Page 52 of 73 PANCREATITIS
Etiology. The pancreas is especially strongly injured at an inflammation because its cells contain the whole arsenal of the proferments possessing potentially destructive action; in case of activation they can quickly melt gland fabric. The activating factors contain in leukocytes, blood serum and bacteria; therefore, any state which is followed by local inflammatory reaction or causes a retrograde infection of pancreatic channels can end with gland autolysis. The pancreatitis reasons at children are listed in tab. 12-13.
In most cases pancreatitis arises at children 10 years are more senior; the acute beginning is usually caused by the effect of drugs, toxins, injuries or viral diseases. The typical injury — falling on a bicycle wheel, however can lead any closed injury or surgical intervention on abdominal organs to injury of a pancreas. Sometimes pancreatitis arises only after a while after accident so communication between an injury and a disease can be tracked only at very careful collecting the anamnesis. The most frequent reason of viral pancreatitis — epidemic parotitis. Pancreatitis symptoms in such cases are imposed on a clinical picture of a basic disease and shown in quite easy form. At Ray's syndrome approximately
Table 12-13. A pancreatitis etiology at children
Idiopathic pancreatitis of Medicine and Tiazida Prednizon's toxins of Alkogol Azatioprin Valprolevaya acid Injury
Viral diseases Epidemic parotitis the Syndrome Flying the Hepatitis A and B Rubella
Infection a virus koksakch In Flu A
Diseases and anomalies of bilious and pancreatic channels Cholelithiasis Ascaridosis
Choledochal cyst Duplikatsionny cysts
Anomalies of a confluence of the general bilious channel
Not merge of dorsal and ventral rudiments of a pancreas Mucoviscidosis System diseases Lupus erythematosus Nodular periarteritis Lipidemia I, IV and V Hypercalcemia types (hyperparathyreosis)
Hereditary pancreatitis in 50% of cases is noted a hyperamilasemia, is frequent during surprisingly long time. However pancreatitis only occasionally dominates in a clinical picture of this syndrome. In every 5th case of acute pancreatitis the reason does not manage to be established at all.
Repeated attacks of pancreatitis are rather rare, but their diagnosis and treatment are connected with great difficulties. At such current often find cholelithiasis or anomalies of development of biliary and pancreatic channels. Besides, recurrent pancreatitis can have a hereditary basis (rare autosomal and dominant type of transfer); there are messages on 281 cases of such form of Pancreatinum in 18 families, mainly among the white population there is USA. The mucoviscidosis is more rare reason as acute, so recurrent pancreatitis; at both forms fabric of gland can be kept sufficiently and process of absorption is not broken.
Clinical manifestations. The leading symptom is the constant irradiating in a back pain in epigastriums. It is followed by nausea and vomiting. The child usually not movably lies on one side. The stomach is blown up, intense. The peristaltics is not listened, dense education is in certain cases palpated. In case of hemorrhagic defeat it is possible to see cyanosis around a navel. At a heavy current there is pleurisy and ascites. Considerable reduction of volume of blood at the expense of a plasma exudate in a pancreas and surrounding fabrics can become the shock reason. High temperature testifies to an extensive necrosis of gland or forming of abscess. In most cases symptoms constantly abate within 3 — 10 days. Longer current or repeated painful attacks for several weeks can be signs of development of pseudocysts which sometimes manage to be propalpirovat. Very seldom initial symptom of pancreatitis is detection in an abdominal cavity of dense education.
Datas of laboratory. Level of serumal amylase in the first 12 h is increased, but then during 24 h can be normalized. At research of pleural or astsitny liquid in them considerable concentration of amylase is also defined. The ratio reaches amylase/creatinine in urine 4 that allows to exclude not pancreatic reasons of a hyperamilasuria, for example epidemic parotitis or a macroamilasemia. A passing hyperglycemia and a glucosuria are possible. Low concentration of calcium in serum — a late and serious symptom, but at children it is observed seldom. On the survey roentgenogram of an abdominal cavity expanded segments of a small bowel (a "sentry" loop) in a pancreas or generalized paralytic impassability of intestines are visible. Gland calcification at children is observed seldom — only in cases of hereditary pancreatitis. On roentgenograms of a stomach and duodenum it is possible to observe outlines of big retroperitoneal pseudocysts which stretch a duodenal loop or displace a kpereda stomach. Ultrasonic scanning can play an important role in detection of pseudocysts. This method in general allows to confirm the diagnosis of pancreatitis as gland fabric density in the period of an inflammation decreases and in process of improvement returns to norm. Stones in channels, narrowing or a curvature of distal pieces of channels, their unusual anatomic structure it is possible to reveal by means of an endoscopic retrograde holangiopankreatografiya. This method is an important component of inspection of the patient with a recurrent form of pancreatitis. Extremely rare effect of chronic recurrent pancreatitis at children is the steatorrhea, it can be observed after corrective operations and in certain cases hereditary pancreatitis.
Treatment. Main goals of treatment — creation of rest for gland and maintenance of the general condition of the patient. Vigor of the held events has to be defined by weight of a current, but in general it is better to revaluate a condition of the patient, than to underestimate. Feeding through a mouth is stopped, constantly suck away a gastric juice by means of a nasal probe, intravenously enter liquids and electrolytes. In one cases it is necessary to transfer the patient to completely parenteral food, in others — to pour in blood or albumine for fight against shock. At severe pains apply anesthetics. Efficiency of anticholinergics and antibiotics is less obvious, but in many clinics they continue to be used actively. Pass to oral administration of food gradually, in process of subsiding of symptoms, but if pains renew, then it is necessary to return to parenteral feeding. Pseudocysts in an initial acute stage it is possible to try to treat conservatively by means of long parenteral food in hope that they will spontaneously resolve. Cysts which continue to increase or persistirut more than 6 weeks, usually it is necessary to drain surgically, At patients with anomaly of channels improvement comes when by means of various surgical methods it is possible to improve outflow of pancreatic juice.