OVERVIEW
Diseases of the biliary system can not only cause acute pancreatitis, but also often cause diffuse or limited recurrent progressive inflammatory changes and fibrosis of the pancreas, which is clinically referred to as biliary chronic pancreatitis or biliary chronic recurrent pancreatitis.
Causes
1. Obstructive factors
It is more common in Europe, Asia and China. The most common cause of obstruction is gallstones. Causes of obstruction in the juxta-jugular region of the Vater include: passage or embedding of gallstones in the juxta-jugular region of the Vater, biliary roundworms, duodenal papillae edema, spasm of the juxta-jugular sphincter, juxta-jugular stenosis, etc. Obstruction of the bilio-pancreatic common pathway leads to reflux of bile into the pancreatic ducts, resulting in bile-induced pancreatic parenchymal injuries. Simple pancreatic duct obstruction is also sufficient to cause pancreatic damage.
2. Excessive alcohol consumption
Excessive alcohol consumption is a major cause of acute pancreatitis in urban America. It is also not uncommon in China. Excessive alcohol consumption is closely related to the development of acute pancreatitis.
3. Overeating
The overindulgence in high protein and high fat foods and the consumption of alcohol can stimulate the excessive secretion of pancreatic juice, and when accompanied by partial obstruction of the pancreatic duct, acute pancreatitis can occur.
4. Hyperlipidemia
Hyperlipidemia is also a cause of acute pancreatitis. Hyperlipidemia can be secondary to nephritis, desiccation therapy and application of exogenous estrogen, and hereditary hyperlipidemia (type I, type V).
5. Hypercalcemia
It often occurs in patients with hyperparathyroidism. Calcium can induce the activation of trypsinogen to destroy the pancreas itself; high calcium can produce pancreatic duct stones causing pancreatic duct obstruction; high calcium can also stimulate the increased secretion of pancreatic juice. Absorbed into the blood through the peritoneum, it increases blood amylase and lipase; a large amount of pancreatic enzymes into the blood can lead to damage to the liver, kidney, heart, brain and other organs, causing multiple organ insufficiency syndrome.
Symptoms
Due to different degrees of lesions, clinical manifestations such as symptoms and signs vary greatly.
1. Abdominal pain
Abdominal pain is the main clinical symptom. The abdominal pain is severe, starting from the middle-upper abdomen, or favoring the right upper abdomen or left upper abdomen, radiating to the back; involving the whole pancreas, the pain radiates to the lower back in the form of a girdle. Alcohol-induced pancreatitis often develops 12 to 48 hours after intoxication, with abdominal pain. Biliary pancreatitis often occurs after a full meal.
2. Nausea and vomiting
Vomiting is often accompanied by abdominal pain that is severe and frequent, and the vomit is gastroduodenal contents, occasionally accompanied by coffee-like contents.
3. Abdominal distension
In the early stage, it is reflex intestinal paralysis, and in severe cases, it can be caused by the stimulation of retroperitoneal cellulitis. The upper small intestine and transverse colon adjacent to the pancreas are paralyzed and dilated. Abdominal distension is predominantly epigastric. Abdominal distension is more obvious when there is fluid in the abdominal cavity: the patient stops defecation and elimination of gas, and the bowel sounds are weakened or lost.
4. Peritonitis
In edematous pancreatitis, the tenderness is limited to the epigastrium, and there is often no obvious muscle tension. In hemorrhagic necrotizing pancreatitis, the pressure pain is obvious, and there is muscle tension and rebound pain, which is more extensive or extends to the whole abdomen.
5. Other
In the early stage, the fever is usually moderate, about 38℃. The combination of cholangitis can be accompanied by chills and high fever. When pancreatic necrosis with infection, high fever is one of the main symptoms. Jaundice can be seen in biliary pancreatitis. Or due to compression of the common bile duct by the edematous pancreatic head. Patients with severe pancreatitis present with a rapid pulse rate, decreased blood pressure, hypovolemia and even shock. Those with acute pulmonary failure have shortness of breath, dyspnea and cyanosis. There may also be psychiatric symptoms, including slowness of sensation, confusion, irritability, psychosis and coma. In a few cases of severe pancreatitis, there may be cyanosis in the left lumbar region (Grey-Turner’s sign) and cyanosis around the umbilicus (Cullen’s sign). Vomiting blood and blood in the stool may occur with gastrointestinal bleeding. Convulsions of the hands and feet may occur when blood calcium is lowered.
Examination
1. Laboratory tests
（Serum amylase is the most widely used diagnostic method. Increased serum amylase can be measured within 24 hours after the onset of the disease, with a marked increase in serum amylase value >500 U/dl (normal value 40-180 U/dl, Somogyi’s method), followed by a gradual decrease to normal over the next 7 days. Urinary amylase measurement is also a sensitive indicator for the diagnosis of the disease. Urinary amylase elevation is slightly delayed but lasts longer than serum amylase. Significantly elevated urinary amylase (normal value 80-300 U/dl, Somogyi’s method) is diagnostic. The higher the measured value of amylase, the higher the rate of correct diagnosis. However, the level of amylase value is not necessarily proportional to the severity of the lesion. A significant rise in serum lipase (normal value 23-300 U/L) is a more objective indicator for the diagnosis of acute pancreatitis. Determination of serum amylase isoenzymes improves the correctness of the diagnosis of this disease.
(2) Others include increased white blood cell count, hyperglycemia, abnormal liver function, low blood calcium, abnormal blood gas analysis and DIC index. Diagnostic puncture is occasionally used for diagnosis, and the puncture fluid is bloody and cloudy. Elevated amylase and lipase have diagnostic significance and are not ideal for diagnosis due to the invasiveness and possible complications of this method.
2. Radiographic diagnosis
(1) Chest X-ray Left lung lower lobe atelectasis, elevated left hemidiaphragm, and left-sided pleural fluid reflect inflammation around the diaphragm and retroperitoneum. It supports the diagnosis of acute pancreatitis but lacks specificity and is a supplementary diagnostic indicator.
(2) Plain film of the abdomen shows the duodenum is inflated, indicating paralytic dilatation of the proximal jejunum. It also shows the sign of interrupted colon, indicating paralyzed dilatation of transverse colon, and no gas shadow in splenic flexure colon and distal colon. Or, gallstone shadow and pancreatic duct stone shadow can be seen, and the disappearance of lumbar large muscle shadow. It is an auxiliary diagnostic method for acute pancreatitis.
(3) Abdominal ultrasound can be helpful for diagnosis; ultrasound scan can detect pancreatic edema and peripancreatic fluid accumulation, and can also detect gallbladder stones and bile duct stones, but its application is limited by the covering of localized inflatable intestinal collaterals.
(4) Enhanced CT scan is a sensitive and widely accepted method to confirm the diagnosis of acute pancreatitis in recent years. Changes in the pancreas include diffuse or focal pancreatic enlargement, edema, necrotic liquefaction, blurring and thickening of peripancreatic tissues, and visible effusion. Complications of acute pancreatitis, such as pancreatic abscesses, pseudocysts, or necrosis, can also be detected, and enhanced CT scans with hypodense necrotic areas (11.1mnol/L), decreased blood calcium (<1.87mmol/L), increased blood urea nitrogen or creatinine, and acidosis; a decrease in Pa02 of <8kPa (<60mmHg) should be considered for acute respiratory distress syndrome (ARDS); even the presence of Disseminated intravascular coagulation (DIC), acute renal failure and so on. The mortality rate is high.
Diagnosis
Diagnosis is mainly based on clinical manifestations, laboratory tests and imaging findings.
Differential diagnosis
The differential diagnosis of this disease should take into account the gastroduodenal, hepatobiliary diseases and other endocrine disorders. The clinical manifestations of non-biliary chronic pancreatitis are basically the same as that of this disease, but the history is obviously different, and there are no signs and symptoms of biliary diseases, so it is not difficult to differentiate. It is easy to be confused with pancreatic cancer and pancreatic cysts.
Complications
1. Diabetes mellitus may be manifested as polydipsia and emaciation, which is usually progressive.
2. Liver cirrhosis, hepatosplenomegaly, ascites, etc.
3. Jaundice with fibrosis of the head of the pancreas, constrictive papillitis, and obstructive jaundice in case of choledocholithiasis.
Treatment
1.Surgery
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: uncertainty of diagnosis; secondary pancreatic infection; biliary tract disease; and worsening of clinical symptoms despite rational supportive therapy.
(1) Surgical treatment of secondary pancreatic infection There are two main surgical methods: ① Dissection to remove necrotic tissue, placement of multiple porous drains for continuous postoperative irrigation, and then suturing the incision. ② Dissection to remove necrotic tissue and partially open drainage of the wound. The transabdominal route is easy to visualize, especially with a transverse epigastric incision for easier intraoperative visualization and manipulation. Intraoperative removal of thick pus and infected necrotic tissue filled with tissue debris, not regular pancreatectomy, avoid dissection with sharp instruments to prevent pancreatic duct injury. The peripancreas is freed and loosened and flushed, and regional drainage is adequate, with multiple drains placed for postoperative irrigation. The wound is partially open for drainage, in addition to adequate drainage, it also facilitates the removal of pancreatic tissue that continues to necrose several times after surgery. Simultaneous gastrostomy, jejunostomy (for enteral nutritional support) and biliary drainage can be performed in the water. Occasionally, single abscess or infected pancreatic pseudocyst can be treated with percutaneous puncture tube drainage.
(2) Management of biliary pancreatitis In severe biliary pancreatitis with embedded stones in the jugular abdomen, combined with biliary obstruction or biliary tract infection, emergency surgery or early (within 72 hours) surgery should be performed to relieve biliary obstruction, remove the stones, and smooth drainage, and according to the condition of the need to choose to perform cholecystectomy or small omental cavity pancreatic area drainage. When available, the stone can be removed by fiberoptic duodenoscopic Oddi sphincterotomy, which is effective and has 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 be able to evacuate the stone on their own during hospitalization and do not require further surgery. Alternatively, patients may be admitted to the hospital for biliary surgery 2-4 weeks after the acute pancreatitis is cured.
2. Drug therapy
According to the clinical manifestations and typing, choose the appropriate treatment method.
(1) Fasting, nasogastric tube decompression Continuous gastrointestinal decompression to prevent vomiting and aspiration. Giving full gastrointestinal power drugs can reduce abdominal distension. The initial stage of acute pancreatitis, mild pancreatitis and those who are not yet infected should be treated non-surgically.
(2) Supplementation of body fluids and prevention of shock All patients should be supplemented with fluids, electrolytes and calories intravenously to maintain circulatory stability and water-electrolyte balance. Preventing hypotension, improving microcirculation, and ensuring pancreatic blood perfusion are beneficial to the treatment of acute pancreatitis.
(3) antispasmodic analgesic Diagnosis is clear, the early onset of symptoms can be given to the analgesic (pethidine), but it is appropriate to give antispasmodic drugs at the same time (scopolamine, atropine), prohibit morphine, so as not to cause spasm of the sphincter of Oddi.
(4) Inhibition of pancreatic exocrine and pancreatic enzyme inhibitors Gastric tube decompression, H2 receptor blockers (such as cimetidine), anticholinergics (such as scopolamine, atropine), growth inhibitors, etc., but the latter is expensive and is generally used in patients with more serious conditions. Trypsin inhibitors, such as peptidase, gabexate, etc., have a certain effect of inhibiting trypsin.
(5) Nutritional support Early fasting, mainly rely on complete parenteral nutrition (TPN). Diet can be resumed when abdominal pain, pressure pain and intestinal obstruction symptoms are reduced. Fat emulsion can be applied as a heat source except for hyperlipidemic patients.
(6) Application of antibiotics Early antibiotic treatment can be given. In severe pancreatitis combined with pancreatic or peripancreatic necrosis, broad-spectrum antibiotics applied intravenously or selective trans-intestinal application of antibiotics can prevent bacterial infections and fungal infections due to intestinal flora shift.
(7) Traditional Chinese medicine (TCM) treatment In the case of basic control of vomiting, TCM is injected through the gastric tube, and the tube is clamped for 2 hours after injection. Commonly used, such as Compound Pancreas Clearing Tang plus reduction: Yinhua, forsythia, Huanglian, Scutellaria baicalensis, Houpu, Citrus aurantium, Mucuna pruriens, safflower, raw rhubarb (after the next). Can also be used alone with raw rhubarb 15g gastric tube infusion, 2 times a day.
(8) Treatment of abdominal exudate The abdominal exudate of acute pancreatitis contains many harmful substances, which can lead to hypotension, respiratory failure, hepatic failure and changes in vascular permeability. In severe pancreatitis, it is generally believed that the abdominal exudate can be self-absorbed. If the abdominal distension is obvious and the abdominal exudate is large, abdominal lavage should be performed.
Precautions
1. The course of biliary chronic pancreatitis is prolonged, the patient should establish confidence in overcoming the disease, actively cooperate with the treatment, and persevere.
2. In case of an acute attack, go to the hospital in time and take further treatment according to acute pancreatitis. If there is no acute attack, you should go to the hospital for regular checkups.
3. Those with diabetes should control their diet according to medical advice and apply hypoglycemic drugs under the guidance of physicians.
4. Those with diarrhea should adopt a diet high in sugar, high in protein and low in fat, or add pancreatic enzyme tablets and other drugs, do not abuse antibacterial drugs.
5. If there is any biliary tract disease, it should be treated actively, and if necessary, surgical treatment should be performed to facilitate the recovery of pancreatic disease.
6. Alcohol must be prohibited, smoking cessation, avoid overfeeding, satiety, so as not to further damage the function of the pancreas.