PANCREATITIS

Pancreatitis is an inflammation of the pancreas. Distinguish between acute and chronic pancreatitis.

Acute pancreatitis - acute inflammatory necrotic lesion of the pancreas - takes the third place in the frequency of occurrence among the acute surgical pathology of the abdominal cavity organs. The disease affects people of blooming age, usually over 30 years old, and old people prone to obesity, as well as those who abuse alcohol. Women are sick three times more often than men. In children, the disease is extremely rare. The leading etiological factors of acute pancreatitis are cholelithiasis, alcohol consumption, pancreatic injury. At the heart of the pathogenesis of acute pancreatitis is the activation of proteolytic enzymes (mainly trypsin) not in the lumen of the intestine, but in the pancreas itself with the development of its self-digestion. Under the influence of lipase, the digestion of fats and the formation of fatty necrosis in the pancreas occur. When it disintegrates and releases enzymes, hemorrhages develop, necroses in the surrounding tissues. In some cases, diffuse peritonitis develops with a characteristic haemorrhagic effusion. Hypovolemia, as well as the release from the pancreas into the blood of biologically active substances (activated enzymes, kinins, histamine), dilating vessels, increasing the permeability of the vascular wall, reducing myocardial contractility, lead to the development of shock.

Clinically, the lighter (edematic) and severe (necrotic) forms of the disease are distinguished. With edematic pancreatitis, the gland is enlarged 2 - 3 times, saturated with serous fluid and tense. Necrotic form, or hemorrhagic pancreatic necrosis, is characterized by hemorrhages, the iron is partially or completely necrotic.

The disease develops suddenly, usually after a copious intake of fatty, meaty foods and (or) alcohol. The most characteristic clinical symptom of acute pancreatitis is severe pain. It is so intense in the most severe form - pancreonecrosis, which leads to a shock with a sharp drop in blood pressure, pallor, cold sweat. Pain usually grows rapidly, does not weaken for a minute, and often does not stop even after the injection of narcotic analgesics. This is explained by the proximity of the pancreas to the solar plexus and the transition to it of the inflammatory process. Even the edematous form of pancreatitis is often accompanied by a sharp pain; Less pain is mild or minor. The pain is localized in the depth of the epigastric region. Often, patients note the surrounding nature, irradiation in the back and both hypochondria. It is noted that with a primary lesion of the head of the pancreas, the pain irradiates to the right hypochondrium, with the tail affected, has a left-sided localization.

For acute pancreatitis is characterized by abundant (sometimes 4-6 l) repeated vomiting at first food, then mucus and bile. Vomiting occurs simultaneously with pains, does not relieve them and intensifies after every sip of water. The cause of it is acute expansion of the stomach, paralysis of the duodenum, which horseshoes around the pancreas.

Characterized by a severe condition, fever, pale skin, erythematous vesicles may appear due to necrosis of subcutaneous fat. With pancreatic necrosis as a reflection of tissue metabolism of hemoglobin, a slight cyanosis of the skin around the umbilical ring (Cullen's symptom), blue-red or greenish-brown staining of the lateral abdomen (Turner's sign) can be observed. Sometimes, when the common bile duct is compressed, an inflammatory infiltrate develops jaundice , which is mechanical (obturation). Quite often, rapid breathing is increased to 28-36 in 1 min due to the involvement of the diaphragm in the pathological process. In the lower parts of the lungs rales are heard, sometimes signs of left-sided pleural effusion are revealed. Changes in the circulatory system are characterized by tachycardia and an almost constant decrease in blood pressure, in severe cases reaching a shock with a drop in pressure to zero. Often the drop in blood pressure has a protracted character and lasts up to a day.

The tongue, as a rule, is dry, densely coated with white coating. Characteristic abdominal distention caused by reflex intestinal paresis. Often there is an isolated swelling of the transverse colon, the mesentery of which, being closely connected with the gland, is quickly involved in the process. With auscultation of the intestine, peristaltic sounds are not audible (intestinal obstruction of a dynamic, paretic nature). Even superficial palpation of the abdomen usually causes a sharp, often intolerable pain in the epigastrium. In the onset of the disease, the abdomen is mild, sometimes there is a protective muscular tension in the epigastric region and tenderness in palpation along the pancreas (Kert's symptom). Characteristic disappearance of pulsations of the abdominal aorta in epigastrium (a symptom of Voskresensky), tenderness in palpation in the left costal-vertebral corner (Mayo-Roxon symptom). The pancreas itself is inaccessible to palpation, but in acute pancreatitis it is often possible to detect infiltrates in epigastrium and hypochondria, which are associated with changes not in the gland itself, but in the omentum (hemorrhages, edema, fatty necrosis). Symptoms of irritation of the peritoneum appear with pancreatic necrosis with the development of peritonitis.

A blood test usually reveals a significant increase in the number of leukocytes due to neutrophils with a shift to the left. In severe cases, sometimes marked leukocytosis . In acute pancreatitis there is a so-called deviation from the usual pathway for the isolation of pancreatic enzymes. As a result of compression of the excretory duct of the gland by swelling, its enzymes do not enter the intestine, but accumulate in the intercellular spaces of the gland, from where they enter the blood and are excreted in the urine. The increased content of pancreatic enzymes in the blood (hyperamilazemia) and in the urine (hyperamilazuria) greatly helps in the diagnosis of acute pancreatitis. However, in the most severe cases of total pancreonecrosis, the majority of the gland cells die, the enzymes are not produced and the content of diastase in the urine remains normal or even below normal, the defeat of the islet cell cells and insufficient insulin production can lead to hyperglycemia and glucosuria. With ultrasound and computed tomography, signs of edema and inflammation are revealed - an increase in the size and heterogeneity of the pancreas (areas of necrosis, suppuration).

The diagnosis of acute pancreatitis in most cases is not particularly difficult. The data of the anamnesis (intake of copious amounts of food and alcohol), intense persistent pain in the upper abdomen (often of the type of shingles), nausea , vomiting , fever , tachycardia , hypotension, soft abdomen and lack of peristalsis, positive Mayo-Robson symptom allow suspected acute pancreatitis . In a hospital, the diagnosis is confirmed by ultrasound, laparoscopy allows you to identify hemorrhagic effusion in the abdominal cavity.

Differential diagnosis : the onset of the disease (sudden epigastric pains, vomiting) makes you think of an acute gastritis, in which, however, the pains never reach this intensity, vomiting is usually not so multiple and relieves pain, there is no muscle tension and such severe soreness in palpation in Epigastrium, as in acute pancreatitis. In cases where acute pancreatitis is most pronounced abdominal swelling, it is sometimes mistakenly diagnosed with intestinal obstruction. The findings of the correct diagnosis are helped by the patient's polling data (hepatic colic in the anamnesis). Differentiation of acute pancreatitis with acute appendicitis occurs mainly when pancreatitis is complicated by diffuse peritonitis, effusion drains along the right lateral canal of the abdomen into the right iliac region, causing severe pain and painfulness upon palpation. Usually this happens with late treatment of patients. In some cases of pancreatitis, when patients experience sudden pains high behind the sternum or in the left half of the chest, a differential diagnosis should be made with angina and myocardial infarction. Assign urine to diastase, electrocardiography. The most difficult to distinguish acute pancreatitis from acute cholecystitis, especially since these diseases often occur together. In acute cholecystitis, pain radiates to the right shoulder or under the right scapula. Cholecystitis often accompanies jaundice . In most cases with cholecystitis, the soreness corresponds to the position of the bladder, sometimes it is possible to palpate the enlarged gallbladder.

Treatment . A patient with acute pancreatitis should be immediately hospitalized in the surgical department and be under constant medical supervision, as pancreatitis can take a catastrophic course, and timely treatment can dampen the process. Among the treatment activities the main thing is rest for the pancreas. Patients are forbidden to take any food for several days, depending on the severity of the condition, usually the duration of therapeutic fasting is about 10 days. On the epigastric region, a cold is prescribed (a bubble with ice). To relieve the spasm of the sphincter, Oddi is prescribed antispasmodics (no-shpa, platyphylline); The antispasmodic effect in this situation is nitroglycerin . The early administration of antispasmodics can significantly reduce the risk of developing pancreatic necrosis. In connection with a large loss of fluid and chlorides with indigestible vomiting, as well as a drop in blood pressure and the threat of shock, intravenous drip is injected with saline, polyglycine, hemodez. At the expressed painful syndrome and absence of doubts in the diagnosis prescribe analgesics (analgin, baralgin). With the goal of preventing purulent complications, early antibiotic therapy is appropriate.

The prognosis with edematic form of acute pancreatitis is favorable, with pancreatic necrosis - very serious (lethality reaches 50-60%). Prevention is to maintain a rational diet, combat alcoholism, timely treatment of diseases of the digestive system.

Chronic pancreatitis is a chronic, periodically exacerbating inflammatory process leading to progressive irreversible anatomical and functional pancreatic damage. The etiological factors of chronic pancreatitis include alcohol abuse, biliary tract, stomach and duodenal ulcer diseases, exposure to chemicals and medications (hypothiazide, corticosteroids), hyperlipidemia, hypercalcemia, hereditary predisposition, protein deficiency.

The clinical picture of chronic pancreatitis consists of pain syndrome, dyspepsia, exo- and endocrine insufficiency, symptoms caused by complications of the disease. Pain can be localized in the left hypochondrium to the left of the navel, sometimes resembling the left-lateral renal colic (with the defeat of the tail), in the epigastrium to the left of the median line (ulcerative variant in the pancreatic body lesion), in the right hypochondrium, often combined with jaundice (when the head of the pancreas Glands); Total lesion of the gland leads to widespread abdominal pain. Pain - permanent or paroxysmal - occurs or intensifies in half an hour after a meal, especially oily or acute, alcohol intake, sometimes at night, increases in the supine position and decreases in sitting position with a slight tilt of the trunk forward. Soreness can also be determined by palpation of the abdomen in the projection of the pancreas. Dyspeptic phenomena (nausea, sensation of rumbling and transfusion in the abdomen, bloating, unpleasant taste in the mouth, belching , heartburn, aversion to fatty foods, nausea) are initially observed only with exacerbation of pancreatitis, and as the disease progresses - constantly. Exocrine insufficiency is manifested by diarrhea, the defeat of the islet apparatus is the development of diabetes mellitus. Complications of chronic pancreatitis may include mechanical jaundice (with the appearance of the symptom of Courvoisier - a palpable painless gallbladder) and portal hypertension (ascites, varicose veins of the legs), the development of abscesses, cysts, calcification of the pancreas. With the progression of the disease, weakness appears, working capacity decreases, in severe cases, mental disorders are possible.

The diagnosis is made on the basis of anamnesis, clinical picture, coprologic examination (in the analysis of stool, a large number of undigested food residues are determined - fat droplets - steatorrhea, muscle fibers - createrorrhea, starch grains - amylorea), ultrasound (local or diffuse pancreatic enlargement with decrease Or increase in echogenicity, widening of its duct, signs of cystic changes), computed tomography (reveal an increase, deformity, heterogeneity of the gland, calcifications, pseudocysts, pancreatic duct dilatation), endoscopic retrograde cholangiopancreatography (allows to assess the status of the ducts of the pancreas and bile ducts).

In severe exacerbation of the disease, patients are hospitalized, the treatment is performed as in acute pancreatitis. With an unchanged exacerbation, outpatient treatment is indicated. Exclude provoking factors (the intake of alcohol, fatty, acute, acidic, canned food) and recommend strict adherence to the diet - frequent fractional meals with restriction of fats and carbohydrates. Drug treatment includes agents that suppress pancreatic secretion - antacids (almagel, vikalin), H2-histamine receptor blockers (ranitidine), cholinolytics (atropine, platyphylline); Inhibitors of pancreatic enzymes (contrikal, gordoks, aminocaproic acid); Anticancer agents (prodektin); Drugs that stimulate the synthesis of trypsin inhibitors (pentoxyl, methyluracil), broad-spectrum antibiotics. To reduce the pain syndrome prescribed spasmolytics (platifillin, no-shpu), non-narcotic analgesics (analgin, baralgin), with severe pain paranephalic or paravertebral neocaine blockade. When expressed dyspeptic phenomena apply enzyme drugs (pancreatin, festal , panzinorm, etc.). At the expressed disturbances of a carbohydrate exchange the symptomatic therapy of a diabetes is shown.

The prognosis with adequate treatment and compliance with these recommendations is favorable. Prevention is to maintain a rational diet, timely treatment of digestive system diseases, including acute pancreatitis.