Abdominal pain with nausea and vomiting

Introduction Abdominal pain with nausea and vomiting is one of the clinical manifestations of acute pancreatitis. Patients 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 increased trypsin content; 3 image examination (ultrasound, CT) showed pancreatic inflammation Or pathological examination of the surgical findings or autopsy confirmed the presence of pancreatitis; 4 can exclude other similar clinical manifestations.

Cause

(1) Causes of the disease

There are many causes of acute pancreatitis, and there are regional differences. In China, more than half of them are caused by biliary diseases. In Western countries, in addition to cholelithiasis, alcohol abuse is also the main reason.

Biliary system disease

Under normal circumstances, the common bile duct and pancreatic duct open to the Vater ampulla 80%, after confluence into the duodenum, this common pipeline is about 2 ~ 5mm long, in this "common channel" or Oddis sphincter Stones, biliary mites or inflammation, edema or spasm caused by obstruction, gallbladder contraction, bile duct pressure exceeds pancreatic duct pressure, bile can be refluxed into the pancreatic duct to activate trypsin to cause self-digestion, the so-called "common pipeline theory" ( Common duct theory), 50% of acute pancreatitis is caused by it, especially bile duct stones are the most common; if the gallstones migrate, the common bile duct, ampulla or bile duct inflammation causes Oddis sphincter dysfunction, such as duodenal cavity Internal hypertension, causing duodenal juice to flow back into the pancreatic duct, activate pancreatic enzyme to produce acute pancreatitis; in addition, when biliary tract inflammation, bacterial toxin releases kinin, which can activate pancreatic digestive enzymes to induce acute pancreatitis through the biliary-pancreatic lymphatic traffic branch .

2. Alcohol or drugs

Alcohol abuse in European and American countries is one of the important causes of acute pancreatitis, and it has also increased in China in recent years. Alcohol can stimulate the secretion of gastrin from the G cells of the antrum, increase the secretion of gastric acid, decrease the pH value in the duodenum, increase the secretion of secretin, and increase the exocytosis of the pancreas. Long-term alcoholism can stimulate the protein content in the pancreas to increase. The protein "embolic" blocks 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. The reason is consistent with the "blocking-secretion strong theory". Some drugs and poisons can directly damage pancreatic tissue, or promote exocytosis of pancreatic juice, or promote pancreatic duct epithelial cell proliferation, acinar dilatation, fibrosis or increase blood lipids, or promote Oddis sphincter spasm and cause acute pancreatitis, such as azole Anthraquinone, adrenocortical hormone, tetracycline, thiazide diuretics, L-asparaginase, organophosphorus insecticides, and the like.

3. Infection

Many infectious diseases can be complicated by acute pancreatitis. 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. Aphids enter the bile duct or pancreatic duct, which can not only be brought into the intestinal fluid, but also brought into the bacteria, which can activate the pancreatic enzyme to cause inflammation.

4. Hyperlipidemia and hypercalcemia

The chance of familial hyperlipidemia with acute pancreatitis is significantly higher than that of normal people. During hyperlipidemia, fat embolism of the pancreatic vessels causes ischemia, telangiectasia, and damage to the vessel wall; in patients with primary hyperparathyroidism, 7% of patients with pancreatitis have severe disease and high mortality; 25% ~45% of patients have pancreatic parenchymal calcification and pancreatic duct stones. Stones can block the pancreatic duct, and calcium ions can activate trypsin, which may be the main cause of pancreatitis.

5. Surgical trauma

Upper abdominal surgery or trauma can cause pancreatitis. Postoperative pancreatitis is more common in abdominal surgery, such as pancreatic, biliary, gastric, and duodenal surgery, and occasionally in non-abdominal surgery. The cause may be intraoperative pancreatic injury, intraoperative contamination, Oddis sphincter edema or dysfunction, and the use of certain drugs after surgery, such as anticholinergic, salicylic acid preparations, morphine, diuretics, and the like. In addition, ERCP can also be complicated by pancreatitis, which often occurs in the case of selective intubation difficulties and repeated pancreatic duct visualization. Under normal circumstances, the success rate of pancreatic duct intubation in ERCP is above 95%, but occasionally after the pancreatic duct is developed, the selective bile duct intubation is not smooth, resulting in multiple repeated pancreatic duct visualization, stimulation and injury. Pancreatic duct opening; or due to aseptic operation is not strict, injecting infectious substances to the distal end of the obstruction pancreatic duct; or injecting excess contrast agent, even leading to pancreatic acinar, tissue development, induced pancreatitis after ERCP. Foreign scholars believe that repeated pancreatic duct visualization more than 3 times, the incidence of pancreatitis after ERCP increased significantly. Lighter only elevated blood urease amylase, severe cases can occur severe pancreatitis, leading to death.

6. Other

(1) vascular factors: atherosclerosis and nodular arteritis, can cause arterial stenosis, pancreatic blood supply.

(2) Late pregnancy: women are easy to have gallstones, hyperlipidemia, increased uterus can compress the pancreas, can cause pancreatic drainage difficulties, pancreatic duct hypertension.

(3) penetrating ulcer: when the duodenal Crohn's disease affects the pancreas, it can release the pancreatic acinar and release pancreatic enzyme to cause pancreatitis.

(4) Mental, genetic, allergic and allergic reactions, diabetes coma and uremia are also factors that cause acute pancreatitis.

(5) 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.

(6) Idiopathic pancreatitis, the cause is unknown 8% to 25%.

(two) pathogenesis

The pathogenesis of acute pancreatitis caused by various causes is different, but it has a common pathogenesis, that is, the pancreas itself is digested by various digestive enzymes of the pancreas. Under normal circumstances, the pancreas can prevent this self-digestion:

1. Pancreatic juice contains a small amount of trypsin inhibitor to neutralize a small amount of activated trypsin.

2. Pancreatic acinar cells have a special metabolic function that prevents pancreatic enzymes from invading cells.

3. The substance that enters the pancreas contains neutralizing trypsin.

4. The pancreatic duct epithelium has a protective layer of mucopolysaccharide. When in some cases the above defense mechanism is destroyed, it can occur.

an examination

Related inspection

Endoscopic pancreatobiliary angiography (ERCP) painless colonoscopy

Symptom

(1) Abdominal pain: Most of the acute pancreatitis is sudden onset, which is characterized by severe upper abdominal pain and more radiation to the shoulders and back. The patient feels a sense of "banding" in the upper abdomen and lower back. The location of abdominal pain is related to the location of the lesion. For example, the lesion of the head of the pancreas is severe. The abdominal pain is mainly in the right upper abdomen and radiates to the right shoulder. If the lesion is in the tail of the pancreas, the abdominal pain is the upper left abdomen and the left shoulder is radiated. The intensity of pain is consistent with the extent of the lesion. 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.

(2) nausea and vomiting: appears at the beginning of the onset, 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.

(3) systemic symptoms: may have 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.

The jaundice caused by these two reasons needs to be identified by combining medical history, laboratory examination, and the like. 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.

2. Signs

(1) Full body sign:

1 position: more lying or side, but hi lying.

2 blood pressure, pulse, breathing: in edematous pancreatitis, there is no significant change, but in hemorrhagic necrotizing pancreatitis, blood pressure can drop, pulse and breathing speed up, and even shock. It is worth mentioning that acute respiratory distress syndrome (ARDS) can occur in acute hemorrhagic necrosis of pancreatitis. This is a very dangerous syndrome that requires early diagnosis and treatment based on medical history, laboratory tests and other methods.

3 tongue coating: more reddish tongue, accompanied by red or purple red infection; tongue white or white greasy, severe cases of yellow greasy or yellow dry.

(2) Abdominal signs:

1 visual examination: 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 localized bulging.

2 palpation: tenderness, rebound tenderness and muscle tension may vary depending on the extent and location of the lesion. Under normal circumstances, there is a degree of tenderness in the upper abdomen, but the tenderness is related to the lesion. The lesion is in the head of the pancreas, the tenderness is in the right upper abdomen; the lesion is in the tail of the pancreas, and the tenderness is in the left upper abdomen; the lesion affects the entire pancreas, and there is tenderness in the upper abdomen. If hemorrhagic necrotizing pancreatitis, abdominal peritoneal fluid for a long time, often full abdominal tenderness, rebound tenderness and muscle tension. In acute pancreatitis, a mass is often found in the upper abdomen. The cause of the mass may be: A. swollen gallbladder, located in the right upper abdomen gallbladder area; B. swollen pancreatic head, located in the right upper abdomen, but in a deep position; C. pancreatic cyst or abscess, mostly round cystic Tumor; D. Inflamed tissue of edema, such as effusion in the omentum, intestine or small omental sac.

3 percussion: When there is flatulence, the percussion is drum sound. If there is exudate in the abdominal cavity, the percussion is voiced and the mobile dullness can be measured.

4 auscultation: the bowel sounds are weakened, when there is intestinal paralysis, it can be "quiet belly."

Differential diagnosis

Differential diagnosis of abdominal pain with nausea and vomiting:

1, fever accompanied by abdominal pain, diarrhea, nausea, vomiting: fever accompanied by abdominal pain, diarrhea, nausea, vomiting refers to the body's abdominal pain, diarrhea, nausea, vomiting due to digestive diseases.

2, right lower quadrant pain with vomiting: typical clinical manifestations of acute appendicitis, gradually appearing pain in the upper abdomen or around the umbilicus, abdominal pain transferred to the right lower abdomen after a few hours. Often accompanied by loss of appetite, nausea or vomiting.

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