What is Chronic Pancreatitis?

The incidence of chronic pancreatitis (CP) is increasing year by year. It is a chronic inflammatory disease with various causes causing irreversible changes in pancreatic tissues and functions. Basic pathological features include chronic inflammatory lesions and interstitial fibrosis of the pancreas, changes in pancreatic parenchymal calcification, pancreatic duct dilatation, and pancreatic duct stones. Clinical manifestations are recurrent epigastric pain and pancreatic endocrine and exocrine dysfunction. In China, the incidence of CP has been increasing year by year, but exact epidemiological data are still lacking.

Basic Information

English name

Chronic Pancreatitis, CP

Visiting department

Gastroenterology

Common locations

pancreas

Common causes

Obstructive factors, excessive drinking, overeating, hyperlipidemia, hypercalcemia, etc.

Common symptoms

Severe and recurrent upper abdominal pain; nausea, vomiting, bloating, fever; upper abdominal tenderness

Causes of chronic pancreatitis

CP has many pathogenic factors, and alcoholism is the main factor. Other causes include biliary diseases, hyperlipidemia, hypercalcemia, autoimmune diseases, congenital abnormalities of the pancreas, pancreatic trauma or surgery, and pancreatic duct stricture caused by acute pancreatitis. Wait. Cationic trypsinogen (PRSS1) gene mutations are common in hereditary pancreatitis. Serine protease inhibitor Kazal I (SPINKl) gene and cystic fibrosis transmembrane conductance regulator (CFTR) gene are common mutation genes in sporadic pancreatitis. . Smoking can significantly increase the risk of CP. Other pathogenic factors are not known as idiopathic CP.

Obstruction

More common in Europe, Asia and China. The most common cause of obstruction is gallstones. Causes of Vater's ampulla obstruction include: gallstones passing through or incarcerated in Vater ampulla, biliary maggots, duodenal papillary edema, ampulla sphincter spasm, ampulla stenosis, etc. The obstruction of the common bile-pancreatic pathway leads to bile reflux into the pancreatic duct, causing bile-induced pancreatic parenchymal damage. Simple pancreatic duct obstruction is also sufficient to cause pancreatic damage.

2. Excessive drinking

Excessive drinking is closely related to the onset of acute pancreatitis.

3. Overeating

In particular, over-eating high-protein, high-fat foods, coupled with drinking, can stimulate excessive secretion of pancreatic juice, and when accompanied by partial obstruction of the pancreatic duct, acute pancreatitis can occur.

4. Hyperlipidemia

It is also a cause of acute pancreatitis. Hyperlipidemia can be secondary to nephritis, castration treatment and application of exogenous estrogen, and hereditary hyperlipidemia (type I, type V).

5. Hypercalcemia

Often occurs in patients with hyperparathyroidism. Calcium can induce trypsinogen activation and destroy the pancreas itself. High calcium can cause pancreatic duct stones and obstruct the pancreatic duct. High calcium can also stimulate increased secretion of pancreatic juice, absorbed into the blood through the peritoneum, and increase blood amylase and lipase. A large amount of trypsin into the blood can cause damage to liver, kidney, heart, brain and other organs, causing multiple organ dysfunction syndrome.

Clinical manifestations of chronic pancreatitis

Abdominal pain

Is the main clinical symptom. Abdominal pain is severe, starting from the middle and upper abdomen, and can also focus on the right upper or left upper abdomen and radiate to the back. Involving the whole pancreas is a belt-like radiating pain to the lower back. Alcohol-induced pancreatitis usually develops within 12 to 48 hours after intoxication and causes abdominal pain. Biliary pancreatitis often causes abdominal pain after a full meal.

2. Nausea and vomiting are often accompanied by abdominal pain

Vomiting is severe and frequent. The vomit is the contents of the gastroduodenum, and may be accompanied by coffee-like contents.

3. Abdominal distension

The early stage is reflex intestinal palsy, which can be caused by retroperitoneal cellulitis in severe cases. Paralysis of the upper small intestine and transverse colon adjacent to the pancreas. Abdominal distension is more than abdomen. Abdominal distension is more obvious when peritoneal effusion occurs. Patients have defecation and exhaustion, and bowel sounds weaken or disappear.

4. Signs of peritonitis

In edema pancreatitis, tenderness is limited to the upper abdomen, and there is often no obvious muscle tension. Hemorrhagic and necrotizing pancreatitis has obvious tenderness, muscle tension and rebound pain, and the scope is wide or extends to the whole abdomen.

5. Other

In the initial stage, it usually shows moderate fever, about 38 ° C. Those with cholangitis may be associated with chills and high fever. When pancreatic necrosis is accompanied by infection, high fever is one of the main symptoms. Jaundice can be seen in biliary pancreatitis, or because the common bile duct is compressed by the edema of the pancreatic head.

Chronic pancreatitis examination

Laboratory inspection

(1) Determination of pancreatin The determination of serum amylase is the most widely used diagnostic method. Increased serum amylase can be detected within 24 hours after onset. Serum amylase increased significantly> 500U / dL (normal value 40-180U / dL, Somogyi method), and then gradually decreased to normal within 7 days. Urine amylase measurement is also a sensitive indicator for the diagnosis of this disease. Urinary amylase rises slightly later, but lasts longer than serum amylase. Urinary amylase significantly increased (normal value 80-300U / dL, Somogyi method) has diagnostic significance. The higher the amylase measurement, the higher the accuracy of the diagnosis. However, the level of amylase is not necessarily proportional to the severity of the disease. A significant increase in serum lipase (normal value of 23 to 300 U / L) is an objective indicator for the diagnosis of acute pancreatitis.

(2) Other items include increased white blood cell count, hyperglycemia, abnormal liver function, hypocalcemia, blood gas analysis, and abnormal DIC indicators.

2. Radiography

Abdominal ultrasound can help diagnose. B-ultrasound can detect pancreatic edema and accumulation of peripancreatic fluid. It can also detect gallbladder stones and bile duct stones, but it is covered by a locally inflated bowel, which limits its application.

Diagnosis of chronic pancreatitis

The diagnosis of CP is mainly based on clinical manifestations and imaging studies. Pancreatic endocrine and exocrine function tests can be used as a supplement to the diagnosis. Pathological diagnosis is the defining criterion for CP diagnosis. The diagnostic criteria and conditions of CP include:

1.1 and more than one type of imaging examination showed characteristic morphological changes of CP;

2. Histopathological examination showed characteristic changes of CP;

3. The patient has typical upper abdominal pain, or abdominal pain that cannot be explained by other diseases, with or without weight loss;

4. Abnormal serum or urine pancreatic enzyme levels;

5. Abnormal pancreatic exocrine function.

Chronic Pancreatitis Treatment

Treatment principle

Eliminate the cause, control symptoms, correct and improve pancreatic endocrine and extracrine insufficiency and prevent complications.

2. Non-surgical treatment

(1) Generally treat smoking and alcohol cessation, adjust diet structure, avoid high-fat diet, supplement fat-soluble vitamins and trace elements, and provide nutritional support for enteral or parenteral nutrition.

(2) When patients with pancreatic exocrine dysfunction treat fatty steatosis, weight loss and malnutrition, they need to add exogenous pancreatin to improve digestive and absorption dysfunction. Microenzyme capsules containing highly active lipase are preferred. It is recommended to take it with meals. Meal is given (3 ~ 4) 10,000 U lipase in meals, and supplementary meal is given (1 ~ 2) 10,000 U lipase in pancreas. Poor results can increase the dose or take proton pump inhibitors in combination.

(3) Treatment of pancreatic endocrine insufficiency According to the degree of progression of diabetes and complications, metformin is generally preferred to control blood sugar, and insulin-promoting drugs are added when necessary. For those with symptomatic hyperglycemia and poor efficacy of oral hypoglycemic drugs, choose insulin treatment. CP patients with diabetes are sensitive to insulin, and special care should be taken to prevent hypoglycemia.

(4) Non-analgesic drugs for pain treatment including pancreatin preparations, antioxidants, etc. can have certain effects on pain relief. Pain treatment mainly depends on the selection of appropriate analgesics. Initially, non-steroidal anti-inflammatory drugs should be selected. Weak opioids can be used for poor results. Strong opioid analgesics can be used when the effect is not relieved or even worsened. Endoscopic therapy or CT, endoscopic ultrasound-guided celiac plexus block suspected CP can relieve pain in the short term. If there is a pancreatic head mass, pancreatic duct obstruction and other factors, surgery should be selected.

(5) Other treatments Autoimmune pancreatitis is a special type of CP, and glucocorticoid therapy is preferred. Efficacy was assessed by monitoring serum IgG4 and imaging review during treatment.

Prognosis of chronic pancreatitis

Drink less alcohol, avoid overeating, prevent and treat biliary tract diseases. Active treatment can relieve symptoms, but it is not easy to cure. Most advanced patients die from complications, and very few people can develop pancreatic cancer.