Acute pancreatitis: diagnostics and first aid
The leading laboratory markers of acute damage are serum amylase and lipase (their concentration exceeds the normal limit by more than three times). Additionally, non-specific signs of systemic inflammation are registered: leukocytosis and an elevated C-reactive protein level. In severe cases with tissue necrosis, hypocalcemia occurs.
The basic management tactics for an acute attack are based on the "cold, hunger, and rest" rule:
- Strict bed rest.
- Therapeutic fasting or a low-calorie diet for the first 2–3 days.
- Local hypothermia (an ice pack on the epigastric region).
Antibacterial therapy is prescribed exclusively for confirmed infectious etiology. In case of purulent complications, surgical intervention is indicated (drainage, necrosectomy). If the pathology is caused by cholelithiasis, treatment of the underlying disease is necessary, up to endoscopic retrograde cholangiopancreatography (ERCP) with papilla sphincterotomy.
Chronic pancreatitis: clinical features
Unlike the acute form, in chronic inflammation, the level of amylase and lipase may remain within reference ranges or even decrease due to progressive fibrosis and the focal nature of the lesion. However, if amylase remains persistently elevated, the presence of pseudocysts, pancreatic ascites, or macroamylasemia must be ruled out.
Among instrumental methods, ultrasound is used (characterized by duct deformation with alternating stricture and dilatation segments), as well as CT, MRI, and ERCP. Radioisotope scanning is considered less accurate.
An important consequence of the chronic process is impaired carbohydrate metabolism. A decrease in insulin secretion leads to hyperglycemia, which is detected in 10–30% of patients. Searching for the cause of the disease (if it is not associated with an obvious toxic or obstructive nature) includes evaluating for autoimmune pancreatitis (analysis for IgG4, anti-TPO, anti-Tg, using HISORt criteria) and hereditary factors.
Management of chronic pancreatitis exacerbation
During an exacerbation, the main goal of pharmacotherapy is the suppression of pancreatic secretion. The drug of choice is a somatostatin analogue — octreotide (Octreotidum).
Clinical effects of the drug:
- Relief of abdominal pain syndrome.
- Resolution of intestinal paresis.
- Normalization of enzyme levels (amylase, lipase, trypsin) in blood and urine.
In pediatric practice, octreotide is administered subcutaneously or intravenously at 25–150 mcg 2–3 times a day for a course of up to 5–7 days. Broad-spectrum antibiotics during an exacerbation are indicated only for obvious signs of systemic inflammation (accelerated ESR, left shift of the leukocyte formula, fever).
Management of patients in remission
After discharge, patients are subject to dispensary follow-up with courses of anti-relapse therapy and sanatorium-resort treatment (mineral waters of Essentuki, Borjomi, and Zheleznovodsk resorts are recommended).
A strict diet is mandatory: frequent, fractional meals in small portions, fat restriction, complete avoidance of alcohol, spicy, and fried foods. In case of exocrine insufficiency, enzyme replacement therapy (pancreatin) is prescribed.
The dose is selected individually based on the lipase level — usually 10,000–25,000 IU per meal (in cystic fibrosis, doses are significantly higher). With pronounced steatorrhea, fat-soluble vitamins (A, D, E, K) are prescribed. Pain syndrome is relieved with analgesics, up to narcotics for severe pain.
Treatment of an acute attack is based on the "CHR" rule: Cold (ice on the abdomen), Hunger (abstinence from food for 2–3 days), and Rest (strict bed rest).
Class and exam questions
How to properly take enzyme preparations?
The drugs are taken during or immediately after a meal, washed down with a sufficient volume of liquid. Enteric-coated forms must not be chewed — this will destroy the protective membrane, and the enzymes will be inactivated in the acidic environment of the stomach.
Why might the simultaneous intake of enzymes and antacids reduce treatment efficacy?
Antacids increase the pH of the gastric contents, which can disrupt the release profile of enzymes from enteric-coated capsules. In such cases, dose adjustment is often required.
Can one rely on a normal amylase level to rule out chronic pancreatitis?
No. In chronic courses, due to parenchymal fibrosis and the death of acinar cells, the enzyme level in serum may remain normal or even decreased.
What else to study on this topic
- Histological structure of the exocrine and endocrine parts of the pancreas
- Hormonal regulation of carbohydrate metabolism: mechanism of action of insulin and glucagon
- Endoscopic retrograde cholangiopancreatography (ERCP) in diagnostics
- Vascularization and autonomic innervation of the pancreas
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