Overview
Recurrent pancreatitis refers to recurrent episodes of pancreatitis, a common disease, can be divided into recurrent acute pancreatitis and chronic recurrent pancreatitis. The former has recurrent episodes of acute pancreatitis with no functional or histologic changes in the pancreas after remission; the latter has recurrent acute episodes on the basis of chronic pancreatitis with functional and structural changes in the pancreas, such as pancreatic calcification and diabetes mellitus. The recurrent attack factors are the same as the first factors, there are biliary tract diseases, alcohol, pancreatic duct obstruction, duodenal descending segment disease, surgery and trauma, metabolic disorders, drugs, infections and systemic inflammatory response. The principle of its treatment is to remove the causative factors and symptomatic supportive therapy.
Causes
1. Biliary tract diseases
Cholelithiasis and biliary tract infection are the main causes of recurrent pancreatitis. As 70%~80% of the pancreatic duct and the common bile duct converge to form a common channel opening in the jugular abdomen of the duodenum, once the stones and roundworms are embedded in the jugular abdomen, the inflammation in the bile duct or the damage to the sphincter of Oddi when the gallstones are migrating, it will make the pancreatic duct outflow channel unsmooth, and the pancreatic duct is under high pressure, which will eventually lead to the occurrence of pancreatitis.
2. Alcohol
Alcohol can promote the secretion of pancreatic fluid. When a large amount of pancreatic fluid is secreted and cannot be adequately drained in a timely manner, the pressure in the pancreatic duct rises, which triggers damage to the alveolar cells. In addition, the oxidative metabolism of alcohol in the pancreas generates a large amount of reactive oxygen species, which can promote the activation of the inflammatory response. The amount of alcohol that triggers pancreatitis varies among individuals. Alcohol is often associated with biliary tract disease, which can lead to pancreatitis.
3. Pancreatic Duct Obstruction
Pancreatic duct stones, roundworms, stenosis, tumors, etc. can cause obstruction of the pancreatic duct and increased pressure in the pancreatic duct. If there is pancreatic division, most of the pancreatic fluid is drained through the narrow paracolic nipple, which is prone to poor drainage and leads to increased intra-pancreatic duct pressure.
4. Surgery and trauma
Laparotomy, blunt abdominal contusion and other injuries to the pancreatic tissue, resulting in serious blood circulation disorders in the pancreas, can cause pancreatitis. Pancreatitis can also be triggered by edema of the duodenal papilla caused by endoscopic retrograde cholangiopancreatography insertion or excessive pressure of injected contrast medium.
5. Metabolic disorders
Hypertriglyceridemia is etiologically related to pancreatitis, possibly associated with lipospheric microemboli affecting microcirculation and pancreatic enzymes breaking down triglycerides to cause toxic fatty acid damage to cells. Because hypertriglyceridemia is also often seen in response to severe stress and inflammation, care should be taken to identify the relationship between acute pancreatitis and hypertriglyceridemia.
Hypercalcemia caused by parathyroid tumors and hypervitaminosis D can lead to calcification of pancreatic ducts, promote early activation of pancreatic enzymes and promote pancreatitis.
6. Infection and systemic inflammation
Can be secondary to acute mumps, influenza A, Chlamydia pneumoniae infection, infectious mononucleosis, coxsackievirus infection, etc., often with the subsidence of the infection and self-relief. When the systemic inflammatory response, the pancreas as one of the damaged target organs can also be damaged by acute inflammation.
7. Diseases of the descending duodenum
Such as the ball after the penetrating ulcer, adjacent to the duodenal papilla diverticulitis, etc. can directly affect the pancreas.
8. Drugs
Thiazide diuretics, azathioprine, glucocorticoids, sulfonamides can promote pancreatitis, mostly occurring in the first 2 months of drug use, with no clear relationship with the dose.
9. Other
Various autoimmune vasculitis, pancreatic vascular embolism and other vascular lesions can affect the blood supply of the pancreas, which is less common. Hereditary acute pancreatitis is an autosomal dominant disease and is clinically rare.
Eating greasy food is often a trigger for the development of pancreatitis, and care should be taken to find the cause. Pancreatitis due to overeating alone is currently rare.
Symptoms
The clinical manifestations of recurrent pancreatitis are mild to moderate acute pancreatitis. Abdominal pain is the most common symptom, typically epigastric pain radiating to the back, nausea and vomiting, fever, limited subxiphoid tenderness, and decreased bowel sounds. Elderly patients are prone to shock, respiratory failure, renal insufficiency and even death.
Examination
1. Amylase
Blood, urine or ascites amylase is elevated.
2.Ultrasonography
Ultrasound of the abdomen is the recommended test used to assist in the diagnosis. Ultrasound reveals a diffuse and homogeneous enlargement of the pancreas, with the pancreatic head greater than 2.5 cm thick, the pancreatic body tail greater than 2 cm thick, and much markedly reduced internal echogenicity. It can be used to evaluate and rule out the presence of biliary system etiology in patients with acute pancreatitis.
3. CT
Contrast-enhanced abdominal CT is not the examination of choice and is considered when the diagnosis is unclear. If the patient’s abdominal pain is not relieved or tends to worsen 24 to 48 hours after admission, enhanced CT is helpful in evaluating the pancreas and surrounding tissues. Enlarged pancreatic parenchymal edema, uneven density of pancreatic parenchyma, and peripancreatic fat liquefaction are seen.
Diagnosis
1. Acute epigastric pain with epigastric pressure or signs of peritoneal irritation.
2. Elevated amylase in blood, urine or ascites.
3. Imaging or surgical findings of inflammation, necrosis and other changes in the pancreas.
Acute pancreatitis is diagnosed if 1 and 2 or 3 are met and other acute abdominal conditions are excluded. The disease is diagnosed when the above criteria are met and there is a history of similar episodes or a clear history of pancreatitis.
Differential diagnosis
When the diagnosis is not clear, it is important to differentiate it from other diseases with acute abdomen.
1. Digestive tract perforation
Patients with gastrointestinal perforation have a history of perforated ulcers or recurrent stomach pains for many years. The pain is a sudden severe cutting or burning pain in the upper abdomen, radiating to the right shoulder and rapidly spreading to the whole abdomen, without fever, with obvious systemic and gastrointestinal symptoms, rapid progression, easy to go into shock, and free gas under the diaphragm can be seen in the X-ray examination.
2. Cholecystitis
Cholecystitis often occurs after a high-fat meal, right upper abdominal cramps radiating to the right shoulder, chills, high fever and jaundice, Murphy’s sign is positive, ultrasonography shows that the gallbladder is enlarged, and strong echoes can be seen in the presence of stones.
3. Acute appendicitis
Patients with acute appendicitis mostly have characteristic metastatic right lower abdominal pain. Obvious pressure and rebound pain in the right lower abdomen.
3. Intestinal obstruction
Intestinal obstruction has obvious abdominal pain, abdominal distension, vomiting, anal cessation of defecation, hyperactive bowel sounds, the appearance of air-over-water sounds or metallic sounds. step-like fluid planes can be seen on X-ray.
4. Inferior wall myocardial infarction
Inferior wall myocardial infarction can be differentiated from this disease by ECG.
Complications
1. Pancreatic fistula: pancreatitis leads to rupture of the pancreatic duct, and pancreatic fluid leaks out of the pancreatic duct for more than 7 days, which is called pancreatic fistula. There can be intra-pancreatic fistula and extra-pancreatic fistula.
2. Pancreatic cyst: Intra-pancreatic, peri-pancreatic fluid accumulation or pancreatic pseudocyst infection may develop into abscess, and the patient has fever, abdominal pain, emaciation and malnutrition symptoms.
Treatment
1. Treatment principle
Remove the cause of disease, control the symptoms, correct and improve the internal and external secretion insufficiency of pancreas and prevent complications.
2. Non-surgical treatment
(1) General treatment: Stop smoking and drinking, adjust diet structure, avoid high-fat diet, supplement fat-soluble vitamins and trace elements, and give enteral or parenteral nutritional support for malnutrition.
(2) Treatment of pancreatic exocrine insufficiency When patients have steatorrhea, weight loss and malnutrition, exogenous pancreatic enzyme preparations need to be supplemented to improve digestion and absorption dysfunction. The first choice is microparticulate pancreatic enzyme capsules containing highly active lipase, which are recommended to be taken with meals, and pancreatic enzymes with (30 to 40) million U of lipase are given with the main meal, and pancreatic enzymes with (1 to 20) million U of lipase are given with the supplementary meal. The dose may be increased or combined with a proton pump inhibitor if results are poor.
(3) Treatment of pancreatic endocrine insufficiency According to the degree of diabetes progression and complications, metformin is generally preferred to control blood glucose, with the addition of pro-insulin secretion drugs if necessary, and insulin treatment is chosen for symptomatic hyperglycemia and poor efficacy of oral hypoglycemic drugs. Patients with diabetes mellitus are sensitive to insulin and need special attention to prevent hypoglycemic episodes.
(4) Pain treatment Non-analgesic drugs, including pancreatic enzymes and antioxidants, can be effective in relieving pain. Pain treatment mainly relies on the selection of appropriate analgesic drugs, the initial choice of non-steroidal anti-inflammatory drugs, ineffective choice of weak opioids, still can not be relieved or even aggravated by the use of strong opioid analgesic drugs. Endoscopic treatment or CT, endoscopic ultrasound-guided abdominal plexus block can provide short-term pain relief. If there are factors such as pancreatic head mass and pancreatic duct obstruction, surgical treatment should be chosen.
(5) Other treatments Autoimmune pancreatitis is a special type of pancreatitis for which glucocorticoid therapy is preferred. Efficacy is assessed by monitoring serum IgG4 and imaging review during treatment.
Questions you may be concerned about
How is recurrent pancreatitis treated?
The treatment of recurrent pancreatitis includes: general treatment such as abstaining from alcohol and smoking and adjusting diet; symptomatic treatment such as reducing pancreatic fluid secretion and controlling pain; and surgery if necessary. The actual treatment should be directed by the doctor.
1. General treatment: It is recommended that patients should adjust their diet, avoid high-fat diet, pay attention to supplementing trace elements and vitamins, and give parenteral or enteral nutritional support if necessary.
2. Symptomatic treatment: reduce the secretion of pancreatic fluid, give enzyme inhibiting drugs, such as growth inhibitor or octreotide; control pancreatic inflammation, give anti-infective drugs, such as cephalosporins (cefoperazone, etc.) treatment.
When the patient’s pain is not obvious, it can be left untreated for the time being. When the pain is obvious, medication can be given. Non-analgesic such as pancreatic enzyme preparations, antioxidants, etc. have a certain effect on pain relief.
3. Surgery: Surgery is not necessary when the condition is mild, but when there are factors such as pancreatic duct obstruction, pancreatic head mass, or when the patient’s acute severe pancreatitis is ineffective with conservative treatment, surgery should be chosen.
In conclusion, if you suffer from recurrent pancreatitis, you should consult the hospital in time and take active treatment to avoid aggravation or recurrence of the disease.
Prognosis
Timely diagnosis and treatment have a good prognosis, and some patients may develop chronic pancreatitis.
Prevention
1. Remove causative factors, such as controlling triglycerides.
2. Early cholecystectomy should be performed for those with cholelithiasis.
3. Reasonable diet, regular diet, avoid overeating, excessive alcohol consumption.