Pancreatitis

Introduction to pancreatitis Pancreatitis is a disease caused by the self-digestion of trypsin in the pancreas. The pancreas is edematous, congested, or bleeding or necrosis. Clinical symptoms such as abdominal pain, bloating, nausea, vomiting, and fever. Test blood and urine amylase levels and so on. Can be divided into acute and chronic two. The pancreas is the second largest digestive gland in the human body and the most digestive organ. The pancreatic juice it secretes is the most important digestive juice in the human body. Under normal conditions, pancreatic juice contains inactive or inactive trypsin in its glandular tissue. The pancreatic juice continuously flows into the duodenum through the common bile duct Oddi sphincter along the pancreatic duct. Due to the presence of bile in the duodenum, and the duodenal mucosa secretes an enterokinase, under the action of both, Trypsinogen begins to transform into a highly active digestive enzyme. If the outflow tract is blocked and the excretion is not smooth, it can cause pancreatitis. Pancreatitis In general, although the pancreatic duct and bile duct flow into the duodenum through a channel, the bile does not flow back into the pancreatic duct because the pressure in the pancreatic duct is higher than the pressure in the bile duct. Only when the pressure of Oddi's sphincter or bile duct is increased, such as stones, tumors are blocked, bile will flow back into the pancreatic duct and enter the pancreatic tissue. At this time, the lecithin contained in the bile is covered by lecithin contained in the pancreatic juice. Enzyme A is decomposed into lysolecithin, which can have a toxic effect on the pancreas. Or when the biliary tract is infected, the bacteria can release the kinase to activate the trypsin, and can also become an active substance that can damage and dissolve the pancreatic tissue. These substances convert the trypsin contained in the pancreatic juice into trypsin, which has strong digestive activity, penetrates into the pancreatic tissue to cause self-digestion, and can also cause pancreatitis. basic knowledge The proportion of illness: 0.003% Susceptible people: no special people Mode of infection: non-infectious Complications: pancreatic abscess pancreatic pseudocysts pseudoaneurysm ascites

Cause of pancreatitis

Biliary system disease (20%):

Biliary stones are the most common. In addition, when biliary tract inflammation, bacterial toxins release kinins, which can activate pancreatic digestive enzymes to cause acute pancreatitis through the biliary-pancreatic lymphatic traffic branch. 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 or drugs (30%):

Long-term alcoholism can stimulate the protein content in the pancreatic juice to increase, forming a protein "embolic" to block the pancreatic duct; at the same time, alcohol can stimulate the duodenal mucosa to cause edema of the nipple and prevent the discharge of pancreatic juice. Some drugs and poisons can directly damage pancreatic tissues such as azathioprine, adrenocortical hormone, tetracycline, thiazide diuretics, L-asparaginase, organophosphorus pesticides, and the like.

Infection (10%):

Many infectious diseases can be complicated by pancreatitis, and the symptoms are not obvious. After the primary disease is healed, pancreatitis subsides spontaneously. Commonly, there are mumps, viral hepatitis, infectious mononucleosis, typhoid fever, sepsis and so on.

Other diseases (20%):

The chance of familial hyperlipidemia with pancreatitis is significantly higher than that of normal people. Atherosclerosis and nodular arteritis can cause stenosis of the arteries and insufficient blood supply to the pancreas. When duodenal Crohn's disease affects the pancreas, pancreatic acinar destruction can be released and pancreatic enzymes can be activated to cause pancreatitis. Pancreatic duct obstruction, pancreatic duct stones, stenosis, tumors, etc. can cause pancreatic juice secretion, pancreatic duct pressure increased, pancreatic duct small branch and pancreatic acinar rupture, pancreatic juice and digestive enzymes infiltrate the interstitial, causing acute pancreatitis. When a small number of pancreas is separated, the main pancreatic duct and the accessory pancreatic duct are shunted and the drainage is not smooth, and may also be related to acute 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.

Nutritional disorders (10%):

A low-protein diet can cause chronic pancreatitis, which is more common in Southeast Asia, Africa, and Latin America. In recent years, it has been found that there is a correlation between high-fat intake and the onset of pancreatitis. Animal experiments have also shown that high-fat intake makes the pancreas sensitive and prone to chronic pancreatitis. Patients in Europe, America, and Japan are often associated with high fat intake.

Genetic factors (10%):

Hereditary pancreatitis is rare and belongs to chromosomal dominant inheritance. Mental, genetic, allergic and allergic reactions, diabetic coma and uremia are also factors that cause acute pancreatitis.

Trauma and surgery (15%):

It is a common cause of acute pancreatitis, which may cause chronic pancreatitis only after severe trauma or injury to the main pancreatic duct.

High risk population

1. Overeating. Alcoholism, overeating, and greasy food make the pancreas exocrine strong, which can easily lead to pancreatitis.

2. Those with biliary system diseases. Biliary system diseases easily activate pancreatic enzymes, causing pancreatitis.

3, suffering from hyperlipidemia and hypercalcemia. Hyperlipidemia and hypercalcemia cause difficulty in excretion of pancreatic juice and may cause pancreatitis.

4. People with a family history of genetics. People with a family history of genetics have a higher chance of developing acute pancreatitis than normal people.

5, the mood is not comfortable. Unhappy feelings, resulting in liver qi stagnation, prone to pancreatitis.

High season

1. Spring is a high incidence of pancreatitis. Spring weather changes volatility, easy to reduce the body's immunity, easily lead to the onset of acute pancreatitis.

2, summer is also a high incidence of pancreatitis. Every hot summer, people have the habit of drinking iced drinks, which makes acute pancreatitis take advantage of it.

3. The incidence of pancreatitis in autumn is also high. In the autumn, people have the habit of tonic, and it is easy to cause pancreatitis when they are greasy.

4. Winter is basically the same as autumn. As the climate turns cold, people's appetite is strong, and overeating, causing pancreatitis.

5. At the same time, the season of alternating seasons is also the high incidence of this disease.

Pancreatitis prevention

Acute pancreatitis is a very serious disease. Acute hemorrhagic necrotizing pancreatitis is particularly dangerous, with rapid onset and high mortality. It is known that the onset of pancreatitis is mainly caused by countercurrent pancreatic juice and pancreatic enzyme damage to the pancreas, and these factors can be prevented.

Biliary disease

Avoid or eliminate biliary tract disease. For example, prevention of intestinal mites, timely treatment of biliary calculi and avoiding acute attacks of biliary tract disease.

2. Alcoholism

People who are suffering from alcoholism suffer from damage to the liver, pancreas and other organs due to chronic alcoholism and malnutrition, and their ability to fight infection is reduced. On this basis, acute pancreatitis can be caused by a single alcohol abuse.

3. Overeating

It can cause gastrointestinal dysfunction, hinder the normal activity and emptying of the intestinal tract, hinder the normal drainage of bile and pancreatic juice, and cause pancreatitis.

Pancreatitis complications Complications Pancreas abscess Pancreatic pseudocysts Pseudoaneurysm Ascites

Mild acute pancreatitis rarely has complications, and severe acute pancreatitis often presents multiple complications. Pancreatic abscess, pseudocyst of the pancreas, organ failure, secondary infections such as abdominal cavity, respiratory tract, and urinary tract. The spread of infection can cause sepsis. In the later stage, due to the extremely low resistance of the body and the large use of antibiotics, fungal infections are prone to occur. A few can evolve into chronic pancreatitis.

Chronic pancreatitis mainly manifests as chronic abdominal pain and pancreatic endocrine and exocrine insufficiency, which is related to the occurrence of pancreatic cancer. It can also trigger a series of other complications. The most common complications are the formation of pseudocysts and mechanical obstruction of the duodenum and common channels. Less common complications include splenic vein thrombosis and portal hypertension. The formation of aneurysms (especially the splenic artery) and pancreatic chest and ascites.

Symptoms of pancreatitis Common symptoms Postprandial episodes of abdominal pain and fever accompanied by abdominal pain, ... abdominal pain with shock in the upper abdomen and lower back have...

Symptom

Acute pancreatitis:

Most of them are sudden onset, which is characterized by severe upper abdominal pain and more radiation to the shoulders and back. The patient feels a sense of "strap" in the upper abdomen and lower back. If it is edematous pancreatitis, abdominal pain is more persistent with increased aggravation, abdominal pain can be relieved by acupuncture or injection of antispasmodic drugs; if hemorrhagic pancreatitis, abdominal pain is very severe, often accompanied by shock, The general analgesic method is difficult to relieve pain. The onset of nausea and vomiting occurs, which is characterized by the inability to relieve abdominal pain after vomiting. The frequency of vomiting is also consistent with the severity of the lesion. In edematous pancreatitis, not only nausea, but also often vomiting 1 to 3 times; in hemorrhagic pancreatitis, vomiting is severe or persistent retching frequently. There may be fever, jaundice and so on. The degree of fever is consistent with the severity of the lesion. Edema pancreatitis, may not have fever or only mild fever; hemorrhagic necrotizing pancreatitis may have high fever, if fever does not retreat, there may be complications, such as pancreatic abscess. The occurrence of jaundice may be caused by concurrent biliary tract disease or compression of the common bile duct by the enlarged pancreatic head.

A very small number of patients have very rapid onset, and may have no obvious symptoms or symptoms soon, that is, shock or death, called sudden death or fulminant pancreatitis.

Chronic pancreatitis:

Light and heavy. There may be no obvious clinical symptoms, and there may be obvious clinical manifestations. Up to 90% of patients have abdominal pain of varying degrees, with intermittent pain for months or years. Suffering from nausea and vomiting when the pain is severe. The abdominal pain of such patients is often characterized by body position. The patient likes to lie in the supine position, sitting position or forward tilt position, and the abdominal pain is increased in the supine position or upright. Mild patients have no symptoms of diarrhea, but in severe cases, the alveolar destruction is excessive, and the secretion is reduced, that is, symptoms appear. It is characterized by abdominal distension and diarrhea. It has 3 to 4 times of stool every day. The amount is large, the color is light, the surface is shiny and bubbles, the stench is mostly acidic, and the patient has signs of weight loss, weakness and malnutrition.

Some symptoms of dyspepsia such as bloating, loss of appetite, nausea, fatigue, weight loss, etc. are common in patients with severe pancreatic function impairment. For example, islet involvement can significantly affect glucose metabolism, and about 10% have obvious symptoms of diabetes. In addition, patients with biliary diseases or biliary obstruction may have jaundice. Pseudocyst formation can reach the abdominal mass. Pancreatic ascites can occur in a small number of patients. In addition, chronic pancreatitis can cause upper gastrointestinal bleeding. Multiple fat necrosis can occur in patients with chronic pancreatitis. Subcutaneous fat necrosis often occurs in the extremities and forms hard nodules under the skin.

2. Signs

Acute pancreatitis

More flat or side, but like to sit still. In hemorrhagic necrotizing pancreatitis, there may be a drop in blood pressure, an increase in pulse and breathing, and even shock. Acute respiratory distress syndrome (ARDS) can occur in acute hemorrhagic necrosis of pancreatitis. The abdomen is flat, but hemorrhagic necrotizing pancreatitis can cause abdominal distension due to intestinal paralysis, and when there is a pancreatic cyst or abscess, there may be a localized bulge. Tenderness, rebound tenderness, and muscle tension can vary depending on the extent and location of the lesion. A mass is often found in the upper abdomen. When the intestine is flatulent, the percussion is a drum sound. If there is exudation in the abdominal cavity, the percussion is voiced and the mobile voiced sound can be measured. In the case of intestinal paralysis, it can be "quiet belly".

Chronic pancreatitis

The patient likes to lie in the supine position, sitting position or forward tilt position, and the abdominal pain is increased in the supine position or upright. According to the experiment, the pancreatic head was stimulated by electricity, and the pain occurred in the right upper abdomen, stimulating the tail of the pancreas, and the pain was in the left upper abdomen. In addition to radiation to the back, a small number of lower chest, kidney area and testicles are released. Cross-strained, there may be radiation pain in the shoulder.

Examination of 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 shows visible fat droplets and non-digested muscle fibers. After the Sudan III alcohol staining, red small spheres of different sizes can be seen. This method can be used as a basic method for simple primary screening.

3. Others such as glucose tolerance test, blood bilirubin, alkaline phosphatase, etc. all contribute to the diagnosis of chronic pancreatitis or help to fully understand the liver function and biliary obstruction.

4. Pancreatic exocrine function test The fat and nitrogen balance test can be used to understand the secretion of lipase and protease. The starch tolerance test can understand the secretion of amylase.

(1) pancreatic stimulation test: intravenous injection of intestinal secretin, cholecys-tokinin-pancreozymin (CCK-PZ) or ceramide (caerulin) can stimulate pancreatic secretion 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 occurs, the amount of secretion decreases.

(2) PABA test: Although it is simple, it has poor sensitivity and is affected by many factors. Patients with severe pancreatic dysfunction 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 . Its sensitivity and specificity are 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, the specificity can reach 78%. Elastase decreased in fecal output during 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 a decrease in pancreatic enzyme secretion in chronic pancreatitis and a decrease in feedback inhibition of CCK-PZ secreting cells.

Blood biochemistry:

1. When the white blood cell count is mild pancreatitis, it may not increase or slightly increase, but in severe cases and infection, it is obviously increased, and neutrophils are also increased.

2. Amylase assay This is one of the important objective indicators for the diagnosis of acute pancreatitis, but it is not a specific diagnostic method. In the early stage of the disease, when there is embolism of the pancreatic blood vessels and some hemorrhagic necrotizing pancreatitis, it may not increase due to severe destruction of pancreatic tissue. Amylase may also increase in the case of shock, acute renal failure, pneumonia, mumps, perforation of ulcer disease, and intestinal and biliary infections. Therefore, when there is an increase in amylase, it is necessary to combine the history, symptoms and signs to rule out the increase of amylase caused by non-pancreatic diseases, in order to diagnose acute pancreatitis. Pancreatic isozymes can be significantly increased. For those who are highly suspected of pancreatitis and normal amylase, whether the amylase of hyperamylasemia is derived from the pancreas, the determination of isozymes is more valuable.

3. Blood chemistry examination of severe pancreatitis, carbon dioxide binding decreased, blood urea nitrogen increased, indicating that the kidneys have been damaged. When the islets are damaged, there may be an increase in blood sugar, but most of them are transient. In hemorrhagic pancreatitis, blood calcium is often lowered, and when it is less than 7 mg%, the prognosis is often poor.

4. Radioimmune trypsin assay (RIA) Because of the amylase assay, there is no specificity for the diagnosis of pancreatitis. With the advancement of immunoassay technology, many scholars are looking for a more accurate diagnostic method, namely pancreatic enzyme radioimmunoassay. Currently, there are roughly the following enzymes: immunologically active trypsin (IRT), elastase II, pancreatic trypsin inhibitor (PSTI), and phospholipase A2 (PLA2).

Film degree exam:

X-ray inspection

Acute pancreatitis

(1) Abdominal plain film: 1 The density of the pancreas is enhanced (due to inflammatory exudation). 2 reflex intestinal stagnation (mainly in the stomach, duodenum, jejunum and transverse colon). 3 diaphragmatic muscle rise, pleural effusion. 4 A small number of cases can be seen with pancreatic stones or biliary stones. 5 The duodenal ring is stagnant, and its inner edge has a flat impression. 6 supine abdominal plain film, showing "transverse colon truncation" sign, that is, colonic hepatic flexion, spleen flexion, even if the position of the transverse colon is still not inflated, which is caused by acute pancreatitis caused by colonic spasm.

(2) upper gastrointestinal barium meal imaging: may see the following signs: 1 pancreatic head enlargement, duodenal ring enlargement. 2 The stomach sinus is under pressure. 3 Duodenum has expansion and deposition. 4 duodenal papillary edema or due to pancreatic head enlargement caused by the "3" sign. 5 pancreatic pseudocysts, visible gastrointestinal compression.

Chronic pancreatitis

(1) Abdominal plain film: Stones and calcifications of the pancreas may be seen.

(2) Upper digestive tract barium meal: may see compression or obstructive changes.

(3) ERCP: It may be seen that the main pancreatic duct has localized expansion and stenosis, or bead-like changes, irregular wall, sometimes visible lumen occlusion, stone or pancreatic duct saclike expansion, etc., according to the main pancreatic duct The diameter of 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 requires different ranges of pancreatic resection.

2. Ultrasound examination

Acute pancreatitis

(1) Increased pancreatic volume: In edematous pancreatitis, the pancreas is enlarged in size. In the case of severe pancreatitis, the enlargement of the pancreas is complicated, and the contour of the pancreas is blurred, the surface is not smooth, and the boundary between the deep surface of the pancreas and the splenic vein is unclear, and sometimes the front and back of the pancreas are difficult to recognize.

(2) Enhancement of pancreatic echo: In the edematous pancreatitis, the echo of the pancreas is enhanced, but in the case of severe pancreatitis, the interior of the pancreas is largely uneven, with strong echoes and irregular low echo areas.

(3) peritoneal exudate: rare in edematous pancreatitis, but more in severe pancreatitis, most of which are diffuse effusion, but also a localized effusion around the pancreas. Pancreatic abscesses and pseudocysts can also be found after treatment.

Chronic pancreatitis

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

According to the above, combined with clinical features, ultrasound can be used as one of the means to identify edema and severe pancreatitis.

3. CT examination

CT scans can also show various pathological changes in the pancreas and its surrounding tissues from mild edema, hemorrhage to necrosis and suppuration. CT can also find effusion around the pancreas and small omentum, edema around the kidney, help early detection and follow-up observation of pancreatic pseudocyst. Because it is not affected by gastro-intestinal gas and obesity, it is an important diagnostic tool for chronic pancreatitis, which can clearly show the gross pathological changes in most cases. According to the CT features of chronic pancreatitis combined with B-mode ultrasound, the imaging changes were divided into the following types: 1 mass type: the pancreas showed localized enlargement, forming a clear-cut, regular-shaped mass, and enhanced CT scan to see uniformity. Enhancement effect, no obvious expansion of gallbladder and pancreatic duct. 2 lumps plus bile duct dilatation: in addition to the lumps are still accompanied by bile duct expansion. 3 diffuse swelling large: showing diffuse enlargement of the pancreas, no clear mass, no obvious expansion of the pancreatic duct. 4 pancreatic and bile duct dilatation type: showing double expansion of pancreas and bile duct, no obvious mass in the head of the pancreas. 5 pancreatic duct dilatation type: showing pancreatic duct expansion throughout. In addition, pancreatic calcification, pancreatic duct stones, pancreatic cysts and other changes can be seen. The above classification is useful for guiding surgical selection.

4. Fiber endoscopy

(1) Fiberoptic endoscopy has no direct diagnostic value. It may be seen that the edema and hyperemia of the gastric duodenal mucosa may be seen in the posterior wall of the stomach (caused by enlarged pancreas).

(2) In addition to the lesions of the duodenal mucosa, the duodenal mucosa can be observed abnormalities or lesions in the duodenal papilla, especially in the case of pancreatitis caused by ampullary incarceration You can see the raised nipple or stone to find the cause directly.

(3) Endoscopic retrograde cholangiopancreatography (ERCP): It is only suitable for the understanding of biliary tract lesions after acute symptom control. Although the judgment of pancreatic duct obstruction can also be made, it may cause pancreatitis to re-emerge and become an injectable pancreatitis, so it is not suitable for routine use.

5. Laparoscopy

Laparoscopy can be useful for acute upper abdominal pain or severe pancreatitis that is not well understood. A series of lesions can be seen through laparoscopy and can be divided into accurate signs and relative signs.

6. Angiography

Angiography can show vascular lesions (such as aneurysms and pseudoaneurysms) in the pancreas and surrounding pancreas.

7. Radionuclide scanning

It is more normal in the early stage of the disease, but in the case of severe pancreatitis, uneven or non-developed or localized radioactive defect areas can be seen.

8. MRI chronic pancreatitis showed a localized or diffuse enlargement of the pancreas, and the T1-weighted image showed a mixed low signal. The post-weighted image appears as a mixed high signal. Chronic pancreatitis is difficult to distinguish from pancreatic cancer on MRI.

9. Other inspection methods

Electrocardiogram, EEG, etc., have no direct help in the diagnosis of this disease, but there are many changes in severe pancreatitis, which can be used as an auxiliary examination method for diagnosis and treatment.

Diagnosis and differentiation of pancreatitis

Diagnosis of acute pancreatitis

Mainly based on clinical manifestations, related laboratory examinations and imaging examinations, clinically not only requires the diagnosis of pancreatitis, but also the evaluation of its disease development, complications and prognosis. Any patient with upper abdominal pain should think of the possibility of acute pancreatitis. This article is a prerequisite for the diagnosis of acute pancreatitis. Especially those who have not diagnosed the upper abdominal pain or given the antispasmodic analgesic can not be relieved, it is more likely to be pancreatitis.

The diagnosis of this disease should have the following four criteria :

1 has typical clinical manifestations, such as abdominal pain or nausea and vomiting, accompanied by upper abdominal tenderness or peritoneal irritation;

2 serum, urine or abdominal puncture fluid has an increase in trypsin content;

3 image examination (ultrasound, CT) showed pancreatitis lesions confirmed by pancreatic inflammation or surgical findings or pathological examination of autopsy;

4 can exclude other similar clinical manifestations of the disease.

Diagnosis of chronic pancreatitis

Clinical manifestations are variable and non-specific, and diagnosis is often difficult. Atypical is more difficult to diagnose. For patients with recurrent acute pancreatitis, biliary tract disease or diabetes, recurrent or persistent upper abdominal pain, chronic diarrhea, and weight loss cannot 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 examinations, upper gastrointestinal endoscopy and related laboratory examinations. The latest diagnostic criteria for chronic pancreatitis (Japan Pancreas Society, 1995) are as follows:

Chronic pancreatitis diagnosis standard

(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 destruction and reduction of exocrine tissue in the pancreas, and irregular fibrosis between the lobes, but interlobular fibrosis was not unique to chronic pancreatitis.

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

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