Pancreatitis: Symptoms and Treatment

Content:

• The 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.

The structure and function of the pancreas

The pancreas has an oblong shape and is located closer to the spine, behind and just below the stomach. For convenience, it distinguishes 3 sections: the head, body and tail (caudal part).

Microscopically in the pancreas there are 2 main sections:

1. The endocrine portion is the islets of Langerhans, which contain cells that produce insulin and some other hormones.
2. The exocrine part produces the pancreatic juice, which is so gassed, consisting of the enzymes necessary for the digestion of proteins, fats and carbohydrates: lipase, trypsin, amylase, maltase, collagenase, etc. 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 intestine is blocked and the enzymes come back, then self-digestion of the pancreas (acute pancreatitis) begins with the subsequent development of insulin-dependent diabetes mellitus.

Types of pancreatitis

Currently, there are many classifications of pancreatitis. By the nature of the flow distinguish pancreatitis:

1. Acute.
2. Chronic.

Acute pancreatitis

Acute pancreatitis is an acute inflammation of the pancreas, based on the death of gland cells due to self-digestion of pancreatic juice enzymes that have returned. Subsequently, a purulent infection may join.

Acute pancreatitis is a very serious disease that, despite modern treatment, often results in the death of a patient: on average, up to 15% die, and with destructive forms of acute pancreatitis, up to 70%.

The reasons

Most often acute pancreatitis develops in the following cases:

• with alcohol intake - up to 70% of all cases of the disease (mainly in men of young and mature age),
• in the presence of gallstone disease - up to 25% or 30% (more often in women),
• surgery on the stomach or other abdominal organs - about 4% or a little more.

Isolated cases of acute pancreatitis are observed due to:

• injuries
• viral infections (for example, when parotitis in children and young people),
• allergies
• duodenal ulcer and other diseases of the gastro-duodenal region,
• poisoning by salts of heavy metals, paints and varnishes, certain medications or other substances,
• congenital anomalies of the structure of the pancreas.

In general, acute pancreatitis is most common after 30 years and in women.

Classification

As a rule, distinguish acute pancreatitis:

1. Interstitial (edematous).
2. Pancreatonecrosis:

2.1. Sterile:

• limited or common
• hemorrhagic, fatty, mixed.

2.2. Infected.

Complications

Complications of acute pancreatitis are numerous, among which the most common and serious are:

1. Local complications:

• formation of infiltration around the pancreas,
• aseptic or septic reflux of retroperitoneal fiber, for example, pelvic, around the kidneys, etc.,
• inflammation of the peritoneum due to the action of pancreatic juice or the addition of infection (abacterial, as well as fibro-suppurative peritonitis),
• the formation of a pseudocyst that can also be infected,
• bleeding into the cavity of the peritoneum or intestines,
• pancreatogenic abscess with localization in the retroperitoneal tissue,
• the emergence of various pancreatic fistulas: gastric, intestinal.

2. General complications:

• development of pancreatic shock,
• development of diabetes
• the occurrence of multiple organ failure syndrome,
• death of the patient.

Features of the disease

There are 4 main stages of acute pancreatitis:

1) Early stage (first 5–7 days). During this period, develop:

• swelling and death of pancreatic cells,
• aseptic inflammation of the organs adjacent to the gland, the peritoneum,
• poisoning of the body by sucking pancreatic decay products with subsequent damage to distant organs: for example, the brain, kidneys, heart and lungs (at this stage the patient may die due to his serious condition).

2) Reactive period (second week from the onset of acute pancreatitis). At this stage most often observed:

• the formation of a dense pancreatic infiltrate,
• fever,
• the occurrence of acute gastric ulcers,
• jaundice.

3) Stage of purulent complications (joins from the end of the second week from the onset of the disease). At this stage, the following occurs:

• formation of phlegmon, abscesses, purulent leakage to other organs, fistulas,
• internal bleeding
• blood poisoning (sepsis).

4) Recovery period:

• mild pancreatitis - recovery in 2–3 weeks, no complications are observed;
• moderate severity - infiltration resolves in 1–2 months, approximately half of the cases of pancreatitis become chronic;
• severe pancreatitis at this stage must pass 2 phases:

a) the depletion phase - a decrease in general immunity and impaired tissue healing, for example: hair loss, bedsores, infectious diseases, thrombophlebitis, depression, asthenic syndrome;

b) recovery phase - the development of pancreatic cysts, the development of diabetes 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. Consider some of them:

1. Pancreatic colic . This acute pain in the first 3 days has a “shingles” character and is felt in the upper abdomen, which can extend into the left clavicle or both shoulder blades, the posterior sections of the lower ribs to the left. Gradually, the intensity of pain decreases, they become dull and last for about 1 week.

2. Vomiting. In acute pancreatitis, it is repeated, painful, does not bring relief. May occur at the onset of the disease, along with pancreatic colic, and at later stages.

3. Heart palpitations . It occurs as a result of general intoxication of the body in the later stages.

4. Temperature increase . It is usually observed from the 3rd day of illness, although in some cases it may occur earlier. In general, the following pattern is observed: the higher the temperature, the more severe the damage to the pancreas is observed.

5. Bloating . It is noted in the initial period, may be combined with delayed stool, gas accumulation or be a sign of the development of peritonitis in the later stages.

6. Formation of infiltrate . This symptom can be determined by the doctor during examination and palpation of the abdomen, on average, starting from the 5th day of the disease.

7. Changes in the total blood count :

• Blood thickening - an increase in hemoglobin to 150 g / l, the number of erythrocytes, a decrease in ESR up to 1-3 mm / h.
• At later stages - a picture of inflammation: ESR increases, leukocytosis.
• In the case of severe complications - reduction of hemoglobin, lymphocytes and blood leukocytes.

8. Urinalysis:

• In milder forms, changes in the urine are not observed.
• An increase in urine diastase from 160 ml / (mgs) and higher in the initial period of the disease.
• With kidney damage: sugar in the urine, the appearance of protein, red blood cells, cylinders and renal epithelium.

9. Blood biochemistry:

• Increasing the concentration of pancreatic enzymes - trypsin, amylase, lipase.
• Increased blood sugar, bilirubin, urea concentration.

Diagnostics

The diagnosis of acute pancreatitis is established by the surgeon on the basis of the data:

• examining and talking with the patient
• laboratory blood tests, urine,
• Ultrasound of the pancreas.

If necessary, a doctor can be appointed:

• FGDs,
• diagnostic puncture of the abdominal wall,
• laparoscopy,
• MRI or CT scan
• radiography of the lungs, stomach, etc.

In general, in acute pancreatitis, it is necessary to identify possible complications as quickly as possible, and then to eliminate them in order to minimize the aggravation of the pathological process.

Treatment of acute pancreatitis

Patients suffering from acute pancreatitis, are subject to immediate hospitalization in the surgical or intensive care unit, in which they are examined in an urgent manner and prescribe the appropriate treatment.

Currently, treatment is based on the following principles:

1. Mild degrees of acute pancreatitis require treatment to a lesser extent than its severe forms.

2. The earlier the treatment is started, the better the results and fewer complications (this also applies to moderate, severe forms).

3. Diet:

• absolute hunger for the first 3-5 days,
• drink plenty of alkaline water without gas to 2 liters daily - from 2 days,
• at the end of hunger - liquid porridges,
• gradual expansion of the diet.

In general, nutrition in acute pancreatitis should be in small portions, but with a high concentration of beneficial substances. Usually allowed per day:

• 200 g of cottage cheese,
• 10–50 ml of cream
• steam cutlets,
• 1–2 bananas
• yogurt,
• low fat boiled fish,
• weak broth,
• cheese,
• bun with butter.

Excluded:

• raw vegetables,
• whole milk,
• roast,
• spicy, spicy,
• strong broth, coffee,
• sour kefir,
• eggs,
• sausage,
• alcohol.

This diet is observed for at least 3 months, and in the case of severe pancreatitis - up to 1 year.

1. Depending on the stage of the disease:

• The early period is detoxification, hemosorption, plasmapheresis, “washing” of the kidneys, intestines and peritoneum by dialysis.
• The period of infectious complications is surgery.

2. Medicinal preparations:

• reduce the production of hormones by the pancreas (platifillin, atropine),
• inhibiting pancreatic function (fluorouracil, ribonuclease),
• antifermental (gordox, contrycal),
• other: dalargin, somatostatin, antibiotics and some other means.

After discharge from the hospital, the patient is observed by a gastroenterologist and treatment consists in preventing the recurrence of acute pancreatitis or exacerbation of the chronic one.

Prevention

In many cases, the development of acute pancreatitis can be avoided. For this you need:

1. Do not overeat.
2. Do not drink alcohol.
3. Promptly treat gallstone disease (remove the gallbladder).
4. Do not use products and medicines of dubious quality.
5. Do not abuse the medication.
6. Lead a healthy lifestyle.

Chronic pancreatitis

Chronic pancreatitis is characterized by the presence of persistent or the occurrence of periodic inflammation of the pancreas, which gradually leads to the development of functional insufficiency of this organ.

Chronic pancreatitis can be almost asymptomatic, as well as under the mask of various other diseases, such as chronic cholecystitis, biliary dyskinesia, peptic ulcer disease, etc.

The reasons

1. Alcohol This is a leading factor in the development of pancreatitis. It is insidious that, in most cases, it does not immediately cause the occurrence of the disease, but after a few years of regular use (from 8 to 18 years). To do this, it is enough to use only 1 half-liter bottle of low-alcohol beer daily.

2. Gallstone disease. Although this disease most often causes acute pancreatitis, in some cases the development of chronic forms of the disease also occurs.

3. Senile and youthful idiopathic pancreatitis . In this case, the reason is unknown. The juvenile form of such pancreatitis is often accompanied by pain, diabetes mellitus and exocrine pancreatic insufficiency. The senile form is characterized by the presence of calcifications in the pancreas, as well as diabetes mellitus and steatorrhea (fatty feces), but the pain is not characteristic.

4. Insufficiency of some trace elements, poor nutrition (for example, tropical pancreatitis) .

5. Pathology of the so-called sphincter of Oddi .

6. Some drugs, for example :

• azathioprine
• NSAIDs
• metronidazole,
• corticosteroids,
• sulfonamides,
• paracetamol,
• estrogens
• tetracycline,
• sulfasalazine,
• furosemide,
• hypothiazide.

7. Elevated blood lipids , especially triglycerides.

8. Heredity and some genetic diseases :

• hemochromatosis,
• cystic fibrosis and some others.

9. Ischemic pancreatic lesion . Observed with pronounced atherosclerosis of the respective vessels.

10. Viral infections . For example, with hepatitis or infectious parotiditis.

11. Smoking.

12. Increased calcium in the blood.

Classification

For the predominant cause of the development of inflammation, chronic pancreatitis is distinguished:

• toxic-metabolic (including alcoholic),
• idiopathic,
• hereditary,
• autoimmune,
• recurrent
• obstructive.

And:

• primary,
• secondary.

Complications

The most common complications of chronic pancreatitis are the following:

• violation of the outflow of bile,
• development of portal hypertension,
• the accession of infection (abscess, para-ephritis, etc.),
• bleeding
• diabetes.

How does the disease develop?

As a rule, over time, there is a worsening of changes in pancreatic tissue, which is reflected in the following stages of the disease:

1. Initial stage. Lasts about 10 years, characterized by alternating periods of exacerbation and remission. In a typical situation, the leading symptom is pain that varies in intensity and location, as well as dyspeptic syndrome, which disappears as treatment progresses.
2. Second stage 10 years after the onset of chronic pancreatitis, the symptoms of exocrine pancreatic insufficiency come to the fore, and the pain gradually subsides.
3. Stage of development of complications. In addition to the development of complications, changes in the localization, intensity of the pain syndrome, and persistent dyspeptic syndrome are inherent in this stage.

Symptoms of chronic pancreatitis

Chronic pancreatitis may be asymptomatic for some time or disguised as other diseases of the abdominal organs. In this case, only a doctor can make an accurate diagnosis.

The main symptoms of classical chronic pancreatitis are as follows:

1. Abdominal pain . It is without clear localization, radiating to the back, it may be encircling:

• with partial or complete blockage of the lumen of the duct - occurs after eating, paroxysmal, stopped by pancreatin or antisecretory drugs;
• as a result of inflammation - does not depend on food intake, irradiation from epigastria to the back area, take place after taking analgesics;
• due to the lack of pancreatic enzymes - pains of a predominantly arching nature, associated with increased gas formation.

2. Signs of exocrine (exocrine) deficiency . It develops due to digestive disorders and the absorption of essential substances from the intestines. It is characterized by:

• stool disorders (up to 6 times per day),
• offensive, oily feces (steatorrhea),
• nausea, vomiting,
• weight loss
• bloating, flatulence,
• rumbling in the stomach, belching,
• symptoms of deficiency of various minerals and vitamins.

3. Intoxication syndrome . In this case, appear:

• general weakness
• loss of appetite
• tachycardia
• temperature rise,
• lowering blood pressure.

4. Biliary hypertension . The main characteristics of the syndrome:

• obstructive jaundice
• on ultrasound: enlarged pancreatic head, choledochus.

5. Endocrine disorders . Meet in 1/3 of patients:

• ketoacidosis
• diabetes,
• tendency to hypoglycemia.

In chronic pancreatitis, Tuzhilin's symptom can be observed - the appearance of bright red spots in the abdomen, back, chest, which are aneurysms and do not disappear when pressed.

Diagnostics

At the first stage, it is necessary to contact a gastroenterologist to make 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:

1. Ultrasound of the pancreas . Allows you to determine the size, density and structure of the body, to identify pseudocysts, calcinates and other education.
2. Endoscopic ultrasonography . The sensor is placed not on the anterior abdominal wall, but in the esophagus, stomach, and duodenum.
3. Computed tomography . Appointed in case of poor visibility of the gland on ultrasound.
4. MRI Well visualizes the ducts of the pancreas.
5. X-ray methods: the identification of calcifications in the area of ​​the organ.

From laboratory methods are usually assigned:

1. General blood test : ESR acceleration, anemia, leukocytosis can be observed.
2. Amylase in the blood, urine : high content.
3. Elastase 1 in feces. It is determined by ELISA and is the “gold standard” for the detection of pancreatitis.
4. Determination of glucose tolerance, determination of blood sugar levels.
5. Coprogram : elevated fat (steatorrhea) and undigested muscle fibers (creatorrhea).
6. Tests, for example : benthiramide, Lund test, secretin-pancreoiminimine, iodolipol, fluorescein dilaurate, etc.

Treatment of chronic pancreatitis

During exacerbation of 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 prescribed additional parenteral nutrition. As the pain subsides, fractional feeding in small portions is allowed, with the restriction of fat.

2. Cold . If you put a bubble with ice on the area of ​​the projection of the pancreas, the secretion of enzymes will decrease slightly.

3. Лекарственные препараты :

• 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.

Стадия ремиссии

Вне обострения на первый план среди лечебных мероприятий выступает соблюдение диеты. Рекомендации при хроническом панкреатите в стадии ремиссии следующие:

1. Полный отказ от алкоголя в любом виде.
2. Дробное питание малыми порциями 5–6 раз в сутки.
3. Запрещаются: маринады, крепкие бульоны, жареная, острая пища, специи, газированные напитки, кофе, чай.
4. Повышенное количество белков: нежирные сорта мяса и рыбы, нежирный творог, неострый сыр.
5. Ограничение животных жиров, а также рафинированных углеводов.

Пища должна подаваться в теплом виде.

Если у пациента наблюдаются похудание, периодические поносы, снижение аппетита, то назначают заместительную терапию следующими препаратами:

• мезим-форте,
• креон,
• пангрол и т.п.

Считается, что ферменты назначены в достаточном количестве, если стул урежается до 3 раз в сутки, уменьшаются явления метеоризма, происходит увеличение массы тела.

Surgical treatment

В некоторых случаях хронический панкреатит лечится оперативно:

• при некупируемой боли,
• развитии осложнений (например, возникновение кровотечения)
• в случае подозрения на рак.

Основными типами операций являются:

• частичная резекция поджелудочной,
• дренирующие операции, позволяющие снизить давление в протоках,
• intersection of some nerve trunks with severe, non-treatable pain

Physiotherapy

• Electrophoresis with novocaine or magnesia.
• Diadynamic.
• Ultrasound therapy.
• SMT therapy

Prevention

The following recommendations will help prevent the development of chronic pancreatitis:

1. Quitting smoking, alcohol.
2. The correct diet (small volumes, fractional).
3. The use of natural, healthy food.
4. Timely treatment of diseases of the liver, duodenum, stomach.

Features of pancreatitis in pregnant women

Unfortunately, chronic pancreatitis can worsen during pregnancy. This is due to some features of the general condition and behavior of pregnant women:

1. Cholelithiasis.
2. Changes in food stereotype.
3. Hypertriglyceridemia and hyperlipidemia (increased triglycerides and lipids in the blood).
4. Hyperparathyroidism (calcium metabolism).
5. Alcoholism, smoking.
6. Features of the behavior of a pregnant woman.
7. Impaired motility of the digestive system.
8. Decreased physical activity.

The following symptoms may indicate the exacerbation of pancreatitis in pregnant women:

• Repeated vomiting in the first half of pregnancy up to 17-22 weeks.
• The appearance of signs of dyspepsia after 12 weeks of pregnancy.

The remaining signs are similar to those with the usual exacerbation of pancreatitis.

The main symptoms of chronic pancreatitis in pregnant women

1. Epigastric pain.
2. Nausea, vomiting.
3. Bad appetite.
4. Decreased mood.
5. Insomnia.
6. Yellow skin and sclera.
7. Headache.
8. Slowing heartbeats.
9. Lowering blood pressure.
10. Temperature rise.
11. Flatulence and bloating.

Treatment of pregnant women with chronic pancreatitis is treated according to standard regimens, but only those drugs that are not contraindicated in pregnancy are prescribed.

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