Chronic recurrent pancreatitis is most often observed with. Modern view of chronic recurrent aphthous stomatitis

Chronic recurrent pancreatitis is a disease that is accompanied by frequent attacks and leads to pancreatic dystrophy. In this article we will talk about what causes relapses, what symptoms the patient may experience, and what treatment the doctor should offer.

Why does the disease return?

A patient who has had mild pancreatitis feels healthy already in the 2-3rd week of illness. Therefore, many decide to return to their usual lifestyle. If gentle conditions for the gland are not observed, then a new attack will not be long in coming. It is usually much heavier. After all, cell damage will be more active in a weakened body. So, the main reasons for frequent relapses are non-compliance with the protective regime. It includes diet, frequent small meals, giving up alcohol and smoking.

In addition to a disrupted diet, concomitant pathology can provoke a new attack of pancreatitis. The second most important factor that initiates inflammation in the pancreas is a diseased gallbladder. The causes of its inflammation are numerous. Stagnation of secretions, the formation of stones, their movement along the ducts, concomitant infection - all this provokes inflammation of the pancreatic tissue. Therefore, by following a diet and following the regime, you can still get a new attack. It is enough just to refuse surgery to remove the diseased gallbladder.

An ulcer or chronic gastritis are also excellent provocateurs of inflammation of the pancreas. Untreated diseases in this area lead to increased acid production. It also stimulates the production of pancreatic juice. A bacterial infection of the stomach (Helicibacter pylori) can lead to relapse of the disease.

Frequent attacks of pancreatitis are characteristic of autoimmune processes. In this case, the cells of the pancreas are attacked by their own body. Autoimmune pancreatitis is extremely rare.

Clinical picture

Recurrent pancreatitis is manifested by the following set of symptoms:

The patient experiences constant pain in the left hypochondrium. They appear after eating. Sometimes the pain attack has a girdling character.
Indigestion. The inflamed tissue does not have time to recover. Enzymes do not perform their functions in processing food. Symptoms include nausea, bloating, vomiting, belching, and flatulence.
Stool disorders. Patients experience constipation alternating with diarrhea.
Dysbacteriosis. The processes of fermentation and decay in the body contribute to the proliferation of pathogenic flora. An imbalance in the intestines can lead to severe infections. The first symptoms are fever and diarrhea.
Weight loss. Impaired functioning of the enzyme system leads to poor absorption of nutrients. The body lacks energy. Sick people lose weight quickly. Against the background of frequent exacerbations, eating is associated with pain, which aggravates the symptoms of cachexia.

The disease develops gradually. The clinical picture intensifies from attack to attack. In some patients, painful symptoms predominate; in others, digestive disorders progress. In any case, chronic pancreatitis causes the patient a lot of discomfort. Only a strict diet and proper treatment will help stop the process.

Therapy

Antispasmodic treatment will help quickly relieve pain symptoms. Intramuscular agents are used initially. Then you can switch to tablets (No-shpa, Drotaverine, Spazmex).

To reduce the activity of the pancreas, treatment must be supplemented with agents that reduce the production of hydrochloric acid. The therapy complex necessarily includes the medications Omeprazole and Pantoprazole. Also, to reduce aggression on the stomach, you can combine this treatment with taking antacids (Gefal, Maalox, Almagel).

The function of the gland is reduced, so food does not receive proper processing. This helps to intensify the processes of fermentation and putrefaction in the intestines. In order for food to be digested well, it is necessary to take enzymes during each snack. Now there is a huge selection of these medicines. The most popular are Pancreatin, Creon, Mezim. The doctor selects the dose. Treatment with low doses will not be adequate. Enzymes partially take over the work of the oppressed gland.

Vitamins should be included in the therapy complex. This appointment is especially important when the patient has symptoms of vitamin deficiency. And almost all patients with chronic pancreatitis come to this conclusion. Treatment should include injectable medications. This is possible for group B drugs.

In severe forms of chronic pancreatitis, Somatostatin or Octreotsid must be prescribed. These artificial hormones inhibit the functioning of the pancreas. However, drugs can only be administered in a hospital during an exacerbation.

Acute and chronic pancreatitis: characteristics of the disease and causes of occurrence

In medicine, it is customary to distinguish two forms of pancreatitis - acute and chronic, which are divided into subtypes. Complications depend on the form of the disease.

Acute pancreatitis

Acute pancreatitis is characterized by the rapid development of necrosis in the pancreas. The organ begins to digest itself, and tissue damage occurs during the process.

The most dangerous complication of the acute form is necrotizing pancreatitis, sometimes leading to complete death of pancreatic tissue. With such a pathology, other organs in the abdominal cavity often begin to suffer.

Necrosis of the pancreas is manifested by severe pain, nausea, vomiting, and high body temperature. In different medical classifications it is divided into subtypes: sterile, infected, fatty, hemorrhagic, mixed, etc.

Chronic pancreatitis

Half of people who have acute pancreatitis develop a chronic form of the disease. This is a sluggish process leading to functional disorders of the pancreas, insufficient secretion production and irreversible changes in the structure of the organ.

Types of disease

In the medical literature there are a number of classification options for the described disease. Let's look at what the most popular one looks like.

Chronic pancreatitis is divided in terms of origin:

1Clinical picture of the pathology
2Types of disease
3What is acute pancreatic inflammation?
4Symptoms of acute form
5 Signs of chronic pathology
6Possible complications
7Types of therapy
8Treatment of the disease

1Clinical picture of the pathology

Pancreatitis is an acute or chronic inflammatory disease of the pancreas of various etiologies. Not everyone knows how it proceeds. Often this pathology leads to destruction and necrosis. Pancreatitis is a group of diseases united by a common clinical picture and pathogenesis. Acute inflammation of the pancreas ranks 3rd in prevalence among all diseases of the abdominal organs.

About half a million cases of this disease are diagnosed every year. Among the patients, males predominate. This is due to a great addiction to alcohol and fatty foods. Of all the diseases, pancreatitis is different in that it most often develops in young people who abuse alcohol.

The peak incidence occurs between 30 and 40 years of age. Often this pathology is combined with gallstone disease. In this case, the main patient population will be elderly people over 60 years of age.

2Types of disease

You need to not only know what pancreatitis is, but also have an idea of its varieties. Based on the nature of the course, the following forms of pancreatitis are distinguished:

spicy;
acute recurrent;
chronic;
chronic during exacerbation.

Complications and consequences of chronic pancreatitis

The described illness is insidious in that during periods of remission the symptoms recede, the patient, in moments of enlightenment, thinks that the disease is cured, and he returns to his usual way of life. Complications of chronic pancreatitis gradually develop; the list includes dangerous diseases.

The most common complications experienced by patients are:

obstructive jaundice (develops due to a disruption in the process of bile outflow from the gallbladder);
internal bleeding due to organ deformation and ulcer formation;
development of infections and abscesses;
formation of cysts and fistulas;
development of diabetes mellitus;
cancerous formations.

In most cases, examination reveals cysts that become a complication of chronic pancreatitis. They represent formations filled with fluid and are diagnosed during ultrasound examination. In this case, surgical intervention is inevitable. Removal takes place using laparoscopic surgery.

If previously the disease occurred in older people, today pathological changes in the pancreas often occur in young people. Improper eating habits lead to the pancreas suffering and losing its functions.

A chronic form of the disease develops, during which the pancreatic juice necessary for normal digestion stops being released into the duodenum. The situation leads to pancreatitis with exocrine insufficiency and the risk of developing diabetes mellitus.

Symptoms and diagnosis

In this case, making a diagnosis on your own is impossible and even dangerous, since many diseases exhibit similar symptoms and localization of pain (for example, gastritis and pancreatitis). For this purpose, it is important to consult a doctor.

Timely diagnosis of the disease will allow you to avoid complications and serious consequences. Many people turn to a gastroenterologist only when the disease is no longer unbearable, but this must be done at the first sign of disruption of the gastrointestinal tract.

It is vitally important to seek help from a doctor. The sooner you can undergo the necessary examination, the more positive the prognosis for recovery.

Pathological changes in the functioning of the pancreas are detected using studies: urine analysis, general and biochemical blood tests, ultrasound examination of the abdominal organs, CTG. At the discretion of the doctor, additional studies are carried out, for example, a breath test, MRI, x-ray, etc.

The most indicative is a urine test for diastase, the result of which indicates the level of a pancreatic enzyme that ensures the breakdown of carbohydrates. The higher the urine diastasis, the stronger the inflammatory process. The norm is 64 units; with illness, the numbers increase hundreds of times.

During periods of exacerbation, patients experience symptoms that may indicate myocardial infarction; to exclude it, an ECG is performed for pancreatitis.

Treatment

Based on a set of indicators obtained, the doctor makes a decision on prescribing effective therapy, which is selected individually. Each doctor initially considers conservative treatment and is only ready to resort to surgical intervention in extreme cases. However, the choice of method directly depends on the condition in which the patient sought help.

Let's consider the main principles of treatment of chronic pancreatitis:

Laparoscopy

If using standard diagnostics it was not possible to identify the features of the pathology, or a diagnosis such as pancreatic necrosis or cystic pancreatitis was made, the doctor decides to perform laparoscopy. The operation is performed in a hospital setting, after which you will need to be observed by a doctor for some time.

This procedure is considered safe, painless, and there are no scars left after the intervention. At the same time, laparoscopy is easily tolerated by patients and does not require long-term rehabilitation.

Folk remedies

The clinical picture of recurrent pancreatitis varies depending on the stage of the disease. During the period of exacerbation, the patient is diagnosed with dyspeptic and pain syndrome, signs of endocrine and exocrine insufficiency.

The patient complains of:

Pain in the epigastrium, left hypochondrium, Shoffard area, surrounding area. The specific location and nature of the sensations may vary depending on the severity of the pathological process and the individual characteristics of the patient.
Dyspepsia, manifested in the form of belching, heartburn, flatulence, diarrhea or constipation. These phenomena are caused by insufficient flow of pancreatic juice into the duodenum and disruption of the digestive process.
Signs of hyperglycemia or hypoglycemia. In the first case, thirst, increased diuresis, loss of body weight, dry skin and mucous membranes are noted, in the second - weakness, dizziness, sweating, and pallor.

Forecast

The prognosis for life is favorable if the patient strictly adheres to the diet and regularly undergoes courses of maintenance treatment. In this case, the number of exacerbations can be reduced by 80% relative to people who ignore the above requirements.

If the etiological factor is preserved, the patient's life expectancy is significantly reduced. Alcohol-dependent patients who are unable to give up alcohol often die within 2-3 years after the first signs of the disease are detected.

In general, chronic pancreatitis allows you to live a fairly long life. Its average duration in patients who comply with the regimen is more than 20 years. Therefore, when the first symptoms of pancreatic damage appear, it is recommended to seek medical help.

Treatment of a serious disease - pancreatitis - requires a serious approach to treatment. The disease will not go away on its own. Any type of pancreatitis requires qualified medical care.

To avoid the development of the disease and subsequent complications, it is imperative to follow the doctor’s recommendations, eat right, lead a healthy lifestyle, listen to your body and seek medical help in a timely manner.

Determining the degree of endocrine insufficiency of the pancreas allows determining the level of glucose in the blood and urine; to detect mild disorders of carbohydrate metabolism, a glucose tolerance test is used using a single or double glucose load. If possible and necessary, examine the level of insulin and glucagon in the blood using the radioimmune method.

Of the instrumental methods for diagnosing chronic pancreatitis, ultrasound is of greatest importance. It allows you to identify the presence, nature and extent of the pathological process in the pancreas. Uneven contours of the gland, changes in its size, density, expansion of the Wirsung duct, the presence of cysts and pseudocysts, and calcification are noted. An important advantage of ultrasound is its non-invasiveness, the absence of contraindications and complications, and especially the ability to identify changes in the liver and biliary tract accompanying pancreatitis, which facilitates differential diagnosis with tumors of the pancreaticoduodenal zone. X-ray examination of the duodenum in conditions of hypotension has not lost its importance. In this case, chronic pancreatitis may be indicated by deformations of the internal contour of its loop, caused by an enlargement of the head of the pancreas, foci of calcification or stones in the area of the pancreas, displacement and deformation of the stomach, ulcers of the stomach and duodenum, usually on the posterior wall , high standing of the left dome of the diaphragm, left-sided pleurisy, atelectasis of the lower lobe of the left lung.

In some cases, according to indications, endoscopic retrograde cholangiopancreatography (ERCP), computed tomography, angiography, radionuclide scanning, intravenous cholecystcholangiography, and fibrogastroscopy are used. Data from these methods do not allow diagnosing chronic pancreatitis, but it helps to clarify some etiopathogenetic factors and assess the condition of neighboring organs.

There is no generally accepted classification of chronic pancreatitis. As a worker they use the one proposed in 1982 by A.L. Grebenev, who proposed to distinguish the following forms of the disease based on clinical characteristics: 1) recurrent (polysymptomatic); 2) painful, when the specified symptom is dominant, 3) latent, which occurs covertly for a long time; 4) pseudotumor with the formation of obstructive jaundice. According to the course, they distinguish stage 1 (mild severity), when signs of exocrine and intrasecretory pancreatic insufficiency are not detected, stage 2 (moderate severity), when they are detected, and stage 3 (severe degree), characterized by persistent “pancreatogenic” diarrhea, progressive exhaustion, polyhypovitaminosis, secondary diabetes mellitus. In addition, the diagnosis is supplemented by an indication of the etiology, phase (exacerbation, remission), the presence of complications and morphological changes in the pancreas.

Chronic pancreatitis must be differentiated primarily from pancreatic cancer, as well as calculous cholecystitis, gastric and duodenal ulcers, chronic enteritis and colitis, and visceral ischemic syndrome.

Basic treatment of exacerbation of chronic pancreatitis includes measures aimed at 1) reducing pancreatic secretion; 2) pain relief; 3) maintaining an effective volume of circulating blood and preventing shock; 4) prevention of septic complications; 5) elimination and inactivation of toxic and vasoactive substances.

Considering that the leading role in the pathogenesis of chronic pancreatitis belongs to the damaging effect of its own active pancreatic enzymes, the main task is to reduce the exocrine function of this organ. In the first 1-3 days of exacerbation, fasting is prescribed, alkaline solutions are taken every 2 hours (sodium bicarbonate, Borjomi, 200 ml). It is possible to use buffered antacids (Almagel, Phosphalugel, Maalox, Gastal) which are prescribed 6-8 times a day. In severe cases, primarily with symptoms of duodenostasis, continuous aspiration of gastric contents is performed through a thin intranasal tube. To enhance the effect, M-anticholinergics (atropine, platyphylline, preferably gastrocepin) are prescribed orally or parenterally, as well as histamine H2 receptor blockers (cimetidine, ranitidine, famotidine). In addition, 5-fluorouracil, which is prescribed intravenously at a rate of -12-15 mg/kg/day, significantly reduces the production of enzymes. in 5% glucose solution for 5 days. It is possible to use antispasmodics (papaverine, no-spa, cerucal, etc.). During the first days of an exacerbation, all patients must be administered intravenously 3 or more liters of fluid, including glucose, electrolytes, albumin solution, plasma, hemodez, which, along with reducing pain and intoxication, prevents the development of hypovolemic shock.

The most important principle of therapy in the acute phase of chronic pancreatitis is pain relief. If the above measures aimed at reducing pancreatic secretion do not have the desired analgesic effect, the following tactics are recommended. Initially, analgesics or antispasmodics are prescribed (2 ml of 50% analgin solution or 5 ml of baralgin 2-3 times a day) or a synthetic analogue of opioid peptides - delargin (5-6 mg per day). If there is no effect, additional antipsychotics are included - droperidol 2 .5-5 mg ( 1-2 ml 0,25% solution) together with 0.05-0.1 mg (1-2 ml of 0.005% solution) fentanyl per day intravenously. And only after this, narcotic analgesics are used - promedol, fortral, etc., excluding morphine. If these measures do not have the desired effect for more than 3-4 days, then this most often indicates the development of complications requiring surgical treatment.

In case of severe exacerbation, to prevent septic complications, it is recommended to administer broad-spectrum antibiotics - semi-synthetic penicillins, cephalosporins in regular doses for 5-7 days. They also have an antisecretory effect.

Currently, most authors have abandoned the use of antienzyme drugs (trasylol, contrical, gordox, etc.), given their low effectiveness and a large number of complications, especially allergic ones. However, aminocaproic acid is used for this purpose (200 ml intravenously). 5% solution 1-2 times a day or orally 2-3 g 3-5 times a day), methyluracil (orally 0.5 g 4 times a day), peritol (4 mg 3 times a day), transfusion plasma.

Disorders of carbohydrate metabolism during exacerbation of chronic pancreatitis are corrected by fractional administration of small doses of simple insulin.

During a subsiding exacerbation and in the remission phase, adherence to diet No. 5p (pancreatic) is important. It should contain an increased amount of protein (120-130 g/day), including 60% of the animal, a slightly reduced amount of fat (up to 70- 80 g), mainly of plant origin and carbohydrates (up to 300-400 g), the total calorie content should be 2500-2800 kcal. It is recommended to eat fractional meals 5-6 times a day in small portions, a chemically and mechanically gentle diet, i.e. limit table salt, alcohol, smoking, spicy foods, seasonings, broths, marinades, smoked meats, canned food, coarse fiber, (cabbage) are strictly prohibited , raw apples), citrus fruits, chocolate, cocoa, coffee, pastry products, peas, beans, ice cream, carbonated drinks. In the presence of exocrine pancreatic insufficiency, replacement therapy with enzymatic drugs is prescribed (Abomin, Digestal, Mezim-Forte, Mercenzyme, Nigedase, Ozaza, Panzinorm, Pancreatin, Pancurmen, Solizim, Somilase, Polyzyme, Trienzyme, Festal, Pancitrate, Creon, etc.). Doses are selected individually according to subjective sensations and the nature of the stool. In case of significant weight loss, courses of anabolic steroids (retabolil, nerobol, methandrostenolone, etc.) are carried out. Correction of hypovitaminosis is carried out by prescribing vitamins B, C, A, E. The causes contributing to the progression of the disease are clarified and, if possible, eliminated (sanitation of the biliary tract, treatment of diseases of the stomach and duodenum, etc.). Adequate treatment, carried out in courses, and in severe cases of chronic pancreatitis continuously, helps to preserve the ability of patients to work.

EXAMPLES OF TESTS

Task 1 The cause of secondary chronic pancreatitis is:

1. cholelithiasis

2. viral infection of the pancreas

3. repeated injuries of the pancreas

4. alcoholism

5. family history

Task 2. A patient with exacerbation of chronic pancreatitis is prescribed a strict, gentle diet containing the physiological norm:

3. carbohydrates

4. calories

Task 3. During a survey radiography of the abdominal cavity, small calcifications were found in the patient, projecting at the level of 2-3 lumbar vertebrae, which was regarded as a sign:

1. cholelithiasis

2. chronic pancreatitis

3. chronic hepatitis

4. liver cirrhosis

Task 4. The clinical picture of chronic pancreatitis is characterized by:

1. weight loss, epigastric pain, diarrhea, diabetes mellitus

2. epigastric pain, constipation, loss of appetite, weight loss

3. loss of appetite, flatulence, diarrhea, fever with chills

4. fever with chills, constipation, flatulence, diabetes mellitus

Task 5. A patient with chronic pancreatitis during a period of remission with insufficiency of exocrine pancreatic function should be recommended a diet with significant restrictions:

3. carbohydrates

4. calories

Task 6. A plain radiography of the abdominal cavity may reveal the following signs:

1. peptic ulcer

2. chronic hepatitis

3. liver cirrhosis

4. chronic pancreatitis

Task 7. Steatorrhea is observed when:

1. chronic gastritis

2. chronic pancreatitis

3. putrefactive dyspepsia

4. fermentative dyspepsia

Task 8. Signs confirming the diagnosis of chronic pancreatitis can be obtained by:

1. gastroscopy, duodenography in conditions of hypotension

2. duodenography in conditions of hypotension, echography

3. irrigoscopy, laparoscopy

4. gastroscopy, laparoscopy

Task 9. Under the influence of what means does the pancreas increase the secretion of juice and bicarbonates:

1. cholecystokinin

2. secretin

3. atropine

Task 10. The most valuable laboratory indicator in the diagnosis of chronic pancreatitis is:

1. leukocytosis

2. level of aminotransferases

3. alkaline phosphatase level

4. urine and blood amylase levels

5. hyperglycemia

Task 11. Which of the following tests is the most essential in the diagnosis of chronic pancreatitis:

1. echography

2. scintigraphy of the pancreas

3. Determination of fat in feces

4. all listed methods

5. none of the above methods

Task 12 In the fight against pain in chronic pancreatitis, you can use all of the following remedies, except:

1. analgin

2. droperidol

4. baralgin

5. novocaine

Task 13. High levels of serum amylase can occur in all conditions except:

1. rupture of a pancreatic cyst

2. chronic congestive heart failure

3. ectopic pregnancy

4. mumps

5. exacerbation of chronic pancreatitis

Task 14. What drug is used to suppress the activity of pancreatic enzymes:

1. antacids

2. anticholinergics

3. cimetidine

4.trasylol

5. Trazicore

Task 15. Chronic recurrent pancreatitis is most often observed with:

1. peptic ulcer

2. cholelithiasis

3. chronic colitis

4. Giardiasis

Task 16. Exacerbation of chronic pancreatitis is characterized by all complaints except:

1. girdle pain in the epigastrium

2. pain in the left hypochondrium, radiating to the back

4. vomiting, bringing relief

5. decreased or lack of appetite

Task 17. The etiological factors of pancreatitis are all except:

1. functional, inflammatory and sclerotic changes in the major duodenal papilla

2. high acidity of gastric juice

3. reflux of bile and intestinal contents into the pancreatic ducts

4. penetration of infection by lymphogenous route from neighboring organs

5. alcohol abuse

Task 18. For the treatment of pancreatitis, all groups of the listed drugs are used, except:

1. M-anticholinergics

2. beta blockers

H. H2-histamine receptor blockers

4. antacids

Task 19. To correct exocrine pancreatic insufficiency in chronic pancreatitis, all drugs are used except:

1. Nigedase

3. somilase

4. cocarboxylaaa

Task 20. Which of the following symptoms appears most early in chronic pancreatitis:

1. weight loss

2. jaundice

H. abdominal pain

4. hyperglycemia

5. calcifications in the pancreas

Task 21. Which sign in the coprogram for chronic pancreatitis is the earliest:

1. creatorrhea

2. steatorrhea

3. amilorrhea

Task 22. What is characteristic of a violation of the intrasecretory function of the pancreas in chronic pancreatitis:

1. decrease in insulin with normal glucagon levels

2. decrease in insulin and glucagon

3. decrease in insulin and increase in glucagon

Task 23. The occurrence of shock during exacerbation of chronic pancreatitis is due to:

1. severe pain syndrome

2. release of vasoactive substances into the blood

3. decreased myocardial contractility

4. all of the above

Task 24. In the diagnosis of exacerbation of chronic pancreatitis, the decisive laboratory indicators are:

1. transaminase level

2. alkaline phosphatase level

3. amylase level

4. bilirubin level

Task 25. Secondary diabetes mellitus developing with chronic pancreatitis is characterized by everything except:

1. tendency to hypoglycemia

2. need for low doses of insulin

3. rare development of vascular complications

4. frequent development of hyperosmolar coma

Task 26. When treating exacerbation of chronic pancreatitis, all drugs are used except:

1. cimetidine

2. ranitidine

3. famotidine

4. guanethidine

5. gastrocepin

ANSWERS: 1-1, 2-1, 3-2, 4-1, 5-2, 6-4, 7-2, 8-2, 9-2, 10-4, 11-1,12-3, 13-2, 14-4, 15-2, 16-4, 17-2, 18-2, 19-4, 20-3, 21-2, 22-2, 23-2, 24-3, 25-4, 26-4

SITUATIONAL TASKS

Task 1 A 44-year-old patient complains of intense pain in the upper abdomen radiating to the left hypochondrium, loss of appetite, belching, and nausea. Such pains recur 1-2 times a year. Four years ago she was operated on for gallstone disease. After 6 months a similar attack occurred, accompanied by the appearance of moderate jaundice and an increase in urine amylase levels. Repeated laparotomy did not reveal any stones in the bile ducts. In recent years, constipation has appeared. On examination: the sclera is subicteric. Postoperative scars on the anterior wall. Pain in the choledochopancreatic zone and Mayo-Robson point. Blood test: leukocytes 6.7 thousand, formula unchanged, ESR 18 mm/hour.

Questions: 1. Make a preliminary diagnosis.

2. List the most significant research methods for diagnosis.

3. Provide a treatment plan.

Answers: 1. Secondary chronic pancreatitis, pseudotumor form stage 1-2, exacerbation phase.

2. Ultrasound examination of the abdominal organs, primarily the pancreas, blood and urine amylase, scatology, blood sugar levels.

3. Diet No. 5p, antacids (Almagel), M-anticholinergics (gastrocepin), antispasmodics (no-spa) If necessary, analgesics (baralgin), enzymes (pancreatin).

Task 2 A 48-year-old patient complains of poor appetite, pain in the left hypochondrium, worsening after eating, bloating, rumbling in the abdomen, and periodic diarrhea. From the anamnesis it was possible to find out that the patient abuses alcoholic beverages; these complaints appeared about 6 years ago. When examining low nutrition, there are red spots on the skin that do not disappear with pressure. On percussion, the liver protrudes from under the edge of the costal arch by 1.5-2 cm, pain is noted in the left hypochondrium and the umbilical region.

Questions: 1. What disease are we talking about?

2. What examination methods should be prescribed to clarify the diagnosis?

3. Why does pain intensify after eating?

Answers: 1. 0 primary chronic pancreatitis of alcoholic etiology.

2. Blood and urine amylase, echography of the pancreas, as well as scatology, fibrogastroscopy, blood sugar.

3. Because after eating, the secretion of pancreatic juice increases and the pressure in the Wirsung duct increases.

Task 3 A 55-year-old patient suffered from calculous cholecystitis for 12 years, with exacerbations 1-2 times a year, when pain in the right hypochondrium, low-grade fever, bitterness in the mouth, and nausea were noted. During a routine clinical examination, the patient was found to have an increase in blood sugar to 7 mmol/l, as well as thickening and a decrease in the size of the pancreas according to ultrasound. The patient does not note any changes in the subjective manifestations of the disease. During external examination of increased nutrition. The skin is of normal color and dry. On palpation of the abdomen there is moderate pain at the point of the gallbladder. Blood and urine tests are unremarkable. Blood and urine amylase, transaminases, bilirubin were within normal limits.

Questions: 1. What can the detected changes in blood sugar levels and echography data of the pancreas indicate?

2. What additional examination methods should be prescribed to the patient and for what purpose?

3. What corrections in the patient’s treatment need to be made?

Answers: 1. Detected changes in blood sugar levels and ultrasound data of the pancreas may indicate the addition of low-symptomatic chronic pancreatitis with endocrine insufficiency in the remission phase.

2. In order to clarify the degree of exocrine insufficiency, it is advisable to prescribe a duodenal examination with a two-channel probe with stimulation by secretin and pancreozymin, and a scatological examination.

3. It is necessary to transfer the patient to table 9, if necessary, prescribe small doses of simple insulin, and if exocrine insufficiency is detected, add enzyme preparations (Pancreatin, Mezim-Forte, etc.).

Task 4 A 42-year-old patient, suffering for 8 years from chronic recurrent pancreatitis after eating a large meal and drinking alcohol, felt severe pain in the epigastrium, of a girdling nature. The latter was accompanied by nausea and a slight rise in temperature. Delivered by ambulance to the emergency department. On examination: the condition is moderate, pale, upon palpation of the abdomen there is pain in the choledochopancreatic area. There is vesicular breathing in the lungs, a clear pulmonary sound to percussion. Heart sounds are muffled, pulse 120 per minute, low filling, blood pressure - 70/40 mm Hg. Art. In the blood test, leukocytes are 10 thousand, the formula is unchanged, ESR is 40 ml/hour. Blood amylase increased 3 times.

Questions: 1. What is your preliminary diagnosis? How to explain the changes in hemodynamics?

2. What tests should the patient perform to clarify the diagnosis?

3. Outline a plan for emergency measures and appointments for the patient.

Answers: 1. Chronic recurrent pancreatitis in the acute phase, complicated by hypovolemic shock.

2. It is necessary to determine the volume of blood volume, hematocrit, creatinine, and blood protein.

3. The patient must be prescribed fasting with the establishment of intranasal pumping of gastric contents through a thin tube, parenteral administration of anticholinergics (platiphylline, atropine), H2-histamine receptor blockers (cimetidine, famotidine), analgesics. In order to bind pancreatic enzymes, IV 200 ml of aminocaproic acid 5% solution 1-2 times a day, transfusion of plasma, albumin, glucose, electrolytes at least 3 liters per day, antihistamines.

Task 5 A 48-year-old patient, at an appointment with a local therapist, complains of periodically occurring moderate pain in the umbilical region, decreased appetite, nausea, rumbling in the abdomen, especially after eating spicy or fatty foods, and copious mushy stools. These complaints have appeared and are increasing in severity over the past 5 years. From the anamnesis it is known that 8 years ago she suffered from mumps. On examination: satisfactory condition, low nutrition. From the respiratory and circulatory system without pathology. The abdomen is somewhat swollen, moderately painful in the umbilical area upon palpation. Liver along the edge of the costal arch. The kidneys and spleen are not palpable.

Questions : 1. Make a preliminary diagnosis and justify it.

2. What diseases need to be differentiated from your suspected pathology?

3. Outline a plan for examining the patient.

Answers: 1. Preliminary diagnosis - chronic pancreatitis.

2. It is necessary to differentiate with diseases of the biliary system (cholecystitis, cholelithiasis), chronic enterocolitis, peptic ulcer.

3. Amylase of blood, urine, ultrasound of the abdominal organs, scatology, blood sugar, glucose tolerance test, duodenal examination with a two-channel probe with stimulation of secretin and pancreozymin, fibrogastroscopy, cholegraphy.

A distinctive feature of chronic recurrent pancreatitis is the more frequent occurrence of painful attacks than in the case of other forms of the disease. It cannot be said that exacerbations are accompanied by severe symptoms, however, poor treatment can lead to the progression of pancreatic disease and the development of other serious ailments of the gastrointestinal tract.

Nature of pain during exacerbations

The intensity and nature of pain directly depends on the severity of pancreatitis and the location of the lesions:

if the head of the pancreas or its body is affected, pain appears at the top of the stomach and radiates to the esophagus;
if the pathology is in the tail of the gland, pain occurs in the left hypochondrium, and sometimes can even radiate to the heart;
if the entire pancreas is affected, the patient will experience girdle pain;
perhaps atypical distribution of pain - in the entire abdomen, in the chest or left epigastrium.

If the patient suffers from other chronic diseases, the pain may be so excruciating that the use of narcotic drugs is required, but doctors do not recommend the use of morphine.

The duration of a painful attack ranges from several hours to two to three days, and in addition to painful spasms, severe vomiting is possible, which does not alleviate the patient’s condition, frequent bowel movements, flatulence and loss of appetite.

Background for the development of the disease

According to recent estimates, in at least 65% of cases of recurrent pancreatitis, the patient is also diagnosed with calculous, chronic or acute cholecystitis, obstructive jaundice or hepatic colic. Particular attention should be paid to the treatment of cholelithiasis if it has been detected. Studies have shown that it is the cause of chronic pancreatitis in only 3-8% of cases, but its presence is an almost 100% guarantee of exacerbations and complications. Even the presence of one stone in the gallbladder with a diameter of more than half a centimeter increases the risk of exacerbations of the recurrent form four times. Therefore, the treatment of cholelithiasis should be given no less attention than pancreatitis itself (the pathogenesis, diagnosis and treatment of the disease is described in the proposed video presentation).

Fundamental principles of therapy

Treatment of relapses involves exclusively fasting for several days and taking painkillers. After the attack subsides, general therapy can begin, including the following important measures:

a mandatory diet excluding spicy, fatty and unhealthy foods, as well as alcohol;
multienzyme therapy, which helps the pancreas produce the necessary substances for digesting food;
use of antisecretory drugs that bind bile acids;
analgesics that relieve symptoms.

Despite the large number of modern drugs offered, most doctors are confident that it is impossible to cure chronic pancreatitis. Nowadays, the main research is focused on the amazing properties of stem cells, and scientists are even growing pancreas from them. However, the application of such techniques in general medicine is still tens, or even hundreds of years away. Therefore, while there are no universal medicines, you need to treat yourself yourself, and most importantly, take care of your health.

– a progressive inflammatory-destructive lesion of the pancreas, leading to disruption of its external and intrasecretory function. With exacerbation of chronic pancreatitis, pain occurs in the upper abdomen and left hypochondrium, dyspepsia (nausea, vomiting, heartburn, bloating), yellowness of the skin and sclera. To confirm chronic pancreatitis, a study of digestive gland enzymes, ultrasound, RCP, and a biopsy of the pancreas are performed. The basic principles of therapy include following a diet, taking medications (antispasmodics, hyposecretory, enzyme and other drugs), and if ineffective, surgical treatment.

General information

Chronic pancreatitis is an inflammatory disease of the pancreas with a long-term relapsing course, characterized by a gradual pathological change in its cellular structure and the development of functional failure. In gastroenterology, chronic pancreatitis accounts for 5-10% of all diseases of the digestive system. In developed countries, chronic pancreatitis has recently become “younger”; previously it was typical for people aged 45-55 years, but now the peak incidence in women is at 35 years of age.

Men suffer from chronic pancreatitis somewhat more often than women; recently, the proportion of pancreatitis due to alcohol abuse has increased from 40 to 75 percent among the factors in the development of this disease. There has also been an increase in the occurrence of malignant neoplasms in the pancreas against the background of chronic pancreatitis. A direct connection between chronic pancreatitis and an increased incidence of diabetes mellitus is increasingly noted.

Reasons

Alcohol is a directly toxic factor for the gland parenchyma. In case of cholelithiasis, inflammation becomes the result of the transfer of infection from the bile ducts to the gland through the vessels of the lymphatic system, the development of hypertension of the biliary tract, or the direct reflux of bile into the pancreas.

Other factors contributing to the development of chronic pancreatitis:

persistent increase in the content of calcium ions in the blood;
hypertriglycerinemia;
use of medications (corticosteroids, estrogens, thiazide diuretics, azathioprine);
prolonged stasis of pancreatic secretion (obstruction of the sphincter of Oddi due to cicatricial changes in the duodenal papilla);
genetically determined pancreatitis;
idiopathic pancreatitis (of unclear etiology).

Classification

Chronic pancreatitis is classified:

by origin: primary (alcoholic, toxic, etc.) and secondary (biliary, etc.);
according to clinical manifestations: painful (recurrent and constant), pseudotumorous (cholestatic, with portal hypertension, with partial duodenal obstruction), latent (clinical unexpressed) and combined (several clinical symptoms are expressed);
according to the morphological picture(calcifying, obstructive, inflammatory (infiltrative-fibrous), indurative (fibro-sclerotic);
according to the functional picture(hyperenzyme, hypoenzyme), according to the nature of the functional disorders they can distinguish hypersecretory, hyposecretory, obstructive, ductular (secretory insufficiency is also divided according to the degree of severity into mild, moderate and severe), hyperinsulinism, hypoinsulinism (pancreatic diabetes mellitus);

Chronic pancreatitis is distinguished by the severity of the course and structural disorders (severe, moderate and mild). During the course of the disease, there are stages of exacerbation, remission and unstable remission.

Symptoms of chronic pancreatitis

Often, the initial pathological changes in the tissues of the gland during the development of chronic pancreatitis occur without symptoms. Or the symptoms are mild and nonspecific. When the first pronounced exacerbation occurs, the pathological disorders are already quite significant.

The main complaint during exacerbation of chronic pancreatitis is most often pain in the upper abdomen, in the left hypochondrium, which can become girdling. The pain is either severely constant or paroxysmal in nature. Pain may radiate to the area of the projection of the heart. The pain syndrome may be accompanied by dyspepsia (nausea, vomiting, heartburn, bloating, flatulence). Vomiting during exacerbation of chronic pancreatitis can be frequent, debilitating, and not bringing relief. The stool may be unstable, diarrhea may alternate with constipation. Decreased appetite and indigestion contribute to weight loss.

As the disease progresses, the frequency of exacerbations usually increases. Chronic inflammation of the pancreas can lead to damage to both the gland itself and adjacent tissues. However, it may take years for clinical manifestations of the disease (symptoms) to appear.

During an external examination, patients with chronic pancreatitis often notice yellowness of the sclera and skin. The shade of jaundice is brownish (obstructive jaundice). Pallor of the skin combined with dry skin. There may be red spots (“red drops”) on the chest and abdomen that do not disappear after pressure.

On palpation, the abdomen is moderately swollen in the epigastrium; in the area of the projection of the pancreas, atrophy of the subcutaneous fatty tissue may be noted. On palpation of the abdomen - pain in the upper half, around the navel, in the left hypochondrium, in the costovertebral angle. Sometimes chronic pancreatitis is accompanied by moderate hepato- and splenomegaly.

Complications

Early complications are: obstructive jaundice due to impaired bile outflow, portal hypertension, internal bleeding due to ulceration or perforation of the hollow organs of the gastrointestinal tract, infections and infectious complications (abscess, parapancreatitis, phlegmon of the retroperitoneal tissue, inflammation of the bile ducts).

Complications of a systemic nature: multiorgan pathologies, functional failure of organs and systems (renal, pulmonary, hepatic), encephalopathy, DIC syndrome. As the disease progresses, bleeding of the esophagus, weight loss, diabetes mellitus, and malignant neoplasms of the pancreas may occur.

Diagnostics

To clarify the diagnosis, the gastroenterologist prescribes laboratory tests of blood, stool, and functional diagnostic methods.

A general blood test during an exacerbation usually shows a picture of nonspecific inflammation. For differential diagnosis, samples are taken for the activity of pancreatic enzymes in the blood (amylase, lipase). Radioimmunoassay reveals an increase in the activity of elastase and trypsin. The coprogram reveals excess fat, which suggests pancreatic enzyme deficiency.

The size and structure of the pancreatic parenchyma (and surrounding tissues) can be examined using abdominal ultrasound, CT scan, or MRI of the pancreas. The combination of ultrasound and endoscopy - endoscopic ultrasonography (EUS) - allows you to examine in detail the tissue of the gland and the walls of the gastrointestinal tract from the inside.

For pancreatitis, endoscopic retrograde cholangiopancreatography is used - a radiopaque substance is injected endoscopically into the duodenal papilla.

If it is necessary to clarify the ability of the gland to produce certain enzymes, functional tests with specific stimulants for the secretion of certain enzymes are prescribed.

Treatment of chronic pancreatitis

Treatment is carried out conservatively or surgically, depending on the severity of the disease, as well as the presence or development of complications.

Conservative therapy

Diet therapy. Patients with chronic pancreatitis during periods of severe exacerbation are recommended to refrain from enteral nutrition; when constipation occurs, diet No. 5B is prescribed. In case of chronic pancreatitis, drinking alcohol is strictly prohibited; spicy, fatty, sour foods, and pickles are removed from the diet. For pancreatitis complicated by diabetes mellitus, control sugar-containing products.
Exacerbation of chronic pancreatitis is treated in the same way as acute pancreatitis (symptomatic therapy, pain relief, detoxification, relieving inflammation, restoring digestive function).
For pancreatitis of alcoholic origin, avoidance of alcohol-containing products is a key treatment factor, which in mild cases leads to symptomatic relief.

Indications for resection.

To prevent exacerbations of chronic pancreatitis, it is necessary to follow all the doctor’s recommendations on diet and lifestyle, and undergo regular examinations (at least 2 times a year). Sanatorium-resort treatment plays an important role in prolonging remission and improving the quality of life of patients with chronic pancreatitis.

Forecast

When following recommendations for the prevention of exacerbations, chronic pancreatitis is mild and has a favorable survival prognosis. If the diet is violated, alcohol intake, smoking and inadequate treatment, degenerative processes in the gland tissue progress and severe complications develop, many of which require surgical intervention and can be fatal.