Pancreatitis in the elderly

The first signs of age-related changes in the pancreas begin to appear at 40-45 years of age. From 55-60, changes in macroscopically visible structures appear. The process of pancreatic atrophy increases, accompanied by a decrease in the number of acini and the cells that make them up. By the age of 80, the mass of the pancreas decreases by 50%.

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

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

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Acute pancreatitis in the elderly

Most often, acute pancreatitis occurs in old age and less often in old age with increased pressure in the pancreatic ducts, which entails damage to acinar cells and their membranes with the release of pancreatic enzymes into the parenchyma, interlobular connective and fatty tissue of the pancreas. Thus, changes in the pancreas itself lead to the activation of pancreatic enzymes with the development of areas of edema and necrosis.

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

Age-related changes in the pancreatic vessels also contribute to disruption of the organ's blood supply, thereby causing a high risk of various forms of acute pancreatitis. In old age, the balance of the coagulation and anticoagulation systems of the blood is disrupted, which increases thrombus formation in the pancreatic vessels and can also lead to acute pancreatitis.

The following forms of acute pancreatitis are distinguished»

• 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, bradykinin, histamine, serotonin), which promote the expansion of the vascular bed, increased permeability of the vascular wall and the occurrence of serous edema of the gland. In acute hemorrhagic pancreatitis, their action is accompanied by changes in the blood coagulation system, death (necrosis) of part of the glandular cells with the occurrence of hemorrhagic edema and necrosis of parts of the pancreas. When large areas of the pancreas are involved in the necrosis processes and when a bacterial infection is added, purulent pancreatitis occurs.

In old and senile age, hemorrhagic pancreatitis is most common in elderly people with the presence of not only hemorrhagic edema, but also varying degrees of necrosis of the pancreatic tissue.

The clinical picture of acute pancreatitis in elderly people differs little from the typical one. Characteristically, there is a rapid onset with the occurrence of pain syndrome in the upper half of the abdomen, the pain is often of a girdle nature with irradiation to the back, behind the sternum. However, although the pain syndrome in the elderly is pronounced, its intensity is usually less than in young people.

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

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Chronic pancreatitis in the elderly

The development of chronic pancreatitis is facilitated by:

1. gallbladder diseases (cholelithiasis, cholecystitis);
2. atrophic gastritis and duodenitis;
3. duodenostasis and duodenogastric reflux.

Recurrent and latent pancreatitis is more common in elderly people. The pathogenesis of chronic pancreatitis is close to the pathogenesis of acute pancreatitis. But at the same time, the process of enzyme activation is not as intense as in patients with acute pancreatitis. In each case of exacerbation of chronic pancreatitis, part of the acinar cells dies and is replaced by connective tissue.

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

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

The latent (erased) form of chronic pancreatitis is caused by exocrine pancreatic insufficiency. In this form of pancreatitis, the pain syndrome is not expressed or it is dull and aching. The pain is localized in the epigastric region and appears in connection with the intake of fatty foods or after overeating, an unstable stomatitis is also noted.

Chronic recurrent pancreatitis in the elderly occurs much less frequently than acute pancreatitis and the latent form of chronic pancreatitis. In this form of pancreatitis, the pain syndrome is characterized by relapses of paroxysmal pain of moderate intensity in the epigastric region and left hypochondrium in combination with pronounced dyspeptic disorders in the form of nausea, bloating, decreased appetite, and unstable stool.

In old and senile age, pain attacks are less pronounced than in young age, and they occur when consuming fatty foods, alcoholic beverages, overeating, and after physical exertion.

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How is pancreatitis treated in the elderly?

A patient with acute pancreatitis is prescribed strict bed rest, fasting for 3-5 days, an ice pack on the stomach. On fasting days, an isotonic solution of sodium chloride with glucose is administered intravenously by drip (no more than 1.5-2 liters per day) to combat intoxication and dehydration. With increased gastric secretion, it is possible to use H2-histamine receptor blockers. To relieve pain, solutions of novocaine (5-10 ml of 0.5% solution), no-shpa (2-4 ml of 2% solution), promedol with isotonic sodium chloride solution are administered intravenously by drip, enhancing the analgesic effect with the use of antihistamines. Treatment with antienzyme drugs (trasylol, tsalol, contrikal) in geriatric patients is rarely carried out due to the absence of clinically pronounced fermentemia and a high risk of allergic reactions. The use of aminocrovin and gelatinol as agents that reduce the activity of pancreatic enzymes is shown.

To combat shock, 1.5-2 liters of 5% glucose solution are administered intravenously by drip, and glucocorticosteroids are used. To prevent the development of secondary infection, antibiotics (semi-synthetic penicillins and cephalosporins) are prescribed.

In case of severe pain attack in elderly and senile people, complete fasting for 24 hours is recommended. Fasting days are held in order to limit gastric secretion and exocrine function of the pancreas. On the first day, you can drink up to 800 ml of liquid, preferably Borjomi (up to 400 ml) and rosehip decoction (up to 400 ml). On the 2nd-5th day - steamed protein omelet, mashed potatoes, slimy oatmeal soup, slimy pearl barley soup, steamed meat puree, meat soufflé. Total per day up to 1000 calories.

From the 6th to the 10th day, the same dietary regimen is followed, but unground boiled chicken, beef, and lean fish are added. The energy content of food increases to 1600 calories. From the 2nd day of exacerbation of the disease, diet No. 5 is prescribed with the energy content of food intended for gerontological hospitals (2400 calories).

Drug therapy during an exacerbation is the same as for acute pancreatitis.

Patients with chronic pancreatitis with secretory insufficiency require the use of enzyme preparations.

Preparations containing pancreatic enzymes are divided into 4 groups according to their composition:

• pancreatic enzymes (pancreolan, pancreatin);
• products that, in addition to pancreatic enzymes, contain added bile elements (Pan Creon);
• drugs that, in addition, contain pepsin, hydrochloric acid (panzinorm);
• drugs that, in addition to pancreatic enzymes and bile elements, also contain intestinal enzymes (festal, digestal).

Outside of an exacerbation of the disease, calcium gluconate and euphyllin are used to increase the activity of the pancreas.

An important part of supportive therapy is: adherence to a diet (fractional, small portions, diet corresponding to table No. 1), exclusion of alcohol and coffee consumption, smoking, courses of exercise therapy, balneotherapy, replacement therapy. Patients should be observed by the attending physician 3-6 times a year. It is advisable to undergo spa treatment in local gastroenterological sanatoriums.