Pancreatitis is a disease of the pancreas caused by the self-digesting effect of trypsin. The pancreas has edema, congestion, or bleeding or necrosis. Clinically, symptoms such as abdominal pain, bloating, nausea, vomiting, and fever appear. Elevated levels of amylase in blood and urine, etc.
Under normal circumstances, pancreatic juice contains inactive pancreatin in its glandular tissue. Pancreatic juice flows continuously into the duodenum through the common bile duct Oddi’s sphincter along the pancreatic duct. Due to the presence of bile in the duodenum and the mucosa of the duodenal wall secreting an enterokinase, under the action of both, Trypsinogen begins to transform into a very active digestive enzyme. If the outflow tract is blocked and the excretion is not smooth, it can cause pancreatitis.
When the sphincter of Oddi’s spasm or the pressure in the bile duct increases, such as stones or tumor blockage, bile will flow back into the pancreatic duct and enter the pancreatic tissue. At this time, the lecithin contained in the bile is replaced by the lecithinase A contained in the pancreatic juice It is decomposed into lysolecithin, which can have a toxic effect on the pancreas. Or when biliary tract infections, bacteria can release kinases to activate pancreatin, which can also become active substances that can damage and dissolve pancreatic tissue. These substances convert pancreatin contained in pancreatic juice into trypsin, which has strong digestive activity and penetrates into pancreatic tissue to cause self-digestion and can also cause pancreatitis.
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1. Acute pancreatitis
It is an acute inflammation caused by pancreatic enzyme digestion of the pancreas and its surrounding tissues. The main manifestations are edema, hemorrhage and necrosis of the pancreas. The most common causes of disease are as follows:
(1) Diseases of the biliary system Bile duct inflammation, stones, parasites, edema, spasm and other diseases cause obstruction of the ampulla, and bile flows back into the pancreatic duct through the common channel, activating pancreatin and causing pancreatitis.
(2) Alcoholism and binge eating. Alcoholism and binge eating make the pancreatic juice secrete vigorously, and the pancreatic duct is not drained smoothly, which causes the pressure of pancreatic juice in the pancreaticobiliary system to increase, resulting in high concentration of protease excretion disorders, and finally leading to the rupture of the pancreatic vesicles and the disease .
(3) Surgery and injury. Surgery in the abdominal cavity such as stomach and biliary tract squeezes into the pancreas, or causes excessive pressure in the pancreaticobiliary duct.
(4) Infection Many infectious diseases can be complicated by acute pancreatitis, and the symptoms are not obvious. If roundworm enters the bile duct or pancreatic duct, it can bring bacteria into it, which can activate pancreatin and cause pancreatic inflammation.
(5) Hyperlipidemia and hypercalcemia Hyperlipidemia, fat embolization of pancreatic blood vessels causes ischemia, telangiectasia, damage to the blood vessel wall, resulting in difficulty in excretion of pancreatic juice; stones can block the pancreatic duct and cause pancreatitis.
2. Chronic pancreatitis
A disease of chronic and progressive destruction of the pancreas caused by recurrent acute pancreatitis.
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Clinical manifestations
1. Acute pancreatitis
There is a history of binge eating or biliary disease before the attack. Acute pancreatitis can be divided into common type and hemorrhagic necrosis type. Hemorrhagic necrosis is rare, but the condition is serious and the mortality rate is high.
(1) Shock patients often experience shock symptoms such as paleness, cold sweats, narrow pulses, decreased blood pressure, etc. There can be many reasons for shock, such as pancreatic juice overflow, stimulating the peritoneum and causing severe pain; pancreatic tissue and intra-abdominal hemorrhage; tissue necrosis, Poisoning caused by protein decomposition, etc. People with severe shock can die if they are not rescued in time.
(2) Abdominal pain. Abdominal pain is often located in the upper middle abdomen, and sometimes radiates to the waist and back in a band shape, which can be relieved by bending or sitting forward; it often occurs suddenly after a lot of drinking or eating, and the severity is different. The milder is dull pain. Severe cases are mostly persistent colic.
(3) Nausea and vomiting Most patients vomit stomach contents or even vomit bile at onset, and abdominal pain does not relieve after vomiting.
(4) Fever Most patients with acute pancreatitis develop moderate fever, which usually lasts for 3 to 5 days.
(5) Patients with water-electrolyte and acid-base imbalances have varying degrees of dehydration. People with frequent vomiting can develop metabolic alkalosis. Severe pancreatitis is often accompanied by metabolic acidosis, hypocalcemia, elevated blood sugar, hypokalemia, Low blood magnesium.
2. Chronic pancreatitis
(1) Abdominal pain is mostly located in the upper abdomen, diffuse, and can radiate to the back and ribs, and is relieved by sitting up or leaning forward.
(2) Pancreatic insufficiency. Indigestion symptoms of varying degrees such as abdominal distension, anorexia, oiliness, weight loss, steatorrhea, etc.; half of the patients develop diabetes due to endocrine dysfunction.
(3) Signs Mild chronic pancreatitis rarely has positive signs, and some cases have mild upper abdominal tenderness; advanced chronic pancreatitis may have symptoms of malnutrition due to steatorrhea; if it has an acute attack, moderate to severe symptoms may occur. Abdominal tenderness.
an examination
1. White blood cell count
If the infection is severe, the total number of white blood cells will increase and the nucleus will shift to the left. Some patients have increased urine glucose, and in severe cases, there are protein, red blood cells and casts in the urine.
2. Determination of blood and urine amylase
Has important diagnostic significance. Normal value: Serum: 8 to 64 Winslow units, or 40 to 180 Somogyi units; Urine: 4 to 32 Winslow units.
In patients with acute pancreatitis, pancreatic amylase overflows out of the pancreas, is quickly absorbed into the blood and excreted in urine, so blood and urine amylase is greatly increased, which is an important laboratory test for the diagnosis of this disease.
The amylase value in severe necrosis type, because the acinar is severely damaged, the production of amylase is very little, so its value does not increase. If the amylase value drops and then rises, it indicates that the condition has relapsed, and if it continues to increase, complications may occur. When the measured value is >256 Wen's unit or >500 Su's unit, the diagnosis of acute pancreatitis is meaningful.
3. Determination of serum lipase
The reason for the increase of its value is the same as that of amylase. It begins to increase 24 hours after the onset of the disease and can last for 5 to 10 days. It is helpful to diagnose the value of late patients.
4. Serum calcium determination
The normal value is not less than 2.12mmol/L (8.5mg/dl). The blood calcium began to decrease two days after the onset of the disease, and it was significant after the 4th to 5th days. In severe cases, it can be reduced to below 1.75mmol/L (7mg/dl), indicating a serious condition and a poor prognosis.
5. Determination of serum metferritin (MHA)
MHA comes from the heme released from the destruction of red blood cells in the bloody pancreatic juice. Under the action of lipase and elastase, it is converted into heme, which is absorbed into the blood and combined with albumin to form heme. Severe patients often develop MHA 12 hours after the onset of the disease. It is positive in patients with severe acute pancreatitis and negative in edema.
6. X-ray inspection
Localized or extensive enteroplegia can be seen in the abdomen. Fluid accumulation in the omental sac. There are calcifications around the pancreas. Elevation of the diaphragm, pleural effusion, and occasionally disc-shaped atelectasis can be seen. When ARDS appears, the lung field is "ground glass".
7. B-ultrasound and CT
Both can show the outline of pancreatic enlargement, the amount and distribution of exudate.
Complications
Mild acute pancreatitis rarely has complications, while severe acute pancreatitis often has multiple complications, such as pancreatic abscess, pancreatic pseudocyst, shock, organ failure, and the abdominal cavity, respiratory tract, etc. Urinary tract and other infections, the spread of infection can cause sepsis. A few can evolve into chronic pancreatitis.
Chronic pancreatitis mainly manifests as chronic abdominal pain and pancreatic endocrine and exocrine insufficiency, which is related to the occurrence of pancreatic cancer. The most common complications are the formation of pseudocysts and mechanical obstruction of the duodenum and common channels.
treat
(1) Acute pancreatitis
1. General treatment
In the early stage of acute pancreatitis, non-surgical treatment should be used for mild pancreatitis and those who have not yet been infected.
(1) Fasting, nasogastric tube decompression, continuous gastrointestinal decompression, to prevent vomiting and aspiration. Gastrointestinal motility drugs can reduce abdominal distension.
(2) Replenish body fluids and prevent shock. All patients should be supplemented with fluids, electrolytes and calories intravenously to maintain stable circulation and balance water and electrolyte. Prevent hypotension and improve microcirculation.
(3) Antispasmodic and analgesic If the diagnosis is clear, analgesics can be given symptomatically in the early stage of onset. But it is advisable to give an antispasmodic at the same time. Disable morphine, so as not to cause Oddis sphincter spasm.
(4) Inhibition of pancreatic exocrine secretion and pancreatin. Gastric tube decompression, H2 receptor blockers, anticholinergics, somatostatin, etc., are generally used for patients with more serious conditions. Trypsin inhibitors such as aprotinin, gabexate, etc. have a certain effect on inhibiting trypsin.
(5) Nutritional support Early fasting mainly depends on total parenteral nutrition (TPN). When the symptoms of abdominal pain, tenderness and intestinal obstruction are relieved, the diet can be resumed. Except for patients with hyperlipidemia, fat emulsions can be used as a heat source.
(6) Application of antibiotics Early antibiotic treatment is given. In severe pancreatitis with pancreatic or peripancreatic necrosis, intravenous application of broad-spectrum antibiotics or selective intestinal antibiotics can prevent bacterial infections caused by the translocation of intestinal flora .
2. Surgical treatment
Pancreatic abscess, pancreatic pseudocyst and pancreatic necrosis combined with infection are serious life-threatening complications of acute pancreatitis. If the diagnosis is uncertain; secondary pancreatic infection; combined with biliary tract disease; despite reasonable supportive treatment, but the clinical symptoms continue to deteriorate, surgery should be performed.
In severe cases, there are two main surgical methods: ① Laparotomy is used to remove necrotic tissue, multiple porous drainage tubes are placed for continuous lavage after the operation, and then the incision is sutured. ②Laparotomy to remove necrotic tissue and open drainage of the wound. During the operation, gastrostomy, jejunostomy (for enteral nutrition support) and biliary drainage can be performed at the same time. Occasionally a single abscess or infectious pancreatic pseudocyst can be treated with percutaneous drainage and catheterization.
In severe biliary pancreatitis with ampullary incarcerated stones, combined with biliary obstruction or biliary tract infection, emergency surgery or early (within 72 hours) surgery, relieve the biliary obstruction, remove the stones, and unblock drainage, and choose according to the condition of the disease. For cholecystectomy or pancreatic drainage of the small omental cavity. Under conditions, the Oddis sphincter can be cut and removed by fiber duodenoscope. The effect is significant and there are few complications.
(Two) chronic pancreatitis
Chronic pancreatitis should be treated for the cause, such as treatment of biliary diseases, abstinence from alcohol; diet therapy, small and frequent meals, high protein, high vitamin, and low-fat diet; pancreatin supplementation; diabetes control; nutritional support therapy. Pancreatic duct drainage and pancreatic surgery are performed when necessary.
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prevention
Acute pancreatitis is a very serious disease. Acute hemorrhagic necrotizing pancreatitis is particularly dangerous, with rapid onset and high mortality. It is known that the onset of pancreatitis is mainly due to pancreatic juice reflux and pancreatic enzyme damage to the pancreas, and these factors can be prevented.
1. Biliary disease
Avoid or eliminate biliary diseases. For example, prevention of intestinal roundworms, timely treatment of biliary stones, and avoidance of acute attacks of biliary diseases.
2. Alcoholism
People who are usually alcoholics suffer from damage to organs such as liver and pancreas due to chronic alcoholism and malnutrition, and their ability to resist infection is reduced. On this basis, acute pancreatitis can be caused by a single drink of alcohol.
3. Binge eating and drinking
It can cause gastrointestinal dysfunction, obstruct the normal activities and emptying of the intestine, hinder the normal drainage of bile and pancreatic juice, and cause pancreatitis.
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