1, treatment
Acute pancreatitis
Acute edematous pancreatitis is mainly treated by palliative care, while hemorrhagic necrotizing pancreatitis should be treated according to the situation. In the process of non-surgical treatment of acute edematous pancreatitis, it is necessary to closely observe the evolution of its course. The treatment of localized pancreatic necrosis is still controversial.
Non-surgical treatment: preoperative preparation for most acute edematous pancreatitis and hemorrhagic necrotizing pancreatitis. Non-surgical treatment includes: prevention and treatment of shock, improvement of microcirculation, spasmolysis, analgesia, inhibition of pancreatic enzyme secretion, anti-infection, nutritional support and prevention of complications.
1. Prevention and treatment of shock and improvement of microcirculation: Transfusion was performed by monitoring the changes of central venous pressure, urine volume, central venous pressure, urine volume and specific gravity. In order to improve microcirculation, appropriate amount of dextran should be given. In addition, according to the electrolyte changes of blood biochemical tests and the acid-base results of blood gas tests, potassium and calcium ions are supplemented to correct the acid-base imbalance.
2. Inhibition of pancreatic secretion: H2 receptor blockers: such as cimetidine, ranitidine and famotidine. Aprotinin: The current dosage is 20,000 units /kg body weight, and intravenous infusion is added, and the course of treatment is 1 week.
3. Spasm and pain relief: The traditional method is intravenous infusion of 0. 1% procaine for vein closure. Moreover, dolantin and atropine can be combined regularly, which can not only relieve pain but also relieve Oddi sphincter spasm. In addition, isoamyl nitrite and nitroglycerin are used for severe pain.
4. Nutritional support: ① Patients with mild pancreatitis without complications do not need nutritional support; ② For moderate and severe acute pancreatitis, early nutritional support should be given (if hemodynamics and cardiopulmonary stability allow); (3) Early nutritional support should provide enough calories through parenteral route; ④ During the operation, patients underwent jejunostomy for enteral nutrition; ⑤ When the patient's symptoms, physical examination and CT images are basically normal, then take a diet with less fat orally.
5. Application of antibiotics: The application of antibiotics in acute hemorrhagic necrotizing pancreatitis is beyond reproach. As the prevention of secondary infection, a certain amount of antibiotics should be used reasonably in acute edematous pancreatitis. In recent years, the frequency of pancreatic infection is Escherichia coli, Klebsiella pneumoniae, Enterococcus, Staphylococcus aureus, Pseudomonas aeruginosa, Pseudomonas mirabilis, Streptococcus, Enterobacter aerogenes and Bacteroides fragilis. The results showed that extended-spectrum antibiotics, imipenem (Tylenol) and ciprofloxacin all had inhibitory effects on the above bacteria (except fragile bacilli). Cefotazol (Fudaxin), cefotaxime, sisomicin, rifampicin and compound sulfamethoxazole can inhibit 5 of the above 9 kinds of bacteria, clindamycin can inhibit 3 kinds of bacteria, and metronidazole can only inhibit fragile bacteria.
6. Peritoneal lavage: Under local anesthesia, make a small incision in the midline of the hypoumbilical abdomen, put in a soft silicone tube that is not easy to break, and then seal the periphery of the silicone tube. The lavage fluid is isotonic, including dextran and glucose 15g/L, potassium 4mmol/L, heparin 100IU/L, ampicillin125 ~ 250mg/L. Abdominal lavage plays a very good role in the early stage, because it reduces the absorption of toxic substances and reduces cardiopulmonary complications. However, the drainage effect is still not ideal, and some pancreatic necrosis or liquefaction can not be taken out of the body. The effect of late drainage and lavage is not as good as that of peripancreatic and retroperitoneal pancreas after laparotomy.
7. Strengthen monitoring: Peri-operative monitoring should be strengthened for acute severe pancreatitis. In acute pancreatitis, the mortality of ARDS is the highest, while renal failure and other complications such as acute ulcer gastrointestinal bleeding and peptic ulcer bleeding in peritoneal pancreatic juice are lower than ARDS.
Surgical therapy
The surgical methods include: incision and decompression of pancreatic capsule; Debridement of pancreatic necrotic tissue; Routine pancreatectomy; Abdominal open occlusion; Abdominal zipper installation and so on.
Chronic pancreatitis
1. Abdominal pain treatment:
General treatment: Patients with chronic pancreatitis must absolutely abstain from drinking and avoid overeating. Use some drugs that may be related to diseases with caution: sulfasalazine, estrogen, glucocorticoid, indomethacin, hydrochlorothiazide, methyldopa, etc. For alcoholic pancreatitis, after absolute prohibition of alcohol, 75% patients can relieve the pain symptoms. If patients with alcoholic pancreatitis continue to drink alcohol, the mortality rate will be greatly increased.
Antibiotics should be used in acute attack, especially in patients with biliary tract infection. If the acute attack is serious, it should be closely monitored and actively treated with somatostatin and other drugs. The treatment of abdominal pain should depend on the degree and duration of pain. The main methods are: analgesic drugs: generally, a small amount of non-narcotic painkillers are used first, such as aspirin, somaitong tablets (painkillers), indomethacin, acetaminophen and other non-steroidal anti-inflammatory drugs, as well as strong analgesic drugs such as bupropion and tramadol. If the abdominal pain is serious and really affects the quality of life, narcotic painkillers such as cocaine, papaverine hydrochloride, pethidine and other opioid derivatives can be used as appropriate, and low-dose morphine sustained-release tablets such as mescandine can also be used. High dose morphine can increase the tension of Oddi sphincter, so it is not suitable for use. Doctors should try to reduce the possibility of addiction when giving painkillers, especially anesthetics. In addition, when using painkillers, pay attention to prevent constipation. Abdominal discomfort caused by constipation may be considered as abdominal pain and painkillers should be added again.
If chronic pancreatitis is aggravated by acute inflammation, its treatment is the same as acute pancreatitis.
Reduce the pressure in the pancreatic duct: If the pressure in the pancreatic duct is too high due to excessive secretion of pancreatic juice, PPI or H2 receptor blockers can prevent pancreatic pain by reducing the secretion of pancreatic juice and increasing the pH value in the duodenum to above 4.5. Pancreatic enzyme preparation: Pancreatic enzyme has different effects on abdominal pain. Octreotide therapy: These drugs can also relieve pain. Take 200 micrograms before each meal; After 4 weeks, the pain relief rate of octreotide G was 65% and that of placebo was 35%. It is not recommended to use it frequently.
Endoscopic stent implantation and sphincterotomy of pancreatic duct: The purpose of endoscopic sphincterotomy of pancreatic duct is to make the pancreatic duct unobstructed, reduce the pressure in the pancreatic duct, reduce the expansion of the pancreatic duct, and thus alleviate the pain of patients. The incision method is 3 ~ 10 mm long at the opening of Vater ampulla nipple at 1 ~ 2, which is different from the sphincterotomy of bile duct, and it is made at1~12. After sphincterotomy, stone removal or drainage tube can be continued. Placement of stent can obviously alleviate pancreatic duct obstruction and relieve abdominal pain symptoms. The diameter, stenosis and distal position of the main pancreatic duct are the main factors that determine the stent and position. Usually, the stent should pass through the narrow distal end, and try to place a stent with a larger diameter.
Surgical treatment: for patients with pain who have failed medical treatment, surgical treatment can be considered. The most commonly used methods are decompression of pancreatic duct and subtotal pancreatectomy. Pancreatic duct decompression often adopts pancreaticojejunostomy, namely Puestow operation. Subtotal pancreatectomy is the removal of a part of the pancreas, usually the tail or head of the pancreas.
For most patients with chronic pancreatitis and abdominal pain, the effect of medical treatment is not ideal; The prospect of endoscopic therapy is optimistic, but further observation and research are needed. Surgical treatment can obviously improve symptoms, but it needs to be compared with other treatment methods in a prospective randomized trial. Improving nerve conduction is generally ineffective, but its methods can be improved. Most patients with chronic pancreatitis do not need strong treatment. If patients only have 1 ~ 2 abdominal pains every 3 ~ 6 months, and their quality of life is not affected, they can be treated with traditional analgesic drugs. Early operation or endoscopic treatment may protect pancreatic function, but it cannot be considered that its indications can be relaxed.
2. Treatment of fatty diarrhea:
Limit the intake of fat, the degree of restriction depends on the severity of fat malabsorption, generally less than 20g per day. If limiting fat intake is ineffective, medication such as drugs must be started.
The first principle of medical treatment is to provide at least 30,000 U of lipase per meal. Taking enteric pancreatin is a very effective method. The purpose of treatment is to control symptoms, not to make fat malabsorption return to normal. Pancreatin has been used in clinic abroad, such as Viokase, Cotazym, Ilozyme and Creon. Generally, these drugs are taken 3-4 times a day before meals, with 30 days as a course of treatment, and those who have conditions can continue to take them after 30 days. Medium-chain triacylglycerol (MCTs) can be used for patients with severe steatorrhea who lose weight and are ineffective in diet and pancreatin therapy. MCTs can provide energy for the body, unlike long-chain triacylglycerol, which requires bile salts and trypsin. MCTs is easily degraded by lipase in stomach and pancreas, and bile is not needed. In addition, MCTs can be directly absorbed by small intestinal mucosa, which has little stimulation on pancreatic secretion. Peptone, a sausage preparation, has been used abroad, taking 3 ~ 4 cans a day for 10 week. It is not recommended to use large doses of pancreatin in clinic.
3. Treatment of diabetes
Diabetes often occurs in patients with severe and advanced chronic pancreatitis, and it only happens when more than 80% of pancreatic tissue is destroyed.
Control diet, cooperate with pancreatin, and strengthen the absorption of fat and protein. Because of the sensitivity to insulin, low-dose insulin should be given, preferably 20 ~ 40u per day, and the blood sugar does not have to drop to normal or below, so it can be properly controlled. Patients should be informed to identify the symptoms of hypoglycemia, closely monitor and pay attention to the principle of individualization to avoid hypoglycemia.
4. Endoscopic therapy
With the continuous improvement of endoscopic diagnosis and treatment technology, more and more endoscopes are used to treat chronic pancreatitis. For mild to moderate chronic pancreatitis, endoscopic treatment can avoid surgery, relieve pain, improve pancreatic function and expand treatment methods. Complications of endoscopic treatment include bleeding, perforation, pancreatic duct injury, postoperative acute pancreatitis and pancreatic abscess.
2. Prognosis
The mortality rate of acute pancreatitis is about 10%, and almost all deaths are the first attack, accompanied by three or more Ranson indexes. The occurrence of respiratory insufficiency or hypocalcemia indicates poor prognosis. The mortality rate of severe necrotizing pancreatitis is 50% or higher, and surgical treatment can be reduced to about 20%. Three weeks or more after the onset of pancreatitis, persistent fever or hyperamylasemia appears, suggesting pancreatic abscess or pseudocyst.
The prognosis of alcoholic pancreatitis is poor. Although some patients can relieve pain by themselves, most patients still have abdominal pain after 10 years. After withdrawal, some patients' pain can be improved, while some patients' pain remains unchanged. Generally speaking, surgery can relieve the symptoms of abdominal pain in a certain period of time, but after a period of time, abdominal pain can still occur. Patients with chronic pancreatitis have poor quality of life and often lose their jobs or retire early. The survival rate of alcoholic pancreatitis is obviously reduced, and the poor prognosis is related to drinking, smoking, liver cirrhosis and late diagnosis. Less than 25% of deaths are directly related to chronic pancreatitis, including postoperative deaths and deaths caused by diabetes and pancreatic cancer. One of the reasons for the low survival rate of chronic pancreatitis is the increased incidence of pancreatic cancer and extrapancreatic cancer. Some patients with alcoholic pancreatitis do not have calcification and endocrine and exocrine dysfunction, and these patients can have long-term abdominal pain relief. The natural course of idiopathic pancreatitis is better than that of alcoholic pancreatitis, which develops slowly to endocrine and exocrine dysfunction and has a long survival time. The prognosis of tropical pancreatitis is also better than that of alcoholic pancreatitis, and most of them die of pancreatic cancer and diabetic nephropathy, rather than malnutrition, tuberculosis and brittle diabetes.
Second, Chinese medicine.
Acute pancreatitis
1, Liver Depression and Qi Stagnation: Treatment: Soothing the liver and regulating qi, harmonizing the stomach and dredging the interior. Prescription: Chaihu Shugan Powder Jiawei Qingyi Decoction 1. Chaihu Shugan Powder focuses on soothing the liver and regulating qi, and is mainly used for treating liver depression and qi stagnation. In the prescription, Bupleurum soothes the liver, Fructus Aurantii Immaturus and Rhizoma Cyperi regulate qi, and the three drugs play the role of soothing the liver and regulating qi. Radix Paeoniae Alba nourishes blood and softens the liver, helps Bupleurum to relieve depression and clear heat, and cooperates with Glycyrrhiza uralensis to relieve pain and stomach; Chuanxiong promotes blood circulation, and Radix Curcumae is added to promote qi circulation to relieve depression and remove blood stasis. These two drugs have analgesic effect. Qingyitang 1 focuses on clearing pancreas and dispersing stagnated qi, and is mainly used for treating heat stagnation and relieving qi. Scutellaria baicalensis Georgi and Coptidis Rhizoma in the prescription. (or picrorhiza picrorhiza) clearing away heat and regulating stomach, Radix Aucklandiae and Rhizoma Corydalis regulating qi, promoting blood circulation and relieving pain, Radix et Rhizoma Rhei (below) purging heat and dredging fu-organs, and Radix Glycyrrhizae harmonizing various medicines, the effects of Radix Paeoniae Alba are the same as above. If nausea and vomiting are serious, add Pinellia ternata and dried tangerine peel, or drop ginger juice on your tongue. If constipation is serious, add mirabilite.
2, spleen and stomach excess heat: treatment: heat and detoxification, Tongli attack. Prescription: Dacheng Qi Tang Jiawei Heqing Yi Tang 1. Dachengqi decoction with honeysuckle, forsythia, dandelion, viola yedoensis, etc. Heqingyitang 1 focuses on clearing away heat and toxic materials, dredging fu organs, and is mainly used for treating excessive internal heat and obstruction of fu organs. Flos Lonicerae, Fructus Forsythiae, Herba Taraxaci and Herba Violae in the prescription have the functions of clearing away heat and toxic materials and purging fire. Rhubarb and mirabilite purge excess heat of Yangming, and relieve constipation and hide yin; Fructus Aurantii Immaturus and Cortex Magnolia Officinalis are used to relieve mass of qi and help purging heat; Bupleurum chinense and Scutellaria baicalensis Georgi clear liver and gallbladder; Paeonia lactiflora can astringe yin to relieve pain and help clear liver and gallbladder; Coptidis Rhizoma clears stomach and relieves annoyance, regulates qi with Radix Aucklandiae and Rhizoma Corydalis, adds Pinellia ternata and stomach to reduce turbidity and stop vomiting, and adds ginger and licorice to coordinate various drugs to increase gastric motility. This syndrome often has obvious signs of blood stasis, and Salvia Miltiorrhiza, Cortex Moutan and Radix Angelicae Sinensis can be added. Add pollen and reed roots when you are thirsty.
3, liver and spleen damp heat: treatment: clearing liver and spleen, purging heat. Prescription: Jiawei Dachaihu Decoction. Dachaihu Decoction with Herba Artemisiae Scopariae, Fructus Gardeniae, Rhizoma Polygoni Cuspidati, Herba Taraxaci, Cortex Magnolia Officinalis and Radix Curcumae focuses on clearing away damp-heat in liver and spleen and purging Yangming fever. Indications: Damp-heat of liver and spleen, Yangming heat stagnation. Bupleurum in the prescription soothes the liver and relieves depression; Scutellaria baicalensis Georgi, Herba Artemisiae Scopariae, Fructus Gardeniae, Rhizoma Polygoni Cuspidati and Herba Taraxaci have the functions of clearing away heat, eliminating dampness and detoxicating, and cooperate with Radix Paeoniae Alba and Rhizoma Corydalis to clear liver and promote gallbladder function. Radix et Rhizoma Rhei, Fructus Aurantii Immaturus and Cortex Magnolia Officinalis purging Yangming fever; Pinellia ternata and stomach turbidity are used to treat vomiting, and ginger and jujube are used to help Pinellia ternata and stomach vomiting and reconcile various drugs. Poria, Atractylodis Rhizoma, Pericarpium Citri Tangerinae and Radix Aucklandiae can be added for patients with obvious damp-heat spleen deficiency syndrome, such as loose stool, abdominal distension and anorexia. Salvia Miltiorrhiza, Radix Curcumae and Radix Paeoniae Rubra are obviously added to the blood stasis syndrome.
Chronic pancreatitis
1. Gastrointestinal heat accumulation
Exogenous pathogens turn into heat when they enter the interior, or overeat spicy and thick taste, and damp-heat food stagnates and accumulates in the interior, causing stagnation of qi and obstruction of fu-organs qi. The clinical symptoms are abdominal distension and pain, refusal to press, epigastric obstruction, nausea and vomiting, dry mouth and constipation. Red tongue with Huang Gan coating and slippery pulse. It is advisable to clear away heat and dampness and attack the interior. Prescriptions of Qingyi Decoction and Dachengqi Decoction: Bupleurum 10g, Fructus Aurantii 10g, Scutellariae Radix 12g, Coptidis Rhizoma 6g, Radix Paeoniae Alba 12g, Radix Aucklandiae 6g, Flos Lonicerae 30g, Rhizoma Corydalis 12g, and Radix et Rhizoma Rhei (below)/kloc.
2. Damp-heat in liver and gallbladder
The invasion of exogenous pathogens or improper diet make damp heat accumulate in the liver and gallbladder, making it lose its ability to stop diarrhea. The clinical symptoms are epigastric pain, hypochondriac pain, anorexia, greasy food, fever, nausea, severe fatigue or jaundice. The tongue coating is yellow and greasy and the pulse is slippery. Treatment should be soothing the liver and benefiting gallbladder, clearing away heat and promoting diuresis. Prescriptions of Qingyi Decoction and Longdan Xiegan Decoction: Radix Gentianae 15g, Herba Artemisiae Scopariae 30g, Fructus Gardeniae 15g, Radix Bupleuri 15g, Radix Scutellariae 12g, Rhizoma Picrorhizae 10g, Radix Paeoniae Alba 12g, Radix Aucklandiae.
3. Spleen deficiency and food stagnation
Deficiency and cold of spleen and stomach, polyphagia, poor spleen transport and transformation, gastrointestinal injury, stagnation of food accumulation, and poor qi movement. The clinical symptoms are nausea, abdominal distension and discomfort after eating, diarrhea, sour stool or indigestion, sallow and emaciated, and fatigue. The tongue is light and fat, with white fur and weak pulse. It is advisable to strengthen the spleen and eliminate stagnation and regulate qi. Compound Qingyi Decoction and Zhi Zhi Huazhi Pill: 20 g of Atractylodis Rhizoma, 65,438 05 g of Jiao Sanxian, 20 g of Poria, 65,438 00 g of Fructus Aurantii Immaturus, 30 g of Flos Lonicerae, 65,438 00 g of Scutellariae Radix, 65,438 00 g of Bupleurum Radix, 20 g of Alismatis Rhizoma, 65,438 00 g of Pericarpium Citri Tangerinae, 30 g of Coicis Semen.
4. Internal resistance due to blood stasis
Long-term illness entering collaterals leads to blood stasis and qi stagnation. The clinical symptoms are aggravated upper abdominal pain, fixed position, swelling of upper abdomen or left flank, calcification or cyst formation in pancreas found by X-ray or B-ultrasound. The tongue is purple and dark or has ecchymosis and petechiae, and the pulse is astringent. Treatment should promote blood circulation to remove blood stasis, regulate qi and relieve pain. The prescription of Shaofu Zhuyu Decoction is: Rhizoma Cyperi 10g, Rhizoma Corydalis 15g, Myrrha 10g, Radix Angelicae Sinensis 10g, Rhizoma Chuanxiong 10g, Radix Paeoniae Rubra 10g and Pollen Typhae/kloc-0.