Diseases of pancreas DAI Chao-Liu 2nd clinical college of China Medical UniversityAcute pancreatitis Anatomy Head, neck.body, tail, uncinate process, Main pancreatic duct (duct of Wirsung) Dorsal pancreatic duct (duct of Santorini) Pancreatic excretion Exocrine (extra secretion) Endocrine（internal secretion):B,A,D,G cellc Causes Gallstones:60%( 3550% in USA) Alcohol:!4% Drug: Azathioprine .6-Mercaptopurine- Pancreas divisum(胰腺分裂;胰分裂) Microlithiasis Metabolic cause Sphincter of Oddi dysfunction Infectious causes Trauma, ascaris worms,HIV- MiscellaneousAcute pancreatitis Pathology acute edematous pancreatitis acute hemorrhagic necrotizing pancreatitis(acute hemorrhagic pancreatitis, acute necrotizing pancreatitis)Acute pancreatitis Pathophysiology Hypersecretion and obstruction Self-enzymatic digestionoLymphatic obstruction Cytokine，infection Decreased arterial perfusionEdematous hemorrhagic necrotizing Acute pancreatitis Clinical finding Abdominal pain Abdominal distention Nausea and vomiting Respiratory failure, confusion, or coma. Low-grade to moderate fever Tachycardia and hypotension Mild jaundice, Pleural effusion. ShockAcute pancreatitisAcute pancreatitis Peritoneal irritation sign （Abdominal tenderness， rebound tenderness and rigidity） Shifting dullness Decreased bowel sounds Cullen sign: discoloration of periumbilical area Grey Turner sign:discoloration of flanks Laboratory finding Amylase and lipase (elevations of amylase are more sensitive but less specific than lipase in the diagnosis of acute pancreatitis ) 500 400 300 200 100 0 0 1H 24H 48H 5DAYAcute pancreatitisBlood amylaseUrine amylaseAcute pancreatitis Serum calcium Serum glucose Blood gas analysis CRP(C-reactive protein) Imunolipase, trypsinogen ,and immuno elastase. ALT and AST (gallstone pancreatitis ) Imaging finding X-ray Dilated loop of small bowel (sentinel loop) Abrupt cessation of gas in the distal transverse colon (colon cutoff sign) Radioopaque densities (biliary calculi) Left-sided pleural effusion B-US: pancreatic edema, ascites- CT: ImportantAcute pancreatitisCT is the best diagnostic test for the diagnosis of acute pancreatitis. Contrast-enhanced CT is excellent for diagnosis of pancreatic necrosisAcute pancreatitis Assessment of severity of acute pancreatitisRansons criteriaOn Admission Within 48 HoursAge 55 years Age 55 years Hematocrit Hematocrit decrease by 10% decrease by 10%WBC 16,000 mm Urea nitrogen increase 5 mg/dl WBC 16,000 mm Urea nitrogen increase 5 mg/dlLDH 350 IU/L Serum calcium 350 IU/L Serum calcium 200 mg/dl Arterial PO 200 mg/dl Arterial PO 250 IU/L Base deficit 4 AST 250 IU/L Base deficit 4 mEq mEq/L/L Estimated fluid sequestration 6 L Estimated fluid sequestration 6 LAcute pancreatitis Glasgow criteria Within 48 Hours Age 55 WBC 15,000 mm LDH 600 IU/L Glucose 180 mg/dl Albumin 45 mg/dl Arterial PO2 8 Scores -SAP Diagnosis and differential Diagnosis Acute edematous pancreatitis and acute hemorrhagic necrotizing pancreatitis Other diseases Acute appendtitis Ileus Perforated gastroduodenal ulcer Biliary disease Ruptured hepatomaAcute pancreatitisClinical finding Amylase CT Abdominal paracentesisAcute pancreatitis Treatment Acute edematous pancreatitisinternal medicine (Emergency surgery is not indicated in mild acute pancreatitis) Acute hemorrhagic necrotizing pancreatitis Supportive care Replacement of fluid and electrolytes Correction of metabolic abnormalities Nutritional support Other measures :nasogastric suction and antibiotics Agents to inhibit pancreatic secretion Have not been found to be useful in altering the course in acute pancreatitis Somatostatin(sandostatin 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 lavage severe, progressive necrotizing pancreatitis or pancreatic abscess. Cholecystectomy recurrent acute pancreatitis and microlithiasis.Surgical sphincteroplasty of the pancreatic sphincter pancreatic sphincter dysfunction outcome is the same as for the endoscopic pancreatic sphincterotomy more invasive requiring laparotomy and duodenotomyAcute pancreatitis Endoscopic therapy 1) acute gallstone pancreatitis 2) recurrent pancreatitis due to pancreatic sphincter dysfunc