Pancreatitis in the elderly

The first signs of age-related changes in the pancreas begin to appear from 40-45 years. Changes in macroscopically visible structures appear with 55-60. The process of atrophy of the pancreas grows, accompanied by a decrease in the number of acini and their constituent cells. By the age of 80, the weight of the pancreas is reduced by 50%.

There is a high mortality of patients with both alcoholic and non-alcoholic chronic pancreatitis (according to a study conducted in 6 countries: Italy, Germany, Sweden, USA, Denmark, Switzerland, within 10 after diagnosis, more than 30% died, within 20 years - more than half of patients).

Acute pancreatitis in the elderly often occurs in the form of pancreatic necrosis.

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

Acute pancreatitis in the elderly

The most common acute pancreatitis occurs elderly and less often - in old age with increased pressure in the pancreatic ducts, which leads to damage to the acinous cells and their membranes with the release of pancreatic enzymes into the parenchyma, interlobular connective and adipose tissue of the pancreas. So changes in the pancreas lead to the activation of the pancreatic enzymes with the development of areas of edema and necrosis.

In elderly and senile age, the conditions for the occurrence of hypertension in pancreatic courses increase: with aging, there is sclerosis of the duct walls, their obliteration, proliferation of the epithelium, leading to cystic degeneration and disruption of secretion; much more often formed gallstones, leading to stagnation of pancreatic juice in the pancreas. In old age, dyskinesia of the biliary tract and duodenum are often found, which contribute to the transfer of bile into pancreatic passages.

Age-related changes in the pancreatic vessels also contribute to impaired blood supply to the organ, thus causing a high risk of various forms of acute pancreatitis. In old age, the balance of coagulating and anticoagulating blood systems is disturbed, which increases thrombus formation in the pancreatic vessels and can also lead to acute pancreatitis.

Distinguish the following forms of acute pancreatitis "

• 1) edematous form;
• 2) acute hemorrhagic;
• 3) purulent pancreatitis in the elderly.

The edematous form of acute pancreatitis is characterized by the predominance of vasoactive substances (trypsin, bradikinin, histamine, serotonin), which contribute to the expansion of the vascular bed, increase the permeability of the vascular wall and the occurrence of serous edema of the gland. In acute hemorrhagic pancreatitis, changes in the blood coagulation system, death (necrosis) of a part of glandular cells with the appearance of hemorrhagic edema and necrosis of the pancreas are added to their action. When involved in the processes of necrosis of large areas of the pancreas and when attaching bacterial infection, purulent pancreatitis occurs.

In elderly and senile age, hemorrhagic pancreatitis is more common in elderly people with the presence of not only hemorrhagic edema, but also some degree of necrosis of pancreatic tissue.

The clinical picture of acute pancreatitis in elderly people differs little from the typical. A strikingly tumultuous beginning with the onset of pain in the upper half of the abdomen, the pain is often shrouded in nature with irradiation in the back, behind the sternum. However, although the pain syndrome in the elderly and has a pronounced character, its intensity is usually smaller than in young people.

In elderly and senile age, repeated persistent vomiting, which does not alleviate the patient's condition, is observed more often than in the young, as it leads to an increase in pressure in the biliary and pancreatic ducts. In this regard, vomiting contributes to the further progression of activation of pancreatic enzymes in pancreatic tissue. Vomiting is usually accompanied by paresis of the stomach and the transverse colon, which is manifested by severe tympanitis in the epigastric region and complete disappearance of intestinal noises.

[7], [8], [9], [10], [11]

Chronic pancreatitis in the elderly

Development of chronic pancreatitis is facilitated by:

1. diseases of the gallbladder (cholelithiasis, cholecystitis);
2. atrophic gastritis and duodenitis;
3. duodenostasis and duodenal-gastric reflux.

More common is recurrent and latent pancreatitis in the elderly. The pathogenesis of chronic pancreatitis is close to the pathogenesis of acute pancreatitis. But at the same time, the activation of enzymes is not as intense as in patients with acute pancreatitis. In each case of exacerbation of chronic pancreatitis, a part of the acinous cells die and is replaced by a connective tissue.

Depending on the phase of the disease, pancreatitis in the elderly has four forms:

1. recurrent;
2. with a constant pain syndrome;
3. pseudotumoral;
4. latent (erased).

The latent (erased) form of chronic pancreatitis is due to the exocrine insufficiency of the pancreas. With this form of pancreatitis, the pain syndrome is not expressed or it is dull, aching. The pains are localized in the epigastric region and appear in connection with the intake of fatty foods or after overeating, there is also an unstable stupa.

Chronic recurrent pancreatitis in the elderly is much less common than acute pancreatitis and a latent form of chronic pancreatitis. With this form of pancreatitis, the pain syndrome is characterized by relapses of paroxysmal pains of moderate intensity in the epigastric region and left hypochondrium combined with pronounced dyspeptic disorders in the form of nausea, bloating, loss of appetite, unstable stool.

In elderly and senile age, painful attacks are less pronounced than at a young age, and they occur when eating fatty foods, alcoholic beverages, overeating, after physical exertion.

[12], [13], [14], [15]

How is pancreatitis treated in the elderly?

The patient with acute pancreatitis shows a strict bed rest, fasting for 3-5 days, an ice pack on the stomach. In the days of fasting, intravenously drip an isotonic solution of sodium chloride with glucose (no more than 1.5-2 liters per day) to combat intoxication and dehydration of the body. With increased gastric secretion, it is possible to use histamine H2-receptor blockers. Novocain solutions (5-10 ml of a 0.5% solution), no-spines (2-4 ml of a 2% solution), promedol with isotonic sodium chloride solution are intravenously dripped intravenously, increasing the analgesic effect with antihistamines. Treatment with antifermental drugs (trasilol, tsolol, countertrial) in geriatric patients is rare, because of the absence of a clinic and pronounced enzyme and a high risk of allergic reactions. The use of aminocine and gelatin is shown as a means of reducing the activity of pancreatic enzymes.

To combat shock intravenously drip 1,5-2 liters of a 5% glucose solution, use glucocorticosteroids. To prevent the development of secondary infection, antibiotics (semisynthetic penicillins and cephalosporins) are prescribed.

At the expressed painful attack at persons of elderly and senile age the full fasting within 24 hours is recommended. Hungry days are held to limit gastric secretion and exocrine function of the pancreas. In the first day you can consume up to 800 ml of liquid in the form of drinking, preferably Borjom (up to 400 ml) and broth of rose hips (up to 400 ml). On the 2-5th day - steam protein omelets, mashed potatoes, oat mucous soup, mushroom soup, mashed meats, meat soufflé. A day in total up to 1000 calories.

From 6th to 10th day the same diet regime, but add unmilled boiled chicken, beef, low-fat fish. The energy intensity of food rises to 1600 calories. From 2 days of exacerbation of the disease diet № 5 with energy consumption of food, prescribed for gerontological hospitals (2,400 calories) is prescribed.

Medication at an exacerbation same, as at an acute pancreatitis.

Patients with chronic pancreatitis with secretory deficiency need the use of enzyme preparations.

Preparations containing enzymes of the pancreas, according to their composition, are divided into 4 groups:

• pancreatic enzymes (pancreolan, pancreatin);
• means, where, in addition to pancreatic enzymes, there is an addition of bile elements (pan creon);
• drugs that, in addition, contain pepsin, hydrochloric acid (panzinorm);
• drugs that, in addition to pancreatic enzymes and bile elements, contain intestinal enzymes (festal, digestal).

Outside the exacerbation of the disease to increase the activity of the pancreas use calcium gluconate and euphyllin.

An important part of maintenance therapy are: adherence to the diet (fractional, small portions, diet corresponding to table number 1), excluding alcohol and coffee, smoking, exercise therapy, balneotherapy, substitution treatment. Patients should be observed by the attending physician 3-6 times a year. It is advisable to sanatorium treatment in local sanatoria of the gastroenterological profile.