Pancreatitis: Modern methods of treatment and prevention

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Pancreatitis: Modern methods of treatment and prevention

I. Definition and classification of pancreatitis

Pancreatitis is an inflammatory disease of the pancreas, characterized by autolysis (self -digestion) of the gland tissue with enzymes, which are usually activated in the duodenum. This can lead to damage to the gland itself, surrounding tissues and even other organs. The severity of pancreatitis varies from a slight, self -caping shape to severe, life -threatening.

The classification of pancreatitis is based on various criteria, including the course, etiology and severity. The main classifications include:

• With the flow:
  • Acute pancreatitis: Sudden inflammation of the pancreas. It is usually allowed after eliminating the provoking factor. It is characterized by sudden, severe abdominal pain.
  • Chronic pancreatitis: Progressive inflammation of the pancreas, leading to irreversible structural changes and impaired its functions. It is characterized by recurrent episodes of pain or constant pain, and can also lead to insufficiency of exocrine and endocrine functions of the pancreatic gland (digestive and diabetes).
• By etiology (reason):
  • Biliary pancreatitis: It is caused by bile stones that block the pancreatic duct. This is the most common cause of acute pancreatitis.
  • Alcoholic pancreatitis: It is caused by excessive alcohol consumption. This is the most common cause of chronic pancreatitis.
  • Hyperyglyceridemic pancreatitis: It is caused by a high level of triglycerides in the blood.
  • Medicinal pancreatitis: It is caused by certain drugs.
  • Idiopathic pancreatitis: The reason is not established.
  • Autoimmune pancreatitis: It is caused by autoimmune processes in which the immune system attacks the pancreas.
  • Hereditary pancreatitis: Caused by genetic mutations.
  • Post-Erchpg Pancreatitis: It occurs after endoscopic retrograde cholangiopancreatography (ERCP).
• In gravity (according to the revised Atlanta classification):
  • Light pancreatitis: Lack of organ failure and local complications.
  • Moderately severe pancreatitis: The presence of transient organ failure (permitted within 48 hours) or local/systemic complications.
  • Severe pancreatitis: The presence of a persistent organ failure (more than 48 hours).

II. Etiology and risk factors of pancreatitis

As mentioned above, the most common causes of pancreatitis are bile stones and alcohol abuse. However, there are many other factors that can contribute to the development of this disease.

• Gallstones: The gall stones that block the common bile duct can cause the casting of bile to the pancreatic duct, leading to inflammation.
• Alcohol: Chronic abuse of alcohol is the main factor in the risk of chronic pancreatitis. The mechanism with which alcohol causes pancreatitis is not fully studied, but it is believed that it includes damage to the pancreatic cells and a violation of the outflow of pancreatic juice.
• Hyperyglyceridemia: A very high level of blood triglycerides (usually> 1000 mg/DL) can cause pancreatitis.
• Medicines: Some drugs, such as thiazide diuretics, azathioprine, 6-mercaptopurin, valproic acid, estrogen and some antibiotics, were associated with the development of pancreatitis.
• Trauma life: Trauma in the abdomen, especially after operations on the abdominal organs, can damage the pancreas and lead to pancreatitis.
• Endoscopic retrograde cholangiopancreatography (ERCP): This procedure, used for the diagnosis and treatment of diseases of the bile ducts and pancreatic ducts, can in rare cases cause pancreatitis.
• Infections: Some infections, such as a pig, cytomegalovirus (CMV) and Koksaki virus, can cause pancreatitis.
• Autoimmune diseases: Autoimmune pancreatitis is a rare form of pancreatitis, in which the immune system attacks the pancreas. It is often associated with other autoimmune diseases such as inflammatory intestinal diseases and shegren syndrome.
• Genetic factors: Hereditary pancreatitis is caused by genetic mutations that affect the function of the pancreas. The most common genes associated with hereditary pancreatitis include PRSS1, Spink1 and CFTR.
• Cystic fibrosis (cystic fibrosis): This genetic disease that affects the lungs and digestive systems can lead to pancreatic insufficiency and pancreatitis.
• Pancreatic tumors: Pancreatic tumors, especially those that block the duct of the pancreas, can cause pancreatitis.
• Idiopathic pancreatitis: In some cases, the cause of pancreatitis remains unknown.

III. Pathophysiology of pancreatitis

Pathophysiology of pancreatitis is a complex process that includes premature activation of pancreatic enzymes in the pancreas, which leads to autolysis (self -digestion) of the gland tissue. Normally, pancreatic enzymes, such as tripsin, chiripripsin, amylase and lipase, are synthesized in the pancreas in the form of inactive wintering and activated only in the duodenum.

With pancreatitis, premature activation of these enzymes occurs inside the pancreas. Activated Tripsin plays a key role in this process, as it activates other pancreatic enzymes, launching a cascade of inflammatory reactions.

Several factors can contribute to the premature activation of pancreatic enzymes, including:

• Blocking the pancreatic duct: Blocking the pancreatic duct, for example, with a gall stone or tumor, leads to an increase in pressure inside the duct and can cause damage to acinar cells (cells that produce pancreatic enzymes). This damage can lead to the release of pancreatic enzymes and their premature activation.
• Direct toxic effects on acinar cells: Alcohol and some drugs can have a direct toxic effect on acinar cells, causing damage and release of pancreatic enzymes.
• Violation of regulatory mechanisms: Normally, there are mechanisms that prevent premature activation of pancreatic enzymes. For example, Tripsin inhibitor (Spink1) neutralizes a thripsin, which was prematurely activated. Violation of these regulatory mechanisms can lead to pancreatitis.

After activation, pancreatic enzymes begin to digest pancreatic tissue, causing inflammation, swelling, hemorrhage and necrosis. Inflammation can also spread to the surrounding tissues and organs, causing systemic complications.

The main pathophysiological processes for pancreatitis include:

• Inflammation: Activated pancreatic enzymes and tissue decay products cause an inflammatory response characterized by leukocytic infiltration, the release of inflammation mediators (such as cytokines) and an increase in blood vessels permeability.
• Edema: Inflammation and increased permeability of blood vessels lead to swelling of the pancreas and surrounding tissues.
• Necrosis: Under the influence of pancreatic enzymes, necrosis (death) of acinar cells and other pancreatic cells occurs. Necrosis can be focal or vast, depending on the severity of pancreatitis.
• Hemorrhage: Damage to the vessels of the pancreas can lead to hemorrhage in the tissue of the gland and surrounding tissues.
• Formation of a pseudocyst: Pseudocysts are clusters surrounded by a fibrous capsule, which can form after acute pancreatitis or with chronic pancreatitis. They contain pancreatic enzymes, liquid and the remains of destroyed tissue.
• The development of complications: Pancreatitis can lead to various complications, such as infection of necrotic tissue, pancreatic abscess, pseudocysts, impaired lung function, kidneys and cardiovascular system.

IV. Clinical manifestations of pancreatitis

The clinical manifestations of pancreatitis vary depending on the form (acute or chronic) and the severity of the disease.

A. Acute pancreatitis:

• Abdominal pain: This is the most common symptom. The pain is usually severe, constant and localized in the upper abdomen, often radiates into the back. The pain can be intensified in the lying on the back and weaken when tilted forward or in the knee-elbow position.
• Nausea and vomiting: These symptoms often accompany abdominal pain. Vomiting may be stubborn and not bring relief.
• Bloating: The stomach can be sophisticated on palpation.
• Fever: An increase in body temperature may indicate an inflammatory process.
• Tachycardia: Charp heartbeat.
• Hypotension: Decrease in blood pressure (in severe cases).
• Jaundice: Yellowing of the skin and sclera (with biliary pancreatitis).
• Signs of dehydration: Dryness of the skin and mucous membranes, decrease in diuresis.
• In severe cases:
  • Respiratory failure: Due to the development of acute respiratory distress syndrome (ARDS).
  • Renal failure: Due to a decrease in blood flow in the kidneys.
  • Shock: Due to hypovolemia (decreasing the volume of circulating blood) and systemic inflammatory reaction.

B. Chronic pancreatitis:

• Abdominal pain: The pain can be constant or recurrent. It is often localized in the upper abdomen and can radiate to the back. The pain can be stupid, aching or acute, and its intensity can vary.
• Steatorrhea: A fat, fetid chair that is difficult to wash off. This is due to a violation of the digestion of fats due to the failure of the pancreatic lipase.
• Weight loss: Due to malabsorption (violations of absorption) of nutrients.
• Diabetes: Chronic inflammation of the pancreas can lead to damage to insulin-producing cells (beta cells), which leads to the development of diabetes.
• Nausea and vomiting: Can occur after eating.
• Bloating: Often found.
• Weakness and fatigue: Due to malabsorption and deficiency of vitamins.
• Jaundice: It can occur with obstruction of the bile ducts.
• Pseudo -vsists: They can cause pain, discomfort and obstruction of neighboring organs.

V. Diagnosis of pancreatitis

Diagnosis of pancreatitis is based on a combination of clinical data, laboratory studies and visualization methods.

A. Laboratory research:

• Amylase blood serum: The level of amylase is usually significantly increased in acute pancreatitis (3-5 times higher than normal). However, the level of amylase can be normal for chronic pancreatitis or with very severe acute pancreatitis, when the pancreas is severely damaged.
• Blood serum lipase: Lipase is considered a more specific pancreatitis marker than amylase. Its level also increases with acute pancreatitis and remains increased longer than amylase.
• General blood test (UAC): It can identify leukocytosis (an increase in the number of leukocytes), which indicates an inflammatory process.
• Biochemical blood test: It can reveal an increase in glucose, bilirubin, alkaline phosphatase and transaminase (ALT and AST).
• Blood serum triglycerides: It should be determined to exclude hyperthyglyceridemic pancreatitis.
• Calcium blood serum: It should be controlled, since hypocalcemia can develop with severe pancreatitis.
• Functional liver tests: Used to evaluate the function of the liver and bile ducts.
• Gaza of arterial blood: Used to assess oxygenation and acid-base balance, especially in patients with respiratory failure.
• Inflammation markers: C-reactive protein (CRC) and Prokalcitonin (PCT) can be used to assess the severity of inflammation and risk of developing infectious complications.
• Calais analysis for elastasis-1: Used to evaluate the exocrine function of the pancreas in chronic pancreatitis. The low level of elastasis-1 indicates pancreatic failure.
• Test for stimulating secretin: Used to evaluate the exocrine function of the pancreas.

B. Visualization methods:

• Ultrasound examination (ultrasound) of the abdominal cavity: It can be used to detect bile stones, expand the bile ducts and assess the size and structure of the pancreas. However, ultrasound may be difficult due to gases in the intestines.
• Computed tomography (CT) of the abdominal cavity with contrast: This is the most informative method of visualization for the diagnosis of acute pancreatitis and evaluate its severity. CT can identify edema, necrosis, hemorrhage, pseudocysts and other complications.
• Magnetic resonance imaging (MRI) of the abdominal cavity with cholangiopancreatography (MRHPG): MRHPG is a non -invasive method that allows you to visualize the bile ducts and a pancreatic duct. MRI can be used to diagnose chronic pancreatitis, detect a pseudocyst, strictur and other anomalies.
• Endoscopic retrograde cholangiopancreatography (ERCP): This is an invasive procedure that is used for the diagnosis and treatment of diseases of the bile ducts and pancreatic ducts. ERCP can be used to remove bile stones, installation of stents and conduct a biopsy. However, ERCPG is associated with the risk of pancreatitis, therefore it should be used only in cases where other methods do not allow the diagnosis or treatment.
• Endoscopic ultrasound (eusy): This is a procedure in which the ultrasonic sensor is attached to the endoscope and enters into the esophagus or stomach. Euzi allows you to get a more detailed image of the pancreas and surrounding tissues than ordinary ultrasound. Eusta can be used to diagnose chronic pancreatitis, detect small tumors and conduct a biopsy.

VI. Treatment of pancreatitis

Treatment of pancreatitis depends on the form (acute or chronic) and the severity of the disease.

A. Treatment of acute pancreatitis:

The purpose of the treatment of acute pancreatitis is to maintain organs, relief pain and prevent complications.

• Conservative treatment:
  • Infusion Therapy: Intravenous administration of fluid to restore the volume of circulating blood and maintain hydration.
  • Anesthesia: Opioid analgesics (for example, morphine, fentalign) are usually used to relieve pain.
  • Starvation: Food and liquid are administered intravenously to give the pancreas to rest.
  • Nutrition: After the acute inflammation subsides, they gradually begin to administer light foods with a low fat content. In severe cases, parenteral nutrition (intravenous administration of nutrients) may be required.
  • Proton pump inhibitors (IPP): Can be used to reduce the secretion of gastric juice and reduce pancreatic stimulation.
  • Antibiotics: They are prescribed only in the presence of signs of infection (for example, necrotic pancreatic tissue).
  • Oxygen therapy: In the presence of respiratory failure.
• Endoscopic treatment:
  • Erchpg with papillosfinchesterotomy: It can be used to remove bile stones from the common bile duct with biliary pancreatitis.
  • Drainage pseudo -Kistyst: Pseudocysts that cause symptoms can be drained endoscopically or surgically.
• Surgical treatment:
  • Necrotomy: Removal of necrotic pancreatic tissue with infected necrosis.
  • Abscess drainage: Drainage of pancreatic abscesses.

B. Treatment of chronic pancreatitis:

The purpose of the treatment of chronic pancreatitis is to relieve pain, improve digestion and prevent complications.

• Conservative treatment:
  • Anesthesia: Analgesics (non -steroidal anti -inflammatory drugs, opioids) are used to relieve pain. In some cases, tricyclic antidepressants or anticonvulsants to treat neuropathic pain may be required.
  • Enzyme drugs: Pancreatic enzymes (lipase, amylase, protease) are accepted with food to improve fat digestion and reduce steatore.
  • Diet: A low fat diet, frequent meals in small portions and the rejection of alcohol are recommended.
  • Vitamin additives: Vitamins A, D, E and K can be added to compensate for malliabsorption.
  • Treatment of diabetes: With the development of diabetes, insulin therapy or taking oral sugar -lowering drugs is required.
• Endoscopic treatment:
  • Dilatation and stenting of pancreatic duct strictures: Pancreatic duct strictures can be expanded and stent to improve the outflow of pancreatic juice.
  • Removing stones from a pancreatic duct: The stones in the pancreatic duct can be removed endoscopically.
  • Drainage pseudo -Kistyst: Pseudocysts that cause symptoms can be drained endoscopically.
• Surgical treatment:
  • Freya operation: Removing part of the pancreatic head with drainage of the pancreatic duct.
  • Operation Begera: Removing the pancreatic head with the preservation of the duodenum.
  • Pancreatectomy: Removal of part or the entire pancreas. It is considered in severe cases when other treatment methods are ineffective.
  • Neurolism of the wanderings: It can be used to relieve pain.

VII. Complications of pancreatitis

Pancreatitis can lead to various complications that can be local (in the pancreas) or systemic (other organs that affect).

A. Local complications:

• Pseudo -vsists: Cloudy fluids surrounded by a fibrous capsule. They can cause pain, discomfort, obstruction of neighboring organs and infection.
• Infected necrosis: Infection of the necrotic pancreatic tissue. Requires antibiotics and surgical or endoscopic drainage.
• Pancreatic abscess: The cluster of pus in the pancreas. Requires drainage.
• Flood education: Anomal channels connecting the pancreas to the skin or other organs.
• Slezer -free thrombosis: It can lead to splenomegaly (an increase in the spleen) and portal hypertension.
• Duodenal obstruction: Squeezing the duodenum due to edema, pseudocysts or fibrosis.

B. System complications:

• Acute respiratory distress syndrome (ARDS): Severe lung damage, characterized by edema of the lungs and respiratory failure.
• Renal failure: Due to a decrease in blood flow in the kidneys and inflammatory processes.
• Hypocalcemia: Reducing the level of calcium in the blood.
• Hyperglycemia: Increasing blood glucose.
• Shock: Due to hypovolemia and systemic inflammatory reaction.
• Polyorgan failure: The defeat of several organs (lungs, kidneys, cardiovascular system).
• Encephalopathy: Disruption of the function of the brain.
• Pancreatic ascites: Closing fluid in the abdominal cavity.
• Death: In severe cases, pancreatitis can lead to death.

VIII. Pancreatitis Prevention

Prevention of pancreatitis is aimed at eliminating risk factors and preventing repeated episodes of the disease.

• Refusal of alcohol: The most important factor in the prevention of alcoholic pancreatitis.
• Treatment of gallstone disease: Removal of the gallbladder (cholecystectomy) is recommended for patients with gallstone disease, especially if they suffered an episode of biliary pancreatitis.
• Triglycerides level control: Patients with hypertriglyceridemia should follow a low fat diet and take medications to reduce triglycerides.
• Cautious use of drugs: Medicines that can cause pancreatitis, or take them with caution, should be avoided.
• Healthy lifestyle: Maintaining a healthy weight, balanced nutrition and regular physical exercises can reduce the risk of pancreatitis.
• Timely treatment of diseases associated with pancreatitis: For example, autoimmune diseases or cystic fibrosis.
• Genetic counseling: Patients with hereditary pancreatitis are recommended genetic counseling.
• Avoid abdominal injuries: Avoid abdominal injuries, especially after operations on the abdominal organs.
• Adequate hydration: Providing sufficient fluid consumption.
• Regular medical examinations: To identify and treat diseases in the early stages.

IX. New methods of treatment with pancreatitis

Despite significant successes in the treatment of pancreatitis, the research and development of new methods continues to improve the results of treatment and reduce the frequency of complications.

• Target therapy: The development of drugs aimed at specific molecular targets participating in the pathogenesis of pancreatitis. For example, tripsin inhibitors and other anti -inflammatory drugs are studied.
• Immunomodulating therapy: The use of drugs that modulate the immune system to reduce inflammation and damage to the pancreas.
• Regenerative medicine: Studies are aimed at restoring damaged pancreatic tissue using stem cells and other methods.
• Minimum invasive surgical techniques: Development of new minimally invasive surgical techniques for the treatment of complications of pancreatitis, such as pseudocysts and infected necrosis.
• Artificial pancreas: The development of devices that automatically control the level of glucose in the blood and administer insulin can improve diabetes in patients with chronic pancreatitis.
• Nutritional support: Development of new nutritional support strategies to improve digestion and assimilation of nutrients in patients with pancreatic failure.
• Genetic therapy: In the future, genetic therapy can be used to treat hereditary pancreatitis by correcting genetic defects.
• Using nanotechnologies: Nanoparticles can be used to deliver drugs directly to the pancreas, which can increase the effectiveness of treatment and reduce side effects.
• Development of new biomarkers: The identification of new biomarkers that can help in the early diagnosis of pancreatitis and the prediction of its severity.
• Using artificial intelligence (AI): AI can be used to analyze large volumes of data and develop individualized approaches to the treatment of pancreatitis.