Pancreatitis: what is this disease and causes

Pancreatitis is an inflammation of the pancreas, which is accompanied by cell destruction and increased enzyme production. The mortality rate in the presence of a necrotizing and infectious type of disease is quite high, especially due to multisystem organ failure. In this article, we will tell you in detail what kind of disease it is - pancreatitis, the causes of its occurrence, as well as how to diagnose and treat this ailment.

Etiology of pancreatitis

Gallstones

Stones that block the flow of bile are the most common cause of pancreatitis. It is believed that obstruction or simply blockage of the passage contributes to the backflow of bile into pancreatic channel, which leads to the activation of enzyme production and subsequent development pancreatitis.

The defeat of the pancreas by helminths and tumors can cause obstruction and accelerate pancreatitis. Cholecystectomy (removal of the gallbladder) in patients with gallstones prevents acute pancreatitis and protects against recurrence.

Stones in the gallbladder are more common in middle-aged women and women of many years. They are small in size and usually pass through the cystic duct, in contrast to large specimens, which cause obstruction and acute pancreatitis.

Read about whether it is possible to cure gallstones in our article.

Alcohol

Alcohol is responsible for 30% of cases of severe pancreatitis and is one of the main causes of its chronic form. It is believed that alcoholic beverages cause the cells of the pancreas to produce lytic enzymes that initiate inflammation and decomposition (autolysis) of the organ.

Hypertriglyceridemia

An increase in triglyceride levels can accelerate pancreatitis, especially above 1000 mg / dL. This happens to children treated with glucocorticosteroids, as well as those with genetic disorders. lipoprotein metabolism, nephrotic syndrome, obesity, hypothyroidism (thyroid problems) and sugar diabetes.

Smoking leads to many diseases, including pancreatitis and pancreatic cancer.

Medication

Some drugs are also involved in the development of inflammation. In this case, the prognosis is not too bad. Common drugs that provoke pancreatitis are: metronidazole, sulfonamides, valproic acid, octeriotide, furosemide, didanosine, azathioprine, pentamidine, 6-mercaptopurine and tetracycline. The mechanism of inflammation is different, but all substances have similar clinical manifestations.

Genetic mutations in the CFTR gene (in patients with cystic fibrosis) and PRSS1 have also been associated with pancreatitis.

Other reasons:

• injury;
• as a result of endoscopic retrograde cholangiopancreatography (ERCP);
• hypercalcemia (increased concentration of calcium in the blood plasma);
• viral infection (eg mumps and cytomegalovirus).

Pathophysiology of pancreatitis

The pancreas produces insulin and secretes digestive enzymes. About 80% of the organ (by weight) is involved in exocrine function (the production of enzymes for the digestion of food).

The exact pathophysiology of acute pancreatitis is unclear. The current understanding is that both extracellular and intracellular factors contribute to its development.

Pancreatitis can result from any event that causes damage to acinar (enzyme-secreting) cells and reduces the ability of the pancreas to secrete zymogen granules.

Systemic Inflammatory Response Syndrome (SIRS) is possible, resulting in systemic shock or pathological inflammatory response in organs and tissues that have been removed from the site damage. If a patient has acute pancreatitis, parenchymal (intracellular) edema first develops, and then necrosis (death) of peripancreatic fats. This condition is called acute edematous pancreatitis.

The clinical picture of pancreatitis

The most characteristic clinical manifestation of the disease is unpleasant abdominal pain that radiates to the back and worsens when bending forward. In severe cases, nausea and vomiting may occur. The acute form of pancreatitis is accompanied by complications in the place of accumulation of pleural fluid, respiratory adult distress syndrome (pulmonary inflammatory disease) and multiple organ failure (organ failure and fabrics).

General examination of patients is notable for the presence of signs of heart failure in combination with hypotension (low pressure), tachycardia (heart palpitations), tachypnea (rapid breathing) and hypoxemia (low oxygen in the blood). Symptoms of pancreatitis are seen in some people with scleral jaundice (gallstone disease), hepatomegaly (alcoholism), or enlarged parotid glands (mumps).

A local examination of the abdomen reveals bloating and tenderness that may be located in the epigastrium (below the xiphoid process) or spread into the intestines. Cullen's symptom is accompanied by bruising in the umbilical region, while Turner's symptom is accompanied by lateral hematomas. Both indicate the presence of retroperitoneal (retroperitoneal) hemorrhage, characteristic of hemorrhagic pancreatitis.

Diagnosis of pancreatitis

Amylase assay

This examination is carried out if the patient has an increased secretion of pancreatic enzymes. In the initial stage of pancreatitis, the level of amylase exceeds the norm by 3 times, but in a couple of days it returns to normal due to the short half-life.

However, increased secretion of amylase is not specific for a severe form of the disease, since it also manifests itself in acute cholecystitis (inflammation of the gallbladder), malignant neoplasms, renal failure and ectopic pregnancy. In the case of alcoholic pancreatitis or hypertriglyceridemia (high lipids in the blood), the test may give an incorrect result, since high amylase levels are not easy to detect.

Lipase assay

In contrast to amylase, this enzyme is more specific, and after the elimination of symptoms, it is still observed in large quantities. Intestinal obstruction, peptic ulcer disease, celiac disease (gluten intolerance) and pancreatic cancer are accompanied by accelerated lipase secretion.

Liver enzyme testing

The test for determining the level of the enzymes ALT and AST in the blood is more accurate in the diagnosis of gallstone pancreatitis than the analysis of the amount of alkaline phosphatase.

Complications

Local complications include:

1. Pancreatic pseudocyst (accumulation of pancreatic secretions).
2. Acute necrosis.
3. Acute peripancreatic fluid accumulation.
4. Venous thrombosis.
5. Infection.

Tomography (CT) for pancreatitis

An abdominal ultrasound can help detect an enlarged pancreas or swelling, fluid buildup, and gallstone disease.

Contrast abdominal CT helps detect the severity and extent of pancreatic inflammation and necrosis, if present. It also helps in identifying the causes of pancreatitis.

MRI without and with contrast allows detecting enlargement and necrosis of the pancreas.

Endoscopic retrograde cholangiopancreatography (ERCP) helps in the diagnosis and treatment of gallstone pancreatitis. When surgery is contraindicated, a papillotomy is performed.

Predicting pancreatitis

Pancreatitis is mild to severe. Most patients with mild illness recover after a few days, while the acute form leads to necrosis, multiple organ failure, and death. Some patients develop recurrent or chronic pancreatitis.

Pancreatitis treatment

The Acute Physiological Disorders and Chronic Condition II Disorders (APACHE) and Systemic Inflammatory Response Syndrome (SIRS) scale are used to determine the severity of the disease.

APACHE score depends on the patient's age and various physiological parameters, which include: temperature, pulse, mean arterial pressure, respiratory rate, level of consciousness, urine volume, sodium, potassium, PH, glucose and calcium.

Treatment for pancreatitis depends on the severity of the disease. In the presence of high APACHE rates and an acute form of the disease, resuscitation is required.

The initial stage of treatment for patients with severe pancreatitis is infusion therapy (the introduction of a special solution into the blood). It must compensate for the loss of fluid in the retroperitoneal and intraperitoneal cavities.

To ensure optimal hydration, it is necessary to monitor the measurement of urine output (volume of urine excreted) and the central venous pressure of patients. Parenteral (intravenous) nutrition is given until the patient complains of abdominal pain and nausea. Then, for the first 48 hours, the patient follows a liquid, low-fat diet.

For severe abdominal pain, fentanyl or meperidine is given. Morphine should be avoided if gallstone pancreatitis is present, as it increases pressure on the sphincter of Oddi.

Antibiotic therapy is for patients with infection, but not for routine administration. Imipenem and cilastatin have been shown to be effective in penetrating pancreatic tissue and preventing abdominal infection.

Video - Pancreatitis: treatment + diet

List of Fat Containing Foods

The best foods for patients with pancreatitis are fruits, vegetables, whole grains, legumes, low-fat dairy products, and lean meats. Servings of healthy fats (avocados, olive oil, oily fish, nuts, and seeds) should be controlled.

Table 1. List of Fat Containing Foods (5 g Fat Per Serving)

Serving Size	Food
1 tbsp. l.	Oil (vegetable, corn, rapeseed, olive, etc.)
1 tbsp. l.	Butter or margarine
1 tbsp. l.	Mayonnaise
1 tbsp. l.	Low fat margarine or mayonnaise
1 tbsp. l.	Salad dressing (mid-priced brand)
1 tbsp. l.	Cream cheese
2 tbsp. l.	Light cream cheese
2 tbsp. l.	Avocado
8 large	Black olives
10 large	Stuffed green olives
1 slice	Bacon
1 average	Whole egg
85 g	Wild Salmon (Farmed salmon contains twice the fat)
1.5 tbsp. l.	Peanut butter

How to eat with pancreatitis, read in our article.

Surgical intervention

Surgical intervention is indicated for patients with an acute form of necrotizing pancreatitis. Thus, it is possible to avoid the development of a hemorrhagic form of the disease, which contributes to the self-destruction of the organ. In the presence of an infection or an abscess of the pancreas, percutaneous (puncture) drainage (insertion into the cavity of the catheter) is done. Otherwise, open surgery is performed with the removal of necrotic and infected tissues.

With gallstone pancreatitis, cholecystectomy (removal of the gallbladder) or endoscopic retrograde cholangiopancreaticography (examination of the biliary tract, gallbladder and ducts pancreas).

Pancreatic pseudocyst

The complications that accompany acute pancreatitis include persistent accumulation of peripancreatic fluid or pseudocysts. They do not have an epithelial wall, but are surrounded by adjacent structures such as the pancreas, colon, omentum, and stomach.

As a rule, pseudocysts are asymptomatic, but sometimes they provoke aching pain and indigestion (painful digestion). Due to the expansion of large cysts, intestinal obstruction can develop along with nausea and vomiting. Digestion of blood vessel walls leads to pseudoaneurysms and gastrointestinal bleeding.

The accumulation of inflammatory fluid in the peritoneal and pleural cavities due to leakage of pancreatic enzymes can lead to infection and sepsis. As a rule, surgical treatment is prescribed, followed by the use of octerotide to control the secretion of enzymes. Endoscopic drainage using a transpapillary or transmural approach involves draining fluid and preventing relapse by inserting a stent into the pancreatic canal or interacting with a cyst through the small intestine (transmural enterocystostomy). For large pseudocysts, open surgical drainage with a small bowel anastomosis is used.

Chronic pancreatitis

The development of acute pancreatitis or its recurrence can lead to a chronic form, accompanied by serious structural and functional disorders of the exocrine and endocrine glands. Complications of chronic pancreatitis include: the formation of a pseudocyst, blockage of the bile duct (can lead to jaundice and cirrhosis of the liver), duodenal obstruction intestines with dyspepsia (painful digestion), portal hypertension (increased pressure in the portal vein system), splenic vein thrombosis and endocrine pancreatic failure.

Patients with chronic pancreatitis can develop diabetes mellitus. Subsequent studies have shown that blood glucose and HbA1c levels determine the presence of diabetes and the appropriate treatment regimen. Symptoms such as weight loss, anorexia, and abdominal pain should indicate the presence of adenocarcinoma (cancer) in patients with chronic pancreatitis. Early diagnosis of pancreatic cancer includes analysis for tumor markers and tomography.

Treatment of a patient with chronic pancreatitis begins with his abstinence from alcohol and smoking. Frequent small meals with medium-chain fatty acids (MCFAs) and pancreatic enzyme preparations stop pancreatic agitation and reduce pain. Opiates and amitriptyline also help reduce pain. Sometimes patients need hospitalization.

Surgical treatment of chronic pancreatitis is aimed at combating unpleasant symptoms and correcting structural complications. A total pancreatectomy or partial pancreas resection is intended to relieve bowel obstruction or to treat cancer. For some patients with persistent pain, doctors may prescribe radiation therapy.