Chronic pancreatitis: classification

Distinguish primary chronic pancreatitis, in which from the outset the inflammatory process is localized in the pancreas, and the so-called secondary, or concomitant, pancreatitis, gradually developing against the background of some other diseases, usually 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 system (chronic gastritis, duodenitis, etc.), which consistently join the underlying disease (primarily because in many diseases of the digestive system the main causes of their origin are the same factors: nutritional errors, alcohol abuse, infectious lesions: bacterial, viral, parasitic, etc.).

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

According to the morphological sign: edematous, sclerotic-atrophic, fibrous (diffuse and diffusive-nodal), pseudocystic form, as well as a form of chronic pancreatitis with calcification of the pancreas ("calcifying pancreatitis").

According to the peculiarities of the clinic: polysymptomatic (including chronic recurrent pancreatitis), pain, pseudotumor, dyspeptic, latent (long-asymptomatic) form; in each case indicate whether there is a phase of remission or exacerbation.

In the course of the disease:

1. pancreatitis of mild severity (stage I - initial);
2. pancreatitis of the mediastinal course (stage II);
3. pancreatitis of severe degree (stage III - terminal, cachectic).

The stages of the disease are established by clinical-morphological and functional signs. At the first stage, signs of a violation of the external and intrasecretory functions of the pancreas are usually not detected; II and especially III stage occur in violation of the exocrine (I-II-III degree) and (or) endocrine function of the pancreas (secondary diabetes mild, moderate, or severe).

At the III stage of the disease persistent "pancreatic" or "pancreatogenic" diarrhea, progressive depletion, polyhypovitaminosis are observed.

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

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

Chronic calcific pancreatitis is characterized by uneven lobular pancreatic lesions, differing in intensity in neighboring lobules. In the ducts, protein precipitates or calcifications, stones, cysts and pseudocysts, stenosis and atresia, as well as atrophy of acinar tissue, are found. For this form of chronic pancreatitis is characterized by a recurrent course with episodes of exacerbation, in the early stages resembling acute pancreatitis.

Chronic inflammatory (parenchymal) pancreatitis is characterized by the development of foci of inflammation in the parenchyma, with the prevalence of mononuclear cells and fibrosis in the infiltrates that replace the parenchyma of the pancreas. With this form of chronic pancreatitis there are no lesions of ducts and calcification in the pancreas. Slowly progressing signs of exo- and endocrine insufficiency and there is no pain syndrome.

Fibrosis of the pancreas is characterized by the replacement of a significant part of the parenchyma of the gland with a connective tissue, progressive exo- and endocrine insufficiency. It develops, as a rule, in the outcome of other forms of chronic pancreatitis.

Clinical forms

1. Latent (painless) form - observed in about 5% of patients and has the following clinical features:
   • pain absent or mild;
   • occasionally patients are disturbed by unintentionally expressed dyspeptic disorders (nausea, burping of eaten food, loss of appetite);
   • sometimes there are diarrhea or mucous stool;
   • laboratory tests reveal violations of the external or intrasecretory function of the pancreas;
   • In a systematic coprological study, steatorrhoea, creatorrhea, amylorrhea are detected.
2. Chronic relapsing (painful) form - is observed in 55-60% of patients and is characterized by periodic attacks of intense shingles or localized in epigastrium, left hypochondrium. During an exacerbation there is a vomiting, there is an increase and edema of a pancreas (according to US and X-ray study), the content of a-amylase in blood and urine rises.
3. Pseudo-tumorous (icteric) form - occurs in 10% of patients, more often in men. With this form, the inflammatory process is localized in the head of the pancreas, causing its increase and the pressure of the common bile duct. The main clinical signs are:
   • jaundice;
   • itching;
   • pain in epigastrium, more to the right;
   • Dyspeptic disorders (due to exocrine insufficiency);
   • darkening of urine;
   • discolored feces;
   • significant reduction in body weight;
   • an increase in the head of the pancreas (this is usually determined by ultrasound).
4. Chronic pancreatitis with persistent pain syndrome . This form is characterized by constant pain in the upper abdomen, radiating to the back, a decrease in appetite, weight loss, unstable stools, flatulence. An enlarged, compacted pancreas can be palpated.
5. C is a cloning form of chronic pancreatitis . This form is characterized by pain in the upper half of the abdomen, worsening after eating; poor appetite; nausea; diarrhea; weight loss; marked violation of the exocrine and endocrine functions of the pancreas. With ultrasound, pronounced compaction and a decrease in the size of the pancreas are determined.

Degrees of gravity

The light course is characterized by the following symptoms:

• exacerbations rare (1-2 times a year) and short, quickly stop;
• pain syndrome moderate;
• without exacerbation the patient's state of health is satisfactory;
• there is no weight loss;
• function of the pancreas is not disrupted;
• Coprologic analysis is normal.

The course of moderate severity has the following criteria:

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

The severe course of chronic pancreatitis is characterized by:

• frequent and prolonged exacerbations with persistent pain and marked dyspeptic syndromes;
• "Pancreatogenic" diarrhea;
• a drop in body weight, down to progressive exhaustion;
• sharp violations of the exocrine function of the pancreas;
• complications (diabetes mellitus, pseudocysts and pancreatic cysts, obturation of choledoch, partial stenosis of the duodenum with enlarged pancreas head, peripancreatitis, etc.).

[1], [2], [3], [4], [5], [6], [7],