Pancreatic necrosis of the pancreas

Pancreatonecrosis is a pathological process accompanied by the death of pancreatic tissue.

It is a complication of inflammatory lesions of the organ, in particular, acute pancreatitis. Mortality in this disease ranges from 40 to 70%, provided that the treatment was started in a timely manner, and was carried out using modern therapeutic techniques.

In case of necrotizing pancreatitis, the tissue dies out of a certain area or the entire PZHZH. This process is triggered by enzymes produced by the cells of the organ, in combination with infectious lesions, peritonitis, or other complications.

What it is?

Pancreatonecrosis is a formidable, serious complication of pancreatitis, which develops in 1% of cases against the background of an acute abdomen. The disease affects predominantly young and able-bodied people. The basis of the pathogenesis of this process is a failure in the protective mechanism of PZHZH, whose action is aimed at preventing the destructive effect of pancreatic enzymes.

In recent years, the number of patients with acute pancreatitis has sharply increased in Russia. The incidence of the disease exceeded the incidence of acute appendicitis in surgical hospitals. Also, the number of patients with destructive lesions of the pancreas increased significantly, and the number of patients with pancreatic necrosis increased to 25%. The average death rate against the background of this disease in various medical institutions rose to 30 - 80%.

It is possible to avoid death only with the timely start of diagnosis, and the appointment of adequate inpatient therapy for people with pancreatic necrosis.

Causes of pancreatic necrosis

According to medical statistics, almost 70% of patients with pancreatic necrosis regularly consumed alcohol. The remaining 30% of patients previously had cholelithiasis. Other causes of the disease may lie in:

  • regular overeating;
  • junk food abuse;
  • past infectious diseases;
  • gastric ulcer and duodenal ulcer;
  • previous operations or injuries of the abdominal organs.

To date, pancreatic necrosis is considered one of the most serious and dangerous non-oncological diseases affecting the abdominal organs. It affects not only the pancreas, but also other digestive organs.

When this disease first appears puffiness of the pancreas tissue, after which they begin to die off. If you do not promptly identify the disease and do not start treatment, then an abscess may well join the pancreatic necrosis.

Classification

Pancreatonecrosis has its own classification. In determining the form of the disease, the scale of the lesion of the pancreas, the presence of complications, as well as certain external factors (if any) are taken into account.

According to the degree of spread of the necrotic process, the disease may be diffuse or local. In the latter case, only a certain part of the gland is affected - the head, body or tail.

The classification by depth of lesion PZHZH divides pancreatic necrosis into:

  1. Surface. Pathological process affects the outer layers of the pancreas. An excessive increase in the level of enzymes leads to rupture of the ducts. Tissues begin to die off directly at the gaps.
  2. Deep. Necrotic changes are recorded in a larger area of ​​the pancreas.
  3. Total. Necrotic processes affect not only PZHZH, but also other organs of the retroperitoneal space.

Pancreatonecrosis has several clinical forms:

  1. Hemorrhagic. This is one of the most severe forms of pancreatic necrosis, which develops under the influence of destructive processes caused by the influence of pancreatic enzymes. As a result, PZHZH becomes edematous, acquires a dark red color with a blue-black tint. In the body of the body internal hemorrhages are detected. It is the hemorrhagic form of pancreatic necrosis that is one of the most common causes of death.
  2. Fatty In this case, the formation of infiltration, which leads to the appearance of tubercles in the tissues of the gland. There may be fluid in the abdomen. With the elimination of inflammation and edema, the affected tissues overgrow with connective tissue structures. In the absence of timely treatment, fatty pancreatonecrosis becomes an acute hemorrhagic form.
  3. Mixed With this form of pancreatic necrosis, the parenchymal, adipose and connective tissues are simultaneously affected.

Separately isolated and post-traumatic form of the disease. It is caused by injuries of the abdominal cavity, received by the patient in various circumstances.

Symptoms of pancreatic necrosis

This disease is extremely difficult to confuse with another, since it is characterized by a pronounced, specific clinical picture.

Pain syndrome

Pain is one of the most common symptoms of pancreatic necrosis. It occurs in the left part of the abdomen, and can give to the chest, shoulder, groin, etc. Often, patients can not accurately indicate the location of the source of pain, so they call it shingles.

Pain syndrome can have different intensity, which directly depends on the severity of PZHZh damage. The more extensive the necrotic process, the less severe the pain will be. This is due to the fact that not only the cells that form the gland, but also the nerve endings die. If the intensity of the pain has decreased, and residual effects of intoxication are present, this is considered an unfavorable prognostic sign.

With pancreatic necrosis, even a strong pain syndrome subsides a little when the patient assumes a prone position with his legs bent and pulled to the stomach.

Symptoms of dehydration

Dehydration (dehydration) develops against the background of constant vomiting, during which the patient's body rapidly loses fluid. Against this background, there is dry skin and mucous membranes, the appearance of plaque on the tongue, a decrease in daily diuresis, which can turn into anuria - no urination, or the release of urine in a volume of up to 300 ml per day. As a result, the patient feels constant thirst and severe dryness in the mouth.

Nausea and vomiting

Almost immediately after the onset of pain, incessant vomiting begins. However, it is not in any way connected with food intake, and even with a high abundance of vomitus, it does not bring relief to the patient. In the excreted fluid, bile and blood clots of various sizes are present. Their appearance is due to the process of destruction of blood vessels that occurs under the influence of elastase.

Bloating and flatulence

With pancreatic necrosis, the pancreas becomes unable to perform its functions. As a result, the processes of decay and fermentation are greatly enhanced in the intestine. Such a violation of the activity of the digestive tract leads to increased gas formation, bloating, bowel disorders, worsening of intestinal peristalsis and gas retention.

Intoxication

In the patient's body, pathogenic bacteria may be absent, but their toxins will still be in the blood, causing intoxication, manifested:

  • temperature rise to 38 degrees and above;
  • general weakness;
  • increased fatigue;
  • tachycardia;
  • increased breathing;
  • shortness of breath;
  • decrease in blood pressure.

Toxic brain damage can trigger encephalopathy. Against this background, there is confusion, inhibition, or, conversely, increased excitability, disorientation. Severe toxemia can lead to a coma.

Redness or pale skin

When toxemia PZHZH throws into the blood substances that expand the blood vessels, which leads to skin flushing. When intoxication develops, the integuments, on the contrary, turn pale, acquire an earthy, yellowish or marble shade. In parallel, they become cold to the touch.

On the stomach, back, in the navel and buttocks, the appearance of blue-violet spots is observed, which are a consequence of internal hematomas and hemorrhages in soft tissues.

Internal bleeding

Under the influence of elastase, the destruction of blood vessels occurs, which leads to the formation of blood effusion in the area of ​​the peritoneum, pleura and pericardium.

Symptoms of peritoneal irritation

The phase of toxemia lasts from 5 to 9 days, and is accompanied by an increase in symptoms, regardless of the therapy. It is followed by the stage of development of purulent and post-necrotic complications, in which the pancreas syndrome increases significantly, and purulent infiltration begins to form in the abdominal cavity. In the area of ​​the organ, the skin becomes hypersensitive, and adjacent internal organs are affected.

At this time, multiple organ failure develops, resulting in toxic hepatitis and nephritis, carditis, impaired respiratory function.

Diagnostics

Diagnosis of pancreatic necrosis is based on:

  1. Medical history and history of the disease. This approach helps to identify the factors that could provoke the development of pathology.
  2. Physical examination, which allows to identify the symptoms and determine the severity of pancreatic necrosis.
  3. Analyzes of urine and blood to detect pancreatic enzymes.
  4. Radiographs with contrast to identify foci of inflammation and deformity of the diseased organ.
  5. Ultrasonogaphy, which helps to detect stones and identify areas of necrosis, as well as record an increase in PJ in volume.
  6. MRI and CT, which are conducted for the purpose of additional research of the pancreas.
  7. EHRG - procedures that make it possible to assess the condition and functioning of the biliary tract.
  8. Diagnostic laparoscopy. This is the most accurate manipulation that helps to accurately diagnose. During the procedure, with the help of a special instrument with a camera (laparoscope), the doctor examines in detail the state of the pancreas and adjacent organs, and identifies necrotic processes.

How to treat pancreatosis?

Pancreatonecrosis requires immediate treatment.

The patient is necessarily hospitalized in a surgical hospital in the intensive care unit. Next, treatment is prescribed to suppress necrotic processes and self-digestion of the pancreas. In parallel, symptoms of toxemia are eliminated, and purulent-septic processes are prevented.

Treatment may be conservative and surgical.

Conservative therapy

Conservative treatment for pancreatic necrosis is based not only on the use of drugs. In addition to pharmacotherapy, it also includes:

  1. Providing complete peace of mind. Moreover, this applies to both mental and physical activity. The patient is assigned bed rest in combination with therapeutic fasting. Any physical activity and eating is prohibited. With this disease, parenteral nutrition, with the use of nutrients. The duration of such feeding of patients with pancreatic necrosis is from 5 to 7 days. In parallel with this, unlimited quantities of alkaline mineral water are allowed.
  2. Relief of pain. To eliminate pain and weaken the spasmodic sphincter of Oddi, the patient is prescribed parenteral administration of antispasmodic drugs (No-Shpy, Platyfillin), non-narcotic analgesics (Paracetamol, Baralgin, Analgin). Regional novocaine blockades can be prescribed, as well as a mixture of glucose with novocaine, administered by 1000-2000 ml by infusion. Perhaps the introduction of narcotic analgesics (Atropine with Promedol, Dimedrol and Novocain).
  3. Blocking the secretion of the stomach, pancreatic cancer and duodenum. In order to suppress pancreatic secretion, antienzyme preparations (Gordox, Trasilol, Kontrykal, etc.) are used for intravenous administration. To inhibit gastric activity, anticholinergics (Atropine) and intestinal lavage with cold solutions are prescribed. Perhaps the appointment of Omeprazole, Pantoprazole - drugs from the group of proton pump inhibitors. In the absence of JCB, choleretic drugs are prescribed, the use of cold compresses on the abdominal area is recommended.
  4. Antibiotic treatment. Antibiotics are prescribed primarily for prophylactic purposes with the aseptic nature of necrosis. Drugs in this group are also needed to suppress bacterial activity in the infected destruction of PZHZH. The most commonly prescribed medications are from a number of cephalosporins (Cefipime) and fluoroquinolones (Ciprofloxacin) in combination with Metronidazole.
  5. Infusion treatment. It is based on the use of glucose solution with insulin, Ringer's solution, sodium chloride. These drugs help to cleanse the body of toxins entering the blood during necrosis of pancreatic tissues and the activity of pathogenic microflora. For the purpose of rehydration, intravenous drip of colloids (Reopoliglukina, Albumin) is indicated. To combat vomiting in / m drug is introduced Tsirukal. Infusion therapy is complemented by the use of diuretics (furosemide), which helps reduce the edema of the pancreas fluid.
  6. Detoxification. Such therapy is based on the use of extracorporal methods: therapeutic plasmapheresis, hemosorption, hemofiltration and peritoneal dialysis.
  7. Hormone therapy with somatostatin. Drugs with this pituitary hormone are administered intravenously to suppress the secretion of gastric juice, as well as inhibiting the exocrine and endocrine functions of the pancreas fluid. In parallel, the drug reduces blood circulation in the internal organs, thereby preventing the opening of bleeding.

Surgery

Almost all patients undergo surgery to remove necrotic zones. Surgical treatment helps to restore the secretion of pancreatic juices, prevent further progression of the disease and prevent its complications. Such manipulation is performed only 5 days after the detection of pancreatic necrosis.

In the transition of inflammation into a purulent form, different methods of surgical intervention are used:

  • puncture;
  • laparoscopic;
  • laparotomic.

Their use is justified by the need to:

  • recovery of pancreatic secretion outflow;
  • removal of necrotic masses and hemorrhagic exudate;
  • elimination of inflammation;
  • stop internal bleeding.

To normalize the work and condition of the internal organs, it may be necessary to perform drainage of the abdominal cavity.

Forecast

Pancreatonecrosis has questionable predictions, which depend on many factors:

  • age of the patient;
  • timeliness of initiation of therapy;
  • forms of the pathological process;
  • the severity and extent of necrotic lesions;
  • the presence of concomitant diseases;
  • adherence to diet and doctor recommendations;
  • the presence of complications;
  • the area of ​​the removed pancreatic tissue and the complexity of the surgical intervention.

In 25% of patients after suffering pancreatic necrosis, diabetes mellitus develops. In addition, the formation of pseudocysts, the recurrence of the disease, the formation of fistulas. Mortality in this pathology is quite high: in the aseptic form, it ranges from 15 to 40%, and in the infected form, it increases to 60%.

Watch the video: Management of Acute Pancreatitis - Stephen Kim, MD. UCLA Digestive Diseases (November 2019).

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