Transcript LECTURE: Diseases of pancreas. Acute and chronic pancreatitis, its

LECTURE:
Diseases of pancreas. Acute and
chronic pancreatitis, its
complications. Etiology,
pathogenesis, clinic and treatment.
Author – reader R.Ya. Kushnir
The basis of disease of pancreas is
degenerative-inflammatory
processes which are considered to
be acute pancreatitis, the so called
autolysis tissue by its own
enzymes.
“Starting” factors of origin of cholelithiasis disease
-an alcohol and food overloads (fat and irritating
products);
- traumas of pancreas;
-separate infectious diseases (parotitis,
mononucleosis)
- infection of bilious ways;
- in 10–20 % of patients the reason of acute
pancreatitis remains unknown (cryptogenic form).
Classification
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(V All-russian convention of surgeons, 1978)
I. Clinico-anatomy forms:
1. Arching form.
2. Fatty pancreatonecrosis.
3. Hemorrhagic pancreatonecrosis.
II. Prevalence of necrosis:
1. Local (focus) damage of gland.
2. Subtotal damage of gland.
3. Total damage of gland.
Classification
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III. Ran across: abortive, progressive.
IV. Periods of disease:
1. Period of hemodynamic violations and
pancreatogenic shock.
2. Period of functional insufficiency of
parenchymatous organs.
3. Period of degenerative and festering
complications.
Clinical passing
• Pain, vomiting and phenomena of
dynamic intestinal obstruction are
considered the most
characteristic signs of acute
pancreatitis.
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Symptoms
The Mondor’s symptom is violet spots on face
and trunk.
The Lagermph's symptom is acute cyanosys of
person.
The Halsted's symptom is cyanosys of abdominal
skin.
The Gray's symptom is cyanosys of lateral walls
of abdomen.
The Kullen's symptom is the yellow colouring of
skin near a belly-button.
Symptoms
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The Korte's symptom is painful resistance as a lumbar bar
in a epigastric area on 6–7 cm higher belly-button.
The Voskresynskyy's symptom is absence of pulsation of
abdominal aorta in an epigastric area.
The Mayo-Robson's symptom is feeling of pain at
pressure by fingers in the left costal-vertebral corner.
The Rozdolskyy's symptom — painfulness at percussion
above pancreas.
The Blumberg's symptom — in patients with acute
pancreatitis more frequently is low-grade.
Clinical passing of
pancreatonecrosis
• The I period (hemodynamic violations
and pancreatogenic shock)
• The II period (insufficiency of
parenchymatous organs)
• The III period (postnecrosis dystrophic
and festering complications)
Variants of clinical passing and
complications
• Clinical passing of disease can be:
• Abortive;
• Slowly;
• Quickly progressive
Diagnosis program
• 1. Anamnesis and physical methods of
inspection.
• 2. General analysis of blood and urine.
• 3. Biochemical blood test (amylase,
bilirubin, sugar).
• 4. Analysis of urine on diastase.
• 5. Sonography.
Diagnosis program
• 6. Computer tomography.
• 7. Cholecystocholangiography.
• 8. Endoscopic retrograde
cholangiopancreatography.
• 9. Laparoscopy.
• 10. Laparocentesis.
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Surgical treatment
Cholecystectomy
Transduodenal sphincteroplasty
Omentopancreatopexy.
Abdominisation of pancreas.
Sequestrectomy
Necrectomy
The resection of pancreas
Pancreatectomy
Chronic pancreatitis
• Chronic pancreatitis is a
progressive inflammation of
pancreas with the periodic
acutening and remission.
Classification
(by O.O. Shalimov)
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1. Chronic fibrous pancreatitis without
violation of patency of main pancreatic duct.
2. Chronic fibrous pancreatitis with violation
of patency of main pancreatic duct, dilatated
ducts of pancreas and hypertension of
pancreatic juice.
3. Chronic fibrous-degenerative pancreatitis.
Classification
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Taking into account clinical passing of chronic pancreatitis,
classification of O.O. Shelagurov (1970) can have some
changes. Such forms are selected:
1. Chronic recurrent pancreatitis.
2. Chronic pain pancreatitis.
3. Chronic painless (latent) pancreatitis.
4. Chronic pseudo tumor-like pancreatitis.
5. Chronic cholecystocholangiopancreatitis
(cholangiogenic pancreatitis).
6. Chronic indurative pancreatitis
Variants of clinical passing
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Chronic recurrent pancreatitis.
Chronic pain pancreatitis.
Chronic painless (latent) pancreatitis.
Chronic pseudo tumor-like pancreatitis.
Chronic cholangiogenic pancreatitis.
Chronic indurative pancreatitis
Diagnosis program
• 1. Anamnesis and physical methods of
inspection.
• 2. General analysis of blood.
• 3. Biochemical blood test (amylase,
bilirubin, sugar).
• 4. Analysis of urine on diastase.
• 5. Coprograma.
Diagnosis program
• 6. Sonography.
• 7. Relaxation duodenogram.
• 8. Cholecystocholangiography.
• 9. Retrograde
cholangiopancreatography.
• 10. Computer tomography.
Surgical methods of treatment
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Operative treatment is done in case of:
1) calcinosis pancreas with the expressed
pain syndrome;
2) violation of patency of duct of pancreas;
3) presence of cyst or fistula of resistance to
conservative therapy during 2–4 months;
4) mechanical icterus on soil of tubular
stenosis of distal part of general bilious duct;
Surgical methods of treatment
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5) compression and thrombosis of portal vein;
6) gallstone disease complicated by chronic
pancreatitis;
7) ulcerous disease of stomach and duodenum
complicated by secondary pancreatitis;
8) duodenostasis, complicated by chronic
pancreatitis;
9) impossibility of exception to operation tumors
or violations of arterial circulation of blood of
pancreas
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Cysts of pancreas
Cyst of pancreas is a cavity, filled by liquid
(pancreatic juice, exudation, pus), intimately
soldered with head, body or tail of organ, is
limited by capsule, which has epithelium on
internal surface.
Pseudocyst (unreal cyst) is a cavity in
pancreas which appears as a result of its
destruction, limited by capsule, that does not
have epithelium on internal surface.
Classification
(by A.N. Bakulev and V.V. Vinogradov, 1952)
• I. Innate cysts of pancreas:
• 1. Dermoid cysts.
• 2. Teratoid cysts.
• 3. Innate adenomas.
• 4. Fibrocystic degeneration.
• 5. Polycystic degeneration.
Classification
• II. Inflammatory cysts:
• 1. Pseudocysts.
• 2. Retention cysts.
• III. Traumatic cysts:
• 1. As a result of direct damage of gland.
• 2. As a result of indirect damage of
gland.
Classification
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IV. Parasite cysts:
1. Echinococcosis glands.
2. Cysticercosis glands.
V. Neoplasty cysts:
1. Cyst-adenoma.
2. Cyst-adenocarcinoma.
3. Cavernous hemangioma.
4. Cystic epithelioma.
Stages of forming of pseudocyst
• I stage (1–1,5 months last) — in the
center of inflammatory process the
cavity of disintegration, which takes
surrounding tissue, appears in an
omentum bag.
• The II stage (2–3 months) is
characterized by the beginning of
forming of capsule of pseudocyst. Cyst
is magnificent, unformed, acute
inflammatory phenomena calms down.
Stages of forming of pseudocyst
• The III stage (3–12 months) is
completion of forming of capsule of
pseudocyst. Last accretes with
surrounding organs.
• The IV stage (begins an in year from the
origin of cyst) is a separated cyst. The
cyst is mobile, easily selected from
connections with surrounding organs.
Diagnosis program
• 1. Anamnesis.
• 2. Biochemical blood test (amylase,
sugar, bilirubin).
• 3. Analysis of urine on diastase.
• 4. Coprograma.
Diagnosis program
• 5. Sonography.
• 6. Contrasting sciagraphy of stomach
and duodenum (relaxation
duodenography).
• 7. Retrograde
pancreatocholangiography.
• 8. Computer tomography.
Choice of treatment method
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On the I stage operation is not used;
On the II stage it is used at suppuration of
pseudocyst (external draining of cyst);
On the III — internal draining of cyst is used.
Marsupialization (opening and sewing down
of cyst to the parietal peritoneum and skin)
is used infrequently;
Choice of treatment method
• On the IV stage external and internal
draining of cyst and radical operations
are applied:
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a) enucleation of cysts (executed very
rarely);
b) distal resection of pancreas with a
cyst.