Chronic Pancreatitis

Symptoms

 cause of pain is stretching of the pancreatic ducts with an increase in pressure in them due to obstructed outflow of secretions. In the occurrence of pain, a certain role is played by the effect of inflammation on the receptor apparatus of the pancreas, as well as ischemia of its parenchyma due to edema and fibrosis. As a rule, pain is localized in the left hypochondrium or epigastric region. Pain can be of different intensity: from minimal to excruciating. Pain radiates to the back, left shoulder, left shoulder blade. Less commonly, pain is in the right hypochondrium or girdle. Pain intensifies 30 minutes after eating and in the supine position. The duration of the pain is usually prolonged, it can be constant or of the type of "colic". 
2.    Dyspeptic syndrome: 
Flatulence, rumbling, salivation, burning sensation in the tongue, change in appetite, belching, nausea, vomiting. 
3.    Syndrome of exocrine insufficiency. 
A change in the nature of the stool, from constipation to its increase, up to pancreatic diarrhea: the stool is mushy in consistency, it is difficult to wash off in the toilet, plentiful, frothy, “fatty” in appearance. Changes in the skin (thinning, diffuse grayish pigmentation, follicular hyperkeratosis), hair and nails (dry and brittle), weight loss up to cachexia, seizures in the corners of the mouth. 
4.    Syndrome of endocrine insufficiency: Hunger, dry mouth, thirst, fear, excessive sweating, tremor of the extremities, due to the development of secondary diabetes. 

5.    Syndrome of protein-energy deficiency:  Progressive weight loss, in severe cases - dehydration. 

6.    Cholestatic syndrome:  Jaundice, pruritus, liver enlargement (characteristic only for the pseudotumorous form of chronic pancreatitis). 
7. Asthenoneurotic syndrome: weakness, weakness, decreased ability to work, irritability, hypochondria. 
8. Intoxication syndrome: fever, artalgia, loss of appetite, weakness. 
9. Pancreaticocardial syndrome: cardialgia, extrasystole, tachycardia, muffled heart tones, arterial hypotension. 
10. Pancreatopleural syndrome:  Signs of reactive exudative pleurisy on the left, less often on both sides, due to the formation of diaphragmatic microfistulas and the penetration of enzymes into the pleural fluid. 
11. Thrombohemorrhagic syndrome: thrombosis in the portal system, in the system of pulmonary, mesenteric, coronary and cerebral vessels. 
12. Syndromes of compression of adjacent organs are characteristic of complicated forms of chronic pancreatitis with the formation of pseudocysts, pseudotumorous pancreatitis, developmental anomalies (annular, accessory pancreas, etc.) And pancreatic cancer. 
13. Duodenal compression syndrome (duodenal intestinal obstruction syndrome) is manifested by a clinical picture of high small bowel obstruction: frequent, exhausting vomiting, leading to dehydration, water-electrolyte disorders and trophic insufficiency. 
14. Syndrome of compression of the splenic and portal vein: pancreatic ascites (occurs with pseudotumorous pancreatitis).
 

Causes

Currently, there are two most common causes of chronic pancreatitis:
1.  Alcohol abuse (50-80% of all cases of chronic pancreatitis).
2.  Cholelithiasis, in which secondary obstructive pancreatitis occurs (35-50%).
In addition, there may be some other reasons for the development of chronic pancreatitis:
3.  Diseases of the gastroduodenal zone:
•  pathology of the major duodenal papilla (papillitis, adenoma of the papilla of vater, failure due to papillosphincterotomy, parafatheral diverticulosis, etc.);
•  chronic ulcer of the stomach or duodenum.
4.  Drugs: nsaids, thiazide and loop diuretics, estrogens, macrolides, tetracyclines, sulfonamides, cytostatics and some other drugs.
5.  Hereditary forms of chronic pancreatitis with autosomal dominant and autosomal recessive inheritance.
6.  Injury of the pancreas with closed injuries of the abdominal organs, with thermal injury, in the postoperative period, as well as after diagnostic and therapeutic manipulations, mainly endoscopic (endoscopic retrograde cholangiopancreatography, endoscopic papillosphincterotomy, etc.).
7.  Poisoning by chemical agents: corrosive poisons, organic acids, alkalis and strong oxidizing agents,
Chlorinated hydrocarbons, organophosphate insecticides, tetraboric acid salts, etc.
8.  Autoimmune pancreatitis. It is possible to develop chronic pancreatitis in diseases of the liver (primary biliary cirrhosis, primary sclerosing cholangitis), intestines (crohn's disease and ulcerative colitis) and sjogren's disease (autoimmune exocrinopathy).
9.  Damage to the pancreas in systemic connective tissue diseases and vasculitis: in rheumatism, systemic lupus erythematosus, scleroderma, polyarteritis nodosa, rheumatoid arthritis, wegener's granulomatosis, thrombotic thrombocytopenic purpura, schonlein-genoch purpura, eosinophilic angiitis, takayasu's aortoarteritis and churg's granulomatosis -strauss.
10.  Damage to the pancreas in bacterial, fungal and viral infections, parasitic invasions.
11.  Damage to the pancreas in metabolic disorders: diabetes, hyperlipidemia, hypercalcemia, chronic renal failure.
12.  Damage to the pancreas during pregnancy.
13.  Ischemia of the pancreas. Ischemic pancreatitis is a fairly common pathological phenomenon that occurs mainly in the elderly and senile age.
14.  Secondary exocrine pancreatic insufficiency in enteritis and celiac disease.
15.  Anomalies in the development of the pancreas.
16.  Idiopathic pancreatitis is diagnosed in cases where it is not possible to identify the etiological factor at the time of the study.

Treatment

Treatment is carried out conservatively or surgically, depending on the severity of the course of the disease, as well as the presence or development of complications.

Conservative therapy

•    Diet therapy. Patients with chronic pancreatitis during a period of severe exacerbation are advised to refrain from enteral nutrition; when stubbing, diet no. 5b is prescribed. In chronic pancreatitis, alcohol consumption is strictly prohibited, spicy, fatty, sour foods, pickles are removed from the diet. With pancreatitis complicated by diabetes mellitus, control of sugar-containing products.

•    Exacerbation of chronic pancreatitis is treated in the same way as acute pancreatitis (symptomatic therapy, pain relief, detoxification, inflammation removal, restoration of digestive function).

•    For pancreatitis of alcoholic origin, the refusal to use alcohol-containing products is a key factor in treatment, in mild cases leading to symptomatic relief.

Tests Required for Diagnosis

To clarify the diagnosis, the gastroenterologist prescribes laboratory tests of blood, feces, methods of functional diagnostics:

•    Laboratory tests. A general blood test during an exacerbation, as a rule, shows a picture of nonspecific inflammation. For differential diagnosis, samples are taken for the activity of pancreatic enzymes in the blood (amylase, lipase). Radioimmunoassay reveals an increase in elastase and trypsin activity. The coprogram reveals an excess of fat, which suggests pancreatic enzyme deficiency.

•    Instrumental methods. The size and structure of the pancreatic parenchyma (and surrounding tissues) can be examined using abdominal ultrasound , ct or mri of the pancreas . The combination of the ultrasound method with endoscopy - endoscopic ultrasonography (eus) allows you to examine in detail the tissue of the gland and the walls of the gastrointestinal tract from the inside. In pancreatitis, endoscopic retrograde cholangiopancreatography is used - a radiopaque substance is injected endoscopically into the duodenal papilla.

•    Functional tests. If necessary, to clarify the ability of the gland to produce certain enzymes, functional tests are prescribed with specific stimulants for the secretion of certain enzymes.

Useful info

Indications for surgical treatment of chronic pancreatitis can be purulent complications ( abscess and phlegmon ), obstruction of the bile and pancreatic ducts, stenosis of the sphincter of oddi, pronounced severe changes in the tissues of the gland (sclerosis, calcification), cysts and pseudocysts of the pancreas, severe course, resistant to conservative therapy .