Pancreatitis with special etiology or pathologic changes and certain specificity in treatment is called special type of pancreatitis, mainly sudden death pancreatitis, tropical pancreatitis, hereditary pancreatitis, drug-associated pancreatitis, and post-operative ERCP pancreatitis.
(1) Sudden death pancreatitis: Sudden death pancreatitis, also known as painless acute necrotizing pancreatitis, often occurs when the pancreas is acutely hemorrhaging or acutely necrotic. The disease is rare, but the prognosis is very poor, and sudden death is the most serious consequence. The cause of sudden death pancreatitis is basically the same as that of acute pancreatitis, and it is most closely related to overeating and drinking, and many sudden death pancreatitis occurs after alcoholism and excessive consumption of high-fat foods.
The exact cause of their sudden death is no more than shock, pulmonary lesions, hypokalemia, disseminated intravascular coagulation, myocardial injury, and central nervous system injury.
Patients with this disease are mostly male young adults and often die suddenly during sleep. The vast majority of patients do not have obvious symptoms and signs before death, a few patients in the days or hours before the death of epigastric discomfort, hidden pain, loss of appetite and other manifestations, but often did not cause patients and their families attention. Most of the patients do not have abdominal pain, probably because the pancreas is rapidly destroyed in a short period of time and the patient quickly enters a coma, unable to clearly tell the symptoms. Death is very rapid, there is no screaming before death, there may be convulsions or urinary incontinence, often too late to check and rescue, the patient has died.
Since most patients are already dead when they arrive at the hospital, it is difficult to determine the cause of death, so it is often given the diagnosis of "cerebrovascular accident", "myocardial infarction", "drug poisoning", etc., which leads to misdiagnosis and underdiagnosis. This leads to misdiagnosis and underdiagnosis, which in turn leads to medical disputes. Because of the rapid development of the disease, it is often too late to rescue and lose the opportunity to treat, so far has not seen the sudden death of pancreatitis rescue success reports. But as long as timely detection, timely rescue, may be cured. When the patient binge drinking, drinking a lot of alcohol or eating too much fat food after the epigastric discomfort, pain and other symptoms, although the condition is not serious, but also to think of this disease, only then can take effective rescue measures.
(2) Tropical pancreatitis: Tropical pancreatitis is a special type of chronic calcific pancreatitis, which is named because of its prevalence in the tropics. It is also called malnutritional pancreatitis or adolescent tropical pancreatitis syndrome because one of the pathogenic factors of this disease may be malnutrition and it mostly involves adolescents. The daily diet of these patients is severely deficient in both calories and protein, often resulting in severe malnutrition. The exact causative factors and pathogenesis of this disease are not well understood, and the possible causes include pancreatic duct obstruction, long-term reduced protein intake, toxic factors in food, viruses and other pathogenic microorganisms, and deficiencies of vitamins and certain trace elements.
The main clinical symptom of tropical pancreatitis is abdominal pain, and at the onset of the disease, in addition to the abdominal signs of an ordinary pancreatitis attack, the more characteristic is the manifestation of generalized malnutrition, such as extreme lethargy, parotid gland enlargement, cyanosis of the lips and mouth, epigastric bulging, etc., and sometimes there can be a malignant malnutrition-like hair and skin changes. The disease develops in adolescence and is often misdiagnosed as an intestinal parasitic infection in childhood. 95% of patients have prolonged and recurrent episodes of abdominal pain, most often localized in the epigastrium, umbilicus and quaternary ribs, with each episode of abdominal pain lasting from a few hours to a few days.
Complications such as juvenile diabetes mellitus and steatorrhea usually occur within a few years of the first symptoms. Malabsorption and diabetes mellitus due to internal and external pancreatic insufficiency are the major complications and causes of death in this disease. Rare complications include peptic ulcer, appendicitis, and obstructive jaundice.
(3) Hereditary pancreatitis: Hereditary pancreatitis, also known as idiopathic hereditary pancreatitis, is an autosomal dominant genetic disease of undetermined cause, mostly found in Caucasians, and is one of the most common causes of chronic pancreatitis in childhood and adolescence. The diagnosis is usually made by tracing the history of the disease after complications such as pancreatic calcification and pancreatic insufficiency develop in young adulthood, and relies mainly on medical history, family history, and retrograde cholangiopancreatography.
If there are no serious complications, the prognosis of the disease is good. Early diagnosis and prompt treatment can reduce complications. Pediatric patients should be treated with medication, while surgical treatment is advocated for adult patients.
The clinical symptoms of this disease appear earlier, mostly in childhood or early childhood, the age of onset of 11 to 17 years old, the youngest for 11 months of infants, a small number of patients may also be adult before the onset of symptoms, the incidence rate is not significant gender differences. The main symptom is recurrent epigastric pain, which can be self-limiting and is often overlooked.
The epigastric pain may radiate to the back, and each attack lasts 1 to 7 days or even longer, and may occur 3 to 4 times a year. The attacks are often accompanied by anorexia, nausea and vomiting. In children, there are no obvious triggers, while in adult patients, the attacks may be triggered by alcoholism, fatty meals, spicy food, fasting and mental stress. In some patients, the symptoms may be relieved and the number of attacks may decrease with age.
The major complications of the disease are due to internal and external secretory insufficiency of the pancreas, such as steatorrhea, malabsorption, diabetes mellitus, pancreatic calcification, pancreatic stones, and pancreatic pseudocysts, with occasional venous thrombosis and pleural bloody exudates. Patients with hereditary pancreatitis should be alerted to pancreatic cancer if they present with changes in the nature of abdominal pain, weight loss, itchy skin, obstructive jaundice, and malaise. For the treatment of hereditary pancreatitis, there should be a difference between pediatric and adult patients. Internal medicine is appropriate for pediatric patients, and surgical treatment is usually not needed unless a pancreatic pseudocyst is found that must be drained or there is a clear anatomical abnormality of the pancreas.
Surgical treatment is favored in adult patients because early surgery is beneficial in controlling symptoms, preventing further damage to the pancreas, and reducing or avoiding complications.
(4) Drug-associated pancreatitis: Drug-associated pancreatitis refers to organic damage to pancreatic function caused by the drug itself or by drug-drug interactions, and can be part of a systemic adverse reaction to the causative drug. The pathogenesis of drug-associated pancreatitis and the relationship between inflammation and the dose of the causative drug are not yet fully understood.
The direct pathogenesis of drug-associated pancreatitis is varied, such as toxicity or immune response, and pancreatitis can occur within 1 month of taking these drugs. Indirect mechanisms are hypercalcemia, local ischemia, intravascular thrombosis, or increased viscosity of the pancreatic fluid.
The symptoms of drug-associated pancreatitis are generally not severe and are self-limiting. It is often a mildly edematous form of pancreatitis, presenting as swelling of the head and/or body of the pancreas, which dissipates relatively quickly. Since some progressive cases are due to hypersensitivity (allergic, anaphylactic) reactions (e.g., azathioprine, sulfasalazine, etc.), there is often a skin reaction, such as flushing of the skin and papules. Severe pancreatitis can occur in only a few cases, and immunocompromised patients can occasionally die.
Once pancreatitis is suspected to be caused by drugs, regardless of whether or not it has been determined what kind of drug is the cause of the disease, the first thing to do is to stop using all the drugs used to terminate the continued damage to the pancreas, and stopping the drug will also help in the differential diagnosis. If the diagnosis is still difficult to determine, according to the condition of the discretionary re-excitation test to clarify the diagnosis. Usually, drug pancreatitis is self-limiting, and most of the cases are mild, no special treatment is needed after stopping the drug, and the symptoms of pancreatitis are gradually relieved after a few days due to the excretion of the drug. However, severe cases must be treated symptomatically, in addition to the use of supportive therapy, to promote drug excretion measures, if the causative drug has been very clear, but also discretionary use of the corresponding antagonist. If pharmacogenic pancreatitis is caused by an immune response, the patient should be clearly informed to avoid the use of the drug again, in order to prevent the problem before it occurs.
(5) Post-ERCP pancreatitis: Post-ERCP pancreatitis is one of the common complications of diagnostic and therapeutic ERCP. In the mild case, it is only an elevation of serum amylase after ERCP, and in the severe case, there are abdominal pain, nausea, vomiting, fever, peritoneal irritation, etc. In a very few cases, severe acute pancreatitis even occurs. In severe cases, abdominal pain, nausea, vomiting, fever, peritoneal irritation and other clinical manifestations occur, and in a very small number of cases, severe acute pancreatitis even occurs and causes death. Although a lot of research work has been done on prevention, the incidence of post-ERCP pancreatitis is still 0-39.5%, which may be related to contrast agent stimulation and improper operation, so it is often called "chemical pancreatitis" or "injectable pancreatitis" in the past. In the past, it was often called "chemical pancreatitis" or "injectable pancreatitis", but now it is called post-ERCP pancreatitis.
The causes of post-ERCP pancreatitis are as follows: underlying pancreatic disease, hepato-pancreatic jugular sphincter dysfunction, intubation difficulties, repeated pancreatic ductography, and duodenal papilla injury. post-ERCP pancreatitis is very similar to the clinical manifestations of acute pancreatitis in general, and usually manifests itself as epigastric pain, nausea, vomiting, abdominal distension, and other symptoms, and occasionally low-grade fever and jaundice after the operation. Physical examination revealed pressure and rebound pain in the epigastrium and left upper abdomen, and diminished bowel sounds.
The pancreas is enlarged on ultrasound and CT. If severe acute pancreatitis occurs, in addition to the above symptoms and signs of significant aggravation, B ultrasound and CT examination of the pancreas can be seen to be significantly enlarged, and can be seen around the pancreas tissue edema, gap disappearance, adhesions, pancreatic parenchyma within the point of vesicular liquefaction necrotic cavity and other manifestations. In general, the diagnosis of post-ERCP pancreatitis is not difficult, according to whether the ERCP operation is smooth or not, and whether the patient has the above symptoms or not, the diagnosis can be confirmed. It must be differentiated from the complications of acute biliary tract infection, embedded residual stones, and digestive tract perforation after ERCP.
Patients with post-ERCP hyperamylasemia only usually recover completely in 2-3 days.
Patients with post-ERCP acute pancreatitis can recover completely within one week after regular treatment. In the case of severe acute pancreatitis, the duration of the disease is significantly prolonged, and hospitalization is required for 2 to 3 weeks, or even longer. However, post-ERCP pancreatitis rarely causes serious complications such as shock, sepsis, abdominal and retroperitoneal abscesses, paralytic intestinal obstruction, liver failure, renal failure, etc. Therefore, the probability of death is relatively small.The treatment principles of post-ERCP pancreatitis are basically the same as those of acute pancreatitis, i.e., to reduce and inhibit the pancreatic secretion, to prevent the secondary infections, and to manage the symptomatic condition.
(6) Acute pancreatitis after laparotomy: Acute pancreatitis after laparotomy is a rare emergency. Clinical manifestations of acute inflammation, abdominal pain, fever, in addition to loss of appetite, nausea, vomiting, oliguria, acute progressive dyspnea, hypocalcemic convulsions, persistent mental disorders and other symptoms.
The etiology of acute pancreatitis after laparotomy is described below. ①Anatomical and operational factors: intra-abdominal organs, such as the biliary tract, stomach, duodenum, spleen and kidneys are adjacent to the pancreas, and it is very easy to cause pancreatic injury during surgery, causing pancreatic edema and bleeding, or even necrosis. Incomplete surgery can also cause pancreatitis, such as biliary tract stones remain and cause pancreatitis. ② obstruction factors: patients affected by anesthesia drugs, postoperative sphincter of Oddi dysfunction, intestinal peristalsis is inhibited, and even paralytic intestinal obstruction; Billroth Ⅱ type of most of the gastrectomy, the input of intestinal collaterals stagnation can be caused by pancreatic fluid discharge obstruction and induced pancreatitis. ③ Pancreatic microcirculatory disorders act as factors that sustain and exacerbate damage in the pathogenesis of acute pancreatitis, manifesting as inadequate tissue perfusion in pancreatic ischemia, or microcirculatory stagnation. ④ Postoperative overeating causes pancreatic hypersecretion.
Postoperative pancreatitis occurs after the surgery of the primary disease, and the condition is more serious, in addition to the general treatment given, the following points should be especially emphasized: ① fasting TPN (complete extragastrointestinal nutrition); ② use of adrenocorticotropic hormone; ③ vasodilator drug therapy; ④ surgical treatment. Once postoperative acute pancreatitis develops into severe pancreatitis, especially with clear infection and obvious systemic toxic symptoms, therefore surgical treatment is of great significance. Surgery should remove as much necrotic tissue as possible, loosen the peripancreatic envelope, and drain the abdominal pancreatic bed adequately.
Prevention: ① the surgeon should be familiar with the local anatomy before surgery, surgical operation should be gentle, careful, avoid rough extrusion of the pancreas during the operation, the lesion organ and the pancreas should be patient sharp separation of close adhesion, biliary surgery, do not rough expansion of sphincter of Oddi, biliary tract downward irrigation should be avoided high-pressure; ② preoperative clean enema, postoperative activities as soon as possible to promote the return of normal bowel function; ③ advise the patient in the postoperative recovery period to avoid storming, to avoid the normalization of intestinal function. Patients should avoid overeating and drinking during the postoperative recovery period.
About the diagnosis of postoperative acute pancreatitis: it is necessary to closely observe the changes of the patient's condition after surgery, for the occurrence of unexplained abdominal pain, nausea, vomiting, fever, etc., as well as gradual or sudden irritability, persistent abdominal distension, convulsions, etc., it should be considered as postoperative pancreatitis, and timely laboratory and imaging tests should be carried out to make a clear diagnosis as early as possible, and timely treatment.