1. Chronic pancreatitis Lykhatska G.V

2. Plan of the lecture  Etiopathogenesis of chronic pancreatitis  Сlassification of chronic pancreatitis  Clinic of chronic pancreatitis  Diagnosis of chronic pancreatitis  Complications of chronic pancreatitis  Differential diagnosis  Treatment of chronic pancreatitis

3. Chronic pancreatitis Chronic pancreatitis  Chronic pancreatitis is a long-standing inflammation of the pancreas that alters its normal structure and functions.

4. Etiology of chronic pancreatitis Primary pancreatitis :  Misuse of alcohol (70-80% of all diagnostic cases )  the systematic eating of fatty foods  influence of drugs ( azathioprine, isoniazide, tetracycline, sulfonamides )  protein deficiency  Hereditary  Ischemic ( in lesions of vascular, which supplies blood pancreas )  Idiopathic

5. Etiology of chronic pancreatitis Etiology of chronic pancreatitis Secondary pancreatitis :  diseases of the biliary tract ( in 30-40% )  disease of duodenum  a primary ( tumors, papillitis ) and a secondary ( dyskinesia of billiary tract )  liver disease  bowel disease  bowel disease  viral infections ( parotitis )  allergic conditions  hyperlipidemia  hyperparathyroidism  injury of the pancreas

6. The pathogenesis of c hronic pancreatitis  The main pathogenetic mechanism of the development of c hronic pancreatitis is acinuses destructive damage acinuses, caused intracellular activation of enzymes pancreas.  Has significance violation of the outflow of pancreatic juice  The progressive fibrosis coused the violation phisiologycal function of the gland.

7. Classification chronic calcified pancreatitis Classification chronic calcified pancreatitis chronic obstructive pancreatitis chronic inflammatory pancreatitis  Chronic pancreatitis of alcoholic etiology  Others forms chronic pancreatitis (chronic pancreatitis unspecified etiology, infectious, recurrent )  Pancreatic cysts  Pancreatic pseudocyst

8. Clinical classification of c hronic pancreatitis The course of the disease :  1. mild severity - signs of violation exocrine and endocrine function not detected.  2. moderate - signs of violation exocrine – and endocrine function  3. severe (terminal) - the presence of resistant pancreatic diarrhea, hypovitaminosis, exhaustion.

9. Clinical classification of c hronic pancreatitis On the functional characteristics On the functional characteristics 1. In violation of exocrine pancreatic function 2. In violation of the endocrine function of the pancreas The phases of desease: - exacerbation, - remission. - exacerbation, - remission. complication complication

10. THE CLINIC The clinical picture of chronic pancreatitis is leading :  pain syndrome  dyspeptic syndrome  Syndrome of the external secretory pancreatic insufficiency and its related syndromes of maldygestion and malabsorption with progressive loss of body weight  Endocrine insufficiency syndrome ( pancreatic diabetes)  asthenic-neurotic syndrome

11. Duration of chronic pancreatitis is divided into 3 phases :  initial stage (1-5 years ) – the most frequent manifestation is the pain  expanded clinical picture (5-10 years ) – main manifestation is the pain, the signs of exocrine insufficiency і, the elements of incretory insufficiency ( hyperglycemia, hypoglycemia )  Remission of active pathological process or development of complications.

12. THE CLINIC The dyspeptic syndrome The dyspeptic syndrome  reduce or loss of appetite,  salivation,  nausea,  vomiting, that does not bring relief  abdominal bloating,  Disorders of defecation (prevalence diarrhea or change diarrhea with constipation ).

13. CLINIC Exogenous deficiency syndrome -  -" pancreatic " diarrhea,creatorea, steatorea.  the loss of body weight with a development of osteoporosis (the bone pain), as a result of excessive removing of calcium and deficiency of vitamin D.

14. The clinical course  Chronic recurrent pancreatitis — the most frequent form for which is characterized by bouts of painful crises, that combined with increasing levels of pancreatic enzymes in the blood and urine, and sometimes with jaundice. in the phase of remission can persist dyspeptic syndrome.  Painful form — is characterized by constant dull pain in the left upper quadrant and by laboratory data, that confirm the diagnosis of pancreatitis ( a history of data transferred pancreonecrosis).  Latent form — is characterized by painless course. The primary are dyspeptic syndrome and a fact of exocrine insufficiency of pancreas.  Psevdotumorz form — is characterized by combination of jaundice with disorders of internal and the external exocrine function of pancreas. Often occurs clinically as cancer of head of pancreas and correct diagnosis is established only after surgery.

15. Laboratory diagnostics :  1. Complete blood count : 25% of patients have a leukocytosis and ESR acceleration.  2. The results of determine the activity of pancreatic enzymes (amylase, lipase, trypsin in the blood and urine— there is an increase of their activity when the desease is exacerbated). 85-90% of patients the creased activity of α-amylase for 1- day of disease, 60-70% of patients for 2-day of disease, 40- 50% for 3-day of disease. Under normal numbers of amylase it possible to use exercise testing : investigate amylase at an altitude of pain, after endoscopy, X-ray. 85-90% of patients the creased activity of α-amylase for 1- day of disease, 60-70% of patients for 2-day of disease, 40- 50% for 3-day of disease. Under normal numbers of amylase it possible to use exercise testing : investigate amylase at an altitude of pain, after endoscopy, X-ray.

16. Diagnosis of exocrine pancreatic insufficiency METHODS:  for the introduction of secretin while preserving exocrine pancreatic function the amount of secretionу is increased,the content of bicarbonate, in response to input the pankreozymin the content of enzymes is increased.  In severe exocrine insufficiency the pathological changes of the test observed in 85-90% of cases.

17. Diagnosis of exocrine pancreatic insufficiency  1. the research of activity in feces of elastase-1.  2. Breathing tests . Breathing tests - during exogenous failure the production of lipase is reduced or, it is absent, and therefore the triglycerides are split a lesser extent and constitute less of 13СО2.  amylase respiratory AP the corn-starch test – the total concentration AP at the end of the 4-o'clock research is less than 10 %, that indicating the presence of deficiency of pancreatic amylase  Protein breathing with IZS- noticed egg white - in patients with chronic pancreatitis the total concentration of 13СО2 through 6 hours 2-3 times lower than in healthy persons, indicating a decrease in activity of trypsin.  3. Koprogram - high content of muscular fibers to digest fiber and neutral fat

18. STANDARD OF noninvasive diagnosis of chronic pancreatitis Degrees of severity of external secretory of pancreatic insufficiency Activity of fecal pancreatic elastase -1 mild 150-200 150-200 mg / g moderate 100 - 150 100 - 150 mg / g severe 100 less than 100 mg / g

19. Ultrasound investigation. Chronic pancreatitis а) calcificates in the head of pancreas; б) Virsungov’s duct; б) Virsungov’s duct; в) pseudocyst of pancreas; в) pseudocyst of pancreas; г) increase of the head of pancreas; г) increase of the head of pancreas; д) spleen vein д) spleen vein

20. Ultrasound investigation. Chronic calcified pancreatitis а) virsungolithiasis б) dilated Virsungov’s duct.

21.  Plain X-ray of abdomen showing showing calcific calcific pancreatitis pancreatitis

22. Instrumental diagnostics Instrumental diagnostics  computed tomography : the diagnostic information similar to ultrasound, is indicated for suspected tumors and cysts of the pancreas ;  magnetically-resonance tomography : helps to visualize normal and pathologically altered pancreatic duct, used for the diagnosis of pancreatic duct stones ;

23. CT scan with central pseudocyst Endoscopic ultrasound overcomes some of the visualisation problems and is probably more sensitive and specific. CT has a sensitivity of up to 90% and specificity of the same order. It will detect variation in ductal diameter, and ectatic side branches, changes in the parenchyma, calcification and complications of chronic pancreatitis such as pseudocyst formation

24. An endoscopic ultrasound image demonstrating a dilated pancreatic duct (markers) in a patient with advanced chronic pancreatitis An endoscopic ultrasound, which allows a highly detailed examination of the pancreatic parenchyma and pancreatic duct, routinely detects abnormalities in patients with chronic pancreatitis (high sensitivity), but the specificity and reproducibility of the test requires further study

25. Instrumental diagnostics  Endoscopic retrograde cholangyiopankreato graphy: reveals impaired patency of the main and secondary ducts. “Chain of lakes" is a classic symptom of chronic pancreatitis (areas of constriction and expansion of virsunhov ducts). It is also possible the segmental or total obstruction of a ductal system of pancreas.  biopsy of pancreas..

26. An endoscopic retrograde cholangiopancreatography image demonstrating minimal pancreatic duct abnormalities in a patient with painful small-duct chronic pancreatitis.

27. An endoscopic retrograde cholangiopancreatography image demonstrating massive pancreatic duct dilatation in a patient with bigduct chronic pancreatitis.

28. COMPLICATIONS :  diabetes mellitus type II ;  pancreas cancer ;  obstructive jaundice ;  pancreatic coma.  cysts and pseudocysts of the pancreas  pancreatic abscess ;  pancreonecrosis ;  infectious complications ( inflammatory infiltrates, suppurative cholangitis, septic conditions, peritonitis )  chronic duodenal obstruction  pancreatic ascites  erosive esophagitis  gastrointestinal bleeding  abdominal angina  reactive arthritis  reactive pleurisy ;  reactive hepatitis ;  anemia.

29. The differential diagnosis The differential diagnosis  Chronic cholecystitis ;  Chronic gastroduodenitis ;  Ulcer disease ;  Cronic hepatitis ;  Bile gallstones disease ;  Pancreas cancer ;  Left-sided renal colic ;  Angina pectoris.

30. Treatment of chronic pancreatitis Main principles :  1. D ietary meal ( №5)  2. Creating functional resting of pancreas  3. Elimination pain syndrome  4. Substitution therapy of exocrine enzyme deficiency  5.Elimination of duodenostasis, athetoid biliary of disorders, pancreatic duct  6. Anti-inflammatory therapy  7. Correction endocrine function of the pancreas  8. Symptomatic therapy

31. Treatment  Diet № 5.Avoiding alcohol  Elimination of pain syndrome: - non- narcotic analgicdrugs (analginum 50% 2-5 ml intramuscularly - non- narcotic analgic drugs (analginum 50% 2-5 ml intramuscularly 2-3 times a day, baralginum 5ml intramuse) -narcotic analgic drugs(promedol 1 ml intramusc. 1-3 times a day) -M-cholinolytics (atropine 0,1% intramusc.,platyfilin 0,2%1-2ml subcutaneously or intramusc.1-2t.a day,gastrocepini 50mg 3 times a day) - Myotropic antispasmodics drugs (papaverin 2% 2 mi, no-shpa 2% 2 ml intramusc - 2 times a day, mabeverin (duspatalin) 200mg 2 times a day);

32. Treatment   -antisecretory drugs (H2 blocking (famotydyn,kvamatel 20mg 2 times a day);omeprazol 20mg,lanzoprazol 30 mg,pantoprazol 40 mg,rabeprazol 20mg,ezomehrazol 20mg-2 times a day; somatostatyn(sandostatyn);central action drugs(dalargin 0,001 mg intraven.or intramus. 2 times a day)

33. Treatment   Therapy of outersecretory enzyme deficiency (penkreatin,kreon,pangrol,mezym)   Elimination of duodenal statis,dyskinetic disorders of biliferous and pancreatic ducts(domperydon(motilium)10mg 3 times a day),cyzaprid) perystil )10 mg 3 times a day);

34. Treatment  Often the acute of CP is accompanied by peripancreatitis, and also by cholangitis.  :Often the acute of CP is accompanied by peripancreatitis, and also by cholangitis.  in such cases, used the antibiotics : augmentun 0,625-1,25 g 2-3 times a day intramusc. (7-10 days); cefobid 1-2 g 2 times a day intramusc (7-10 days); dorsycyclinпо 0,1 g 1-2 times a day (6-8 days); for inefficiency- abaktal(pefloksacyn) 0,4 g 2 times a day, symamed 0,5 g 1 times a day.

35. Treatment   In cases of edema of the pancreas: Anti-enzyme therapy(kontrykal-1-2 times a day 20000un;gordoks-100000 un.during 5-7 days) -correction of endocrine function -correction of dysbioz: antiseptic drugs (nifuroksazyd – 200 mg 4 times a day, furazolidon – 100mg 4 times a day); probiotics (bifi-form – 1-2 caps. 2 times a day, symbiter – 1-2 doses before sleep)   Physiotherapy (electrophoresis, diadynamo- therapy)   Sanatorium – resort treatment

36. Thank you for your attention!