The treatment of acute pancreatitis should be selected according to the severity of the lesion. In principle, non-surgical treatment is available for lighter cases, and medical management is the main focus, while active support and surgical management are needed for heavy biliary pancreatitis and its secondary lesions, such as pancreatic abscesses and pseudopancreatic cysts, in order to save lives.
(I) Non-surgical treatment
1.Antispasmodic and analgesic
(1) Dulcolax, atropine intramuscular injection. Apply when the abdominal pain is severe. It is not suitable to use morphine alone for pain relief because it causes spasm of Oddi sphincter, and the combination of atropine can counteract the spasm caused by it with good effect.
(2) Acupuncture treatment: body acupuncture: Yanglingquan, Feosanli, Neiguan, Ha Juxu, Zhongguancestra, etc. Ear acupuncture takes the pancreatic area and biliary area.
(3) If the pain is not relieved, use 0.1% nufcaine 300-500ml, intravenous drip.
2, control diet and gastrointestinal decompression in light cases can enter a small amount of light juice, avoid eating fatty, irritating food, severe cases need to strictly prohibit diet to reduce or inhibit pancreatic secretion. In severe cases or obvious abdominal distension, gastrointestinal decompression should be performed to extract gastric juice, reduce gastric acid to stimulate the duodenum to produce glucagon, cholecystokinin, etc., so as to reduce pancreatic secretion and prevent paralytic intestinal obstruction.
During fasting, fluid, caloric supplementation and nutritional support should be given. Maintain water-electrolyte balance, correct hypocalcemia, hypomagnesia, acidosis and hyperglycemia, etc. If necessary, total parenteral nutrition (TPN) can be given to maintain water-electrolyte and caloric supply. The advantage is that it can reduce pancreatic secretion, make the digestive tract rest and compensate for the body’s catabolism.
3, application of antibiotics are generally used penicillin, streptomycin, gentamicin, ampicillin, sulfobenzylpenicillin, vanguardycin, etc. To control anaerobic bacterial infection, metronidazole can be used at the same time. Because the pancreas bleeding necrosis, tissue proteolytic products are often a good medium for bacterial reproduction, so in heavy cases should be used as early as possible, can play a role in the prevention of secondary infection and prevent complications.
4, pancreatic enzyme inhibitors commonly used.
① Peptidase (Trasylol), with anti-protease and pancreatic vasodilator effect. The first amount of 200,000μ, and later 200,000μ/6 hours, intravenous. Or 200,000μ, 2 times/day, intravenous for 5 days.
②5-FU, a cytotoxic drug, can inhibit DNA and RNA synthesis, reduce pancreatic enzyme secretion, and have inhibitory effects on trypsin and phospholipase A. 100-500mg daily, IV, or 250mg added to 5% glucose solution 500ml IV, can be repeated once in 24 hours.
5, give the anticholinergic drugs atropine, 654-2, scopolamine, prudensine, to inhibit pancreatic secretion, it is appropriate to apply early and repeatedly. At the same time, the acid control agent methandienol 200mg, 4 times/day, aluminum hydroxide gel, sodium bicarbonate should be given orally to neutralize gastric acid and inhibit pancreatic juice secretion. Glucagon has a certain effect on the inhibition of pancreatic exocrine secretion and can also be used.
6, hormone application is generally not advocated because it can cause acute pancreatitis. However, heavy pancreatitis with shock; toxic symptoms are obvious, suspected sepsis, or sudden deterioration of the condition; severe respiratory distress, especially in the presence of ARDS; or with tight adrenal cortex insufficiency, should be given hydrocortisone 500 ~ 1000mg, or dexamethasone 20 ~ 40mg, static, for three days, and gradually reduce the amount to stop using. It can reduce the inflammatory reaction, reduce capillary permeability and edema.
7.Chinese medicine treatment.
① Qing Pancreatic Soup No.Ⅰ: It is suitable for edema type pancreatitis, especially for liver stagnation, spleen and stomach dampness and heat. Formulation composition: Chai Hu 15g, Huang Ling 9g, Hu Lian 9g, Hang Shao 15g, Mu Xiang 9g, Yuan Hu 9g, Sheng Jun 15g, Mannichol 9g (flushed). One dose daily, two decoctions, divided into two doses.
②Clear Pancreatic Soup No. II: For biliary ascariasis pancreatitis, which can dredge liver and regulate Qi, and expel roundworms and calm roundworms. Formula composition: Chai Hu 15g, Scutellaria baicalensis 9g, Forsythia lanceolata 9g, Mucuna pruriens 9g, Betel nut 30g, Radix et Rhizoma Pinelliae 30g, Bitter Dong Pi 30g, Radix et Rhizoma Sinensis 3g, Mangosteen 9g (for dosing). One dose and two decoctions per day, divided into two doses. This two-dose formula is suitable for most acute pancreatitis. Clinically, it can be added or subtracted according to the symptoms, adding Erhua and Lianxiao when heat is heavy, and adding Mushroom Chen, Mast, and Gentian Herb when damp-heat is heavy. For vomiting, add ochre and bamboo rhizome.
For accumulation of food, add Lycopodium and Jiao Sanxian; for pain, add Chuan Dongzi and Yuanhuosuo; for chest fullness, add Houpu and Citrus aurantium; for shoulder and back pain, add Guadua, Allium and Fangfeng.
8, anti-shock: heavy people often early shock, mainly due to a large amount of extravasation of body fluids, can make the loss of circulating volume of 40%, so the appearance of hypovolemic shock, is the cause of early death, so based on central venous pressure, blood pressure, urine volume, red blood cell pressure and electrolyte monitoring, replenishment of balanced salt solution, plasma, fresh whole blood, human albumin, dextrose and other plasma bulking agents and electrolyte solution, in order to restore effective The circulating volume and electrolyte balance should be maintained, while acid-base balance should be maintained. After the above situation is improved, and after excluding hypotension caused by cardiac insufficiency, vasoactive drugs that raise blood pressure can be applied, with dobutamine being preferred.
In addition, broad-spectrum antibiotics and hormones should be given to mobilize the body’s stress capacity to improve the effect. At the same time, renal function should be protected, diuretics should be applied, and peritoneal dialysis should be performed if necessary. In case of respiratory failure, arterial blood gas analysis should be performed, high-flow oxygen should be administered, and tracheotomy and positive pressure breathing should be performed if necessary. If there is cardiac insufficiency, cardiac stimulants should be given in time. Resuscitation should be done in collaboration with relevant physicians in order to achieve success.
(B) Surgical treatment
1. Indications.
① heavy pancreatitis with severe shock, diffuse peritonitis, intra-abdominal exudate, intestinal paralysis, peripancreatic abscess and gastrointestinal hemorrhage.
(②Cholestatic pancreatitis is clear, or combined with cholestatic sepsis.
③ Those with severe disease, non-surgical treatment is ineffective, high fever and toxic symptoms are obvious.
④In cases of epigastric trauma, progressive abdominal pain, elevated amylase, and suspected pancreatic injury, immediate surgical exploration should be performed.
⑤ Those with multiple recurrent attacks and confirmed duodenal papillary stenosis or pancreatic duct stenosis and stones.
(6) Those with concurrent abscess or pseudopancreatic cyst.
2.Surgical methods.
① Pancreatic peritoneal dissection and drainage: It is suitable for those with obvious pancreatic swelling, which can reduce the tension of the pancreas and help improve pancreatic blood flow and reduce abdominal pain. After incision, a clear and adequate abdominal drainage or double-lumen tube drainage is placed in the small omental sac to reduce secondary intra-abdominal damage, exudation and necrosis and prevent infection.
② Lesion removal: Removal of necrotic tissue from the pancreas can prevent serious infection and the development of necrotic lesions, but do not injure the pancreatic duct and pay attention to local hemostasis. It is appropriate to perform it 7 to 10 days after the onset of the disease.
(iii) Pancreatic resection: including partial or total pancreatectomy. Generally, only the necrotic part is removed to avoid the development of pancreatic necrosis and infection and to reduce the occurrence of complications. In specific cases such as 75% pancreatic necrosis or severe damage to the duodenum, total pancreatectomy (GDP) can be performed, which has been reported to be successful, but the mortality rate is high and the operation is difficult, and exogenous insulin is required for lifelong maintenance during survival.
④Continuous peritoneal lavage: It can eliminate toxic substances in the peritoneal cavity that affect the whole body, such as exuded enzymes, necrotic tissue, proteolytic products, bacteria, toxins and exudate, which is beneficial to the prognosis of this disease. A porous silicone plastic tube can be inserted through the abdominal wall, and balanced salt solution containing heparin and antibiotics can be injected into the abdominal cavity, 1000-1500 ml each time, after about 15-20 minutes, kept for 20-30 minutes, and then the lavage solution can be released. Depending on the change of exudate, repeat every 1 to 2 hours, taking care not to injure the intestinal canal and aggravate respiratory distress when the injection volume is large.
⑤ Biliary tract surgery: Biliary tract stones and roundworms should be treated appropriately to improve the surgical efficacy, but do not perform more invasive surgery.