Chronic pancreatitis: causes of the disease, symptoms of chronic pancreatitis, treatment, prevention, ICD-10 code, results

Diseases of the pancreas, primarily chronic pancreatitis, represent damage to the pancreas by various etiological (causal) factors, but having a progressive relapsing course with disruption of the intrasecretory (hormonal) and exocrine (enzymatic) functions of the pancreas, its gradual atrophy and replacement of pancreatic cells with connective ( fibrous) tissue.

Chronic pancreatitis refers to diseases that are characterized by a variety of nonspecific manifestations that depend on the phase of the disease, the cause, and the condition of other digestive organs.

Disease history

A separate section of gastroenterology—pancreatology—is devoted to the study of pancreatitis. The first mention of the pancreas is contained in the works of Aristotle, but a detailed study of the pathological processes associated with this organ was not carried out at that time. The study of the physiology of this part of the digestive system is complicated by its specific location in the body. Significant advances in research occurred at the turn of the nineteenth and twentieth centuries.

The first full-fledged studies were carried out by:

R.Friz (1889);
H.Chairi (1886);
I.L. Dolinsky (1894).

The incidence of chronic pancreatitis increases every year. The risk group began to include men 40-55 years old and children 10-14 years old. Research into the pancreas and pathologies associated with its development continues. Experts are inventing not only new methods for studying patients, but also treatment options for the inflammatory process.

Types of chronic pancreatitis

By origin, chronic pancreatitis can be primary or secondary. In the first case, the disease develops against the background of damage to the gland by a specific factor (alcohol, toxins). In the second, the disease is a complication of other pathological processes (for example, disturbances in the functioning of the digestive organs). According to the severity of the course, CP can be mild, moderate or severe. Chronic pancreatitis always develops with periods of remission and exacerbation.

Features of HP of different forms:

The disease is a serious problem, so the slightest suspicion of pancreatitis should be a reason to consult a doctor.

with a mild course, exacerbations occur once or twice a year (there are no disturbances in the exocrine function of the glands, pain is easily relieved with antispasmodics and analgesics, other signs of CP do not appear);
with moderate severity, exacerbations become more frequent up to three or four times a year (the exocrine function of the gland is impaired, pain symptoms are more pronounced, the patient may experience a decrease in appetite, weight loss, tests confirm the inflammatory process);
in severe cases, exacerbations occur on average five or six times a year (the pain syndrome is pronounced, difficult to relieve, body weight decreases to critical levels, diarrhea becomes regular, the clinical picture of the patient’s health is supplemented by most of the symptoms characteristic of CP).

Classification

Additional classification of CP is carried out according to the morphological and clinical picture, as well as clinical manifestations. Determining the specific type of chronic pancreatitis is necessary to prescribe the most effective treatment and make prognoses for the patient.

It is difficult to independently diagnose the form of the disease due to a number of similar symptoms.

Classification:

according to the morphological picture (obstructive, fibrosclerotic, inflammatory, calcifying);
according to clinical manifestations (latent, mixed, recurrent, permanent, pseudotumorous);
according to the functional picture (hypoenzyme, hyperenzyme);
by the nature of functional deviations (obstructive, hyposecretory, hypersecretory, ductular);
a separate category includes pancreatic diabetes mellitus (hypoinsulinism, hyperinsulinism).

1) Healthy pancreas. 2) Inflammation of the pancreas.

Symptoms

The clinical picture appears within 2-3 hours after exposure to the provoking factor. Symptoms of this disease include such manifestations as:

Pain that gets worse when eating. But it is not as strong as with other pancreatic diseases;
The pain may be accompanied by vomiting. In the vomit, you can notice impurities of bile or mucus. It is mainly localized in the upper abdomen with transition to the hypochondrium.
The person shows signs of intoxication, blood pressure drops, and body temperature rises.
Children have approximately the same symptoms. But in addition to the symptoms described, the baby may also experience stool upset. The baby's stool turns yellow and mucus appears. Sometimes he is constipated. In addition, his urine becomes dark and his skin takes on a yellowish tint. An infant may suddenly begin to cry.

Causes of the disease

CP is one of the common consequences of gallstone disease and excessive consumption of alcoholic beverages. These factors can disrupt the functioning of the digestive organs in a short period of time (especially in the absence of timely treatment).

With cholelithiasis, the infection enters the gland tissue through the lymphatic system, with bile or through the bile ducts. Alcohol is highly toxic to the pancreatic parenchyma.

Other causes of HP:

cystic fibrosis;
genetic predisposition;
peptic ulcer and its complications;
autoimmune disorders;
increased level of calcium ions in the blood;
uncontrolled use of medications;
consequences of helminthic lesions of the digestive system;
complications of atherosclerotic diseases;
intoxication with harmful substances (ammonia, arsenic);
complications of pancreatitis of unknown etiology.

Consequences

Without adequate treatment, the disease can cause irreversible changes in tissues. Ignoring the disease, lack of diet and treatment can lead to complications such as pancreatic necrosis. This process cannot be stopped. In addition, conditions such as:

Formation of ulcers;
Internal bleeding;
Formation of fistulas in the digestive organs;
Death of stomach and pancreas tissue;
Pancreatic shock.

Symptoms

The first changes in the functional state of the pancreas develop asymptomatically. Disturbances in the functioning of the digestive system are minor and mildly expressed (mild pain that quickly resolves on their own, changes in stool consistency).

From the moment of the first exacerbation of the inflammatory process, the symptoms intensify and are accompanied by painful attacks. The pain may be constant or intermittent.

Symptoms of HP:

Signs of exacerbation of chronic pancreatitis: paroxysmal pain;
girdle pain;
pain in the left hypochondrium;
constant pain in the epigastric zone;
pain on palpation of the abdomen;
alternating diarrhea with constipation;
frequent and debilitating vomiting;
regular feeling of nausea;
yellowness of the sclera;
pallor of the skin.

Complications

Pancreatitis may be accompanied by the following complications:

stagnation of bile with the appearance of pain in the right hypochondrium, nausea, bitterness in the mouth, formation of gallstones;
infectious diseases - purulent inflammation of the bile ducts, peritonitis, sepsis;
the formation of large cavities in the pancreatic tissue;
bleeding caused by damage to the esophagus, gastric or duodenal ulcer;
thrombosis of the veins of the liver and spleen;
pleurisy - accumulation of fluid in the cavity around the lungs, ascites - effusion in the abdominal cavity;
compression or narrowing of the lumen of the duodenum, deterioration of its patency;
hypoglycemic crisis - a condition caused by a lack of glucagon, manifested by severe weakness, muscle tremors, sweating, palpitations, impaired consciousness;
pancreas cancer.

Diagnostic examination

A gastroenterologist diagnoses chronic pancreatitis. After the initial examination, the patient is prescribed laboratory and instrumental examination methods. Deviations in test results will indicate the presence of an inflammatory process. Instrumental techniques will allow you to study the general condition of the pancreas and the digestive system as a whole.

In some cases, patients are recommended to undergo additional examination by specialized specialists.

Laboratory diagnostics

The purpose of laboratory diagnostics is to determine the general health of the patient and identify the inflammatory process. The progression of CP is indicated by increased activity of amylase and lipase, trypsin, elastase and excess fat. Some indicators make it possible to determine enzyme insufficiency of the pancreas before conducting an instrumental examination.

Laboratory diagnostic methods:

general blood and urine analysis;
blood biochemistry;
coprogram;
stool examination;
radioimmunoassay.

Instrumental diagnostics

Instrumental diagnostics make it possible to accurately determine the nature of the inflammatory process, the extent of its spread and draw up a clinical picture of the disease. In some cases, several procedures (ultrasound, CT) are performed to confirm the diagnosis. If the process of identifying pathology is complicated by additional factors, then the list of necessary procedures expands.

Instrumental diagnostics:

Ultrasound of the abdominal organs;
endoscopic ultrasonography;
CT or MRI of the pancreas;
X-ray examination;
tests with stimulants of secretion or enzyme activity;
retrograde cholangiopancreatography.

Differential diagnosis

The symptoms of chronic pancreatitis may resemble other pathologies. Differential diagnosis of the inflammatory process should be carried out with a perforated ulcer, intestinal obstruction, acute appendicitis and cholecystitis, as well as intestinal vein thrombosis. In some cases, the manifestations of CP resemble myocardial infarction. This pathology should also be excluded when examining the patient.

Diagnosis

When the first signs of reactive pancreatitis appear, a series of clinical and biochemical tests are performed. This type of disease is quite difficult to diagnose. In order to detect reactive pancreatitis, a set of procedures is carried out and some tests are collected, namely:

General urine analysis;
X-ray of the abdominal cavity;
Ultrasound of the abdominal cavity (it will show all the processes that occur in the peritoneum);
MRI;
Blood analysis;
Gastroscopy (will show all existing inflammations and their severity).

With the help of these tests, the doctor will be able to fully familiarize himself with the existing pathology.

Complication of the disease

Complications of CP are divided into early and systemic. Pancreatitis provokes a violation of the outflow of bile, which can result in obstructive jaundice. Even in the early stages of development, the inflammatory process can cause internal bleeding, infectious complications, abscesses, damage to the biliary tract or phlegmon of the retroperitoneal tissue. These conditions are life-threatening and, in the absence of adequate treatment, pose a threat to life.

Disease progression

CP is a progressive disease. The inflammatory process disrupts the intrasecretory and exocrine functions of the pancreas. The course of the disease has a long-term relapsing nature. In severe cases, a change in the cellular structure of the gland occurs and its functional failure develops.

It is not recommended to self-medicate, because the sooner you visit a specialist, the sooner a serious problem with the pancreas can be identified. Systemic complications:

encephalopathy;
functional failure of the lungs, liver and kidneys;
diabetes;
malignant formations;
esophageal bleeding;
critical loss of body weight;
death.

Description of the pathology

The pancreas has two main functions:

the production of digestive enzymes, which enter the duodenum through the ducts, where they are activated and participate in the breakdown of proteins and fats;
secretion of hormones - insulin and glucagon, which are released into the blood and regulate glucose levels.

If the patency of the ducts is disrupted for any reason, the pressure of pancreatic juice in them increases. Damage to gland cells occurs. In acute pancreatitis, the mechanism of “self-digestion” of tissues is triggered. The result of chronic inflammation is a constant deficiency of digestive enzymes, replacement of glandular cells with connective tissue, with a subsequent weakening of not only exocrine function, but also the production of hormones.

Treatment

The goal of therapy for chronic pancreatitis is to relieve pain symptoms, maximize the period of remission, and improve the functional parameters of the pancreas. In the absence of effectiveness of conservative and drug treatment, the only way to alleviate the patient’s condition may be surgical intervention. The scale of the operation depends on the stage of development of the inflammatory process and the degree of damage to the digestive system.

Treatment regimen

The treatment regimen for chronic pancreatitis is drawn up individually. Mandatory stages of therapy are taking medications and diet therapy. If treatment occurs using surgical techniques, then the patient’s tendency to recovery will depend on proper rehabilitation.

Rehabilitation therapy is not inferior in importance to basic medical methods.

Approximate treatment plan:

diet therapy (table No. 5b);
symptomatic therapy;
detoxification procedures;
relief of the inflammatory process;
restoration of digestive function;
replacement of pancreatic enzymes;
surgical intervention (if indicated);
maintenance and rehabilitation therapy;
prevention of complications of the inflammatory process;
regular examination by a gastroenterologist.

Drug treatment

Medicines for the treatment of CP are selected taking into account the individual clinical picture of the patient’s health status. Some of the drugs are recommended for long-term course use. The drug therapy schedule should not be violated. If treatment for CP is stopped earlier than recommended, the period of remission may be shortened.

Examples of medicines:

enzyme-containing drugs (Pancreatin, Creon);
analgesics for pain relief (Papaverine, No-Shpa);
antacids (Maalox, Almagel);
proton pump inhibitors (Rabeprazole);
drugs from the group of prokinetics (Cerucal, Motilium);
anti-inflammatory drugs (Diclofenac);
drugs to reduce gland secretion (Sandostatin);
antisecretory drugs (Omeprazole).

Surgery

For patients with CP, surgical treatment is prescribed in rare cases. The main methods of treating pathology of this type are medication and diet therapy. The need for surgery arises when there is no tendency to recovery or serious complications occur. In some cases, emergency surgical procedures are performed to save the patient's life.

Surgical procedure options:

sanitation and opening of purulent foci (phlegmon, abscesses);
sphincterotomy (for sphincter blockage);
pancrectomy (the operation can be complete or partial);
removal of the gallbladder (if indicated);
removal of stones from the pancreatic ducts;
partial gastrectomy;
creation of circumferential bile outflows (to relieve the load on the pancreatic ducts).

Diet

Diet therapy is one of the main methods of treating CP. If you allow errors in nutrition at any stage of treatment of the inflammatory process, then the tendency to recovery will be significantly reduced. In addition, taking prohibited foods will provoke an attack of pancreatitis. Fried, spicy, salty, fatty foods, marinades, some vegetables (radish, radish), mushrooms, sour fruits and alcoholic drinks should be excluded from the diet.

Vegetables that are strictly prohibited for pancreatitis.

Allowed to include in the diet:

lean meats and poultry;
boiled pureed vegetables;
steam omelettes;
vegetarian soups;
pasta;
porridge with water or milk;
fruits with low acidity levels;
low-fat dairy products;
low-fat fish (boiled).

When preparing dishes, it is recommended to give preference to the methods of steaming, boiling or stewing. Meals are taken up to six times a day (in small portions). It is important to avoid overeating and starvation. As an addition to diet therapy, you can use medicinal mineral waters (alkaline types of Essentuki, Borjomi).

Sample menu

Breakfast	Steam omelette, tea or dried fruit compote, oatmeal with blueberries
Lunch	Banana (or fruit salad), glass of low-fat yogurt
Dinner	Vegetarian soup, boiled turkey with carrots, reduced fat cheese, apple juice
Afternoon snack	Baked apple, low-fat cottage cheese
Dinner	Rice with lean fish, boiled carrots, whole grain bun, dried fruit compote or tea
Before bedtime	Three wheat-oat bread, a glass of skim milk

Treatment protocol for patients with acute pancreatitis

Classification of acute pancreatitis, formulation of diagnosis.

Etiology of the disease:

1. Acute alcoholic-alimentary pancreatitis.

2. Acute biliary pancreatitis (cholelithiasis, parafaterial diverticulum, papillitis, opisthorchiasis).

3. Acute traumatic pancreatitis (due to trauma to the pancreas, including in the operating room or after ERCP).

4. Other etiological forms (autoimmune processes, vascular insufficiency, vasculitis, medicinal, infectious diseases), allergic, dishormonal processes during pregnancy and menopause, diseases of nearby organs.

Severity of the disease:

1. Mild acute pancreatitis. Pancreatic necrosis does not form in this form of acute pancreatitis (edematous pancreatitis) and organ failure does not develop.

2. Severe acute pancreatitis. It is characterized by the presence of organ and multiple organ failure, peripancreatic infiltrate, the formation of pseudocysts, and the development of infected pancreatic necrosis (purulent-necrotic parapancreatitis).

Pancreatic necrosis:

Prevalence of the process: small focal pancreatic necrosis (the volume of damage to the pancreas according to ultrasound and CT < 30%; large-focal pancreatic necrosis (the volume of damage to the pancreas according to ultrasound and CT from 30 to 50%)); subtotal pancreatic necrosis (the volume of damage to the pancreas according to ultrasound and CT > 50 - 75%; total pancreatic necrosis > 75 (damages of the entire pancreas according to ultrasound and CT).
Localization of the process: head (right type), isthmus and body (central type), tail (left type).
Flow phases:
phase (enzymatic toxemia) – endotoxicosis, organ failure, enzymatic peritonitis, omentobursitis, parapancreatitis; period - 7-10 days from the onset of the disease;
phase (aseptic sequestration) – formation of sequesters of the pancreas and parapancreatic tissue, delimited parapancreatic fluid accumulations (pseudocyst); period 10-21 days from the onset of the disease;
phase (purulent-septic complications) - abscess of the omental bursa, purulent parapancreatitis, retroperitoneal phlegmon, purulent peritonitis, arrosive and gastrointestinal bleeding, digestive fistulas, sepsis; period - later than 21 days from the onset of the disease.

Diagnosis of acute pancreatitis.

The diagnostic program includes: clinical, laboratory and instrumental verification of the diagnosis of acute pancreatitis; stratification of patients into groups depending on the severity of the disease; constructing a detailed clinical diagnosis.

Verification of the diagnosis of acute pancreatitis includes: physical examination - assessment of the clinical and anamnestic picture of acute pancreatitis; laboratory tests - general clinical blood test, biochemical blood test (including a-amylase, lipase, bilirubin, ALT, AST, alkaline phosphatase, urea, creatinine, electrolytes, glucose), general clinical urine test, coagulogram, blood group, rhesus factor; plain X-ray of the abdominal cavity (increased diameter of small intestinal loops, fluid levels), chest X-ray (hydrothorax, discoid atelectasis, high diaphragm dome, hyperhydration of the parenchyma, ARDS pattern), ECG; Ultrasound of the abdominal cavity - assessment of the presence of free fluid, assessment of the condition of the pancreas (size, structure, sequesters, fluid inclusions), assessment of the condition of the biliary tract (hypertension, stones), assessment of intestinal motility.

Patients with a presumptive clinical diagnosis of acute pancreatitis are advised to undergo endoscopy (differential diagnosis with ulcerative lesions of the gastroduodenal zone, examination of the gastroduodenal zone).

Stratification of patients according to the severity of acute pancreatitis according to the following criteria:

1. Severe pancreatitis (more than one of the criteria):

signs of SIRS (2 or more clinical signs: body temperature >38°C or <36°C; heart rate>90 beats/min; respiratory rate>20/min; PaCO2<32 mmHg, leukocytes >12x9/l or <4.0×9/l or immature forms >10%);
a-amylase > 500 units/l, lipase > 100 units/ml
hypocalcemia <1.87 mmol/l, blood hemoglobin >150 g/l or hematocrit >40 units, hyperglycemia >10 mmol/l; C-reactive protein >120 mg/l;
arterial hypotension (systolic blood pressure <90 mm Hg)
respiratory failure (P02<60 mmHg);
renal failure (oligoanuria, creatinine >177 µmol/l);
liver failure (hyperfermentemia);
cerebral insufficiency (delirium, stupor, coma);
coagulopathy (platelets <100x*/l, fibrinogen <1.0 g/l);
Ranson scale - 3 or more points;
Balthazar-Ranson index - 3 or more points.

2. Mild acute pancreatitis: absence of criteria for severe acute pancreatitis in the presence of a clinical and instrumental picture of acute pancreatitis.

Ranson scale for acute pancreatitis.

Indicator under study	Alcoholic pancreatitis	Biliary pancreatitis
On admission:
patient's age	Over 55 years	More than 70 years
leukocytosis	More than 16,000 mm3	More than 18,000 mm3
blood plasma glucose	More than 11.1 mmol/l	More than 11.1 mmol/l
Serum LDH	More than 700 ME	More than 400 ME
Serum AST	More than 250 ME	More than 250 ME
In the first 48 hours:
decrease in hematocrit	More than 10% of normal	More than 10% of normal
increase in serum residual nitrogen levels	More than 5 mg%*	More than 2 mg%*
calcium concentration	More than 8 mg%**	More than 8 mg%**
arterial blood pO2	More than 60 mm Hg. st
foundation deficiency	More than 4 mEq/L	More than 5 mEq/L
estimated fluid loss (sequestration)	More than 6 l	More than 4 l

— Each indicator in the table is scored as 1 point.

Pancreatitis severity index according to Balthazar - Ranson .

Normal appearance of the pancreas – 0 points

Increased pancreas size

Signs of inflammation of parapancreatic tissue – 2 points

Enlargement of the pancreas and the presence of fluid in the anterior perinephric space – 3 points

Accumulation of fluid in 2 or more areas of parapancreatic tissue – 4 points

Necrosis <30% of parenchyma – 2 points

Necrosis of 30-50% of the parenchyma - 4 points

Necrosis >50% of parenchyma - 6 points

Patients with severe pancreatitis are hospitalized in the surgical intensive care unit.

Patients with mild pancreatitis are hospitalized in the surgical department.

Treatment of patients with mild acute pancreatitis.

Basic treatment complex:

fasting for 48 hours;
gastric probing and aspiration of gastric contents;
local hypothermia (cold on the stomach);
analgesics and NSAIDs;
antispasmodics;
infusion therapy in a volume of up to 40 ml per 1 kg of patient’s body weight with forced diuresis for 24-48 hours;
inhibitors of gastric secretion: omeprazole 40 mg – 2 times a day intravenously;
octreotide 100 mcg – 3 times a day subcutaneously.

In dynamics, the following are assessed daily: SIRS criteria, a-amylase. Requirements for treatment results: relief of pain, clinical and laboratory confirmation of resolution of the active inflammatory process.

Lack of effect from analgesic and antispasmodic therapy for 12-48 hours, rapidly progressing jaundice, absence of bile in the duodenum during endoscopy, signs of biliary hypertension according to ultrasound indicate stenosis of the terminal part of the common bile duct (impacted stone of the common bile duct, papillitis). In this case, EPST is indicated. In acute pancreatitis, EPST is performed without ERCP!

Monitoring the general somatic and local status of patients with severe acute pancreatitis:

general clinical and biochemical blood test - daily;
Ultrasound of the abdominal cavity - every 48 hours;
MSCT of the abdominal cavity – the first 24 hours; subsequently – every 5 days.

Treatment tactics in patients with severe acute pancreatitis in the phase of pancreatogenic toxemia.

The main type of treatment for acute pancreatitis in the toxemia phase is complex intensive conservative therapy.

Basic therapy for acute pancreatitis is supplemented with the following components:

- intensive inhibition of pancreatic secretion (octreotide 300 mcg x 3 times a day subcutaneously or 1000 mcg per day by continuous infusion) until a-amylase and lipase levels are normalized;

- prolonged epidural anesthesia;

— the dose of infusion solutions should be at least 40-60 ml/kg of the patient’s body weight per day; high-volume infusion therapy includes balanced crystalloid solutions and colloid solutions (in a 2:1 combination of crystalloids and colloids);

— rheologically active therapy: colloids in combination with antiplatelet agents, UFH (15-20 thousand units per day) or LMWH; introduction of antioxidants;

— extracorporeal detoxification: extended venovenous hemodiafiltration and serial plasmapheresis;

— installation of a nipple tube for enteral nutrition beyond the duodeno-jejunal junction with simultaneous installation of a naso-gastric tube for gastric decompression; introduction of electrolyte solutions into the small intestine (1 - 2 liters/day) in the first 24-48 hours; subsequent enteral nutrition with oligomeric and polymeric nutritional mixtures;

— providing mixed parenteral-enteral nutritional support with a caloric intake of at least 2000 kcal per day.

Surgical tactics:

Surgical interventions via laparotomy during the phase of enzymatic toxemia are contraindicated. According to indications, minimally invasive interventions are used - percutaneous punctures and drainages, laparoscopy, EPST.

Percutaneous puncture and drainage of acute fluid accumulations under ultrasound control can reduce the level of endogenous intoxication.

Foci of acute fluid accumulations located in the omental bursa, retroperitoneal tissue, and in cases where laparoscopic drainage of acute fluid accumulations in the abdominal cavity is impossible (the severity of the patient’s condition, the patient has previously undergone several operations on the abdominal cavity, a giant ventral hernia) are subject to puncture.

For small volumes of fluid (<100 ml) and complete aspiration, repeated percutaneous punctures followed by ultrasound control are preferable. If the volume of fluid is >100 ml, or the accumulation could not be evacuated completely, or it has recurred, or fistulography has established a connection with the pancreatic duct, or growth of microflora in the aspirate has been obtained, percutaneous drainage of this fluid accumulation is indicated.

Emergency decompression of the biliary tract in patients with acute biliary pancreatitis is indicated in the following cases: there is no effect from conservative therapy within 6-12 hours; impacted calculus BDS; increasing phenomena of obstructive jaundice; progression of acute cholecystitis and/or cholangitis.

In case of diagnosed residual or recurrent choledocholithiasis, choledocholithiasis against the background of chronic calculous cholecystitis, acute obstructive cholangitis, papillitis or papillostenosis, EPST without ERCP is indicated! If it is impossible to perform EPST, percutaneous transhepatic microcholecystostomy under ultrasound guidance is indicated. If it is impossible to achieve adequate decompression from the above approaches, percutaneous transhepatic cholangiostomy is indicated. In case of herniation of a calculus in the area of the major duodenal papilla, preference is given to endoscopic papillogomy.

Indications for laparoscopy:

- clinical picture of peritonitis with the presence of ultrasound signs of free fluid in the abdominal cavity;

— the need for differential diagnosis with other acute diseases of the abdominal organs.

Objectives of laparoscopy:

Confirmation of the diagnosis of acute pancreatitis: the presence of edema of the root of the mesentery of the transverse colon; the presence of effusion (pink, raspberry, cherry, brown) with amylase activity 2-3 times higher than blood amylase activity); presence of steatonecrosis; extensive hemorrhagic permeation of the retroperitoneal tissue;
Exclusion of other acute surgical pathology of the abdominal organs;
Removal of peritoneal exudate and drainage of the abdominal cavity.

Therapeutic tactics in patients with severe pancreatitis in the phase of aseptic sequestration.

The clinical and morphological form of acute pancreatitis in the aseptic sequestration phase is a postnecrotic pancreatic pseudocyst, the formation period of which ranges from 4 weeks and on average up to 6 months.

Outcomes of acute pancreatitis in the phase of aseptic sequestration:

1) in small focal forms - resolution of infiltration;

2) for large-focal forms - aseptic sequestration with the formation of a cyst or cysts;

3) in common forms - in the focus of pancreatogenic destruction there are large zones of infiltration and multiple foci of fluid accumulations without visible clear boundaries and sizes;

4) Infection of areas of pancreatogenic destruction (development of purulent complications).

Diagnostic criteria for the aseptic sequestration phase:

— decrease in the severity of SIRS, absence of signs of an infectious process;

— Ultrasound and CT signs of aseptic destruction in the lesion (continued increase in the size of the pancreas, blurred contours and the appearance of fluid in the parapancreatic and retroperitoneal tissue with subsequent formation of pseudocysts, visualization of sequesters in the pancreatic tissue and in the parapancreatic tissue).

Treatment during the aseptic sequestration phase.

Continuation of basic infusion-transfusion therapy aimed at replenishing water-electrolyte, energy and protein losses according to indications.
Medical nutrition: oral nutrition (table No. 5); enteral or parenteral nutritional support with a total caloric intake of at least 2000 kcal/day.
Systemic antibiotic prophylaxis (cephalosporins of III-IV generations or fluoroquinolones of II-III generations in combination with metronidazole).
Immunotherapy with correction of cellular and humoral immunity.

Surgical tactics in patients with acute pancreatitis during the period of aseptic destructive complications.

Indication for surgical interventions is the presence of circumscribed peripancreatic fluid accumulations (with or without sequestration).

The priority is to perform minimally invasive percutaneous interventions under ultrasound or CT control.

Percutaneous punctures under ultrasound control are indicated in the presence of liquid formations with a volume of no more than 100 ml. Systematic punctures can serve as a definitive method of surgical care or allow deferment of radical surgery.

Percutaneous drainage under ultrasound control is performed in the presence of fluid accumulations with a volume of more than 100 ml. Drainage of a cyst involves aspiration and lavage sanitation of the cyst cavity and assessment of the adequacy of drainage using dynamic fistulography.

Surgical interventions using laparotomy and (or) lumbotomy access are carried out if there are technical restrictions on the safe performance of puncture interventions (location on the intended trajectory of the intervention of the colon, spleen, large vessels, pleural sinus); when the tissue component (sequestra) predominates in the fluid accumulation or acute pseudocyst.

In case of focal process, mini-laparotomy (pararectal, transrectal, oblique in the hypochondrium) or mini-lumbotomy should be used. If the process is widespread, a wide median laparotomy, a wide lumbotomy, or a combination of both should be used.

In conditions of completed sequestration and complete necrosequestrectomy, the operation should be completed with “closed” drainage of the resulting cavity with 2 lumen drains, according to the number of branches of the cavity that are brought to the abdominal wall outside the surgical wound. The wound is sutured tightly. In the postoperative period, aspiration and lavage treatment is carried out until the cavity is obliterated.

In case of incomplete sequestration and incomplete necrosequestrectomy, the operation should be completed with “open” drainage with 2 luminal drainages according to the number of branches of the cavity, removed outside the wound through counter-apertures and insertion of tampons into the resulting cavity through the surgical wound. The wound is partially sutured and a bursoomentostomy or lumbostomy is formed to access the site of destruction during subsequent programmatic sanitation. Aspiration and lavage treatment, dressings with additional necrosequestrectomy and changing tampons are carried out along the drainages until the cavity is cleaned, followed by the application of secondary sutures to the wound and the transition to closed drainage.

Small pancreatic pseudocysts (less than 5 cm) are not advisable to operate; they are subject to dynamic observation. Large pancreatic pseudocysts (more than 5 cm) are subject to surgical treatment as planned in the absence of complications. The operation of choice for an immature (unformed) pseudocyst (lifespan less than 6 months) is external drainage. A mature (formed) pseudocyst (lifespan is more than 6 months) is subject to surgical treatment as planned.

Therapeutic tactics in patients with severe pancreatitis in the phase of purulent-septic complications.

Clinical and morphological manifestations of acute pancreatitis in the phase of purulent-septic complications are:

1. Infected pseudocyst - a local accumulation of infected fluid and areas of the pancreas, sometimes containing sequestra; differs from an abscess in the absence of a granulation shaft;

2. Pancreatic abscess - occurs as a result of melting and infection of foci of necrosis with the secondary formation of fluid in them, is an encysted accumulation of pus, contains a small amount of necrotic tissue; necrotic changes in the gland and retroperitoneal tissue are minimal;

3. Infected pancreatic necrosis is a diffuse bacterial inflammation of necrotic pancreatic tissue and/or peripancreatic adipose tissue, extending deep into the retroperitoneal space, without a fibrous capsule or localized accumulations of pus.

Diagnostic criteria for the phase of purulent-septic complications:

1. Clinical and laboratory manifestations of the infectious process: progression of clinical and laboratory indicators of SIRS at the 3rd week of the disease; high levels of markers of acute inflammation (C-reactive protein - more than 120 g/l and procalcitonin - more than 2 ng/ml); lymphopenia, increased ESR, increased fibrinogen concentration; deterioration of the patient's condition according to integral assessment systems.

2. Instrumental criteria for suppuration: CT signs (increase during observation of fluid formations in the focus of pancreatogenic destruction and/or the presence of gas bubbles) and/or positive bacterioscopy results obtained by fine-needle puncture.

Surgical tactics in patients with acute pancreatitis in the phase of purulent-septic complications.

If purulent complications develop, urgent surgical intervention is indicated.

Minimally invasive puncture interventions (puncture and drainage) are indicated in the presence of clearly demarcated purulent accumulations (fluid collections, pancreatic abscess, infected pseudocyst) without a pronounced tissue component (sequestra). It should be considered optimal to install two drains into the abscess cavity, followed by installation of a flushing system.

Surgical interventions using laparotomy and lumbotomy approaches are indicated in cases of significant spread of the process in the retroperitoneal tissue or in case of a limited process with the presence of large necrotic fragments in the abscess cavity. The main method of sanitation of purulent-necrotic foci is necrosequestrectomy, which can be either single-stage or multi-stage.

The optimal access is extraperitoneal, in the form of a lumbotomy with an extension of the incision on the abdominal wall towards the rectus abdominis muscle, which allows, if necessary, to supplement this access with laparotomy.

The method of completion of the operation depends on the adequacy of the necrosequestrectomy. With complete removal of necrotic tissue, “closed” drainage is possible with double-lumen drainages according to the number of branches of the cavity with drainage being removed through counter-apertures on the abdominal wall. Aspiration and lavage sanitation is carried out through drainages in the postoperative period.

In case of incomplete removal of necrotic tissue, “open” drainage with double-lumen drainages according to the number of branches of the cavity should be used, in combination with packing the cavity through the surgical wound and leaving access for subsequent program revisions and necrectomies in the form of omentobursostomy and (or) lumbostomy. Aspiration and lavage sanitation is carried out through drainages in the postoperative period.

Monitoring the adequacy of drainage and the condition (size) of drained cavities should be carried out using fistulography, ultrasound and CT every 7 days. Ineffectiveness of drainage (according to clinical and instrumental data) or the appearance of new purulent foci is an indication for reoperation with additional necrectomy and drainage.

If arrosive bleeding develops in the focus of purulent destruction, the bleeding area should be inspected, sequesters removed, the bleeding site sutured (temporary hemostasis) and ligation of vessels outside the purulent focus should be performed (final hemostasis). It is prohibited to apply sutures to the vessel wall in the purulent defect area. If it is impossible to ligate vessels outside the purulent focus, distal pancreatectomy and splenectomy are indicated.

Antibacterial therapy for acute pancreatitis.

• Antibiotic prophylaxis is not indicated in patients with severe acute pancreatitis in the phase of enzyme toxemia.

• In patients in the phase of purulent-septic complications, empirical therapy is considered:

Piperacillin-tazobactam 4.5 g IV every 6 hours

Cefepime 1 g IV every 8 hours PLUS metronidazole 500 mg IV every 8 hours

Ciprofloxacin 400 mg IV every 12 hours PLUS metronidazole 500 mg IV every 8 hours

Penetration of selective antibiotics into the pancreas.

Good (>40%): fluoroquinolones, carbapenems, ceftazidime, cefepime, metronidazole, piperacillin-tazobactam

Poor (<40%): aminoglycosides, first generation cephalosporins, ampicillin.

Duration of antimicrobial therapy.

For infected pancreatic necrosis, continued antibiotic therapy is indicated for 14 days after surgical treatment. Continuation of antibiotic therapy during this time is required for patients due to the risk of colonization or infection with resistant organisms and drug toxicity.

How to help yourself during an attack of pancreatitis?

If the diagnosis of chronic pancreatitis is confirmed and the patient is able to independently determine the attack, then several recommendations can be used to alleviate the condition. At the first manifestation of CP or too severe pain symptoms, only a qualified specialist can provide proper assistance (you should consult a doctor or call an ambulance).

Algorithm of actions:

elimination of pain (Paracetamol);
relief of spasm (Drotaverine, No-Shpa);
decreased acidity of gastric juice (Omeprazole, Maalox, Phosphalugel);
decreased pancreatic secretion (Creon, Mezim);
hunger, cold and rest (you cannot eat food during the day, you can apply a cold compress to the painful area, any stress on the body is excluded).

Prevention

Primary prevention of CP includes standard rules of a balanced diet, a healthy lifestyle and giving up bad habits. If the disease is detected, then after the course of therapy it is necessary to follow all the doctor’s recommendations. Errors in nutrition, excessive physical activity, alcohol and other negative factors will shorten the period of remission and increase the intensity of symptoms of attacks.

Prevention measures:

quitting smoking and alcohol abuse;
compliance with the drinking regime (at least one and a half to two liters of water per day);
limiting the amount of fatty, fried, salty foods in the diet (spicy foods, marinades, spices and seasonings);
compliance with the rules of a healthy diet (sufficient content of healthy elements and vitamins in the menu);
balanced diet with the exception of overeating.

Forecast

In CP, the mortality rate reaches 50%. In most cases, the cause of death in patients is complications of the inflammatory process. The development of the disease can be asymptomatic for a long time, but the progression of the pathology does not stop without adequate therapy. In case of CP, the patient should be regularly examined by a gastroenterologist (at least once every six months).

Timely therapy provides:

persistent and long-term remissions;
slowing down the inflammatory process;
reduction of pain symptoms during exacerbation attacks.

Video on the topic: Chronic pancreatitis. What are the symptoms? How to treat? What can and cannot be eaten?