Chronic pancreatitis - Classification

A distinction is made between primary chronic pancreatitis, in which the inflammatory process is localized in the pancreas from the very beginning, and the so-called secondary, or concomitant, pancreatitis, which gradually develops against the background of some other diseases, usually of the digestive system (chronic gastroenterocolitis, peptic ulcer, etc.). In primary pancreatitis, the main symptoms are caused by this disease, but it can also be combined with other diseases of the digestive organs (chronic gastritis, duodenitis, etc.), which are successively added to the main disease (primarily because in many diseases of the digestive organs, the main causes of their occurrence are the same factors: alimentary errors, alcohol abuse, infectious lesions: bacterial, viral, parasitic, etc.).

In secondary pancreatitis, the clinical picture is dominated by the symptoms of the underlying disease, while the manifestations of pancreatitis (as well as other concomitant diseases, if any) recede "into the background". The division of pancreatitis (as well as a number of other diseases) into primary and secondary (concomitant) is also of great practical importance, from the very beginning it directs the doctor to treat the underlying disease first, since without the effectiveness of this therapy it is impossible to achieve success in treating the accompanying suffering.

According to morphological features: edematous, sclerotic-atrophic, fibrous (diffuse and diffuse-nodular), pseudocystic forms, as well as a form of chronic pancreatitis with calcification of the pancreas (“calcifying pancreatitis”).

According to clinical features: polysymptomatic (including chronic recurrent pancreatitis), painful, pseudotumor, dyspeptic, latent (long-term asymptomatic) forms; in each case, it is indicated whether there is a remission or exacerbation phase.

According to the course of the disease:

1. mild pancreatitis (stage I - initial);
2. moderate pancreatitis (stage II);
3. severe pancreatitis (stage III - terminal, cachexic).

The stages of the disease are determined by clinical, morphological and functional signs. At stage I, signs of disturbance of the external and endocrine functions of the pancreas are usually not detected; stage II and especially stage III occur with disturbance of the external secretory (I-II-III degrees) and (or) endocrine functions of the pancreas (secondary diabetes mellitus mild, moderate or severe).

At stage III of the disease, persistent “pancreatic” or “pancreatogenic” diarrhea, progressive exhaustion, and polyhypovitaminosis are observed.

According to the Marseille-Rome classification (1989), adopted in European countries, the following clinical forms of chronic pancreatitis are distinguished.

Chronic obstructive pancreatitisdevelops as a result of obstruction of the main pancreatic duct. The lesion occurs distal to the obstruction site, it is uniform and is not accompanied by the formation of stones inside the ducts. In the clinical picture of this form of chronic pancreatitis, constant pain syndrome predominates. In chronic obstructive pancreatitis, surgical treatment is indicated.

Chronic calcific pancreatitischaracterized by uneven lobular lesions of the pancreas, varying in intensity in adjacent lobules. Protein precipitates or calcifications, stones, cysts and pseudocysts, stenosis and atresia, as well as atrophy of the acinar tissue are found in the ducts. This form of chronic pancreatitis is characterized by a recurrent course with episodes of exacerbation, resembling acute pancreatitis in the early stages.

Chronic inflammatory (parenchymatous) pancreatitischaracterized by the development of foci of inflammation in the parenchyma with a predominance of mononuclear cell infiltrates and fibrosis areas that replace the parenchyma of the pancreas. In this form of chronic pancreatitis, there is no damage to the ducts and calcifications in the pancreas. Signs of exo- and endocrine insufficiency progress slowly and there is no pain syndrome.

Pancreatic fibrosischaracterized by the replacement of a significant portion of the gland parenchyma with connective tissue, progressive exocrine and endocrine insufficiency. It usually develops as a result of other forms of chronic pancreatitis.

Clinical forms

1. Latent (painless) form- observed in approximately 5% of patients and has the following clinical features:
   • pain is absent or mild;
   • periodically, patients are bothered by mild dyspeptic disorders (nausea, belching of eaten food, loss of appetite);
   • sometimes diarrhea or mushy stools appear;
   • laboratory tests reveal disturbances in the exocrine or endocrine function of the pancreas;
   • systematic coprological examination reveals steatorrhea, creatorrhea, and amylorrhea.
2. Chronic recurrent (painful) form - observed in 55-60% of patients and characterized by periodic attacks of intense pain of a girdle nature or localized in the epigastrium, left hypochondrium. During an exacerbation, vomiting occurs, an enlargement and swelling of the pancreas are observed (according to ultrasound and X-ray examination), the content of a-amylase in the blood and urine increases.
3. Pseudotumor (icteric) form- occurs in 10% of patients, more often in men. In this form, the inflammatory process is localized in the head of the pancreas, causing its enlargement and pressure on the common bile duct. The main clinical signs are:
   • jaundice;
   • skin itching;
   • pain in the epigastrium, more on the right;
   • dyspeptic disorders (caused by exocrine insufficiency);
   • darkening of urine;
   • discolored stool;
   • significant weight loss;
   • enlargement of the head of the pancreas (usually this is determined using ultrasound).
4. Chronicpancreatitis with constant pain syndrome. This form is characterized by constant pain in the upper abdomen, radiating to the back, loss of appetite, weight loss, unstable stool, flatulence. An enlarged, compacted pancreas can be palpated.
5. C sclerosing form of chronic pancreatitis. This form is characterized by pain in the upper abdomen, which intensifies after eating; poor appetite; nausea; diarrhea; weight loss; severe impairment of the exocrine and endocrine functions of the pancreas. Ultrasound reveals severe compaction and a decrease in the size of the pancreas.

Severity levels

Mild course is characterized by the following symptoms:

• exacerbations are rare (1-2 times a year) and short-lived, quickly relieved;
• pain syndrome is moderate;
• outside of exacerbation, the patient's health is satisfactory;
• no weight loss;
• pancreatic function is not impaired;
• coprological analysis is normal.

The course of moderate severity has the following criteria:

• exacerbations are observed 3-4 times a year, and occur with a typical long-term pain syndrome;
• pancreatic hyperfermentemia is detected;
• a moderate decrease in the exocrine function of the pancreas and weight loss are determined;
• Steatorrhea, creatorrhea, and aminorrhea are observed.

Severe chronic pancreatitis is characterized by:

• frequent and prolonged exacerbations with persistent pain and severe dyspeptic syndromes;
• “pancreatogenic” diarrhea;
• loss of body weight up to progressive exhaustion;
• severe disturbances of the exocrine function of the pancreas;
• complications (diabetes mellitus, pseudocysts and cysts of the pancreas, obstruction of the common bile duct, partial stenosis of the duodenum due to an enlarged head of the pancreas, peripancreatitis, etc.).

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