Diagnosis of chronic pancreatitis

Early diagnosis of pancreatitis is based on the combined use of laboratory-instrumental methods of investigation both during the pain crisis and further observation for the purpose of clarifying the etiology, the stage of the disease, the morphological features of the organ, the condition of the duct system, the degree of disturbances in the external and intrasecretory function, assessment of the state of adjacent digestive organs and the choice of effective treatment tactics.

Anamnesis

Anamnesis provides an analysis of the developmental features of the child in different periods of life, the nature of nutrition, heredity, the timing of the onset of early symptoms of the disease.

Physical examination

It should be assessed trophic status of the patient, clinical symptoms of the disease, the nature of the chair.

Laboratory research

• Blood chemistry:
  • the activity of amylase, lipase, serum trypsin;
  • the content of creatinine, urea, glucose and calcium;
  • activity of transaminases, alkaline phosphatase, y-glutamyltranspeptidase, concentration of proteins of the acute phase of inflammation;
  • the content of insulin, C-peptide, glucagon.
• Clinical blood test.
• Clinical analysis of urine (activity of amylase, lipase, glucose).

The increase in the concentration of amylase, lipase, trypsin and its inhibitors in the serum, as well as amylase, lipase in the urine reflects the activity of the inflammatory process in the pancreas and indicates pancreatitis. Amylase belongs to the group of indicator enzymes. The level of amylase in healthy children is constant. The activity index of amylase supports renal and extrarenal elimination of the enzyme, it practically does not depend on the functional state of other enzyme-producing organs. Determination of the activity of amylase in the urine is an informative and convenient screening test for pancreatic diseases. A long-term increase in the activity of amylase in the urine, even against the background of a normal concentration of the enzyme in the blood, may indicate a complicated course of chronic pancreatitis or the formation of a false cyst. In acute pancreatitis, the content of amylase in blood and urine increases by 10 times or more. The frequency of detection of hyperfermentemia depends on the phase of the disease and the timing of admission to hospital. It is informative to study isoenzymes of amylase, especially with normal total amylase activity.

Normal or slightly increased activity of enzymes in blood and urine in patients does not exclude the chronic process in the pancreas. In this case, for the diagnosis of chronic pancreatitis, provocative tests are used: the activity of serum ferments on an empty stomach and after stimulation is examined. Hyperfermentemia ("evasion phenomenon") after the introduction of stimuli may indicate a pathological process in the gland or an obstacle to the outflow of pancreatic juice. The high diagnostic informative value of the study of the activity of elastase in the blood, which rises earlier and lasts longer than changes in the activity of other pancreatic enzymes, is proved.

Exocrine pancreatic insufficiency with microscopic examination of fecal smear is characterized by an increase in the content of neutral fat (steatorrhea) and undigested muscle fibers (createrorrhea). At an easy degree of a lesion of a pancreas the coprogram can be not changed.

At present, the definition of fecal elastase-1, which is included in the group of standard methods for studying the pancreas, is widespread. Elastase-1 does not degrade when passing through the intestine, this parameter is not affected by the use of pancreatic enzymes. The immunoenzymatic method of elastase-1 diagnostics is more informative, highly specific (93%) and allows to assess the degree of impairment of the exocrine function. The elastase-1 content is normally 200-550 μg / g of feces, with moderate exocrine insufficiency of 100-200 μg / g. At a severe degree, less than 100 μg / g.

Functional methods of pancreas research

The leading role in the study of the condition of the gland belongs to functional methods, most often using direct tests of external secretion evaluation. Direct methods for studying pancreatic secretion - determination of the concentration of pancreatic enzymes, bicarbonates in duodenal secretion or pancreatic juice in basal conditions (on an empty stomach) and after the introduction of various stimulants, which allows one to assess the reserve capabilities of the organ.

The most complete picture of the exocrine activity of the pancreas is given by the study with intestinal hormones (secretion stimulants) secretin (1 U / kg) and pancreosimine (1 U / kg). The secretin-pancreosimine test is the "gold standard" for diagnosing the pancreatic pathology necessary for verifying the diagnosis of chronic pancreatitis.

Disorders of the secretory function can be characterized by 3 pathological types of pancreatic secretion:

• hypersecretory type - increasing the concentration of pancreatic enzymes with a normal or increased volume of secretion and bicarbonate content. It occurs with exacerbation of pancreatitis, reflects the initial shallow inflammatory changes in the pancreas associated with the hyperfunction of acinar cells;
• hypoxecretory type - a decrease in the activity of enzymes against a background of normal or reduced volume of juice and bicarbonates, indicating a qualitative insufficiency of pancreatic secretion. It often occurs with chronic pancreatitis, which occurs with fibrotic changes in the organ;
• obturation type - a decrease in the amount of pancreatic juice for any content of enzymes and bicarbonates. This variant of secretion occurs when the ducts of the pancreas become obstructed (stenosing papillitis, duodenitis, sphincter spasm of Oddi, choledocholithiasis, obturation of the fater nipple, duct anomalies, etc.).

The first 2 types can be considered as transient, reflecting different stages of the progression of inflammatory changes in the gland. In children, there is a violation of the enzyme-synthesizing function of the pancreas, a decrease in bicarbonate and secretion can be observed only in severe pancreatic insufficiency.

All these pathological types of secretion reflect a different degree of functional and morphological changes in the pancreas, which provides a differentiated approach to treatment.

An indirect method of studying pancreatic secretion, including the determination of the activity of pancreatic enzymes in duodenal juice after food stimulation (Lund test) and with the introduction of pancreatic stimulants inside, has not been extended in pediatric practice due to the low sensitivity of the methodology and the complexity of evaluating the final products of hydrolysis.

Instrumental research

Instrumental methods for examining the pancreas include transabdominal ultrasound, endoscopic ultrasonography, CT, MRI, endoscopic retrograde pancreato- cholangiography. The survey radiography of the abdominal cavity (diagnosis of calcifications in the projection of the pancreas) and radiopaque examination of the upper gastrointestinal tracts have not lost their significance. One of the stages in the evaluation of the anatomical and topographic relationships of the gastroduodeno-choledochoconstipase complex.

Ultrasound of the pancreas is the leading method for diagnosing morphological changes in the gland, allowing to establish the change in size, echo density, the presence of hypo-and hyperechoic formations, the condition of the duct system. With a recurring course of chronic pancreatitis, the contour of the gland is often uneven, the parenchyma is densified, contains hyperechoic areas (fibrosis or microcalcinosis). Cysts are often diagnosed. Repeated ultrasound can evaluate the effectiveness of treatment, detect complications and determine the prognosis. Ultrasonic semiotics of pancreatitis depends on the degree and stage of the pathological process.

A new method for qualitative assessment of the morphological structure of the pancreas with the use of physiological load was developed (patent No. 2163464, 2001). For this purpose, the ratio of the sum of the gland size after the nutritional load to the sum of these fasting indices is calculated. The increase in the sum of linear sizes of the pancreas after taking a standard breakfast of less than 5% indicates a high probability of chronic pancreatitis. With an increase in size by 6-15%, reactive pancreatitis is diagnosed. Ratio above 16% - an indicator of the normal postprandial response of the pancreas.

With endoscopic retrograde pancreatocholangiography, the duct system of the pancreas and bile ducts is studied in detail. On pancreatocholangiograms, you can see various anomalies in the development of gland ducts, uneven contours in the form of stenoses and extensions, contrast retardation or accelerated drainage of ducts, calcium deposition inside the ducts, calcification of pancreatic parenchyma. Simultaneously diagnose changes in biliary tract.

Endoscopic ultrasonography allows for examination of the duodenum in order to detect erosions, ulcers or diverticula, the zone of the Fater's nipple - for the diagnosis of papillitis, to assess the condition of the biliary and pancreatic ducts.

The main indications for CT and magnetic resonance cholangiopancreatography are a complicated course of chronic pancreatitis, a suspicion of a volumetric process in the pancreas and adjacent digestive organs.

Differential diagnostics

The necessary and complex stage of the diagnosis of chronic pancreatitis in children is the exclusion of a number of diseases that occur with similar symptoms: cystic fibrosis, erosive and ulcerative lesions of the stomach and duodenum, diseases of the biliary tract (cholelithiasis, cholangitis, developmental anomalies). Difficulties arise in differential diagnostics with small intestine diseases, with a marked syndrome of malabsorption (celiac disease, disaccharidase insufficiency, chronic enteritis, etc.). To establish the final diagnosis it is possible at consecutive performance of the diagnostic report confirming a pathology of a pancreas. Chronic pancreatitis is characterized by pain syndrome, exocrine insufficiency, inflammatory-dystrophic process (positive amylase, elastase and other tests) and changes in pancreatic structure (ultrasound, CT, endoscopic retrograde pancreatocholangiography, etc.).

Differential diagnosis of dyspankreatism, reactive and chronic pancreatitis

Symptom	Dispensivenessism	Reactive pancreatitis	Chronic pancreatitis
Definition	Invertible function disturbances without morphological changes	Interstitial OP on the background of gastroduodenal or biliary diseases	Inflammatory-degenerative process with development of fibrosis and exocrine insufficiency
Pain	Steady, spilled	Intense, above the navel and to the left, radiating to the left and back	Relapses in pain or weak persistent pain
Soreness	Epigastria, hypochondria, the point of Mayo-Robson	Zones: Shoffara, Guber-Gritsa; Points: Kacha, Mayo-Robson	Zones: Shoffar, Huberritsa; the point of Kach, Mayo-Robson
Dyspeptic disorders	Nausea, flatulence, belching	Nausea, vomiting, flatulence, sometimes short-term diarrhea	Polyphecia, stool kashitseobrazny, brilliant, sometimes alternating diarrhea and constipation
Coprogramme	Norm	Norm or unstable steatorrhea	Steatorea with neutral fat, less often with creatine
Amylase of blood and urine	Incrementally increased	Increased	May be elevated or normal
Ultrasound	Increase in the size of parts of the pancreas (can be normal)	Increased pancreas, fuzzy contours, decreased echogenicity	Hyperechogenicity of the pancreas, changes in shape, size, contours, widening of the Virpsong's duct
EGDS	Signs of duodenitis, papillitis	Signs of duodenitis, papillitis	There are options

Indications for consultation of other specialists

With a severe condition of the patient with chronic pancreatitis, persistent pain abdominal syndrome, development of complications, a consultation of a pediatric surgeon, an endocrinologist is shown. The presence of a volumetric process in the gland requires consultation of a pediatric oncologist. To confirm the hereditary nature of pancreatitis, a geneticist consultation is recommended.

With concomitant diseases of other organs and systems, consultation of physicians of appropriate specialties (pulmonologist, endocrinologist, nephrologist, neurologist, etc.) is necessary.

[1], [2], [3], [4], [5], [6], [7], [8]