Chronic pancreatic aggravation and treatment. Chronic pancreatitis - symptoms, causes, treatment, diet and exacerbation in adults. Diet and nutritional principles

Chronic pancreatitis is considered a progressive damage to the pancreas of an inflammatory nature, which provokes disruptions of exocrine and intrasecretory functions. This, in turn, leads to a decrease in the production of enzymes involved in digestion, important hormones (for example, insulin) and a number of biologically active substances. Therefore, all patients need to identify the symptoms in time and follow the timely and adequate treatment prescribed by the doctor.

What is chronic pancreatitis?

Chronic pancreatitis is an inflammatory disease of the pancreas of a long recurrent course, characterized by a gradual pathological change in its cellular structure and the development of functional failure.

As a result of progression such a disease, the secretion of enzymes in the gland decreases - trypsin and lipase. Because of this, the blood circulation of the organ is significantly impaired, the connective tissue grows, and specific scars, areas with sclerosis are formed.

Most often, the disease occurs due to alcohol abuse for a long time. In men, chronic pancreatitis of the pancreas can develop if they drink for more than 15 years, in women with alcohol abuse for more than 10 years.

Causes

The main mechanism for the development of chronic pancreatitis is an increase in pressure in the pancreatic duct and stagnation of pancreatic juice in it. Prolonged stagnation in the duct leads to disruption of its structure, as a result of which the enzymes of the pancreas easily penetrate into their own tissue, destroying its cells (autolysis) and the development of a chronic inflammatory process

It may take 10-15 years, when the signs of chronic pancreatitis become so obvious that there will be no doubts about the diagnosis. The disease can occur due to:

• Cholecystitis, or chronic form.
• or the duodenum.
• Infectious lesions - typhoid or typhus, viral.
• Excessive drinking.
• An unregulated diet.
• Atherosclerotic disease.
• Penetration into the body.
• Intoxication with harmful substances - arsenic, phosphorus, mercury, lead.

Stages of development of the chronic form

Pancreatitis stage
Easy	Adults at this time begin to torment the first symptoms of the disease. The stage can last for several years. In some cases, the disease progresses very quickly. Number of exacerbations 1-2 times a year.
Average	The stage of development of persistent clinical symptoms. Patients show signs of endocrine and exocrine insufficiency. People eat very little, complain of pain in the abdomen. 3-4 exacerbations are observed per year. They are longer than with a mild course. In sick people, body weight decreases. The exocrine function of the pancreas is moderately reduced, pancreatic hyperenzymemia is observed.
Heavy	Regular and prolonged attacks (more than 5 times during the year) with intense hostile sensations and pronounced symptoms. Weight is dramatically reduced to exhaustion, which is indicated by diarrhea. Sometimes adverse effects can be added - duodenal stenosis.

Chronic pancreatitis symptoms

Often, the initial pathological changes in the tissues of the gland during the development of chronic pancreatitis occur without symptoms. Or the symptomatology is mild and nonspecific. When the first pronounced exacerbation occurs, the pathological disorders are already quite significant.

Chronic pancreatitis is a condition accompanied by:

• Painful discomfort, and the degree of intensity can be different. The place of localization is the epigastric region and the left hypochondrium. The pain is present either constantly, or appears paroxysmal. After the patient eats something, the symptom will intensify.
• Dyspeptic disorders- nausea, urge to vomit, feeling of heaviness in the abdomen, an unpleasant aftertaste in the mouth,. The patient may have an aversion to fatty foods, and sometimes the appetite disappears.
• For many years, the patient can claim unpleasant symptoms in the form of short-term pain sensations that bother him 15 minutes after eating. Discomfort lasts from one hour to 3-5 days. The place of their concentration is the upper abdomen, sometimes pain is felt near the heart or to the left of the chest or lumbar region. In certain situations, it is encircling. You can lower its strength by bending forward or squatting.
• The patient's skin becomes a mild yellow color. The same applies to the sclera. The yellowness of the skin disappears from time to time.
• Due to a lack of pancreatic enzymes the process of breaking down complex molecules of the food we eat into smaller ones that can be absorbed in the intestines is disrupted. In this regard, with pancreatitis, even increased nutrition may be accompanied by a decrease in body weight, lack of vitamins in the body, dry skin, brittle nails, lack of iron in the body () and other symptoms.

With chronic pancreatitis, pain occurs as a result of:

• problems with the outflow of pancreatic juice;
• an increase in the volume of gland secretion;
• pancreatic ischemia;
• inflammation of the surrounding tissue;
• changes in nerve endings;
• squeezing organs nearby.

With the development of the disease exacerbation rate tends to increase. Chronic inflammation of the pancreas can damage both the gland itself and adjacent tissues. However, it may take years before clinical manifestations of the disease (symptoms) appear.

Aggravation

Chronic pancreatitis can be exacerbated for two of the most common reasons:

• taking large doses of alcohol;
• dysfunction of the biliary tract.

There are also many reasons that are less important, but significantly increase the frequency of exacerbations of chronic pancreatitis:

• regular intake of small doses of alcohol;
• a tendency to overeat;
• smoking;
• overweight;
• eating a sick amount of fat;
• taking medications;
• infectious diseases;
• frequent stress.

In most cases, signs of exacerbation of chronic pancreatitis appear in the form of constant, sharp and severe pain felt under the ribs, reflected in the back.

• Often the pain is atypical, disguised as other diseases, it is most pronounced in the upper back, blurred over the abdomen.
• Sometimes the pain radiates to the chest, to the side, being felt in the depths of the body, which is characteristic of an exacerbation of pancreatitis.

Characteristic signs of exacerbation of chronic pancreatitis:

1. Severe pain, which can be dull or sharp in the abdominal cavity without clear localization, intensifying after eating and radiating to the back.
2. Frequent diarrhea with an admixture of fatty particles in the stool.
3. Feeling of bitterness in the mouth.
4. Vomiting interspersed with bile, difficult to remedy.
5. Severe nausea.
6. Loss of appetite.
7. White coating on the tongue.

All of the above signs can appear as a whole bouquet, or one by one. If a person suffers from severe severe pain, then dyspeptic syndrome may occur, in which the patient's well-being is rapidly deteriorating.

Complications

If competent and complete treatment of chronic pancreatitis is not carried out in time, then the following complications will begin to actively progress against its background:

• pancreatic ascites;
• diabetes mellitus of the pancreatogenic type;
• abscess;
• the formation of phlegmon in the retroperitoneal space;
• inflammatory process in the excretory ducts;
• duodenal obstruction in a chronic form;
• B12 deficiency anemia;
• portal hypertension;
• gastrointestinal bleeding may occur due to rupture of the pseudocyst;
• the formation of tumors of a malignant nature.

Diagnostics

Treatment of chronic pancreatitis can be carried out by both a therapist and a gastroenterologist. With the development of endocrine insufficiency, consultation with an endocrinologist is indicated, with compression of the surrounding organs - a surgeon.

The diagnosis can be made only after the implementation of such research methods:

• changes in the content of elastase in urine - the main method of clinical study of the patient;
• detection of steatorrhea - the presence of undigested fat in the feces;
• performing a research test for stimulation of the gland;
• CT according to indications;
• doing a blood glucose test and taking a glucose susceptibility test.

How is chronic pancreatitis treated?

When describing a plan for the upcoming treatment to the patient, the doctor sets quite definite goals. Necessary:

• eliminate pain;
• to provide the pancreas with peace;
• reduce her secretory activity;
• compensate for the deficiency of pancreatic enzymes;
• to correct the disturbed metabolism of carbohydrates (if necessary).

To achieve these goals in the non-surgical treatment of patients with all types of chronic pancreatitis, different methods should be used.

The complex effect of various therapeutic factors (diet therapy, medications, physiotherapy procedures, etc.) is more effective.

Medications

For chronic pancreatitis, the following medications may be prescribed:

1. Enzyme-containing products... Aimed at reducing the load on the pancreas and accelerating the process of tissue regeneration. Digestive enzymes facilitate the process of digestion and assimilation of food, facilitate the work of the gastrointestinal tract. With their constant intake, nausea disappears, appetite appears. Enzyme-containing drugs include: Creon, Pancreatin, etc.
2. Antacids reducing acidity. According to the principle of action, they are divided into: absorbable (Rennie) and non-absorbable (Almagel,). Suction tubes provide quick but short-term relief. The action of non-absorbable is longer, the effect occurs some time after administration.
3. Analgesics are aimed at relieving the pain that occurs with pancreatitis during an exacerbation. Antispasmodics (No-shpa, Papaverine) are prescribed to relieve spasms of the main pancreatic duct.
4. Antisecretory drugs(Famotidine, Omeprazole) are prescribed to neutralize the acid.
5. Anti-inflammatory drugs(Diclofenac) reduce pain by reducing inflammation in the pancreas.
6. Decrease in active secretion of the gland, drugs (Octreotide, Sandostatin), are used for exacerbation of chronic pancreatitis, with severe pain syndrome that does not stop antispasmodics.
7. Prokinetics (Motilium, Cerucal) are used to suppress nausea about vomiting, during an exacerbation.

Treatment for exacerbation of chronic pancreatitis

The peculiarities of the treatment of a severe attack consists of strict adherence to bed rest, diet and taking appropriate medications only in a hospital setting, since there is a real threat not only to health, but also to human life. Before the arrival of an ambulance, the patient should be given first aid:

• Absolute hunger.
• Apply cold to the pancreas area.
• Complete rest and bed rest.

Many patients would like to clarify how long an exacerbation of chronic pancreatitis can last? Doctors emphasize that in most episodes, the relapse of the disease does not exceed 7 days.

Auxiliary drugs for pain relief:

• enzymes (Creon or Pangrol);
• antispasmodics (drotaverine or papaverine);
• proton pump inhibitors (lansoprazole, rabeprazole).

For the purpose of unloading the pancreas, the following are used:

• a diet with a strict restriction of fat or complete fasting for several days;
• complete elimination of alcohol and smoking;
• octreotide is a drug analogous to the pancreatic hormone somatostatin.

Operation

Surgical operations for chronic pancreatitis:

• sphincterotomy for blockage of the sphincter of Oddi;
• excision of stones in the ducts of the pancreas with calculus obstruction;
• opening and sanitation of purulent foci (abscesses, phlegmon, cysts);
• pancrectomy (full or partial);
• vasectomy, splanchectomy (operations of excision of nerves that regulate the secretion of the gland), partial
• excision of the stomach (resection);
• removal of the gallbladder in case of complications from the large bile duct and gallbladder;
• techniques for creating circumferential bile outflows to relieve stress from the main pancreatic ducts (virsungoduodenostomy, etc.).

Diet and nutritional principles

In adults, the disease becomes chronic, which means that nutrition should be given due attention, since it can prevent exacerbations. Each exacerbation entails replacement of the normally functioning tissue of the gland with fibrous tissue. Therefore, over the years, the patient develops exocrine and intrasecretory gland insufficiency.

Basic nutritional principles for chronic pancreatitis:

1. Diet No. 5p for chronic pancreatitis provides for the introduction of more protein foods into the diet by eliminating fatty foods and carbohydrates. It is also necessary to give up coarse vegetable fibers and fatty meats.
2. Fried foods are not allowed. It is recommended to cook food in a double boiler, stew and bake in its own juice.
3. All foods that cause dyspepsia and enhance the production of enzymes are also excluded from the menu.
4. Food for the diet of a patient with chronic pancreatitis should be balanced in composition, meals are served warm and semi-liquid.
5. The food is fractional, consists of 5-6 meals, with small portions.
6. A complete ban on the consumption of alcoholic beverages eliminates the main risk factor for the pancreas.
7. new foods should be introduced into the diet carefully, in small portions.
8. at the slightest malaise, you should abandon until more complete stabilization of the pancreas;
9. the recommendation to thoroughly chew food is also appropriate for a healthy body, but in case of pancreatic disease, this rule should be observed especially carefully, even if puree soup is served.

The diet for exacerbation of chronic pancreatitis, despite the restrictions, is very diverse. It is allowed to include in the diet:

• lean meat and poultry;
• boiled lean fish;
• vegetarian vegetable pureed soups;
• vegetarian soups with rice, noodles, buckwheat, semolina, oatmeal;
• boiled mashed vegetables (potatoes, carrots, zucchini, cauliflower, pumpkin);
• 2 egg omelets;
• low-fat dairy products, non-acidic and low-fat cottage cheese, sour cream and cream in moderation, fermented milk products;
• ripe fruits with low acidity, pureed berries, baked apples;
• compotes and weak tea with lemon;
• a moderate amount of butter and vegetable oil;
• porridge cooked in water and milk in a 1: 1 ratio;
• boiled pasta;
• sugar-free biscuits and homemade wheat bread crumbs.

Dishes with sokogonny action are contraindicated for patients:

• meat,
• bone,
• mushroom and fish broths,
• fried foods.

Avoiding alcoholic beverages is fundamentally important, since they are strong stimulants of pancreatic secretion.

During the period of remission the list of products is expanded and the inclusion of vegetables and fruits already and in their raw form is shown. Vegetables are used in salads, side dishes, vinaigrettes and as independent dishes. In addition to cereals, you can make pilaf with dried fruits and boiled meat, pasta, cereals. Soups are cooked not mashed and beetroot soup, borscht and cabbage soup are carefully introduced. Homemade sauces and spices are used to improve the taste.

In chronic pancreatitis, a therapeutic course of mineral water intake is often prescribed. To achieve the effect, they drink water not to quench their thirst, but according to the recommendations of the reception, certain types of it and according to the specified system.

Prescribe a course of water intake of the brands Essentuki No. 4, Borzhomi and Smirnovskaya, which have a special effect on the pancreas:

• prevent stagnant processes in the bile ducts, in the pancreas itself;
• reduce the risk of inflammatory processes;
• normalize the work of the stomach and intestines.

Prophylaxis

In order not to learn how to treat chronic pancreatitis, it is necessary to engage in timely prevention of the disease, which includes:

• to give up smoking;
• exclusion of the use of alcoholic beverages;
• adherence to a diet;
• regular preventive examinations by narrow specialists.

Chronic pancreatitis should be treated under the supervision of a gastroenterologist. When the first signs described in the article appear, be sure to go through the diagnostics to make an accurate diagnosis.

Pancreatitis is a group of diseases characterized by inflammation of the pancreas in adults and children. Pancreatic enzymes are not released into the duodenum, but remain and self-digest. After digestion, toxins are released: getting into the blood, they are transferred to other organs, harm them. How the exacerbation of chronic pancreatitis passes, the symptoms and treatment, as well as what to do, are described below.

Inflammation can occur in:

• acute form;
• acute form of relapse;
• chronic form;
• as an exacerbation of chronic pancreatitis.

Symptoms of exacerbation of pancreatitis appear as:

1. Dull, sharp pains under the ribs, passing into the area of ​​the scapula, the whole back.
2. Bitterness in the mouth, dryness, white coating on the tongue.
3. Nausea, loss of appetite, weight loss, sometimes vomiting. The latter will be present even in the absence of food: the patient vomits bile.
4. Diarrhea, while feces have a greasy sheen, particles of undigested food. Sometimes there is an alternation of diarrhea with constipation.
5. Possible, up to 38 degrees, chills, signs of vitamin deficiency.
6. Weakness, poor health, drowsiness, shortness of breath, low blood pressure, "grayness" of the skin are noted.
7. In a horizontal position, symptoms may intensify - it becomes easier if you sit down, leaning forward.

The attack can last up to a week, while the symptoms will be pronounced, and pain, nausea - constant. If they are not pronounced, the attack can last for a long time - up to 1-2 months.

Also, pain may not have a clear place (for example, spread to the entire back or lumbar region) and intensify after eating, at night.

Pancreas position

Establishing diagnosis

Since the problem already exists, it is impossible to delay the visit to the doctor: since the attacks negatively affect the digestion process, and toxins poison the entire body.

Any treatment for exacerbation of chronic pancreatitis begins with confirmation of the diagnosis, since similar symptoms appear in other diseases.

The patient has to pass:

• blood test: biochemical, for sugar content;
• stool analysis;
• general urine analysis;
• X-ray, ultrasound of the peritoneum;
• gastroscopy;

Additionally, a survey is being conducted. With its help, they determine how long an attack can last, the causes of pathology.

Read more about analyzes for pancreatitis and other pathologies of the pancreas in

Treatment

Treatment of the pancreas with exacerbation of pancreatitis:

• taking medications;
• adherence to a diet;
• prevention of re-exacerbation.

Medicines and diet are prescribed only by a doctor after examination and taking into account the concomitant pathology of the patient. If the drugs give analgesic and anti-inflammatory effects, eliminate the unpleasant symptoms of the disease, then the diet provides the glands with functional rest.

Traditional medicine can only be taken without exacerbation. In an acute period, they are more likely to cause harm.

After stopping the exacerbation of pancreatitis, the patient can be recommended the following measures:

1. Prophylaxis in health resorts: Mineralnye Vody, Kislovodsk and Zheleznovodsk, Truskavets (Ukraine), Karlovy Vary (Czech Republic).
2. Treatment of diseases that indirectly affect the state of the pancreas (cholecystitis, gastroduodenitis, cholelithiasis).

Medication

Mild and moderate exacerbation can be treated at home, after taking tests and consulting a doctor. Patients with severe disease should be hospitalized.

Medicines for the treatment of exacerbation of chronic pancreatitis:

• analgesics and antispasmodics for the purpose of pain relief (Duspatalin, No-shpa, Buscopan);
• prokinetics to normalize the motor function of the gastrointestinal tract, relieve nausea and vomiting (domperidone, Cerucal, Ondansetron);
• antisecretory agents in order to ensure functional rest of the pancreas, reduce the acidity of gastric juice (Omeprazole, Rabeprazole, Ranitidin, Almagel A, T);
• antibiotics are used only if there are bacterial complications;
• proteolysis inhibitors (Gordox) and somatostatin analogs (Octreotide) are highly effective against pancreatitis and are prescribed for severe pathology.

Any medications should be prescribed by a doctor, since he takes into account not only the patient's condition, but also the other chronic diseases he has, will determine the duration of treatment.

It is important to know that synthetic pancreatic enzymes (Creon, Pancreatin, Micrasim) are contraindicated in acute pancreatitis and exacerbation of chronic pancreatitis.

Diet

The diet includes:

1. 2-3 days fasting: reduces the activity of enzyme production, soothes the gland. Only drink should enter the stomach: warm non-carbonated water, weak tea, rosehip broth, additionally inject nutrients intravenously or through a gastric tube. Allowed 1.5-2 liters of drink per day - 50 ml every hour or 200 ml 6 times a day. Alkaline water is allowed ("Narzan", "Essentuki-17", "Borjomi") - sip several times a day. Water is excluded with bouts of vomiting, nausea.
2. Fractional nutrition - in small portions up to 7 times pureed, liquid food rich in carbohydrates, which weakly stimulate the pancreas. Shown are milk oat soups and cereals without butter, sugar, rice broth, carrot, mashed potatoes, apple jelly without sugar, low-fat fermented milk products. Serving size should be 2-3 tablespoons.
3. Over the next 14 days, portions are gradually increased to 200-300 grams of food. Food is prepared without salt, sugar, in liquid, pureed form.
4. The patient is transferred to diet No. 5p. It consists of boiled, stewed, baked food.

In the exacerbation stage, it should be accompanied by the exclusion of products that cause an abundant secretion of gastric juice: pickles, marinades, spices, spicy, fried and fatty, as well as strong broths. Pork, lamb, goose and duck are excluded, all fats, except for light vegetable oils - corn and olive.

ethnoscience

It can be decoctions of plants and fees, alcoholic tinctures, including sage, wormwood, immortelle, horsetail, oats, St. John's wort and other herbs.

It is important to remember that traditional medicine is not a panacea: it can help improve the condition, but not cure it. Any use of herbs should be coordinated with a doctor and used only in conjunction with medicines and diet.

Prophylaxis

It includes:

• diet and maintenance of a healthy weight;
• giving up bad habits: smoking and alcohol;
• regular intake of medications prescribed by a doctor;
• visiting spas and healing waters on the advice of a doctor.

These actions will help to avoid another exacerbation.

First aid

If pancreatitis has worsened, properly provided first aid will slow down development and alleviate the condition.

Help is:

What is forbidden to do at home:

• Apply cold, as this will lead to vasoconstriction and spasm.
• Give painkillers (for example, "Analgin", "Spazmalgon"), as their effect will complicate the diagnosis.
• Give enzymes (for example, "Mezim", "Festal"), as they will only aggravate the situation.
• Flush the stomach yourself. It is only allowed to induce vomiting if the patient is severely nauseous.

An exacerbation of pancreatitis is an extremely dangerous condition characterized by pain and poisoning of the body with toxins. In such a case, it is necessary to consult a doctor as soon as possible and begin treatment, and before that apply first aid.

Chronic pancreatitis is a pancreatic disease characterized by inflammation of the organ tissue, which persists for six months or more. In chronic pancreatitis, the cells of the pancreas, which produce digestive enzymes, are destroyed. In place of the destroyed cells, connective tissue is formed. For this reason, patients with chronic pancreatitis have digestive problems. In addition, because the hormones insulin and glucagon are secreted in the pancreas, inflammation can lead to the development of diabetes mellitus and hypoglycemic conditions (conditions caused by a sharp decrease in blood glucose levels).

Another result of long-term inflammation of the gland is the formation of stones and cysts (cavities with fluid) in it, which can impede the outflow of pancreatic juice from the pancreas, and (due to the anatomical proximity of the gland to the hepatic bile ducts) can create an obstacle to the secretion of bile into the duodenum, which leads to the development of obstructive jaundice.

It is the increase in hydrostatic pressure inside the pancreas and the activation of enzymes inside its ducts (normally, enzymes that break down protein are activated only in the lumen of the duodenum) that is given the leading role in the development of pain in chronic pancreatitis.

Chronic pancreatitis: causes.

In 70% of cases, alcohol abuse is to blame for the development of chronic pancreatitis. Often, the disease develops as a result of an abundance of fatty and fried foods in the diet, a large amount of protein (especially against the background of excessive consumption of alcoholic beverages). In some cases, pancreatitis occurs, on the contrary, against the background of a very low protein diet.

Among other reasons, it is worth mentioning heredity, gastric ulcer and gallstone disease, autoimmune diseases and the use of certain drugs (glucocorticoids, tetracycline, sulfasalazine, etc.)

Chronic pancreatitis: symptoms.

Patients with chronic pancreatitis are worried about abdominal pain, indigestion and endocrine disorders (diabetes mellitus, hypoglycemic conditions).

Pain. The vast majority (85%) of patients have pain in the upper abdomen. In the first years of the illness, it is often intense, burning. With a long-term current disease, the pain becomes less pronounced. It can be spilled, encircling, but more often the discomfort is localized in the left or right hypochondrium, or in the epigastric region. Many patients notice the connection of pain with food intake: it appears or intensifies 20-30 minutes after eating and is often provoked by a violation of the diet: the use of fatty, spicy, baked foods, raw vegetables and fruits (especially citrus fruits). In some cases, the pain may be permanent and not go away even in the intervals between meals.

Indigestion to one degree or another, it is present in all patients with chronic pancreatitis, since the pancreas produces enzymes involved in the digestion of fats (lipase), carbohydrates (amylase), and protein (trypsin, chymotrypsin). There is bloating, increased gas formation, flatulence, rumbling in the abdomen, belching, nausea. There may be vomiting, which does not bring relief.

A characteristic symptom of chronic pancreatitis is a change in the nature of the stool: it becomes frequent (2-4 times a day), abundant, has a mushy consistency, gray color, fetid odor. Often, with a pronounced insufficiency of the enzymatic function of the gland, the feces become shiny in appearance and are poorly washed off the walls of the toilet bowl, because contains a large amount of undigested fat. No less typical for patients with pancreatitis and the alternation of diarrhea and constipation.

Since both pain and dyspeptic symptoms are usually associated with food intake, many patients begin to eat less often and less. Poor digestibility of food and malnutrition leads to weight loss in patients (with a pronounced violation of the enzymatic function of the pancreas). In addition, in severe cases, hypovitaminosis A, D, E, K may occur. For this reason, patients with chronic pancreatitis may notice bone pain, deterioration of night vision, and neurological disorders.

In some patients, the islets of Langerhans are destroyed, in which insulin and glucagon are synthesized. If the production of insulin suffers more, the patient develops diabetes mellitus - the blood glucose level rises, thirst, profuse urination, and the need to eat large amounts of food appear. In the case when the pancreas is unable to provide the proper level of glucagon in the blood, hypoglycemic states develop: wolf hunger, severe weakness, trembling in the body, sweating appear. Hypoglycemia can seriously damage the brain, which is supplied with glucose.

With an exacerbation of chronic pancreatitis, all symptoms are aggravated: the pain can become unbearable, cutting, the nature of the stool changes (diarrhea is likely to develop), symptoms of diabetes mellitus may appear.

If the outflow of pancreatic enzymes from the gland is impaired, their partial penetration into the bloodstream may occur, which will lead to the development of life-threatening systemic complications, such as hypovolemic shock, acute renal failure, etc.

Chronic pancreatitis: diagnosis.

To diagnose the disease, the doctor will prescribe an analysis of feces (coprogram), where undigested fat can be detected in patients with pancreatitis.

In the diagnosis of pancreatitis, ultrasound, computed and magnetic resonance imaging (CTG and MRI) of the organ can help.

ERCP, endoscopic retrograde cholangiopancreatography, is a research method in which an endoscope in the duodenum reveals the place where the bile ducts and pancreatic ducts (large duodenal papilla) open. Through it, the ducts are filled with a contrast agent, after which an x-ray of the liver and pancreas is taken. This method of research allows you to assess the patency of the ducts, to detect stones, cysts, suspicious tumor formation.

The LUNDT test is often used to assess the functional state of the pancreas. During the LUNDT test, during the study, the patient drinks a special mixture (containing fat, glucose solution, etc.), which causes an increase in the secretion of duodenal hormones, secretin and pancreozymin. The pancreas reacts to the presence of these hormones in the intestinal lumen by producing pancreatic juice, which is collected using a special probe for 2 hours.

Secretin-pancreasimin test - during this examination, as in the LUNDT test, duodenal juice is collected using a probe within 2 hours, but pancreosimin and secretin are injected as stimulants for the pancreas.

Chronic pancreatitis treatment.

Treatment for chronic pancreatitis during remission includes:

I. Strict adherence to diet. Since it is the errors in the diet that become the trigger mechanism for each subsequent exacerbation, and each exacerbation leads to the irreversible loss of functioning cells of the pancreas, it becomes clear that adherence to the diet is a very important point in maintaining the health of the organ.

The patient should stop drinking alcohol, fatty, fried, smoked food, canned food and marinades. Food preference should be given to steamed or boiled foods.

You should limit the intake of dairy products (milk, cheese, cottage cheese, etc.) to 200 ml per day.

From meat, it is worth giving preference to non-fatty beef (and not pork), lean poultry meat (chicken, turkey, etc.). You can eat non-fatty fish, black caviar.

Vegetable soups should be prepared containing cereals.

When cooking porridge, you can add a small amount of milk, or cook it in water.

You should limit the consumption of yeast dough products (they are allowed no more than 1 time a week), but you can use dry biscuits, stale white, and black bread in your diet.

The daily diet of patients with chronic pancreatitis should contain no more than 1 chicken egg per day. Eggs can be used to make a steam omelet.

II. Replacement therapy with enzyme preparations. In chronic pancreatitis, the glandular tissue is replaced by connective tissue, as a result of which the enzymatic function of the pancreas is disrupted. For this reason, many patients require the appointment of drugs containing lipase, amylase, trypsin, chymotrypsin. The doctor should select the dose of enzyme preparations, since their overdose can lead to the development of intestinal inflammation (colitis).

Enzyme preparations should not be chewed, because they are covered with a special enteric coating that prevents the release of the active substance in the stomach. Otherwise, the enzymes are inactivated by the action of acidic gastric juice before reaching the duodenum.

Since the production of lipase decreases in the first place in pancreatitis, the activity of the enzyme preparation is determined by the activity of the lipase. Therefore, the digital designation next to the name of the drug indicates the activity of the enzymes contained in the capsule.

Enzyme preparations include:

• Pancreatin - 250-500 mg, applied 3-6 times a day immediately before meals. Drink with water or fruit juice.

Pancreatin is part of many enzyme preparations: Panzinorm, Creon, Mezima forte, Ermital, etc.

• Panzinorm 10000 - take 1-2 capsules with each meal, including a light snack. The maximum number of capsules per day is 15.
• Creon 10000/25000 - take 1 capsule at each meal.
• Mezim forte (Mezim forte 1000) - use 1-2 capsules at each meal without chewing.

III. Elimination of pain. Often, patients with chronic pancreatitis are worried about constant aching abdominal pain in the projection of the pancreas. Since there are several mechanisms for the development of pain syndrome (violation of the outflow of pancreatic juice along the ducts, activation of enzymes inside the pancreas, etc.), drugs of several pharmacological groups can be used to eliminate pain.

1. Proton pump blockers. They suppress the production of hydrochloric acid in the stomach, which stimulates the secretion of digestive enzymes by the pancreas.

Proton pump blockers include:

• Omeprazole (Omez) - 20 mg 1-2 r / day;
• Lansoprazole (Lanzap, Acrylanz) - 30 mg 1-2 times a day;
• Pantoprazole (Nolpaza) - 40 mg once a day;
• Rabeprazole (Pariet) - 20 mg once a day. If necessary, a constant half dose is possible.
• Esomeprazole (Nexium) - 20-40 mg once a day. Swallow without chewing with water.

2. Blockers of H2-histamine receptors:

• Famotidine (Kvamatel) 20-40 mg 2 times a day.
• Ranitidine (Zantak, Ranisan) 150 mg 2 times a day.

3. Antispasmodics. These drugs lower the pressure in the pancreatic duct system, which leads to a decrease in pain in the patient.

Antispasmodic drugs include:

• Drotaverin (No-shpa, Spazmol) - 40 mg, 1-2 tab. 2-3 times a day.
• Mebeverin (Duspatalin) - 200 mg 2 times a day 20 minutes before meals, drink without chewing.

4. Non-steroidal anti-inflammatory drugs. They reduce inflammation and prevent the destruction of the glandular tissue of the pancreas.

Of the NSAIDs in chronic pancreatitis, the following are most often used:

• Diclofenac (Voltaren, Ortofen) 75 mg 1-2 times a day by mouth for 2-3 weeks.

IV. Treatment of diabetes mellitus (if any). It is carried out according to the standard scheme, as a rule, with insulin preparations during the period of exacerbation and with the help of sugar-lowering tablets during the period of remission. A feature of the treatment of diabetes mellitus in pancreatic patients is a significant decrease in the need for hypoglycemic drugs (or the complete disappearance of the clinic of diabetes mellitus) against the background of enzyme replacement therapy.

Treatment of chronic pancreatitis during an exacerbation.

Since the exacerbation of chronic pancreatitis is a serious condition and can be aggravated by the development of hypovolemic shock and other serious complications, the treatment of such patients in most cases is carried out in a hospital.

The general principles of treatment are as follows:

In the first two days, complete hunger is prescribed. If fasting for more than two days is indicated, the patient is prescribed parenteral nutrition, which implies intravenous administration of nutrients.

Starting from the third day, the patient is allowed to eat, but not more than 200 ml at a time, the food should be frequent, and the food should not be greasy (especially it is worth limiting animal fats). Preference in food should be given to carbohydrates (but not easily digestible, such as, for example, sweets), not solid food. Patients it is forbidden eat meat and fish broths, fatty meats, canned food and carbonated drinks, foods containing a large amount of fiber (raw vegetables). Alcohol is strictly prohibited.

Some patients may require continuous aspiration (suction) of gastric juice using a tube for several days.

In the early days of the disease, proton pump inhibitors, H2-histamine receptor blockers, antacids (maalox, phospholugel, almagel, etc.), nonsteroidal anti-inflammatory drugs (diclofenac) are prescribed intravenously, and then in tablet form.

When diagnosing inflammation of the large duodenal papilla, antibiotics (ampiox, cephaperazone, doxycycline, azithromycin, etc.) can be used.

If systemic complications develop (hypovolemic shock, organ failure), symptomatic treatment should be prescribed based on the clinical situation.

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Treatment goals for chronic pancreatitis:

• Reduction of clinical manifestations of the disease (pain syndrome, exocrine insufficiency syndrome, etc.).
• Prevention of the development of complications.
• Prevention of recurrence.

During the period of exacerbation of chronic pancreatitis, the main therapeutic measures are aimed at relieving the severity of the inflammatory process and inactivating pancreatic enzymes. During the period of remission, treatment is mainly reduced to symptomatic and replacement therapy.

During the period of pronounced exacerbation of chronic pancreatitis, treatment, as in acute pancreatitis, must be carried out in a hospital (in an intensive care unit, in a surgical or gastroenterological department). Consequently, at the first sufficiently clear signs of an exacerbation of the disease, the patient should be hospitalized, since it is extremely difficult to predict the further development of the disease in the conditions of staying at home, without constant medical supervision and timely correction of therapeutic measures, that is, the prognosis is unpredictable.

Usually, cold is prescribed to the epigastric region and the area of ​​the left hypochondrium (rubber "bladder" with ice), or the so-called local gastric hypothermia is carried out for several hours.

In the first 2-3 days "functional rest" is necessary for the pancreas. For this purpose, patients are prescribed hunger and are allowed to take only liquid in an amount of 1-1.5 l / day (200-250 ml 5-6 times a day) in the form of mineral water Borzhom, Jermuk, etc., similar in composition, in warm, without gas, in small sips, as well as weak tea, rosehip broth (1-2 glasses per day). Often it is necessary to resort to constant through-probe (it is better to use a thin transnasally inserted probe) aspiration of gastric juice (especially in the absence of effect in the first hours from other therapeutic measures and the presence of anamnestic indications of gastric hypersecretion in previous examinations), since hydrochloric acid of gastric juice, entering the duodenum the intestine and acting on its mucous membrane through the release of secretin, stimulates pancreatic secretion, that is, the conditions of "functional rest" of the pancreas, despite the patient's abstinence from food intake, are not observed. Considering that when the patient is lying on his back, gastric juice mainly accumulates in the area of ​​the body and the fundus of the stomach, it is in these parts of it that the aspiration holes of the probe should be installed. Control of the correct installation of the probe is carried out by assessing the length of the inserted part of the probe or radiographically (it is advisable to use radiopaque probes for this purpose), as well as by the "success" of aspiration of acidic gastric contents. Regardless of whether gastric juice is aspirated or not, patients are prescribed antacids 5-6 times a day (Bourget mixture, almagel, antacid-astringent mixture having the following composition: kaolin - 10 g, calcium carbonate, magnesium oxide and bismuth subnitrate 0 , 5 g - the powder is taken in the form of a suspension in warm water - 50-80 ml - or injected through a tube or given to the patient to drink slowly, in small sips) or other drugs that bind hydrochloric acid of gastric juice. If the patient undergoes constant aspiration of gastric juice, it is temporarily stopped while taking the antacid and for another 20-30 minutes.

Recently, in order to suppress gastric secretion, H2-receptor blockers have been used, which have a powerful antisecretory effect: cimetidine (belemet, histodil, tagamet, cinamet, etc.) and newer drugs - ranitidine (zantac) and famotidine.

Cimetidine (and its analogs) is prescribed orally 200 mg 3 times a day and 400 mg at night, so that its daily dose is 1 g for a person weighing about 65-70 kg. There are forms of these drugs for intramuscular and intravenous administration, which is preferable in case of exacerbation of pancreatitis (for example, ampoules of histodil, 2 ml of a 10% solution). Ranitidine is prescribed 150 mg 2 times a day or 300 mg once at night, famotidine 20 mg 2 times a day or once at night; in acute pancreatitis and exacerbation of chronic pancreatitis, their parenteral administration is preferable. The use of somatostatin in the treatment of exacerbations of chronic pancreatitis is considered promising, but further research is needed in this direction.

The following schemes of combined treatment for pancreatic exocrine insufficiency with enzyme, antacid, anticholinergic agents and H2-receptor blockers are used.

• I. Enzyme + antacid preparation.
• II. Enzyme preparation + H2-receptor blocker (cimetidine, ranitidine, etc.).
• III. Enzyme + antacid preparation + H2-receptor blocker.
• IV. Enzyme drug + H2 receptor blocker + anticholinergic drug.

For the same purpose, as well as to relieve pain, patients are often prescribed anticholinergics (atropine sulfate, 0.5-1 ml of a 0.1% solution subcutaneously, metacin, 1-2 ml of a 0.1% solution subcutaneously, platifillin 1 ml each 0 , 2% solution subcutaneously several times a day, gastrocepin or pyrenzepin - 1 ampoule intramuscularly or intravenously, etc.). In order to "relieve swelling" of the pancreas in the acute period of the disease, it is often recommended to prescribe diuretic drugs, and although there are no sufficiently convincing data on this issue in the literature (many conflicting reports are published), these recommendations, in our opinion, deserve attention. P. Banks (1982), a well-known American specialist in diseases of the pancreas, with the edematous form of pancreatitis, especially recommends the use of diacarb not only as a diuretic, but also a drug that also lowers gastric secretion.

Elimination of pain during exacerbation of pancreatitis is achieved by prescribing, again, anticholinergics and myotropic antispasmodics (no-shpa, papaverine hydrochloride) in order to relax the sphincter of the hepato-pancreatic ampoule, reduce the pressure in the duct system and facilitate the flow of pancreatic juice into and bile from the ducts duodenum. Some gastroenterologists recommend the use of nitroglycerin and other nitro drugs, which also relax the sphincter of the hepato-pancreas ampoule. It should be noted that ambulance doctors have been using nitroglycerin for a relatively long time and often successfully to relieve an attack (at least temporarily) of cholelithiasis. Quite well reduces the tone of the sphincter of the hepato-pancreatic ampoule of aminophylline with intramuscular (1 ml of a 24% solution) or intravenous (10 ml of a 2.4% solution in 10 ml of a 20% glucose solution) administration.

With persistent and sufficiently severe pain, analgin (2 ml of a 50% solution) or baralgin (5 ml) is additionally administered, often combining them with the introduction of antihistamines: diphenhydramine 2 ml of a 1% solution, suprastin 1-2 ml of a 2% solution, tavegil 2 ml 0.1% solution or other drugs in this group. Antihistamines, in addition to their main action, also have a sedative, mild hypnotic (especially diphenhydramine) and antiemetic effect, which is very useful in this case. Only in the absence of an effect, they resort to the help of narcotic analgesics (promedol), but in no case do they inject morphine, since it increases the spasm of the sphincter of the hepato-pancreatic ampoule.

For the purpose of detoxification, hemodez is administered intravenously; with strong, difficult to stop vomiting, hypohydration, hypovolemia occur, which in turn impairs the blood supply to the pancreas and contributes to the progression of the disease. In these cases, in addition to hemodesis, albumin solutions, plasma and other plasma-substituting fluids are also administered.

Broad-spectrum antibiotics in large enough doses (ampicillin 1 g 6 times a day by mouth, gentamicin 0.4-0.8 mg / kg 2-4 times a day intramuscularly, etc.) are widely used in exacerbation of chronic pancreatitis. However, according to many gastroenterologists, antibiotic therapy in acute pancreatitis and exacerbation of chronic pancreatitis in most cases does not improve the clinical course of the disease and, by prescribing them, one can only count on preventing the infection of necrotic masses and preventing the formation of abscesses.

Finally, the last direction of therapeutic measures for pancreatitis is the suppression of the activity of pancreatic enzymes using intravenous antienzyme drugs: trasilol, contrikal or gordox. Currently, their effectiveness is denied by many, although, perhaps, over time, with a clearer definition of the indications for their use, they will be useful in certain forms of the disease and in its early stages. Some authors report the successful use of peritoneal dialysis in especially severe cases in order to remove activated pancreatic enzymes and toxic substances from the abdominal cavity.

Some gastroenterologists with exacerbation of chronic pancreatitis successfully treated with heparin (10,000 units daily) or aminocaproic acid (150-200 ml of 5% solution intravenously, for a course of 10-20 infusions), but these data need additional verification. The use of corticosteroid hormones recommended by some gastroenterologists is, according to many others, hardly justified.

All these measures are performed in the first hours of an exacerbation of the disease; in the absence of an effect, the doctor has to look for an explanation for this, exclude possible complications, and decide on the expediency of already surgical treatment of the disease.

In cases of successful therapy and subsiding of symptoms of exacerbation, the gastric aspiration probe can be removed after 1-1.5-2 days, however, treatment with antacids and H2-receptor blockers is continued. Allow food to be eaten in very small portions 5-6 times a day (type 5p diet, including slimy cereal soups, pureed porridge in water, a small amount of protein omelet, freshly prepared cottage cheese, meat soufflé from lean meat, etc.). This diet is low in calories, severely restricting fat, mechanically and chemically sparing. In the following days, the diet is gradually and gradually expanded, taking into account the further dynamics of the disease, however, fatty, fried, spicy foods and foods that cause a strong stimulation of the secretion of digestive juices are prohibited. In the coming days, the doses of the administered drugs are reduced, some of them are canceled, leaving for 2-3 weeks, and if indicated and for a longer period, only antacids and H2-receptor blockers. In most cases, the stabilization of the patient's condition is achieved within 1-1.5-2 weeks from the start of treatment.

The main goal of all therapeutic measures for chronic pancreatitis in the remission stage is the desire to achieve a complete cure for the disease (which is not always possible with a long-term illness - 5-10 years or more), to prevent recurrence of the disease, and if complete cure is impossible, then elimination (according to as far as possible) of his symptoms, causing suffering to the patient.

Elimination of the etiological factor of the disease is of paramount importance. In case of alcoholic pancreatitis, these are urgent, reasoned recommendations to stop drinking alcohol, explaining its harm to patients, and, if necessary, treatment for alcoholism. With the so-called cholecystopancreatitis, conservative or surgical treatment of cholecystitis, gallstone disease.

Regulation of nutrition and adherence to a certain diet is of the utmost importance - limiting or completely excluding foods that sharply stimulate the functions of the pancreas (excluding animal fats from the diet, especially pork fat, lamb fat, fried, spicy foods, strong meat soups, broths, etc. .).

Methods of pathogenetic treatment are currently not well developed. The recommendations to use corticosteroid drugs for this purpose should be taken very carefully, mainly their appointment is justified in case of adrenal insufficiency.

In the period of remission of chronic pancreatitis, some patients feel quite satisfactory (some patients with stage I of the disease and some patients with stage II); in many patients, certain symptoms of suffering persist (pain, dyspeptic disorders, progressive loss of body weight, etc.). In some cases, only subjective signs of the disease are noted, in others - and changes detected by a doctor or with special research methods (mostly patients with stage II and especially stage III of the disease). In all cases, a differentiated, individualized choice of therapeutic measures is required.

The advice, periodically encountered in the medical literature, to use so-called immunomodulators in chronic pancreatitis (some authors recommend levamisole, taktivin, etc.), apparently, should also be taken very carefully. First, it is far from always clear that "immunological link" of the pathogenesis of chronic pancreatitis, which (and how) should be influenced. Secondly, in these cases, the maximum possible immunological studies and dynamic immunological control are required - all this is still very difficult to implement in practice.

During the period of remission of the disease, despite the relatively good general well-being of a number of patients, and in some cases even complete or almost complete absence of symptoms of the disease, patients with chronic pancreatitis must strictly observe the food intake (5-6 times a day). It is advisable to eat exactly "on schedule" at the same hours, with approximately equal time intervals between each meal. It is necessary to strongly warn patients about the need for the most thorough chewing of food. Some relatively hard food products (tough varieties of apples, tough boiled meat, etc.) should be recommended to be eaten in a chopped (wiped or rolled through a meat grinder) form.

Considering that in chronic pancreatitis, endocrine pancreatic insufficiency (secondary diabetes mellitus) often occurs, for prophylactic purposes, patients with chronic pancreatitis should be advised to limit (or, best of all, exclude) the “simplest” carbohydrates - mono- and disaccharides, in the first place sugar.

In the absence of symptoms of the disease and the well-being of patients, special drug therapy is not required.

With the drug therapy of chronic pancreatitis, they strive to achieve the following main goals:

1. relief of pancreatic pain, in some cases quite painful;
2. normalization of digestive processes in the small intestine, disturbed due to a lack of pancreatic enzymes;
3. normalization or at least some improvement of absorption processes in the small intestine;
4. compensation for insufficiency of intestinal absorption by intravenous (drip) administration of albumin, plasma or special complex drugs for parenteral nutrition (containing essential amino acids, monosaccharides, fatty acids, basic ions and vitamins);
5. compensation of endocrine insufficiency of the pancreas (if it occurs).

In the edematous form of chronic pancreatitis, the complex of therapeutic measures includes diuretics (diacarb, furosemide, hypothiazide - in normal doses), veroshpiron. The course of treatment is 2-3 weeks.

In cases where patients with chronic pancreatitis complain of pain in the left hypochondrium (presumably caused by damage to the pancreas), an attempt should be made to establish whether they are caused by edema (and, consequently, enlargement) of the pancreas, stretching of its capsule, chronic perineural inflammation, solaritis, or blockage of the main duct with a stone. Depending on the cause, appropriate medications are also selected. In case of blockage of the main duct with calculus or spasm of the sphincter of the hepato-pancreatic ampoule, anticholinergic and myotropic antispasmodic drugs are prescribed (atropine sulfate orally at 0.00025-0.001 g 2-3 times a day, subcutaneous injections at 0.25-1 ml 0.1 % solution; metacin orally 0.002-0.004 g 2-3 times a day, gastrocepin or pirenzepine 50 mg 2 times a day 30 minutes before meals, orally or parenterally - intramuscularly or intravenously, 5-10 mg 2 times a day, no-shpu 0.04-0.08 g 2-3 times a day by mouth or 2-4 ml of a 2% solution intravenously, slowly and other drugs of these groups). With sufficiently strong and persistent pain caused by perineural inflammation or solaritis, non-narcotic analgesics can be recommended (analgin intramuscularly or intravenously, 1-2 ml of a 25% or 50% solution 2-3 times a day, baralgin 1 - 2 tablets inside 2- 3 times a day or in case of severe pain intravenously slowly 1 ampoule - 5 ml - 2-3 times a day). In extreme cases, and for a short time, promedol can be prescribed (internally 6.025-0.05 g 2-3 times a day or 1 - 2 ml of a 1% or 2% solution subcutaneously also 2-3 times a day). Morphine should not be prescribed even with very severe pain, primarily because it causes spasm of the sphincter of the hepato-pancreas ampoule and worsens the outflow of pancreatic juice and bile, thereby it can contribute to the progression of the pathological process in the pancreas.

In some patients, severe pain could be stopped by perirenal or paravertebral novocaine blockade. In some cases, it was possible to relieve excruciating pain using the reflexotherapy method (apparently due to the psychotherapeutic effect?). Some physiotherapy procedures give a good effect. For more than 4 years in our clinic for chronic pancreatitis (painful form), electroregging (a variant of the electrophoresis method) of counterkal is successfully used for this purpose - 5000 IU of counterkal in 2 ml of 50% dimexide solution. UHF is also used in athermal dosage and some other physiotherapeutic methods.

With unbearably severe pain in some cases, you have to resort to surgical treatment.

With solarium and solargia, ganglion blockers and antispasmodics may be quite effective (gangleron 1-2-3 ml of 1> 5% solution subcutaneously or intramuscularly, benzohexonium 1-1.5 ml of a 2.5% solution subcutaneously or intramuscularly or other drugs of this group ).

If in patients with chronic pancreatitis there are signs of exocrine pancreatic insufficiency (insufficient content of enzymes in the pancreatic juice - lipase, trypsin, amylase, etc.), which can be judged when patients develop dyspeptic symptoms, "pancreatogenic" diarrhea, characteristic changes in the results of coprological studies : steatorrhea is persistently noted, to a lesser extent - creato- and amilorrhea - it is necessary to prescribe medications containing these enzymes and facilitate the digestion of nutrients in the small intestine.

When recommending certain preparations containing pancreatic enzymes to patients with chronic pancreatitis, it should be borne in mind that they are difficult to standardize, even preparations of the same company, released at a certain time interval, may differ somewhat in their activity. Therefore, the effect of the use of these drugs is not in all cases. It is also necessary to take into account the individual characteristics of the patient's body: some patients are better helped by some drugs, others by others. Therefore, when prescribing certain enzyme preparations, it is imperative to ask the patient which of these drugs helped better and were better tolerated when used in the past.

The tactics of using enzyme preparations recommended by different schools of gastroenterologists are somewhat different. So, you can prescribe preparations of pancreatic enzymes before meals (approximately 20-30 minutes) or during meals, at each meal. In patients with increased or normal gastric secretion, it is better to prescribe pancreatic enzymes before meals and in combination with antacids, preferably liquid or gel-like, including "alkaline" mineral water such as Borzhom, Smirnovskaya, Slavyanovskaya, Jermuk, etc. This recommendation is due to the fact that that pancreatic enzymes are most active with a neutral or slightly alkaline reaction of the medium pH 7.8-8-9. At pH below 3.5, lipase activity is lost, trypsin and chymotrypsin are inactivated by pepsin of gastric juice. With hypochlorhydria and especially gastric achilia, it is advisable to prescribe preparations of pancreatic enzymes during meals.

Recently, preparations containing pancreatic enzymes have been recommended to be taken in combination with H2-receptor blockers (cimetidine, ranitidine or famotidine), which most strongly suppress gastric secretion.

Each patient, taking into account the severity of the disease, should select an individual dose of enzyme preparations (1-2 tablets or a capsule 3-4-5-6 times a day up to 20-24 tablets a day). In some cases, according to our observations, the combination of a standard drug (panzinorm, festal, etc.), containing three main enzymes, with pancreatin is more effective than a double increase in the dose of this drug. Apparently, this is due to the fact that, in addition to the main ones - lipase, trypsin and amylase, pancreatin also contains other pancreatic enzymes - chymotrypsin, exopeptidases, carboxypeptidases A and B, elastase, collagenase, deoxyribonuculease, ribonuclease mal, lactase, , esterase, alkaline phosphatase and a number of others.

In the literature, the question is widely discussed in what dosage form pancreatic enzymes are most effective - in the form of tablets (dragees) or in capsules? Apparently, the use of pancreatic preparations in the form of a powder or small granules enclosed in a capsule that dissolves in the small intestine is more justified than in the form of tablets or dragees (a priori), since there is insufficient confidence that the tablet preparations are sufficiently fast and timely dissolve in the duodenum or jejunum, and do not "slip" in an insoluble form into the more proximal parts of the small intestine, without taking part in the digestive processes.

Some gastroenterologists in especially severe cases of chronic pancreatitis recommend prescribing pancreatic enzyme preparations in large doses every hour (except for a night's sleep), regardless of food intake - 16-26-30 tablets or capsules per day. Perhaps this tactic has some advantages - a uniform flow of pancreatic enzymes into the intestine (after all, given the rather long retention of food in the stomach and its portioned entry into the intestine, the digestive processes in the small intestine go on almost continuously, therefore, the need for pancreatic enzymes exists almost constantly - the small intestine is almost never without chyme).

Enhancing the effectiveness of enzyme therapy is achieved in cases where it is necessary, by the parallel administration of drugs that inhibit gastric secretion (of course, not in cases where gastric achilia occurs). The most effective for this purpose is the combination of H2-receptor blockers (ranitidine or famotidine, etc.) with anticholinergics (atropine sulfate, metacin, gastrocepin).

The use of anticholinergics, in addition to their inhibitory effect on gastric secretion (recall that acidic active gastric juice inhibits the action of pancreatic enzymes, for which a neutral or slightly alkaline reaction of the environment is optimal, and it inactivates or destroys some of them), but also slows down the passage of nutrients in the small intestine. This last action of anticholinergics increases the residence time of the chyme in the small intestine, which promotes digestive processes and absorption (for example, lengthening the contact time of the final products of digestion with the mucous membrane of the small intestine noticeably enhances their absorption).

The effectiveness of treatment with drugs of pancreatic enzymes and control of the correctness and adequacy of the selected dose of drugs is carried out, focusing on the dynamics of subjective sensations of patients and some objective indicators: a decrease or disappearance of dyspeptic symptoms, flatulence, a tendency to normalize or complete normalization of stool frequency and the nature of stool, the results of repeated scatological microscopic studies, slowing down the decrease or the emergence of a tendency towards positive dynamics of the patient's body weight.

Extremely cautious (if not generally negative) should be taken to the recommendations of some gastroenterologists for exocrine pancreatic insufficiency to use secretin and pancreozymin hormones to stimulate its function. Firstly, their action is very short-lived (several tens of minutes), and secondly, and, apparently, this is the main thing - trying to stimulate the function of the pancreas, you can cause an exacerbation of pancreatitis.

The next direction of therapeutic measures for chronic pancreatitis, especially for patients with stage II or III of the disease, is compensation for impaired absorption processes in the small intestine. It has been established that insufficient absorption of the final products of hydrolysis of nutrients (amino acids, monosaccharides, fatty acids, etc.) in chronic pancreatitis occurs mainly due to the action of two factors: disturbances in digestive processes and secondary inflammatory lesions of the mucous membrane of the small intestine. If the first factor can be compensated in most cases with an adequate dose of pancreatic enzymes, then it is possible to reduce inflammation in the mucous membrane by using drugs that have a local protective (enveloping and astringent) effect on the mucous membrane. For this purpose, the same means are usually used as in chronic enteritis and enterocolitis - basic bismuth nitrate 0.5 g each, kaolin (white clay) 4-10-20 g per dose, calcium carbonate 0.5 g each. Each of these drugs can be taken either separately 5-6 times a day, preferably as a suspension in a small amount of warm water, or, preferably, together (you can drink this combination in the indicated doses at one time in the form of a powder) also 4-5 -6 times a day. You can also use some medicinal plants, infusions or decoctions of which have an astringent effect: an infusion of marshmallow root (5 g per 200 ml of water), a decoction of Potentilla rhizome (15 g per 200 ml of water), rhizome with cyanosis roots (15 g per 200 ml of water), infusion or decoction of bird cherry fruits (10 g per 200 ml of water), infusion of alder seedlings (10 g per 200 ml of water), infusion of St. John's wort (10 g per 200 ml of water), infusion of chamomile flowers (10-20 g per 200 ml of water), etc.

Patients with chronic pancreatitis with more pronounced exocrine insufficiency (II-III degree) and symptoms of malabsorption in order to increase the intake of easily digestible nutrients necessary to cover energy costs and restore body weight are prescribed in addition to the usual dietary recommendations (diet No. 5p) special nutritional mixtures ( enpits) or, in their absence, infant formula. Formulas for parenteral nutrition, enriched with vitamins and necessary ions (such as the drug Vivonex, produced abroad), are especially useful. Because not all nutritional formula tastes good and people have decreased appetite, these nutritional mixtures can be gavaged 1-2-3 times a day between meals.

In even more severe cases, with pronounced malabsorption and significant weight loss, patients are prescribed additional special preparations for parenteral nutrition (casein hydrolyzate, aminocrovin, fibrinosol, amikin, polyamine, lipofundin, etc.). All these drugs are administered intravenously, very slowly (starting from 10-15-20 drops per minute, then after 25-30 minutes a little faster - up to 40-60 drops per minute), 400-450 ml 1-2 times a day; the duration of each dose is 3-4 hours, the intervals between injections of these drugs are 2-5 days, for a course of 5-6 injections. Of course, these infusions can only be performed in a hospital setting. In order to eliminate hypoproteinemia, blood plasma can also be used.

Patients with a significant decrease in body weight in order to improve the absorption of protein by the body are prescribed anabolic steroid hormones: methandrostenolone (dianabol, nerobol) at 0.005-0.01 g (1-2 tablets of 5 mg) 2-3 times a day before meals, retabolil ( intramuscularly in the form of an oil solution) 0.025-0.05 g is injected 1 time in 2-3 weeks, for a course of 6-8-10 injections. Clinically, treatment with these drugs is manifested in an improvement in appetite, a gradual increase in the body weight of patients, an improvement in their general condition, and in cases with calcium deficiency and osteoporosis, in the acceleration of bone calcification (while providing additional intake of calcium salts into the body).

With prolonged pancreatitis due to secondary involvement in the inflammatory process of the small intestine and malabsorption, signs of vitamin deficiency are often noted in it. Therefore, patients are shown multivitamins (3-4 times a day, 1-2 pills) and individual vitamins, especially B2, Bb, B12, nicotinic and ascorbic acid, as well as fat-soluble vitamins, primarily A and D. With obvious signs of vitamin deficiency, some vitamins, especially necessary, can be administered additionally in the form of injections. It should be remembered that with a long course of chronic pancreatitis, there may be a deficiency of vitamin Bi2 and the resulting anemia. With a lack of iron ions in the body, anemia can also occur, with a simultaneous lack of both vitamin B12 and iron ions - mixed, polydeficiency anemia, with insufficient absorption of Ca 2+, osteoporosis gradually develops. Therefore, with a decrease in these ions (Ca 2+, Fe 2 "1") in the blood serum of patients, especially when clinical signs of their insufficiency are detected, their additional administration should be provided, preferably parenteral. So, calcium chloride is injected 5-10 ml of a 10% solution into a vein daily or every other day slowly, very carefully. Ferrum Lek is administered intramuscularly or intravenously at 0.1 g per day in appropriate ampoules for intramuscular (2 ml) or intravenous (5 ml) administration. The drug is administered intravenously slowly.

Intrasecretory pancreatic insufficiency requires appropriate corrections of dietary and therapeutic measures - as in diabetes mellitus. According to many gastroenterologists, diabetes mellitus occurs in approximately 30-50% of patients with non-calcifying pancreatitis and in 70-90% of patients with calcifying pancreatitis. At the same time, it is believed that a decrease in glucose tolerance occurs even more often and occurs earlier than steatorrhea appears. It should be borne in mind that diabetes mellitus, which occurs against the background of chronic pancreatitis, has its own characteristics: the defeat of the inflammatory-sclerotic process of the pancreatic islets reduces the production of not only insulin, but also glucagon. The course of symptomatic diabetes in this disease and hyperglycemia are very labile. In particular, the introduction of even small doses of insulin may be accompanied, due to insufficient production of glucagon, by a significant drop in blood glucose that is inadequate to the dose of injected insulin. Insufficient production of glucagon also explains the relatively rare occurrence of diabetic ketoacidosis in such patients, since in this case the ability of the liver tissue to convert free fatty acids into acetoacetic and beta-hydroxybutyric acids is reduced. In the literature, there is a relatively rare occurrence of some complications of diabetes mellitus in chronic pancreatitis - retinopathy, nephropathy, microangiopathy, vascular complications. In the treatment of secondary (symptomatic) diabetes mellitus in patients with chronic pancreatitis, in addition to an appropriate diet, oral antihyperglycemic drugs that increase glucose tolerance should be mainly used.

It is believed that it is advisable for patients with chronic pancreatitis periodically, 3-4 times a year, to be treated with drugs that have a stimulating effect on metabolic processes (pentoxil, which is prescribed at 0.2-0.4 g per dose, or methyluracil at 0.5- 1 g 3-4 times a day). The course of treatment with one of these drugs is 3-4 weeks. Previously, simultaneously with these drugs, the so-called lipotropic drugs were prescribed - methionine or lipocaine, but their effectiveness is low.

After the removal of acute phenomena and in order to prevent an exacerbation, resort treatment is further recommended in Borjomi, Yessentuki, Zheleznovodsk, Pyatigorsk, Karlovy Vary and in local sanatoriums of a gastroenterological profile.

Patients with chronic pancreatitis are not shown types of work in which it is impossible to adhere to a clear diet; in case of a severe course of the disease, it is necessary to refer patients to VTEK to determine the disability group.

Based on the pathogenesis of chronic pancreatitis, treatment should be aimed at solving the following tasks:

• decrease in pancreatic secretion;
• relief of pain syndrome;
• carrying out enzyme replacement therapy.

Surgical treatment of chronic pancreatitis

Surgical treatment of chronic pancreatitis is indicated for severe painful forms of chronic pancreatitis, when the pain is not relieved by any therapeutic measures: with cicatricial-inflammatory stenosis of the common bile and (or) main duct, abscess formation or the development of a cyst of the gland. The nature of the operation in each case is determined by the characteristics of the course of the inflammatory process in the pancreas and the nature of the complication that has arisen. So, with unbearably severe pain, splancnectomy and vagotomy are performed, ligation or obstruction of the main duct with acrylic glue, etc. or the head of the pancreas, etc.), pancreatoduodenal resection, drainage of the main duct and other types of surgical interventions, the nature of which is determined by the specific characteristics of each case of the disease. Naturally, in the postoperative period, dietary and therapeutic measures are carried out, as in the exacerbation of pancreatitis, and in the long term, depending on the characteristics and severity of the course, as in the chronic form of the disease.

We did not have to observe cases of self-cure of chronic pancreatitis. However, as our experience shows, a significant improvement in the course of the disease under the influence of systematic therapeutic measures in patients undergoing dispensary observation, and the occurrence of persistent remission over a long period of observation (for 5-7 years or more) is quite possible in most patients.

Non-drug treatment

The diet should not stimulate the secretion of pancreatic juice. With pronounced exacerbations, hunger (table 0) and hydrocarbonate-chloride waters are prescribed for the first 3-5 days. If necessary, prescribe parenteral nutrition: protein solutions (albumin, protein, plasma), electrolytes, glucose. It helps to reduce intoxication and pain and prevents the development of hypovolemic shock.

With duodenostasis, gastric contents are aspirated with a thin probe.

After 3-5 days, the patient is transferred to oral nutrition. Eating should be frequent, small portions. Limit the intake of foods that can stimulate the secretion of the pancreas: fats (especially those subjected to heat treatment), acidic foods. Limit the use of calcium-rich dairy products (cottage cheese, cheese).

The daily diet should contain 80-120 g of easily digestible proteins (egg white, boiled lean meat, fish), 50-75 g of fat, 300-400 g of carbohydrates (preferably in the form of polysaccharides). With good individual tolerance, raw vegetables are not excluded.

The use of alcohol, spicy food, canned food, carbonated drinks, sour fruits and berries, sour fruit juices is prohibited.

Replacement therapy for exocrine pancreatic function

Mild steatorrhea, not accompanied by diarrhea and weight loss, can be corrected by diet. The indication for the appointment of enzymes is steatorrhea with a loss of more than 15 g of fat per day, combined with diarrhea and weight loss.

Doses of enzyme preparations depend on the degree of pancreatic insufficiency and the patient's desire to follow a diet. To ensure the normal process of digestion with adequate nutrition in patients with severe exocrine insufficiency, it is necessary to take 10,000-30,000 IU of lipase with each meal.

The enzyme preparations used should not lower the pH of gastric juice, stimulate pancreatic secretion. Therefore, it is preferable to prescribe enzymes that do not contain bile and extracts of the gastric mucosa (pancreatin).

Enzyme preparations are prescribed for life. It is possible to reduce doses while following a strict diet with restriction of fat and protein and increase them when the diet is expanded. Indicators of a correctly selected dose of enzymes are stabilization or increase in body weight, cessation of diarrhea, steatorrhea and creatorrhea.

In the absence of the effect of prescribing large doses of enzymes (30,000 units for lipase), a further increase in doses is inappropriate. The reasons may be concomitant diseases: microbial contamination of the duodenum, helminthic invasions of the small intestine, precipitation of bile acids and inactivation of enzymes in the duodenum as a result of a decrease in pH. In addition to enzyme inactivation at low pH, the secretion of bile and pancreatic juice with a low enzyme content increases. This leads to a decrease in the concentration of enzymes. At a low pH of the duodenal contents, it is recommended to combine the intake of enzymes with antisecretory drugs (proton pump inhibitors, blockers of H 2 histamine receptors).

Further patient management

After stopping the exacerbation of chronic pancreatitis, a low-fat diet, constant enzyme replacement therapy is recommended.

Patient education

It is necessary to explain to the patient that the intake of enzyme preparations should be constant, the patient can adjust the dose of enzymes depending on the composition and volume of food intake.

It is important to explain that long-term use of enzyme preparations does not lead to the development of secondary exocrine insufficiency.

Chronic pancreatitis prognosis

Strict adherence to the diet, refusal to drink alcohol, the adequacy of maintenance therapy significantly reduce the frequency and severity of exacerbations in 70-80% of patients. Patients with chronic alcoholic pancreatitis live up to 10 years with a complete refusal to consume alcoholic beverages. If they continue to drink alcohol, then half of them die early. Persistent and long-term remission of chronic pancreatitis is possible only with regular maintenance therapy.

People rarely give importance to what they eat and how much. Improper nutrition, accompanied by stress, overexertion or emotional stress, leads to the fact that the body responds with inflammatory processes. The pancreas suffers in this case more often than others, there is a disease called pancreatitis. It is important to remember that if you do not make treatment, the disease will develop into a chronic one. In order to take timely measures to combat the disease, you should know how the exacerbation of chronic pancreatitis manifests itself - the symptoms, the treatment prescribed by the doctor will help you choose the right therapy.

Signs of exacerbation of pancreatitis

Disease and pancreatitis, including, does not occur without reason. The main signs of exacerbation of chronic pancreatitis are:

• the presence of gallstone disease;
• diagnosed cholecystitis;
• there are stressful situations or constant experiences;
• violation of diet and treatment in the acute form of the disease;
• excessive alcohol consumption;
• improper nutrition (the predominance of spicy, fatty and salty in the diet).

Symptoms of exacerbation of chronic pancreatitis

Exacerbation of pancreatitis, symptoms of which are manifested in the form of sharp pain, indicate that it is necessary to undergo a course of rehabilitation therapy. Additional signs that changes are occurring in the pancreas that require attention are:

• back pain;
• pain in the area of ​​the shoulder blades and between them;
• pain in the left hypochondrium;
• nausea;
• vomit;
• bitterness in the mouth;
• dryness;
• weakness;
• lack of appetite;
• constant urge to defecate;
• diarrhea;
• headache;
• failures in the work of the heart;
• an increase in body temperature (on average up to 38.5);
• bile secretion;
• hard stomach;
• Bad mood;
• weight loss;
• bloating is noted;
• drowsy state.

The attack can last from 1 to 7-8 days. In addition, the symptoms of chronic pancreatitis in the acute stage may not go away - pain and nausea are constantly present. In the event that the pain is constant, but weakly expressed, then it can last up to 1-2 months - the course of the exacerbation stage is sluggish, but requires attention. It is also noted that pain may worsen at night.

Important! The manifested symptoms of exacerbation of pancreatitis indicate that the problem already exists and requires treatment. That is why an immediate consultation with a doctor (therapist and gastroenterologist) is necessary.

Phases of the course of the disease

With an exacerbation of the pancreas, treatment is prescribed based on the phase in which the process is. Each of them has specific manifestations and symptoms. So in the first phase, the formation of inflammation occurs - a source of pain. It lasts up to 5 days. During this period, pain manifestations may be imperceptible, there is a deterioration in well-being, pulling sensations in the abdomen, and stool disturbances.

The second phase is characterized by increasing severity - symptoms of exacerbation of chronic pancreatitis become pronounced. Consultation with a doctor is necessary, since many manifestations of the disease are similar to the symptoms of other diseases, for example, poisoning. An accurate diagnosis can be made by a doctor based on the diagnostics performed. This will eliminate all mistakes and prescribe an effective therapy.

Diagnostics of the disease in the acute phase

If a person notes signs of an exacerbation of pancreatitis, then he needs to be diagnosed. It includes:

• blood test (biochemistry);
• stool analysis;
• blood test (sugar);
• urine analysis (general);
• ultrasound of the peritoneum;
• X-ray;
• gastroscopy;
• Passing functional tests.

Additionally, the doctor feels the abdomen, interviews the patient in order to identify the duration of the attack and the symptoms that are present at a given time.

Treatment of exacerbation of chronic pancreatitis

Aggravation of the pancreas requires treatment. It is assigned based on the survey data obtained. Therapy includes:

• drug treatment;
• the use of traditional medicines;
• diet;
• prevention.

with exacerbation of the pancreas treatment

In order to relieve the main symptoms, it is important to know how to calm the pancreas during an exacerbation. The main advice is fasting, since it is required to remove the load from the pancreas and, in general, from the gastrointestinal tract.

Diet nutrition is an integral part of the recovery process. In addition to dietary restrictions, you need to know what to drink with an exacerbation of pancreatitis. The table for symptoms of acute pancreatitis should consist of low-fat foods, baked goods, sweet and spicy, are completely excluded. Salt and pickles are also banned until complete recovery.

Symptoms of an exacerbation of the pancreas - pain requires a person to refuse to eat at all in the first 2-3 days, or, if this is impossible, to eat in minimal quantities. In addition, from the 4th to the 10th day of the diet, it is gradually allowed to eat porridge - semolina, oatmeal, rice, and also include vegetable purees, meat, which should be lean, in the diet. Baked apples and a little honey are allowed as desserts. You can drink rosehip decoctions, juices diluted with water (except for banana and grape), green tea.

In order not to provoke another attack of pancreatitis, it is recommended to adhere to fractional nutrition, as well as to eat up to 7 times a day in small portions so as not to burden the stomach. In parallel, medications should be taken to produce a sufficient amount of enzymes.

Disease prevention

After the signs of an exacerbation of the pancreas disappear, a course of rehabilitation therapy will be carried out and good indicators of repeated tests have been achieved, prevention will be required. It includes:

• continuation of dietary nutrition (relaxed restrictions);
• taking a course of drugs;
• folk remedies.

All this will allow you to remove negative feelings at home if they reappear. Signs of exacerbation of chronic pancreatitis will allow you to remove the recipes of traditional medicine. Decoctions and infusions made from medicinal plants will help to effectively solve the problem of the recurrence of pain.

Traditional medicine recipes

Effective recipes that help maintain pancreatic health are easy to prepare. You need to take:

• corn silk - 20 g;
• celandine -20 g (dry);
• dandelion root - 10 g;
• anise seeds - 10 g;
• bird highlander - 10 g;
• violet tricolor (flowers) - 10 g.

All ingredients need to be poured with 2 glasses of water and boiled. After boiling, cook for another 7 minutes, strangling the heat to minimum values. After that, strain the resulting broth and take 3-4 ml 30 minutes before meals for 14 days.

Another recipe that can be used for both treatment and prevention:

• dill seeds - 2 tbsp;
• chamomile flowers (dry) -20 g;
• immortelle flowers - 2 tbsp;
• hawthorn fruits - 10 g (crushed).

The components are poured into 4 glasses of water, brought to a boil. After they must be removed from the heat and wrapped around the container until the broth cools completely. Strain the resulting liquid and drink 85 ml after each meal. Apply for at least 5 days or until the symptoms of exacerbation of chronic pancreatitis completely disappear.

Another simple and good recipe:

• golden mustache - 3 leaves (just cut);
• water - 3 glasses.

The ingredients should be mixed and heated, then boiled. After boiling, leave on low heat for another 15 minutes, then remove from heat and strain so that only liquid remains. Reception to start with 1 tablespoon, the maximum amount is 125 ml (the volume increases gradually). The course is up to 10-14 days.

Thus, you can cure an attack of exacerbation of chronic pancreatitis, knowing its symptoms. Therapy should be carried out in a complex - the activities are consistent. It is recommended for this time to reduce physical activity and general activity, strictly adhere to the rules of taking medication, diet. Follow-up prevention is the key to success and good health.