Roch acute pancreatitis. Chronic pancreatitis modern classification

Biliary pancreatitis is one of the forms of acute pancreatitis that develops against the background of cholelithiasis or on the background of diseases duodenum and a large duodenal papilla, accompanied by stagnation of bile in the ducts.

This pancreatitis is relatively recently singled out as a separate nosological form. This is due to the fact that the disease has a special clinical course, a clear etiology and pathogenesis. This means that the approach to treatment, diagnosis and prevention this disease has its own characteristics.

The disease can occur in acute and chronic form. If there is an acute process in the patient's body, then it is customary to talk about biliary pancreatitis, if the disease has taken a chronic form, then they talk about biliary-dependent pancreatitis.

Etiology

Biliary pancreatitis is widespread throughout the world. The anatomical and functional similarity of the pancreatobiliary system causes the occurrence of the disease against the background of the pathology of the biliary system in 50% of cases.

The disease has a polyetiological nature. At its core, inflammation of the organ occurs a second time, that is, infectious agents are brought in from other organs and systems, and pancreatitis itself occurs against the background of another pathology. It could be:

gallstone disease (chronic calculous cholecystitis, choledocholithiasis).
Dyskinesia of the biliary tract.
Congenital strictures and other anomalies of the biliary tract and gallbladder.
Functional or organic disorders of the duodenum and large duodenal sphincter (between the main bile duct and the intestinal cavity).
Liver diseases (hepatitis, cirrhosis).

Pathogenesis

The mechanisms of inflammation development in biliary-dependent pancreatitis are diverse. There are three routes of infection:

Lymphogenic. In this case, infectious agents are brought into the pancreas from the liver, gallbladder or bile ducts through the lymphatic vessels. After purulent fusion of the organ tissue occurs, the disease takes an acute form and, if not intervened in time, can quickly lead to lethal outcome.
Hypertensive. Bile is an aggressive agent. It contains special compounds that can break down any organic matter. If the work of the biliary tract is impaired (or the function of the sphincter of Oddi is impaired), bile stagnation occurs. The constant accumulation of bile leads to the fact that it is thrown back into the pancreatic ducts, after which it begins to aggressively act on the gland itself. Aseptic chronic inflammation which is called biliary-dependent pancreatitis.
Duadenopancreatic reflux. In diseases of the duodenum, there is a violation of intestinal motility, an intra-intestinal increase in pressure. All this contributes to a violation of the outflow of bile from the choledoch into the intestinal cavity, and biliary-dependent pancreatitis occurs.

Clinical forms of biliary pancreatitis

The disease proceeds in several stages:

Mild form (edematous).
Sterile pancreatic necrosis.
Infected pancreatic necrosis.

Inflammation can affect both part of the gland (head, body, tail), and the entire organ.

Clinical picture of the disease

The clinic of biliary-dependent pancreatitis consists of several symptoms.

Pain is the first symptom that makes patients see a doctor. It can be shingles in nature or radiate to the back or hypochondrium. With biliary pancreatitis, pain occurs after taking fried, fatty foods, since such dishes are choleretic. Pain occurs a couple of hours after the last meal, but can also be observed at night on an empty stomach. Due to the long digestion of fats, pain can be observed for several hours.
Dyspeptic disorders (vomiting, nausea, flatulence, bitterness in the mouth, a feeling of heaviness in the stomach, bitter belching, retention or absence of feces). More often, patients notice repeated vomiting of food, which occurs at the height of pain. Vomiting does not bring relief, and new urges arise after a few minutes.
Symptoms of intoxication: fever, weakness, loss of appetite.
Jaundice: icteric staining of the sclera, oral mucosa, nail plates, skin.

Important! If these symptoms take a protracted nature and have been bothering the patient for a month or more, then this is a sign of a chronic inflammatory process. From this point on, they talk about chronic biliary-dependent pancreatitis.

Read also: Chronic pancreatitis- a modern view of the problem

Diagnostics and laboratory research methods

The diagnosis of biliary-dependent pancreatitis is made after collecting the patient's complaints and anamnesis, an objective examination of the patient. The presence of predisposing diseases in a patient (cholelithiasis, liver disease or duodenal disease) will help to suspect a malfunction of the pancreas.

On examination, it is worth paying attention to the staining of the sclera and mucous membranes, to palpate the abdomen. As a rule, with biliary pancreatitis, the abdomen is not available for deep palpation in the epigastric and hypochondral regions. In addition, there is pain in the projection points of the gallbladder.

To confirm the presence of the disease, additional laboratory and instrumental research methods are prescribed:

General clinical analysis blood (outside of an exacerbation of biliary pancreatitis, a moderate increase in the number of leukocytes is observed, with an exacerbation - a pronounced leukocytosis with a shift leukocyte formula to the left).
Blood chemistry. Here they look at the amount of liver enzymes: amylase (with an exacerbation of biliary pancreatitis, the value can be 10 times higher or higher), transferases (AsAT, AlAT), alkaline phosphatase, lipase.
Analysis of feces for the presence of fat in it.
Ultrasound procedure is the gold standard for diagnosis. At the same time, voluminous dense formations are found in gallbladder or in its ducts, bile stasis, thickened wall of the gallbladder, diffuse changes pancreas (heterogeneous structure, uneven contours, edema, calcifications and petrifications in the tissue of the organ).
Dynamic cholecystography and ERCP (endoscopic retrograde cholangiopancreatography) will help determine if there are changes in the major duodenal papilla and terminal calving of the pancreatic ducts. During ERCP, papillosphincterotomy is often done to remove the calculus and relieve hypertension in the bile ducts.
EFGDS (esophagogastroduodenoscopy) is performed in all patients with suspected biliary pancreatitis. During the examination, the digestive tract is completely examined. Particular attention is paid to the area of the large duodenal papilla, examining it for the presence of fibrotic changes, strictures and other pathological processes.

Read also: Pancreatic steatosis: features of the course and diagnosis

Treatment of biliary-dependent pancreatitis

In mild cases, preference is given to conservative therapy. The main thing here is to strictly follow a diet and take antisecretory drugs.

If there are stones in the gallbladder or its ducts, they resort to surgical intervention, during which they are removed. The operation is also performed with advanced forms of biliary-dependent pancreatitis, when necrosis of the gland tissue is already observed. This operation is an emergency, performed according to vital indications.

Diet

With an exacerbation of biliary pancreatitis, patients are prescribed hunger for the first 4-5 days. This reduces the enzymatic load on the pancreas, creates functional rest for it. Then the patient is prescribed a sparing diet (table No. 5) with a restriction of fatty, salty, fried, canned food.

Important! Carbonated and alcoholic drinks, dishes that increase the load on the pancreas, and indigestible foods are completely excluded from the diet.

With biliary pancreatitis, the emphasis is on protein foods, which come from lean meats and fish, cereals and dairy products. From drinks, teas, decoctions, dried fruit compotes, jelly are allowed. During the day, you can consume up to 50 grams of sugar and a piece of dried (not fresh) bread.

Conservative treatment

In parallel with the diet, drug therapy is prescribed:

Fighting pain. In the presence of pain, antispasmodics are prescribed (no-shpa, papaverine, platifillin, etc.). It may be that the pain is due to atony of the gallbladder. In this case, on the contrary, substances that spasm smooth muscles (domperidone, cerucal, etc.) are used. The latter improve intestinal motility, thereby improving digestion.
antisecretory therapy. With exacerbation of biliary-dependent pancreatitis, it is important to suppress the enzyme-forming function of the pancreas. To do this, prescribe Famotidine, Ranitidine or the drug latest generation- Octreotide. At the same time, gastric secretion is blocked by omeprazole, which helps to restore the pancreas.
Anticoagulant therapy. It is carried out with low molecular weight heparins, which prevent the formation of blood clots in the vessels of the gland, improve microcirculation, and increase blood flow to the organ.

If there is a spasm of the sphincter of the major papilla, then a myotropic antispasmodic is prescribed - Mebeverine. This improves the circulation of bile, relieves hypertension and congestion in the ducts.

In the presence of calculi of small diameter, deoxycholic acid preparations are added to the therapy of biliary-dependent pancreatitis, which help dissolve stones and remove them into the intestinal cavity (eg Ursosan).

The lack of pancreatic secretion is compensated replacement therapy. At the same time, enzyme preparations (eg Creon) are prescribed, which improve abdominal digestion, relieve hypertension. Thus, they accelerate the outflow of bile and normalize the work of the digestive tract.

Currently, a huge number of classifications of pancreatitis have been developed. We will consider the most widely used. It should be borne in mind that acute and chronic pancreatitis are completely different diseases. Each of them has its own set of classifications.

Classification of acute pancreatitis

According to the severity, two forms of acute pancreatitis are distinguished:

Light
Severe (accompanied by destruction of the pancreas, multiple organ failure, systemic complications)

According to the scale and nature of the lesion of the pancreas, acute pancreatitis is divided into five types:

Hydropic. Occurs without destruction of the pancreas. It is characterized by the reversibility of the pathological process. Surgery usually not required.
Sterile pancreatic necrosis. Separate sections of the pancreas are destroyed by their own enzymes. There are no infectious complications.
Infected pancreatic necrosis. Destruction of the pancreas is accompanied by infection.
Pancreatic abscess. A cavity filled with pus forms in the pancreas. It occurs as a result of infection.
Pseudocyst. A cavity is formed in the pancreas, which is filled with fluid (blood, pancreatic juice, exudate).

Clinical forms of acute pancreatitis:

Interstitial. It is characterized by swelling of the pancreas and surrounding tissue. There are no complications. The integrity of the organ is preserved.
Necrotic. Acute inflammation of the pancreas, accompanied by complications.

In turn, necrotizing pancreatitis is divided into two forms:

Local. The pathological process does not go beyond the pancreas.

Common. Systemic complications may occur:

multiple organ failure
bleeding (pancreatogenic or gastric)
metabolic and electrolyte disturbances
DIC

Necrotizing pancreatitis is also divided into forms, based on the extent of destruction of the pancreas. It can be focal and widespread.

Focal pancreatic necrosis may have small, medium or large foci.

Widespread pancreatic necrosis can be subtotal or total. These clinical forms of the disease most often end in death.

Classification of chronic pancreatitis

By morphological features There are five types of chronic pancreatitis:

interstitial
inductive
parenchymal
cystic
pseudotumorous

As you know, during chronic pancreatitis, there are stages of exacerbation, when the symptoms of pancreatic inflammation worsen, and stages of remission, when there are almost no manifestations of the disease. Depending on the frequency of exacerbations, the classification of chronic pancreatitis involves its division into three types;

rarely recurrent
often recurrent
persistent (symptoms are constantly present)

Chronic pancreatitis is manifested by different symptoms. Depending on the dominant syndrome, five types of the disease are distinguished:

painful
Hyposecretory (characterized by severe insufficiency of the excretory function of the pancreas)
Hypochondriacal (symptoms of neuropsychiatric disorders predominate)
Latent (almost no symptoms)
Combined (no dominant syndrome)

Depending on the causes of chronic pancreatitis, it can be:

biliary-dependent (the cause was the pathology of the biliary tract)
alcoholic
dysmetabolic (the cause of pancreatitis is hemochromatosis, diabetes, hyperparathyroidism and other diseases accompanied by metabolic disorders)
infectious
drug
idiopathic (cause of pancreatitis unknown)

The classification of chronic pancreatitis also includes its complications. They are divided into 5 groups:

Infectious (abscess, cholangitis)
Inflammatory ( kidney failure, cyst, bleeding from the gastrointestinal tract)
Portal hypertension (compression of the portal vein)
Endocrine (diabetes mellitus, hypoglycemia)
Violation of the outflow of bile.

There are a lot of classifications of both acute and chronic pancreatitis. Only those of them are given that are most often used by doctors during staging.

Pancreatitis is a disease that affects the main organ digestive system- pancreas. Despite the fact that inflammation can occur in only two forms (acute and chronic), the classification of pancreatitis is quite large. Both the acute form of the disease and the chronic form have their own subgroups, which will be discussed now.

Types of disease

With the development of pancreatitis, the digestive enzymes produced by the pancreas are not released into the duodenum, as it should be, but remain inside the organ, starting to digest its own tissues. As a result, the patient's condition worsens greatly. He appears severe pain in the area of the right hypochondrium, there are frequent bouts of nausea, vomiting and diarrhea.

At the same time, various failures occur in the body, entailing a violation of the functionality of others. internal organs and systems. And if a person does not start treating pancreatitis in a timely manner, this can lead to various complications, among which the most dangerous are diabetes mellitus, pericarditis, kidney and liver failure.

Important! Despite the fact that pancreatitis is characterized by severe clinical picture, to establish an accurate diagnosis, you will need to undergo a complete examination, since the same symptoms can occur with the development of other diseases.

In the event that, according to the results of the examination, inflammatory processes in the pancreas were revealed, regardless of the form (acute or chronic), the patient must immediately begin treatment, since delay in this case can cost him his life.

Speaking about what types this disease has, it should be noted that today there are different classifications of pancreatitis proposed by various scientists. However, most doctors use the most simplified version of the classification, which distinguishes the following types of pancreatitis:

spicy;
obstructive, in which pathological expansion of the ducts, occlusions and stones are observed in the pancreas;
acute recurrent;
non-obstructive chronic;
calcifying chronic, during the development of which salts accumulate in the gland;
chronic recurrent, manifested in an acute form (with the development of such pancreatitis, pancreatic cells are damaged and no longer recover).

Visual differences between a healthy pancreas and an inflamed one

The simplest classification of pancreatitis was put forward by scientists at the International Medical Symposium in Marseille in 1983, which physicians still use to this day. It suggests the following division of this disease:

acute;
acute recurrent;
chronic;
exacerbation of a chronic

Each of these forms of pancreatitis has its own characteristics, so only a qualified specialist should deal with their treatment.

Chronic form

Depending on the cause, the chronic form of the disease can be primary and secondary. Moreover, secondary pancreatitis occurs among patients much more often than primary, and the cause of its development is mainly other diseases, damaging organs gastrointestinal tract such as the stomach or gallbladder. Also, the chronic form of the disease may occur due to inadequate or untimely treatment of acute pancreatitis, however, this phenomenon is very rare, since when the disease develops in an acute form, it manifests itself suddenly pain syndrome, due to which patients are immediately hospitalized.

Atlanta pancreatitis classification presented by scientists in 1992

But it is generally accepted that the main cause of the development of chronic pancreatitis is various malfunctions in the gastrointestinal tract against the background of malnutrition and bad habits. A special role in its development is played by the abuse of alcoholic beverages.

As mentioned above, each form of this disease has its own classification. There are many of them, but the most popular is the Roman classification of this disease. It involves the division of chronic pancreatitis into the following subspecies.

Chronic calcifying

It is the most common form of pancreatitis and is characterized by simultaneous inflammation of several separate sections of the pancreas, the intensity of which can vary significantly (the organ is affected pointwise). With the development of chronic pancreatitis pancreatitis, the pancreatic ducts can become clogged and die, which leads to complete organ dysfunction. As a rule, the onset of this disease occurs against the background of a sharp decrease in the production of lithostatin, which is a low molecular weight protein secreted by the exocrine part of the pancreas. Litostatin is an inhibitor of the growth of calcium carbonate crystals. And when the pancreatic juice is oversaturated with this salt, crystals grow, which causes blockage of the pancreatic ducts and disruption of the release of digestive enzymes into the duodenum.

Chronic obstructive

The development of this form of the disease occurs against the background of obstruction of the large ducts of the pancreas. In this case, a complete lesion of the organ occurs, as well as significant modifications in its endocrine part. Unfortunately, chronic obstructive pancreatitis is not amenable to drug treatment. With its development, urgent surgical intervention is required.

Chronic fibrous-indurative

In this case, there is also a complete lesion of the pancreas, in which fibrotic changes in the structure of its tissues. At the same time, the organ retains its secretory function, but does not perform it in full.

Fibrosis of the pancreas

When this disease occurs, fibrotic changes are also observed in the tissues of the gland, but in this case they are very pronounced and lead to a loss of the ability to perform a secretory function, followed by the death of the tissues of the organ (the occurrence of necrosis).

In addition to the subtypes of chronic pancreatitis described above, this disease also includes pancreatic cysts and abscesses that occur in it. These pathological conditions also lead to disruption of the production of digestive enzymes, swelling of the ducts and their blockage, which causes the development of this disease.

Acute pancreatitis is the development of severe inflammation in the pancreas, which leads to the appearance of an acute pain attack, which, as a rule, occurs in the upper abdomen and extends to the right hypochondrium. In this case, the pain becomes even more pronounced after eating. They may be accompanied by bouts of nausea, vomiting, diarrhea, and bloating.

A distinctive clinical feature of acute pancreatitis is that during its development there is a change skin and sclera - they acquire a yellowish tint. There may also be an increase in heart rate and the appearance of cyanotic spots on the arms and legs.

In other words, the clinical manifestations of acute pancreatitis are significantly different from the signs of chronic development. And they also have their own classification, and more than one. The first classification is used by surgeons and involves determining the type of disease only after the implementation of surgery.

Types of acute pancreatitis

This classification implies the division of acute pancreatitis into the following types:

easy;
moderate;
heavy.

With the development of a mild form of acute pancreatitis, significant pathological changes in the work and structure of the pancreas is not observed. When moderate pancreatitis occurs, transient organ failure and systemic deposits are observed. But in a severe form of the disease, persistent insufficiency is diagnosed with local systemic complications that can lead to death.

As already mentioned, there is another classification of acute pancreatitis, which is actively used by therapists and gastroenterologists. It suggests the division of this disease into 4 subspecies:

edematous. It is considered one of the mildest forms of acute pancreatitis. With its development in the tissues of the pancreas, no serious changes are noted. It is easily treatable and is manifested by slight yellowing of the skin and sclera, increased heart rate and pain in the upper abdomen. In a laboratory blood test, an elevated level of fibrin (PRF) is noted.
Limited pancreatic necrosis. A severe form of the disease, which is very difficult to treat. With its development, foci of necrosis of various sizes appear in the parenchyma of the pancreas (they can be small, medium and large). The clinic of this disease includes nausea, severe vomiting, flatulence, fever, signs of tachycardia, severe pain in the epigastric region, as well as detection in analyzes advanced level glucose and decreased hematocrit.
Diffuse pancreatic necrosis. It has several more names - segmental and distal. With its development, all anatomical regions of the pancreas are affected. At the same time, necrotic changes are noted not only in the parenchyma of the organ, but also in the vessels, as well as in large secretory ducts. Clinically, diffuse pancreatic necrosis manifests itself in the same way as limited, only in this case it can be noted sharp decrease the amount of urine excreted per day (oliguria), fever and stomach bleeding, which are manifested by acute pain syndrome. And when conducting laboratory studies, hypoxia, hyperglycemia and hypocalcemia are noted. The patient's condition with the development of diffuse pancreatic necrosis is severe.
Total pancreatic necrosis. This type of disease is characterized by necrotic changes in all tissues of the pancreas, which pass to the retroperitoneal tissue. With its development, there is a sharp increase in the level of stomach acidity, intoxication of the body, decreased sensitivity and shock (the most severe complication of pancreatic necrosis).

This is what the pancreas looks like in the development of total pancreatic necrosis

Classification of pancreatitis according to the mechanism of development

There is another classification, which implies the division of pancreatitis into subspecies depending on the cause of its occurrence:

post-traumatic. It is observed in 8% of patients. The main reasons for its development are open and closed injuries abdominal cavity obtained during surgical interventions, diagnostic instrumental measures, chemical and thermal burns. Closed mechanical injuries are considered the most dangerous, which can lead to organ rupture. But it should be noted that when they are received, severe internal bleeding is not always observed. In most cases, the injury manifests itself as a slight deformity of the gland and a slight deterioration in the general condition. Acute attacks of pain are absent, which prevents timely diagnosis. And this often leads to fatal consequences.
Biliary. Occurs in 9% of patients. The mechanism of development of this form of pancreatitis is based on congenital anomalies in the structure of the pancreas and bile ducts, cysts and stone deposits that prevent the normal outflow of bile. Biliary pancreatitis can proceed in a closed and open type, and the rate of its development depends on the state of the ductal system. In addition to the fact that during its formation necrotic changes are observed in the tissues of the gland, they can also be subjected to suppuration.
Cholecystogenic. This form of the disease develops due to a violation of the outflow of bile into the duodenum and its exit into the pancreatic ducts. As a result, the production of pancreatic juice increases and puts a strong load on the ductal systems, because of which they cannot withstand and are destroyed, which causes the development of necrotic processes in the tissues of the gland.
immunodependent. This form of pancreatitis is characterized by increased sensitivity of lymphocytes to antigens, as a result of which they migrate into the gland and provoke the development of hemorrhagic edema in it. However, the outflow of digestive enzymes in immune-dependent pancreatitis is not disturbed, which distinguishes it from other forms of the disease.
Contact. It is extremely rare, occurring in only 1.5% of patients. The main reason for its development is peptic ulcer of the stomach and duodenum with penetration into the pancreas, which provokes a violation of its tissues and the formation of a crater.
Angiogenic. The main "provokers" of angiogenic pancreatitis are such pathological conditions as arteriolosclerosis, extravascular occlusion and thromboangiitis, which cause ischemia and vascular embolism, as well as impaired blood supply to the organ with the subsequent development of necrotic processes.

Some forms of pancreatitis do not respond to medical treatment and require urgent surgical intervention.

The classification of pancreatitis is very large. But despite this, doctors still use more simplified options, subdividing this disease into only two groups - acute and chronic. Naturally, in order to prescribe treatment, it will be necessary to determine the exact type of disease, but regardless of the form in which the disease occurs (acute or chronic), the first health care in the event of a pain attack, it is carried out in the same way. And further treatment is determined on an individual basis only after the relief of pain.

In the treatment of any disease, a very important element is the correct diagnosis. From this moment, the subsequent selection of medicines and curative measures. For many centuries, doctors have tried to most accurately characterize such a difficult disease as pancreatitis. Over time, with the development of medical science and the discovery of new diagnostic possibilities, the classification of pancreatitis has changed. Let's consider its main approaches.

Why classify inflammation of the pancreas

Pancreatitis, or inflammation of the pancreas, is a group of diseases and symptoms. The classification of acute pancreatitis, as well as chronic, is based on the following data:

etiology (origin) of the disease
degree of organ damage;
The nature of the course of the disease;
the impact that pathology has on other body systems.

Such specification helps the specialist in making an accurate diagnosis, which is important for developing an effective plan to combat pathology.

Obsolete classification options

The first classification was proposed in 1946. She characterized the chronic form of pathology caused by alcohol abuse. The next classification of 1963 was formulated at the Marseille Conference. Here, the etiology of the disease and morphological characteristics were described in more detail. Over the following years, international medical organizations amendments and additions were made to the classification of the disease.
According to the nature of the course of the disease, since 1983, the following types of pancreatitis began to be distinguished:

latent, characterized by the absence of clinical manifestations;
pain, suggesting the presence of constant or periodic pain;
painless, suggesting serious morphological and functional disorders, possible complications.

Such a classification did not justify itself because of the difficulty in determining the degree of damage to the tissues of an organ based on the data of radiation studies.

In 1988, the following classification was proposed in Rome:

inflammatory pancreatitis;
indurativny, or fibrosclerotic;
obstructive;
calcifying.

The inflammatory form of the disease only in some cases provokes severe complications. The fibrous-sclerotic form of the disease is also observed infrequently. It is characterized by an increase in the concentration of pancreatic secretion.

After collecting an uncountable amount of information, the medical community has come to the latest version of the classification. The latest changes were made by scientists from Germany in 2007.

An obstructive variant is diagnosed with a complication of the outflow of pancreatic juice. Calcifying is observed in most cases of alcoholic origin of the disease, characterized by heterogeneous destruction of the organ with the formation of stones.

Other approaches

The main classification of pancreatitis is based on the development of the disease:

spicy;
acute recurrent;
chronic;
exacerbation of a chronic

It is often difficult to draw a line that distinguishes acute recurrent pancreatitis from exacerbation of chronic.

Types of pancreatitis of the pancreas are also characterized by associated pathological processes or conditions.

Local complications:

peritonitis;
pseudocyst;
hemorrhages inside the peritoneum;
pancreatogenic abscess;
fistulas.

Systemic:

pancreatogenic shock;
infectious-toxic shock;
multiple organ failure.

Determination of the main forms of the disease according to V. T. Ivashkin

In 1990, Doctor of Medical Sciences V. T. Ivashkin, together with his colleagues, proposed to systematize the types of pancreatitis in accordance with various factors, due to which, when making a diagnosis, the pathology is described as accurately as possible.

V. T. Ivashkin - on the right

Due to occurrence:

biliary-dependent;
alcoholic;
dysmetabolic;
infectious;
drug;
idiopathic.

According to the course of the disease:

rarely recurrent;
often recurrent;
with persistent symptoms.

By morphology:

interstitial edematous;
parenchymal;
fibrous-sclerotic (indurative);
pseudotumorous (false tumor, hyperplastic);
cystic.

According to the symptoms of the disease:

painful;
hyposecretory;
asthenoneurotic;
hidden;
combined.

Interstitial edematous

The inflammatory process continues for more than 6 months. Studies of pancreatic tissues show heterogeneity of structure and echogenicity, an increase in the volume of the gland. A third of patients develop complications.

Recurrent chronic

It is characterized by frequent exacerbations, but there are practically no changes in the morphological picture and complications. The patient is often worried about diarrhea, which is quickly eliminated after taking enzymes.

Indurative chronic

There is indigestion and increased pain. Half of the patients develop secondary pathological processes. Ultrasound examination shows an increase in the width of the duct and compaction of the gland.

Pseudotumorous chronic

7 out of 10 patients complain of a deterioration in well-being, quickly lose weight, and other complications appear. Studies show significant changes in the organ in size and expansion of the ducts.

Cystic variant of chronic

Studies show an increase in the organ, the growth of connective tissue caused by prolonged inflammation, the ducts are dilated. Pain is quite tolerable, but more than 50% of patients have other pathologies.

Subtypes depending on the factors of occurrence

Since the concept of pancreatitis summarizes the various forms of the disease and their symptoms, an important aspect of the classification is the etiology (origin) of the disease and the first clinical manifestations associated with it.

Biliary

Biliary pancreatitis, or cholecystopancreatitis, occurs against the background of damage to the liver and bile ducts.

Clinical manifestations: biliary colic, jaundice, digestive disorders, weight loss, diabetes mellitus.

Alcoholic

It is considered one of the most difficult. It occurs due to chronic dependence, and sometimes - after a single use of alcohol.

Clinical manifestations: severe pain in the upper abdomen, vomiting, fever, diarrhea.

destructive

As a result of destructive pancreatitis, or pancreatic necrosis, the tissues of the pancreas are destroyed, which leads to failure of all organs.

Clinical picture: sharp pain, vomiting, increased heart rate, impaired brain function, changes in blood and urine tests.

Drug

Drug-induced pancreatitis occurs after taking certain medications.

Clinical manifestations: pain, indigestion.

Parenchymal

Parenchymal pancreatitis is classified as chronic. With this disease, the glandular tissue of the pancreas becomes inflamed.

Clinical manifestations: pain, nausea, vomiting, diarrhea or constipation, excessive salivation.

pseudotumorous

It is characterized by an increase in the volume of the organ, which makes one suspect an oncological tumor. It's actually not cancer.

Symptoms: obstructive jaundice, pain, indigestion.

Classification of acute pancreatitis

Acute pancreatitis is an acute inflammatory process that occurs in the pancreas. It is dangerous by irreversible changes in the tissues of the organ with their death (necrosis). Necrosis is usually accompanied by a purulent infection.

By forms

The modern classification according to the form of pathology distinguishes the following types of pancreatitis:

edematous pancreatitis;
sterile pancreatic necrosis;
diffuse pancreatic necrosis;
total-subtotal pancreatic necrosis.

Because of

The etiological classification distinguishes:

alimentary, or food, develops due to eating too fatty, spicy, fried foods;
alcoholic - a type of food or separate view diseases arising from the use of alcoholic beverages;
biliary appears as a consequence of the pathology of the liver, gallbladder and its ducts;
medicinal, or toxic-allergic, occurs due to exposure to allergens or drug poisoning;
infectious - the pathology is caused by exposure to viruses, bacteria;
traumatic develops after injury to the peritoneum;
congenital is caused by genetic disorders or pathologies of intrauterine development.

According to the severity of the disease, mild, moderate and severe pancreatitis is distinguished.

The mild version involves no more than two exacerbations per year, slight changes in the function and structure of the gland. The patient's weight remains normal.
The average aggravates up to four times a year. The patient's body weight decreases, pain intensifies, signs of hyperfermentemia are observed, and blood and stool test values change. Ultrasound examination shows the deformation of the pancreatic tissue.
Severe pancreatitis aggravates more than five times a year with severe pain. The weight of the patient decreases, the process of digestion and other vital functions of the body are disturbed. Possible death of the patient.

Chronic pancreatitis and its classification

In most cases, chronic pancreatitis occurs, which is considered the result of acute illness and is divided into two phases: remission and exacerbation.

Based on the frequency of exacerbations, the following varieties were distinguished:

rarely recurrent;
often recurrent;
persistent.

By stage of progression and severity

Another type of classification divides changes in severity and their effect on the body:

fibrosis - proliferation of connective tissue and its replacement of pancreatic tissues;
fibrous-indurative pancreatitis - modification of the tissue of the organ and deterioration of the outflow of pancreatic juice;
obstructive pancreatitis appears as a result of blockage of the ducts of the gland due to gallstones or pancreatic tumors;
calcifying pancreatitis - calcification of areas of the gland with blockage of the ducts.

By forms

According to the degree of organ damage and changes in blood and urine tests, the following types of pancreatitis are distinguished:

edematous pancreatitis. Light form, the structure of the organ does not change. A blood test shows the presence of inflammation. Clinical manifestations: epigastric pain, nausea, fever, jaundice.
Small focal pancreatic necrosis. One of the parts of the organ is inflamed and subject to destruction. Clinical picture: more severe pain, vomiting, bloating, fever, constipation, increased blood sugar, decreased hemoglobin.
Mid-focal pancreatic necrosis. It has a larger area of tissue damage. Clinical manifestations are supplemented by a decrease in the amount of urine, intoxication, internal bleeding. A blood test shows a decrease in calcium levels. Requires emergency medical care.
Total-subtotal pancreatic necrosis. The entire organ is affected, which affects the disruption of the functioning of other organs. High probability of death.

Because of

Due to the occurrence of the classification of chronic and acute pancreatitis, they are similar:

drug;
infectious;
biliary;
alcoholic;
dysmetabolic.

Modern classification of chronic pancreatitis according to Khazanov et al.

The classification of chronic pancreatitis, developed in 1987 by the doctor A.I. Khazanov, involves the division of the disease as follows:

Subacute. It is an exacerbation of chronic pancreatitis, the clinical picture is similar to acute pancreatitis, only lasting more than 6 months. Pain and intoxication are not very pronounced.
Recurrent. In turn, it is divided into rarely recurrent, often recurrent, and persistent. The pain is not strong, the shape and size of the organ is not changed. There is only a slight compaction of the structure of the gland.
Pseudotumorous. Part of the body increases and thickens. The disease is accompanied by jaundice due to a violation of the outflow of bile as a result of obstructive inflammation of the organ.
Inductive. The organ shrinks and thickens, loses its normal shape. It suggests the accumulation of calcifications in the pancreatic ducts, jaundice, severe pain.
Cystic. Cysts or abscess are found, most often of a small size. The pain is inconsistent.

Other nuances of classification

To the extent of the variety of manifestations and course of the disease, many types of pancreatitis in each classification can be further divided into subtypes.

For example, cysts can be defined as a complication of a disease or a variant of it:

There are such forms of pancreatic necrosis:

hemorrhagic;
fatty;
mixed.

When creating each version of the classification of the disease, doctors took into account such characteristics as the causes of its occurrence, systemic complications, and failure of other organs. In some cases, the classification becomes too complex and impractical, but the use of multiple criteria opens up the possibility of making the most objective diagnosis.

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The most reasonable and quite popular among clinicians was the Cambridge classification of structural changes in the pancreas in CP (1983), based on the gradation of structural changes according to the severity based on the data of radiation methods of examination - ERCP, CT, ultrasound (Table 4-5).

The classification is convenient for clinical use, but has disadvantages: it does not cover early stages CP, which are not characterized by structural changes in the pancreas visible to the naked eye; data of radiation methods may not provide information about the irreversibility of structural changes in the pancreas (the main difference between OP and CP).

In addition, it only partially reflects the clinical characteristics of CP - the symptoms of the disease that lead the patient to see a doctor.

Table 4-5. Cambridge classification of structural changes in the pancreas in chronic pancreatitis

A step forward in pancreatology was the International Marseilles Classification (1984), based on the division of pancreatitis into pathogenetic forms, each of which has a peculiar pathomorphology and features of the clinical picture.

In accordance with this classification, "pancreatitis" is a term denoting a whole range of inflammatory changes in the pancreas and tissues around it (from edema to fatty and hemorrhagic necrosis), and in the vast majority of cases, with a favorable course, the changes are reversible.

With an unfavorable outcome, the paralancreatic effusion and areas of necrosis may become infected, disappear spontaneously, or be delimited by an omental bursa or pseudocysts that form. Acute recurrent pancreatitis - AP, repeated two or more times under the influence of any causative factor. Previously, it was believed that both variants of OP often end happily, i.e. full restoration of the pancreas, both morphologically and functionally.

According to this classification, recurrent CP does not clinically differ from recurrent AP, i.e. manifests with sharp attacks. At the same time, morphological and functional changes persist and progress with time (destruction of acini, their inflammatory infiltration, swelling and edema of vessel walls, proliferation of connective tissue). The fundamental difference between CP itself and the above forms is atrophy of the acini and islets of Langerhans, a pronounced proliferation of connective tissue, which is clinically accompanied by a decrease in the severity of CP attacks against the background of progression of endo- and exocrine insufficiency organ.

In the Marseilles classification of pancreatitis (1984), in addition to the main forms of the disease (acute and chronic pancreatitis), the term "obstructive pancreatitis developing proximal to obstruction of the MPD" was introduced.

Indeed, if necrosis captures part of the latter, then in the future, stenosis of the MPD may develop with the occurrence of obstructive CP, characterized by specific morphological features: diffuse atrophy of the acinar parenchyma and fibrosis of the pancreas. The severity of structural and functional changes in the pancreas in obstructive CP may decrease after the elimination of obstruction.

Marseilles-Rome classification of diseases of the pancreas (1988) systematized clinical, morphological and etiological characteristics, as well as variants of the course of AP and CP.

According to the Marseilles-Roman classification, OP and three morphological forms of CP were distinguished:
. calcific CP, the most common (50-95% of cases). Its morphological features include irregular fibrosis, a heterogeneous distribution of areas of varying degrees of damage within the lobules of the gland or areas of different density between adjacent lobules. Intraductal protein precipitates or plugs are always present, and in later stages, calcified precipitates (stones); atrophy and stenosis of the ducts are possible. Structural and functional changes can progress even after elimination of the etiological factor;

Obstructive CP is characterized by dilatation of the ductal system proximal to ductal occlusion caused, for example, by a tumor or scar. Morphological features include atrophy of acinar cells and uniform diffuse fibrosis of the pancreatic parenchyma. The presence of protein precipitates and stones is not typical. Structural and functional changes may be reversible after elimination of the causative factor of obstruction;

Inflammatory CP is characterized by progressive loss of the exocrine parenchyma due to the development of dense fibrosis of the pancreas and against the background of a chronic inflammatory process. At histological examination noted infiltration by mononuclear cells.

According to the Marseilles-Roman classification, CP is classified as a complicated course of CP. The most common complications of CP include retention cysts, pseudocysts, necrotic pseudocysts. In severe cases, infection of cysts or pseudocytosis is observed, leading to the occurrence of pancreatic abscesses.

There is an opinion that the division of CP into separate clinical and morphological forms is not sufficiently substantiated, since when studying large fragments of the surgically removed pancreas, a different morphological picture can be found in its different departments. In one area of the gland, foci of necrosis with inflammatory infiltration predominate, while in the other, the inflammatory process has already resolved and the gland is represented by growths. fibrous tissue with dilated ducts and immured islets of Langerhans. As the disease progresses, the severity of sclerotic changes increases.

Taking into account the fact that the clinical and morphological classifications adopted in the past do not meet modern requirements in the light of modern ideas about the pathophysiology of the disease, which makes it difficult to use them in the clinic, the most convenient in practical terms are classifications that combine the etiological causes of the disease and its clinical and morphological peculiarities.

The most acceptable classifications that meet the above requirements are the classifications proposed by V.T. Ivashkin et al. (1990) and Ya.S. Zimmerman (1995), but both classifications can be considered somewhat outdated regarding the etiology of pancreatitis in light of recent discoveries in pancreatology.

Classification B,T. Ivashkina et al. (1990)

. According to morphological features:
- interstitial-edematous;
- parenchymal;
- fibrous-sclerotic (indurative);
- hyperplastic (pseudotumorous);
- cystic.

By clinical manifestations:
- pain variant;
- hyposecretory;
- asthenoneurotic (hypochondriac);
- latent;
- combined.

According to the nature of the clinical course:
- rarely recurrent;
- often recurrent;
- persistent.

By etiology:
- biliary-dependent;
- alcoholic;
- dysmetabolic (diabetes mellitus, hyperparathyroidism, hypercholesterolemia, hemochromatosis);
- infectious;
- medicinal;
- idiopathic.

Complications:
- violations of the outflow of bile;
- portal hypertension (subhepatic form);
- infectious (cholangitis, abscesses);
- inflammatory changes (abscess, cyst, parapancreatitis, enzymatic cholecystitis, erosive esophagitis, gastroduodenal bleeding, including Mallory-Weiss syndrome, pneumonia, effusion pleurisy, acute respiratory distress syndrome, paranephritis, acute renal failure);
- endocrine disorders (pancreatogenic diabetes mellitus, hypoglycemic conditions).

Classification Ya.S. Zimmerman (1995)

By etiology:
- primary:
. alcoholic;
. with kwashiorkor;
. hereditary ("family");
. drug;
. ischemic;
. idiopathic;

According to clinical manifestations:
- pain option:
. with recurrent pain;
. with constant (monotonous) moderate pain;

- pseudotumorous:
. with cholestasis;
. with duodenal obstruction;

- latent (painless);
- combined.

According to morphological features:
- calcifying;
- obstructive;
- infiltrative-fibrous (inflammatory);
- indurative (fibrosclerotic).

Functionally:
- with violation of external secretion of the pancreas:
. hypersecretory type;
. hyposecretory type (compensated, decompensated);
. obstructive type;
. ductular type;

- with violation of the endocrine function of the pancreas:
. hyperinsulinism;
. hypofunction of the insular apparatus (pancreatic diabetes mellitus).

According to the severity of the flow:
- light;
- moderate;
- hard.

Complications:
- early: obstructive jaundice, portal hypertension (subhepatic form), intestinal bleeding, retention cysts and pseudocysts;
- late: steatorrhea and other signs of maldigestion and malabsorption; duodenal stenosis; encephalopathy; anemia; local infections (abscess, parapancreatitis, reactive pleurisy, pneumonitis, paranephritis); arteriopathy lower extremities, osteomalacia.