Pankreonekroz – the destructive disease of a pancreas which is a complication of sharp pancreatitis and leading to development of polyorgan insufficiency. Carry the sharp surrounding belly-ache, persistent vomiting, tachycardia and encephalopathy to manifestations of a pankreonekroz. Laboratory diagnostics assumes determination of level of alpha amylase; tool – carrying out a survey X-ray analysis of an abdominal cavity, ultrasonography, KT and MPT of a pancreas, RHPG, diagnostic laparoscopy. Treatment includes conservative actions (oppression of proteolytic enzymes, restoration of outflow of juice of a pancreas, desintoxication and anesthesia) and surgery.
Pankreonekroz is the heaviest complication of pancreatitis, strikes generally young able-bodied people, makes 1% of all cases of a sharp stomach. Failure of mechanisms of internal protection of a pancreas against the destroying effect of pancreatic enzymes is the cornerstone of pathogenesis of a pankreonekroz. Recently in Russia the quantity of sharp pancreatitis increases – this pathology comes to the second place after an acute appendicitis in surgical hospitals. Also the number of destructive forms of pancreatitis, in particular a pankreonekroza - to 20-25% grows. In different clinics the lethality at destruction of a pancreas reaches 30-80%. The leading way of decrease in a lethality at a pancreas necrosis – timely diagnostics, hospitalization and the early beginning of pathogenetic treatment.
Reasons of a pankreonekroz
The development reasons, both pancreatitis, and a pankreonekroz, violations of a diet and incidental alcohol intake usually are. Researches in the field of gastroenterology showed that pankreonekrozam usually suffer the people not inclined to constant alcohol intake. Nevertheless, in most cases the beginning of a pankreonekroz is preceded by an episode of the use of alcohol in large numbers. At the patients having chronic alcoholism the chronic pancreatitis which is seldom becoming complicated pankreonekrozy practically always develops. The first symptoms of a disease can appear hours or days later after action of provocative factors.
Violation of local protective mechanisms of a pancreas is the cornerstone of pathogenesis of a pankreonekroz. Plentiful meal and alcohol leads to considerable strengthening of external secretion, restretching of channels of a pancreas, violation of outflow of pancreatic juice. Increase in intra pro-current pressure provokes parenchyma hypostasis, destruction of atsinus of a pancreas, premature activation of proteolytic enzymes which lead to a massive necrosis of fabric of gland (self-digestion). Activation of a lipase causes a necrosis of fatty cages, elastaza – destruction of a vascular wall. The activated enzymes and products of disintegration of fabrics, thanks to influence of an elastaza, get to a blood-groove, having toxic effect on all bodies and fabrics. First of all the liver, kidneys, heart, a brain suffer.
Depending on what damaging mechanisms are in the lead in pathogenesis, allocate the fatty, hemorrhagic and mixed forms of a pankreonekroz. If increase in activity of a lipase prevails, there is a destruction of fatty tissue of a pancreas. The lipase gets out of limits of the pancreatic capsule, causing emergence of the centers of a necrosis in a big and small epiploon, peritoneum leaves, a bryzheyka, internals. The fatty form of a pankreonekroz usually terminates in development of the hardest chemical aseptic peritonitis, polyorgan insufficiency.
In case of prevalence of microcirculator violations the pancreas angiospasm leading to bystry increase of hypostasis of a parenchyma develops. Within several hours or days the toksemiya gradually leads to paresis of a vascular wall, expansion of vessels and delay of a blood-groove in gland fabrics. All this promotes the raised tromboobrazovaniye, and further – to development of an ischemic necrosis. Activation of an elastaza causes destruction of a vascular wall at first in the thickness of a pancreas, then and in other bodies. Finally it leads to hemorrhagic treatment , to hemorrhages in internals and zabryushinny cellulose. A sign of a hemorrhagic pankreonekroz is the exudate in an abdominal cavity with blood impurity.
If activity of an elastaza and lipase are approximately at one level, the mixed form of a pankreonekroz develops. In this case the phenomena of a fatty necrosis and a hemorrhagic imbibition are expressed are identical. At a pankreonekroza alpha amylase level also considerably increases, however in pathogenesis this fact does not play any role. Measurement of level of amylase has only clinical value.
Symptoms of a pankreonekroz
Development of clinic of a pankreonekroz happens in three stages. Purulent pancreatitis, sharp alcoholic pancreatitis, biliarny pancreatitis, hemorrhagic pancreatitis can precede this state. At the first stage active reproduction of bacteria in a pancreas causes the expressed toksinemiya and strengthening of pancreatic enzymatic activity. The patient is disturbed by fever, vomiting, instability of a chair. At the second stage of a disease there is a purulent and enzymatic fusion of fabrics of gland to formation of one or several cavities. At the last stage inflammatory process extends to surrounding fabrics, resulting in polyorgan insufficiency and the death of the patient.
The disease has the sharp beginning, usually patients accurately connect emergence of the first symptoms with errors in a diet and alcohol intake. About 70% of patients come to a hospital in a condition of strong alcoholic intoxication that speaks about very bystry development of pathological changes in a pancreas.
As the first symptom the acute surrounding pain irradiating in the left half of a stomach and waist, the left shoulder usually acts. Bezbolevy forms of a pankreonekroz do not happen. Between expressiveness of a pain syndrome and weight of a necrosis of a pancreas there is a direct dependence. Distribution of destructive changes on the nervous terminations leads to gradual reduction of a pain syndrome, in combination with the remaining intoxication it is a bad predictive sign.
After a while after emergence of pain the unrestrained vomiting which is not connected with meal and not giving relief develops. Emetic masses contains bile, blood clots. Because of vomiting dehydration which is shown dryness of skin and mucous develops, language is laid over, rate of a diuresis gradually decreases. The intestines meteorizm develops, the vermicular movement is weakened, the delay of gases and a chair is noted. Intoxication and dehydration are followed by fever.
At fizikalny survey the abdominal distension is noted, on side surfaces of a forward belly wall and a waist cyanotic spots appear (display of internal hematomas, hemorrhages in soft fabrics). Integuments earthy and pale or icteric, marble, cold. Tachycardia, arterial hypotonia, the speeded-up superficial breath are a symptom of heavy intoxication. Toksemiya, fluctuations of level of glucose in blood, a giperfermentemiya lead to damage of a brain and development of encephalopathy which is expressed by confusion of consciousness, excitement, a disorientation, up to development of a coma (approximately at a third of patients).
Progressing of inflammatory process leads to significant increase in a pancreas in sizes, to formation of infiltrate in an abdominal cavity. By fifth days from the beginning of a disease it is possible not only to propalpirovat infiltrate, but also to see with the naked eye. In a projection of a pancreas the skin giperesteziya appears. The specified pathological shifts in an organism lead to formation of polyorgan insufficiency against the background of heavy toxic hepatitis, nephrite, a carditis, respiratory violations.
Pankreonekroz can be complicated by shock, peritonitis, abscess of an abdominal cavity, gastrointestinal bleedings. From local complications abscess, a cyst or a false cyst of a pancreas, fermental insufficiency, pancreas fibrosis, phlegmon of zabryushinny cellulose, a GIT ulcer, thrombosis vorotny and mezenterialny veins often meet.
Diagnostics of a pankreonekroz
Survey of the patient has to be carried out in common by the gastroenterologist, the surgeon, the resuscitator. Existence of a pankreonekroz assumes extreme weight of a condition of the patient therefore in all cases hospitalization in intensive care unit is recommended. In office constant definition of enzymes of a pancreas in blood and urine is made. A bad predictive sign is the progressing growth of level of amylase or sharp jump of this indicator.
The survey X-ray analysis of abdominal organs allows to reveal indirect signs of inflammatory process. Introduction of contrast substance can give the chance to visualize pancreas fistulas. Ultrasonografiya of a pancreas and bilious ways points to existence of stones in bile-excreting channels, increase and change of structure of gland, the anekhogenny centers of a necrosis in a stomach cavity. It is possible to visualize pathological changes with MRT of a pancreas, MRPHG, a computer tomography in more detail. To investigate a condition of the removing channels of a pancreas, the retrograde holangiopankreatografiya allows to establish the reason of stagnation of pancreatic juice. In difficult cases the diagnostic laparoscopy – the most exact way of visualization and diagnosis, assessment of a condition of a pancreas and surrounding fabrics and bodies is carried out.
The differential diagnosis is carried out with intestinal impassability, sharp inflammatory diseases of an appendix, a gall bladder, bilious colic, thrombosis of mezenterialny vessels, perforation of hollow body, a myocardial infarction, a rupture of aneurism of a belly aorta.
Treatment of a pankreonekroz
Treatment of a pankreonekroz is begun with ensuring absolute rest to the inflamed pancreas. Physical activities, an enteroalimentation are completely excluded, washing of a stomach cool solutions can be appointed. The main directions of treatment are anesthesia, neutralization of proteolytic enzymes, dezintoksikatsionny therapy.
Adequate anesthesia includes introduction of analgetics (if necessary - narcotic), spazmolitik, a pancreas capsule section, novokainovy blockade. Reduction of hypostasis of gland under the influence of diuretics leads to fading of a pain syndrome (as leads to weakening of a tension of the pancreatic capsule). Desintoxication is carried out by a large amount of infusion solutions under control of a diuresis. Add to infusion solution . Antihistaminic medicines are surely appointed. For the purpose of prevention of purulent complications antibacterial therapy is carried out by antibiotics of a broad spectrum of activity. Symptomatic treatment includes antishock actions, restoration of function of other bodies and systems.
Practically in all cases of development of a pankreonekroz performing surgical treatment for restoration of outflow of pancreatic juice, removals of necrotic masses (a pancreas nekrektomiya) is required. In the first five days from the beginning of pathological process it is not recommended to carry out surgery as still it is impossible to estimate necrosis level at these terms, but the risk of secondary infection and postoperative complications increases.
At a stage of a purulent inflammation in an abdominal cavity various techniques (punktsionny, laparoscopic, laparotomny) restoration of outflow from channels of a pancreas can be used; elimination of necrotic masses, inflammatory and hemorrhagic exudate; stops of intra belly bleeding. For improvement of a condition of internals drainage of an abdominal cavity can be required.
Forecast and prevention of a pankreonekroz
Drawing up the forecast for patients with pankreonekrozy is very complex challenge as depends on many circumstances. Considerably the forecast in the presence of one or several of the following factors worsens: age more than fifty five years, more than 16Õ109/l, a hyperglycemia, a gipokaltsiyemiya, metabolic acidosis, arterial hypotension, increase in level of urea, LDG and nuclear heating plant, considerable losses of liquid from the blood course in fabric. Existence of seven of the specified criteria provides to 100% the patient's lethality. Prevention of a pankreonekroz consists in the timely request for medical care, an early initiation of treatment including surgical.