Transcript 13. Chronic pancreatitis

Chronic
pancreatitis
Lykhatska G.V
Plan of the lecture
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Etiopathogenesis of chronic pancreatitis
Сlassification of chronic pancreatitis
Clinic of chronic pancreatitis
Diagnosis of chronic pancreatitis
Complications of chronic pancreatitis
Differential diagnosis
Treatment of chronic pancreatitis
Chronic pancreatitis
 Chronic pancreatitis is a long-standing
inflammation of the pancreas that alters its
normal structure and functions.
Etiology of chronic
pancreatitis
Primary pancreatitis :
 Misuse of alcohol (70-80% of all diagnostic cases )
 the systematic eating of fatty foods
 influence of drugs (azathioprine , isoniazide ,
tetracycline , sulfonamides )
 protein deficiency
 Hereditary
 Ischemic (in lesions of vascular , which supplies blood
pancreas )
 Idiopathic
Etiology of chronic pancreatitis
Secondary pancreatitis :
 diseases of the biliary tract (in 30-40%)
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disease of duodenum
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a primary (tumors,papillitis) and a secondary
(dyskinesia of billiary tract)
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liver disease
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bowel disease
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viral infections (parotitis )
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allergic conditions
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hyperlipidemia
 hyperparathyroidism
 injury of the pancreas
The pathogenesis of chronic
pancreatitis
 The main pathogenetic mechanism of the
development of chronic pancreatitis is
acinuses destructive damage acinuses ,
caused intracellular activation of enzymes
pancreas .
 Has significance violation of the outflow of
pancreatic juice
 The progressive fibrosis coused the violation
phisiologycal function of the gland.
Classification
chronic calcified pancreatitis
chronic obstructive pancreatitis
chronic inflammatory pancreatitis
 Chronic pancreatitis of alcoholic etiology
 Others forms chronic pancreatitis (chronic
pancreatitis unspecified etiology , infectious ,
recurrent )
 Pancreatic cysts
 Pancreatic pseudocyst
Clinical classification of
chronic pancreatitis
The course of the disease :
 1. mild severity - signs of violation exocrine and
endocrine function not detected .
 2. moderate - signs of violation exocrine – and
endocrine function
 3. severe (terminal) - the presence of resistant
pancreatic diarrhea , hypovitaminosis , exhaustion .
Clinical classification of
chronic pancreatitis
On the functional characteristics
1. In violation of exocrine pancreatic function
2. In violation of the endocrine function of the
pancreas
The phases of desease:
-exacerbation, -remission .
complication
THE CLINIC
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The clinical picture of chronic pancreatitis is leading :
pain syndrome
dyspeptic syndrome
Syndrome of the external secretory pancreatic
insufficiency and
its related syndromes of
maldygestion and malabsorption with progressive
loss of body weight
Endocrine
insufficiency
syndrome(pancreatic
diabetes)
asthenic-neurotic syndrome
Duration of chronic pancreatitis
is divided into 3 phases :
 initial stage(1-5 years) – the most frequent
manifestation is the pain
expanded clinical picture (5-10 years) –
main manifestation is the pain, the signs of
exocrine insufficiencyі, the elements of
incretory insufficiency (hyperglycemia,
hypoglycemia)
Remission of active pathological process
or development of complications.
THE CLINIC
The dyspeptic syndrome
 reduce or loss of appetite ,
 salivation ,
 nausea ,
 vomiting , that does not bring
relief
 abdominal bloating ,
 Disorders
of
defecation
(prevalence
diarrhea
or
change
diarrhea
with
constipation ).
CLINIC
Exogenous deficiency syndrome  -"pancreatic "
diarrhea,creatorea,
steatorea.
 the loss of body weight with a
development of osteoporosis (the bone
pain), as a result of excessive removing
of calcium and deficiency of vitamin D.
The clinical course
 Chronic recurrent pancreatitis
— the most frequent form for which
is characterized by bouts of painful crises, that combined with
increasing levels of pancreatic enzymes in the blood and urine, and
sometimes with jaundice . in the phase of remission can persist
dyspeptic syndrome.
 Painful form—is characterized by constant dull pain in the left upper
quadrant and by laboratory data, that confirm the diagnosis of
pancreatitis (a history of data transferred pancreonecrosis).
 Latent form— is characterized by painless course. The primary are
dyspeptic syndrome and a fact of exocrine insufficiency of pancreas.
 Psevdotumorz form— is characterized by combination of jaundice with
disorders of internal and the external exocrine function of pancreas.
Often occurs clinically as cancer of head of pancreas and correct
diagnosis is established only after surgery.
Laboratory diagnostics :
 1. Complete blood count :
25% of patients have a leukocytosis and ESR acceleration.
 2. The results of determine the activity of pancreatic
enzymes (amylase, lipase, trypsin in the blood and urine—
there is an increase of their activity when the desease is
exacerbated).
85-90% of patients the creased activity of α-amylase for 1day of disease, 60-70% of patients for 2-day of disease, 4050% for 3-day of disease. Under normal numbers of amylase
it possible to use exercise testing : investigate amylase at
an altitude of pain, after endoscopy, X-ray.
Diagnosis of exocrine
pancreatic insufficiency
METHODS:
 for the introduction of secretin while preserving
exocrine pancreatic function the amount of
secretionу is increased
,the content of
bicarbonate, in response to input the
pankreozymin the content of enzymes is
increased.
 In
severe
exocrine
insufficiency
the
pathological changes of the test observed in
85-90% of cases.
Diagnosis of exocrine
pancreatic insufficiency
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1. the research of activity in feces of elastase-1.
2. Breathing tests
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. Breathing tests - during exogenous failure the production of lipase is
reduced or, it is absent , and therefore the triglycerides are split a lesser
extent and constitute less of 13СО2.
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amylase respiratory AP the corn-starch test – the total concentration AP at
the end of the 4-o'clock research is less than 10 %, that indicating the
presence of deficiency of pancreatic amylase
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Protein breathing with IZS- noticed egg white - in patients with chronic
pancreatitis the total concentration of 13СО2 through 6 hours 2-3 times
lower than in healthy persons, indicating a decrease in activity of trypsin.
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3. Koprogram - high content of muscular fibers to digest fiber and neutral fat
STANDARD OF noninvasive
diagnosis of chronic pancreatitis
Degrees of severity of
external secretory of
pancreatic
insufficiency
Activity of fecal pancreatic
elastase -1
mild
150-200 mg / g
moderate
100 - 150 mg / g
severe
less than 100 mg / g
Ultrasound investigation.
Chronic pancreatitis
а) calcificates in the head of
pancreas;
б) Virsungov’s duct;
в) pseudocyst of pancreas;
г) increase of the head of
pancreas;
д) spleen vein
Ultrasound investigation. Chronic
calcified pancreatitis а) virsungolithiasis
б) dilated Virsungov’s duct.
 Plain X-ray of
abdomen
showing
calcific
pancreatitis
Instrumental diagnostics
 computed tomography : the diagnostic
information similar to ultrasound, is indicated
for suspected tumors and cysts of the
pancreas;
 magnetically-resonance tomography :
helps to visualize normal and pathologically
altered pancreatic duct, used for the
diagnosis of pancreatic duct stones;
CT scan with central
Endoscopic ultrasound pseudocyst
overcomes some of the
visualisation
problems and is
probably more sensitive
and specific.
CT has a sensitivity of up
to 90% and specificity of
the same order.
It will detect variation in
ductal diameter, and
ectatic side branches,
changes in the
parenchyma, calcification
and complications of
chronic
pancreatitis such as
pseudocyst formation
An endoscopic ultrasound image
demonstrating a dilated pancreatic duct
(markers) in a patient with advanced
chronic pancreatitis
An endoscopic
ultrasound, which allows a highly
detailed examination of the
pancreatic parenchyma and
pancreatic duct, routinely
detects abnormalities in patients
with chronic pancreatitis (high
sensitivity),
but the specificity and
reproducibility of the test requires
further study
Instrumental diagnostics
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Endoscopic retrograde cholangyiopankreato
graphy: reveals impaired patency of the main
and secondary ducts. “Chain of lakes" is a
classic symptom of chronic pancreatitis
(areas of constriction and expansion of
virsunhov ducts). It is also possible the
segmental or total obstruction of a ductal
system of pancreas.
biopsy of pancreas.
An endoscopic retrograde
cholangiopancreatography image
demonstrating minimal pancreatic duct
abnormalities in a patient with painful
small-duct chronic pancreatitis.
An endoscopic retrograde
cholangiopancreatography image
demonstrating massive pancreatic duct
dilatation in a patient with bigduct
chronic pancreatitis.
COMPLICATIONS :
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 chronic duodenal
obstruction
 pancreatic ascites
 erosive esophagitis
 gastrointestinal bleeding
 abdominal angina
 pancreatic abscess ;
 reactive arthritis
 pancreonecrosis ;
 reactive pleurisy ;
 infectious complications
 reactive hepatitis ;
(inflammatory infiltrates ,
suppurative cholangitis , septic  anemia .
diabetes mellitus type II ;
pancreas cancer ;
obstructive jaundice ;
pancreatic coma .
cysts and pseudocysts of
the pancreas
conditions , peritonitis)
The differential diagnosis
 Chronic cholecystitis ;
 Chronic gastroduodenitis ;
 Ulcer disease ;
 Cronic hepatitis ;
 Bile gallstones disease ;
 Pancreas cancer ;
 Left-sided renal colic ;
 Angina pectoris .
Treatment of chronic pancreatitis
Main principles :
 1. Dietary meal (№5)
 2. Creating functional resting of pancreas
 3. Elimination pain syndrome
 4. Substitution therapy of exocrine enzyme
deficiency
 5. Elimination of duodenostasis , athetoid
biliary of disorders , pancreatic duct
 6. Anti-inflammatory therapy
 7. Correction endocrine function of the
pancreas
 8. Symptomatic therapy
Treatment
 Diet № 5.Avoiding alcohol
 Elimination of pain syndrome:
- non-narcotic analgic drugs (analginum 50%
2-5 ml intramuscularly 2-3 times a day, baralginum
5ml intramuse)
-narcotic analgic drugs(promedol 1 ml intramusc. 1-3
times a day)
-M-cholinolytics (atropine 0,1% intramusc.,platyfilin
0,2%1-2ml subcutaneously or intramusc.1-2t.a
day,gastrocepini 50mg 3 times a day)
-Myotropic antispasmodics drugs (papaverin 2% 2 mi,
no-shpa 2% 2 ml intramusc - 2 times a day, mabeverin
(duspatalin) 200mg 2 times a day);
Treatment
 -antisecretory drugs (H2 blocking
(famotydyn,kvamatel 20mg 2 times a
day);omeprazol 20mg,lanzoprazol 30
mg,pantoprazol 40 mg,rabeprazol
20mg,ezomehrazol 20mg-2 times a day;
somatostatyn(sandostatyn);central action
drugs(dalargin 0,001 mg intraven.or
intramus. 2 times a day)
Treatment
 Therapy of outersecretory enzyme
deficiency
(penkreatin,kreon,pangrol,mezym)
 Elimination of duodenal statis,dyskinetic
disorders of biliferous and pancreatic
ducts(domperydon(motilium)10mg 3
times a day),cyzaprid) perystil )10 mg 3
times a day);
Treatment
 :Often the acute of CP is accompanied by
peripancreatitis, and also by cholangitis.
 in such cases, used the antibiotics :
augmentun 0,625-1,25 g 2-3 times a day
intramusc. (7-10 days); cefobid 1-2 g 2 times a
day intramusc (7-10 days); dorsycyclinпо 0,1 g
1-2 times a day (6-8 days); for inefficiencyabaktal(pefloksacyn) 0,4 g 2 times a day ,
symamed 0,5 g 1 times a day .
Treatment
 In cases of edema of the pancreas:
Anti-enzyme therapy(kontrykal-1-2 times a
day 20000un;gordoks-100000 un.during
5-7 days)
-correction of endocrine function
-correction of dysbioz: antiseptic drugs
(nifuroksazyd – 200 mg 4 times a day,
furazolidon – 100mg 4 times a day);
probiotics (bifi-form – 1-2 caps. 2 times a
day, symbiter – 1-2 doses before sleep)
Thank you for your attention!