Pancreatitis: symptoms and treatment
- Structure and function of the pancreas
- Acute pancreatitis
- Chronic pancreatitis
- Features of pancreatitis in pregnant women
Pancreatitis is a disease characterized by acute or chronic inflammation of the pancreas. Over the past 10 years, it began to occur in adults 3 times, and in adolescents 4 times more often than before.
Structure and function of the pancreas
The pancreas has an elongated shape and is located closer to the spine, behind and just below the stomach. For convenience, it distinguishes 3 departments: head, body and tail (caudal part).
Microscopically in the pancreas, there are 2 main departments:
- Endocrine part - islets of Langerhans, in which there are cells that produce insulin and some other hormones.
- The exocrine part produces the so-called pancreatic juice, consisting of enzymes necessary for digesting proteins, fats and carbohydrates: lipase, trypsin, amylase, maltase, collagenase, and the like. Many of these enzymes are activated already in the duodenum, where they enter through the pancreatic duct. If, for some reason, the exit into the gut is blocked and the enzymes come back, then pancreatic self-piercing begins (acute pancreatitis) followed by the development of insulin-dependent diabetes mellitus.
Types of pancreatitis
Currently, there are many classifications of pancreatitis. By the nature of the current, pancreatitis is distinguished:
Acute pancreatitis is an acute inflammation of the pancreas, which is based on the death of the gland cells due to self-digestion of the pancreatic juice returned by enzymes. Later, a purulent infection can join.
Acute pancreatitis is a very serious disease, which despite modern treatment often ends with the patient's death: on average, up to 15% die, and in destructive forms of acute pancreatitis - up to 70%.
The most common acute pancreatitis develops in the following cases:
- when taking alcohol - up to 70% of all cases of the disease (mainly in young and mature men),
- in the presence of cholelithiasis - up to 25% or 30% (more often in women),
- surgery on the stomach or other organs of the abdominal cavity - about 4% or slightly more.
Single cases of development of acute pancreatitis are observed due to:
- viral infections (for example, parotitis in children and youth),
- ulcerous disease of DPC and other diseases of the gastro-duodenal region,
- poisoning with salts of heavy metals, paints, some medical preparations or other substances,
- congenital anomalies of pancreatic structure.
In general, acute pancreatitis is most common after 30 years and in women.
As a rule, distinguish acute pancreatitis:
- Interstitial (swelling).
- Pancreatic necrosis:
- limited or widespread,
- hemorrhagic, fatty, mixed.
Complications of acute pancreatitis are numerous, among which the most common and serious are:
1. Local complications:
- the formation of an infiltrate around the pancreas,
- aseptic or septic phlegmon of retroperitoneal tissue, for example, pelvic, around the kidneys, etc.,
- inflammation of the peritoneum due to the action of pancreatic juice or attachment of infection (abacterial, as well as fibro-purulent peritonitis),
- the formation of pseudocysts that can also be infected,
- bleeding into the cavity of the peritoneum or intestine,
- pancreatogenic abscess with localization in retroperitoneal tissue,
- the emergence of various pancreatic fistulae: gastric, intestinal.
2. Complications of a general nature:
- development of pancreatogenic shock,
- development of diabetes mellitus,
- the emergence of a syndrome of multiple organ failure,
- death of the patient.
Features of the course of the disease
There are 4 main stages of acute pancreatitis:
1) Early stage (first 5-7 days). During this period:
- edema and death of pancreatic cells,
- aseptic inflammation of organs adjacent to the gland, peritoneum,
- poisoning the body with sucked up pancreatic decomposition products, followed by damage to distant organs: for example, the brain, kidneys, heart and lungs (at this stage, the death of the patient due to its severe condition is possible).
2) Reactive period (the second week from the onset of acute pancreatitis). At this stage most often observed:
- formation of a dense pancreatic infiltrate,
- occurrence of acute gastric ulcers,
3) The stage of purulent complications (it is joined from the end of the second week from the onset of the disease). At this stage, the following takes place:
- the formation of phlegmon, abscesses, purulent swelling in other organs, fistulas,
- internal bleeding,
- infection of blood (sepsis).
4) Recovery period:
- an easy course of pancreatitis - recovery in 2-3 weeks, complications are not observed;
- moderate severity - the infiltrate resolves within 1-2 months, approximately in half of the cases the pancreatitis becomes chronic;
- severe pancreatitis at this stage necessarily passes 2 phases:
a) phase of exhaustion - reduction of general immunity and worsening of tissue healing, for example: hair loss, pressure sores, infectious diseases, thrombophlebitis, depression, asthenic syndrome;
b) the recovery phase - development of the pancreatic cyst, the development of diabetes mellitus or chronic pancreatitis.
Symptoms of acute pancreatitis
Symptoms of acute pancreatitis depend on the stage of the process, as well as the severity of the disease. Let's consider some of them:
1. Pancreatic colic . This acute pain in the first 3 days has a "girdling" character and is felt in the upper abdomen, which can give to the left collarbone or both scapulae, the posterior sections of the lower ribs to the left. Gradually the intensity of pain decreases, they become blunt and last about 1 week.
2. Vomiting. In acute pancreatitis, it is multiple, painful, does not bring relief. It can occur at the onset of the disease with pancreatic colic, and at later stages.
3. Heart palpitations . It arises from the general intoxication of the organism at later stages.
4. Increase in temperature . As a rule, it is observed from the 3rd day of the disease, although in some cases it may occur earlier. In general, the following pattern is observed: the higher the temperature, the stronger the damage of the pancreas is observed.
5. Bloating . It is noted in the initial period, can be combined with a delay of stool, accumulation of gases or a sign of the development of peritonitis in later stages.
6. Formation of infiltrate . This symptom can be determined by the doctor at the examination and palpation of the abdomen, on average from the 5th day of the disease.
7. Changes in the general blood test :
- Blood thickening - an increase in hemoglobin up to 150 g / l, the number of red blood cells, a decrease in ESR to 1-3 mm / h.
- At later stages - the picture of inflammation: ESR increases, leukocytosis.
- In case of severe complications, a decrease in hemoglobin, lymphocytes and blood leukocytes.
8. General analysis of urine:
- With mild forms, changes in urine are not observed.
- Increase in urine diastase from 160 ml / (mgs) and higher in the initial period of the disease.
- When the kidneys are affected: sugar in the urine, the appearance of protein, erythrocytes, cylinders and kidney epithelium.
9. Biochemistry of blood:
- Increase in the concentration of pancreatic enzymes - trypsin, amylase, lipase.
- Increase in blood sugar, bilirubin, urea concentration.
The diagnosis of acute pancreatitis is established by the surgeon on the basis of the data:
- examination and conversation with the patient,
- laboratory tests of blood, urine,
- Ultrasound of the pancreas.
If necessary, the doctor may be appointed:
- diagnostic puncture of the abdominal wall,
- MRI or CT,
- radiography of the lungs, stomach and the like.
In general, acute pancreatitis should be as quickly as possible to identify possible complications, and then eliminate them, in order to minimize the aggravation of the pathological process.
Treatment of acute pancreatitis
Patients suffering from acute pancreatitis are immediately hospitalized in the surgical or resuscitation department, where they are examined in urgent order and prescribed appropriate treatment.
Currently, treatment is based on the following principles:
1. Mild degrees of acute pancreatitis require less treatment than heavy forms.
2. The earlier the treatment is started, the better the results and the fewer complications (this also applies to moderate, severe forms).
- absolute hunger for the first 3-5 days,
- abundant drinking of alkaline water without gases up to 2 liters daily - from 2 days,
- at the end of hunger - liquid porridge,
- gradual expansion of the diet.
In general, nutrition in acute pancreatitis should be small portions, however, with a high concentration of nutrients. Usually allowed per day:
- 200 g of cottage cheese,
- 10-50 ml of cream,
- steam cutlets,
- 1-2 bananas,
- lean boiled fish,
- not strong broth,
- bun with butter.
- raw vegetables,
- whole milk,
- spicy, spicy,
- strong broth, coffee,
- sour kefir,
This diet is observed for at least 3 months, and in case of severe pancreatitis - up to 1 year.
1. Depending on the stage of the disease:
- Early period - detoxification, hemosorption, plasmapheresis, "washing" of the kidneys, intestines and peritoneum by dialysis.
- The period of infectious complications is surgical intervention.
- reducing the production of hormones by the pancreas (platyphylline, atropine),
- inhibiting the function of the pancreas (fluorouracil, ribonuclease),
- antifermentnye (gordoks, kontrikal),
- other: dalargin, somatostatin, antibiotics and some other means.
After discharge from the hospital, the patient is observed at the gastroenterologist and the treatment consists in preventing recurrence of acute pancreatitis or exacerbation of chronic.
In many cases, the development of acute pancreatitis can be avoided. To do this you need:
- Do not overeat.
- Do not drink alcohol.
- Timely treatment of cholelithiasis (remove the gallbladder).
- Do not use products and drugs of questionable quality.
- Do not abuse medication.
- Lead a healthy lifestyle.
Chronic pancreatitis is characterized by the presence of a permanent or occurrence of periodic inflammation of the pancreas, which gradually leads to the development of functional deficiency of this organ.
Chronic pancreatitis can occur almost asymptomatically, as well as under the mask of various other diseases, for example: chronic cholecystitis, biliary dyskinesia, peptic ulcer, etc.
1. Alcohol. This is the leading factor in the development of pancreatitis. Cowarene in that in most cases, the occurrence of the disease leads not immediately, but after several years of its regular use (from 8 to 18 years). To do this, it is sufficient to use only one half-liter bottle of low-alcohol beer every day.
2. Gallstone disease. Although this disease most often causes acute pancreatitis, however, in some cases, there is a development of chronic forms of the disease.
3. Adolescent and juvenile idiopathic pancreatitis . In this case, the cause is unknown. The juvenile form of such pancreatitis is often accompanied by pain, diabetes and exocrine pancreatic insufficiency. The old form is characterized by the presence of calcification in the pancreas, as well as diabetes and steatoreia (fatty feces), but the pain is not characteristic at all.
4. Insufficiency of some microelements, meager food (for example, tropical pancreatitis) .
5. The pathology of the so-called sphincter of Oddi .
6. Some medications, for example :
7. Elevated levels of lipids in the blood , especially triglycerides.
8. Heredity and some genetic diseases :
- cystic fibrosis and some others.
9. Ischemic damage to the pancreas . It is observed with sharply expressed atherosclerosis of the corresponding vessels.
10. Viral infections . For example, with hepatitis or infectious parotitis.
12. Elevated levels of calcium in the blood.
For the predominant cause of inflammation, chronic pancreatitis is distinguished:
- toxic-metabolic (including alcoholic),
The most common complications of chronic pancreatitis are the following:
- violation of outflow of bile,
- development of portal hypertension,
- infection (abscess, paranephritis, etc.),
How does the disease develop?
As a rule, over time, there is an aggravation of changes in pancreatic tissue, which is reflected in the following stages of the disease:
- Initial stage. Lasts for about 10 years, characterized by alternating periods of exacerbation and remission. In a typical situation, the leading symptom is a different intensity and location of the pain, as well as a dyspeptic syndrome, which disappears as the treatment progresses.
- The second stage . Ten years after the onset of chronic pancreatitis, signs of exocrine insufficiency of the pancreas come to the forefront, and the pain gradually subsides.
- Stage of complications development. In addition to the development of complications, changes in localization, intensity of pain syndrome, and persistent dyspeptic syndrome are inherent in this stage.
Symptoms of Chronic Pancreatitis
Chronic pancreatitis may for some time be asymptomatic or mask for other diseases of the abdominal cavity. In this case, an accurate diagnosis can only be made by a doctor.
The main symptoms of classical chronic pancreatitis are as follows:
1. Pain in the abdomen . It without a clear localization, irradiates into the back, can be girdling:
- with partial or complete blockage of the lumen of the duct - occurs after eating, paroxysmal, is stopped by pancreatin or antisecretory drugs;
- as a result of inflammation - does not depend on food intake, irradiation from epigastrium to the back area, pass after taking analgesics;
- because of a deficiency in the enzymes of the pancreas - pain predominantly bursting in nature, associated with increased gas production.
2. Signs of exocrine (exocrine) insufficiency . It develops as a result of digestive disturbances and absorption of necessary substances from the intestine. It is characterized by:
- disorders of stool (up to 6 times a day),
- fetid, fatty stool (steatorrhea),
- nausea, vomiting,
- weight loss,
- bloating, flatulence,
- rumbling in the belly, belching,
- symptoms of deficiency of various minerals and vitamins.
3. Intoxication syndrome . In this case, there are:
- general weakness,
- decreased appetite,
- tachycardia ,
- temperature increase,
- lowering of blood pressure.
4. Biliary hypertension . The main characteristics of the syndrome:
- mechanical jaundice,
- on ultrasound: an increase in the head of the pancreas, compression of the choledochus.
5. Endocrine disorders . Occurs in 1/3 of the patients:
- tendency to hypoglycemia.
In chronic pancreatitis, there may be a symptom of Tuzhilin - the appearance of bright red spots in the abdomen, back, chest, which are aneurysms and do not disappear when pressed.
At the first stage, the gastroenterologist should be consulted to establish and clarify the diagnosis. He will talk with the patient, conduct his examination and appoint some types of additional laboratory and instrumental examination, for example:
- Ultrasound of the pancreas . Allows you to determine the size, density and structure of the organ, identify pseudocysts, calcifications and other formations.
- Endoscopic ultrasonography . The sensor is placed not on the anterior abdominal wall, but in the esophagus, stomach and 12-colon.
- Computer tomography . Appointed in case of poor visibility of the gland on ultrasound.
- MRI . Well visualizes the pancreatic ducts.
- Radiographic methods: the detection of calcifications in the area of the organ.
From laboratory methods are usually appointed:
- General blood test : acceleration of ESR, anemia, leukocytosis may be observed.
- Amylase in the blood, urine : increased content.
- Elastase 1 in feces. It is determined by the ELISA method and is the "gold standard" for the detection of pancreatitis.
- Determination of glucose tolerance, determination of blood sugar level.
- Coprogram : increased fat (steatorrhea) and undigested muscle fibers (creatorrhea).
- Tests, for example : bentiramide, Lund test, secretin-pancreosimine, iodolipolvic, fluorescein-dilaurate and the like.
Treatment of chronic pancreatitis
During an exacerbation of a chronic pancreatitis
1. Fasting . The more intense the pain, the longer the fasting period should be. To maintain the strength of the patient these days, he is given additional parenteral nutrition. As the pain subsides, fractional meals are allowed in small portions, with a restriction of fats.
2. Cold . If you put an ice pack on the projection area of the pancreas, the secretion of enzymes will decrease slightly.
3. Medications :
- Снижение выработки ферментов — соматостатин, октреотид.
- Антацидные на 2–3 недели — ранитидин, омепразол, фамотидин.
- Ферменты (начинают принимать после прекращения голода) — мезим-форте, панкреатин. Препараты, содержащие желчь, при обострении хронического панкреатита запрещены (например, фестал, энзистал, дигестал).
- Анальгетики и спазмолитики — анальгин, новокаин, эуфиллин, нитроглицерин, атропин, различные «литические коктейли» и др.
- Ингибиторы протеолитических ферментов — контрикал, гордокс, метилурацил, аминокапроновая кислота (в зарубежной медицине могут не использоваться).
- Прокинетики для уменьшения тошноты — церукал, мотилиум.
- Антибиотики в случае инфекционных осложнений — цефалоспорины, пенициллины, карбенициллины, аминогликозиды, фторхинолоны.
Вне обострения на первый план среди лечебных мероприятий выступает соблюдение диеты. Рекомендации при хроническом панкреатите в стадии ремиссии следующие:
- Полный отказ от алкоголя в любом виде.
- Дробное питание малыми порциями 5–6 раз в сутки.
- Prohibited: marinades, strong broths, fried, spicy food, spices, carbonated drinks, coffee, tea.
- Increased number of proteins: low-fat varieties of meat and fish, low-fat cottage cheese, faint cheese.
- Restriction of animal fats, as well as refined carbohydrates.
Food should be served warmly.
If the patient is losing weight, periodic diarrhea, a decrease in appetite, then prescribe substitution therapy with the following drugs:
- pangrol and the like.
It is believed that the enzymes are prescribed in sufficient quantity, if the stool is cut to 3 times a day, the phenomena of flatulence decrease, and the body weight increases.
In some cases, chronic pancreatitis is treated promptly:
- with non-curable pain,
- development of complications (eg, bleeding)
- in case of suspected cancer.
The main types of operations are:
- partial resection of the pancreas,
- drainage operations, allowing to reduce the pressure in the ducts,
- the intersection of certain nerve trunks with strong, unaffordable pains
- Electrophoresis with novocaine or magnesia.
- The diadynamic.
- Ultrasound therapy.
Warn the development of chronic pancreatitis will help the following recommendations:
- Refusal from smoking, alcohol.
- The correct mode of supply (small volumes, fractional).
- The use of natural, healthy food.
- Timely treatment of diseases of the liver, 12 duodenal ulcer, stomach.
Features of pancreatitis in pregnant women
Unfortunately, chronic pancreatitis can become worse during pregnancy. This is due to some features of the general condition and behavior of pregnant women:
- Changes in the dietary stereotype.
- Hypertriglyceridemia and hyperlipidemia (increased triglycerides and lipids in the blood).
- Hyperparathyroidism (impaired calcium metabolism).
- Alcoholism, smoking.
- Peculiarities of the behavior of a pregnant woman.
- Disturbance of the motility of the digestive system.
- Decreased physical activity.
On exacerbation of pancreatitis in pregnant women may indicate the following symptoms:
- Multiple vomiting in the first half of pregnancy until 17-22 weeks.
- The appearance of signs of dyspepsia after 12 weeks of pregnancy.
The remaining signs are similar to those in the usual exacerbation of pancreatitis.
The main symptoms of chronic pancreatitis in pregnant women
- Pain in epigastrium.
- Nausea, vomiting.
- Poor appetite.
- Decreased mood.
- Yellowness of the skin and sclera.
- Slowing heart rate.
- Reduced blood pressure.
- Temperature increase.
- Flatulence and bloating.
Treatment of pregnant women with chronic pancreatitis is treated according to standard schemes, but only those drugs that are not contraindicated in pregnancy are prescribed.
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