Treatment of chronic pancreatitis

The goal of treating chronic pancreatitis is to create functional rest for the pancreas, relieve pain, inhibit pancreatic secretion, and prevent the development of complications.

Indications for hospitalization

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

Non-drug treatment of chronic pancreatitis

The basic principles of treating chronic pancreatitis include the mandatory prescription of therapeutic nutrition with a reduced fat content and a physiological protein norm to ensure the functional rest of the pancreas.

Therapeutic nutrition for chronic pancreatitis is based on mechanical, thermal and chemical sparing of the pancreas, suppression of hyperfermentemia, reduction of congestion in the ducts and duodenum, and reduction of reflex excitability of the gallbladder.

By now, a concept of nutritional support for pancreatitis has been developed, the attitude to the duration of the "starvation" diet, parenteral (PP) and enteral nutrition (EN) has been revised. It has been proven that starvation increases the rate of lipolysis, provokes hypo- and dysproteinemia, metabolic acidosis, and aggravates degenerative changes in the pancreas.

Nutritional support involves full feeding 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 patient's trophological status. Early parenteral nutrition and enteral nutrition accelerate reparative processes in the gastrointestinal tract. The nutritional support algorithm is adjusted taking into account the patient's condition; diet No. 5a is indicated. Therapeutic nutrition is pharmacotherapy of various metabolic disorders - the main way of high-quality provision of the patient's energy-plastic needs.

In severe cases of chronic pancreatitis, complete parenteral nutrition is prescribed - the only way of protein-energy nutritional support in such a situation. Modern drugs for parenteral nutrition allow to normalize nitrogen, energy and water-salt metabolism; they include donors of plastic material for protein synthesis (amino acid solutions), carbohydrate solutions (maltodextrose) and fat emulsions that promote immobilization of pancreatic lipase circulating in the blood and replenishment of the deficiency of essential omega-3 and omega-6 fatty acids.

Amino acid solutions (aminosteril, aminosol, polyamine, etc.) are administered intravenously; the daily protein requirement for children is 2-4 g/kg. A solution of aminosol is prescribed at a dose of 600 kcal intravenously by drip at a rate of 20-40 per minute, 500-1000 ml/day, for newborns weighing up to 5 kg - 100-200 ml/day, for children weighing more than 5 kg - 1000 ml/day.

Fat emulsions intralipid or lipofundin10-20% should make up 5-10% of the caloric value of the diet. A 10% solution of lipofundin is administered intravenously by drip, administered at a rate of 20-30 per minute at a rate of 1-2 g/kg per day (10-20 ml/kg per day), a 20% solution at 5-10 ml/kg per day, the maximum daily dose is 4 g/kg.

Glucose provides the main caloric value of parenteral nutrition mixtures. In children of the first year of life, the daily requirement for glucose reaches 25-30 g/kg per day. Parenteral nutrition solutions also include water, electrolytes, minerals and vitamins. The effectiveness of parenteral nutrition is assessed by stabilization of the child's body weight, an increase in serum albumin, hemoglobin levels and restoration of gastrointestinal motility.

When the pain syndrome and dyspeptic disorders subside, the child is transferred to enteral nutrition through a nasogastric tube (installed in the jejunum) or oral formula. If the main functions of the gastrointestinal tract are preserved, preference is given to early enteral nutrition, which has a number of advantages. If with parenteral nutrition the gastrointestinal tract is excluded 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, then with enteral nutrition the rate of entry of nutrients into the cell is regulated by mechanisms that maintain homeostasis.

In case of pancreatitis, children are prescribed the mixtures "Nutrien", "Nutrizon", "Pentamen" and others. The fats of the mixtures are represented by triglycerides containing medium-chain fatty acids, easily hydrolyzed by pancreatic lipase and absorbed in the blood vessels of the portal vein, bypassing the lymphatic system. Medium-chain fatty acids in the composition of the mixture for enteral nutrition reduce osmolarity, increase the absorption of macronutrients, and reduce the volume of stool. Specialized mixtures can be used in the form of cocktails or drinks (second breakfast or afternoon snack).

Drug treatment of chronic pancreatitis

In the acute period of pancreatitis, pain relief is of utmost importance, for which a combination of analgesics and antispasmodics is most often used. Metamizole sodium is prescribed orally to children aged 2-3 years at 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 at 0.1-0.2 ml / 10 kg, but not more than 2 g per day. Paracetamol orally to children aged 6-12 months is prescribed at 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 old - 0.5 g 2-3 times a day. Papaverine is prescribed orally, subcutaneously, intramuscularly and intravenously. Children from 6 months to 1 year old - 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. Drotaverine is given orally to children 1-6 years old at 0.001-0.02 g 1-2 times a day, 6-12 years - 0.02 g 1-2 times a day. A 2% solution of the drug is administered intramuscularly or intravenously to children 1-4 years old at 0.5 ml: 5-6 years old - 0.75 ml; 7-9 years - 1.0 ml; 10-14 years - 1.5 ml 1-3 times a day.

M-anticholinergics are also used to reduce pain. Platyphylline is prescribed orally, subcutaneously, intramuscularly at 0.2-3 mg per dose, depending on age: the highest single dose is 0.01 g, daily - 0.03 g. Hyoscine butylbromide is prescribed orally to children under 6 years old - 10 mg 3-5 times a day, over 6 years old - 1-20 mg 3-5 times a day subcutaneously, intramuscularly or intravenously: children under 3 years old 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 rest for the pancreas and suppress gastric secretion, antisecretory agents are used: selective H2-histamine receptor blockers _, proton pump inhibitors. These drugs are indicated 1-2 times a day or once at night for 2-3 weeks. Ranitidine is prescribed to children orally, 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 orally to children under 7 years old at 20 mg per day: over 7 years old - 20-40 mg per day for 14-21 days. Omeprazole is prescribed orally or intravenously at 20 mg per day for 7-10 days.

Correction of the motor function of the stomach, duodenum, and bile ducts is achieved by prescribing drugs that normalize evacuation activity. Domperidone is prescribed orally to children over 5 years old at 5 mg 2 times a day, over 10 years old - 10 mg 2 times a day for 7-10 days. Cisapride is prescribed orally to children under 1 year old at 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 analogue of endogenous somatostatin. The introduction of octreotide quickly relieves pain, significantly inhibits the secretion of the pancreas, stomach, liver, small intestine, inhibits gastrointestinal motility, reduces intraductal hypertension, suppresses the secretion of biologically active substances (secretin, cholecystokinin, pancreozymin, hydrochloric acid, pepsin). The anti-inflammatory effect of octreotide is associated with stabilization of cell membranes, blockade of cytokinogenesis, production of prostaglandins. The duration of action of the drug is 10-12 hours, it is administered subcutaneously and intravenously, children under 7 years old are prescribed 25-50 mcg, over 7 years old - 50-100 mcg 2-3 times a day for 5-10 days.

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

Enzyme replacement therapy for chronic pancreatitis is aimed at eliminating disorders of fat, protein and carbohydrate digestion. In pediatric practice, preference is given to enzyme preparations that are resistant to hydrochloric acid due to the acid-resistant shell, have a lipase activity of at least 25,000 U per dose, have an optimum action in the pH range of 5-7, mix evenly and quickly with food, include microcapsules no more than 2 mm in diameter, quickly releasing enzymes in the duodenum. The most effective microgranulated enzymes are Creon and Pancitrate.

Enzyme preparations approved for use in children of different ages are Creon 10,000 and Creon 25,000. The dose of enzymes is selected individually until a therapeutic effect is achieved, taking into account the dynamics of clinical and laboratory parameters. Upon achieving remission, the patient is transferred to maintenance treatment with pancreatic enzymes. Creon 10,000 (2500-3333 U of lipase) is prescribed orally to children under 1 year of age for every 120 ml of breast milk or formula - 1/4-1/3 capsule, the maximum dose should not exceed 10,000 U per 1 kg of body weight per day, children over 1 year of age and adults - 1-2 capsules per meal, 1/2-1 capsule with a light snack, the maximum dose is no more than 15,000-20,000 U per 1 kg of body weight per day. Pancreatin is prescribed orally to children under 1 year old at 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 proven that when any exogenous enzyme is introduced into the duodenum, the feedback mechanism blocks the production of pancreatic enzymes, reduces pancreatic secretion, reduces intraductal pressure, and alleviates pain. The criteria for an adequate dose of digestive enzymes are an increase in the child's body weight, a decrease in flatulence, and normalization of stool and coprogram indicators.

To achieve the maximum therapeutic effect of replacement therapy, it is recommended to prescribe antacids that suppress the action of hydrochloric acid in the gastric juice. It is advisable to use non-absorbable antacids containing aluminum and magnesium compounds (Almagel, Maalox, Phosphalugel). The use of calcium carbonate and magnesium oxide is considered inappropriate, these drugs can aggravate steatorrhea. Aluminum phosphate is prescribed orally to children under 6 months at 4 g (1/4 sachet or 1 teaspoon) up to 6 times a day, after 6 months - 8 g (1/2 sachet or 2 teaspoons) up to 4 times a day, children over 6 years old - 16-32 g (1-2 sachets) 2-3 times a day, 1 hour after meals for 14-21 days. Aluminum hydroxide is prescribed orally to children under 7 years of age at 5 ml 3 times a day, over 7 years of age - 10-15 ml 3 times a day (1 hour after meals and at night).

In case of severe exacerbation of chronic pancreatitis, the patient is administered rheopolyglucin, glucose-salt solutions, 10-20% albumin solution, FFP. Albumin is used as a 10% solution, administered intravenously by drip of 100 ml per day, for a total of 3-5 administrations. FFP is used intravenously by drip of 100-200 ml per day, for a total of 3-5 administrations. Antibacterial treatment is indicated to prevent secondary infection, in case of risk of formation of cysts, fistulas, peritonitis and development of other complications. Amoxicillin/clavulanic acid is prescribed orally to children under 1 year old at 0.187-0.234 g; 1-7 years - 0.375-0.468 g; 7-14 years - 0.750-0.936 g in 3 doses, intravenously at the age of 1 month to 12 years, 90 mg/kg of body weight per day is administered, over 12 years - 3.6-4.8 g per day per administration. Cefotaxime is used intramuscularly and intravenously at 50-100 mg/kg per day in 2-4 administrations.

In case of exocrine pancreatic insufficiency, correction of the content of fat-soluble vitamins (A, D, E, K), as well as vitamin C and group B is pathogenetically justified. The effectiveness of treatment of chronic pancreatitis is assessed by the dynamics of pain and dyspeptic syndromes, normalization of enzyme activity in the blood and urine, coprogram indicators, fecal elastase content and an increase in the child's body weight.

Surgical treatment of chronic pancreatitis

In case of developmental anomalies of the organs of the gastroduodenocholedochopancreatic 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 the external and internal secretory function. An important factor in the complex treatment of chronic pancreatitis is spa treatment, including at balneological resorts.

Forecast

In children, complex treatment of pancreatitis allows to stabilize the process and compensate for the impaired functions of the gastrointestinal tract. In some patients with a severe course of the disease against the background of anomalies of the duodenum, bile ducts, pancreas structure, hereditary nature of the pathology, development of complications, the prognosis is less favorable. Successful treatment results can be achieved with the correct 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.