Chronic pancreatitis - Symptoms.

The symptoms of chronic pancreatitis are highly variable: they differ during periods of remission and exacerbation of the disease, and depend on the characteristics of the clinical course (clinical form) of the disease, its stage, and a number of other factors.

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Pain syndrome

The localization of pain depends on the damage to the pancreas:

• pain in the left hypochondrium to the left of the navel occurs when the tail of the pancreas is affected,
• pain in the epigastric region, to the left of the midline, - with damage to the body,
• pain to the right of the midline in the Chauffard zone - with pathology of the head of the pancreas.

In case of total organ damage, the pain is diffuse, in the form of a "belt" or "half-belt" in the upper abdomen. The pain occurs or intensifies 40-60 minutes after eating (especially large, spicy, fried, fatty foods). The pain intensifies when lying on the back and weakens when sitting with a slight forward bend. It can radiate to the heart area, to the left shoulder blade, left shoulder, imitating angina, and sometimes to the left iliac region.

The pains can be periodic, lasting from several hours to several days, usually occurring after eating, especially spicy and fatty food, alcohol, or constant, intensifying after eating. Constant, excruciating pains force the use of strong painkillers, including narcotics, which is highly undesirable, since this can later lead to drug addiction.

Sometimes, in the presence of other signs of pancreatitis, pain may be completely absent - the so-called painless form.

The main causes of pain in chronic pancreatitis are increased pressure in the pancreatic ducts due to impaired secretion outflow, as well as inflammatory and sclerotic changes in the parenchyma of the gland and adjacent tissues, leading to irritation of the nerve endings.

Constant pain is caused by residual inflammation in the pancreas and the development of complications such as pseudocyst, stricture or stone of the pancreatic duct, stenosing papillitis, or solaritis, which often occurs with this disease.

During an exacerbation of the disease, the enlarged pancreas can put pressure on the celiac plexus, causing severe pain. In this case, patients take a characteristic pose - they sit leaning forward. Often, due to severe pain, patients limit their food intake, which becomes one of the reasons for losing weight.

It should be noted that, except for pain (which can be observed in the early stages of the disease ), all other symptoms of chronic pancreatitis usually appear in the later stages of the disease.

Patients with chronic pancreatitis often experience various dyspeptic symptoms: loss or absence of appetite, belching, salivation, nausea, vomiting, flatulence, bowel disorders (predominantly diarrhea or alternating diarrhea and constipation). Vomiting does not bring relief.

Many patients complain of general weakness, rapid fatigue, adynamia, and sleep disturbances.

Pronounced changes in the head of the pancreas during pancreatitis (edema or development of fibrosis) can lead to compression of the common bile duct and the development of mechanical jaundice.

Symptoms of chronic pancreatitis also depend on the stage of the disease: Stages II and especially III are characterized by impaired excretory and endocrine functions of the pancreas, more pronounced clinical symptoms and more severe changes revealed by laboratory and instrumental methods. Most patients experience constant and paroxysmal pain, dyspeptic disorders become more pronounced, digestion of food products and intestinal absorption, including vitamins, are impaired. Diarrhea (so-called pancreatogenic diarrhea) with a high fat content (difficult to flush from the toilet) predominates in the clinic. Patients with low body weight predominate. In some cases, with prolonged pancreatitis, a decrease in the intensity of pain or its complete disappearance is noted.

Exocrine insufficiency

Exocrine pancreatic insufficiency is characterized by a disruption of intestinal digestion and absorption processes, and the development of excessive bacterial growth in the small intestine. As a result, patients experience diarrhea, steatorrhea, flatulence, loss of appetite, and weight loss. Later, symptoms characteristic of hypovitaminosis occur.

The following causes aggravate exocrine pancreatic insufficiency:

• insufficient activation of enzymes due to deficiency of enterokinase and bile;
• disruption of the mixing of enzymes with food chyme, caused by motor disorders of the duodenum and small intestine;
• destruction and inactivation of enzymes due to excessive growth of microflora in the upper intestine;
• deficiency of dietary protein with the development of hypoalbuminemia and, as a consequence, disruption of the synthesis of pancreatic enzymes.

An early sign of exocrine pancreatic insufficiency is steatorrhea, which occurs when pancreatic secretion decreases by 10% compared to the norm. Mild steatorrhea is usually not accompanied by clinical manifestations. With severe steatorrhea, the frequency of diarrhea varies from 3 to 6 times a day, the stool is abundant, foul-smelling, mushy, with a greasy sheen. Steatorrhea decreases and may even disappear if the patient reduces the intake of fatty foods or takes pancreatic enzymes.

A significant proportion of patients experience weight loss due to exocrine pancreatic insufficiency and disruption of digestion and absorption processes in the intestine, as well as due to limited food volume due to pain. Weight loss is usually facilitated by loss of appetite, careful adherence to a strict diet by patients, sometimes fasting due to fear of provoking a pain attack, as well as limiting the intake of easily digestible carbohydrates by patients with diabetes mellitus, which complicates the course of chronic pancreatitis.

Deficiency of fat-soluble vitamins (A, D, E and K) is observed rarely and mainly in patients with severe and prolonged steatorrhea.

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Endocrine insufficiency

Approximately 1/3 of patients develop carbohydrate metabolism disorders in the form of hypoglycemic syndrome, and only half of them have clinical signs of diabetes mellitus. The development of these disorders is based on damage to the cells of the islet apparatus, resulting in a deficiency of not only insulin, but also glucagon. This explains the peculiarities of the course of pancreatogenic diabetes mellitus: a tendency to hypoglycemia, the need for low doses of insulin, the rapid development of ketoacidosis, vascular and other complications.

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Objective research

It is possible to palpate the pancreas only in the case of cystic and tumor processes.

When palpating the abdomen, the following painful areas and points are determined:

• Chauffard's zone- between the vertical line passing through the navel and the bisector of the angle formed by the vertical and horizontal lines passing through the navel. Pain in this zone is most characteristic of localization of inflammation in the region of the head of the pancreas;
• Gubergrits-Skulsky zone- similar to the Chauffard zone, but located on the left. Pain in this zone is characteristic of the localization of inflammation in the body of the pancreas;
• Desjardins point- located 6 cm above the navel along the line connecting the navel with the right armpit. Pain at this point is characteristic of localization of inflammation in the area of the head of the pancreas;
• Gubergritz point- similar to Desjardins point, but located on the left. Pain at this point is observed with inflammation of the tail of the pancreas;
• Mayo-Robson point- located on the border of the outer and middle third of the line connecting the navel and the middle of the left costal arch. Pain at this point is characteristic of inflammation of the tail of the pancreas;
• area of the costovertebral angle on the left- with inflammation of the body and tail of the pancreas.

Many patients have a positive Grothsign- atrophy of the pancreatic fatty tissue in the area of the projection of the pancreas on the anterior abdominal wall. The symptom of "red droplets" may be noted - the presence of red spots on the skin of the abdomen, chest, back, as well as a brownish color of the skin over the pancreas.

Dyspeptic syndrome(pancreatic dyspepsia) is quite typical for chronic pancreatitis, especially often it is expressed during exacerbation or severe course of the disease. Dyspeptic syndrome is manifested by increased salivation, belching of air or eaten food, nausea, vomiting, loss of appetite, aversion to fatty foods, bloating.

Weight loss- develops as a result of restrictions in food (pain decreases during fasting), as well as in connection with the violation of the exocrine function of the pancreas and absorption in the intestine. Weight loss is also facilitated by a decrease in appetite. Weight loss is especially pronounced in severe forms of chronic pancreatitis and is accompanied by general weakness and dizziness.

Pancreatogenic diarrhea and syndromes of insufficient digestion and absorption are typical for severe and long-term forms of chronic pancreatitis with a pronounced disorder of the exocrine function of the pancreas. Diarrhea is caused by disorders of the secretion of pancreatic enzymes and intestinal digestion. The abnormal composition of the chyme irritates the intestines and causes diarrhea. Disturbance in the secretion of gastrointestinal hormones is also important. In this case, the release of large quantities of foul-smelling mushy feces with a greasy sheen (steatorrhea) and pieces of undigested food is typical.

A positive phrenicus symptom is determined (pain when pressing between the legs of the sternocleidomastoid muscle at the place of its attachment to the clavicle). Patients have a body weight deficit. Small bright red spots of a round shape, 1-3 mm in size, can be found on the skin of the chest, abdomen, back, which do not disappear when pressed (Tuzhilin's symptom), a sign of the action of activated pancreatic enzymes. Dryness and peeling of the skin, glossitis, stomatitis caused by hypovitaminosis are also typical.

The course and complications of chronic pancreatitis

The course of chronic pancreatitis without appropriate treatment is usually progressive, with more or less pronounced, rarely or frequently occurring periods of exacerbations and remissions, gradually ending in focal and (or) diffuse reduction of the pancreatic parenchyma, formation of more or less diffusely widespread areas of sclerosis (fibrosis), occurrence of pseudocysts, deformation of the duct system of the organ, alternation of areas of expansion and stenosis, and often the ducts contain compacted secretion (due to protein coagulation), microliths, often diffuse-focal calcification of the gland is formed (chronic calcifying pancreatitis). As the disease progresses, a certain pattern is observed: with each new exacerbation, areas of hemorrhage and parenchyma necrosis are usually detected in the pancreas less and less often (apparently due to the progression of sclerotic processes), the function of this most important organ of the digestive system is increasingly impaired.

Complications of chronic pancreatitis include the development of abscess, cyst or calcification of the pancreas, severe diabetes mellitus, thrombosis of the splenic vein, development of cicatricial-inflammatory stenosis of the main duct, as well as BSD with the development of mechanical jaundice, cholangitis, etc. Against the background of long-term pancreatitis, secondary development of pancreatic cancer is possible.

Rare complications of severe pancreatitis may include "pancreatogenic" ascites and intestinal interloop abscess. Ascites in pancreatitis is a fairly serious complication of the disease, it occurs in patients with severe exocrine pancreatic insufficiency, with hypoalbuminemia (due to digestive disorders in the intestine and insufficient absorption of amino acids, especially during an exacerbation of chronic pancreatitis). One of the causes of ascites in pancreatitis may also be thrombosis of the vessels of the portal vein system.