Hemorrhagic pancreonecrosis.

Hemorrhagic pancreatic necrosis is an extremely severe pathology of the pancreas, in which a process of rapid and practically irreversible death of its cells occurs.

In most cases, acute hemorrhagic pancreatic necrosis occurs with acute pancreatitis or develops during an exacerbation of the chronic form of inflammation of the pancreas.

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Causes hemorrhagic pancreonecrosis.

Experts associate the causes of hemorrhagic pancreatic necrosis with factors such as:

• inflammation of the pancreas, accompanied by its partial dysfunction and disruption of the normal outflow of pancreatic juice;
• intoxication of the body with ethanol in chronic alcoholism;
• constant reflux of pancreatic juice into the pancreatic ducts (usually occurs with gallstones);
• infectious lesions of the bile ducts and bile ducts (cholangitis, cholecystitis);
• thrombohemorrhagic or DIC syndrome (disseminated intravascular coagulation), developing during acute bacterial and viral infections, after chemotherapy for cancer, and also when exposed to high doses of ionizing radiation;
• autoimmune diseases (hemorrhagic vasculitis);
• traumatic damage to the organ parenchyma, including during surgical interventions.

But whatever the initial cause that led to the diagnosis of local or total hemorrhagic pancreatic necrosis (i.e. the death of part or all cells), the disease necessarily affects the acinus - the secretory section of the pancreas, the cells of which produce enzymes that are part of the pancreatic juice. All forms of pancreatic necrosis occur when the activity of these enzymes reaches an abnormally high level, and they begin to negatively affect the tissue of the organ - hydrolyze its proteins. In addition, the elastase enzyme can even damage the walls of blood vessels, which leads to hemorrhages. In clinical gastroenterology, this phenomenon is often called autoaggression of pancreatic enzymes.

Hemorrhagic pancreatic necrosis develops due to the aggressive effects of trypsin, chymotrypsin and elastase (pancreatopeptidase E) - the main proteolytic (breaking down protein molecules) enzymes of the pancreas, which are necessary for the digestion of protein foods.

While studying the causes of hemorrhagic pancreatic necrosis, gastroenterologists came to the conclusion that a failure in the complex humoral process of regulating the production of digestive enzymes plays an important role in the pathogenesis of this disease. And many hormones participate in it. Thus, the secretion of proteolytic enzymes is inhibited by the hormones glucagon and somatostatin (produced by the cells of the islets of Langerhans in the pancreas), calcitonin (synthesized by the thyroid gland), as well as special serum proteins antitrypsins. Stimulators of enzyme production and their activity are: secretin synthesized by the mucous membrane of the small intestine, cholecystokinin (pancreozymin) produced by the duodenum, as well as insulin, gastrin and, of course, serotonin, the lion's share of which is synthesized in the small intestine and pancreas.

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Symptoms hemorrhagic pancreonecrosis.

The most characteristic symptoms of hemorrhagic pancreatic necrosis are:

• acute, sometimes unbearable pain, localized in the left hypochondrium and radiating to the lumbar region, the left half of the chest and shoulder;
• coated tongue and a feeling of dry mouth;
• nausea and repeated vomiting that does not bring relief;
• abdominal bloating, flatulence and diarrhea;
• increased body temperature and fever;
• hyperemia of the facial skin;
• blue-purple spots on the anterior wall or on the sides of the peritoneum;
• sudden increases and decreases in blood pressure;
• shortness of breath and rapid pulse;
• reduction in the volume of urine excreted;
• mental disorders (states of general agitation or inhibition).

Acute hemorrhagic pancreatic necrosis causes a state of collapse in almost a fifth of patients, and a coma or acute mental disorder in a third. The formation of a pancreatic-retroperitoneal fistula leads to the contents of the pancreas, particles of its dead tissue, and hemorrhagic exudate entering the abdominal cavity. This is what causes an abscess of the peritoneal tissue and purulent peritonitis.

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Diagnostics hemorrhagic pancreonecrosis.

Diagnosis of hemorrhagic pancreatic necrosis is carried out not only on the basis of examination of the patient, but also with the help of ultrasound or CT of the abdominal organs.

In addition, the following laboratory tests help to establish an accurate diagnosis and differentiate pancreatitis from other acute gastrointestinal pathologies:

• blood test for levels of pancreatic enzymes (alpha-amylase, trypsin, elastase, phospholipase, cholesterol esterase, etc.);
• urine test for trypsinogen and uroamylase;
• gastric juice analysis for acidity levels;
• analysis of pancreatic juice for enzyme and bicarbonate content (probing);
• stool analysis (coproscopy) for residual fat content;
• analysis of the composition of exhaled air (for triglycerides, amylase, etc.);
• endoscopic retrograde cholangiopancreatography;
• percutaneous puncture of the necrosis zone.

To clarify the diagnosis, in some cases, laparoscopy of the abdominal cavity is performed, which allows one to finally confirm the extent of damage to the pancreas and assess the condition of all abdominal organs.

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Treatment hemorrhagic pancreonecrosis.

Usually, patients with pancreatic necrosis are admitted to medical institutions by calling emergency medical care. Treatment of hemorrhagic pancreatic necrosis is carried out exclusively in a hospital setting (often in the intensive care unit). The efforts of doctors are aimed at simultaneously solving several strategic tasks, namely: stopping the pain syndrome, temporarily blocking the enzymatic activity of the pancreas, relieving spasms and thereby increasing the patency of the gland ducts, reducing the production of gastric juice and lowering its pH (and thus minimizing the load on the pancreas), as well as preventing the development of infection and removing toxins from the body that are formed during necrotic cell decay.

For this purpose, a number of appropriate medications are used in the therapy of hemorrhagic pancreatic necrosis. For pain relief, such antispasmodics and analgesics as No-shpa, Papaverine, Platyphylline hydrotartrate, Ketanov are administered. Novocaine blockade quickly relieves pain - the introduction of a solution of Novocaine mixed with glucose or Promedol mixed with Atropine Sulfate and Diphenhydramine into the peritoneal-lumbar regions.

To inhibit the activity of proteolytic enzymes, intravenous infusions and drip infusions of Contrikal, Trasilol, Gordox, Pantripin, Fluorofur, Ribonuclease are used. To reduce the acidity level of gastric juice to at least pH 5.0 - in parallel with complete fasting - Atropine, Ephedrine, Cimetidine, Quamatel (intravenously) are used. Antibiotics (most often Kanamycin, Gentamicin, Cephalexin or Ceporin) are used to prevent suppuration in the pancreas and abdominal cavity.

Based on the test results, the presence or absence of an obvious effect from the measures taken and the general condition of the patient, a decision is made on surgical intervention. When acute hemorrhagic pancreatic necrosis is not accompanied by concomitant infection, laparoscopic or percutaneous (transcutaneous) drainage of the abdominal cavity is performed. If there are significant volumes of serous or hemorrhagic exudate in the abdominal cavity, intracorporeal (intra-abdominal) blood purification is performed - peritoneal dialysis.

Infected total hemorrhagic pancreatic necrosis may require resection of the pancreas or a more radical operation - pancreatectomy, that is, removal of the pancreas.

Prevention

Prevention of hemorrhagic pancreatic necrosis consists of prevention of pancreatitis – proper nutrition and abstinence from alcohol. It has been scientifically proven that if you drink only 80 ml of strong alcohol every day for several years, pancreatitis is guaranteed.

It is also necessary to promptly treat cholecystitis, biliary dyskinesia, gallstone disease, gastric ulcer and duodenal ulcer.

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Forecast

The prognosis of hemorrhagic pancreatic necrosis can be characterized by figures from medical statistics: on average, in 50% of cases the outcome of this pathology is fatal. And the cause of death in hemorrhagic pancreatic necrosis is general intoxication of the body caused by purulent peritonitis.

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