Chronic pancreatitis: drug and surgical treatment

The goals of treatment of chronic pancreatitis are:

• Reduction of clinical manifestations of the disease (pain syndrome, exocrine insufficiency syndrome, etc.).
• Prevention of complications.
• Prevention of recurrence.

During an exacerbation of chronic pancreatitis, the main treatment measures are aimed at relieving the severity of the inflammatory process and inactivating pancreatic enzymes. During remission, treatment is mainly limited to symptomatic and replacement therapy. [ 1 ]

During a severe exacerbation of chronic pancreatitis, treatment, as with acute pancreatitis, is necessarily carried out in a hospital (in the intensive care unit, in the surgical or gastroenterological departments). Therefore, at the first fairly clear signs of an exacerbation of the disease, the patient must be hospitalized, since it is extremely difficult to predict the further development of the disease while the patient is at home, without constant medical supervision and timely correction of treatment measures, i.e. the prognosis is unpredictable. [ 2 ]

Usually, cold is prescribed to the epigastric region and the left hypochondrium (a rubber “bubble” with ice) or so-called local gastric hypothermia is carried out for several hours.

In the first 2-3 days, the pancreas needs "functional rest". For this purpose, patients are prescribed fasting and allowed to drink only liquid in the amount of 1-1.5 l/day (200-250 ml 5-6 times a day) in the form of mineral water Borjomi, Jermuk, etc., similar in composition, warm, without gas, in small sips, as well as weak tea, rosehip decoction (1-2 glasses per day). It is often necessary to resort to constant trans-probe (it is better to use a thin transnasal probe) aspiration of gastric juice (especially if there is no effect in the first hours from other therapeutic measures and there are anamnestic indications of gastric hypersecretion in previous examinations), since hydrochloric acid of gastric juice, entering the duodenum and acting on its mucous membrane through the release of secretin, stimulates pancreatic secretion, i.e. the conditions of "functional rest" of the pancreas, despite the patient's abstinence from food intake, are not observed. Considering that when the patient is lying on his back, gastric juice mainly accumulates in the body and fundus of the stomach, it is in these parts that the aspiration holes of the probe should be installed. Control of the correct installation of the probe is carried out by assessing the length of the inserted part of the probe or radiologically (it is advisable to use radiopaque probes for this purpose), as well as by the "success" of aspiration of acidic gastric contents. Regardless of whether gastric juice is aspirated or not, patients are prescribed antacids 5-6 times a day (Burge's mixture, Almagel, antacid-astringent mixture with the following composition: kaolin - 10 g, calcium carbonate, magnesium oxide and bismuth subnitrate 0.5 g each - the powder is taken as a suspension in warm water - 50-80 ml - or administered through a tube or given to the patient to drink slowly, in small sips) or other drugs that bind hydrochloric acid of gastric juice. If the patient undergoes constant aspiration of gastric juice, it is temporarily stopped for the duration of taking the antacid and for another 20-30 minutes. [ 3 ]

Recently, in order to suppress gastric secretion, H2-receptor blockers have been used, which have a powerful antisecretory effect: cimetidine (belomet, histodil, tagamet, cinamet, etc.) and newer drugs - ranitidine (zantac) and famotidine.

Cimetidine (and its analogues) are prescribed orally at 200 mg 3 times a day and 400 mg at night, so that its daily dose is 1 g for a person weighing about 65-70 kg. There are forms of these drugs for intramuscular and intravenous administration, which is preferable in case of exacerbation of pancreatitis (for example, ampoules of histodil with 2 ml of 10% solution). Ranitidine is prescribed at 150 mg 2 times a day or a single dose of 300 mg at night, famotidine at 20 mg 2 times a day or a single dose at night; in case of acute pancreatitis and exacerbation of chronic pancreatitis, their parenteral administration is preferable. The use of somatostatin in the treatment of exacerbations of chronic pancreatitis is considered promising, but further research is needed in this area.

The following combination treatment regimens are used for pancreatic exocrine insufficiency: enzymes, antacids, anticholinergics and H2-receptor blockers. [ 4 ]

• I. Enzyme + antacid preparation.
• II. Enzyme preparation + H2-receptor blocker (cimetidine, ranitidine, etc.).
• III. Enzyme + antacid drug + H2-receptor blocker.
• IV. Enzyme preparation + H2-receptor blocker + anticholinergic drug.

For the same purpose, as well as for pain relief, patients are often prescribed anticholinergic drugs (atropine sulfate 0.5-1 ml of 0.1% solution subcutaneously, metacin 1-2 ml of 0.1% solution subcutaneously, platifillin 1 ml of 0.2% solution several times a day subcutaneously, gastrocepin or pirenzepin - 1 ampoule intramuscularly or intravenously, etc.). In order to "remove swelling" of the pancreas in the acute period of the disease, it is often recommended to prescribe diuretics, and although there is no sufficiently convincing data on this issue in the literature (many conflicting reports are published), these recommendations still, in our opinion, deserve attention. P. Banks (1982), a well-known American specialist in pancreatic diseases, especially recommends using diacarb for the edematous form of pancreatitis not only as a diuretic, but also as a drug that also reduces gastric secretion.

Pain relief during exacerbation of pancreatitis is achieved by prescribing primarily anticholinergics and myotropic antispasmodics (no-shpa, papaverine hydrochloride) in order to relax the sphincter of the hepatopancreatic ampulla, reduce pressure in the duct system and facilitate the flow of pancreatic juice and bile from the ducts into the duodenum. Some gastroenterologists recommend the use of nitroglycerin and other nitro drugs, which also relax the sphincter of the hepatopancreatic ampulla. It should be noted that nitroglycerin has been used for a relatively long time and often successfully by emergency physicians to relieve an attack (at least temporarily) of cholelithiasis. Euphyllin effectively reduces the tone of the sphincter of the hepatopancreatic ampulla when administered intramuscularly (1 ml of a 24% solution) or intravenously (10 ml of a 2.4% solution in 10 ml of a 20% glucose solution).

In case of persistent and rather severe pain, analgin (2 ml of 50% solution) or baralgin (5 ml) are additionally administered, often in combination with the administration of antihistamines: diphenhydramine 2 ml of 1% solution, suprastin 1-2 ml of 2% solution, tavegil 2 ml of 0.1% solution or other drugs of this group. Antihistamines, in addition to their main effect, also have a sedative, mild hypnotic (especially diphenhydramine) and antiemetic effect, which is very useful in this case. Only if there is no effect, resort to the help of narcotic analgesics (promedol), but in no case administer morphine, as it increases the spasm of the sphincter of the hepatopancreatic ampulla.

For the purpose of detoxification, hemodesis is administered intravenously; with severe, difficult-to-stop vomiting, hypohydration and hypovolemia occur, which in turn worsens the blood supply to the pancreas and contributes to the progression of the disease. In these cases, in addition to hemodesis, albumin solutions, plasma and other plasma-substituting fluids are also administered.

Broad-spectrum antibiotics in fairly large doses (ampicillin 1 g 6 times a day orally, gentamicin 0.4-0.8 mg/kg 2-4 times a day intramuscularly, etc.) are widely used in exacerbations of chronic pancreatitis. However, according to many gastroenterologists, antibacterial therapy for acute pancreatitis and exacerbations of chronic pancreatitis in most cases does not improve the clinical course of the disease and, by prescribing them, one can only count on preventing infection of necrotic masses and preventing the formation of abscesses. [ 5 ], [ 6 ]

In destructive pancreatitis, cytostatics (5-fluorouracil, cyclophosphamide, etc.) are also recommended, especially with regional administration into the celiac trunk. In cases of total pancreatic necrosis and purulent complications, their administration is contraindicated. [ 7 ]

Finally, the last line of treatment for pancreatitis is the suppression of pancreatic enzyme activity using intravenously administered antienzyme drugs: trasylol, contrical, or gordox. At present, their effectiveness is denied by many, although, perhaps, with time, with a clearer definition of the indications for their use, they will prove useful in certain forms of the disease and in its early stages. Some authors report the successful use of peritoneal dialysis in particularly severe cases in order to remove activated pancreatic enzymes and toxic substances from the abdominal cavity.

Some gastroenterologists have successfully treated exacerbations of chronic pancreatitis with heparin (10,000 IU daily) or aminocaproic acid (150-200 ml of a 5% solution intravenously by drip, for a course of 10-20 infusions), but these data require additional verification. The use of corticosteroid hormones, recommended by some gastroenterologists, is hardly justified in the opinion of many others.

All these measures are carried out in the first hours of exacerbation of the disease; if there is no effect, the doctor has to look for an explanation for this, exclude possible complications, and decide on the advisability of surgical treatment of the disease. [ 8 ], [ 9 ]

In cases of successful therapy and subsidence of exacerbation symptoms, the gastric aspiration tube can be removed after 1-1.5-2 days, but treatment with antacids and H2-receptor blockers is continued. Food intake is allowed in very small portions 5-6 times a day (diet type 5p, including mucous cereal soups, strained porridge on water, a small amount of protein omelet, freshly prepared cottage cheese, meat soufflé from lean meat, etc.). This diet is low-calorie, with a sharp restriction of fat, mechanically and chemically gentle. In the following days, the diet is gradually and little by little expanded taking into account the further dynamics of the disease, but fatty, fried, spicy dishes and products that cause strong stimulation of the secretion of digestive juices are prohibited. In the coming days, the doses of administered medications are reduced, some of them are cancelled, leaving only antacids and H2-receptor blockers for 2-3 weeks, and if indicated, for a longer period. In most cases, stabilization of the patient's condition is achieved within 1-1.5-2 weeks from the start of treatment.

The main goal of all treatment measures for chronic pancreatitis in the remission stage is to achieve a complete cure for the disease (which is not always possible with a long-term illness - 5-10 years or more), to prevent relapses of the disease, and if a complete cure is not possible, then to eliminate (as far as possible) its symptoms that cause suffering to patients.

Of utmost importance is the elimination of the etiological factor of the disease. In alcoholic pancreatitis, these are urgent, reasoned recommendations to stop drinking alcohol, explaining to patients its harm, and, if necessary, treatment for alcoholism. In so-called cholecystopancreatitis, conservative or surgical treatment of cholecystitis, cholelithiasis. [ 10 ]

Of utmost importance is the regulation of nutrition and adherence to a certain diet - limiting or completely eliminating from food products that sharply stimulate the functions of the pancreas (eliminating from the diet animal fats, especially pork, mutton fat, fried, spicy dishes, strong meat soups, broths, etc.).

Pathogenetic treatment methods are currently not well developed. Recommendations to use corticosteroids for this purpose should be treated with caution; their use is mainly justified in cases of adrenal insufficiency.

During the period of remission of chronic pancreatitis, some patients feel quite satisfactory (some patients with stage I of the disease and individual patients with stage II); many patients still have some symptoms of suffering (pain, dyspeptic disorders, progressive weight loss, etc.). In some cases, only subjective signs of the disease are noted, in others - changes revealed by the doctor or by special research methods (mainly these are patients with stage II and especially with stage III of the disease). In all cases, differentiated, individualized choice of treatment measures is necessary.

The advice periodically encountered in medical literature to use so-called immunomodulators in chronic pancreatitis (some authors recommend levamisole, taktivin, etc.) should apparently also be treated with great caution. Firstly, it is far from always clear what "immunological link" in the pathogenesis of chronic pancreatitis should be influenced (and how). Secondly, in these cases, the maximum possible immunological studies and dynamic immunological control are necessary at present - all this is still very difficult to implement in practice.

During the period of remission of the disease, despite the relatively good general health of a number of patients, and in some cases even a complete or almost complete absence of symptoms of the disease, patients with chronic pancreatitis must strictly adhere to the meal schedule (5-6 times a day). It is advisable to eat exactly "on schedule" at the same time, with approximately equal time intervals between each meal. It is necessary to strongly warn patients about the need to chew food very thoroughly. Some relatively hard foods (hard apples, hard boiled meat, etc.) should be recommended to be eaten chopped (mashed or minced).

Considering that chronic pancreatitis often causes endocrine pancreatic insufficiency (secondary diabetes mellitus), for preventive purposes, patients with chronic pancreatitis should be advised to limit (or better yet, eliminate) the “simplest” carbohydrates in their diet – mono- and disaccharides, primarily sugar. [ 11 ]

If there are no symptoms of the disease and the patient feels well, no special drug therapy is required.

In drug therapy of chronic pancreatitis, the following main goals are sought to be achieved:

1. relief of pancreatic pain, which in some cases is quite excruciating;
2. normalization of digestive processes in the small intestine, disrupted due to a lack of pancreatic enzymes;
3. normalization or at least some improvement of absorption processes in the small intestine;
4. compensation for insufficient intestinal absorption by intravenous (drip) administration of albumin, plasma or special complex drugs for parenteral nutrition (containing essential amino acids, monosaccharides, fatty acids, essential ions and vitamins);
5. compensation for endocrine pancreatic insufficiency (if it occurs).

In the edematous form of chronic pancreatitis, diuretics (diacarb, furosemide, hypothiazide - in normal doses), veroshpiron are included in the complex of therapeutic measures. The course of treatment is 2-3 weeks.

In cases where patients with chronic pancreatitis complain of pain in the left hypochondrium (presumably caused by damage to the pancreas), one should try to establish whether it is caused by edema (and, therefore, enlargement) of the pancreas, stretching of its capsule, chronic perineural inflammation, solar effusion, or blockage of the main duct by a stone. Depending on the cause, appropriate medications are selected. In case of blockage of the main duct by a calculus or spasm of the sphincter of the hepatopancreatic ampulla, anticholinergic and myotropic antispasmodic drugs are prescribed (atropine sulfate orally at 0.00025-0.001 g 2-3 times a day, subcutaneous injections of 0.25-1 ml of a 0.1% solution; metacin orally at 0.002-0.004 g 2-3 times a day, gastrocepin or pirenzepine at 50 mg 2 times a day 30 minutes before meals orally or parenterally - intramuscularly or intravenously at 5-10 mg 2 times a day, no-shpa at 0.04-0.08 g 2-3 times a day orally or 2-4 ml of a 2% solution intravenously, slowly and other drugs from these groups). In case of severe and persistent pain caused by perineural inflammation or solar effusion, non-narcotic analgesics can be recommended (analgin intramuscularly or intravenously 1-2 ml of 25% or 50% solution 2-3 times a day, baralgin 1-2 tablets orally 2-3 times a day or in case of particularly severe pain intravenously slowly 1 ampoule - 5 ml - 2-3 times a day). In extreme cases and for a short period, promedol can be prescribed (orally 6.025-0.05 g 2-3 times a day or 1-2 ml of 1% or 2% solution subcutaneously also 2-3 times a day). Morphine should not be prescribed even for very severe pain, primarily because it causes spasm of the sphincter of the hepatopancreatic ampulla and impairs the outflow of pancreatic juice and bile, thereby it can contribute to the progression of the pathological process in the pancreas. [ 12 ], [ 13 ]

In some patients, severe pain was relieved by paranephric or paravertebral novocaine blockade. In some cases, excruciating pain was relieved by reflexotherapy (apparently due to the psychotherapeutic effect?). Some physiotherapeutic procedures have a good effect. For over 4 years, our clinic has been successfully using contrical electroregulation (a variant of the electrophoresis method) for this purpose in chronic pancreatitis (painful form) - 5000 U of contrical in 2 ml of a 50% solution of dimethyl sulfoxide. UHF in athermal dosage and some other physiotherapeutic methods are also used. [ 14 ]

In cases of unbearably severe pain, in some cases it is necessary to resort to surgical treatment.

In case of solaritis and solargia, ganglionic blockers and antispasmodics can be quite effective (gangleron 1-2-3 ml of 1>5% solution subcutaneously or intramuscularly, benzohexonium 1-1.5 ml of 2.5% solution subcutaneously or intramuscularly, or other drugs of this group).

If patients with chronic pancreatitis show signs of exocrine pancreatic insufficiency (insufficient content of enzymes in pancreatic juice - lipase, trypsin, amylase, etc.), which can be judged by the occurrence of dyspeptic phenomena, "pancreatogenic" diarrhea, characteristic changes in the results of coprological studies: steatorrhea is persistently noted, to a lesser extent - creato- and amylorrhea - it is necessary to prescribe medications containing these enzymes and facilitating the digestion of nutrients in the small intestine.

When recommending certain drugs containing pancreatic enzymes to patients with chronic pancreatitis, it should be taken into account that they are difficult to standardize; even drugs from the same company, released at a certain interval, may differ somewhat in their activity. Therefore, the effect of using these drugs is not stable in all cases. It is also necessary to take into account the individual characteristics of the patient's body: some patients are better helped by some drugs, while others are helped by others. Therefore, when prescribing certain enzyme preparations, it is necessary to inquire from the patient which of these drugs helped better and were better tolerated when used in the past.

The tactics of using enzyme preparations recommended by different schools of gastroenterologists differ slightly. Thus, pancreatic enzyme preparations can be prescribed before meals (approximately 20-30 minutes) or during meals, at each meal. In patients with increased or normal gastric secretion, it is better to prescribe pancreatic enzymes before meals and in combination with antacids, preferably liquid or gel-like, including "alkaline" mineral water such as Borjomi, Smirnovskaya, Slavyanovskaya, Jermuk, etc. This recommendation is due to the fact that pancreatic enzymes are most active at a neutral or slightly alkaline reaction of the environment pH 7.8-8-9. At pH below 3.5, lipase activity is lost, trypsin and chymotrypsin are inactivated by pepsin in gastric juice. In case of hypochlorhydria and especially gastric achylia, it is advisable to prescribe pancreatic enzyme preparations during meals. [ 15 ]

Recently, it has been recommended to take drugs containing pancreatic enzymes in combination with H2-receptor blockers (cimetidine, ranitidine or famotidine), which most strongly suppress gastric secretion.

Each patient should be prescribed an individual dose of enzyme preparations, taking into account the severity of the disease (1-2 tablets or capsules 3-4-5-6 times a day up to 20-24 tablets per day). In some cases, according to our observations, a combination of a standard preparation (panzinorm, festal, etc.), containing three main enzymes, with pancreatin is more effective than doubling the dose of this preparation. Apparently, this is explained by the fact that pancreatin, in addition to the main ones - lipase, trypsin and amylase, also contains other pancreatic enzymes - chymotrypsin, exopeptidases, carboxypeptidases A and B, elastase, collagenase, deoxyribonuclease, ribonuclease, lactase, sucrase, maltase, esterases, alkaline phosphatase and a number of others. [ 16 ]

The question of which dosage form of pancreatic enzymes is most effective - in tablets (pills) or in capsules - is widely discussed in the literature. Apparently, the use of pancreatic preparations in the form of powder or small granules enclosed in a capsule that dissolves in the small intestine is more justified than in the form of tablets or pills (a priori), since there is insufficient confidence that tablet preparations dissolve quickly and promptly enough in the duodenum or jejunum, and will not "slip" in an insoluble form into more proximal parts of the small intestine, without participating in digestive processes.

Some gastroenterologists in particularly severe cases of chronic pancreatitis recommend prescribing pancreatic enzyme preparations in large doses every hour (except at night), regardless of food intake - 16-26-30 tablets or capsules per day. Perhaps this tactic has some advantages - a uniform flow of pancreatic enzymes into the intestine (after all, given the rather long delay of food in the stomach and its portioned entry into the intestine, digestive processes in the small intestine occur almost continuously, therefore the need for pancreatic enzymes exists almost constantly - the small intestine is almost never without chyme).

The effectiveness of enzyme therapy is enhanced in cases where it is necessary by the parallel administration of drugs that suppress gastric secretion (of course, not in cases where gastric achylia occurs). The most effective for this purpose is a combination of H2-receptor blockers (ranitidine or famotidine, etc.) with anticholinergics (atropine sulfate, metacin, gastrocepin).

The use of anticholinergics, in addition to their inhibitory effect on gastric juice secretion (recall that acidic active gastric juice interferes with the action of pancreatic enzymes, for which a neutral or slightly alkaline reaction of the environment is optimal, and it inactivates or destroys some of them), also slows down the passage of nutrients through the small intestine. This last action of anticholinergics increases the time that chyme remains in the small intestine, which promotes digestive processes and absorption (thus, lengthening the time of contact of the final products of digestion with the mucous membrane of the small intestine significantly increases their absorption). [ 17 ]

The effectiveness of treatment with pancreatic enzyme preparations and control of the correctness and adequacy of the selected dose of preparations is carried out, focusing on the dynamics of the subjective sensations of patients and some objective indicators: a decrease or disappearance of dyspeptic phenomena, flatulence, the emergence of a tendency towards normalization or complete normalization of the frequency of stool and the nature of bowel movements, the results of repeated coprological microscopic studies, a slowdown in the decrease or the emergence of a tendency towards positive dynamics of the patient's body weight. [ 18 ]

One should be extremely cautious (if not downright negative) about the recommendations of some gastroenterologists to use secretin and pancreozymin hormones to stimulate the function of the pancreas in cases of exocrine pancreatic insufficiency. Firstly, their effect is very short-lived (several tens of minutes), and secondly - and this is probably the main thing - trying to stimulate the function of the pancreas can cause an exacerbation of pancreatitis.

The next direction of therapeutic measures in chronic pancreatitis, especially for patients with stage II or III of the disease, is compensation for impaired absorption processes in the small intestine. As has been established, insufficient absorption of the final products of hydrolysis of nutrients (amino acids, monosaccharides, fatty acids, etc.) in chronic pancreatitis occurs mainly due to the action of two factors: impaired digestive processes and secondary inflammatory damage to the mucous membrane of the small intestine. If the first factor can be compensated in most cases by an adequate dose of pancreatic enzymes, then it is possible to reduce inflammatory processes in the mucous membrane by using drugs that have a local protective (enveloping and astringent) effect on the mucous membrane. For this purpose, the same means are usually used as for chronic enteritis and enterocolitis - basic bismuth nitrate 0.5 g, kaolin (white clay) 4-10-20 g per dose, calcium carbonate 0.5 g. Each of these drugs can be taken either separately 5-6 times a day, preferably in the form of a suspension in a small amount of warm water, or, which is preferable, together (you can drink this combination in the indicated doses per dose in the form of powder) also 4-5-6 times a day. You can also use some medicinal plants, infusions or decoctions of which have an astringent effect: infusion of marshmallow root (5 g per 200 ml of water), decoction of cinquefoil rhizome (15 g per 200 ml of water), rhizome with roots of bluehead (15 g per 200 ml of water), infusion or decoction of bird cherry fruits (10 g per 200 ml of water), infusion of alder fruits (10 g per 200 ml of water), infusion of St. John's wort (10 g per 200 ml of water), infusion of chamomile flowers (10-20 g per 200 ml of water), etc.

Patients with chronic pancreatitis with more pronounced exocrine insufficiency (grades II-III) and symptoms of malabsorption are prescribed special nutritional mixtures (enpits) or, in their absence, infant nutritional mixtures in addition to the usual dietary recommendations (diet No. 5p) in order to increase the intake of easily digestible nutrients necessary to cover energy expenditure and restore body weight. Particularly useful are mixtures for parenteral nutrition enriched with vitamins and essential ions (such as the drug Vivonex, produced abroad). Since not all nutritional mixtures have a pleasant enough taste and, in addition, patients may have a decreased appetite, these nutritional mixtures can be introduced into the stomach through a tube 1-2-3 times a day between meals.

In even more severe cases, with pronounced malabsorption phenomena and significant weight loss of patients, special preparations for parenteral nutrition are additionally prescribed (casein hydrolysate, aminokrovin, fibrinosol, amikin, polyamine, lipofundin, etc.). All these preparations are administered intravenously, very slowly (starting with 10-15-20 drops per minute, then after 25-30 minutes somewhat faster - up to 40-60 drops per minute) 400-450 ml 1-2 times a day; the duration of each dose is 3-4 hours, the intervals between the administration of these preparations are 2-5 days, for a course of 5-6 infusions. Of course, these infusions can only be carried out in a hospital setting. Blood plasma can also be used to eliminate hypoproteinemia.

Patients with significant weight loss are prescribed anabolic steroid hormones to improve protein absorption by the body: methandrostenolone (dianabol, nerobol) 0.005-0.01 g (1-2 tablets of 5 mg) 2-3 times a day before meals, retabolil (intramuscularly in the form of an oil solution) 0.025-0.05 g administered once every 2-3 weeks, for a course of 6-8-10 injections. Clinically, treatment with these drugs is manifested in improved appetite, gradual weight gain in patients, improvement of their general condition, and in cases with calcium deficiency and osteoporosis, also in accelerated bone calcification (with additional intake of calcium salts into the body).

In long-term pancreatitis, due to secondary involvement of the small intestine in the inflammatory process and impaired absorption in it, signs of vitamin deficiency are often observed. Therefore, patients are prescribed multivitamins (1-2 tablets 3-4 times a day) and individual vitamins, especially B2, B6, B12, nicotinic and ascorbic acid, as well as fat-soluble vitamins, primarily A and D. In case of obvious signs of vitamin deficiency, individual, especially essential, vitamins can be additionally administered in the form of injections. It should be remembered that with a long course of chronic pancreatitis, vitamin B12 deficiency and the resulting anemia may be observed. Anemia may also occur with a deficiency of iron ions in the body; with a simultaneous deficiency of both vitamin B12 and iron ions - mixed, polydeficiency anemia; with insufficient absorption of Ca2 ^+, osteoporosis gradually develops. Therefore, when these ions (Ca ²⁺, Fe ² " ¹ ") in the blood serum of patients decrease, especially when clinical signs of their deficiency are detected, their additional administration should be ensured, preferably parenteral. Thus, calcium chloride is administered 5-10 ml of a 10% solution into a vein daily or every other day slowly, very carefully. Ferrum Lek is administered intramuscularly or intravenously at 0.1 g per day in appropriate ampoules for intramuscular (2 ml) or intravenous (5 ml) administration. The drug is administered intravenously slowly. [ 19 ], [ 20 ]

Endocrine pancreatic insufficiency requires appropriate corrections of dietary and therapeutic measures - as in diabetes mellitus. According to many gastroenterologists, diabetes mellitus occurs in approximately 30-50% of patients with non-calcifying and 70-90% of patients with calcifying pancreatitis. At the same time, it is believed that decreased glucose tolerance occurs even more often and occurs earlier than steatorrhea. It should be borne in mind that diabetes mellitus that occurs against the background of chronic pancreatitis has its own characteristics: damage to the pancreatic islets by the inflammatory-sclerotic process reduces the production of not only insulin, but also glucagon. The course of symptomatic diabetes in this disease and hyperglycemia are very labile. In particular, the introduction of even small doses of insulin can be accompanied by a significant, inadequate to the dose of insulin administered, drop in blood glucose due to insufficient production of glucagon. Insufficient production of glucagon also explains the relatively rare occurrence of diabetic ketoacidosis in such patients, since in this case the ability of liver tissue to convert free fatty acids into acetoacetic and beta-hydroxybutyric acids is reduced. The literature notes the relatively rare occurrence of some complications of diabetes mellitus in chronic pancreatitis - retinopathy, nephropathy, microangiopathy, vascular complications. In the treatment of secondary (symptomatic) diabetes mellitus in patients with chronic pancreatitis, in addition to an appropriate diet, oral hypoglycemic agents should be used, increasing glucose tolerance.

It is believed that it is advisable for patients with chronic pancreatitis to undergo periodic treatment, 3-4 times a year, with drugs that stimulate metabolic processes (pentoxyl, which is prescribed at 0.2-0.4 g per dose, or methyluracil at 0.5-1 g 3-4 times a day). The course of treatment with one of these drugs is 3-4 weeks. Previously, so-called lipotropic agents - methionine or lipocaine - were prescribed simultaneously with these drugs, but their effectiveness is low.

After the acute symptoms have subsided and in order to prevent further exacerbation, spa treatment in Borjomi, Essentuki, Zheleznovodsk, Pyatigorsk, Karlovy Vary and local gastroenterological sanatoriums is recommended.

Patients with chronic pancreatitis are not recommended to do types of work that make it impossible to adhere to a strict diet; in severe cases of the disease, patients must be referred to a medical and social expert commission to determine their disability group. h [ 21 ]

[ 22 ]

Indications for hospitalization

Chronic pancreatitis in the acute stage is an indication for inpatient treatment due to the threat to the patient's life and the need for parenteral administration of drugs and additional research methods.

Based on the pathogenesis of chronic pancreatitis, treatment should be aimed at solving the following problems:

• decrease in pancreatic secretion;
• pain relief;
• conducting enzyme replacement therapy.

Surgical treatment of chronic pancreatitis

Surgical treatment of chronic pancreatitis is indicated for severe painful forms of chronic pancreatitis, when pain is not relieved by any therapeutic measures: with cicatricial-inflammatory stenosis of the common bile duct and (or) main bile duct, abscess formation or development of a cyst of the gland. The nature of the operation in each case is determined by the features of the course of the inflammatory process in the pancreas and the nature of the complication that has arisen. Thus, in case of unbearably severe pain, splanchnectomy and vagotomy, ligation or obstruction of the main duct with acrylic glue, etc. are performed. In other, also severe cases, distal or proximal resection of the pancreas is performed (with a pseudocyst, with a rare limited inflammatory process, mainly in the area of the tail or head of the pancreas, etc.), pancreatoduodenal resection, drainage of the main duct and other types of surgical interventions, the nature of which is determined by the specific features of each case of the disease. Naturally, in the postoperative period, dietary and therapeutic measures are carried out, as in the case of an exacerbation of pancreatitis, and in the long term, depending on the characteristics and severity of the course - as in the chronic form of the disease.

We have not observed cases of spontaneous healing of chronic pancreatitis. However, as our experience shows, significant improvement in the course of the disease under the influence of systematically conducted therapeutic measures in patients under dispensary observation, and the occurrence of stable remission over a long period of observation (over 5-7 years or more) is quite possible in most patients.

Non-drug treatment

The diet should not stimulate the secretion of pancreatic juice. In severe exacerbations, fasting (table 0) and hydrocarbonate-chloride waters are prescribed for the first 3-5 days. If necessary, parenteral nutrition is prescribed: protein solutions (albumin, protein, plasma), electrolytes, glucose. It helps reduce intoxication and pain syndrome and prevents the development of hypovolemic shock.

In case of duodenostasis, aspiration of gastric contents is performed with a thin probe.

After 3-5 days, the patient is transferred to oral nutrition. Food intake should be frequent, in small portions. Limit the intake of products that can stimulate pancreatic secretion: fats (especially those that have undergone heat treatment), sour products. Limit the consumption of dairy products rich in calcium (cottage cheese, cheese).

The daily diet should contain 80-120 g of easily digestible proteins (egg whites, boiled lean meat, fish), 50-75 g of fats, 300-400 g of carbohydrates (preferably in the form of polysaccharides). If there is good individual tolerance, raw vegetables are not excluded.

It is prohibited to consume alcohol, spicy foods, canned foods, carbonated drinks, sour fruits and berries, and sour fruit juices.

Replacement therapy of exocrine pancreatic function

Mild steatorrhea, not accompanied by diarrhea and weight loss, can be corrected by diet. The indication for prescribing enzymes is steatorrhea with a loss of more than 15 g of fat per day, combined with diarrhea and weight loss. [ 23 ]

The doses of enzyme preparations depend on the degree of pancreatic insufficiency and the patient's desire to follow a diet. To ensure normal digestion with adequate nutrition in patients with severe exocrine insufficiency, it is necessary to take 10,000-30,000 U of lipase with each meal.

The enzyme preparations used should not reduce the pH of gastric juice or stimulate pancreatic secretion. Therefore, it is preferable to prescribe enzymes that do not contain bile and gastric mucosa extracts (pancreatin).

Enzyme preparations are prescribed for life. Doses can be reduced by following a strict diet with limited fat and protein, and increased by expanding the diet. Indicators of a correctly selected enzyme dose are stabilization or increase in body weight, cessation of diarrhea, steatorrhea and creatorrhea. [ 24 ]

If there is no effect from the administration of large doses of enzymes (30,000 U for lipase), further increase in doses is inappropriate. The reasons may be concomitant diseases: microbial seeding of the duodenum, helminthic invasions of the small intestine, precipitation of bile acids and inactivation of enzymes in the duodenum as a result of a decrease in pH. In addition to enzyme inactivation, at low pH, the secretion of bile and pancreatic juice with a reduced enzyme content increases. This leads to a decrease in the concentration of enzymes. At low pH of duodenal contents, it is recommended to combine enzyme intake with antisecretory drugs (proton pump inhibitors, H2-histamine receptor blockers ₎.

Further management of the patient

After the exacerbation of chronic pancreatitis has been relieved, a low-fat diet and constant replacement therapy with enzyme preparations are recommended.

Patient education

It is necessary to explain to the patient that the intake of enzyme preparations should be constant; the patient can adjust the dose of enzymes depending on the composition and volume of food consumed.

It is important to explain that long-term use of enzyme preparations does not lead to the development of secondary exocrine insufficiency.

Prognosis of chronic pancreatitis

Strict adherence to a diet, refusal to drink alcohol, and adequate maintenance therapy significantly reduce the frequency and severity of exacerbations in 70-80% of patients. Patients with chronic alcoholic pancreatitis live up to 10 years with complete refusal to drink alcohol. If they continue to drink alcohol, half of them die before this period. Stable and long-term remission of chronic pancreatitis is possible only with regular maintenance therapy.