The dominant symptom of recurrent pancreatitis is. Symptoms and treatment of chronic recurrent pancreatitis. Fundamental Principles of Therapy

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Recurrent chronic pancreatitis

Clinical manifestations of chronic recurrent pancreatitis

The pathological process, which is accompanied by pronounced changes in the functions of the pancreas and has a cyclical subacute period (periodic exacerbations), is called chronic recurrent pancreatitis.

The disease develops over several years. Progressive disturbances of its main functions occur in the pancreas. The gland ceases to produce enzymes in the right amount, does not control the production of hormones (insulin), which regulate blood sugar levels.

Such disorders are caused by dystrophic changes in the parenchyma, which form gradually and lead to the formation of stones in the ducts and tissues of the pancreas.

Causes leading to the development of the disease

Recurrent pancreatitis is called the disease of civilization. Recently, the number of cases in developed countries has doubled. The main reason for its development is the social factor: alcohol and low-quality products. Their use causes systematic poisoning of the body and excessive activation of the pancreas. This leads to a large release of the secret, which accumulates in the pancreas itself and gradually begins to destroy it.

According to statistics, the disease is more common in thin men of working age. In women, the chronic form occurs after suffering acute pancreatitis.

To provoke the development of recurrent pancreatitis can:

• cholelithiasis;
• injury, poisoning;
• chronic infections, intoxications;
• psychogenic factor (stress).

Separately, among the reasons, it is worth noting smoking, which causes spasm of small vessels and capillaries, which leads to ischemia (reduced blood supply) of parenchymal organs. As a result, connective tissue develops in the organ instead of parenchyma, resulting in functional disorders.

Clinical picture

Symptoms of recurrent pancreatitis increase gradually and cause significant concern only during periods of exacerbation. Patients have persistent indigestion. In case of violation of the secretory function of the gland, enzymes do not fully break down food, food is not able to be fully absorbed in the intestines, and as a result, semi-digested food is excreted from the body. Patients often have diarrhea with a frequency of stools up to 5-6 times a day, there is a deterioration in the condition every day.

Since in the chronic course of the disease the body does not receive all the necessary trace elements, patients tend to lose weight.

The main symptoms of chronic recurrent pancreatitis are loose stools and systematic weight loss despite adequate food intake.

The disease develops with characteristic pain symptoms. During remission, patients feel dull pain in the left hypochondrium and in the epigastric region after each meal. Sometimes the pain is girdle in nature, and is given to the back. In rare cases, the pain radiates to the chest, which resembles an angina attack.

During periods of exacerbation, patients experience debilitating recurrent pain, which is poorly relieved by analgesics. To relieve pain, a person takes a fetal position: lying on his side, with his back bent and his knees pressed to his chest.

Periodic sharp pains are the result of necrotic changes in the pancreatic ducts, which can be:

• blockage by retention cysts - neoplasms of the gland that appear when the outflow of secretions is disturbed;
• formation of necrotic structures (large postnecrotic cysts);
• inflammation.

Diagnostic methods

Recurrent pancreatitis is diagnosed quite easily and almost always unmistakably. Main directions in research:

The main stages in the treatment

The main thing in treatment is to provide physiological rest to the pancreas. It must be "disconnected" from the secret generation process. For this purpose, enzymes of animal origin are prescribed - Pancreatin, Creon, Mezim.

There is an opinion that long-term use of enzyme preparations is addictive, as a result of which, after stopping their use, the pancreas cannot function independently. This is nothing more than a myth. Long-term intake of enzymes, on the contrary, has a beneficial effect on the further work of the gland.

Simultaneously with enzyme therapy, secretolytics are prescribed, for example, Omez insta, Omeprazole. They not only reduce secretion, but also lower the acidity of gastric juice. This matters, since enzymes are not effective in an acidic environment.

To alleviate the pain symptom, antispasmodics are prescribed. During inflammation of the gland, pressure on the ducts increases, which provokes pain. Antispasmodic drugs relax the walls and mouth of the duct, the pain recedes.

Possible Complications

If chronic pancreatitis is not treated, the following pathologies may develop:

1. mechanical jaundice. The head of the pancreas enlarged due to scarring compresses the bile ducts. Bile does not enter the intestinal lumen, accumulates, then absorbed into the blood.
2. Compression of the portal vein (the vessel that carries blood to the liver) from an inflamed gland. Venous blood stagnates in the walls of the stomach, esophagus, causing varicose veins. The vessels do not withstand, intense bleeding occurs with a fatal outcome.
3. Violation of the intrasecretory function of the gland. Changes in carbohydrate metabolism lead to diabetes mellitus.

In addition, complications are possible in which surgical treatment is indicated:

• postnecrotic cysts with abscess formation (suppuration);
• false aneurysms (communication of the cyst cavity with arterial blood flow);
• the presence of inflammatory changes in the organ, in which it is impossible to eliminate the pain syndrome with medication.

Diet for exacerbation of chronic recurrent pancreatitis

At the stage of exacerbation, you need to follow the main rule: cold, hunger and peace. With severe pain, follow a hungry diet for 1-2 days, it is only allowed to drink alkaline water.

After pain relief:

• cereal or vegetable soups without cabbage;
• cereals;
• protein omelets;
• compotes;
• lean meat (poultry, rabbit) in the form of meatballs, meatballs, steam cutlets.

Dairy products can only be fat-free, in limited quantities. Vegetables and fruits, steamed or baked. Alcohol, fatty meats, butter, smoking, marinades, pickles are strictly prohibited.

You will learn about the causes of development and treatment of chronic pancreatitis from the video:

peptic.ru

Symptoms and treatment of chronic recurrent pancreatitis

Inflammatory-dystrophic pathology of the glandular tissue of the pancreas is defined in medicine as chronic pancreatitis. In the recurrent form, pain attacks appear much more often. The disease occurs in middle-aged and elderly people.

Etiology of chronic pancreatitis

Pathology develops against the background of acute inflammation of the gland or cholelithiasis. This is due to the flow of infected bile to the pancreatic duct. Another provocateur is the activation of pancreatic enzymes.

Other factors include poisoning:

1. Arsenic.
2. Phosphorus.
3. cobalt.
4. Lead.
5. Alcohol.

Symptoms of pathology occur against the background of improper or irregular food intake, a systematic lack of vitamins and proteins. Plays the role of circulatory disorders in the pancreas. This is associated with thrombosis, embolism, which appear due to changes in the vascular system.

The main role in the pathogenesis of the disease belongs to the activity of proteolytic enzymes. This leads to autolysis of the parenchyma. Another provocateur is the appearance of spasms or neoplasms, which interferes with the release of pancreatic juice into the duodenum.

Inflammation either affects the organ completely, or is limited only to the tail or head.

The main types of pathology

Gastroenterologists distinguish the following types of the chronic form of this disease:

• cystic;
• fibrous-indurative;
• obstructive;
• calcifying.

With cystic pancreatitis, a large number of small neoplasms appear. For the fibrous-indurative variety of the disease, the appearance of calculi is characteristic. A healthy cell is replaced by connective tissue. This contributes to a decrease in the functioning of the body. With calcifying pancreatitis, stones appear in the ducts of the gland.

The obstructive variety is rare. It occurs against the background of blockage of the main duct. This is due to the growth of neoplasm and scar.

Stages of development of chronic pancreatitis

Depending on the clinical picture, there are five forms of chronic pancreatitis:

• sclerosing;
• painful;
• latent;
• icteric;
• recurrent.

With a sclerosing form, mechanical jaundice appears. This occurs against the background of compression of the area of ​​the common bile duct. The initial stage of latent pancreatitis is characterized by an asymptomatic course. Over time, a person loses weight, he feels sick, the greasy feces are poorly washed off.

With pain, excruciating painful sensations are constantly present. Often they occur over several months. They differ in low intensity and increase if a person deviates from the diet.

The incidence of icteric pancreatitis varies from 5 to 10% of all cases. Mostly this form of the disease is observed in people who are addicted to alcohol. There are signs of functional insufficiency of the organ. The patient loses weight, dyspeptic disorders appear.

What are the symptoms

The development of the inflammatory process in the pancreas is characterized by the following features:

1. Pain in the epigastric region.
2. Weight loss.
3. Diarrhea.
4. Pain syndrome in the left hypochondrium.
5. The development of diabetes.

It is diagnosed in about 60% of all cases. The recurrent form of chronic pancreatitis is characterized by alternating periods of remissions and exacerbations. There are signs of cholestasis. After that, fistulas and neoplasms are formed. A person complains of very severe pain in the upper abdomen. It is of an enveloping character. The temperature rises, at the same time the patient is very chilly.

Chronic pancreatitis in the acute phase is accompanied by an increase in the concentration of pancreatic enzymes in the blood and urine. When remission occurs, clinical manifestations decrease.

Painful syndrome is replaced by severe hunger. But the patient cannot eat food, because this leads to the appearance of painful sensations in the left side of the abdomen. There is an intense secretion of saliva. The person is disgusted with food.

How long an exacerbation of chronic pancreatitis lasts depends on the intensity of the painful syndrome, as well as on how the person reacts to it. When the course of the disease is characterized by the presence of dull pain, they most often do not go to the doctor. At first, attacks occur 2-3 times / 12 months. Gradually they become more frequent. After 1 year, with a recurrent course of chronic pancreatitis, pain worries a person at least 4 times / 30 days. Increases the duration of seizures. At the initial stage, painful sensations are present for 20-30 minutes. If the disease is not treated, the relapse lasts up to 5 days.

Development of latent pancreatitis

It is very difficult to identify a painless form of pathology. The latent course of chronic pancreatitis is diagnosed only after a thorough medical examination. Pathology develops against the background of acute gastritis of the duodenum or stomach. Treatment is prescribed on the basis of laboratory studies of organ enzymes.

The clinical picture of latent pancreatitis does not differ from the symptoms of other forms of this pathology. A special symptom is excruciating pain syndrome.

Diagnosis

Doctors resort to a functional study of the organ. The blood serum is analyzed for the content of:

• trypsin inhibitors;
• lipases;
• diastasis.

Gastroenterologists attach great importance to x-rays. Chronic pancreatitis in the acute stage is very important to differentiate with intestinal obstruction, cholecystitis, ulcers, pancreatic head cancer, heart attack.

Features of the treatment of the chronic stage

Treatment of chronic pancreatitis in the acute stage involves urgent hospitalization of the patient. The first few days after the attack, the patient is shown fasting. It is allowed to drink only non-carbonated alkaline mineral water. After that, the doctor prescribes a strict diet. One must follow it at all times.

With severe exacerbations, antibiotics are recommended. The most effective drugs are Ceparin, Tetracycline, Levomycetin. If a person suffers from very severe pain, the doctor resorts to paravertebral or pararenal novocaine blockade. The use of the following non-narcotic analgesics and anticholinergics is prescribed:

1. Baralgin.
2. Quateron.
3. Platifillina.
4. Atropine.
5. Metacin.

With exocrine insufficiency of the organ, the patient will have to undergo replacement therapy. During treatment, enzyme preparations are prescribed. The most powerful drug is Pancreatin. It can be combined with Intestopan, Cotazim, Triferment. The use of vitamins A, B2-B12 brings great benefits to the body.

Relapses are stopped by antispasmodic, choleretic drugs, as well as anticholinergics. Therapy is carried out for 20-30 days for every 90-120 days.

With a latent form, the patient is prescribed the use of infusions and decoctions of medicinal herbs. It is recommended to drink enveloping medicines. Choleretic drugs, anabolic hormones bring benefits to the body.

Treatment of exacerbation of chronic pancreatitis at home involves following the protein-carbohydrate diet prescribed by the doctor. The patient is forbidden to eat fatty meats, fish. It is recommended to abandon canned food, smoked meats, store-bought sweets, fizzy drinks. The intake of alcohol is strictly prohibited.

It is desirable that the food be fractional. The minimum daily dosage of proteins is 150 grams. Around 60, it must be of animal origin. The amount of fat should be reduced to 70 grams / 24 hours.

If conservative treatment fails, the doctor decides on surgical intervention. Also, the operation is prescribed for suspected malignant degeneration.

What is important to remember

The patient's condition improves only when he fulfills all the requirements of his doctor. Violation of the diet, non-compliance with the regimen is fraught with dangerous consequences.

pancreotit-med.com

Chronic recurrent pancreatitis, causes, symptoms, therapy

In 1963, at the International Marseille Conference, a classification of 5 types of pancreatitis was adopted. So, by agreement of leading experts in the field of gastroenterology, the main groups were derived:

• Acute pancreatitis.
• Acute recurrent pancreatitis with biological and clinical recovery of the digestive organ.
• Chronic recurrent pancreatitis, characterized by acute attacks and incomplete restoration of the tissue structure of the pancreas.
• Obstructive pancreatitis, which is caused by a violation of the patency of the flow glandular canal and the presence of stone formation.
• Non-obstructive chronic form of pancreatitis, which is characterized by functional and / or anatomical damage to the organ of the digestive system.

In this article, we will try to give a complete assessment of all clinical manifestations, causes, symptomatic signs, diagnostic methods and methods of treating one of the types of the chronic course of the disease - chronic recurrent pancreatitis.

Causes and clinical manifestation of the disease

Chronic recurrent pancreatitis is observed most often with cholelithiasis, or cholelithiasis, which is characterized by the formation of calculi (stones) in the gallbladder or bile ducts. Alcohol abuse in combination with abundant irrational nutrition is considered to be a causal factor in the occurrence of a chronic form of pancreatic disease. Other causes of chronic pancreatitis include:

• viral damage to the digestive organ;
• mechanical damage leading to concussion of the pancreas;
• endoscopic or surgical intervention leading to a traumatic condition;
• psychogenic impact: nervous strain, stressful situation;
• spastic state of blood vessels;
• muscle atrophy at the outlet of the pancreatic and / or bile ducts.

Equally important is the attitude of a sick person to smoking.

Important! According to statistics from the World Health Organization (WHO), the risk of disease in smokers is increased by 75%.

In chronic pancreatitis, the recurrent course of the disease is characterized by exocrine insufficiency, that is, inadequate production of exocrine glandular substances (digestive enzymes) by the pancreas. The recurrent state of chronic pancreatitis is the result of an acute form of the disease, in which a pseudocyst forms in the pancreas. Accumulating fluid, it increases in size and, due to squeezing neighboring anatomical organs, causes pain, while disrupting the functional work of the duodenum, stomach, and the entire digestive system. The progression of the disease leads to depletion of the glandular tissue, growth (fibrosis), replacement of the connective tissues of the pancreatic parenchyma.

Important! Chronic parenchymal pancreatitis with recurrent pain can cause recurrence of the acute form of pancreatitis.

How to recognize the chronic course of the disease by symptomatic signs

As a rule, before the onset of the pain syndrome, the patient has steatorrhea, that is, the feces are greasy and shiny in color, have a fetid odor and are poorly washed off with water from the walls of the toilet bowl. Due to a violation of the bile outflow in some patients, the so-called obstructive jaundice appears, which stains the skin in yellow. In the future, the pancreatic "drama" continues to cause discomfort to a person. The pain syndrome has a girdle character, which radiates to the left side of the back, affecting the area of ​​the scapula, hypochondrium and epigastrium, that is, the projection area of ​​the stomach. During a diagnostic examination, as a result of palpation, specialists note an immovable seal in the umbilical zone, which may indicate the onset of a cancerous neoplasm on the pancreas. Other clinical symptoms of recurrent pancreatitis in chronic course include:

• deterioration in the patient's well-being;
• flatulence, diarrhea, and constipation;
• nausea and constant vomiting;
• increased salivation.

Often the cause of such symptoms is a violation of dietary norms of nutrition and / or abuse of alcoholic beverages. Also, emotional overstrain and / or stressful situations can cause another attack of chronic exacerbation of the digestive organ. Pain syndrome can cause discomfort to a person from several hours to 5-7 days.

Important! At the first symptomatic signs of recurrent chronic pancreatitis, you should immediately contact a gastroenterologist or a local therapist who will provide qualified medical care and suggest further therapeutic actions.

Diagnosis and complex therapy in a relapsing condition

In addition to the standard diagnostic examination, which includes ultrasound scanning (ultrasound) of the abdominal organs and computed tomography, it is necessary to determine the functional state of the exocrine system of the digestive organ. Mandatory laboratory analysis of excrement (coprogram) - microscopic examination to identify undigested food. The estimated state of the exocrine system of the pancreas allows you to determine further actions on the effectiveness of enzyme replacement therapy and select the appropriate program of complex medical intervention.

Treatment of chronic recurrent pancreatitis requires an individual approach to each patient, since age, gender and physiological characteristics of the patient should be taken into account. The general scheme of complex treatment includes therapeutic starvation in the first 2-4 days of inpatient treatment and a strict diet in the following days. The most common and rational is dietary nutrition according to the method of M. I. Pevzner (diet No. 5). The diet was developed by the author in the middle of the 20th century and is popular today.

Important! Dietary table number 5 is the optimal amount of organic components (proteins, fats and carbohydrates) that a person needs according to his physiological needs in diseases of the digestive system, liver, gallbladder and bile ducts at any stage of exacerbation.

The daily energy value of the consumed products should not exceed 2000-2500 kcal. The daily norm of consumption of organic substances is considered to be:

• carbohydrates - 250-350 g;
• fats - 70-80 g;
• proteins - 90-100 g.

All food products must be thermally processed, that is, baked in the oven or boiled. The recommended daily number of meals should be at least 5-6 times. The traditional scheme of drug treatment is the diagnostic standard No. 125 dated April 17, 1998, developed by the Ministry of Health of the Russian Federation, which provides for the use of pharmacological drugs. The therapeutic approach is as follows:

1. In the case of a chronic or acute course of the disease, urgent and continuous aspiration of pancreatic juice is necessary, as well as intravenous administration of pharmacological preparations that provide a secretory decrease in gastric contents. These include Ranitidine, Famotidine and other pharmacological combinations.
2. If necessary, a certain amount of insulin is administered to the patient to avoid hypovolemic shock.
3. To suppress gastric and pancreatic secretion and to relieve pain, inhibitors are administered: Rabeprazole, Omeprazole, Esomeprazole and other pharmacological drugs.
4. Enzymatic toxemia, which determines the severity of the disease, is eliminated by forcing doses of diuretics: Mannitol, Lasix and other drugs.

In addition, it is necessary to ensure a decrease in blood pressure in the bile duct system of the pancreas. This is achieved with the help of myotropic antispasmodics (Mebeverin, Drotaverin, etc.) and anticholinergics (Platifillin, Gastrocepin, etc.). All further actions on drug treatment should be aimed at restoring pancreatic secretion and ensuring high-quality outflow in the bile ducts. If necessary, antibiotic therapy is applied. The indication for surgical intervention is the failure of the pharmacological correction of the digestive organ.

Prognosis for chronic pancreatitis

A favorable prognosis for survival in a chronic condition can be achieved with a strict diet, cessation of smoking and alcohol consumption, adequate and timely medical intervention, and also subject to all the recommendations of the attending physician. Severe complications can lead to death.

Take care of yourself and be always healthy!

netpankreatita.ru

How is chronic recurrent pancreatitis treated?

• Diagnosis of the disease
• Treatment of the disease

Chronic recurrent pancreatitis, treatment of this disease - such issues are of interest to patients.

If you look in a medical reference book, you can see that pancreatitis in Latin means “inflammation of the pancreas”. And if chronic recurrent pancreatitis occurs, as a rule, it remains with a person throughout life.

Chronic pancreatitis is a form of the disease, the symptoms of which progress throughout the life of the patient, resulting in a process of atrophy and loss of direct functionality of the pancreas.

The chronic form of pancreatitis occurs due to the transferred acute form.

By itself, such a problem does not develop, but is a consequence of a violation of the production of an enzyme (trypsin) of the pancreas, which in the future can lead to the complete destruction of its tissue. Trypsin deficiency occurs when the body does not produce enough protein.

If compared with the chronic form, then during the recurrent stage, self-destruction of the pancreatic tissue occurs not only pronouncedly, as during its exacerbation.

The main distinguishing feature of recurrent pancreatitis is the frequent onset of pain attacks than in other forms of pancreatitis. An exacerbation of the problem may be accompanied by severe symptoms, and if the treatment is delayed, then the disease progresses in the future, which can lead to the development of serious complications in the gastrointestinal tract.

Let's find out the nature of the pain syndrome during chronic recurrent pancreatitis. It should be noted that the intensity of the pain syndrome directly depends on the neglect of the disease and the location of the lesion:

1. When the head or body of the pancreas is affected, pain is felt at the top of the organ with recoil into the esophagus.
2. In the process of exacerbation in the tail of the pancreas, the pain syndrome occurs in the left hypochondrium with recoil to the region of the heart.
3. During the period of damage to the entire pancreas, pain can be characterized as girdle.
4. Specialists also distinguish a large-scale manifestation of pain syndrome, covering the entire body: the abdomen, chest and left epigastric region.

Sometimes the severity of the pain syndrome is so strong that for its localization it is necessary to resort to the use of narcotic drugs. However, the use of morphine is strictly prohibited.

The duration of the attack can last from several hours to 3 days. Painful spasms are observed, which may be accompanied by vomiting, loose stools, flatulence, and loss of appetite.

Favorable factors for the development of such a problem

According to medical statistics, in 65% of cases the cause of the development of the disease is calculous, chronic or acute cholecystitis, obstructive jaundice or hepatic colic. If you have been diagnosed with gallstone disease, then do not start its treatment, as this can cause the development of chronic recurrent pancreatitis.

Laboratory studies have shown that in the chronic stage of the disease, only in 3-8% of cases there is a 100% start of the disease. Even if at least one stone is present in the gallbladder, there is a risk of exacerbation of the recurrent form. That is why the treatment of the gastrointestinal tract cannot be started.

Relapses of the disease will occur until a complete recovery of the body occurs. It must be remembered that in chronic recurrent pancreatitis, attacks return, and depending on the degree of damage to the organ, the pain can be localized:

• in the epigastrium;
• in the left hypochondrium;
• radiate to the chest;
• or have an enclosing character.

You should know that pain almost always occurs suddenly and lasts for several hours. The pain syndrome is poorly relieved by antispasmodics and requires the use of non-narcotic analgesics. When the peak state of the pain syndrome occurs, sometimes vomiting occurs and a lightened state of the body sets in.

In addition to the gag reflex, one can also distinguish such manifestations of the problem as loss of appetite, belching, flatulence, and stool disorders.

There are no exact statistics on the incidence of chronic pancreatitis, and therefore the literature provides very diverse information on this issue.

It should be noted that the disease of chronic pancreatitis has become much more common than before, and that it should be given more attention than it has been so far, and not to be forgotten when differentiating from other diseases of the abdominal organs. This increase in the incidence of chronic pancreatitis depends mainly on excessive excess in the intake of rich fatty and spicy foods, alcohol, and other etiological factors.

Clinical picture and course

Chronic pancreatitis most often occurs between the ages of 30 and 70. More often among women.

Clinical manifestations of chronic pancreatitis can be varied and depend on the location and stage of the inflammatory process, the duration of the disease, the severity of functional disorders of the external and intrasecretory activity of the pancreas, etc. Based on this, various classifications of clinical forms of chronic pancreatitis are proposed in the literature.

By origin, chronic pancreatitis should be divided into the following two groups. 1. Primary chronic pancreatitis that occurs during the development of inflammatory processes primarily in the pancreas itself. They can develop with a lack of protein nutrition, chronic alcoholism, chronic circulatory disorders and the development of arteriolosclerosis in the gland, etc. 2. Secondary chronic pancreatitis, which develops secondary to a primary disease of other organs.

According to the clinical manifestations of chronic pancreatitis, it is advisable to distinguish the following clinical forms of it.
1. Chronic recurrent pancreatitis: a) in the acute stage; b) in remission.

2. Chronic pancreatitis with constant pain.

3. Pseudotumor form of chronic pancreatitis. 4. Latent "painless" form of chronic pancreatitis. 5. Sclerosing form of chronic pancreatitis.

Of these forms, the first two and especially chronic recurrent pancreatitis are most common. The so-called painless form of chronic pancreatitis is extremely rare; in other forms, the leading symptom is pain, which is more often localized in the epigastric region or the left hypochondrium and less often in the right hypochondrium. Often they are shingles in nature and can be permanent or occur paroxysmal.

In chronic recurrent pancreatitis, pain manifests itself in the form of an acute attack lasting several days, after which remission occurs. In other forms of pancreatitis, they are permanent. Pain can be of varying intensity and be accompanied by dyspeptic symptoms: poor appetite, nausea, belching, vomiting. There may be diarrhea alternating with constipation. Often, patients with chronic pancreatitis experience significant weight loss and the development of diabetes mellitus. In cases of pronounced fibrosis or inflammatory edema of the head of the pancreas, obstructive jaundice may develop. Sometimes gastrointestinal bleeding can join these symptoms.

On palpation of the abdomen, a slight soreness in the pancreas may be noted. It is possible to palpate the gland only in cases of its sharp compaction or the development of a cyst or abscess in it. In addition to these complications, in some cases, calcification of the gland and the development of sharp fibrosis in it may be noted. In patients with chronic pancreatitis, liver enlargement and its functional disorders are often found. Sometimes these changes may be accompanied by splenomegaly due to vein thrombosis. Perhaps the development of hypochromic, macrocytic anemia. During the exacerbation of the process, neutrophilic leukocytosis, accelerated ROE are observed. Some cases of chronic pancreatitis can occur with pronounced eosinophilia, sometimes reaching up to 30-50%. In severe forms of chronic pancreatitis, the level of transaminase and aldolase increases, and the protein fractions of blood serum also change. During an exacerbation, there may be a violation of electrolyte metabolism - a decrease in sodium and calcium in the blood and an increase in potassium.

Diagnosis
In addition to the clinical picture characteristic of this disease, a functional study of the pancreas is of great importance. Examine the blood serum for the content of diastase, lipase, trypsin and trypsin inhibitors, urine - for diastase; determine in the duodenal contents in the dynamics of the concentration of pancreatic enzymes, the volume of pancreatic secretion and the content of bicarbonates in it after the use of pancreatic stimulants, especially secretin. In addition, feces are examined for fat content and muscle fibers.

The study of the functional state of the pancreas can also be carried out by the method of radioactive isotopes.

The study of the functional state of the pancreas (see) in chronic pancreatitis should be comprehensive, which will give a more correct idea of ​​this body and better help in the diagnosis of the disease.

For the diagnosis of chronic pancreatitis, studies of the intrasecretory function of the pancreas are also important by deriving glycemic curves after a double load of glucose, which are often pathological.

Great importance is now attached to the X-ray method of research.

Chronic pancreatitis has to be differentiated from many diseases of the abdominal cavity - cholecystitis, biliary dyskinesia, peptic ulcer, intestinal obstruction caused by a malignant tumor, cancer of the head of the pancreas and the nipple of Vater, especially in the presence of obstructive jaundice, sprue, and sometimes with myocardial infarction.

When differentiating from these diseases, a detailed history, duodenal sounding and X-ray examination of the gastrointestinal tract, biliary and urinary tract are of great importance. But it is sometimes especially difficult to differentiate between the sclerosing form of chronic pancreatitis and cancer of the pancreatic head. Such a difficulty in diagnosis often occurs even among surgeons on the operating table. In these cases, pancreatography and pancreatic biopsy are currently resorted to during surgery.

Treatment

Treatment of patients with chronic pancreatitis can be conservative or surgical, depending on the severity of the disease, the clinical form of pancreatitis, the localization of the process, etc.

At the onset of the disease and with mild clinical manifestations, it is necessary to carry out conservative treatment. In advanced cases that led to calcification of the parenchyma of the gland or the development of a sharp stenosis of the sphincter of Oddi, bile (common bile) and pancreatic ducts that are not amenable to conservative treatment, with a pseudotumorous form, as well as with the development of obstructive jaundice due to obstruction of the bile duct by a pronounced sclerotic process in the head of the pancreas, or with the development of complications (cyst, abscess), surgical treatment is recommended (see above-Surgical treatment of acute pancreatitis).

In the period of exacerbation of chronic pancreatitis, treatment is carried out in the same way as in acute pancreatitis.

Conservative treatment sets itself the following tasks: to stop the progression of the process; reduce and stop pain; eliminate violations of the external and intrasecretory function of the pancreas, if any.

Regarding the diet in chronic pancreatitis, there are different points of view. While some authors (N. I. Leporsky, F. K. Menshikov, G. M. Mazhdrakov and others) recommend prescribing a diet rich in carbohydrates, with a sharp restriction of fats, with the exception of juice substances, others (I. S. Savoshchenko, V. A. Shaternikov, S. A. Tuzhilin, and others), on the contrary, consider it the most appropriate to use a diet containing a large amount of protein. Recent authors recommend that patients with chronic pancreatitis use a diet containing 150 g of protein (60-70% of the protein should be of animal origin), 80 g of fat (of which 85-90% should be of animal origin), 350 g of carbohydrates (calories 2800 kcal) . At the same time, meals should be frequent, "fractional" - about 6 times a day. In addition, vitamins are prescribed, especially of group B (B2, B6, B12), nicotinic, ascorbic acid and vitamin A, as well as lipotropic substances (lipocaine, choline, methionine). Prohibit alcohol, fatty foods (fatty meat, fish, etc.), herring, sour cream, lard, sausages, canned meat and fish, smoked products.

With symptoms of exocrine pancreatic insufficiency, it is necessary to prescribe pancreatic preparations: pancreatin, pancreolizate, pancreon and other drugs at a dosage of 3 to 8 g per day.

Patients suffering from chronic pancreatitis with symptoms of stasis in the pancreatic ducts, it is desirable to systematically conduct duodenal sounding or prescribe choleretic agents. To suppress pancreatic secretion, it is necessary to use alkali (Borjomi mineral water), atropine, belladonna preparations, platyfillin inside.

If chronic pancreatitis is accompanied by inflammation of the bile and pancreatic ducts, patients should be prescribed antibiotics.

In case of violation of carbohydrate metabolism, an appropriate diet is used and, if necessary, insulin therapy.

To reduce pain, pararenal or paravertebral blockade, intravenous administration of a 0.25% solution of novocaine, subcutaneous administration of promedol, omnopon are recommended. Some authors suggest using opium, nitroglycerin, ephedrine, barbiturates, intravenous administration of aminophylline to eliminate pain.

With an exacerbation of the inflammatory process in the pancreas, accompanied by sharp pains, antienzymatic therapy (trazilol, iniprol, zymophren) is indicated, leading to a significant improvement in the general condition and subsidence of the pain syndrome. Some authors suggest in this case to carry out X-ray therapy on the area of ​​the pancreas.

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 palpated.

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.

Recurrent pancreatitis, which has a microbial code of 10 K85.0, is characterized by attacks of pancreatic pathology, which can recur from time to time, or, as they say, recur against the background of provoking factors, occurring in the form of a mild form of pancreatic lesion of the pancreas. This type of pathology is divided into acute recurrent pancreatitis and chronic. But, it is worth noting that this division is very conditional, since the appearance of painful attacks within 6 months from the onset of the development of pathology refers to the acute form of relapse, and after 6 months, to chronic. In this review, we will take a closer look at the pathological disease of the pancreas, accompanied by a pronounced change in the performance of this organ and the cyclicity of periods of exacerbations, referred to as chronic recurrent pancreatitis, its causes, symptoms and possible treatment.

Causes and clinical manifestations of the disease

The recurrent form of pancreatic pathology is a disease of the modern civilized world. The main reason for the continuous development of this pathology is the negative impact of social factors, such as alcohol-containing drinks and low-quality foods, the use of which contributes to the systematic poisoning of the entire human body and an excessive level of activation of the pancreas. In combination, all these factors provoke an intensive release of pancreatic secretions, which do not have time to be completely consumed in the processes of the digestive tract and begin to accumulate in the cavity of the gland, gradually having a devastating effect on the parenchymal organ.

According to statistics, a recurrent form of pathology often develops in males of mature and advanced age. Women are exposed to this pathology only after the attack of an acute attack of pancreatic gland disease.

A child in adolescence and less can also be subjected to the development of this pathology against the background of hereditary predisposition.

The presence of the following factors can have a provoking effect on the development of the disease:

• progressive stage of gallstone pathology;
• traumatization of the abdominal cavity;
• development of a chronic infectious disease;
• stressful influences.

Clinical signs of pathology, first of all, begin to manifest themselves in the form of the development of steatorrhea, or the presence of fatty compounds in the feces, which have a fetid odor, greasy sheen and an increased level of stickiness.

Violation of the processes for the outflow of bile in the patient's body against the background of the development of pathology often leads to the formation of yellowness of the skin. After that, painful sensations begin to appear, which have an irradiating character with a gradual return to the back, shoulder blades and epigastric zone. Also observed:

• aggravation of the general well-being of the patient;
• development of diarrhea, constipation and flatulence;
• regular feeling of nausea and vomiting;
• systematic weight loss;
• increased levels of salivation.

It is worth noting that the recurrence of chronic pancreatic pathology can be caused by emotional overstrain, and pain attacks can accompany a person, both for 3-5 hours and for 5-6 days.

Favorable factors for the development of the disease

Favorable factors contributing to the development of recurrent pancreatic lesions of the gland are:

• alcoholism;
• smoking;
• gallbladder disease;
• disturbed diet;
• ulcerative lesions of the stomach cavity;
• genetic predisposition.

It is also worth noting that living in areas with unfavorable environmental conditions increases the risk of developing pathological processes in the pancreatic cavity.

Diagnosis of pathology

The recurrent form of pancreatic pathology is diagnosed quite simply and almost always with accurate results and a correct diagnosis. Basic diagnostic procedures:

1. , contributing to the visualization of the heterogeneity of the structural structure of the gland, through the detection of calcifications, and its increase in size.
2. Conducting fibrogastroscopy to assess the condition of the stomach and duodenum 12.
3. CT diagnostics, which allows to identify pathological changes in the parenchyma of the gland, as well as their intensity of development and the extent of damage to the parenchymal organ.
4. With the help of an assessment of the state of the pancreatic ducts.

It is also prescribed to take blood tests for and fecal masses for a scatological study.

How is recurrent pancreatitis treated?

Treatment of recurrent pancreatitis consists in conducting drug therapy that contributes to the maximum restoration of the state of the affected organ, and in the further use of traditional medicine that helps maintain the performance of the parenchymal gland and prevent subsequent relapses. It is also worth noting that taking medications will not give such effective results without following a special dietary diet with table number 5.

Conservative treatment

The main objective of conservative treatment is to ensure complete rest of the pancreas and reduce its secretory functionality. For this purpose, enzymatic preparations are prescribed in the form of Pancreatin, Mezim or Creon.

Along with the use of enzyme preparations, drugs are prescribed that reduce the secretory functionality of the gland, such as Omez, Omeprazole and other generics, which also help to reduce the level of gastric acidity.

To remove painful discomfort, antispasmodic drugs are used. And also for the maximum relief of digestive processes, it is recommended to use mineral water, Borjomi or Essentuki.

Treatment at home

Treatment of recurrent exacerbation of pancreatitis is necessary even after drug therapy, while already at home. For this purpose, it is recommended to regularly use medicinal infusions, decoctions or teas based on medicinal herbs, among which the most effective are:

• immortelle;
• calendula;
• chamomile.

Diet food

When pancreatic pathology begins, the rule of 3 golden truths becomes the main principle of treatment: cold, hunger and peace.

With an intense manifestation of the pain syndrome, it is recommended to exclude all food intake for 2-3 days, only alkaline drinking is allowed until the patient's general condition is alleviated.

After the retreat of pain, it is recommended as food:

• vegetable soups, or soups based on cereals, but without cabbage;
• various cereals;
• omelettes based on chicken protein;
• dried fruits compote;
• white meat of rabbit and poultry.

Exceptions must be:

• canned and salted foods;
• alcoholic drinks;
• fat meat;
• smoked meats;
• fried foods.

Prognosis and prevention of the disease

A favorable outcome of the medical history will be ensured subject to the observance of preventive measures to prevent re-exacerbation, consisting in the following aspects:

• adherence to a therapeutic diet;
• complete exclusion of the use of alcohol and tobacco;
• compliance with all the instructions of the attending physician;
• timely treatment of all pathological processes in the body.

In the absence of prevention and maintaining an unhealthy lifestyle, the disease can lead to serious complications and even death.

Bibliography

1. Zhukov N.A., Zhukova E.N., Afanasyeva S.N., Clinical forms of chronic recurrent pancreatitis and their pathogenetic features. M.: Medicine, 2004
2. Khazanov A.I., Vasiliev A.P., Spesivtseva V.N. et al. Chronic pancreatitis, its course and outcomes. M.: Medicine, 2008
3. Maev I.V., Kucheryavy Yu.A. Modern approaches to the diagnosis and treatment of chronic pancreatitis. The quality of life. The medicine. 2004 No.2(5), pp. 65–69.
4. Okhlobystin A.V., Buklis E.R. Modern possibilities of treatment of chronic pancreatitis. Attending doctor. 2003 #5, pp. 32–36.
5. Under the editorship of Professor I.V. Mayeva Chronic pancreatitis (Algorithm for diagnosis and treatment tactics). Teaching aid.
6. Minushkin O.N. Maslovsky L.V. Evsikov A.E. Evaluation of the efficacy and safety of the use of micronized polyenzyme preparations in patients with chronic pancreatitis with exocrine pancreatic insufficiency breast cancer, section "Gastroenterology" No. 17 2017, pp. 1225-1231.

Chronic recurrent pancreatitis is an inflammatory disease of the pancreas that occurs for six months or more. It is characterized by slow replacement of the parenchyma with connective tissue fibers. Pathology code according to ICD-10 - K 85.0-K 86.3. The frequency of occurrence reaches 0.6% of the world's population. In 95% of cases, a calcifying form of the disease occurs. The remaining 5% is equally divided between obstructive and parenchymal pancreatitis.

Chronic pancreatitis is characterized by diffuse changes in the structure of the pancreas.

The main etiological factor in the occurrence of pancreatitis in men is alcohol abuse, which accounts for up to 50% of all identified cases of the disease. The occurrence of pathology leads to daily, for several years, the consumption of ethyl alcohol in the amount of 80 ml or more per day. In women, the disease often develops in diseases of the biliary tract. The number of patients suffering from dyskinesias and cholecystitis reaches 40%.

Note: in the 90s of the XX century, as well as in the early 2000s of the XXI century, the number of alcoholic pancreatitis among men and women was almost equal. This was due to the rapid growth of women's dependence on alcohol. Today the situation is gradually returning to the previous indicators.

Other causes of chronic inflammation of the pancreas include:

• infections (infectious parotitis);
• pancreatic injury;
• hyperlipidemia in disorders of fat metabolism and obesity;
• toxic, including medicinal, effects (tetracycline, NSAIDs, sulfonamides);
• malnutrition (in the daily diet less than 30 g of fat and 50 g of protein);
• idiopathic factors.

The term "idiopathic pancreatitis" implies that the true etiological factor of the disease has not been established. It is believed that such forms of pathology arise as a result of a genetic predisposition.

Symptoms and Diagnosis

Diarrhea is one of the signs of enzyme deficiency.

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, herpes zoster. 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.

Recurrent acute pancreatitis (a disease in the acute stage) leads to the occurrence of steatorrhea - an increase in the amount of fat in the feces. At the same time, the patient's stool has a liquid consistency, is offensive, has a greasy sheen.

In the remission stage, the disease does not manifest itself in any way. Sometimes the patient has mild pain or a feeling of heaviness in the epigastrium, there may be minor violations of the excretory function of the intestine. The transition from remission to exacerbation is most often associated with errors in the diet. The diagnosis is made on the basis of a patient interview, laboratory tests of feces and blood, imaging methods (CT, ultrasound, MRI). Differential diagnosis is carried out with diseases such as cholecystitis, enteritis, peptic ulcer, abdominal ischemic syndrome, oncological pathology.

Treatment

Gordox - a remedy necessary to reduce the activity of pancreatic juice

Treatment of recurrent pancreatitis in remission is mainly in compliance with a sparing diet. The patient is strictly contraindicated in spicy, excessively salty, sour, bitter dishes. It is recommended to use boiled and steamed products, completely abandon alcohol, reduce the number of cigarettes smoked to the minimum possible. The diet is for life. High adherence to the principles of clinical nutrition minimizes the risk of exacerbations.

At the beginning of the exacerbation, the patient is assigned hunger. The regime is kept from 3 to 5 days. If prolonged fasting is necessary, parenteral nutrient solutions are prescribed (Kabiven, Aminoplasmal in combination with 5% glucose). When the patient's condition improves, the diet No. 5P is used, which implies complete chemical, thermal and mechanical sparing. The diet includes low calorie foods. The patient receives 1800 kcal per day, 80 g of protein, 60 g of fat and 200 g of carbohydrates. Later, he is transferred to a relatively complete diet according to the second diet option (2300 kcal, proteins, fats and carbohydrates 110, 80 and 350 g, respectively). In both cases, meals are taken fractionally, 5-6 times a day.

Drug therapy is aimed at pain relief, relieving inflammation, compensation for exo- and endocrine insufficiency, and reducing the enzymatic activity of pancreatic juice. For the purpose of analgesia, non-steroidal anti-inflammatory drugs (ketorol, analgin) or medical drugs are used. To compensate for enzymatic deficiency, the patient receives appropriate drugs (creon, mezim). In the presence of pancreatogenic diabetes mellitus, insulin injections are prescribed. The production of their own enzymes is minimized with the help of selective type m-cholinergic blockers (ranitidine, famotidine). In severe cases, drugs such as gordox or contrycal are used.

Note: it is not recommended to prescribe ranitidine to young and middle-aged men, since the drug negatively affects potency. For this category of patients, the choice should be made in favor of famotidine.

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.