Pancreatitis

Pancreatitis is an inflammation of the pancreas. There are two main forms - acute and chronic pancreatitis.

[ 1 ], [ 2 ]

Acute pancreatitis

There are 4 forms: edematous pancreatitis, fatty pancreatic necrosis, hemorrhagic pancreatic necrosis, purulent pancreatitis. During pancreatic necrosis, there are 3 phases of the disease: enzymatic toxemia, temporary remission, sequestration and purulent complications. The prevalence of the process can be limited, subtotal and total. In fatty pancreatic necrosis, the foci of necrosis can be focal and confluent.

Pancreatitis has a leading symptom - severe pain in the upper abdomen of a girdle nature with irradiation to the lower back, left arm, shoulder blade, neck on the left. The intensity of pain is associated with irritation of receptors, increased pressure in the common bile duct and pancreatic ducts, chemical action of trypsin. Therefore, the severity of the pain syndrome is not an indicator of the severity of the process. The most severe pain is observed in edematous pancreatitis and hemorrhagic pancreatic necrosis, when the innervation is not impaired.

On the contrary, with damage to the nerve endings, the pain decreases, but intoxication and dehydration increase. If peritoneal syndrome does not develop, the pain does not increase with coughing, straining, deep breathing. Nausea and vomiting are usually present, vomiting is sometimes uncontrollable, debilitating, but, unlike intestinal obstruction, brings at least temporary relief. There may be flatulence, intestinal paresis, which increase as destruction in the gland develops, sometimes this requires differential diagnostics with intestinal obstruction.

The skin is usually pale, with a grayish or cyanotic tint, and half of the patients have mechanical jaundice. In pancreatic necrosis, characteristic symptoms appear: cyanosis of the skin of the abdomen and peripheral areas of the body (Halsted's symptom), severe cyanosis of the navel and the skin around it (Grunwald's symptom) or yellowness and pallor of the skin around the navel (Cullen's symptom), cyanosis of the fatal surfaces of the abdomen (Gray-Turner's symptom), the appearance of purple-marbled spots on the body. The skin temperature rises, and its increase is characteristic of destructive forms of pancreatitis.

Acute pancreatitis in the early stages is characterized by abdominal distension, it is soft, sharply painful on palpation in the epigastrium (when the pancreas is brought out in position, it is enlarged in size, doughy in consistency, painful). With destruction, the pain on palpation of the abdomen increases, rigidity of the muscles in the epigastrium appears (Kerte's symptom), pulsation of the aorta disappears (Voskresensky's symptom), the navel is sharply painful on palpation (Dumbadze's symptom), pain on palpation in the left costovertebral angle (Mayo-Robson's symptom).

Characteristic pain points are revealed - when pressing in the area of the anterior-inner surface of the lower third of the left leg, the pain in the epigastrium sharply increases (Onyskin's symptom or Mayo-Robson point).

[ 3 ], [ 4 ], [ 5 ], [ 6 ], [ 7 ], [ 8 ]

How to recognize acute pancreatitis?

In diagnostics, it is important not only to establish the 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 intoxication and dehydration syndrome, the dynamics of blood amylase and urine diastase activity are of great importance, which not only confirm the presence of pancreatitis (although they can be elevated in other pathological conditions), but also reflect the dynamics of the process.

Of the instrumental methods of examination, preference is given to ultrasound, plain radiography of the abdominal organs, and laparoscopy. In the presence of hypovolemia, an ECG is mandatory to exclude myocardial infarction.

Chronic pancreatitis

Chronic pancreatitis is classified as an inflammatory-degenerative process. It is clinically manifested as one of the components of the cholecysto-pancreato-duodenal syndrome. The following are distinguished: recurrent (stages of exacerbation and remission), painful, calculous, indurative (pseudotumorous), latent chronic pancreatitis.

Palpation examination of the pancreas should be carried out in Grott's poses to remove it from the hypochondrium:

1. lying on your back with your fists placed under your lower back;
2. standing with the body tilted forward and to the left;
3. on the right side with the knees bent. In this case, if the patient is not obese, the density of the gland, its size, the zones of maximum pain during palpation (head, body, tail of the gland) are determined.

Clinically, chronic pancreatitis is accompanied by a characteristic pain syndrome: girdle pain with total damage to the gland, or pain in the epigastrium, left or right hypochondrium with local forms; there may be irradiation of pain to the back at the level of the X-XII thoracic vertebrae, the navel, the left shoulder and under the shoulder blade, sometimes in the heart area, usually the pain intensifies in the supine position and decreases in the prone position and on all fours. Dyspeptic disorders accompanying pancreatitis are varied and of varying severity: belching, nausea, loss of appetite, aversion to fatty foods, sometimes vomiting, unstable stool - constipation with bloating is replaced by diarrhea, patients often lose weight, become irritable, and their ability to work decreases. Pain attacks often develop after errors in diet (eating fatty and spicy foods, alcohol), physical activity, only with the painful form the pain is constant,

During attacks of pain, the abdomen is moderately distended and painful on superficial palpation, transverse rigidity of the muscles in the upper abdomen is determined. There may be a positive Voskresensky symptom (absence of aortic pulsation in the epigastrium) or Bailey's symptom (increased aortic pulsation, more often with indurative pancreatitis). The Mayo-Robson symptom may be detected. If the process is localized in the head, Desjardins' pain point can be detected - approximately 5-7 cm from the navel along the line connecting the navel with the right axillary fossa (corresponds to the projection of the distal duct onto the abdominal wall) or pain in the cholecystopancreatic zone of Chauffard (5-7 cm above the navel to the right and left of the midline). In some cases, the Kara symptom is revealed - hyperesthesia along the innervation of the VIII-X thoracic segment on the left, the Shelagurov symptom - some atrophy of the subcutaneous tissue in the area of the projection of the pancreas on the anterior abdominal wall. Stones in the ducts can cause the development of mechanical jaundice.

[ 9 ], [ 10 ]

How to recognize chronic pancreatitis?

The examination should begin with the two most informative methods - abdominal ultrasound and FGDS. General clinical laboratory tests reveal signs of inflammation only during exacerbations. Increased urine diastase, even during exacerbations, is insignificant or does not occur at all, but an increase in blood trypsin activity, a sharp decrease in alpha-amylase and lipase in the duodenal contents are typical. Pancreatitis is characterized by a decrease in endocrine function, with obvious sclerosis, the development of typical diabetes mellitus is noted, in the initial stages, a decrease in glucose tolerance is noted (fasting blood glucose test and after a sugar load). Stool examination during exacerbations can reveal the presence of undigested muscle fibers (creatorrhea) and neutral fats (steatorrhea).

X-ray methods of examining the pancreas have been rarely used lately. On plain radiography, a chain of stones in the pancreatic duct, decreased mobility of the left dome of the diaphragm, and blurred contours of the left lumbar muscle (Gobier's symptom) can be detected against the background of a distended intestine. Contrast examination of the stomach and duodenum can reveal indirect signs: displacement of the stomach upward and forward, unfolding of the horseshoe of the duodenum, presence of a filling defect along the medial contour, deformation of the intestine in the area of the Vater's papilla (Flostberg's symptom). In doubtful cases and for differential diagnosis with pancreatic tumors, the clinical picture of which differs little from chronic pancreatitis, magnetic resonance imaging is indicated.