PancreatitisPancreatitis. . Diaseses of Diaseses of the intestinethe intestine: : enteritisenteritis, , colitiscolitis. . DiagnosticsDiagnostics. . Main Main principles of teratmentprinciples of teratment

N. Bilkevych

Chronic pancreatitisChronic pancreatitis ( (CPCP) -) -

Chronic inflammatory affection of Chronic inflammatory affection of pancreatic gland pancreatic gland parenchymawhich lasts over parenchymawhich lasts over 6 6 monthmonth з з with exocrinic with exocrinic parenchymal destructionparenchymal destruction, , fibrosisand on later stages - fibrosisand on later stages - endocrinic parenchymal endocrinic parenchymal destructiondestruction..

The pancreas is an elongated, tapered gland The pancreas is an elongated, tapered gland that is located behind the stomach and that is located behind the stomach and secretes digestive enzymes and the hormones secretes digestive enzymes and the hormones

insulin and glucagon.insulin and glucagon.

The pancreas is located The pancreas is located posterior to the posterior to the abdomen. It contains abdomen. It contains cells that secrete the cells that secrete the hormone insulin, and hormone insulin, and cells that secrete cells that secrete digestive enzymes that digestive enzymes that aid in the breakdown of aid in the breakdown of food in the food in the gastrointestinal tract. gastrointestinal tract. The pancreas secretes The pancreas secretes these enzymes into the these enzymes into the pancreatic duct, which pancreatic duct, which joins the common bile joins the common bile duct from the liver and duct from the liver and drains into the small drains into the small intestine.intestine.

EthiologyEthiology Primary pancreatitisPrimary pancreatitis:: AlAlссohol abuseohol abuse ( (70-80%)70-80%) Systematic fat food intakeSystematic fat food intake MedicamentsMedicaments ((azathioprinazathioprin, , izoniazidizoniazid, , tetracyclinetetracycline, , sulfa sulfa

drugsdrugs)) Protein defficiencyProtein defficiency ( (kwashiorkorkwashiorkor))

HereditaryHereditary Ischemic Ischemic ((affection of pancreaticvesselsaffection of pancreaticvessels)) IdiopaticIdiopatic

EthiologyEthiology

EthiologyEthiology Secondary pancreatitisSecondary pancreatitis : : diseases of bile ductsdiseases of bile ducts ( (30-40 %)30-40 %)               diseases of a duodenumdiseases of a duodenum       pthology of duodenal papilla:primary pthology of duodenal papilla:primary ((tumor,papilitistumor,papilitis) ) and secondaryand secondary

((oddy’s sphincter dyskinesiaoddy’s sphincter dyskinesia, , skarsskars))               diseases of a liverdiseases of a liver               diseases of intestinediseases of intestine               viralinfectionsviralinfections ( (epidemic parotitisepidemic parotitis))               allergyallergy               hyperlipidemiahyperlipidemia               hyperparathyreosishyperparathyreosis traumastraumas

Clinical classificationClinical classificationAccording to functional characteristicsAccording to functional characteristics    

1. 1. With exocrinic functional disordersWith exocrinic functional disorders. .

2.2. With endocrinic disorders With endocrinic disorders. . Phase of the diseasePhase of the disease::

--exacerbationexacerbation, -, -remissionremission..

ComplicationsComplications

Clinical patternClinical patternLeading syndromesLeading syndromes::

PainPain DyspepsyDyspepsy Exocrinic secratory disfunction and syndromes Exocrinic secratory disfunction and syndromes

of maldigestia and malabsorption with of maldigestia and malabsorption with progressive body weight loss progressive body weight loss

Exocrinic secratory disfunction Exocrinic secratory disfunction ((pancreatic pancreatic diabetes mellitusdiabetes mellitus))

Asthenic syndromeAsthenic syndrome

Clinical patternClinical patternPain syndromePain syndrome

Dejarden’s pointDejarden’s point

Shoffar’s Shoffar’s zonezone

Mayo-Robson’s pointMayo-Robson’s point

Clinical patternClinical patternDyspeptic syndromeDyspeptic syndrome

Appetite is decreased or Appetite is decreased or absentabsent, ,

hypersalivationhypersalivation,, nauseanausea, , Vomiting without benefitionVomiting without benefition,, meteotismmeteotism, , Disordered stoolDisordered stool ( (prevalence prevalence

of diarrhoea or change of of diarrhoea or change of diarrhoea and constipationdiarrhoea and constipation).).

Clinical patternClinical pattern

Syndrome of exogenous dysfunctionSyndrome of exogenous dysfunction - - -“-“pancreaticpancreatic" " diarrhoea is characterised with diarrhoea is characterised with

large volumelarge volume((polyfecaliapolyfecalia),), of greish color, with unpleasant of greish color, with unpleasant smell and fatty smell and fatty ((steatorrhoeasteatorrhoea). ).

body mass loss with frequent development of body mass loss with frequent development of osteoporosisosteoporosis ( (painin bonespainin bones)) because of because of calcium loss andvitamin calcium loss andvitamin D D deficiency deficiency..

Clinical patternClinical pattern

Spider angiomataSpider angiomata

Red spots on the skin Red spots on the skin of the chest, of the chest,

abdomen and back. abdomen and back. They are round, They are round, don’t disappear don’t disappear after pressing in after pressing in

them them ((microaneurismsmicroaneurisms))

Clinical courseClinical course: : Chronic recidivatingChronic recidivating pancreatitis pancreatitis — — often develops, it is characterized by often develops, it is characterized by

pain attacks combined with increased level of pancreatic enzymes in blood pain attacks combined with increased level of pancreatic enzymes in blood serum and urine, sometimes with jaundiceserum and urine, sometimes with jaundice. . In remission dyspeptic In remission dyspeptic syndrome may be preserved.syndrome may be preserved.

Pain formPain form —— is characterized by permanent dull pain in right is characterized by permanent dull pain in right hypochondrium and typical laboratory findings. In anamnesis there are hypochondrium and typical laboratory findings. In anamnesis there are data about pancreonecrosisdata about pancreonecrosis..

Latent formLatent form — — is characterized by painless course, dyspeptic syndrome and is characterized by painless course, dyspeptic syndrome and exocrinic infuficiency prevailexocrinic infuficiency prevail..

Pseudotumorous formPseudotumorous form — — is characterized by combination of jaundice,is characterized by combination of jaundice, exocrine and endocrine insufficiencyexocrine and endocrine insufficiency.. May be entrangled with cancer of May be entrangled with cancer of pancreaspancreas ..

Laboratory diagnosticsLaboratory diagnostics:: 1. 1. Complete blood countComplete blood count::

inin 25 % – 25 % – leucocytosisleucocytosis, , increased ESRincreased ESR..

2.2. Asessment of pancreatic enzymes in the blood Asessment of pancreatic enzymes in the blood ((amylaseamylase, , lipaselipase, , tripsin in blood and urinetripsin in blood and urine — — increased in exacerbationincreased in exacerbation).).

!!!!!!increased level of increased level of α- α-amylaseamylase onon 1- 1-st day of the diseasest day of the disease inin 85-90 % 85-90 % of casesof cases, , onon 22--nt day nt day – – inin 60-70 %, 60-70 %, onon 33--rd day rd day – – inin 40-50 %. 40-50 %.

Instrumental diagnosticsInstrumental diagnostics

Instrumental diagnosticsInstrumental diagnostics

computer tomographycomputer tomography:: diagnostic diagnostic information similliar toultrasound examination,information similliar toultrasound examination, is executet in suspition on cancer or cysts of the is executet in suspition on cancer or cysts of the glandgland;;

                 MRT: visualization of normal and MRT: visualization of normal and pathologically changed pancreatic ductspathologically changed pancreatic ducts, , stonesstones;;

Endoscopic Endoscopic examinatioexaminationn

An endoscope, with a camera on An endoscope, with a camera on its end, is passed down the its end, is passed down the esophagus, through the stomach, esophagus, through the stomach, and into the small intestine. The and into the small intestine. The entrance of the pancreatic duct entrance of the pancreatic duct into the small intestine can be into the small intestine can be viewed through the endoscope. A viewed through the endoscope. A special instrument on the end of special instrument on the end of the endoscope can then be the endoscope can then be passed into the pancreatic duct passed into the pancreatic duct and the gallstone is extracted. and the gallstone is extracted. Very rarely pancreatitis is severe Very rarely pancreatitis is severe enough to require surgery, which enough to require surgery, which is usually performed when the is usually performed when the pancreas becomes infected. Dead pancreas becomes infected. Dead pancreatic tissue is removed, and pancreatic tissue is removed, and the area around the pancreas is the area around the pancreas is washed clean. Patients who washed clean. Patients who require such treatment usually require such treatment usually have prolonged hospital stays and have prolonged hospital stays and are seriously ill. are seriously ill.

  

This upper abdominal CT scan This upper abdominal CT scan shows inflammation and swelling shows inflammation and swelling of the pancreas caused by acute of the pancreas caused by acute

infection (pancreatitis).infection (pancreatitis).

CT scan of the upper abdomen CT scan of the upper abdomen showing multiple white-colored showing multiple white-colored calcifications. These occur in calcifications. These occur in

chronic pancreatitis.chronic pancreatitis.

TreatmentTreatmentMain principlesMain principles::

1. 1. DietDiet ( ( NN 5 5 pp) ) 2. 2. Functional rest of pancreasFunctional rest of pancreas 3. 3. Elimination of painElimination of pain Replacement therapy of exocrinic Replacement therapy of exocrinic

disfunctiondisfunction 5.5. Elimination of duodenostasisElimination of duodenostasis, ,

dyskinesia of bile and pancratic ductsdyskinesia of bile and pancratic ducts 6. 6. Antiinflammatory therapyAntiinflammatory therapy 7. 7. Endocrinic disfunction correctionEndocrinic disfunction correction 8. 8. Symptomatic therapySymptomatic therapy

Functional rest of Functional rest of pancreaspancreas

Fasting or marked limitation of fats in a dietFasting or marked limitation of fats in a diet regulatory peptidesregulatory peptides:: - -somatostatinsomatostatin

((decreases gastrin secretiondecreases gastrin secretion and stimulation of and stimulation of exocrinic secretion), dalargin, exocrinic secretion), dalargin, ((decreases gastric decreases gastric and pancreatic secretion, analgethic)and pancreatic secretion, analgethic)

Proton pompinhibitorsProton pompinhibitors ((omeprazolomeprazol 20 мг, 20 мг, lansoprasollansoprasol, , pantoprasol etcpantoprasol etc); );

Н2-Н2-histaminobloquers: famotidin, kwamatel, histaminobloquers: famotidin, kwamatel, ranitidinranitidin) )

Functional rest of Functional rest of pancreaspancreas

М-М-cholinoliticscholinolitics – – decrease decrease gastric and pancreatic gastric and pancreatic secretion, spasmolyticsecretion, spasmolytic ( (plathyphilinplathyphilin 0,2% 1-2 0,2% 1-2 ml ml ii//mm 1-2 1-2 tt//dayday, , gastrocepingastrocepin) )

AntacidesAntacides - ( - (maaloxmaalox,,phosphalugelphosphalugel))EnzimesEnzimes - - decrease production of pancreas own decrease production of pancreas own

enzymesenzymes. . Drugs protected with ac out against Drugs protected with ac out against stomach juice and those withut pepsin and bile stomach juice and those withut pepsin and bile acidsacids ( (pangrolpangrol 10 10 000 000-20-20 000 000 UNUN х 3 х 3 tt//dd, , CreonCreon 1010000000-25-25000000-40-40000 UN000 UN х3 х3 tt//dd, , MezymMezym- - forteforte 1010000000 1-2 1-2 tabltabl х 3 х 3tt//dd). ).

Antienzyme preparationsAntienzyme preparations ( (protease protease inhibitorsinhibitors) – ) – in hyperenzymemiain hyperenzymemia

NaturalNatural::

- - ContricalContrical

2020000000-40-40000000 UnUn//dd

- - TrasilolTrasilol

5050000000-100-100000000 UnUn//dd

- - GordoxGordox 1,2 1,2 mlnmln UnUn//dd

synteticsyntetic:: Aminacapronic acid Aminacapronic acid 5 5

% 150-200 % 150-200 mlml ii//vv , 1 , 1 gg 3 3 tt//dd per osper os

MetiluracilMetiluracil pentoxilpentoxil

Elimination of painElimination of pain Cold on abdomenCold on abdomen spasmolyticsspasmolytics ((papaverinpapaverin 2% 2 2% 2 mlml, , No-spaNo-spa 2% 2 2% 2 mlml ii//vv - -

2 2 t/dt/d,, duspatalinduspatalin 200200mgmg 2 2 t/dt/d);); Novocaine solutionNovocaine solution 0,25% 200 0,25% 200 mlml ii//vv dropsdrops.. AntihistaminsAntihistamins Narcotic analgethics except of morphinNarcotic analgethics except of morphin analgethics analgethics ( (analginanalgin 50% 2-5 50% 2-5 mlml ii//mm 2-3 2-3 t/dt/d, , baralginbaralgin 5 5

mlml ii//mm ); ); Bloque of plexus solarisBloque of plexus solaris Elimination of dyskinesiaElimination of dyskinesia domperidonedomperidone ( (motiliummotilium 10 10 mgmg 3 3 t/dt/d), ), cisapiridcisapirid ( (prepulsidprepulsid, , peristilperistil 10 10 mgmg З З t/dt/d););

Diseases of intestineDiseases of intestine

Chronic enteritisChronic enteritis – – polyethioigic diseasepolyethioigic disease, , based ondystrophic changes in small based ondystrophic changes in small intestine. It causes decrese of its barrier intestine. It causes decrese of its barrier function, digestion and absorptionfunction, digestion and absorption,, contamination of upper parts of intestine contamination of upper parts of intestine with large amount of microbes as well as with large amount of microbes as well as to secondary metabolic and immune to secondary metabolic and immune disordersdisorders, , nervous system disfunctionnervous system disfunction

EthiologEthiologyy InfectionsInfections::

dysenteriadysenteria, , microsporidiosismicrosporidiosis,,

cyclosporescyclospores, , salmonellosissalmonellosis,,

Staphilococcus and Staphilococcus and othersothers,,

virusesviruses ((rotavirusrotavirus, , enteral adenovirusenteral adenovirus), ),

Protozoa, helmints Protozoa, helmints invasioninvasion ((lamblia, lamblia, opistorchia etc)opistorchia etc)

Alimentary factorsAlimentary factors Gamma-irradiationGamma-irradiation Toxic medicamentsToxic medicaments OperationsOperations Chronic diseasesChronic diseases Blood flow Blood flow

disordersdisorders

Salmonella typhiSalmonella typhi, , Yersinia enterocoliticaYersinia enterocolitica

Clinical patternClinical pattern1). 1). Local enteral Local enteral

syndromesyndrome;;- - diarrhoeadiarrhoea - ме- меteorismteorism - - abdominal pain abdominal pain

(around the navel)(around the navel) - - gurgling in the gurgling in the

abdomenabdomen - - steatorrhoea and steatorrhoea and

polyfecaliapolyfecalia - - pain by palpation in pain by palpation in

medail part of abdomen medail part of abdomen and on theleft sideand on theleft side, , above the navel at the above the navel at the level level ХІІ ХІІ thoracicthoracic – І – І lumbar vertebralumbar vertebra ((Porges’s symptomPorges’s symptom))

2). 2). General enteral General enteral syndromesyndrome

Disordes of fat Disordes of fat metabolismmetabolism

Changes inmany Changes inmany organs (endocrine, organs (endocrine, blood-creating, blood-creating, digestive)digestive)

Morphologically proved inflammatory Morphologically proved inflammatory or inflammatory dysthrophic process or inflammatory dysthrophic process of intestinal mucosaof intestinal mucosa, , which which prpagates on alllarge intestine prpagates on alllarge intestine ((pancolitispancolitis) ) or its separate parts or its separate parts ((segmentary colitissegmentary colitis).).

Chronic colitisChronic colitis

Clinical patternClinical patternLeading syndromesLeading syndromes

1. 1. PainPain2. 2. Intestinal dyspepsiaIntestinal dyspepsia3. 3. disbacteriosisdisbacteriosis

Intestinal dydpepsiaIntestinal dydpepsia Disordes of stool: Disordes of stool: diarrhoea in the diarrhoea in the

morning or after mealsmorning or after meals. Stool . Stool appearance: appearance: small portions, watery, with small portions, watery, with mucus. Tenesmes, feeling of incomplete mucus. Tenesmes, feeling of incomplete emptying of bowels. emptying of bowels.

Diarrhoesdevelops after fatty food, cold Diarrhoesdevelops after fatty food, cold meal, milk, species, products with plant meal, milk, species, products with plant fibers. Bad smell af fecesfibers. Bad smell af feces..

DisbacteriosisDisbacteriosisInhibition of normal intestinal microflora Inhibition of normal intestinal microflora

(biphido- and lactobacteria, E. Coli). (biphido- and lactobacteria, E. Coli). Overdevelopment of other Overdevelopment of other microorganisms (proteus, candida microorganisms (proteus, candida fungi, cytobacter, clebsiella etc)fungi, cytobacter, clebsiella etc). .

As a result the patient developed As a result the patient developed meteorism, diarrhoeameteorism, diarrhoea..

DiagnosticsDiagnostics..

1. 1. anamnesis (acute anamnesis (acute intestinal infections in intestinal infections in the past, poor the past, poor nutrition,prolonged nutrition,prolonged usage of antibiotics, usage of antibiotics, mashroomspoisoningm mashroomspoisoningm contact with chemicals)contact with chemicals)

Coprologic Coprologic investigationinvestigation

Bacteriologic Bacteriologic examination of examination of fecesfeces

Endoscopic Endoscopic examinationexamination

IrrigoscopyIrrigoscopy

TreatmentTreatment DietDiet AntibioticsAntibiotics Elimination of Elimination of dehydration and abdominal dehydration and abdominal

and rectal pain or discomfort. and rectal pain or discomfort. Antidiarrheal drugs are usually Antidiarrheal drugs are usually

prescribed, such as Kaopectate, Lomotil, prescribed, such as Kaopectate, Lomotil, Paregoric or Imodium.Paregoric or Imodium.

EnzymesEnzymes Simeticon (aspumisan)Simeticon (aspumisan) ProbioticsProbiotics Bowel cramps may be alleviated with Bowel cramps may be alleviated with

antispamodic drugs, such as antispamodic drugs, such as No-spaNo-spa.. Some patients with radiation enteritis can be Some patients with radiation enteritis can be

fed through a tube leading into the stomach fed through a tube leading into the stomach provided the small intestine is functioning provided the small intestine is functioning normally. Otherwise, they may require normally. Otherwise, they may require parenteral alimentation, which means that a , which means that a nutrient solution is given solution is given intravenously..

Inflammatory bowel Inflammatory bowel disease..disease..

Inflammatory bowel diseases (IBD) include a Inflammatory bowel diseases (IBD) include a group of chronic disorders that cause inflammation group of chronic disorders that cause inflammation or ulceration in the small and large intestines. Most or ulceration in the small and large intestines. Most often IBD is classified as:often IBD is classified as:

Ulcerative colitisUlcerative colitis--causes ulceration and --causes ulceration and inflammation of the inner lining of the colon and inflammation of the inner lining of the colon and rectum.rectum.

Crohn's diseaseCrohn's disease-an inflammation that extends into -an inflammation that extends into the deeper layers of the intestinal wall, and also the deeper layers of the intestinal wall, and also may affect other parts olayers of the f digestive may affect other parts olayers of the f digestive tract, including the mouth, esophagus, stomach, and tract, including the mouth, esophagus, stomach, and smdigestive small all intestinesmdigestive small all intestine..

Ulcerative colitis and upper GI Ulcerative colitis and upper GI diseasedisease

Ulcerative small Ulcerative small bowel lesions in pts bowel lesions in pts with ulcerative with ulcerative colitiscolitis

Diffuse, Diffuse, confined to confined to mucosa, no mucosa, no granulomasgranulomas

Upper GI involvement and ulcerative colitis Upper GI involvement and ulcerative colitis Duodenum : FriabilityDuodenum : Friability

Upper GI involvement and ulcerative colitis Upper GI involvement and ulcerative colitis Duodenum : Friability & GranularityDuodenum : Friability & Granularity

Upper GI involvement and ulcerative colitisUpper GI involvement and ulcerative colitisAphthous gastritis : Crohn or UCAphthous gastritis : Crohn or UC

DefinitionDefinition

CROHN’S CROHN’S DISEASE DISEASE

A nonspecific chronic transmural A nonspecific chronic transmural inflammatory disease that most commonly inflammatory disease that most commonly affects the distal ileum and colon but may affects the distal ileum and colon but may occur in any part of the GI tract.occur in any part of the GI tract.

EtiologyEtiology

The fundamental cause of Crohn's The fundamental cause of Crohn's disease is unknowndisease is unknown

The spectrum of The spectrum of CROHN DISEASECROHN DISEASE presentations presentations includes gastroduodenitis, jejunoileitis and includes gastroduodenitis, jejunoileitis and ileitis, ileocolitis, ileitis, ileocolitis, ccolitisolitis

7% 33%

45% 15%

Endoscopic Endoscopic sspectrum pectrum of Cof CDD includes includes a) a) aphthous ulcerations aphthous ulcerations amid normal colonic amid normal colonic mucosalmucosal vasculature;vasculature; b) b) deeper, punched-deeper, punched-out ulcers in ileal out ulcers in ileal mucosa; mucosa; cc)) a single colonic a single colonic linear ulcer;linear ulcer; dd)) deep colonic deep colonic ulcerations forming a ulcerations forming a stricture.stricture.

X-ray showing abnormal X-ray showing abnormal terminal ileum in Crohn's terminal ileum in Crohn's diseasedisease

The typical perianal skin tag The typical perianal skin tag of Crohn's of Crohn's DiseaseDisease

Enterocutaneous fistulae in Enterocutaneous fistulae in Chrohn'sChrohn'sdiseasedisease