Pancreatitis, or inflammation of the pancreas, is considered the most dangerous disease due to the often emerging complications that threaten the patient’s life. The death of organ tissues as a result of the aggressive action of its own enzymes leads to structural destruction of the pancreas, the release of toxins into the general bloodstream, and the formation of systemic pathologies. This process is called pancreatic necrosis and is a complication that causes death in almost half of the cases (according to some data - 80%).
The defeat of the blood vessels of the pancreas, occurring against the background of the inflammatory process, often leads to the formation of hemorrhages in the parenchyma. Such hematomas further aggravate the pathological process by squeezing the ducts and making it difficult for the organ to drain. Hemorrhagic pancreatonecrosis is formed, where vascular disorders come out on top in the destruction of the gland.
Causes and mechanism of development
In most cases, the hemorrhagic pancreatitis in an acute form becomes the background (and primary) disease, that is, the initial phase of pancreatic tissue destruction by enzymes and the inflammatory process. It is characterized by the destruction of the vascular walls, the release of blood into the interstitial spaces, the formation of hemorrhages. These formations begin to squeeze the still functional parts of the body, which makes it difficult for both the activity of the gland and its regeneration.
In some cases, the rupture of blood vessels or thinning of their walls does not occur, and blood clots are formed, which is associated with systemic processes. They clog the vessels, resulting in some parts of the gland are left without oxygen and begin to die. Such hemorrhagic pancreatitis, turning into necrosis, is more correctly called ischemic, that is, initially having cell death, the inflammatory process joins a little later.
Hemorrhages become sites of necrosis
Regardless of what caused the damage to parts of the pancreas or the entire organ as a whole, the effects of enzymes, hemorrhages or tissue ischemia, they very quickly begin to break down. In their place are formed foci of decay, where blood accumulates, interstitial fluid, a huge amount of toxins. All these substances begin to flow into the bloodstream, "poisoning" the body. With hemorrhagic pancreatitis, turning into necrosis, the kidneys, heart, liver, brain suffer.
There are several reasons that can cause acute pancreatitis, complicated by necrosis. They can be represented as follows:
- excessive intake of alcohol;
- excessive consumption of fatty, spicy, smoked food;
- background diseases of the liver and gallbladder (cholecystitis, cholelithiasis, biliary dyskinesia);
- bleeding disorders;
- autoimmune pathologies (systemic vasculitis);
- pancreatic damage during injuries or surgical interventions.
As clinical practice shows, acute hemorrhagic pancreatic necrosis often develops in young and middle age, and alcohol and nutritional errors become provoking factors. At the same time, patients in most cases are not “drinkers”, but a single dose of an excess amount of ethanol can lead to terrible destructive consequences in the gland. In alcoholics, the constant supply of alcohol in the body very rarely becomes the cause of pancreatic necrosis, and chronic pancreatitis often develops, followed by hardening of the pancreas.
Symptoms of acute pancreatic necrosis increases very quickly, within a few hours and up to one day. At the beginning of the pathological process, when the consciousness is still clear, the patient can clearly associate the onset of the disease with the use of, for example, a large amount of alcohol (such patients are in a state of severe intoxication). Then, when pronounced intoxication syndrome and brain damage is formed, clouding and loss of consciousness occurs.
Therefore, medical care should be provided to the patient on an emergency basis. Such patients are urgently hospitalized in the intensive care unit, since literally every minute can be decisive for a person.
In general, the clinical signs of hemorrhagic pancreatic necrosis are very similar to acute pancreatitis, but their appearance and growth occurs very quickly. In addition, during the first days from the onset of necrosis, kidney damage begins to manifest itself, and neurological and mental disorders are formed.
The most typical symptoms of pancreatic necrosis are as follows:
- Sharp increasing pain in the upper abdomen and left hypochondrium, extending to the left side. In the first hours of necrosis, the severity of pain corresponds to the severity of the pathology and the degree of destruction of the pancreas. But then, when the death of nerve endings begins in the organ, the flow of pain impulses stops. The presence of severe intoxication with a tendency to ease the pain is considered a prognostically unfavorable sign.
- Repeated vomiting that occurs soon after the onset of pain and leads to dehydration of the person (in vomit - mucus, bile and blood).
- Dry skin and mucous membranes as a result of dehydration, which have a pale hue.
- Dry tongue, coated with white bloom.
- Intoxication syndrome (fever, chills, great weakness, lack of appetite).
- Vascular disorders that manifest changes in blood pressure. Most often it falls, leading to collapse (fainting).
- The development of flatulence due to slower intestinal motility and lack of stool.
- Decreased diuresis or lack of urination.
- Formation of encephalopathy, or brain damage (confusion, disorientation, agitation, then these symptoms become comatose).
In addition, extensive hemorrhages that form during hemorrhagic pancreatonecrosis can be visually observed on the skin of the abdomen in front and sides. They look like cyanotic (cyanotic) spots against the background of pale and cold skin.
Characteristic bruises on the skin allow you to make the correct diagnosis
The rapid death of the tissues of the organ and the capsule, which occurs during the destruction, especially total, after a few hours leads to the formation of very dangerous consequences. The contents of the pancreas, fragments of necrotic tissue, hemorrhagic exudate, toxins go beyond the limits of the organ, that is, into the abdominal cavity. Peritonitis begins, the formation of purulent abscesses in the peritoneum and other internal organs, sepsis (general blood infection) develops. All these processes leave the patient with virtually no chance of survival.
The speed of diagnostic measures and the correct diagnosis directly determine the success of therapy and prognosis. In the emergency room of the inpatient of a patient, who is usually in a very serious condition, they are examined by several doctors (general practitioner, gastroenterologist, surgeon, resuscitator). Anamnesis data is clarified from the accompanying people, complaints, if possible, from the patient himself. The condition of the skin, the presence of pain points, the degree of diuresis, clarity of consciousness are assessed.
The necessary analyzes are urgently taken:
- blood to determine the content of enzymes (amylase, lipase, trypsin, elastase);
- urine for amylase;
- using sensing takes gastric juice and pancreatic secretion, which determine the enzymes and the degree of acidity;
- coprogram for fat content.
In addition to laboratory diagnostics, instrumental methods are used. This ultrasound, radiography, CT, MRI. If necessary, laparoscopy or endoscopy is used, which allows, directly by eye contact, to assess the state of the pancreas and the whole abdominal cavity.
All tests for pancreatic necrosis are carried out urgently.
All diagnostic methods, simultaneously with the specification of the diagnosis of pancreatitis or acute pancreatic necrosis, can eliminate other pathologies that occur with similar symptoms. These are acute intestinal obstruction, acute appendicitis, acute cholecystitis, perforated gastric ulcer, rupture of the abdominal aorta, vascular thrombosis of the abdominal cavity.
Therapy of necrosis is complex and is a combination of conservative and radical methods. In the first few days from the onset of pancreatic necrosis, surgical intervention is not recommended, since a possible secondary infection against the background of rapid "melting" of pancreatic tissues can greatly worsen the patient's condition. During this period, preference is given to conservative treatment.
It aims to:
- reduced pain intensity;
- release of the pancreas from secretions;
- reduction of intraorgan pressure;
- elimination of toxins from the body.
To neutralize and remove enzymes from the pancreas, Trasilol, Contrycal, and Ribonuclease are used. It is also important to reduce the acidity of gastric juice with Atropine, Ephedrine. The use of diuretics leads to a decrease in edema in the organ and a decrease in the pressure of the capsule on the parenchyma. The "cleansing" of blood from toxins, that is, detoxification, is carried out by administering blood substitutes and then forcing diuresis using diuretics.
Hemorrhagic pancreatic necrosis often requires surgery
After a few days, if the effectiveness of conservative methods is small, an operation is performed. During the surgical procedure, hemorrhagic and necrotic masses are removed, the patency of the ducts of the gland is restored, and the blood flow is corrected. Total hemorrhagic pancreatic necrosis requires organ resection or its complete removal.
The prognosis for all forms of hemorrhagic pancreatic necrosis is ambiguous. The percentage of mortality is very high, mainly due to concomitant systemic lesions, but there is always the possibility of recovery.