The cause of this disease is still not well understood, the cause of pancreatitis is related to excessive alcohol consumption, gallstones in the bile ducts, etc.
1, obstruction factors
Bile reflux due to bile duct roundworms, lack of special jug abdominal stones embedded, narrowing of duodenal papilla, etc. If the lower end of the bile duct is obviously obstructed, the pressure in the bile duct is very high, and the high pressure bile flows back into the pancreatic duct, causing the rupture of the pancreatic alveoli, and pancreatic enzymes enter the pancreatic interstitium and pancreatitis occurs.
2. Alcohol factor
Long-term drinkers are prone to pancreatitis, on the basis of which, when a large amount of alcohol and overeating, promote the secretion of pancreatic enzymes, resulting in a sudden rise in pressure in the pancreatic duct, causing the rupture of the pancreatic vesicles, pancreatic enzymes into the interstitium between the vesicles and promote acute pancreatitis. Alcohol and high-protein, high-fat food intake at the same time, not only increased pancreatic enzyme secretion, but also can cause hyperlipoproteinemia. This is when pancreatic lipase breaks down triglycerides to release free fatty acids and damage the pancreas.
3, vascular factors
Acute embolism and obstruction of the small arteries and veins of the pancreas can lead to acute pancreatitis due to acute blood circulation disorders in the pancreas. The stimulation of pancreatic enzymes causes embolism of the lymphatic ducts, veins and arteries in the interstitium, followed by ischemic necrosis of the pancreas.
4.Trauma
Trauma to the pancreas causes rupture of the pancreatic duct, spillage of pancreatic fluid and insufficient blood supply after trauma, leading to acute heavy pancreatitis.
5.Infection factors
Acute pancreatitis can occur with various bacterial infections and viral infections, and viruses or bacteria enter the pancreatic tissue through the blood or lymph and cause pancreatitis. In general, this infection is simple edematous pancreatitis, the occurrence of hemorrhagic necrotizing pancreatitis is less.
6, metabolic diseases
Can be related to hypercalcemia, hyperlipidemia and other conditions.
7.Other factors
Such as drug allergy, hemochromatosis, genetics, etc.
Clinical manifestations
The main symptoms of acute edematous pancreatitis are abdominal pain, nausea, vomiting, and fever, while hemorrhagic necrotizing pancreatitis may present with shock, high fever, jaundice, abdominal distention and even intestinal paralysis, peritoneal irritation signs, and subcutaneous bruises.
1.General symptoms
(1) Abdominal pain: the earliest symptom, often occurs after overeating or extreme fatigue, mostly sudden onset, located in the epigastric center or left. The pain is continuous and progressive, like a knife cut. The pain radiates to the back and the hypochondrium. In case of hemorrhagic necrotizing pancreatitis, the onset of the disease will be a short time after the onset of total abdominal pain, acute abdominal distension, and soon after the onset of shock of varying severity.
(2) nausea, vomiting: frequent episodes, initially into the food bile-like material, progressive aggravation of the disease, soon into intestinal paralysis, then vomit material for fecal-like.
(3) Jaundice: Acute edematous pancreatitis occurs less often, accounting for about 1/4, while in acute hemorrhagic pancreatitis occurs more often.
(4) Dehydration: Dehydration in acute pancreatitis is mainly due to intestinal paralysis and vomiting, while heavy pancreatitis can develop severe dehydration and electrolyte disturbances in a short period of time. In hemorrhagic necrotizing pancreatitis, severe dehydration can occur a few hours to 10 hours after the onset of the disease, with no or little urination.
(5) Due to massive inflammatory exudation from the pancreas, resulting in necrosis and limited abscesses of the pancreas, body temperature may rise to varying degrees. In the case of mild pancreatitis, the body temperature is generally within 39°C and can drop in 3 to 5 days. In the case of heavy pancreatitis, the temperature is often 39 to 40°C, often with delirium, which does not subside for several weeks, and manifestations of toxemia.
(6) A few hemorrhagic necrotizing pancreatitis, pancreatic fluid and even necrotic dissolved tissue along the tissue gap to the subcutaneous, and dissolve the subcutaneous fat, and capillary rupture bleeding, so that the local skin is blue-purple, some can melt into large pieces, in the waist before the lower abdominal wall, but also in the umbilicus.
(7) The location of the pancreas is deep in the general light edematous pancreatitis has pressure pain deep in the upper abdomen, and a few have obvious pressure pain in the anterior abdominal wall. In acute heavy pancreatitis, due to its large amount of pancreatic lysis, necrosis and hemorrhage, the anterior and posterior peritoneum are involved, the whole abdominal muscles are tight, indurated, the whole abdomen is distended, and there may be a large amount of inflammatory ascites, and mobile turbid sounds may appear. Bowel sounds disappear and paralytic intestinal obstruction appears.
(8) Due to the inflammatory stimulation of exudate, reactive pleural effusion may appear, with the left side being the most common, which may cause ipsilateral pulmonary atelectasis and respiratory distress.
(9) A large amount of necrotic tissue accumulates in the small omental sac, and a bulging mass can be seen in the epigastrium, which is painful to palpation and often has unclear borders. In a few patients, signs such as pressure pain in the abdomen are no longer obvious, but there is still high fever, increased white blood cell count and even regular manifestations like “partial intestinal obstruction”.
2.Local complications
(1) Pancreatic abscess: It often appears 2 to 3 weeks after the onset of the disease. At this time, the patient has high fever with toxic symptoms, increased abdominal pain, a mass in the upper abdomen can be found, and the white blood cell count is significantly elevated. The puncture fluid is purulent, and the culture has bacterial growth.
(2) Pancreatic pseudocyst: mostly formed 3-4 weeks after the onset of the disease. Physical examination often reveals a mass in the upper abdomen, and large cysts can compress adjacent tissues to produce corresponding symptoms.
3. Systemic complications
There are often complications such as acute respiratory failure, acute renal failure, heart failure, gastrointestinal bleeding, pancreatic encephalopathy, sepsis and fungal infection, hyperglycemia, etc.
Examination
1.Blood routine
Most of them have increased white blood cell count and left shift of neutrophil nucleus.
2.Blood and urine amylase measurement
Serum (pancreatic) amylase starts to rise 6-12 hours after the onset of the disease, and starts to fall 48 hours, lasting for 3-5 days. The diagnosis of the disease can be confirmed if the serum amylase exceeds 3 times the normal value.
3.Serum lipase measurement
Serum lipase often begins to rise 24 to 72 hours after the onset of the disease and lasts for 7 to 10 days. It has diagnostic value for patients with acute pancreatitis who are diagnosed late after the disease and has a high specificity.
4. Amylase endogenous creatinine clearance ratio
In acute pancreatitis, it may be due to the increase in vasoactive substances that increase glomerular permeability and increase in renal clearance of amylase while the clearance of creatinine remains unchanged.
5.Serum orthoferric albumin
When intra-abdominal hemorrhage, erythrocyte destruction releases hemoglobin, which can be changed into ortho-ferric hemoglobin by the action of fatty acid and elastase, and the latter is combined with albumin to form ortho-ferric albumin, which is often positive when severe pancreatitis starts.
6.Biochemical examination
Temporary elevation of blood glucose, persistent fasting blood glucose higher than 10mmol/L reflects pancreatic necrosis and suggests poor prognosis. Hyperbilirubinemia is seen in a small number of clinical patients, and mostly returns to normal 4-7 days after the onset.
7.X-ray abdominal plain film
It can exclude other acute abdominal diseases, such as visceral perforation, “sentinel loop” and “colonic cut sign” are indirect indications of pancreatitis, diffuse blurred shadow of lumbar major muscle with unclear edges suggest the presence of pneumoperitoneum, and intestinal paralysis or paralytic intestinal obstruction can be found.
8.Abdominal ultrasound
Ultrasound in acute pancreatitis can show enlarged pancreas and abnormal echogenicity in and around the pancreas; it can also understand the situation of gallbladder and bile duct; later it has diagnostic significance for abscess and pseudocyst, but the patient’s abdominal distension often affects its observation.
9.CT imaging
It can help to determine the severity of acute pancreatitis and whether nearby organs are involved.
Differential diagnosis
Acute pancreatitis should be differentiated from the following diseases.
1. Acute perforation of peptic ulcer
A more typical history of ulcer, sudden increase in abdominal pain, abdominal muscle tension, loss of hepatic turbid sounds, and free gas under the diaphragm as seen on X-ray fluoroscopy can be differentiated.
2. Cholelithiasis and acute cholecystitis
There is often a history of biliary colic, the pain is located in the right upper abdomen, often radiating to the right shoulder, Murphy’s sign is positive, blood and urine amylase is mildly elevated, ultrasound and x-ray cholangiography can make a clear diagnosis.
3.Acute intestinal obstruction
Abdominal pain is paroxysmal, abdominal distension, vomiting, hyperactive intestinal sounds, with air over water sound, no exhaust, visible intestinal pattern, abdominal X-ray can be seen in the plane of liquid and gas.
4.myocardial infarction
History of coronary heart disease, sudden onset, sometimes the pain is limited to the upper abdomen, electrocardiogram shows images of myocardial infarction, elevated serum cardiac enzymes, normal blood and urine amylase.
Treatment
1.Non-surgical treatment
Prevention and treatment of shock, improvement of microcirculation, antispasmodic, analgesic, inhibition of pancreatic enzyme secretion, anti-infection, nutritional support, prevention of complications, and some measures to strengthen intensive care, etc.
(1) Prevention and treatment of shock to improve microcirculation Fluids, electrolytes and calories should be actively replenished to maintain circulatory stability and water-electrolyte balance.
(2) Inhibit pancreatic secretion ① H2 receptor blocker; ② peptidase inhibition; ③ 5-fluorouracil; ④ fasting and gastrointestinal decompression.
(3) Antispasmodic and analgesic should be given regularly, the traditional method is intravenous drip of 0,1% procaine for intravenous closure. And can be used regularly with dulcolax and atropine, both pain relief and can release the Oddi sphincter spasm, morphine is prohibited, so as not to cause the Oddi sphincter spasm. In addition, isoamyl nitrite, glyceryl nitrite, etc. used in severe pain, especially in older patients, can release the spasm of the sphincter of Oddi to a certain extent, while the coronary artery blood supply is also very beneficial.
(4) Nutritional support in acute heavy pancreatitis, the body’s catabolism is high, inflammatory exudate, long-term fasting, hyperthermia, etc., the patient is in negative nitrogen balance and hypoproteinemia, so nutritional support is needed, while giving nutritional support, but also to make the pancreas does not secrete or less secretion.
(5) The application of antibiotics for acute pancreatitis is one of the indispensable elements of comprehensive treatment. The application of antibiotics in acute hemorrhagic necrotizing pancreatitis is unquestionable. Acute edematous pancreatitis, as the prevention of secondary infection, should be reasonable use of a certain amount of antibiotics.
(6) Peritoneal cavity lavage can be done for those who have a lot of exudation in the abdominal cavity, so that the fluid containing a lot of pancreatic enzymes and toxin substances in the abdominal cavity can be diluted and eliminated from the body.
(7) Strengthen monitoring.
(8) Indirect hypothermia therapy.
2.Surgical treatment
Although there is limited regional pancreatic necrosis and exudation, if there is no infection and the symptoms of systemic toxicity are not very serious, there is no need to operate urgently. If there is infection, the patient should be treated surgically accordingly.
Prognosis
The mortality rate of acute pancreatitis is about 10%, and almost all deaths are from the first episode. The presence of respiratory insufficiency or hypocalcemia suggests a poor prognosis. Severe necrotizing pancreatitis has a mortality rate of 50% or higher, which can be reduced to about 20% with surgical treatment.