2. Definition of the problem
Pancreatitis is a common nonbacterial
inflammatory disease caused by
activation, interstitial liberation, and
autodigestion of the pancreas by its own
enzymes. The process may or may not be
accompanied by permanent morphologic
and functional changes in the gland.
This pathological state is differed from the
other acute abdominal diseases by damage of
different zones and spaces (parapancreatic
space, paracolon, paranephron, mediastinum).
The term “acute pancreatitis” was suggested
and was separated into individual nosologic
unit by Chiari in 1880.
3. Nowadays acute pancreatitis is on the third place
among the abdominal pathology
Actuality and practical importance
1730
1490
2379
2783
4482
5627
6800
12630
7164
14821
0
2000
4000
6000
8000
10000
12000
14000
16000
1975 1985 1995 2003 2005
acute pancreatitis chronic pancreatitis
Morbidity rate of pancreatitises in Republic of Belarus
4. Etiology of acute
pancreatitis
Gallstone disease.
Biliary dyskinesia.
Duodenostasis.
Bile reflux into the pancreatic duct
(common ampulla).
Alimentary disorders (fat food).
Long standing alcohol abuse.
Infectious diseases.
Intoxication.
Trauma of the pancreas.
5. Phase of development Clinical forms
1. Edema of pancreas.
2. Necrosis of pancreas.
3.Phase of melting and
sequestration of necrotic
focuses
а) in aseptic conditions.
b) in conditions of purulent
and putrefactive infection.
Interstitial pancreatitis
(serofluid (serous),
serohemorrhagic, hemorrhagic).
Necrotic pancreatitis
(hemorrhagic, fatty (adipose).
Infiltrative-necrotic pancreatitis
Purulo-necrotic pancreatitis.
Fulminant form
Classification of acute pancreatitis (according to V.I. Filin)
6. Clinical findings and symptoms
The acute attack frequently begins following a large
meal and consists of severe epigastric pain that
radiates through to the back. The pain is unrelenting
and usually associated with nausea, vomiting and
retching. In severe cases, the patient may collapse from
shock.
The pain is typically localized in epigastrium but
frequently involves one or both upper quadrants. On
occasion, it may be felt in the lower abdomen, one or
both shoulders, or in the lower chest. The pain is usualy
described as being of rapid onset, slowly increasing to a
maximal severity, and then remaining constant.
The pain may have a pleuritic component and be
associated with rapid but shallow respirations.
Frequntly, the pain is described as being boring or
knife-like sensation that passes strait through to the
mid-central back from the epigastrium.
7. Laboratory examination
Hyperleukocytosis: (20-40 th.)
Turning of the differential blood count to
the left side.
Increasing of erythrocyte sedimentation
rate (ESR).
Toxic granulosity of neutrophils.
Hyperglycemia.
Hyperbilirubinemia.
Hypocalcemia.
Hypopotassemia.
Phenomenon of enzymes’ deviation (tripsin,
lipase, amylase) – in blood (in urine).
8. Complex treatment patients with destructive pancreatitis is
carried out only at ICU (intensive care unit).
The main trends and methods of complex therapy are :
1. Reduction of pancreatic secretory stimuli and
inactivation of enzymes (Oral intake is withheld
and a nasogastric tube is inserted to aspirate gastric content,
gastric secretion is neutralized by injectins of cimetidine,
almagel, enzyme inhibitors (gordox, trasilol, contrical)
2. Treatment of pain (different blockades, complex
analgetics (narcotic anlgetics)
3. Treatment of acute hemodynamic disorders (plasma
substitutes, ganglionic blockers, antihistaminic agents,
steroids, anticoagulants).
Conservative treatment
9. Preparations of choose in patients with
pancreonecrosis are:
carbapenems,
fluoroquinolones + metronidazole,
cephalosporins III-IV generation + metronidazole,
purificated penicillins (piperacillin/tazobactam,
ticarcillin/klavunat
Surgical treatment (indications)
Infected pancreonecrosis and/or pancreatogenic abscess, ceptic
phlegmon of retroperitoneal tissues, purulent peritonitis
State or progressive organs’ failure in spite of complex intensive
conservative therapy for 1-3 days
In patients with squire of pancreatic parenchyma necrosis more than
50% (according to KT-angiography
Association of acute destructive pancreatitis with acute destructive
cholecystitis
Urgent complications of acute pancreatitis (bleeding, destruction of
visceral hollow organ)
Pancreatogenic (enzymatic, abacterial peritonitis is the indication for
laparoscopic sanation and draining of abdominal cavity.
10. Surgical treatment
Goal: adequate draining of abdominal cavity and
retroperitoneal space.
Aprouches:
Upper middle-line
Transverse
Lateral
lumbar
Operation: necrsecvestrectomy + sanation +
draining omental bursa and retroperitoneal space.
Decompression of bile tract.
