Pancreatitis is a non infectious inflammation, mainly classified asacute pancreatitisandchronic pancreatitis。Acute pancreatitis is caused by multiple causes of pancreatic tissue edema, hemorrhage, necrosis and other acute injuries, while chronic pancreatitis is caused by various causespancreasLocal or diffuse chronic progressive inflammation, accompanied by irreversible damage to the internal and external secretion function of the pancreas.The main causes of pancreatitis in China aregallstoneThe pancreatic juice caused by poor drainage can also be caused by long-term drinking.The high-risk groups include patients with biliary obstructive diseases, patients with biliary stones and long-term alcoholism.Pancreatitis is not contagious.
The symptoms of pancreatitis vary from person to person. Typical symptoms include acute abdominal pain, nausea and vomiting, fever, and possible symptoms related to acute multiple organ dysfunction and failure, such ashypotensionandshock, dyspnea, oliguria or anuriaUpper gastrointestinal bleeding、sudden deathEtc.Among them, the first symptom of acute pancreatitis is usually abdominal pain, which may radiate to the waist and back, and the pain is aggravated after eating.
The way to treat pancreatitis mainly depends on the severity of the disease and the specific symptoms of the patient.For patients with mild illness and acute pancreatitis without infection, non-surgical treatment can be used.If the condition is serious, medical treatment or surgical treatment should be considered.For chronic pancreatitis, the treatment focuses on the etiology, such as treatment of biliary diseases, abstinence from alcohol, etc.Diet is also part of the treatment, and patients are generally advised to follow a low-fat diet.
Pancreatitis has always been an important research object in the medical field, and some new breakthroughs have been made in recent years.Significant progress has been made in the study of early diagnosis and effective treatment of diseases.At the same time, researchers also continue to pay attention to the pathogenesis of pancreatitis in order to find more effective prevention and control strategies.
TCM disease name
pancreatitis
Foreign name
Pancreatitis
Visiting department
Department of Gastroenterology and Emergency Department
Multiple population
Male patients are significantly higher than female patients in the population around 55 years old
Pancreatitis can be caused by many factors. In foreign countries, long-term drinking is the main cause of pancreatitis, while in China, it is mainly due togallstoneToPancreatic juiceInflammation of pancreas due to poor drainage.Therefore, the most common cause in China is biliary obstructive disease.
The symptoms of pancreatitis may be different due to different causes and severity of illness. Patients with acute pancreatitis may experience different forms of pain from those with chronic pancreatitis.
Typical symptoms of acute pancreatitis include:
Acute abdominal pain: often the first symptom.The middle left upper abdomen and even the whole abdomen suddenly start to ache, ranging from mild to severe. The pain may radiate to the waist and back, and the pain will be aggravated after eating.If peritonitis is caused, the pain can spread from the middle left upper abdomen to the whole abdomen.
Nausea and vomiting: most patients have nausea and vomiting at the onset of the disease. Some vomitus are stomach contents, and some are brown liquid.
Fever: When secondary bacterial infection occurs, fever often occurs and lasts for several days.
Related symptoms of acute multiple organ dysfunction and failure: hypotension and shock, dyspnea, oliguria or anuria, upper gastrointestinal bleeding, sudden death, etc.
Typical symptoms of chronic pancreatitis include:
Abdominal pain: pain in the upper abdomen, which can spread to the back, and the pain will be aggravated after full eating, eating high-fat food or drinking.Accompanied by upper stomach fullness and belching.Severe abdominal pain may be accompanied by nausea and vomiting.
Fat diarrhea: intolerance to greasy food, manifested by increased defecation frequency, foamy, foul smelling stool, and oily surface.
Elevated blood sugar: chronic damage to the pancreas can lead to diabetes.
Medical treatment
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In case of continuous mild abdominal pain, an outpatient appointment can be made.
In case of acute abdominal pain, or severe restlessness or inability to find a more comfortable position, please see the emergency department in time.
The doctor will diagnose pancreatitis by asking the patient or his family members about the development history of the disease course, and doing physical examination. After the initial judgment of the disease condition, further laboratory and imaging examinations will be conducted to diagnose pancreatitis. At the same time, the severity of the disease will be estimated and the cause of the disease will be identified.
Chronic pancreatitis with atypical symptoms is complicated and difficult to diagnose.Doctors usually advise patients to do imaging examination, make a suspicion judgment, and then make a diagnosis based on follow-up observation and evaluation.
Visiting department
Department of Gastroenterology and Emergency Department.
Relevant inspection
There are differences in the examination methods for diagnosing chronic pancreatitis and acute pancreatitis, as shown below:
acute pancreatitis
The examinations related to acute pancreatitis include blood examination and imaging examination. First of all, blood should be drawn for laboratory examination, that is, blood samples of patients should be collected and sent to the laboratory for testing, includingamylase、lipase、Blood biochemistry、routine blood test、High sensitivity C-reactive proteinEtc;The imaging examinations are mainly chest and abdomen X-ray, CT, abdominal ultrasound, etc.
Blood test
Serum amylase: the serum amylase starts to rise in the first 2~12 hours after the onset of acute pancreatitis. A positive examination result can indicate pancreatitis, but the degree of increase has no exact relationship with the severity of the disease.
Serum lipase: the serum lipase starts to rise 24~72 hours after the onset of the disease, and the positive significance of the test result is the same as that of amylase.
Other markers: The degree of blood glucose rise can reflect the degree of pancreatic necrosis.Lipid test(Blood triglyceride level) can determine whether the cause of pancreatitis is caused by hyperlipidemia.C-reactive protein can help diagnose the severity of the disease.
Blood routine test and blood biochemistry: the number and type of white blood cells can help judge the infection.Liver and kidney function examination can help doctors judge whether there is liver and kidney function damage;If glutamic pyruvic transaminase, alkaline phosphatase and bilirubin are elevated, it may indicate biliary pancreatitis.
matters needing attention
Do not eat greasy and high protein food before blood drawing, avoid drinking a lot of alcohol, and maintain a normal life pattern.
Blood biochemical examination: fasting for 8 hours before blood drawing, generally do not eat after 10 o'clock the previous night, and draw blood on an empty stomach the next morning.
Cooperate with the doctor when drawing blood. After drawing blood, press the needle hole for about 5 minutes to avoid local bruising.
Imaging examination
X-ray plain film: calcification and stone shadow in the pancreas region can be seen, which is helpful for preliminary judgment of the condition.This examination is not recommended for those who are preparing for pregnancy or are pregnant.Remove clothing with metallic substances before inspection.Position according to the doctor's advice.
Computed tomography (CT): CT scan can image the pancreas, gallbladder and bile duct, determine whether there is pancreatic edema and necrosis, and judge the severity of the disease;Local pancreatic complications such as fluid accumulation around the pancreas and pseudocysts can also be found;Pain caused by other causes was excluded.Fasting 4 hours before examination to avoid strenuous exercise.Do not take laxatives 2 days before the examination, and do not take metal containing drugs, such as gastrointestinal contrast agents, one week before the examination.Before the inspection, remove the underwear or other articles with metal substances at the inspection site.
Abdominal ultrasound: in most cases, ultrasound can show the specific location of gallstones, and can also show the expansion of the common bile duct, which is a screening method for biliary etiology of pancreatitis.Eight hours before the ultrasonic examination, it is necessary to fast food and water. During the examination, it is necessary to take off the heavy coat, leaving only shirts, bottoms, sweaters and other personal clothing.
chronic pancreatitis
Blood test
Serum amylase: serum amylase can be slightly increased, and can be significantly increased in acute attack.
Blood routine test: When combined with biliary tract infection, the white blood cells in blood can increase.
Blood biochemistry: blood bilirubinalkaline phosphataseIt is helpful to understand whether there is biliary obstruction, so as to help judge the cause of chronic pancreatitis.
Measurement of pancreatic exocrine function
At present, there are few relevant examinations, and most hospitals have not carried out them.
N-benzoyl-L-tyrosine p-aminobenzoic acid (BT-PABA) test: after patients take BT-PABA orally, check the concentration of p-aminobenzoic acid in blood and urine, which can indirectly reflect the function of pancreatic chymotrypsin secretion.During the examination, it is enough to cooperate with the doctor.
Detection of fecal elastase content: to understand the exocrine function of pancreas is more accurate than BT-PABA test.
Detection of fecal fat: the patient is required to take fat meal for three consecutive days, collect stool for three days, and check whether the amount of fat in stool exceeds 7g within 24 hours to help diagnose pancreatic exocrine function and judge the degree of pancreatic function damage.
Measurement of pancreatic endocrine function
Determination of blood glucose and insulin: patients may haveblood sugarThe plasma insulin level was decreased.
Determination of pancreatic polypeptide (PP): The fasting and postprandial plasma levels of pancreatic polypeptide in patients with chronic pancreatitis can be significantly reduced.
Determination of serum cholecystokinin: serum cholecystokinin in patients with chronic pancreatitis can be significantly increased.
Imaging examination
X-ray examination: finding calcified spots or stones of the pancreas can help diagnose chronic pancreatitis.
Endoscopic ultrasonography: by entering the stomach through the mouth with the help of endoscope, the pancreas and its surrounding tissue structure can be observed closely, providing more accurate information for the diagnosis of chronic pancreatitis.Cooperate with the doctor to check, and inform the doctor in time if there is any discomfort.
Abdominal CT: can make a clear diagnosis and judge the grading of chronic pancreatitis.Metal clothing and metal implants, such as dentures, heart stents, contraceptive rings, etc., shall not be carried during the examination. In case of these conditions, the doctor shall be informed.
Endoscopic retrograde cholangiopancreatography (ERCP): irregular or cystic dilatation, stenosis, obstruction of pancreatic ducts, pancreatic schisis, and biliary diseases can be found.If you are allergic to contrast medium, please inform your doctor in advance.ERCP is an invasive examination, and it is usually not used alone as an examination means.
Magnetic resonance imaging (MRI): search for abnormalities of gallbladder, pancreas and duct, which is the same as CT scanning.A small amount of water is available in the morning of the inspection day.Fasting for 4 hours before examination, and gastrointestinal barium meal examination cannot be performed one week before examination.Remove all metal objects before entering the examination room. If you have undergone cardiac pacemaker, heart artificial metal valve replacement, metal contraceptive ring and other operations, you should inform the doctor to avoid injury during the examination.
Pathological and cytological examination
Endoscopic ultrasound-guided fine needle aspiration of pancreatic tissue for pathological examination, or ERCP examination of pancreatic duct secretion as cytological examination, can differentiate chronic pancreatitis and pancreatic cancer.Keep your abdomen clean, relax and cooperate with the doctor.
differential diagnosis
For acute pancreatitis and chronic pancreatitis, including the differential diagnosis of mass autoimmune pancreatitis not specifically described above, doctors will focus on different aspects.
Diseases such as peptic ulcer, cholelithiasis, acute intestinal obstruction and myocardial infarction can also cause symptoms such as epigastric pain, which should be differentiated from acute pancreatitis.In acute pancreatitis, there are usually incentives such as heavy drinking and overeating, followed by epigastric pain, often accompanied by nausea, vomiting, abdominal distention and other manifestations. After examination, there are often positive findings such as extremely high serum amylase, swollen pancreas shown by CT/MRI.
Chronic pancreatitis needs to be differentiated from biliary tract disease, chronic liver disease and intestinal absorption dysfunction.Patients with chronic pancreatitis often have a personal history of gallstones, pancreatitis, long-term alcoholism, etc. It is not difficult to diagnose through blood tests, imaging examinations, etc.
Massive autoimmune pancreatitis
When mass type autoimmune pancreatitis occurspancreatic cancerIdentification is particularly important.It may be necessary to conduct fine needle biopsy under the guidance of EUS, or even open exploration to determine the nature of the tumor.
treatment
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For patients with mild acute pancreatitis and no infection, non operative treatment should be used first. If serious complications, such as pancreatic abscess, pancreatic pseudocyst and pancreatic necrosis combined with infection, or combined with biliary diseases, do not improve and continue to deteriorate after conservative treatment, minimally invasive treatment should be considered, and surgery should not be performed in the acute phase as far as possible.
Chronic pancreatitis is mainly treated by etiology, such as treatment of biliary diseases and abstinence from alcohol;If necessary, pancreatic duct drainage and surgical treatment should be performed.
Acute treatment
The treatment in the acute phase is mainly aimed at acute pancreatitis. The following contents describe the treatment in the acute phase of acute pancreatitis according to its severity,
Mild acute pancreatitis
Monitoring: all patients in acute phase need close monitoring.
Support treatment: First, rapid rehydration treatment. Crystal solution is preferred. At the same time, appropriate colloidal solution, vitamins and trace elements are added.Improve the blood volume of patients and prevent pancreatic necrosis.
Rest and short-term fasting: Generally, enteral or parenteral nutrition is not required.When symptoms disappear, bowel sounds return to normal, and hunger occurs, diet can be resumed.
Others: The doctor will give pain relief treatment to those with severe abdominal pain, such asPethidine。Biliary pancreatitis may require antibiotic treatment, and acute pancreatitis caused by other causes generally do not use antibiotics.
Moderate and severe acute pancreatitis
Monitoring: Such patients should be actively transferred to the intensive care unit. When hypoxemia and acute respiratory distress syndrome (ARDS) occur, positive pressure mechanical ventilation is required to assist respiration.Patients with severe paralytic intestinal obstruction need to be continuously aspirated by nasogastric tube to decompress gastrointestinal tract.
Liquid resuscitation: 24 hours is the golden period for liquid resuscitation.At the beginning of the disease, the amount of fluid replacement needed every day is 3500~4000ml.Ringer's lactic acid solution is often used.In addition, certain energy and electrolyte shall be added to maintain electrolyte and acid-base balance.
Prevention and anti infection treatment: the persistence of systemic inflammatory response syndrome will increase the risk of infection.However, preventive anti infection treatment is not recommended.When the infection is suspected or confirmed, it is necessary to receive broad-spectrum antibiotic treatment as soon as possible. It is recommended to use the step-down strategy for the selection of antibiotics, that is, from high to low.Common antibiotics include:Imipenem cilastatin、cefatriaxoneEtc.
Nutritional support: parenteral nutrition can be temporarily implemented first. After the disease tends to ease, consider starting oral enteral nutrition as early as 48~72 hours, which plays an important role in maintaining the intestinal function of patients and preventing infection and other complications.
Reduce pancreatic secretion: pancreatic enzyme activity, somatostatin and its analogues (octreotide) can directly inhibit pancreatic exocrine secretion, improve abdominal pain and other symptoms to some extent, and reduce amylase activity.
General treatment
Mainly for chronic pancreatitis:
Etiological treatment: abstinence is the basis for the treatment of chronic pancreatitis, others include biliary diseases;causeHypercalcemia、HyperlipidemiaMetabolic disorders;
Treatment of pancreatic secretory insufficiency: if there is fat diarrhea, sufficient pancreatin preparation is needed to replace the treatment, which can improve the digestive and absorption dysfunction;At the same time, PPI or H2 receptor antagonist can inhibit gastric acid secretion, reduce the destruction of gastric acid on pancreatic enzymes, and improve the drug efficacy.Patients with diabetes need insulin.
Pain treatment: mainly depends on the selection of appropriate analgesic drugs, including non steroidal anti-inflammatory drugs (such asAcetaminophen）And non opioid analgesics.
Endoscopic treatment: it can relieve some patients' abdominal pain. Endoscopic treatment mainly includes stent placement, pancreatic sphincterotomy or biliary sphincterotomy, pancreatic duct or bile duct lithotomy, etc.
medication
Antibiotics are used to prevent and control infection;
Use of trypsin active somatostatin and its analogues（octreotide）It can directly inhibit pancreatic exocrine secretion and relieve pain and other symptoms;
If fat diarrhea needs to be replaced with sufficient pancreatin preparation, it can improve the digestive and absorption dysfunction;
At the same time, PPI or H2 receptor antagonist can inhibit gastric acid secretion, reduce the damage of gastric acid to pancreatic enzyme, and improve the drug efficacy;
Patients with diabetes need to use insulin;
Appropriate use of analgesics.
surgical treatment
Early operation should be avoided in acute pancreatitis;Whether to carry out surgical treatment for chronic pancreatitis should be judged according to the individual condition of the patient.
Moderate and severe acute pancreatitis: in case of pancreatic necrosis and infection, pancreatic abscess, multiple organ failure, sepsis, shock, abdominal compartment syndrome, pancreatic pseudocyst, suspected abdominal organ perforation or intestinal necrosis, possible complicationspancreatic cancerWhen pancreatic enlargement compresses the common bile duct and causes serious complications such as obstructive jaundice, splenic vein thrombosis and portal hypertension, bleeding, surgery may be required.The operation methods mainly include: percutaneous drainage, endoscopic drainage, laparoscopic or open surgery.
Chronic pancreatitis: intractable pain that cannot be alleviated through medical treatment, or some special disease factors (such as pancreatic duct stones, pancreatic duct stricture with pancreatic duct obstruction, biliary tract obstruction, duodenal obstruction, portal hypertension, pancreatic ascites or cysts and other complications), doctors may recommend surgical treatment to reduce pain, improve drainageManage complications.The main surgical methods include pancreatic duct drainage and pancreatectomy.
TCM treatment
The TCM treatment of the disease is not supported by evidence-based medical evidence, but some TCM treatment methods or drugs can alleviate symptoms. For the treatment of patients with chronic pancreatitis, it is recommended to go to regular medical institutions and treat under the guidance of doctors.
prognosis
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Patients with mild acute pancreatitis can recover in about 1 week without sequelae.After active treatment, severe patients may still have pancreatic pseudocysts, pancreatic abscesses, splenic vein embolism and other complications, with pancreatic secretion insufficiency, and the overall mortality is about 15%.Patients with unexplained etiology will often recur, and acute pancreatitis can be converted to chronic pancreatitis.
The prognosis of chronic pancreatitis also depends on whether the etiology is removed.The data report shows that the mortality rate of chronic pancreatitis is 3.6 per 100000, and the quality of life in the later stage is poor due to many complications and the inability to cure them.
complication
PseudocystAcute pancreatitis can cause pus and necrotic tissue to accumulate in the pancreas and form cysts. Ruptured large pseudocysts can cause complications such as intracystic hemorrhage and infection.
Infection: Acute pancreatitis can make the pancreas susceptible to bacterial infection.
Renal failure: acute pancreatitis may causeRenal failureIf the renal failure is serious and persistent, dialysis treatment may be required.
Respiratory disorders: acute pancreatitis can affectPulmonary function, causing the oxygen content in the blood to drop to a dangerously low level.
Diabetes: chronic pancreatitis can damage pancreatic cells, resulting indiabetes。
Malnutrition: acute and chronic pancreatitis can reduce digestive enzymes produced by the pancreas, leading to diarrhea and malnutrition.
Pancreatic cancer: chronic pancreatitis causes long-term inflammation of the pancreas, which is a risk factor for pancreatic cancer.
prevention
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Acute pancreatitis is a serious disease,Acute hemorrhagic necrotizing pancreatitisIt is especially dangerous, with rapid onset,mortalityHigh.It is known that pancreatitis is mainly caused by pancreatic juice reflux andPancreatinDamage to the pancreas can be prevented against these factors.
People who usually drink heavily due to chronic alcoholism andinnutritionThe liver, pancreas and other organs were damaged, and the anti infection ability decreased.On this basis, acute pancreatitis can be caused by a heavy drinking.
Overeating
Can causeGastrointestinal disorders, so that the normal activity and emptying of the intestinal tract will be obstructedbileAnd normal drainage of pancreatic juice, causing pancreatitis.
