Pancreatic Diseases
Pancreatic Cancer
[History taking
1. unexplained weight loss.
2, progressive worsening of low back pain, affecting sleep.
3.Maldigestion and malabsorption, steatorrhea.
4.Jaundice, mostly progressive.
Physical examination】
1, abdominal mass, note whether it is accompanied by vascular murmur.
2, abdominal distension, ascites.
3, gallbladder distension.
4, jaundice.
Auxiliary examinations
1, liver and kidney function, blood glucose, amylase test.
2, carcinoembryonic antigen (CEA) determination.
3.Fecal routine attention to lipid drops and occult blood test.
4.B ultrasound examination.
5.Low tension duodenal barium angiography.
6, retrograde cholangiopancreatography (ERCP) by fiberoptic duodenoscopy.
7, jaundiced patients can be percutaneous liver puncture cholangiography (PTC).
8, CT, ECT, MRI and ultrasound endoscopy can be performed when available.
9. fine needle aspiration for pancreatic cytology if necessary.
10.TV laparoscopy or dissection for pathological biopsy.
Diagnosis】
Based on the medical history, physical examination and auxiliary examination results, most of them can be clearly diagnosed. It should be noted that the tumor is located in the head, body, tail or whole pancreas, whether the cancer has metastasis to abdominal lymph nodes and liver, and the relationship between the cancer mass and superior mesenteric vessels, splenic vessels and abdominal aorta.
Differential diagnosis]
Diseases that need to be differentially diagnosed are.
1, chronic pancreatitis.
2, islet tumor of the pancreas.
3, carcinoma of the lower bile duct or embedded stones.
4.Duodenal descending and papillary tumors.
Treatment principles
1, non-surgical treatment: no exact efficacy, can be used for pre-surgical preparation, post-surgical treatment and comprehensive treatment measures.
(1) Correction of water-electrolyte disorders, anemia and hypoproteinemia.
(2) Application of vitamin K and improvement of coagulation mechanism.
(3) supportive, symptomatic treatment.
(4) Prophylactic antibiotic application.
(5) Poor sensitivity of chemotherapeutic drugs.
(6) Radiotherapy: can be performed intraoperatively.
2.Surgical treatment.
(1) Indications for surgery: cases with good general condition, no distant metastases and clear diagnosis. If the diagnosis is uncertain, intraoperative tumor biopsy and frozen pathological section examination are feasible.
(2) Surgical modalities.
(1) Pancreatic body caudal resection, applicable to left hemipancreatic tumor, mostly requires simultaneous removal of the spleen. For cases with small tumor, early stage of disease, no lymphatic metastasis, and non-combined chronic pancreatitis, pancreatic caudal resection with preservation of the spleen can be considered.
(2) Duodenectomy of the head of the pancreas, which is suitable for cancer of the head of the pancreas, without preserving the pylorus in principle, in order to facilitate the removal of lymph nodes above the head of the pancreas.
(3) total pancreatectomy for multicentric pancreatic cancer and pancreatic cancer with intrapancreatic metastases.
4) biliary-intestinal and gastrointestinal anastomosis, which is applicable to unresectable cancer of the head of the pancreas. to relieve biliary and gastroduodenal obstruction.
5) Peripancreatic abdominal sympathetic plexus dissection for advanced pancreatic cancer with intractable low back pain. It can also destroy the abdominal sympathetic plexus and thoracic sympathetic plexus by injection of anhydrous alcohol under the guidance of B-ultrasound and CT.
【Curative effect standard
1.Cure: radical resection of tumor, disappearance of symptoms and signs, no surgical complications.
2. Improvement: palliative resection of the tumor, reduction of symptoms and signs or palliative treatment such as biliary-intestinal anastomosis, gastrointestinal anastomosis and sympathetic plexus resection only, and disappearance of symptoms and signs.
3.Ineffective treatment or untreated patients.
Discharge criteria]
Those who have reached the clinical efficacy of cure and improvement.
Acute pancreatitis
History taking]
1, abdominal pain: pay attention to the location, nature, speed of development and accompanying symptoms (nausea, vomiting, fever, jaundice, etc.).
2, causative factors: pay attention to alcoholism, overeating, high-fat meals, drugs and acute infectious diseases.
3. history of biliary tract disease and abdominal surgery, history of trauma.
Physical examination]
1, abdominal pressure pain and range, the presence of muscle tension, rebound pain.
2, abdominal distension, diminished bowel sounds and mobile turbid sounds.
3, the presence of Gray~Turner sign (subcutaneous purple ecchymosis in the lumbar region) and Cullen sign (purple coloring around the umbilicus).
4, blood pressure, pulse, body temperature and mental changes, pay attention to the presence of shock and consciousness disorders.
Auxiliary examination
1, blood (urine, ascites) amylase, blood lipase examination.
2.B ultrasound or/and CT examination.
3, abdominal X-ray plain examination.
4.Blood routine, red blood cell pressure product, blood glucose, serum electrolytes and blood gas analysis.
5. Liver and kidney function tests, noting elevated SGOT and LDH.
Diagnosis and differential diagnosis
Based on the history, signs and auxiliary examinations, the diagnosis of acute pancreatitis is mostly free of difficulties, but the type should be noted. Ransons 11 indicators can help to classify and judge the prognosis, the first 5 of which are checked at the time of admission and the last 6 within 48 hours of hospitalization, and positive results of 3 or less are considered mild and ≥3 are considered severe.
Appendix: Ranson indicators.
1, age above 55 years.
2, blood glucose (BS) of 11 μmol/L or more.
3, white blood cell (WBC) 16 109/L or more.
4. lactate dehydrogenase (LDH) of 700 U/dl or more.
5. glutamic oxalacetic transaminase (SGOT) of 250 U (FranKel method) or more.
6.Red blood cell pressure (Ht) decreased by 10%.
7, serum calcium (Ca++) less than 2mmo1/L.
8, alkaline reserve (BE) less than -4mmo1/L.
9, urea nitrogen (BUN) increased by more than 1.8 mmo1/L.
10, partial pressure of oxygen (PaOz) less than 8kPa.
11, loss of body fluid greater than 6L.
Differential diagnosis of diseases mainly include acute cholangitis, acute upper gastrointestinal perforation, strangulated intestinal obstruction, etc.
【Treatment principles】.
1.Non-surgical treatment.
(1) fasting, continuous gastrointestinal decompression.
(2) antispasmodic and analgesic, the use of dulcolax should be used simultaneously with atropine.
(3) Inhibit pancreatic secretion, apply 5-FU, H2 receptor antagonist, santoprene or stanozolam.
(4) Anti-infection, anti-shock, correction of water-electrolyte imbalance and acid-base metabolism disorder.
(5) Nutritional support.
2.Surgical treatment.
(1) Indications for surgery.
(1) severe pancreatitis, non-surgical treatment is ineffective, the peritoneal irritation signs aggravated.
(2) combined with peripancreatic infection or extra-pancreatic organ lesions.
3) Complicated pancreatic abscess.
(4) Other surgical emergencies cannot be excluded.
(2) Surgical modalities.
(1) pancreatic envelope dissection, clear or conventional partial pancreatectomy.
2) biliary tract exploration, drainage and, if necessary, removal of the gallbladder.
3) decompressive gastrostomy.
4) nutritional jejunostomy.
(5) abdominal irrigation and drainage tube placement.
(3) Postoperative management.
(1) Same as non-operative treatment.
(2) Keep the irrigation and drainage tubes open.
3) close monitoring of the condition and attention to the prevention and control of complications.
(4) TPN within 2 weeks after surgery, 2 weeks after the injection of nutrient solution through the jejunostomy tube, from PPN + PEN gradually over to TEN.
【Efficacy criteria
1.Cure: disappearance of symptoms and signs, healing of incision in surgical patients, no complications or disappearance of complications.
2, improved: symptoms, signs and symptoms reduced, or surgical complications stable, need to postpone for further treatment.
3, not healed: symptoms, signs aggravated or untreated.
Discharge criteria]
Those who achieve clinical cure or improvement.