Pancreatonecrosis is one of the most severe diseases of the abdominal organs and in 1% of situations it causes an acute abdomen. Pancreatic necrosis is more often (in 70% of cases) diagnosed in young people and can be both a separate nosological unit and it can also be a complication of acute pancreatitis.
The chances of survival after destruction (destruction) of the pancreas are small and amount to 30–60% even with adequate and timely treatment, and in the case of total pancreatic necrosis, they are zero. In recent years there has been an increase in the incidence of the disease, which is 6 - 9%. Pancreatic necrosis is equally often diagnosed in both men and women.
Pancreatonecrosis and its types
Pancreatic necrosis is a disease of the pancreas that causes the death of its cells due to the development of an inflammatory process in the organ. As a result, iron undergoes destructive (destructive) processes and multiple organ failure develops. Pancreatic necrosis is more likely not a complication of acute pancreatitis, but its stage, and is characterized by a severe course and rapid progression.
The disease is classified according to the following parameters:
- Depending on the prevalence of the destructive process:
- limited necrosis (small, medium and large-focal),
- common necrosis (subtotal - almost all of the gland is affected, and total - gland is damaged in its entirety).
- Whether or not an infection is present in the pancreas:
- Depending on the course of the disease:
In turn, sterile necrosis of the pancreas is divided into three clinical and anatomical forms:
- adipose (develops slowly, in a 4–5 day period and has a better prognosis),
- hemorrhagic pancreatic necrosis (rapidly progressing, accompanied by internal bleeding),
- mixed pancreatic necrosis (occurs more often than other forms).
The development of the disease contributes to 3 main factors:
As a result of this factor, bile is pumped from the 12th bowel to the pancreas, which activates the proenzymes and triggers enzymatic reactions. In this case, with pancreatic necrosis, the reasons are postoperative complications of the abdominal organs, blunt abdominal injuries, endoscopic manipulations, vasculitis / thrombophlebitis of pancreatic vessels, disorders of the sphincter of Oddi, located in the 12th bowel gland, anomalies of the development of the gland, food poisoning.
The risk group for the development of pancreatic necrosis
The disease can occur in any person, but there is a risk group that increases the chances of necrotization of the pancreas:
- chronic alcoholics,
- people with gallstone disease
- patients with hepatic pathology and pancreatic pathology,
- diseases of the digestive tract,
- drug addicts,
- patients with congenital malformations of the digestive tract.
Pathology development mechanism
The basis of the mechanism of development of this disease is a disorder of the local protective forces of the gland. The development of pancreatic necrosis proceeds in 3 stages:
Pancreas affected by pancreatic necrosis
As a result of the etiological factor, the external secretion of the pancreas is significantly increased, its ducts are over-stretched, and the outflow of pancreatic juices is disturbed. Increased intraductal pressure causes swelling of the parenchyma of the organ, destruction of small areas of the gland (acini) and increased action of proteolytic enzymes, which causes massive damage (necrosis) of the gland. That is, the body begins to digest itself. If lipase is activated, fat cells are necrotized, and if the elastase is activated, the vascular wall is destroyed. Toxins (tissue breakdown products) and activated enzymes enter the bloodstream due to the destruction of vascular walls and have a toxic effect on all organs. The first affects the liver and kidneys, heart and brain (multiple organ failure develops).
The development of one or another clinical-anatomical form of the disease depends on the predominance of the activity of lipase and elastase. If the activity of lipase is exceeded to a greater degree, the adipose tissue of the gland is destroyed, and then the areas of the large and small omentum, peritoneum, mesentery and internal organs are necrotized. This form of gland necrosis is called fatty.
If microcirculatory disorders predominate, a vasospasm of the organ occurs, which causes its rapid edema. Within a few hours, toxemia causes paresis of the vascular walls, their expansion and slowing down of the movement of blood in the tissues of the organ. These processes increase blood clots, and then lead to the development of ischemic necrosis. Strengthening the action of elastase contributes to the destruction of the walls of blood vessels in the thickness of the gland, and later in other organs. As a result, the iron is soaked with blood, hemorrhages develop in the internal organs and retroperitoneal tissue, an effusion with blood appears in the abdominal cavity. This form of the disease is called hemorrhagic necrosis of the gland.
With the same level of lipase and elastase activity, they speak of a mixed form of necrosis.
An abscess forms in the pancreas and in the internal organs.
In the pancreas and in the retroperitoneal tissue purulent changes develop.
Symptoms of pancreatic necrosis
Pancreatic necrosis of the pancreas has such an obvious clinical picture that it is difficult to confuse the symptoms of the disease with any other pathology.
The cardinal sign of necrosis of the pancreas is pain. Pain occurs in the left half of the abdomen, radiating to the shoulder, back, groin or chest. Often the patient can not describe the exact location of pain and calls the pain surrounding. The intensity of the pain syndrome can be different and depends on the severity of necrosis of the gland. The further the destructive process in the organ has progressed, the pain becomes less pronounced due to the death of nerve endings in the gland. Easing pain and lingering symptoms of intoxication are a “poor” prognostic sign.
The pain sensations are somewhat weakened in the position on the side with the legs bent at the knees and brought to the stomach, therefore the patient with this disease takes the described forced position.
Signs of intoxication
Toxins of bacteria (bacteria themselves may not be present in the blood) circulating in the bloodstream cause intoxication of the body. The temperature rises (up to 38 and higher), the general weakness joins, the heartbeat and breathing become more frequent, shortness of breath appears, arterial pressure decreases. The effect of toxins on the brain leads to encephalopathy. Consciousness of the patient is confused, the patient is agitated or slowed down, disoriented. In severe toxemia, coma may develop.
Hyperemia or pale skin
In the phase of toxemia, the pancreas releases vasoactive substances into the blood (dilates blood vessels), which is manifested by reddening of the skin. Later, with the development of intoxication, the integuments turn pale, acquire earthy, marble or icteric and become cold to the touch. On the sides on the abdomen, on the back, buttocks and in the area of the navel appear blue-violet spots resulting from internal hematomas and hemorrhages in soft tissues. Subcutaneous hemorrhages are not observed in all cases of necrosis of the pancreas.
Symptoms of peritoneal irritation
The toxaemia stage lasts 5–9 days and is characterized by an increase in symptoms regardless of the intensive treatment carried out. The next stage is the formation of purulent and post-necrotic complications. The pancreas due to inflammation increases significantly in size, and purulent infiltration begins to form in the stomach. In the area of the pancreas, the skin becomes too sensitive (hyperparesthesia). Multiple organ failure develops (toxic hepatitis and nephritis, carditis and respiratory disorders).
Complications of pancreatic necrosis include:
- shock (infectious-toxic or pain),
- abdominal abscess,
- gastrointestinal bleeding,
- suppuration pancreas, pancreas cyst,
- enzyme deficiency
- retroperitoneal fiber abscess,
- ulcers of the stomach and intestines,
- thrombosis of the portal, splenic, mesenteric veins,
The diagnosis of acute pancreatic necrosis of the pancreas is established on the basis of history and specific complaints, examination of the patient and additional examination.
- complete blood count (leukocytosis, neutrophil granularity, increased ESR, increased hematocrit due to dehydration),
- amylase, elastase, trypsin in the urine and blood (significantly increased),
- blood sugar (increased)
- blood calcitonin (its level increases with severe inflammation and infection, in particular with infected gland necrosis),
- growth of C-reactive protein (a sign of inflammation),
- the growth of liver enzymes (AST, ALT).
- Ultrasound of the pancreas and biliary tract (the presence of calculi in the biliary tract, enlarged gland size, heterogeneous structure and uneven contours of the organ, fluid in the abdominal cavity and retroperitoneal space, foci of necrosis, cysts and abscesses and their localization)
- computed tomography (enlarged gland, dilated pancreatic duct, foci of necrosis, inflammation of the tissue around the pancreas, effusion in the abdominal cavity),
- radiography of the abdomen,
- Magnetic resonance imaging,
- puncture of the liquid formations pancreas followed by the tank. seeding material, detection of microorganisms and their sensitivity to antibiotics),
- angiography of vascular gland,
- retrograde cholangiopancreatography (ductal pancreas condition),
- diagnostic laparoscopy.
When diagnosing pancreatic necrosis, treatment should begin immediately. The patient is necessarily hospitalized in the surgical department in the intensive care unit. An in-patient complex therapy is carried out aimed at suppressing the processes in the pancreas and its self-digestion, eliminating the symptoms of toxemia, preventing the development of septic complications. The sooner and more actively the treatment of necrosis of the gland is started, the greater the chances for the patient to recover. The treatment is carried out by conservative and surgical methods.
Conservative therapy includes:
- Providing complete rest (bed rest) and therapeutic fasting
The patient is prohibited any physical activity, eating. Nutrition is carried out parenterally, with nutrients for 5-7 days. Allowed to drink without restrictions, preferably alkaline mineral water.
- Suppression of pain syndrome
Relief of pain and relaxation of the sphincter of Oddi is achieved by parenteral administration of antispasmodic drugs (no-spa, platyphylline), non-narcotic analgesics (paracetamol, baralgin, analgin), regional novocainic blockade, intravenous infusions of 1000 - 2000 ml of glucose-novocaine mixture. The introduction of narcotic drugs (promedol with atropine, dimedrol and novocaine) is allowed, with the exception of morphine, which spasm the Oddi's sphincter. See Pancreatic Medication.
- Blocking pancreas, stomach and duodenum secretion
To reduce the secretory activity of the pancreas and inactivate proteases, anti-enzyme agents are introduced intravenously (gordox, contrycal, trasilol). Suppression of gastric secretion is provided by the introduction of anticholinergics (atropine) and gastric lavage with cold solutions. It also reduces the gastric secretion of omeprazole, pantoprazole - proton pump inhibitors. If there is no concomitant gallstone disease, choleretic drugs are prescribed to unload the pancreas ducts and bile ducts. Local hypothermia (cold on the stomach) is also provided, which not only reduces the secretion of the pancreas and other organs, but also reduces pain.
Antibacterial drugs for destruction of the pancreas are prescribed for prophylactic purposes in case of aseptic pancreatic necrosis and for suppression of pathogenic microflora in infected pancreatic necrosis. Of the antibiotics, cephalosporins (cefipime) with fluoroquinolones (ciprofloxacin) are used in combination with metronidazole.
To cleanse the bloodstream from toxins and aggressive pancreatic enzymes, massive infusion therapy is prescribed (glucose with insulin, Ringer's solution, saline). To replenish fluid volume and improve the rheological properties of blood, colloids (reopolyglukine, albumin) are injected intravenously. Suppression of vomiting is provided by intramuscular injection of cercula. Infusion therapy is prescribed in combination with diuretics (furosemide), which provides forced diuresis and reduces pancreatic edema.
Extracorporal detoxification methods are used: therapeutic plasmapheresis, hemosorption, peritoneal dialysis, hemofiltration.
The hormone hypothalamus, somatostatin, is injected intravenously. It suppresses the secretion of gastric juice and the exocrine and endocrine function of the pancreas. Also, the drug reduces blood flow in the internal organs and prevents internal bleeding.
With the development of pancreatic necrosis, in many cases, surgery is indicated. The purpose of surgical intervention is to restore the outflow of pancreatic juices, remove necrotic foci and inflammatory hemorrhagic exudate, drainage of the abdominal cavity and retroperitoneal space, stop intra-abdominal bleeding. The surgical treatment is delayed for several days (4 - 5 days), until the acute process subsides, the hemodynamics are restored and the patient is stabilized. Immediate surgical treatment is indicated in the case of subtotal and total necrosis of pancreas, purulent peritonitis, pancreatogenic abscess. In the case of an infected destructive lesion of the gland, preference is given to laparotomic operations that provide wide access to the abdominal cavity. In addition, during surgery, it is often necessary to remove adjacent organs (the gallbladder with destructive cholecystitis, the spleen). Often, reoperation is required due to the continued self-destruction of the pancreas. Radical surgical treatment includes sequestrectomy (removal of necrotic masses), resection of the pancreas (removal of a part of an organ), and pancreathectomy (removal of an organ completely).
In case of sterile necrosis of the pancreas, it is preferable to perform minimally invasive surgical interventions (laparoscopic sanation and drainage of the abdominal cavity, percutaneous puncture).
Care and Rehabilitation
Temporary disability of the patient after surgery lasts a long time (up to 3 - 4 months or more). In the postoperative period, the quick recovery of the patient depends on the care and rehabilitation measures. The first two days of the operation were performed in the intensive care unit, where he is monitored for blood pressure, electrolyte levels and blood sugar, hematocrit, and urine indicators.With a stable condition and hemodynamic parameters, the patient is transferred to the general surgical ward. The first 2 days after surgery is shown fasting. From the third day a sparing diet is allowed:
- not sweet tea with crackers,
- pureed soups in vegetable broth,
- rice and buckwheat porridge (milk / water ratio is 1/1),
- protein omelet (half an egg a day),
- dried bread is included in the diet on day 6,
- cottage cheese,
- butter (15 gr.).
For the night is allowed a glass of yogurt or warm water with honey.
In the first week after surgery, all dishes are steamed, after 7–10 days, boiled lean meat and fish are introduced into the diet in small quantities.
Discharge from the hospital is carried out in 1.5 - 2 months.
In the first days after discharge, the patient is recommended full physical rest (bed rest). Obligatory dieting and afternoon nap are mandatory. After 10–14 days, short outdoor walks are allowed, the duration of which increases over time. During the rehabilitation period do not allow overwork. Reading, watching TV, walking and not heavy household duties should not last long and stop if the patient felt bad.
Rehabilitation activities include:
- taking insulin-containing tablets (regulation of blood glucose),
- multienzyme preparations (promote the absorption of food),
- physical therapy,
Recommendations for diet with pancreatic necrosis:
- fractional meals up to 6 times a day, in small portions,
- eating at the same time
- completely eliminate alcohol and smoking,
- food temperatures should be room temperature (too hot and cold dishes are prohibited),
- food should be chopped (mashed or chopped),
- dishes are steamed, stewed and stewed.
- fresh bread and pastry,
- corn, millet, pearl barley,
- beans, peas, beans, lentils,
- fatty meats, poultry and fish,
- chocolate, cocoa, strong tea and coffee,
- canned and sausages, smoked meats,
- pickles and marinades,
- fast food,
- mushrooms and mushroom broth,
- meat and fish broths,
- white cabbage (in any form),
- spicy and sour vegetables (sorrel, green onions, radishes, spinach, radish, garlic),
- margarine and animal fats, lard,
- whole milk and fermented milk products,
- eggs in any form and yolk,
- grapes, figs, dates.
- dried bread
- low fat cottage cheese,
- vegetable soups,
- porridge on milk-water mixture (1/1),
- boiled macaroni,
- kefir, yogurt low fat,
- omelette from egg whites,
- lean fish, meat and poultry (beef, chicken, pollock, flounder),
- boiled vegetables (beetroot, cauliflower, zucchini, pumpkin),
- freshly squeezed juices
- butter (not more than 15 g. per day),
- vegetable oil (no more than 30 gr.),
- unsweetened dry biscuits.
With pancreatic necrosis, the prognosis is questionable and depends on many factors (how quickly and adequately the treatment was started, the patient's age, the form of the disease, the presence of comorbidity, adherence to medical recommendations and diet, the amount of surgical intervention).
In 25% of patients who have suffered a destructive form of pancreatitis, diabetes develops. Pseudocysts are also often formed, chronic recurrent pancreatitis occurs, and pancreatic fistulae are formed. Mortality in this disease is quite high. With aseptic necrosis of the pancreas, it is 15 - 40%, and when infected, it reaches 60%.
First of all, it is necessary to put a sick person in bed, put cold on the abdominal area (approximately in the middle part) (ice bubble or whatever is on hand). Eating and drinking are strictly prohibited. Also not shown is the intake of analgesics and enzyme preparations (smears the picture of the disease). To relieve pain (with skill), intramuscularly inject papaverine or no-silo. Immediately call an ambulance.
As it is not sad, but "sit" on a sparing diet will have a lifetime. But do not despair, in life, except for tasty and harmful food, alcohol and cigarettes, there is a lot of beauty. Visit museums and theaters, go outdoors, find a hobby, read, write poems, chat with friends.
In no case. When a person is so ill that he wants to die and dig in, taking different decoctions and infusions will delay the time of rendering specialized assistance, and thus worsen the prognosis of the disease and may even lead to death.
First of all, the errors in the diet. In second place is physical and emotional stress. In addition, relapse can cause diseases of the gastrointestinal tract (gastric and duodenal ulcers, exacerbation of cholecystitis) and the development of complications of necrosis of the pancreas.
Causes of pancreatic necrosis
Causes of development, as pancreatitis, and pancreatic necrosis, usually are violations of the diet and occasional alcohol intake. Studies in the field of gastroenterology have shown that people who are not prone to regular alcohol use usually suffer from pancreatonecrosis. However, in most cases, the beginning of pancreatic necrosis is preceded by an episode of drinking in large quantities. Patients suffering from chronic alcoholism almost always develop chronic pancreatitis, rarely complicated by pancreatic necrosis. The first signs of the disease may appear after hours or days after the action of provoking factors.
The basis of the pathogenesis of pancreatic necrosis is a violation of the local protective mechanisms of the pancreas. Abundant food and alcohol intake leads to a significant increase in external secretion, overstretching of the pancreatic ducts, disruption of the outflow of pancreatic juices. Increased intraductal pressure provokes swelling of the parenchyma, destruction of pancreatic acini, premature activation of proteolytic enzymes, which lead to massive necrosis of the gland tissue (self-digestion). Activation of lipase causes necrosis of fat cells, elastase - destruction of the vascular wall. Activated enzymes and tissue breakdown products, due to the effect of elastase, enter the bloodstream, exerting a toxic effect on all organs and tissues. The first to suffer are the liver, kidneys, heart, brain.
Depending on which damaging mechanisms lead in the pathogenesis, fatty, hemorrhagic, and mixed forms of pancreatic necrosis are isolated. If the increase in lipase activity prevails, the fatty tissue of the pancreas is destroyed. Lipase falls outside the pancreatic capsule, causing the appearance of foci of necrosis in the large and small omentum, sheets of peritoneum, mesentery, internal organs. The fatty form of pancreatic necrosis usually ends with the development of the most severe chemical aseptic peritonitis, multiorgan failure.
In the case of the predominance of microcirculatory disorders, a spasm of the pancreatic vessels develops, leading to a rapid increase in the swelling of the parenchyma. Within a few hours or days, toxemia gradually leads to paresis of the vascular wall, dilation of blood vessels and slowing blood flow in the tissues of the gland. All this contributes to increased thrombosis, and further development of ischemic necrosis. Activation of elastase causes destruction of the vascular wall, first in the thickness of the pancreas, then in other organs. Ultimately, this leads to hemorrhagic soaking of the pancreas, hemorrhages in the internal organs and retroperitoneal tissue. A sign of hemorrhagic pancreatic necrosis is effusion in the abdominal cavity with blood.
If the activity of elastase and lipase are approximately at the same level, a mixed form of pancreatonecrosis develops. In this case, the phenomena of fat necrosis and hemorrhagic imbibition are expressed the same. With pancreatic necrosis, the level of alpha-amylase also significantly increases, but this fact plays no role in the pathogenesis. Measuring the level of amylase has only clinical significance.
Treatment of pancreatic necrosis
Treatment of pancreatic necrosis begins with ensuring complete rest of the inflamed pancreas. Physical activity, enteral nutrition are completely excluded, gastric lavage with cool solutions can be prescribed. The main areas of treatment are pain relief, the neutralization of proteolytic enzymes, detoxification therapy.
Adequate analgesia includes the introduction of analgesics (if necessary - narcotic), antispasmodics, pancreatic capsule dissection, novocainic blockade. Reduction of edema of the gland under the influence of diuretics leads to the extinction of pain syndrome (as it leads to a weakening of the tension of the pancreatic capsule). Detoxification is carried out with a large number of infusion solutions under the control of diuresis. Aprotinin is added to the infusion solution. Antihistamines are required. In order to prevent suppurative complications, antibacterial therapy with broad-spectrum antibiotics is carried out. Symptomatic treatment includes anti-shock measures, restoration of the function of other organs and systems.
In almost all cases of pancreatic necrosis, surgical treatment is required to restore the outflow of pancreatic juices, to remove necrotic masses (pancreas necrotomy). In the first five days from the beginning of the pathological process, it is not recommended to perform surgery, because it is still impossible to assess the level of necrosis during these periods, but the risk of secondary infection and postoperative complications increases.
At the stage of purulent inflammation in the abdominal cavity, a variety of techniques (puncture, laparoscopic, laparotomic) can be used to restore the outflow from the pancreatic ducts, eliminate necrotic masses, inflammatory and hemorrhagic exudates, stop intra-abdominal bleeding. To improve the condition of the internal organs, drainage of the abdominal cavity may be required.
Prognosis and prevention of pancreatic necrosis
Preparing a prognosis for patients with pancreatic necrosis is a very difficult task, since it depends on many circumstances. Significantly worse prognosis when one or more of the following factors are present: age more than fifty-five years, leukocytosis more than 16x10 9 / l, hyperglycemia, hypocalcemia, metabolic acidosis, hypotension, increased urea, LDH and AST, significant loss of fluid from the bloodstream in tissue. The presence of seven of these criteria ensures 100% mortality of the patient. Prevention of pancreatic necrosis is the timely request for medical care, early treatment, including surgery.
The most frequent complications of pancreatic necrosis
With the progression of pathology pancreatic enzymes penetrate into the general bloodstream and spread throughout the body. The blood vessels of the body expand, the permeability of their walls increases, as a result, the blood partially enters the intercellular space. This leads to pancreatic edema, hemorrhage in the tissue behind the peritoneum and gland tissue. What complications are fraught with pancreatic necrosis?
The effects of inflammation and tissue necrosis in pancreatic necrosis are irreversible, among them:
- parapancreatic infiltration,
- peritoneal hemorrhagic effusion,
- pancreatic peritonitis,
- retroperitoneal aseptic phlegmon.
This complication of pancreatic necrosis affects not only the pancreas and the tissue behind the peritoneum, but also the nearby organs - the duodenum, stomach, spleen, and others.
Parapancreatic infiltration is formed as a result of aseptic inflammation that occurs as a reaction of the immune system to necrotic tissue of an organ. The pancreas and adjacent organs are soldered together with an inflammatory fluid that fills the entire abdominal cavity or its upper part.
Three possible outcomes of parapancreatic infiltrate:
- cyst formation
- transition to purulent option.
Cystic formations in the gland are formed if the infiltration does not resolve within 3 months. When joining the infection, the result may be a purulent organ damage, retroperitoneal phlegmon, peritonitis, abscess.
Symptoms in the formation of infiltration is not pronounced:
- general condition is satisfactory
- the temperature does not rise or stays at the level of subfebrile (37-38 ° C),
- in urine and blood the level of amylase is increased,
- leukocyte blood count does not change or moves to the left (increased neutrophils).
The exact picture of the development of complications is determined using ultrasound diagnostics.
Therapy for parapancreatic infiltrate includes:
- therapeutic diet No. 5, and in severe cases, enteral support - intraintestinal drip administration of electrolyte solutions, antioxidants, glutamine, glucose,
- the use of antimicrobial agents from the group of fluoroquinolones and cephalosporins in combination with metronidazole,
- immunomodulatory drugs.
The operation to pump out infiltration resulting from pancreatic necrosis is called laparoscopic dialysis. It is carried out when a liquid with blood impurities is present in the abdominal cavity. It also introduces a solution of sodium chloride, antimicrobial agents and novocaine. Dialysis is continued until the infiltrate becomes transparent and the level of amylase in it does not decrease.
Another consequence of pancreatic necrosis is peritonitis, in which the serous cover of the abdominal cavity is inflamed and fluid accumulates in it with a high concentration of pancreatic enzymes. The frequency of development is 60-70%.
Clinical signs of pancreatic peritonitis are:
- bouts of severe pain in the left hypochondrium and epigastric region,
- blue skin, especially in the abdomen, the navel is colored yellowish blue,
- increased heart rate
- lowering blood pressure
- nausea and vomiting,
- the muscles of the abdominal wall are strained
- temperature 39-40 ° C
- moderate bloating due to gas and stool retention
- in the blood and urine increased levels of diastase,
- severe cases of severe intoxication, collapse, psychosis.
Therapy for this effect with pancreatic necrosis is as follows:
- relief of pain,
- infusion therapy,
- forcing diuresis,
- use of NSAIDs - Lornoxicam, and antibiotics from the group of carbapenems - Meropenem, Imipenem-Cilastatin.
With the ineffectiveness of the above measures, surgical removal of tissues that have died as a result of pancreatic necrosis, sanitation of the suppurative focus and drainage of the abdominal cavity are carried out.
Hemorrhagic peritoneal effusion
This is one of the most severe complications of pancreatic necrosis, the enzymes of the gland are highly active, the necrosis of the body progresses, bleeding develops, tissues are soaked in blood and other organs are involved in this process. Due to purulent intoxication, this complication often becomes the cause of death.
- acute pain in left hypochondrium
- nausea, frequent vomiting,
- dry mouth
- facial flushing,
- bluish spots on the abdomen,
- diarrhea, flatulence,
- sudden pressure drops
- shortness of breath, tachycardia,
- anxiety or, on the contrary, lethargy, sometimes mental disorders,
- chills, fever up to fever and confusion.
In the treatment of hemorrhagic effusion with pancreatic necrosis are shown:
- antispasmodics - Atropine, Papaverine - to relax the pancreatic ducts and improve the outflow of fluid from it,
- enzyme blockers - Gordox, Kontrykal, Antagozan - to reduce the activity of pancreatic proteases,
- antibiotics in the development of infection
- antisecretinics - Famotidine, Omez - reduce the secretion of the stomach, thereby reducing the activity of the gland,
Surgical intervention is indicated for the ineffectiveness of conservative treatment of complications.
Aseptic retroperitoneal phlegmon
Phlegmon is an acute inflammation of fatty tissue that has no boundaries - pus evenly impregnates tissue. With this complication of pancreatic necrosis, pathogenic microorganisms penetrate into the retroperitoneal space with blood or lymph from the site of infection, or during surgery.
- in the early stages malaise, chills and temperatures up to 38.5 ° C,
- pain develops later - from a pulsating or pulling back pain to spreading to other organs,
- pain increases with movement and change of body position.
Treatment of complications consists in opening phlegmon, removing purulent contents and injecting antibiotics into it. If the phlegmon is diagnosed late, then irreversible intoxication and sepsis are fatal.
Prediction and life after surgery
With complications of pancreatic necrosis, the prognosis is rarely favorable, in general, the mortality rate reaches 70%. Unfortunately, more than half of patients with pancreatic necrosis die on the operating table. The risk of death increases with a late request for medical care, as well as in the presence of such conditions as:
- high level of urea
- age after 50 years
- lack of calcium ions in the blood,
- metabolic acidosis,
- significant release of plasma from the blood vessels in the tissue.
If the treatment of pancreatic necrosis and its complications is successful, for the rest of your life, you must follow a strict diet, undergo an ultrasound every six months to monitor changes in tissues, vessels and organs, and to pass laboratory tests.
The rules of therapeutic nutrition are as follows:
- banned fresh vegetables and fruits, sweets, milk, fatty foods, alcoholic and carbonated drinks,
- steaming or stewing,
- food temperature should be close to room temperature, hot and cold under the ban.
Be sure to remember that an immediate appeal to the doctor at the first symptoms of the onset of complications can save a life.
See how the laparoscopic peritoneal dialysis is performed in the video:
Organ complications of pancreatic necrosis
Necrosis of pancreatic tissue without immediate emergency assistance leads to the release of a large number of enzymes in the vessels, causing them to expand. Due to the increased permeability of the walls, the enzymes enter the intercellular spaces. The gland swells, hemorrhages appear in its tissues and retroperitoneal tissue, leading to irreversible processes, including the earliest and most common:
- hemorrhagic effusion,
- retroperitoneal abscess or phlegmon.
The development of parapancreatic infiltrate occurs not only in the gland, but also in neighboring organs. Affected:
The process can go to the gallbladder, liver, cause changes in the lower intestine. Soldering between them occurs with the participation of exudate, filling the upper part of the abdominal cavity or the whole of its space. Infiltration formation is a reaction of the body’s immune system to necrotic tissue of the gland. The process itself is aseptic at this stage, the infection is absent. Therefore it is possible:
- reverse development - resorption,
- cyst formation
- purulent option.
If during 3 months the infiltration has not disappeared, cysts appear. This is a warning of a possible severe complication.
The addition of infection leads to:
- to purulent damage to the pancreas,
This significantly worsens the condition and prognosis of the disease.
Differentiating parapancreatic infiltration and making a diagnosis without additional methods of research is difficult. This is due to the scarce clinical manifestations due to the aseptic process:
- the general condition is not disturbed, the patient has no complaints,
- the temperature is normal, only subfebrile is sometimes observed - an increase to 37–37.9 degrees Celsius,
- in the general analysis of blood, except for neutrophilic shift to the left (not always), there are no changes.
You can suspect a complication during the ultrasound examination of the retroperitoneal space, blood and urine tests for the content of pancreatic enzymes: in biochemical analyzes, an increased level of amylase is determined, with an ultrasound examination - characteristic changes.
Peritonitis - inflammation of the serous leaf of the abdominal cavity, leading to accumulation of fluid with a high content of enzymes. The frequency of this complication is 60–70%. Manifests a bright clinical picture of acute abdomen. Appear:
- paroxysmal pain of high intensity, without clearly defined localization, sometimes defined in the left hypochondrium and epigastrium,
- signs of acute abdomen: anterior abdominal wall tension and all positive symptoms of inflammation,
- severe intoxication: febrile to 40 and above, tachycardia, a drop in blood pressure, nausea, vomiting, flatulence,
- collapse - a sharp decrease in blood pressure and a drop in cardiac activity.
- complete blood count - leukocytosis and high ESR,
- biochemical - diastasis of urine and blood exceeds the norm.
Peritoneal hemorrhagic effusion is one of the causes of death from pancreatic necrosis. It is the most severe complication. Highly active enzymes lead to the progression of necrosis and mass cell death. There is massive bleeding, the tissues of the organ are soaked with blood. Neighboring organs are involved in the process, infection joins, purulent intoxication develops. The disease progresses rapidly, urgent resuscitation is necessary.
Clinically, it resembles a sharp stomach, but all the signs of it are expressed to the maximum. Suddenly develops:
- hyperthermia - temperature reaches 41–42 degrees Celsius,
- violent chills and disturbed consciousness
- inhibition or agitation,
- heart palpitations, blood pressure instability,
- dagger pain - intense intolerable attacks of acute abdominal pain, mainly in the left hypochondrium,
- nausea, repeated vomiting,
- diarrhea and flatulence.
Retroperitoneal phlegmon is an inflammation of fatty tissue without clear boundaries, which is acute. Pathogenic microflora with blood or lymph penetrates into the tissue from the purulent focus of infection or during the operation. Clinical symptoms suggest the development of complications:
- febrile temperature (38–38.5 degrees Celsius and above),
- pain in the lumbar region - a pulsating or pulling nature with irradiation into the abdominal cavity with the involvement of other organs in the pathological process,
- increased pain when moving or changing body position.
In addition to these organ lesions of pancreatic necrosis, often develop:
- deep vein thrombosis with dysfunction of the pelvic organs,
- hepatobiliary stricture,
- gastrointestinal bleeding,
- ulcers of the stomach and intestines,
- enzyme deficiency.
Is there any chance of surviving the disease?
In order to survive pancreatic necrosis, emergency hospitalization in the surgical department is necessary. The agonizing process of cell death proceeds rapidly, can be fulminant and be completed within one to two hours. If necrosis has become total - death occurs in 100% of cases. To interrupt a closed pathological circle, urgent resuscitation and surgery are needed. In this case, it is possible to save life.
Initially, the patient enters the intensive care unit, where all emergency treatment measures are taken to bring the patient out of shock. Detoxification, anesthesia is carried out, and a complete functional peace of the pancreas is created. Approximately on day 5, when the boundaries and scales of organ damage become clear, necrectomy is performed.
But this is not always the case. If the lesion is total in nature, and the score goes to the clock, the operation is performed immediately, sometimes the pancreas is removed completely - pancreatotomy. The patient must be fixed in order to carry out further manipulations on washing the installed drainage systems, and he may be in this position for a long time.
The duration of treatment after surgery is long, takes more than six months or a year. The prescribed diet is compulsory - table No. 5 according to Pevzner. In the future, under the supervision of a gastroenterologist, it may change to table number 1 and its modifications. Only a specialist can determine how long you need to be on a strict diet.
In addition to the diet, prescribed to receive enzyme preparations, having a good tip about the treatment of pancreatitis, and a number of medications that are necessary for good health. All prescriptions must be strictly followed - this is the only way to improve the quality of life after surgery.
Mortality statistics for pancreatic necrosis
Statistics show that death with necrosis that occurs begins in 40–70% of cases. The reasons:
- late visit to a doctor
- extensive area of lesion of the body
- the addition of infection
- the number of developed complications (more than three).
The final diagnosis in such cases is already made by the pathologist, and not by the gastroenterologist or surgeon.
With pancreatic necrosis (PN), the mortality rate is high (with a total process of up to 100%), and there is no tendency to decrease. In 97% of severe PN, mortality in patients is due to complications, including postoperative ones. The necrotic process itself can often regress, but complications develop rapidly and lead to devastating consequences.
Statistical data on mortality in case of MO are depressing: out of 10 patients, 2 to 9 die in the hospital, or from severe complications or new diseases after discharge. The figures are even more terrible given the fact that sick people of working age get sick - from 30 to 50 years.
After suffering pancreatic necrosis, the patient’s ability to work is limited or is completely lost. In the future, surgical intervention may again be required due to the development of complications of PN or arising in the process of the main operation.
Causes of death in pathology
Mortality rate at PN reaches 70%, the prognosis is rarely favorable. According to statistics, more than half of patients die on the operating table during urgent surgical treatment. The risk of death depends on the time of treatment for specialized medical care. Play a role:
- advanced age (after 50 years),
- blood urea exceeding the norm
- metabolic acidosis,
According to numerous studies, the main causes of death include:
- early manifestations of toxemia,
- long-term septic complication option.
Due to their development, every fourth patient experiences multiple organ failure. The cause of death in the later stages - toxic shock.
Important factors are also:
- excessive duration of alcohol intake is typical of male patients,
- violation of the diet and excessive consumption of fatty, spicy and fried foods,
- cholelithiasis - often develops in women, if the patient does not adhere to the recommendations on medical nutrition,
- constant stressful situations.
Rehabilitation period after surgery
After surgical treatment, patients are faced with problems associated with the emerging postoperative complications, and not with the continuing symptoms of pancreatic necrosis. During this period, it is necessary to observe a surgeon, an endocrinologist, and a rehabilitologist.
After suffering severe pancreatic necrosis in 70% of cases, patients remain in a rehabilitation center or intensive care unit under the supervision of doctors for a long time - up to one year. As the sparing mode and full rest is appointed, the patient remains on a bed rest. Over time, this leads to muscle atrophy and the development of flexion contracture of the legs. Moreover, weak muscles do not maintain the body weight of the person himself. To avoid this, it is recommended to do a massage, perform a set of special exercises that strengthen the muscles.
Due to autolysis (self-digestion of the gland in the acute period), digestion is severely impaired. The patient loses up to 50% of body weight. In the postoperative rehabilitation period, it is important to observe a therapeutic diet, so as not to aggravate the process and restore weight. It is recommended to eat mashed food in small portions 6–8 times a day.
Strict adherence to the diet prescribes the exclusion from the diet of spicy, fatty, fried, pickled foods, alcohol, carbonated drinks, strong tea and coffee, chocolate. The list of prohibitions is large, but every patient should know it in order not to violate the diet.
With dietary compliance, the patient returns to his former life and does not experience pain or discomfort. Disruption of the diet leads to death.
How to prevent the fatal consequences of pancreatitis?
Pancreatonecrosis after surgical and conservative treatment, if a person has survived, refers to diseases that can be controlled. If there is a desire to live, then the person lives with such a diagnosis, following the recommendations, and the death does not threaten. It is also necessary to monitor the emotional state, avoid stress, follow the rules of healthy eating, attend dispensary examinations and consult a doctor without self-medicating. Prevention of complications includes the abandonment of bad habits: to abandon the use of strong and low alcohol beverages. Subject to these rules, well-being may remain satisfactory.
Care and rehabilitation period
Temporary disability of the patient after conducting lasts for 3-4 months. In the postoperative period, the recovery rate of the patient depends on the care and nature of rehabilitation measures. During the first two days the patient is in the intensive care unit, where constant monitoring of blood pressure, urine, hematocrit, blood sugar and electrolytes is provided. With the stabilization of the state and the presence of satisfactory hemodynamic parameters, the patient is transferred to a general ward. During the first 48 hours after surgery, the patient is shown fasting. On the third day a sparing diet is allowed:
15 g butter,
unsweetened tea with crackers,
buckwheat and rice porridge (in the ratio of milk with water 1/1),
liquid mashed soups cooked in vegetable broth,
dried bread is allowed on day 6 of the diet,
protein omelet (half an egg a day).
At night you can drink a glass of warm water with honey or yogurt.
All dishes in the first week after the operation are steamed, after 7-10 days, fish and lean boiled meat are introduced into the diet in small quantities.
Discharge from the hospital is made in 1.5-2 months.
In the first days after discharge, the patient must observe complete physical rest (bed rest). Be sure to attend an afternoon nap and diet.After 10-14 days it is allowed to conduct short walks in the fresh air, gradually their duration should be increased. During the rehabilitation period it is forbidden to overwork. Simple household chores, walks, watching TV or reading should be short-lived, if the patient is feeling unwell, such “activities” should be stopped.
Rehabilitation measures include:
taking tablets containing insulin to regulate glucose levels
multienzyme preparations (for better digestion of food),
Recommendations for nutrition in the presence of pancreatic necrosis:
fractional meals about 6 times a day, in small portions,
food intake should be at one time
it is necessary to completely eliminate smoking and alcohol,
dishes must be steamed, stewed or boiled,
food should be chopped (chopped or wiped),
The temperature of ready meals should correspond to room temperature (it is forbidden to eat too cold or hot dishes).
dates, figs, grapes,
yolk and eggs in any form,
fermented milk products and whole milk,
lard, animal fats, margarine,
sour and spicy vegetables (garlic, radish, spinach, radish, spring onions, sorrel),
fish and meat broths,
pickles and pickles,
smoked meats, sausages and canned goods
strong coffee, tea, cocoa, chocolate,
fatty fish, poultry, meat,
lentils, beans, peas, beans,
barley, wheat, corn grits,
short pastry, fresh bread.
savory dry biscuits,
vegetable oil (not more than 30 grams),
butter (not more than 15 grams),
freshly squeezed juices
boiled vegetables (pumpkin, zucchini, cauliflower, beet),
lean meat and poultry, fish (flounder, pollock, chicken, beef),
yogurt low-fat or kefir,
porridge on the water-dairy mixture (in proportion 1/1),
low fat cottage cheese,
With pancreatic necrosis, the prognosis is very doubtful and depends on many factors (how adequately and quickly the treatment was carried out, the amount of surgery, diet and medical recommendations, the presence of comorbidities, the form of the disease, the age of the patient).
In 25% of patients who have suffered a destructive form of pancreatitis, diabetes mellitus develops further. Also quite often pseudocysts are formed and recurrent chronic pancreatitis develops, fistulae are formed. This disease has a high level of mortality. In the presence of aseptic necrosis of the pancreas, the mortality rate is 15-40%, while with an infected person it reaches 60%.
What is the provision of first aid to the patient, if his relatives suspected pancreatonecrosis?
First of all, you need to put the patient in bed, put ice on his stomach area (approximately in the middle of the abdomen). It is strictly forbidden to eat or drink. Also not shown is the use of enzyme preparations or analgesics. To relieve pain, if you have the skills, you need to introduce the patient intramuscularly "No-shpu" or "Papaverine." Call an ambulance immediately.
How long after the transfer of pathology need to follow a diet?
It is not unfortunate, but to maintain a sparing diet will be for life. However, do not despair, because human life, in addition to cigarettes, harmful (but tasty) food and alcohol provides a lot of beautiful things. You can listen to music, relax in nature, read, chat with family, write poetry.
Is it possible to apply and what folk remedies for the diagnosis of pancreatic necrosis?
In no case, it is unsafe. When a person is very bad and there is a desire to die, the reception of various infusions and decoctions will significantly postpone the provision of adequate assistance, respectively, the prognosis of the disease will deteriorate significantly, which can even lead to death.
What can trigger the development of relapse pathology?
In the first place, the cause of relapse may be errors in the diet. Following the diet is emotional and physical stress. In addition, the development of relapse can be triggered by the presence of pathology of the gastrointestinal tract (exacerbation of cholecystitis, duodenal ulcer or stomach ulcer) and the development of complications of pancreatic necrosis.
What are the chances of surviving pancreatonecrosis?
Many often ask the question about what are the chances of surviving pancreatonecrosis? Unfortunately, no doctor can give accurate predictions, since the outcome of pancreatic necrosis, in many respects, depends both on the amount of necrotic changes in the gland and on the presence of aggravating factors. For example, with biliary pancreatic necrosis in non-drinking young and middle-aged patients, in the absence of chronic diseases of the heart, kidney, liver, pancreatonecrosis and the chances of surviving it are greatest. I will not invent statistics, but this is obvious. By the way, the first part of the material on adult pancreatitis is read here.
(I propose to get acquainted with the collection, which contains not only useful, but also inexpensive and tasty dishes for pancreatitis).
Survival is also due to the development of complications from other organs. Complications can vary in severity from mild to extremely severe and, thus, pancreatic necrosis of the pancreas and death are very close to each other.
Causes of the disease
Regarding the causes of the disease, it is worth going back to the beginning of the article, where we talked about the ugly attitude to the pancreas, which we often and deeply show.
Yes, yes - it is malignant food, "sprinkled" with a merciless share of alcohol, and often also surrogate, is the root cause of pancreatic necrosis.
However, not everything is so simple - not only drug addicts and alcoholics lead the risk group.
Unfortunately, it includes quite respectable people who, due to life circumstances and the will of fate, have acquired this deadly disease.
Causes leading to pathology:
- duodenal ulcer and gastric ulcer,
- abdominal trauma,
- complications after surgery,
- various infectious and viral invasions,
- congenital pathology and malformations of the digestive tract.
Video about pancreatic necrosis from an expert:
Main symptoms and complications
Long-term practice of studying and combating pancreatic necrosis allows us to conclude that its destructive attack on the body occurs, as a rule, very quickly.
For no apparent reason, the patient suddenly begins to feel heaviness in the abdomen and bouts of nausea, which are transformed into prolonged, debilitating vomiting.
With the further development of the disease, acute pain in the left hypochondrium appears. Some symptoms may resemble a heart attack, however, the doctor diagnoses that the pancreas sends these signals during a back pancreatic necrosis location.
Irradiation (spread of pain) under the scapula and into the left shoulder is also a characteristic symptom of this disease.
Other symptoms that characterize pancreatic necrosis:
- Protracted vomiting, without apparent relief.
- Temperature increase, chills, fever.
- The appearance of painful color of the skin: blanching and redness of the skin.
- Paresis or intestinal paralysis is a neurological syndrome characterized by a lack of intestinal motor activity (peristalsis), with the result that excrement is not removed from the body.
- Increased heart rate, shortness of breath.
- Due to vomiting - dehydration, drying of the mucous in the mouth.
- The stomach is swollen, muscles in the upper part of it are tense.
- Urination decreases or completely stops.
- On the navel, on the buttocks, costal arch from the back appear characteristic bluish spots.
- There comes a general weakness or, as they say in the people, - a broken body.
- The imbalance of the patient’s mental state is manifested: unmotivated agitation, anxiety, confusion of thoughts, speech, consciousness, loss of space-time orientation, general inhibition.
- As a result of deep damage to the vessels, gastric and intestinal bleeding opens.
Destructive changes associated with damage to the pancreas, can provoke the following complications:
- The formation of voids filled with pus and necrotic masses, threatening the spread of an abscess.
- Development in the body of pseudocysts and cysts.
- The occurrence of fibrosis, as a result of which the dead working cells are replaced by simple connective tissue, while the lost functional load is not restored.
- Restriction of pancreatic secretion - enzymatic failure.
- Acute purulent inflammation is a retroperitoneal cellulitis phlegmon.
- The occurrence of thrombosis in the mesenteric vessels and portal vein.
The progressive development of pancreatic necrosis causes not only an increase in the size of the pancreas, but also leads to the formation of infiltrates - atypical seals consisting of lymph, blood and dead cells. On the fifth day, the infiltration is easily detected by palpation.
Symptoms of pancreatic necrosis are not clearly expressed, clearly pointing to this disease. Other diseases have similar manifestations. Therefore, for more accurate diagnosis, more differentiated laboratory tests are required, using various tools.
- Hemogram Clinical analysis, which determines the increased content of leukocytes in the blood, the appearance of toxic granularity of neutrophils, an increase in the erythrocyte sedimentation rate (ESR).
- A blood test for amylase - an enzyme of pancreatic juice. Pancreatonecrosis significantly increases its content.
- Test for determining the amount of calcitonin in the blood. For a better understanding, it is worth explaining that calcitonin is a hormone involved in the exchange of calcium in the blood. Its increased content indicates the progression of the disease.
- Ultrasound procedure. It is an ultrasound that allows you to visually identify the uneven structure of the gland and its edema, as well as state an increase in the space between the pancreas and the posterior pancreas wall.
- Magnetic resonance and computed tomography (MRI and CT). More modern tools, based on the use of X-rays, which make it possible to study the organ in three-dimensional vectors. This medical practice allows you to identify specific lesions, including small lesions, as well as effusions (accumulation of biological fluid) in the abdominal cavity.
- Puncture (perforation) of necrotic biological formations, with a view to their further study (seeding).
- Angiography. One of the differentiated techniques, which allows using a contrast X-ray study to study the state of the vessels.
- Laparoscopy. This modern surgical operation allows the doctor to “look inside” without an incision and examine the affected areas of the pancreas and more accurately diagnose types of pancreatic necrosis.
Comprehensive treatment of pathology
Without a doubt, pancreatonecrosis is precisely the disease that does not tolerate delay, the patient needs immediate hospitalization.
Often, doctors are powerless against fulminant pancreatic necrosis, the development of which occurs within a few hours. Total pathological process is uncontrollable and uncontrolled. Such a life outlook and death await chronic alcoholics and drug addicts.
Therefore, we repeat that only hospitalization and inpatient treatment under the supervision of experienced personnel can save the patient. Only there the doctor is able to choose the strategy and tactics of treating the patient, using conservative or surgical methods.
The process of prevention and treatment of pancreatic toxemia and toxemia disorders takes a lot of time and effort from both the patient and the attending physician.
It consists of many forms and methods:
- Anti-enzyme therapy.
- Detoxification (plasmapheresis and forced diuresis). These medical activities are carried out with the aim of destroying and neutralizing toxins.
- Syndromic therapy of pain shock and hypovolemia (decrease in circulating blood volume).
- Elimination of DIC - this disorder characterizes the worsening of blood coagulation.
- Corrective infusion therapy - elimination of water-electrolyte imbalance caused by dehydration and blood loss.
- Prevention of septic complications.
- Drug correction of the kidneys, lungs, liver, central nervous system with a general intoxication of the body.
Surgical intervention at an early stage allows to localize and prevent the spread of purulent-septic complications with total and extensive necrosis.
Types of surgery:
- Sequestrectomy - removal on the pancreas of various sites of dead tissue.
- Gland resection - sectoral removal of part of the affected organ.
- Pancreathectomy is the most radical surgery. What is it, what is its essence, why does it sound so disturbing? The radicalism consists in the fact that during the operation the pancreas and part of the duodenum are removed completely (see photo).
Projections after therapy
After the course of therapeutic measures, the patient lives in hope of recovery, which, by the way, is one of the determining factors for the onset of positive dynamics.
However, in severe diseases, a prognosis after surgery is a thankless task, especially when it comes to pancreatonecrosis. And in this case, which is perfectly explicable, doctors are extremely cautious in order not to instill excessive patient optimism in the patient and in his relatives.
The prospect of recovery worsens significantly when the patient has one of the following factors, and even worse when they add up:
- The patient is more than fifty years old.
- The content of leukocytes in the blood of more than 10 * 109 / l, which characterizes leukocytosis.
- Hyperglycemia - high blood sugar.
- Metabolic acidosis is a violation of acid-base balance due to increased release of hydrochloric acid.
- Hypocalcemia. This is a condition where the amount of calcium in the blood plasma falls below 1.87 mmol / l.
- Hypotension - a decrease in blood pressure by 20% relative to the normal daily average.
- Increased levels of urea, enzymes LDH and AST.
- Significant dehydration.
Video story from the patient who had recovered:
The stories of surviving patients suffering from pancreatic necrosis do not sound like memories, but more like a reminder and edification to those who still do not appreciate the joy of every day, guided by a pernicious principle - we live once, we all have to try and we will all there, mercilessly destroying the life God-given .