Acute pancreatitis pathogenesis Modern medical research believes that bile duct disorders, ethanol poisoning, overeating, pancreatic duct obstruction, hyperlipidemia and hypercalcemia are the main causes of its development. The synthetic digestive juices can cause “self-digestion” of the pancreas, which can erode the pancreas and dissolve the elastic tissues, and the rapid development of systemic inflammatory reactions. The theory of pancreatic microcirculatory disorders is one of the important mechanisms in the pathogenesis of pancreatitis, and pancreatic blood flow disorders are present throughout the development of acute pancreatitis, and pancreatic necrosis is positively correlated with inadequate pancreatic perfusion. Thus, an effective treatment strategy should be to improve microcirculation and protect the viability of pancreatic tissue, not only to maintain hemodynamic stability. Heat toxicity is the basic pathogenesis of acute pancreatitis, blood stasis is the inevitable evolution of the pathogenesis, and spleen and stomach dysfunction, dysregulation of circulation and internal Qi exist throughout the development of the disease.
Acute pancreatitis belongs to the category of “abdominal pain” and “vomiting” in Chinese medicine, and Chinese medicine believes that the main cause of this disease is dampness and heat, stasis and obstruction, and pain if it does not pass. On the basis of modern medical treatment to stabilize the internal environment, inhibit the secretion of pancreatic fluid, decompress the stomach and intestines, and laxative treatment, together with Chinese herbal medicine to clear heat and detoxify the body, pass through the lining and attack, benefit qi and nourish yin, activate blood circulation, and acupuncture point injection, it can rapidly improve the symptoms of intestinal paralysis, open up the gastrointestinal channels, and reduce the inflammatory reaction. Rhubarb can also promote intestinal peristalsis, eliminate intestinal paralysis, help drainage of bile and pancreatic juice and control of bile duct inflammation, and achieve the purpose of “the six internal organs are used to pass, and pass is not painful”. The microcirculatory disorder is an important factor in the deterioration of acute pancreatitis, so activating blood circulation and removing blood stasis can also help improve pancreatic microcirculation and promote the recovery of the pancreas. In the First Affiliated Hospital of West China, Sichuan University, more than 80% of pancreatitis is treated in the Department of Integrative Medicine. The effect is remarkable.
Treatment methods
1. Non-surgical treatment is suitable for the initial stage of acute pancreatitis, mild pancreatitis and those who are not yet infected.
(1) Close observation and monitoring 1) monitoring of vital signs such as mental, blood pressure, pulse, respiration, urine volume, body temperature, etc. 2) regular measurement of blood, urine amylase, blood electrolytes, serum calcium, blood glucose, blood white blood cell count, blood gas analysis, etc. Do dynamic ultrasound and CT examination if necessary. 3) Closely observe the occurrence of systemic complications, such as shock, changes in cardiac, pulmonary and renal functions.
(2) Reduce pancreatic secretion 1) fasting and gastrointestinal decompression: to reduce gastric acid secretion, aspirate gastric contents, prevent entry into the duodenum to stimulate pancreatic secretion, and reduce abdominal distension. 2) anticholinergic drugs: such as metformin, ranitidine and other drugs that inhibit gastric acid secretion to reduce pancreatic exocrine secretion. 3) application of growth inhibitors: such as santodine and stanozolam, which can effectively inhibit the secretory function of the pancreas.
(3) Anti-shock, fluid supplementation, and enhanced nutritional support: maintain water and electrolyte balance and supplement calories.
(4) Antibiotic application: Early antibiotic treatment is given for the purpose of prophylaxis and prevention of bacterial and fungal infections caused by intestinal bacterial translocation.
(5) Inhibition of pancreatic enzymes: early application of pancreatic enzyme inhibitors in critically ill patients to inhibit the synthesis of pancreatic enzymes.
(6) Antispasmodic and analgesic: After the diagnosis is clear, methylphenidate can be given for pain, but antispasmodics (scopolamine, atropine) should be given at the same time. Morphine is prohibited to avoid spastic contraction of the 0ddi sphincter.
(7) Peritoneal lavage: used for severe pancreatitis with obvious abdominal distension and more abdominal exudate. Method: Place a peritoneal tube at the level of the pancreas in the umbilicus with a 2-finger poke, insert an outflow tube under the umbilicus to reach the lowest level of the abdominal cavity, instill 1000 ml through the infusion tube within 15 minutes, and after 30 minutes of clamping, open the outflow tube for 1 hour, and repeat this until the peritoneal lavage fluid is not cloudy and the amylase measurement is normal.
2.Surgical treatment
(1) Indications for surgery for acute pancreatitis
(1) Unclear diagnosis.
(2) Secondary pancreatic infection.
(3) Combined with biliary tract disease.
(4) Clinical symptoms continue to deteriorate after treatment by non-surgical therapy.
The purpose of surgery is to remove pancreatic enzymes, toxic substances and necrotic tissues.
(2) Surgical methods
(1) Dissection to remove the pancreas and surrounding necrotic tissues: According to the lesions of the pancreas and its surrounding tissues, the peritoneum of the pancreas and the surrounding retroperitoneum are incised to remove as much necrotic tissue as possible. In some cases, regular pancreatic resection is feasible, but caution should be exercised so as not to remove too much normal tissue.
(2) Adequate drainage: Because the necrotic process of pancreatitis is a dynamic change, the tissue that has not been necrotic at the time of surgery can still be necrotic after surgery, therefore, after removing the necrotic tissue, multiple drains need to be placed; or open the wound with saline gauze for drainage. The necrotic tissue can be removed again later under anesthesia. Double trocar drainage is also available, and postoperative irrigation is performed to continue drainage of necrotic tissue and exudate.
(3) Other treatment: If the biliary tract is diseased, intraoperative attention should be paid to removing gallstones, biliary roundworms, etc., and placing a “T” tube for bile drainage. If necessary, a gastrostomy should be performed for gastrointestinal decompression; a jejunostomy should be performed for the infusion of nutritional elements.
Combination of Chinese and Western medicine treatment features
1. In the acute stage of pancreatitis, our department selects Chaiqinchengqi Tang plus reduction, Qingxia Yihuo treatment (clearing heat and detoxifying, Tongli attacking, benefitting Qi and strengthening spleen, activating blood circulation), Chinese medicine emphasizes temporality, preferably 100-120ml/q1h, and gastrointestinal decompression after nasal or oral feeding. Use it frequently to promote the recovery of gastrointestinal power and open up the gastrointestinal channels.
2, Chinese medicine rectal drip into our department with large Cheng Qi Tang plus or minus enema, heavy use of rhubarb, mannitol, with oral Chinese medicine, in the early stage of pancreatitis, with oral Chinese medicine, emphasizing the full amount, suggesting q2h~q4h enema, gradually reduce the times after the improvement of intestinal paralysis symptoms. Promote the recovery of gastrointestinal power.
3.Acupoint injection can use neostigmine acupuncture point injection of the feet three miles to promote intestinal dynamics.
4.Therapeutic treatment with Chinese herbal medicine seal pack and baking lamp using Chinese herbal medicine applied externally on the pancreas and its exuding parts, together with infrared baking lamp to promote the absorption of pancreatic juice.
During the recovery period of pancreatitis, the use of Chinese herbal medicine to regulate the spleen and stomach and to regulate the qi and blood can effectively reduce the complications of pancreatitis through the diagnosis and treatment of Chinese medicine.