Brief introduction
Acute pancreatitis is one of the common acute abdominal diseases, mostly seen in young adults, with women being higher than men (about 2:1). Its incidence is second only to acute appendicitis, intestinal obstruction, acute cholecystitis gallstone disease. The main cause is an acute inflammation of the pancreatic digestive enzymes caused by obstruction of the pancreatic duct, sudden increase of pressure in the pancreatic duct, and impaired hemolymph circulation of the pancreas.
Acute pancreatitis is an acute inflammation caused by pancreatic enzymes digesting the pancreas and its surrounding tissues, mainly manifested as inflammatory edema, hemorrhage and necrosis of the pancreas, acute hemorrhagic necrotizing pancreatitis accounts for about 2.4-12%, and its morbidity and mortality rate is high, reaching 30-50%. The rate of misdiagnosis of this disease is as high as 60-90%.
Etiology
(1) Biliary tract diseases. Cholecystitis, cholelithiasis, etc.
(2) Alcoholism and overeating.
(3) Duodenal papilla lesions. Duodenal ulcer or inflammation.
(4) Other factors: mumps, viral hepatitis, abdominal surgery, abdominal trauma, certain drugs can also cause pancreatitis attacks.
Lesions
The disease can be divided into two types of acute edematous (or interstitial) pancreatitis and acute hemorrhagic necrotizing pancreatitis according to different lesion manifestations.
1. Acute edematous (interstitial) pancreatitis is more common, accounting for about 3/4 or more of all cases of acute pancreatitis. The lesions are mostly confined to the tail of the pancreas. The pancreatic gland is enlarged and hardened, with interstitial congestion and edema and infiltration of neutrophils and mononuclear cells. Sometimes limited fat necrosis may occur without bleeding. The prognosis for this type is better, and the lesions often subside and heal within a short period of time after treatment.
2, acute hemorrhagic necrotizing pancreatitis is less common. The onset of this type is acute, and the condition and prognosis are more serious than the edematous type. The lesion is characterized by extensive pancreatic necrosis and hemorrhage, accompanied by a mild inflammatory response. On visual inspection, the pancreas is enlarged, soft, hemorrhagic, dark red, and with blurred lobular structures. Foci of fatty necrosis in the form of cloudy yellow-white spots or small patches were scattered in the pancreas, greater omentum and mesentery. The necrotic foci are formed by the overflow of pancreatic fluid, in which lipase breaks down neutral fat into glycerol and fatty acids, which in turn combine with calcium ions in the tissue fluid to form insoluble calcium soap.
Microscopically, the pancreatic tissue showed large areas of coagulative necrosis with blurred cellular structures and necrosis in the walls of the small interstitial vessels, which was the cause of pancreatic hemorrhage. Neutrophil and mononuclear cell infiltration was seen around the necrotic pancreatic tissue. If the patient passes the acute phase, the inflammatory exudate and necrotic material will be gradually absorbed, and local fibrosis will occur and heal or turn into chronic pancreatitis.
Classification
Acute pancreatitis can be divided into the common type and the hemorrhagic necrotic type. The hemorrhagic-necrotic type is less common, but it is serious and has a high mortality rate.
Clinicopathological links
1. Shock patients often present with shock symptoms. The causes of shock can be various, such as severe pain due to pancreatic fluid overflow and stimulation of the peritoneum; bleeding in the pancreatic tissue and abdominal cavity; tissue necrosis, organismal toxicity caused by protein decomposition, etc. Severe shock can be fatal if not rescued in time.
2, peritonitis due to acute pancreatic necrosis and pancreatic fluid overflow, often causing acute peritonitis.
3, enzyme changes in pancreatic necrosis, due to the overflow of pancreatic fluid, which contains a large number of amylase and lipase can be absorbed into the blood and excreted from the urine. Clinical examination of the patient’s serum and urine amylase and lipase levels are commonly elevated, which can help in the diagnosis.
4, serum ion changes in the patient’s blood calcium, potassium, sodium ion levels decreased. The cause of the decrease in blood calcium, recent studies believe that the pancreatic alpha cells are stimulated to secrete glucagon during acute pancreatitis, the latter can cause the thyroid gland to secrete calcitonin, which inhibits the freeing of calcium from the bone, resulting in a decrease in blood calcium due to the lack of replenishment of calcium consumed by fat necrosis during pancreatitis. The decrease of blood potassium and sodium may be caused by persistent vomiting.
Rescue measures
(1) Immediately after the onset of the disease, fasting and abstaining from food and water will aggravate the condition. After the abdominal pain disappears and the body temperature is normal, gradually resume the diet, starting with a small amount of liquid food and prohibiting meat and protein-based diet. If eating causes relapse, it means that fasting and water fasting should be continued.
(2) Effective pain relief and inhibition of pancreatic secretion of digestive enzymes. Atropine 0.5 mg, intramuscular injection; analgesic new 30 mg intramuscular injection; analgesic, phenobarbital can be applied. In severe cases, Dulcolax 100 mg can be injected intramuscularly. 0.25% procaine saline 500 ml can be administered intravenously.
(3) If the abdominal distension is obvious, give lower gastric tube gastrointestinal decompression.
(4) When the patient shows signs of shock such as wet and cold extremities, weak pulse, and decreased blood pressure, try to keep warm, elevate the lower extremities, and send to the hospital for resuscitation as soon as possible.
(5) Hemorrhagic necrotizing pancreatitis can be removed surgically by removing necrotic pancreatic tissue or performing abdominal lavage to reduce the damage to the tissue.
(6) Chinese herbal medicine to clear the pancreatic intestine to treat common type of pancreatitis is effective. It can be used. To avoid turning into chronic pancreatitis.
Treatment method
According to the clinical manifestations and typing, choose the appropriate treatment method.
1, non-surgical treatment of the initial stage of acute pancreatitis, light pancreatitis and those who are not yet infected should be treated non-surgically.
(1) Fasting, nasogastric tube decompression: continuous gastrointestinal decompression to prevent vomiting and aspiration. Administration of full gastrointestinal motility drugs can reduce abdominal distension.
(2) Replenish body fluids and prevent shock: All patients should receive intravenous fluid, electrolytes and calories to maintain circulatory stability and water-electrolyte balance. Preventing hypotension, improving microcirculation and ensuring pancreatic perfusion are beneficial to the treatment of acute pancreatitis.
(3) Antispasmodic and analgesic: If the diagnosis is clear. Early onset of the disease can be given symptomatic analgesics (pethidine). But it is appropriate to give antispasmodics (scopolamine, atropine) at the same time. Morphine is prohibited to avoid causing spasm of the sphincter of Oddi.
(4) Inhibition of pancreatic exocrine secretion and pancreatic enzyme inhibitors: gastric tube decompression, H2 receptor blockers {such as cimetidine), proton pump inhibitors (such as omeprazole), anticholinergics (such as scopolamine, atropine), growth inhibition, etc. Trypsin inhibitors such as peptidase, gabex, etc. have -certain inhibitory effect on trypsin.
(5) Nutritional support: early fasting. Mainly rely on complete parenteral nutrition (TPN). When abdominal pain, pressure pain and intestinal obstruction symptoms are reduced, diet can be resumed. Except for hyperlipidemic patients, fat emulsion can be applied as a source of heat.
(6) Application of antibiotics: Early antibiotic treatment is given. In severe pancreatitis combined with pancreatic or peripancreatic necrosis, broad-spectrum antibiotics applied intravenously or selective transintestinal application of antibiotics can prevent bacterial infection and fungal infection caused by intestinal flora displacement.
(7) Chinese herbal medicine treatment: In the case of basic control of vomiting. Inject herbal medicine through gastric tube and clamp the tube for 2 hours after injection. Commonly used such as compound Qing Pancreas Tang with addition and subtraction: Yinhua, Lianjia, Huanglian, Scutellaria, Houpao, Citrus aurantium, Mu Xiang, Safflower and raw rhubarb (later down). Raw rhubarb 15g can also be used alone for intragastric instillation. 2 times a day.
(8) Treatment of abdominal exudate: The abdominal exudate of acute pancreatitis contains a variety of harmful substances that can cause hypotension, respiratory failure, liver failure and changes in vascular permeability. In severe pancreatitis, it is generally believed that abdominal exudate can be absorbed on its own. If the abdominal distension is obvious, abdominal lavage should be done if there is a lot of abdominal exudate.
2. Surgical treatment of pancreatic abscess, pancreatic pseudocyst and pancreatic necrosis combined with infection are serious life-threatening complications of acute pancreatitis. Indications for surgical treatment of acute pancreatitis include.
(i) Uncertain diagnosis;
(ii) Secondary pancreatic infection;
(iii) Combined biliary tract disease;
(4) Continued deterioration of clinical symptoms despite reasonable supportive therapy.
(1) Surgical treatment of secondary pancreatic infection: There are two main surgical methods.
① Dissection to remove necrotic tissue and placement of multiple porous drains for continuous postoperative irrigation. The incision is then closed.
(ii) Dissection to remove necrotic tissue and partial open drainage of the incision. The transepithelial route is easily revealed, especially by using a transverse epigastric incision for easier intraoperative exposure and manipulation. The thick pus and infected necrotic tissues filled with tissue debris are removed intraoperatively, and regular pancreatic resection is not performed, avoiding dissection with sharp instruments to prevent pancreatic duct injury. The peripancreatic area is freed and loosened and flushed, and regional drainage should be adequate with multiple drainage tubes placed for postoperative irrigation.
The trauma is partially open to drainage, which, in addition to adequate drainage, also facilitates the removal of continued necrotic pancreatic tissue several times postoperatively. Gastrostomy, jejunostomy (for enteral nutritional support) and biliary drainage can be performed simultaneously in water. Occasionally, a single abscess or infected pancreatic pseudocyst can be treated with percutaneous puncture and drainage.
(2) Management of biliary pancreatitis: In severe biliary pancreatitis. In cases with embedded stones in the jugular abdomen, combined with biliary obstruction or biliary infection, emergency surgery or early surgery (within 72 hours) should be performed to relieve biliary obstruction, remove stones, unblock drainage, and choose cholecystectomy or small omental pancreatic area drainage according to the condition. If available, the stone can be removed via fiberoptic duodenoscopic Oddi sphincterotomy, which has significant efficacy and few complications.
If the patient does not have biliary obstruction or infection, non-surgical supportive therapy should be performed, and after remission, elective biliary surgery should be performed before discharge to avoid recurrence after discharge. Some patients may drain the stone on their own during hospitalization and do not need further surgery. Alternatively, patients may be admitted for biliary surgery 2 to 4 weeks after the acute pancreatitis is cured.