Pancreatitis: myths and reality of treatment forever

Pancreatitis: myths and reality of treatment forever

I. Understanding pancreatitis: anatomy, physiology and etiology

IA Anatomy of the pancreas: key player in digestion and endocrinology

The pancreas is a vital organ located deep in the abdominal cavity behind the stomach. It can be conditionally divided into three main parts: the head, body and tail. The pancreatic head tightly adjacent to the duodenum (the beginning of the small intestine), and the tail extends in the direction of the spleen.

• Structure: Under the microscope, the pancreas consists of two main types of fabric: exocrine and endocrine.

  • Exocrine fabric: It makes up about 95% of the mass of the gland and consists of acinus – small accumulations of cells that produce pancreatic juice. This juice contains the enzymes necessary for the splitting of proteins (proteases, such as tripsin and chipripsin), fats (lipase) and carbohydrates (amylase).
  • Endocrine fabric: It makes up the islands of Langerganes – small groups of cells scattered across the gland. These islands produce hormones that regulate blood sugar. The main types of cells in the islands of Langerganes:
    • Alfa cells: Glucagon, hormone, increasing blood sugar is produced.
    • Beta cells: Insulin, a hormone that reduces blood sugar is produced.
    • Delta-cells: Somatostatin, hormone, inhibiting the release of both insulin and glucagon, as well as other hormones are produced.
    • PP cells: Pancreatic polypeptide is performed, which plays a role in the regulation of appetite and intestinal motility.

• Control system: Exocrine cells emit pancreatic juice into small ducts, which merge into larger ducts. These ducts, in turn, are connected to the main pancreatic duct (virtual duct). Virsungs the duct passes through the entire length of the gland and flows into the duodenum along with the common bile duct, forming the muders of the papilla. An additional duct (Santorine Prove) can also exist and fall into the duodenum independently.

IB Puncture Physiology: Double function – digestion and regulation of blood sugar

The functions of the pancreas can be divided into two main categories: exocrine and endocrine.

• Exocrine function (digestion): The pancreas plays a key role in digestion, developing pancreatic juice containing enzymes necessary for the splitting of macronutrients.

  • Enzymes:

    • Amylase: Cloths starch and other complex carbohydrates into simpler sugars.
    • Lipase: He breaks down fats (triglycerides) into fatty acids and glycerin.
    • Proteases (trippsin, chimotrypsin, carboxypeptidase): The proteins are split into peptides and amino acids.

  • Secretation Regulation: The secretion of pancreatic juice is regulated by hormones, such as secretin and cholecystokinin (CCK), which are produced by duodenal cells in response to food from the stomach. Secretin stimulates the release of bicarbonates that neutralize acidic gastric juice entering the duodenum. CCK stimulates the release of enzymes.

• Endocrine function (regulation of blood sugar): The islands of Langerganes of the pancreas produce hormones that are critical to maintain the normal level of blood sugar.

  • Insulin: Reduces blood sugar, stimulating the cells (especially the liver, muscles and adipose tissue) absorb glucose from the blood and use it as a source of energy or stored in the form of glycogen (in the liver and muscles) or fat (in adipose tissue).
  • Glucagon: Increases blood sugar, stimulating the liver to split glycogen into glucose and release it into the blood. It also stimulates gluconeogenesis – the process of glucose formation from other sources, such as amino acids and glycerin.
  • Somatostatin: Inhibits the release of both insulin and glucagon, thereby adjusting the balance between them.
  • Pancreatic polypeptide: He plays a role in the regulation of appetite, intestinal motility and the secretion of gastric juice.

IC etiology of pancreatitis: factors that cause inflammation of the pancreas

Pancreatitis is inflammation of the pancreas. It can be acute (sudden beginning) or chronic (prolonged inflammation, leading to irreversible damage). There are many factors that can cause pancreatitis.

• Gallstone disease: The most common cause of acute pancreatitis. The gall stones can block the general bile duct or veils of the papilla, preventing the outflow of pancreatic juice and causing its accumulation in the pancreas, which leads to autodigestia (self -digesting) of the gland tissue.

• Alcohol abuse: The second most common cause of pancreatitis, especially chronic. Alcohol has a toxic effect on the cells of the pancreas, causing inflammation and damage. The mechanism of this effect is complicated and includes an increase in the viscosity of pancreatic juice, the formation of protein plugs in the ducts, the activation of pancreatic enzymes inside the gland and damage to mitochondria.

• Hyperyglyceridemia: A high level of blood triglycerides (usually above 1000 mg/DL) can cause pancreatitis. Triglycerides are broken down with lipase, and splitting products can be toxic for pancreatic cells.

• Hypercalcemia: A high level of calcium in the blood can cause pancreatitis by stimulating the activation of pancreatic enzymes inside the gland and damaging the cell.

• Trauma: The stupid abdominal injury, surgery on the abdominal cavity or endoscopic retrograde cholangiopancreatography (ERCPG) can damage the pancreas and cause pancreatitis.

• Infections: Some infections, such as a pig, cytomegalovirus (CMV) and Koksaki virus, can cause pancreatitis.

• Medicines: Some drugs, such as azatioprine, mercaptopurin, valproic acid, didanosine, estrogen and tetracycline, can cause pancreatitis as a side effect.

• Autoimmune diseases: Some autoimmune diseases, such as systemic lupus erythematosus (SLE), shegren syndrome and autoimmune pancreatitis, can cause inflammation of the pancreas.

• Genetic factors: Some genetic mutations, such as CFTR mutations (cystic fibrosis), PRSS1 gene (hereditary pancreatitis) and Spink1 gene (tripsin inhibitor), may be predisposed to the development of pancreatitis.

• Idiopathic pancreatitis: In some cases, the cause of pancreatitis remains unknown.

II. Acute pancreatitis: clinical picture, diagnosis and treatment

II.A. Clinical picture of acute pancreatitis: from mild dyspepsia to severe system reaction

Acute pancreatitis is a sudden inflammation of the pancreas. Symptoms can vary from lungs to very severe, depending on the degree of inflammation and the presence of complications.

• Abdominal pain: This is the main symptom of acute pancreatitis. The pain is usually localized in the upper abdomen (epigastrium) and can radiate to the back. The pain is often described as constant, acute or dull, and can be intensified after eating, especially after eating fatty foods.

• Nausea and vomiting: Nausea and vomiting are frequent symptoms of acute pancreatitis. They can be caused by inflammation of the pancreas, irritation of the stomach and intestines, as well as a violation of the motility of the gastrointestinal tract.

• Bloating: Bloating (flatulence) is also often found in acute pancreatitis. It can be caused by a violation of digestion, the accumulation of gases in the intestines and paralytic Ileus (temporary stopping of intestinal motor skills).

• Fever: Light fever (body temperature up to 38 ° C) can be observed with acute pancreatitis. A higher temperature may indicate the presence of infection.

• Far heartbeat (tachycardia): Far heartbeat can be caused by pain, dehydration and systemic inflammatory reaction.

• Reduced blood pressure (hypotension): Reduced blood pressure can be caused by dehydration, blood loss (in severe cases) and a systemic inflammatory reaction.

• Jaundice: Jaundice (yellowing of the skin and sclera of the eyes) can be observed with acute pancreatitis caused by gallstone disease, when the gallstone blocks the overall bile duct.

• Signs of bleeding: In severe cases of acute pancreatitis, bleeding in the abdominal cavity can occur, which manifest in the form of bruises on the sides (symptom of Kullin) and around the navel (symptom of Gray Terner).

• Respiratory failure: In severe cases of acute pancreatitis, acute respiratory distress syndrome (ARDS) may develop, which is characterized by shortness of breathing and low oxygen in the blood.

II.B. Diagnosis of acute pancreatitis: laboratory and instrumental methods

The diagnosis of acute pancreatitis is based on the clinical picture, laboratory data and the results of instrumental research.

• Laboratory research:

  • Amylase blood serum: The level of amylase in the blood serum is usually significantly increased in acute pancreatitis (3 times and higher than normal). However, the level of amylase can be increased in other diseases, such as mumps, diseases of the gall bladder and renal failure.
  • Blood serum lipase: Lipaza is a more specific marker of acute pancreatitis than amylase. The level of lipase in the blood serum is also usually increased in acute pancreatitis.
  • General blood test: A total blood test can show an increased amount of leukocytes (leukocytosis), which indicates inflammation.
  • Biochemical blood test: A biochemical blood test can show an increased level of glucose, lipids (triglycerides), bilirubin and liver enzymes.
  • Electrolytes of blood serum: Electrolytes of blood serum (sodium, potassium, chlorine) can be disturbed in acute pancreatitis.
  • Calcium blood serum: The level of calcium in the blood serum can be low in acute pancreatitis (hypocalcemia).
  • Kidney function: The level of creatinine and urea in the blood serum is evaluated to evaluate the function of the kidneys.

• Instrumental research:

  • Ultrasound examination (ultrasound) of the abdominal cavity: Ultrasound can help detect the gallstones, the expansion of the bile ducts and signs of pancreatic inflammation.
  • Computer tomography (CT) of the abdominal cavity: CT is a more sensitive method than ultrasound, and can help identify signs of pancreatic inflammation, pancreatic necrosis necrosis, fluid accumulation around the pancreas and other complications of acute pancreatitis. CT is usually used to assess the severity of pancreatitis and to detect complications.
  • Magnetic resonance imaging (MRI) of the abdominal cavity: MRI can be used to assess the condition of the pancreas and bile ducts. MRHPG (magnetic resonance cholangiopancreatography) is a specialized MRI, which is used to visualize the bile and pancreatic ducts.
  • Endoscopic retrograde cholangiopancreatography (ERCP): ERCPG is an invasive procedure in which the endoscope is introduced through the mouth into the duodenum. Then, a contrast medium is introduced into the bile and pancreatic ducts, and x -rays are taken. ERCPH can be used to diagnose and treatment diseases of the bile and pancreatic ducts, such as gallstones and strictures. ERCPG is not used routinely to diagnose acute pancreatitis, but can be shown in cases where there is a suspicion of bile ducts by bile stone.

II.C. Treatment of acute pancreatitis: supporting therapy and elimination of the cause

Treatment of acute pancreatitis is aimed at alleviating the symptoms, maintaining the function of organs and eliminating the cause of inflammation.

• Supporting therapy:

  • Starvation: Patients with acute pancreatitis are usually recommended to starve for several days to give the pancreas to rest. Food is usually resumed gradually, starting with liquid food with low fat.
  • Infusion Therapy: Intravenous fluid administration is necessary to replenish the loss of fluid caused by vomiting and diarrhea, and to maintain the normal volume of circulating blood.
  • Anesthesia: Anesthetic drugs, such as opioids (for example, morphine, fentanil), are used to relieve pain.
  • Anti -rate drugs: Anti -rate drugs are used to reduce nausea and vomiting.
  • Proton pump inhibitors (IPP): IPP (for example, omeprazole, pantoprazole) can be prescribed to reduce the acidity of gastric juice and reduce the stimulation of the pancreas.
  • Oxygen therapy: Oxygen therapy may be necessary in cases of respiratory failure.
  • Antibiotics: Antibiotics are prescribed only in cases where there are signs of infection, such as fever, leukocytosis and purulent contents in abscesses.

• Elimination of the reason:

  • Erchpg with the removal of bile stones: If acute pancreatitis is caused by gallstone disease, an ERCP with the removal of bile stones from the common bile duct can be shown. This procedure helps restore the normal outflow of bile and pancreatic juice and prevent further inflammation of the pancreas.
  • Cholecystectomy: After the relief of acute pancreatitis caused by gallstone disease, patients are usually recommended by cholecystectomy (removal of the gallbladder) to prevent repeated attacks of pancreatitis.
  • Continuing alcohol consumption: Patients with acute pancreatitis caused by alcohol abuse must stop drinking alcohol.
  • Treatment of hypertriglyceridemia: Patients with acute pancreatitis caused by hypertriglyceridemia must observe a low fat diet and take drugs that reduce the level of triglycerides (for example, fibrates, omega-3 fatty acids).
  • Treatment of hypercalcemia: Patients with acute pancreatitis caused by hypercalcemia should treat the underlying disease that caused hypercalcemia.

II.D. Complications of acute pancreatitis: from local to system

Acute pancreatitis can lead to various complications that can be either local (in the pancreas) and systemic (affecting other organs and systems).

• Local complications:

  • Peripanceic fluid: Closing fluid around the pancreas. This is a common phenomenon in acute pancreatitis, which is usually resolved independently.
  • Pancreatic pseudokist: The accumulation of liquid, surrounded by a capsule of fibrous tissue. Pseudocysts can form a few weeks after acute pancreatitis. They can be asymptomatic or cause pain, nausea, vomiting and other symptoms. In some cases, pseudocysts can be infected or exploded.
  • Pancreatic abscess: The cluster of pus in the pancreas. Pancreatic abscesses usually develop after infection of necrotic tissue. They can cause fever, pain and other symptoms.
  • Pancreatic necrosis: The death of pancreatic tissue. Necrosis can be sterile (non -infected) or infected. Infected necrosis is a serious complication that requires surgical treatment.
  • Bleeding: Bleeding from the pancreas or surrounding vessels. Bleeding can be caused by vascular erosion by the inflammatory process or the rupture of pseudoenerism.
  • Thrombosis of the gate vein or spleen vein: Thrombosis (the formation of a blood clot) in the gate vein or spleen vein.

• System complications:

  • Acute respiratory distress syndrome (ARDS): A severe lung disease, which is characterized by shortness of breathing and low oxygen in the blood. The ARDS can develop as a result of a systemic inflammatory reaction caused by acute pancreatitis.
  • Renal failure: Reducing the function of the kidneys. Renal failure can be caused by dehydration, hypotension and toxic effects of inflammatory mediators on the kidneys.
  • Cardiovascular failure: Reducing the function of the heart. Cardiovascular deficiency can be caused by hypotension, dehydration and toxic effects of inflammatory mediators on the heart.
  • Disseminized intravascular coagulation (DVS-syndrome): A severe impaired blood coagulation, which can lead to bleeding and thrombosis. DIS-syndrome can develop as a result of a systemic inflammatory reaction caused by acute pancreatitis.
  • Sepsis: Blood infection. Sepsis can develop as a result of infection of necrotic tissue or pancreatic abscesses.
  • Metabolic disorders: Acute pancreatitis can lead to metabolic disorders such as hyperglycemia (increased blood sugar), hypoglycemia (reduced blood sugar) and hypocalcemia (reduced blood calcium).

III. Chronic pancreatitis: progressive damage and irreversible changes

III.A. Clinical picture of chronic pancreatitis: pain, digestive disorder and endocrine dysfunction

Chronic pancreatitis is a progressive inflammatory pancreatic disease, which leads to irreversible structural and functional changes. Symptoms of chronic pancreatitis can be similar to the symptoms of acute pancreatitis, but they are usually more persistent and progress over time.

• Abdominal pain: This is the main symptom of chronic pancreatitis. The pain is usually localized in the upper abdomen (epigastrium) and can radiate to the back. The pain can be constant or periodic, acute or stupid. The pain can be intensified after eating, especially after eating fatty foods. In some cases, the pain can be very strong and exhausting, significantly reducing the quality of the patient’s life.

• Digestive violation (malabsorption): Chronic pancreatitis can lead to digestion due to insufficient production of pancreatic enzymes (exocrine deficiency). This can lead to:

  • Stealer: The allocation of a fat stool (feces becomes light, voluminous and difficult to wash off).
  • Weight loss: Insufficient absorption of nutrients can lead to weight loss.
  • Vitamin deficiency: Insufficient assimilation of vitamins, especially fat -soluble vitamins (A, D, E, K), can lead to various symptoms, such as night blindness (vitamin A), osteoporosis (vitamin D), neurological disorders (vitamin E deficiency) and blood coagulation (vitamin K deficiency).
  • Meteorism and bloating: Digestion can lead to the accumulation of gases in the intestines and bloating.

• Endocrine dysfunction (diabetes): Chronic pancreatitis can damage the islands of Langerganes, which will lead to insufficient production of insulin and the development of diabetes. Diabetes caused by chronic pancreatitis usually requires insulin treatment.

• Nausea and vomiting: Nausea and vomiting can be caused by pain, impaired motility of the gastrointestinal tract and steator.

• Fatigue: Fatigue can be caused by pain, digestive disorders, nutrient deficiency and diabetes.

• Jaundice: Jaundice can be observed with chronic pancreatitis if there is obstruction of the common bile duct due to fibrosis or strictor formation.

III.B. Diagnosis of chronic pancreatitis: visualization of the pancreas and assessment of its function

The diagnosis of chronic pancreatitis is based on the clinical picture, the results of visualization studies and the assessment of the function of the pancreas.

• Visualization studies:

  • Computer tomography (CT) of the abdominal cavity: CT can identify signs of chronic pancreatitis, such as calcifiers in the pancreas, the expansion of the pancreatic duct, pancreatic atrophy and pseudo -worshipers.
  • Magnetic resonance imaging (MRI) of the abdominal cavity: MRI can be used to assess the condition of the pancreas and bile ducts. MRHPG (magnetic resonance cholangiopancreatography) is a specialized MRI, which is used to visualize the bile and pancreatic ducts. MRHPG can identify strictures, expansion and other abnormalities of the pancreatic duct.
  • Endoscopic ultrasonography (EUS): Eus is a procedure in which an ultrasonic sensor is inserted into the stomach or duodenum using an endoscope. Eus allows you to get detailed images of the pancreas and surrounding organs. Eus can identify the early signs of chronic pancreatitis, which are not visible on CT or MRI. EUS can also be used to take pancreatic biopsy.
  • The radiography of the abdominal cavity: The radiography of the abdominal cavity can detect calcifiers in the pancreas, but it is less sensitive than CT or MRI.

• Pancreatic function assessment:

  • Fecal elastasis-1: This is a test that measures the amount of elastasis-1 enzyme in feces. The low level of elastasis-1 indicates the exocrine deficiency of the pancreas. This test is non -invasive and relatively easy to execute.
  • Pancreatic secretory test: This test measures the number of pancreatic enzymes produced by the pancreas in response to stimulation. This test is more invasive than the fecal elastas-1 test, and is usually performed only in specialized centers.
  • Test for absorption D-strokes: This test measures the intestinal ability to absorb D-cylose, sugar. Violation of the absorption of the D-stroke may indicate malabsorption caused by exocrine pancreatic failure.

III.C. Treatment of chronic pancreatitis: pain relief, digestion and diabetes control

Treatment of chronic pancreatitis is aimed at relieving pain, maintenance of digestion, diabetes control and preventing complications.

• Relief of pain:

  • Anesthetic drugs: Anesthetic drugs, such as non -steroidal anti -inflammatory drugs (NSAIDs), acetaminophen and opioids, can be used to relieve pain. Opioids should be used with caution, as they can cause addiction.
  • Pancreatic enzymes: Pancreatic enzymes can reduce pain by suppressing the secretion of pancreatic enzymes by the pancreas.
  • Nervous blockade: Nervous blockade (for example, blockade of the celiac plexus) can be used to block pain signals from the pancreas.
  • Surgical treatment: Surgical treatment (for example, pancreatic resection, pancreatic, pancreatic) may be necessary in cases where the pain is not treated with other methods.

• Maintaining digestion:

  • Pancreatic enzymes: Pancreatic enzymes help to digest fats, proteins and carbohydrates. They should be taken with each meal.
  • Low fat diet: Low fat diet can reduce steator and other symptoms of malabsorption.
  • Vitamins and minerals: Vitamins and minerals, especially fat -soluble vitamins (A, D, E, K), can be necessary to prevent a feed of nutrients.

• Diabetes control:

  • Insulin: Insulin is usually necessary to control blood sugar in patients with diabetes caused by chronic pancreatitis.
  • Diet: A diet developed for diabetics can help control the blood sugar.
  • Exercise: Regular physical exercises can help improve blood sugar control.

• Other treatment methods:

  • Continuing alcohol consumption: Patients with chronic pancreatitis caused by alcohol abuse must stop drinking alcohol.
  • Complications treatment: Complications of chronic pancreatitis, such as pseudocysts, strictures of the bile ducts and duodenal obstruction, may require specific treatment.
  • Endoscopic treatment: Endoscopic treatment can be used to treat strictures of pancreatic ducts, removal of stones from pancreatic ducts and drainage pseudocyst.

III.D. Complications of chronic pancreatitis: local and systemic problems

Chronic pancreatitis can lead to various complications that can be both local and systemic.

• Local complications:

  • Pseudocysts of the pancreas: The accumulation of liquid, surrounded by a capsule of fibrous tissue. Pseudocysts can form as a result of chronic pancreatitis. They can be asymptomatic or cause pain, nausea, vomiting and other symptoms. In some cases, pseudocysts can be infected or exploded.
  • Pancretical duct strictures: Narrowing of the pancreatic duct. Stictures can cause pain, violation of the outflow of pancreatic juice and pancreatic failure.
  • Stictures of the common bile duct: Narrowing of the common bile duct. Stictures can cause jaundice, cholangitis (inflammation of the bile ducts) and liver failure.
  • Duodenal obstruction: Clogging of the duodenum. Duodenal obstruction can cause nausea, vomiting and bloating.
  • Pancreatic cancer: Chronic pancreatitis increases the risk of pancreatic cancer.

• System complications:

  • Diabetes sugar: Chronic pancreatitis can damage the islands of Langerganes, which will lead to insufficient production of insulin and the development of diabetes.
  • Malibsorption: Chronic pancreatitis can lead to digestion due to insufficient production of pancreatic enzymes (exocrine deficiency).
  • Osteoporosis: The deficiency of vitamin D and calcium caused by malabsorption can lead to osteoporosis.
  • Depression: Chronic pain and digestive disorders can lead to depression.
  • Dependence on opioids: Long -term use of opioids to relieve pain can lead to dependence.

IV. Myths and reality in the treatment of pancreatitis forever

IV.A. Myth: Pancreatitis is incurable, and it will have to live with it all your life.

Reality: Although the complete cure of chronic pancreatitis, as a rule, is impossible due to irreversible damage to the pancreatic tissue, a significant improvement in the quality of life and the control of symptoms are quite achievable. Acute pancreatitis, in most cases, is completely cured with timely and adequate therapy. The key factor is to identify and eliminate the cause of pancreatitis.

• Acute pancreatitis: With the successful treatment of acute pancreatitis and eliminating the cause (for example, the removal of bile stones, the cessation of alcohol use), the pancreas can recover to its normal state. Patients can return to normal life without any long-term consequences.

• Chronic pancreatitis: Although damage to the pancreas in chronic pancreatitis is often irreversible, effective treatment and management of symptoms can significantly improve the quality of the patient’s life. This includes pain relief, digestive maintenance, diabetes and preventing complication