The most common form of acute pancreatitis is biliary pancreatitis, which accounts for about 75% of the total number of cases. The pathogenesis and principles of management are unique. 100 years ago, the German pathologist Opie proposed the hypothesis that the common channel of the bile and pancreatic ducts and the reflux of bile into the pancreatic duct lead to pancreatitis. The basic point is that the end of the pancreaticobiliary ducts converge into a common channel that opens into the duodenal papilla, and the mucosal damage caused by stones passing through the Oddi sphincter causes edema and stenosis of the duodenal papilla and obstruction of the pancreatic and biliary ducts, and the reflux of bile and pancreatic juice, which causes increased pressure in the pancreatic ducts and self-digestion of pancreatic tissue, leading to recurrent episodes of acute pancreatitis. The downward migration of small stones or tiny gallstones (≤3mm in diameter) in the gallbladder is the most common cause of biliary pancreatitis, and stones can be found in the stool of 70% of patients with pancreatitis. Therefore, removing stones and relieving obstruction of the pancreatic and biliary ducts are important means of treating cholestatic pancreatitis and controlling its development.
Clinical manifestations of acute biliary pancreatitis.
(1) Abdominal pain
The most important symptom (about 95% of patients) is sudden onset of epigastric or left epigastric continuous severe pain or cutting-like pain, epigastric waist with a girdling sensation, often occurs after a full meal or alcohol consumption, accompanied by paroxysmal intensification, can be enhanced by eating, can spread to the umbilicus or the whole abdomen. It often radiates to the left shoulder or both sides of the low back. The pain site is usually in the middle and upper abdomen, such as inflammation of the head of the pancreas is predominant, often in the right side of the middle and upper abdomen; such as pancreatic body and tail inflammation is predominant, often in the middle and upper abdomen and left upper abdomen. The pain can be relieved when bending or sitting forward. Sometimes morphine alone is not effective. If combined with bile duct stones or bile duct roundworms, there is right upper abdominal pain and biliary colic.
(2) Nausea and vomiting
2/3 of patients have this symptom, with frequent episodes, early reflexive, content of food, bile. The late stage is caused by paralytic intestinal obstruction, and the vomit is fecal-like. If you vomit roundworms, it is mostly pancreatitis complicated by biliary ascariasis. In alcoholic pancreatitis, vomiting often occurs during abdominal pain, and in biliary pancreatitis, vomiting often follows the onset of abdominal pain.
(3) Abdominal distension
In heavy cases, it is caused by the irritation of intra-abdominal exudate and retroperitoneal bleeding, and in paralytic intestinal obstruction, it is caused by the accumulation of gas and fluid in the intestine.
(4) Jaundice
About 20% of patients develop jaundice to varying degrees 1 to 2 days after the disease. The cause may be the coexistence of bile duct stones, causing bile duct obstruction, or an enlarged pancreatic head pressing the lower end of the common bile duct or impaired liver function jaundice, the heavier the jaundice, the more serious the disease, the prognosis is not
(5) Fever
Mostly moderate fever: between 38° and 39°C, usually decreasing gradually after 3 to 5 days. However, in heavy cases, the fever can last for many days without decreasing, suggesting pancreatic infection or abscess formation and toxic symptoms, and in severe cases, the temperature may not rise. When combined with cholangitis, there may be chills and high fever.
(6) Hand and foot twitching
It is caused by a decrease in blood calcium. It is caused by the action of lipase that enters the abdominal cavity, so that the fatty tissue on the large omentum and peritoneum is digested and decomposed into glycerol and fatty acid, the latter combined with calcium as insoluble fatty acid calcium, thus the serum calcium drops, if the serum calcium is <1.98mmol/L (8mg%), it indicates serious illness and poor prognosis.
(7) Shock
Most commonly seen in acute hemorrhagic necrotizing pancreatitis, due to massive peritoneal and retroperitoneal bleeding, intestinal paralysis, fluid accumulation in the intestinal cavity, vomiting resulting in loss of body fluids causing hypovolemic shock. In addition, absorption of large amounts of proteolytic products, leading to the development of toxic shock. The main manifestations are irritability, cold sweat, thirst, cold extremities, thin pulse, shallow and rapid breathing, decreased blood pressure, and low urine. In severe cases, cyanosis, dyspnea, delirium, coma, rapid pulse, blood pressure cannot be measured, no urine, BUN>100mg%, renal failure, etc.
(8) Acute respiratory failure
The clinical features are sudden onset of progressive respiratory distress, hyperventilation, cyanosis, anxiety, sweating, etc., which cannot be relieved by conventional oxygen therapy.
(9) Acute renal failure
Acute renal failure can occur in 23% of people with severe acute pancreatitis, with a mortality rate of up to 80%. The cause of its occurrence is related to hypovolemia, shock and the role of pancreatic kinin. Pancreatic enzymes cause abnormal blood clotting and a hypercoagulable state, which produces microcirculatory disorders and leads to renal ischemia and hypoxia.
(10) Circulatory failure
Severe pancreatitis can cause heart failure and arrhythmias, the latter of which can be cool like myocardial infarction.
(11) Pancreatic encephalopathy
The incidence is about 5.9%-11.9%, manifested as neuropsychiatric abnormalities, lack of orientation, mental confusion, accompanied by fantasy, hallucinations, manic state, etc. It is often transient and can be complete. It is often transient and can be completely normalized, but it can also leave mental abnormalities.
Principles of management of biliary pancreatitis
For the treatment of biliary pancreatitis, the first thing to identify the presence of biliary obstructive lesions, where there is biliary obstruction, ERCP and EST lithotripsy, drainage treatment should be performed urgently. If endoscopic treatment is not available, open surgery should be performed, including cholecystectomy, common bile duct lithotomy, T-tube drainage, and small omental sac pancreatic drainage as needed, and conservative treatment should be used for those without biliary obstruction. EST decompression and drainage. To prevent recurrence of acute biliary pancreatitis, early cholecystectomy should be performed after the inflammation subsides. With the development of minimally invasive techniques, intraoperative cholangiography (IOC) through the cholecystic duct after laparoscopic resection of the gallbladder (LC) and removal of common bile duct stones by mesh basket technique is also widely used.
Acute biliary paJlcrealitis (ABP) is a serious disease with rapid onset, rapid progression, many complications and high mortality rate, accounting for 70% of acute pancreatitis, with mortality rates of 2%-22% and 10%-40% abroad.