Chronic pancreatitis: symptoms

Symptoms of chronic pancreatitis are very variable: it is different in the period of remission and exacerbation of the disease, depends on the clinical course (clinical form) of the disease, its stage and a number of other factors.

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

Pain syndrome

The localization of pain depends on the defeat of the pancreas:

• pain in the left hypochondrium to the left of the navel occurs when the pancreatic tail is affected,
• pain in the epigastric region, to the left of the median line, - with damage to the body,
• pain to the right of the median line in the Shoffar zone - with pathology of the pancreas head.

With total organ damage, the pain is diffuse in nature, in the form of a "belt" or "half-belt" in the upper abdomen. Pain develops or intensifies 40-60 minutes after eating (especially abundant, spicy, fried, fatty). The pain increases in the position lying on the back and weakens in the sitting position with a slight inclination forward. She can irradiate to the heart area, to the left scapula, the left shoulder, imitating stenocardia, and sometimes to the left iliac region.

The pain can be periodic, lasting from several hours to several days, usually occurring after eating, especially acute and fatty, alcohol, or persistent, worse after eating. Constant, painful pains force to apply strong painkillers right up to narcotic pains, which is highly undesirable, since in the future it can lead to addiction.

Sometimes, in the presence of other signs of pancreatitis, pain can be completely absent - the so-called painless form.

The main causes of pain in chronic pancreatitis are increased pressure in the ducts of the pancreas due to violation of the secretion outflow, as well as inflammatory and sclerotic changes in the parenchyma of the gland and adjacent tissues, leading to irritation of the nerve endings.

Constant pains are caused by residual phenomena of inflammation in the pancreas and the development of complications such as pseudocyst, stricture or stone of the pancreatic duct stenosing papillitis, or solaritis, which often occurs in this disease.

During an exacerbation of the disease, the enlarged pancreas can put pressure on the celiac plexus, causing severe pain. In this case, the patients occupy a characteristic posture - they sit, leaning forward. Often because of severe pain, patients restrict themselves to eating, which becomes one of the reasons for weight loss.

It should be noted that, in addition to pain (which may occur in the early period of the disease ), all other symptoms of chronic pancreatitis usually appear in later stages of the disease.

Often in patients with chronic pancreatitis, various dyspeptic phenomena are noted: a decrease or lack of appetite, an eructation of air, salivation, nausea, vomiting, flatulence, stool disorder (diarrhea or alternating diarrhea and constipation predominate). Vomiting of relief does not bring.

Many patients complain of general weakness, fatigue, adynamy, sleep disturbance.

Expressed changes in the head of the pancreas with pancreatitis (edema or fibrosis) can lead to compression of the common bile duct and the development of mechanical jaundice.

Symptoms of chronic pancreatitis also depend on the stage of the disease: II and especially III stage occur with impaired excretory and incretory functions of the pancreas, more pronounced clinical symptoms and more severe changes revealed by laboratory and instrumental methods. The majority of patients have constant and paroxysmal pains, dyspeptic disorders become more pronounced, food digestion and intestinal absorption, including vitamins, are disrupted. The clinic prevails diarrhea (so-called pancreatogenic diarrhea) with a high fat content (it is difficult to wash off the toilet). Patients with a reduced body weight predominate. In some cases with a prolonged course of pancreatitis there is a decrease in the intensity of pain or their complete disappearance.

Exocrine insufficiency

External pancreatic insufficiency of the pancreas is characterized by a violation of the processes of intestinal digestion and absorption, the development of excess bacterial growth in the small intestine. As a result, patients develop diarrhea, steatorrhea, flatulence, loss of appetite, weight loss. Later, there are symptoms characteristic of hypovitaminosis.

External pancreatic insufficiency is aggravated by the following reasons:

• inadequate activation of enzymes due to a deficiency of enterokinase and bile;
• disturbance of mixing enzymes with food chyme, caused by motor disorders of the duodenum and small intestine;
• destruction and inactivation of enzymes due to excessive growth of microflora in the upper intestine;
• deficiency of dietary protein with the development of hypoalbuminemia and, as a consequence, a violation of the synthesis of pancreatic enzymes.

An early sign of exocrine pancreatic insufficiency is steatorrhea, which occurs when the pancreatic secretion is reduced by 10% compared with the norm. Light steatorrhea, as a rule, is not accompanied by clinical manifestations. With severe steatorrhea, the frequency of diarrhea varies from 3 to 6 times a day, a stool profuse, fetid, mushy, with a greasy shine. The steatorrhea decreases and can even disappear if the patient reduces the intake of fatty foods or takes pancreatic enzymes.

A significant part of patients observe weight loss due to exocrine insufficiency of the pancreas and disruption of the processes of digestion and absorption in the intestine, as well as in connection with the restriction of the volume of food due to pain. Weight loss is usually caused by loss of appetite, strict adherence to strict diet, sometimes starvation due to fear of provoking a painful attack, as well as limiting the intake of easily digestible carbohydrates for people with diabetes mellitus complicating the course of chronic pancreatitis.

Deficiency of fat-soluble vitamins (A, D, E and K) is observed rarely and mainly in patients with severe and prolonged steatorrhea.

[6], [7], [8], [9], [10]

Endocrine insufficiency

Approximately 1/3 of patients develop disorders of carbohydrate metabolism in the form of hypoglycemic syndrome, and only half of them observe clinical signs of diabetes mellitus. The development of these disorders is based on the defeat of the cells of the islet apparatus, resulting in a deficiency not only of insulin, but also of glucagon. This explains the peculiarities of the course of pancreatogenic diabetes mellitus: the tendency to hypoglycemia, the need for low doses of insulin, the sharp development of ketoacidosis, vascular and other complications.

[11], [12], [13], [14], [15], [16]

Objective research

Palpating the pancreas is possible only with cystic and tumor processes.

When palpating the abdomen, the following painful zones and points are identified:

• Shoffar zone - between the vertical line passing through the navel and the bisector of the angle formed by the vertical and horizontal lines passing through the navel. Soreness in this zone is most typical for the localization of inflammation in the head of the pancreas;
• the Gubergritsa-Skulsky zone is similar to the Shoffar zone, but is located on the left. Soreness in this zone is typical for the localization of inflammation in the pancreas body;
• point Dejardin - located 6 cm above the navel along the line connecting the navel with the right axillary cavity. Soreness at this point is typical for the localization of inflammation in the head of the pancreas;
• Point Gubergritsa - is analogous to the point of Desjardins, but is located on the left. Soreness at this point is observed with inflammation of the tail of the pancreas;
• point Mayo-Robson - is located on the border of the outer and middle third of the line connecting the navel and the middle of the left costal arch. Soreness at this point is characteristic for inflammation of the tail of the pancreas;
• the area of the costal-vertebral angle on the left - with inflammation of the body and tail of the pancreas.

Many patients have a positive sign of Grot - the atrophy of pancreatic fat in the area of the projection of the pancreas on the anterior abdominal wall. There may be a symptom of "red droplets" - the presence of red spots on the skin of the abdomen, chest, back, and brownish skin color over the pancreas.

Dyspeptectic syndrome (pancreatic dyspepsia) - is quite typical for chronic pancreatitis, especially often it is expressed with exacerbation or severe course of the disease. Dyspeptic syndrome is manifested by increased salivation, belching with air or eaten food, nausea, vomiting, loss of appetite, aversion to fatty food, bloating.

Weight loss - develops due to restrictions in food (with fasting the pain decreases), as well as due to a violation of the exocrine function of the pancreas and absorption in the intestine. Loss of appetite also contributes to weight loss. The drop in body weight is especially pronounced in severe forms of chronic pancreatitis and is accompanied by general weakness, dizziness.

Pancreatogenic diarrhea and syndrome of inadequate digestion and absorption are characteristic of severe and long-lasting forms of chronic pancreatitis with pronounced impairment of the exocrine function of the pancreas. Diarrhea is caused by impaired excretion of pancreatic enzymes and intestinal digestion. The abnormal composition of chyme irritates the intestines and causes the appearance of diarrhea. Significant and a violation of the secretion of gastrointestinal hormones. This is characterized by the release of large quantities of foul-smelling messy feces with a fatty shine (steatorrhea) and pieces of undigested food

Determine a positive frenicus-symptom (pain when pressing between the legs of the sternocleidomastoid muscle at the point of attaching it to the collarbone). In patients, a deficiency of body weight is observed. On the skin of the chest, abdomen, back, you can find small bright red spots of round shape, 1-3 mm in size, do not disappear when pressed (a symptom of Tuzhilin), a sign of the action of activated pancreatic enzymes. Also dry and flaky skin, glossitis, stomatitis due to hypovitaminosis are typical.

The course and complications of chronic pancreatitis

The course of chronic pancreatitis without appropriate treatment is usually progressive, with more or less pronounced, rarely or often occurring periods of exacerbations and remissions, gradually resulting in focal and (or) diffuse reduction of the pancreatic parenchyma, the formation of more or less diffusely spread areas of sclerosis (fibrosis), the onset pseudocyst, deformation of the organ duct system, alternation of expansion and stenosis, and often the ducts contain a condensed secret (following coagulation of proteins), microliths, it is often formed diffuse-focal calcification of the gland (chronic calcifying pancreatitis). As the disease progresses, there is a definite regularity: with each new exacerbation, the patches of hemorrhage and necrosis of the parenchyma are becoming less and less common in the pancreas (apparently due to the progression of sclerotic processes), the function of this major organ of the digestive system is increasingly disrupted.

Complications of chronic pancreatitis are the occurrence of abscess, cyst or calcification of the pancreas, severe diabetes mellitus, splenic vein thrombosis, development of cicatricial inflammatory stenosis of the main duct, as well as BSD with the development of mechanical jaundice, cholangitis, etc. Against the background of long-term pancreatitis, the secondary development of cancer pancreas.

Rare complications of severe pancreatitis may be "pancreatogenic" ascites and intestinal intercellular abscess. Ascites in pancreatitis is a fairly serious complication of the disease, it occurs in patients with severe exocrine pancreatic insufficiency, with hypoalbuminemia (due to digestive disorders in the intestine and insufficiency of absorption of amino acids, especially during exacerbation of chronic pancreatitis). One of the causes of ascites in pancreatitis can also be thrombosis of the vessels of the portal vein system.