4.Venous drainage The venous drainage of the pancreas and duodenum follows the arterial supply ,The veins are usually superficial to the arteries and the frenquency of anomalies is similar
Acute fluid collections,30-50% 10% of them fluid collections progress to develop a wall of fibrous tissue, pseudocysts If cysts less than 6 cm in diameter nonoperation
NEOPLASMS OF EXOCRINE PANCREAS
PANCREAS CANCER
1. Epidemiology 11/100000/year incidence rate relative stable In China, during last two decade increased two fold
2.Pancreatic ducts The main pancreatic duct (Wirsung) run the entire length of the pancreas and joins the common duct to empty into duodenum at the ampula of Vater
The mortality rate(severe)10-20%, with half deaths in the first 2 week as the result of SIRS, induced multisystem organ failure,remaning necrosis/infection,and hemorrhge
PANCREAS
Anatomy and Physiology
1.Structure:Pancreas is a glanodular structure located in the retroperitoneum. Anterioly,the pancreas is covered at the distal head and neck by the pylorus and the transverse mesocolon,the neck and body are covered anteriorly by the posterior gastric wall.The anterior surface is covered by a peritoneal leaf(lesser sac)
(4)Treating the underlying cause



Gallstone pancreastitis;ERCP(stone extraction) 6 week later undergo cholecystectomy Endoscopic sphinctrotomy
(5) Preventing and treating complications Infection of pancreatic and peripancreatic necrosis complicates 30-70% of cases of ANP and most commonly become established during the second to third weeks after onset of disease

Infected necrosis
FNA(CT guide) for diagnosis(95%) Surgical intervention (debrided and drainage) Necrosectomy with lavage Prophylactic antibiotics

Pseudocysts
mon channel Variations in the relation between the intra pancreatic portion of the common bile duct and the main pancreatic duct at the ampula of Vater. A short common channel contain flow from both secretary system.



Inhibit activated pancreatic enzymes (Somatastatin,Octreotide) Platlet activating factor antagonist -Lexiparfant Other adjuncts: glucagons, fresh frozen plasma, anticholinergics, peritoneal lavage
3.Arterial supply The celiac and superior mesenteric arteries supply blood to the pancreas through their major branches.Some variations of hepatic arteries in relation to the pancreas
* Glascow system
(2) CT Scaning
It’s most important imaging test for AP and is useful in comforming the diagnosis,assessing disease severity, and detecting complications.
300000/year in USA hospitalized 4000 deaths. 75% of cases are attributable to either gallstone or alcohol.
20% of cases severe, it’s defined as associated with one or more of the following: necrosis, distant organ failure, local complications ( hemorrhage, abscess, pseudocyst)
The normal duct is only 2-4 mm in diameter, and contains 20 secondary branches. Pancreatic duct pressureis15 to 30 mmHg. Whereas that in the common bile duct is only 7-17 mmHg. This differential is thought to prevent reflux bile
Grey Turner’s sign:blue discoloration of the flanks (blood dissects into subcutaneous tissue Cullen’s sign: umbilicus blue discoloration Fox’s sign: Inguinal region blue discoloration
1.Classification and definition
2. Pathophysiology * Mild: interstitial (edematous) pancreatitis * Severe: associated with necrotizing pancreatitis, have undergone tissue necrosis with vascular inflammation and thrombosis being prominent features
(3)Minimizing progression of pancreatic inflammation and injury


Bowel rest (nothing by mouth) Limit stimulation of pancreatic exocrine secretion Severe cases used TPN
The pancreas is routinely divided into the head, the neck,the body and the tail. The pancreas is almost enteraly retroperitoneal and has close relationship with numerous surrounding structures
Laboratory tests Imaging tests US,CT,MRI
Assessment of disease severity (1) Scoring system * Ranson criteria On adimssion 1.Age > 55 year 2.Wbc > 16000 3.Glucose > 200 mg / dl ctase dehydrogenase > 350IU /L 5.Glutamine-oxaloacetic transminase > 250 IU / L





After 48 hour 1. Hct < 10% 2. Blood urea nitrogen > 5 mg/dl 3. Calcium < 8mg / dl 4. PaCO2 < 60 mmHg 5. Base deficit > 4 mEq / L 6. Fluid sequestration > 6L