Pancreatitis chronic

Pancreatitis is chronic (acute pancreatitis see Surgical diseases) - chronic inflammation of the pancreas Usually occurs in the middle and old age, more often in women, distinguish primary chronic pancreatitis and secondary, or accompanying, developing against other digestive tract diseases (chronic gastritis, cholecystitis , Enteritis, etc.). In chronic, prolonged acute pancreatitis may occur, but more often it is formed gradually against the backdrop of chronic cholecystitis, cholelithiasis or under the influence of unsystematic irregular nutrition, frequent consumption of acute and fatty foods, chronic alcoholism, especially in combination with a systematic deficit In the food of proteins and vitamins, penetration of the stomach or duodenal ulcer into the pancreas, atherosclerotic vascular disease of the pancreas, infectious diseases (especially in infectious parotitis, typhoid and typhus, viral hepatitis), certain helminthiases, chronic intoxications with lead, mercury, phosphorus, Arsenic.

Pathogenesis: delay in excretion and intraorganic activation of pancreatic enzymes - trypsin and lipase, performing autolysis of the parenchyma of the gland, reactive growth and scarring of the connective tissue, which then leads to sclerosis of the organ, chronic impairment of blood circulation in the pancreas. In the progression of the inflammatory process, autoaggression processes are of great importance. In chronic pancreatitis of infectious origin, the pathogen can enter the pancreas from the lumen of the duodenum (for example, with dysbacteriosis) or from the bile ducts through the pancreatic ducts in an ascending manner, which is promoted by dyskinesia of the digestive tract, accompanied by duodeno- and choledocho-pancreatic reflux. Predicting spasms, inflammatory stenosis or swelling of the fater's nipple that prevent the release of pancreatic juice into the duodenum, as well as the deficiency of the Oddi sphincter, which facilitates the free entry of duodenal contents into the pancreatic duct, especially the enterokinase that activates trypsin, predispose to the onset of chronic pancreatitis. The inflammatory process can be diffuse or limited only to the region of the head or tail of the pancreas. Distinguish between chronic edematous (interstitial), parenchymal, sclerosing and calculous pancreatitis.

Symptoms, course. Pain in the epigastric region and the left hypochondrium, dyspepsia, diarrhea, weight loss, diabetes mellitus. The pain is localized in the epigastric region to the right with the primary localization of the process in the head of the pancreas, when involved in the inflammatory process of its body - in the epigastric region to the left, with the defeat of its tail - in the left hypochondrium; Often the pain irradiates in the back and has a shrouding character, can irradiate to the heart area, imitating angina. Pain can be permanent or paroxysmal and appear after a while after taking fatty or spicy food. There is a pain in the epigastric region and the left hypochondrium. Often there is a painful point in the left costal-vertebral corner (the Mayo-Robson symptom). Sometimes the zone of cutaneous hyperesthesia is determined, respectively, in the area of ​​innervation of the eighth thoracic segment to the left (Kacha symptom) and some atrophy of subcutaneous fat in the area of ​​the projection of the pancreas on the anterior wall of the abdomen.

Dyspeptic symptoms in chronic pancreatitis are almost constant. Frequent loss of appetite and aversion to fatty foods are common. However, when developing diabetes, on the contrary, patients can feel strong hunger and thirst. Often observed increased salivation, belching, attacks of nausea, vomiting, flatulence, rumbling in the abdomen. Stupa in mild cases is normal, in more severe cases - diarrhea or alternating constipation and diarrhea. Characteristic of pancreatic diarrhea with the liberation of a profuse, mildew, fetid stench with fatty shine; A scatological study reveals steatori, creator, and kitarinorei.

In the blood - moderate hypochromic anemia, during an exacerbation - an increase in ESR, neutrophilic leukocytosis, hypoproteinemia and disproteinemia due to the increased content of globulins. With the development of diabetes mellitus hyperglycemia and glucosuria are detected, in more severe cases - violations of electrolyte metabolism, in particular hyponatremia. The content of trypsin, antitrypsin, amylase and lipase in the blood and amylase in the urine rises during the exacerbation of pancreatitis, as well as in obstructions to the outflow of pancreatic juice (inflammatory swelling of the gland head and compression of ducts, cicatricial stenosis of the falcon nipple, etc.). In duodenal contents, the concentration of enzymes and the total volume of juice in the initial period of the disease may be increased, but with a pronounced atrophic sclerotic process in the gland these indicators decrease, pancreatic hypoecretion takes place. Duodenorentgenography reveals deformations of the inner contour of the duodenal loop and the impression caused by an increase in the head of the pancreas. Echography and radioisotope scanning show the size and intensity of the shade of the pancreas; In a diagnostically complex case, a computed tomography scan is performed.

The course of the disease is protracted. According to the peculiarities of the course, chronic recurrent pancreatitis, pain, pseudotumor, latent form (rarely found) is isolated. Complications: abscess, cyst or calcification of the pancreas, severe diabetes mellitus, splenic vein thrombosis, scar-inflammatory stenosis of the pancreatic duct and duodenal papilla, etc. With sclerosing form of chronic pancreatitis, there may be subhepatic (mechanical) jaundice due to the passing of the segment passing through it Of the common bile duct of a glandularized gland. Against the background of long-term pancreatitis, the secondary development of pancreatic cancer is possible.

Chronic pancreatitis is differentiated primarily from a pancreatic tumor, with pancreatoangiorentgenography, retrograde pancreatocholangiography (viraungography), echography and pancreatic radioisotope scanning becoming important. There may be a need for differential diagnosis of chronic pancreatitis with cholelithiasis, peptic ulcer disease of the stomach and duodenum (the possibility of combining these diseases should be taken into account), chronic enteritis and, more rarely, other forms of pathology of the digestive system.

Treatment. In the initial stages of the disease and in the absence of serious complications - conservative; During the exacerbation of the treatment is advisable to conduct in a hospital gastroenterological profile (during a sharp exacerbation treatment is the same as in acute pancreatitis).

Nutrition patient should be fractional, 5-6-time, but in small portions. Exclude alcohol, marinades, fried, fatty and spicy food, strong broths that have a significant stimulating effect on the pancreas. The diet should contain an increased number of proteins (table number 5) in the form of low-fat varieties of meat, fish, fresh low-fat cottage cheese, neostrago cheese. The content of fats in the diet is moderately limited (up to 80-70 g per day), mainly due to pork, lamb fat. With a significant steatoroye content of fat in the diet is further reduced (up to 50 g). Limit hydrocarbons, especially mono- and disaccharides; With the development of diabetes, the latter completely excluded. Food is given in a warm form.

In cases of exacerbations, antifoam agents (trasilen, countertrial or pantripine) are prescribed; In less acute cases, preparations of metabolic action (pentoxyl 0.2-0.4 g per dose, methyluracil 1 g 3-4 times a day for 3-4 weeks), lipotropic drugs-lipocaine, methionine. Antibiotics are indicated for severe exacerbations or abscess of the pancreas. With severe pain paranephalic or paravertebral neocaine blockade, non-narcotic analgesics, baralgin are shown, in especially severe cases, narcotic analgesics combined with anticholinergic and antispasmodics. With exocrine insufficiency of the pancreas, substitute enzyme preparations are prescribed: pancreatin (0.5 g 3-4 times a day), abomin, cholenzyme, festal, panzinorm and others; Multivitamins. After removal of acute phenomena and with the aim of preventing exacerbation, resort treatment in Borjomi, Essentuki, Zheleznovodsk, Pyatigorsk, Karlovy Vary and in local sanatoriums of the gastroenterological profile is recommended in the future. Patients with chronic pancreatitis are not shown the types of work in which it is impossible to comply with a clear diet; In case of severe disease - transfer to a disability.

Surgical treatment is recommended for severe painful forms of chronic pancreatitis, scar-inflammatory stenosis of the common bile and (or) pancreatic duct, abscessing or development of the gland cyst.

Prevention. Timely treatment of diseases that play an aetiological role in the onset of pancreatitis, the elimination of the possibility of chronic intoxications contributing to the development of this disease (industrial, as well as alcoholism), the provision of rational nutrition and the regime of the day.