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Pancreatitis
Last reviewed: 17.10.2021
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Acute pancreatitis
There are 4 forms: edematous pancreatitis, fatty pancreonecrosis, hemorrhagic pancreonecrosis, purulent pancreatitis. During the pancreatic necrosis, 3 phases of the disease are distinguished: enzyme toxemia, temporary remission, sequestration and purulent complications. The prevalence of the process can be limited, subtotal and total. With fat pancreatic necrosis, foci of necrosis can be focal and draining.
Pancreatitis has a leading symptom - severe pain in the upper half of the belly of a shingling character with irradiation in the lower back, left arm, scapula, neck on the left. The intensity of pain is associated with irritation of the recessors, increased pressure in the common bile duct and ducts of the pancreas, chemical exposure to trypsin. Therefore, the severity of the pain syndrome is not an indicator of the severity of the process. The most pronounced pain is noted with edematic pancreatitis and hemorrhagic pancreatic necrosis, when innervation is not impaired.
On the contrary, with the loss of nerve endings, pain is reduced, but intoxication and dehydration are increasing. If the peritoneal syndrome does not develop, the pain does not increase with coughing, straining, deep breathing. Nausea and vomiting are present, as a rule, vomiting sometimes indomitable, debilitating, but, unlike intestinal obstruction, brings at least temporary relief. There may be flatulence, intestinal paresis, which grow as the destruction develops in the gland, sometimes this requires differential diagnosis with intestinal obstruction. .
The skin is usually pale, with a grayish or cyanotic hue, in half of the patients the phenomenon of mechanical jaundice. With pancreatic necrosis, characteristic symptoms appear: cyanosis of the skin of the abdomen and peripheral parts of the body (Halstead's symptom), a sharp cyanosis of the navel and the skin around it (Grunwald symptom), or jaundice and pale skin around the navel (Cullen's symptom), cyanosis of the fatal surfaces of the stomach (Gray Turner symptom ), the appearance of violet-marble spots on the trunk. The skin temperature rises, and its growth is characteristic for destructive forms of pancreatitis.
Acute pancreatitis in the early stages is characterized by bloating, it is mild, sharply painful when palpated in epigastrium (when inferred by position, the pancreas is enlarged in size, the testic consistency is painful). During the destruction, the pain increases with palpation of the abdomen, stiff muscles appear in the epigastrium (Kurt's symptom), the pulsation of the aorta disappears (Voskresensky's symptom), the navel is sharply painful on palpation (Dumbadze's symptom), palpation pain in the left costal vertebral corner (Mayo-Robson symptom ).
Characteristic painful points are revealed - when pressing in the antero-inner surface of the lower third of the left shin, pain in the epigastrium (Onyskin's symptom or the Mayo-Robson point) increases sharply.
[6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18]
How to recognize acute pancreatitis?
In diagnosis, it is important not only to establish a diagnosis of pancreatitis, which in most cases is not difficult, but also to track the dynamics of the process, especially not missing the transition to destruction. In addition to assessing the general condition, local manifestations, manifestations of the syndrome of intoxication and dehydration, the dynamics of the activity of blood amylase and urine diastase are important, which not only confirm the presence of pancreatitis (although they can be increased in other pathological states), but also reflect the dynamics of the process.
Of the instrumental methods of research, preference is given to ultrasound, an overview radiography of the abdominal cavity, laparoscopy. In the presence of hypovolemia, an ECG is necessary to exclude myocardial infarction.
Chronic pancreatitis
Chronic pancreatitis belongs to the category of inflammatory-degenerative processes. Clinically manifested as one of the constituents of cholecysto-pancreato-duodenal syndrome. Distinguish: relapsing (stages of exacerbation and remission), pain, calculosis, indurative (pseudotumorous), latent chronic pancreatitis.
Palpatory examination of the pancreas should be performed in the Grotto postures to remove it from the hypochondrium:
- lying on his back with his fists under his waist;
- standing with the torso bending forward and to the left;
- on the right side with knees bent at the knees. In this case, if the patient is not obese, the density of the gland, its size, the zones of maximum pain in palpation (head, body, tail of the gland) is determined.
Clinically, chronic pancreatitis is accompanied by a characteristic pain syndrome: shingles with total lesion of the gland, or epigastric pain, left or right hypochondrium with local forms; there may be an irradiation of pain in the back at the level of X-XII thoracic vertebrae, navel, left shoulder and under the scapula, sometimes in the heart area, usually the pain intensifies in the position on the back and decreases in the position on the abdomen and on all fours. Dyspeptic disorders accompanying pancreatitis are diverse and of varying severity: belching, nausea, decreased appetite, aversion to fatty foods, sometimes vomiting, unstable stools - constipations with bloating are replaced by diarrhea, often patients lose weight, become irritable, work capacity decreases. Painful attacks often develop after errors in the diet (the intake of fatty and spicy food, alcohol), physical activity, only with painful form of pain is permanent,
During painful attacks, the stomach, moderately swollen and painful with superficial palpation, the transverse rigidity of the muscles in the upper abdomen is determined. There may be a positive symptom of Voskresensky (absence of pulsation of the aorta in the epigastrium) or Bailey's symptom (increased pulsation of the aorta, more often with inducible pancreatitis). Mayo-Robson's symptom can be detected. When the process is localized in the head, you can identify the pain point of Dejardin - about 5-7 cm from the navel along the line connecting the navel to the right axillary cavity (corresponds to the projection on the abdominal wall of the distal duct) or soreness in the cholecystopancreatic zone of Schofar (5-7 cm above the navel to the right and left of the median line). In some cases, the symptom Kara - hyperesthesia during the innervation of VIII-X thoracic segment to the left, the symptom of Shelagurov - some atrophy of subcutaneous, fiber in the area of the projection of the pancreas on the anterior abdominal wall is revealed. Stones in the ducts can cause the development of mechanical jaundice.
How to recognize chronic pancreatitis?
The examination should begin with the two most informative methods - abdominal ultrasound and FGD. General clinical methods of laboratory investigation reveal signs of inflammation only during the period of exacerbation. An increase in urine diastase, even during exacerbations, is insignificant or not at all, but typically an increase in the activity of blood trypsin, a sharp decrease in alpha-amylase and lipase in duodenal contents. Pancreatitis is characterized by a decrease in the incretory function, with obvious sclerosis, there is a development of a typical diabetes mellitus, in the initial stages there is a decrease in glucose tolerance (fasting blood glucose and after a sugar load). Examination of feces during exacerbations can reveal the presence of undigested muscle fibers (createrorrhea) and neutral fats (steatorrhea).
X-ray methods of studying the pancreas are rarely used recently. On a review radiography, you can identify with a swollen bowel a chain of stones in the duct of the pancreas, a decrease in the mobility of the left dome of the diaphragm and the blurring of the contours of the left lumbar muscle (Gobier's symptom). In the contrast study of the stomach and duodenum, indirect signs can be revealed: the upward and anterior displacement of the stomach, the unfolding of the horseshoe of the duodenum, the presence of a defect in filling the medial contour, and the deformation of the intestine in the region of the Fatberg nipple (Flostberg symptom). In doubtful cases and for differential diagnosis with pancreatic tumors, the clinic of which differs little from chronic pancreatitis, magnetic resonance imaging is shown.