LECTURE: Diseases of pancreas. Acute and chronic pancreatitis, its complications. Etiology, pathogenesis, clinic and treatment. Author – reader R.Ya. Kushnir

The basis of disease of pancreas is degenerative-inflammatory processes which are considered to be acute pancreatitis, the so called autolysis tissue by its own enzymes.

“Starting” factors of origin of cholelithiasis disease - an alcohol and food overloads (fat and irritating products); - traumas of pancreas; - separate infectious diseases (parotitis, mononucleosis) - infection of bilious ways; - in 10–20 % of patients the reason of acute pancreatitis remains unknown (cryptogenic form).

Classification (V All-russian convention of surgeons, 1978) I. Clinico-anatomy forms: 1. Arching form. 2. Fatty pancreatonecrosis. 3. Hemorrhagic pancreatonecrosis. II. Prevalence of necrosis: 1. Local (focus) damage of gland. 2. Subtotal damage of gland. 3. Total damage of gland.

Classification III. Ran across: abortive, progressive. IV. Periods of disease: 1. Period of hemodynamic violations and pancreatogenic shock. 2. Period of functional insufficiency of parenchymatous organs. 3. Period of degenerative and festering complications.

Clinical passing Pain, vomiting and phenomena of dynamic intestinal obstruction are considered the most characteristic signs of acute pancreatitis.

Symptoms The Mondor’s symptom is violet spots on face and trunk. The Lagermph's symptom is acute cyanosys of person. The Halsted's symptom is cyanosys of abdominal skin. The Gray's symptom is cyanosys of lateral walls of abdomen. The Kullen's symptom is the yellow colouring of skin near a belly-button.

Symptoms The Korte's symptom is painful resistance as a lumbar bar in a epigastric area on 6–7 cm higher belly-button. The Voskresynskyy's symptom is absence of pulsation of abdominal aorta in an epigastric area. The Mayo-Robson's symptom is feeling of pain at pressure by fingers in the left costal-vertebral corner. The Rozdolskyy's symptom — painfulness at percussion above pancreas. The Blumberg's symptom — in patients with acute pancreatitis more frequently is low-grade.

Clinical passing of pancreatonecrosis The I period (hemodynamic violations and pancreatogenic shock) The II period (insufficiency of parenchymatous organs) The III period (postnecrosis dystrophic and festering complications)

Variants of clinical passing and complications Clinical passing of disease can be: Abortive; Slowly; Quickly progressive

Diagnosis program 1. Anamnesis and physical methods of inspection. 2. General analysis of blood and urine. 3. Biochemical blood test (amylase, bilirubin, sugar). 4. Analysis of urine on diastase. 5. Sonography.

Diagnosis program 6. Computer tomography. 7. Cholecystocholangiography. 8. Endoscopic retrograde cholangiopancreatography. 9. Laparoscopy. 10. Laparocentesis.

Surgical treatment Cholecystectomy Transduodenal sphincteroplasty Omentopancreatopexy. Abdominisation of pancreas. Sequestrectomy Necrectomy The resection of pancreas Pancreatectomy

Chronic pancreatitis Chronic pancreatitis is a progressive inflammation of pancreas with the periodic acutening and remission.

Classification (by O.O. Shalimov) 1. Chronic fibrous pancreatitis without violation of patency of main pancreatic duct. 2. Chronic fibrous pancreatitis with violation of patency of main pancreatic duct, dilatated ducts of pancreas and hypertension of pancreatic juice. 3. Chronic fibrous-degenerative pancreatitis.

Classification Taking into account clinical passing of chronic pancreatitis, classification of O.O. Shelagurov (1970) can have some changes. Such forms are selected: 1. Chronic recurrent pancreatitis. 2. Chronic pain pancreatitis. 3. Chronic painless (latent) pancreatitis. 4. Chronic pseudo tumor-like pancreatitis. 5. Chronic cholecystocholangiopancreatitis (cholangiogenic pancreatitis). 6. Chronic indurative pancreatitis

Variants of clinical passing Chronic recurrent pancreatitis. Chronic pain pancreatitis. Chronic painless (latent) pancreatitis. Chronic pseudo tumor-like pancreatitis. Chronic cholangiogenic pancreatitis. Chronic indurative pancreatitis

Diagnosis program 1. Anamnesis and physical methods of inspection. 2. General analysis of blood. 3. Biochemical blood test (amylase, bilirubin, sugar). 4. Analysis of urine on diastase. 5. Coprograma.

Diagnosis program 6. Sonography. 7. Relaxation duodenogram. 8. Cholecystocholangiography. 9. Retrograde cholangiopancreatography. 10. Computer tomography.

Surgical methods of treatment Operative treatment is done in case of: 1) calcinosis pancreas with the expressed pain syndrome; 2) violation of patency of duct of pancreas; 3) presence of cyst or fistula of resistance to conservative therapy during 2–4 months; 4) mechanical icterus on soil of tubular stenosis of distal part of general bilious duct;

Surgical methods of treatment 5) compression and thrombosis of portal vein; 6) gallstone disease complicated by chronic pancreatitis; 7) ulcerous disease of stomach and duodenum complicated by secondary pancreatitis; 8) duodenostasis, complicated by chronic pancreatitis; 9) impossibility of exception to operation tumors or violations of arterial circulation of blood of pancreas

Cysts of pancreas Cyst of pancreas is a cavity, filled by liquid (pancreatic juice, exudation, pus), intimately soldered with head, body or tail of organ, is limited by capsule, which has epithelium on internal surface. Pseudocyst (unreal cyst) is a cavity in pancreas which appears as a result of its destruction, limited by capsule, that does not have epithelium on internal surface.

Classification (by A.N. Bakulev and V.V. Vinogradov, 1952) I. Innate cysts of pancreas: 1. Dermoid cysts. 2. Teratoid cysts. 3. Innate adenomas. 4. Fibrocystic degeneration. 5. Polycystic degeneration.

Classification II. Inflammatory cysts: 1. Pseudocysts. 2. Retention cysts. III. Traumatic cysts: 1. As a result of direct damage of gland. 2. As a result of indirect damage of gland.

Classification IV. Parasite cysts: 1. Echinococcosis glands. 2. Cysticercosis glands. V. Neoplasty cysts: 1. Cyst-adenoma. 2. Cyst-adenocarcinoma. 3. Cavernous hemangioma. 4. Cystic epithelioma.

Stages of forming of pseudocyst I stage (1–1,5 months last) — in the center of inflammatory process the cavity of disintegration, which takes surrounding tissue, appears in an omentum bag. The II stage (2–3 months) is characterized by the beginning of forming of capsule of pseudocyst. Cyst is magnificent, unformed, acute inflammatory phenomena calms down.

Stages of forming of pseudocyst The III stage (3–12 months) is completion of forming of capsule of pseudocyst. Last accretes with surrounding organs. The IV stage (begins an in year from the origin of cyst) is a separated cyst. The cyst is mobile, easily selected from connections with surrounding organs.

Diagnosis program 1. Anamnesis. 2. Biochemical blood test (amylase, sugar, bilirubin). 3. Analysis of urine on diastase. 4. Coprograma.

Diagnosis program 5. Sonography. 6. Contrasting sciagraphy of stomach and duodenum (relaxation duodenography). 7. Retrograde pancreatocholangiography. 8. Computer tomography.

Choice of treatment method On the I stage operation is not used; On the II stage it is used at suppuration of pseudocyst (external draining of cyst); On the III — internal draining of cyst is used. Marsupialization (opening and sewing down of cyst to the parietal peritoneum and skin) is used infrequently;

Choice of treatment method On the IV stage external and internal draining of cyst and radical operations are applied: a) enucleation of cysts (executed very rarely); b) distal resection of pancreas with a cyst.