ChronicChronic pancreatitispancreatitis

Lykhatska G.VLykhatska G.V

Plan ofPlan of thethe lecture lecture Etiopathogenesis of chronic pancreatitisEtiopathogenesis of chronic pancreatitis ССlassification of chronic pancreatitislassification of chronic pancreatitis Clinic of chronic pancreatitisClinic of chronic pancreatitis Diagnosis of chronic pancreatitisDiagnosis of chronic pancreatitis Complications of chronic pancreatitisComplications of chronic pancreatitis DDifferential diagnosisifferential diagnosis Treatment of chronic pancreatitisTreatment of chronic pancreatitis

Chronic pancreatitisChronic pancreatitis

Chronic pancreatitisChronic pancreatitis is a long-standing is a long-standing inflammation of the pancreas that alters its inflammation of the pancreas that alters its normal structure and functionsnormal structure and functions..

Etiology ofEtiology of chronic chronic pancreatitispancreatitis

Primary pancreatitisPrimary pancreatitis :: Misuse of alcoholMisuse of alcohol ((70-80% 70-80% of all diagnostic casesof all diagnostic cases )) the systematic eating of fatty foodsthe systematic eating of fatty foods influence of drugsinfluence of drugs ((azathioprineazathioprine , , isoniazideisoniazide , ,

tetracyclinetetracycline , , sulfonamidessulfonamides )) protein deficiencyprotein deficiency HereditaryHereditary IschemicIschemic ((in lesions of vascularin lesions of vascular , , which which supplies bloodsupplies blood

pancreaspancreas )) IdiopathicIdiopathic

Etiology ofEtiology of chronic pancreatitischronic pancreatitis

Secondary pancreatitisSecondary pancreatitis :: diseases of the biliary tractdiseases of the biliary tract ((in 30-40%in 30-40%))

           disease of duodenumdisease of duodenum    a primarya primary ((tumorstumors,,papillitispapillitis) ) and a secondaryand a secondary

((dyskinesiadyskinesia of billiary tractof billiary tract) )

            liver diseaseliver disease             bowel diseasebowel disease              

viral infectionsviral infections ((parotitisparotitis ))             allergic conditionsallergic conditions             hyperlipidemiahyperlipidemia           hyperparathyroidismhyperparathyroidism

injury of the pancreasinjury of the pancreas

The pathogenesis ofThe pathogenesis of cchronic hronic pancreatitispancreatitis

The main pathogenetic mechanismThe main pathogenetic mechanism of the of the development of development of cchronic pancreatitishronic pancreatitis is is acinusesacinuses destructive damage acinusesdestructive damage acinuses , , causedcaused intracellular activation of enzymesintracellular activation of enzymes pancreaspancreas . .

Has significance violation of theHas significance violation of the outflow of outflow of pancreatic juicepancreatic juice

The progressive fibrosis coused theThe progressive fibrosis coused the violationviolation phisiologycal function of the glandphisiologycal function of the gland..

ClassificationClassification

chronic calcified pancreatitischronic calcified pancreatitis

chronic obstructive pancreatitis chronic inflammatory pancreatitis

Chronic pancreatitis of alcoholic etiologyChronic pancreatitis of alcoholic etiology Others Others formsforms chronic pancreatitis chronic pancreatitis ((cchronic hronic

pancreatitis unspecified etiologypancreatitis unspecified etiology , infectious, infectious , , recurrentrecurrent ) )

Pancreatic cystsPancreatic cysts Pancreatic pseudocystPancreatic pseudocyst

Clinical classification ofClinical classification of cchronic hronic pancreatitispancreatitis

The course of the diseaseThe course of the disease :: 1. mild severity1. mild severity - signs of- signs of violation exocrineviolation exocrine andand

endocrine function endocrine function not detectednot detected .. 2. moderate - signs of2. moderate - signs of violation exocrineviolation exocrine – – andand

endocrine function endocrine function 3. severe3. severe (terminal) - the presence of resistant(terminal) - the presence of resistant

pancreatic diarrheapancreatic diarrhea , hypovitaminosis, hypovitaminosis , , exhaustion exhaustion ..

Clinical classification ofClinical classification of cchronic hronic pancreatitispancreatitis

On the functional characteristicsOn the functional characteristics   

1. 1. In violation of exocrine pancreatic functionIn violation of exocrine pancreatic function

2.2. In violation of the endocrine function of the In violation of the endocrine function of the pancreaspancreas

The phases of deseaseThe phases of desease::

--exacerbationexacerbation, -, -remissionremission ..

complicationcomplication

THE CLINICTHE CLINIC The clinical picture of chronic pancreatitis is leadingThe clinical picture of chronic pancreatitis is leading ::

pain syndromepain syndrome dyspeptic syndromedyspeptic syndrome Syndrome of the external secretory pancreatic Syndrome of the external secretory pancreatic

insufficiencyinsufficiency andand its related syndromesits related syndromes ofof maldymaldyggestionestion andand malabsorptionmalabsorption with progressive with progressive loss of body weightloss of body weight

Endocrine insufficiency syndromeEndocrine insufficiency syndrome((pancreatic pancreatic diabetesdiabetes) )

asthenic-neurotic syndromeasthenic-neurotic syndrome

Duration of chronic Duration of chronic pancreatitis is divided into 3 pancreatitis is divided into 3

phasesphases :: initialinitial stagestage(1-5(1-5 yearsyears) – ) – the most frequent the most frequent

manifestation is the painmanifestation is the painexpanded clinical pictureexpanded clinical picture (5-10 (5-10 yearsyears) – ) –

main manifestation main manifestation isis the painthe pain,, the the signs of signs of exocrine insufficiencyexocrine insufficiencyі, і, the the elements of elements of incretory insufficiencyincretory insufficiency ( (hyperglycemiahyperglycemia, , hypoglycemiahypoglycemia))

Remission of active pathological processRemission of active pathological process oror development of complications.development of complications.

THE CLINICTHE CLINIC The The dyspeptic syndromedyspeptic syndrome

reduce or loss of appetitereduce or loss of appetite , , salivationsalivation ,, nauseanausea , , vomitingvomiting ,, that that does not bring does not bring

reliefrelief abdominal bloatingabdominal bloating , , Disorders of defecation Disorders of defecation

(prevalence diarrhea(prevalence diarrhea or or changechange diarrhea diarrhea withwith constipationconstipation ).).

CLINICCLINIC

Exogenous deficiency syndromeExogenous deficiency syndrome - - -"-"pancreaticpancreatic " " diarrheadiarrhea,creatorea,,creatorea,

steatoreasteatorea. . the the loss of body weight loss of body weight withwith a a

development of osteoporosisdevelopment of osteoporosis ( (the bone the bone painpain), ), as a result ofas a result of excessive removing excessive removing of calcium and deficiency ofof calcium and deficiency of vitamin Dvitamin D..

The clinical courseThe clinical course Chronic recurrent pancreatitisChronic recurrent pancreatitis — — the most frequent formthe most frequent form for which for which

is characterized by bouts of painful crisesis characterized by bouts of painful crises, , that combined with increasing that combined with increasing levels of pancreatic enzymes in the blood and urinelevels of pancreatic enzymes in the blood and urine, , andand sometimes with sometimes with jaundicejaundice . . in the phase of remission can persist dyspeptic syndrome. in the phase of remission can persist dyspeptic syndrome.

Painful formPainful form——is characterized by constant dull pain in the left upper is characterized by constant dull pain in the left upper quadrantquadrant andand by laboratory databy laboratory data, , thatthat confirm the diagnosis of confirm the diagnosis of pancreatitispancreatitis ( (a history of data transferred pancreonecrosis)a history of data transferred pancreonecrosis)..

Latent formLatent form— — is characterized by painless courseis characterized by painless course.. The The primaryprimary are are dyspeptic syndrome dyspeptic syndrome andand a fact of exocrine insufficiency of pancreas a fact of exocrine insufficiency of pancreas..

Psevdotumorz formPsevdotumorz form— — is characterized by combination of jaundice with is characterized by combination of jaundice with disorders ofdisorders of internal and the external exocrine function of pancreasinternal and the external exocrine function of pancreas. . Often occurs clinically as cancer of head of pancreas Often occurs clinically as cancer of head of pancreas andand correct correct diagnosis is established only after surgerydiagnosis is established only after surgery. .

Laboratory diagnosticsLaboratory diagnostics :: 1. 1. Complete blood countComplete blood count ::25% of patients have a leukocytosis25% of patients have a leukocytosis and and ESR accelerationESR acceleration..

2.2. The results of determine the activity of pancreatic The results of determine the activity of pancreatic enzymesenzymes ( (amylaseamylase, , lipaselipase, , trypsin in the blood and urinetrypsin in the blood and urine— — there is an increase of their activity when the desease is there is an increase of their activity when the desease is exacerbatedexacerbated).).

85-90% of patients85-90% of patients the the creased activity of creased activity of α-α-amylase for 1-amylase for 1-day of diseaseday of disease,, 60-70%60-70% of patients for of patients for 2 2-day-day of diseaseof disease, , 40-40-50% 50% forfor 3-day3-day of diseaseof disease. . Under normal numbers of amylase Under normal numbers of amylase it possible to use exercise testing it possible to use exercise testing : : investigate amylase at investigate amylase at an altitude of painan altitude of pain, , after endoscopyafter endoscopy, , X-ray.X-ray.

Diagnosis of exocrine Diagnosis of exocrine pancreatic insufficiencypancreatic insufficiency

METHODSMETHODS:: for the introduction of secretin while preserving for the introduction of secretin while preserving

exocrine pancreatic function theexocrine pancreatic function the amount of amount of secretionsecretionуу is increased is increased ,,the content of the content of bicarbonate,bicarbonate, in response to input the in response to input the pankreozymin the content of enzymes is pankreozymin the content of enzymes is increased.increased.

In severe exocrine insufficiency theIn severe exocrine insufficiency the pathological changes of thepathological changes of the test observed in test observed in 85-90% of cases85-90% of cases..

Diagnosis of exocrine Diagnosis of exocrine pancreatic insufficiencypancreatic insufficiency

1.1. the research of activity in feces of elastase-1 the research of activity in feces of elastase-1.. 2.2. Breathing tests Breathing tests

.. Breathing tests Breathing tests - - during exogenous failure the production of lipase is during exogenous failure the production of lipase is reduced reduced oror,, it is absent , it is absent , and therefore the triglycerides are split a lesser and therefore the triglycerides are split a lesser extent and constitute less of extent and constitute less of 13СО2.13СО2.

amylase respiratory APamylase respiratory AP the the corn-starch test corn-starch test – – the the total concentrationtotal concentration AP at AP at the the end of the 4-o'clock researchend of the 4-o'clock research is less than is less than 10 %, 10 %, that that indicating the indicating the presence of deficiency of pancreatic amylasepresence of deficiency of pancreatic amylase

Protein breathing Protein breathing with IZS with IZS- - noticed egg white noticed egg white - - in patients within patients with cchronichronic pancreatitispancreatitis the total concentration of the total concentration of 13СО213СО2 through 6 hours 2-3 times through 6 hours 2-3 times lower than in healthy personslower than in healthy persons,, indicating a decrease in activity of trypsinindicating a decrease in activity of trypsin..

3. 3. Koprogram Koprogram -- high content of muscular fibers to digest fiber and neutral fat high content of muscular fibers to digest fiber and neutral fat

STANDARD OF noninvasive STANDARD OF noninvasive diagnosis of diagnosis of cchronichronic pancreatitispancreatitis

Degrees of severity of external secretory of

pancreatic insufficiency

Activity of fecal pancreatic elastase -1

mild 150-200 150-200 mg / g

moderate 100 - 150 100 - 150 mg / g

severe less than 100 100 mg / g

Ultrasound investigationUltrasound investigation.. Chronic pancreatitisChronic pancreatitis

а) а) calcificates in the head of calcificates in the head of pancreaspancreas;;

б) б) VirsungovVirsungov’’s ducts duct; ;

в) в) pseudocyst of pancreaspseudocyst of pancreas; ;

г) г) increase of the head of increase of the head of pancreaspancreas;;

д) д) spleen veinspleen vein

Ultrasound investigationUltrasound investigation. . CChronic hronic calcified pancreatitis calcified pancreatitis а)а) virsungolithiasis virsungolithiasis б) б)

dilated Virsungovdilated Virsungov’’s duct.s duct.

Plain X-ray of abdomenPlain X-ray of abdomen showing showing calcific calcific pancreatitispancreatitis

Instrumental diagnosticsInstrumental diagnostics

computed tomographycomputed tomography :: the the diagnostic diagnostic information similar to ultrasoundinformation similar to ultrasound, , is indicated is indicated for suspected tumors and cysts of the for suspected tumors and cysts of the pancreaspancreas;;

  magnetically-resonancemagnetically-resonance tomography tomography :: helps to visualize normal and pathologically helps to visualize normal and pathologically altered pancreatic ductaltered pancreatic duct, , used for the used for the diagnosis of pancreatic duct stonesdiagnosis of pancreatic duct stones;;

CT scan with central CT scan with central pseudocyst pseudocyst Endoscopic ultrasound

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 An endoscopic ultrasound image demonstrating a dilated pancreatic duct demonstrating a dilated pancreatic duct

(markers) in a patient with advanced chronic (markers) in a patient with advanced chronic

pancreatitispancreatitis

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 diagnosticsInstrumental diagnostics Endoscopic retrogradeEndoscopic retrograde cholangyiopankreato cholangyiopankreato

graphygraphy: : reveals impaired patency of the main reveals impaired patency of the main and secondary ductsand secondary ducts.. “Chain of lakes" “Chain of lakes" is a is a classic symptom of cclassic symptom of chronichronic pancreatitispancreatitis ((areas of constriction and expansion of areas of constriction and expansion of virsunhov ductsvirsunhov ducts). ). It is also possible the It is also possible the segmental or total obstruction of a ductal segmental or total obstruction of a ductal system of pancreas. system of pancreas.

biopsybiopsy of pancreasof pancreas..

..

An endoscopic retrograde An endoscopic retrograde cholangiopancreatography image cholangiopancreatography image

demonstrating minimal pancreatic duct demonstrating minimal pancreatic duct abnormalities in a patient with painful small-abnormalities in a patient with painful small-

duct chronic pancreatitis.duct chronic pancreatitis.

An endoscopic retrograde An endoscopic retrograde cholangiopancreatography image cholangiopancreatography image

demonstrating massive pancreatic duct demonstrating massive pancreatic duct dilatation in a patient with bigduct chronic dilatation in a patient with bigduct chronic

pancreatitis.pancreatitis.

COMPLICATIONSCOMPLICATIONS :: diabetes mellitus type IIdiabetes mellitus type II ;; pancreas cancerpancreas cancer ;; obstructive jaundiceobstructive jaundice ;; pancreatic comapancreatic coma .. cysts and pseudocysts of cysts and pseudocysts of

the pancreasthe pancreas pancreatic abscesspancreatic abscess ;; pancreonecrosispancreonecrosis ;; infectious complicationsinfectious complications

((inflammatory infiltratesinflammatory infiltrates ,, suppurative cholangitissuppurative cholangitis , , septic septic conditionsconditions , , peritonitisperitonitis))

chronic duodenal chronic duodenal obstructionobstruction

pancreatic ascitespancreatic ascites erosive esophagitiserosive esophagitis gastrointestinal bleedinggastrointestinal bleeding abdominal anginaabdominal angina reactive arthritisreactive arthritis reactive pleurisyreactive pleurisy ;; reactive hepatitisreactive hepatitis ;; anemiaanemia ..

The differential diagnosisThe differential diagnosis

Chronic cholecystitisChronic cholecystitis ;; Chronic gastroduodenitisChronic gastroduodenitis ;; Ulcer diseaseUlcer disease ;; Cronic hepatitisCronic hepatitis ;; Bile Bile gallstonesgallstones diseasedisease ;; Pancreas cancerPancreas cancer ;; Left-sided renal colicLeft-sided renal colic ;; Angina pectorisAngina pectoris . .

Treatment of chronic pancreatitisTreatment of chronic pancreatitis Main principlesMain principles : :

1. 1. DDietary meal (ietary meal (№5) №5) 2. 2. Creating functional resting of pancreasCreating functional resting of pancreas 3. 3. Elimination pain syndromeElimination pain syndrome 4.4. Substitution therapy ofSubstitution therapy of exocrine exocrine

enzyme deficiencyenzyme deficiency 5.5. Elimination of duodenostasisElimination of duodenostasis , athetoid , athetoid

biliary of disordersbiliary of disorders , , pancreatic ductpancreatic duct 6. 6. Anti-inflammatory therapyAnti-inflammatory therapy 7. 7. Correction endocrine function of the Correction endocrine function of the

pancreaspancreas 8. 8. Symptomatic therapySymptomatic therapy

TreatmentTreatment Diet Diet № 5№ 5.Avoiding .Avoiding alcoholalcohol Elimination of pain syndromeElimination of pain syndrome:: - - non-non-narcotic narcotic analganalgiicc drugs (analginum 50% drugs (analginum 50%

2-5 ml 2-5 ml intramuscularlyintramuscularly 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 antispasmodicsMyotropic antispasmodics drugs drugs ((papaverin papaverin 2% 2 2% 2 mimi, , no-shpano-shpa 2% 2 2% 2 mlml intramuscintramusc - 2 - 2 times a daytimes a day,, mabeverin mabeverin ((duspatalinduspatalin) ) 200200mgmg 2 2 times a daytimes 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 Often the acute of CP is accompanied by peripancreatitisperipancreatitis, , and also by cholangitisand also by cholangitis..

in such cases, used the antibiotics in such cases, used the antibiotics : : augmentunaugmentun 0,625-1,250,625-1,25 gg 2-32-3 times a day times a day intramusc. (intramusc. (7-10 7-10 days)days); ; cefobid cefobid 1-2 1-2 gg 2 2 times a times a dayday intramusc (intramusc (7-107-10 days) days);; dorsycyclindorsycyclinпо 0,1 по 0,1 gg 1-2 1-2 times a day (times a day (6-8 6-8 days)days);; for inefficiency- for inefficiency- abaktal(pefloksacynabaktal(pefloksacyn) 0,4 ) 0,4 gg 2 2 times a day times a day , , symamed symamed 0,5 0,5 gg 1 1 times a day 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)

Physiotherapy (electrophoresis, diadynamo- therapy) Sanatorium – resort treatment

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