Hemorrhagic pancreatitis is an extremely severe form of damage to the pancreas, characterized by the rapid destruction of the parenchyma of the organ and blood vessels by its own enzymes, resulting in necrosis, hemorrhages and peritonitis. The main signs of the disease are intense pain syndrome and toxemia; the condition of patients is critical. Diagnosis is based on the determination of a significant increase in enzyme activity, ultrasound signs of pancreas damage and diagnostic laparoscopy or laparotomy data. Anti–enzyme, detoxification therapy, anesthesia are carried out, if ineffective, surgical treatment.
Meaning
Hemorrhagic pancreatitis is one of the most severe forms of damage to the pancreas, accompanied by rapid activation of proteolytic enzymes, the development of organ necrosis, impregnation of the parenchyma with blood and bleeding. At the same time, other organs are involved in the process, hemorrhagic peritoneal effusion is formed, enzymatic aseptic peritonitis develops. Regardless of the cause, the lesion always affects the acinuses (secretory areas of the pancreas that produce enzymes) and blood vessels.
The disease is characterized by severe pain syndrome and intoxication, hemodynamic disorders, complete collapse of the pancreas and death within the first day is possible. According to statistics, 60% of patients with hemorrhagic pancreatitis develop mental disorders, a third of patients have delirium and coma. A feature of this form of pancreatitis is a critically high increase in the level of pancreatic enzymes – 7-9 times, the presence of foci of hemorrhages in the peritoneum, ligamentous apparatus. This is one of the most severe pathologies in modern gastroenterology with an extremely high mortality rate.
Causes of hemorrhagic pancreatitis
Hemorrhagic pancreatitis develops when exposed to factors that cause rapid activation of the enzyme systems of the gland. The main causes of gastroenterologists include inflammatory processes accompanied by a violation of the outflow of pancreatic juice, intoxication with ethanol and other substances, reflux of secreted juice into the ducts of the gland with cholelithiasis, DIC syndrome, the effect of high doses of ionizing radiation, traumatic organ damage and autoimmune disorders.
Pathogenesis
Partial or complete organ damage develops when a critical concentration of pancreatic enzymes is reached – the gland parenchyma is self-digested with trypsin and chymotrypsin (autoaggression), the enzyme elastase destroys the walls of blood vessels. The organ tissue is soaked with blood, aggressive substances enter directly into the abdominal cavity, causing peritonitis. An important role belongs to the violation of humoral factors regulating the production of digestive enzymes. The inhibitory effect on their secretion is provided by somatostatin, glucagon, calcitonin and antitrypsin proteins, stimulating – secretin, pancreosimin, gastrin, insulin and serotonin.
Symptoms of hemorrhagic pancreatitis
Pathology is a severe form of acute pancreatitis, in which violent symptoms develop within a few hours. The main sign is a pronounced pain syndrome. The pain can be of a shingling nature, radiate to the lumbar region or spread throughout the abdomen; it is expressed constantly, somewhat decreases in the position with the legs brought to the abdomen. At the beginning of the disease, there is a discrepancy between subjective pain sensations and relatively little pain during palpation. The intensity of the sensations corresponds to the degree of damage to the pancreas. In some cases, collapse develops.
Due to an increase in the concentration of vasoactive substances in the blood, hyperemia of the skin occurs. It is possible to develop gastrointestinal bleeding, the appearance of exudative pleurisy – effusion in the pleural cavity, which may have a hemorrhagic character. Also characterized by dry tongue, impaired kidney function, tachycardia and a decrease in blood pressure. With the increase of toxemia, the heart rate increases significantly (up to 160-180 per minute) against the background of normal or slightly elevated body temperature, diuresis decreases up to anuria. These signs are prognostically unfavorable.
During hemorrhagic pancreatitis, there are three periods that rapidly replace each other. The first period is characterized by pronounced hemodynamic disorders and pancreatogenic shock. Within a few hours, pronounced toxemia is formed with a generalized violation of microcirculation and central hemodynamics. A typical pain syndrome develops rapidly, in 20% of cases – pancreatogenic shock with an extremely severe general condition of the patient.
The second period is accompanied by the addition of symptoms of functional failure of vital organs: respiratory failure increases, the phenomenon of toxic damage to the liver, kidneys (with an increase in azotemia and creatinine levels). Mental disorders are characterized by agitation, anxiety, inappropriate behavior; delirium and coma may develop. The third period occurs after a few days, is determined by post-necrotic dystrophic and purulent complications: apostematous pancreatitis is formed, retroperitoneal phlegmon and purulent peritonitis are possible.
Diagnostics
Laboratory methods play an important role in the diagnosis of hemorrhagic pancreatitis. Since the acinar part of the gland is destroyed extremely quickly, the concentration of pancreatic enzymes increases rapidly. Already in the first hours, the activity of alpha-amylase is twice the norm, after five hours it increases 5-9 times. An increase in the level of elastase is also characteristic. During an emergency ultrasound of the abdominal organs, an increase in the size of the pancreas, heterogeneity of the structure due to foci of hemorrhages and necrotic changes is determined.
Diagnostic laparoscopy is highly informative, which makes it possible to detect hemorrhagic effusion in the abdominal cavity, signs of enzymatic aseptic peritonitis, as well as specific foci of hemorrhages in the large omentum and gastrointestinal ligament. In case of a critical condition of the patient, a laparotomy is performed, during which the abdominal cavity is audited, the condition of the pancreas is assessed and therapeutic manipulations are performed. Pathology is differentiated from other acute diseases of the abdominal cavity (perforation of stomach ulcers, intestinal infarction, acute intestinal obstruction).
Treatment for hemorrhagic pancreatitis
Suspicion of the presence of the disease is an indication for emergency hospitalization of the patient in the department of surgery or intensive care with intensive therapy. Treatment is aimed at relieving pain syndrome, toxemia, stopping further damage to the gland, preventing purulent complications. Antispasmodics, analgesics, glucose-novocaine mixture, antihistamines are administered parenterally. Regional novocaine blockade, drip administration of saline solution with protease inhibitors (aprotinin, kontrikal) is carried out.
In order to stop the production of enzymes in hemorrhagic pancreatitis, complete starvation is necessarily prescribed, in addition to protease inhibitors, cytostatics and ribonuclease are used. To relieve pain, promedol with atropine is found. Pathology is usually accompanied by infectious complications, therefore, antibacterial therapy is carried out from the first day. Correction of pancreatogenic toxemia is achieved by the appointment of anti-enzyme therapy, regulation of water-electrolyte balance, hypovolemia. Extracorporeal hemocorrection (plasmapheresis) is highly effective.
In case of ineffectiveness of conservative therapy, surgical treatment of hemorrhagic pancreatitis is performed, which consists in opening the capsule of the gland, draining it, removing necrotic areas, novocaine blockade around the organ. With extensive damage to the pancreas (subtotal or complete necrosis), radical surgical intervention is necessary – resection of a part of the gland or pancreatectomy (complete removal).
Prognosis and prevention
Hemorrhagic pancreatitis is the most unfavorable form of the disease in prognostic terms – a fatal outcome occurs in 50% of cases, even with timely assistance. The main cause of death is pancreatogenic toxemia. Prevention consists in excluding the use of alcoholic beverages, proper nutrition, timely detection and treatment of diseases of internal organs (in particular, cholecystitis, cholelithiasis and gastric ulcer).
Literature
- Pancreatic resection versus peritoneal lavation for acute fulminant pancreatitis. A randomized prospective study. Kivilaakso E, Lempinen M, Mäkeläinen A, Nikki P, Schröder T.
Ann Surg. 1984 Apr;199(4):426-31. link - Management of asparaginase induced hemorrhagic pancreatitis complicated by pseudocyst. Greenstein R, Nogeire C, Ohnuma T, Greenstein A. Cancer. 1979 Feb;43(2):718-22. link
- Direct Peritoneal Resuscitation in the Setting of Hemorrhagic Pancreatitis. McKenzie J, Quinones PM, Mentzer CJ, Kruse EJ. Am Surg. 2017 Nov 1;83(11):e441-e443. link
- Acute pancreatitis. Geokas MC. Calif Med. 1972 Aug;117(2):25-39. link
- The current status of recognition and treatment of severe necrotizing pancreatitis. Baker RJ, Duarte B. Surg Annu. 1986;18:129-44. link
