Chronic recurrent pancreatitis occurs most often with. Modern view on 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 can be observed in a patient, and what treatment a doctor should offer.

Why is the disease returning?

A patient who has had mild pancreatitis feels healthy already at the 2-3rd week of illness. Therefore, many decide to return to their usual way of life. If at the same time sparing conditions for the gland are not observed, then a new attack will not take long. 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 a diet, frequent fractional meals, avoiding alcohol and smoking.

In addition to a disturbed diet, comorbidities can provoke a new attack of pancreatitis. The second most important factor initiating inflammation in the pancreas is a diseased gallbladder. The reasons for its inflammation are numerous. Stagnation of the secret, the formation of stones, their movement along the ducts, concomitant infection - all this provokes inflammation of the pancreatic tissue. Therefore, following a diet and following the regimen, you can still get a new attack. It is enough just to refuse the operation for the removal of the diseased gallbladder.

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

Frequent attacks of pancreatitis are characteristic of autoimmune processes. In this case, the cells of the pancreas attack 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 girdle character.
Indigestion. The inflamed tissue does not have time to recover. Enzymes do not perform their function of processing food. Symptoms are manifested by nausea, bloating, vomiting, belching, flatulence.
Chair disorders. In patients, constipation alternates with diarrhea.
Dysbacteriosis. The processes of fermentation and decay in the body contribute to the reproduction of pathogenic flora. Imbalances in the gut can lead to severe infections. The first symptoms are fever and diarrhea.
Weight loss. Disturbed work of the enzyme system leads to poor absorption of nutrients. The body lacks energy. Patients quickly lose weight. Against the background of frequent exacerbations, eating is associated with pain, which exacerbates the symptoms of cachexia.

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

Therapy

Spasmolytic treatment will help to quickly relieve pain symptoms. In the beginning, intramuscular means are used. Then you can switch to tablets (No-shpa, Drotaverine, Spazmeks).

To reduce the activity of the pancreas, treatment must be supplemented with agents that reduce the production of hydrochloric acid. The complex of therapy necessarily includes the drugs Omeprazole, 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 the food does not receive proper processing. This contributes to the strengthening of 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 drugs. The most popular are Pancreatin, Creon, Mezim. The dose is selected by the doctor. Treatment with low doses will not be adequate. Enzymes partially take over the work of the oppressed gland.

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

In severe forms of chronic pancreatitis, it is necessary to prescribe Somatostatin or Octreocid. These artificial hormones inhibit 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 rapid development of necrosis in the pancreas. The body begins to digest itself, during the process tissue damage occurs.

The most dangerous complication of the acute form is necrotizing pancreatitis, sometimes leading to the complete death of pancreatic tissues. 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, high body temperature. In various medical classifications, it is divided into subtypes: sterile, infected, fatty, hemorrhagic, mixed, and so on.

Chronic pancreatitis

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

Varieties of the disease

In the medical literature, there are a number of options for classifying the described disease. Consider what the most popular looks like.

Chronic pancreatitis is subdivided in terms of origin:

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

1Clinical picture of pathology

Pancreatitis is an acute or chronic inflammatory disease of the pancreas of various etiologies. How it flows, not everyone knows. 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 is the 3rd most common among all diseases of the abdominal cavity.

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 differs in that it most often develops in young people who abuse alcohol.

The peak incidence occurs between the ages of 30 and 40. Often this pathology is combined with cholelithiasis. In this case, the main contingent of patients will be elderly people over 60 years old.

2 Types of disease

It is necessary not only to know what pancreatitis is, but also to have an idea about its varieties. According to the nature of the course, the following forms of pancreatitis are distinguished:

spicy;
acute recurrent;
chronic;
chronic in the period of exacerbation.

Complications and consequences of chronic pancreatitis

The described ailment is insidious in that during periods of remission, the symptoms recede, it seems to the patient at moments of enlightenment that the disease has been 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 in patients are:

obstructive jaundice (develops due to a violation of the outflow of bile from the gallbladder);
internal bleeding due to deformation of organs and the formation of ulcers;
development of infections and abscesses;
the formation of cysts and fistulas;
development of diabetes;
cancer formations.

In most cases, the examination reveals cysts that become a complication of chronic pancreatitis. They represent formations filled with liquid, are diagnosed in the process of ultrasound examination. In this case, surgical intervention is inevitable. Removal takes place with the help of laparoscopic surgery.

If earlier the disease occurred in the elderly, today pathological changes in the pancreas often occur in young people. Improper eating habits cause the pancreas to suffer and lose function.

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

Symptoms and Diagnosis

It is impossible and even dangerous to make a diagnosis on your own in this case, since many diseases show 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 avoid complications and serious consequences. Many turn to a gastroenterologist only when the disease is already unbearable, but this is required at the first sign of disruption of the gastrointestinal tract.

It is vital to seek medical help. The sooner you can pass the necessary examination, the more positive the prognosis for recovery.

Pathological changes in the work of the pancreas are detected using research: urinalysis, 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 diastasis, the result of which indicates the level of a pancreatic enzyme that provides the breakdown of carbohydrates. The higher the urine diastasis, the stronger the inflammatory process. The norm is 64 units, with a disease, 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 the set of indicators obtained, the doctor decides on the appointment of effective therapy, which is selected individually. Each doctor initially considers conservative treatment and only in extreme cases is ready to resort to surgical intervention. However, the choice of method directly depends on the condition in which the patient asked for help.

Consider the main principles of the 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, after which it is required to be observed by a doctor for some time.

This procedure is considered safe, painless, and no scars remain 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 about:

Soreness in the epigastrium, left hypochondrium, Chauffard zone, surrounding. The specific localization and nature of 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 due to insufficient intake of pancreatic juice into the duodenum and a violation of the digestive process.
Signs of hyperglycemia or hypoglycemia. In the first case, there is thirst, increased diuresis, weight loss, dry skin and mucous membranes, in the second - weakness, dizziness, sweating, pallor.

Forecast

The prognosis for life is favorable if the patient strictly adheres to the diet and regularly undergoes supportive treatment. At the same time, the number of exacerbations can be reduced by 80% relative to people who ignore the above requirements.

While maintaining the etiological factor, the life of the patient 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 time.

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 load of glucose. If possible and necessary, examine the level of insulin and glucagon in the blood by radioimmunoassay.

Of the instrumental methods for the diagnosis of chronic pancreatitis, ultrasound is of the greatest importance. It allows you to identify the presence, nature and extent of the pathological process in the pancreas. There are uneven contours of the gland, a change in its size, density, expansion of the Wirsung duct, the presence of cysts and pseudocysts, calcification. An important advantage of ultrasound is its non-invasiveness, the absence of contraindications and complications, and especially the possibility of detecting changes in the liver and biliary tract associated with pancreatitis, which facilitates differential diagnosis with tumors of the pancreatoduodenal zone. Has not lost its value x-ray examination of the duodenum in conditions of hypotension. At the same time, chronic pancreatitis may be indicated by deformations of the internal contour of its loop, due to an increase in the head of the pancreas, foci of calcification or stones in the area of the pancreas, displacement and deformation of the stomach, stomach ulcers and duodenal ulcers, usually on the back 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, fibrogastroscopy are used. The data of these methods do not allow diagnosing chronic pancreatitis, but it helps to clarify some etiopathogenetic factors, to assess the state of neighboring organs.

There is no generally accepted classification of chronic pancreatitis. As a working one, they use the one proposed in 1982 by A.L. Grebenev, who proposed to distinguish the following forms of the disease according to the characteristics of the clinic: 1) recurrent (polysymptomatic); 2) pain, when the indicated symptom is dominant, 3) latent, long-term secret; 4) pseudotumor with the formation of obstructive jaundice. The course distinguishes stage 1 (mild severity), when signs of external and intrasecretory pancreatic insufficiency are not detected, stage 2 (moderate severity), when they are determined and stage 3 (severe), 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 from calculous cholecystitis, gastric and duodenal ulcers, chronic enteritis and colitis, visceral ischemic syndrome.

The basic treatment of exacerbation of chronic pancreatitis includes measures aimed at 1) reducing pancreatic secretion; 2) relief of pain syndrome; 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.

Given 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, hunger is prescribed, alkaline solutions are taken every 2 hours (sodium bicarbonate, Borjomi, 200 ml each). It is possible to use buffer antacids (almagel, phosphalugel, maalox, gastal) which are prescribed 6-8 times a day. In severe cases, first of all, with symptoms of duodenostasis, continuous aspiration of gastric contents is carried out through a thin intranasal probe. To enhance the effect, M-anticholinergics (atropine, platifillin, preferably gastrocepin) are prescribed orally or parenterally, as well as histamine H2 receptor blockers (cimetidine, ranitidine, famotidine). In addition, significantly reduces the production of enzymes 5-fluorouracil, which is prescribed in / in the rate of -12-15 mg / kg / day. in 5% glucose solution for 5 days. It is possible to use antispasmodics (papaverine, no-shpa, cerucal, etc.). During the first days of exacerbation, all patients need to inject 3 or more liters of fluid intravenously, including glucose, electrolytes, albumin solution, plasma, hemodez, which, along with a decrease in pain and intoxication, prevents the development of hypovolemic shock.

The most important principle of therapy in the phase of exacerbation of chronic pancreatitis is the relief of pain. If the above measures aimed at reducing pancreatic secretion did not have the proper analgesic effect, the following tactic is recommended. Initially, analgesics or antispasmodics are prescribed (2 ml of 50% solution of analgin 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, neuroleptics are additionally 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 i.v. And only after that, they use narcotic analgesics - 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.

With a pronounced exacerbation, for the prevention of septic complications, it is recommended to administer broad-spectrum antibiotics - semi-synthetic penicillins, cephalosporins in normal doses for 5-7 days. They also have an antisecretory effect.

At present, most authors have abandoned the use of antienzymatic drugs (trasylol, contrical, gordox, etc.), given their low efficiency and a large number of complications, especially allergic ones. However, for this purpose, aminocaproic acid is used (in / in 200 ml 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 the fractional administration of small doses of simple insulin.

During a fading exacerbation and in the remission phase, 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 vegetable origin and carbohydrates (up to 300-400 g), the total calorie content should be 2500-2800 kcal. Recommended fractional meals 5-6 times a day in small portions, a chemically and mechanically sparing diet, i.e. limit table salt, alcohol, smoking, spicy dishes, seasonings, broths, marinades, smoked meats, canned food, coarse fiber, (cabbage , raw apples), citrus fruits, chocolate, cocoa, coffee, pastry, peas, beans, ice cream, carbonated drinks. In the presence of exocrine pancreatic insufficiency, replacement therapy with enzymatic preparations is prescribed (abomin, digestal, mezim-forte, merkenzim, nigedaza, opaza, panzinorm, pancreatin, pankurmen, solizim, somilase, polyzyme, trienzyme, festal, pancitrate, creon, etc.). Doses are selected individually according to subjective sensations and the nature of the stool. With severe weight loss, courses are carried out with anabolic steroids (retabolil, nerobol, methandrostenolone, etc.). Correction of hypovitaminosis is carried out by prescribing vitamins of groups B, C, A, E. The causes that contribute to the progression of the disease are clarified and, if possible, eliminated (sanation of the biliary tract, treatment of diseases of the stomach and duodenum, etc.). Adequate treatment, carried out by courses, and in severe cases of chronic pancreatitis continuously, contributes to the preservation of the working capacity of patients.

EXAMPLES OF TESTS

Task 1 The cause of secondary chronic pancreatitis is:

1. cholelithiasis

2. viral damage to the pancreas

3. repeated injuries of the pancreas

4. alcoholism

5. burdened heredity

Task 2. A patient with an exacerbation of chronic pancreatitis is prescribed a strict sparing diet containing a physiological norm:

3. carbohydrates

4. calories

Task Z. Plain radiography of the abdominal cavity of the patient revealed small calcifications projecting at the level of 2-3 lumbar vertebrae, which was regarded as a sign of:

1. cholelithiasis

2. chronic pancreatitis

3. chronic hepatitis

4. cirrhosis of the liver

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 in remission with insufficiency of exocrine pancreatic function should be recommended a diet with a significant restriction:

3. carbohydrates

4. calories

Task 6. Plain radiography of the abdominal cavity may reveal signs of:

1. peptic ulcer

2. chronic hepatitis

3. cirrhosis of the liver

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 during:

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. aminotransferase level

3. alkaline phosphatase level

4. the level of amylase in urine and blood

5. hyperglycemia

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

1. sonography

2. scintigraphy of the pancreas

3. determination of fat in feces

4. all methods listed

5. none of the listed methods

Task 12 In the fight against pain in chronic pancreatitis, all of the listed means can be used, with the exception of:

1. analgin

2. droperidol

4. baralgin

5. novocaine

Task 13. A high level of serum amylase can be in all conditions, except for:

1. rupture of a pancreatic cyst

2. chronic congestive heart failure

3. ectopic pregnancy

4. mumps

5. exacerbation of chronic pancreatitis

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

1. antacids

2. anticholinergics

3. cimetidine

4. trasilol

5. trazikor

Task 15. Chronic recurrent pancreatitis occurs most often 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 that brings 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 the infection by the 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-cholinolytics

2. beta blockers

Z. blockers of H2-histamine receptors

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 the earliest in chronic pancreatitis:

1. slimming

2. jaundice

Z. abdominal pain

4. hyperglycemia

5. calcifications in the pancreas

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

1. creatorrhea

2. steatorrhea

3. amylorrhea

Task 22. What is typical for 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. decrease in myocardial contractility

4. all of the above

Task 24. In the diagnosis of exacerbation of chronic pancreatitis, the decisive of the laboratory parameters is:

1. level of transaminases

2. alkaline phosphatase level

3. amylase level

4. bilirubin level

Task 25. For secondary diabetes mellitus that develops in chronic pancreatitis, everything is characteristic, 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. In the treatment of 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. Similar pains are repeated 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 the level of urine amylase. At repeated laparotomy, stones in the bile ducts were not found. In recent years, constipation has appeared. On examination: subicteric sclera. Postoperative scars on the anterior wall. Pain in the choledochopancreatic zone and the Mayo-Robson point. In the blood test: leukocytes 6.7 thousand, the formula is not changed, ESR 18 mm/hour.

Questions: 1. Make a preliminary diagnosis.

2. List the most important research methods for diagnostics.

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, coprology, blood sugar levels.

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

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

Questions: 1. What disease can we talk about?

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

3. Why does the pain syndrome increase after eating?

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

2. Amylase of blood and urine, 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 pains in the right hypochondrium, subfebrile temperature, bitterness in the mouth, and nausea were noted. During a scheduled dispensary examination, the patient revealed an increase in blood sugar up to 7 mmol/l, as well as compaction and a decrease in the size of the pancreas according to ultrasound. The patient does not notice any changes in the subjective manifestations of the disease. With an external examination of increased nutrition. The skin is of normal color, dryish. On palpation of the abdomen, moderate pain at the point of the gallbladder. Blood tests, urine without features. Blood and urine amylase, transaminases, bilirubin are within normal limits.

Questions: 1. What can the detected changes in blood sugar level and pancreatic ultrasound data indicate?

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

3. What correction in the treatment of the patient should be done?

Answers: 1. The detected changes in the blood sugar content and the ultrasound data of the pancreas may indicate the addition of chronic pancreatitis of an asymptomatic form with endocrine insufficiency in the remission phase.

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

3. It is necessary to transfer the patient to the 9th table, if necessary, prescribe small doses of simple insulin, if exocrine insufficiency is detected, add enzyme preparations (pancreatin, mezim-forte, etc.).

Task 4 A 42-year-old patient who has been suffering from chronic recurrent pancreatitis for 8 years after eating a lot of food and drinking alcohol felt severe pain in the epigastrium of a girdle character. The latter was accompanied by nausea, a slight rise in temperature. Delivered by ambulance to the emergency department. On examination: the state of moderate severity, pale, on palpation of the abdomen, pain in the choledochopancreatic zone. In the lungs, vesicular breathing, percussion clear pulmonary sound. The heart sounds are muffled, the pulse is 120 per minute, small filling, blood pressure - 70/40 mm Hg. Art. In the blood test, leukocytes are 10 thousand, the formula is unchanged, the ESR is 40 ml/hour. Blood amylase increased 3 times.

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

2. What tests should be performed for the patient to clarify the diagnosis?

3. Outline a plan of urgent 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 BCC, hematocrit, creatinine, blood protein.

3. The patient must be prescribed hunger with the establishment of intranasal pumping of gastric contents through a thin probe, parenteral administration of anticholinergics (platifillin, atropine), H2-histamine receptor blockers (cimetidine, famotidine), analgesics. In order to bind pancreatic enzymes in / in 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 the appointment of a local therapist complains of recurrent moderate pain in the umbilical region, loss of appetite, nausea, rumbling in the abdomen, especially after taking spicy or fatty foods, plentiful mushy stools. These complaints have appeared and are growing in their severity over the past 5 years. From the anamnesis it is known that 8 years ago she suffered from mumps. On examination: the condition is satisfactory, reduced nutrition. On the part of the respiratory and circulatory organs without pathology. The abdomen is somewhat swollen, moderately painful in the umbilical region on palpation. Liver on the edge of the costal arch. Kidneys, spleen are not palpable.

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

2. With what diseases it is necessary to differentiate the pathology you suspect?

3. Outline a plan for examining the patient.

Answers: 1. The preliminary diagnosis is 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, coprology, blood sugar, glucose tolerance test, duodenal examination with a two-channel probe with secretin and pancreozymin stimulation, fibrogastroscopy, cholegraphy.

A distinctive feature of chronic recurrent pancreatitis is a more frequent onset of pain 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.

The nature of pain during exacerbations

The intensity and nature of pain directly depends on the neglect of pancreatitis and the localization of lesions:

if the head of the pancreas or its body is affected, the pain manifests itself at the top of the stomach and radiates into the esophagus;
if the pathology is in the tail of the gland, pain occurs in the left hypochondrium, and sometimes can even be given to the heart;
if the entire pancreas is affected, the patient has girdle pain;
perhaps atypical distribution of pain - in the entire abdomen, in the chest or left epigastric region.

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

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

Background for the development of the disease

According to recent estimates, at least 65% of cases of recurrent pancreatitis in a patient are 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 almost a 100% guarantee of triggering exacerbations and complications. Even the presence of a single stone in the gallbladder with a diameter of more than half a centimeter increases the risk of exacerbations of the recurrent form by four times. Therefore, the treatment of cholelithiasis should be given no less attention than pancreatitis itself (the pathogenesis, diagnosis and treatment of the disease are described in the proposed video presentation).

Fundamental Principles of Therapy

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

a mandatory diet that excludes spicy, fatty and junk food, as well as alcohol;
polyenzyme therapy, which helps the pancreas to produce the necessary substances for the digestion of food;
the use of antisecretory drugs that bind bile acids;
analgesics that relieve symptoms.

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

- a progressive inflammatory-destructive lesion of the pancreas, leading to a violation of its external and intrasecretory function. With exacerbation of chronic pancreatitis, pain occurs in the upper abdomen and left hypochondrium, dyspeptic symptoms (nausea, vomiting, heartburn, bloating), yellowness of the skin and sclera. To confirm chronic pancreatitis, a study of digestive enzymes, ultrasound, ERCP, pancreatic biopsy is performed. The basic principles of therapy include adherence to a diet, taking medications (antispasmodics, hyposecretory, enzymatic and other drugs), in case of ineffectiveness - surgical treatment.

General information

Chronic pancreatitis is an inflammatory disease of the pancreas of a long relapsing course, characterized by a gradual pathological change in its cellular structure and the development of functional insufficiency. In gastroenterology, chronic pancreatitis accounts for 5-10% of all diseases of the digestive system. In developed countries, chronic pancreatitis has recently become “younger”, if earlier it was typical for people aged 45-55, now the peak incidence in women is 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. An increase in the occurrence of malignant neoplasms in the pancreas against the background of chronic pancreatitis was also noted. Increasingly, there is a direct connection between chronic pancreatitis and an increase in the incidence of diabetes mellitus.

The reasons

Alcohol is directly toxic to the gland parenchyma factor. In cholelithiasis, inflammation results from the passage 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;
the use of drugs (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 unknown etiology).

Classification

Chronic pancreatitis is classified:

by origin: primary (alcoholic, toxic, etc.) and secondary (biliary, etc.);
according to clinical manifestations: pain (recurrent and permanent), pseudotumorous (cholestatic, with portal hypertension, with partial duodenal obstruction), latent (unexpressed clinic) 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(hyperenzymatic, hypoenzymatic), according to the nature of functional disorders, hypersecretory, hyposecretory, obstructive, ductular (secretory insufficiency is also divided according to 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, stages of exacerbation, remission and unstable remission are distinguished.

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, pathological disorders are already quite significant.

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

With the development of the disease, the frequency of exacerbations, as a rule, increases. Chronic inflammation of the pancreas can lead to damage to both the gland itself and adjacent tissues. However, it may take years before clinical manifestations of the disease (symptoms) appear.

During an external examination in patients with chronic pancreatitis, yellowness of the sclera and skin is often noted. The shade of jaundice is brownish (obstructive jaundice). Paleness of the skin in combination with dry skin. On the chest and abdomen, there may be red spots ("red drops") that do not disappear after pressure.

On palpation, the abdomen is moderately swollen in the epigastrium, in 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, retroperitoneal cellulitis, inflammation of the biliary tract).

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

Diagnostics

To clarify the diagnosis, the gastroenterologist prescribes laboratory tests of blood, feces, methods of functional diagnostics.

A general blood test during an exacerbation, as a rule, 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 an excess of fat, which suggests pancreatic enzyme deficiency.

The size and structure of the pancreatic parenchyma (and surrounding tissues) can be examined using abdominal ultrasound, CT or MRI of the pancreas. The combination of the ultrasound method with 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.

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

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

Treatment of chronic pancreatitis

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

Conservative therapy

Diet therapy. Patients with chronic pancreatitis during a period of severe exacerbation are advised to refrain from enteral nutrition; when stubbing, diet No. 5B is prescribed. In chronic pancreatitis, alcohol consumption is strictly prohibited, spicy, fatty, sour foods, pickles are removed from the diet. With pancreatitis complicated by diabetes mellitus, control of sugar-containing products.
Exacerbation of chronic pancreatitis is treated in the same way as acute pancreatitis (symptomatic therapy, pain relief, detoxification, inflammation removal, restoration of digestive function).
For pancreatitis of alcoholic origin, the refusal to use alcohol-containing products is a key factor in treatment, in mild cases leading to symptomatic relief.

indications for resection.

To prevent exacerbations of chronic pancreatitis, you must follow all the doctor's recommendations on diet and lifestyle, regularly (at least 2 times a year) undergo an examination. Spa treatment plays an important role in prolonging remission and improving the quality of life of patients with chronic pancreatitis.

Forecast

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