Biliary pancreatitis

Biliary pancreatitis is considered as a secondary inflammatory lesion of the pancreas in the pathology of the liver and biliary tract (hepatobiliary system). This is a kind of chronic pancreatic disease, in which every aggravation follows or coincides with bile-stone attacks (registered by different authors from 25 to 90%).

There is an increase in this type of pancreatitis among adults 3 times, and in children - 4. Observations link him to the patients' refusal to perform operative treatment with the recorded migration of the stone to the bile ducts because of the hopes for conservative therapy.

Most often full of sick women. Some authors argue that biliary-dependent changes in the pancreas rank first in the frequency of injury, displacing alcoholic pancreatitis.

In ICD-10, virtually no explanation is given of what is biliary pancreatitis. According to the type of current, it can be referred to as acute and chronic. And according to the code K 86.1 - "other pancreatitis" without specifying the origin.

The mechanism of development

Involvement of pancreatic inflammation in diseases of the liver, gallbladder and ducts is possible in several ways. The infection passes to the parenchyma of the gland on the lymphatic vessels, pancreatitis proceeds according to the type of parenchymal, but captures the ducts. The mechanical obstruction in the form of a stone in the common bile duct creates an increased pressure, promotes stagnation of the secretion in the main duct of the gland and its edema.

Violated the work of the fecer papilla of the duodenum, through which the secret of the pancreas and bile come together. Conditions are created for the transfer of bile into the pancreatic duct with subsequent inflammation. In this case, active hepatitis is important.

The pathology of the liver causes the transition to bile a significant number of peroxide compounds and free radicals. They are strong damaging factors when entering the pancreatic tissue.

The formation of biliary sludge (sediment) - occurs with cholecystitis and cholangitis due to a violation of the physical and chemical properties of bile. Part of the components precipitate in the form of salts, microcysts. Moving they injure the mucous membrane, increase the inflammation and swelling of the feces papilla, and clog the outlet.

As a result, bile does not enter the duodenum, but is transferred to the pancreatic duct, where the pressure is already increased due to stagnation. The consequence is the activation of pancreatic juice enzymes, the destruction of the protective barrier, the opening of the gate for infectious agents.

The main organs associated with the pancreas are anatomically and functionally

What diseases contribute to the occurrence of biliary pancreatitis?

These variants of pathogenesis are typical for many diseases of the hepatobiliary system. Therefore, biliary-dependent pancreatitis arises as an addition and complication:

• cholelithiasis (in 2/3 cases);
• congenital anomalies of biliary and pancreatic ducts;
• violations of the motor function (dyskinesia) of the gallbladder and pathways;
• chronic cholecystitis;
• hepatitis and cirrhosis;
• local pathology of the Fater's nipple in connection with inflammation, spastic contraction, blockage with a stone, cicatricial changes;
• parasitic lesions of the liver and gallbladder.

The provoking factors can be:

• eating disorders, the use of products that stimulate biliary excretion;
• treatment with medicines with choleretic properties;
• a sharp decrease in weight.

Biliary-dependent pancreatitis occurs in acute or more often in chronic form. Acute - occurs against the background of an attack of cholelithiasis, sharply aggravates the condition of the patient, is the cause of deaths. Chronic - lasts up to six months or more. The exacerbations are replaced by remissions. The outcome depends on the results of treatment of the biliary tract, compliance with the diet.

Symptoms of biliary pancreatitis

The most typical manifestations of biliary pancreatitis are: pain syndrome and intestinal dyspepsia caused by exocrine insufficiency.

Characteristics of pain syndrome

Pain occurs in 90% of patients, only in rare cases a painless variant of the course is possible. Localized in the epigastric region, irradiate in both directions, in the right shoulder, lower back.

Pain occurs 2.5-3 hours after eating, at night. Acute pain can occur immediately after drinking soda water. It causes a spasm of the sphincter of Oddi and provokes pain. The most common cause is a violation of diet: the intake of fatty and fried foods, alcohol, spicy sauces and seasonings, marinades and pickles, smoked products.

Patients describe pain as "shingles"

Signs of enzymatic insufficiency

Inflammatory process in pancreatic cells disrupts both endocrine and exocrine function. The defeat of the islets of Langerhans causes a decrease in the production of insulin with hormonal disorders of carbohydrate metabolism. During an attack, a significant increase or decrease in the level of glucose in the blood is possible.

Exocrine (exocrine) changes relate to the lack of intake of a sufficient number of pancreatic enzymes in the small intestine. The secretion of the gland contains more than 20 kinds of enzymes that ensure the breakdown of fats, proteins and their transfer into digestible biological substances. Biliary pancreatitis in chronic course causes a gradual replacement of secreting cells with scar tissue.

Pancreatic insufficiency is manifested by intestinal dyspepsia:

• liquid stool several times a day with stinking feces covered with oily film (steatorrhea);
• flatulence;
• a feeling of "grumbling" in the abdomen;
• decreased appetite;
• nausea;
• belching and heartburn.

Additional symptoms

Over time, patients lose weight. There are signs of avitaminosis (dry skin, cracks in the corners of the mouth, brittle hair, nails, bleeding gums) and loss of electrolytes. Intoxication entering the blood slag causes nausea, fever.

The defeat of nervous regulation affects the work of sphincters. In patients, there is a reflux of bile in the stomach, signs of gastritis, a feeling of bitterness after belching.

The combination with cholelithiasis promotes the transition to the blood of bilirubin and yellowing of the skin, the sclera

Differential diagnostics

Clinical signs of biliary-dependent pancreatitis may be concealed behind another pathology of the gastrointestinal tract. Therefore in diagnostics it is necessary to exclude:

• peptic ulcer of the stomach and duodenum;
• intestinal tumors;
• antral gastritis;
• viral hepatitis;
• pancreatic tumors;
• chronic non-calculous cholecystitis.

Diagnosis of biliary pancreatitis

Diagnosis of pancreatitis of biliary origin does not differ from standard studies on pancreatic disease. Required are:

• the general analysis of a blood - reveals a leukocytosis, acceleration of an ESR, shift of the formula to the left (an indicator of an inflammation);
• biochemical tests - the level of transaminases (alanine and aspartic), alkaline phosphatase, bilirubin, cholesterol, amylase increases 3-6 times, the protein content decreases, which indicates poor performance of the liver and gallbladder;
• about the violation of the endocrine function signals an increase in the level of glucose in the blood, the appearance of sugar in the urine;
• it is important to identify increased diastase of urine;
• analysis of feces for coprogram - changes with a significant loss of exocrine function: fat, undigested fibers, starch are detected;
• diagnostic tests with specific substances - injected into the stomach, then by blood analysis, the appearance of cleavage products (markers of the secretory activity of the gland) is tracked;
• X-ray method reveals the broken patency of the biliary tract;
• ultrasound examination of the liver, biliary system and pancreas allows to detect concrements in the biliary and pancreatic courses, in the sphincter of Oddi, the increased size of the organ;
• Ultrasound ultrasound and computed tomography are considered more effective.

Shadows of stones on the survey radiograph of the abdominal cavity are rarely detected, the method of contrast cholecystography is more informative

Treatment of biliary pancreatitis

Treatment scheme includes 4 directions:

• withdrawal of pain syndrome;
• measures to restore the external and internal secretory function of the pancreas;
• carrying out detoxification;
• prevention of infectious complications.

The effect is possible only if these actions follow the inevitable elimination of the pathology of the bile ducts.

Diet

For the first three days the doctor sets the hunger when exacerbation occurs. Only drinking alkaline mineral water without gas is allowed. Then gradually the main food products are introduced into the menu. The number of feedings is increased up to 6 times a day, portions are small, all meals must be processed mechanically, boiled.

It is strictly forbidden to prepare fried, smoked products. The patient is restricted in the diet of fats, the carbohydrates are monitored. In the daily diet should contain no more than 80 grams of fat, 350 grams of carbohydrates, and the number of proteins increases to 120 g.

It is forbidden sweets, culinary products, fatty meat, butter put in a plate is limited. Protein intake is compensated by cereals (buckwheat, rice, oatmeal), dairy products (cottage cheese, casseroles), meat and fish meatballs, meatballs, steam cutlets. Juices are recommended only fresh, diluted with water. Fruits and vegetables are stewed.

Medications

To relieve the pain, spasmolytics are used (Atropine, Platifillin). To provide temporary "rest" of the pancreas, drugs blocking H2-histamine receptors (Ranitidine, Kwamatel), a blocker of Octreotide secretion are needed.

The inhibitory effect on excess enzymes is provided by enzymatic preparations containing lipase, proteases (Pancreatin, Pansinorm, Creon). The body, not lacking these substances, blocks its own production in the pancreas. Depending on the severity of intoxication, intravenously injected Hemodez, Polyglukin.

Antibiotics are used to eliminate inflammation, usually use aminopenicillins, cephalosporins, metronidazole, macrolides, aminoglycosides. Symptomatic therapy requires patients with chronic course of the disease and during the recovery period. A complex of vitamins is prescribed, which supports the dosage of enzymatic agents.

Eliminate the spasm of the sphincter of Oddi help M-holinoblokatory (Gastrotsepin)

Care should be taken to take cholagogue preparations. With a tendency to form concretions, one must take into account their multidirectional action. Strengthening the motility of the bile ducts and stimulating the production of bile may provoke an exacerbation. Perhaps only suitable tools that normalize the chemical composition and prevent the precipitation of mineral sediment.

Surgery

Biliary pancreatitis requires the removal of obstructions to the outflow of bile. This is an indispensable condition for the normalization of pancreatic secretion into the duodenum. Removal of the stone is done endoscopically through the gallbladder or direct access to cholecystectomy.

Possible complications

The most common complication of untreated biliary pancreatitis is the parenchymal variant, where the inflammation is localized in the cells of the gland tissue.

Early complications are the consequences of intoxication:

• shock;
• acute renal and hepatic insufficiency;
• gastrointestinal bleeding;
• encephalopathy;
• pancreatic necrosis;
• development of an abscess in the pancreas;
• intestinal obstruction;
• mechanical jaundice;
• diabetic coma.

Late include: the formation of pseudocyst and fistula, ascites, narrowing of the intestinal lumen

Prognosis and prevention

Timely treatment of calculous cholecystitis, cholangitis allows to prevent the defeat of the pancreas. It is especially important to decide on an operation to remove the stone. The planned minimal intervention is less difficult to tolerate by patients than surgery in the presence of biliary pancreatitis.

Compliance with the patient's postoperative period and diet helps to eliminate signs of inflammation and achieve full recovery. An unfavorable prognosis awaits a person with a prolonged course of cholelithiasis, repeated exacerbations of pancreatitis. The gland gradually sclerizes, which affects the other digestive organs.

Disturbances in the biliary system can lead to severe damage to the pancreas and digestion in general. In the treatment should be used in time to surgically remove stones in the bile ducts.