Destructive pancreatitis

Destructive pancreatitis is an extremely unfavorable form of the course of acute inflammation of the pancreas. The disease is accompanied by necrosis( necrosis) of tissue sites of the organ with cell death and termination of functions.

Unlike interstitial( edematous) pankreanekroz form accompanied by corrosion of pancreatic parenchyma own enzymes aseptic( without involvement of pathogenic microorganisms) proceeds quickly in inflammation purulent. The possibility of treatment is limited to the first hours and days. The lethal outcome, according to different data, is observed in 25-40% of cases.

Causes of

Most cases of destructive pancreatitis are a consequence of chronic alcoholism( up to 60%).Under the influence of alcohol, the pancreas intensifies the secretion of the juice, but it can not be completely removed into the duodenum, since the main duct and the large papilla are compressed by swelling.

As a result, the pressure in the small lead-out structures is significantly increased. In a third of cases, pancreatic necrosis of the pancreas is provoked by diseases of the biliary tract. Patients at the same time found stones in the gallbladder or ducts( up to 80% of cases).

Anomalies in the development of the organ, expressed in the narrowing of the outflow tract, are important. Defeat can occur with various diseases as a result of compression, impaired innervation of the pancreatic tissue.

Other causes of destructive pancreatitis include:

• improper diet with predominance of heavy for digestion of meat, fatty, spicy, fried foods;
• long breaks in food;
• peptic ulcer disease;
• suffered abdominal trauma, including surgical interventions with complications;
• bacterial, viral and parasitic infection in the body, helminths;
• violation of blood supply to the gland with ischemia, thromboembolism, severe atherosclerotic process in the vessels of the abdominal cavity.

There are cases of pancreatitis caused by an overdose or a negative effect of drugs, an endoscopy procedure. The most dangerous combination of several reasons.

anatomical connection allows casting of bile into the pancreas

mechanism of development and the phase of the destructive process

far as inflammation of the pancreas is associated with gallstone disease( cholelithiasis), explains the old, but so far a satisfactory theory of "general anatomical canal."Modern data made it possible to isolate during the pancreatitis phase of pathological changes leading ultimately to pancreatic necrosis in the pancreas. They determine the clinical form of the disease.

It is believed that pancreanecrosis is formed as much as possible after 72 hours and then does not progress, but in severe cases this process occurs at a faster rate( 24-36 hours).The initial phase( enzymatic) lasts about 5 days. Serous inflammation is accompanied by an edema of the organ.

Reactive phase - occurs in the second week of the disease, is caused by the reaction of all body systems to foci of necrosis in the gland itself and in the surrounding cellulose. The phase of melting and sequestration - comes in the third week, can last several months. Cavities( sequestration) in the parenchyma of the pancreas and in the field of retroperitoneal tissue appear on the fourteenth day.

The pathological process can develop in two ways:

• aseptic( sterile) - without infection, leads to the formation of postnecrotic fistulas and cysts;
• septic - joins the spread of pathogens, developing septic complications( abscesses in the abdominal cavity and retroperitoneal space, streaks, peritonitis, omentobursit, tracts, sepsis).

Hemorrhagic edema passes to necrosis of pancreatic parenchyma sections

Types of pancreatonecrosis

Destructive pancreatitis is always accompanied by more or less pronounced signs of pancreatic necrosis. Its classification combines anatomical principles with a violation of the morphology of the tissues, the presence of infection and complicating conditions during the course of the disease.

Sterile pancreanecrosis is distinguished:

• by localization to the gland located in the head( head), in the caudal part or with total organ damage;
• , depending on the morphological structure on hemorrhagic, fatty, mixed;
• on the degree of capture of the gland on the small- and large-focal, subtotal.

Pancreatic necrosis with infection is considered as a complicated inflammation. Isolate individual forms:

• abscessing - in the cellulose around the pancreas, peritoneum, between the intestinal loops, under the diaphragm, into the pelvis;
• formation of an infiltrate in the surrounding tissue;
• enzymatic peritonitis;
• phlegmon on the background of general sepsis in retroperitoneal tissue surrounding the pancreas, intestine, pelvic organs;
• bleeding caused by arthrosis( this is necrotic decay of the vascular wall);
• jaundice caused by impaired biliary tract obstruction;
• cavity formation( pseudocysts) with a high probability of suppuration;
• formation of external and internal fistulas from the ducts, when the pancreatic necrotic cavity is emptied into other organs( intestines, stomach, bronchus, pleural and abdominal cavities).In destructive pancreatitis, 30-55% of patients develop.

What is pancreatic necrosis for the human body?

Destructive pancreatitis is considered a multi-organ pathology due to the effect on virtually all physiological systems of a person. The stages of the development of disorders are distinguished:

• Hemodynamic - lasts up to five days from the onset of the disease. The toxic effect of enzymes released into the bloodstream leads to the accumulation of various biologically active substances( kinins, disintegrating protein), which causes a shock state of the patient, toxicosis.
• Functional - is accompanied by a failure of the function of internal organs, occurs to the third day, depends on the prevalence of pancreatic necrosis.
• Local complications of - are formed in the near-pancreatic zone after infection( abscesses, infiltrates, phlegmon).They can spread to the peritoneum and retroperitoneal tissue, cause peritonitis, sepsis.

According to the degree of damage to the body, 2 forms are distinguished. Not severe - occurs in 95% of patients with pancreatitis. The pathological process is either limited to the stage of infiltration, or by foci of necrosis in diameter no more than 10 mm. Toxic effect does not reach the degree of shock. Mortality among patients does not exceed 3%.Severe - is observed in 5% of cases, pancreatic necrosis is widespread( large, subtotal or total lesions).Severe toxicosis, shock. The lethality reaches 60%.

How is pancreatic necrosis manifested?

Symptomatic of pancreatic necrosis in acute pancreatitis is pronounced. In surgery, it is customary to distinguish the classic triad of Mondor - characteristic pain, vomiting and flatulence. Pain syndrome - is characterized by suddenness, propensity to arise in the evening or at night( after overeating heavy food, drinking alcohol, on holidays).

Intensity is extremely pronounced( in 40-45% of patients), it is constant, does not subside when the body position changes, spasmolytic injection, the patient is excited, screams for pain, in 10% of cases there is shock, loss of consciousness. Thus, 6% of patients assess pain as moderate. Their severity is associated with the form and stage of pathology.

Localized pains over the navel, in the zone of epigastrium, irradiate in both sides of the upper abdomen, back, scapula( shingles).The patient feels pain in the lower back, chest. Vomiting - arises at the height of pain, repeated many times. In vomit masses first eaten food, then bile, slime.

The patient loses fluid, the body is dehydrated by debilitating vomiting. The abdomen is swollen, in severe cases, gas and feces are delayed. Common manifestations include:

• "acute" facial features of the patient, cyanotic lips;
• excitation or co-location;
• reduced pressure and tachycardia;
• temperature reaction with a constant level of about 38 degrees( with the acceleration and weakness of the pulse is an important diagnostic feature), at the stage of infection attachment a sharp "jump" and a drop in temperature with chills, pouring sweat;
• shortness of breath.

This is an indication of the likelihood of arsive internal bleeding

Diagnosis

It is difficult to diagnose only by clinical manifestations. It is important to take into account important information from laboratory and instrumental research methods. In the analysis of blood - the defeat of the pancreas indicate: pronounced leukocytosis, shift the formula to the left, a significant increase in ESR, from the biochemical tests the most significant increase in amylase and lipase in the serum( diastase in the urine).

On the chest X-ray, the sites of atelectasis( alveolar folding), effusion in the pleural cavity are revealed. Ultrasound examination is effective in 50-75% of cases, in the remaining pancreas it is impossible to detect after the accumulation of gases in the intestine. The ultrasound shows:

• the growth of the gland in size, swelling against the background of clearly defined boundaries in the initial stage;
• blurring of contours in pancreatic necrosis caused by heterogeneity of structures, hypoechoic parenchyma tissue sites in necrosis sites;
• accumulation of fluid in the abdominal cavity or in the gland bag.

The method of laparoscopy( examination of the abdominal organs with the help of an optical device inserted through the incision of the abdominal wall) shows a characteristic brown effusion in the abdominal cavity or in the gland bag during hemorrhagic pancreatic necrosis, yellowish white plaques in the gland zone, on the mesentery of the intestine, the walls of the intestines -, while the effusion of the liquid is negligible. When a fluid is collected for analysis, a high activity of the enzymes is detected.

When computer tomography is performed, increased gas production does not affect the quality of the study, therefore the method is more informative.

Diagnostic criteria for

Patients are most often admitted to the surgical department for emergency indications. In such cases, the diagnosis should focus on the most likely signs. These include:

• typical clinical manifestations associated with prior intake of alcohol, fatty and spicy foods, concomitant cholelithiasis, chronic cholecystitis;
• characteristic laboratory indicators( especially hyperactivity of pancreatic enzymes);
• confirming the data of ultrasound.

For diagnosis, at least two of the following characteristics are necessary. A desirable but not mandatory study is laparoscopy and the study of the composition of exudate( the activity of amylase should be 2-3 times higher in the serum).At the same time, signs of the severity of the disease have been confirmed.

Severe course is confirmed:

• with clinical symptoms of peritonitis;
• with tachycardia or bradycardia;
• hypotension below 100 mm Hg. Art.on the upper level;
• decreased urine output( less than 250 ml in 12 hours);
• symptoms of brain damage( encephalopathy) in the form of excitability, inhibition;
• by changing skin color( spots, marbling, hyperemia);
• characteristic changes in blood tests;
• revealed on the ECG diffuse metabolic disorders, myocardial ischemia.

The presence of two or more signs confirms the severe form of the disease. This is taken into account in the direction of the patient for treatment in the intensive care unit and intensive care unit or in the general surgical department. For diagnosis, it is necessary to immediately determine the state of the bile ducts, the role of outflow in the formation of pancreatic destruction.

To do this, fibrogastroscopy is performed( reveals the absence of bile in the duodenum), use ultrasound data on concrements. When identifying the wedging stone of the large duodenal papilla, it must be removed by laparoscopic method.

What is used for treatment?

Treatment of destructive pancreatitis in a mild form requires a complex conservative approach. The task is to ensure:

• complete rest of the pancreas( regimen, diet);
• outflow of bile and secretion of the duct;
• blocking of excess enzyme production;
• prevention of infection;
• restoration of blood circulation in the pancreas and the body;
• withdrawal of toxicosis;
• compensation of water-electrolyte losses;
• therapy of intestinal paresis;
• stimulation of immunity;
• fight against ischemia of organs with the help of antioxidants.

For the removal of shock and its effects, complete anesthesia is necessary. Analgesics and spasmolytic drugs in this case are poorly effective. They resort to a novocain blockade with the introduction of a solution into the cellulose behind the pancreas. Achievement of functional dormancy of the pancreas is ensured:

• by hunger in the early days, by a ban on drinking( you can only moisten your mouth);
• by excretion( aspiration) through a probe of gastric and duodenal contents;
• local hypothermia( put a cold on the stomach).

Drugs

For the removal of intoxication, intravenous fluids of 2-2.5 liters per day should be used with the use of diuretics. Preparations Dextran, Pentoxifylline restore the broken microcirculation of blood in the pancreas.

The total volume includes colloidal and saline solutions( Reopoliglyukin, Refortan, Albumin), plasma substitutes

. Special drugs include drugs that block the secretory activity of the gland, they are administered in the first three days( Octreotide, Quatemal, 5-fluorouracil).To counter-enzymes are Contrikal, Gordoks. Among antibiotics, the most appropriate group is a wide range or two drugs at once( Metronidazole, Fluoroquinolones).

Symptomatic drugs should be given attention to support the cardiovascular system. Assign a small dose of glycosides. In the recovery period, immunomodulators and vitamins are used. The criterion for effective treatment of pancreatic necrosis is the formation of a purified cyst in the pancreatic necrosis zone.

Who is shown the operation on the pancreas?

Surgical treatment is vital in the case of:

• attaching infection to the pancreatonecrosis zone, identifying abscesses, septic phlegmon in retroperitoneal tissue, with purulent peritonitis;
• no response to conservative therapy, multiple organ failure, observed from 24 hours to three days;
• detection with computed tomography of the area of ​​extensive necrosis is more than half of the organ parenchyma;
• if necrotic changes spread to the retroperitoneal space;
• occurrence of enzymatic( abacterial) peritonitis.

For operational treatment, the optimal tactic is selected taking into account the prevalence of the lesion. With extensive necrosis, it is necessary to remove the entire pancreas and gall bladder, sometimes - the spleen.

Operation is completed by mandatory drainage of the abdominal cavity for fluid removal and administration of antibiotics inside the

. Food during the rehabilitation period

. During the recovery period, the patient will need to strictly follow the dietary diet. The menu is built in compliance with the basic requirements for unloading and preserving the pancreas. Features of the diet included in the table number 5n.

The patient's basic requirements will have to be met for the rest of his life:

• food to cook only in a boiled form, steamed, mechanically crushed;
• the amount of protein in the diet should be provided by low-fat meat, fish dishes, cottage cheese( average 150 g / day);
• carbohydrates are limited to 350 g, most of all due to sweets, honey;
• excludes products that stimulate the release of pancreatic juice and increased gas formation( any broth, cabbage, tomatoes, legumes, mushrooms);
• the weight of the resolved fats to 80 g decreases;
• should be fed every 3-4 hours in small portions.

Patients are not allowed to drink alcohol, beer, carbonated drinks, coffee, fat, sausages, canned goods, fresh pastries, rye bread, raw vegetables rich in fiber, yogurt.

Destructive pancreatitis is a severe disease. Its outcome is largely determined by the timeliness of therapy. Occurrence of symptomatology of the oedemal stage requires immediate intervention, qualified treatment. You can not count on folk methods and the results of a diet.