Comprehensive treatment of chronic pancreatitis

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The basic principle of the treatment is to remove the cause, and to control symptoms, improve function and treatment of complications of pan


The basic principle of the treatment is to remove the cause, and to control symptoms, improve function and treatment of complications of pancreatic focus; emphasize treatment in individualized treatment principle; pay attention to local treatment and systemic treatment, comprehensive treatment of etiological treatment and symptomatic treatment, conservative treatment and surgical treatment combined. At present, most treatment aims to reduce pancreatic exocrine pancreas to "rest", but the effect is poor. The basic purpose of treatment is to relieve pain, correct pancreatic insufficiency and complications.

1 general treatment

(1) patients with chronic pancreatitis should be given absolute abstinence from alcohol.

(2) with some possible and the pathogenesis of the drug: sulfasalazine, estrogen, glucocorticoid, indomethacin, hydrochlorothiazide, methyldopa etc..

(3) in patients with chronic pancreatitis due to loss of appetite, diarrhea and malabsorption, especially fatty diarrhea, often with weight loss and malnutrition, should be given high calorie, high protein, high sugar, high vitamin and low fat diet. Guarantee the supply of total daily calories is to supplement the pancreatin. 40% of the total calories should be supplied by sugar, the daily supplement of protein is not less than 100 ~ 200g, half of which should be animal protein, such as fish, meat and eggs, etc.. The supply of fat should emphasize the addition of water soluble, easy to be absorbed by the body of medium chain fatty acids, which absorb the entry of the next vein rather than the intestinal lymphatic system. Some long-chain fatty acids have a strong stimulating effect. For patients with chronic diarrhea, should pay attention to add enough fat soluble vitamins, such as A, D, E, K and B vitamins, appropriate to add a variety of trace elements. To a severe loss of pancreatic exocrine function in advanced chronic pancreatitis patients can also use parenteral nutrition (TPN) treatment, namely from intravenous feeding of glucose, Intralipid, amino acid and preparation of albumin, electrolytes, fat soluble vitamins, to ensure the supply of heat. TNP treatment for several weeks or months, but also to maintain a few years of reports.

(4) antibiotics should be used in patients with acute exacerbation, especially in patients with biliary tract infection. Such as acute exacerbation of severe performance, should be closely monitored and use somatostatin and other drugs active treatment.

2 abdominal pain is the main symptom of chronic pancreatitis. The degree of pain may be caused by occasional postprandial discomfort with persistent abdominal pain associated with nausea, vomiting, and weight loss. Abdominal pain seriously affects the quality of life of patients, and may lead to narcotic analgesic addiction.

(1) causes of abdominal pain:

Acute inflammation of the pancreas: chronic pancreatitis can often occur many times of acute inflammation, each attack symptoms similar, but the general follow-up of abdominal pain when compared to first, the second light.

Involvement of the nervous system: inflammation of the nervous system that governs the pancreas is another important cause of chronic pancreatitis. Research has found that the number of pancreatic interlobular and intralobular nerve bundles increased, the diameter increased, and the disintegration of peripheral nerve myelin, when myelin disintegration occurs, accumulation of inflammatory cells in peripheral nerve, release of inflammatory mediators stimulates nerve endings, causing pain; but it is not clear why the similar changes also occurred in patients with painless.

The increase of pancreatic duct pressure: many studies have observed that chronic pancreatitis, pancreatic parenchyma dilatation of the pancreatic ductal, pseudocyst internal and abdominal pain in chronic pancreatitis in surgery can be found in the pancreatic duct pressure increased significantly after the operation, the pressure back to normal.

The common channel or duodenal stenosis: is usually caused by pancreatic fibrosis, and abdominal pain, see the specific complications and treatment "".

(2) treatment: the treatment of abdominal pain should be based on the degree of pain and duration of the patient. In some cases, it is very difficult to control the pain, and it should be noted that many studies have found that nearly 30% of cases. The current treatment is to take comprehensive measures. Main methods are:

The analgesic drugs: is generally the first to use a small amount of non narcotic analgesics, such as aspirin, Helicid tablets (Compound Aminopyrine Phenacetin Tablets), indomethacin, paracetamol and non steroidal anti-inflammatory drugs and bucinnazine (AP-237), tramadol and other strong analgesics. If severe abdominal pain, does affect the quality of life, can use of narcotic analgesics, such as cocaine, papaverine hydrochloride and pethidine opioid derivatives, morphine sustained-release tablets can also be used in small doses, such as Mae Kangding, tension of high-dose morphine can increase the sphincter of Oddi, should not be used. Doctors should try to reduce the likelihood of addiction to painkillers, especially narcotics. In addition, the use of painkillers, pay attention to prevent constipation, and abdominal discomfort caused by constipation may be abdominal pain and was again treated with analgesics.

To reduce the inflammation of the pancreatic parenchyma: chronic pancreatitis, as a result of acute inflammation and worsen the condition, the treatment of acute pancreatitis and the same, there is no prevention of acute inflammation of the specific diet.

The prohibition: prohibition is necessary, especially for alcoholic pancreatitis, Rechabite after 75% of the patients with pain remission. The mortality of patients with alcoholic pancreatitis is greatly improved if they continue to drink.

The lower the pressure in the pancreatic duct:

A. inhibited secretion:

A. proton pump inhibitors (PPI) and H2 receptor blockers: if the pancreatic secretion caused by excessive pancreatic duct pressure is too high and cause pain, then use the PPI or H2 blockers can reduce the secretion of pancreatic juice, will increase to more than 4.5 pH in the duodenum and prevent pancreatic pain.

B.: pancreatin pancreatic enzyme replacement therapy used to reduce pain in patients with chronic pancreatitis. The method can be used for the initial treatment of most patients with severe abdominal pain. The treatment mechanism of oral pancreatin through inhibition of the feedback loop in the duodenum, regulating the release of CCK, and CCK is the hormone stimulated pancreatic secretion of digestive enzymes. Trypsin can inactivate CCK, but it has a decreased secretion in chronic pancreatitis, and pancreatic cancer can be corrected by the addition of trypsin, which can reduce CCK mediated pancreatic secretion. Efficacy evaluation: enzyme therapy effect is not a part of abdominal pain, patients on placebo response rate. One of the reasons for the poor effect is the inhibition of trypsin activity need feedback loop is very high, in fact very short residence time of protease in the duodenum, which can also explain the reason of the failure of some trypsin release agent.

C.: octreotide in the treatment of these drugs can relieve pain. Its mechanism is to reduce the secretion of the pancreas, so that the pancreas in a temporary "rest" state, so that the pressure in the pancreatic duct to reduce pain relief. In a randomized double-blind study in a prospective, before each meal given 200 g octreotide, for 4 consecutive weeks, the pain relief rate was 65%, 35% for placebo. At this point, is not recommended for routine use.

B. endoscopic stent placement and pancreatic sphincterotomy: the use of this method is based on chronic pancreatitis in patients with abdominal pain may be due to the dysfunction of Oddi sphincter and stenosis of the main pancreatic duct. The purpose of endoscopic sphincterotomy is to make the pancreatic duct unobstructed, reduce the pressure in the pancreatic duct, and reduce the expansion of the pancreatic duct. Open method is in 1 ~ 2 Vater of ampullary point cut to 3 ~ 10mm long, and biliary sphincterotomy, the latter is open between 11 to 12 points. After sphincterotomy, can continue to take stones or placed drainage tube, etc.. Stent placement can significantly reduce pancreatic duct obstruction and relieve abdominal pain. The diameter of the main pancreatic duct, the degree of stenosis and the most distal position are the main factors that determine the position of the stent and the stent. Efficacy evaluation: endoscopic sphincterotomy for most cases, the effect is not good, but there are exceptions. Endoscopic stenting is effective in some cases. There was a group of patients with pancreatic duct stenosis or primary pancreatic duct stones who were treated with stent implantation and 50% months of pain relief. One of the problems with endoscopic stent placement is that the morphology of chronic pancreatitis in 80% of the normal appearance of the pancreas may be altered after stenting, and its long-term consequences are unclear. Up till now, the pain of chronic pancreatitis treated by endoscopic interventional therapy is not yet mature, and further prospective randomized controlled trials are needed.

C. surgical treatment:

Surgical treatment should be considered for patients with failed medical treatment. The most commonly used is pancreatic duct decompression and subtotal resection of the pancreas. Puestow is often used in pancreatic duct decompression. Subtotal resection of the pancreas is part of the removal of the pancreas, usually the tail of the pancreas or the head of the pancreas. Decompression of the pancreatic duct was effective in 80% of patients with pain, but in many cases the symptoms recurred within a period of 1 years. For patients who are not effective in the treatment of pancreatic jejunal anastomosis, the second subtotal resection of the pancreas can improve the symptoms of the patients. It has been reported that early decompression of the pancreatic duct by decompression surgery can prevent subsequent pancreatic dilatation caused by impaired function. But there are also observed, even though pancreaticojejunostomy, pancreatic exocrine function, also to damage. Therefore, it is still advocated that surgery is only applicable to patients with chronic pancreatitis who have abdominal pain and pancreatic duct dilation (> 6cm).

The blocking of the abdominal nerve: percutaneous ethanol or steroids or endoscopic injection of celiac plexus when celiac plexus blocking, can alleviate or reduce pain a few hours or a few months, but the overall effect is not ideal. Moreover, ethanol injection can cause orthostatic hypotension and mild hemiplegia. Therefore, the application of this method is limited; it is recommended to be used for the treatment of pancreatic cancer. The use of steroids to block the nerves was better than ethanol, but only 50% of the patients had some pain relief. In these patients, the symptoms often recur within 2 to 6 months, but the treatment is effective.

The antioxidant treatment: the data show that the deficiency in patients with chronic pancreatitis are antioxidants. Some reports suggest that antioxidant therapy can relieve the pain to a certain extent, but still need further study.

Summary: for most patients with chronic pancreatitis, abdominal pain, not satisfied with the medical treatment; endoscopic treatment of optimism, but need further investigation; surgical treatment can significantly improve the symptoms, but also to conduct a prospective randomized trial with other treatment methods, comparative analysis of the effect; through the improvement of nerve conduction generally ineffective, but the method improved.

Most patients with chronic pancreatitis do not require strong treatment. If the patient every 3 to 6 months to have only 1 to 2 abdominal pain, and its quality of life has not been affected, you can use traditional pain medication. Early surgery or endoscopic treatment may protect the pancreas, but it cannot be considered that it can be relaxed.

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