Management of Biliary and Duodenal Complications of Chronic Pancreatitis

Biliary stricture and duodenal obstruction have been increasingly recognized as complications of chronic pancreatitis. The anatomical relationship of the distal common bile duct and the duodenum with the head of the pancreas is the main factor for their involvement in chronic pancreatitis. In hospitalized patients with pancreatitis, the incidence of biliary stricture and duodenal obstruction is reported to be about 6% and 1.2%, respectively. For patients requiring an operation for chronic pancreatitis the incidence increases to 35% for biliary stricture and 12% for duodenal obstruction. Fibrosis around the distal common bile duct can cause stenosis with obstruction of bile flow. Clinically, the presentation of these patients ranges from being asymptomatic with elevated alkaline phosphatase or bilirubin, or both, to being septic with cholangitis. Jaundice, cholangitis, hyperbilirubinemia, and persistent elevation of serum alkaline phosphatase occur more frequently in patients with pancreatitis with a biliary stricture. A twofold elevation of alkaline phosphatase is a marker of possible common duct stenosis in patients with chronic pancreatitis. The incidence of both biliary cirrhosis and cholangitis in these patients is about 10%. ERCP reveals a characteristic long, smoothly tapered stricture of the intrapancreatic common bile duct. In duodenal obstruction, the factors that convert self-limiting edema to chronic fibrosis and stricture formation are unknown, but ischemia superimposed on inflammation may be the major cause. These patients present with a prolonged history of nausea and vomiting. Barium studies typically show a long constricting lesion of the duodenum, and endoscopy reveals reactive inflammatory changes in a narrowed duodenum. Operation is indicated in patients with common bile duct strictures secondary to chronic pancreatitis when there is evidence of cholangitis, biliary cirrhosis, common duct stones, progression of stricture, elevation of alkaline phophatase and/or bilirubin for over a month, and an inability to rule out cancer. The operation of choice is either choledochoduodenostomy or choledochojejunostomy. A cholecystoenterostomy is less favored because of its higher failure rate (23%). Endoscopic stenting plays a role in patients who are unfit for surgery, but it is not recommended as definitive therapy. For duodenal obstruction, failure to resolve the obstruction with 1–2 weeks of conservative therapy is an indication for bypass. The operation of choice is a gastrojejunostomy. Not uncommonly, combined obstruction of the pancreatic duct, common bile duct, and duodenum will develop. Combined drainage procedures or resection are used to manage these problems.     

Biliopancreatic reflux—pathophysiology and clinical implications

The common bile duct and the main pancreatic duct open into the duodenum, where they frequently form a common channel. The sphincter of Oddi is located at the distal end of the pancreatic and bile ducts; it regulates the outflow of bile and pancreatic juice. In patients with a pancreaticobiliary maljunction, the action of the sphincter does not functionally affect the junction. Therefore, in these patients, two-way regurgitation (pancreatobiliary and biliopancreatic reflux) occurs. This results in various pathological conditions of the biliary tract and the pancreas. Biliopancreatic reflux could be confirmed by: operative or postoperative T-tube cholangiography; CT combined with drip infusion cholangiography; histological detection of gallbladder cancer cells in the main pancreatic duct; and reflux of bile on the cut surface of the pancreas. Biliopancreatic reflux occurs frequently in patients with a long common channel. Although the true prevalence, degree, and pathophysiology of biliopancreatic reflux remain unclear, biliopancreatic reflux is related to the occurrence of acute pancreatitis. Obstruction of a long common channel easily causes bile flow into the pancreas. Even if no obstruction is present, biliopancreatic reflux can still result in acute pancreatitis in some cases.     

Complete obstruction of the lower common bile duct caused by autoimmune pancreatitis: is biliary reconstruction really necessary?

Recent observations suggest that an immune response is involved in the development of chronic pancreatitis. We report a case of autoimmune pancreatitis in a patient who showed complete obstruction of the lower common bile duct. A 63-year-old man was admitted to a local hospital, complaining of appetite loss and back pain. The patient had obstructive jaundice, and percutaneous transhepatic gallbladder drainage was performed. Fluorography through the biliary drainage catheter showed complete obstruction of the lower common bile duct. The patient had no history of alcohol consumption and no family history of pancreatic disease. Physical examination revealed an elastic hard mass palpable in the upper abdomen. Abdominal ultrasound and abdominal computed tomography (CT) scans showed enlargement of the pancreas head. While autoimmune pancreatitis was highly likely, due to the patients high serum immunoglobulin level, the possibility of carcinoma of the pancreas and/or lower common bile duct could not be ruled out. Laparotomy was performed, and wedge biopsy samples from the pancreas head and body revealed severe chronic pancreatitis with infiltration of reactive lymphocytes, a finding which was compatible with autoimmune pancreatitis. Cholecystectomy and biliary reconstruction, using choledochojejunostomy, were performed, because the complete bile duct obstruction was considered to be irreversible, due to severe fibrosis. After the operation, prednisolone (30mg/day) was given orally for 1 month, and the entire pancreas regressed to a normal size. Complete obstruction of the common bile duct caused by autoimmune pancreatitis has not been reported previously; this phenomenon provides an insight into autoimmune pancreatitis and provokes a controversy regarding whether biliary reconstruction is needed for the treatment of complete biliary obstruction caused by autoimmune pancreatitis.     

Surgical therapy of inflammatory and malignant strictures of the common bile duct

Although there are growing possibilities of interventional endoscopic treatment of benign and malignant stenosis of the distal common bile duct the definitive operative drainage by terminolateral hepaticojejunostomy is in many cases the therapy of choice. In patients with chronic pancreatitis and bile duct stricture the modified duodenum preserving pancreatic head resection ("Beger operation") enables a resection of the inflammatory mass together with a drainage of the bile. Of 391 patients from our clinic being operated due to a bile duct stricture 337 underwent a biliary drainage together with a pancreatic head resection. Early postoperative biliary complications were in 0.3 % strictures of the duct and 1.5 % bile fistulas. Half of those complications could be managed conservatively. In high volume centers the operative therapy of distal common bile duct stenosis is a safe procedure with high patency rate.     

Problems of pancreatitis

Pancreatitis is not one disease but several and perhaps many. Diagnosis is imperfect in all forms and the usual lack of histologic material has hampered attempts to understand the pathogenesis and possible interrelationships of the different forms of pancreatic inflammation. Acute pancreatitis does not as a rule evolve into chronic pancreatitis, even after multiple recurrences. Recurrent acute attacks can be ended by identifying and treating the factor causing the disease, including recently recognized entities such as accessory papilla stenosis associated with pancreas divisum. Attempts to improve the treatment of severe acute pancreatitis are focussing upon preventing injury to pancreatic cell structures, enhancing endogenous mechanisms for capture and disposal of activated enzymes, and upon early detection and debridement of damaged pancreatic and peripancreatic tissues. Pancreatic duct stricture or obstruction as a consequence of scarring from necrotizing pancreatitis may produce recurrent symptoms, now designated as obstructive pancreatitis. Obstructive pancreatitis has its own unique histologic characteristics and is appropriately treated by resection of the blocked segment of pancreas when the point of obstruction is distal to the papilla. Chronic pancreatitis differs from acute or obstructive pancreatitis in that it is difficult or impossible to halt its progression. The role of intraductal protein precipitates, whether of enzymes or perhaps of other unique pancreatic secretory proteins, in the pathogenesis of the disease is being evaluated. The goal of surgical treatment is not to cure, but to reduce pain, overcome associated obstruction of the bile duct or duodenum, and to treat pancreatic duct disruptions including pseudocysts and internal pancreatic fistulas. Because continuing deterioration of pancreatic function is to be expected in chronic pancreatitis, maximum conservation of pancreatic tissue by avoiding resectional procedures is advisable. This report is the gist of a paper read by A. L. W. at the 86th Annual Meeting of the Japanese Surgical Society, Tokyo, Japan, 1986     

胆肠胰结合部及其邻近区域外科手术的改进

目的: 总结几种胆肠胰部新型手术及其疗效 。方法及结果: 分析9例行胆肠胰部手术的特点及疗效。其中胰头部胰管及近邻手术3例;胆总管下端及壶腹部手术3例;十二指肠及近邻手术3例。根据各病例的病理及临床特点,设计并实施相应的新型手术方法,如胰头后侧径路主胰管切开取石术,胰头下部切除、钩突胰管空肠Roux-Y吻合术、经壶腹胆总管末端穿透伤直视下修补术、十二指肠节段切除术等,均获良好疗效 。结论: 本文介绍的新手术方法适合胆肠胰部的特殊病症,可有效预防胰、胆、十二指肠瘘等并发症。     

Subtotal resection of the head of the pancreas combined with ductal obliteration of the distal pancreas in chronic pancreatitis.

Subtotal resection of the head of the pancreas combined with duct obliteration of the distal pancreas by prolamine was performed in 12 selected patients who had chronic alcohol-induced pancreatitis with most destruction in the proximal pancreas. The main indication for operation was intractable pain. There was no postoperative mortality but morbidity was high when no pancreaticojejunostomy was constructed. After a follow-up period of 32 months, lasting pain relief was obtained in 10 patients; pseudocyst formation occurred in three patients; calcification of the distal pancreas, absent before operation, was demonstrated in four of six patients; six of 11 nondiabetic patients became hyperglycemic either abruptly (1 patient) or progressively (5 patients); quality of life improved in most patients. This procedure preserves the stomach, duodenum, spleen, distal pancreas and common bile duct if possible. However, pancreatic ductal obliteration with prolamine does not prevent relapses of chronic pancreatitis.     

保留十二指肠的胰头切除术实用外科血管解剖学研究

目的研究胰头和十二指肠之间的血管解剖 ,为临床上开展关于十二指肠、胰头以及胆总管末端手术提供解剖学基础。方法对 30例甲醛固定的成人尸体和 10例新鲜尸体的十二指肠、胆总管下段及Vater壶腹的血液供应进行解剖研究。结果十二指肠降部和水平部血运由胰十二指肠前、后动脉弓及分支供应 ;胆总管下段血运主要是由胰十二指肠上后动脉供应 ;Vater壶腹血运主要是由胰十二指肠上后动脉发出的乳头动脉供应。结论胰十二指肠前、后动脉弓是供应十二指肠降部和水平部、胆总管下段和Vater壶腹的主要动脉。在行保留十二指肠的胰头切除术时应注意保护前、后动脉弓。     

Groove pancreatitis masquerading as pancreatic carcinoma.

The clinicopathologic and radiologic features of groove pancreatitis masquerading as pancreatic carcinoma in eight Japanese patients were reviewed. All patients were men with a mean age of 58 years. Three patients complained of abdominal pain whereas others had jaundice. The jaundice fluctuated in one patient. Four patients had several episodes of pancreatitis, and four patients were alcoholics. Radiologically, a duodenal stricture was evident in five patients, biliary stenosis in six, pancreatic duct stenosis in four, and a mass in the pancreatic head in six. The biliary stenosis was characterized by smooth tapering, which improved after biliary drainage in three cases. Of the four patients who underwent angiography, two showed an encasement of vessels, one a hypervascular mass, and the other no abnormality. All patients underwent a pancreatoduodenectomy for suspected pancreatic carcinoma. However, the histopathologic diagnosis was chronic pancreatitis confined to the groove between the distal common bile duct, duodenum, and pancreas. The duodenum showed scarring and hyperplasia of the Brunner's gland. The biliary stenosis was produced by fibrosis and chronic inflammation around the distal common bile duct. Groove pancreatitis presents various clinical features, such as biliary obstruction, duodenal stenosis, and pancreatic mass, and often masquerades as pancreatic head carcinoma. This condition should be kept in mind when making a diagnosis of pancreatic head carcinoma to avoid an unnecessary radical operation.     

Utility of Staging Laparoscopy in Subsets of Peripancreatic and Biliary Malignancies

OBJECTIVE: To determine the relative benefit of staging laparoscopy in peripancreatic and biliary malignancies. SUMMARY BACKGROUND DATA: Staging laparoscopy has been used in a variety of peripancreatic and biliary malignancies. The utility of the technique in subsets of these types of cancer has not been systematically compared. METHODS: One hundred fifty-seven patients underwent laparoscopy after conventional tumor staging; 89 were also staged with laparoscopic ultrasonography. Diagnostic categories were cancer of the pancreatic head and uncinate process, cancer of the body and tail of pancreas, cancer of the extrahepatic bile duct, cancer of the gallbladder, and cancer of the ampulla of Vater/duodenum. RESULTS: In patients with cancer of the head of the pancreas, metastatic disease or vascular invasion was discovered frequently by laparoscopy (31%), whereas in ampullary/duodenal cancer it was never found. The laparoscopic findings in cancer of the head of the pancreas had an important influence on treatment decisions, whereas in cancer of the ampulla/duodenum, laparoscopy had no effect on clinical decisions. Laparoscopy also substantially influenced the treatment of gallbladder cancer; in other tumor types, results were intermediate. Laparoscopic ultrasonography was valuable in cancer of the head of the pancreas. CONCLUSIONS: The utility of staging laparoscopy depends on diagnosis. It is recommended for continued use in pancreatic head and gallbladder cancers but not in ampullary malignancies.     

Experimental studies on reflux of pancreatic juice into the biliary tract, with special reference to the effects in the hepato-biliary system

The purpose of this study was to evaluate an effect of reflux of the pancreatic juice into the bile duct on the hepato-biliary system. Forty mongrel dogs including 35 adults and 5 puppies were used and divided into two groups according to the procedures to induce the reflux Group I (15 adults and 2 puppies): the main pancreatic duct was anastomosed to the fundus of the gallbladder. Group II (20 adults and 3 puppies): the duodenal pouch including the opening of the main pancreatic duct was anastomosed to the fundus of the gallbladder. In this model the pancreatic juice flowed into the bile duct after activation within the duodenum. Amylase and phospholipase A2 activities in the bile increased in both groups. Activation of phospholipase A2 was more dominant in Group II than in Group I. Pure pancreatic phospholipase A2 was activated only if the pancreatic juice was mixed with bile and its activation became more dominant when it entered into the duodenum. In both groups, the bile duct was dilated, and histology showed destruction of the mucosa and elastic fibers with inflammatory cell infiltration. These changes were especially severer in Group II with reflux of the pancreatic enzymes activated within the duodenum. In the liver, mild fibrosis and inflammatory cell infiltration in the portal area were observed. On the pathogenesis of hepato-biliary changes due to reflux of the pancreatic juice into the bile duct, phospholipase A2 is one of the most important factors among pancreatic enzymes.     

Autoimmune Pancreatitis and Concurrent Small Lymphocytic Lymphoma: Not Just a Coincidence?

Case

A 76-year-old gentleman presented with painless jaundice, weight loss, and anorexia. Computed tomography imaging revealed fullness of the pancreatic head and multiple enlarged retroperitoneal lymph nodes. Cholangiogram revealed a distal common bile duct stricture. Due to concerns of malignancy, the patient underwent operative exploration. Several enlarged lymph nodes in the aortocaval region and a firm hard mass in the pancreatic head were found. Frozen section from one of the lymph nodes was suspicious for low-grade lymphoma. A pancreaticoduodenectomy was performed. Histologic analysis of the pancreatic head revealed a lymphoplasmacytic infiltrate with stromal fibrosis consistent with autoimmune pancreatitis. The retroperitoneal lymph nodes were involved by small lymphocytic lymphoma.

Discussion

Autoimmune pancreatitis is the most common benign diagnosis after pancreatic resection for presumed malignancy. It has a well-documented association with autoimmune conditions, such as Sjögren’s syndrome, inflammatory bowel disease, and sclerosing cholangitis. Additionally, chronic lymphocytic leukemia–small lymphocytic lymphoma is often associated with autoimmune phenomena, most notably autoimmune hemolytic anemia. However, an association between autoimmune pancreatitis and small lymphocytic lymphoma has not been previously described. To our knowledge, this is the first reported case of a patient with concurrent autoimmune pancreatitis and small lymphocytic lymphoma.     

Simplified pancreatoduodenectomy for complex blunt pancreaticoduodenal injury

A 34-year-old man admitted to our de- partment with complex blunt pancreaticoduodenal injury af- ter a car accident. The wall of the first, second, and third portions of the duodenum was extensively lacerated, and the pancreas was longitudinally transected along the supe- rior mesenteric vein-portal vein trunk. The pancreatic head and the uncinate process were devitalized and the distal common bile duct and the proximal main pancreatic duct were completely detached from the Vater ampulla. The length of the stump of distal common bile located at the cut surface of remnant pancreas was approximately 0.6 cm. A simplified Kausch-Whipple＇s procedure was performed after debride- ment of the devitalized pancreatic head and resection of the damaged duodenum in which the stump of distal common bile duct and the pancreatic remnant were embedded into the jejunal loop. Postoperative wound abscess appeared that eventually recovered by conservative treatment. Dur- ing 16 months follow-up the patient has been stable and healthy. A simplified pancreaticoduodenectomy is a safe alternative for the Whipple procedure in managing complex pancreaticoduodenal injury in a hemodynamically stable patient.     

慢性胰腺炎的个体化外科干预

慢性胰腺炎发病机制复杂,病情进展多变,导致外科干预时机及手术方式的选择存在一定困难。慢性胰腺炎的治疗应依据个体化原则去除病灶,尽量保存正常胰腺实质,延缓胰腺内、外分泌功能损害的进程,改善患者生命质量,降低胰腺癌发生的风险。慢性胰腺炎患者早期可考虑保守和内镜治疗,胰管梗阻、狭窄合并结石、胰腺实质广泛钙化等慢性胰腺炎患者则需手术治疗。Frey术适合以胰管扩张和胰管结石为主的慢性胰腺炎患者,Beger术适合以胰头部炎性肿块或胰头部钙化为主的慢性胰腺炎患者。     

A duodenum-preserving and bile duct-preserving total pancreatic head resection with associated pancreatic duct-to-duct anastomosis

A duodenum-preserving pancreatic head resection technique was first reported in 1980, but the indications have been limited to benign pancreatic disease as it involves a subtotal pancreatic head resection. In 1988 we detailed a duodenum-preserving total pancreatic head resection (DPTPHR) technique. This procedure involved a total pancreatic head resection and as such expanded the indications for this approach to include tumorigenic masses. The original method involved closure of the proximal pancreatic duct and an anastomosis of the pancreatic duct of the distal pancreas to a newly created small hole in the duodenum (we termed this a "pancreatoduodenostomy"). Our current technique involves a duct-to-duct anastomosis of the proximal pancreatic duct and the distal pancreas to better preserve anatomic structure. DPTPHR was performed in 26 patients from 1988 to 2002, including 12 cases of DPTPHR with pancreatoduodenostomy and 14 cases of DPTPHR with pancreatic duct-to-duct anastomosis. No differences were observed between the two methods with respect to operative time or blood loss during surgery. Postoperatively, there was one case of cholecystitis and one case of pancreatitis in a patient who underwent a pancreatoduodenostomy; both of these patients were treated conservatively with curative intent. No complications were observed in the group undergoing duct-to-duct anastomosis. The advantage of duct-to-duct anastomosis is that the pancreatic head is totally resected, thus allowing removal of neoplastic disease such as an intraductal papillary mucinous tumor and also therapy for chronic pancreatitis. A key benefit of this procedure is that sphincter function of the duodenal papilla is preserved permitting drainage of pancreatic/bile juice into the duodenum, preserving a more physiologic state than is the case after a pancreatoduodenostomy. Supported in part by a Grant-in-Aid for Scientific Research (63480311) from the Ministries of Education, Science, and Culture of Japan.     

胰管开口炎性病变导致的慢性阻塞性胰腺炎的诊断和外科治疗

目的 探讨胰管开口部位炎性病变导致的慢性阻塞性胰腺炎的诊断和外科治疗方式.方法 对我院自2002年1月至2010年11月收治的28例慢性阻塞性胰腺炎患者的临床资料进行回顾性总结.其中13例患者血清淀粉酶和脂肪酶升高伴有反复急性腹痛,经影像学检查显示胰管全程扩张改变,外科探查明确诊断为胰管开口部位炎性病变导致的慢性阻塞性胰腺炎.对此13例患者的临床表现、诊断方法、手术探查发现和治疗方法进行分析,并对术后的状况包括疼痛复发、生活质量、胰腺的影像学变化和血清胰腺酶学进行随访观察.结果 13例患者均具有典型的慢性阻塞性胰腺炎的临床表现,但12例患者的影像学表现有别于十二指肠乳突、壶腹或胰腺导管内肿瘤导致的慢性阻塞性胰腺炎的图像特征,手术探查和影像学揭示多数患者的胆胰共同通道过短或存在胰腺分裂畸形,对12例患者实施十二指肠乳突、壶腹及胰管开口切开成形术或副乳突切开成形术,术后随访结果显示均未再伴有胰腺酶学升高的急性腹痛发作.结论 以胰管扩张为主而不伴有胆管慢性梗阻是胰管开口炎性病变导致的慢性阻塞性胰腺炎的影像学特征,十二指肠乳突炎症或副乳突炎症时容易在过短的胆胰共同通道或胰腺分裂畸形的患者中引发胰管开口的狭窄而发生慢性阻塞性胰腺炎,纠正胰管开口狭窄、改善胰管引流的局部成形术是简单、有效的治疗方法.     

胰管开口炎性病变导致的慢性阻塞性胰腺炎的诊断和外科治疗

目的 探讨胰管开口部位炎性病变导致的慢性阻塞性胰腺炎的诊断和外科治疗方式.方法 对我院自2002年1月至2010年11月收治的28例慢性阻塞性胰腺炎患者的临床资料进行回顾性总结.其中13例患者血清淀粉酶和脂肪酶升高伴有反复急性腹痛,经影像学检查显示胰管全程扩张改变,外科探查明确诊断为胰管开口部位炎性病变导致的慢性阻塞性胰腺炎.对此13例患者的临床表现、诊断方法、手术探查发现和治疗方法进行分析,并对术后的状况包括疼痛复发、生活质量、胰腺的影像学变化和血清胰腺酶学进行随访观察.结果 13例患者均具有典型的慢性阻塞性胰腺炎的临床表现,但12例患者的影像学表现有别于十二指肠乳突、壶腹或胰腺导管内肿瘤导致的慢性阻塞性胰腺炎的图像特征,手术探查和影像学揭示多数患者的胆胰共同通道过短或存在胰腺分裂畸形,对12例患者实施十二指肠乳突、壶腹及胰管开口切开成形术或副乳突切开成形术,术后随访结果显示均未再伴有胰腺酶学升高的急性腹痛发作.结论 以胰管扩张为主而不伴有胆管慢性梗阻是胰管开口炎性病变导致的慢性阻塞性胰腺炎的影像学特征,十二指肠乳突炎症或副乳突炎症时容易在过短的胆胰共同通道或胰腺分裂畸形的患者中引发胰管开口的狭窄而发生慢性阻塞性胰腺炎,纠正胰管开口狭窄、改善胰管引流的局部成形术是简单、有效的治疗方法.     

胰管开口炎性病变导致的慢性阻塞性胰腺炎的诊断和外科治疗

目的 探讨胰管开口部位炎性病变导致的慢性阻塞性胰腺炎的诊断和外科治疗方式.方法 对我院自2002年1月至2010年11月收治的28例慢性阻塞性胰腺炎患者的临床资料进行回顾性总结.其中13例患者血清淀粉酶和脂肪酶升高伴有反复急性腹痛,经影像学检查显示胰管全程扩张改变,外科探查明确诊断为胰管开口部位炎性病变导致的慢性阻塞性胰腺炎.对此13例患者的临床表现、诊断方法、手术探查发现和治疗方法进行分析,并对术后的状况包括疼痛复发、生活质量、胰腺的影像学变化和血清胰腺酶学进行随访观察.结果 13例患者均具有典型的慢性阻塞性胰腺炎的临床表现,但12例患者的影像学表现有别于十二指肠乳突、壶腹或胰腺导管内肿瘤导致的慢性阻塞性胰腺炎的图像特征,手术探查和影像学揭示多数患者的胆胰共同通道过短或存在胰腺分裂畸形,对12例患者实施十二指肠乳突、壶腹及胰管开口切开成形术或副乳突切开成形术,术后随访结果显示均未再伴有胰腺酶学升高的急性腹痛发作.结论 以胰管扩张为主而不伴有胆管慢性梗阻是胰管开口炎性病变导致的慢性阻塞性胰腺炎的影像学特征,十二指肠乳突炎症或副乳突炎症时容易在过短的胆胰共同通道或胰腺分裂畸形的患者中引发胰管开口的狭窄而发生慢性阻塞性胰腺炎,纠正胰管开口狭窄、改善胰管引流的局部成形术是简单、有效的治疗方法.     

自身免疫性胰腺炎的诊断

自身免疫性胰腺炎（AIP）是由自身免疫介导,以梗阻性黄疸、胰腺肿大、胰管不规则狭窄、淋巴浆细胞浸润并纤维化、伴或不伴胰外器官受累为特征．对激素治疗敏感的一种特殊类型的慢性胰腺炎。临床上AIP诊断十分困难,且临床及病理医师对其亦认识不足,误诊率较高。因AIP常以梗阻性黄疸、胰腺肿大为特征,故易误诊为胰腺肿瘤而采取不必要的手术切除。增加对AIP的认识,提高诊断正确率,对改善AIP的诊断现状和治疗水平尤为重要。     

胰头部肿块型慢性胰腺炎诊断与治疗

胰头部肿块型慢性胰腺炎从临床表现上很难与胰头癌相鉴别,目前已将发生于胰头部的肿块型慢性胰腺炎视为胰腺癌发生的癌前病变。影像学检查在肿块型慢性胰腺炎诊断中起着重要作用,对于手术指征的掌握、胰头部肿块的可切除性、手术方式的选择以及手术困难程度的估计很有帮助。胰头部肿块型慢性胰腺炎的手术方式是直接针对胰头的,不同的手术方法包括胰十二指肠切除术（保留或不保留幽门的Whipple手术）和胰头部分切除加胰管引流术（Frey 手术,Beger 手术）。胰头肿块型慢性胰腺炎一旦诊断明确即应积极手术治疗,手术方式尽可能采用胰十二指肠切除术,因为它不仅切除了胰头部肿块、解除了胆道和胰管及十二指肠的梗阻,而且也去除了胰头癌的潜在病因;如胰头肿块巨大,行胰十二指肠切除有极大风险,可考虑行保留十二指肠的胰头切除术。