Medicines for pancreatitis of the pancreas: list of the best drugs

What is pancreatitis?

Pancreatitis is an inflammation of the pancreas; it can be very severe and even life-threatening.
The pancreas secretes enzymes that are necessary for the digestion and absorption of food by the intestines. It also produces important hormones (insulin, somatostatin and glucagon) and protects the duodenum from acid that comes from the stomach.

Why does pancreatitis occur?

Malfunction of the gland is provoked by:

alcoholism,
cholelithiasis,
excess intake of fatty foods,
some medications, etc.

Often the cause is narrowed or blocked ducts of the gland. As a result, enzymes secreted by the pancreas accumulate in it and begin to destroy it itself. The gland becomes inflamed (Fig. 1).

Then, instead of going to the duodenum, these enzymes enter the blood, poisoning the body. Read more about the development of the disease in the article “Pancreatitis”

Figure 1. Development of pancreatitis. Source: health.harvard.edu

Pancreatitis can occur in two forms: acute and chronic. In acute cases, unexpected inflammation of the pancreas occurs. It can lead to the death of an organ or its parts and its replacement with connective tissue and fat. In the best case, acute pancreatitis goes away on its own: there is no need for hospitalization. At worst, it becomes chronic. With it, the structure of the organ changes: the ducts become clogged, the gland tissue becomes covered with scars.

There are known cases of recurrent pancreatitis. Its features are acute pain, but against the background of a changed structure of the pancreas.

Causes of pancreatitis

Factors that provoke the onset of the inflammatory process and persistent disruption of the enzymatic function of the pancreas:

structural defects of the digestive system;
dyskinesia of the biliary tract and gallbladder;
severe stress;
cystic fibrosis;
hypothyroidism;
infectious and inflammatory diseases of the gastrointestinal tract;
intoxication with chemicals;
parasitic infections;
mechanical injuries of the abdominal organs as a result of compression, blows, falls;
long-term use of medications: antibiotics, glucocorticosteroids.

Living in environmentally unfavorable regions and dietary errors can affect the health of the pancreas. The risk of pancreatitis increases consumption of alcohol, refined, fatty foods, fried foods, canned, smoked foods, and overeating.

Symptoms of chronic and acute pancreatitis

Symptoms usually appear after excessive consumption of alcohol and fatty foods. Pancreatitis is characterized by:

constant severe pain in the left hypochondrium or girdle pain in the epigastrium (upper abdomen),
repeated vomiting,
swelling in the upper abdomen,
cardiopalmus,
low blood pressure,
change in stool (at the beginning of the disease, stool is normal, then diarrhea occurs, fatty spots are present in the stool, the smell is sharp and unpleasant),
weight loss, lack of appetite (in chronic form).

In the chronic form, the pain may be dull and aching in the middle of the abdomen. If recurrent pancreatitis occurs, the acute pain returns. Over time, the pain is replaced by a lack of enzymes, which leads to bloating after eating. The chronic form may be accompanied by decreased appetite and loss of the small intestine's ability to absorb nutrients (malabsorption). A lot of fat comes out with feces; it has an unpleasant odor, is lighter than normal and has greasy stains. This form is also fraught with the formation of false cysts in the gland, which increase the risk of pancreatic cancer.

Methods for diagnosing pancreatitis

For most patients, the reason for going to the clinic is regular abdominal pain, loss of appetite, heaviness in the stomach and other obvious signs of pathology. Chronic inflammation can be discovered accidentally during medical examination. Methods for diagnosing pancreatitis:

Blood chemistry. Classic signs of health problems: high ESR, leukocytosis. With pancreatitis, the levels of trypsin, amylase and lipase increase.
Examination of urine and feces samples. They show an increase in amylase and changes in the levels of other enzymes. The coprogram shows the presence of undigested food residues.
Ultrasound of the abdominal organs. An informative method that determines changes in the size and structure of the pancreas, concomitant inflammation of nearby bile ducts and liver.
MRI. Prescribed for the differential diagnosis of pancreatitis in complex or controversial cases, with a severe course of the process.

Treatment Basics

The approach to treating pancreatitis varies depending on the form of the disease. In acute severe form of pancreatitis, when there is pain and constant vomiting, the patient is hospitalized. In case of a chronic disease and in the absence of relapses, hospitalization is not required; doctors fight the cause of the disease with the help of drugs.

Acute pancreatitis on a CT image. Photo: Hellerhoff / (Creative Commons Attribution-Share Alike 3.0 Unported license)

After admission to the hospital with acute pancreatitis, the patient is not fed, as a rule, for the first 48 hours. A tube is inserted into the stomach to remove its contents. If there are complications (bleeding, acute intestinal obstruction, suppuration, etc.), the patient is referred for surgery.

Next, the doctor prescribes various medications to reduce the load on the gland, reduce pain and prevent the development of infection.

With pancreatitis, control of the production of pancreatic digestive enzymes is vital. Lack of oral nutrition in the first week after the attack is over is the most effective way of such control. Therefore, parenteral nutrition is used, that is, intravenous infusion through a dropper, or enteral nutrition, in which nutritional mixtures are administered through a tube.

Pancreatitis can occur with a complication in the form of death of part of the pancreas or the entire organ (pancreatic necrosis). In this case, doctors adhere to a conservative method of treatment with the help of medications. In case of infected pancreatic necrosis, the use of antibiotics is mandatory. If conservative treatment does not help and the patient progresses to multiple organ failure, suppuration, pancreatic necrosis or pancreatic cancer, surgery is prescribed.

At the first stage, doctors prefer to minimize surgical intervention in the body. First, puncture and drainage of the pancreas and retroperitoneum are performed. To do this, using small incisions, special tubes (drains) are inserted inside, which remove excess liquid and wash the cavity with special solutions.

In case of a more severe condition of the patient and widespread damage to the gland, they resort to alternative treatment tactics, which include:

laparotomy, that is, external drainage, in which incisions are made in the abdominal wall,
resection of the gland or removal of it entirely.

Removing the gland is an extreme measure; it is resorted to in a situation where the organ can no longer be restored. It is possible to live without a gland, but you will have to artificially maintain its functions: take insulin, enzyme preparations and follow a very strict diet.

How to cope with an attack of pancreatitis?

The main task when severe pain occurs is to provide the gland with cold, hunger and peace. You should not eat anything and consult a doctor immediately. To relieve inflammation, you need to put a cold compress on your stomach.

Drug treatment of pancreatitis in adults

Medicines play an important role in the treatment of pancreatitis. They carry several functions at once:

restoration of enzyme deficiency,
restoration of hormonal levels,
improvement of metabolic processes,
fight inflammation
preventing spasms,
normalization of blood circulation,
pain relief,
compensation of water-electrolyte losses and plasma losses.

The range of prescribed medications can be large; it is important to strictly follow the doctor’s instructions and take all necessary medications on time.

6 tips to help you remember to take your medications

Many drugs for pancreatitis need to be taken regularly, without missing the next dose. To quickly adapt to life during illness, follow these simple tips:

It is important to take digestive enzymes and some other medications before meals. At first, it is useful to say to yourself: “First medicine, then food.” The idea is to make taking your medications as routine as washing your hands and using a tissue.
Use a medication organizer. The cells in it can be associated with the time of day or the next meal; some organizers are equipped with a timer and can sound a sound signal. At the end of the month, using the pill box, it is easy to track whether all medications were taken on time (Fig. 2).
Keep the tablets in a visible place. Don't forget to put them in your bag when you leave home. If you use a lunch box, place your pills in or next to it.
Tell your friends and family about your illness. Someone close to you can tell you to take your medicine on time if you forget about it.
Listen to yourself. Renewal of symptoms may clearly indicate missed medications.
Some medications are better taken twice than not taken at all. Consult with your doctor which of your tablets can be taken in double doses without harm to your health, so you will not be afraid to take the tablet again if you do not remember when you took the medicine.

Figure 2. Medicine organizer. Source: freepik.com

Features of prescribing drugs for pancreatitis in women

Acute pancreatitis in pregnant women is a rare occurrence. Research suggests only three cases out of 10,000. However, as pregnancy progresses, the risk of developing the disease increases. Therefore, the treatment of such patients should be approached very carefully.

There is no agreement among doctors regarding the use of antibiotics during pregnancy. When choosing a medication, the doctor takes into account the severity of the disease, associated complications, and gestational age. In some cases, a positive outcome for the mother is the decisive factor in prescribing antibiotic therapy, even despite the risks of impaired fetal development. In the absence of infection in the bile ducts, as a rule, antibiotics are not prescribed.

Mild forms of pancreatitis may go away on their own. The doctor prescribes antihyperlipidemic drugs, insulin, heparin and diet. In severe cases, the question of termination of pregnancy comes up. The decision depends on many factors and is made by the doctor in each individual case.

Venous parenteral nutrition catheters may cause pregnancy complications. Enteral feeding is preferred, using a tube that passes through the nose and esophagus into the intestines.

Drug treatment of pancreatitis in children

Doctors agree that pancreatitis in children is difficult to diagnose. The reasons for its appearance differ from cases with adults, but the disease itself is more treatable.

Most often, pancreatitis in children occurs against the background of other diseases. Thus, the causes may be inflammation of other organs: the stomach and duodenum (gastroduodenitis), gall bladder (cholecystitis), intestines (enterocolitis), or peptic ulcer. Other causes include the use of certain medications, anatomical features of the gastrointestinal tract, and abdominal trauma.

Treatment is aimed at eliminating the cause of the disease and preventing dangerous consequences. Children are prescribed the same medications as adults. The dosage of each medication is determined by the doctor.

Diet is the basis of treatment of childhood pancreatitis. Overeating or poor nutrition (excessive amounts of canned and fatty foods) can trigger inflammation. It is important to follow fractional meals in small portions, limit the amount of fat, sugar and salt, and absolutely exclude fried and pickled foods, sweet carbonated water, chocolate and ice cream from the diet. For more information about nutrition for pancreatitis, read the article “Diet for pancreatitis.”

What are the functions of the pancreas?

The pancreas performs two important functions.

It produces enzymes (digestive enzymes) and releases them into the duodenum. Enzymes in the digestive tract break down carbohydrates, proteins and fats. This is the so-called exocrine function.
Another function is endocrine , which is performed by beta cells of the islets of Langerhans, producing insulin (hormone), and alpha cells, producing glucagon. Insulin controls the level of glucose (sugar) in the blood. It acts against hyperglycemia (high blood sugar) and glucagon corrects hypoglycemia (low blood sugar). Insulin also promotes the absorption of glucose in the liver, where it is stored in the form of glycogen, and then used during stress and exercise. When the islets of Langerhans produce little insulin, glucose levels rise and there is a risk of developing diabetes, etc.

Drugs

The main task in the treatment of pancreatitis is to get rid of the cause that caused the inflammation and prevent the onset of complications. Therefore, doctors prescribe a whole course of tablets that should help the digestive system cope with the malfunction (Fig. 3).

Figure 3. To treat pancreatitis, medications of different directions of action are used. Source: MedPortal

Antispasmodics for pancreatitis

Antispasmodics are prescribed to relieve pain and muscle spasms. They can be administered intramuscularly or intravenously. The main ones include those containing drotaverine, mebeverine, pinaverium bromide, m-anticholinergics (metocinium iodide, atropine).

Enzymes and antienzyme drugs for pancreatitis

With pancreatitis, the gland is unable to produce enzymes necessary for digestion. Therefore, the patient must receive them from outside. In addition, the introduction of enzymes allows the gland to reduce their production and rest. Enzymes are prescribed only in the absence of exacerbation. They are divided into those that contain pancreatin (with and without bile components), and those that contain only components of plant origin (simethicone, chymopapain).

In acute pancreatitis, intoxication of the body occurs. Enzymes accumulate in the pancreas and, instead of going further to the duodenum, enter the blood. Anti-enzyme drugs are used to cleanse the body and relieve stress on the pancreas. They are drunk in the first 5 days from the onset of the disease. The main active ingredient of such drugs is aprotinin.

Important! Enzyme preparations must be taken with every meal. The enzyme preparation, its dosage and duration of treatment are determined only by the doctor. Under no circumstances should you take enzymes for acute pain. Such pain indicates worsening inflammation in the pancreas. Taking enzymes in this case will lead to increased intraductal pressure, which in the future will lead to blockage of blood vessels and necrosis.

Antacids

Hydrochloric acid, which is contained in gastric juice, triggers the work of the pancreas. The more of this acid, the more actively the iron works. With pancreatitis, increased activity of the organ leads to pain and complications. Antacids are used to reduce acidity in the stomach. They contain algeldate and magnesium hydroxide, which neutralize stomach acid. Doctors give preference to drugs in liquid form.

Antisecretory

Antisecretory drugs reduce the production of hydrochloric acid, which is contained in gastric juice. Its excessive amount leads to the fact that the alkaline pancreatic secretion is not able to neutralize the acidity of the environment. It is the alkaline environment that provides the best conditions for digestion, so its restoration is one of the tasks in the fight against pancreatitis. Another function of such drugs is to have a cytoprotective effect. They increase the secretion of protective mucus, increase blood flow to the digestive system and promote scar healing.

H2 blockers

These are antihistamine antisecretory agents. Their action is aimed at preventing the excitation of H2 receptors, which stimulate the work of all glands: salivary, gastric, pancreas. They reduce the acidity of gastric juice, delay the production of hydrochloric acid and pepsin, which breaks down protein. These include drugs containing famotidine, ranitidine, etc.

Proton pump inhibitors

Medicines whose purpose is to block the work of the proton pump located in the gastric mucosa and thereby reduce the acidity of the stomach by reducing the production of hydrochloric acid. The same acid that is necessary for digestion, but in large quantities leads to gastritis, and then to ulcers. Such drugs are benzimidazole derivatives. This includes drugs containing omeprazole, pantoprazole, lansoprazole, etc.

pharmachologic effect

Antienzyme drugs block the most powerful pancreatic enzyme, trypsin. Trypsin breaks down proteins (proteins) through a biochemical process called proteolysis. That is why antienzyme drugs are also called proteolysis inhibitors. At the same time, the processes of self-digestion in the pancreas stop and toxins - autolysis products - stop being released into the blood.

Antienzyme drugs additionally have a hemostatic effect by blocking the action of other protease enzymes in the blood responsible for the breakdown of proteins. In particular, antienzyme drugs inhibit the activity of the enzyme fibrinolysin (plasmin), which is responsible for the destruction of fibrin threads that stabilize blood clots, thereby preventing bleeding from stopping.

In addition, antienzyme drugs have a nonspecific anti-inflammatory effect.

Other medications for pancreatitis

Depending on the form and phase of the disease in each individual case, based on symptoms and test results, the doctor prescribes additional medications.

Antibiotics

To combat inflammation and pus, as well as to prevent serious consequences in the form of necrosis, sepsis and abscess, antibiotics and antimicrobial agents are needed. The duration of the course usually does not exceed 7–14 days. Carbapenems, cephalosporins, fluoroquinolones, and metronidazole are usually used. In the hospital, such drugs are administered parenterally (intramuscularly or intravenously).

Vitamins

Digestive insufficiency is usually accompanied by a lack of vitamins. Before prescribing vitamin preparations, doctors always send for analysis to find out which vitamins are missing. As a rule, fat-soluble vitamins A, D, E and K are prescribed, since they are responsible for the metabolism of proteins, fats and carbohydrates. They also help enzymes function and protect against pancreatic cancer.

Anti-inflammatory drugs for pancreatitis

In addition to antibiotics, doctors prescribe non-steroidal anti-inflammatory drugs and analgesics. In particular, non-narcotic analgesics (diclofenac, piroxicam, meloxicam, metamizole sodium, etc.). They relieve inflammation and pain.

Is it possible to take choleretic drugs?

Gallstone disease is one of the main causes of pancreatitis. Therefore, choleretic substances, which help prevent stagnation of bile and reduce the load on the pancreas, are on the list of drugs to combat this disease. It must be borne in mind that in acute pancreatitis and exacerbation of the chronic form, choleretic drugs are contraindicated. They are taken only during the period of remission.

Iron supplements

The use of iron supplements in the treatment of pancreatitis is not common practice. In some cases, taking enzyme preparations can lead to a deterioration in the absorption of iron and, consequently, its deficiency in the body. According to other data, the consumption of iron supplements by patients after acute pancreatitis affected carbohydrate metabolism.

Preparations for restoring intestinal microflora

In addition to the basic treatment complex, bifidobacteria and lactobacilli are prescribed. They are designed to restore microflora especially after taking antibiotics. Such drugs are the prevention of dysbiosis, in which the microbial composition of the intestine is disrupted.

What drops are falling

Infusion solutions are prescribed in the form of droppers. This therapy is aimed at maintaining water and electrolyte composition. This includes colloidal and crystalline solutions. They replenish lost energy, protein and plasma.

Plasmapheresis

Plasmapheresis is used to cleanse the body of toxins. During this procedure, blood is taken, the patient's plasma, which contains toxins, is filtered, and donor plasma is returned.

Chronic pancreatitis: diagnosis and treatment

Chronic pancreatitis is a group of diseases (variants of chronic pancreatitis), which are characterized by various etiological factors, the presence of focal necrosis in the pancreas against the background of segmental fibrosis with the development of functional failure of varying severity [1]. The progression of chronic pancreatitis leads to the appearance and development of atrophy of glandular tissue, fibrosis and replacement of cellular elements of the pancreatic parenchyma with connective tissue. The literature of recent years contains publications that provide the opinions of some researchers about the stages of the course (progression) of chronic pancreatitis. According to one of them [6], the initial period of the disease, the stage of exocrine pancreatic insufficiency and the complicated version of the course of chronic pancreatitis are distinguished - tumors of this organ; however, apparently, other variants of the course of chronic pancreatitis are also possible.

Clinical manifestations of chronic pancreatitis

Analysis of medical documents of patients sent from outpatient clinics to a hospital for further examination and treatment with a preliminary diagnosis of “pancreatitis” (“exacerbation of chronic pancreatitis”), and medical records of patients who, as a result of the examination, were diagnosed with “exacerbation” as the main one chronic pancreatitis” showed that often both diagnoses are not true. It was found that in some cases there was no data indicating the presence of chronic pancreatitis at all, while in others it was a case of chronic pancreatitis in remission. As the examination showed, patients were forced to consult a doctor for medical help due to exacerbation of peptic ulcer disease, exacerbation of chronic gastritis, reflux esophagitis or other diseases, the combination of which with chronic pancreatitis has been studied only in a few studies [2, 11].

An analysis of medical histories of patients with pancreatic diseases showed that even today, despite the emergence of new diagnostic methods, a thorough ascertainment of patient complaints and medical history, as well as a physical examination remain the most important part of the initial examination. The choice of the most important laboratory and instrumental methods for a particular patient, allowing to identify or exclude chronic pancreatitis, as well as possible underlying or concomitant diseases, largely depends on them.

The main symptoms of exacerbation of chronic pancreatitis: more or less pronounced (sometimes intense) attacks of pain, most often localized in the left hypochondrium and/or in the epigastric region, whether associated or not with food intake, often occurring after eating; various dyspeptic disorders, including flatulence, the appearance of malabsorption with the occurrence of steatorrhea and subsequent decrease in body weight (various symptoms, including the frequency of their occurrence and intensity, considered as possible signs of chronic pancreatitis, are not always combined with each other).

When examining patients with chronic pancreatitis (during the period of exacerbation), some of them can reveal a whitish coating on the tongue, a decrease in body weight and skin turgor, as well as signs of hypovitaminosis (“sticking” in the area of the corner of the mouth, dryness and flaking of the skin, brittle hair and nails etc.), “ruby droplets” on the skin of the chest and abdomen [5]. Reddish spots may appear on the skin of the chest, abdomen and back, remaining when pressed. On palpation of the abdomen, pain is noted in the epigastric region and left hypochondrium, including in the area of the projection of the pancreas. In many patients (during an exacerbation), it is possible to identify a positive Mayo-Robson symptom (pain in the area of the left costovertebral angle), Gray-Turner symptom (subcutaneous hemorrhages on the lateral surfaces of the abdomen, cyanosis in the lateral surfaces of the abdomen, or around the navel - Cullen's symptom ), Voskresensky’s symptom (a dense, painful formation located in the area of the pancreas is palpated, resulting from swelling of it and surrounding tissues, covering the pulsating aorta; as the swelling of the pancreas disappears against the background of adequate treatment of patients, pulsation of the aorta appears again), Groth’s symptom (atrophy subcutaneous fatty tissue of the anterior abdominal wall, to the left of the navel in the projection of the pancreas), Grunwald's symptom (ecchymoses and petechiae around the navel and in the gluteal regions as a result of damage to peripheral vessels), Kach's symptom (violation of muscle protection, which is usually noticeable upon palpation of the abdomen) , less often - pain at the Desjardins point and/or at the Shafar point.

With an exacerbation of chronic pancreatitis, the appearance of nodules that are painful on palpation, similar in appearance to erythema, is also possible, which is associated with subcutaneous damage to the tissue in the legs, as well as the occurrence of thrombosis of the superior mesenteric, splenic and portal veins. The appearance of fat necrosis can subsequently lead to trauma to the pancreatic ducts with the appearance of pancreatic pseudocysts in these areas. Often, only when the latter increase in size may clinical symptoms appear (most often pain in the upper abdomen).

With the progression of chronic pancreatitis, in addition to the symptoms of exocrine pancreatic insufficiency, it is also possible to develop intrasecretory pancreatic insufficiency with clinical manifestations considered characteristic of diabetes.

Diagnostics. In principle, to diagnose exacerbations of chronic pancreatitis, including possible complications of this disease, it is usually recommended to use the following methods:

in order to assess the activity of the inflammatory process in the pancreas - determination of the levels of amylase, lipase, various so-called “inflammatory” cytokines (interleukins I, II, VI and VIII, tumor necrosis factor (TNF-a), platelet activating factor (PAF), etc. .); carrying out an elastase test (enzyme immunoassay method);
in order to determine the state of exocrine pancreatic insufficiency - a) analysis of clinical data to assess the amount (volume) of feces excreted by patients, determining the presence/absence of steatorrhea and creatorrhoea; b) assessment of indicators of laboratory research methods - secretin-pancreozymin test (cerulein), bentyramine test (PABA test), coprological test (determination of elastase-1) using monoclonal antibodies, Lund test;
in order to identify organic lesions of the pancreas and nearby organs - instrumental research methods: plain radiography, ultrasound (ultrasound), computed tomography, esophagogastroduodenoscopy with endoscopic cholangiopancreatography, radionucleide cholecystography and/or intravenous cholangiography;
additionally, in order to identify pancreatic tumors, a study of tumor markers (CA 19-9, EEA), targeted laparoscopic or surgical (open) so-called “fine-needle” biopsy.

One cannot help but wonder about the availability of some of these methods. It is quite clear that a number of the above examinations can be carried out (for various reasons) only in specialized hospitals. However, is it always necessary to use all of the above methods when there is a suspicion of exacerbation of chronic pancreatitis (including for the purpose of excluding or identifying chronic pancreatitis in remission) and its complications? It is obvious that in practice it is necessary to use, first of all, those methods that are available in a particular medical institution. In doubtful cases, patients should be referred to specialized hospitals.

The main clinical symptoms considered characteristic of exocrine pancreatic insufficiency: various dyspeptic disorders, including flatulence, pain that occurs more often in the upper abdomen, weight loss, steatorrhea. When assessing the amylase level, it is necessary to take into account that the amylase level increases at the beginning of an exacerbation of chronic pancreatitis, reaching a maximum at the end of the first day; on the 2nd–4th day the amylase level decreases; on the 4th–5th day it normalizes. (A “crossover” between the levels of amylase and lipase is possible—a decrease in the first while the second increases.) Unlike the level of amylase, the level of lipase often increases from the end of 4–5 days and remains elevated for about 10–13 days, then decreases.

Exocrine pancreatic insufficiency is known to arise and progress as a result of impaired hydrolysis of proteins, fats and carbohydrates by pancreatic enzymes in the lumen of the duodenum. Therefore, it is very important to promptly assess the appearance of stool, its consistency, color and volume. Often the first signs of the appearance of exocrine pancreatic insufficiency can be judged only on the basis of microscopic examination of the patients’ stool. In the presence of exocrine pancreatic insufficiency, signs of digestion disorders (steatorrhea, creatorrhoea, amilorrhea) can be detected in the stool of patients.

It is known that steatorrhea (the appearance of a significant amount of undigested triglycerides in the stool due to insufficient entry of lipase into the duodenum) occurs when the secretion of pancreatic lipase is below 10% compared to normal. However, in some patients, the appearance of clinical symptoms is possible even with a significantly lower level of lipase secretion (15–20%), which largely depends on the composition of the food, its volume and other factors, including treatment with certain medications, as well as the presence of “extrapancreatic” disease in some patients. At the same time, there is an increase in the volume of feces, the latter becomes soft (“thindy”); due to the appearance of fatty “inclusions”, the feces acquire a whitish-white color (sometimes it becomes “shiny”). When flushing feces with water, a “greasy” stain remains at the bottom of the toilet.

Creatorrhea (the appearance in the stool of a significant amount of undigested muscle fibers, i.e. proteins) is possible with insufficient intake of various proteases (primarily trypsin and chemotrypsin) into the duodenum.

The appearance of starch in the feces of patients, due to a violation of its hydrolysis, is observed with a deficiency of pancreatic amylase, which is usually considered as a typical sign of amilorrhea.

Ultrasound is currently considered one of the accessible, effective, and not burdensome examination methods for patients. The presence of chronic pancreatitis, according to ultrasound, is usually judged by identifying heterogeneity of the pancreatic parenchyma, a diffuse increase in echogenicity, blurred and uneven contours of this organ.

When carrying out differential diagnosis, it is necessary to take into account that, unlike chronic pancreatitis, acute pancreatitis most often has a moderate, non-progressive course (after eliminating the acute “attack”). The occurrence of exocrine and/or intrasecretory pancreatic insufficiency is possible in 10–15% of cases with severe acute necrotizing pancreatitis [8]. It must also be remembered that the most common causes of acute pancreatitis are diseases of the bile ducts (38%) and alcohol abuse [12, 17].

Exocrine pancreatic insufficiency can appear not only in patients with chronic pancreatitis (most often) and cystic fibrosis (cystic fibrosis), but also after gastric resection for cancer and pancreatic resection for persistent hyperinsulinemic hypoglycemia of newborns, with inflammatory bowel diseases, with celiac disease ( gluten enteropathy, sprue), diabetes mellitus, acquired immunodeficiency syndrome (AIDS), Sjögren's syndrome, enterokinase deficiency, the so-called syndrome of “excess bacterial growth in the small intestine”, various diseases that result in blockage of the ducts of the pancreaticoduodenal zone with stones, and also disorders that appear after gastrectomy, which should be taken into account when carrying out differential diagnosis.

Observations show that we can talk about other diseases that come to the fore, worsening the condition and shortening the life of patients. Timely detection of these diseases and adequate treatment are of no small importance. There are cases when patients seek medical help whose chronic pancreatitis is in remission, while the deterioration of their condition in one period or another may be due to another disease, which must also be taken into account during the examination.

Therapy of chronic pancreatitis. Treatment of patients with chronic pancreatitis largely depends on the severity of its exacerbation (including the presence or absence of various complications), manifested by various, more or less pronounced symptoms in pain, dyspeptic, hypoglycemic, so-called “metabolic” and/or “icteric” » options. Often it is not possible to accurately determine one or another clinical variant.

The main approach to treating patients with chronic pancreatitis in order to improve their condition involves carrying out, if necessary, the following therapeutic measures:

elimination of pain and dyspeptic disorders, including clinical manifestations of exocrine and intrasecretory pancreatic insufficiency;
elimination of inflammatory changes in the pancreas and concomitant lesions of other organs, which in some cases makes it possible to prevent the occurrence of complications;
treatment of complications requiring surgical treatment (performing the necessary operation);
prevention of complications and rehabilitation of patients;
improving quality of life.

The appearance of complications of chronic pancreatitis largely determines the progression of the disease, and often significantly changes (intensifies) the clinical manifestations of chronic pancreatitis.

In case of severe exacerbation of chronic pancreatitis, as is known, in the first 2-3 days, patients are recommended to refrain from eating, take hydrocarbonate-chloride waters (Borjomi and some others) 200-250 ml up to 5-7 times a day (in order to inhibit juice secretion pancreas). In the future, it is advisable to use a diet developed for the 5P table in the treatment of patients. If necessary, drugs intended for enteral and parenteral nutrition are used in the treatment of patients. Only in cases of severe gastro- and duodenostasis is continuous aspiration of the stomach contents performed through a thin rubber probe. As the patient’s condition improves, the patient’s diet gradually expands (up to 4–5 times a day), primarily the amount of protein increases. Patients are not recommended to consume fatty and spicy foods, sour apples and fruit juices, alcoholic and carbonated drinks, as well as foods that promote or increase flatulence.

In principle, in the treatment of patients with chronic pancreatitis, depending on their condition, various drugs are used: those that reduce pancreatic secretion, most often antacids (phosphalugel, Maalox, Almagel, etc.); H2-histamine receptor antagonists (Zantac, quamatel, gastrosidin, etc.); proton pump inhibitors (omeprazole, rabeprazole, esomeprazole, lansoprazole, etc.); anticholinergics (gastrocepin, atropine, platifillin, etc.); enzyme preparations (for exacerbation of chronic pancreatitis), in the absence of exocrine pancreatic insufficiency - pancitrate 20,000 or Creon 25,000, one capsule every 3 hours or 2 capsules 4 times a day during the fasting period (in the first 3 days) and one capsule at the beginning and at the end of a meal after resuming food intake. Other enzyme preparations that do not contain bile acids can be used in equivalent dosages [3]: sandostatin, etc.; agents that suppress the activity of pancreatic enzymes (contrical, gordox, trasylol, etc.); antispasmodics (no-spa, buscopan, etc.), prokinetics (motilium, cerucal, etc.), painkillers (baralgin, non-steroidal anti-inflammatory drugs, etc.), antibiotics, plasma replacement solutions (hemodez, reopolyglucin, 5–10% solution glucose, etc.) etc.

Enzyme preparations are widely used in the treatment of patients with chronic pancreatitis in order to inhibit pancreatic secretion according to the so-called “feedback” principle - an increased concentration of enzyme preparations (primarily trypsin) in the duodenum and other parts of the small intestine leads to a decrease in the secretion of cholecystokinin, which has recently played a significant role in stimulating the exocrine function of the pancreas (enzyme production). It has been noted that the use of enzyme preparations in the treatment of patients with chronic pancreatitis in some of them makes it possible to reduce the incidence and intensity of pain syndrome [15]: inhibition (inhibition) of the secretory function of the pancreas makes it possible to reduce intraductal pressure and, accordingly, reduce the intensity of pain syndrome. The use of pancreatic enzymes remains the main method of elimination and malabsorption to this day.

For the treatment of patients with exocrine pancreatic insufficiency, a number of medications have been developed, among which a significant place is given to enzyme preparations (for replacement therapy) containing a significant amount of lipase (up to 30,000 units per single meal in order to improve primarily the absorption of fats). They are covered with a special shell (within which there are small-sized microtablets or granules), which protects enzymes, primarily lipase and trypsin, from destruction by gastric juice. This membrane is quickly destroyed in the duodenum, and in the initial part of the jejunum, enzymes are quickly “released” and activated in an alkaline environment. These enzyme preparations are characterized by the absence of bile acids, which can increase pancreatic secretion and can even contribute to the appearance of diarrhea.

Replacement therapy is indicated when more than 1.5 g of fat is excreted in the feces per day, as well as in the presence of steatorrhea in patients with dyspeptic symptoms (diarrhea) and/or loss (reduction) of body weight. When treating patients with severe steatorrhea (copious “shiny” stool), the initial (single) dose of lipase should be at least 6,000 units, if necessary it is increased to 30,000 units per day [3].

Recently, pancitrate and Creon are most often used in the treatment of patients with chronic pancreatitis with exocrine pancreatic insufficiency in Russia.

In principle, the dose of the enzyme preparation is determined taking into account the severity of exocrine pancreatic insufficiency and the nosological form of the disease. The daily dose of an enzyme preparation for adult patients most often averages from 30,000 to 150,000 units. However, with complete insufficiency of the exocrine function of the pancreas, the dose of the enzyme preparation increases depending on the daily requirement, which to a certain extent depends on the patient’s body weight. The duration of treatment with enzyme preparations is determined by the attending physician and depends on the condition of the patients. Some researchers [10, 12, 13] recommend prescribing enzyme preparations for a course of 2–3 months, followed by maintenance therapy for another 1–2 months until symptoms disappear completely. Obviously, to increase the effectiveness of enzyme preparations, it is advisable for patients to take drugs that inhibit acid formation in the stomach (see below).

Unfortunately, 5–10% of patients with chronic pancreatitis with exocrine pancreatic insufficiency do not respond or respond poorly to treatment with enzyme preparations [7]. It is known that with exacerbation of chronic pancreatitis, a more or less pronounced decrease in the production of bicarbonates is possible, the consequence of which is a violation of “alkalinization” in the duodenum. That is why in the treatment of patients with exocrine pancreatic insufficiency, antacid drugs (Almagel, phosphalugel, Maalox, Gastal, Gelusil Lac) are used to neutralize the acid secreted by the parietal cells of the mucous membrane into the gastric cavity, H2-histamine receptor antagonists (ranitidine, famotidine) and inhibitors proton pump (omeprazole, lansoprazole, rabeprazole, esomeprazole) in therapeutic dosages to inhibit hydrochloric acid (preventing the inactivation of enzymes in the duodenum). The use of these drugs makes it possible to increase the effectiveness of enzyme therapy, including enhancing the effect of lipase. A decrease in gastric acidity increases the percentage of fats that are in an emulsified state and become more accessible to lipase.

When deciding on the advisability/inappropriateness of using antacid drugs in the treatment of patients suffering from exocrine pancreatic insufficiency, the following fact must be taken into account: antacid combination drugs containing magnesium or calcium reduce the effectiveness of enzyme preparations.

In order to compensate for the so-called “nutrient” deficiency, it is advisable to use medium-chain triglycerides, in particular tricarbonate, as well as B vitamins and fat-soluble vitamins A, D, E, K.

To treat insufficiency of exocrine pancreatic function, many doctors continue to use pancreatin. Standard treatment with pancreatin in a dose of up to 8 tablets taken with meals can stop azoorrhea and reduce (but not completely eliminate) steatorrhea [16]. In the majority of patients with this therapy, a completely satisfactory nutritional state and a relatively asymptomatic “course” of exocrine pancreatic insufficiency are achieved. In such cases, additional inclusion in the treatment of patients with H2-histamine receptor antagonists (Zantac, quamatel, gastrosidin) or proton pump inhibitors (in addition to standard treatment with pancreatin) in most patients quickly eliminates (significantly reduces) steatorrhea and alleviates painful diarrhea. Similar results can be achieved by using bicarbonates in the treatment of patients.

It should be noted that with the progression of chronic pancreatitis with exocrine pancreatic insufficiency, intrasecretory pancreatic insufficiency can gradually develop. Factors such as malnutrition, including protein deficiency, which cause direct or indirect damaging effects on the pancreas, can also affect the endocrine part of this organ [9]. This is explained by the fact that the exocrine and intrasecretory parts of the pancreas are closely connected and influence each other during the life of the organ as a whole.

In the treatment of endocrine disorders that occur in some patients with chronic pancreatitis, it is necessary to take into account the likelihood of hypoglycemia and “calorie” insufficiency, which indicates the inappropriateness of limiting the amount of carbohydrates in the diet of patients. It must also be remembered that drinking alcohol increases the likelihood of developing hypoglycemia - this should be taken into account when selecting insulin dosages.

Yu. V. Vasiliev , Doctor of Medical Sciences, Professor of the Central Research Institute of Gastroenterology, Moscow

For questions regarding literature, please contact the editor.

Features of taking medications for pancreatitis

For pancreatitis, any self-medication is strictly contraindicated, even taking painkillers. The doctor determines the method of treatment, selects medications and their dosage strictly individually for each patient. The duration of treatment depends on the form of the disease, its severity, as well as on the patient’s body’s response to a particular drug. It is important not to forget about the medicine: take medications regularly and at the strictly designated time.

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Complications after taking medications

Medicines for pancreatitis, like any medicine, can lead to complications. Antibiotics - for digestive upset, non-steroidal anti-inflammatory drugs - for complications in the gastrointestinal tract and cardiovascular system. Enzyme preparations can cause allergies and lead to iron deficiency. Antisecretory drugs, although they are considered drugs with a minimum of side effects, can cause withdrawal syndrome: the appearance of heartburn and sometimes pain in the sternum after stopping their use. Even vitamins, if taken immoderately and without prior testing, can become not just a useless, but also a dangerous supplement.

Is it possible to cure pancreatitis forever?

The likelihood of recovery from pancreatitis depends on the form of the disease and its cause. Sometimes a mild form is caused by eating a lot of fatty foods or drinking alcohol. In this case, the inflammation can go away on its own without leaving any traces: excess fluid will not form around the organ, the ducts will not be blocked, which means enzymes will not accumulate in the gland.

Another thing is alcoholism, complications of gallstone disease, the presence of inflammation or tumors in other organs of the digestive system. Pancreatitis as a concomitant disease requires strict medical supervision. If the situation is advanced: the structure of the organ is changed or part of it dies (pancreatic necrosis), then there is no talk of cure. After completing a course of mandatory drug therapy, patients will have to undergo maintenance therapy, a strict diet, and a complete cessation of alcohol and smoking. According to doctors, the patient should be monitored for at least three months. Physical activity will become a good habit. Physical education improves metabolic processes, helps control weight and cleanses toxins.

Prevention of pancreatic diseases

It should be remembered that the functioning of the gland is most negatively affected by alcohol, smoking, irregular meals, fried, spicy and fatty foods. All this should be avoided. The diet should be healthy. You need to eat four to five times a day, and moderation in food is also important.

Pancreatic diseases should be taken seriously and be thoroughly examined in order to receive optimal treatment.

Our clinic offers modern diagnostic methods with consultation of experienced specialists for the treatment of pancreatic diseases. Don’t delay until later and make an appointment with a gastroenterologist right now.

Sources

Minutes of the meeting of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan No. 23 dated December 12, 2013. Acute pancreatitis.
St. Petersburg State Medical University named after Academician I. P. Pavlov. Department of Faculty Therapy, author: Honored Doctor of the Russian Federation, Associate Professor E. V. Kraevsky. Chronic pancreatitis.
Clinical protocol for diagnosis and treatment No. 18 of the Expert Council of the Republican State Enterprise at the Republican Center for Healthcare Development of the Ministry of Health and Social Development of the Republic of Kazakhstan dated November 30, 2015. Chronic pancreatitis in children.
First St. Petersburg State Medical University named after. acad. I.P. Pavlova. Treatment of acute pancreatitis. Authors: S. F. Bagnenko, N. V. Rukhlyada, A. D. Tolstoy, V. R. Goltsov.

Indications for use

Antienzyme drugs are used for diseases that are accompanied by a violation of the outflow of pancreatic juice from the pancreas: acute pancreatitis, exacerbations of chronic pancreatitis, severe injuries of the pancreas, pancreatic tumors, swelling of the walls of the duodenum with long-term active intake of alcohol.

Anti-enzyme drugs are also used to prevent severe bleeding and severe blood loss in case of operations on the heart, cardiac (coronary) vessels, lungs, etc.