Protocols for the diagnosis and treatment of acute pancreatitis
Acute pancreatitis (OP) characterized by the development of pancreatic edema (edematous pancreatitis) or primary aseptic pancreatic necrosis (destructive pancreatitis) followed by an inflammatory reaction. Acute destructive pancreatitis has a phase course, and each of its phases corresponds to a certain clinical form.
Phase I - enzymatic , the first five days of the disease, during this period there is the formation of pancreatic necrosis of various lengths, the development of endotoxicosis (the average duration of hyperenzymemia is 5 days), and in some patients, multiple organ failure and endotoxin shock. The maximum period for the formation of pancreatic necrosis is three days, after this period it does not progress further. However, in severe pancreatitis, the period of formation of pancreatic necrosis is much shorter (24-36 hours). It is advisable to distinguish two clinical forms: severe and non-severe OP.
Severe acute pancreatitis. The frequency of occurrence is 5%, lethality is 50-60%. The morphological substrate of severe OP is widespread pancreatic necrosis (large-focal and total-subtotal), which corresponds to severe endotoxicosis.
Mild acute pancreatitis. The frequency of occurrence is 95%, lethality is 2-3%. Pancreatic necrosis in this form of acute pancreatitis either does not form (pancreatic edema), or is limited and does not spread widely (focal pancreatic necrosis - up to 1.0 cm). Non-severe OP is accompanied by endotoxicosis, the severity of which does not reach a severe degree.
Phase II - reactive (2nd week of the disease), characterized by the reaction of the body to the formed foci of necrosis (both in the pancreas and in the parapancreatic tissue). The clinical form of this phase is a peripancreatic infiltrate.
III phase - melting and sequestration (starts from the 3rd week of the disease, can last several months). Sequesters in the pancreas and retroperitoneal tissue begin to form from the 14th day from the onset of the disease. There are two possibilities for this phase:
aseptic melting and sequestration – sterile pancreatic necrosis; characterized by the formation of postnecrotic cysts and fistulas;
septic meltdown and sequestration- infected pancreatic necrosis and necrosis of parapancreatic tissue with the further development of purulent complications. The clinical form of this phase of the disease is purulent-necrotic parapancreatitis and its own complications (purulent-necrotic swells, abscesses of the retroperitoneal space and abdominal cavity, purulent omentobursitis, purulent peritonitis, arrosive and gastrointestinal bleeding, digestive fistulas, sepsis, etc.) .
Patients with a diagnosis of "acute pancreatitis" should, if possible, be referred to multidisciplinary hospitals.
The pancreas is an organ that synthesizes hormones involved in metabolic processes, such as insulin, and enzymes involved in the digestive process. Documents with clinical recommendations indicate that diseases affecting the pancreas develop in connection with an unhealthy lifestyle, alcohol abuse, malnutrition, and less often can be caused by trauma to an internal organ or be a consequence of developmental pathology. A common inflammatory disease is chronic pancreatitis. Clinical recommendations for the diagnosis and treatment of the disease include the medical experience of domestic and foreign pancreatology.
general information
National clinical guidelines describe pancreatitis as a long-term inflammatory disease of the pancreas. According to the description, the disease causes irreversible morphological changes leading to a decrease in organ function. Chronic pancreatitis flows into acute if a person does not pay attention to the main signs indicating the development of the disease.
According to the statistics given in the clinical guidelines, exacerbation of pancreatitis in 15-20% of cases ends in death. Secondary complications, infectious diseases that develop as a result of exacerbation can also lead to death.
Etiology
The recommendations indicate that pancreatitis occurs due to various factors. The development of the disease is influenced by an unhealthy lifestyle, for example, alcohol abuse, fatty foods, smoking. This is toxic or metabolic pancreatitis.
Other types of chronic illness:
- Idiopathic, which is characterized by pain at the onset of the disease and the rapid development of insufficiency of enzymes involved in digestion.
- Hereditary, developing in the presence of the n34s mutation, CFTR, SPINK. These are genes responsible for the regulation of pancreatic secretory function, the manifestation of other diseases, such as cystic fibrosis.
- Autoimmune, appearing against the background of other diseases. It is characterized by an increase in the level of IgG 4 in the blood serum.
- Recurrent, acute pancreatitis.
- Obstructive, developing due to injuries, stenosis of the sphincter of Oddi, tumors, duodenal cysts.
Prevalence and ICD-10 coding
Factors contributing to pancreatitis:
- alcohol and tobacco use;
- damage to the pancreas as a result of abdominal trauma, surgery, diagnostic procedures;
- uncontrolled long-term use of medications that have a detrimental effect on the pancreas;
- food poisoning;
- genetic predisposition or heredity;
- improper nutrition.
The most common chronic pancreatitis is caused by alcohol and tobacco use.
Chronic pancreatitis cannot be completely cured. During this disease, the pancreas is destroyed gradually, slowly.In about every 4 cases, the cause of pancreatitis cannot be established.
Classification
- chronic alcoholic etiology;
- other chronic pancreatitis associated with the factors described above, for example, hormonal deficiency, heredity, autoimmune diseases, other intestinal diseases;
- false cyst of the pancreas.
According to the nature of the disease, pancreatitis is distinguished:
- rarely recurrent;
- often recurrent;
- with symptoms that are always present.
Acute pancreatitis is associated with a complicated course of the disease. The recommendations indicate that exacerbation is most often associated with:
- violation of the outflow of bile;
- inflammatory processes;
- other pathologies, for example, malignant or benign formations, cholecystitis, paranephritis, postoperative period.
The main symptom by which pancreatitis is diagnosed is the presence of pain in the epigastric region.
Diagnostics
Pain in chronic pancreatitis is the primary symptom of the disease. Factors such as the location and nature of the pain are important. A doctor will suspect a chronic disease affecting the pancreas if the pain:
- give in the back;
- weaken when a person takes a sitting position or leans forward.
In some cases, the pain may recur, interspersed with pain-free periods, but may be permanent. This is how inflammation occurs due to alcohol abuse. The recommendations indicate that alcoholic pancreatitis may be accompanied by bouts of nausea, flatulence. Over time, it is possible to develop insensitivity to glucose, that is, diabetes.
Depending on the stage of the pathology, the symptoms will differ. The recommendations noted that pain is almost not typical for the preclinical period. In the later stages, a person will begin endocrine insufficiency, which will lead to atrophy of the pancreas.
Delay in establishing an accurate diagnosis can have tragic consequences. Therefore, if you have any doubts, you should consult your doctor immediately. You cannot make a diagnosis on your own. When choosing diagnostic methods play a role:
- accessibility of the study;
- skill or experience in conducting similar procedures among medical personnel;
- degree of invasiveness.
Complaints, history taking and examination
During the diagnosis, the doctor takes into account complaints about the presence and nature of pain in the abdomen. When collecting an anamnesis, the presence of other diseases (chronic, hereditary, autoimmune), the lifestyle that a person leads, the amount of alcohol consumed, the degree of development of hypoglycemia, possible operations on the gastrointestinal tract, and injuries are important.
Laboratory and instrumental research methods
Doctors resort to the following methods of instrumental diagnostics indicated in the clinical guidelines:
- radiography of the epigastric region, which reveals organ calcification;
- Ultrasound - the procedure can detect pancreatitis in the later stages;
- computed tomography, on the basis of which it is possible to judge the degree of atrophy of the gland;
- magnetic resonance is a modern accurate method for examining internal organs, which allows you to identify pancreatic necrosis, tumors of the gland.
The instrumental methods listed in the recommendations allow the study of physical characteristics, for example, the size and contour of the pancreas, tissue density. During the study, attention is paid to the duodenum, the state of the ducts (pancreatic and bile), and the splenic vein.
With pancreatitis, changes occur in all these organs, for example, the pancreas increases, expansion of the ducts is observed, thrombosis of the splenic vein develops.
Instrumental studies are not the only diagnostic methods. The recommendations prescribe that a person be given blood tests (general and biochemical) to track the possible development of hypoglycemia.
Liver function in people who abuse alcohol and eat improperly is impaired, so a person may additionally be prescribed an analysis for liver enzymes.
Treatment tactics
Clinical recommendations for the treatment of pancreatitis include drug therapy, lifestyle changes, especially nutrition. In rare cases, surgery, pancreatic resection may be indicated, but doctors in most cases try to get by with enzyme replacement therapy.
Chronic pancreatitis in children and adults can be treated on an outpatient basis if the disease is mild. According to clinical guidelines, hospital treatment is indicated during an exacerbation of pancreatitis. The main goal is to stop the pain syndrome, prevent complications and achieve stable remission.
Medical therapy
Recommendations for chronic pancreatitis prescribe to combine drug therapy with diet and adhere to fractional nutrition. If the acute stage has passed, fats can be included in the menu, but in other cases, fatty foods should be excluded, giving preference to protein, carbohydrate dishes.
With exocrine pancreatic insufficiency, doctors prescribe enzyme replacement therapy, focusing on changes in the level of coprological elastase, an enzyme found in feces. Reduced elastase indicates inflammatory processes occurring in the pancreas. The goal of replacement therapy is to stop steatorrhea and normalize pancreatic function.
Pancreatitis can be caused by long-term medications such as potassium and vitamin D, so treatment includes monitoring the medications the person is prescribed for other conditions.
Open and endoscopic surgeries
According to the recommendations, the stage of the disease and concomitant symptoms may serve as an indication for surgical intervention or refusal of it. Surgical intervention is performed if a person has signs of a developing complication, if the exacerbation cannot be cured by traditional methods.
Endoscopic procedures are prescribed if drug therapy fails, pain cannot be stopped, and the inflammatory process is accompanied by a rapid deterioration in the condition.
Complications and prognosis of the disease
A common complication of chronic pancreatitis is pancreatic pseudocysts, which occur as a result of pancreatic necrosis in place of dead tissue. Neoplasms can compress the blood vessels that feed the internal organs, manifest as pain in the upper abdomen. Due to edema and fibrosis of the pancreas, a person may develop jaundice, because the enlarged organ compresses the bile duct.
- thrombosis of the splenic vein;
- ulcers and obstruction of the duodenum;
- oncological diseases.
Rehabilitation and prevention
The most effective method of preventing inflammation of the pancreas is dietary fractional nutrition. A person with pancreatitis should completely avoid alcohol and smoking. Doctors recommend changing your lifestyle, spending more time outdoors, walking, and playing sports.
During the rehabilitation period, a strict diet and therapeutic exercises are prescribed, which helps to restore working capacity.
Chronic pancreatitis with exocrine insufficiency develops with a prolonged inflammatory process in the pancreas (over 10 years). As a result of the replacement of the parenchyma with connective tissue, the organ loses the ability to fully perform its endocrine and exocrine function.
The disease is very serious, as it leads to partial or complete loss of the pancreas.
The main symptoms of the pathology are dyspeptic disorders, abdominal pain, bouts of nausea, pale skin, tachycardia, shortness of breath, decreased ability to work and constant fatigue.
The main sign of inflammation of the pancreas and a violation of its function is the presence of undigested food particles and an admixture of fat in the feces. The basis of diagnosis is the study of feces. The components of effective therapy are special nutrition, the intake of enzymatic agents and proton pump blockers.
General information about chronic pancreatitis
Over the past 30 years, the number of patients suffering from pancreatitis has more than doubled. This phenomenon is explained by alcohol abuse, cholelithiasis, an inactive lifestyle, as well as regular intake of fatty and fried foods. Doctors note that pancreatitis has become “younger”: now the pathology is diagnosed on average at the age of 39, when earlier the average age was 50 years.
The pancreas is an exocrine and intrasecretory organ. External secretion is the production of pancreatic juice, and internal secretion is the production of hormones.
Pancreatitis occurs when digestive enzymes are activated in the gland itself. As a result, the body begins to "self-digest". Chronic pancreatitis (CP) is one of the forms of diseases characterized by dystrophic changes in the pancreas. With the constant progression of the pathology, fibrosis is observed, the disappearance or wrinkling of the acini (structural units of the pancreas), a change in the structure of the ducts, and the formation of stones in the parenchyma.
According to ICD-10, CP of alcoholic etiology and others are distinguished. According to other classifications, there are biliary-dependent, parenchymal-fibrous and obstructive CP.
Unlike the acute form, the chronic form of the disease has a mild clinical picture or proceeds along with concomitant diseases, for example, stomach and duodenal ulcers, chronic cholecystitis, biliary dyskinesia, etc.
Complaints of a patient suffering from chronic pancreatitis may be associated with:
- aching pain in the right hypochondrium;
- increased gas formation;
- bouts of nausea and a feeling of bitterness;
- dyspeptic disorder.
Often, due to violations of the rules of diet therapy against the background of chronic pancreatitis, acute appears, in which complete abstinence from food is shown. This disease is incurable, therefore, requires constant monitoring and medication.
Most experts distinguish two stages in the course of chronic pancreatitis /
Stage I (first 10 years) - alternating exacerbations and remissions, dyspeptic disorders are not expressed, epigastric pains are felt /
Stage II (more than 10 years) - subsidence of pain, increased dyspeptic disorder.
It is at the second stage that chronic pancreatitis develops with excretory insufficiency, which is characterized by a significant lesion of the pancreas.
Causes of exocrine insufficiency
Sugar level
The process of "self-digestion" leads to degenerative changes in the parenchyma and disruption of the outflow of pancreatic juice. Against the background of these processes, secretory, or glandular, pancreatic tissue is replaced by scar tissue. As a result, these parts of the organ cannot perform an exocrine function.
It should be noted that chronic pancreatitis is not the only reason for the development of exocrine insufficiency. Another reason for this phenomenon may be cystic fibrosis, an autoimmune disease that affects organs that produce biological fluid. These include the digestive tract, respiratory tract, pancreas, genitals, sweat glands, oral and nasal cavities.
Chronic pancreatitis and cystic fibrosis are the primary mechanisms for exocrine insufficiency. The secondary mechanisms of its development include a pathological process in which the intake of digestive enzymes into the duodenum does not improve the process of assimilation of food.
This is due to their insufficient activation, inactivation and segregation disturbance. Pancreatitis with exocrine insufficiency arising from secondary causes has certain features. Basically, the course of this disease occurs according to the following "scenario":
- The mucous membrane of the small intestine is affected by many negative factors. As a result, the production of cholecystokinin and secretin is reduced.
- This process provokes a drop in intraduodenal pH below 5.5. This means that pancreatic enzymes will not be activated.
- There is a violation of the movement of food through the small intestine. Unactivated digestive enzymes begin to mix with particles of incoming food.
- As a result, the process of decay develops - an ideal condition for pathogenic bacteria. Various infections join the reproduction of harmful microflora. An increase in the number of bacteria leads to the destruction of digestive enzymes.
- Stagnation of pancreatic juice occurs, which is accompanied by a deficiency of bile and enterokinase.
As a rule, during the total removal of the pancreas (gastrectomy), both primary and secondary mechanisms are involved.
Classification and signs of pathology
Exocrine insufficiency should be classified according to several criteria - the causes that cause pathology and concomitant diseases.
The main manifestations of insufficiency of external secretion are:
- Intolerance to fatty, fried and smoked foods. If the patient eats such food, after a while he will feel heaviness in the stomach. Then colicky pains are added. After emptying the stomach, mushy stools are observed - the main symptom of pancreatitis. In it, you can see impurities of mucus (fat) and particles of undigested food. The frequency of going to the toilet is 3-6 times a day. The fat content of stools is easy enough to determine: stool particles often leave marks on the toilet because they are difficult to flush with water.
- Signs of a lack of fat-soluble vitamins. As a result of their deficiency, pain in the bones is observed, they become more brittle. Hypovitaminosis of vitamin D leads to convulsions, vitamin K - a violation of blood clotting, vitamin A - "night blindness" and dry skin, vitamin E - a decrease in libido, infectious diseases.
- Symptoms associated with deficiency of pancreatic proteases. These enzymes break down proteins. Their deficiency leads to B12-deficiency anemia, which is characterized by decreased ability to work, shortness of breath, pale skin, tachycardia and rapid fatigue. Due to the insufficient amount of nutrients, a rapid decrease in body weight is observed.
These pathological processes concern mainly adults. In childhood, pancreatitis with impaired exocrine function develops extremely rarely. Inflammation of the organ occurs for other reasons - diseases of the small intestine, cholelithiasis, various injuries of the abdominal region, duodenal obstruction, impaired development of the pancreas and pancreatic ducts.
Diagnostic methods and therapy
Noticing the signs, a person needs to seek medical help.
The loss of precious time can lead to complete damage to the pancreas and its removal.
Most effective method diagnosis of the disease is the analysis of feces. It helps to determine the level of pancreatic elastase-1.
The results of the research can be:
- 200-500 mcg/g - normal exocrine function;
- 100-200 mcg / g - mild and moderate degree of exocrine insufficiency;
- Less than 100 mcg / g - a severe degree of pathology.
Diet plays a key role in the treatment of the disease. Among the basic rules of special nutrition for exocrine insufficiency, it is necessary to highlight:
- Meal intervals should not exceed 4 hours.
- You need to eat in small portions 5-6 times a day.
- Avoid excessive consumption of food in the evening and at night.
- Exclude fried, fatty and smoked foods from the diet.
- Give preference to food of plant origin.
- Completely refrain from drinking alcohol.
The basis of the diet is carbohydrate-containing foods - vegetables, fruits, cereals. They are sources of dietary fiber, vitamins, essential micro and macro elements. The consumption of foods such as legumes, cabbage, eggplant, flour products is not recommended, as they increase gas formation in the stomach.
In addition to diet therapy, patients should take medications. The basis of therapy is the following drugs:
- Digestive enzymes that improve the process of assimilation of food (Mezim, Creon, Panzinorm). They are taken during a meal, the dosage depends on the amount of food eaten and its composition.
- Proton pump blockers that help digest food (Lansoprazole, Esomeprazole, Omeprazole). The action of drugs is aimed at creating an alkaline reaction in the upper gastrointestinal tract.
In this case, self-medication is by no means possible. Following all the instructions of the doctor, you can achieve a positive therapeutic effect. As a result, colicky pains and diarrhea will pass, and there will be no admixture of fat and undigested particles in the feces. From time to time the patient is re-examined. The normalization of the digestive process is evidenced by a decrease in the fat content in feces to 7 g.
Experts will talk about chronic pancreatitis in the video in this article.
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