Chronic pancreatitis - Treatment

The goals of treatment of chronic pancreatitis:

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

During the exacerbation of chronic pancreatitis, the main treatment measures are aimed at alleviating the severity of the inflammatory process and inactivation of pancreatic enzymes. In the period of remission, treatment is mainly reduced to symptomatic and substitution therapy.

In the period of acute exacerbation of chronic pancreatitis, treatment, as in acute pancreatitis, is mandatory in the hospital (in the intensive care unit, in the surgical or gastroenterological units). Therefore, with the first sufficiently clear signs of exacerbation, the patient should be hospitalized, since it is extremely difficult to predict the further development of the disease in the conditions of the patient's stay, without constant medical control and timely correction of medical measures, that is, the forecast is unpredictable.

Usually, a cold is prescribed for the epigastric region and the zone of the left hypochondrium (a rubber "bubble" with ice) or the so-called local gastric hypothermia for several hours.

In the first 2-3 days, a "functional rest" for the pancreas is necessary. To this end, the patient is prescribed a hunger and is allowed to take 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 Borzhom, jermuk, etc., close in composition, in warm form, without gas, in small sips, as well as weak tea, broth of wild rose (1-2 cups per day). It is often necessary to resort to a constant over-probe (it is better to use a fine transfusion probe) for aspiration of gastric juice (especially in the absence of effect during the first hours of other medical measures and the presence of anamnestic indications of gastric hypersecretion in previous examinations), because hydrochloric acid of gastric juice, entering the duodenum gut and acting on its mucosa via secreten secretion, stimulates pancreatic secretion, i.e., the conditions of "functional to oya "pancreas despite the patient's abstinence from food, are not met. Given that when the patient is lying on his back, gastric juice mainly accumulates in the area of the body and the bottom of the stomach, it is in these areas of his stomach that aspiration holes of the probe should be installed. Control of the correct installation of the probe is performed by evaluating the length of the inserted part of the probe or radiologically (preferably using radiopaque probes for this purpose), and also on 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 (Bourges, Almagel, antacid-astringent mixture having the following composition: kaolin - 10 g, calcium carbonate, magnesium oxide and bismuth subnitrate by 0 , 5 g - powder is taken as a suspension in warm water - 50-80 ml - or injected through a probe or given to drink slowly, in small sips) or other drugs that bind hydrochloric acid of gastric juice. If the patient is undergoing a constant aspiration of gastric juice, it is temporarily discontinued for the time of taking the antacid and for another 20-30 minutes.

Recently, with the aim of suppressing gastric secretion, blockers of H2 receptors have been used that have a powerful antisecretory action: cimetidine (whitemet, histodil, tagamet, cynamet, etc.) and more new drugs - ranitidine (zantac) and famotidine.

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

The following schemes of combined treatment for pancreatic exocrine insufficiency with enzyme, antacid, anticholinergics and H2-receptor blockers are used.

• I. Enzyme + antacid preparation.
• II. Enzyme preparation + blocker of H2 receptors (cimetidine, ranitidine or others).
• III. Enzyme + antacid preparation + blocker of H2 receptors.
• IV. Enzyme preparation + blocker of H2-receptors + anticholinergic drug.

For the same purpose, as well as for pain relief, patients are often prescribed anticholinergic agents (atropine sulfate 0.5-1 ml 0.1% solution subcutaneously, metacin 1-2 ml 0.1% solution subcutaneously, platifillin 1 ml 0 , 2% solution several times a day subcutaneously, gastrotsepin or pirentsepin - 1 ampoule intramuscularly or intravenously, etc.). With the aim of "removing the edema" of the pancreas during an acute period of the disease, it is often recommended to prescribe diuretics, and although there are not enough convincing data on this issue in the literature (many contradictory reports are published), these recommendations, in our opinion, deserve attention. P. Banks (1982), a famous American specialist in pancreatic diseases, with a papilled form of pancreatitis, especially recommends the use of diacarb not only as a diuretic, but also a drug that also reduces gastric secretion.

Elimination of pain during exacerbation of pancreatitis is achieved primarily by anticholinergics and myotropic antispasmodics (no-sppa, papaverine hydrochloride) in order to relax the sphincter of the hepatic pancreatic ampulla, to lower the pressure in the duct system and to facilitate the entry of pancreatic juice and bile from the ducts into duodenum. Some gastroenterologists recommend the use of nitroglycerin and other nitro drugs, which also relax the sphincter of the hepatic-pancreatic ampulla. It should be noted that nitroglycerin has been used for quite some time now and often with success by doctors of "first aid" to relieve the attack (at least temporarily) of cholelithiasis. It is not bad to reduce the tone of the sphincter of the hepatic pancreatic ampulla euphyllene when administered intramuscularly (1 ml of a 24% solution) or intravenously (10 ml of a 2.4% solution in 10 ml of 20% glucose solution).

With persistent and sufficiently strong pain, additionally injected with analgin (2 ml of 50% solution) or baralgin (5 ml), often combining them with the administration of antihistamines: dimedrola 2 ml 1% solution, suprastin 1-2 ml 2% solution, Tavegil 2 ml 0.1% solution or other preparations of this group. Antihistamines, in addition to their main action, also have sedative, mild hypnotic (especially diphenhydramine) and antiemetic effect, which in this case is very useful. Only in the absence of effect resort to the help of narcotic analgesics (promedol), but in no case do not inject morphine, since it enhances spasm of the sphincter of the hepatic-pancreatic ampulla.

For the purpose of detoxification, intravenously inject haemodesis; with a strong, hard-to-stomach vomiting, hypohydration occurs, hypovolemia, which in turn worsens the blood supply of the pancreas and contributes to the progression of the disease. In these cases, in addition to haemodesis, solutions of albumin, plasma and other plasma-replacing fluids are also introduced.

Antibiotics of a broad spectrum of action in sufficiently large doses (ampicillin 1 g 6 times a day inwards, gentamycin 0.4-0.8 mg / kg 2-4 times a day intramuscularly, etc.) are widely used in exacerbation of chronic pancreatitis. However, according to many gastroenterologists, antibiotic therapy for acute pancreatitis and exacerbation of chronic in most cases does not improve the clinical course of the disease and, by designating them, one can count only on preventing infection of necrotic masses and preventing the formation of abscesses.

In destructive pancreatitis, cytotoxic agents (5-fluorouracil, cyclophosphamide, etc.) are also recommended, especially when administered regionally to the celiac trunk. With total pancreatic necrosis and suppurative complications, their administration is contraindicated.

Finally, the last line of treatment for pancreatitis is the suppression of the activity of pancreatic enzymes with the help of intravenously injected anti- enzymes: trasilol, contrikal or gordoksa. Currently, many of them deny their effectiveness, although, probably, over time, with a clearer definition of indications for their use, they will prove useful in certain forms of the disease and its early stages. Some authors report the successful use of peritoneal dialysis in especially severe cases with the aim of removing activated pancreatic enzymes and toxic substances from the abdominal cavity.

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

All these measures are carried out in the first hours of the exacerbation of the disease, in the absence of the effect, the doctor has to seek an explanation for this, exclude possible complications, and decide whether the surgical treatment of the disease is advisable.

In cases of successful therapy and suppression of symptoms of exacerbation, the gastric aspiration probe can be removed after 1-1,5-2 days, but treatment with antacid drugs and H2-receptor blockers continues. Allow food intake in very small portions 5-6 times a day (diet type 5p, including mucous cereal soup, mashed porridge on the water, a small amount of protein omelet, freshly prepared cottage cheese, meat soufflé from low-fat meat, etc.). This diet is low-calorie, with a sharp restriction of fat, mechanically and chemically sparing. In the following days, the diet is gradually and gradually expanded to take into account the further dynamics of the disease, but fatty, fried, spicy dishes and foods that cause strong stimulation of the secretion of digestive juices are banned. In the coming days, doses of injected drugs are reduced, some of them are canceled, leaving for 2-3 weeks, and with indications and for a longer period, only antacids and H2-receptor blockers. In most cases, the stabilization of patients is achieved after 1-1,5-2 weeks from the start of treatment.

The main goal of all medical measures for chronic pancreatitis in the stage of remission is the desire to achieve a complete cure of the disease (which is not always possible with long-term illness - 5-10 years or more), preventing recurrence of the disease, and if complete cure is impossible, then elimination the least possible) of his symptoms, causing suffering to patients.

The most important is the elimination of the etiologic factor of the disease. When alcoholic pancreatitis is an urgent, reasoned recommendation to stop drinking alcohol, explaining to patients their harm, in necessary cases - treatment for alcoholism. With the so-called cholecystopancreatitis conservative or surgical treatment of cholecystitis, cholelithiasis.

The most important are the regulation of nutrition and the observance of a certain diet - the restriction or complete exclusion of foods that dramatically stimulate the functions of the pancreas (excluding from the diet of animal fats, especially pigs, lamb fat, fried, spicy dishes, strong meat soups, broths, etc. .).

Methods of pathogenetic treatment are currently not well developed. To recommendations to apply for this purpose corticosteroids should be treated very cautiously, in general their use is justified in case of insufficiency of adrenal function.

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

To the advice periodically encountered in the medical literature, to apply in the case of chronic pancreatitis, so-called immunomodulators (some authors recommend levamisole, tactivin, etc.), it seems, should also be taken very cautiously. First, it is far from clear that the "immunological link" of the pathogenesis of chronic pancreatitis, which (and how) should be affected. Secondly, in these cases, the greatest possible currently available immunological studies and dynamic immunological control - all this in practice is still very difficult to implement.

During the period of remission of the disease, despite the relatively good overall health of some patients, and in some cases - even complete or almost complete absence of symptoms of the disease, patients with chronic pancreatitis should strictly comply with the regime of food intake (5-6 times a day). It is advisable to take food exactly "on schedule" at the same hours, with approximately equal time intervals between each meal. It is necessary to strongly warn patients about the need for thorough chewing food. Some relatively solid food products (hard varieties of apples, hard boiled meat, etc.) should be recommended to be eaten in crushed (grated or rolled through a meat grinder) form.

Given that chronic pancreatitis often results in an incremental insufficiency of the pancreas (secondary diabetes mellitus), with the preventive goal of a patient with chronic pancreatitis, it should be recommended in the diet to limit (or best exclude) the "simplest" carbohydrates - mono- and disaccharides, in the first place sugar.

In the absence of symptoms of the disease and well-being of patients, special drug therapy is not required.

When drug therapy of chronic pancreatitis seek to achieve the following main goals:

1. relief of pancreatic pain, in some cases - rather painful;
2. normalization of digestive processes in the small intestine, impaired due to a lack of pancreatic enzymes;
3. normalization or at least some improvement in the absorption processes in the small intestine;
4. compensation of intestinal insufficiency by intravenous (drop) injection of albumin, plasma or special complex medicines for parenteral nutrition (containing essential amino acids, monosaccharides, fatty acids, basic ions and vitamins);
5. Compensation for the incremental insufficiency of the pancreas (if it occurs).

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

In cases where patients with chronic pancreatitis complain of pain in the left hypochondrium (presumably due to pancreatic injury), one should try to establish whether they are caused by edema (and, consequently, by an increase) in the pancreas, by dilatation of its capsule, chronic perineural inflammation, solarite or obstruction of the main duct with a stone. Depending on the reason, appropriate medications are selected. In case of obstruction of the main duct with concrement or spasm of the sphincter of the hepatic pancreatic ampullum, anticholinergic and myotropic antispasmodics are prescribed (atropine sulfate inwards at 0.00025-0.001 g 2-3 times a day, subcutaneous injections of 0.25-1 ml 0.1 % solution, metacin orally to 0,002-0,004 g 2-3 times a day, gastrocepine or pyrenzepine 50 mg 2 times a day for 30 minutes before meals inside or parenterally - intramuscularly or intravenously 5-10 mg 2 times a day, but-shpu to 0,04-0,08 g 2-3 times a day inwards or 2-4 ml of a 2% solution intravenously, slowly and other preparations of these groups). With sufficiently strong and persistent pain due to perineural inflammation or solaritis, it is possible to recommend non-narcotic analgesics (analgin intramuscularly or intravenously for 1-2 ml of 25% or 50% solution 2-3 times a day, baralgin 1 to 2 tablets inside 2- 3 times a day, or in case of especially severe pain, intravenously slowly 1 ampoule - 5 ml - 2-3 times a day). In extreme cases and for a short time, you can prescribe promedol (inside of 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 with very severe pain, primarily because it causes spasm of the sphincter of the hepatic pancreatic ampulla and worsens the outflow of pancreatic juice and bile, thereby it can contribute to the progression of the pathological process in the pancreas.

In some patients, severe pain was managed to be quenched with a paranephric or paravertebral novocaine blockade. In some cases it was possible to remove painful pains with the help of reflexotherapy (apparently, due to the psychotherapeutic effect?). A good effect is given by some physiotherapy procedures. For more than 4 years, in our clinic with chronic pancreatitis (painful form), it is successfully used for this purpose electrorepression (variant of the electrophoresis technique) kontrikala - 5000 ED contrikala in 2 ml of a 50% solution of dimexide. UHF is also used in athermic dosage and some other physiotherapeutic methods.

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

With solarization and sollarion, ganglion blockers and spasmolytics can be effective (ganglionone 1-2-3 ml 1> 5% solution subcutaneously or intramuscularly, benzohexonium 1-1.5 ml 2.5% solution subcutaneously or intramuscularly or other drugs of this group ).

If in patients with chronic pancreatitis there are signs of exocrine insufficiency of the pancreas (insufficient content of enzymes in the pancreatic juice - lipase, trypsin, amylase, etc.), which can be judged in patients with dyspepsia, "pancreatogenic" diarrhea, characteristic changes in the results of coprological studies : steatorea is steadily observed, to a lesser extent - creato and amylorea - it is necessary to prescribe medications containing these enzymes and facilitate digestion in the small intestine of nutrients.

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

The tactics of using enzyme preparations, recommended by different schools of gastroenterologists, are somewhat different. So, you can prescribe pancreatic enzyme preparations before meals (approximately 20-30 minutes) or during meals, with 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 Borzhom, Smirnovskaya, Slavyanovskaya, Djermuk, etc. This recommendation is due to the fact, that pancreatic enzymes are most active with a neutral or slightly alkaline reaction medium pH 7.8-8-9. At pH below 3.5, lipase activity is lost, trypsin and chymotrypsin are inactivated by pepsin of gastric juice. With hypochlorhydria and especially gastric Achilles, it is advisable to prescribe pancreatic enzyme preparations during meals.

Recently, preparations containing enzymes of the pancreas are recommended to be taken, combining them with H2-receptor blockers (cimetidine, ranitidine or famotidine), which most strongly suppress gastric secretion.

Each patient, taking into account the severity of the disease should choose an individual dose of enzyme preparations (1-2 tablets or capsule 3-4-5-6 times a day to 20-24 tablets per day). In some cases, according to our observations, a combination of a standard drug (panzinorm, festal, etc.) containing three basic enzymes with pancreatin is more effective than a double increase in the dose of this drug. Apparently this is explained by the fact that pancreatin, in addition to the main lipase, trypsin and amylase, also contains other enzymes of the pancreas - chymotrypsin, exopeptidase, carboxypeptidase A and B, elastase, collagenase, deoxyribonuclease, ribonuclease, lactase, saccharase, maltase , esterase, alkaline phosphatase and a number of others.

In the literature, the question is widely debated, in what form of drug pancreatic enzymes are most effective - in the form of tablets (dragees) or capsules? Apparently, the use of pancreatic preparations in the form of powder or small granules encapsulated in a capsule dissolving in the small intestine is more justified than in the form of tablets or pills (a priori), since there is insufficient confidence that tableted preparations are fast and timely dissolve in the duodenum or jejunum, and not "slip" in an insoluble form into the more proximal parts of the small intestine without taking part in the digestive processes.

Some gastroenterologists in especially severe cases of chronic pancreatitis recommend that pancreatic enzyme preparations should be given in large doses every hour (except for night sleep), regardless of the meal - 16-26-30 tablets or capsules per day. Perhaps this tactic has some advantages: a uniform intake of pancreatic enzymes into the intestine (in fact, given the rather long delay in food in the stomach and its portioning into the intestine, the digestive processes in the small intestine are almost continuous, so the need for pancreatic enzymes exists almost constantly - the small intestine practically does not happen without chyme).

Strengthening the effectiveness of enzyme therapy is achieved, when necessary, by concurrent administration of drugs that inhibit gastric secretion (of course, not in cases where there is gastric Achilles). The most effective for this purpose is the 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 secretion (recall that acidic active gastric juice prevents the action of pancreatic enzymes, for which the neutral or slightly alkaline reaction of the medium is optimal, and some of it inactivates or destroys), but also slows the passage of nutrients in the small intestine. This last action of anticholinergic agents increases the residence time of the chyme in the small intestine, which contributes to digestive processes and absorption (for example, lengthening the contact time of the end products of digestion with the mucous membrane of the small intestine appreciably enhances their absorption).

The effectiveness of treatment with preparations of pancreatic enzymes and control of the correctness and adequacy of the selected dose of drugs is carried out, focusing on the dynamics of subjective sensations of patients and some objective indicators: reduction or disappearance of dyspeptic phenomena, flatulence, a tendency toward normalization or complete normalization of stool frequency and the nature of stool, Microscopic studies, slowing down the decline or the emergence of a trend towards a positive hydrochloric dynamics of patient body weight.

Extremely cautious (if not altogether negative) should be taken to the recommendations of some gastroenterologists with exocrine pancreatic insufficiency of the pancreas used to stimulate its function of hormones secretin and pancreosimin. First, their effect is very short-term (several tens of minutes), and secondly - and, apparently, this is the main thing - in an attempt to stimulate the function of the pancreas, you can cause an exacerbation of pancreatitis.

The next direction of therapeutic measures for chronic pancreatitis, especially for patients with stage II or III disease, is compensation for impaired absorption processes in the small intestine. As it was 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: disturbances in the digestive processes and secondary inflammatory lesions of the small intestinal mucosa. If the first factor can be compensated in most cases by an adequate dose of pancreatic enzymes, then it is possible to reduce the inflammatory processes in the mucosa by using drugs that have local protective (enveloping and astringent) action on the mucosa. For this purpose, usually the same means are used as for chronic enteritis and enterocolitis, nitrate of basic bismuth 0.5 g, kaolin (clay white) 4-10-20 g per reception, calcium carbonate 0.5 g. Each of these preparations can be taken either separately 5-6 times a day, it is better in the form of a suspension in a small amount of warm water, or, preferably, together (you can drink this combination in the indicated doses for one dose in the form of a powder) also 4-5 -6 times a day. You can also use some lekarstvennye plants, infusions or decoctions of which have an astringent effect: infusion from the root of the althaea (5 g per 200 ml of water), a decoction from the rhizome root (15 g per 200 ml of water), rhizome with the roots of the cyanosis (15 grams per 200 ml of water), infusion or decoction of cherry fruit (10 g per 200 ml of water), infusion of auricles (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 to 200 ml of water), etc.

Patients with chronic pancreatitis with more severe exocrine insufficiency (grade II-III) and malabsorption symptoms in order to increase the intake of necessary nutrients for absorbing the energy expenditure of easily assimilated nutrients and restoring the body weight are prescribed in addition to the usual dietary recommendations (diet No. 5p) enfilment) or, in their absence, infant formula. Especially useful are mixtures for parenteral nutrition, enriched with vitamins and necessary ions (such as the drug Viveonex, which is produced abroad). Since not all nutritional formulas have a pleasant enough taste and, in addition, the appetite may be reduced in patients, these nutrient mixtures can be introduced into the stomach through a probe 1-2-3 times a day between meals.

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

Patients with significant weight loss in order to improve the absorption of protein by the body are prescribed anabolic steroid hormones: methandrostenolone (dianabol, nerobol) 0,005-0,01 g (1-2 tablets 5 mg) 2-3 times daily before meals, retabolil ( intramuscularly in the form of an oil solution) to 0.025-0.05 g injected 1 time in 2-3 weeks, for a course of 6-8-10 injections. Clinically, treatment with these drugs manifests itself in improving the appetite, gradually increasing the body weight of patients, improving their general condition, and in cases involving calcium deficiency and osteoporosis, and in accelerating the calcification of bones (with additional calcium salts supplied to the body).

With long-term pancreatitis due to secondary involvement in the inflammatory process of the small intestine and impaired absorption, it often shows signs of vitamin deficiency. Therefore, patients are shown multivitamins (3-4 times a day for 1-2 tablets) and individual vitamins, especially B2, VB, B12, nicotinic and ascorbic acid, as well as fat-soluble vitamins, primarily A and D. With obvious signs of vitamin deficiency, separate , especially necessary, vitamins can be injected additionally in the form of injections. It should be remembered that with a prolonged course of chronic pancreatitis, vitamin B2 deficiency and the anemia caused by it can be observed. If there is a lack of iron ions in the body, anemia can also occur, while vitamin B12 is deficient at the same time, and iron ions are mixed, polydeficiency anemia, with insufficient absorption of Ca ²⁺, osteoporosis gradually develops. Therefore, when these ions (Ca ²⁺, Fe ² " ¹ ") are lowered in the blood serum of patients, especially if clinical signs of their insufficiency are revealed, their additional administration, parenteral, should be ensured. So, calcium chloride inject 5-10 ml of 10% solution into the vein daily or every other day slowly, very carefully. Ferrum Lek is administered intramuscularly or intravenously, 0.1 g per day in appropriate ampoules for intramuscular (2 ml) or intravenous (5 ml each) administration. Intravenously, the drug is administered slowly.

Intra-secretory insufficiency of the pancreas 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 not calcifying and in 70-90% of patients with calcifying pancreatitis. It is believed that a decrease in glucose tolerance occurs even more often and occurs earlier than steatorrhea appears. It should be borne in mind that diabetes mellitus, arising on the background of chronic pancreatitis, has its own peculiarities: the defeat of the inflammatory-sclerotic process of pancreatic islets 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 administration of even small doses of insulin may be accompanied by insufficient production of glucagon by a significant, inadequate dose of insulin administered by a drop in blood glucose. Insufficient production of glucagon is also explained by the relatively rare occurrence in such patients of diabetic ketoacidosis, since in this case the ability of liver tissue to convert free fatty acids into acetoacetic and beta-hydroxybutyric acids decreases. In the literature, there is a relatively rare occurrence of certain 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 the appropriate diet, it is necessary to mainly use oral sugar-lowering drugs that increase glucose tolerance.

It is believed that the patient with chronic pancreatitis is advisable periodically, 3-4 times a year, to conduct treatment with drugs that have a stimulating effect on metabolic processes (pentoxil, which is prescribed by 0.2-0.4 g per reception, or methyluracil 0.5- 1 g 3-4 times a day). The course of treatment with one of these drugs is 3-4 weeks. Previously, simultaneously with these drugs, so-called lipotropic drugs - methionine or lipocaine - were prescribed, but their effectiveness is not high.

After removal of acute events and with the aim of preventing exacerbation, resort treatment in Borjomi, Essentuki, Zheleznovodsk, Pyatigorsk, Karlovy Vary and in local sanatoriums of the gastroenterological profile is recommended in the future.

Patients with chronic pancreatitis do not show types of work in which it is impossible to follow a strict diet; in case of severe disease it is necessary to refer patients to VTEK to determine the disability group.

[1], [2], [3]

Indications for hospitalization

Chronic pancreatitis at the stage of exacerbation serves as an indication for inpatient treatment in connection with the threat to the life of the patient and the need for parenteral administration of drugs, additional methods of research.

Based on the pathogenesis of chronic pancreatitis, treatment should be directed to the following tasks:

• decrease in pancreatic secretion;
• relief of pain syndrome;
• conducting substitution enzyme therapy.

Surgical treatment of chronic pancreatitis

Surgical treatment of chronic pancreatitis is indicated in severe painful forms of chronic pancreatitis, when pain is not stopped by any therapeutic measures: in cicatrical-inflammatory stenosis of the common bile and (or) main ducts, abscessing or development of the gland cyst. The nature of the operation in each case is determined by the peculiarities of the course of the inflammatory process in the pancreas and the nature of the complication that has arisen. For example, with intolerably strong pains, a splanchnectomy and vagotomy, a ligation or obstruction of the main duct with acrylic glue, etc. Are performed. In other cases that are also difficult to carry out, distal or proximal resection of the pancreas is performed (with a pseudocyst, with a rarely encountered limited inflammatory process, mainly in the tail region or pancreatic head, etc.), pancreatoduodenal resection, drainage of the main duct and other types of surgical interventions, the nature of which is determined by specific features of each case of the disease. Naturally, in the postoperative period, dietary and therapeutic measures are carried out, as with 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.

Cases of self-healing of chronic pancreatitis we did not have to observe. However, as our experience shows, a significant improvement in the course of the disease under the influence of systematically conducted treatment measures in patients on dispensary observation and the emergence of persistent remission over a long period of observation (for 5-7 years or more) is quite possible in most patients.

Non-drug treatment

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

In duodenosis, aspiration of gastric contents is carried out with a thin probe.

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

In the daily diet should be 80-120 g of easily digestible proteins (egg protein, boiled meat of low-fat varieties, fish), 50-75 grams of fat, 300-400 g of carbohydrates (preferably in the form of polysaccharides). With a good individual tolerance, raw vegetables are not ruled out.

It is forbidden to drink alcohol, spicy food, canned food, carbonated drinks, sour fruits and berries, sour fruit juices.

Substitution therapy of exocrine pancreatic function

Lightweight steatorrhoea, not accompanied by diarrhea and weight loss, can be adjusted by diet. Indication for the appointment of enzymes is steatorea with loss of more than 15 grams of fat per day, combined with diarrhea and weight loss.

Doses of enzyme preparations depend on the degree of pancreatic insufficiency and the patient's desire to follow a diet. To ensure the normal process of digestion with adequate nutrition in patients with severe exocrine insufficiency, 10 000-30 000 units of lipase intake is required with each meal.

Used enzyme preparations should not reduce the pH of gastric juice, stimulate pancreatic secretion. Therefore, the appointment of enzymes that do not contain bile and extracts of the gastric mucosa (pancreatin) is preferred.

Enzyme preparations are prescribed for life. It is possible to reduce doses while observing a strict diet with a restriction of fat and protein and increase them with the expansion of the diet. The parameters of a correctly selected dose of enzymes are stabilization or weight gain, cessation of diarrhea, steatorrhea and creatonrhea.

In the absence of effect from the appointment of large doses of enzymes (30 000 units per lipase), further increase in doses is not advisable. Causes may be associated diseases: microbial contamination of the duodenum, intestinal worm infestations, precipitation of bile acids and inactivation of enzymes in the duodenum as a result of a decrease in pH. In addition to inactivation of enzymes at low pH, the secretion of bile and pancreatic juice with a reduced content of enzymes increases. This leads to a decrease in the concentration of enzymes. At a low pH of the duodenal contents, it is recommended to combine the intake of enzymes with antisecretory drugs (proton pump inhibitors, histamine H ₂ -receptor blockers ).

Further management of the patient

After relief of an exacerbation of a chronic pancreatitis, a diet with a low fat content is recommended, a constant replacement therapy with enzyme preparations.

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 amount of food taken.

It is important to explain that prolonged intake of enzyme preparations does not lead to the development of secondary exocrine insufficiency.

Prognosis of chronic pancreatitis

Strict adherence to diet, refusal to drink alcohol, adequacy of 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 alcoholic beverages. If they continue to consume alcohol, half of them die before this time. Persistent and prolonged remission of chronic pancreatitis is possible only with regular maintenance therapy.