Acute fatty pancreatic necrosis. How does hemorrhagic pancreatic necrosis proceed? How is the diagnosis

Pancreatic necrosis of the pancreas is an extremely dangerous destructive disease that in most cases develops against the background of an attack of acute pancreatitis. This pathological condition is extremely dangerous, since even with timely complex treatment, the risk of death is high.

Most often, pancreatic necrosis affects young people from 20 to 35 years old. This pathological condition, even with a favorable outcome of the acute period, further reduces the duration and quality of life of the patient. Pathology equally affects both men and women.

Classification

There are several classifications of the disease. Depending on the prevalence of the process, pancreatic necrosis can be:

common;
limited.

In addition, pathology is divided into types depending on the presence of an infectious agent. According to this parameter, pancreatic necrosis can be:

sterile;
infected.

The sterile variant of the disease is divided into 3 clinical and anatomical forms, including:

hemorrhagic;
fatty;
mixed.

Depending on the characteristics of the course, this disorder can be progressive and abortive.

The reasons

Despite the fact that pancreatic necrosis can, under some circumstances, occur in any person, some categories of people more often suffer from it. Predisposing factors include:

chronic alcoholism;
pathology of the pancreas and liver;
cholelithiasis;
malnutrition;
chronic diseases of the digestive tract;
long-term injecting drug use;
congenital malformations.

In most cases, pancreatic necrosis occurs as a result of drinking a large dose of alcohol or fatty foods. The simultaneous influence of these two factors during heavy feasts increases the risk of developing a pathological condition. This is an alimentary mechanism for the development of the disease.

Somewhat less often, pancreatic necrosis of the pancreas appears as a result of obstruction biliary tract. In this case, the movement of stones leads to blockage of the ducts, which increases the pressure inside the organ and the permeability of the vessel walls. There is an early activation of enzymes produced by the pancreas, which leads to the digestion of this organ.

There is also a reflux variant of the development of pancreonerosis. In this case, bile is thrown into the pancreas from the duodenum, as a result of which a severe enzymatic reaction is triggered.

Often pathological process occurs after endoscopic operations performed on the abdominal organs, after blunt trauma abdomen and thrombophlebitis and vasculitis of the vessels of the pancreas.

Symptoms of pancreatic necrosis of the pancreas

The clinical picture of the development of pancreatic necrosis of the pancreas is difficult to confuse with other diseases. This pathological condition occurs in acute form. Patients complain of intense pain in the right hypochondrium, radiating to the shoulder, shoulder blade, groin or chest. A person cannot accurately determine the localization of unpleasant sensations. Severity pain syndrome directly depends on the prevalence of pancreatic lesions.

In most cases, the further the pathological process has advanced, the less pronounced the pain syndrome becomes, which is the result of death. nerve fibers located in the tissues of the body. If the patient lies on his right side and draws his legs to his stomach, discomfort may become less pronounced.

Pancreatic necrosis of the pancreas is often accompanied by the following signs of the pathological process:

nausea;
vomit;
dry skin and mucous membranes;
bloating;
increased gas formation;
redness or pallor of the skin;
gastrointestinal bleeding.

Approximately 5-9 days after the onset of the disorder, postnecrotic and purulent complications appear. The pancreas, due to persistent inflammatory and necrotic processes, greatly increases in size.

First aid

When symptoms of a pathological condition appear, it is necessary to call an ambulance, since pancreatic necrosis therapy should be carried out under conditions. Before the arrival of doctors, it is necessary to measure the patient's temperature and blood pressure. A heating pad should be applied to the area of the right hypochondrium with cold water. A person needs to ensure complete rest, because. jerky movements may worsen the condition. You need to open windows to allow air flow.

The patient should breathe shallowly sharp breaths. This will reduce the intensity of pain. It is advisable to carry out a gastric lavage and an enema to free the rectum from stool. The patient must refuse food completely. Water can be consumed in small portions, not exceeding 50 ml. To reduce the intensity of the pain syndrome, you can use, and. Other medicines it is better not to use until the arrival of doctors.

Diagnostics

When a characteristic clinical picture of this pathological condition appears, the patient needs an urgent consultation with a gastroenterologist. To make a diagnosis, the doctor conducts an external examination, history taking and prescribes the following studies:

common and ;
determination of the level of liver enzymes;
pancreas;
vascular angiography;
retrograde cholangiopancreatography.

Diagnostic laparoscopy may be indicated to determine the nature of the damage to the gland in the tail, body, or head.

Treatment of pancreatic necrosis

In most cases, therapy is conservative methods. The patient requires hospitalization and compliance with a sparing diet throughout the entire period. acute course pathology. To stop the manifestation of pancreatic necrosis, drug therapy is prescribed. In cases where conservative therapy does not allow to achieve a pronounced improvement, doctors may prescribe surgical intervention to eliminate the focus of necrotic tissue damage and sanitation of abscesses.

Diet

During the first 3-10 days after the onset of an acute attack of pancreatic necrosis, the patient is shown treatment. After that, the patient must follow the Pevzner diet No. 5b. Allowed foods and dishes include:

boiled;
mucous membranes on the water;
low-fat, curdled milk and;
wiped ;
low-fat varieties of fish and meat;
in limited quantities;
biscuit;
dried bread.

From the diet it is necessary to completely exclude fresh and baking, canned food, sausages and semi-finished products. In addition, you can not eat strong meat and mushroom broths, dishes with a high content of spices, fast food, pickles, marinades, etc.

Medical

To eliminate the inflammatory process and symptomatic manifestations, drugs belonging to the following groups are prescribed:

analgesics;
novocaine blockade;
vasotonics;
anticholinergics;
to suppress enzymatic activity.

Requires targeted detoxification treatment. For this purpose, infusion therapy is prescribed. In addition, peritoneal dialysis is often used to stabilize the condition.

Rehabilitation

If the patient survives an acute attack of pancreatic necrosis, he becomes temporarily disabled for at least 3-4 months. Discharge from the hospital is carried out 1.5-2 months after the attack. In the first month, the patient is required to dose activity and avoid physical overload.

It is necessary to follow the diet prescribed by the doctor and take the drugs necessary for the normal functioning of the digestive tract. After stabilization of the patient's condition, physiotherapy and therapeutic exercises are prescribed. In most cases, patients require maintenance and adherence to a special diet for the rest of their lives.

Food

Dishes for patients who have experienced acute pancreatic necrosis of the pancreas are steamed or boiled. Portions should be small. Products in the patient's diet are introduced gradually. Food should be consumed 6 times a day at the same time. Dishes should be served to the patient in crushed form. Hot and cold should be avoided. The temperature of the dishes should be at room temperature. must be completely excluded.

Effects

Progressive necrotic decomposition of the pancreas leads to a complete violation of its function. Many patients who have had this pathological condition develop chronic pancreatitis which cannot be completely cured. In places of localization of purulent abscesses, false cysts may form.

In addition, due to a violation of the production of necessary enzymes, patients experience various digestive dysfunctions. Often, after the completion of the acute period of the course of pancreatic necrosis of the organ, a persistent violation of the lipid composition of the blood is detected. Diabetes mellitus is one of the severe consequences of pancreatic tissue necrosis.

Complications

In most cases of pancreatic necrosis, patients experience the appearance of severe complications.

In the process of defeat by the necrotic process of the pancreas, other vital organs and systems are often affected.

Organ

Against the background of the acute course of pancreatic necrosis, the inflammatory process often spreads to the liver tissue, which leads to the development of hepatitis. Common organ complications observed in pancreatic dysfunction include:

carditis;
nephritis;
encephalopathy;
respiratory disorders.

This often leads to the development of multiple organ failure. In the presence of such complications, death occurs in almost 100% of cases.

Purulent

Even with a favorable course, the necrotic process in the pancreas causes the appearance of such purulent complications as:

peritonitis;
phlegmon of retroperitoneal tissue;
abscess of the abdominal organs;
fistulas;
ulcers.

With the penetration of purulent contents from the pancreas into the bloodstream, it may develop septic shock. The occurrence of these complications requires immediate surgical intervention.

Pancreatic necrosis is a lesion of the pancreas, in which the prognosis after surgery for normal life will not please patients. This is associated with extremely severe damage and loss of function in many internal organs responsible for normal work GIT. Therefore, with pancreatic necrosis, increased mortality. Therapy of the disease is carried out only by surgical intervention, which is traumatic in the treatment.

It is a dependent pathology and comes as a consequence of acute pancreatitis. In its class, the disease is on a par with cholecystitis, gallstone pathology. On the this moment other than surgery, no other treatment has yet been invented.

The main and only cause of the disease is pancreatic necrosis, in which the self-digestion of the pancreatic organ and the death of tissue cells, ducts occurs. Not always acute pancreatitis ends with tissue necrosis, but in 15% of total weight affected, they get the disease in the form of consequences of the disease.

The occurrence of pathology for a person has its own reasons:

increased pressure in the ducts of the gastrointestinal tract;
increased secretion of enzymes and pancreatic juice in the pancreatic organ system;
activation of digestive juice in the excretory ducts;
abuse of alcoholic products;
open ulcers of the stomach, 12 duodenal ulcer;
overeating fatty foods, which provokes a sharp exacerbation of pancreatitis;
problems with the gallbladder;
infections;
viral diseases;
peritoneal injury;
transferred operations on the digestive tract.

The consequence that occurs from acute pancreatitis - tissue necrosis (pancreatic necrosis), is considered a terrible disease, which in most cases is fatal for the victim.

Developing, acute pancreatitis creates, and this stops the outflow of pancreatic juice and enzymes. By creating stagnation in the ducts, they begin to activate and corrode the walls and tissues of organs. Absence quick treatment, provokes the appearance of tissue necrosis and abscess, which makes the prognosis for treatment unfavorable in the future.

To a greater extent, necrosis is observed when these causes begin to progress simultaneously, this leads to strong manifestations acute pancreatitis and eating the tissues of the organs surrounding the gland, which provokes peritonitis of the peritoneum. Getting inside the abdominal cavity, and enzymes, cause severe harm delicate film structure of the intestines, which leads to adhesions and a secondary focus of necrosis. The operation is the one and only way to save a human life in case of pancreatic necrosis and the possible relief of progressive peritonitis of the peritoneal organs.

Stages of development of necrotizing pancreatitis

Pancreatic necrosis has three stages of development, in which untimely detection of pathology can significantly harm the human body and lead to death:

The first stage of pancreatic necrosis. Toxins accumulate in the blood of the victim and harmful bacteria. There is a problem of detecting microbes in the blood, so it is difficult to determine the disease at this stage.
The second stage of pancreatic necrosis. Since the cause of the first stage has not yet been identified, this causes delayed treatment and the occurrence of an abscess that affects the pancreas and neighboring organs of the gastrointestinal tract.
The third stage of pancreatic necrosis. Purulent inflammatory processes in the pancreas and peritoneum, and this leads to death.

With pancreatic necrosis, only timely and correct definition diagnosis of the pancreas, will create conditions for urgent operation and give you a chance to avoid death.

Symptoms of pathology

The first and main call for pancreatic necrosis is acute pain in the left hypochondrium. Therefore, it is necessary to understand what pain symptoms gives the human pancreas:

deceptive pain in the heart muscle is created;
shoulder pain.

All these symptoms indicate a problem in the gland, and the pain effects are also blunted by the fetal position, pulling the knees to the chest, which only confirms the diagnosis. In addition to the listed signs, frequent vomiting may also occur, after which there is no relief, which leads to dehydration.

In the bloodstream of the affected person, or rather in his plasma, there is high concentration vasoactive components, which leads to reddening of the skin, face. With serious consequences, it will be the other way around, severe pallor of the skin.

At the time of the appearance of pancreatic necrosis of the gland, in the affected organism, the concentration of elastase greatly increases. With a strong increase, blood vessels of a person are destroyed, which leads to bleeding in the gastrointestinal tract. During this period, blood clots are observed with vomiting stools. And you can also see physical changes- purple spots on the navel and buttocks of an affected person.

Pancreatic necrosis carries symptoms and complications, as well as consequences that require urgent surgery, which will give the sick person a chance to survive.

Surgery

With pancreatic necrosis, surgery is indispensable without surgery. In often this is one way out, which will be a chance for recovery. But this is possible only with timely surgical care to the patient. Many are interested in whether it is possible to do without surgery for pathology. It is possible, but if the disease is detected at an early stage of development and does not have side effects, but this rarely happens.

This pathology, almost in a matter of hours, destroys a person, so it is necessary to quickly solve this problem and strictly adhere to the requirements of doctors. Only a correct diagnosis and timely assistance will save the victim from a surgical operation.

What are the indications for a surgical operation for pancreatic necrosis:

infectious type of necrosis;
the appearance of an abscess;
hemorrhagic effusion;
pain shock is not stopped with the help of analgesics;
septic phlegmon;
a large lesion with necrosis;
peritonitis;
Surgery for pancreatic necrosis consists of a step-by-step approach:

1. The main goal of the first operation:

drying out of necrotic tissues;
installation of drainage tubes to remove liquid through them;
relieving pressure on neighboring human organs;
relief of affected areas from other organs of the peritoneum.

2. The next operation involves working on the ducts. If this cannot be done operationally, then this operation carried out in a minimally invasive manner.

Depending on the severity of the pathology, complex treatment with the use of physiotherapy, which increases the chances of transferring pathology into stable remission.

Why do patients die

Acute pancreatic necrosis of the pancreas is a disappointing prognosis even before and after surgery. Why is this happening?

Death is possible in such cases:

in acute pancreatitis, gland cells die off, necrosis of human tissues and organs occurs;
the walls of the intestine during peritonitis are destroyed, which leads to severe infection of the peritoneum;
the liver, kidneys, heart, blood vessels are affected, which also begin to collapse under the action of pancreatic enzymes and juice;
the heart can not cope with a strong load and stops;
blood pressure drops;
there is an increase in pressure in the choleretic ducts, which leads to severe intoxication of the body;
sphincter of Oddi, stops passing enzymes through itself and digestive juice leading to organ failure and peritonitis.

All this leads to death, so you need to take care of your health and, at the first sign, undergo the necessary diagnosis of the whole organism.

Life after treatment

After surgery for pancreatic necrosis, the patient is placed on a dispensary record at the place of residence. Every 6 months he must pass complete diagnostics organism and. When conducting ultrasound, the state of the pancreas, liver, kidneys, and intestines is of particular importance. Urine and blood tests will tell about the patient's condition and possible complications in the postoperative period.

AT given period rehabilitation, the patient needs:

undergoing physiotherapy;
therapeutic light gymnastics;
walks in the open air;
abdominal massages;
after eating, rest is prescribed;
it is forbidden to irritate the patient, as this will give impetus to the pancreas.

After surgery for pancreatic necrosis, how long do they live? There is no clear idea and prognosis, but basically everything depends on the correct implementation of the nutritional norms prescribed by the doctor and the correct observance of medical measures.

And there are factors that influence this:

degree of damage;
age;
the correctness of the treatment;
the extent of the necrosis lesion;
chronic diseases associated with pancreatic necrosis.

Getting a disability

With pancreatitis, there are three groups for disability:

1. The first group of disability.

if the patient has a constant failure of the gastrointestinal tract;
dystrophic condition of the victim;
there is no way to take care of your body;
restriction in motor functions.

2. The second group of disability.

periodic bleeding;

3. The third group of disability.

if there are no complications after the operation;
the pancreatic gland is working normally, but manifests itself with attacks every six months and mild discomfort.

The third group allows you to lead a working life without strong physical exertion.

If pancreatic necrosis develops, there are chances of survival, but the outcome depends on many factors: age, severity of the condition, area of the lesion, concomitant diseases, and the timing of the start of treatment.

Given the high mortality rates from pancreatic necrosis, efforts modern medicine directed to search effective methods that can increase the likelihood of recovery and enable the patient to live after a serious illness.

– disability for the rest of your life?

If tissue death of a significant part of the gland occurs (total or subtotal process), the patient rarely manages to survive, despite the timely provision of adequate assistance. Cell necrosis occurs at lightning speed: sometimes the organ dies in a few hours. Even if a timely operation is performed, it is not always possible to achieve a positive result, and the chance to save a life is reduced to zero.

Often, pancreatic necrosis is so severe that complete recovery does not occur. The head, body and tail of the organ are involved in the destruction process. The most optimistic prognosis after surgery is survival, which leads to disability. In this case, the person is significantly limited in working capacity.

Contraindications after suffering pancreatic necrosis include:

psycho-emotional stress;
heavy physical labor;
classes that require a violation of the diet;
activity in contact with hepato- or pancreatic poisons.

All of the above conditions are strictly prohibited after suffering pancreatic necrosis, since they can lead to the development relapse with a fatal outcome.

Organ complications of pancreatic necrosis

Necrosis of pancreatic tissue without immediate treatment emergency care leads to the release of a large number of enzymes into the vessels, causing their expansion. Due to the increase in the permeability of the walls, enzymes enter the intercellular spaces. The gland swells, hemorrhages appear in its tissues and retroperitoneal tissue, which leads to irreversible processes, among which are the earliest and most common:

infiltrate;
hemorrhagic effusion;
retroperitoneal abscess or phlegmon.

Infiltrate

The development of parapancreatic infiltrate occurs not only in the gland, but also in neighboring organs. Are affected:

duodenum;
stomach;
spleen.

The process can go to the gallbladder, liver, cause changes in lower sections intestines. They are soldered together with the participation of exudate, which fills upper part abdominal cavity or all of its space. The formation of an infiltrate is a reaction immune system organism on necrotic tissue of the gland. The process itself is aseptic at this stage, there is no infection. Therefore it is possible:

reverse development - resorption;
formation of cysts;
purulent variant.

If within 3 months the infiltrate has not disappeared, cysts appear. This is a warning about a possible severe complication.

Accession of infection leads to:

to purulent lesions of the pancreas;
peritonitis;
abscess
phlegmon.

This significantly worsens the condition and prognosis of the disease.

Differentiate parapancreatic infiltrate and make a diagnosis without additional methods research is difficult. It is associated with scarce clinical manifestations due to the aseptic process:

the general condition is not disturbed, the patient has no complaints;
the temperature is normal, only sometimes subfebrile condition is observed - an increase to 37–37.9 degrees Celsius;
in general analysis blood, except for a neutrophilic shift to the left (not always), there are no changes.

A complication can be suspected when performing ultrasound of the retroperitoneal space, blood and urine tests for the content of pancreatic enzymes: in biochemical analyzes elevated levels of amylase, ultrasound examination- characteristic changes.

Peritonitis

Peritonitis - inflammation of the serous layer of the abdominal cavity, leading to the accumulation of fluid with great content enzymes. The frequency of this complication is 60–70%. It is manifested by a bright clinical picture of an acute abdomen. Appear:

paroxysmal pain of high intensity, without a clearly defined localization, sometimes determined in the left hypochondrium and epigastrium;
signs of an acute abdomen: tension in the anterior abdominal wall and all the positive symptoms of inflammation;
severe intoxication: fever up to 40 and above, tachycardia, fall blood pressure, nausea, vomiting, flatulence;
psychosis;
collapse - a sharp decline BP and heart failure.

In the analyses:

- leukocytosis and high ESR;
biochemical - diastasis of urine and blood exceeds the norm.

Hemorrhagic effusion

Peritoneal hemorrhagic effusion is one of the causes of death from pancreatic necrosis. It is the most severe complication. Highly active enzymes lead to the progression of necrosis and mass death cells. Massive bleeding occurs, the tissues of the organ are saturated with blood. Neighboring organs are involved in the process, an infection joins, purulent intoxication develops. The disease is rapidly progressing, urgent resuscitation is necessary.

Clinically, it resembles an acute abdomen, but all its signs are maximally expressed. Suddenly develops:

hyperthermia - the temperature reaches 41–42 degrees Celsius;
severe chills and impaired consciousness;
lethargy or agitation;
heart palpitations, blood pressure instability;
dyspnea;
dagger pain - intense intolerable bouts of acute pain in the abdomen, mainly in the left hypochondrium;
nausea, repeated vomiting;
diarrhea and flatulence.

Phlegmon

Retroperitoneal phlegmon - inflammation of fatty tissue without clear boundaries, which occurs acutely. Pathogenic microflora with a blood or lymph flow penetrates into the tissue from a purulent focus of infection or during an operation. Clinical symptoms suggest the development of complications:

febrile (38–38.5 degrees Celsius and above);
pain in lumbar region- pulsating or pulling nature with irradiation into the abdominal cavity when other organs are involved in the pathological process;
increased pain when moving or changing body position.

In addition to the listed organ lesions of pancreatic necrosis, often develop:

fistulas;
deep vein thrombosis with dysfunction of the pelvic organs;
strictures of the hepatobiliary zone;
gastrointestinal bleeding;
ulcers of the stomach and intestines;
enzyme deficiency.

Is there any chance of surviving the disease?

Survival of pancreatic necrosis requires emergency hospitalization in surgery department. The painful process of cell death proceeds rapidly, it can be lightning fast and be completed within one to two hours. If necrosis has become total, death occurs in 100% of cases. To interrupt the vicious pathological circle, an urgent resuscitation and operations. In this case, life can be saved.

Initially, the patient enters the intensive care unit, where all measures are taken to emergency care to bring the patient out of shock. Detoxification, anesthesia is carried out, complete functional rest of the pancreas is created. Approximately on the 5th day, when the boundaries and extent of the damage to the organ become clear, a necrectomy is performed.

But it doesn't always happen at that time. If the lesion is total, and the clock counts, the operation is performed immediately, sometimes the pancreas is completely removed - pancreatotomy. The patient must be fixed for further manipulations to flush the installed drainage systems, and in this position he can be for a long time.

After the operation is long, takes more than six months or a year. AT without fail the prescribed diet is observed - table number 5 according to Pevzner. In the future, under the supervision of a gastroenterologist, it can change to table number 1 and its modifications. Only a specialist can determine how long you need to be on a strict diet.

In addition, an appointment is scheduled enzyme preparations having good review about the treatment of pancreatitis, and a number of other medicines that are necessary for wellness. All prescriptions must be strictly followed - this is the only way to improve the quality of life after surgery.

Death statistics for pancreatic necrosis

Statistics show that a lethal outcome in the onset of necrosis occurs in 40–70% of cases. The reasons:

late visit to the doctor;
extensive area of organ damage;
joining the infection;
the number of developed complications (more than three).

The final diagnosis in such cases is already made by a pathologist, and not by a gastroenterologist or surgeon.

With (PN), the mortality rate is high (with a total process - up to 100%), and there is no downward trend. In 97% of severe PI, mortality in patients is due to complications, including postoperative ones. The necrotic process itself can often regress, but complications develop rapidly and lead to devastating consequences.

The statistics on mortality in PN are depressing: out of 10 patients, from 2 to 9 die in the hospital or from severe complications or new diseases after discharge. The numbers are even more frightening given the fact that people of working age fall ill with PN - from 30 to 50 years.

After suffering pancreatic necrosis, the patient's ability to work is limited or completely lost. In the future, surgical intervention may be required again due to the development of complications in PN or arising during the main operation.

Causes of death in pathology

Mortality in PN reaches 70%, the prognosis is rarely favorable. According to statistics, more than half of patients die on the operating table during urgent surgical treatment. The risk of death depends on the timing of the request for a specialized medical assistance. Playing a role:

old age (after 50 years);
hypotension;
diabetes;
blood urea, exceeding the norm;
metabolic acidosis;
leukocytosis.

According to numerous studies, the main causes of death include:

early manifestations of toxemia;
distant septic variant of the complication.

Because of their development, every fourth patient has multiple organ failure. The cause of death in the later stages was infectious-toxic shock.

Important factors are also:

excessive duration of admission - typical of male patients;
violation of the diet and excessive consumption of fatty, spicy and fried foods;
cholelithiasis - more often develops in women if the patient does not adhere to the recommendations for therapeutic nutrition;
constant stressful situations.

Recovery period after surgery

After surgical treatment, patients face problems associated with emerging postoperative complications and not with ongoing symptoms of pancreatic necrosis. During this period, the supervision of a surgeon, endocrinologist, rehabilitologist is necessary.

After suffering severe pancreatic necrosis, in 70% of cases, patients remain in a rehabilitation center or intensive care unit under the supervision of doctors long time- up to one year. Since a sparing regimen and complete rest are prescribed, the patient is on bed rest. Over time, this leads to muscle atrophy and the development of flexion contracture of the legs. Moreover weak muscles cannot support the body weight of the person himself. To avoid this, it is recommended to do massage, perform complexes special exercises that help strengthen muscles.

Due to autolysis (self-digestion of the gland in acute period) digestion is grossly disturbed. The patient loses up to 50% of body weight. In the postoperative rehabilitation period it is important to follow a therapeutic diet so as not to aggravate the process again and restore weight. It is recommended to eat pureed food in small portions 6-8 times a day.

Strict adherence to the diet prescribes the exclusion from the diet of spicy, fatty, fried, pickled foods, alcohol, carbonated drinks, strong tea and coffee and chocolate. The list of prohibitions is long, but every patient should know it so as not to break the diet.

Subject to diet food the patient returns to his former life and does not experience or discomfort. Violation of the diet leads to death.

How to prevent the fatal consequences of pancreatitis?

Pancreatic necrosis after surgical and conservative treatment, if the person survived, refers to diseases that can be controlled. If there is a desire to live, then a person lives with such a diagnosis, following the recommendations, and there is no danger of death. It is also necessary to follow emotional state, avoid stress, follow the rules of a healthy diet, attend dispensary examinations and consult a doctor without self-medication. Prevention of complications includes bad habits: Refrain from drinking strong and low-alcohol drinks. Subject to these rules, health can remain satisfactory.

Bibliography

Bondarchuk O.I., Kadoshchuk T.A. Laparoscopic drainage of the abdominal cavity in pancreatic necrosis. In the materials of the IX Conference of Surgeons-Hepatologists of Russia and CIS countries, St. Petersburg. Annals of surgical hepatology. 2002 No. 1 pp. 187–188.
Brekhov E.I., Mironov A.S. Modern technologies in the diagnosis and treatment of pancreatic necrosis. In the materials of the anniversary conference dedicated to the 10th anniversary of the Society of Endoscopic Surgeons of Russia "Ensuring the safety of endosurgical operations". Endoscopic Surgery 2006 No. 1 p. 24.

The most urgent problems of surgery remain: early forecast occurrence of pancreatic necrosis, prevention of infection of the pancreas, variety of the clinical picture (difficulties in rapid diagnosis), choice surgical tactics at an early stage of pancreatic necrosis.

Another problem is social aspect- awareness by patients of risk factors and scale of this pathology. That is, deviations from the doctor's preventive instructions are one of the most common causes of acute pancreatitis and pancreatic necrosis.

General information about the disease

is a complication of acute pancreatitis (inflammation of the pancreas), consisting in varying degrees cell death this body and the development of severe clinical symptoms.

Pancreatic necrosis is not a disease of alcoholics! As a rule, when chronic use alcohol, chronic pancreatitis develops with a gradual loss of exocrine pancreatic function. Pancreatic necrosis, most often, is formed with occasional intake of a large volume of ethanol-containing drinks, animal fats.

Consuming significant amounts of alcohol and fatty foods(more than 95% of all pancreatic necrosis).
Gallstone disease, decompensated biliary dyskinesia.
Acute surgical pathology of another organ(penetration in gastric ulcer, etc.)
Acute chemical poisoning.
Traumatic injury to the pancreas.
Congenital malformations of the pancreas.
Shock (septic, hemorrhagic, traumatic - a condition leading to multiple organ failure).
Surgical interventions in history(adhesive disease).
Iatrogenic pancreatic necrosis (a rare event when after endoscopic examination gland develops acute pancreatitis and pancreatic necrosis).

Significant income ethyl alcohol and animal fats in the digestive tract leads to hyperfunction of the pancreas. If a person has problems with the outflow of pancreatic juice from the gland, it suddenly activates great amount highly active pancreatic enzymes (phospholipase, trypsin, chymotrypsin, elastase and others).

First, trypsinogen is released from damaged cells, transforming into trypsin, kallikrein and kallidin are activated. When exposed to these enzymes, histamine and serotoxin are released, which activate blood protein factors (Hageman and plasminogen).

Due to damage to the microvasculature of the pancreas, all enzymes penetrate into the general bloodstream and cause a general vascular spasm (on short period), after which dilatation (expansion) of the vessels occurs, the permeability of the walls of the vessels increases, the blood plasma freely leaves the vascular bed, pancreatic edema develops (at this stage, internal bleeding into the retroperitoneal space often occurs). As in any organ system, the slowing down of blood flow (stasis) leads to the formation blood clots- blood clots.

Vascular thrombosis leads to dysmetabolic disorders in cells (hypoxia, acidosis), areas of necrosis are formed in the pancreatic parenchyma. Lipases (enzymes that break down fat molecules) are released from dying cells. A large number of lipases can provoke necrosis not only in the pancreas, but also in the omentum, fatty tissue of the retroperitoneal space, etc.

In addition to local damage, general intoxication develops due to the effect of pancreatic enzymes on systemic vessels. Inadequate vascular tone leads to circulatory disorders in other organs, cellular and organ degeneration, acid-base, water-electrolyte disorders develop, protein synthesis, carbohydrate and fat metabolism slow down. Without pathogenetic correction pharmacological preparations multiple organ failure develops

An important link in the development and severity of the course of pancreatic necrosis are protease inhibitors - special blood proteins that protect against the effects of their own and foreign proteolytic enzymes (including the pancreas) on cell metabolism. The greater the concentration of protease inhibitors and their binding capacity, the less pronounced will be the development of pancreatic necrosis. This function is individual for each organism, determined genetically, so the clinical picture of pancreatitis is so diverse.

According to the prevalence of necrosis:

focal- necrosis of one anatomical region of the pancreas: head, body, tail or parts thereof;
diffuse (segmental)- all parts of the pancreas are affected (and not only the parenchyma, but also the vessels, ducts, nerves).

Depth of injury:

surface- necrosis of the outer layers of the gland. It usually ruptures when the superficial pancreatic ducts rupture, when juices containing proteolytic enzymes accumulate between the outer surface of the pancreas and its capsule;
deep- necrosis of more than half of the pancreas, part of the tissue remains viable;
total- death of the whole organ. Often the process goes to the omentum and retroperitoneal fatty tissue.

According to the nature of the clinical course:

abortive course - a moderate form of pancreatic necrosis. Tissue (interstitial) edema develops around the foci of necrosis. Compensatory inhibitory systems cope with the amount of vasoactive enzymes released from the gland, spontaneous recovery occurs (subject to drug treatment);
progressive course - the concentration of vasoactive enzymes in the blood exceeds the compensatory abilities of the body. Deep or total necrosis of the gland develops, hemodynamic disturbances, multiple organ failure, there is a high probability of sudden pancreatogenic shock, spontaneous internal bleeding and further infection of the pancreas;
regressing course - the clinical symptoms of pancreatic necrosis gradually "fades away" within 20 - 30 days. Against the background of pancreatic edema, pseudocysts (connective tissue capsules with pancreatic fluid) are formed. Sometimes pseudocysts reach a significant size, which leads to a displacement of the stomach, gallbladder, liver with a violation of their functions;
relapsing course - typical for persons suffering from alcoholism. Special clinical form developing against the background of chronic dystrophic changes in the pancreas with periods of sudden exacerbation. Relapses in this case repeat several times in a lifetime and become more and more severe, often leading to death;
fulminant pancreatic necrosis is the most dangerous form. Necrosis of the gland and the clinical picture develop in a few hours. Rapidly developing hemodynamic disturbances, multiple organ failure and shock. Lethality is about 90%.

According to the mechanism of occurrence:

hypersecretory - the most common form. It is formed against the background of excessive release of pancreatic enzymes against the background of alcohol and fatty foods;
traumatic - develops against the background of blunt abdominal trauma, surgical interventions, diagnostic manipulations;
biliary - against the background of a violation of the outflow of bile from the liver(cysts, tumors, developmental anomalies). With this option, pancreatic necrosis is often complicated by the addition bacterial infection, the development of phlegmon of fatty tissue of the retroperitoneal space;
mechanical - due to obstruction of the common bile duct and impaired bile entry into the duodenum, the pancreas begins to produce an increased amount of pancreatic juice, which destroys it;
immune - autoimmune inflammation of the pancreas(destruction of pancreas cells by own lymphocytes) gradually leads to its death;
contact - develops against the background of a complicated peptic ulcer of the stomach or duodenum 12(penetration of the ulcer);
vascular - this form is typical for those suffering from atherosclerosis and other vascular diseases people (usually the elderly). Gradual vascular stenosis leads to blood stasis and the development of dysmetabolic disorders in the pancreas.

According to the clinical form:

hemorrhagic pancreatic necrosis- macrofocal or total necrosis of the pancreas. It develops extremely quickly and is accompanied by a pronounced clinical picture (multiple organ failure). High lethality;
fatty pancreatic necrosis- the formation of foci of necrosis, which merge with each other, a connective tissue capsule is formed around. Without drug therapy goes into a hemorrhagic form;
mixed pancreatic necrosis.

According to the presence of complications:

uncomplicated;
complicated(infection, bleeding, shock, etc.).

According to the severity of the flow:

mild degree- individual foci of necrosis in the gland;
average degree- large foci of necrosis without confluence;
severe degree- total necrosis of the pancreas;
extremely severe degree- Complicated total necrosis.

Pain in pancreatic necrosis is observed in 100% of cases and can only vary in intensity. In 4-5% of patients, the pain is of a moderate nature, the majority experience severe pain, and in 8-10%, unbearable pain, which can lead to pain shock. Most often, the painful area is located in the left hypochondrium, epigastrium. Sometimes the pain radiates to the back, shoulder, heart, shoulder blade, etc. Non-steroidal anti-inflammatory drugs do not give the desired effect in pancreatic necrosis.

Dyspeptic syndrome: repeated vomiting that does not bring relief, nausea, bloating.

Metabolic and vascular disorders: redness of the face, pallor of the skin of the extremities, tachycardia (increased heart rate), tachypnea (increased respiratory rate), dry mouth, tremor, increased sweating, disorders of the nervous system (hyperesthesia, convulsions, depression of consciousness, etc.).

Locally: in the area of the pancreas, an infiltrate (dense formation) can be palpated. The infiltrate is formed depending on the type of pancreatic necrosis (with fat - most quickly, with hemorrhagic - in the later stages, with the dominance of general symptoms).

The appearance of purple (purple) spots on the side walls of the abdomen.

Halstead's sign- purple spots on the anterior abdominal wall.

Grunvold's symptom- purple spots around the navel.

Davis sign- purple spots on the buttocks, lower back.

Pancreatic necrosis can hide under the "mask" of others surgical pathologies (acute appendicitis with ascending process, cholecystitis, perforated ulcer stomach or duodenum, peritonitis), cardiac diseases, radicular syndrome with osteochondrosis. Therefore, timely differential diagnosis very important as soon as possible!

Interrogation and inspection: Most often, the diagnosis can be verified at the stage of collecting an anamnesis ( typical signs - recent appointment large amounts of alcohol, fatty foods).
Severe pain in the left hypochondrium, vomiting, palpation of the infiltrate in the pancreas - important symptoms to make a diagnosis.

Laboratory diagnostics:

general blood analysis- carried out routinely, allows you to identify common signs of inflammation in the body (leukocytosis, accelerated ESR);
general urine analysis- a sharply elevated level of amylase indicates inflammatory or necrotic processes in the pancreas;
blood chemistry- with pancreatitis / pancreatic necrosis, an increase in the level of pancreatic enzymes is found: amylase, lipase, trypsin and others;
tests to assess exocrine pancreatic function- PABA test, Lund test, etc.;
fecal analysis to determine the presence of enzymes and assess digestion.

Instrumental diagnostics:

plain radiography of the abdominal organs- a simple graphic method of research. Allows you to identify indirect signs inflammation, pancreatic edema, large foci of necrosis;
ultrasound procedure- a fast and accurate method for determining inflammatory and necrotic changes in the pancreas;
MRCP- magnetic resonance cholangiopancreatography. The use of a magnetic tomograph to examine the entire hepatopancreatic system (liver, bile ducts, gallbladder, pancreas and its ducts). The method is extremely precise and non-invasive;
diagnostic laparoscopy- invasive research method. The anterior abdominal wall is punctured with a hollow tube through which a video camera is passed. When carrying out such a procedure, the surgeon can assess the current state of the pancreas directly on the monitor screen.

The final diagnosis of "pancreatic necrosis" can only be established after a histological examination of the pancreatic tissue.

In most cases, patients with pancreatic necrosis are in extremely serious condition and require permanent care in the intensive care unit. The use of invasive diagnostic methods is often impossible, because of the risk of worsening the course of the disease.

Complications

Complications are:

massive toxemia (toxic, pancreatic shock)- a significant intake of pancreatic enzymes into the general circulation leads to irreversible circulatory disorders, nervous regulation and death;
purulent complications- infection of the damaged pancreas can lead to the formation of abscesses and phlegmon of the retroperitoneal space, peritonitis, pleural empyema, sepsis;
bleeding- under the influence of aggressive enzymes, arrosive internal bleeding often occurs (extremely poor prognosis, because surgery for hemostasis itself can destabilize the patient's condition);
Exocrine and endocrine pancreatic insufficiency- complications late period. These complications can be successfully corrected using pharmacological therapy.

All patients with pancreatic necrosis should be hospitalized in the intensive care unit!

The first 5-7 days after the onset of the disease surgery is not carried out, since it is impossible to accurately assess the extent of pancreatic necrosis. At the same time, the risk of worsening the course of pancreatic necrosis, infection, and the development of arrosive bleeding increases significantly.

The patient needs strict bed rest and complete rest. Pharmacological therapy is carried out:

detoxification therapy (correction of water-salt and protein balance)- introduction of colloid and crystalloid solutions intravenously;
analgesic therapy- the introduction of painkillers (including narcotic and mixed), antispasmodics, novocaine blockade;
antibiotic therapy- for the prevention of infectious complications;
hepatocardioprotectors- medicines to protect the liver and heart;
symptomatic therapy- correction of urination, defecation, neurological and vascular disorders.

Surgical treatment is the excision of necrotic areas of the pancreas, drainage of the retroperitoneal space antiseptic solutions, installation of drainage for the outflow of fluid. Postoperative period usually long.

Pancreonecrosis of the pancreas, the prognosis after surgery in most cases is doubtful. The further quality of life of the patient depends on many factors: the volume of necrosis of the gland, the speed of rendering medical care, presence or absence of complications, age and accompanying illnesses. Postoperative patients require long-term dispensary observation by a gastroenterologist and surgeon.

To date, mortality in this pathology ranges from 70% to 90%. Questions remain relevant early diagnosis and prevention of life-threatening conditions (shock, bleeding, sepsis).

Most common cause the development of pancreatic necrosis remains the use of a significant amount of alcoholic beverages and fatty foods.

In the diagnosis of pancreatic necrosis, "wait and see" tactics are most often used, since the patient's serious condition does not allow for many diagnostic procedures.

Treatment of pancreatic necrosis must necessarily be carried out in the intensive care unit and intensive care unit under constant monitoring of vital signs. Operative treatment is postponed until the patient's condition stabilizes.

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The people say: whoever is lucky is loaded on him, which fully applies to. This one is our life important organ works with a double load, in its own way - a multi-machine, performing two secretory functions in parallel: internal (endocrine) and external (exocrine).

Works, works, rarely reminding himself. True, all this for the time being. And all that she requires from us, and does not require, but asks, is only a careful and respectful attitude towards her modest person.

So, no, dear, get it - here's spicy, fatty, and smoked food for you. Few? Get "in the appendage" a fair share of regularly consumed alcohol. And she is poor, besides this, and there are enough other sores.

Well, who will survive after this? And it started, went, fell down. Up to the most serious ailments, which is pancreatic necrosis.

Pancreatic necrosis and its types

Speaking of pancreatic necrosis, it must be emphasized that this serious disease is caused by deep damage to the cells of the pancreas, their necrosis and irretrievable loss. It leads to the complete disappearance of the functions of a vital organ.

Pathology develops with the appearance of many factors that provoked this disease. Unfortunately, death from pancreatic necrosis occurs in 70% of cases of diseases, especially when the addition of negative circumstances that have transferred the disease to an irreversible and untreatable stage.

When classifying and describing pancreatic necrosis, doctors take into account various factors:

stages of development of necrosis;
areas that have been affected;
complications that have arisen.

Considering all this, several types of it are distinguished:

small-focal or local, where one of the parts of the organ has been affected;
mid-focal;
macrofocal;
diffuse or total, when all structures of the pancreas are affected, including large secretory ducts, vessels and tissues.

In addition, given the nature and duration of the course of the disease, the disease is graded:

acute edematous abortive;
when there is a rapid and irreversible death of gland cells;
pancreatic necrosis of the fatty form;
widespread and focal;
progressive and sluggish;
hemostatic, functional, purulent destructive.

By sign infectious process necrosis is divided into two groups:

infected;
aseptic and sterile.

The most favorable chances of survival are given by edematous pancreatic necrosis. At this stage, all the changing pathology occurs due to edema of the parenchyma (functionally active cells) and an increase in pressure on pancreocytes.

Reasons for the development of the disease

Concerning the causes of the disease, it is worth once again returning to the beginning of the article, where we talked about the ugly attitude towards the pancreas, which we often and densely show.

Yes, yes - it is harmful nutrition, “sprinkled” with a merciless share of alcohol, and often also a surrogate one, that is the root cause of pancreatic necrosis.

However, not everything is so simple - not only drug addicts and alcoholics lead the risk group.

Unfortunately, it also includes quite respectable people who, by virtue of life circumstances and by the will of fate, acquired this deadly disease.

Causes leading to pathology:

duodenal ulcer and stomach ulcer;
injury to the abdominal cavity;
complications after surgical operations;
cholelithiasis;
various infectious and viral invasions;
congenital pathology and malformations of the gastrointestinal tract.

Video about pancreatic necrosis from an expert:

Main symptoms and complications

Long-term practice of studying and combating pancreatic necrosis allows us to conclude that its detrimental attack on the body occurs, as a rule, very quickly.

without explicitly expressed reasons the patient suddenly begins to feel heaviness in the abdomen and bouts of nausea, which are transformed into prolonged, debilitating vomiting.

At further development The disease is manifested by acute pain in the left hypochondrium. Some symptoms may resemble a heart attack, but the doctor diagnoses that such signals are sent by the pancreas at the posterior location of pancreatic necrosis.

Irradiation (spread of pain) under the shoulder blade and in left shoulder is also a characteristic feature of this disease.

Other symptoms characterizing pancreatic necrosis:

Prolonged vomiting, without the onset of obvious relief.
Fever, chills, fever.
The appearance of a painful skin color: blanching and redness of the skin.
Paresis or paralysis of the intestine neurological syndrome characterized by the absence of intestinal motor activity(peristalsis), as a result of which excrement is not excreted from the body.
Rapid heart rate, shortness of breath.
Due to vomiting - dehydration of the body, drying of the mucous membrane in the mouth.
The abdomen swells, the muscles in its upper part tighten.
Decreased or completely stopped urination.
Around the navel, on the buttocks, costal arch from the back, characteristic cyanotic spots appear.
There comes a general weakness or, as the people say, a weakness of the body.
Unbalance appears mental state patient: unmotivated excitement, anxiety, confusion of thoughts, speech, consciousness, loss of spatio-temporal orientation, general lethargy.
As a result deep defeat vessels open gastric and intestinal bleeding.

Destructive changes associated with damage to the pancreas can provoke the following complications:

The formation of voids filled with pus and necrotic masses, threatening the spread of an abscess.
The development of pseudocysts and cysts in the body.
The occurrence of fibrosis, as a result of which dead working cells are replaced by simple connective tissue, while the lost functional load is not restored.
Restriction of pancreatic secretion - enzymatic deficiency.
Acute purulent inflammation is a phlegmon of the retroperitoneal tissue.
The occurrence of thrombosis in the mesenteric vessels and portal vein.

The progressive development of pancreatic necrosis causes not only an increase in the size of the pancreas, but also leads to the formation of infiltrates - atypical seals consisting of lymph, blood and dead cells. On the fifth day, the infiltrate is calmly detected by palpation.

Diagnostic methods

The symptoms of pancreatic necrosis are not clearly expressed, clearly indicating this particular disease. Other diseases have similar manifestations. Therefore, for an accurate diagnosis, more differentiated laboratory research, using various tools.

These include:

Hemogram. Clinical analysis determining increased content leukocytes in the blood, the appearance of toxic granularity of neutrophils, an increase in the erythrocyte sedimentation rate (ESR).
A blood test for amylase is an enzyme in pancreatic juice. Pancreatic necrosis significantly increases its content.
Test for determining the amount of calcitonin in the blood. For a better understanding, it is worth explaining that calcitonin is a hormone involved in calcium metabolism in the blood. Its increased content indicates the progression of the disease.
. It is ultrasound that allows you to visually identify the uneven structure of the gland and its edema, as well as to state an increase in the space between the pancreas and the posterior pancreatic wall.
Magnetic resonance and computed tomography (MRI and CT). A more modern application-based toolkit x-rays, making it possible to study the organ in three-dimensional vectors. This medical practice allows you to identify specific lesions, including small ones, as well as effusions (accumulation biological fluid) in the abdominal cavity.
Puncture (piercing) of necrotic biological formations for the purpose of their further study (sowing).
Angiography. One of the differentiated methods, which allows using a contrast X-ray examination to study the state of the vessels.
Laparoscopy. This is a modern surgical operation that allows the doctor to “look” inside without an incision and examine the affected areas of the pancreas and more accurately diagnose types of pancreatic necrosis.

Complex treatment of pathology

Without a doubt, pancreatic necrosis is precisely the disease that does not tolerate delay, the patient needs immediate hospitalization.

Important! Self-medication and treatment of pancreatic necrosis at home is not only criminal negligence, but also a possible cause of sudden death.

Often, doctors are powerless in front of fulminant pancreatic necrosis, the development of which occurs within a few hours. The total pathological process is uncontrolled and uncontrolled. Such a life perspective and death await chronic alcoholics and drug addicts.

Therefore, we repeat that only hospitalization and treatment in a hospital under the supervision of experienced personnel can save the patient. Only there the doctor is able to choose the strategy and tactics of treating the patient, using conservative or surgical methods.

The process of prevention and treatment of pancreatogenic toxemia and toxemic disorders takes a lot of time and effort from both the patient and the attending physician.

It consists of many forms and methods:

antienzymatic therapy.
Detoxification (plasmapheresis and forced diuresis). These medical activities are carried out with the aim of destroying and neutralizing toxins.
Syndromic therapy of pain shock and hypovolemia (decrease in circulating blood volume).
Elimination of DIC - this disorder characterizes the deterioration of blood coagulation.
Corrective infusion therapy - elimination of water and electrolyte imbalance caused by dehydration and blood loss.
Prevention of purulent-septic complications.
Drug correction of the work of the kidneys, lungs, liver, central nervous system with general intoxication organism.

Surgical intervention at an early stage makes it possible to localize and prevent the spread of purulent-septic complications in total and extensive necrosis.

Types of surgical operations:

Predictions after therapy

After the course therapeutic measures the patient lives with the hope of recovery, which, by the way, is one of the determining factors for the onset of positive dynamics.

However, in case of severe diseases, giving a prognosis after surgery is a thankless task, especially when it comes to pancreatic necrosis. And in this case, which is completely understandable, the doctors behave with extreme caution so as not to inspire excessive optimism in the patient and his relatives.

The prospect of recovery is significantly worsened when the patient has one of the following factors, even worse when they are summed up:

The patient is over fifty years of age.
The content of leukocytes in the blood is more than 10 * 109 / l, characterizing leukocytosis.
- high blood sugar.
Metabolic acidosis is a violation of the acid-base balance due to increased secretion of hydrochloric acid.
Hypocalcemia. This is a condition when the amount of calcium in the blood plasma falls below 1.87 mmol / l.
Arterial hypotension is a decrease in blood pressure by 20% relative to the normal daily average.
Increased levels of urea, LDH and AST enzymes.
Significant dehydration.

Video story from a recovered patient:

The stories of surviving patients suffering from pancreatic necrosis do not sound like memories, but more like a reminder and edification to those who still do not appreciate the joy of every day, guided by the pernicious principle - we live once, everything needs to be tried and we will all be there, ruthlessly destroying the life given by God .