Hemorrhagic pancreatic necrosis

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

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

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

Causes of the hemorrhagic pancreatic necrosis

The reasons for hemorrhagic pancreatic necrosis are associated with factors such as:

• inflammation of the pancreas, accompanied by partial dysfunction and a violation of normal outflow of pancreatic juice;
• intoxication of the body with ethanol in chronic alcoholism;
• constant reflux of pancreatic juice into the pancreatic ducts (it happens, as a rule, with stones in the gallbladder);
• infectious lesions of bile ducts and bile ducts (cholangitis, cholecystitis);
• thrombohemorrhagic or DVS-syndrome (disseminated intravascular coagulation), developing with acute bacterial-viral infections, after chemotherapy of oncological diseases, as well as exposure to high doses of ionizing radiation;
• autoimmune diseases (hemorrhagic vasculitis);
• traumatic damages to the parenchyma of the organ, including surgical interventions.

But no matter what the initial reason led to the diagnosis of local or total hemorrhagic pancreatic necrosis (that is, the death of some or all of the cells), the disease necessarily affects the acinus - the secretory department 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 - hydrolyse its proteins. In addition, the enzyme elastase can damage even 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 action of trypsin, chymotrypsin and elastase (pancreato peptidase E), the main proteolytic (protein-splitting protein molecules) of the pancreas enzymes, which are necessary for the digestion of protein foods.

Investigating the causes of hemorrhagic pancreatic necrosis, gastroenterologists came to the conclusion that an important role in the pathogenesis of this disease is played by a malfunction in the complex humoral process of regulating digestive enzyme production. And it involves a lot of hormones. So, 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), and special serum antitrypsin proteins. The stimulators of enzyme production and their activity are: secretin, synthesized by the mucosa of the small intestine, produced by the duodenum of cholecystokinin (pancreosimin), as well as insulin, gastrin and, of course, serotonin, the lion's share of which is synthesized in the small intestine and pancreas.

[8], [9], [10]

Symptoms of the hemorrhagic pancreatic necrosis

The most characteristic symptoms of hemorrhagic pancreatic necrosis are manifested as:

• acute, sometimes intolerable pain, localized in the left hypochondrium and giving into the lumbar region, to the left half of the thorax and shoulder;
• lined tongue and dry mouth sensation;
• nausea and not bringing relief to repeated vomiting;
• bloating of the abdominal cavity, flatulence and diarrhea;
• fever and fever;
• hyperemia of the facial skin;
• blue-purple spots on the front wall or on the sides of the peritoneum;
• stepwise increase and lowering of blood pressure;
• shortness of breath and rapid pulse;
• decrease in the volume of excreted urine;
• disorders of the psyche (the state of general excitement or inhibition).

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

[11], [12], [13]

Diagnostics of the hemorrhagic pancreatic necrosis

Diagnosis of hemorrhagic pancreonecrosis is carried out not only on the basis of examination of the patient, but also by using ultrasound or CT of the abdominal cavity organs.

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

• a blood test for the level of pancreatic enzymes (alpha-amylase, trypsin, elastase, phospholipase, cholesterol esterase, etc.);
• urine analysis for trypsinogen and uroamylase;
• the analysis of gastric juice on the level of acidity;
• analysis of pancreatic juice for the content of enzymes and bicarbonates (probing);
• analysis of feces (coproscopy) for the content of residual fats;
• analysis of the composition of exhaled air (on triglycerides, amylase, etc.);
• endoscopic retrograde pancreatocholangiography;
• percutaneous puncture of the necrosis zone.

To clarify the diagnosis in some cases, laparoscopy of the abdominal cavity is performed, which allows us to finally verify the degree of pancreatic damage and assess the condition of all the organs of the abdominal cavity.

[14], [15], [16], [17]

Treatment of the hemorrhagic pancreatic necrosis

Usually patients with pancreatic necrosis get to medical institutions on the call of emergency medical care. Treatment of hemorrhagic pancreatic necrosis is carried out exclusively in a hospital (often in the intensive care unit). The efforts of doctors are aimed at simultaneously solving several strategic tasks, namely: to stop the pain syndrome, temporarily block the enzymatic activity of the pancreas, relieve spasms and thereby increase the patency of the gland ducts, reduce the production of gastric juice and reduce its pH (and thus minimize load on the pancreas), as well as prevent the development of infection and remove from the body the toxins that are formed during necrotic decay of cells.

To this end, a number of appropriate medications are used in the treatment of hemorrhagic pancreatic necrosis. For anesthesia, such antispasmodics and analgesics as No-shpa, Papaverin, Platifillin hydrotartate, and Ketanov are administered. Quickly relieves pains of the Novocain blockade - the introduction of the abdominal lumbar solution of Novocain in a mixture with glucose or Promedol in a mixture with Atropine sulphate and Dimedrolum.

To inhibit the activity of proteolytic enzymes, intravenous infusions and drip infusions of Contrikal, Trasilol, Gordoksa, Pantripina, Ftorafur, Ribonuclease are used. To reduce the level of acidity of gastric juice to at least pH 5.0 - in parallel with a complete starvation - used Atropine, Ephedrine, cimetidine, Kvamatel (intravenously). Antibiotics (most often - Kanamycin, Gentamicin, Cephalexin or Ceporin) are used to prevent suppuration in the pancreas and abdominal cavity.

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

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

Prevention

Prevention of hemorrhagic pancreatic necrosis is the prevention of pancreatitis - proper nutrition and refusal of alcohol. Scientifically established: if for several years every day to drink only 80 ml of strong alcohol, then pancreatitis is guaranteed.

It is also necessary to treat cholecystitis, dyskinesia of the bile ducts, cholelithiasis, stomach and duodenum ulcers in time.

[18], [19], [20]

Forecast

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

[21], [22], [23], [24]