What can trigger chronic pancreatitis?

The leading cause of chronic pancreatitis is alcohol abuse. According to foreign authors obtained in recent years, the frequency of alcoholic pancreatitis ranges from 40 to 95% of all etiologic forms of the disease.

The consumption of 100 g of alcohol or 2 liters of beer daily for 3-5 years leads to histological changes in the pancreas. Clinically expressed manifestations of chronic pancreatitis develop in women after 10-12 years, and in men - 17-18 years from the beginning of systematic drinking. There is a linear relationship between the risk of developing pancreatitis and the number of daily consumed alcohol, starting with a minimum dose of 20 g per day. According to Duibecu et al. (1986), in many patients with chronic pancreatitis, the daily intake of alcohol was 20 to 80 g, and the duration of its use before the onset of symptoms of the disease - 5 years or more.

In the development of alcoholic pancreatitis, a certain genetically determined predisposition also matters. The development of chronic alcoholic pancreatitis is also promoted by a combination of alcohol abuse and excessive intake of food rich in fats and proteins.

Diseases of the bile duct and liver

Diseases of the bile ducts are the cause of the development of chronic pancreatitis in 63% of patients. The main mechanisms of the development of chronic pancreatitis in diseases of the biliary tract are:

• transition of infection from the bile duct to the pancreas along the general lymphatic pathways;
• the difficulty of outflow of pancreatic secretion and the development of hypertension in the pancreatic ducts with the subsequent development of edema in the pancreas. This situation occurs when there are stones and a stenosing process in the common bile duct;
• biliary reflux into the ducts of the pancreas; while bile acids and other bile ingredients have a damaging effect on the duct epithelium and pancreatic parenchyma and promote the development of inflammation in it.

The development of chronic pancreatitis in diseases of the biliary tract is largely promoted by chronic liver diseases (chronic hepatitis, cirrhosis). Dysfunction of the liver in these diseases determines the production of pathologically altered bile containing a large number of peroxides, free radicals, which, when ingested together with bile in the pancreatic ducts, initiate in them the precipitation of proteins, the formation of stones, the development of inflammation in the pancreas.

Diseases of the duodenum and large duodenal nipple

The development of chronic pancreatitis is possible with a pronounced and long-lasting chronic duodenitis (especially with atrophy of the duodenal mucosa and endogenous secretin deficiency). The mechanism of the development of chronic pancreatitis in inflammatory-dystrophic lesions of the duodenum corresponds to the basic theories of M. Boger's pathogenesis theory.

With the pathology of the duodenum, the development of chronic pancreatitis is very often associated with reflux of the contents of the duodenum into the ducts of the pancreas. Duodenopancreatic reflux occurs when:

• presence of insufficiency of the large duodenal nipple (hypotension of the sphincter of Oddi);
• development of duodenal stasis, which causes an increase in intra-duodenal pressure (chronic duodenal obstruction);
• combinations of these two states. With hypotension of the sphincter of Oddi, his blocking mechanism is broken, hypotension of the biliary and pancreatic ducts develops, duodenal contents are thrown into them and as a result cholecystitis, cholangitis, pancreatitis develop.

The main causes that lead to insufficiency of the large duodenal nipple are passage through it of stone, development of papillitis, violation of motility of the duodenum.

Chronic violation of duodenal patency may be due to mechanical and functional reasons. Among the mechanical factors, the ring-shaped pancreas, cicatricial narrowing and compression of the duodeno-junction junction with upper-bilobial vessels (arteriomesenteric compression), cicatricial changes and lymphadenitis in the region of the Treitsa ligament, the leading loop syndrome after the beating of the stomach by Billroth II or gastroenterostomy, etc. Are among the mechanical factors.

The motor dysfunction of duodenum is of great importance in the development of chronic disturbance of duodenal patency: in the early stages of hyperkinetic, in the subsequent - in a pronounced hypokinetic type.

The development of chronic pancreatitis is facilitated by the diverticula of the duodenum, especially the parotid. When the pancreatic and bile ducts enter the diverticulum cavity, spasm or atony of the sphincter of Oddi develops and the outflow of bile and pancreatic secretion on the diverticulitis soil occurs. When the ducts enter the 12-colon near the diverticulum, the ducts can be compressed by a diverticulum.

The development of chronic pancreatitis can be a complication of peptic ulcer of the stomach and duodenum - with the penetration of an ulcer located on the back of the stomach or duodenum, into the pancreas.

Alment factor

It is known that abundant food intake, especially oily, spicy, fried provokes an exacerbation of chronic pancreatitis. Along with this, a significant decrease in the protein content in the diet contributes to a decrease in the secretory function of the pancreas and the development of chronic pancreatitis. Proof of the great role of protein deficiency in the development of chronic pancreatitis are fibrosis and atrophy of the pancreas and its pronounced secretory deficiency in liver cirrhosis, malabsorption syndrome. Promotes the development of chronic pancreatitis is also polyhypovitaminosis. In particular, it has been established that hypovitaminosis A is accompanied by metaplasia and desquamation of the pancreatic epithelium, duct obstruction and the development of chronic inflammation.

With a deficiency of protein and vitamins, the pancreas becomes much more sensitive to the effects of other etiological factors.

Genetically caused disorders of protein metabolism

Possible development of chronic pancreatitis associated with genetic disorders of protein metabolism, due to excessive excretion in the urine of individual amino acids - cysteine, lysine, arginine, ornithine.

Effect of medications

In a number of cases, chronic pancreatitis can be caused by the taking (especially prolonged) of certain medicines: cytostatics, estrogens, glucocorticoids, etc. The most common association is the recurrence of pancreatitis with treatment with glucocorticoid drugs. The mechanism of development of chronic pancreatitis with long-term treatment with glucocorticoids is not known exactly. The role of a significant increase in the viscosity of pancreatic secretion, hyperlipidemia, and high-blood coagulation in the pancreatic vessels is assumed. The cases of development of chronic pancreatitis against the background of treatment with sulfonamides, nonsteroidal anti-inflammatory drugs, thiazide diuretics, inhibitors of cholinesterase are described.

Viral infection

It has been established that some viruses can cause both acute and chronic pancreatitis. The role of the hepatitis B virus (it is capable of replicating in pancreatic cells), the Coxsaki virus of subgroup B.

Studies have shown the presence of antibodies to the Coxsackie B virus antigen in 1/3 of patients with chronic pancreatitis, and more often in individuals with HLA CW2 antigens. A convincing proof of the role of viruses in the development of chronic pancreatitis is the detection of antibodies to RNA in 20% of patients, which is associated with the replication of RNA-containing viruses.

Violation of blood circulation in the pancreas

Changes in blood vessels that supply blood to the pancreas (pronounced atherosclerotic changes, thrombosis, embolism, inflammatory changes in systemic vasculitis) can cause the development of chronic pancreatitis. In the pathogenesis of so-called ischemic pancreatitis, pancreas ischemia, acidosis, activation of lysosomal enzymes, excessive accumulation of calcium ions in cells, an increase in the intensity of free radical oxidation processes and the accumulation of peroxide compounds and free radicals, activation of proteolysis enzymes.

Hyperlipoproteinemia

Hyperlipoproteinemia of any genesis (both primary and secondary) can lead to the development of chronic pancreatitis. With hereditary hyperlipidemia, the symptoms of pancreatitis appear from childhood. Most often, chronic pancreatitis develops in patients with hyperchylomicronemia (I and V types of Hyperlipoproteinemia by Fredriksen). In the pathogenesis of hyperlipidemic pancreatitis, the obstruction of the gland vessels by fat particles, the fatty infiltration of acinous cells, the appearance of a large number of cytotoxic free fatty acids formed as a result of intensive hydrolysis of triglycerides under the influence of excessively secreted lipase are important.

Hyperparathyroidism

According to modern data, chronic pancreatitis occurs in hyperparathyroidism in 10-19% of cases and its development is due to excessive secretion of parathyroid hormone and hypercalcemia. An increase in the content of free Ca2 ⁺ in acinar cells stimulates the secretion of enzymes; a high level of calcium in pancreatic secretion promotes activation of trypsinogen and pancreatic lipase and, consequently, autolysis of the pancreas. In this case, calcium precipitates in an alkaline environment in the form of calcium phosphate, the formation of duct stones, and calcification of the gland develops.

Postponed acute pancreatitis

Chronic pancreatitis is often not an independent disease, but only the phase state, continuation and outcome of acute pancreatitis. The transition of acute pancreatitis to chronic is observed in 10% of patients.

Genetic predisposition

There are data confirming the involvement of genetic factors in the development of chronic pancreatitis. Thus, it was found that in patients with chronic pancreatitis, antigens of the system HLAA1, B8, B27, CW1 and, much less often, CW4 and A2, are more often compared to healthy pancreatitis. In patients who have detected anti-pancreatic antibodies, the antigen HLAB15

Idiopathic chronic pancreatitis

Etiological factors of chronic pancreatitis can be established only in 60-80% of patients. In other cases, it is not possible to identify the etiology of the disease. In this case, they talk about idiopathic chronic pancreatitis.

The diagnosis of chronic pancreatitis according to the Marseilles-Rome classification (1989) requires a morphological examination of the pancreas and endoscopic retrograde cholangio-pancreatography, which is not always available. When diagnosing a disease, it is possible to indicate the etiology of the disease.