1. Acute and chronic pancreatitis

2. Beautiful as celestial angel, as demon incidious and ills (about the pancreas prof. Tolstoy A.D.).

3. Anatomy of the pancreas

4. Passage of bile and pancreatic juice

5. Function of the pancreas
Internal secretor
External secretor
Hormones
Pancreatic juice
Insulin
Glucagon
Kallecrein
Lypocain

6. Ferments, content in the pancreatic juice
Tripsin
Amilasa
Maltasa
Lypasa
ids pt pe
tes
dra
bohy
car s t a f
(starch)
Simple sugars
(glucose)
Amino acids
Glycerin and fat acids

7. Acute pancreatitis
Acute disease of pancreas in the base of which the degenerative-inflammatory processes are laying, inducted by the autolysis of the tissues of the gland with the own ferments.

8. Spreading of the acute appendicitis among the acute surgical diseases
Acute cholecystitis
Acute pancreatitis

9. Classification of the acute pancreatitis (Atlante, 1992)
Hypostatic pancreatitis
Sterile pancreonecrosis (by the currency: light, hard; spreading: limited, spreaded).
Infected pancreonecrosis (by the currency: light, hard; spreading: limited, spreaded).
Pancreatic cyst
Pancreatogeneous abscess

10. Classification of the acute pancreatitis (Filin V.I., 1994)
Stages of the acute pancreatitis
Clinical forms of the acute pancreatitis
Мелкоочаговый ПНЗ
Hypostatic AP
Fermentative stage
Крупноочаговый ПНЗ
Necrotic AP
Тотально-субтот. ПНЗ
Reactive stage
Infiltrate-necrotic pancreatitis and parapancreatitis
Aseptic form
Fermentative omentobursitis
Sequestration stage
Festering-necrotic pancreatitis and parapancreatitis
Septic form
Dissolvation
Stage of the upshots
Formation of the necrotic cysts
External pancreatic fistula
Chronic pancreatitis

11. Pathogenesis of the acute pancreatitis
Exogenous reasons of the AP
Endogenous reasons of the AP
I. Biochemial components
1. Stimulation of the hormones of the GIP
2. Activity of the lipolytic ferments
3. Defeat of the fermentative balance
4. Accumulation of the intermediate exchange
5. Production of the mediators of inflammation
6. Activation of the kallecrein-kinin and thrombine system
Hypostatic pancreatitis
II. Immunological componentes
1. Reducing of the humoral and cellular immunitete
2. Autoallergic reactions
Ischemia of the organ
Change of the biochemistry of the tissues and defeat of the wholeness of the tissues
Sterile pancreonecrosis
Activity of the proteolytic ferments (tripsin, elastasa and defeat of the walls of the vessels)
Hemorrhagic imbibition
III. Microbe componentes
Festering PNZ

12. Acute hypostatic pancreatitis
Pathologic anatomy
Acute hypostatic pancreatitis

13. Sterile pancreonecrosis
Pathologic anatomy
Sterile pancreonecrosis

14. Infected pancreonecrosis
Pathologic anatomy
Infected pancreonecrosis

15. Clinic picture of the acute pancreatitis
Pain localisate in the epigastria, may irradiate to the lumbar area (Meyo-Robson symptom), right scarula (Boas symptom), right arm and right supraclavicular area (Mussi symptom), left half of chest.
Retching repeating nerve-racking, sometimes becomes untamable.
Some patients with acute pancreatitis mark ballooned abdomen.
The abdomen of the patient may be ballooned. The intestinal peristaltic may be increased or doesn’t heard. The regional effort of the pancreas marks in its projection. (Certe symptom).

16. Skin symptoms, typical to the acute pancreatitis
- Mondor symptom – violet spots on the skin of body and face, alternate with the areas of pallor skin;
- Holsted symptom – cyanosis of the skin of the abdomen;
- Turner symptom – cyanosis of the skin of the lateral surfaces of the abdomen and lumbar area;
- Grunvald symptom – petechial rash on the skin of the umbilical area.

17. Laboratory diagnostic
Leucocytosis with the movement to the left, increased SES.
Increased amilasa (more than 128 un. by Volgemuth).
Hyperfibrinogenemia and increased contention of C-reactive peptid.

18. Laboratory diagnostic
Procalcitonin test
Norma – to 0,3 ng/ml
Factor over than 0,8 ng/ml witness about diffuse pancreonecrosis

19. Instrumental diagnostic - US
Specific signs
Increased sizes of the gland, jaggy of the borders, not homogenous parenchyma, dilatation of the Wirsungi’s duct, presence of the liquid in the omental bag
Not specific signs
Presence of the liquid in the abdominal and pleural cavities, paresis of the intestine

20. US picture of the acute pancreatitis

21. Instrumental diagnostic - US
Definition of the distance between the aorta and left lobe of liver
40 ММ – NORMA,
From 40 to 50 мм – hypostatic pancreatitis,
мм – limited pancreonecrosis,
Over 64 мм – diffuse pancreonecrosis

22. Specific methods of research
From the special methods of research for the diagnostic of the acute pancreatitis are using: X-ray, computer tomography, US diagnostic, endoscopic research (esophagogastroduodeno
fibroscopy)

23. Wirsungography

24. Compute tomography

25. Nucleus-magnet tomography

26. Celiacography

27. Angiographic semiotic of the pancreas at the different forms of AP
Changes of the arteries of the pancreas
Changes of the blood circulation in the parenchyma of the gland
Changes of the arterial vessels around the pancreas
Limited pancreonecrosis
Narrowing of the vessels, thrombosis of the vessels
Local reducing of the blood circulation, later – venous stage
Forcing back of the common hepatica, gastro-duodenal arteries, sometimes the diameter of the hepatica artery becomes more wide than lienalis
Diffuse pancreonecrosis
Thrombosis of the vessels
Reducing of the arterial blood circulation up to full disappearance of the vascular picture, stopping or absence of the spleenogramm
Thrombosis of the main arteries of the stomach and duodenum

28. Laparoscopic signs of the acute pancreatitis
«Glass» at the pancreonecrosis
«Stearine atheries» at the pancreonecrosis
«Stearine atheries» and threads of fibrin at the pancreonecrosis

29. Clinic scale of the diagnostic of the acute pancreatitis
I. Main clinic signs (frequency of the symptoms over 70%) – pain in the epigastria; increased diastasa of blood; retching, not giving reducing
II. Additional clinic signs (frequency of the symptoms over %) – mistakes in feeding, fat meal, alcohol, gall stone disease in anamnesis, bilerubinemia in anamnesis over 30 mcmol/l at the absence of GSD, diarrhea, rigid anterior abdominal wall, leucocytosis over 15*109/l
III. Possible clinic signs клинические признаки (frequency of the symptoms less than 20%) - pallor, cyanosis of the skin, enxiety, excitement, the frequency of the heart beats more than 120 or less than 60 in a minute, the frequency of the breathing actions more than 25 in a minute; hyperglycemy more than 10 mmol/lat the absence of the diabetes; hypoproteinemyless than 50g/l; hematocrit more than 45% or fibronogen more than 6 g/l; balloned abdomen (paresis of the intestines); absence of the pulsation of the abdominal aorta at the palpation
At the presence of the 3 main signs; 2 main and 2 additional signs; 1 main , 1 additional and 2 possible clinic signs the acute pancreatitis is diagnose

30. The disease isn’t diagnosed The disease is diagnosed
Comparative results of the diagnostic of the acute pancreatitis in different clinic groups
The disease isn’t diagnosed
The disease is diagnosed

31. Diseases, with which it is necessary to differentiate the acute pancreatitis
Perforative ulcer
of the stomach
and duodenum
Acute appendicitis
Acute intestinal
obstruction
Thrombosis or emboly
of the mesenterial
vessels
Acute cholecystitis

32. Differential-diagnostic criterions of the sterile pancreonecrosis (Tolstoy А.D., 2002)
I. Main signs:
1. Diagnostic of the hypostasis in the first 24 hours from the beginning of the disease;
2. Hemorrhagic character of the hypostatic fluid (the color from pink to cerise);
3. Not homogenous color of the peritoneal liquid (light in the inferior departments, derk in the omental bag);
4. Large volume of the peritoneal liquid (coefficient of the exudation > 50 ml/hour);
5. General state of the patient (tachycardia, hypotension, olygouria) doesn’t correspond to the minimal pathological findings.
II. Additional signs:
1. The first attack of the acute pancreatitis;
2. Obesity;
3. Absence of the GSD

33. Systems of the estimation of the state of the patients with the acute pancreatitis
1. Scales APACHE, APACHE-II, APACHE-III;
2. Scales TISS, TISS-28, TISS-76;
3. Scales SAPS, SAPS-2;
4. Scales MPM;
5. Scale of Renson – by the clinic parameters;
6. Scale of Renson – by the data of CT;
7. Scale of M.I. Prudkov;
8. Scale of V.B. Krasnorogov;
9. Scale of А.D. Tolstoy;
10. Scale of R.V. Vashetko.

34. Estimation of the gravity of the acute pancreatitis
I. By the clinic-laboratory factors
Degrees of the AP
Pulse, b/min
BP, mm.h.p.
Diuresis, ml/dayт
Concentration , un.
Light
<100
>100
>1000
<0,5
Middle
90-100
0,5-1,0
Heavy
>120
<90
<500
>1,0
II. By the data of computer tomography А
Normal pancreas В
Increased pancreas without involving of the surround tissues С
Middle increased pancreas with the signs of parapancreatitis D
One parapancreatic gathering of the liquid E
two or more extrapancreatic gatherings of the liquid

35. Estimation of the gravity of the acute pancreatitis
III. By the efficiency of the 6-12 hours basis therapy (Vashetko R.V., 2000)
1. Hungry;
2. Cold onto the abdomen;
3. Nasogastral aspiration;
4. Novocain blockade;
5. Introducing of the spasm- and cholinolitics i/v;
6. Infusion of the 2-3 liters of the cristalloids with the forced diuresis.
«all passed» - light AP;
«became better» - middle hard AP;
«hasn’t become better or became worse» - hard AP.
IV. By the character of the peritoneal exudates (Krasnorogov V.B., 2000)
Serous exudates – light AP;
Pink of ceris exudates – middle AP;
Chocolate or crimson – hard AP.

36. System of the prognosis of the gravity of AP at the firs day of thee disease (Tolstoy А.D., 2000)
I. Main signs:
1. Skin symptoms (marble, cyanosis, echomosis on the abdomen, hyperemia of the face);
2. Hemorrhagic exudates (first 12 hours – pink-cerise color, hours – chocolate);
3. Pulse > 120 in a minute. Или < 60 in a minute;
4. olygo- or anuria;
5. Haemolysis or fibrinolysis in the whey of blood;
6. Inefficiency or deterioration after 6-hours basis therapy
II. Additional signs:
1. Absence of the attacks of the AP in anamnesis;
2. Second half of the pregnancy or recent birth (6 months ago);
3. Immediately admition for the medical help and/or hospitalization in the first 6 hours from the beginning of the disease;
4. Alarm diagnosis of the pre-hospital stage («infarct», «perforation» и ets.);
5. Enxiety or braking;
6. Hyperglucemy over 7 mmol/l;
7. Leucocytosis over 14*109/l;
8. Bilerubinemy over 30 mcmol/l at the absence of the GSD;
9. Haemoglobine > 150 g/l.

37. Modern principles of the conducting of the patients with the acute pancreatitis
1. Maximal conservative treatment.
2. Differentiated conservative therapy depend on the stage and form of the disease.
3. Constant not invasive (US, CT) and invasive (by the indications – laparoscopy, transcutaneus puncture) control of the state of the pancreas and surround tissues.
4. Carrying out of the operative treatment at the presence of festering complications of the acute pancreatitis, phenomena of the mechanical jaundice and cholangitis.
5. Minimal trauma of the pancreas.

38. Components of the conservative treatment of the AP
I. Basis therapyтерапия:
1. Hungry;
2. Cold onto the abdomen;
3. Nasogastral aspiration;
4. Novocain blockade;
5. Introducing of the spasm- and cholinolytics i/v;
6. Infusion of 2-3 liters of the cristalloids with the forced diuresis.
II. Intensive therapeutic complex:
1. Normalization of the system and organ microcirculation (rheopolyglucin, refortan, heparin, surolexid);
2. Extracorporal detoxication (serial plasmoferesis, cryoplasmoferesis);
3. Cytocin blockade (introducing of the antoferments);
4. Antosecretorial therapy;
5. Reconstruction of the hydro-electrolite, metabolic and peptic losses;
6. Liquidation of the “acis srtess”;
7. Correction of the immune defeats (roncoleucin, timogen, cycloferon).

39. LIACT

40. Extracorporal methods of detoxication
Detoxication with the using of xenospleen
Haemosrbtion

41. Cathterization of the lienalis artery

42. Catheterization of the common hepatic artery

43. Catheterization of the celiac trunk

44. Surgical treatment at the acute pancreatitis is indicated
At the combination of the acute pancreatitis with the destructive forms of acute cholecystitis;
At the pancreatogeneous peritonitis at the impossibility of performing of the laparoscopic drainage of the abdominal cavity;
At the festering complications of the acute pancreatitis: anscess of the omental bag, flegmona of the extraperitoneal space .

45. Treatment of the biliar pancreatitis

46. Open operations
Panccreonecrosis
Necrectomy
Drainage of the OB

47. Laparoscopic drainage

48. Drainage and lavage of the omental bag

49. Omentobursostomy

50. Surgical tactic at the pancreonecrosis
to days
Laparoscopy, sanation and drainage of the abdominal cavity
At the ferment peritonitis (at the sterile pancreonecrosis)
Cholecystectomy, cholangiostomy, drainage of the OB
At the presence of the destructive cholecystitis, MJ, cholangitis (at the sterile pancreonecrosis)
Laparotomy, sanation and drainage of the abdominal cavity
At the progress of the syndrome of the system inflammatory reaction, inefficiency of the therapy, suspicion to the infection (at the sterile pancreonecrosis); at the infected pancreonecrosis
over days
Laparotomy, sanation, necrsecvesterectomy and drainage of the abdominal cavity
At the progress of the syndrome of the system inflammatory reaction, inefficiency of the therapy, suspicion to the infection (at the sterile pancreonecrosis)
At the sterile and infected pancreonecrosis
Spreading of the pancreonecrosis
Located
Spreaded
Access
Middle laparotomy
Middle laparotomy+lumbotomy at the spreading to the extraperitoneal area
Character of the surgical intervention
«close» conduction
Method of combined “open” and “close” conduction
Optimal regime of repeating sanations
«by requirement»
«by programme»

51. Алгоритм лечебных мероприятий
Form and gravity of the AP
Treating actions
At the insufficiency
Hypostatic form
Basis therapy
Basis therapy including sandostatin, ingibitors of proteas, forsed diuresis
Sterile pancreonecrosis, light currency
Conservative therapy including rheopreparates, stimulating drugs, parenteral feeding
LIACT(inefficiency of the LIACT during hours is the indication to extracorporal methods of detoxication, absence of the effect of which is the indication to the operation)
Sterile pancreonecrosis, hard currency
LIACT,
extracorporal methods of detoxication
Absence of the effect during hours is the indication to the operation
Infected pancreonecrosis
Operation -

52. Chronic pancreatitis (pancreatitis chronica)
The notion “chronic pancreatitis” (ХП), by modern presentations marks chronic polyetiologic inflammatory-degenerative process in the pancreas, characterizing with the long lasting currency.

53. Classification of the chronic pancreatitis
Recidivate pancreatitis. This form appears at the patients, passed the acute inflammation of the pancreas. Its essence is in periodically repeating attacks of the acute pancreatitis.
Painful pancreatitis. For this form of pancreatitis the presence of constant pain of different strength, local sated in the epigastria and irradiate to the lumbar area and left under-rib is characterized..
Pseudotumoros form of the chronic pancreatitis is characterised with the development of significant compaction of the tissue of the head of pancreas, that induct the compression of the bile duct and appearance of the mechanical jaundice. The main signs of this form of the pancreatitis are pain in the right under-rib and epigastria, sliming down, dyspeptic defeats, slow developing jaundice of scleras and skin.

54. Classification of the chronic pancreatitis
4. Indurative form of chronic pancreatitis develops at the gall stone disease, diseases of big duodenal teat, chronic alcoholism and passes with the dfeats of external and internal function of thee pancreas.
5. Calculous form is characterized with the development of the concrements in the parenchima of the pancreas or its ducts system. The manifestations of the calculous pancreatitis are similar with the clinic picture of the recidivate pancreatitis.
6. Cyst form. At this form of the pancreatitis the cysts are develop in the tissue of the pancreas. The cyst are separated to true and false.

55. Etiology of the chronic pancreatitis
1) Chronic alcoholism,
2) Gall stone disease and choledoholithyasis,
3) post-traumatic obstruction of the pancreatic ducts,
4) Influence of the chemical materials, including medicines,
5) hyperlipidemy,
6) Insufficient peptid feeding,
7) Hereditary aptitude,
8) Hyperparathyreoidism (hypercalciyemia),
9) mucoviscedosis,
10) Idiopathic factors.

56. Clinic picture of the chronic pancreatitis
The main signs of the CP are:
Painful syndrome;
Digestive defeats (different dyspeptic efeats, pancreatogeneous diarrheas);
Malabsorbtion (syndrome of insufficiency of the intestinal suction), connected with the development of the extrasecretorial insufficiency of the pancreas;
Sliming down; defeats of the function of the insulin apparate and different manifestations of secondary added diabetes; calcinates in the pancreas;
Symptoms, given by the development of the complications of the CP biliar hypertension, pancreatis cysts, segmental portal hypertension, pancreatic cysts, dupdenal stenosis and ets.

57. US
True cyst of the pancreas

58. Diagnostic of the chronic pancreatitis
Computer tomography: calcificates of the pancreas

59. Computer tomography Computer tomography of the pancreas:
The cyst looks as homogenous formation.

60. Treatment of the chronic pancreatitis
The main method of treatment of the chronic pancreatitis is conservative.
At the period between attacks the treatment consist of special diet.
The main moments at the treatment of the chronic pancreatitis at the intensification are: liquidation of the pain and spasm of the Oddy’s sphincter with the help of analgesics and spasmolitics; promotion of the functional calmness of the pancreas because of the diet.

61. Operative treatment
pancreaticojejunostomy: а – by Cattell; b – by Catlell in the modification of А.А.Shalimov; c - by Puestow-I; d - by Puestow-II