Chronic pancreatitis recommendations. Chronic pancreatitis clinical guidelines. Prevention and follow-up

Modern pancreatology is a dynamically developing branch of gastroenterology, which is naturally reflected in the growing number of national (including Russia) consensus documents (guidelines) on the diagnosis and treatment of chronic pancreatitis (CP), characterized by the presence of contradictory or ambiguous recommendations. To level out such inconsistencies, for the first time it was decided to create the first European clinical protocol, compiled in compliance with the principles of evidence-based medicine and containing scientifically based recommendations on key aspects of the conservative and surgical treatment of CP. Systematic reviews of the scientific literature were conducted using predefined clinical questions by 12 interdisciplinary expert working groups (EWGs). Various ERGs considered the etiology of CP, instrumental diagnosis of CP using imaging methods, diagnosis of exocrine pancreatic insufficiency (PIN), surgical, drug and endoscopic treatment of CP, as well as issues of treatment of pancreatic pseudocysts, pancreatic pain, malnutrition and nutrition, pancreatogenic diabetes mellitus, The natural history of the disease and quality of life in CP were assessed. Coverage of the main provisions of this consensus, which are more in demand among gastroenterologists, their analysis and the need for adaptation to Russian clinical practice were the goals of writing this article.

Keywords: chronic pancreatitis, exocrine pancreatic insufficiency, diagnosis, treatment, pancreatin preparations.

For quotation: Bordin D.S., Kucheryavyi Yu.A. Key positions of pan-European clinical recommendations for the diagnosis and treatment of chronic pancreatitis in the focus of a gastroenterologist // RMZh. 2017. No. 10. pp. 730-737

The key points of the pan-European clinical guidelines for the diagnosis and treatment of chronic pancreatitis in the focus of gastroenterologist
Bordin D.S. 1 , 2 , Kucheryavy Yu.A. 3

1 Moscow Clinical Scientific And Practical Center named after A.S. Loginov
2 Tver State Medical University
3 Moscow State Medical Dental University named after A.I. Evdokimov

Modern pancreatology is a dynamically developing branch of gastroenterology, that naturally results in a growing number of national (including Russia) guidelines for the diagnosis and treatment of chronic pancreatitis (CP), characterized by conflicting or ambiguous recommendations. To compensate such inconsistencies there was taken a decision to make the first European clinical protocol, compiled with observation of the principles of the evidence-based medicine and containing scientifically grounded recommendations on key aspects of conservative and surgical treatment of CP. Twelve interdisciplinary expert working groups (EWG) made systematic literature reviews on the pre-formulated clinical questions. Various ERGs considered the CP etiology, CP diagnostics tools using imaging techniques, diagnosis of pancreatic exocrine insufficiency, surgical, medical and endoscopic treatment, as well as issues of treatment of pancreatic pseudocysts, pancreatic pain, malnutrition and nutrition, pancreatogenic diabetes, natural history of disease and quality of life at CP. The aims of writing this article were the coverage of the main provisions of this consensus, which are in demand among gastroenterologists, their analysis and the need to adapt them to Russian clinical practice.

Key words: chronic pancreatitis, pancreatic exocrine insufficiency, diagnosis, treatment, pancreatin preparations.
For citation: Bordin D.S., Kucheryavy Yu.A. The key points of the pan-European clinical guidelines for the diagnosis and treatment of chronic pancreatitis in the focus of gastroenterologist // RMJ. 2017. No. 10. P. 730–737.

The key positions of pan-European clinical guidelines for the diagnosis and treatment of chronic pancreatitis are presented.

Introduction

Recent years have been marked by a rethinking of our understanding of chronic pancreatitis (CP), which is due to breakthroughs in diagnosis and discoveries in the genetics and pathophysiology of the disease. The pool of randomized clinical trials (RCTs) in patients with CP has also naturally been updated. This trend was picked up by regional gastroenterological and pancreatological associations (including Russia) with the aim of creating a large number of national consensus documents (guidelines) on the diagnosis and treatment of CP. In general, such clinical recommendations are similar in essence, but noteworthy are the variations in the number of provisions and approaches to achieving consensus, and the presence of contradictory or ambiguous decisions. To level out such inconsistencies, for the first time it was decided that it was necessary to create international clinical guidelines for the diagnosis and treatment of CP. A working group on the “Unification of principles for the diagnosis and treatment of CP in Europe” (HaPanEU) was established in collaboration with the United European Gastroenterology (UEG), the result of which was the first European clinical protocol compiled in accordance with the principles of evidence-based medicine, published in March 2017. Twelve interdisciplinary expert working groups (EWGs) performed systematic reviews of the scientific literature to answer 101 predefined clinical questions. Thus, ERG 1 considered the issues of the etiology of CP, ERG 2 and 3 - issues of instrumental diagnosis of CP using imaging methods, ERG 4 - issues of diagnosing exocrine pancreatic insufficiency (EPI), ERG 5, 6 and 7 - issues of surgical, drug and endoscopic treatment HP respectively; ERG 8, 9 and 10 – issues of treatment of pancreatic pseudocysts (PZ), pancreatic pain, malnutrition and nutrition, ERG 11 – issues of pancreatogenic diabetes mellitus, ERG 12 – natural course of the disease and quality of life in CP. Recommendations were classified using the Recommendation Assessment, Development and Review system, and responses were assessed by the entire EWG using the online Delphi method. The EWGs presented their recommendations at the annual meeting of the Joint European Association of Gastroenterology in 2015. At this one-day interactive conference, relevant comments were made and each recommendation was agreed upon by a plenary vote (Test and Evaluation Authority). After a final round of revisions based on these comments, a draft document was produced and sent to external reviewers. The vote count classified 70% as “strong” and the plenary vote found “high agreement” on 99 (98%) recommendations. Thus, the proposed HaPanEU / United European Gastroenterological Association 2016 clinical protocol contains evidence-based recommendations on key aspects of conservative and surgical treatment of CP, compiled on the basis of modern scientific data, which dictates the need for their analysis and adaptation to Russian clinical practice. This is the purpose of this article, created to help practicing physicians in their work. Since it is impossible to reflect in one article all the information processed and reported by the ERG, below are discussed those questions and statements that are most relevant in the work of a gastroenterologist, therapist, and general practitioner. For each clinical question, criteria for evidence and applicability of scientific evidence were proposed:
1. Recommendation: degree of conviction of the recommendation according to the GRADE system (1 – high, 2 – low).
2. Quality of the evidence base (A – high, B – average, C – low).
3. Level of consensus of the decision (high/low) during plenary voting.

Etiology of CP (ERG 1)

Question 1-1. What needs to be done to determine the etiology of CP in adult patients?
Statement 1-1. In patients with CP, a complete and detailed history, laboratory tests, and imaging studies should be obtained (GRADE 2C, high agreement).
Comments. CP is an inflammatory disease of the pancreas with, as a rule, a long history, which leads to the replacement of the gland's own tissue with fibrous tissue, the development of endocrine and/or exocrine insufficiency of the pancreas. Patients with CP have an increased risk of developing pancreatic cancer. The most common risk factor for CP is alcohol abuse, and the risk increases exponentially, and the specific type of alcohol consumed does not matter. The amount and duration of alcohol consumption required for the development of CP have not yet been clearly established. Some authors talk about alcohol consumption at a level of at least 80 g/day for at least 6 years. Smoking is an independent risk factor for CP and leads to the progression of CP, so all patients should be advised to quit smoking.
Genetic factors also contribute to the development of CP. The most important genetic risk factors are changes in the genes for cationic trypsinogen (PRSS1), serine protease inhibitor Casal-1 (SPINK1), and carboxypeptidase A1 (CPA1). Other genes that indicate genetic susceptibility include cystic fibrosis transmembrane conductance regulator (CFTR), chymotrypsinogen C (CTRC) and carboxylestrolipase (CEL).
To diagnose CP and attempt to determine the etiology, it is necessary to collect a complete history of life and disease, conduct a clinical examination, including imaging studies and functional tests. The etiology of CP is determined after a thorough examination of the patient, taking into account all known risk factors, including assessment of alcohol history and smoking history, determination of latent commitment to alcohol (for example, using the AUDIT questionnaire), as well as using a screening block of laboratory parameters ( triglyceride level, ionized calcium level to exclude primary hyperparathyroidism; level of carbohydrate-deficient transferrin/phosphatidylethanol) in the blood and family history.
In accordance with current consensus recommendations, autoimmune pancreatitis (AIP) should be excluded, including when no other etiology can be identified. Signs of AIP include elevated levels of serum immunoglobulin IgG4, the presence of autoantibodies to lactoferrin and carbonic anhydrase, as well as typical signs of AIP using imaging techniques.
Cholecystolithiasis and/or choledocholithiasis in themselves are not considered risk factors for the development of CP. Whether anatomical abnormalities, such as pancreas divisum, increase the risk of CP is still a matter of debate; however, in the presence of additional risk factors, a split pancreas can lead to the development of CP. If the etiological factor cannot be identified, genetic screening for variants in susceptibility genes can be suggested.
Recent clinical guidelines have classified CP into various forms (calcific, obstructive, autoimmune and sulcal). groove pancreatitis)). This classification is based on clinical signs, morphological characteristics and response to treatment. In calcific CP, for example, there is perilobular fibrosis and destruction of the acinar apparatus with inflammatory cell infiltration. Obstructive CP develops as a secondary process due to the destruction of part of the pancreas with the development of block and distal dilatation of the pancreatic duct, subsequent atrophy of acinar cells and fibrosis. The characteristics of AIP are discussed in detail below. Finally, sulcal pancreatitis affects the groove between the head of the pancreas, the duodenum and the bile duct.
Question 1-4. Should the diagnosis of AIP be excluded in all patients with pancreatitis?
Statement 1-4. If the etiology of CP cannot be established in a patient, then the diagnosis of AIP should be excluded (GRADE 2C, high agreement).
Comments. AIP is a rare form of the disease, accounting for up to 5% of all CP with gender differences in favor of men (2:1 ratio). Approximately 5% of patients with suspected pancreatic cancer are eventually diagnosed with AIP. Conditionally specific for AIP are recurrent abdominal pain and obstructive jaundice in approximately 50% of patients. There are 2 types of AIP. In AIP type 1, the serum level of IgG4 is elevated in most cases, and the histological picture corresponds to lymphoplasmacytic sclerosing pancreatitis (LPSP) with obliterative phlebitis and periductular fibrosis. In type 2 AIP, serum IgG4 levels remain within the normal range, and histological findings include idiopathic ductal-concentric pancreatitis (IDCP) and granulocytic epithelial lesions. If AIP type 1 is often combined with a wide range of IgG4-associated diseases, then AIP type 2 may be accompanied by ulcerative colitis. An important feature of AIP is a good response to immunosuppressive therapy, the timely administration of which can help normalize the exocrine and endocrine functions of the pancreas. However, making the diagnosis of AIP remains challenging because patients with this disease often present with atypical symptoms. Thus, AIP may underlie any inflammation of the pancreas, therefore, it is necessary to perform a comprehensive diagnosis.

Classification

Question 1-5. Is there a recommended classification system that should be used when determining the etiology of a disease?
Statement 1-5. There is no optimal classification system for CP with etiology; existing classification systems need to be studied in RCTs with morbidity and mortality endpoints. Only in this way will it be possible to recommend in the future the most valid classification system for CP (GRADE 2C, high agreement).
Comments. Classification systems are of great importance for determining patient management strategies, since treatment strategy cannot be based solely on the type and extent of morphological changes in the pancreas, but must include the results of clinical, functional and imaging studies. To date, a generally accepted classification system has not been created. The most well-known classifications are:
1. Manchester classification.
2. ABC classification.
3. M-ANNHEIM classification.
4. TIGAR-O classification.
5. Rosemont classification.
The Manchester classification uses imaging techniques and clinical features of CP. The severity of the disease largely depends on the presence of exocrine and/or endocrine insufficiency or the presence of complications, while the results of imaging studies are of secondary importance. The ABC classification is based on the same provisions as the Manchester classification. The Rosemont classification was developed for the diagnosis of CP using endo-ultrasound. The M-ANNHEIM classification system combines the degree, severity and clinical characteristics of CP, and takes into account the disease severity index. The TIGAR-O classification includes 6 etiological groups of CP: toxic-metabolic, idiopathic, genetic, autoimmune, obstructive CP and recurrent acute pancreatitis. Thus, the factor of the etiology of CP is taken into account only in the TIGAR-O and M-ANNHEIM classifications.

Clinical course of CP

Question 1-6. Can CP progress in different ways?
Statement 1-6. Depending on the etiology, CP is characterized by different clinical course and long-term complications (GRADE 1B, high agreement).
Comments. The course of CP and the risk of developing pancreatic cancer vary significantly between different etiological groups. Calcification, exocrine and endocrine insufficiency develop in patients with alcoholic and hereditary CP after a shorter period of time than in other etiologies. Quitting alcohol consumption can reduce the rate of disease progression and reduce pancreatic pain. Smoking is recognized as an independent risk factor for the development of CP and pancreatic calcification. In patients with early onset CP (<20 лет), особенно наследственной этиологии, риск рака ПЖ значительно увеличивается, и отказ от курения может снизить риск в этой группе . При наследственном ХП риск развития аденокарциномы ПЖ возрастает в 69 раз, в то время как при другой этиологии – в 13 раз . Риск развития аденокарциномы ПЖ не связан с генотипом , ранний дебют заболевания у этих пациентов и более продолжительное течение болезни являются основными причинами повышенного риска развития рака ПЖ. Комбинация различных генетических факторов риска или прочих факторов риска, например, pancreas divisum with genetic mutations may increase the risk of developing CP. Therefore, the correct determination of the etiology of the disease by the doctor is important.

Diagnostics

Question 2-1. What is the best imaging modality for making the diagnosis of CP?
Statement 2-1. Endo-ultrasound, MRI and CT are considered the best imaging modalities for diagnosing CP (GRADE 1C, high agreement).
Comments. The most common methods of imaging the pancreas are ultrasound, endo-ultrasound, MRI, CT and ERCP. A meta-analysis aimed at obtaining pooled estimates of the sensitivity and specificity of various imaging modalities used to evaluate CP (42 studies, 3392 patients) showed that endo-ultrasound, ERCP, MRI and CT have comparable high diagnostic accuracy in the initial diagnosis of CP. Endo-ultrasound and ERCP are superior to other imaging methods, and ultrasound is considered the least accurate method. ERCP today is not considered as a diagnostic test for CP due to significant invasiveness, local inaccessibility, and high cost. The results of the meta-analysis are consistent with previously published German clinical practice guidelines S3.
Question 2-2. Which method is most suitable for detecting pancreatic calcifications?
Statement 2-2. CT is the most appropriate method for detecting pancreatic calcifications, and non-contrast-enhanced CT is preferred for detecting microcalcifications (GRADE 2C, high agreement).
Comments. Pancreatic calcification is a common finding in patients with CP. It is estimated that 90% of patients will develop calcification during long-term follow-up, especially in patients with alcoholic CP. Imaging with portal phase CT with bolus contrast enhancement has moderate sensitivity and very high specificity (approaching 100%) for detecting intraductal stones. However, small calcifications may appear in the shadow of the contrasted pancreatic parenchyma; thus, non-contrast phase CT may be a necessary adjunct to portal phase CT with bolus contrast enhancement to visualize calcifications missed in the later phase.
Question 2-3. To make a diagnosis of CP, is it sufficient to perform an MRI/MRCP study to assess the unevenness of the contour of the main pancreatic duct (MPD), its pathologically altered lateral branches, strictures and dilations?
Statement 2-3. The presence of signs typical of CP on MRI/MRCP is considered sufficient to establish a diagnosis; however, MRI/MRCP findings within the normal range do not always exclude the presence of mild forms of the disease (GRADE 1C, high agreement).
Comments. MRCP relies heavily on T2-weighted images to detect ductal narrowing, dilatation, and filling defects in CP with moderate to high accuracy comparable to ERCP. However, in mild CP, MRCP is characterized by relatively low sensitivity, inferior to ERCP in detecting subtle changes in the MLP and its side branches.
Question 2-4. What are the advantages of intravenous (IV) administration of secretin during MRCP for the diagnosis of CP?
Statement 2-4. The use of secretin increases the diagnostic potential of MRCP in the evaluation of patients with confirmed/suspected CP (GRADE 1C, high agreement).
Comments. IV administration of secretin stimulates the exocrine function of the pancreas and increases the excretion of secretions by the pancreatic ductal system, which provides the following benefits:
1. Better visualization of the MLP and pathologically altered side branches compared to those with MRCP without stimulation, which ensures an increase in the sensitivity of diagnosing CP from 77% to 89%.
2. The ability to perform a quantitative assessment of exocrine pancreatic function, which correlates with the severity of pancreatitis.
3. The theoretical possibility of diagnosing intraductal papillary mucinous tumor of the pancreas, which should be proven in specially designed studies.
Question 2-6. What is the role of abdominal ultrasound in suspected CP?
Statement 2-6. Abdominal ultrasound can only be used to diagnose more severe CP (GRADE 1A, high agreement).
Comments. Abdominal ultrasound is usually the first imaging modality used in patients with abdominal pain and suspected CP. Ultrasound is widely available in most institutions, including for repeat examinations without the risks associated with other imaging modalities (x-rays and/or contrast agents). The sensitivity and specificity of ultrasound (67% / 98%) is lower than that of CT (75% / 91%) and endo-ultrasound (82% / 91%), respectively, which is determined by the dependence of ultrasound results on the experience and knowledge of the diagnostician, and also difficult visualization of the pancreas in obese patients, with flatulence, etc.
Question 2-7. What is the role of abdominal ultrasound in confirmed CP?
Statement 2-7. Ultrasound can be prescribed to patients with suspected complications of CP (GRADE 2C, high agreement).
Comments. Ultrasound can be used to visualize complications of CP, such as fluid collections, pseudocysts, exacerbation of CP, and pseudoaneurysms. There are no RCTs comparing ultrasound with other imaging modalities. Ultrasound can also be used for diagnostic and therapeutic interventions on the pancreas under ultrasound guidance (biopsy, drainage).
Question 2-8. What are the indications for contrast-enhanced endo-ultrasound?
Statement 2-8. Endo-ultrasound with contrast may improve diagnostic accuracy in patients with CP with cystic and solid lesions in the pancreas (GRADE 1C, high agreement).
Comments. Contrast enhances accuracy in the description of focal lesions of the pancreas, but there are no RCTs evaluating contrast in endo-ultrasound in patients with CP. Standard B-mode ultrasound does not differentiate pseudotumorous CP from pancreatic cancer. On contrast, ductal adenocarcinoma is usually hypoechoic in the arterial phase due to its low vascularity, whereas focal CP usually demonstrates contrast enhancement similar to that seen in the surrounding pancreatic parenchyma. In CP with a long history, heterogeneous hypovascularization due to fibrosis may be observed, which significantly complicates the differential diagnosis with pancreatic cancer.
Question 2-9. What is the role of endo-ultrasound in patients with suspected CP?
Statement 2-9. Endo-ultrasound is the most sensitive imaging modality for diagnosing early CP, and its specificity increases with the number of diagnostic criteria (GRADE 1B, high agreement).
Comments. Endo-ultrasound is the most sensitive imaging method for diagnosing CP. Certain criteria for CP have been developed, divided into parenchymal and ductal. To make a diagnosis of CP, a threshold sum of 3–4 criteria is most often used. Recognizing that not all criteria are equally important, the Rosemont classification proposes specific diagnostic criteria for endo-ultrasound, indicating their specific validity. Compared with histological examination as the gold standard, the sensitivity of endo-ultrasound exceeds 80% and the specificity reaches 100%.

Diagnosis of EPI

Question 3-2. What are the clinical consequences of varying degrees of pancreatic failure?
Statement 3-2. Taking into account the large reserve capacity of the pancreas, “mild” and “moderate” EPI can be compensated by the body itself, and obvious steatorrhea occurs already when the secretion of pancreatic lipase decreases to<10% от нормы («тяжелая»/«декомпенсированная» недостаточность). Однако пациенты с «компенсированной» ВНПЖ также имеют повышенный риск мальнутриции (в частности, жирорастворимых витаминов с соответствующими клиническими последствиями) (GRADE 1В, высокая согласованность).
Comments. Patients with steatorrhea typically complain of weight loss and more frequent bowel movements during the day with fatty, large stools that are difficult to flush down the toilet (mostly occurring after high-fat meals). By reducing fat in the diet, steatorrhea may be absent. Clinical symptoms and signs of impaired absorption of fat-soluble vitamins include: vitamin K deficiency - ecchymosis; vitamin E deficiency – ataxia, peripheral neuropathy; vitamin A deficiency – visual impairment, xerophthalmia; Vitamin D deficiency – muscle contractions or spasms, osteomalacia and osteoporosis. In addition, the clinical consequences of EPI may include hyperoxaluria, oxalate stones in the urinary tract, renal failure, and impairment of cognitive function and hence performance. Decreased absorption of fat-soluble vitamins is also possible in the absence of steatorrhea in patients with mild to moderate EPI.
Question 3-5. Is it possible to diagnose or exclude EPI using various imaging methods (morphological studies)?
Statement 3-5.1. CP symptoms (morphological changes) and functional impairment usually develop in parallel, although not always (GRADE 1B, high agreement).
Comments. In most patients with CP, there is an association between the severity of morphological and functional changes, but in 25% of patients there is a discrepancy between them.
Question 3-6. What analysis/research is indicated for diagnosing EPI in clinical practice?
Statement 3-6. In a clinical setting, it is necessary to conduct a non-invasive functional study of the pancreas. The fecal elastase-1 (FE-1) test is widely available, and the 13C-mixed triglyceride breath test (13C-MTG-DT) appears to be an alternative screening option. The use of MRCP with secretin can also be used as a method of diagnosing EPI, but it provides only semi-quantitative data (Grade 1B, agreement was not indicated by the authors in the original publication, but in the opinion of the authors of this publication, the agreement should be of a high level due to the large number of evidence-based relevant studies ).
Comments. Determination of FE-1 (elastase test) is a very simple and widely available test for indirect and non-invasive assessment of pancreatic secretion. Unfortunately, the elastase test does not rule out mild to moderate EPI. The threshold value of PE-1 indicating EPI is less than 200 μg/g. The possibility of false-positive results due to stool dilution should be taken into account and a monoclonal test should be used in clinical practice.
Fat absorption coefficient (FAC) is considered the gold standard for diagnosing steatorrhea in severe EPI and is the only test approved by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) for the diagnosis and monitoring of fat replacement. enzyme therapy in clinical trials. The CAF test requires patients to follow a strict diet containing 100 g of fat per day for 5 days and collect all stool for the last 3 days of that 5-day period. KAJ indicator< 93% считается патологическим. К недостаткам метода относятся применимость только при тяжелой ВНПЖ, низкая специфичность (ложноположительные результаты при множестве причин вторичной панкреатической недостаточности или непанкреатической мальабсорбции), низкая доступность, трудоемкость, сложности логистики. Поэтому в некоторых европейских странах он больше не используется.
13C-GH-DT is an alternative to the QAF test, both for diagnosing EPI and for assessing the effectiveness of pancreatin therapy in clinical practice, and new modifications of the test can detect mild and moderate EPI. However, this test also has limitations regarding specificity (false-positive results for non-pancreatic fat malabsorption) and is not yet widely available. The test is only commercialized in some European countries. In Russia, this test is also not available due to the lack of substrate (13C-labeled triglycerides).
Only direct tests requiring collection of duodenal juice in response to hormonal stimulation (secretin and/or cholecystokinin) can quantify pancreatic exocrine secretion and reliably determine the presence of mild to moderate EPI. Based on this, they were adopted as a standard. Previously, these tests were performed by inserting a nasoduodenal tube, although endoscopic versions of the procedure have been developed and are now preferred in the United States and some European countries. However, regardless of which specific method is used to collect duodenal juice, the examination itself is invasive, time-consuming and expensive, and can only be performed in specialized centers.
Question 3-7. Is a functional study of the pancreas always required when diagnosing CP?
Statement 3-7. To diagnose CP, a functional study is required (GRADE 2B, high agreement).
Comments. The diagnosis of CP is based on a combination of clinical, histological, imaging and functional criteria. Proof of exocrine dysfunction using functional studies is especially indicated in the case of diagnostics in patients with CP with inconclusive morphological data. Additionally, exocrine function is taken into account in some diagnostic and classification systems.
Question 3-8. Should a functional study of the pancreas be performed after diagnosing CP?
Statement 3-8. Every patient newly diagnosed with CP should be screened for EPI (GRADE 1A, high agreement).
Comments. Even with convincing morphological signs of CP, clinical symptoms of EPI do not always appear at the time of diagnosis, and the absence of symptoms does not reliably exclude exocrine insufficiency.
Question 3-10. Should pancreatic function testing be performed to monitor pancreatin enzyme replacement therapy (ERRT)?
Statement 3-10. To assess the effectiveness of PPTP, in most cases it is enough to ensure normalization of nutritional status and improvement of clinical symptoms. If symptoms of EPI persist even despite adequate PTSD, a functional test (13C-GH-DT or QAF test) is recommended to assess the effectiveness of treatment (GRADE 2B, high agreement).
Comments. Typically, when patients with EPI are treated with adequate EPTA, rapid improvement in clinical symptoms and an increase in weight/body mass index are observed. The effect of treatment should also be assessed by determining indicators of nutritional status in the blood serum over time, since the absence of symptoms does not exclude the presence of latent EPI.
Question 3-12. What parameters in the blood allow you to determine malnutrition?
Statement 3-12. Tests should be performed for proven markers of malnutrition: prealbumin, retinol binding protein, 25-OH cholecalciferol (vitamin D), and minerals/trace elements (including serum iron, zinc, and magnesium) (GRADE 2C, high agreement).
Comments. Malnutrition (exhaustion) caused by EPI is no different from malnutrition due to other causes, which determines the absence of strictly specific markers of pancreatogenic malnutrition.

Drug treatment of exocrine pancreatic insufficiency (ERG 6)

Question 4-2.1. What are the indications for PPTP in CP?
Statement 4-2.1. SFTP is indicated for patients with CP and EPI in the presence of clinical symptoms or laboratory signs of malabsorption. An appropriate nutritional assessment (GRADE 1A, high agreement) is recommended to identify signs of malnutrition.
Comments. EPI in CP is clearly associated with biochemical markers of malnutrition (emaciation). The classic indication for PETP is steatorrhea with fecal fat excretion > 15 g/day. However, quantification of fats in feces is often not carried out. Therefore, indications for FTRT are also pathological results of a functional study of the pancreas in combination with clinical signs of malabsorption or anthropometric and (or) biochemical signs of malnutrition. These symptoms include weight loss, diarrhea, severe flatulence, and abdominal pain. Low values ​​of the most common markers of nutritional deficiency (fat-soluble vitamins, prealbumin, retinol-binding protein and magnesium) are also an indication for the use of EFT. In uncertain situations, it is allowed to prescribe ZFTP for 4–6 weeks as a trial experimental pharmacotherapy regimen.
Question 4-2.2. Which enzyme preparations are considered preferable?
Statement 4-2.2. The drugs of choice for EPI are microencapsulated pancreatin preparations in an enteric coating, size up to 2 mm. Micro or mini tablets measuring 2.2–2.5 mm may also be effective, although there is much less scientific evidence on this. Comparative RCTs various There are no enzyme preparations (GRADE 1B, high agreement).
Comments. The effectiveness of pancreatic enzyme preparations depends on a number of factors: a) connection with food intake; b) synchronized evacuation along with food; c) adequate segregation in the duodenum; d) rapid release of enzymes in the duodenum.
Effective pancreatin preparations are presented in a dosage form in the form of pH-sensitive microspheres/microtablets with an enteric coating, which protects enzymes from gastric acid and allows them to quickly release pancreatin at pH 5.5 in the duodenum. Enteric-coated drugs have demonstrated higher efficacy than conventional non-enteric-coated drugs. A recent Cochrane review assessing the effectiveness of pancreatin in cystic fibrosis with EPPI demonstrated superior efficacy of microencapsulated formulations compared with enteric-coated tablets.
Question 4-2.3. How should you take pancreatin preparations?
Statement 4-2.3. Oral pancreatin preparations should be distributed evenly throughout the day at all main and additional meals (GRADE 1A, high consistency).
Comments. The effectiveness of pancreatic enzymes depends on the adequacy of mixing pancreatin microparticles with chyme, which determines the need to take the drug with meals. If you need to take more than 1 capsule per meal, it is reasonable to divide the entire dose into fractions throughout the meal.
Question 4-2.4. What is the optimal dose of pancreatin for EPI on the background of CP?
Statement 4-2.4. The recommended minimum dose of lipase for initial therapy is 40-50 thousand units with main meals and half this dose with intermediate meals (GRADE 1A, high agreement).
Comments. The recommended initial dose is about 10% of the dose of lipase physiologically secreted in the duodenum after a normal meal, i.e., to digest normal food, a minimum lipase activity of 90,000 units is required, which is achieved by summing up endogenously secreted enzymes and exogenously (orally) supplied enzymes.
Question 4-2.5. How to evaluate the effectiveness of RFTP?
Statement 4-2.5. The effectiveness of FTP can be objectively judged by the relief of symptoms associated with maldigestion (steatorrhea, weight loss, flatulence) and the normalization of the nutritional status of patients. In patients who have not sufficiently responded to treatment, the use of pancreatic function tests (FA or 13C-GH-DT analysis) in the setting of FTRT may be useful (GRADE 1B, high agreement).
Comments. Although resolution of clinical signs of malabsorption is generally considered the most important criterion for the success of EFT, which is associated with improved quality of life, more recent studies have demonstrated that relief of symptoms is not always combined with normalization of nutritional status. A recent review confirms that the optimal way to assess the effectiveness of EFT is to normalize parameters of nutritional status, both anthropometric and biochemical.
The lack of a full effect of ZFTP may be due to secondary mechanisms. The success of PPTP cannot be assessed by the concentration of PE-1, since in this case only the concentration of the natural human enzyme is measured, and not the therapeutically administered enzyme contained in pancreatin. Fecal chymotrypsin excretion testing does not provide information about the effects of TFTP on digestion and nutrient absorption; however, it can be used to test compliance (low values ​​indicate incorrect drug administration). Only 13C-GH-DT allows effective assessment of fat absorption and is suitable for monitoring the effectiveness of PETP.
Question 4-2.6. What should be done if the clinical response is unsatisfactory?
Statement 4-2.6. If the clinical response to EFT is unsatisfactory, the dose of enzymes should be increased (double or triple) or a proton pump inhibitor (PPI) should be added to therapy. If these therapeutic strategies are unsuccessful, another cause of the digestive disorder should be sought (GRADE 2B, high agreement).

Protocols for diagnosis and treatment of acute pancreatitis

Acute pancreatitis (AP) characterized by the development of pancreatic edema (edematous pancreatitis) or primary aseptic pancreatic necrosis (destructive pancreatitis) followed by an inflammatory reaction. Acute destructive pancreatitis has a phase course, and each phase corresponds to a specific clinical form.

Phase I – enzymatic , the first five days of the disease, during this period the formation of pancreatic necrosis of varying extent, the development of endotoxemia (the average duration of hyperenzymemia is 5 days), and in some patients, multiple organ failure and endotoxin shock. The maximum period for the formation of pancreatic necrosis is three days, after this period it does not progress further. However, with severe pancreatitis, the period of formation of pancreatic necrosis is much shorter (24-36 hours). It is advisable to distinguish two clinical forms: severe and non-severe AP.

Severe acute pancreatitis. The incidence is 5%, mortality is 50-60%. The morphological substrate of severe AP is widespread pancreatic necrosis (large focal and total-subtotal), which corresponds to severe endotoxicosis.

Mild acute pancreatitis. The incidence is 95%, mortality is 2-3%. Pancreatic necrosis in this form of acute pancreatitis either does not form (swelling of the pancreas) or is limited in nature and does not spread widely (focal pancreatic necrosis - up to 1.0 cm). Mild AP is accompanied by endotoxemia, the severity of which does not reach a severe degree.

Phase II – reactive (2nd week of the disease), is characterized by the body’s reaction to the formed foci of necrosis (both in the pancreas and in the parapancreatic tissue). The clinical form of this phase is peripancreatic infiltrate.

Phase III – melting and sequestration (starts from the 3rd week of the disease, can last several months). Sequesters in the pancreas and retroperitoneal tissue begin to form from the 14th day from the onset of the disease. There are two possible options for the course of this phase:

aseptic melting and sequestration – sterile pancreatic necrosis; characterized by the formation of postnecrotic cysts and fistulas;

septic meltdown and sequestration– infected pancreatic necrosis and necrosis of parapancreatic tissue with further development of purulent complications. The clinical form of this phase of the disease is purulent-necrotic parapancreatitis and its own complications (purulent-necrotic leaks, abscesses of the retroperitoneal space and abdominal cavity, purulent omentobursitis, purulent peritonitis, arrosive and gastrointestinal bleeding, digestive fistulas, sepsis, etc.) .

Patients diagnosed with acute pancreatitis should, if possible, be sent to multidisciplinary hospitals.

The most dangerous of the pathological processes that occur in the pancreas is chronic pancreatitis, which develops over a long period of time.

It affects the functioning of adjacent organs and also provokes dangerous complications.

This is a long-term inflammatory disease of the pancreas, which manifests itself with irreversible changes that cause pain or persistent deterioration in function.

The disease in question requires following a special diet, drug treatment, and in some situations, surgical intervention.

Since the chronic form of pancreatitis has various causes and differs in the degree of poisoning, pathology therapy involves immediately calling an ambulance and sending the patient to the hospital for further examination.

The diagnosis is made taking into account attacks of abdominal pain, manifestations of insufficiency of pancreatic exocrine function in a patient who constantly drinks alcohol.

In contrast to acute pancreatitis, in chronic pancreatitis there is rarely an increase in the content of enzymes in the bloodstream or urine, so when this happens, it is possible to suggest the formation of a pseudocyst or pancreatic ascites.

The choice of imaging methods is based on the availability of the technique, the presence of the necessary skills among specialists and the invasiveness of the diagnostic method.

• Radiography. In 1/3 of situations, this procedure helps to identify pancreatic calcification or stones inside the duct. This will make it possible to eliminate the need for subsequent diagnostics to confirm the disease. The degree of certainty of evidence is 4. The level of strength of recommendations is C.
• Transabdominal ultrasound. This diagnostic measure lacks sensitivity and specificity. Infrequently provides information that is sufficient to identify pathology. Its main purpose will be to eliminate other factors of pain in the abdominal cavity. The degree of credibility of recommendations is A.
• CT scan with contrast agent injection. Today it is considered the method of choice for the initial diagnosis of the disease. The most effective method for determining the location of pancreatic stones. The strength of the recommendations is B.
• Endoscopic ultrasound. The method is minimally invasive. Used for medicinal purposes. It is considered the most proven method for visualizing changes in the parenchyma and ducts of the pancreas at the initial stage of chronic pancreatitis.
• ERCP. High probability of detecting the disease in question.

Lead tactics

The tactics for managing a patient with this pathology are based on the following components:

• Establishing a diagnosis of chronic pancreatitis;
• An attempt to identify the origin of the disease;
• Establishing the stage;
• Diagnosis of pancreatitis;
• Development of a therapeutic regimen;
• Prognosis based on the current situation and the chosen treatment regimen.

Conservative treatment

Conservative therapy for patients with the disease in question is aimed at relieving symptoms and preventing the occurrence of adverse consequences; the following tasks are highlighted:

• refusal to use alcoholic beverages and tobacco smoking;
• identifying provoking factors of pain in the abdominal cavity and reducing their intensity;
• therapy for insufficiency of pancreatic exocrine function;
• detection and treatment of endocrine insufficiency in the initial stages before the formation of adverse consequences;
• nutritional support.

Behavior change

Complete exclusion from drinking alcoholic beverages is recommended to reduce the incidence of dangerous consequences and deaths.

It is extremely difficult to identify the role of tobacco smoking with excessive consumption of alcoholic beverages as a provoking factor that affects the course of chronic pancreatitis, since it often accompanies excessive alcohol consumption.

However, refusing to drink alcohol does not slow down the progression of the pathological process in all cases.

In such a situation, patients with the disease in question are recommended to quit smoking. Level of credibility of recommendations C.

Relief of abdominal pain

Often pain is caused by pseudocysts, duodenal stenosis, and severe duct obstruction.

In a situation where clinical diagnosis confirms the presence of an unpleasant pathology and substantiates the relationship with abdominal pain, endoscopic and surgical treatment methods are required at the initial stage of therapy.

Typically, such cases are discussed collectively by specialists from various fields to develop an optimal treatment regimen.

The duration of continuous treatment with paracetamol is no more than 3 months with monitoring of the patient’s well-being and blood counts. Strength of recommendations - C.

Treatment of exocrine pancreatic insufficiency

Impaired digestibility of fats and proteins manifests itself only when the functioning of the pancreas deteriorates by more than 90%.

Surgery on this organ can provoke the formation of exocrine insufficiency and the implementation of enzyme replacement treatment.

Proper and timely therapy makes it possible to prevent dangerous consequences and reduce mortality due to malnutrition.

The purpose of replacement treatment will be to improve the patient’s ability to consume, process and assimilate a certain amount of basic food components.

Laboratory signs for such therapy:

• steatorrhea;
• chronic diarrhea;
• nutritional deficiency;
• pancreatic necrosis, severe form of chronic pancreatitis;
• undergone surgery on the pancreas with impaired passage of food;
• condition after surgery on this organ with manifestations of exocrine insufficiency.

Prescription of enzyme replacement treatment of the pancreas is recommended for patients with chronic pancreatitis and insufficiency of exocrine function, as it helps improve the processing and absorption of fats.

Treatment of endocrine insufficiency of the pancreas

Dietary nutrition for pancreatogenic diabetes mellitus requires correction of malabsorption. Fractional meals are used in preventive measures for hypoglycemia.

If insulin treatment is prescribed, the target glucose level corresponds to that for type 1 diabetes mellitus.

It is necessary to teach the patient to prevent severe hypoglycemia, to focus on avoiding alcoholic beverages, to increase physical activity, and to eat small meals.

When treating diabetes mellitus with chronic pancreatitis, it is recommended to monitor the glucose level in the bloodstream in order to prevent adverse consequences. Convincingness of recommendations -V.

Surgery

In case of complex pathological process, in some situations with intractable pain in the abdominal cavity, endoscopic or surgical therapy is prescribed.

The decision is made by doctors who specialize in the treatment of pancreatic diseases.

In the normal course of the pathology, invasive intervention is aimed at correcting changes in the ducts of a given organ and inflammation of the parenchyma.

The decision to carry out an operation must be balanced, taking into account all the risks of adverse consequences.

It is necessary to exclude other factors of pain in the gastrointestinal tract. Such treatment will be necessary if there is no adequate relief of discomfort within 3 months of conservative therapy, as well as if there is a significant deterioration in the quality of life.

Endoscopic treatment

There are no studies evaluating the effect of endoscopic therapy on pancreatic function in patients.

Treatment for pseudocysts is not prescribed regardless of their size. Drainage may be more appropriate than surgical intervention, as it has a better benefit/risk profile.

Prevention and follow-up

Preventive measures for chronic pancreatitis are based on extrapolation of research data, according to the results of which it is possible to suggest that eliminating the consumption of alcoholic beverages and smoking is the reason that reduces the likelihood of progression of the disease in question.

It is likely that more significant provoking factors for exacerbation of chronic pancreatitis will be obesity, overeating and hypokinesia after eating, and a constant lack of antioxidants in food products.

However, it should be remembered that some patients scrupulously adhere to a strict diet in order to prevent a re-attack of the disease.

As a result, they can become nutritionally deficient. Based on the above, based on the results of various studies, the following lifestyle changes are recommended to prevent the disease in question:

• articulate meals (up to 6 times a day, in small portions with even distribution of fatty foods), avoidance of overeating;
• taking various foods with a low concentration of fats and cholesterol (unrefined vegetable fats are limited only to those patients who are overweight);
• drawing up a menu with the required amount of dietary fiber, which is contained in grains, vegetables and fruits;
• maintaining a balance between the food eaten and physical activity (in order to stabilize body weight to achieve optimal weight, taking into account age indicators).

For the purpose of effective primary prevention of chronic pancreatitis, it would be optimal to conduct a total dispensary control of the population for the timely detection of the disease of the bile ducts in question, hyperlipidemia.

However, today this idea has no practical implementation on the planet, since it requires significant material investments.

The validity of such tactics can be confirmed by pharmacoeconomic diagnostics.

However, such studies are unlikely due to the relatively low incidence rates of chronic pancreatitis.

These instructions are a comprehensive practical guide to eliminating the disease in question.

Useful video

Chronic pancreatitis with exocrine insufficiency develops with a long-term inflammatory process in the pancreas (over 10 years). As a result of the replacement of parenchyma with connective tissue, the organ loses the ability to fully perform endocrine and exocrine functions.

The disease is very serious because it leads to partial or complete loss of the pancreas.

The main symptoms of the pathology are dyspeptic disorders, abdominal pain, attacks of nausea, pale skin, tachycardia, shortness of breath, decreased ability to work and constant fatigue.

The main sign of pancreatic inflammation and dysfunction is the presence of undigested food particles and fat in the stool. The basis of diagnosis is the examination of stool. The components of effective therapy are special nutrition, the use of enzymatic agents and proton pump blockers.

General information about chronic pancreatitis

Over the past 30 years, the number of patients suffering from pancreatitis has more than doubled. This phenomenon is explained by alcohol abuse, cholelithiasis, a sedentary lifestyle, as well as regular intake of fatty and fried foods. Doctors note that pancreatitis has become “younger”: now the pathology is diagnosed on average at the age of 39 years, when previously the average age was 50 years.

The pancreas is an exocrine and intrasecretory organ. External secretion is the production of pancreatic juice, and internal secretion is the production of hormones.

Pancreatitis occurs when digestive enzymes in the gland itself are activated. As a result, the organ begins to “self-digest.” Chronic pancreatitis (CP) is one of the forms of the disease, which is characterized by dystrophic changes in the pancreas. With constant progression of the pathology, fibrosis, disappearance or shrinkage of acini (structural units of the pancreas), changes in the structure of the ducts, and the formation of stones in the parenchyma are observed.

According to ICD-10, CP of alcoholic etiology and others are distinguished. According to other classifications, there are biliary-dependent, parenchymal-fibrous and obstructive CP.

Unlike the acute, chronic form of the disease has a mild clinical picture or occurs together with concomitant diseases, for example, stomach and duodenal ulcers, chronic cholecystitis, biliary dyskinesia, etc.

Complaints of a patient suffering from chronic pancreatitis may be associated with:

• aching pain in the right hypochondrium;
• increased gas formation;
• attacks of nausea and a feeling of bitterness;
• dyspeptic disorder.

Often, due to violations of the rules of diet therapy, acute pancreatitis appears against the background of chronic pancreatitis, in which complete abstinence from food is indicated. This disease is incurable and therefore requires constant monitoring and medication.

Most experts distinguish two stages in the course of chronic pancreatitis/

Stage I (first 10 years) – alternating exacerbations and remission, dyspeptic disorders are not expressed, pain is felt in the epigastric area /

Stage II (more than 10 years) – pain subsides, dyspeptic disorder intensifies.

It is at the second stage that chronic pancreatitis develops with excretory insufficiency, which is characterized by significant damage to the pancreas.

Causes of exocrine insufficiency

Sugar level

The process of “self-digestion” leads to dystrophic changes in the parenchyma and disruption of the outflow of pancreatic juice. Against the background of these processes, the secretory, or glandular, tissue of the pancreas is replaced by scar tissue. As a result, these parts of the organ cannot perform exocrine function.

It is worth noting that chronic pancreatitis is not the only cause of the development of exocrine insufficiency. Another cause of this phenomenon may be cystic fibrosis, an autoimmune disease that affects organs that produce biological fluid. These include the digestive tract, respiratory tract, pancreas, genitals, sweat glands, oral and nasal cavities.

Chronic pancreatitis and cystic fibrosis are the primary mechanisms in which exocrine insufficiency occurs. The secondary mechanisms of its development include a pathological process in which the entry of digestive enzymes into the duodenum does not improve the process of food absorption.

This is due to their insufficient activation, inactivation and segregation violation. Pancreatitis with exocrine insufficiency arising from secondary causes has certain features. Basically, the course of this disease occurs according to the following “scenario”:

1. The mucous membrane of the small intestine is affected by many negative factors. As a result, the production of cholecystokinin and secretin decreases.
2. This process provokes a drop in intraduodenal pH below 5.5. This means that pancreatic enzymes will not be activated.
3. There is a disruption in the movement of food through the small intestine. Unactivated digestive enzymes begin to mix with particles of incoming food.
4. As a result, the process of decay develops - an ideal condition for pathogenic bacteria. Various infections are associated with the proliferation of harmful microflora. An increase in the number of bacteria leads to the destruction of digestive enzymes.
5. Stagnation of pancreatic juice occurs, which is accompanied by a deficiency of bile and enterokinase.

As a rule, with total removal of the pancreas (gastrectomy), both primary and secondary mechanisms are involved.

Classification and signs of pathology

Exocrine insufficiency should be classified according to several criteria - the causes of pathology and concomitant diseases.

The main manifestations of external secretion deficiency are:

1. Intolerance to fatty, fried and smoked foods. If a patient eats such food, after a while he will feel heaviness in his stomach. Then colicky pain is added. After emptying the stomach, mushy stool is observed - the main symptom of pancreatitis. You can see impurities of mucus (fat) and particles of undigested food in it. The frequency of going to the toilet is 3-6 times a day. The fat content of stool is quite easy to determine: particles of feces often leave marks on the toilet bowl, since they are difficult to wash off with water.
2. Signs of a lack of fat-soluble vitamins. As a result of their deficiency, pain in the bones is observed and they become more brittle. Hypovitaminosis of vitamin D leads to seizures, vitamin K - blood clotting disorders, vitamin A - "night blindness" and dry skin, vitamin E - decreased libido, infectious diseases.
3. Symptoms associated with pancreatic protease deficiency. These enzymes break down proteins. Their deficiency leads to B12 deficiency anemia, which is characterized by decreased ability to work, shortness of breath, pale skin, tachycardia and rapid fatigue. Due to insufficient amounts of nutritional components, a rapid decrease in body weight is observed.

These pathological processes mainly affect adults. In childhood, pancreatitis with impaired exocrine function develops extremely rarely. Inflammation of the organ occurs for other reasons - diseases of the small intestine, cholelithiasis, various injuries of the abdominal region, duodenal obstruction, impaired development of the pancreas and pancreatic ducts.

Diagnostic methods and therapy

Having noticed signs, a person needs to seek medical help.

Loss of precious time can lead to complete damage to the pancreas and its removal.

The most effective method for diagnosing the disease is stool analysis. It helps determine the level of pancreatic elastase-1.

The results of the study may be:

• 200-500 mcg/g – normal exocrine function;
• 100-200 mcg/g – mild to moderate degree of exocrine insufficiency;
• Less than 100 mcg/g is a severe degree of pathology.

Diet plays a key role in treating the disease. Among the basic rules of special nutrition for exocrine insufficiency, it is necessary to highlight:

1. Meal intervals should not exceed 4 hours.
2. You need to eat small portions 5-6 times a day.
3. Avoid excess consumption of food in the evening and at night.
4. Eliminate fried, fatty and smoked foods from your diet.
5. Give preference to foods of plant origin.
6. Completely stop drinking alcoholic beverages.

The basis of the diet is carbohydrate-containing foods - vegetables, fruits, cereals. They are sources of dietary fiber, vitamins, essential micro- and macroelements. It is not recommended to consume foods such as legumes, cabbage, eggplants, and flour products, as they increase gas formation in the stomach.

In addition to diet therapy, patients must take medications. The basis of therapy is the following drugs:

1. Digestive enzymes that improve the process of food absorption (Mezim, Creon, Panzinorm). They are taken during a meal, the dosage depends on the volume of food eaten and its composition.
2. Proton pump blockers that help digest food (Lansoprazolol, Esomeprazole, Omeprazole). The action of the drugs is aimed at creating an alkaline reaction in the upper gastrointestinal tract.

In this case, you should not self-medicate under any circumstances. By following all the doctor’s instructions, you can achieve a positive therapeutic effect. As a result, colicky pain and diarrhea will go away, and there will be no admixture of fat and undigested particles in the stool. From time to time the patient undergoes re-examination. The normalization of the digestive process is indicated by a decrease in the fat content in feces to 7 g.

Experts will talk about chronic pancreatitis in the video in this article.

Chronic pancreatitis is a progressive disease of the pancreas, accompanied by an increase in inflammatory and destructive changes in the structure of the organ. Pancreatitis occurring in a chronic form is listed under ICD 10 codes - K86.0 -K86.1

Chronic pancreatitis is a progressive disease of the pancreas, accompanied by an increase in inflammatory and destructive changes in the structure of the organ.

Stages

In medical practice, the most common classification of pancreatitis is based on the severity of organ damage. According to this principle, there are 3 stages of the process.

At stage 1 of the disease, there are no pronounced signs of impairment of internal and external secretory function. Manifestations of pathology occur periodically against the background of eating junk food. The duration of this stage of pancreatitis can be more than a year.

At stage 2 of pancreatitis, symptoms persist constantly. In this case, manifestations of a decrease in secretory function may be observed.

In medical practice, the most common classification of pancreatitis is based on the severity of organ damage; according to this principle, 3 stages of the process are distinguished.

At stage 3 of pancreatitis, critical damage to pancreatic tissue is observed. The intra- and exocrine function of the organ is disrupted. Severe complications often occur at this stage of the pathological process.

What does the pancreas look like in chronic pancreatitis?

With chronic pancreatitis, pathological changes in the structure of the organ increase gradually. Frequent relapses of inflammation lead to the death of parts of the gland tissue. During the period of remission, the affected areas become overgrown with fibrosis.

The connective tissue is not only unable to perform the function of healthy pancreatic cells, but also leads to deformation of the remaining healthy areas. All tissues of this organ are affected, including the islet epithelium of blood vessels, ducts, acini, nerves, etc.

With pancreatitis occurring in a chronic form, pathological changes in the structure of the organ increase gradually, frequent relapses of inflammation lead to the death of parts of the pancreatic tissue.

Due to the fact that the enzymes produced by the pancreas cannot be removed from the organ due to tract obstruction, pseudobrushes are formed that do not have an epithelial lining inside. Inside relatively recently formed formations of this type, tissues affected by necrosis with a small admixture of blood are often detected.

In especially severe cases, such pseudocysts may be damaged by pathogenic microflora.

When the pancreas is incised along the ducts, many small cystic formations filled with purulent contents are often discovered. Gradually, the functionality of the parenchyma and glandular tissue decreases.

Classification

Pathology can be primary or secondary. Depending on the etiology, pancreatitis is distinguished:

• infectious;
• alcoholic;
• dysmetabolic, etc.

Pancreatitis can be primary and secondary in nature, along the course it can be painful, latent and combined, and can be divided into types according to morphological characteristics.

Depending on the course, it can be painful, latent and combined. Based on morphological characteristics, the following species are distinguished:

• atrophic;
• cystic;
• fibrous, etc.

Depending on the preservation of the secretory and excretory functions, pancreatitis can occur either without such disorders or with intra- and exocrine insufficiency without exacerbation.

Pancreatitis with endo- and exocrine insufficiency has an unfavorable course.

Causes

The main reasons for the development of the chronic form of pancreatitis are alcohol abuse and the progression of gallstone disease. Due to the systematic consumption of alcoholic beverages, intoxication of the body with decay products is observed.

The main reasons for the development of the chronic form of pancreatitis are alcohol abuse and the progression of gallstone disease.

The development of cholelithiasis not only affects the possibility of normal outflow of bile, but also contributes to the addition of an infection that can spread to the pancreatic tissue, causing their inflammatory damage.

Pathology can develop after removal of the gallbladder due to progressive gallstone disease.

If a person abuses unhealthy food from a young age, this creates conditions for potential problems with the organ. In addition, factors contributing to the development of chronic pancreatitis are identified. These include:

• excess calcium in the blood;
• cystic fibrosis;
• diseases of the gastrointestinal tract;
• thyroid dysfunction;
• food poisoning;
• abdominal organ injuries;
• taking certain medications;
• gastrointestinal infections;
• obesity;
• circulatory disorders;
• endocrine diseases;
• frequent exposure to stressful situations.

If a person abuses unhealthy food from a young age, this creates conditions for potential problems with the organ.

The development of this pathology may be due to genetic abnormalities that are inherited. An idiopathic variant of the disease is also possible, which develops for no apparent reason.

Symptoms

In the early stages of the disease, when remission occurs, no signs of pathology are observed. At the same time, during an exacerbation, indirect symptoms may be present, including belching, short-term bowel movements and bad breath, which may indicate other diseases of the gastrointestinal tract.

Chronic pancreatitis may be indicated by the appearance of minor pain and heaviness after eating fatty and fried foods. However, already during this period, the appearance of a problem in the pancreas may be indicated by echo signs of the disease, including increased tissue density and foci of forming pseudocysts.

As pancreatitis progresses, patients experience attacks of dizziness and blood pressure increases.

During the period of exacerbation of pancreatitis at stages 2 and 3 of the disease, severe vomiting and diarrhea can cause dehydration in a matter of hours.

Patients with pancreatitis experience symptoms of discomfort in the back and shoulder blade, intense pain, characteristic rumbling sounds in the abdomen, etc.

As pancreatitis progresses, exacerbations become common. They are accompanied by severe symptoms. Patients complain of the following conditions:

• severe diarrhea;
• intense pain syndrome;
• discomfort in the back and shoulder blade;
• characteristic rumbling sounds in the stomach;
• bitterness in the mouth;
• constant burping;
• nausea;
• vomiting;
• increased body temperature;
• sudden weight loss;
• headache;
• skin itching;
• decreased appetite.

During the period of exacerbation at stages 2 and 3 of the disease, severe vomiting and diarrhea can cause dehydration in a matter of hours. Attacks of dizziness appear, blood pressure rises, and other signs of this condition are noted.

If the ducts are damaged due to the inflammatory process and swelling of the soft tissues, obstructive jaundice occurs.

Subsequently, as the disease goes into remission, the nature of the stool changes. Constipation may occur.

Diagnostics

If signs of pathology appear, the patient requires consultation with a gastroenterologist, who can perform an external examination, collect anamnesis and prescribe tests. Determining the nature of the damage to the gland requires performing studies such as:

• radiography;
• Pancreatoangioradiography.

An example of the formulation of a diagnosis in a patient’s chart may look like this: chronic pancreatitis, accompanied by pain, combined, stage 2.

If signs of pathology appear, the patient requires consultation with a gastroenterologist, who can perform an external examination, collect anamnesis and prescribe tests.

Ultrasound

With this form of pancreatitis, ultrasound reveals changes in the tissues of the gland, including:

• increase in duct up to 2 mm or more;
• notches on the borders of the organ;
• increase in organ size;
• pseudocysts;
• diffuse changes.

In the presence of atrophy, ultrasound can reveal a decrease in organ size.

Analyzes

Stool and blood tests are performed to confirm the diagnosis. When performing a coprogram in the stool of a person suffering from pancreatitis, excess fat caused by a lack of enzyme production is detected. A test is performed to determine the activity of enzymes in the blood, including lipase and amylase. Radioimmunoassay is performed to confirm trypsin and elastase activity.

In chronic pancreatitis, ultrasound reveals changes in the tissues of the pancreas; in the presence of atrophy, ultrasound can reveal a decrease in the size of the organ.

A test is performed to determine the activity of enzymes in the blood, including lipase and amylase.

When performing a coprogram in the stool of a person suffering from pancreatitis, excess fat caused by a lack of enzyme production is detected.

Treatment

Chronically persistent inflammation of pancreatic tissue requires complex therapy and patient compliance with recommendations issued by doctors. Medicines are selected to suppress inflammation and restore organ function. You must follow a special diet. In severe cases, surgery is required.

Drug therapy

For this form of pancreatitis, medications belonging to the following groups are prescribed:

• antienzyme;
• choleretic;
• antispasmodics;
• analgesics;
• proton pump inhibitors;
• H2 blockers;
• enzymes;
• antacids;
• antibiotics.

The use of medications can eliminate the inflammatory process, relieve spasms and relieve pain.

Medicines are selected taking into account the current condition. The use of medications can eliminate the inflammatory process, relieve spasms and relieve pain.

Diet

A person suffering from pancreatitis needs a complete, high-calorie and easily digestible diet. You should eat food 5-6 times a day. Portions should be small. Products are introduced into the diet gradually so as not to create an increased load on the pancreas.

Surgical

Surgical interventions for the chronic form of the disease are performed only when absolutely necessary. Stones are often excised to relieve duct obstruction. A sphincterotomy may be performed if there is evidence of blockage of the sphincter of Oddi. If necessary, sanitation of purulent foci and resection of areas of fibrosis that interfere with the functioning of healthy organs are performed. In addition, a complete or partial pancreatectomy may be performed.

Surgical interventions for the chronic form of the disease are performed only when absolutely necessary.

Nutrition

The diet should be balanced and include plenty of protein. Recommended foods and dishes for this disease include:

• boiled vegetables and fruits;
• puree soups;
• lean meat and fish;
• fermented milk food;
• porridge.

Fried, smoked, marinades, preservatives, semi-finished products and other harmful foods should be excluded from the diet. Fatty fish and meat are not allowed. You need to completely avoid carbonated and alcoholic drinks. If the patient adheres to the rules of a healthy diet starting from the first days of the onset of pathology, then complete recovery is possible.

You should eat food 5-6 times a day, portions should be small; if the patient adheres to the rules of a healthy diet starting from the first days of the onset of pathology, then full recovery is possible.

The diet of a patient with chronic pancreatitis should be balanced and include a lot of protein.

Fried, smoked, marinades, preservatives, semi-finished products and other harmful foods should be excluded from the diet.

Why is it dangerous?

The chronic form of pancreatitis gradually leads to the destruction of the pancreas. This contributes to disruption of the production of enzymes and hormones. In severe cases, pancreatitis not only makes the patient’s normal life impossible, but also causes premature death.

Risk factors

The patient’s reluctance to follow the specialist’s recommendations, which relate not only to taking medications, but also to giving up bad habits, increases the risk of an unfavorable outcome. Non-compliance with the diet worsens the prognosis.

Statistics for Russia

The development of the disease is often observed in young people. At the same time, the number of patients increases every year. Exact statistics for Russia have not been established, but according to available data, there are at least 50 patients per 10 thousand people.

Premature mortality due to progression of pancreatitis reaches 6-8%.

Complications

The pancreas is extremely important for the functioning of the entire body, therefore, against the background of pancreatitis, complications such as:

• disturbances in the outflow of bile;
• false aneurysms of arterial vessels in the gland;
• cysts in the organ;
• abscesses;
• diabetes.

Often the first manifestations of the pathology of pancreatitis are observed in people over 50 years of age.

Can it turn into cancer?

Chronically persistent inflammation of pancreatic tissue creates conditions for malignant cell degeneration.

Features in adults

Due to the characteristics of the body and the specificity of unfavorable factors in adults and children, the chronic type of pancreatitis can have significant differences in its course.

In men

Since men often ignore the first manifestations of the disease, trying to delay the period of giving up alcohol and other bad habits, their pancreatitis often occurs in an aggressive form.

Mortality cases in men from this disease are recorded more often than in women.

Specifics in women

In women, the chronic type of pancreatitis often occurs in a latent form. The process of destruction of the pancreas lasts for many years if there are no additional factors in the form of alcoholism or other pathologies that could spur the development of the disease.

Elena Malysheva. Symptoms and treatment of chronic pancreatitis

Chronic pancreatitis - symptoms, nutrition and treatment

In the elderly

Often the first manifestations of pathology are observed in people over 50 years of age. This is associated not only with maintaining an unhealthy lifestyle throughout the entire previous life, but also with age-related changes.

Reviews

Vladislav, 57 years old, Moscow

About 2 years ago I had an attack of pancreatitis. I went to the doctor and was diagnosed with a chronic form. The doctor prescribed a diet. Of the drugs I used only No-shpu and Pancreatin.

Grigory, 40 years old, Surgut

In my youth I drank a lot and had other bad habits, but about 5 years ago I felt the consequences of this. Acute inflammation of the gland turned chronic. Now I strictly follow a diet and have completely given up alcohol to prevent exacerbations. I take enzymes prescribed by the doctor and choleretic agents.

For many patients, a doctor’s entry in an outpatient chart is tantamount to a death sentence, in which the doctor adds “chronic” to the name of the disease in the medical history. There is nothing reassuring in such a formulation.

A specific property of chronic diseases is the fact that the disease lasts for years in the patient and requires constant treatment, which, unfortunately, only alleviates the symptoms and prevents the deterioration of the patient’s health, but does not cure completely. This type of disease is characterized by periods of remission and relapse. As a rule, the chronic form cannot be cured; a specialist prescribes restraining therapy. The statements also correspond to chronic inflammation of the pancreas. Before studying in detail the specifics of diagnosing and eliminating the disease, you will need to understand the terminology. Let's study the specifics of the disease.

Specifics of pancreatitis

Pancreatitis is an inflammatory disease that occurs in the human pancreas. The organ is located in the abdominal cavity and is equipped with two functions:

• Endocrine (internal). The gland produces hormones, the main of which is insulin. The hormone is important for regulating sugar levels in the body.
• Exocrine (external). The function is responsible for the production of pancreatic juice and delivery to the stomach in the required quantity. The juice contains enzymes that ensure the breakdown and absorption of proteins, carbohydrates and fats contained in the food consumed.

Treatment of chronic pancreatitis depends on the form of development (edematous, parenchymal, sclerosing, calculous).

The meaning of the disease is that the pancreatic duct stops supplying gastric juice, and the organ becomes inflamed. Juice production continues, and enzyme secretion disturbances are observed. Enzymes that have an alkaline structure normally begin to act when leaving the gland, keeping the organ tissues safe. In chronic pancreatitis, the process of enzyme activation is disrupted, and the substances begin to act within the organ.

The danger of the disease lies in the fact that the enzymes contained in the juice, which do not find a way out, directly corrode the inflamed internal organ. Chronic pancreatitis develops against the background of other chronic diseases of the digestive system. The disease develops into a chronic form from an acute one. Symptoms and treatment of the disease depend on the causes of inflammation.

Causes

The main cause of inflammation is considered to be disruption of the duct and stagnation of pancreatic juice. If previously doctors diagnosed “chronic pancreatitis” more often to older people, mainly women, now the disease affects different sex and age groups of the planet’s population. The increase in the incidence rate is associated with the incorrect lifestyle inherent in most people.

Risk group

The disease is more common among older people. With age, natural processes in the body slow down, including the work of the pancreas. A large percentage of inflammation occurs in people suffering from alcohol and drug addiction. Frequent drinking of alcohol causes exacerbation attacks. Repeated periodically, attacks can develop into a chronic form. Alcohol abuse causes exacerbation of chronic pancreatitis.

Close attention to health is paid to people who have a hereditary predisposition to the disease. Scientists suspect the occurrence of genetic mutations. Hereditary predisposition makes the pancreas vulnerable. Working in hazardous industries increases the risk of developing the disease. It is much easier to cure the disease if you eliminate the risks that provoke inflammation from your life.

Factors contributing to the disease

It is important for people who fall into these groups to understand that their risk of getting sick is much higher. Treatment of chronic pancreatitis is more difficult. It is imperative to avoid factors that provoke the development of the disease:

• Prolonged stress;
• Infections;
• Taking medications that cause intoxication of the body;
• Fasting, diets;
• Injuries;
• Eating junk food.

Chronic pancreatitis of the pancreas often develops against the background of other chronic diseases: gastritis, stomach ulcers, inflammation of the gallbladder and others. Cholecystitis is especially dangerous.

Symptoms of the disease

Chronic pancreatitis is a disease that lasts for many years. Characterized by periods of exacerbation and remission. In the early stages, it is difficult to determine the diagnosis. Patients refer to general malaise and do not seek help from a doctor. Signs of chronic pancreatitis are easier to detect during exacerbation of the disease. Then the symptoms are similar to the clinical picture of the acute form.

1. Weight loss. The patient loses weight for no apparent reason, and regaining body weight is difficult.
2. Pain in the epigastric region and in the left upper part of the abdominal cavity. With chronic pancreatitis, the pain is dull and aching.
3. Natural digestive processes are disrupted. The patient experiences nausea, often accompanied by vomiting, heartburn, and heaviness.

Exacerbation of chronic pancreatitis is characterized by increased symptoms. During exacerbations, symptoms are easier to notice. A characteristic sign is a violation of the stool. Due to the lack of sufficient juice, food is not broken down sufficiently. The stool becomes foul-smelling and becomes greasy.

In chronic pancreatitis, a violation of the endocrine function of the internal organ is detected. Because of this, the body produces insufficient amounts of hormones, including insulin. Lack of insulin in the body leads to diabetes.

Diagnosis and treatment

If symptoms of chronic pancreatitis are detected, you should immediately consult a doctor. It is important to understand the seriousness of the disease. If you delay treatment, irreversible consequences are possible that will lead to death. In addition, against the background of this disease, others arise that are no less dangerous. And therapy for one disease is tolerated much easier by the body than for several at the same time.

Appointment with a specialist

If you suspect inflammation, first consult a therapist. The doctor collects anamnesis and draws up a general clinical picture. When a therapist diagnoses “chronic pancreatitis,” the symptoms and complaints expressed by the patient are confirmed by additional studies. The observed symptoms are recognized as characteristic of most diseases of the digestive system. This is where the difficulty of making a diagnosis lies. Therefore, the diagnosis of chronic pancreatitis requires careful research. Diagnosis stages:

1. Taking anamnesis, listening to complaints;
2. Visual examination of the patient;
3. Palpation (palpation) to determine the boundaries of internal organs;
4. Laboratory research;
5. Instrumental research.

The last two stages are considered decisive for the diagnosis of chronic pancreatitis. Therefore, let's look at them in more detail. Laboratory diagnostics includes examination of the patient’s blood, urine and stool. Laboratory diagnostics are most effective if studies are carried out when chronic pancreatitis is in the acute stage. This study aims to determine the levels of enzymes in the human body, especially amylase. In chronic pancreatitis, the level of this enzyme increases significantly 2-3 hours after the onset of an exacerbation. The level of lipase in the body increases and remains elevated for a period of up to two weeks.

A considerable amount of information is provided by a general and biochemical blood test. In patients diagnosed with chronic pancreatitis, there is an increase in the level of leukocytes. This is typical for every inflammatory process. Biochemical analysis registers a decrease in proteins in the blood. The amount of fat in feces is also recognized as an important indicator in diagnosing the disease.

There are several signs that help diagnose chronic pancreatitis:

1. The pulsation of the aorta under the sternum is difficult to palpate;
2. Formation of bruises in some areas of the abdominal cavity;
3. When tapping the pancreas area, painful sensations occur;
4. Pain when palpating the area between the spine and ribs on the left.

Diagnosis and treatment of the disease is determined with greater accuracy through the use of medical equipment. The equipment is widely used in instrumental diagnostic methods.

Instrumental diagnostics

Chronic pancreatitis is often diagnosed using instrumental diagnostic methods. The most common method is ultrasound examination. This method of visualizing internal organs helps determine the size and structure of organ tissue.

Echo signs of chronic inflammation during ultrasound examination:

• Uneven contour of the organ;
• Presence of cysts;
• Increased echogenicity of the gland;
• Presence of stones in the duct;
• Dilation of the duct in uneven lobes.

The radiography method is prescribed to the patient by the attending physician to determine the presence of stones in the pancreas and ducts. Computed tomography helps to obtain information about tissue necrosis of an internal organ and identifies tumors and cysts.

Endoscopy is a method of visual examination of an organ using a video camera. This is a surprisingly informative method. Using a digital endoscope, you can get an extremely clear image of the internal organs and assess their condition. In chronic pancreatitis, endoscopy allows one to study the effect of inflammation on other internal organs.

Specifics of treatment

A doctor who studies inflammation of the pancreas specializes in gastroenterology. Therefore, with the question “how to treat the pancreas,” they turn to a gastroenterologist. Many methods have been developed to treat the disease. The choice depends on the specifics and form of the disease. The main goal of the prescribed treatment is to reduce the risk of complications. Therefore, therapy is aimed at relieving pain and preventing exacerbations. The treatment method also depends on the stage of the disease.

During an exacerbation, the pain syndrome is relieved first. During exacerbations, treatment of pancreatitis is best done while in a hospital, under the constant supervision of doctors. In the first days, patients are recommended to fast; only certain liquids are allowed to be consumed. When the exacerbation passes, the intensity of treatment is reduced and replacement therapy is prescribed for further treatment of the patient. The point is to take enzyme preparations. Pain syndrome is reduced with the help of antispasmodics. Additionally, the doctor prescribes medications that reduce gastric secretion.

In addition to drug treatment, therapy includes adherence to certain nutritional rules. The patient now needs to follow a diet and visit a gastroenterologist for life.

Diet for patients with pancreatitis

A patient diagnosed with chronic pancreatitis continues treatment throughout his life. This concerns a special diet that will need to be followed to avoid complications. In the first few days of the acute form, experts do not recommend eating food. Nutrients are introduced into the body through a tube. You are allowed to drink only still mineral water and rosehip decoction on your own. Further, it is allowed to eat jelly-like foods and foods that will not cause the secretion of pancreatic juice.

When the exacerbation passes, the patient is allowed to begin taking carbohydrate products of a uniform consistency. These are porridges, pureed soups and the like. Ten days after the attack, the patient is advised to consume fermented milk products and steamed lean meat.

Chronic pancreatitis will require adherence to nutritional rules throughout life. The patient will have to avoid eating fatty, spicy, fried foods. Completely exclude alcohol, mushrooms, baked goods and sweets. It is also important to consider the way you eat. You need to use small portions. This will help avoid unnecessary stress on the pancreas. Compliance with diet and nutritional rules, coupled with therapy prescribed by a doctor, is the answer to the question of how to treat chronic pancreatitis.

A healthy diet and stopping smoking and drinking alcohol are recognized as important ways to prevent pancreatic diseases. Remember this to exclude yourself from the risk group. Chronic pancreatitis is difficult to treat, requiring both moral and material costs. It is easier to avoid the occurrence of disease if you follow the rules of a healthy lifestyle.

In addition, prevention will help avoid other dangerous diseases. Therefore, healthy people, before wondering how to treat the disease, should study in more detail the methods of preventing pancreatitis.

In the structure of diseases of the digestive system, a share of 5.1 to 9% belongs to chronic pancreatitis (CP). With these ailments, the pancreas is affected and an inflammatory process begins. As a result, degenerative changes occur in the organ. Initially, the pathological process may occur in the tail of the pancreas, its head or middle part. The outcome of the disease is damage to the entire organ. Some people who suffer from chronic pancreatitis eventually die. The mortality rate in the world averages about 11%.

More about the disease

So, what is chronic pancreatitis? Experts use this term to designate a whole group of pancreatic diseases. All diseases are characterized by the following features:

• phase-progressive course with episodes of acute pancreatitis;
• focal, segmental or diffuse damage to the pancreatic parenchyma with subsequent replacement with connective tissue;
• changes in the duct system of the organ;
• formation of cysts, pseudocysts, stones and calcifications;
• development of endocrine and exocrine insufficiency.

The fact that there are different types of disease is evidenced by the International Statistical Classification, Tenth Revision. Chronic pancreatitis ICD-10 is divided into:

• CP of alcoholic etiology (code K86.0);
• other CP - infectious, recurring, relapsing, unspecified etiology (code K86.1).

The most common causes of chronic pancreatitis

Most often, the disease occurs due to alcohol abuse over a long period of time. In men, chronic pancreatitis of the pancreas can develop if they drink for more than 15 years. In women, the likelihood of developing the disease increases with alcohol abuse for more than 10 years.

Alcohol is not the only factor contributing to the development of chronic pancreatitis. The cause of the disease may be smoking. Substances that enter the lungs with smoke penetrate the blood and spread throughout the body, having a negative effect on all internal organs, including the pancreas.

Other causes of the disease

Other factors causing chronic pancreatitis (ICD-10 code - 86.0 and 86.1) include:

• abuse of fatty foods, long-term protein-free diet;
• various diseases of the gastrointestinal tract (neoplasms, cholecystitis, etc.);
• overweight, obesity;
• taking certain medications (Azathioprine, Furosemide, Prednisolone, synthetic estrogens, Erythromycin, Ampicillin, etc.);
• infection with viruses (cytomegalovirus, hepatitis B, C, etc.).

Studies conducted in recent years have shown that there is hereditary chronic pancreatitis of the pancreas. This is an autosomal dominant disease with incomplete penetrance (with different frequencies of gene expression in the phenotype of carriers). In sick people, hereditary chronic pancreatitis manifests itself quite early. However, the final stage occurs later than in other forms of the disease.

Forms of pancreatitis

There are different classifications of the disease. One of them is a list of the following forms of chronic pancreatitis:

1. Recurrent. It occurs in 55-60% of cases. With this form, periods of remission are replaced by exacerbations of the pathological process.
2. Constant pain. This form is found much less frequently (in 20% of cases). With it, patients complain of constant pain, localized in the upper abdomen and radiating to the back.
3. Pseudotumor (icteric). The incidence of this form of chronic pancreatitis is 10%. The pathological process is characterized by the development of inflammation in the head of the pancreas and compression of the common bile duct.
4. Painless (latent). The form is detected in 5-6% of cases. The pain associated with the disease is mild or not felt at all. Dyspeptic disorders periodically occur due to impaired functioning of the pancreas.
5. Sclerosing. With this form, pain occurs in the upper abdomen. They intensify after meals. The pain is accompanied by nausea, loose stools, and weight loss. When performing an ultrasound examination, specialists notice a decrease in size and thickening of the pancreas.

According to the Marseille-Roman classification, there are such forms of pancreatitis as calcific, obstructive, parenchymal and fibrosis. With the first of them, uneven lobular lesions of the pancreas are observed. Pseudocysts, cysts, calcifications, and stones appear in the ducts. What is chronic pancreatitis in obstructive form? With this type of disease, the internal organ is affected evenly. Stones do not form, and obstruction of the main pancreatic duct is observed. In the parenchymal form, foci of inflammation develop in the parenchyma. Calcifications are not formed, the ductal system is not affected. Fibrosis is characterized by the replacement of the parenchyma of an internal organ with connective tissue. Because of this process, exo- and endocrine insufficiency progresses.

Symptoms of the disease

Speaking about what chronic pancreatitis is, it is worth considering the signs of this disease. In the early stages, during periods of exacerbation, attacks are observed. They are characterized by pain in the epigastric region. In most cases they radiate posteriorly. Girdle pain is much less common. In people suffering from chronic pancreatitis, attacks occur due to the impact of provoking factors on the body. These include eating fatty foods, alcoholic and carbonated drinks.

The disease is also characterized by dyspeptic syndrome. Approximately 56% of sick people report nausea and vomiting. In 33% of cases, weight loss is observed, in 29% - flatulence, in 27% - loss of appetite. The disease may also cause symptoms such as general weakness, fatigue, and decreased ability to work.

The course of chronic pancreatitis

Experts distinguish 4 stages in the development of the disease:

1. Preclinical stage. At this stage, sick people do not notice the symptoms of chronic pancreatitis. The disease is often detected incidentally during an ultrasound or computed tomography scan of the abdominal organs.
2. The stage of initial manifestations in the development of such a disease as chronic pancreatitis. At this time, adults begin to suffer from the first symptoms of the disease. The duration of the stage can be several years. In some cases, the disease progresses very quickly.
3. Stage of development of permanent clinical symptoms. Patients develop signs of endocrine and exocrine insufficiency. People eat very little and complain of stomach pain.
4. Final stage. The pain becomes less pronounced. People are losing weight noticeably. At the final stage, various complications of chronic pancreatitis arise due to pancreatic atrophy, endocrine and exocrine insufficiency. One of them is cancer of the named internal organ.

Depending on the characteristics of the development of chronic pancreatitis, mild, moderate and severe forms of the disease are distinguished. With a mild course, periods of exacerbation occur rarely (1-2 times a year). The pain is moderate. The functions of the pancreas are not impaired.

What is moderate chronic pancreatitis? This is a disease in which there are 3-4 exacerbations per year. They last longer than with mild pancreatitis. In sick people, body weight decreases. The exocrine function of the pancreas is moderately reduced, and pancreatic hyperenzymemia is observed.

In severe cases of the disease, exacerbations are frequent and prolonged. The pain is accompanied by severe dyspeptic syndrome.

Treatment of the disease: goals and necessary measures

For chronic pancreatitis, therapy is prescribed to achieve the following goals:

• reduction of clinical manifestations of the disease;
• prevention of relapses;
• reducing the likelihood of complications of the disease.

Specialists prescribe non-drug treatment and drug therapy to their patients. If necessary, surgical intervention is performed. Treatment of chronic pancreatitis in adults can be carried out both at home and in the hospital. The indication for hospitalization is the transition of the disease to the acute stage, because it is during this period that the patient’s life is threatened and the need for parenteral administration of drugs arises.

Non-drug treatment

Nutrition plays an important role in the treatment of chronic pancreatitis. In case of severe exacerbations, fasting days (1-3 or more) and abundant alkaline drinking are indicated. According to indications, parenteral or enteral (introduction of nutrients into the colon using a special tube) nutrition is prescribed. Thanks to this measure, it is possible to stop the secretion of the pancreas, intoxication decreases and the pain syndrome becomes weaker.

After normalization of the condition, sick people are transferred to oral nutrition. Meals should be frequent and divided. The daily menu consists of slimy soups, vegetable purees, and liquid pureed milk porridges. Drinks allowed are compotes, jelly, weak tea, mineral water, and rosehip decoction.

The following products are necessarily excluded:

• causing flatulence;
• containing coarse fiber;
• stimulating the production of digestive juices;
• rich in extractive substances.

With chronic pancreatitis, is it possible to eat fish and meat broths, mushroom and strong vegetable broths, canned food, smoked meats, sausages, fatty fish and meats, fried foods, raw vegetables and fruits, baked goods, confectionery, black bread? All these products are prohibited during exacerbation of the disease, so they should be abandoned. You also need to remove spices, ice cream, and alcohol from your menu.

During remissions, the diet changes slightly. People diagnosed with chronic pancreatitis of the pancreas are allowed to eat pasta, raw vegetables and fruits, soft, mild cheeses, and baked fish. Puree soups can be replaced with regular vegetarian ones (cabbage should be excluded from the ingredients). Porridges can be crumbly or thicker.

Pharmacotherapy of chronic pancreatitis

The goal of drug therapy at the first stage is to ensure functional rest of the pancreas. This is achieved through:

1. Taking large doses of modern multienzyme drugs. Such medications include Mezim-Forte, Creon, and Pancitrate.
2. Maximum inhibition of acidic gastric secretion using histamine H2 receptor blockers (Ranitidine, Famotidine) or proton pump inhibitors (Omeprazole, Esomeprazole). The drugs are administered parenterally or taken orally.
3. Administration of Octreotide or Sandostatin. These drugs are synthetic analogs of the hormone somatostatin. Thanks to them, hypertension in the pancreatic ductal system is reduced, and due to this, pain is weakened and relieved.

If therapeutic measures aimed at reducing pancreatic secretion do not have an analgesic effect, doctors prescribe non-narcotic or narcotic analgesics. “Analgin”, “Ketoprofen”, “Paracetamol” - any drug for chronic pancreatitis can be prescribed by a doctor from the first group of drugs. Among the drugs related to narcotic analgesics, Promedol, Tramal, Fortral can be selected.

Treatment of chronic pancreatitis in adults may also include enzyme replacement therapy. Indications for its use are excretion of more than 15 g of fat per day in feces, diarrhea, rapid loss of body weight. Multienzyme drugs are “Abomin”, “Forte-N”, “Creon”, “Pancreatin”, “Festal”, “Pankreoflat”, “Digestal”, “Wobenzym”.

Surgical treatment of the disease

In some cases, chronic pancreatitis requires surgery. The indications are:

• pain that is not relieved with medications and diet;
• the presence of abscesses and cysts in the pancreas;
• obstruction of the bile ducts, which cannot be resolved using the endoscopic method;
• duodenal stenosis;
• fistulas in the pancreas with the development of pleural effusion or ascites;
• suspected cancer, not confirmed cytologically or histologically.

“Chronic pancreatitis, symptoms and treatment in adults” is an important medical topic that requires attention. This is an insidious disease, a progressive and irreversible process. However, treatment is still necessary. It allows you to prolong the life of sick people, relieves the unpleasant symptoms characteristic of chronic pancreatitis. For example, if you follow the recommendations on diet, abstinence from alcohol, and proper drug therapy, patients live up to 10 years. Half of those who do not seek medical help and continue to drink alcohol, smoke, and eat poorly die before this time.