Acute pancreatitis

Acute pancreatitis

Acute pancreatitis - an enzymatic lesion of pancreas. This process has autocatalytic character and frequently comes to an end with an organ self-digestion. The lesion of pancreas as consequence of influence of unfavorable factors can clinically show from insignificant painful sensations to the hardest enzymatic shock.

Among patients women prevail: it, apparently, is bound to higher frequency of occurrence at them a cloelithiasis and lipometabolism disturbances. An appreciable part of patients - persons of elderly and senile age.

Causative Factors

Now causative factors strictly a pancreatitis can be divided on two basic bunches:

  • Causing difficulty of outflow of pancreatic juice and an intraduct hypertensia
  • leading to a primary lesion of acinar cells

In this connection distinguish a pancreatitis hypertension-ductal and initially-acinar forms

The most serious forms of an acute pancreatitis at the human educe at a combination of 3 factors:

  1. An acute intraduct hypertensia
  2. Hypersecretions
  3. Intracanalicular activation of pancreatic enzymes

The acute is cholic-pancreatic ductal hypertensia and bile reflux in pancreat ducts easily arise at subitaneous blockage of an ostium major duodenal papilla, educing at a spastic stricture and an Oddi's sphincter dyskinesia, a choledocholithiasis, inflammatory and cicatrical narrowings of a papilla, hit in ducts of ascarides, papillomas of the big duodenal papilla, etc. the Oddi's sphincter Spastic stricture can be a consequence as various is excitatory-reflex influences from receptors of gepato-duodenogastric region, and an immediate boring of sympathetic and parasympathetic parts of NANOSECOND. Vagus nerve excitation causes a hypersecretion of pancreatic juice and a spastic stricture of an Oddi's sphincter and a stasis in system of pancreatic ducts. Region the big duodenal papilla is especially sensitive. The trauma of this region during operative measures on bile-excreting pathes, a stomach, 12-tiperstnoj to an intestine, a pancreas head quite often comes to an end with occurrence of an acute postoperative pancreatitis.

Besides a biliary-pancreatic reflux the duodeno-pancreatic reflux can appear the pancreatitis cause. If in the first case pancreatic enzymes are activated by bile in the second the activator is enterokinase. A flowing duodenal contained in pancreatic ducts probably at an ostium major duodenal papillaи rising of intraduodenal pressure. At the human the supertension in 12-tiperstnoj to an intestine can become perceptible at duodenostasis, the mechanical duodenal impassability caused by annular pancreas, a cicatrical stenosis and a tumour, a peptic ulcer and a diverticulum, arteriomesenteric impassability, a syndrome of a resulting loop, etc.

The acute pancreatic hypertensia as the cause of an acute pancreatitis in the conditions of a hypersecretion educes at acute or chronic impassability of pancreatic ducts. These kinds of impassability cause the congenital both got deformations and narrowings, an epithelium metaplasia, an occlusion of ducts slime, putty and stones, and also their prelum out of - and intrapancreatic formations.

Causal to factors of 2 bunches, reacting in the conditions of normal intraduct pressure and leading to a primary lesion of acinar cells, are: a circulatory disturbance in pancreas, an allergy, metabolic disturbances, hormonal alterations, various toxic influences, infection contaminations and a trauma.

The role of the alimentary factor in a parentage of an acute pancreatitis can be surveyed in 3 aspects:

  1. Squirrels, Adepses, alcohol, etc. Cause the expressed secretion of the pancreatic juice rich with protein and poor bicarbonates, that at inadequate outflow can serve as the cause of development of an alimentary pancreatitis
  2. The enhanced secretory activity of acinar cells at excessive alimentary borings or a protein deficient food is accompanied by irreciprocal damages of intracellular organoids and development of a metabolic pancreatitis
  3. The excessive use of mainly albuminous and fat nutrition causes an organism sensibilization albuminous metabolites that frames congenial conditions for development of an allergic pancreatitis

The special form is represented by the acute pancreatitis bound to congenital or got disturbance of a lipometabolism with sharply expressed hyperlipemia. The constant hyperlipemia accompanying an alcoholism, various anemias, to a mechanical icterus and other morbid conditions has great value. The acute pancreatitis at a hyperlipemia educes owing to a fatty vascular embolism of pancreas. In an aetiology of an acute pancreatitis the certain role is carried out by endocrine disturbances. The cases of the pancreatitis which has arisen because of a hyperparathyreosis when a major factor promoting development of disease, rising of level Ca in blood as it is of great importance in Trypsinum and lipase activation is are known.

In a parentage of pancreatonecroses the certain role is played by a glucagon influencing activity of a lipase, bicarbonate and fermental secretion of pancreas, and as on function and blood supply GASTROINTESTINAL TRACT. In some cases the acute pancreatitis appears at women during pregnancy or in an early puerperal period. It, besides disturbance of functions of bile-excreting system, is caused also by hormonal rearrangement of an organism in the given season, proceeding with the toxicosis phenomena, and blood supply disturbance in pancreas.

The acute pancreatitis can arise at a venenating with chemical Materials (a salvarsan, phosphorus, alkalis, acids, etc.). In such cases the acute toxic pancreatitis is one of components extended a stalemate. Process in the abdominal lumen, caused by an endogenous intoxication.

Thus, the acute pancreatitis is polyetiological disease to which disbolism more often contribute, diseases of bile-excreting system, other organs of digestion, disease of cardiovascular system, abuse by alcohol and other alimentary disturbances.

Clinical Classifications

Depending on a phase of development of pathological process it is possible to secure 4 forms of an acute pancreatitis: acute intersticial, corresponding to an edema phase (serous, hemorrhagic, it is serous-gemorragicheskogo), acute necrotic, expressing a phase of formation of a necrosis (with a hemorrhagic component or without it); infiltrative-necrotical and it is purulent-nekrotichesky, corresponding to a phase of fusion and a sequestration of the necrotic locuses.

For simplification of a choice of tactics of treatment, volume of infusional therapy and correct interpreting of the form of a pancreatitis excrete easy, average and serious degrees of an intoxication. Easy degree (meeting usually at a serous edema of pancreas) is characterised by a satisfactory general condition of the patient, moderate pains in epigastriums, a nausea, unitary vomiting, absence of symptoms of a boring of the peritoneum, not variated colour of integuments, a pulse rate within 88-90 impacts in a minute, the normal or slightly raised BP, high digits uroamilase, small activity of Trypsinum and a lipase, kept or slightly lowered BCV (deficiency of 7-15 %), a moderate leukocytosis, subfebrile temperature.

Average degree of an intoxication (it is observed at finely focal necrosis of a gland) shows persistent pains in epigastriums which do not disappear at application spasmolytics and analgetics, pallor and cyanotic integuments, repeated vomitings, a strain of muscles in epigastric range, a pulse rate to 100-110 beats/min, falling of a BP below initial level, rising peripheric and central venous pressure depression (CVP), high digits uroamilase, early high activity of Trypsinum and a lipase, depression of level Ca and the raised maintenance of sialine acids, reduction BCV (deficiency of 16-35 %), diuresis depression, lifting of a body temperature to 38 C°.

Serious degree of an intoxication (arises at a widespread necrosis of a gland) differs a serious general condition of the patient, severe pains in epigastric range, excruciating vomiting, sharply acyanotic or cyanochroic integuments, quite often icterus, appearance of symptoms of a peritonitis, a pulse rate over 120 beats/min, falling of level of a BP and CVP, depression uroamilase, activity of Trypsinum and a lipase, level Ca, a hypouresis, up to full anuria, sharp depression BCV (deficiency of 36-50 %), a heat, appreciable disturbance of function of heart, a liver, lungs, nephroses.

Semiology

Clinical implications of an acute pancreatitis depend on many factors - from the form and the season of disease, degree of an intoxication, presence and character of complications and concomitant diseases. Medical actions spent at a pre-hospital stage or in a hospital, promote disappearance or sharp weakening of the basic symptoms of a pancreatitis, complicating that its recognition.

The most constant symptom of an acute pancreatitis is the megalgia, as a rule, expressed in range actually epigastriums, on the pancreas course, arising subitaneously, appearing quite often after the alimentary overload, often irradiating in a back, in right, left or both scapulas, the left costovertebral angle, the left shoulder girdle. Sometimes the pain accrues gradually, has colicy character and is not so intensive.

The second for frequency (80-92 % of patients) a symptom of an acute pancreatitis is repeated vomiting not bringing simplification which usually appears at once after a pain (but can and precede it) and is accompanied, as a rule, by a constant nausea. A body temperature in the beginning normal or subfebrile. "Scissors" - backlog of a body temperature from a pulse rate are characteristic.

In diagnostics of an acute pancreatitis many clinicians give great value to change of a coloration of integuments. The icterus in the disease beginning meets was rarely. Pallor of integuments is is more often characteristic. Appearing later akro - and the general cyanosis is caused by breath disturbance, a toxic lesion of capillars and is characteristic for serious forms of a pancreatitis. Therefore it always is a bad prognostic sign. Dryness of tongue at an acute pancreatitis, as well as at other acute surgical diseases of a gaste, reflects degree of a dehydration of an organism. The gaste is blown up in the beginning only in epigastric range, on a course cross-section-obodochnoj intestines (a symptom the Bond), and later - on all extent. The strain of muscles of an abdominal wall is localised in the beginning only in a pancreas projection. Participation in a defence reaction of muscles of all gaste testifies to pancreatitis complication enzymatic, and then and a purulent peritonitis at which simultaneously find positive and Blumberg sign. Ortner's symptom confirms participation of a gallbladder in pathological process and happens positive approximately at 32 % of patients. At research of peripheric blood at 61-80 % of patients the augmentation of number of leucocytes and alteration of the formula of white blood to the left, and at 54-82 % - a lymphopenia is taped. There are changes from red blood much less often. The anaemia is bound to an exit of erythrocytes in intersticial space at augmentation of permeability of a vascular side, their destruction under the influence of proteolytic enzymes.

Daily urine definition (if necessary - the sentry) which indicators can specify in intoxication degree is obligatory. In urine the proteinuria, a microhematuria, a cylindruria and other pathological admixings is taped.

Biochemical researches, and first of all - definition of activity of enzymes of pancreas have the special diagnostic value. As not all patients arrive in a hospital during the first hours diseases hyperactivity of these enzymes is found in 82,5-97,2 % of cases. Therefore normal indicators of enzymes of blood and urine do not exclude presence of an acute pancreatitis. With augmentation of time of disease frequency of a hyperenzymemia decreases. Certain value has definition quantitative and bilirubin quality indicators in blood.

At research of cardiovascular system of the patient it is necessary to effect electrocardiogram putting off as she allows to exclude (or, on the contrary, to confirm) a myocardial infarction.

The important role in diagnostics of an acute pancreatitis belongs to survey roentgenography and a chest fluoroscopy and an abdominal lumen with which help it is possible to exclude a number of the general surgical diseases of organs of a gaste and to find signs of a lesion of pancreas. The poperchno-colon inflation - a symptom the Bond - and other parts of an intestine, distance augmentation between the big curvature of a stomach and cross-section-obodochnoj an intestine is often found. The X-ray inspection GASTROINTESTINAL TRACT allows to catch indirect signs of a pancreatitis: expansion of a horseshoe and a prelum of a descending loop 12-tiperstnoj intestines, prelums and shifts of a stomach and 12-tiperstnoj intestines, and appreciable disturbance of their evacuation (12,6 %). The selective angiography (mezenteriko - and celiacography) gives the chance to tap direct signs of an acute pancreatitis even at entering of patients in serotinal terms of disease when indicators of activity of enzymes of blood and urine become normal. Besides, by means of an angiography such complications, as a clottage of large arterial and venous fulcrums are found, etc.

Scenning pancreas allows to define degree of a lesion of function of acinar cells and to tap deformation and augmentation of the organ. With introduction in practice of surgery of endoscopic and non-invasive methods of research value of two last methods has considerably decreased.

Esophagogastroduodenoscopy carries out an auxiliary role in diagnostics of an acute pancreatitis. The most typical endoscopic signs are the protrusion of a back side of a stomach and a picture of an acute gastroduodenitis. At a serious pancreatitis the erosive and hemorrhagic gastroduodenitis, a papillitis and reflux-pyloritis signs is more often taped.

Huge diagnostic possibilities the laparoscopy puts at disposal of clinicians. Direct signs of an acute pancreatitis are: plaques of a fatty necrosis on a peritoneum, an epiploon, a hemorrhagic exudate, puffiness of an epiploon, a mesentery of an intestine, a fat, a hyperemia and a peritoneum imbibition. Among indirect signs note: a stomach and transverse colon paresis, a congestive gallbladder. High activity of enzymes of pancreas in a peritoneal exudate at a laparoscopy completely confirms the diagnosis of an acute pancreatitis.

The big diffusion was received by non-invasive methods of diagnostics. Their advantages concern: absence of necessity of application of contrast mediums and additional preparation of patients, easy shipping and high diagnostic possibility. Application of a thermography of range of pancreas allows to diagnose an acute pancreatitis in 70 % of cases. On thermograms fields of the raised brightness of the various dimensions, forms, structure and intensity are taped.

The echoscopy (ultrasonic research) pancreas allows to establish the correct diagnosis in 75 % of cases.

The perspective should consider an axial computer x-ray tomography which allows to tap fields of inspissation, depression, stones and cystic lumens in a parenchyma of a gland in diameter to 2 sm

Diagnosis of Various Forms of disease

  1. The acute intersticial pancreatitis is characterised by rapidity, a relative brevity of flow of disease. Clinical implications of an edema of a gland usually disappear during 3-7, and acute pathomorphologic changes - 10-14 days. In most cases at an edema easier disease, rather weak expression of aboriginal signs of disease is observed. The painful syndrome and vomiting are less expressed and quickly pass under the influence of conservative treatment, the picture of change from cardiovascular system, a liver, nephroses is insignificant. There are no expressed metabolic disturbances and was rarely there are reactive changes from a thoracal lumen (disturbance of function of a diaphragm, atelectases of lungs, pleurites). For a hydropic pancreatitis high efficacyy of conservative therapy is characteristic.
  2. An acute necrotic pancreatitis. The widespread necrosis of pancreas proves to be true first of all duration of disease. Clinically necrosis implications to keep not less than 3 4 weeks, and pathomorphologic changes in iron are caught even through 1,5 - 2 months and with a discoloration of integuments (pallor with a Crocq's disease), with a strong long abdominal pain, repeated vomiting, with involving in pathological process of the vital organs. The collaptoid state of patients testifies to the necrotic form also at entering in a hospital. Aboriginal signs of a necrosis of a gland are more expressed and to keep, as a rule, much more longly. For a gland necrosis absence of fast effect is characteristic at conservative treatment. However, pathogenetic therapy in due time begun and spent in full can quickly enrich a condition of patients, making thereby false impression about disease. Fast increase of a leukocytosis with alteration of white blood to the left is observed. With 2-3го day the ESR raises, concentration of a fibrinogen, the S-jet protein is gradually enlarged. All enzymes, except for an amylase, show high activity.
  3. An acute infiltrativno-necrotic pancreatitis. This form educes usually at presence at the sick large and widespread locuses of a necrosis of pancreas and a retroperitoneal fat when their fusion and a sequestration proceed in aseptic conditions. In this case in aseptic reactive process are involved not only a gland and a retroperitoneal fat, but also surrounding organs. The most important objective sign is palpated in region glands the infiltrate arising for 5-7th day and later from the beginning of an attack. This conglomerate is not enough painful, has no accurate borders and becomes more expressed at a premise under a back of the patient of a pillow or the platen. The condition of the patient more often moderately severe, becomes perceptible the appetite depression, moderately expressed pallor of integuments, is frequent - a paresis GASTROINTESTINAL TRACT. Temperature, as a rule, subfebrile, the leukocytosis with neutrophilic alteration is moderately expressed. Indicators of an ESR, the S-jet protein, a fibrinogen are raised. At congenial disease the infiltrate in epigastric range gradually resolves and disappears not earlier than in 3 4 weeks.
  4. The Is purulent-Nekrotichesky pancreatitis. This form also arises in a phase of fusion and a sequestration of the necrotic locuses when the is purulent-putrefactive infection contamination inpours into pancreas and a retroperitoneal fat. Fusion of the necrotic locuses usually begins from 5 7th days, and a sequestration - in 2 3 weeks and later from the disease beginning. For an is purulent-necrotic pancreatitis it is characteristic:
    • More long and high leukocytosis (15-17 thousand/microlitre) with sharp alteration of the formula of white blood to the left, augmentation of an ESR, a fibrinogen, the S-jet protein
    • the Appreciable anaemia and changes from urine
    • the Expressed and longly defined aboriginal symptoms: a tumescence and morbidity in epigastric range, an inflation of the top half or all gaste, an ascites, a peritonitis, an edema of a hypodermic fat in the field of a loin and lateral parts of a gaste, etc.
    • deeper disturbances of albuminous, carbohydrate, electrolytic exchanges (hypo-and dysproteinemia, a hypocalcemia)
    • Frequent complications in the form of acute gastroduodenal ulcers and erosions, an erosive gastroduodenal bleeding, fistulas GASTROINTESTINAL TRACT, pancreatic fistulas, a phlebothrombosis and a thrombophlebitis of system of a portal vein, a purulent parapancreatitis, a peritonitis, a sepsis, etc.

Treatment of acute pancreatitis

In treatment of an acute pancreatitis the operative method offered by German surgeon Korbe in 1894 However a high lethality (90 10 0 %) even from the very beginning prevailed has at that time forced to concern this method frostily. Now mainly conservative method of treatment of an acute pancreatitis is conventional. However medical tactics is dictated mainly by the disease form. If at an intersticial and necrotic pancreatitis crucial importance has timely carrying out of conservative therapy and, to a lesser degree, operation, and at infiltrative-necrotical - only conservative treatment purulent-nekroticheskaja the form demands an obligatory operative measure.

Modern conservative therapy of an acute pancreatitis solves following problems:

  1. Pain and spastic stricture liquidation, microcirculation enriching in iron
  2. Struggle against a shock and homeostasis restoration
  3. Depressing of an exocrine secretion and activity of enzymes of a gland
  4. Struggle against a toxemia
  5. Normalisation of activity of lungs, hearts, nephroses, a liver
  6. Preventive maintenance and treatment of complications

In different phases and the seasons of development of an acute pancreatitis the various operative measures, pursuing two main objectives are justified:

  • to Stop an acute attack of disease and not to admit a lethal outcome
  • to Warn relapse of an acute pancreatitis after an extract of the patient from a hospital

For the best decision of the basic questions of surgical treatment and operation at patients with an acute pancreatitis (depending on a phase of development and the disease season) divide into 3 bunches:

1. Early, carried out during the first hours and days of disease in the acute season of an edematization or a gland necrosis. Indications to early operations:

  • Difficulty at diagnosis statement
  • the Diffuse enzymatic peritonitis with the phenomena of the expressed intoxication
  • the Combination of a pancreatitis to a destructive cholecystitis
  • the Obstructive jaundice

After introduction in practice of urgent surgery of the laparoscopy, allowing to define the form of a pancreatitis and to define a condition of biliary system, the number of early operations has decreased. Besides, laparoscopic lavage can be used as preoperative preparation of the patient.

At certain indications early operations come to an end with a pancreatectomy and sanation of biliary system.

2. Operations in a phase of fusion and a sequestration of the necrotic locuses of pancreas and a retroperitoneal fat which are effected usually on 2-3rd week from the disease beginning. At treatment of patients in this phase probably in time to remove dead tissues of a gland and a retroperitoneal fat, that is will in due time execute a necretomy (after 10th day of disease) or a sequestectomy (on 3 4th week from the disease beginning). 3. The serotinal (delayed) operations spent in a planned order in a subsiding or full liquidation of pathological changes of pancreas. These operations are shown at those diseases of organs of a gaste which can cause a pancreatitis or promote its development (cholically-stone disease, a cholecystitis, gastroduodenal impassability, duodenostasis, a diverticulum 12-tiperstnoj intestines, impassability of a pancreatic duct, etc.) . They are referred on the prevention of relapse of an acute pancreatitis by operative sanation of cholic pathes and other organs of digestion, and also the pancreas.

The primary goal of operation on pancreas consists in building of the conditions excluding development of a hypertensia in pancreatic ducts.

< Prev   Next >