PancreatitisPancreatitis. . Diaseses of Diaseses of the intestinethe intestine: : enteritisenteritis, , colitiscolitis. . DiagnosticsDiagnostics. . Main Main principles of treatmentprinciples of treatment

N. Bilkevych

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.

Chronic pancreatitisChronic pancreatitis ( (CPCP) -) - Chronic inflammatory Chronic inflammatory

affection of pancreatic affection of pancreatic gland parenchymagland parenchyma which which lasts over lasts over 6 6 monthmonth з з with with exocrinic parenchymal exocrinic parenchymal destructiondestruction, , fibrosisfibrosis and and on later stages - on later stages - endocrinic parenchymal endocrinic parenchymal destructiondestruction..

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

((azathioprinazathioprin, , izoniazidizoniazid, , tetracyclinetetracycline, , sulfa drugssulfa drugs))

Protein defficiencyProtein defficiency ((kwashiorkorkwashiorkor))

HereditaryHereditary Ischemic Ischemic ((affection of affection of

pancreaticpancreatic vesselsvessels)) IdiopaticIdiopatic

Secondary pancreatitisSecondary pancreatitis : : diseases of bile ductsdiseases of bile ducts ( (30-30-

40 %)40 %)               diseases of a duodenumdiseases of a duodenum       pathology of duodenal pathology of duodenal

papilla:primary papilla:primary ((tumor,papilitistumor,papilitis) ) and and secondarysecondary ( (oddy’s sphincter oddy’s sphincter dyskinesiadyskinesia, , skarsskars))

              diseases of a liverdiseases of a liver               diseases of intestinediseases of intestine               viralinfectionsviralinfections ( (epidemic epidemic

parotitisparotitis))               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 Exocrinic secratory disfunction

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

Exocrinic secratory disfunction Exocrinic secratory disfunction ((pancreatic diabetes mellituspancreatic diabetes 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 patternSyndrome 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 patternSpider 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))

Laboratory diagnosticsLaboratory diagnostics:: 1. 1. Complete blood countComplete blood count:: inin 25 % – 25 % – leucocytosisleucocytosis, , increased ESRincreased ESR..

2.2. Assessment of pancreatic enzymes in the blood Assessment of pancreatic enzymes in the blood ((amylaseamylase, , lipaselipase, , tripsine in blood and urinetripsine 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 computer

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

                 MRT: visualization MRT: visualization of normal and of normal and pathologically changed pathologically changed pancreatic ductspancreatic 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 into entrance of the pancreatic duct into the small intestine can be viewed the small intestine can be viewed through the endoscope. A special through the endoscope. A special instrument on the end of the instrument on the end of the endoscope can then be passed endoscope can then be passed into the pancreatic duct and the into the pancreatic duct and the gallstone is extracted. Very rarely gallstone is extracted. Very rarely pancreatitis is severe enough to pancreatitis is severe enough to require surgery, which is usually require surgery, which is usually performed when the pancreas performed when the pancreas becomes infected. Dead pancreatic becomes infected. Dead pancreatic tissue is removed, and the area tissue is removed, and the area around the pancreas is washed around the pancreas is washed clean. Patients who require such clean. Patients who require such treatment usually have prolonged treatment usually have prolonged hospital stays and are seriously ill. hospital stays and 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 in panceratic ductsdyskinesia of bile in panceratic 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, , dalargindalargin__ Proton pomp inhibitorsProton pomp inhibitors ((omeprazolomeprazol); ); Н2-Н2-histaminobloquers: famotidin, kwamatelhistaminobloquers: famotidin, kwamatel)) М-М-cholinolythicscholinolythics Spasmolytics - Spasmolytics - ( (plathyphilinplathyphilin, , gastrocepingastrocepin) ) AntacidesAntacides - ( - (maaloxmaalox,, phosphalugel phosphalugel)) EnzimesEnzimes - ( - (pangrolpangrol 10 10 000 000-20-20 000 000, , CreonCreon 10 10000000-25-25000000-40-40000 UN000 UN, ,

MezymMezym- - forteforte). ). Antienzyme preparationsAntienzyme preparations ( (protease inhibitorsprotease inhibitors) ) Contrical ,Contrical ,

Trasilol, Trasilol, Gordox, Aminacapronic acid, Metiluracil, pentoxilGordox, Aminacapronic acid, Metiluracil, pentoxil Elimination of painElimination of pain

Elimination of dyskinesia Elimination of dyskinesia domperidonedomperidone ( (motiliummotilium))..

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 intestine. It causes decrese of

o its barrier function, its barrier function, o digestion and absorptiondigestion and absorption,, o contamination of upper parts of intestine contamination of upper parts of intestine

with large amount of microbeswith large amount of microbeso secondary metabolic and immune secondary metabolic and immune

disordersdisorders, , nervous system disfunctionnervous system disfunction

EthiologEthiologyy InfectionsInfections::

dysenteriadysenteria, , microsporidiosismicrosporidiosis,,

cyclosporescyclospores, , salmonellosissalmonellosis,,

Staphilococcus and Staphilococcus and othersothers,,

virusesviruses ((rotavirusrotavirus, , enteral enteral adenovirusadenovirus), ),

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

Salmonella typhiSalmonella typhi, , Yersinia enterocoliticaYersinia enterocolitica

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

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 the left sideand on the left 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 in many Changes in many 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 propagates on alllarge intestine propagates 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 morning diarrhoea in the morning

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

Diarrhoea develops after intake of fatty food, Diarrhoea develops after intake of fatty food, cold meal, milk, species, products with cold meal, milk, species, products with plant fibers. Bad smell of fecesplant fibers. Bad smell of 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..

TreatmentTreatment DietDiet AntibioticsAntibiotics Elimination of Elimination of dehydration dehydration

and abdominal and rectal and abdominal and rectal pain or discomfort. pain or discomfort.

Antidiarrheal drugs are Antidiarrheal drugs are usually prescribed, such as usually prescribed, such as Kaopectate, Lomotil, Kaopectate, Lomotil, Paregoric or Imodium.Paregoric or Imodium.

EnzymesEnzymes Simeticon (espumisan)Simeticon (espumisan) 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..

AA group of chronic group of chronic disorders that cause disorders that cause inflammation or inflammation or ulceration in the ulceration in the small and large small and large intestines. intestines. Ulcerative Ulcerative colitisCrohn'scolitisCrohn's diseasedisease

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

DefinitionDefinition CROHN’S CROHN’S DISEASE DISEASE

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

EtiologyEtiology The fundamental cause of The fundamental cause of

Crohn's disease is unknownCrohn's disease 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

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