What is the danger of pancreatic necrosis and how to deal with the disease, the first symptoms of the disease

Pancreatic necrosis (ICD code - 86.8.1) is a pathology in which there is a complete and irreversible loss of pancreatic cells.

The disease is the most severe complication of acute pancreatitis, is rare, but severe and can be fatal.

Mortality in pancreatic necrosis reaches from 30% to 80%, depending on the volume and adequacy of the assistance provided, the patient's age, the degree of neglect of the process and other facts.

Classification and reasons

In order to understand more clearly the general information about this ailment, we will briefly understand the classification.

So, the disease is distinguished:

• the largest area of ​​damage to the affected organ: small focal, medium focal, large focal, subtotal, total.
• By the presence / absence of pathogenic (pathogenic) microflora: sterile and infected. Sterile pancreatic necrosis is further subdivided into hemorrhagic, fatty, and mixed.
• By types: limited and common. The first type includes small-, medium-, large-focal pancreatonecrosis, and the widespread - subtotal and total lesion.
• By stages: shock with polyhedral insufficiency, necrosis of the parenchyma with the attachment of infectious agents, infection, the formation of abscesses, retroperitoneal phlegmon.

The disease develops as a complication of acute pancreatitis, which most often occurs as a result abuse of alcoholic beverages and / or long-term systematic violation of the regimen nutrition. Fatty and fried foods, heavy food, and fast food are especially dangerous for the pancreas. Pancreatitis, and then pancreatic necrosis, can provoke self-medication with certain types of medications, deliberate or deliberate use of poisons, abdominal trauma, extensive abdominal surgery, professional harm.

Development mechanism

The basis of the pathogenesis of the disease is a violation of the local defense mechanisms of the glandular tissue of the affected organ. Acute pancreatitis leads to increased secretion of digestive enzymes, spasm of the sphincter of Oddi and increased pressure in the bile and pancreatic ducts. Normally, enzymes, passing through the sphincter of Oddi, enter the intestinal lumen and only there activate their activity, starting their main function - splitting the food lump.

But the spasmodic sphincter of Oddi ceases to pass enzymes, they quickly accumulate in the glandular tissue of the pancreas. Since bile is not evacuated, it begins to penetrate into the ducts of the gland, causing premature activation of pancreatic enzymes, and a destructive process begins. First, the compounds that digest fats "wake up", therefore, first of all, the cell membranes disintegrate, making the cell defenseless. Somewhat later, it is the turn of enzymes that uncouple proteins. Thus, the entire cell dies, its self-digestion occurs, and pancreatic necrosis occurs.

Diagnostics

If there is a suspicion of destruction of the pancreas, a joint examination of the patient is carried out. A gastroenterologist, resuscitator, surgeon is invited to make a collegial decision. The patient is admitted to an intensive care unit, where pancreatic enzymes in urine and blood are regularly monitored. The attending physician should be alerted by a sharp increase in the amount of amylase, which significantly worsens the prognosis for the patient.

If we take into account only the patient's complaints, then pancreatonecrosis is quite difficult to distinguish from acute pancreatitis. But destructive changes are well visualized by an ultrasound study. This is one of the most informative and accessible diagnostic procedures. If necessary, it is replaced by MRI of the pancreas, computed tomography, retrograde cholangiopancreatography. If the clinical case is especially severe, then diagnostic laparoscopy is indicated - a low-traumatic operation with the help of optical technology, which allows visualizing not only the affected organ, but also the surrounding fabrics.

Pancreatic necrosis: symptoms and treatment depending on the stage of the disease

The symptoms clearly correspond to the three stages of the course of the disease. The first stage begins sharply. As a rule, it is preceded by purulent, acute alcoholic, biliary or hemorrhagic pancreatitis. Active reproduction of pathogenic flora leads to general intoxication of the body and increased secretion of pancreatic enzymes.

The second stage of the course of the disease begins from the moment the tissues of the suffering organ melt. The glandular cells destroy both purulent bacteria and digestive enzymes. In addition, cavities are formed, their number often varies. At the third stage, the inflammatory process captures nearby organs and tissues, against the background of toxinemia, multiple organ failure develops and the patient dies.

Symptoms

With the development of pancreatic necrosis, the first symptoms appear almost immediately after the action of the provoking factor. As a rule, the patient is admitted to the surgical hospital in alcoholic intoxication, which confirms the acute onset of the disease.

The pain radiates to the left side of the abdominal cavity and to the subscapularis, less often to the lower back and lower abdomen. The most common concern is intense girdle pain. But the pain syndrome can begin to subside. This suggests that the nerve pathways undergo destruction, they die, which only confirms the death of the pancreas.

In a matter of minutes or hours, indomitable vomiting joins the intense pain. It quickly dehydrates the patient, but does not bring any relief.

Against the background of growing intoxication and dehydration, the symptomatic picture appears:

• fever;
• flatulence;
• weakening of intestinal peristalsis;
• reduction of urine output;
• lack of a chair.

With a close physical examination, you can see internal hematomas, which are visible in the form of cyanotic spots in the umbilical, lumbar region. The skin becomes earthy, covered with cold, sticky sweat, facial features are sharpened. Severe yellowness of the sclera, palms, or entire skin may appear. When listening to cardiac activity, tachycardia is noted against the background of a persistent drop in blood pressure.

Blood glucose is unstable, its values ​​fluctuate within significant limits. An excess of digestive enzymes disrupts the work of the brain, which is manifested by a decrease in mental activity, confusion of consciousness, and motor excitability. Approximately 30% of patients, against the background of complete disorientation in space, fall into a coma.

The active reproduction of pathogenic bacteria leads to the formation of purulent cavities, which are visible in just a few days at the site of the pancreas. Abscesses can open into the abdominal cavity, causing profuse internal bleeding. Against the background of growing multiple organ failure, death occurs.

General methods and medicines

Before starting drug therapy, the patient is provided with a complete lack of physical activity and bed rest. Food intake is strictly prohibited, but drinking must be present in full. There is a debate about placing the bladder on the projection area of ​​the pancreas, so the doctor chooses the tactics at his discretion.

Drug therapy are aimed at 3 directions: high-quality anesthesia, neutralization and suppression of the secretion of proteolytic enzymes, and the fight against intoxication. To relieve pain, narcotic and non-narcotic drugs are used. Antispasmodic and combined agents give a good effect. Diuretics such as Furosemide, Lasix will reduce swelling. Anesthesia is carried out to prevent the development of painful shock.

Detoxification therapy consists in the introduction:

• saline with Aprotinin, glucose with insulin, Ringer's solution;
• colloids: Albumin, Reopolyglucin;
• diuretics for forced diuresis.

As a detoxification, the use of peritoneal dialysis, plasmapheresis, hemofiltration, hemosorption is shown. To suppress the reproduction of pathogenic flora and prevent the development of sepsis, antibiotic therapy is prescribed as soon as possible. The drugs of choice include Cefepim, Levofloxacin, Gatifloxacin, and the reserve drugs - Imipenem, Meropenem.

Along with the appointment of antibiotics, for the prevention of the development of intestinal dysbiosis, probiotics and prebiotics are prescribed, the use of live intestinal bacteria with food. Shown are antihistamines, anti-shock therapy, symptomatic treatment of chronic somatic diseases, intramuscular administration of Cerucal to suppress persistent exhausting vomiting.

Operations

The main goal of any surgical intervention for pancreatic necrosis is to restore the outflow of pancreatic juice and remove dead glandular tissue (sequestrectomy). To establish an outflow, not only puncture, but also laparotomy, laparoscopic techniques will allow. The operation is indicated after 5 days after the onset of the development of the disease and the provision of assistance through the administration of drugs. At the stage of purulent fusion of the gland, interventions may be needed to revise areas of necrosis, stop internal bleeding, and install drains.

The operation is not postponed if subtotal or total necrosis of the glandular tissue of the affected organ, purulent peritonitis (inflammation of the peritoneum), pancreatogenic abscess has developed. Surgery is often repeated, and in the most severe cases, the pancreas is removed in parts or completely.

Care and rehabilitation period

The postoperative period should take place in a surgical hospital, and the first few days - in the intensive care unit. The patient is provided with bed rest, regular dressings, and drainage care.

Rehabilitation measures include:

• adherence to dietary recommendations;
• insulin replacement therapy;
• taking enzyme preparations;
• Exercise therapy;
• physiotherapy exercises;
• physiotherapy.

A relapse of the disease can provoke excessive physical activity and nervous strain, because in the rehabilitation period of the patient is protected in every possible way from stressful situations and provides conditions for rest and timely rest. Performing light household chores should stop at the first sensations of fatigue. The sick leave is written out for 3 - 4 months.

Pancreatic necrosis of the pancreas: preventive measures and prognosis

The main dietary recommendation for pancreatic necrosis of an inflamed pancreas is complete hunger. Any food is forbidden, if it is not possible to defeat the ailment, intravenous nutrition is prescribed. This is the only way to relieve the stress on the pancreas and avoid patient exhaustion. In the early period of rehabilitation, when there is hope for the preservation of the functions of the suffering organ, the use of 1 - 2 crackers per day is allowed.

As the patient recovers, the diet is expanded by appointing table number 5. Alcohol, fatty, coarse foods, consisting of a large number of ingredients, are removed from the diet. It is recommended to include in the menu finely chopped semi-liquid dishes with a normal thermal regime, fractionally, 5-6 times a day.

Forecast and prevention

Death in hemorrhagic pancreatic necrosis most often occurs during the first 1 - 2 days, with fat - in 4 - 5 days, although, with the provision of full medical care, it is possible to save life the patient. The prognosis sharply worsens if the patient is over 55 years old, leukocytosis was more than 16 × 109 / l, there is a persistent increase in the level blood glucose, urea, or calcium, metabolic acidosis, internal bleeding, or multiple organ failure failure.

But the diagnosis of "Pancreatic necrosis of the pancreas" can be prevented by timely and adequate treatment of acute pancreatitis, strictly observe medical prescriptions and dietary recommendations, excluding from the diet the use of alcoholic beverages and harmful food.