Modern problems of science and education. Classifications of chronic pancreatitis Two main types of pancreatitis

Acute pancreatitis is a disease of the pancreas resulting from autolysis of pancreatic tissues by lipolytic and activated proteolytic enzymes, manifested by a wide range of changes - from edema to focal or extensive hemorrhagic necrosis. In most cases (about 90%), there is a slight tissue autolysis, accompanied only by pancreatic edema and moderate pain. In severe cases, fatty or hemorrhagic tissue necrosis occurs with severe metabolic disorders, hypotension, fluid sequestration, multiple organ failure, and death. After acute pancreatitis, pancreatic function usually returns to normal. In chronic pancreatitis, residual effects persist with impaired pancreatic function and periodic exacerbation.

Among the urgent surgical diseases of the abdominal organs, acute pancreatitis occupies the 3rd place in frequency, second only to acute appendicitis and acute cholecystitis. More often people of mature age (30-60 years) get sick, women - 2 times more often than men.

Etiology and pathogenesis. The pathogenesis of acute pancreatitis is not well understood. The main etiological factor is autolysis of the pancreatic parenchyma, which usually occurs against the background of hyperstimulation of exocrine function, partial obstruction of the ampulla of the major duodenal papilla, increased pressure in the Wirsung duct, bile reflux into the Wirsung duct. Acutely developing intraductal hypertension causes damage and increased permeability of the walls of the terminal ducts. Conditions are created for the activation of enzymes, their release beyond the ducts, infiltration of the parenchyma and autolysis of the pancreatic tissue.

In patients with cholelithiasis, a temporary obstruction of the outflow of bile leads to an increase in pressure and its reflux into the pancreatic duct. These changes are associated with the migration of small stones or sand (microlithiasis). A favorable condition for biliary hypertension is the presence of a common channel (ampoules) for the outflow of bile and pancreatic juice. In support of this theory, one can cite the fact that the common canal (ampulla), according to cholangiography, in people with pancreatitis, is observed in almost 90% , and in persons with cholelithiasis who did not have a history of episodes of pancreatitis - only 20-30%.

Often the cause of acute pancreatitis is excessive alcohol consumption and fatty foods. It is known that alcohol increases the tone and resistance of the sphincter of Oddi. This can cause difficulty in the outflow of exocrine pancreatic secretions and an increase in pressure in the small ducts. Experimental studies have shown that enteral alcohol increases the pressure in the pancreatic ducts and increases the permeability of the walls of small ducts for macromolecules of pancreatic juice. There are reports that large protein molecules can cause difficulty in the outflow of pancreatic juice. Alcohol enhances the secretion of gastric juice and the production of hydrochloric acid, which stimulates the production of secretin, which causes exocrine hypersecretion of the pancreas, and creates prerequisites for increasing pressure in the ducts. Thus, conditions are created for the penetration of enzymes into the parenchyma, the activation of proteolytic enzymes, and the autolysis of pancreatic cells.

Depending on the cause of intraductal hypertension, biliary and alcoholic pancreatitis are distinguished. These types of pancreatitis account for 90% of all pancreatitis. Each of them has certain features in the clinical course and outcome of the disease. Rarer causes of acute pancreatitis include open and closed injuries abdomen, intraoperative damage to the gland tissue, atherosclerotic occlusion of the visceral branches of the abdominal aorta, portal hypertension, certain drugs (corticosteroids, estrogenic contraceptives and tetracycline antibiotics).

Necrosis of pancreocytes and tissue surrounding the pancreatic lobules occurs at the very beginning of the process under the influence of lipase. Lipase penetrates into the cell, hydrolyzes intracellular triglycerides with the formation of fatty acids. In the damaged cells of the gland, intracellular acidosis develops with a pH shift to 3.5-4.5. Under conditions of acidosis, inactive trypsinogen is transformed into active trypsin, which activates phospholipase A, releases and activates lysosomal enzymes (elastase, collagenase, chymotrypsin, etc.). The content of phospholipase A and lysolecithin in the pancreatic tissue in acute pancreatitis increases significantly. This indicates its role in autolysis of the gland tissue. Under the influence of lipolytic, activated proteolytic enzymes, microscopic or macroscopically noticeable foci of fatty necrosis of the pancreatic parenchyma appear. Against this background, elastase lyses the walls of venules and interlobular connective tissue septa. As a result of this, extensive hemorrhages occur, the transformation of fatty pancreatic necrosis into hemorrhagic occurs. Thus, the proteolytic and lipolytic phases of the development of acute destructive pancreatitis are interconnected with each other.

Leukocytes rush to the foci of primary necrosis. The accumulation of leukocytes around the foci of necrosis means the development of a protective inflammatory reaction, accompanied by hyperemia and edema. To delimit foci of necrosis and eliminate necrotic tissue, macrophages, leukocytes, lymphocytes, endothelial cells secrete pro-inflammatory (IL-1; IL-6; IL-8) and anti-inflammatory (IL-4; IL-10, etc.) interleukins, active oxygen radicals . Small foci of necrosis as a result of this reaction are demarcated, subjected to lysis, followed by elimination of decay products. These processes cause a moderate local reaction to inflammation in the body.

With extensive necrosis, macrophages, neutrophilic leukocytes, and lymphocytes are subjected to excessive stimulation, the production of interleukins and oxygen radicals increases, and gets out of control of the immune system. The ratio of pro- and anti-inflammatory interleukins changes. They damage not only the tissues of the gland, but also other organs. Tissue necrosis is caused not so much by interleukins themselves as by active oxygen radicals, nitric oxide (N0) and the most aggressive peroxynitrile (ONOO). Interleukins only pave the way for this: they reduce the tone of venous capillaries, increase their permeability, and cause capillary thrombosis. Changes in the microvasculature are caused mainly by nitric oxide. The inflammatory reaction progresses, the zone of necrosis expands. The local reaction to inflammation turns into a systemic one, the systemic inflammation response syndrome (Systemic Inflammatory Response Syndrome) develops. The severity of the patient's condition correlates with high blood levels of IL-6, IL-8. At elevated concentrations in the blood, a high degree probability can predict multiple organ dysfunction and failure.

Changes in the microvasculature lead to the movement of a significant part of the body fluid into the interstitial space. Dehydration occurs, BCC decreases, water-electrolyte disturbances and a violation of the acid-base state occur. Against the background of an increased concentration of interleukins and hyperenzymemia, foci of necrosis appear on the omentum and peritoneum. Effusion in abdominal cavity contains amylase and other pancreatic enzymes in high concentration. Toxic products circulating in the blood have a direct toxic effect on the heart, kidneys, liver, and central nervous system. The severity of the systemic response syndrome to inflammation increases in accordance with increasing ischemia, an increase in the concentration of NO, cytokines, hypoxia and dystrophy in the vital important organs. Intoxication combined with hypovolemia quickly leads to the development of shock. Disseminated intravascular coagulation (DIC) and multiple organ failure occur.

Subsequently, after 10-15 days, the phase of sequestration and fusion of dead areas begins. Sequesters and the fluid accumulated near them may remain aseptic for some time. Their infection and suppuration with the formation of parapancreatic and retroperitoneal abscesses occur due to the translocation of bacteria from the lumen of the paralyzed intestine, which occurs in response to pathological changes in the pancreas and retroperitoneal tissue. In the late period, false cysts of the pancreas are formed in the zone of necrosis.

Classification. According to the nature of changes in the pancreas, there are: 1) edematous or interstitial pancreatitis; 2) fatty pancreatic necrosis; and 3) hemorrhagic pancreatic necrosis.

The edematous or abortive form of pancreatitis develops against the background of minor, microscopic damage to the cells of the pancreas. The edema phase can turn into a necrosis phase within 1-2 days. With progressive pancreatitis, fatty pancreatic necrosis develops, which, as hemorrhages develop, turns into hemorrhagic with the formation of extensive edema in the retroperitoneal tissue and the appearance of hemorrhagic effusion in the abdominal cavity (pancreatogenic aseptic peritonitis). In some cases, mixed forms of pancreatitis are observed: hemorrhagic pancreatitis with foci of fatty necrosis and fatty pancreatic necrosis with hemorrhages (Fig. 14.2).

Depending on the prevalence of the process, focal, subtotal and total pancreonecrosis are distinguished.

According to the clinical course, abortive and progressive course of the disease is distinguished. According to the phases of the course of severe forms of acute pancreatitis, a period of hemodynamic disorders is distinguished - pancreatogenic shock, functional insufficiency (dysfunction) internal organs and the period of purulent complications, coming in 10-15 days.

Rice. 14.2. Acute mixed - fatty and hemorrhagic pancreatitis.

Pathological picture. With the edematous form of pancreatitis, microscopic foci of necrosis are found. Due to edema, the pancreas increases in volume. In most patients, the development of the pathological process stops at this stage.

With progressive pancreatitis, macroscopically noticeable fat necrosis develops. The pancreas in these cases becomes dense, on the cut it has a variegated appearance due to multiple foci of necrosis. Cellular elements in these foci are not differentiated, around them there is leukocyte infiltration of tissues, perifocal aseptic inflammation. In the foci of fatty necrosis of the omentum, parietal and visceral peritoneum, in the preperitoneal and subcutaneous adipose tissue, pleura, pericardium, lumps of calcium soaps (fatty acid crystals) are formed. They have a cloudy whitish color (stearin plaques). The binding of calcium in the foci of necrosis leads to a decrease in its concentration in the blood. There is a direct relationship between the concentration of calcium, the prevalence of fat necrosis and the severity of the patient's condition.

Around the pancreas there is a dense infiltrate, which often involves the stomach, omentum, mesentery of the transverse colon, retroperitoneal tissue. In the abdominal cavity there is usually a cloudy serous exudate, in the pleural cavities - sympathetic pleurisy with a small amount of serous effusion.

With hemorrhagic pancreatic necrosis, the pancreas is enlarged, dense, with foci of hemorrhages around small vessels; due to the abundance of hemorrhages, it becomes purple-black. On the incision, alternation of dark red necrosis foci with areas of fatty necrosis and unchanged parenchyma is revealed, in the abdominal cavity - hemorrhagic exudate. Visceral and parietal peritoneum dull (aseptic peritonitis). The small and large intestines are swollen with gas and fluid accumulated in the lumen. With such changes, the protective barrier of the mucous membrane is violated. The walls of the intestine become permeable to bacteria and endotoxins, which leads to the transformation of aseptic peritonitis into widespread purulent. In the future, as the disease progresses, extensive areas of pancreatic necrosis appear.

In the stage of complications, foci of necrosis and exudate become infected, peritonitis, abscesses or phlegmon of retroperitoneal tissue, peritoneal sepsis develop. Later, one or more false cysts are formed. Infected cysts contain a cloudy brown liquid, remnants of unmelted dead tissue. With the ongoing purulent process in the parapancreatic retroperitoneal tissue, "paths of necrosis" are formed in the form of purulent streaks that spread to the adipose tissue at the root of the mesentery of the transverse colon and lateral canals. In those who died within 7 days from the onset of the disease, congestive plethora and pulmonary edema, degeneration of parenchymal organs prevail. In those who died later than the specified period, purulent complications predominate in 77%.

Clinical picture and diagnosis. The clinical symptoms of acute pancreatitis depend on the morphological form, the period of development and the severity of the systemic reaction to inflammation syndrome. In the initial period of the disease (1-3 days), both with edematous (abortive) form of pancreatitis and with progressive pancreatitis, patients complain of sharp, persistent pain in the epigastric region, radiating to the back (girdle pain), nausea, repeated vomiting.

Pain can be localized in the right or left quadrant of the abdomen. There is no clear connection between pain and the localization of the process in the pancreas. Sometimes the pain spreads throughout the abdomen. With alcoholic pancreatitis, pain occurs 12-48 hours after intoxication. With biliary pancreatitis (cholecystopancreatitis), pain occurs after a heavy meal. In rare cases, acute pancreatitis occurs without pain, but with a pronounced systemic reaction syndrome, manifested by hypotension, hypoxia, tachycardia, respiratory failure, impaired consciousness. With this course of the disease, acute pancreatitis can be diagnosed using ultrasound, computed tomography, and laboratory tests.

In the early stages from the onset of the disease, objective data are very scarce, especially in the edematous form: pallor skin, slight yellowness of the sclera (with biliary pancreatitis), slight cyanosis. The pulse may be normal or accelerated, the body temperature is normal. After infection of the foci of necrosis, it rises, as with any purulent process.

The abdomen is usually soft, all departments are involved in the act of breathing, sometimes some bloating is noted. Shchetkin-Blumberg's symptom is negative. Approximately 1-2% of seriously ill patients on the left side wall of the abdomen appear cyanotic, sometimes with a yellowish tinge of spots (Gray Turner's symptom) and traces of resorption of hemorrhages in the pancreas and retroperitoneal tissue, indicating hemorrhagic pancreatitis. The same spots can be observed in the navel (Cullen's symptom). Percussion is determined by high tympanitis over the entire surface of the abdomen - intestinal paresis occurs due to irritation or phlegmon of the retroperitoneal tissue or concomitant peritonitis. With the accumulation of a significant amount of exudate in the abdominal cavity, there is a dullness of percussion sound in the sloping parts of the abdomen, which is easier to detect when the patient is on his side.

On palpation of the abdomen, pain in the epigastric region is noted. There is no tension of the abdominal muscles in the initial period of development of pancreatitis. Only occasionally noted resistance and pain in the epigastrium in the area of the pancreas (Kerte's symptom). Palpation in the left costovertebral angle (projection of the tail of the pancreas) is often painful (Mayo-Robson symptom). With fatty necrosis of the pancreas, an inflammatory infiltrate is formed early. It can be determined by palpation of the epigastric region. Due to paresis and swelling of the transverse colon or the presence of infiltration fails to clearly define the pulsation abdominal aorta(symptom of Resurrection). Peristaltic noises are already weakened at the very beginning of the development of pancreatitis, disappear as the pathological process progresses and peritonitis appears. Percussion and auscultation of the chest revealed a sympathetic effusion in the left pleural cavity in a number of patients.

With very severe pancreatitis, a syndrome of a systemic response to inflammation develops, the functions of vital organs are disturbed, respiratory failure occurs, manifested by an increase in respiratory rate, adult respiratory distress syndrome (interstitial pulmonary edema, accumulation of transudate in the pleural cavities), cardiovascular insufficiency (hypotension , frequent thready pulse, cyanosis of the skin and mucous membranes, a decrease in BCC, CVP, minute and stroke volume of the heart, signs of myocardial ischemia on the ECG), hepatic, renal and gastrointestinal insufficiency (dynamic intestinal obstruction, hemorrhagic gastritis). In most patients, a mental disorder is observed: agitation, confused consciousness, the degree of violation of which should be determined by the points of the Glasgow scale.

Functional disorders of the liver are usually manifested by icteric coloration of the skin. With persistent obstruction of the common bile duct, obstructive jaundice occurs with an increase in the level of bilirubin, transaminases, and an increase in the liver. Acute pancreatitis is characterized by an increase in amylase and lipase in the blood serum. Significantly increases the concentration of amylase (diastase) in the urine, in the exudate of the abdominal and pleural cavities. With total pancreatic necrosis, the level of amylase decreases. A more specific study for the early diagnosis of pancreatitis is the determination of serum trypsin, a-chymotrypsin, elastase, carboxypeptidase, and especially phospholipase A, which plays a key role in the development of pancreatic necrosis. However, the complexity of their determination hinders the wide use of these methods.

The acid-base state undergoes a shift to acidosis, against which the intake of intracellular potassium into the blood increases while its excretion by the kidneys decreases. Hyperkalemia dangerous for the body develops. A decrease in the calcium content in the blood indicates the progression of fatty necrosis, the binding of calcium by fatty acids released as a result of the action of lipase on fatty tissue in the foci of necrosis. Small foci of steatonecrosis occur on the omentum, parietal and visceral peritoneum ("stearin spots"). The calcium content below 2 mmol/l (norm 2.10-2.65 mmol/l, or 8.4-10.6 mg/dl) is a prognostically unfavorable indicator.

Diagnosis of acute pancreatitis is based on anamnesis data (appearance of sharp pains in the abdomen after heavy meals, alcohol intake or exacerbation of chronic calculous cholecystitis), physical, instrumental and laboratory data.

Ultrasound procedure. Significant assistance in the diagnosis is provided by ultrasound, which makes it possible to establish etiological factors (cholecysto- and choledocholithiasis), to identify edema and an increase in the size of the pancreas, the accumulation of gas and fluid in swollen intestinal loops. Signs of pancreatic edema are an increase in its volume, a decrease in the echogenicity of the gland tissue and

decrease in the degree of signal reflection. With necrosis of the pancreas, unsharply limited areas of reduced echogenicity or the complete absence of an echo signal are detected. Spread of necrosis outside the pancreas ("necrosis tracks"), as well as abscesses and false

cysts can be visualized with great accuracy on ultrasound (Fig. 14.3; 14.4; 14.5). Unfortunately, the possibilities of ultrasound are often limited due to the location in front of the pancreas of the intestine, swollen with gas and liquid, covering the gland.

Computed tomography is a more accurate method for diagnosing acute pancreatitis compared to ultrasound. There are no obstacles for carrying it out. The reliability of diagnosis increases with intravenous or oral enhancement with a contrast material. Enhanced computed tomography allows you to more clearly identify diffuse or local enlargement of the gland, edema, foci of necrosis, fluid accumulation, changes in the parapancreatic tissue, "necrosis tracks" outside the pancreas, as well as complications in the form of abscesses and cysts.

Magnetic resonance imaging is a more advanced diagnostic method. It provides information similar to that obtained with computed tomography.

X-ray examination reveals pathological changes in the abdominal cavity in most patients: isolated dilatation of the transverse colon, segments of the jejunum and duodenum adjacent to the pancreas, sometimes radiopaque calculi in the bile ducts, in the pancreatic duct, or calcium deposits in its parenchyma (mainly with alcoholic pancreatitis). With volumetric processes in the pancreas (false cysts, inflammatory infiltrates, abscesses), a change in the location (pushing to the sides) of the stomach and duodenum is observed. X-ray examination reveals signs of paralytic ileus, effusion in the pleural cavity, discoid atelectasis of the basal parts of the lungs, often associated with acute pancreatitis. The study of the stomach and intestines with a contrast agent in the acute period of the disease is contraindicated.

Esophagogastroduodenoscopy is performed for gastrointestinal bleeding from acute erosions and ulcers, which are complications of acute (most often destructive) pancreatitis. Retrograde cholangiography in acute pancreatitis is contraindicated, since this procedure additionally increases the pressure in the main pancreatic duct.

Laparoscopy is indicated for an unclear diagnosis, if necessary, laparoscopic installation of drains for the treatment of acute pancreatitis. Laparoscopy allows you to see the foci of steatonecrosis (stearin spots), inflammatory changes in the peritoneum, gallbladder, penetrate into the cavity of the lesser omentum and examine the pancreas, install drains for the outflow of exudate and wash the cavity of the lesser omentum. If it is impossible to use laparoscopy to take peritoneal exudate and conduct diagnostic lavage, a so-called "groping" catheter can be inserted into the abdominal cavity through a puncture in the abdominal wall (laparocentesis).

Electrocardiography is necessary in all cases, both for differential diagnosis with acute myocardial infarction, and for assessing the state of cardiac activity in the process of developing the disease.

To assess the condition of patients and to predict the outcome of the disease, a number of tests and criteria based on indicators of impaired physiological functions and laboratory data have been proposed. Even one definition of the amount of fluid sequestered (the amount of fluid injected minus the amount of urine excreted) is important in determining the severity of the disease. If fluid sequestration exceeding 2 liters per day persists for 2 days, then there is reason to consider pancreatitis severe, life-threatening for the patient. If this figure is less, then pancreatitis can be considered moderate or mild. The Renson criteria are often used to predict and assess the severity of acute pancreatitis. Such criteria at the onset of the disease are age (more than 55 years), leukocytosis over 16,000, blood glucose over 200 mg%, transaminase (ACT) over 250, serum lactate dehydrogenase over 350 i.u./l. Criteria that develop within 24 hours are: a decrease in hematocrit by more than 10%, an increase in blood urea by more than 8 mg%, a decrease in calcium to a level of less than 8 mg / l, arterial blood p0 2 less than 60 mm Hg, deficiency bases over 4 meq / l, determined fluid sequestration over 600 ml. Morbidity and lethality correlate with the number of identified criteria. The probability of a fatal outcome in the presence of 0-2 criteria is 2%, with 3-4 criteria - 15%, with 5-6 criteria - 40% and with 7-8 criteria - up to 100% . More complex, but more universal is the ARASNE-P scale (an abbreviation from English - Acute Physiology Assessment and Chronic Health Evaluation). The assessment of the patient's condition is made according to the severity of violations of physiological functions, chronic diseases, age of the patient. The identified scores allow you to objectively and visually determine the severity of the disease, the effectiveness of ongoing therapeutic measures, compare the advantages and disadvantages. different methods treatment in groups of patients comparable in severity.

Differential diagnosis. Differential diagnosis should be carried out primarily with thrombosis of the mesenteric vessels, since in this disease, sudden sharp pains, a state of shock with a soft abdomen and normal body temperature may resemble acute pancreatitis. Paralytic ileus and peritonitis occur in both diseases. With an unclear diagnosis, it is advisable to perform an upper mesentericography.

According to clinical data, myocardial infarction is difficult to differentiate from acute pancreatitis, since in the acute phase of pancreatitis, ECG changes characteristic of myocardial infarction sometimes occur. Both in the case of mesenteric bowel infarction and myocardial infarction, ultrasound helps to differentiate these diseases. Acute cholecystitis and its complications can be relatively easily distinguished by the typical clinical picture and ultrasound symptoms. Acute pancreatitis must be differentiated from perforated gastric and duodenal ulcers, strangulation small bowel obstruction, dissecting aortic aneurysms, and renal colic.

Complications. Acute pancreatitis can be accompanied by numerous complications. The heaviest of them are:

hypovolemic shock;

multiple organ failure, including acute renal failure, resulting from the progression of the syndrome of a systemic reaction to inflammation and the development of shock;

pleuropulmonary complications, manifested by respiratory failure due to the development shock lung, exudative pleurisy, atelectasis of the basal parts of the lungs, high standing of the diaphragm;

liver failure (from mild jaundice to severe acute toxic hepatitis, which develops as a result of shock and the influence of toxic enzymes and protein substances); disease contributes to biliary tract and accompanying cholangitis;

abscesses of the pancreas and extrapancreatic abscesses in the retroperitoneal tissue, the appearance of which is due to an infection that easily develops in the foci of necrosis;

external pancreatic fistulas are more often formed at the site of drainage or postoperative wound; internal fistulas usually open into the stomach, duodenum, small and large intestine;

widespread purulent peritonitis occurs when a para-pancreatic abscess ruptures into the free abdominal cavity or translocation of bacteria from the intestine into the free abdominal cavity, aseptic pancreatogenic peritonitis becomes purulent;

bleeding resulting from vascular erosion (blood from the abdominal cavity is released out through the wound or through the drainage channel).

Internal bleeding is most often the result of erosive gastritis, stress ulcers, Mallory-Weiss syndrome, and also in connection with disorders in the hemostasis system (coagulopathy of consumption).

Late complications of pancreatic necrosis include pseudocysts. Necrotized pancreatic tissue with extensive necrosis does not completely resolve. It encapsulates and turns into a postnecrotic pseudocyst due to the formation of a connective tissue capsule around the focus of necrosis. The contents of the cyst may be sterile or purulent. Sometimes spontaneous resorption of cysts occurs (most often when it communicates with the excretory ducts of the pancreas).

1) excessive activation of the pancreas' own enzymes (trypsinogen, chymotrypsinogen, proelastase, lipase)

2) an increase in intraductal pressure and difficulty in the outflow of pancreatic juice with enzymes from the gland

As a result, autolysis (self-digestion) of the pancreatic tissue occurs; areas of necrosis are gradually replaced by fibrous tissue.

Alcohol is both a good stimulant for the secretion of hydrochloric acid (and it already activates pancreatic enzymes), and leads to duodenostasis, increasing intraductal pressure.

Chronic pancreatitis: ICD classification 10

This classification is modern and the most widely used today. According to this classification World Organization Healthcare lists new diseases every ten years, this also includes chronic pancreatitis. The modern classification gives each disease its own cipher, so even if the doctor does not understand a foreign language, using this cipher, he will be able to understand what kind of disease he is talking about.

So, according to this classification, chronic pancreatitis has two forms:

form of alcoholic origin;
other forms of this pathology.

Classification

In the classification of acute inflammation, the phases of development of inflammation and destructive changes are taken into account. The scale and nature of the lesion of the gland itself, as well as organs located within the abdominal cavity and behind the peritoneum, are assessed.

According to the severity, there are the following forms of the disease:

mild - edematous;
severe - multiple organ failure develops, local and systemic complications appear.

Depending on the nature and extent of the lesion of the gland, there are:

edematous form, or interstitial acute pancreatitis;
pancreatic necrosis without symptoms purulent inflammation(aseptic);
infected pancreatic necrosis;

To assess the functional and morphological state of the gland allow: biochemical blood test, coprocytogram, ultrasound examination of the organs of the retroperitoneal space and abdominal cavity, laparoscopy, fine needle aspiration biopsy and CT.

In addition, in the diagnosis of pancreatitis, the following criteria are taken into account:

the nature of necrotic changes: fatty, hemorrhagic, mixed;
the prevalence of the process: small-focal, large-focal, subtotal;
localization: capitate, caudal, with damage to all parts of the gland.

Acute pancreatitis is a serious diagnosis. The outcome depends on how quickly the disease is detected and first aid is provided.

If the disease is mild, conservative methods are usually used. For this purpose, a diet is used and medications. In the first days of the disease, hunger is prescribed.

When the disease becomes severe, extensive necrosis, abscesses, cysts, peritonitis develop, it cannot do without surgical intervention.

To minimize the possibility of developing or exacerbating pancreatitis, it is necessary to limit alcohol consumption, use it correctly and as directed by a doctor. medicines, in a timely manner to treat existing diseases.

There are several options for classifying acute pancreatitis. They are important for their correct determination and further therapy.

By stage of progression and severity

Currently there are characteristics for three degrees:

mild (does not imply major changes, following a diet and recommendations can make many negative processes reversible);
medium (possible complications and a quick transition to a severe stage of progression in the absence of treatment);
severe (involves serious complications, some of which can lead to necrosis and death).

In any degree, acute pancreatitis is dangerous and requires immediate hospitalization, as it can develop rapidly and lead to complications.

So, the classification of acute pancreatitis may differ according to the factors of its origin, forms of pathology and severity. Let's take a closer look at each category.

Category by origin

Each type has its own symptoms, indicators and principles of treatment.

The classification of acute pancreatitis has several varieties. Clinicians divide the disease according to certain characteristics.

According to the scale and nature of the gland lesion, 5 types of pancreatitis were identified:

hydropic;
sterile pancreatic necrosis;
infected;
pancreatogenic abscess;
pseudocyst.

Also, to determine the exact disease, doctors derived a causal classification. Acute pancreatitis is divided into food, biliary, gastrogenous, ischemic, infectious, toxic-allergic, congenital and traumatic.

To quickly determine the severity of an acute type of pathology, doctors distinguish clinical forms diseases:

interstitial - edema of the pancreas and fiber;
necrotic - a serious inflammation with complications.

Chronic disease is divided into 2 stages - exacerbation and remission. Based on the frequency of re-inflammation, clinicians have identified types of chronic pancreatitis:

rare relapses;
frequent relapses;
persistent (persistent symptoms).

Chronic pancreatitis is characterized in practice by various symptoms, under the influence of which another systematization of species has been created. Depending on the dominant feature, the following ailments are distinguished:

painful;
hyposecretory;
hypochondria;
latent;
combined.

Acute pancreatitis and chronic have certain causes that form the disease. Therefore, according to the etiological factor, the classification of these two types of ailment is a bit similar:

biliary-dependent;
alcoholic;
dysmetabolic;
infectious;
drug;
idiopathic.

The classification of chronic pancreatitis is also compiled according to the form of complications. According to this principle, physicians distinguish 5 forms of the disease:

infectious - an abscess develops, cholangitis;
inflammatory - progressive kidney failure, cyst, bleeding from the gastrointestinal tract;
portal hypertension - compression of the portal vein;
endocrine - diabetes mellitus, hypoglycemia is formed;
failure in the outflow of bile.

As a result of the development of the disease and the manifestation of new causes of the disease, the types of pancreatitis identified by the scientist Ivashkin are considered obsolete on the basis of etiology. The doctor proposed a complete classification of the disease, which was divided according to many factors and allowed physicians to make an accurate diagnosis.

The form of development of the disease is different. In this regard, the doctor singled out a separate section of the classification under the varieties of pancreatitis by structure:

interstitial-edematous;
parenchymal;
inductive;
hyperplastic;
cystic.

According to the signs of the disease, they identified:

painful option;
hyposecretory;
astheno-neurotic or hypochondriacal;
latent;
combined.

According to the strength of the course of the disease:

rare repetitions of inflammation;
frequent repetitions;
persistent.

Varieties of pathology associated with complications:

violations of the outflow of bile;
portal hypertension;
infectious diseases;
inflammatory disorders;
endocrine diseases.

Primary reasons:

alcohol;
heredity;
medicines;
ischemic;
idiopathic;

Secondary reasons:

Pain option:

with temporary pain;
with constant pain;

According to the morphological index:

calcifying;
obstructive;
infiltrative fibrous;
inductive.

The functionality of the organ also influenced the classification. Therefore, the following types are distinguished:

hypersecretory type;
hyposecretory type;
obstructive type;
ductular type;
hyperinsulinism;
hypofunction of the insular apparatus.

The disease can occur in three different stages:

light;
moderate;
heavy.

I. According to morphological features: interstitial-edematous, parenchymal, fibrous-sclerotic (indurative), hyperplastic (pseudotumorous), cystic

II. According to clinical manifestations: pain variant, hyposecretory, asthenoneurotic (hypochondriac), latent, combined, pseudotumorous

III. The nature clinical course: rarely recurrent (one exacerbation in 1-2 years), often recurrent (2-3 or more exacerbations per year), persistent

IV. By etiology: biliary-dependent, alcoholic, dysmetabolic, infectious, medicinal

There are several classifications of acute inflammation of the pancreas. They provide a division of the disease into types, taking into account the nature, prevalence and degree of damage to the pancreas. In addition, complications caused by acute inflammation of the digestive organ are taken into account.

The classification used in medicine today was based on the provision on the division of pathology into types, which was adopted at the International Symposium in Atlanta in 1992.

According to this provision, the following forms of the disease were distinguished:

Acute pancreatitis (mild, severe).
Pancreatic necrosis (sterile, infected).
Infected accumulation of fluid in the pancreatic tissue and peripancreatic tissue.
Pancreatic pseudocyst.
Pancreatic abscess.

Subsequently, this classification was revised and supplemented several times.

According to Savelyev

The doctor suggested isolating the following types violations:

edematous (interstitial) pancreatitis;
sterile pancreatic necrosis;
infected pancreonecrosis.

Sterile pancreatic necrosis also has the following forms:

according to the prevalence of the inflammatory process - small-focal, large-focal, subtotal;
according to the type of changes in the tissues of the gland - fatty, hemorrhagic, mixed;
by localization - caudal, capitate, affecting all parts of the pancreas.

Chronic pancreatitis is an inflammation of the pancreas, often diagnosed in older and middle-aged patients. Pathology is often formed in women, some scientists compare this with excessive production of specific hormones.

Clinicians distinguish between chronic, secondary and concomitant pancreatitis (which develops against the background of other diseases of the gastrointestinal tract). Pathology in acute form in the absence of adequate therapy can become chronic. Chronic pancreatitis often develops against the background of cholecystitis, cholelithiasis. This phenomenon can be provoked by unbalanced nutrition, systemic alcohol consumption, and smoking.

It should be borne in mind that there is no modern unified classification of chronic pancreatitis.

Etiology

- phase-progressive segmental or diffuse degenerative, destructive changes in its exocrine part;

- atrophy of glandular elements (pancreocytes) and their replacement with connective (fibrous) tissue;

- changes in the ductal system of the pancreas with the formation of cysts and calculi;

- varying degrees of violations of the exocrine and endocrine functions of the pancreas.

The important medical and social significance of the CP problem is due to its wide distribution among the working population (CP usually develops at the age of 35-50 years).

The frequency of CP worldwide is clearly increasing: over the past 30 years, more than a twofold increase in incidence has been noted.

According to many authors, the prevalence of CP among the population of various countries varies from 0.2 to 0.68%, and among patients with gastroenterological profile reaches 6-9%. Every year, CP is registered in 8.2-10 people per 100 thousand of the population.

The prevalence of the disease in Europe is 25-26.4 cases per 100,000 adults. A significant increase in the prevalence of CP was registered in Russia; The incidence of CP among young people and adolescents has increased 4 times over the past 10 years.

The incidence of CP in Russia is 27.4-50 cases per 100 thousand adults and 9-25 cases per 100 thousand children. In the practice of an outpatient gastroenterologist, patients with CP account for approximately 35-45%, in the gastroenterological department of a hospital - up to 20-45%.

Apparently, this trend is due, firstly, to an increase in alcohol consumption and, accordingly, an increase in the number of patients with alcoholic CP; secondly, irrational unbalanced nutrition and, as a result, a high incidence of cholelithiasis (GSD).

Exocrine pancreatic insufficiency is difficult to correct, often persists and progresses (despite enzymatic replacement therapy) and inevitably leads to violations of the nutritional status of patients and dystrophic changes internal organs.

The disease is characterized by a long-term chronic, progressive course, which has an extremely negative impact on the quality of life of patients and leads to partial or complete disability. Disability in CP reaches 15%.

The prognosis of the disease is determined by the nature of the course of pancreatitis: frequent exacerbations of the pain form of CP are accompanied by high risk development of complications, mortality in which reaches 5.5%.

At the same time, there is also an overdiagnosis of CP. A wide variety of digestive disorders, often not associated with the pancreas, in particular the “echogenic heterogeneity” of the pancreas, detected by ultrasound, are often considered as unreasonable criteria for diagnosing CP.

In this regard, the classification of CP is very important, as it reflects modern views on the etiology and pathogenesis of this pathology, determines the clinical variants of the disease, modern diagnostic and therapeutic approaches.

For a long time in pancreatology, the recommendations of the experts of the I International Symposium on Pancreatitis (Marseille, 1962) dominated. In the classification adopted on it, acute pancreatitis (AP) and CP were distinguished, which was divided into forms - recurrent painless with exo- and endocrine insufficiency and pain.

This classification approached the classification proposed by N.I. Leporsky in 1951 and adopted at the plenum of the All-Union Scientific Society of Gastroenterologists (Chernivtsi, 1971). In the same place, it was recommended to additionally isolate the pseudotumorous form of CP.

Further developers of the classification of CP, mainly surgeons, proposed to distinguish between parenchymal CP without damage to the ducts and ductal CP, which occurs with expansion and deformation of the main pancreatic duct.

a) calcifications;

b) expansion and deformation of the ductal system of the gland;

c) inflammatory infiltration, formation of cysts.

2. Obstructive CP, characterized by expansion and (or) deformation of the ductal system, atrophy of the parenchyma and diffuse fibrosis proximal to the site of duct occlusion.

a) latent, or subclinical, CP, in which morphological changes are found in the pancreas, dysfunction of the organ in the absence of distinct clinical symptoms illness;

b) pain CP, characterized by the presence of periodic or persistent pain in the abdomen;

c) painless CP occurring with exo- and (or) endocrine pancreatic insufficiency with or without complications.

With undoubted progress and merits

II of the Marseille classification, it is not relevant for a wide clinical practice because its use requires endoscopic retrograde cholangiopancreatography (ERCP) and pancreatic biopsy followed by histological examination, which is fraught with great difficulties.

Home Ι Pancreatitis

Pancreatitis is a common disease, the cause of which is the bad habits of the person himself, poor nutrition, or the development of underlying diseases of the internal organs. The defeat of the pancreas turns into a gradual deterioration in well-being and the risk of death.

Doctors distinguish several forms of such a disease, and it is about the features of its classification that will be discussed below.

Simplified version of the classification

In addition to the chronic and acute forms, doctors often distinguish initial stage. It is believed that it is at the initial level that the disease is easiest to defeat. However, pancreatitis rarely manifests itself from the first days of development, and that is why patients start the problem.

The most painful is acute form pancreatitis. A patient suffering from it regularly complains of pain, his temperature rises, nausea and fatigue appear.

The chronic form is much easier to control, but the development of pancreatitis to such a limit turns into regular troubles.

Detailed classification of the disease

Cysts and abscesses of the pancreas in some cases are classified as chronic classification categories, and sometimes as complications of pancreatitis. In turn, gland cysts are also divided into several types:

In order to correctly classify acute or chronic pancreatitis, a visual examination of the patient, anamnesis, palpation examination (palpation of pain points of the projection of the pancreas on the anterior abdominal wall), laboratory research and additional methods diagnostics - ultrasound, MRI or MSCT.

Sometimes it is possible to make an accurate diagnosis and attribute pancreatitis to one group or another only after surgery - endoscopic or open surgery.

The classification of acute pancreatitis is based on the following features: causes, disease-causing(etiological forms), and the severity of the course of the disease.

Etiological forms

alimentary (food) and alcohol;
biliary (associated with the state of the biliary system);
traumatic;
others.

According to this classification, one can distinguish the following reasons acute pancreatitis:

Overeating and alcohol abuse (including one-time) are the cause of the alimentary and alcoholic form of the disease.
Inflammation or absence of the gallbladder and ducts located outside the liver, as well as common duct stones, provoke the development of the biliary form.
Trauma of the pancreas, including iatrogenic, caused by medical intervention (carrying out surgical operation or diagnostic procedure) leads to a traumatic form.

Reasons for the development of other forms:

Classification according to the severity of the current

There are mild (edematous) and moderate and severe (destructive) forms.

The light form is characterized by the following features:

uniform edema of the organ without signs of inflammation in it and adjacent tissue;
microscopic foci of necrosis, not visualized with hardware diagnostics;

minor violations of the functions of the body;
no severe complications;
rapid adequate response to conservative treatment;
complete regression of pathological changes.

Severe forms of pancreatitis are accompanied by:

local complications of a destructive (destructive tissue) nature, affecting only the pancreas and adjacent tissues;
systemic complications from distant organs;
irreversible anatomical defects and persistent functional failure of both the pancreas and other organs.

The prevalence of necrotic process (cell death) on the pancreas due to destructive acute pancreatitis is classified as follows:

small-focal pancreatic necrosis - less than 30% of the organ is affected;
macrofocal pancreatic necrosis - lesion 30-50%;
subtotal pancreatic necrosis - lesion 50-75%;
total pancreatic necrosis - defeat more than 75%.

This classification is very popular and widely used throughout the world. According to her, there are four forms this disease:

Obstructive. This form is characterized by inflammatory processes in the pancreas. In this case, there is a blockage of the main ducts by tumors, adhesions, or by the course of the inflammatory reactions themselves.

Calcifying pancreatitis is the most common today. In this case, the tissues are destroyed focally, thus forming intraductal stones. This kind of this disease is most often found in people who consume a huge amount of alcoholic beverages.
The indurated form is extremely rare, as it is characterized by tissue atrophy.
Formation of cysts and pneumocysts.

The Cambridge classification of chronic pancreatitis is very popular among Western physicians. It is based on the gradation of changes in the pancreas at different stages of the course of the disease. According to this classification, the following stages of the disease are distinguished:

The pancreas is in normal condition. In this case, the organ has a normal structure and functions correctly.
Pathological changes of a chronic nature. In this case, only minor changes in the pancreas are observed.

Mild pathological changes are characterized by changes in the lateral ducts.
Pathological changes of a moderate nature. In this case, it is already possible to notice changes not only in the lateral ducts, but also in the main one. Usually small cysts and necrotic tissue form at this stage.
Significant pathological changes. In this case, in addition to all the changes described above, large cysts and stones can also form.

What causes chronic pancreatitis

In fact, this disease can begin to develop for several reasons, as well as their combination. Pay attention to the reasons that, according to doctors, are most often the cause of this pathology:

excessive abuse of alcoholic beverages;
the use of certain medications;
increased levels of calcium in the blood;

improper fat metabolism;
the development of the disease is not excluded as a result of poor heredity;
Also, the disease can make itself felt when there is insufficient intake of nutrients in the body.

Signs of pathology

In order to better understand what the classification of chronic pancreatitis is, you need to understand what symptoms it has. this pathology. And so, what signs you should pay attention to:

pain in the abdomen;
improper digestion, which will have symptoms such as copious fatty stools, bloating, significant weight loss, food intolerance and weakness of the whole body;
in some cases on running stages of the disease chronic pancreatitis may begin to develop diabetes mellitus;
in bile ducts pressure rises and gastric dyspepsia syndrome is detected.

Diagnostic methods

There are several methods for diagnosing the disease. But most often the best results are obtained when they are combined.

Inspection

The initial examination of the patient is the most important method of diagnosis. With its help, possible pallor and cyanosis of the skin and limbs, as well as jaundice in severe cases, is determined. Blood spots and navel, on the face and from the sides of the abdomen can also be detected. They usually talk about violations of the blood supply to the tissues.

Feeling in such cases can reveal the following symptoms:

abdominal tension (symptom of pancreatic necrosis);
pain in the left hypochondrium.

An important factor is also the questioning and study of the patient's medical history.

Laboratory procedures

The following tests will help determine acute pancreatitis and the form of the disease:

complete blood count (reveals signs of inflammation and dehydration);
biochemical analysis of urine (determines the level of electrolytes and an increase in the level of amylase and C-active protein as a sign of inflammation);
a blood test for glucose (with pancreatitis, its level is often elevated).

Application of devices and tools

Questioning, examination and tests are often not enough for an accurate diagnosis to identify the cause of the disease. Also in the diagnosis it is important to use the following methods:

ultrasound procedure;
radiography;
cholecystopancreography;
tomography (computer and magnetic resonance);
laparoscopy.

These techniques allow you to visualize the pancreas, ducts and gallbladder, determine their size and deviations from the norm, as well as identify the density and presence of neoplasms. Based on these studies, it is possible to determine the diagnosis quite accurately, therefore, before starting medical examination the patient must follow some recommendations on the regimen of the day and nutrition.

1. Sonography of the pancreas: determination of its size, echogenicity of the structure

2. FGDS (normal duodenum, like a "crown", goes around the pancreas; with inflammation, this "crown" begins to straighten out - an indirect sign of chronic pancreatitis)

3. Radiography of the gastrointestinal tract with a passage of barium: the contours of the duodenum are changed, the symptom of "backstage" (the duodenum straightens and moves apart, like backstage on a stage, with a significant increase in pancreas)

4. CT - mainly used for differential diagnosis CP and pancreatic cancer, tk. their symptoms are similar

5. Retrograde endoscopic cholangioduodenopancreatography - through the endoscope, a special cannula enters the papilla of Vater and injects contrast, and then a series of radiographs is taken (allows you to diagnose the causes of intraductal hypertension)

a) KLA: during exacerbation - leukocytosis, acceleration of ESR

b) OAM: during exacerbation - an increase in diastase

c) BAC: during exacerbation - an increase in the level of amylase, lipase, trypsin

c) coprogram: neutral fat, fatty acids, undigested muscle and collagen fibers

Treatment Methods

Therapeutic methods of treatment consist in carrying out the following manipulations:

To relieve pain and relieve spasms, a novocaine blockade is performed in combination with the introduction of drugs with an antispasmodic spectrum of action.
For 2-3 days from the first attack, the intake of any food is excluded, as rest, hunger and applying a cold compress to the area of \u200b\u200bthe greatest manifestation of pain.
On the third day, parenteral nutrition, aspiration of stomach contents, administration of antacids and proton pump inhibitors are prescribed.
It is also prescribed to take proteolysis inhibitors to deactivate pancreatic enzymes and drugs of the detoxification spectrum of action.
To prevent the development of infectious processes, antibiotic drugs are prescribed.

At diagnosis mild form pancreatic pathology therapeutic methods treatment starts positive results for 5-6 days already.

1. In case of exacerbation - table number 0 for 1-3 days, then table number 5p (pancreatic: restriction of fatty, spicy, fried, spicy, peppery, salty, smoked foods); all food is boiled; meals 4-5 times / day in small portions; refusal to drink alcohol

2. Relief of pain: antispasmodics (myolytics: papaverine 2% - 2 ml 3 times / day / m or 2% - 4 ml in saline IV, drotaverine / no-shpa 40 mg 3 times / day, M-cholinergic blockers: platyfillin, atropine), analgesics (non-narcotic: analgin 50% - 2 ml / m, in severe cases - narcotic: tramadol inside 800 mg / day).

3. Antisecretory drugs: antacids, proton pump blockers (omeprazole 20 mg in the morning and evening), H2 receptor blockers (famotidine 20 mg 2 times / day, ranitidine) - reduce the secretion of gastric juice, which is a natural stimulant of pancreatic secretion

4. Protease inhibitors (especially with intense pain syndrome): Gordox, contrical, trasilol, aminocaproic acid IV drip, slowly, in saline or 5% glucose solution, octreotide / sandostatin 100 mcg 3 times / day s / c

5. Replacement therapy (with insufficiency of exocrine function): pancreatin 0.5 g 3 times / day during or after meals, creon, pancitrate, mezim, mezim-forte.

6. Vitamin therapy - to prevent trophic disorders as a result of malabsorption syndrome

7. Physiotherapy: ultrasound, sinusoidal currents of various frequencies, laser, magnetotherapy (with exacerbation), thermal procedures: ozocerite, paraffin, mud applications (in remission)

After the diagnosis of acute pancreatitis is established, treatment should be started immediately, in a hospital setting.

First aid

You should immediately call a doctor. Prior to his arrival, it is necessary to ensure peace.

This is due to the following reasons:

in severe forms, conventional analgesics from a home medicine cabinet are unlikely to stop pain syndrome;
in mild forms, the use of anesthesia can blur the picture, making it difficult to diagnose;
oral medication (as well as food, drink) can aggravate the severity of the condition due to increased secretion of pancreatic juice.

Self-medication at home is unacceptable. Acute pancreatitis should be treated by a qualified specialist. Only this condition minimizes the probability possible complications with an unfavorable outcome.

Treatment of mild acute pancreatitis

Edematous acute pancreatitis can be treated with conservative methods in the surgical department of the hospital. In such cases, it is important to reduce the secretion of pancreatic juice and neutralize pancreatic enzymes. Patients are usually prescribed:

complete hunger for two or three days;
removal of stomach contents;
intravenous infusions;
antienzymatic drugs;
antihistamines (H 2 blockers);
antispasmodics;
pain relief (non-steroidal anti-inflammatory drugs).

Smoking in the early days is also strictly prohibited. In some cases, doctors prohibit smoking only for the reason that it is a bad habit. However, in this case, the ban is quite justified, even one smoked cigarette can adversely affect the course of acute pancreatitis: any irritation of the oral cavity receptors leads to the separation of pancreatic juice, especially rich in enzymes.

From the third or fourth day, you can take food in small quantities - pureed cereal decoctions, sweet weak tea, stale bread. Later, table No. 5p is assigned.

Treatment of severe forms of pancreatitis

In view of the development of enzymatic endotoxicosis in such patients, which causes insufficiency of a number of organs, they should be treated in the intensive care unit.

Chronic pancreatitis, the etiology of which can be diverse, is very important to start treating on time, otherwise this pathology can lead to the formation of other diseases. Usually chronic form pathologies are very difficult to cure with conservative methods, so experts suggest resorting to surgical intervention.

Do not make hasty conclusions, visit several doctors, and based on the received general recommendations decide on a further treatment plan.

Do not forget that the treatment process should be aimed at the elimination of pain, the removal of inflammatory processes, as well as the process of removing bile from the body.

Postoperative

This type of disease develops due to surgical treatment pathologies of the abdominal organs (stomach, gallbladder, duodenum). The inflammatory reaction is provoked by direct or indirect mechanical action on the pancreatic tissue. The patient's condition is characterized as extremely serious. There is intoxication severe pain in the abdomen, bloating, vomiting, stool retention.

Possible complications of the disease

If the disease is severe, the risk of developing such complications is high:

Pancreatogenic abscess, phlegmon of the retroperitoneal space.
Arrosive bleeding from damaged vessels.
enzymatic peritonitis. Perhaps the development of bacterial inflammation of the peritoneum.
Mechanical, or obstructive, jaundice (as a result of compression and swelling of the papilla of Vater, through which a normal outflow of bile occurs).
The pseudocysts are sterile or infected.
Digestive internal or external fistulas.

edematous pancreatitis

This is the most favorable form of the disease, in which there is a pronounced edema of the parenchyma of the gland, small areas of necrosis. The pain syndrome is characterized by moderate intensity and is localized in the upper abdomen. The patient may complain about constant nausea, occasional vomiting and upset stool.

Pancreatic necrosis

With pancreatic necrosis, a significant part of the organ dies, including the islets of Langerhans, which are responsible for the production of insulin. In more severe cases in pathological process parapancreatic tissue is involved.

The disease is most often fulminant in nature with the development of multiple organ failure. At the initial stages, the patient experiences unbearable pain in the abdomen, repeated vomiting. Characterized by a rise in temperature, the appearance of signs of dehydration. As the necrosis progresses, the pain becomes dull (a large number of nerve endings), consciousness is disturbed and symptoms of shock are recorded.

Initially, the process develops without the participation of microbial flora, so this pancreatic necrosis is called sterile. In the case of a bacterial or fungal infection, the appearance of pus indicates infected pancreatic necrosis.

Abscess of the pancreas

A severe form of any pancreatitis can be complicated by the formation of a local purulent focus, limited from the surrounding tissues by a thin capsule. The pathological focus is well visualized on ultrasound or CT.

Since an abscess is a "encapsulated" pus, the patient is in a serious condition, has a high fever. The pain acquires a clearer localization, vomiting is repeated. In a clinical blood test, a high leukocytosis, a neutrophilic shift and an accelerated ESR are detected. In addition, acute-phase indicators of inflammation (procalcitonin, C-reactive protein, orzomucoid) increase.

Infected pancreatic cyst

A cyst is a cavity filled with fluid. It is limited by a wall consisting of thinned tissue of the gland. The cyst can communicate with the pancreatic ducts, compress surrounding organs, and become infected. In rare cases, this complication is asymptomatic and is a finding during an ultrasound scan.

In the clinical picture of cysts, the presence of a local pain syndrome, sensitivity to palpation of this area are distinguished. When the bacterial flora is attached, the body temperature rises rapidly, weakness, pale skin, chills appear, pain intensifies.

Acute pancreatitis can be complicated by local and systemic pathological changes. Local complications affect both the pancreas itself and the retroperitoneal tissue. They are divided into aseptic and purulent.

Prevention of acute pancreatitis

It is often easier to avoid a disease than to treat it. This is especially true of the most common form of acute pancreatitis - alcohol (alimentary). To preventive measures relate:

alcohol abuse and overeating (especially fatty foods) should be avoided;
timely treatment of gallstone disease;
prevention and timely treatment of common infectious diseases.

Acute pancreatitis - dangerous disease, complications of which can lead to disability and death. It must be treated by qualified professionals. In case of timely and adequate medical care 90% of patients are cured completely.

Classification of pancreatitis

Pancreatitis is a severe form of pancreatic disease that can take various forms depending on the type of injury and its duration. The main cause of the disease are bad habits and abuse of spicy and fried foods.

Classification and types of disease are subforms of the disease used to make a diagnosis. Classification required for appointment medicines and diet. Clinicians distinguish two forms of development of pancreatitis, which are used in practice:

spicy
chronic

Each of the types of pancreatitis can have its own forms of progression and severity. Forms, in turn, are divided into four types. Pancreatitis is also classified for 7 reasons. We will discuss the features of the classification in more detail below.

The classification of pancreatitis is the allocation of individual varieties of this disease, which have different causes and clinical picture. Therapeutic tactics for each of them will also be individual. Pancreatitis is inflammatory disease pancreas, which is one of the most common in the clinic of internal diseases.

The most common causes of its development are malnutrition and alcohol abuse. The number of patients with pancreatitis worldwide is growing rapidly. Until recently, pancreatitis was classified as age-related, that is, it was mainly the elderly who suffered from it. However, due to the popularity of unhealthy foods, more and more children and adolescents with its symptoms are turning to the doctor every year.

Two main types of pancreatitis

The main classification of pancreatitis involves dividing it into 2 main groups: acute and chronic pancreatitis. These are not stages of the same disease. It's perfect different kinds inflammation of the pancreas, treatment tactics in each case will be different.

Due to development:
1. (reason - disruption of the gallbladder),
2. with alcohol abuse,

3. due to metabolic disorders,

4. against the background of medication, idiopathic (the cause is not exactly known).
According to clinical manifestations:
1. pain form,
2. violation of the digestive process (decrease in the production of enzymes),

3. hypochondriacal (the patient makes many complaints that do not correspond to the real picture),

4. covert treatment,

5. mixed type(which combines the previous options).

There are also separate classifications of the disease according to morphological changes and presence. Each of them has its own treatment approaches. Therapy should be chosen by a general practitioner or

Source: https://medaboutme.ru/zdorove/publikacii/stati/sovety_vracha/klassifikatsiya_pankreatita/

Modern ideas about the classification of chronic pancreatitis

Chronic pancreatitis (CP) is a group of chronic diseases of the pancreas (PZ) of various etiologies, predominantly of an inflammatory nature, characterized by:

phase-progressive segmental or diffuse degenerative, destructive changes in its exocrine part;
atrophy of glandular elements (pancreocytes) and their replacement with connective (fibrous) tissue;
changes in the ductal system of the pancreas with the formation of cysts and stones;
varying degrees of violations of exocrine and endocrine functions of the pancreas.

The important medical and social significance of the CP problem is due to its wide distribution among the working population (CP usually develops at the age of 35-50 years). The frequency of CP worldwide is clearly increasing: over the past 30 years, more than a twofold increase in incidence has been noted.

According to many authors, the prevalence of CP among the population of various countries varies from 0.2 to 0.68%, and among patients with gastroenterological profile reaches 6-9%. Every year, CP is registered in 8.2-10 people per 100 thousand of the population.

The incidence of CP in Russia is 27.4-50 cases per 100 thousand adults and 9-25 cases per 100 thousand children. In the practice of an outpatient gastroenterologist, patients with CP account for approximately 35-45%, in the gastroenterological department of a hospital - up to 20-45%.

Important in clinical and social terms are such features of CP as a progressive course with a gradual increase in exocrine insufficiency; pain and dyspepsia that persist for a long time and quickly recur with any nutritional error, causing, on the one hand, the need for frequent expensive medical measures and dispensary observation, and on the other hand, requiring the patient to constantly follow a diet and take enzyme preparations.

Attention!

Exocrine pancreatic insufficiency is difficult to correct, often persists and progresses (despite enzyme replacement therapy) and inevitably leads to violations of the nutritional status of patients and degenerative changes in internal organs.

The prognosis of the disease is determined by the nature of the course: frequent exacerbations of the pain form of CP are accompanied by a high risk of complications, the mortality rate of which reaches 5.5%. At the same time, there is also an overdiagnosis of CP. A wide variety of digestive disorders, often not associated with the pancreas, in particular, the "echogenic heterogeneity" of the pancreas, identified with, are often considered as unreasonable criteria for diagnosing CP.

In this regard, the classification of CP is very important, as it reflects modern views on the etiology and pathogenesis of this pathology, determines the clinical variants of the disease, modern diagnostic and therapeutic approaches.

Classification of chronic pancreatitis

For a long time, pancreatology was dominated by the recommendations of the experts of the I International Symposium on Pancreatitis (Marseille, 1962). In the classification adopted on it, acute pancreatitis (AP) and CP were distinguished, which was divided into forms - recurrent painless with exo- and endocrine insufficiency and pain.

Further developers of the classification of CP, mainly surgeons, proposed to distinguish between parenchymal CP without damage to the ducts and ductal CP, which occurs with expansion and deformation of the main pancreatic duct.

At the II International Symposium on Pancreatitis (Marseille, 1983), the classification of CP was revisited. It was decided to abandon the formulations "acute recurrent pancreatitis" and "chronic recurrent pancreatitis", since in clinical practice they cannot be clearly differentiated. Then it was decided to allocate the following forms of CP:

CP with focal necrosis, segmental or diffuse fibrosis with or without:

calcifications;
expansion and deformation of the ductal system of the gland;
inflammatory infiltration, formation of cysts.

CP is obstructive, characterized by expansion and (or) deformation of the ductal system, atrophy of the parenchyma and diffuse fibrosis proximal to the site of duct occlusion.

Depending on the clinical symptoms identified:

latent, or subclinical, CP, in which morphological changes are found in the pancreas, dysfunction of the organ in the absence of distinct clinical symptoms of the disease;
pain CP, characterized by the presence of periodic or persistent pain in the abdomen;
painless CP occurring with exo- and (or) endocrine insufficiency of the pancreas with or without complications.

With undoubted progress and merits

II of the Marseille classification, it is not relevant for wide clinical practice, since its use requires endoscopic retrograde cholangiopancreatography (ERCP) and pancreatic biopsy followed by histological examination, which is very difficult.

In this regard, it became necessary to create a classification close to Marseilles, but based mainly on clinical and laboratory parameters and data obtained using ultrasound and computed tomography (CT).

In this regard, the Rome Classification of HP (Rome, 1989) was of intermediate importance, which proposed to single out:

chronic calcific pancreatitis. The most common cause is alcohol consumption. As a result of inflammation and changes in the structure of the smallest pancreatic ducts, the secretion thickens with the formation of plugs rich in protein and calcium. In this process, an important role is played by a decrease in the concentration of lithostatin (a protein that prevents stone formation);
chronic obstructive pancreatitis. It is observed with pronounced narrowing of the main pancreatic duct or its large branches, or Vater's nipple. Causes of development: alcohol, cholelithiasis, trauma, tumor, birth defects. Occurs infrequently;
chronic parenchymal fibrous (inflammatory) pancreatitis. It is a relatively rare form of the disease.

The presented classification is widely used in developed countries. However, the weak point in this classification was the allocation of "calcifying pancreatitis". It can include cases both with the presence of calcifications of the gland, and with their absence, allowing the possibility of their development in the future.

The International Classification of Diseases (ICD-10, 1999) distinguishes:

CP of alcoholic etiology (K 86.0);
other CP (CP of unknown etiology, infectious, recurrent) (K86.1).

It should be emphasized that this international classification is statistical and represents CP in an extremely concise manner, without covering important features of the disease. The ICD-10 cannot replace the clinical classification of CP. In recent years, our country has become widespread clinical classification HP proposed by V.T. Ivashkin et al. The main options are presented in table. one.

Among the new modern classifications that take into account the most complete causes of pancreatitis, it is necessary to highlight the etiological classification of TIGAR-O: Toxic-metabolic (toxic-metabolic), Idiopathic (idiopathic), Genetic (hereditary), Autoimmune (autoimmune), Recurrent and severe acute pancreatitis (recurrent and severe acute pancreatitis), or Obstructive (obstructive) (Table 2),

as well as the multifactorial classification M-ANNHEIM: Multiple Alcohol (alcohol), Nicotine (nicotine), Nutrition (nutrition), Hereditary (heredity), Efferent (carrying out), Immunological (immunological), Metabolic (metabolic).

The TIGAR-O classification is focused on understanding the causes of CP and the choice of appropriate diagnostic and therapeutic tactics. This is its main advantage and convenience for practitioners.

The literature describes such rare forms of CP as tropical and hereditary CP, the etiology and pathogenesis of which are not fully understood. Hereditary pancreatitis is an autosomal dominant type of inheritance with incomplete penetrance.

The etiological classification of TIGAR-O represents the four most studied genes whose mutations predispose to the development of hereditary pancreatitis: the cationic trypsinogen gene (PRSS1), the cystic fibrosis gene (CFTR), the pancreatic secretory trypsin inhibitor (SPINK) gene, and the α1-antitrypsin polymorphism gene.

Before recent years tropical pancreatitis was associated with the nutritional habits of patients. Due to the unclear etiology of tropical CP, the TIGAR-O classification treats tropical CP as a variant of idiopathic CP.

To date, ideas about etiological factors tropical HP have changed. Researchers are increasingly inclined to the idea of the hereditary nature of the disease. In addition, the development of CP is facilitated by the influence of unidentified external factors, the search for which continues.

The M-ANNHEIM classification provides for the definition clinical stages HP.

The course of CP is divided into two phases: asymptomatic and with the presence of clinical manifestations. The latter includes four stages (I, II, III, IV), and each of them has substages, including the development of severe complications.

Asymptomatic phase of CP:

0 - subclinical CP:

a period without symptoms (determined by chance, for example, at autopsy);
acute pancreatitis (AP) - the first episode (possibly the beginning of CP);
OP with severe complications.

CP with clinical manifestation:

Stage I - without pancreatic insufficiency:

Relapse of AP (no pain between episodes of AP).
Recurrent or persistent abdominal pain (including pain between episodes of OP).
I a/b with severe complications.

Stage II - exo- or endocrine insufficiency of the pancreas:

isolated exocrine (or endocrine) insufficiency without pain;
isolated exocrine (or endocrine) insufficiency with pain;
II a/b with severe complications;

Stage III - exo- and endocrine insufficiency of the pancreas in combination with pain:

exocrine and endocrine insufficiency of the pancreas (with pain, including requiring treatment with analgesics);
III a with severe complications.

stage - a decrease in the intensity of pain (the stage of "burnout" of the pancreas):

exocrine and endocrine insufficiency of the pancreas in the absence of pain, without severe complications;
exocrine and endocrine pancreatic insufficiency in the absence of pain, with severe complications.

The advantages of this classification are that it covers almost all aspects of the course of the disease, does not require invasive, in particular, morphological research methods, uses accessible and understandable terminology, and is based on practical criteria.

According to the intensity of pain and the duration of the disease, patients with CP can be divided into three groups. Comparing these two parameters revealed inverse relationship between them: the longer the disease, the less pain.

Currently, to assess the presence, degree and localization of pain in the clinic, psychological, psychophysiological and neurophysiological methods are used, most of which are based on a subjective assessment of their feelings by the patients themselves.

The simplest way to quantify pain is to use a rank scale. The numerical rating scale consists of a sequential series of numbers from 0 to 10. Patients are asked to rate their pain sensations with numbers from 0 (no pain) to 10 (the worst possible pain).

When comparing the identified clinical, laboratory and morphological data, three variants of the course of CP were identified:

option A - the duration of the disease is less than 5 years, severe pain syndrome, the level of pancreatic fecal elastase (E-1) is slightly reduced, but significantly (pv0.05), there is an increase in the content of acetylcholine (Ax) in the blood (p<0,05) и серотонина (5-НТ) (р<0,05), высокий уровень провоспалительных цитокинов, умеренное повышение холецистокинина (ХЦК) и снижение секретина. В ткани ПЖ выявляются воспаление и отек;
option B - the duration of the disease is from 5 to 10 years, the level of E-1 is significantly reduced (below 100 μg / g), the pain syndrome is moderate, 5-HT begins to predominate (p<0,05), как стимулятор секреторной активности ПЖ. Остаются высоким ХЦК и низким секретин. Прогрессируют фиброзные изменения, выявляется кальциноз в ткани ПЖ;
variant C - duration of the disease from 10 years or more, mild pain syndrome, a further increase in the concentration of 5-HT is observed, which leads to decompensation of the regulatory mechanisms of the secretory activity of the pancreas. An increase in CCK and a decrease in the content of secretin persisted. The protective properties of duodenal mucus are reduced. Against the background of a decrease in the level of endogenous insulin, the clinical picture of diabetes mellitus develops in 30% of cases.

This classification is of no practical importance due to the complexity of determining Ax, 5-HT and CCK in the daily practice of physicians. In 2009, M. Buchler et al. proposed a staged (A, B, C) classification system for CP, taking into account both the clinical manifestations of the disease and the results of imaging methods.

To classify CP, in addition to taking into account the etiological factor, the authors propose to use one clinical criterion or the presence of distinct complications of the disease in conjunction with pathological changes detected by imaging methods or using direct functional pancreatic tests.

Stage A. CP is determined at the initial manifestations of the disease, when there are still no complications and there are no clinical manifestations of exocrine and endocrine dysfunction (no steatorrhea, diabetes mellitus). However, subclinical signs of the disease (eg, impaired glucose tolerance or reduced exocrine function without steatorrhea) may already be present.

Stage B(intermediate). It is determined in patients with identified complications of the disease, but without signs of steatorrhea or diabetes mellitus. In the diagnosis, it is necessary to indicate the type of complication.

Stage C. It is the final stage of CP, when the presence of fibrosis leads to clinical manifestations of exocrine and endocrine insufficiency, while complications may not be diagnosed. This stage is divided into subtypes:

C1 (presence of endocrine disorders);
C2 (presence of exocrine disorders);
C3 (presence of exo- or endocrine disorders and/or complications).

Recently, such a rare form of CP as autoimmune pancreatitis (AIP) has been described, in which the diagnosis and choice of treatment tactics present certain difficulties. AIP is a variant of CP that occurs in the absence of gallstones, pancreas divisum (split pancreas), alcohol abuse, or other factors that cause CP.

Ultrasound may show a diffuse or local enlargement of the pancreas with diffuse hypoechogenicity of the affected areas. The classic CT sign of AIP is a "sausage-like" thickening of the pancreas with homogeneous attenuation, moderate enhancement with contrast, with a peripheral hypodense rim. With this form, there is a loss of lobular structure, a minimal reaction of peripancreatic fat and an increase in regional lymph nodes.

With long-term AIP, atrophy of the pancreatic tail is almost always observed. Typical changes in serological tests include an increase in the plasma level of 0xE3;-globulins or immunoglobulins, in particular IgG4, the presence of antinuclear antibodies, as well as antibodies to lactoferrin, carbonic anhydrase II, and smooth muscles.

Histological criteria for AIP are periductal lymphoplasmacytic infiltration or fibrosis, phlebitis obliterans, and an increased content of IgG4-positive plasma cells in the tissues of the pancreas. In the domestic literature, there are only a few reports of proven cases of AIP and the effectiveness of its treatment.

This is due to the relative rarity of this disease, diagnostic difficulties, but mainly due to the lack of information about the existence and possibility of detecting and treating this form of CP.

Source: https://www.mediasphera.ru/issues/dokazatelnaya-gastroenterologiya/2013/1/032305-2260201317

Acute pancreatitis: modern classification system

Acute pancreatitis (AP) is one of the most common emergency pathologies of the gastrointestinal tract. In recent studies under the auspices of WHO, a constant increase in the annual incidence of OP has been noted, which ranges from 4.9 to 73.4 cases per 100,000 population.

Attention!

In Russia, the incidence of OP is 20–80 people per 100,000 population; in Russian hospitals, OP ranks third among acute surgical abdominal diseases and accounts for 12.5% of all acute surgical abdominal pathology.

Of all forms of acute pancreatitis, the most significant level is accompanied by acute severe pancreatitis (ATP), developing in 20-30%. The number of patients who develop infected pancreatic necrosis, late multiple organ failure and other severe purulent-destructive complications of acute pancreatitis - arrosive bleeding, duodenal fistula, small and large intestinal fistulas, and pancreatic fistula is increasing.

At the same time, in the Russian Federation, at least 2 million rubles are spent on the treatment of patients with infected pancreatic necrosis in intensive care units for one month. For the successful treatment of this severe pathology, it is important to develop unified approaches to treatment based on a unified classification.

However, in Russia the attitude towards the classification of EP is still ambiguous. In 2000, at the IX All-Russian Congress of Surgeons in Volgograd, V.S. Savelyev conducted a survey of surgeons from 18 regions of the Russian Federation regarding the classification of OP they use.

The result of the survey was unexpected. 12% of surgeons did not use the classification in their work at all, 53% preferred the international classification Atlanta - 1992, the rest worked according to the outdated classifications of V.S. Saveliev (1983) and S.A. Shalimova (1990) .

The international community of pancreatic surgeons is constantly working on the issues of a unified strategy in the diagnosis and treatment of OP. An international group of 40 experts from 15 international and national associations of pancreatic surgeons in 1992 prepared and reported at the International Congress on September 11–13, 1992 in Atlanta (USA) the first substantiated classification system for OP.

Over the past more than 20 years, some important aspects of the classification have been revised by international groups of the world's leading pancreatologists in accordance with the deepening of knowledge about the pathophysiology, morphology, course of OP, and also taking into account the emergence of new diagnostic capabilities. In 2007, at the initiative of M.G. Sarr (USA) once again created an international working group on the 3rd revision of the classification of OP Atlanta 1992.

For 5 years, experts have studied international experience in the diagnosis and treatment of OP in large-scale studies, and in 2013 the text of the third revision of the OP classification - 2012 was published and recommended for use.

Below we present the most significant, in our opinion, criteria, classification points and prognostic scales for a practitioner recommended by an international working group for use in wide practice.

Diagnostic criteria

The diagnosis of "acute pancreatitis" is made when at least two of the three signs listed below are detected:

abdominal pain characteristic of acute pancreatitis;
an increase in the level of serum lipase or serum amylase by 3 times in relation to the upper limit of the norm;
detection of characteristic features with ultrasound and contrast-enhanced CT, MRI.

The onset of the disease is considered to be the time of onset of typical abdominal pain. Pancreonecrosis is exposed in the presence of a diffuse or focal area of non-viable parenchyma of the pancreas (PJ) more than 3 cm in diameter or occupying more than 30% of the PZh (according to radiation diagnostic methods).

Items of the international classification Atlanta-92 third revision (2012).

Section A. By type of acute pancreatitis

Interstitial edematous acute pancreatitis
Necrotizing acute pancreatitis

Section B. According to the clinical picture and severity

Easy	Moderate severity	Heavy
Without organ failure (less than 2 points on the Marshall scale) No local or systemic complications	Transient organ failure, (greater than 2 Marshall scores in one or more of the three systems, persisting no more than 48 hours) and/or local or systemic complications of acute pancreatitis without persistent organ failure	Persistent organ failure (greater than 2 Marshall scores in one or more of the three systems, persisting for more than 48 hours) Death in the early period and/or local or systemic complications of acute pancreatitis

Modified Marshall score for acute pancreatitis

Organ systems	Points
Organ systems	0	1	2	3	4
Respiratory system (PaO2/FiO2)	>400	301–400	201–300	101–200	≤101
Kidneys: (plasma creatinine, μmol/l) (plasma creatinine mg/dl)
	<1,4	1,4–1,8	1,9–3,6	3,6–4,9	>4,9
The cardiovascular system (BP mm/Hg) without inotropic support	>90	<90 increases with infusion	<90 does not increase during infusion	<90	<90

Acute mild pancreatitis is characterized by a rapid response to fluid therapy, usually within 3 to 7 days. Does not require a stay in the ICU, no need for surgical treatment. Frequency - 80–85% of patients with OP. Morphologically corresponds to interstitial edematous pancreatitis, microscopic necrosis of the pancreatic parenchyma is rare.

Acute pancreatitis of moderate severity is characterized by transient organ dysfunction, which can be stopped by appropriate infusion therapy within 48 hours.

Morphologically, there are local or diffuse areas of non-viable pancreatic parenchyma of various prevalence and localization, necrosis of peripancreatic tissues of various prevalence and localization. OP of moderate severity can occur with or without complications of acute pancreatitis.

Acute severe pancreatitis is accompanied by permanent or progressive organ dysfunction, which is not stopped by infusion therapy for more than 48 hours. Morphologically, there is necrosis of the pancreatic parenchyma and / or peripancreatic tissues of various prevalence and localization; sterile or infected; the formation of acute fluid accumulations and other local complications of acute pancreatitis. Severe pancreatitis occurs in 15–20% of patients.

Section B. Phases of the course of acute pancreatitis

Early phase - 1-2 weeks from the onset of the disease. It is characterized by activation of the cytokine cascade due to severe inflammation in the pancreas. Clinically, there is a manifestation of SIRS with a high risk of developing organ failure and pancreatogenic shock.
Late phase - later than the first or second weeks of the disease. It develops only in patients with acute pancreatitis of moderate severity and severe AP, is characterized by the development of local complications, more often purulent, leading to transient or permanent organ failure.

Section D. Complications of acute pancreatitis

Local complications of acute pancreatitis

Extrapancreatic manifestations and systemic complications

1. Acute fluid collections

2. Acute pancreatic necrosis unrestricted - sterile / infected

3. Acute peripancreatic necrosis, undelimited - sterile or infected

4. Acute, circumscribed pancreatic necrosis - sterile or infected.

5. Acute, circumscribed peripancreatic necrosis

(extrapancreatic necrosis) - sterile or infected

6. Pancreatic pseudocyst (sterile or infected)

1. Cholecystolithiasis.

2. Choledocholithiasis.

3. Expansion of the extrahepatic bile ducts.

4. Portal vein thrombosis.

5. Varicose veins of the esophagus and stomach.

6. Arterial pseudoaneurysm.

7. Hydrothorax.

9. Spread of inflammation to the stomach, duodenum, colon, kidney.

10. Necrosis of the colon wall

Morphological criteria for the severity of OP according to the Balthazar scale

The scores for the severity of pancreatitis and the prevalence of necrosis are summarized. The maximum severity is 10 points, the minimum is 0 points.

Clinical criteria for severity of AP for non-biliary pancreatitis

according to the Ranson scale

The presence of each attribute is estimated at 1 point, the absence - 0 points, all points are summed up. The predictive value of the scale is as follows: in the presence of 2 or less points, mortality is less than 1% (mild pancreatitis), from 3 to 5 points - mortality up to 15% (moderate severity of pancreatitis), from 6 to 8 points - mortality up to 40% and 9 or more points - lethality up to 100% (6 or more points - severe pancreatitis).

For the correct choice of access and volume of surgery, a standardized assessment of the localization of the retroperitoneal tissue lesion is necessary. For these purposes, the most convenient for us is the following scheme with the allocation of zones of pancreatogenic aggression.

Peripancreatic tissue. Fiber located around the pancreas and directly adjacent to its surface. Its main part can be adequately drained through a bursoomentostomy.

S1 - left upper quadrant of the retroperitoneum. Fiber located to the left of the spine and above the mesentery of the colon. It is often involved in the process along with parapancreatic, and its drainage requires extraperitoneal counter-opening in the left lumbar region.

S2 - left lower quadrant of the retroperitoneum. Fiber located to the left of the spine and below the mesentery of the colon. As a rule, it is a consequence of the progression of pancreatogenic aggression from S1, and for its adequate drainage, in addition to bursoomentostomy and an incision in the left lumbar region, an extraperitoneal division of the entire retroperitoneal tissue to the left of the spine and an extraperitoneal contraperture in the left iliac region are required.

D1 - right upper quadrant of the retroperitoneum. Fiber located to the right of the spine and above the mesentery of the colon.

A significant part of it is difficult to reach from the lumen of the omental sac; for its drainage, the upper transrectal subhepatic access through the abdominal cavity with elements of duodenal mobilization according to Kocher and extraperitoneal counter-opening in the right lumbar region is used.

D2 - right lower quadrant of the retroperitoneum. Fiber located to the right of the spine and below the mesentery of the colon. As a rule, it is a consequence of the progression of pancreatogenic aggression from D1, and for its adequate drainage, extraperitoneal division of the entire retroperitoneal tissue to the right of the spine and extraperitoneal contraperture in the right iliac region are additionally required.

Thus, the lack of standardized approaches to diagnostic and therapeutic algorithms plays a role in the continuing high overall and postoperative mortality in severe AP. To overcome this situation, it is critically necessary to introduce scientifically based modern classification schemes into wide surgical practice.

Acute pancreatitis is characterized by severe inflammation of the pancreas, the organ is noticeably enlarged. Puffiness appears, an infection develops in the areas of destruction, and then spreads beyond the zone. The disease is accompanied by severe pain in the abdomen and emissions of substances that harm the body. A patient with acute inflammation, as a rule, feels pain after eating.

The main causes of occurrence

Acute pancreatitis is inextricably linked with the lifestyle of the patient. When alcohol is abused, a person is at great risk. Alcohol, together with harmful fatty foods rich in proteins, fast food provoke the formation of inflammatory processes. The causes are cholelithiasis, endocrine disease, abdominal trauma and drugs that adversely affect the pancreas.

Development process

When eating fatty foods containing an abundance of proteins, the work of the pancreas is enhanced, enzymes are produced that are involved in the digestion of food. Enzymes must travel through the ducts of the pancreas to reach the intestines.

In people susceptible to the disease, the gland functions poorly, proteins remain in the ducts, forming protein plugs. As a result, enzymes cannot continue their journey through the ducts, penetrate into the pancreatic tissue and begin to digest the organ, not food. The result is acute inflammation. In addition to junk food, alcohol, more precisely, acetaldehyde, which is formed during decay, negatively affects the gland.

Symptoms

With this form of the disease, patients experience a lack of appetite, general weakness and fever. There are severe pains in the abdomen, radiating to the back. The process is accompanied by bloating, vomiting and nausea.

The classification of acute pancreatitis depends on the form, scale and nature of the lesion, the period of illness and complications. There are four types of acute inflammation:

diffuse. With this form, the patient's condition deteriorates strongly and sharply. Accompanied by fever, gastric bleeding and oliguria.
- a mild form of the severity of the disease, treatable, does not imply significant changes in the tissues of the gland.
Total. It is characterized by loss of sensitivity, shock, severe intoxication, a sharp increase in the level of acidity in the patient's body.
Limited. Accompanied by pain in the abdomen, vomiting, tachycardia, jaundice and fever. Unfortunately, modern medicine has not developed effective methods of dealing with this type of disease, it is extremely difficult to treat.

In addition to the classification described, mild, moderate and severe pancreatitis is distinguished. With a mild form of difficulty in work and changes in the structure of the body are not observed. With moderate severity, systemic complications and transient organ failure appear. In severe cases, the likelihood of death is high. This type suggests local systemic complications and persistent organ failure.

In acute relapsing disease, pancreatic attacks appear. The disease ends with a complete restoration of tissues. There are cases in which the tissue has not fully recovered, a focus of fibrosis is formed. Often then the acute becomes chronic.

Chronic pancreatitis

This period of the disease is characterized by duration and stability. In this phase, there is no particular threat to the patient's body. There is a constant risk of acute inflammation. Acute pancreatitis forces you to follow a diet, and with a long remission, you should not abandon the diet. It is prescribed to periodically see a doctor to monitor the course of the disease.

Pathological changes in the gland persist after the elimination of the action of provoking factors. Morphological and functional disorders in the work of the pancreas continue to progress.

There are two types of chronic pancreatitis: primary and secondary. The first period is characterized by duration and the absence of frequent manifestations of symptoms. The second period is distinguished by the fact that damage to the gland and disturbances in the functioning of the organ constantly disturb a person.

Causes of the disease

Chronic pancreatitis is formed against the background of other diseases. For example, chronic enteritis, gastritis or cholecystitis. Frequent consumption of spicy, fatty foods, irregular meals, alcohol abuse, infectious diseases, lack of proteins and vitamins in the diet - all this can serve as the formation and development of the inflammatory process. Also, the disease sometimes occurs when small stones move along the bile ducts. may become chronic, but this option is rare.

The manifestation of the disease

A patient with a similar form of the disease is concerned about pain in the depths of the abdomen, spreading upwards. It often occurs if unauthorized foods that provoke inflammation are allowed to eat. The pains are either short-lived (for several minutes), or long-term (up to four hours), sometimes constant. There is bloating, nausea, loss of appetite, heartburn, vomiting, excessive gas formation and loose stools.

The classification of chronic pancreatitis involves the allocation of types of disease: calcific, obstructive, fibrous-indurated and pancreatic fibrosis. The latter type is based on tissue necrosis, the inability of the pancreas to perform a secretory function. Fibrous-indurative inflammation is accompanied by a strong change in the tissues of the organ.

Chronic recurrent pancreatitis has a similar focus to acute recurrent pancreatitis to a lesser extent.

Calcifying pancreatitis

The most common form of the disease is calcifying chronic pancreatitis. The classification adopted in Marseilles determined the form of the disease as the most severe. From 45% to 90% of all cases - chronic calcific pancreatitis.

Often the cause is the abuse of alcoholic beverages. It is distributed unevenly over the affected areas. The pathogenesis is associated with a lack of secretion of the protein of pancreatic stones (lithostatin). As a result of this form of the disease, the structure of the pancreas changes and minor ducts become inflamed with emerging plugs. This leads to the formation of stones.

Obstructive chronic pancreatitis

This type of disease is formed due to compression of the duct, through which the juice from the pancreas enters the duodenum. In severe cases, the disease spreads to nearby branches. The lesion of the obstruction site develops evenly. Accompanied by prolonged recurrent abdominal pain, bloating, nausea and vomiting, frequent loose stools, gradual weight loss, obstructive jaundice and other symptoms.

It is more often formed due to duodenitis, anatomical formation of the duodenum, pancreatic tumors, birth defects, alcohol abuse, or after operations and injuries. Surgery is usually prescribed.

Pancreatitis is a disease in which the main organ of the digestive system, the pancreas, is affected. Despite the fact that inflammation can occur in only two forms (acute and chronic), the classification of pancreatitis is quite large. Both the acute form of the disease and the chronic form have their own subgroups, which will be discussed now.

Types of disease

With the development of pancreatitis, the digestive enzymes produced by the pancreas are not released into the duodenum, as it should be, but remain inside the organ, starting to digest its own tissues. As a result, the patient's condition worsens greatly. He develops severe pain in the right hypochondrium, there are frequent bouts of nausea, vomiting and diarrhea.

At the same time, various failures occur in the body, entailing a violation of the functionality of other internal organs and systems. And if a person does not start treating pancreatitis in a timely manner, this can lead to various complications, among which the most dangerous are diabetes mellitus, pericarditis, kidney and liver failure.

Important! Despite the fact that pancreatitis is characterized by a pronounced clinical picture, a complete examination will be required to establish an accurate diagnosis, since the same symptoms can occur with the development of other diseases.

In the event that, according to the results of the examination, inflammatory processes in the pancreas were revealed, regardless of the form (acute or chronic), the patient must immediately begin treatment, since delay in this case can cost him his life.

Speaking about the types of this disease, it should be noted that today there are different classifications of pancreatitis proposed by various scientists. However, most doctors use the most simplified version of the classification, which distinguishes the following types of pancreatitis:

spicy;
obstructive, in which pathological expansion of the ducts, occlusions and stones are observed in the pancreas;
acute recurrent;
non-obstructive chronic;
calcifying chronic, during the development of which salts accumulate in the gland;
chronic recurrent, manifested in an acute form (with the development of such pancreatitis, pancreatic cells are damaged and no longer recover).

Visual differences between a healthy pancreas and an inflamed one

The simplest classification of pancreatitis was put forward by scientists at the International Medical Symposium in Marseille in 1983, which physicians still use to this day. It suggests the following division of this disease:

acute;
acute recurrent;
chronic;
exacerbation of a chronic

Each of these forms of pancreatitis has its own characteristics, so only a qualified specialist should deal with their treatment.

Chronic form

Depending on the cause, the chronic form of the disease can be primary and secondary. Moreover, secondary pancreatitis occurs among patients much more often than primary, and the cause of its development is mainly other diseases that affect the organs of the gastrointestinal tract, for example, the stomach or gallbladder. Also, the chronic form of the disease may occur due to inadequate or untimely treatment of acute pancreatitis, however, this phenomenon is very rare, since when the disease develops in an acute form, it manifests itself with a sudden pain syndrome, due to which patients are immediately hospitalized.

Atlanta pancreatitis classification presented by scientists in 1992

But it is generally accepted that the main cause of the development of chronic pancreatitis is various malfunctions in the gastrointestinal tract against the background of malnutrition and bad habits. A special role in its development is played by the abuse of alcoholic beverages.

As mentioned above, each form of this disease has its own classification. There are many of them, but the most popular is the Roman classification of this disease. It involves the division of chronic pancreatitis into the following subspecies.

Chronic calcifying

It is the most common form of pancreatitis and is characterized by simultaneous inflammation of several separate sections of the pancreas, the intensity of which can vary significantly (the organ is affected pointwise). With the development of chronic pancreatitis pancreatitis, the pancreatic ducts can become clogged and die, which leads to complete organ dysfunction. As a rule, the onset of this disease occurs against the background of a sharp decrease in the production of lithostatin, which is a low molecular weight protein secreted by the exocrine part of the pancreas. Litostatin is an inhibitor of the growth of calcium carbonate crystals. And when the pancreatic juice is oversaturated with this salt, crystals grow, which causes blockage of the pancreatic ducts and disruption of the release of digestive enzymes into the duodenum.

Chronic obstructive

The development of this form of the disease occurs against the background of obstruction of the large ducts of the pancreas. In this case, a complete lesion of the organ occurs, as well as significant modifications in its endocrine part. Unfortunately, chronic obstructive pancreatitis is not amenable to medical treatment. With its development, urgent surgical intervention is required.

Chronic fibrous-indurative

In this case, there is also a complete lesion of the pancreas, in which fibrous changes are observed in the structure of its tissues. At the same time, the organ retains its secretory function, but does not perform it in full.

Fibrosis of the pancreas

When this disease occurs, fibrotic changes are also observed in the tissues of the gland, but in this case they are very pronounced and lead to a loss of the ability to perform a secretory function, followed by the death of the tissues of the organ (the occurrence of necrosis).

In addition to the subtypes of chronic pancreatitis described above, this disease also includes pancreatic cysts and abscesses that occur in it. These pathological conditions also lead to disruption of the production of digestive enzymes, swelling of the ducts and their blockage, which causes the development of this disease.

Acute pancreatitis is the development of severe inflammation in the pancreas, which leads to the appearance of an acute pain attack, which, as a rule, occurs in the upper abdomen and extends to the right hypochondrium. In this case, the pain becomes even more pronounced after eating. They may be accompanied by bouts of nausea, vomiting, diarrhea, and bloating.

A distinctive clinical feature of acute pancreatitis is that during its development there is a change in the skin and sclera - they acquire a yellowish tint. There may also be an increase in heart rate and the appearance of cyanotic spots on the arms and legs.

In other words, the clinical manifestations of acute pancreatitis are significantly different from the signs of chronic development. And they also have their own classification, and more than one. The first classification is used by surgeons and involves determining the type of disease only after the implementation of surgery.

Types of acute pancreatitis

This classification implies the division of acute pancreatitis into the following types:

easy;
moderate;
heavy.

With the development of a mild form of acute pancreatitis, significant pathological changes in the work and structure of the pancreas are not observed. When moderate pancreatitis occurs, transient organ failure and systemic deposits are observed. But in a severe form of the disease, persistent insufficiency is diagnosed with local systemic complications that can lead to death.

As already mentioned, there is another classification of acute pancreatitis, which is actively used by therapists and gastroenterologists. It suggests the division of this disease into 4 subspecies:

edematous. It is considered one of the mildest forms of acute pancreatitis. With its development in the tissues of the pancreas, no serious changes are noted. It is easily treatable and is manifested by slight yellowing of the skin and sclera, increased heart rate and pain in the upper abdomen. In a laboratory blood test, an elevated level of fibrin (PRF) is noted.
Limited pancreatic necrosis. A severe form of the disease, which is very difficult to treat. With its development, foci of necrosis of various sizes appear in the parenchyma of the pancreas (they can be small, medium and large). The clinic of this disease includes nausea, severe vomiting, flatulence, fever, signs of tachycardia, severe pain in the epigastric region, as well as the detection of elevated glucose levels in the analyzes and a decrease in hematocrit concentration.
Diffuse pancreatic necrosis. It has several more names - segmental and distal. With its development, all anatomical regions of the pancreas are affected. At the same time, necrotic changes are noted not only in the parenchyma of the organ, but also in the vessels, as well as in large secretory ducts. Clinically, diffuse pancreatic necrosis manifests itself in the same way as limited one, only in this case there may be a sharp decrease in the amount of urine excreted per day (oliguria), fever and gastric bleeding, which are manifested by acute pain syndrome. And when conducting laboratory studies, hypoxia, hyperglycemia and hypocalcemia are noted. The patient's condition with the development of diffuse pancreatic necrosis is severe.
Total pancreatic necrosis. This type of disease is characterized by necrotic changes in all tissues of the pancreas, which pass to the retroperitoneal tissue. With its development, there is a sharp increase in the level of stomach acidity, intoxication of the body, decreased sensitivity and shock (the most severe complication of pancreatic necrosis).

This is what the pancreas looks like in the development of total pancreatic necrosis

Classification of pancreatitis according to the mechanism of development

There is another classification, which implies the division of pancreatitis into subspecies depending on the cause of its occurrence:

post-traumatic. It is observed in 8% of patients. The main reasons for its development are open and closed injuries of the abdominal cavity obtained during surgical interventions, diagnostic instrumental measures, chemical and thermal burns. Closed mechanical injuries are considered the most dangerous, which can lead to organ rupture. But it should be noted that when they are received, severe internal bleeding is not always observed. In most cases, the injury manifests itself as a slight deformity of the gland and a slight deterioration in the general condition. Acute attacks of pain are absent, which prevents timely diagnosis. And this often leads to fatal consequences.
Biliary. Occurs in 9% of patients. The mechanism of development of this form of pancreatitis is based on congenital anomalies in the structure of the pancreas and bile ducts, cysts and stone deposits that prevent the normal outflow of bile. Biliary pancreatitis can proceed in a closed and open type, and the rate of its development depends on the state of the ductal system. In addition to the fact that during its formation necrotic changes are observed in the tissues of the gland, they can also be subjected to suppuration.
Cholecystogenic. This form of the disease develops due to a violation of the outflow of bile into the duodenum and its exit into the pancreatic ducts. As a result, the production of pancreatic juice increases and exerts a strong load on the ductal systems, because of which they cannot withstand and are destroyed, which causes the development of necrotic processes in the tissues of the gland.
immunodependent. This form of pancreatitis is characterized by increased sensitivity of lymphocytes to antigens, as a result of which they migrate into the gland and provoke the development of hemorrhagic edema in it. However, the outflow of digestive enzymes in immune-dependent pancreatitis is not disturbed, which distinguishes it from other forms of the disease.
Contact. It is extremely rare, occurring in only 1.5% of patients. The main reason for its development is peptic ulcer of the stomach and duodenum with penetration into the pancreas, which provokes a violation of its tissues and the formation of a crater.
Angiogenic. The main "provokers" of angiogenic pancreatitis are such pathological conditions as arteriolosclerosis, extravascular occlusion and thromboangiitis, which cause ischemia and vascular embolism, as well as impaired blood supply to the organ with the subsequent development of necrotic processes.

Some forms of pancreatitis do not respond to medical treatment and require urgent surgical intervention.

The classification of pancreatitis is very large. But despite this, doctors still use more simplified options, subdividing this disease into only two groups - acute and chronic. Naturally, in order to prescribe treatment, it will be necessary to determine the exact type of disease, but regardless of the form in which the disease occurs (acute or chronic), first aid in the event of a pain attack is carried out in the same way. And further treatment is determined on an individual basis only after the relief of pain.