Chronic pancreatitis - Causes, Symptoms and Treatment .MF .
Symptoms of chronic pancreatitis
Treatment of chronic pancreatitis
Complications and prognosis
Chronic pancreatitis - a group of diseases of the pancreas variants, which are characterized by the presence of pancreatic focal necrosis on the background of segmental fibrosis with the deterioration of functions cancer of varying severity.Progression of chronic pancreatitis and leads to the development of atrophy (depletion) of glandular tissue, fibrosis and replacement by connective tissue cellular elements pancreatic parenchyma.
main causes of chronic pancreatitis:
1) alcohol - alcoholic pancreatitis (more common in men older than 35 years) in a dose of 20-80 mg of ethanol / day.for 8-12 years.Protein diet and smoking further compound while for pancreatitis;
2) biliary tract disease and duodenal - biliary pancreatitis (usually women);
• cholelithiasis is the cause of chronic pancreatitis in 35-56% of cases;
• pathology of the sphincter of Oddi (stenosis, strictures, inflammatio
• duodenitis and peptic ulcer disease.Thus, peptic ulcer disease 12 duodenal ulcer in 10,5-16,5% of cases is the direct cause of chronic pancreatitis.
Chronic pancreatitis that develops in cholelithiasis, choledocholithiasis, is more common in women 50ti-60 years.Typically, such patients are signs of the metabolic syndrome: obesity, hyperlipidemia, susceptibility to hypertension, ischemic heart disease, breach of tolerance carbohydrates, hyperuricemia and / or hyperuricosuria.
These two points are the most likely, and most often become causes of chronic pancreatitis.Less common causes:
3), cystic fibrosis (often children);
4) hereditary pancreatitis.The most common in northern Europe, its frequency is about 5% of all cases.Suspected hereditary form of pancreatitis allow no apparent reason, and cases of pancreatitis in the family of the patient's relatives;
5) idiopathic pancreatitis.When at the time of the study the cause has not been established - 10 to 30% of pancreatitis.Recent studies have shown that the cause of idiopathic pancreatitis may be cholesterol microcrystals and calcium granules bilirubinate mikrosferolity;
6) other reasons:
• autoimmune pancreatitis,
• systemic diseases and vasculitis,
• viral (Coxsackie, CMV) and bacterial infections,
• worm infestation (opistorhoz),
• metabolic disorders (hyperlipidemia, diabetes mellitus, chronic renal failure andet al.),
• dyscirculatory disorders (ischemic pancreatitis),
• abnormal development of the pancreas,
• trauma, acute poisoning.
Symptoms of chronic pancreatitis
Chronic pancreatitis - a slowly progressive inflammatory disease of the pancreas, accompanied by necrosis (tissue necrosis cancer) in combination with fibrosis and leads to progressive deterioration of the body even after the termination of the pathogenic effects, which led to the disease.Conventionally, a chronic pancreatitis say when the inflammatory process in the pancreas continues for more than 6 months.Chronic pancreatitis usually occurs with episodes of exacerbation and remission (remission of the disease).
It is important to distinguish between acute and chronic pancreatitis, because there are fundamental differences in the tactics of treatment of such patients.Make it sometimes is extremely difficult, since the aggravation of chronic pancreatitis in their symptoms very similar to acute pancreatitis and acute pancreatitis, in turn, may remain unrecognized (in 60% of cases!), Flowing under the masks of other diseases of the gastrointestinal tract or in their accompaniedand even then it goes into chronic.
Options chronic pancreatitis
Chronic obstructive pancreatitis is caused by obstruction of the main pancreatic duct tumors, inflammation of the duodenal papilla or stenosis, duodenitis due to Crohn's disease, closed abdominal trauma and surgical operations piloroduodenalnoy zone, the presence of pancreatic pseudocysts,congenital anomalies (doubling of the flow).Cholelithiasis and choledocholithiasis, biliary sphincter of Oddi dysfunction and pancreatic types are the main reasons for the formation of chronic obstructive pancreatitis.Pancreatic defeat uniform and not accompanied by the formation of stones in the gland duct.The main symptom is a constant pain.
If calcifying chronic pancreatitis found in the ducts protein precipitates or calcifications, stones, cysts and pseudocysts, atresia and stenosis, as well as atrophy of the acinar tissue.For this form of chronic pancreatitis is characterized by recurrent course with episodes of exacerbation, reminiscent of the early stages of acute pancreatitis (chronic recurrent pancreatitis).As a rule, this is the root cause of chronic pancreatitis is alcohol.
Group calcific pancreatitis are alcohol pancreatitis, pancreatitis develops when exposed to organic solvents, some of the chemical compounds, drugs and pancreatitis, which began as a result of hyperlipidemia, hypercalcemia of hyperparathyroidism, chronic viral infections (including those with chronic HCV- and HBV-infection), congenital changes in pancreatic ducts (doubling the pancreatic duct).
Hereditary pancreatitis with autosomal dominant inheritance with incomplete penetration also refers to a group of pancreatitis and calcification occurs in children 10-12 years or 30-40 years old.It is indistinguishable from conventional forms of pancreatitis, accompanied by recurrent attacks of abdominal pain, 8-10 years 20% of patients joins diabetes and in 15-20% of patients - severe steatorrhea.The absence of other causes, and an indication of the cases of pancreatitis in the family make reasonable suspicion of a hereditary form of chronic pancreatitis.
Chronic pancreatitis parenchymal characterized by the development of foci of inflammation in the parenchyma with a predominance of mononuclear cell infiltrates in and areas of fibrosis, which replace the parenchyma of the pancreas.In this form of chronic pancreatitis are no defeat ducts and calcifications in the pancreas.Leading symptoms are slowly progressive signs of exocrine and endocrine insufficiency and lack of pain (painless form).
most commonly observed clinical syndromes in chronic pancreatitis are:
• abdominal pain syndrome,
• exocrine pancreatic insufficiency syndrome,
• syndrome of endocrine disorders,
• dyspeptic syndrome,
• biliary hypertension syndrome.
pain in chronic pancreatitis
often develop a painful form of chronic pancreatitis is preceded painless, latent stage of varying duration, masquerading epigastric discomfort, flatulence, unstable chair with a tendency to diarrhea with the presence of undigested fat in the stool or steatorrhea.Repeated attacks painful form of chronic pancreatitis pancreatic insufficiency formed mainly affecting the exocrine or endocrine function with the development of type 2 diabetes.
pain can occur as during exacerbation and in remission phase of chronic pancreatitis.It has no clear localization, originating in the upper or middle abdomen on the left or in the middle, gives to the back, sometimes it takes the character shingles.More than half of the patients the pain is very intense.
Localization of pain in chronic pancreatitis
causes of pain in chronic pancreatitis the following:
1) acute inflammation of the pancreas (damage to the parenchyma and capsule);
2) pseudocyst with perifocal inflammation;
3) obstruction and dilatation of the pancreatic and bile duct;
4) The fibrosis in the sensory nerves, leading to compression of them;
5), the pressure of the surrounding nerve plexus enlarged pancreas;
- stenosis and sphincter of Oddi dyskinesia.
- Pain associated with pseudocysts and ductal obstruction, significantly worse during or immediately after a meal.Pain is usually encircling, paroxysmal.Significantly reduce pain antisecretory drugs and drugs of pancreatin (Panzinorm) that reduce the secretion of pancreatic through a feedback mechanism.
- Inflammatory pain is not dependent on food intake, localized, usually epigastric, radiating to the back.Relieves pain are analgesics (NSAIDs, in severe cases - narcotic analgesics)
- exocrine pancreatic insufficiency leads to bacterial overgrowth in the small intestine, which is also a cause of pain in a significant proportion of patients with chronic pancreatitis.These pain caused by increased pressure in the duodenum.
In the later stages of chronic pancreatitis, with the development of fibrosis, pain diminish and may disappear in a few years.Then come to the fore symptoms of exocrine insufficiency.
symptoms of exocrine insufficiency
exocrine pancreatic insufficiency manifests itself in violation of processes of intestinal digestion and absorption.Symptoms:
• diarrhea (stool from 3 to 6 times a day),
• steatorrhea (occurs with a decrease in pancreatic secretion by 10%, mushy stool, offensive, with a greasy luster).
• weight loss,
• recurrent vomiting,
• loss of appetite.
Quite rapidly evolving bacterial overgrowth in the small intestine syndrome, its symptoms:
• rumbling in the stomach,
later joined by symptoms characteristic of hypovitaminosis - anemia, weakness, skin changes, hair metabolism.The basis
exocrine pancreatic insufficiency based on the following mechanisms:
- destruction of acinar cells, resulting in decreased synthesis of pancreatic enzymes;
- obstruction of the pancreatic duct, breaking the flow of pancreatic juice into the duodenum;
- decrease in secretion of bicarbonates ductal epithelium leads to acidification of the duodenum content to pH 4 and below, resulting in the denaturation of the pancreatic enzymes and bile acid precipitation.
Symptoms of biliary hypertension
biliary hypertension syndrome is expressed in obstructive jaundice and cholangitis and appears relatively often.Up to 30% of patients in the acute stage of chronic pancreatitis are transient or persistent hyperbilirubinemia.Causes of the syndrome - an increase in the pancreatic head with compression of its terminal part of the common bile duct, choledocholithiasis and pathology of major duodenal papilla (concrements, stenosis).
symptoms of endocrine disorders in chronic pancreatitis
found in approximately one third of patients.At the core of these violations is loss of pancreatic islet cell apparatus, so that there is a shortage not only of insulin and glucagon.This explains the peculiarities of pancreatogenic diabetes: a tendency to hypoglycemia, the need for lower doses of insulin, a rare development of ketoacidosis, cardiovascular and other complications.
Symptoms of chronic pancreatitis caused by enzyme release
• Intoxication syndrome manifested by general weakness, loss of appetite, low blood pressure, tachycardia, fever, leukocytosis and increased ESR.
• Symptom Tuzhilin (a symptom of "red droplets"): the appearance of bright red spots on the skin of the chest, back and abdomen.These spots are vascular aneurysms and do not disappear when pressed.
diagnosis of chronic pancreatitis
diagnosis of chronic pancreatitis is quite complicated and is based on three main features: the typical history (pain attacks, alcohol abuse), the presence of exocrine and / or endocrine disease and the identification of structural changes of the pancreas.Often, the diagnosis of chronic pancreatitis is formed after prolonged observation of patients who have clinical signs that suggest the presence of chronic pancreatitis.
blood biochemistry.The level of amylase, lipase serum often remains normal or reduced in the period of the attack of pancreatitis, which is explained by a decrease in the number of acinar cells that produce these enzymes.With the combination of alcoholic pancreatitis, impaired liver function tests may be identified with alcoholic liver disease.In 5-10% of cases of chronic pancreatitis are signs of compression vnutripankreaticheskoy of the bile duct due to edema or fibrosis of the pancreatic head, which is accompanied by jaundice, increased levels of direct bilirubin and serum alkaline phosphatase.
impaired glucose tolerance develops in 2/3 patients, diabetes - 30% of patients with chronic pancreatitis.
exocrine insufficiency becomes apparent and can be easily detected in the development of malabsorption syndrome, in which the fat in the stool can determine the quality (color of the Sudan) or the quantitative method.The secretory failure at an earlier stage is detected with the help of pancreatic function tests.
in clinical practice for the diagnosis of chronic pancreatitis is introduced enzyme immunoassay method for the determination of elastase-1 in serum and stool of patients for assessing the exocrine function of the pancreas.
Diagnostics chronic pancreatitis
Tool data to confirm the assumption that the presence of chronic pancreatitis can be considered quite informative.Uses:
- ultrasound of the abdominal cavity;
- endoscopic ultrasound, spiral CT and magnetic resonance imaging of the pancreas.
ERCP reveals stenosis of duct obstruction localization, structural changes of small ducts, intraductal calcifications and protein traffic jams, but at the same time there is a high risk of developing acute pancreatitis
Differential diagnosis of pancreatitis
Symptoms of pancreatitis refers to signs of "acute abdomen".This means that it is necessary to distinguish from acute pancreatitis, abdominal surgical pathology, namely from a perforated ulcer;acute cholecystitis;bowel obstruction;intestinal vein thrombosis;myocardial infarction.
perforated ulcer.Perforation (perforation) of the stomach or intestinal ulcers is different from acute pancreatitis "dagger of pain."Linked to this pain with penetration of gastric or intestinal contents in the peritoneum, which causes a reflex tension anterior abdominal wall, or the so-called wooden belly.This is not typical for pancreatitis.Vomiting with ulcer perforation is very rare.The patient lies still.A patient with pancreatitis is restless, tossing in bed.Panoramic X-ray indicates gas in the abdominal cavity with a perforated ulcer.The final diagnosis is based on ultrasound or laparoscopy.
Acute cholecystitis.Sometimes quite difficult to distinguish between these two pathologies.But in favor of cholecystitis will speak the predominant localization of pain right side radiating to the right shoulder area.When the ultrasound can determine the localization of inflammation, but it is worth remembering that can accompany pancreatitis cholecystitis.
Acute intestinal obstruction.The pain of intestinal obstruction cramping and pain in pancreatitis constant nagging.On radiographs of the colon is inflated with pancreatitis, but no bowls Kloybera.
Mezotromboz.Mezotromboz most often affects older people with cardiovascular disease.Symptoms of this rapidly growing, but they are not related to food intake.Allow doubt help laparoscopy, or angiography.
Myocardial infarction.Upon arrival at the hospital conducted a standard electrocardiography, distinguish pancreatitis from myocardial infarction is not difficult.