Overview
Ascaris lumbricoides acute pancreatitis is relatively rare in clinical practice, and is caused by a series of chemical inflammation of the pancreas due to the obstruction of bile and pancreatic juice drainage caused by Ascaris lumbricoides entering the pyelopelvic or pancreatic ducts of the lack of specialties. Clinically, acute edematous pancreatitis is common, and some patients may develop hemorrhagic necrotizing pancreatitis.
Etiology
It is a series of chemical inflammation of the pancreas caused by the obstruction of bile and pancreatic juice drainage due to the entry of roundworms into the pyelopelvic or pancreatic ducts of the pancreas.
Symptoms
1. Symptoms
(1) Abdominal pain Almost all patients have abdominal pain, the site of the epigastric region, mostly to the waist and back radiation, accompanied by nausea, vomiting, the pain can be manifested as a drill-like or colicky pain, can be unchanged for many hours or even days, nausea, vomiting, and positional changes and general gastrointestinal antispasmodic drugs can not alleviate the symptoms of abdominal pain, coughing, deep breathing can aggravate the abdominal pain.
(2) Nausea, vomiting and abdominal distension mostly appear after the onset of the disease, manifested as vomiting food and bile in the stomach, sometimes patients can vomit roundworms, patients are often accompanied by abdominal distension, and even paralytic intestinal obstruction can occur.
(3) Fever: Patients have moderate or higher fever, which usually lasts for 3 to 5 days. If the patient’s temperature lasts for more than 1 week, or if the temperature rises gradually with elevated leukocytes, it is necessary to be vigilant for secondary infections, such as pancreatic abscess or biliary tract infections.
(4) Hypotension or shock is mainly seen in hemorrhagic necrotizing pancreatitis, which can occur suddenly in a few patients or gradually after other complications, mainly due to insufficient effective blood volume, bradykinin causing peripheral vasodilatation, release of myocardial inhibitory factor from pancreatic necrosis, and concurrent infections or gastrointestinal bleeding.
(5) Water, electrolyte and acid-base balance disorders Patients may suffer from metabolic alkalosis due to frequent vomiting, often with varying degrees of dehydration, and severe patients may suffer from significant dehydration and metabolic acidosis, accompanied by a decrease in blood potassium, blood calcium and blood magnesium.
(6) Other Acute patients may suffer from acute respiratory failure or adult respiratory distress syndrome, and may also suffer from other organ failure, such as renal and cardiac failure. Some patients have pancreatic encephalopathy, which is characterized by mental abnormality and confusion, lack of orientation, accompanied by fantasy, hallucination and mania.
2. Physical signs
Acute edematous pancreatitis is characterized by mild abdominal signs, often inconsistent with the patient’s complaints, due to the pancreas for the posterior peritoneal organs, the patient’s performance for the epigastric tenderness, no rebound pain and muscle tension, may be accompanied by abdominal distension and less intestinal sounds. Hemorrhagic necrotizing pancreatitis often shows signs of acute peritonitis, i.e., abdominal muscle tension, abdominal pressure and rebound pain, accompanied by paralytic intestinal obstruction, intestinal sounds are weak or absent, and ascites is seen in some patients, which is mostly hemorrhagic ascites, and abdominal mobile turbid sounds are positive. Grey-Turner’s sign and Gullen’s sign can be seen in a few patients, which is due to pancreatic enzymes, necrotic tissues and hemorrhage along the peritoneal space and muscle layer infiltration of the abdominal wall, respectively, up to the two sides of the rib abdomen and umbilicus, resulting in skin color change, and pancreatic abscess or pancreatic cyst can be found in patients with epigastric mass, patients with jaundice in early stage of the pancreatic head inflammatory edema, the common bile duct or the jugular abdominal roundworms caused by the blockage of the late jaundice. Jaundice in the late stage is mostly caused by pancreatic abscess or cyst compressing the common bile duct or hepatocellular damage. When severe pancreatic necrosis and calcification lead to hypocalcemia, the clinical condition can be seen as convulsions of the hands and feet.
Examination
1. White blood cell count
There are leukocytosis and left shift of neutrophil nuclei.
2. Amylase measurement
There are two types of amylase in normal blood, namely salivary type and pancreatic type, and the elevated amylase in acute pancreatitis is mainly of pancreatic type, and the current clinical examination method only measures pancreatic amylase, which has high specificity. Serum amylase begins to rise 6 to 12 hours after the onset of the disease, and then begins to fall in 48h, continuing for several days, serum amylase more than 5 times the normal can confirm the diagnosis of the disease. It is worth noting that the level of serum amylase is not necessarily parallel to the patient’s condition. In hemorrhagic necrotizing pancreatitis, amylase may be lower than normal or normal, and in other diseases such as acute gastrointestinal perforation, acute cholecystitis, cholelithiasis, and acute intestinal obstruction, serum amylase may rise, but usually not more than two times the normal. Urine amylase rises about 6 hours later than serum amylase, and is greatly affected by the patient’s urine output.
3. Amylase, endogenous creatinine clearance ratio (Cam/Ccr%)
Cam/Ccr% is clinically normalized at 1% to 4%. In acute pancreatitis, the increase in renal clearance of amylase and the unchanged clearance of creatinine can cause an increase in this ratio, which is usually up to 3 times. In other causes of serum hyperamylasemia, this value is usually normal or lower than normal, but in patients with diabetic ketoacidosis and renal insufficiency, this ratio can be elevated.
4. Serum lipase
Serum lipase rises about 24 hours later than serum amylase and lasts longer than serum amylase, and it is mostly used in the diagnosis of patients with late diagnosis.
5. Serum normoferritin
When the patient has intra-abdominal hemorrhage, due to the massive destruction of red blood cells, the hemoglobin released combines with albumin to form n-ferritin. It can appear 72 hours after the onset of the disease, and a positive result indicates that the patient has severe hemorrhagic necrotizing pancreatitis.
6. Biochemical tests
Most patients have a temporary elevation of blood glucose, which returns to normal after 3 to 5 days. If the patient’s blood glucose continues to rise more than 10mmol/L, it indicates that the pancreatic necrosis is serious and the prognosis is not good. Clinical laboratory tests of transaminase and lactate dehydrogenase are also commonly elevated, in addition, there is often a temporary hypocalcemia, such as the patient’s blood calcium is less than 1.75mmol / L and convulsions of the hands and feet also indicates that the hemorrhagic necrotizing pancreatitis; if the patient’s PaO2 is less than 60mmHg, the clinic should be vigilant about the emergence of adult respiratory distress syndrome.
7. Abdominal radiographs
It can exclude other acute abdominal diseases such as perforation, and can also detect intestinal paralysis or diagnose paralytic intestinal obstruction.
8.Ultrasound of abdomen
Ultrasound has diagnostic significance for pancreatic enlargement, pancreatic abscess and pancreatic pseudocyst. When roundworms block the pancreatic duct, solid parallel strong light bands can be seen in the pancreatic duct, which are not accompanied by acoustic shadows in the back, and real-time dynamic observation does not show any obvious peristaltic movement of the light bands.
9.CT
CT examination is not affected by the gas in the intestinal cavity, it can clearly show the lesions of the pancreas and its surrounding organs, and can distinguish edema type and necrotic type of pancreatitis and its severity.
10. Endoscopy
Endoscopy can detect the blockage of the pancreaticobiliary duct by roundworms and remove them. It is especially suitable for elderly patients, especially those who cannot tolerate surgical treatment.
Diagnosis
The diagnosis of Ascaris lumbricoides pancreatitis can be made on the basis of the patient’s typical clinical manifestations and laboratory tests, and the ultrasound finding of striated echogenic bands in the pancreatic duct.
Differential diagnosis
This disease should be differentiated from the following diseases.
1. Peptic ulcer perforation
The patient has a history of typical ulcer disease, sudden onset of abdominal pain, physical examination of the liver turbid tone boundary disappears, X-ray fluoroscopy or abdominal plain film can be seen under the diaphragm free gas, can be differentiated.
2. Acute cholecystitis, cholelithiasis
Patients with a history of biliary colic, pain in the right upper abdomen, Murphy’s sign is positive, ultrasound and cholecystography can be identified.
3. Acute intestinal obstruction
The patient has paroxysmal abdominal pain, nausea, vomiting, stop defecation and gas evacuation, liquid and gas plane can be seen in abdominal plain film, which can be distinguished.
4. Acute myocardial infarction
A history of coronary heart disease, sudden onset, typical electrocardiogram and dynamic evolution of cardiac enzyme profile can be identified.
Complications
Local complications, systemic complications, multi-organ failure, chronic pancreatitis and diabetes mellitus. Local complications include pancreatic abscess or pancreatic cyst, which mostly appear in 2-3 weeks of the disease, manifested by high fever, abdominal pain, symptoms of intoxication and epigastric mass; pancreatic cyst mostly forms in 3-4 weeks of the disease, which can compress adjacent tissues and cause corresponding symptoms. Systemic complications often include sepsis or secondary infections (fungal infections) and gastrointestinal bleeding; multi-organ failure can be manifested as renal, cardiac and other organ failure, diffuse intravascular coagulation and adult respiratory distress syndrome.
Treatment
1. Internal medicine treatment
For patients with severe disease, early nutritional supportive therapy; antispasmodic and analgesic treatment, without paralytic intestinal obstruction can be given to patients with atropine, etc., and pethidine is added to patients with severe pain; at the same time, to reduce the exocrine pancreas, the clinic generally uses the following methods, such as fasting, gastrointestinal decompression, H2 receptor antagonists or proton pump inhibitors. The use of growth inhibitors such as octreotide can inhibit pancreatic fluid secretion caused by various reasons, reduce complications such as postoperative pancreatic fistula, and shorten hospitalization time. Antibiotics can be given to prevent and control concurrent infections. Intravenous nutritional support therapy should be given during fasting. In addition, traditional Chinese medicine can be given.
2.Endoscopic treatment
Endoscopic worm extraction has been carried out both at home and abroad. When combined with stones, roundworm displacement in the pancreatic duct and pancreatic necrosis, endoscopic worm extraction may be limited, and surgical treatment can be given.
3. Surgical treatment
Surgery must be considered in the following cases: ① the diagnosis of acute pancreatitis is clear, and the condition still progresses to acute peritonitis after active medical treatment. ② Ascaris lumbricoides obstructing the pancreaticobiliary ducts to relieve the obstruction and endoscopic removal of worms is unsuccessful. ③ Acute hemorrhagic necrotizing pancreatitis diagnosis is not clear, and can not exclude other non-surgical acute abdominal disease requiring caesarean section. ④ Complicated pancreatic abscess and pancreatic pseudocyst, long time and risk of rupture and hemorrhage, or when the abscess needs to be drained.
Prognosis
If hemorrhagic necrotizing pancreatitis occurs, the patient’s prognosis is critical.