1、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,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,2003-3,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,2003-3,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,2003-3,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
2、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,2003-3,2003-3,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,2003-3,共同通道,2003-3,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,2003-3,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，
3、可控制胰腺的内外分泌,2003-3, 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,2003-3,Acute Pancreatitis,Xu 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,急性胰腺炎诊断及分级标准初稿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20
4、01 年12 月第39卷第12期,2003-3,Acute pancreatitis,Life-threatening inflammatory disorder of the pancreas Abrupt onset and unpredictable course Variable severity and duration Self-limited but remarkable morbidity and mortality,2003-3,Aetiology,Elusive but sometimes attributable to a specific cause Obstructi
5、ve Excessive drinking Deranged Diet Hyperlipidemia hypercalcinemia Traumatic Hemodynamic：ischmic,2003-3,Pathogenesis,Bile reflux Self-digestion Trypsinogen activation Inflammatory mediators: IL, TNF Microcirculation and acinar injuryCytokine cascade Two-hit hypothesis of the cytokine-induced systemi
6、c inflammatory response syndrome(SIRS) MODS , MOF DIC , ARDS,（p 649）,2003-3,Classification,Non-obstructive : alcoholic Obstructive : biliaryAcute edematous pancreatitis Acute hemorrhgic and necrotic pancreatitis,（p 650）,2003-3,Clinical manifestation,Abdominal pain Vomiting Abdominal distention Perit
7、onitis Fever, jaundice, Gray-Turner sign,Cullen sign,（p 650）,2003-3,Laboratory findings,Blood and urine amylase detection Lipase, WBC, LF, Blood Sugar, Blood gas, hypocalcinemia Fluid from abdominal paracentesis,2003-3,Imaging modalities for diagnosis,Conventional abdominal ultrasonography Serial en
8、hanced computed tomography (CE-CT) ERCP MRCP Endoscopic ultrasonography Others: X-ray,2003-3,*,*,*,*,2003-3,stone,2003-3,2003-3,2003-3,Early (2-3d) Systemic Cardiovascular，pulmonary，renal，metabolic Intermediate (2-5w) Septic Abdominl，pancreatic，retroperitoneal Pancreatic / peripancreatic fat necrosi
9、s Pseudocysts Late (Months) Vascular /hemorrhagic,Complications,2003-3,Complications,Specific treatment options,Early detection and objective evaluation,imaging,clinical,2003-3,局部并发症,2003-3,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。,2003-3,胰
10、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50150Hu）,2003-3,2003-3,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。,2003-3,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表现。它发生于重症胰腺炎的后期，常
11、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。,2003-3,2003-3,2003-3,multiple organ dsysfuction syndrome (MODS),Necrosis,infection,sepsis,50% death,2003-3,Prediction of severity,aim Immediately selecting on admissionSimple scoring system Good biochemical marker,2
12、003-3,Classification system,General evaluation John Ranson score (1974):5(on admission) +6(48hr) Imrie score:8 (WBC,Ca,sugar,PO2,LF) APACHE II score (1985):12+ageChronic health+coma Atlanta classification system(1992) Local evaluation Beger criteria (1985) Balthazar CT classification system (1990):I
13、,II,III GRADE MODS evaluation Marshall MODS score system(1995):6 systems/organs involved,2003-3,Inflammatory mediators C-reactive protein(CRP) Upstream cytokines: IL-6,IL-8 Trypsinogen activation markers TAP,2003-3,Clinical classification,Mild acute pancreatitis ( MAP ) Severe acute pancreatitis ( S
14、AP ),（p 651）,2003-3,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,2003-3,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,2003-3,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
15、引流不畅，窦道经久不愈，伴有消化道瘘。,2003-3,Treatment,2003-3,Management strategies,Largely supportive surgery Optimal timing and indications Limited role Development of novel and more specific therapies are needed,2003-3,Conservative treatment (Non-operative),2003-3,Acute reaction phase,Usually monitoring in ICU Ant
16、i-shouk Pancreas rest Antibiotic prophylaxis Adequate analgesia Microcirculation improvement - Chinese traditional medicine Nutritional management,2003-3,General infection phase,Sensitive antibiotic General support Serial CT,2003-3,Residual infection phase,Prevention and treatment of late complicati
17、ons Enhanced enteral nutrition and support,2003-3,Nutritional management,Mild-moderate No specialized nutritional support severe Early aggressive nutritional support Parenteral nutrition(PN) - ? TPN Enteral nutrition(EN) enteral feeding via jejunum infusion,2003-3,II. Surgical treatment,2003-3,Surgi
18、cal intervention indication,Infected necrosis or deteriorating multi-organ failure despite maximal ICU treatment Specific surgical complications,（p 652）,2003-3,III. Biliary pancreatitis,2003-3,Obstuctive jaundice or cholangitis Urgent Urgent ERCP /EST/NBD Without biliary complications Non-beneficial
19、 for urgent intervention Suspected retained stones Electively intervention,Mainly depending on biliary symptoms,2003-3,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,2003-3,2003-3,2003-3,Chronic Pancreatitis,2003-3,2003-3,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,2003-3,2003-3,2003-3,2003-3,Thanks !,2003-3,
