Biliary pancreatitis: symptoms, prognosis and treatment

Chronic pancreatitis is a chronic inflammatory-dystrophic disease of the pancreas, which, as the pathological process progresses, causes disruption of the patency of its ducts and significant impairment of the functions of the pancreas.

Chronic pancreatitis is a fairly common disease: in different countries, the incidence of chronic pancreatitis is 5–7 new cases per 100,000 people. Moreover, over the past 40 years there has been an approximately twofold increase in the incidence of pancreatitis. This is due not only to improved methods for diagnosing chronic pancreatitis, but also to an increase in alcohol consumption in some countries and increased exposure to adverse environmental factors that weaken various protective mechanisms.

Acute and chronic pancreatitis are often considered as two separate diseases. The thing is. that in 60% of patients the acute phase of pancreatitis remains unrecognized or is recognized as a foodborne toxic infection, cholelithiasis, etc. Therefore, it becomes clear that chronic pancreatitis is an acute outcome.

Chronic biliary pancreatitis

The chronic form of PD is characterized by a long course (symptoms of the pathology persist for at least six months). The inflammatory process is provoked by diseases of the bile ducts. The consequence of the pathology is partial or complete loss of the hormone-releasing and enzymatic functions of the pancreas. The chronic form of PD is accompanied by regular constipation or diarrhea, pain, weight loss and lack of appetite, as well as jaundice of the skin.

Treatment of chronic pancreatitis

Treatment of patients with uncomplicated chronic pancreatitis is carried out by a gastroenterologist, it is aimed at:

• elimination of pain syndrome,
• compensation for exocrine insufficiency,
• compensation for endocrine insufficiency.

One of the main problems in the treatment of patients with chronic pancreatitis is the timely diagnosis of complications and referral of the patient to a specialized surgical gastroenterological center for consultation and possible surgical treatment. The sooner the patient receives qualified help, the greater the chance of maintaining pancreatic function and a high quality of life.

In turn, a competent diagnosis of chronic pancreatitis is not possible without a qualified assessment of changes in the pancreatic parenchyma and its ductal system by doctors, and this is only possible in specialized clinics with extensive experience in the treatment of pancreatitis. Therefore, we recommend that patients with pancretitis who are repeatedly admitted to the hospital with exacerbation of chronic pancreatitis, or with constant pain, ask the attending physician to refer him for treatment to such a clinic in order to avoid diagnostic errors.

The possibilities of conservative treatment in the chronic phase of pancreatitis are limited; There are practically no medications that specifically affect the development of chronic pancreatitis. Therefore, the main efforts should be aimed at alleviating pain, rational diet therapy, correction of exocrine and intrasecretory pancreatic insufficiency, as well as eliminating the causes of pancreatitis by relieving the inflammatory process in the biliary tract and combating the patient’s alcohol addiction.

The need for diet therapy is due to a decrease in body weight in patients with chronic pancreatitis and the presence of vitamin deficiency; it is also an important means of preventing exacerbations of pancreatitis. The presence of signs of exocrine pancreatic insufficiency (weight loss, steatorrhea, increased gas formation) requires replacement therapy with modern drugs with a high lipase content, facilitating the correction of steatorrhea and impaired absorption of fat-soluble vitamins. The use of microgranular preparations in capsules protected with a special coating (Creon) prevents the deactivation of lipase in the acidic environment of the stomach.

Taking enzyme and antisecretory drugs also has an analgesic effect, since by increasing the content of proteases in the lumen of the initial intestine, it can reduce the secretion of pancreatic enzymes and reduce pressure in the ductal system and pancreatic tissues.

Indications for surgical treatment of chronic pancreatitis

Complications of pancreatitis are an indication for surgical treatment. To eliminate complications, direct operations on the pancreas are performed. Their arsenal is diverse, taking into account various options for damage to the gland, but they are all divided into two large groups - operations aimed at draining the main pancreatic duct, and the second group - operations aimed at resection of the fibrous tissue of the pancreas itself.

Author: Ph.D. Alexander Vladimirovich Makarenko – Head of the Department of Pancreatic Surgery, Russian Center for Functional Surgical Gastroenterology

For more complete information or face-to-face consultation, you can contact the author by phone +79615172073 or by email. ( )

Acute biliary pancreatitis

The acute form of PD develops against the background of an inflammatory process in the biliary tract. The danger of an attack lies in the high risk of death of the patient in the absence of timely medical care. Acute PD manifests itself in the form of intense pain symptoms, uncontrollable vomiting (mainly at night), jaundice of the skin, constipation or diarrhea. After a period of remission, repeated attacks may occur.

(A) Pancreatic duct obstruction by gallstone. (B) Opie’s “common channel” theory. (B) the presence of obstruction of both ducts by a gallstone without reflux of bile into the pancreatic duct.

Causes

Bile, produced by the liver and stored in the gallbladder, is necessary for the digestion of food. In the normal state, the substance passes through the bile flow into the duodenum. With pathological changes, bile is thrown into the pancreatic duct. The organ begins to digest its own tissues. This process leads to the destruction of the pancreas. The result is the development of biliary pancreatitis.

The development of PD can be triggered by the following factors:

• pathological changes in the composition and properties of bile;
• dyskinesia of the bile ducts or gallbladder;
• complications of liver cirrhosis;
• entry of pathogenic microorganisms into the bile as a result of the inflammatory process in neighboring organs;
• uncontrolled use of choleretic drugs;
• development of inflammatory processes in the bile ducts and gallbladder;
• pathology of the major duodenal papilla;
• progression of hepatic exocrine insufficiency;
• damage to the pancreatic ducts by stones;
• formation of stones in the bile ducts or gallbladder;
• the presence in the diet of a large number of products with a choleretic effect;
• progression of cholangitis;
• consequences of chronic cholecystitis;
• biliary sludge and cholelithiasis;
• congenital anomalies of the biliary tract.

Recommendations from a gastroenterologist

Biliary pancreatitis is a disease that develops against the background of diseases of the liver and gallbladder. If PD is not treated in time, you will eventually have to undergo surgery and have a long recovery after treatment. It is better and cheaper to see a doctor regularly, take courses of necessary medications and stick to a diet. This is the only way to continue living a full life, without disability or serious health problems. In order to get a doctor's consultation online, chat with the doctor on duty.

Symptoms

The main symptom of biliary pancreatitis is pain. Localization of pain can occur in the left or right hypochondrium. The attacks resemble short-term spasms or are regular. A provoking factor for pain syndrome is the consumption of certain categories of food (for example, salty, spicy, fatty or fried foods).

Other symptoms of PD may vary depending on the stage of the disease and the overall health of the digestive system.

Main symptoms:

• 
  A risk factor for the development of the biliary form of the disease is overeating. jaundice of the skin and sclera;

• attacks of vomiting combined with attacks of pain localized in the digestive organs;
• frequent urge to defecate (loose stools, particles of undigested food may be present in the stool);
• heaviness in the stomach (with regular pain);
• lack of appetite (an inevitable consequence of the symptom is weight loss);
• regular attacks of nausea and uncontrollable vomiting;
• depressive disorders;
• increased body temperature;
• pain in the joints;
• general weakness of the body and excessive fatigue.

Distinctive features of PD are a feeling of bitterness in the mouth (or bitter belching) and regular constipation. Against the background of regular difficulties in the process of bowel movement, the patient may develop intestinal obstruction. Painful attacks with biliary-dependent pancreatitis last longer than other forms of this disease.

The pain is most often localized in the right hypochondrium (rather than in the left) and can move to the right arm, lower back or right shoulder blade.

Main symptoms

Pancreatitis occurs in acute or chronic form. In the first case, the symptoms manifest themselves as pronounced pain in the upper abdomen, nausea, and vomiting. The only correct decision in this case would be to immediately go to an ambulance and not self-medicate.

Chronic PD requires constant monitoring of well-being and medication. It is very convenient to see a gastroenterologist; an online doctor can provide consultation, which is very convenient. The practicing doctor will observe the patient and periodically prescribe tests and change medications.

The acute stage and the chronic course can be distinguished by a number of signs. Symptoms characteristic of exacerbations of biliary pancreatitis:

• temperature rises;
• the skin and sclera of the eyes turn yellow;
• problems with bowel movements appear;
• I feel nauseous all the time.

Symptoms of chronic PD:

• weight loss;
• loss of appetite;
• slight discomfort in the upper abdomen.

You need to understand that PD is a disease with which you can live and work fully. If you see a competent doctor, you can reduce the risk of exacerbations of pathology to zero.

It is important to know the key differences between biliary forms of pancreatitis and others. 5 distinctive symptoms:

1. Increased pain symptoms after taking choleretic tablets or food. The attacks vary in duration.
2. Constant constipation. Lack of treatment can lead to intoxication of the body and intestinal obstruction. Diarrhea is very rare with biliary pancreatitis.
3. Hepatic colic. They manifest as stabbing sensations on the side, under the shoulder blade and in the lumbar region on the right side.
4. Yellowing of the sclera of the eyes and skin.
5. Feeling of bitterness in the mouth.

At least one of the listed symptoms is a reason to see a doctor, otherwise you will have to undergo very long and expensive treatment. Experienced practicing gastroenterologists are ready to answer your question right now.

Diagnostics

If signs of PD appear, it is recommended to undergo examination by a gastroenterologist. The doctor must not only determine the stage of development of the pathology, but also identify the reasons that provoked it (the underlying disease of the digestive system). An obligatory step in the examination is a study of the composition of the blood and urine (general and biochemical tests).

Instrumental methods for examining the patient’s health status are selected depending on the existing clinical picture, complaints and collected medical history.

Diagnostic methods:

• 
  Delayed treatment leads to death. 25% of patients, ignoring the disease, become disabled. Ultrasound of the pancreas;

• bile culture;
• cholangiopancreatography using a contrast agent;
• CT or MRI;
• radiography;
• percussion;
• urine test (in PD the presence of glucose is noted);
• general blood test (leukocyte count and ESR);
• parasitological analysis;
• biochemical blood test (lipase, amylase and sugar content).

How to treat

Treatment of PD is carried out comprehensively. The main goal of therapy is to eliminate the factor that provoked the pathological reflux of bile. At this stage, medication or surgical techniques may be used. Eliminating the root cause of the disease significantly reduces the risk of re-development of pancreatitis and the pathology becoming chronic. The second part of the therapy is aimed at pain relief and maximum improvement of the functional state of the liver, gallbladder and pancreas.

Stages of treatment for PD:

• relief of pain and relief of the patient’s condition;
• detoxification therapy;
• restoration of the secretion process of the pancreas;
• prevention of infectious pathological processes;
• removal of stones (if any);
• restorative therapy.

Conservative treatment

In the absence of complications that pose a threat to the patient’s life, treatment of PD is carried out using a conservative method. Therapy includes taking certain groups of drugs, following a diet and replenishing the supply of vitamins in the body.

The treatment regimen is drawn up individually. Medicines for the treatment of acute and chronic pancreatitis are different.

Examples of drugs for the treatment of PD:

• antispasmodics for pain relief (No-Shpa, Duspatalin);
• enzyme preparations to improve the functional state of the pancreas (Pancreatin, Creon, Mezim);
• ursodeoxycholic acid preparations for dissolving small stones (Ursosan, Ursofalk);
• medications from the prokinetic category (Motilium, Cerucal, Domperidone);
• combined agents (Hepatofalk, Odeston);
• proton pump blockers (Emanera, Omeprazole).

Surgery for biliary pancreatitis

In recent years, the number of patients with biliary pancreatitis has approximately doubled. The need for surgical intervention arises in the presence of complications. Indications for surgery are cicatricial narrowing or obstruction of the bile ducts, cholelithiasis or tumors of the papilla of Vater. When choosing surgical methods, specialists give preference to low-traumatic procedures (endoscopic options using micro-instruments and a camera). If it is not possible to use such methods, open laparotomy operations are performed.

Types of surgical intervention:

• laparoscopy (the operation is performed through small incisions in the abdominal wall);
• lithotripsy (a procedure for crushing stones using special equipment);
• laparotomy (the procedure is aimed at removing the gallbladder and stones; the operation is performed by opening the anterior abdominal wall).

Folk ways to combat the disease

Herbal medicine is a good addition to traditional therapy. Some medicinal herbs contain components that not only improve the general condition of the digestive system, but also accelerate the tendency to recovery, have a beneficial effect on the composition of bile and to some extent stop the inflammatory process. Decoctions from such plants are prepared according to the standard procedure (a teaspoon of herb or a mixture of herbs is poured with boiling water, infused and consumed in small portions).

Medicinal plants for the treatment of PD:

• celandine;
• tansy;
• fennel;
• white birch leaves;
• dandelion;
• immortelle;
• corn silk;
• calendula;
• peppermint.

BILIARY DYSFUNCTION: definition, classification, diagnosis, treatment

Definition (pathomorphological background)

Despite the fact that they try to consider the biliary system (the system of bile ducts and sphincters that regulate the flow of bile) separately from the main organ (liver), it is part of it and functions in accordance with this.

The hepatocyte is conventionally divided into 3 independent units: sinusoidal, lateral and canalicular parts. The apical (canalicular) part of the cytoplasmic membrane of the hepatocyte differs in histological and biochemical properties and is involved in the formation of the lumen of the bile capillary. Each liver cell takes part in the formation of several bile canaliculi (BCs). At the periphery, the bile duct lobules merge into the bile ducts themselves, which pass at the exit into the interlobular connective tissue into interlobular tubules, which, merging, form interlobular ducts of the first order (second - when they are already lined with prismatic epithelium). Tubular-acinous mucous glands, a connective tissue membrane, and elastic fibers appear in their walls. The interlobular ducts, merging, form large hepatic ducts - lobar, leaving the liver and, in turn, forming the common hepatic duct, the continuation of which is the common bile duct, its beginning is considered to be the junction of the hepatic duct with the cystic duct. The common bile duct is divided into supraduodenal, retroduodenal, retropancreatic, intrapancreatic and intramural sections.

The distal part of the common bile duct passes through the thickness of the head of the pancreas, and the duct opens on the posterior wall of the descending duodenum, 2–10 cm below the pylorus. According to various authors, the width of the ducts can vary: common bile duct (GC) - from 2 to 4 mm; hepatic - from 0.4 to 1.6 mm; cystic - from 1.5 to 3.2 mm. According to x-ray data, the width of the coolant duct is from 2 to 9 mm; according to ultrasound - in the presence of a gallbladder (GB) - from 2 to 6 mm, and without a gallbladder - from 4 to 10 mm. The capacity of the gallbladder ranges from 30 to 70 ml. At the junction of the gallbladder and the cystic duct, the muscle fibers take a circular direction, forming the sphincter of the gallbladder duct (Lutkens). Motor innervation is carried out by the sympathetic and parasympathetic nervous system. Nerve plexuses are present in all layers of the biliary system. Sensitive fibers of the gallbladder can only perceive stretching.

Bile secretion occurs continuously throughout the day, with some fluctuations. From 0.5 to 2.0 liters of bile are secreted per day. The direction of bile movement is determined by the interaction of hepatic secretion, the rhythmic activity of the sphincters of the terminal part of the common bile duct, the sphincter of the gallbladder, the cystic duct valve and the absorptive function of the mucous membrane of the gallbladder and all ducts, which creates pressure gradients. From the hepatic ducts and the common bile duct, bile enters the gallbladder at the moment of closure of the sphincter of Oddi (it plays a decisive role in creating the pressure gradient). The sphincter of Oddi outside of digestion is not constantly closed, and small portions of bile systematically enter the duodenum. After the end of the digestive phase, bile enters the gallbladder for 3 or more hours. Most researchers believe that the extrahepatic bile ducts are never at rest, and their active peristalsis is considered from the point of view of regulation of bile flow; duodenal tone (intraluminal pressure) also affects the output of bile. The motor reaction of the gallbladder and sphincter of Oddi is directly dependent on the quantity and quality of food, as well as on the emotional state of a person.

The musculature of the sphincter of Oddi is independent of the musculature of the duodenum. The sphincter of Oddi consists of: the actual sphincter BDS (Westphal sphincter), which ensures the separation of the ducts from the duodenum; the sphincter of the common bile duct itself; sphincter of the pancreatic duct.

The work of the entire biliary system is strictly coordinated, which is ensured by nervous and humoral regulation. The regulatory influence of endogenous peptides from the endorphin group is still not entirely clear. The basic principle of the entire regulatory system is multi-level self-regulation (including locally produced hormones and biologically active substances).

The regulatory component is very complex under physiological conditions and is not completely clear in various pathologies of this system.

Classification, identification of clinical variants of dysfunction, diagnostic approaches

Functional diseases of the biliary tract are a complex of clinical symptoms that develop as a result of motor-tonic dysfunction of the gallbladder, bile ducts and sphincters.

According to the latest International Classification, instead of the definition of “functional diseases of the biliary tract” (Rome Consensus, 1999), the term “dysfunctional disorders of the biliary tract” has been adopted. Moreover, regardless of the etiology, they are usually divided into 2 types: gallbladder dysfunction and sphincter of Oddi dysfunction.

In the latest International Classification of Diseases (ICD-10), under the heading K82.8 only “dyskinesia of the gallbladder and cystic duct” is highlighted and under the heading K83.4 – “spasm of the sphincter of Oddi”.

The parasympathetic and sympathetic parts of the autonomic nervous system, as well as the endocrine system, take part in the regulation of the motor activity of the biliary system, providing a synchronized sequence of contraction and relaxation of the gallbladder and sphincter apparatus.

It has been shown that moderate irritation of the vagus nerve causes coordinated activity of the gallbladder and sphincters, and severe irritation causes spastic contraction with delayed bile evacuation. Stimulation of the sympathetic nerve helps relax the gallbladder. Of the gastrointestinal hormones, cholecystokinin-pancreazimin (CCK-PZ) has the maximum effect, which, along with contraction of the gallbladder, helps relax the sphincter of Oddi. The incentive for the production of CCK-PZ is fatty foods, and the nervous regulatory influences are the pressure gradient and its change.

The main cause of disorders of the rhythmic activity of the biliary system is inflammatory processes in the liver, leading to disruption of bile synthesis, a noticeable decrease in pressure in the ductal system and gall bladder and, in connection with this, to constant spastic contraction of the sphincter of Oddi.

Various surgical interventions (cholecystectomy, vagotomy, gastrectomy) also lead to significant dysfunction of the biliary system. Unlike the processes occurring in other digestive organs, the formation of bile occurs continuously, but the flow of bile into the intestines is noted only during certain phases of digestion. This is ensured by the reserve function of the gallbladder and its rhythmic contractions with sequential relaxation of the sphincters of Lutkens and Oddi. Relaxation of the gallbladder is accompanied by closure of the sphincter of Oddi.

There are primary and secondary dysfunctional disorders. Primary ones are rare and average 10–15%. In this case, a decrease in the contractile function of the gallbladder may be associated both with a decrease in muscle mass (rarely) and with a decrease in the sensitivity of the receptor apparatus to neurohumoral stimulation. Moreover, a small number of receptors can be genetically determined and acquired, due to inflammatory, dystrophic and metabolic disorders. Secondary dysfunctional disorders of the biliary tract can be observed with hormonal disorders, treatment with somatostatin, premenstrual syndrome, pregnancy, systemic diseases, diabetes, hepatitis, liver cirrhosis, jejunostomy, as well as with existing inflammation and gallstones. Moreover, the presence of these diseases does not imply a stable failure of regulatory systems and the perceptive apparatus - we are talking about varying degrees of disorders in different periods, phases of the course of diseases; in connection with this, there is an “undulation” of disorders, up to periods of rather long stability, but with an “easy” transition of this system from stability to motor disorders. Psycho-emotional overload, stressful situations, and general neuroses are important. The vast majority of patients who have undergone cholecystectomy are characterized by insufficiency of the sphincter of Oddi with continuous flow of bile; spasm is less common. Another common cause of biliary disorders is distal gastrectomy, which leads to decreased hormonal regulation and hypotony of the gallbladder.

The classification of dysfunctional disorders of the biliary tract is presented in the table.

For ease of perception and more convenient application in practice, the classification presents unidirectional disorders, although in life they are more often complex in nature, with a predominance of one of the components.

Clinical manifestations are quite well known: with hyperkinetic disorders, colicky pain of varying intensity occurs without irradiation or with irradiation to the right, to the back, sometimes to the left half of the abdomen (with the involvement of the pancreatic ductal system). With hypokinesia - dull pain in the right hypochondrium, a feeling of pressure, fullness, increasing with changes in body position and with an increase in intra-abdominal pressure, changing the pressure gradient for bile flow. Common to different forms of dysfunction are bitterness in the mouth, bloating, and unstable stools.

So, the central symptom of gallbladder dysfunction is the biliary type of pain, and the only objective characteristic can be considered delayed emptying of the gallbladder. Available diagnostic methods do not explain the cause of this phenomenon. There may be several causative factors. It is impossible to exclude such moments as a violation of filling or a decrease in the sensitivity of the gall bladder’s receiving apparatus.

Diagnostic criteria for gallbladder dysfunction are episodes of severe constant pain localized in the epigastrium or in the right upper quadrant of the abdomen, with the following features characteristic:

• episodes lasting 30 minutes or more;
• symptoms occur 1 or more times in the previous 12 months;
• constant nature of pain, decreased daily activity of patients and the need to consult a doctor;
• lack of evidence of organic pathology causing symptoms;
• presence of dysfunction of gallbladder emptying.

A very important objective symptom of impaired gallbladder motility is the ultrasound phenomenon of “sludge” (sediment), which, according to our data [1], can be presented in 2 variants: a) diffuse; b) near the wall. The parietal variant, depending on the clinical situation, can be characterized as “inflammatory”. If there is no inflammation, then the sediment elements that form it are quite large. The entire clinical symptom complex should also be analyzed: nausea and vomiting, irradiation, provoking factors (food, its quality, etc.).

With regard to sphincter of Oddi dysfunction, 4 clinical and laboratory types are distinguished (3 types of biliary dysfunction and 1 type of pancreatic dysfunction). The diagnostic criteria are based on an attack of biliary pain and 3 laboratory and instrumental signs: an increase in AST and/or alkaline phosphatase by 2 or more times with double determination; slower removal of contrast agents during ERCP (more than 45 minutes); expansion of the common bile duct more than 12 mm (studies are carried out during an attack).

The first type of dysfunction is characterized by pain and 3 signs.

The second type of dysfunction is characterized by pain and 1 or 2 signs.

The third type is only an attack of pain.

The fourth type - pancreatic - is characterized by “pancreatic” pain and an increase in the level of amylase or lipase (with mild pain); an increase in enzymes (amylase, lipase) may be absent.

In cases where endoscopic retrograde pancreatic cholangiography excludes the absence of stricture pathology, monometry of the biliary and pancreatic sphincters is indicated.

The World Congress of Gastroenterology (Bangkok, 2002) determined that evidence-based medicine does not require consensus, but rather evidence. Congress participants concluded that sphincter of Oddi dysfunction should not be classified as a clearly defined disease, but as a condition with a variable dysfunction/symptom relationship. It was particularly emphasized that impaired gallbladder emptying is well known as a consequence of inflammatory damage, mechanical obstruction or autonomic denervation. In the absence of these conditions, it is unclear whether delayed gallbladder emptying can be considered a specific clinical problem (nosological entity).

Some principles of treatment of dysfunctional biliary disorders

Considering the above, it should be noted that the main goal of treating patients with dysfunctional disorders of the biliary tract is to restore the normal flow of bile and pancreatic secretion through the biliary and pancreatic ducts. In this regard, treatment objectives include:

• restoration, and if impossible, replenishment of bile production (with the development of chronic biliary insufficiency, which is understood as a decrease in the amount of bile and bile acids entering the intestine 1 hour after the introduction of an irritant. Patients after cholecystectomy almost always develop dysfunction of the sphincter of Oddi, since from normal functioning of the biliary system excludes the gallbladder, and in connection with this, there is an irreplaceable loss of bile acids with the development of chronic biliary insufficiency, which causes both digestive disorders and dysfunctional disorders);
• increased contractile function of the gallbladder (if it is insufficient);
• decreased contractile function of the gallbladder (with its hyperfunction);
• restoration of the tone of the sphincter system;
• restoration of pressure in the duodenum (on which an adequate pressure gradient in the biliary tract depends).

Until now, diet therapy plays a significant role in the system of treatment measures. The general principles of the diet are a diet with frequent meals of small amounts of food (5-6 meals a day), which helps normalize pressure in the duodenum and regulates the emptying of the gallbladder and ductal system. Alcoholic drinks, carbonated water, smoked, fatty and fried foods, and seasonings are excluded from the diet - due to the fact that they can cause spasm of the sphincter of Oddi. When selecting a dietary diet, the influence of individual nutrients on the normalization of the motor function of the gallbladder and biliary tract is taken into account. Thus, with the hyperkinetic type of dysfunction, the consumption of foods that stimulate contraction of the gallbladder should be sharply limited - animal fats, vegetable oils, rich meat, fish and mushroom broths. With hypotension of the gallbladder, patients usually tolerate weak meat and fish broths, cream, sour cream, vegetable oils, and soft-boiled eggs well. Vegetable oil is prescribed in a teaspoon 2-3 times a day 30 minutes before meals for 2-3 weeks. To prevent constipation, dishes that promote bowel movement are recommended (carrots, pumpkin, zucchini, greens, watermelons, melons, prunes, dried apricots, oranges, pears, honey). This is especially important, since a normally functioning intestine means normalization of intra-abdominal pressure and the presence of normal movement of bile into the duodenum. The use of dietary bran (with sufficient water) is important not only for the functioning of the intestines, but also for the motility of the biliary tract, especially the gallbladder, which has sediment.

Among the drugs that affect the motor function of the gastrointestinal tract, the following are used: anticholinergic drugs, nitrates, myotropic antispasmodics, intestinal hormones (CCC, glucagon), choleretics, cholekinetics.

Anticholinergics , by reducing the concentration of intracellular calcium ions, lead to muscle relaxation. The intensity of relaxation depends on the initial tone of the parasympathetic nervous system, but when using drugs in this group, a wide range of side effects are observed: dry mouth, difficulty urinating, blurred vision, which significantly limits their use.

Nitrates (nitroglycerin, nitromint, sustonite, nitro-time, nitrong forte, nitro poppy, nitrocor, nitrosorbide, cardonite) through the formation of free nitric oxide radicals in smooth muscles, which activate the cGMP content, lead to their relaxation. However, these drugs have significant cardiovascular and other side effects. The development of tolerance makes them unsuitable for long-term therapy.

Non-selective calcium channel blockers (nifedipine, verapamil, diltiazem, etc.) are able to relax smooth muscles, including the biliary tract, but this requires the highest possible doses, which practically excludes the use of these drugs due to pronounced cardiovascular effects.

Some antispasmodics selectively block calcium channels (dicetel, panaveria bromide, spasmomen) and primarily act at the level of the colon, where they are metabolized. 5–10% of these drugs are absorbed and metabolized in the liver and can work at the level of the biliary tract. This aspect requires further research, and indirect effects associated with the restoration of the pressure gradient have been noted and can be used.

Currently, among the myotropic antispasmodics, the drug hymecromone (odeston) attracts attention, which has a selective antispasmodic effect on the sphincter of Oddi and the sphincter of the gallbladder. Odeston is effective in patients with dysfunction of the biliary tract, has a choleretic effect, eliminates biliary insufficiency, as well as dysfunction of the sphincter of Oddi, its hypertonicity, including in patients after cholecystectomy.

Among other myotropic antispasmodics, duspatalin should be noted, which selectively affects the tone of the sphincter of Oddi (directly and indirectly); it lacks a universal antispasmodic effect (and, therefore, side effects), but does not have a choleretic effect and in this is inferior to odeston.

For hypofunction of the gallbladder, the main approach to treatment should be pharmacotherapeutic.

The use of drugs that enhance gallbladder motility.

Choleretics:

• preparations containing bile or bile acids: allochol, dehydrocholic acid, lyobil, cholenzyme;
• synthetic drugs: oxafenamide, nicodine, cyclone;
• herbal preparations: hofitol, flamin, holagogum, corn silk, etc.

Cholekinetics: magnesium sulfate, olive oil and other oils, sorbitol, xylitol, holosas, etc.

The choice of drug, which is a very important, if not the main issue, depends on how quickly the effect of therapy is needed. If the fastest possible effect on the patient’s body is required, then it is better to use cholekinetics, and the effect depends on the dose of the drug; if a long course of treatment is necessary, then bile-containing drugs are used; if an anti-inflammatory effect is also required, then the choice should be made in favor of synthetic drugs, but the course of treatment with them will be short-lived; when the patient simultaneously has liver pathology, the choice should be made in favor of hophytol, which has a choleretic and protective effect.

Use of drugs with prokinetic effects

(motilium, debridate). This may also include myotropic antispasmodics: dicetel, spasmomen, duspatalin, halidor, no-spa. It should be remembered that their effects, as a rule, are indirect (they reduce either the tone of the sphincter of Oddi or the pressure in the duodenum). Their effectiveness is dose-dependent, so selection of an effective dose is necessary.

The use of drugs that reduce inflammation and visceral hyperalgesia. Nonsteroidal anti-inflammatory drugs: anopyrin, upsarin UPSA, dikloberl, naklofen, ketanov, solpaflex, brustan, ketonal, movalis, donalgin, ambene, celebrex and low doses of tricyclic antidepressants (amizol, saroten, elivel, melipramine, coaxil).

It is necessary to pay attention to other aspects of treatment. For dysfunction of the sphincter of Oddi: when establishing the first type, papillosphincterotomy is required; type two or three - the possibility of prescribing drug therapy is allowed. It should be borne in mind that hormones (CKC, glucagon) can temporarily reduce the tone of the sphincter of Oddi; Nitrates give a very short-term effect. Botulinum toxin is a strong inhibitor of acetylcholine release. Using it as an injection into the sphincter of Oddi reduces its pressure, improves bile flow and brings relief, but the effect of treatment is transient. For the pancreatic type of dysfunction of the sphincter of Oddi, the standard therapy is surgical sphincteroplasty and pancreatic lithoplasty (drug treatment is carried out only at the stage of absence of complications).

Conclusion

Recently, the attention of the medical community has been drawn to functional disorders of the gastrointestinal tract in general and the biliary system in particular. This is largely due to the fact that with regard to functional disorders there is still hope for their cure, as well as for successful prevention or delay in time of the development of organic pathology (including oncology) that is more severe in prognosis. Today, diagnostic approaches to the treatment of the diseases we have discussed, presented in this article, are being developed. In addition, this work reflects the large arsenal of medications at the disposal of the doctor, who has the opportunity to choose a drug or complex depending on the pathogenetic characteristics of a particular disorder.

Literature

1. Sokolov L.K., Minushkin O.N. et al. Clinical and instrumental diagnosis of diseases of the organs of the hepatopancreatoduodenal zone. - M., 1987.
2. Minushkin O. N. Dysfunctional disorders of the biliary tract (pathophysiology, diagnosis and treatment approaches). - M., 2002.
3. Kalinin A.V. Functional disorders of the biliary tract and their treatment//Clinical perspectives of gastroenterology, hepatology. - 2002. - No. 3. - P. 25–34.
4. Yakovenko E. P. et al. Dysfunction of the sphincter of Oddi associated with cholecystectomy (diagnosis, treatment) // Practitioner. - 2000. - No. 17. - P. 26–30.
5. Nasonova S.V., Tsvetkova L.I. Experience of using odeston in the treatment of chronic diseases of the gallbladder and biliary tract // Ros. and. gastroenterology, hepatology, coloproctology. - 2000. - No. 3. — P. 87–90.
6. Nasonova S.V., Lebedeva O.I. Odeston in the treatment of chronic diseases of the hepatobiliary system // Military Med. magazine. - 2001. - No. 3. P. 49–53.
7. Yakovenko E. P. et al. Odeston in the treatment of diseases of the biliary tract // Practicing physician. - 2001. - No. 19. - P. 30–32.

O. N. Minushkin , Doctor of Medical Sciences, Professor, Medical Center of the Administration of the President of the Russian Federation, Moscow

Treatment prices

The cost of therapy for PD depends on many factors - the general clinical picture of the patient’s health, the degree of progression of the secondary disease, and the set of procedures necessary for treatment. If the patient is examined in a public institution, then the main costs will involve drug therapy.

When observed in paid clinics, the price of diagnosis and treatment of PD will be several times higher. The average cost of therapy is 8,000 rubles.

Diet: do's and don'ts

Following a diet for PD can achieve stable remission. Products from the diet should not have an irritating effect on the digestive organs. The basis of nutrition is the principles of Diet No. 5. Protein foods should predominate in the diet. You should not eat fatty, salty, fried, smoked or spicy foods. Alcoholic and carbonated drinks, berries and fruits with a sour taste, white cabbage, legumes, mushrooms, butter, sour cream, egg yolk, strong coffee or tea are excluded from the menu.

It is forbidden to eat sorrel, radishes, spinach, bananas, dates, cranberries, onions, garlic, bell peppers, radishes and grapes.

The following products should be present in the diet:

• 
  In case of acute pancreatitis, patients should forever forget about fatty foods, hot seasonings, smoked foods, sour fruits and vegetables, borscht and vegetable soups;

• chicken egg whites;
• lean meats (chicken, beef, fish);
• slightly stale bread;
• vinaigrette, vegetable salads;
• pumpkin, oatmeal, buckwheat porridge;
• dairy products with reduced fat content;
• apples (non-acidic varieties);
• compotes from fresh berries and fruits;
• vegetable oils;
• dried fruit compotes;
• vegetable puree.

During exacerbation of PD, therapeutic fasting is recommended. Eating any food can provoke an increase in the symptoms of the inflammatory process. Dietary nutrition involves the inclusion of alkaline mineral waters (Borjomi, Essentuki) in the diet.

The duration of the diet depends on the clinical picture of the patient’s health condition. In some cases, you have to follow dietary rules throughout your life.

Diet food, menu

Nutrition for PD involves following several important rules. Meals should be taken 5-6 times a day (the volume of one serving is no more than 250 g). When preparing dishes, preference should be given to steaming, boiling or stewing methods. The amount of carbohydrates in the menu is reduced to 250 g per day, fats - to 80 g per day.

Particular attention is paid to the level of proteins in the diet (the body should receive at least 120 g of this substance per day). The temperature of food when consumed should not exceed 50 degrees.

Sample menu

Other dietary rules:

• the menu should contain dishes prepared according to dietary recipes;
• the time interval between meals should be at least three hours;
• when eating food, it must be chewed thoroughly (dishes should have the consistency of mousses, puddings, purees);
• It is not recommended to drink food with food (you should drink liquid an hour after eating).

The diet for acute pancreatitis is extremely strict and consistent.

Complications

The main cause of complications of PD is the lack of timely therapy. The pathological process can provoke the formation of purulent foci, abnormal formations, critical proliferation of pancreatic tissue or their death. Some complications are incompatible with life. If you ignore the symptoms of PD, the patient's risk of death increases.

Other complications:

• pancreatic necrosis;
• encephalopathy;
• abscesses;
• diabetic coma;
• diabetes;
• cysts;
• fistulas;
• pancreasclerosis;
• obstructive jaundice.

The biliary form of inflammation of the pancreas, if not treated in a timely manner, leads to peritonitis.

Prevention

Biliary pancreatitis is a secondary disease that develops against the background of other pathologies. The main preventive measure in this case is timely prevention and treatment of the root cause (cholelithiasis, diseases of the digestive system, gallbladder and pancreas).

Proper nutrition, giving up bad habits, providing the body with sufficient physical activity and regular examinations with a gastroenterologist help reduce the risk of such ailments.

Other preventive measures:

• if regular deviations occur in the digestive system, it is necessary to undergo examination in a medical institution and identify the cause of their manifestation;
• all diseases associated with the pancreas, liver, gall bladder and digestive tract organs should be treated fully and in a timely manner;
• Particular attention to lifestyle and diet should be paid to patients with congenital anomalies of the biliary system and persons who have undergone surgery on the digestive organs.

Video on the topic: What kills the pancreas?

Causes of development of chronic pancreatitis

The main causes of chronic pancreatitis - alcoholic and biliary (bile) - are more common in developed countries with high consumption of alcohol, protein and fat.

Alcohol abuse (alcoholic pancreatitis). The leading cause is from 40 to 95% of all forms of pancreatitis, mainly in men. It is difficult to recognize its nature. When interviewed, the patient often states that he drinks “like everyone else, no more.” However, a patient with alcoholic pancreatitis consumes significantly more alcohol than is recommended by modern medical principles. The pancreas is more sensitive to alcohol than the liver (toxic doses for the liver are 1/3 greater than doses for the pancreas). The type of alcoholic beverages (there is a myth that expensive alcohol is harmless) and the method of drinking them do not have a decisive influence on the development of chronic pancreatitis. Clinically pronounced manifestations develop in women after 10-12 years, and in men after 17-18 years from the onset of systematic alcohol abuse.