Treatment of chronic pancreatitis

The goal of chronic pancreatitis

Creation of functional dormancy for the pancreas, relief of pain syndrome, inhibition of pancreatic secretion, prevention of complications.

Indications for hospitalization

The manifestation and exacerbation of chronic pancreatitis should be considered indications for hospitalization.

Non-pharmacological treatment of chronic pancreatitis

The main principles of treatment of chronic pancreatitis provide for the mandatory appointment of therapeutic nutrition with a lower fat content and physiological protein norm to ensure functional dormancy of the pancreas.

Therapeutic diet in chronic pancreatitis is based on mechanical, thermal and chemical shaking of the pancreas, suppression of hyperfermentemia, reduction of stagnation in the ducts and duodenum, reduction of the reflex excitability of the gallbladder.

To date, the concept of nutritional support for pancreatitis has been developed, the attitude to the duration of the "hungry" diet, parenteral (PP) and enteral nutrition (EP) has been revised. It is proved that fasting increases lipolysis rates, provokes hypo- and disproteinemia, metabolic acidosis, aggravates degenerative changes in the pancreas.

Nutritional support provides complete nutrition with partial or complete parenteral and enteral nutrition. The main goal of the method is to provide the body with high-energy substances (carbohydrates, lipids), plastic material (amino acids), as well as correction of metabolic disorders and restoration of the trophic status of the patient. Early parenteral nutrition and enteral nutrition accelerate the reparative processes in the digestive tract. Algorithm of nutritional support is adjusted taking into account the patient's condition, diet No. 5a is shown. Therapeutic diet is a pharmacotherapy of various metabolic disorders - the main way of qualitative provision of energy-consuming needs of the patient's body.

In severe chronic pancreatitis, full parenteral nutrition is prescribed, the only way of protein-energy nutritional support in such a situation. Modern preparations for parenteral nutrition allow normalizing nitrogenous, energy and water-salt metabolism; they include donators of plastic material for protein synthesis (amino acid solutions), solutions of carbohydrates (maltodextrose) and fat emulsions that promote the immobilization of pancreatic lipase circulating in the blood and replenish the deficiency of essential omega-3 and omega-6 fatty acids.

Amino acid solutions (aminostearil, aminosol, polyamine, etc.) are administered intravenously, in children the daily requirement for proteins is 2-4 g / kg. Assign a solution aminosolav dose of 600 kcal intravenously drip at a rate of 20-40 per minute, 500-1000 ml / day, the newborn with a body weight of up to 5 kg - 100-200 ml / day, children with a body weight of more than 5 kg - 1000 ml / day .

Fat emulsions of intralipid or lipofundin 10-20% should be 5-10% of caloric intake. Intravenous 10% lipofundine-drop solution is administered, injected at a rate of 20-30 per minute from the calculation of 1-2 g / kg per day (10-20 ml / kg per day), 20% solution at 5-10 ml / kg per day, maximum The daily dose is 4 g / kg.

Glucose provides the basic caloric content of mixtures for parenteral nutrition. In children of the first year of life, the daily requirement for glucose is 25-30 g / kg per day. Solutions for parenteral nutrition also include water, electrolytes, minerals and vitamins. The effectiveness of parenteral nutrition is assessed by stabilizing the child's body weight, increasing the serum albumin content, hemoglobin level, and restoring the gastrointestinal motility.

When the pain syndrome and dyspeptic disorders abate, the child is transferred to enteral nutrition through a nasogastric tube (installed in the jejunum) or by taking the mixture through the mouth. With the preservation of the main functions of the gastrointestinal tract, preference is given to early enteral nutrition, which has a number of advantages. If the parenteral nutrition of the digestive tract is turned off from digestion, which leads to a decrease in the content of digestive enzymes and the cessation of their active circulation in the "small intestine-blood-tissue" system, with enteral nutrition, the rates of nutrient supply to the cell are regulated by mechanisms that support homeostasis.

In pancreatitis, children are prescribed mixtures of Nutrien, Nutrizone, Pentamen, etc. Fats of the mixtures are triglycerides containing fat medium-chain acids, which are easily hydrolyzed by pancreatic lipase and absorbed into the blood vessels of the portal vein, bypassing the lymphatic system. Fatty medium chain acids in the enteral feed mixture reduce osmolality, increase the absorption of macronutrients, reduce the volume of the stool. Specialty mixtures can be used in the form of cocktails or drinks (breakfast or snack).

Drug treatment of chronic pancreatitis

The most important value in the acute period of pancreatitis is attached to the elimination of the pain syndrome, for which the combination of analgesics and antispasmodics is most often used. Metamizole sodium is prescribed inside of children 2-3 years of 50-100 mg: 4-5 years - 100-200 mg; 6-7 years - 200 mg. 8-14 years - 250-300 mg 2-3 times a day, intramuscularly or intravenously 50% solution of 0.1-0.2 ml / 10 kg, but not more than 2 grams per day. Paracetamol is administered to children within 6-12 months of 0.0025-0.05 g; 2-5 years - 0.1-0.15 g; 6-12 years - 0.15-0.25 g 2-3 times a day; over 12 years - 0.5 g 2-3 times a day. Papaverin is administered by mouth, subcutaneously, intramuscularly and intravenously. Children from 6 months to 1 year - 10 mg; 1-2 years - 20 mg; 3-4 years - 30 mg; 5-6 years -40 mg; 7-10 years - 50 mg; 10-14 years - 100-200 mg per day. Drotaverin is given to children 1-6 years in the 0,001-0,02 g 1-2 times a day, 6-12 years - 0.02 g 1-2 times per day. Intramuscularly or intravenously injected 2% solution of the drug for children 1-4 years of 0.5 ml: 5-6 years - 0.75 ml; 7-9 years - 1.0 ml; 10-14 years - 1.5 ml 1-3 times a day.

In order to reduce the pain syndrome, M-holinoblockers are also used. Platifillin is prescribed by mouth, subcutaneously, intramuscularly at 0.2-3 mg per reception, depending on age: the highest single dose is 0.01 g daily - 0.03 g. Hyoscine butyl bromide is prescribed to children younger than 6 years - 10 mg 3-5 times per day, over 6 years - 1-20 mg 3-5 times a day subcutaneously, intramuscularly or intravenously: children under 3 years of age 5 mg 3-4 times a day; 3-6 years - 10 mg 3-4 times a day; over 6 years - 20 mg 3 times a day.

To create functional dormancy of the pancreas and suppress gastric secretion, antisecretory drugs are used: selective blockers of histamine H ₂ receptors, proton pump inhibitors. These drugs are shown 1-2 times a day or once a night for 2-3 weeks. Ranitidine is prescribed to children inside, intramuscularly or intravenously at 2-8 mg / kg 2-3 times a day (no more than 300 mg per day) for 14-21 days. Famotidine is given to children up to 7 years of age for 20 mg per day: over 7 years - 20-40 mg per day for 14-21 days. Omeprazole is administered orally or intravenously at 20 mg per day, for 7-10 days.

Correction of the motor function of the stomach, duodenum, bile ducts is achieved by prescribing drugs that normalize evacuation activity. Domperidone inwards for children over 5 years of age appoint 5 mg 2 times a day, 10 years older - 10 mg 2 times a day for 7-10 days. Cisapride inwards for children up to 1 year is prescribed 1-2 mg 2 times a day; 1-5 years - 2.5 mg; 6-12 years - 5 mg; over 12 years - 5-10 mg 3 times a day for 7-14 days.

The main drug used to inhibit pancreatic hyperfermentemia during exacerbation of pancreatitis is octreotide, an analog of endogenous somatostatin. The introduction of octreotide quickly suppresses the pain syndrome, significantly inhibits the secretion of the pancreas, stomach, liver, small intestine, inhibits the motility of the gastrointestinal tract, reduces intraprotective hypertension, inhibits the secretion of biologically active substances (secretin, cholecystokinin, pancreosimin, hydrochloric acid, pepsin). The anti-inflammatory effect of octreotide is associated with the stabilization of cell membranes, blockade of cytokine genesis, production of prostaglandins. The duration of the drug is 10-12 hours, injected subcutaneously and intravenously, children under 7 years are prescribed 25-50 μg, older than 7 years - 50-100 μg 2-3 times a day for 5-10 days.

To cope with the intense pain syndrome, pancreatic enzymes are widely used, the analgesic effect of which is due to the fact that when the proteolytic enzymes (trypsin) enter the duodenum, secretion of secretin and cholecystokinin is inhibited, pancreatic secretion is inhibited, pressure in the ducts and parenchyma of the gland decreases, and pain intensity decreases.

The substitution enzyme therapy of chronic pancreatitis is aimed at eliminating digestion disorders of fats, proteins and carbohydrates. In pediatric practice, preference is given to enzyme preparations resistant to the action of hydrochloric acid due to an acid-resistant shell, which has a lipase activity of at least 25,000 units per dose, having an optimum of action in the pH range of 5-7, uniformly and rapidly mixing with food containing microcapsules, not more than 2 mm in diameter, rapidly releasing enzymes in the duodenum. The most effective are microgranular creams and pancitrate enzymes.

Enzyme preparations approved for use in children of different ages - creon 10 000 and creon 25 000. The dose of enzymes is selected individually to obtain a therapeutic effect, taking into account the dynamics of clinical and laboratory indicators. Upon achievement of remission, the patient is transferred to supporting treatment with pancreatic enzymes. Creon 10 000 (2500-3333 ED lipase) is prescribed inside to children under 1 year for every 120 ml of breast milk or milk formula - 1 / 4-1 / 3 capsules, the maximum dose should not exceed 10 000 units per 1 kg of body weight per day , children over 1 year and adults - 1-2 capsules for meals, 1 / 2-1 capsules with a light snack, the maximum dose is not more than 15 000-20 000 units per 1 kg of body weight per day. Pancreatin for children younger than 1 year is prescribed by 0.1-0.15 g; 1-2 years - 0.2 g, 3-4 years - 0.25 g; 5-6 years - 0.3 g: 7-9 years - 0.4 g; 10-14 years - 0.5 g 3-6 times a day.

It has been proved that when any exogenous enzyme is introduced into the duodenum by feedback mechanism, the production of its own pancreatic enzymes, the reduction of pancreatic secretion, the reduction of intraprotective pressure and the stifling of the pain syndrome occur. Criteria for an adequate dose of digestive enzymes include an increase in the body weight of the child, a decrease in flatulence, normalization of the stool, and the indicators of the coprogram.

To achieve the maximum therapeutic effect of the substitution treatment, it is shown the appointment of antacid drugs that suppress the action of hydrochloric acid of gastric juice. It is advisable to use nonabsorbable antacids containing compounds of aluminum and magnesium (diamond, maalox, phosphalugel). The use of calcium carbonate and magnesium oxide is considered impractical, these drugs can aggravate steatori. Aluminum phosphate inside for children up to 6 months is prescribed to 4 g (1/4 sachet or 1 teaspoon) to 6 times a day, after 6 months - 8 grams (1/2 sachet or 2 teaspoons) up to 4 times a day, children over 6 years - 16-32 g (1-2 packets) 2-3 times a day, 1 hour after meals for 14-21 days. Aluminum hydroxide is administered to children under 7 years of age by 5 ml 3 times a day, over 7 years - 10-15 ml 3 times a day (1 hour after meals and at night).

In severe exacerbation of chronic pancreatitis, the patient is injected with rheopolyglucin. Glucose-salt solutions, 10-20% albumin solution, FFP. Albumin is used in the form of a 10% solution, intravenously dripped 100 ml per day, with only 3-5 injections. FFP used intravenously drip for 100-200 ml per day, only 3-5 injections. Antibacterial treatment is indicated for the prevention of secondary infection, with the threat of the formation of cysts, fistulas, peritonitis and the development of other complications. Amoxicillin / clavulanic acid for children younger than 1 year is prescribed by mouth at 0.187-0.234 g; 1-7 years - 0.375-0.468 g; 7-14 years - 0.750-0.936 g for 3 doses, intravenously at the age of 1 month to 12 years, 90 mg / kg of body weight per day, over 12 years - 3.6-4.8 g per day for administration. Cefotaxime is used intramuscularly and intravenously at 50-100 mg / kg per day for 2-4 injections.

With exocrine pancreatic insufficiency, the correction of the content of fat-soluble vitamins (A, D, E, K), and also vitamin C and group B is pathogenetically substantiated. The effectiveness of treatment of chronic pancreatitis is assessed by the dynamics of pain and dyspeptic syndromes, normalization of enzyme activity in blood and urine, coprograms, the content of fecal elastase and the increase in the body weight of the child.

Surgical treatment of chronic pancreatitis

With anomalies in the development of gastroduodeno-choledochoconstrictive zone, destructive pancreatitis and various complications of chronic pancreatitis, surgical treatment is indicated.

Further management

The condition of patients with chronic pancreatitis should be monitored for a long time, the duration of observation depends on the form of pancreatitis, the course and degree of impairment of external and intrasecretory functions. An important factor in the complex treatment of chronic pancreatitis is sanatorium and spa treatment, including in balneological resorts.

Forecast

At children complex treatment of a pancreatitis allows to achieve stabilization of process and indemnification of the broken functions GASTROINTESTINAL TRACT. In some patients with severe disease on the background of duodenal anomalies, biliary tract, pancreas structure, hereditary pathology, complications, the prognosis is less favorable. To achieve successful results of treatment can be with the proper organization of rehabilitation of patients, which prevents the progression of chronic pancreatitis, improves the quality of life and medical and social adaptation of the child.