Chronic pancreatitis

Introduction to chronic pancreatitis Chronic pancreatitis (chronic pancreatitis) is a persistent, permanent lesion of pancreatic tissue and function due to various factors. Different degrees of acinar atrophy, pancreatic duct deformation, fibrosis and calcification, and varying degrees of pancreatic exocrine and endocrine dysfunction occur in the pancreas. Clinical manifestations include abdominal pain, diarrhea or steatorrhea, weight loss and malnutrition such as pancreatic insufficiency. The symptoms of chronic pancreatitis are rare in China, and it is difficult to diagnose. basic knowledge The proportion of sickness: 0.00652% Susceptible people: no special people Mode of infection: non-infectious Complications: pancreatic pseudocysts, abdominal pain, pancreatic fistula

Causes of chronic pancreatitis

The causes of chronic pancreatitis are affected by many factors. The common causes are alcohol overdose and biliary diseases (mainly gallstones). In the past 10 years, there are more alcoholic pancreatitis in European and American countries, accounting for 41%-78. %, cholelithiasis is only 0% to 8%, idiopathic is 9% to 45%, Japan reported 71% alcohol, 8% to 11.3% cholelithiasis, and 27% idiopathic, similar to Europe and America, domestic There are few reports of chronic pancreatitis. Most reports suggest that gallstones account for about 30% to 50%, and alcohol is less, and some reasons are unknown.

The reason for the low incidence of alcoholic pancreatitis in Chinese may be: 1 statistical data is incomplete, there should be national statistical results of large-scale cases of unified diagnostic criteria, in order to draw conclusions; 2 people's living habits are different from the West, Japan, Westerners The Japanese use low-alcohol and beer as drinks, and drink it for a long time. The Chinese prefer high-alcohol and drink less.

Other causes of chronic pancreatitis are: trauma and surgery, metabolic disorders, nutritional disorders, genetic factors, endocrine abnormalities, etc., are intended to be described below.

Biliary disease (26%):

Mainly for bile duct stones, Oddi sphincter inflammation and edema caused by stones incarceration caused by duodenal nipple obstruction caused by pancreatic juice stasis, increased pancreatic duct pressure, resulting in small pancreatic duct and acinar rupture, pancreatic juice deep into the pancreatic stroma, After trypsin activation, it leads to a series of pancreatic enzyme chain reaction and self-digestion. Repeated obstruction and pancreatic juice secretion increase, leading to repeated inflammation of the pancreas. Eventually fibrosis causes chronic pancreatitis. In clinical ascending cholelithiasis surgery, the surgeon often licks. And the swelling, hardening, uneven texture of the pancreatic head chronic inflammation, is typical of biliary pancreatitis.

In addition, bile duct mites, Oddi sphincter edema, hernia, fiber stenosis, deformity, tumors, etc. can cause obstruction of the lower common bile duct and pancreatic duct, leading to chronic pancreatitis.

Alcohol abuse (20%):

The cause of chronic pancreatitis caused by alcohol is not fully understood. It is generally considered that: 1 alcohol stimulates the increase of gastric acid secretion, stimulates the duodenum to secrete secretin and trypsin, which causes the secretion of pancreatic juice to increase, and alcohol stimulates the duodenal mucosa. Oddi sphincter spasm, resulting in increased pancreatic duct pressure; 2 alcohol-induced pancreatic juice protein and bicarbonate concentration increased, pancreatic juice protein and calcium combined to form a stable deposit, attached to the small pancreatic duct wall, forming protein plug The stenosis and obstruction of the pancreatic duct, resulting in atrophy and necrosis of the acinar epithelium, interstitial inflammation and fibrosis; 3 alcohol directly causes degeneration of acinar cytoplasm, mitochondrial swelling, lipid accumulation, pancreas Tube epithelial cell damage, etc.

Trauma and surgery (18%):

Trauma and surgery are common causes of acute pancreatitis. Chronic pancreatitis may occur after severe trauma or injury to the main pancreatic duct. Chronic abdominal pancreatic injury or extensive contusion of pancreatic tissue may lead to chronic pancreatitis. Pathological or penetrating ulcers in the posterior wall of the stomach can also cause destruction of pancreatic tissue and form chronic pancreatitis.

Metabolic disorders (10%):

In patients with hyperlipidemia, the incidence of chronic pancreatitis is relatively high. It is believed that there is a higher concentration of chylomicrons and free fatty acids in the pancreatic capillaries during hyperlipidemia, which causes embolism and damage to the capillaries. It may also be due to hyperlipidemia, increased blood viscosity, increased blood flow resistance in venules and venules, blood stasis, thrombosis leading to pancreatic tissue ischemia, chronic pancreatitis, alcohol, pregnancy, oral contraception Drugs, long-term use of estrogen and vitamin A can cause hyperlipidemia.

Nutritional disorders (5%):

Low-protein diet can lead to chronic pancreatitis, which is more common in Southeast Asia, Africa and Latin America. In recent years, there has been a correlation between high-fat intake and the incidence of pancreatitis. Animal experiments have also shown that high-fat intake makes the pancreas sensitive and prone to chronic disease. Pancreatitis, patients in Europe, America, and Japan are often associated with high fat intake.

Genetic factors (5%):

Hereditary pancreatitis is rare and belongs to chromosomal dominant inheritance.

Congenital malformations of the biliary tract such as pancreatic duct isolation, abnormal bile duct and pancreatic duct often accompanied by chronic pancreatitis, mostly due to poor pancreatic drainage.

Endocrine abnormalities: hypercalcemia can occur when hyperparathyroidism is hyperthyroidism, about 7% to 19% with chronic pancreatitis, hypercalcemia, increased calcium in pancreatic juice, easy to precipitate in acidic pancreatic juice Pancreatic stones; high calcium can still activate pancreatic enzymes to promote pancreatitis.

When the adrenal cortex is hyperactive, cortisol can increase the secretion and viscosity of the pancreas, leading to pancreatic juice excretion, and increased pressure to cause pancreatitis.

Pathogenesis

Due to the severity of the disease, the pathology has a large change. The surface of the pancreas is smooth, but uneven, with wood or stone-like hardness, volume is reduced, the cut surface is white, the main pancreatic duct is narrow, the distal end is dilated, and the heavy one can affect the first and second grades. Branches, the ends of which often form a saclike shape, the tube has white or colorless liquid, most of which have no bacterial growth. It is often seen that the protein precipitates as the precursor of the stone, and the cysts of different sizes can be seen in the head and neck, which are connected with the main pancreatic duct. Compression of surrounding organs, sometimes forming sinus with surrounding tissues, hardening around the pancreas can affect adjacent tissues, such as common bile duct stricture, stomach, duodenal artery stenosis, portal vein compression or thrombosis can cause portal hypertension.

Microscopic examination showed degeneration and necrosis of gland cells, intertrochanteric tubule dilatation, fibrous tissue hyperplasia, inflammatory cell infiltration and tissue sclerosis, vascular changes were not significant, and islet involvement was the latest. In about 27% of cases, gland cells were severely affected or even disappeared, but islets still Clearly visible.

The pathophysiological changes are characterized by a large amount of protein secreted by pancreatic acinar cells, and the liquid and bicarbonate secreted by the pancreatic duct cells do not increase, presumably due to the secretion of pancreatic protein (Lithostathine) and GP2 (a form of pancreatic acinar cells) The concentration of the tubular protein is decreased and is easily precipitated in the pancreatic duct, which is closely related to the formation of chronic pancreatitis.

Extra-pancreatic tissue changes, often biliary system lesions, peptic ulcer disease, pancreatic vein thrombosis, portal hypertension is not uncommon, a small number of patients have ascites formation and pericardial effusion, fat necrosis type can appear subcutaneous tissue necrosis, forming subcutaneous Nodule.

Chronic pancreatitis prevention

prevention

1. Active prevention and treatment of related diseases. Biliary diseases are common diseases of the elderly, and frequently-occurring diseases. Active prevention and treatment of biliary diseases is an important measure to prevent chronic pancreatitis in the elderly. In addition, diseases related to the onset of this disease, such as parathyroid glands Hyperfunction, hyperlipidemia, etc. must also be actively prevented.

2, active and thorough treatment of acute pancreatitis, a large number of elderly patients with chronic pancreatitis, a history of acute pancreatitis, speculated that the incidence of this disease may be related to the acute cure of acute pancreatitis, therefore, suffering from acute pancreatitis Those must be treated aggressively and completely cured so as not to leave behind.

3, do not drink alcohol, drink less, long-term alcohol abuse is likely to cause chronic alcoholism, alcoholism is one of the important causes of chronic pancreatitis, so from the beginning of youth should develop a good habit of not drinking alcohol or just a small amount of drinking, if In patients with chronic pancreatitis, in order to prevent the disease from developing, it is necessary to completely stop drinking.

4, diet, careful diet, prevent overeating, is very important to prevent this disease, at the same time, the elderly should be light diet, eat less spicy and sweet, alcoholic wine thick taste, to prevent the disease caused by intestinal heat.

5, pleasant mood, good mood, the elderly should avoid the sorrowful anger and other bad mental stimulation, happy mood, then the air is smooth, blood circulation, can prevent the disease.

Chronic pancreatitis complications Complications pancreatic pseudocyst abdominal pain pancreatic fistula

Chronic pancreatitis mainly manifests as chronic abdominal pain and pancreatic and exocrine insufficiency. It is related to the occurrence of pancreatic cancer and can cause other complications. The most common complication is the formation of pseudocyst and duodenum. Mechanical obstruction of the common channel, less common complications include splenic vein thrombosis and portal hypertension, the formation of pseudoaneurysms (especially the splenic artery) and pancreatic chest, ascites, and chronic pancreatitis will be described in detail below. Complications and their handling.

1, pseudocyst

(1) Mechanism of formation: There are two important mechanisms for chronic pancreatitis complicated with pseudocysts:

1 The pressure in the pancreatic duct leads to rupture of the pancreatic duct, extravasation of the pancreatic juice, and the pancreatic juice is often clear due to no active inflammation.

2 active inflammation with fat necrosis (may also have necrosis of the pancreatic parenchyma), pancreatic juice from the small pancreatic duct extravasation, due to necrotic tissue, pancreatic juice often discoloration.

(2) Pseudocysts occur in about 10% of cases of chronic pancreatitis. The pseudocysts can be single or multiple, large or small, located in the pancreas, and most pseudocysts are connected to the pancreatic duct. Rich in digestive enzymes, the wall of pseudocyst is composed of adjacent structures, such as stomach, transverse colon, gastric colonic omentum and pancreas. The intima of pseudocyst is composed of fiber or granulation tissue, and it is distinguished from pancreatic true cyst by endothelium. Open, pseudocyst is generally asymptomatic, but can cause abdominal pain or biliary obstruction through mechanical compression. When it erodes blood vessels, it can cause bleeding, infection or ulceration, leading to the formation of pancreatic fistula or ascites. Diagnosis of pseudocyst It can be confirmed by CT or ultrasonography. If the drainage has been placed, the amylase level of the cyst fluid can be measured, and if it is increased, it can be diagnosed as a pseudocyst.

(3) Treatment:

1 drainage: indications for drainage include rapid increase of cysts, cysts compressing surrounding tissues, causing abdominal pain and signs of infection. The drainage methods include percutaneous drainage and internal drainage. The former requires placement of the drainage tube for several weeks until the cyst disappears, possibly with concurrent infection. According to the location of the pseudocyst and the existing facilities, endoscopic or surgical treatment can be performed. 80% of the cases are effective endoscopic treatment, the recurrence rate of the cyst is 20%, and the mortality rate is 3%.

2 surgical treatment including cyst gastrostomy, cyst duodenal ostomy and Rou-X-en-Y cyst jejunostomy, cysts limited to the tail of the pancreas can be used for distal resection of the pancreas.

2, biliary or duodenal obstruction

(1) Symptomatic obstruction of biliary tract and/or duodenum: occurred in 5% to 10% of cases of chronic pancreatitis. Duodenal obstruction mainly manifests as postprandial abdominal pain and early satiety; abdominal pain and abnormal liver function (including hyperbilirubinemia) often suggest bile duct stricture, this complication is more common in patients with pancreatic duct dilatation, mainly due to inflammation or fibrosis of the pancreatic head, caused by pseudocyst, ERCP is most commonly used for biliary obstruction The diagnosis, MRCP can also get the same quality of biliary imaging, and may eventually replace ERCP, duodenal obstruction can be clearly diagnosed by upper gastrointestinal endoscopy.

(2) Treatment: If the obstruction caused by pseudocyst is treated, the above method can be used. Otherwise, gastric jejunostomy and common bile duct anastomosis can be used. Benign stenosis of the biliary tract can be performed under endoscopic stenting. Decompression because it reverses secondary biliary fibrosis caused by biliary obstruction.

3, pancreatic chest, ascites

(1) Pancreatic chest and ascites formation: may be due to rupture of the pancreatic duct, forming a fistula with the abdominal cavity and thoracic cavity, or the collapse of the pseudocyst into the chest, abdominal cavity, clinically, pancreatic ascites may be presented Serous, bloody or chylorrhea, the latter two are rare, pancreatic pleural effusion is more common on the left side, with chronic, progressive, recurrent and pleural effusion, can also be serous, bloody or The chyle is characterized by the analysis of the nature of ascites or pleural effusion by abdominal or chest puncture. If the amylase in the effusion increases, especially above 1000 U/L, it has a great diagnostic value.

(2) Treatment: Non-surgical treatment includes repeated puncture, diuretic, octreotide and parenteral nutrition. If the pancreatic duct is ruptured, endoscopic stent placement is effective in a short period of time, and long-term efficacy depends on the disease.

4, splenic vein thrombosis

(1) splenic vein thrombosis: the incidence of chronic pancreatitis is about 2%, which is caused by spleen vein compression, acute exacerbation of chronic pancreatitis and vascular disease caused by fibrosis, clinically The manifestations of portal hypertension, such as the fundus or lower esophageal varices, can cause gastrointestinal bleeding, and occasionally occlusion of the superior mesenteric vein or portal vein.

(2) splenectomy is effective.

5, the formation of pseudoaneurysm

(1) In chronic pancreatitis, the incidence of pseudoaneurysms is 5% to 10%, and the mechanism is three:

1 The digestive enzyme released when accompanied by acute inflammation is activated and has a digestive effect on the blood vessel wall.

2 pseudocysts increase and then erode blood vessels.

3 pancreatic duct rupture, resulting in the formation of pseudocysts rich in digestive enzymes, often located near the artery.

Pseudoaneurysm can cause gastrointestinal bleeding, which can be slow, intermittent bleeding, or acute hemorrhage. The affected blood vessels are often close to the pancreas, including the splenic artery, hepatic artery, gastroduodenal artery and pancreatic 12 The intestinal artery, CT or MRI can be found in the lesion, which is characterized by a cystic structure similar to a pseudocyst in the pancreas. Color ultrasound can show the blood flow inside the pseudoaneurysm.

(2) Mesenteric angiography can confirm the diagnosis, and at the same time, embolization treatment of pseudoaneurysm can be performed during this operation. Surgical treatment is difficult and has certain risks.

6, acute pancreatitis

(1) Chronic pancreatitis may have acute inflammation of the pancreas, mostly interstitial, and may also be manifested as necrotizing pancreatitis, which may lead to the occurrence of pancreatic and liver abscesses in the late stage. Pancreatic necrosis may also occur after chronic pancreatitis. And abscess.

(2) The treatment is roughly the same as acute pancreatitis.

7, pancreatic calcification and pancreatic duct stones

(1) Pancreatic calcification: a common feature of chronic pancreatitis caused by various reasons. The presence of chronic pancreatic calcification also suggests pancreatic duct stones. It should be noted that other causes of pancreatic calcification, such as cystic neoplasms, hemangioma, should be excluded. And hematoma, etc., in alcoholic pancreatitis, about 25% to 60% of patients with pancreatic calcification, more than 8 years after the onset of symptoms, only 50% to 60% of patients with pancreatic calcification with steatorrhea or Dominant diabetes, it is found that pancreatic calcification does not indicate end-stage chronic pancreatitis.

(2) Treatment: In addition to endoscopic stone removal, extracorporeal shock wave lithotripsy and surgery, oral citrate treatment can also be used for pancreatic duct stones. Foreign studies have found that citrate can increase the solubility of pancreatic stone, orally every day. 5 to 10 g of citrate, 38.9% of patients after 3 to 27 months, the pancreas was reduced.

8, pancreatic cancer

Chronic pancreatitis is an important risk factor for pancreatic cancer, especially alcoholic, hereditary and tropical pancreatitis. The incidence rate is about 4%. There is no effective monitoring method. It is difficult to detect early lesions, ERCP, in CA19-9. CT and endoscopic ultrasound are also difficult to diagnose. When there is difficulty in identification, surgical exploration should be performed.

9, pancreatic fistula

(1) including pancreatic external hemorrhoids and internal hemorrhoids: external hemorrhoids often occur in pancreatic biopsy, pancreatic necrosis, surgical drainage, intraoperative pancreatic injury or abdominal blunt trauma, internal hemorrhoids often occur in the main pancreatic duct of chronic pancreatitis or After the rupture of the pseudocyst, often combined with pancreatic chest, ascites, alcoholic pancreatitis is prone to internal hemorrhoids.

(2) Treatment:

1 treatment of external hemorrhoids: TPN and fasting have been used before, and proved to be effective. In recent years, it has been found that the use of octreotide 50 ~ 100g, once every 8 hours, is a safe and effective measure to close the external hemorrhoids, but the treatment has been Long may inhibit gallbladder emptying and induce cholelithiasis, and it is expensive. In recent years, endoscopic stent placement is used, and the rupture site of the catheter is displayed by ERCP. The Vater ampulla enters the main pancreatic duct and is placed in the stent. 6 weeks, the second ERCP was taken out. If there is still external hemorrhoids, the stent can be placed again and octreotide is used to reduce the amount of pancreatic juice. Octreotide is often used to prevent complications such as pancreatic fistula during perioperative period.

2 treatment of internal hemorrhoids: the use of TPN and repeated extraction of pleural effusion and ascites, also proved to be effective, can also be used octreotide, endoscopic stent placement and surgical treatment.

10. Other complications

(1) The occurrence of bone damage is relatively rare, mainly including osteomalacia and idiopathic femoral head necrosis.

(2) Chronic pancreatitis with steatorrhea, often lack of fat-soluble vitamins A, D, E, K.

(3) Vitamin B12 malabsorption occurs in 50% of cases of severe chronic pancreatitis. After oral administration of trypsin, the absorption of vitamin B12 can be restored to normal.

(4) Patients with chronic pancreatitis have a higher rate of Giardia infection due to immune dysfunction. If steatorrhea is ineffective for pancreatic enzyme treatment, stool examination should be performed to rule out Giardia infection.

(5) Occasionally, patients with chronic pancreatitis may have partial or complete stenosis of the transverse or descending colon.

Chronic pancreatitis symptoms Common symptoms Abdominal pain Ascites persistent pain Venous thrombosis Pancreatic fibrosis Diabetes weak bloating Upper gastrointestinal bleeding Bleeding

Different in severity, there may be no obvious clinical symptoms, and there may be obvious clinical manifestations.

1. Abdominal pain: Up to 90% of patients have different degrees of abdominal pain. They occur once every few months or years. They are persistent pain, mostly in the middle and upper abdomen. They are dull or dull, and can be left or right. Often radiated to the back, the pain site is consistent with the inflammation site. According to the experiment, the pancreatic head is stimulated by electricity. The pain occurs in the right upper abdomen, stimulating the tail of the pancreas. The pain is in the left upper abdomen. In addition to radiating to the back, a few are down to the chest and the kidney area. And the testicles are released, the sputum is involved, there may be shoulder radioactive pain, the pain is persistent, deep, the light only has a sense of pressure or burning, there is little sputum-like feeling, drinking, high-fat, high-protein diet can induce symptoms When the pain is severe, accompanied by nausea and vomiting, the abdominal pain of such patients often has the characteristics of body position. The patient likes to lie in the recumbent position, sitting position or anteversion position, and the abdominal pain is increased in the supine position or erect.

2, diarrhea: mild patients without diarrhea symptoms, but in severe cases, the alveolar destruction is excessive, the secretion is reduced, that is, symptoms appear, manifested as abdominal distension and diarrhea, 3 to 4 times a day, a lot of color, pale, shiny surface and Bubbles, malodors, mostly acidic reactions, due to fat digestion, absorption disorders, increased fat in the feces, in addition, there are still indigestible muscle fibers in the feces, due to the loss of a large amount of fat and protein, patients with weight loss, weakness and nutrition Bad performance.

3, other: some symptoms of dyspepsia such as abdominal distension, loss of appetite, nausea, fatigue, weight loss and other symptoms are common in patients with severe pancreatic function impairment, such as islet involvement can significantly affect glucose metabolism, about 10% have obvious symptoms of diabetes, in addition Patients with biliary diseases or biliary obstruction may have jaundice. Pseudocysts may touch the abdominal mass. A few patients may have pancreatic ascites. In addition, chronic pancreatitis may cause upper gastrointestinal bleeding. The reason is: pancreatic fiber. Chemotherapy or cyst formation oppression of the splenic vein, portal vein thrombosis can be caused by portal hypertension, and the probability of patients with chronic pancreatitis complicated with peptic ulcer is high, alcoholic gastric mucosal injury can occur in patients with persistent alcoholism, multiple patients with chronic pancreatitis can occur Fat necrosis, subcutaneous fat necrosis often occurs in the limbs, which can form hard nodules under the skin.

Examination of chronic pancreatitis

Laboratory inspection

1. When the acute attack occurs, the white blood cells are elevated, and various pancreatic enzyme activities are increased. The pancreatic enzyme activity in the interictal phase is normal or low.

2. Fecal examination: The fat droplets and the indigestible muscle fibers can be seen under the microscope. After the Sudan III alcohol staining, red small spheres of different sizes can be seen. This method can be used as the basic method for simple primary screening.

3, other: such as glucose tolerance test, blood bilirubin, alkaline phosphatase, etc. are helpful in the diagnosis of chronic pancreatitis or to help comprehensively understand the liver function and biliary obstruction.

4, pancreatic exocrine function test: fat and nitrogen balance test, you can understand the secretion of lipase and protease, starch tolerance test can understand the secretion of amylase.

(1) Pancreatic stimulation test: Insulin secretion can be stimulated by intravenous administration of secretin, cholecys-tokinin-pancreozymin (CCK-PZ) or ceramide (caerulin). The pancreatic juice was taken out from the duodenal drainage tube on time, and the amount of pancreatic juice, sodium bicarbonate and various pancreatic enzyme secretions were observed. When chronic pancreatitis was observed, the secretion was reduced.

(2) PABA test: Although it is simple, but the sensitivity is poor, the factors affected are more, and those with severe pancreatic function damage are prone to have positive results.

(3) Fecal chymotrypsin assay showed a 49% decline in early chronic pancreatitis, and 80% to 90% of patients with severe advanced chronic pancreatitis decreased significantly.

(4) Cholesterol-13c-octanoic acid breath test: It is also a non-invasive method for examining pancreatic exocrine function. For example, the decrease of cholinesterase secreted by the pancreas can be measured by exhaled 13c-labeled CO 2 , and its sensitivity and The specificity is good.

(5) Recent reports have also shown that the determination of elastase content in feces is important for chronic pancreatitis, with a sensitivity of 79%. For example, except for small intestine diseases, its specificity can reach 78%, and elastase is Fecal output is reduced in chronic pancreatitis.

(6) Determination of CCK-PZ content in blood by radioimmunoassay is helpful for the diagnosis of chronic pancreatitis. The normal fasting is 60pg/ml, and the chronic pancreatitis can reach 8000pg/ml. This is due to pancreatic enzyme in chronic pancreatitis. Decreased secretion is caused by attenuated feedback inhibition of CCK-PZ secreting cells.

Film degree exam

1, ordinary X-ray inspection:

1 abdominal plain film: may see the stone and calcification of the pancreas;

2 upper digestive tract barium meal: may see compression or obstructive changes;

3ERCP: It may be seen that the main pancreatic duct has localized dilatation and stenosis, or bead-like changes, irregular wall, sometimes occlusion of the lumen, saccular expansion of the stone or pancreatic duct, etc., according to the diameter of the main pancreatic duct, Chronic pancreatitis is divided into large pancreatic duct type (diameter 7mm) and pancreatic duct (diameter 3mm). The former is suitable for drainage surgery, and the latter is required for different range of pancreatectomy.

2, B-ultrasound:

It can show pancreatic pseudocysts, dilated pancreatic ducts and deformed pancreas, and can suggest a combined biliary tract disease.

3, CT: is an important diagnostic tool for chronic pancreatitis, can clearly show the gross pathological changes in most cases, according to the CT features of chronic pancreatitis combined with B-ultrasound, the imaging changes are divided into the following types:

(1) Mass type: The pancreas is localized and enlarged, forming a clear-cut, regular-shaped mass. The enhanced CT scan shows a uniform enhancement effect, and the gallbladder and pancreatic duct have no obvious expansion;

(2) lumps plus bile duct dilatation: in addition to the lumps are accompanied by bile duct dilatation;

(3) diffuse swelling: showing diffuse enlargement of the pancreas, no exact mass, and no obvious expansion of the pancreatic duct;

(4) pancreas, bile duct dilatation type: showing pancreas, bile duct dilatation, no obvious mass in the head of the pancreas;

(5) pancreatic duct dilatation type: showing pancreatic duct dilatation, in addition to pancreatic calcification, pancreatic duct stones, pancreatic cysts, etc., the above classification is conducive to guiding surgical selection.

4. MRI:

In chronic pancreatitis, the pancreas showed localized or diffuse enlargement. T1-weighted images showed mixed low signals; post-weighted images showed mixed high signals. On MRI, chronic pancreatitis was difficult to distinguish from pancreatic cancer.

Diagnosis and diagnosis of chronic pancreatitis

diagnosis

The clinical manifestations of chronic pancreatitis are variable and non-specific, and the diagnosis is often difficult. Atypical is more difficult to confirm the diagnosis. For recurrent acute pancreatitis, biliary tract disease or diabetes, there are recurrent or persistent upper abdominal pain, chronic Diarrhea, weight loss can not be explained by other diseases, the disease should be suspected, clinical diagnosis is mainly based on medical history, physical examination and supplemented with necessary X-ray, ultrasound or other imaging examination, upper gastrointestinal endoscopy and related laboratory examination, etc. The latest diagnostic criteria for chronic pancreatitis (Japan Pancreas Society, 1995) are as follows:

1, the standard of diagnosis of chronic pancreatitis

(1) There is pancreatic stone in the abdominal B-ultrasound tissue.

(2) CT intracranial calcification confirmed by pancreatic stones.

(3) ERCP: The pancreatic duct and its branches in the pancreatic tissue are irregularly expanded and unevenly distributed; the main pancreatic duct is partially or completely obstructed and contains pancreatic stones or protein emboli.

(4) Secretion test: reduced bicarbonate secretion, accompanied by decreased pancreatic enzyme secretion or discharge.

(5) Histological examination: tissue sections showed visible destruction of pancreatic exocrine tissue, and there was flaky irregular fibrosis between the lobes, but interlobular fibrosis was not unique to chronic pancreatitis.

(6) Catheter epithelial hyperplasia or dysplasia, cyst formation.

2, highly suspected chronic pancreatitis standard

(1) Abdominal ultrasonography of the pancreas is abnormal, the pancreatic duct is irregularly expanded or the pancreas outline is irregular.

(2) CT pancreas contour is irregular.

(3) ERC: only the main pancreatic duct is irregularly dilated, and the pancreatic duct is filled with defects, suggesting non-calcified pancreatic stones or protein emboli.

(4) Secretion test: only the secretion of bicarbonate is reduced, or the secretion and discharge of pancreatic enzyme are reduced.

(5) Non-intubation test: The benzoic acid-amide-p-aminobenzoic acid (BT-PABA) test and the fecal chymotrypsin test were abnormal at different times.

(6) Histological examination: tissue sections showed interlobular fibrosis, and one of the following abnormalities: decreased exocrine tissue, Langhans cell cluster separation or pseudocyst formation.

In the diagnosis, it should not be considered which clinical type, and try to apply the feasible examination method to determine the cause of the disease. In many cases, it can only be temporarily suspected as chronic pancreatitis, and then through long-term treatment and follow-up observation to confirm the diagnosis.

Differential diagnosis

1. Abdominal pain caused by other causes: such as peptic ulcer, biliary tract disease, mesenteric vascular disease and gastric malignant tumor.

2. Determine whether steatorrhea is caused by pancreatic diseases: steatorrhea caused by chronic pancreatitis, pancreatic CT and ERCP examinations are often found abnormally. If pancreatic duct stenosis is predominant, pancreatic tumors should be excluded.

3, identification of pancreatic malignant tumors: both can cause pancreatic mass and abdominal pain or painless jaundice, it is difficult to distinguish between the two, including ERCP, MRCP and endoscopic ultrasound, if CA19-9 More than 1000U / ml or CEA significantly increased, it is helpful for the diagnosis of pancreatic cancer, but often in advanced pancreatic cancer, can also be diagnosed by ERCP brushing, endoscopic ultrasonography and finding adjacent lymph nodes. When the above test is negative and cannot be distinguished, a pathological biopsy is performed by surgery.

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