Gallstone pancreatitis is a chronic inflammatory disease of the pancreas, which occurs as a result of damage to the liver and VVP (bile ducts). It is manifested by biliary colic, dyspeptic phenomena, jaundice, diabetes mellitus and weight loss. The diagnosis is made after ultrasound of the hepatobiliary system, CT or MRI of the abdominal organs, a number of functional tests. Medication therapy is prescribed. A prerequisite for healing is adherence to a strict diet and abstinence from alcohol. Surgical intervention is performed in the presence of concretions in the gallbladder.
ICD 10
K86.1
Meaning
Gallstone pancreatitis is a persistent disease of the pancreas, closely associated with inflammatory and other diseases of the hepatobiliary system. Worldwide, the incidence of pancreatitis has more than doubled over the past decades; at the same time, in the United States, this indicator has tripled among adults, and fourfold among children. One of the most common conditions for the occurrence of chronic pancreatitis is GI (cholelithiasis) – pancreatitis with it is detected in 25-90% of cases.
Exacerbations of the disease are usually associated with the migration of the stone along the biliary tract. In this situation, surgical treatment is recommended for the patient. If the patient refuses the operation, he should be warned that with repeated colic, the scope of intervention may be much wider. Timely treatment of diseases of the biliary ducts leads to a decrease in the frequency of pancreatitis of biliary genesis.
Causes of gallstone pancreatitis
Even more than thirty years ago, leading gastroenterologists pointed out that diseases of the biliary tract are the cause of pancreatitis in more than 60% of patients. Gallstone pancreatitis can occur in the following diseases: gastrointestinal tract, abnormalities of the structure of the bile and pancreatic ducts, dyskinesia of the gallbladder, chronic cholecystitis, cirrhosis of the liver, pathology of the fater’s nipple (inflammation, spasm, stricture, blockage of the stone). To provoke an exacerbation of chronic pancreatitis, the intake of foods or medications with a choleretic effect, a sharp weight loss.
Pathogenesis
There are several mechanisms for the development of gallstone pancreatitis. The first is realized through the spread of infection with HDL to the pancreas through the lymphatic pathways. The second occurs in the presence of stones in the common bile duct, leading to the development of hypertension in the ducts of the pancreas, followed by pancreatic edema.
The third mechanism is the throwing of bile into the pancreatic ducts in the pathology of the Fater papilla (the place of opening of the common duct of the liver and pancreas into the duodenum). As a result, the ducts and pancreatic tissue themselves are damaged, and the inflammatory process develops. The latter will be aggravated by inflammatory liver diseases, since they contain a huge amount of free radicals and peroxide compounds in the bile thrown into the pancreas, which significantly damage the pancreas.
Research in the field of modern gastroenterology has discovered another mechanism of the inflammatory process in biliary pancreatitis – the formation of biliary sludge. With cholecystitis and subsequent dysfunction of the gallbladder, the physico-chemical state of the bile is disturbed, some of its components precipitate with the formation of microcells – this is the biliary sludge. When moving along the ZHVP, this sediment injures the mucous membrane, causing narrowing of the ducts and the fater papilla. The stenosis of the latter leads to a violation of the secretion of bile into the 12 duodenum and its discharge into the pancreatic ducts, as well as to stagnation of secretions in the ducts of the pancreas.
As a result of stagnation, the activation of pancreatic enzymes contained in the secret does not occur in the intestinal cavity, but in the ducts. The protective barrier of the pancreas is damaged, and the infection easily penetrates into the gland tissue. Large gallbladder stones can cause blockage of the common bile duct or the Oddi sphincter, which will also lead to bile reflux into the pancreatic ducts.
Gallstone pancreatitis symptoms
The clinic of this disease is similar to other gastrointestinal diseases: gastric and duodenal ulcers, intestinal tumors, antral gastritis, viral hepatitis, pancreas tumors, chronic stone-free cholecystitis and others. Therefore, in the presence of the following symptoms, these diseases should be excluded first of all, besides they can support a chronic inflammatory process in the pancreas.
In 90% of cases, pain syndrome is dominant in pancreatitis. Abdominal pain can be localized in the epigastrium, radiate to both hypochondria, right shoulder, back. Usually, the pain appears 2-3 hours after eating or at night, sometimes immediately after drinking carbonated drinks, provoking spasm of the Oddi sphincter. Most often, pain occurs after a violation of the diet – the use of fatty, fried, spicy and extractive foods. Pain may be accompanied by fever, nausea, the appearance of bitterness in the mouth. With a complete blockage of the fater’s nipple with a stone, mechanical jaundice appears – the skin and mucous membranes are stained.
With the development of the inflammatory process in the tissues of the pancreas, its endo– and exocrine function is disrupted. Endocrine disorders are characterized by disorders of carbohydrate metabolism (hyperglycemia or hypoglycemia during an attack), and exocrine disorders are characterized by enzyme insufficiency of the pancreas with subsequent digestive failures. The patient has loose stools several times a day, while the stool is grayish, greasy, fetid. Worries about flatulence, rumbling in the stomach. Dyspeptic phenomena also include belching, heartburn, decreased appetite. Against the background of diarrhea, increased fat loss, digestive disorders, there is a decrease in body weight. The phenomena of vitamin and mineral deficiency are increasing.
Complications
Gallstone pancreatitis in the absence of proper treatment can have a number of complications. The early ones include dysfunction of other organs and systems (shock, acute liver failure, acute respiratory failure, encephalopathy, gastrointestinal bleeding, intestinal obstruction, pancreatic abscess, pancreatic necrosis, diabetic coma, jaundice of mechanical genesis) and late complications (pseudocysts, ascites, fistulas, narrowing of the intestine).
Diagnostics
In clinical and biochemical blood tests in chronic gallstone pancreatitis, inflammatory changes, an increase in the level of bilirubin, cholesterol and alkaline phosphatase, a decrease and a violation of the ratio of basic proteins are noted. The level of amylase in the blood and urine increases 3-6 times. Changes in the coprogram usually occur after the loss of function of more than 90% of exocrine cells: these are undigested muscle fibers, starch, neutral fat. A number of tests are carried out with the introduction of substances into the stomach that, under the action of pancreatic enzymes, should be cleaved with the release of specific markers. By the presence of these markers in the blood, the external secretory function of the pancreas is judged.
Ultrasound of the hepatobiliary system and ultrasound of the pancreas allows to assess the presence of concretions in the VVP and pancreatic ducts, the general condition of the pancreas. The most effective in terms of detecting stones is endoscopic or intra-current ultrasound. A more informative method (up to 90%) is CT of the biliary tract, especially if it is performed with the introduction of a contrast agent. ERCP are also widely used in the diagnosis of diseases of the biliary and pancreatic ducts.
Gallstone pancreatitis treatment
Not only a gastroenterologist takes part in the treatment, but also an endoscopist, a surgeon. The main condition for stopping the progression of the disease and preventing exacerbations is the cure of the underlying disease. If necessary, stones are removed or the condition of the fater’s nipple is improved (preferably by endoscopic method).
In case of exacerbation of pathology, treatment should include the removal of pain syndrome (analgesics and antispasmodics), correction of external and internal secretory functions of the pancreas, detoxification, prevention of infectious complications (antibiotics). Usually, in the first three days of exacerbation, therapeutic fasting is recommended, non-carbonated alkaline mineral waters should be drunk. After resuming nutrition, you should limit the amount of fat in the diet, strictly take into account the intake of carbohydrates. Food should be taken in frequent portions, in compliance with mechanical and thermal care.
To reduce the destructive effect of activated pancreatic enzymes, somatostatin, proton pump inhibitors, protease inhibitors are prescribed. Microspherical enzymes are prescribed to restore enzymatic dysfunction of the pancreas, and hypoglycemic agents are prescribed to normalize blood sugar levels. Surgical treatment is carried out only in the presence of concretions and pathology of the Oddi sphincter.
Prognosis and prevention
The prognosis of gallstone pancreatitis with timely treatment of calculous cholecystitis and cholangitis is favorable. Failure to perform timely surgery may lead to deterioration of the process, with subsequent exacerbation, extended surgical intervention may be required. In case of non-compliance with dietary recommendations, refusal of treatment, alcohol consumption, the outcome is unfavorable.
Prevention of this form of chronic pancreatitis is timely diagnosis and treatment of diseases of the hepatobiliary system, if necessary, surgical removal of concretions. In the presence of symptoms of gallstone pancreatitis, a diet should be followed to prevent exacerbations, avoid the use of choleretic products and medicines. It is necessary to undergo regular examination by a gastroenterologist (annually).
