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THE KURSK STATE MEDICAL UNIVERSITY
Department of surgical diseases № 1
Bening pancrestic DISEASE
Information for self-training of English-speaking students
The chair of surgical diseases N 1 (Chair-head - prof. S.V.Ivanov)
By professor O.I. Ochotnickov
KURSK-2010
CHRONIC PANCREATITIS
Chronic pancreatitis isn’t independent disease, it’s the phase condition, continue and result of acute pancreatitis. Besides, attacks of acute pancreatitis may be considered as episode in chronic pancreatitis development. This phase is characterized by oedema of pancreatic tissue, seldom by necrosis and hemorrhage. It leads to fibrose or calcinosis of the pancreas.
So, chronic pancreatitis is chronic relapsing process, which includes in itself episodes of acute oedema and necrosis of the pancreas, outside of it development of pancreatic sclerosis and parenchyma atrophy are presented.
The most important link in chronic pancreatitis development acute attack is. Total necrotic pancreatitis leads usually to patient death, large focal necrosis is being finished by secvestration with subsequent connective tissue transformation or pseudocyst formation. Oedema form of acute pancreatitis is being finished by progressive fibrose of the pancreas with extra- and intrasecretory insufficiency.
It is known, that with presence of common symptoms of chronic pancreatitis pathogenesis, which are characterized by tendency to atrophy of glandular elements and its connective tissue transformation, there are peculiarities of disease development, which are determinated by its etiological factors. For example, in the base of alcohol pancreatitis some lesions of protein precipitation is. In the base of chronic bile pancreatitis intermittent papilla Vatery impassability lies.
As etiological classification of chronic pancreatitis the following can be used /Hollender/
1. Main factors
· Gallstone disease
· Alcoholism
· Postoperative pancreatitis
· Endoscopical procedures on bile and pancreatic ducts
· Abdominal trauma
2. Seldom factors
· Endocrinal diseases
· Pregnancy
· Drugs pancreatitis
· Immune and allergical factors
· Neurogenic pancreatitis
· Congenital pancreatitis
· Viral and parasitogenic pancreatitis
3. Shock and acidosis caused pancreatitis
One of the most important etiological factor of pancreatitis gallstone disease is. Frequence of pancreatitis is known to be depending on duration of gallstone disease. In cases of more then 5-years disease presence, chronic pancreatitis can be found in 35% of patients.
The possibility of necrotic pancreatitis appearance due to bile reflux into the main pancreatic duct was proved by Opie in 1901. This observation has been lied into the base of “common canal theory” According it, there are so anatomical conditions, then, combined opening of the common bile duct and the main pancreatic duct into the duodenum gives possibility for bile pouring into pancreatic ducts due to papilla Vatery obstruction.
By researches of a lot of authors the anatomical conditions for “common canal“ are established to be found in 65-80% of patients. But incarcerated stones of papilla Vatery are found in 3-5% of patients only. Bile stones are known can lead to intermittent impassability of distal part of the common bile duct due to not direct stone obstruction of papilla Vatery, but long time spasm of hepato-pancreatic sfincter.
Among factors, promoting to realize this mechanism, are divided following: plural bile stones, wide cystic duct, that gives some possibilities for migration into the common bile duct.
Last time much attention is payed to microcholedocholitiasis in pathogenesis of papillospasm, papillostenosis and secondary pancreatitis. This microstones cann’t be found by traditional instrumental methods, such as US-examination or X-Ray cholangiography. It may be verify by coprological examination after attack of acute pancreatitis.
Neoptolenus in 1989 has formulated the theory of “persisting choledocholitiasis”. The author divides two phases of pancreatitis development. In first stage some small stones lead to papilla Vatery spasm, and bile is pouring into pancreatic ducts. Then more big stone leads to impassability of papilla Vatery.
But, sometimes, may be found some forms of pancreatitis against background of gallstone disease, but without any lesions of bile ducts and papilla Vatery. In this kind of pancreatitis, which can be named as cholecystopancreatitis, there are no enough causes to say about any important role of bile-pancreatic reflux. Cholecystectomy in this condition usually doesn’t cure this pancreatitis. It is foundation to think, that in some cases of accompanying presence of bile stone disease and pancreatitis is explained by the presence of same common etiological factors for gallstone disease and pancreatitis, for example, chronic duodenal impassability, duodenal diverticulums. In this cases the resolving of secondary changes in bile duct cann’t give any possibilities for pancreatitis cure.
Alcohol pancreatitis
For pancreatitis due to alcohol the most severe morphological changes are characterized. Alcohol influence to the pancreas can be explained by direct and mediate damages of acinar cells.
In pathogenesis of alcohol chronic pancreatitis main significance belongs to following:
1. Hyperstimulation of external secretory function of the pancreas
2. Retention of pancreatic duct with intraductal pressure increase due to protein precipitation in it.
Alcohol has a stimulative effect to the pancreas. This influence is realized by neurological and hymoral agents. Besides, alcohol has some spastic influence for papilla Vatery so does morfinum.
Pathological morphology of chronic pancreatitis
Acute and chronic pancreatitis are characterized by necrosis of acinar cells with appearance of inflammatory reaction and its late transformation into connective tissue. By macroscopical view the gland more often has increase size, fibrose capsule is sclerotic changed. There are some focuses of old necrosis with yellow color. In hystological examination the gland has a lot of fibrose fields with leukocytes inflammation.In pancreatic tissue false cysts can be found. The main pancreatic duct is twist with small stones.
Nerves trunks, which are following in connective tissue become hypertrophycal with inflammatory infiltration. Nerves nodes are changed too. By Mallet-Guy this changes can explain constant pain syndrome in cases of chronic pancreatitis.
In general, all pathological changes of the pancreas may be characterized as:
· chronic indurative pancreatitis
· chronic pseudocyst pancreatitis
· chronic pseudocalculose pancreatitis
Clinical picture
There are several clinical forms of chronic pancreatitis. They are following:
1. Chronic relapsing pancreatitis. It is the most spreading clinical form. It can be consequence of acute pancreatitis. Intermittent acute attacks are characterized for this clinical form. The attack is described as pain crisis. The crisis is accompanying by increase level of pancreatic enzymes in the blood and the urine, sometimes - jaundice. During acute attack not only pancreas oedema develops, but necrotic pancreatitis can be too. Though in patients with long time anamnesis of chronic pancreatitis necrotic changes are rare. It is explained by atrophy of functional active gland cells and their transformation into fibrose tissue.
2. Chronic painful pancreatitis. In this cases pain syndrome is constant. The pain is dull ache, gnawing. In anamnesis of the patients quite often pancreonecrosis occurs. Besides pain syndrome there are weithloss and dyspeptical complaints.
3. Latent pancreatitis. This variant of chronic pancreatitis, sometimes, is being described as painless. But it isn’t true, because some pain takes place in it too. But on first line in the cases functional lesions of the pancreas going out.
4. Pseudotumorose pancreatitis. Stable obstructive jaundice is the most important clinical sign of this form. So, the clinical picture of this form is meeting often in cases of pancreatic cancer. But in patients with chronic pancreatitis the jaundice is accompanying by some pain syndrome and manifestations of extra- and intrasecretory pancreatic insufficiency. Correct diagnosis in this cases is quite difficult not only before surgical procedure, but during it too. Often, only long time medical supervision gives possibility for determination of correct diagnosis.
5. Some researches describe the 5-th form of chronic pancreatitis - chronic cholecystopancreatitis. But independently on presence or absence gallstone disease, pancreatitis may be relapse, painful or latent.
The base point in diagnosis formation in cases of chronic pancreatitis pain syndrome is. Pain syndrome absence in this disease is very rare. Determination of extrasecretory functional lesions of the pancreas may be consider as corroboration of chronic pancreatitis. They are: progressive weithloss in accompanied of safe appetite, abundant, fast stool with notdigestive food remainders.
The diagnosis of chronic pancreatitis is corroborated by addition of diabetes mellitus or, rare, hypoglycemical conditions.
One of the manifestations of chronic pancreatitis some specific complications are
· The presence of pancreatolitiasis
· The exposure of intrapancreatic part of the common bile duct
· The presence of enzymaemia against background of pain attacks.
· Considerable lesions of extrasecretory function of the pancreas
· Expose of cyst after pain attack.
· Accompanying plural fluid with considerable maintenance of pancreatic enzymes
Instrumental diagnose of chronic pancreatitis
US-examination. The method gives possibility to expose one of the three variants of chronic pancreatitis:
1. secondary, accompanying with bile stone disease
2. pancreatitis, complicated by cysts
3. primary pancreatitis without pancreatic cysts
Valuable diagnostic information may be received by X-Ray examination. In cases of stones pancreatitis, they may be found. Besides, X-Ray examination gives possibility to expose the increase of pancreatic masses.
Often it is necessary to use RPCG, sometimes - CT-scanning.
Surgical treatment of chronic pancreatitis
Today, surgical correction of chronic pancreatitis should pursue following aims:
· Pain syndrome resolving
· Management of pancreatic complications
· Probably, preservation of pancreatic function
Of cause, surgical procedures cann’t cure the disease, but they are stopping their development.
In cases of secondary cholangyogenic pancreatitis it’s necessary to resolve etiological factors of the disease. It creates conditions for prophylaxy of some complications and accompanied lesions of pancreato-bile system. But in cases of primary pancreatitis and in some forms of secondary pancreatitis etiotropical treatment is impossible.
Among different clinical syndromes of chronic pancreatitis pain once is one of the most important, first of all from the positions of indications for surgical management. In 1/3 of patients with chronic pancreatitis indications for surgical treatment are connected with sings of pancreatogenic stenosis of the common bile duct and the duodenum or segmental portal hypertension.
Among complications of chronic pancreatitis indications for surgical corrections are being appeared in cases of presence of pseudocysts, pancreatic fistulas, late suppurative complications.
All operations in cases of chronic pancreatitis are divided into 5 groups. They are:
1. Operations on adjoining organs
· operations on bile ducts and papilla Vatery
· operations on digestive organs
2. Direct surgical procedures on the pancreas
· pancreatic resection
· internal drain procedures of pancreatic ducts and cysts
· pancreatic duct occlusion
· external drain procedure of pancreatic ducts and cysts
3. Palliative operations
· surgical procedures on nerve system
· cryodestroying of the pancreas
4. Endoscopic procedures on the pancreas and its ducts
5. “Closed” surgical operations are creating under US- and CT-control
The indications for surgical operations on bile ducts are appearing in two forms of chronic pancreatitis. At first - cholangiogenic pancreatitis, in which the lesions of gallbladder, common bile duct and papilla Vatery are the causes of secondary changes of the pancreas. At second - primary pancreatitis alcohol etiology with development of tubular stenosis of intrapancreatic part of the common bile duct.
In some cases chronic pancreatitis is occurring due to chronic duodenal impassability. It can has been corrected by two main surgical modes.
· with keeping of duodenal passage
· with switch off duodenal passage.
Among this operations the most wellknown the following are: the dissection of Treic ligament, duodenointestinal anastomosis, antrumectomy with vagotomy.
Among direct surgical procedures on the pancreas different kinds of pancreatic resection are using. They are:
· distal resection
· near-total pancreatectomy
· sectoral pancreatectomy
· pancreato-duodenal resection /Wipple procedure/
· total pancreatoduodenectomy
For today the most spread operation in cases of chronic pancreatitis some internal drain procedures are. Main pancreatic duct hypertension is known to be the cause of pain syndrome and one of important factor of chronic pancreatitis development. This condition, besides, can lead to appearance of some disease complications, such as pseudocysts, external pancreatic fistulas. So, it is obviously, that internal pancreatic duct drainage is expedient. But, it’s known from literature, that internal drainage procedures don’t influence on reversible development of atrophy and fibrose changes of the pancreas.
The main conditions for successful internal drain procedures the proved occlusion or stenosis of proximal part of the main pancreatic duct are. Internal drain procedures may by realized as:
1. Dissection and plastic of main pancreatic duct opening
2. Longitudinal pancreatointestinostomy by Puestou I, II or terminal pancreatointestinostomy by Du Vale
Among other surgical modes different sorts of main pancreatic duct occlusion are used. Exception of exsocrinal pancreatic secretion function leads to pain disappearance. But this method has very strict indications. The most important condition for it - severe fibrose transformation of the pancreas.
Good results after surgical correction of chronic pancreatitis due to distal pancreatectomy or Wipple procedure are being reached in 60-80%, after Puestou procedure - in 65-85% and in 40-60% after transduodenal plastic of main pancreatic duct opening. Surgical procedures on vegetative nerve system lead to positive results less then 50% with relapse in a 2-6 months.
TEST - QUESTIONS
1. Etiological classification of chronic pancreatitis includes following, except
· Main factors
· Seldom factors
· Parasitogenic pancreatitis @
· Shock and acidosis caused pancreatitis
2. Main etiological factors of chronic pancreatitis includes following, except
· Endocrinal diseases @
· Pregnancy @
· Gallstone disease
· Alcoholism
· Postoperative pancreatitis
· Endoscopical procedures on bile and pancreatic ducts
· Abdominal trauma
· Immune and allergical factors @
3. Microcholedocholitiasis can be found by:
· US-examination
· X-Ray cholangiography
· Coprological examination @
4. In pathogenesis of alcohol chronic pancreatitis main significance belongs to following, except
· Hyperstimulation of external secretory function of the pancreas
· Retention of pancreatic juice with intraductal pressure increase due to protein precipitation in it.