下是由局灶性坏死液化继发感性坏死液化继发感染而形成的。染而形成的。2003-32003-32003-3 multiple organ multiple organ dsysfuctiondsysfuction syndrome(MODS)syndrome(MODS)Necrosisinfectionsepsis50%death2003-3Prediction of severityn naimn nImmediately selecting on admissionn n Simple scoring system n n Good biochemical marker2003-3Classification systemn nGeneral evaluationGeneral evaluationn nJohn John RansonRanson score(1974):5(on admission)+6(48hr)score(1974):5(on admission)+6(48hr)n nImrieImrie score:8(WBC,Ca,sugar,PO2,LF)score:8(WBC,Ca,sugar,PO2,LF)n nAPACHE II score(1985):12+ageAPACHE II score(1985):12+ageChronic health+coma Chronic health+coma n nAtlanta classification system(1992)Atlanta classification system(1992)n nLocal evaluation Local evaluation n nBegerBeger criteria(1985)criteria(1985)n nBalthazar CT classification system(1990):I,II,III GRADEBalthazar CT classification system(1990):I,II,III GRADEn nMODS evaluationMODS evaluationn nMarshall MODS score system(1995):6 systems/organs involved Marshall MODS score system(1995):6 systems/organs involved 2003-3n nInflammatory mediatorsInflammatory mediatorsn nC-reactive protein(CRP)n nUpstream cytokines:IL-6,IL-8n nTrypsinogenTrypsinogen activation markers activation markersn nTAP2003-3Clinical classification n nMild acute pancreatitis (MAP)n nSevere acute pancreatitis(SAP )（p 651）2003-3SAP的临床诊断的临床诊断n n急性胰腺炎伴有脏器功能障碍，或出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现坏死、脓肿或假性囊肿等局部并发症者，或两者兼有症者，或两者兼有n nAPACHE II 评分评分 8n nBalthazar CT分级系统分级系统 II级级2003-3SAP的严重度分级的严重度分级n n无脏器功能障碍者为无脏器功能障碍者为I 级级n n伴有脏器功能障碍者伴有脏器功能障碍者为为II 级级2003-3SAP的病程分期的病程分期n急性反应期：自发病至急性反应期：自发病至2周左右，常可有休克、周左右，常可有休克、呼衰、肾衰、脑病等主要并发症。呼衰、肾衰、脑病等主要并发症。n全身感染期：全身感染期：2 2 周到周到2 2 个月左右，以全身细菌感个月左右，以全身细菌感染、深部真菌感染（后期）或双重感染为其主要染、深部真菌感染（后期）或双重感染为其主要临床表现。临床表现。n残余感染期：时间为残余感染期：时间为2 2 3 3 个月以后，主要临床个月以后，主要临床表现为全身营养不良，存在腹膜后或腹腔内残腔，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，伴有消化道瘘常常引流不畅，窦道经久不愈，伴有消化道瘘。2003-3Treatment2003-3Management strategiesn nLargely supportiven nsurgeryn nOptimal timing and indicationsn nLimited role n nDevelopment of novel and more specific therapies are needed2003-3I.Conservative treatment(Non-operative)2003-3Acute reaction phasen nUsually monitoring in ICUUsually monitoring in ICUn nAnti-Anti-shoukshoukn nPancreas restPancreas restn nAntibiotic prophylaxisAntibiotic prophylaxisn nAdequate analgesiaAdequate analgesian nMicrocirculation improvement-Chinese Microcirculation improvement-Chinese traditional medicinetraditional medicinen nNutritional managementNutritional management2003-3General infection phasenSensitive antibioticnGeneral support nSerial CT2003-3Residual infection phasen nPrevention and treatment of late complicationsn nEnhanced enteral nutrition and support2003-3Nutritional managementn nMild-moderate n nNo specialized nutritional support No specialized nutritional support n nseveren nEarly aggressive nutritional supportEarly aggressive nutritional supportn nParenteralParenteral nutrition(PN)-?TPN nutrition(PN)-?TPN n nEnteralEnteral nutrition(EN)nutrition(EN)enteralenteral feeding via jejunum infusion feeding via jejunum infusion 2003-31.II.Surgical treatment2003-3Surgical intervention indicationn nInfected necrosis or deteriorating multi-organ failure despite maximal ICU treatmentn nSpecific surgical complications（p 652）2003-31.III.Biliary pancreatitis2003-3n nObstuctive jaundice or cholangitisn nUrgent Urgent ERCP/EST/NBD Urgent Urgent ERCP/EST/NBD n nWithout biliary complicationsn nNon-beneficial for urgent interventionNon-beneficial for urgent interventionn nSuspected retained stones n nElectively interventionElectively interventionMainly depending onMainly depending on biliary biliary symptoms symptoms2003-3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水肿性急性坏死性急性坏死性急性胆源性急性胆源性急性非胆源性急性非胆源性梗阻型梗阻型 非非梗阻型梗阻型已已感染感染 未未感染感染内科治疗内科治疗急诊手术急诊手术内科治愈后内科治愈后胆道手术胆道手术择期择期手术手术内科治疗内科治疗2003-32003-32003-3Chronic Pancreatitis2003-32003-3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）减轻病人痛苦（腹痛、脂肪泻）减轻病人痛苦（腹痛、脂肪泻）减轻病人痛苦（腹痛、脂肪泻）促使胰液引流通畅促使胰液引流通畅促使胰液引流通畅促使胰液引流通畅防治急性发作防治急性发作防治急性发作防治急性发作改善营养改善营养改善营养改善营养调整胰腺功能调整胰腺功能调整胰腺功能调整胰腺功能分非手术治疗和手术治疗分非手术治疗和手术治疗分非手术治疗和手术治疗分非手术治疗和手术治疗2003-32003-32003-32003-3Thanks!2003-3