Pathology of acute pancreatitis

2021-01-27 12:00 AM

Pancreatic enzymes usually increase 4 to 12 hours after pain in acute pancreatitis, Amylase usually decreases after 3-4 days, in acute pancreatitis must increase more than 3 times normal.

Preamble

Acute pancreatitis is an acute condition of the pancreas, which can range from oedematous pancreatitis to acute necrotizing pancreatitis, in which the degree of necrosis is related to the severity of the disease. The term haemorrhage has little clinical significance because a greater amount of interstitial bleeding can be found in acute pancreatitis as well as in other disorders such as trauma to the pancreas or pancreatic tumour and also in severe congestive heart failure.

Whole disease

Pebbles.

Due to alcohol causes acute pancreatitis and chronic pancreatitis.

After laparoscopic abdominal surgery and upstream biliary tract imaging.

Injury to the abdomen.

Metabolism.

Infections: mumps, viral hepatitis, roundworm.

Due to drugs.

Peptic ulcer stuck to the pancreas.

Duodenal diverticula.

The pancreas is split in two.

Mechanism of pathogenesis

Congestion and reflux theory

Due to stones, worms, and tumours, the cause of acute pancreatitis. This blockage is often accompanied by reflux of activated pancreatic juice, possibly accompanied by bile juices that are factors that cause pancreatic enzyme activation.

Change the permeability of the pancreatic duct

Normally, the lining of the pancreas does not allow permeability of> 3000Da molecules, the increase in permeability occurs in the presence of acetylsalicylic acid, histamine, Calcium and Prostaglandin E2. The epithelial barrier can then permeate molecules from 20,000 to 25,000 Da. This allows the release of phospholipases A, Trypsin and elastase into the interstitial pancreatic tissue to induce acute pancreatitis.

Self-destruction theory

This theory suggests that enzymes such as trypsinogen, Chymotrypsinogen, proélastase and phospholipase A2 are activated in the pancreas to cause acute pancreatitis.

Theory of excessive oxidation

According to this theory, acute pancreatitis is initiated due to the overproduction of oxidative free radicals and activated peroxide due to the enzyme induction of the P450 microsomal system.

Clinical

Stomach-ache

Pain often starts suddenly with acute abdominal pain, pain can range from mild to very severe, frequent and exacerbated in acute worm pancreatitis, starting with bile duct-type worms.

Vomit

Vomiting is also a common symptom (70-80%).

Bloating

Due to gastroparesis and intestinal paralysis is also common.

Infectious syndrome

In the case of worms and stones, it can occur on the first or second day, while in acute alcoholic pancreatitis usually arrives late after 5-7 days due to superinfection. In severe form of necrotic haemorrhage, severe systemic symptoms with toxic infection syndrome, abdominal distention and widespread pain may have a surgical abdominal sign. There are also signs of internal bleeding or bruised plaques around the navel or hip area (Cullen and Turner marks).

Jaundice

May be due to the cause of worms or stones or in the case of an inflamed pancreas or oedema compresses the bile ducts.

Subclinical

Amylase blood

Usually increase 4 to 12 hours after pain, in acute pancreatitis, Amylase oedema usually decreases after 3-4 days, in acute pancreatitis must increase more than 3 times normal.

Urinary amylase

Amylase is absorbed and eliminated in the urinary tract, so it usually increases more slowly after 2-3 days, usually peaks on days 4 - 5 and lasts 5-7 days.

The ratio of urinary amylase to blood amylase is 1, 7 to 2.

Blood lipase

Usually increased parallel to blood amylase but more specific. It takes longer but the quantification is complicated and takes a lot of time so it is practically less applicable. Normal blood lipase 250v / L.

Blood sugar

Initially due to the release of Glucagon, may cause hyperglycaemia or necrosis of the island of Langerhans, blood sugar can be greater than 11 mmol / l.

Blood calcium

There is a decrease in severe acute pancreatitis usually occurs on 2 - 3 and lasts a few weeks, blood calcium <2mmol / l is a severe prognosis.

LDH

Increased necrotic acute pancreatitis when LDH> 350Ul / l means a severe prognosis.

PO2

Usually, 60 mmHg occurs in 25% of necrotic pancreatitis, especially in cases of respiratory distress syndrome in adults.

CBC

Neutrophils are high, especially acute pancreatitis caused by worms and stones when leukocytes> 16000 / mm3 are a severe factor.

Ultrasound of the pancreas

Large pancreas, poorer structure than usual, ultrasound also helps to detect fluid in the abdomen, worms, stones or its complications such as abscesses and pancreatic pseudo-cysts.

Density tomography (CT Scanner): There are 5 stages A, B, C, D, E. Significantly prognostic.

X-ray

Often of little value in the diagnosis of acute pancreatitis in cases of extensive paralysis that may have an upright loop.

Diagnose

Implementing the quadrants

Pancreatitis should be considered when the patient has acute abdominal pain in the epigastric region and lower left flank with excessive vomiting, the whole body has the infectious syndrome, a lot of bloating, the examination of the obvious pancreatic pain points in combination with blood or urinary amylase> 3 times normal or purification factor> 5. Ultrasound or density tomography has an image of acute pancreatitis.

Differential diagnosis

Empty organ perforation:

In particular, peptic ulcer perforation, it is necessary to base on a history of ulcers with knife-stab pain, the examination of surgical abdominal signs and loss of pre-hepatic turbidity, an unprepared abdominal film with a sickle under the diaphragm. Here, blood amylase is not high, increased only 2-3 times normal.

Acute cholecystitis:

Need-based on the history of gallstones, liver cramps, liver symptoms with large liver, large and painful gallbladder, jaundice, ultrasound helps detect large gallbladder thick wall.

Intestinal obstruction, intussusception:

Heart attack:

Often the elderly have a history of angina, the painless examination of pancreatic sites. Amylase based on blood amylase and electrocardiogram and the enzyme CPK, CPK-MB and blood Troponin increase.

Symptoms

In place

Pancreatic abscess: Severe infection, high fever of 39 - 40 0 C lasting for more than 1 week, the pancreatic area is very painful, the examination has a very painful plaque, determined by ultrasound or density tomography.

Pancreatic cysts: In the 2nd - 3rd week, the examination of the pancreas with tension and pressure, amylase is still 2 - 3 times high, super numeric with empty echo block, density tomography has similar signs.

The burden due to perforation or rupture of pancreatic duct or pseudocyst to the abdomen in case of haemorrhagic acute pancreatitis due to vascular necrosis causing haemorrhage in the abdomen.

Body

Lungs: The most effusion is left lung bottom, atelectasis or left basilar pneumonia. The most serious complication is respiratory distress syndrome in adults.

Cardiovascular: Reducing blood pressure or shock which is caused by a combination of infectious factors, poisoning, haemorrhage and drainage.

Blood: Can cause intravascular clotting syndrome (CIVD) as in the case of necrotic haemorrhagic enteritis.

Gastrointestinal: Acute peptic ulcer, as a complication. Stress due to pain or infection, intoxication and often manifests itself as haemorrhage. Door vein embolism.

Kidney: Minimize or anuria due to functional renal failure due to reduced circulating volume, necrosis of the kidney and adrenal is a rare complication caused by inflammation from the pancreas. Thrombophlebitis and renal artery are a common complication of thrombophlebitis.

Metabolic complications: Hyperglycaemia or hypocalcaemia.

Treatment

Treatment of acute pancreatitis is of the nature of surgical emergency combined with emergency resuscitation; In addition to general treatment in acute pancreatitis, attention should be paid to the treatment of causes and complications, for example, in acute worms, it is necessary to immediately use antihistamines and antibiotics, in acute pancreatitis due to stones. combined treatment to eliminate stones.

Treatment of acute pancreatitis is often

Treatment principles: Most acute pancreatitis is oedema (85 - 90%), mainly treated with medical methods and the disease will regress after 5-7 days. The usual measures are:

Help the pancreas to rest reduces pain and reduce secretion by fasting, drinking gastric juice.

Hydration and electrolyte replacement: In acute pancreatitis due to inability to eat or drink, fever, vomiting and drainage, the patient is often dehydrated. In severe cases due to the phenomenon of inflammatory secretions and increased vascular permeability, it is necessary to transfer colloids or have high molecular weight.

Feeding by mouth until the pain symptoms are much reduced before gradually starting to feed, starting with sugar water, then sugar paste and porridge to reduce the secretion of the pancreas.

Choline inhibitors are less effective in inhibiting pancreatic secretion but also cause bloating and surgical concealment.

The real pain relievers are only used when fasting and aspiration methods do not relieve pain, but do not use morphine because of the risk of Oddi muscle spasm, dolargan or Viscéralgin can be used.

Antibiotics: In acute alcoholic pancreatitis is only used to fight superinfection, so it is usually used slowly. In contrast, in acute pancreatitis caused by worms, the infection is very early, so antibiotics should be used at the beginning, usually by injection antibiotics such as: Ampicillin, Gentamycin. In case of severe infections, a combination of cephalosporin and quinolone is required; If the infection is severe and prolonged, it is necessary to use an anaerobic antibiotic such as the Imidazole group, Beta Lactamin or the anaerobic Macrolide group (Clindamycin, Dalacine).

In acute pancreatitis caused by roundworm, worms that enter the biliary tract, especially in the early stage when the worms are still alive and partially enter the biliary tract, the use of fast-acting helminths has proved very effective. This is considered to be the cause treatment that helps to relieve pain and cure the disease very quickly.

In acute pancreatitis due to stones: Nowadays it is possible to use upstream Chol angioscopy and endoscopy to help diagnose while dissecting Oddi sphincter and pulling or dissolving stones.

In acute pancreatitis necrotic haemorrhage: Often accompanied by dizziness, therefore, need intensive treatment with fluid and electrolyte replacement. If blood albumin is reduced much <60g / l, it is necessary to infuse colloidal pressure solutions such as albumin, plasmagen or high molecular weight solution such as Rhéodex; If there is bleeding (HC decreased> 1 million or Hct decrease> 10%), blood transfusion is required. Also need to use vasopressors such as dopamine or Dobutamine (Dobutrex).

Practical application

Fasting: Usually 2-3 days until the pain is much reduced, start to gradually feed little by little with sugar water then gradually switch to eating porridge, at first the liquid sugar porridge gradually thickens, should watch for signs stomach-ache.

Gastric aspiration: By placing the gastric tube to absorb gastric juice continuously, it is possible to store the sonde.

Infusion: Usually 2-3 litres / day by ringer lactate or with sodium chloride and isotonic glucose.

In the case of acute helminthic pancreatitis, it is necessary to give early helminthic drugs with lévamisole 50mg or 150mg tablets, 150mg orally or crushed dose pumped through the tube; palmoat de pyrantel, 125mg tablet 10 mg/kg, Mébendazole 200mg, 600mg or 400mg or 400mg albendazole tablets. Simultaneously use antibiotics early such as ampicillin intramuscular dose 2g / day and gentamycin, dose 3-5 mg/kg / day.

Treatment of acute pancreatitis can exudate

Need to actively suck the stomach and fully rehydrate and electrolytes, usually, the gastric aspiration time lasts 5-7 days, when withdrawing the sonde to carefully monitor epigastric pain, the amount of compensated fluid is higher because here Dehydration, electrolytes and protein are often higher due to fever, vomiting more, severe intestinal paralysis and especially more secretions in the abdomen, often compensated daily fluid can be up to 3-4 litres, pay attention to add fluid of high molecular weight or albumin; At the same time, increasing antibiotics, mainly a combination of gentamycin in the above dose combined with cephalosporins such as cefotaxime, ceftriaxone or cefuroxime at 3g / day or quinolones such as ofloxacin 400 mg/day, ciprofloxacin 1000 mg/day intravenously or anti-antibiotic gas such as Metronidazole at a dose of 1,000 mg/day intravenously within 1 hour.

Treatment of severe acute pancreatitis

Severe acute pancreatitis is the term to describe the form of acute, necrotic haemorrhagic pancreatitis. However, in addition to the factor of necrotic haemorrhage, there are also problems of excessive secretion of fluid in the abdomen through the current inflammatory fluid flow mechanism (coulée inflammatory), as well as the toxic infection-causing pancreatic abscess. Factors causing severe acute pancreatitis. This is a very serious medical emergency; the death rate can be up to 80%.

Medical treatment:

The patient must first be placed in an emergency internal surgical resuscitation unit. Inserting a Swan ganz catheter is large enough to be able to help with fluids.

Nurturing the patient: It is important to provide adequate nutrition and rich energy. No matter how severe the progression of acute pancreatitis is required to provide optimal energy with 60 calories/kg of weight, an average of 3,000 - 3,500 calories/day, mainly glucides and lipids. Initially, it was sugar feeding, placing the catéther under the blow. Immediately when there is a lot of pain relief and there is no symptom of intestinal obstruction, switch to gastrointestinal feeding by placing a double-barrel gastrointestinal catheter: short barrel placed before the pyloric, 30-40 cm long barrel in the first segment colon.

Adjusting electrolyte water and acid-base balance: By infusion of solutions of sugar, salt (electrolytes) and albumin. It is important to maintain a normal hemodynamic level, the proper dilution of the blood to allow the easy capillary exchange to avoid embolism due to increased sebum.

The amount of fluid should be based on the pulse and blood pressure, Hct, electrolytes and especially central venous pressure. Usually 3 - 4 liters/day, in severe cases up to 10L in the first 48 hours.

It is best to infuse Ringer lactate. If not, pass 1/2 sugar and 1/2 isotonic salt. Per 1 litre of fluid per 1 unit of human serum albumin (12.5 g).

If red blood cells decrease> 1 million or Hct decrease> 10%, need a fresh blood transfusion or Block red blood cells.

Treatment of Kidney Failure: In the early stages, it is usually a functional renal failure, the latter being due to damage to the kidney tubules. Prevented in the first place by fine regulation of hemodynamic. In case of acute renal failure need to use Mannitol 20% fast infusion or Lasix to do the urinary test, sometimes need to use high dose Lasix 0.5-1g / 24 hours. Failure to do this requires haemodialysis, but in these cases, the prognosis is usually very severe.

Continuous gastric aspiration: This is a very effective measure to help reduce gastric juice secretion, pancreatic juice, reduce stomach gas; helps the pancreas to rest so it has a very good analgesic effect. This is also a means to help track stomach bleeding.

Treatment of pleural effusion and acute respiratory failure: If there is much pleural effusion need drainage. Acute respiratory failure requires mechanical ventilation, corrected under blood gas monitoring.

Anti-shock: If the above positive measures have been fully implemented, but dizziness still occurs, it is necessary to use vasopressors and raise blood pressure such as: Dopamine 200mg tube can give an average dose of 10μg / Kg/minute. Dobutamine has many advantages over dopamine, dose 5μg / kg/ph. Adrénalin and even Noradrénalin.

Pain relievers: Use only when aspirating does not relieve pain, sometimes the pain is so unbearable that the patient can cause pain; Therefore, it is necessary to fight pain for patients with Dolargan 100mg, 2-3 ampoules/day or Meperidine 100mg intramuscularly.

Attention is not to use Morphin because it can cause sphincter spasm, Oddi. Xylocaine 2% can be used, a dose of 0, 5 - 1 g dissolved in 500 ml of intravenous glucose solution or blocked around the pancreas.

Yeast inhibitors: It has been shown that pancreatic enzyme inhibitors such as Traxylol, Zymogen or the factor inhibitor Kunitz (Inhibiteur de Kunitz) are not effective. Protease inhibitors such as aprotinin, gabexate are only effective when used very early, especially for prevention. Currently, people use Somatostatin such as Sandostatin, Octriotide at a dose of 200 - 400 μg / ng subcutaneously or intravenously and then intravenously by an electric pump, has shown to be effective in inhibiting pancreatic enzyme secretion but should be given early.

Anticoagulants: It seems theoretically plausible in the context of overly severe inflammation that has the potential to cause CIVD syndrome. But in fact, in these cases, pancreatic haemorrhage should not be used anticoagulants.

Free radicals’ inhibitors: According to the current mechanism in acute pancreatitis and the role of free oxidizing radicals and peroxides. H. Sanfey has used Superoxide dismutase to inhibit these radicals but has not been clinically effective so far.

Antibiotics: Acute pancreatitis caused by worms and stones often occurs and very soon, mainly Gr (-) intestinal, especially E. Coli, so antibiotics should be given from the beginning. In severe acute pancreatitis should combine Aminoglycosides such as Gentamycin 160 mg/day with cephalosporins such as cefotaxime 3g / day, or ceftriaxone 2g / day. Or the combination of cephalosporine with quinolones such as ciprofloxacin 1g / day, or ofloxacin 400 mg/day by intravenous injection.

If the infection persists or if anaerobic superinfection is suspected, the combination of meterronidazole intravenous should be added 1g / day. The course is usually 10-15 days depending on the type of bacteria, the degree of damage and the progress of the disease.

In acute alcoholic pancreatitis, the infection is usually slow, so when the infection is usually very severe, it also needs coordination and broad-spectrum as mentioned above.

Strong anti-secreting acid HCL: Can be used to prevent stress and also inhibits the secretion of gastric juice and pancreatic juice. Ranitidine 150 - 300mg or Famotidine 20-40mg intravenously or intravenously, omeprazole 40mg / ng or pantoprazole 40mg / ng to maintain gastric juice pH> 4.

Peritoneal wash: In combination with the above-mentioned medical treatments, the peritoneal wash helps to remove toxins and bacteria. Applied in the early stages of acute necrotizing pancreatitis, it relieves pain and dizziness, improves respiratory failure, helps reduce Amylase and lipase in blood and urine, increases blood calcium. Improves water and electrolyte disturbances and acid-base balance. In some cases, beneficial for extra-pancreatic disorders. In one study by Fagniez showed that it helps reduce morbidity and mortality rates in severe acute pancreatitis. But secondary complications such as sepsis, pancreatic abscess did not change much.

Ultrasound or CT-guided aspiration: Used to treat an abscess or pancreatic pseudo-cyst. Under the guidance of ultrasound and CT, the necrosis foci are identified, the needle is inserted to the aspiration needle to remove pus, bacteria and toxins caused by infectious inflammation and necrosis.

Surgical treatment:

In the absence of a stone: Surgery is indicated depending on the results of resuscitation and medical treatment. In the case of resuscitation does not improve or is only transient and then severe. The goal is to remove necrotic pancreatic tissue, stop bleeding and drain. Can travel by sideline, backline, or anterior line through the peritoneum.

In the case of stones or worms: If the acute worm pancreatitis is in the early stages of the first few days, rapid-acting helminths such as lévamísole or Pyrantel, Albendazole can be given. If that fails, the worms can be pulled through endoscopy or surgery.

If the stone is caused, especially when the stone is> 0.5mm in size and stuck to the Oddi sphincter, the stone will be taken through endoscopy combined with dissecting Oddi sphincter (Sphincterotomy), then pulling the stone with Dormia or Ballon or gravel by mechanical machine and then pulling gravel by the above means. Combined with haemostatic surgery to remove necrotic or purulent tissue. Surgery can be performed early 24 - 48 hours early. In case of shock, need to raise blood pressure before surgery.