Take Care of Your Pancreas!

Depending on the phase acute pancreatitis (AP) has a polymorphic sonographic picture. Diagnostic accuracy of non-invasive ultrasonic tomography (UST) in verification of the stage of development of AP and character of its complications usually does not exceed 80 % that makes puncture biopsy necesssary.

The basic method to choose the zone to intake the material and make fine-needle biopsy is to reveal necrosis zones with the help of estimation of the blood flow in the pancreatic area in a regimen of color doppler mapping and make comparative estimation of the amount of doppler signals in the thickness of the pancreas and its surface. A 50 % decrease in number of doppler signals serves as a precise marker of necrosis and the destructive process in the pancreas.

Diagnostic fine-needle puncture biopsy (PB) with microbiological and cytologic examination of the aspirate is necessary with patients suspected of the destructive form of AP. Results of PB allow to use LIM under utrasonic guidance differentially and to choose the proper medical treatment in case of various forms of pancreatitis.

When diagnostic fine-needle puncture is used efficiency of the traditional ultrasonic investigation of various forms acute pancreatitis is increased.

Speaking of diapeutic interventions, a series of paracentetic interventions is applied at pseudocysts with the size no more than 5 cm and volume up to 40 ml. Expediency of sanation paracentetic interventions in pseudocysts is justified in case of an uncomplicated “acute” cyst of small size and in some cases of complicated pseudocysts with the absence of safe access to the cavity of the cyst to make a drainage. Efficiency of paracentetic treatment is usually low and pseudocysts are often formed.

In other cases various percutaneous drainings from nidi of infection are usually made. With patients having pseudocyst of the pancreas drainage № 8-12 Fr is performed (according to the technique of Seldinger). Also percutaneous draining with the use of drainages № 8-12 Fr is carried out with some patients with infected pseudocysts; the installation of two drainages at the top and bottom pole of the cyst with an active aspiration of the content is made with 4 of them. Telescopic tight bougieurage of the primary paracentetic canal to the calibre of the used drainage tube (8-11 mm) is made with some patients with pancreatogenic abscess.

With some groups of patients having pseudocysts of the pancreas LIM with installation of drainages are the most effective. The complete medical effect with patients with abscesses of the abdominal cavity attained more than 90 percent. Draining of nidi is the most effective in case of omentobursitis. Efficiency of a series of punctures, combination of punctures and drainages, installations of drainages under ultrasonic guidance is the subject for further improvement.

Diagnostic efficiency of ultrasonic tomography (UST) with low-invasive manipulations (LIM) in differential diagnostics of various morphological forms of acute pancreatitis (AP) can be represented in the following table (one of the first examinations). LIM under ultrasonic guidance are specifying diagnostics, therefore, specificity is constant.

A combination of paracentetic treatments (diapeutic LIM) and drainage installation is the basis of the medical LIM in case of complicated acute pancreatitis. Manipulations are carried out in the certain sequence. There is a combination of aspirating needles and drainages of various diameter and type. As a matter of fact, frequency of a puncturation also changes. Medical programs are usually based on the results of organoleptic and analytical examination of the material.

Diagnostic multifocal puncture biopsy (PB) is the next stage of AP diagnosis. The purpose of PB is to verify microbiological and morphological nature of diffuse changes. It is carried out according to diagnostic paracentetic regimens: different needles are applied subsequently while frequency of PB is changed.

According to statistical processing of microbiological and cytologic conclusions, in case of the edematic interstitial form of acute pancreatitis a moderate number of inflammatory elements and a large number of blood elements are often revealed. A large number of blood and inflammatory elements and a moderate quantity of necrotic massess is typical of the necrotic form of AP. The infiltrative necrotic form of AP is characterized by a large number of necrotic masses and inflammatory elements. A large number of necrotic massess and inflammatory elements is also typical of the purulo-necrotic form of AP. The aspirate taken from the abscess cavity usually contains modified blood elements, necrotic masses and inflammatory elements. Exacerbation of the chronic recurrent form of pancreatitis is characterized by inflammatory elements and low-prismatic epithelium with a low degree of proliferation. The cytologic picture of pseudocysts of the pancreas contains inflammatory and blood elements and elements of the cystous cavity.

The majority of patients usually have a negative bacterial inoculation. Microbiological investigation often brings positive results. In most cases bacterial flora constitutes conditional pathogenic enterobacteria of the gram-negative spectrum. Frequency of infection caused by gram-positive agents attained is low (about 25 %).

During exacerbation of chronic recurrent pancreatitis there were various changes of sonographic picture which generally were a result of diffuse or local spread of the acute inflammatory process. The volume of the pancreas was enlarged, mainly due to the head, less often the tail. In case of aparent exacerbation of pancreatitis indistinct differentiation of contours of the organ was observed.

To determine the condition of the blood flow in the pancreatic area and specify the localization the necrosis zone patients were examined with the use of colour doppler mapping and energy dopplerography.

During the interstitial edematic form of AP intensifying vascularization of the pancreas parenchyma was intensified what was evident from the increase in the number of coloue singnals in a separate section of the parenchyma. As the edema was intensified the resistance index and the pulsatory index in parenchymatous arterias rose more than 0,86 and 2,15. However in case of the intensive edema of the pancreas the parenchymatous blood flow was slowed down but the blood flow in efferent vessels remained the same. Deformation of the parenchymatous vascular pattern in the zone of the apparent inflammation and venous-arterial shunting were typical of the necrotic form of AP. As the pathological process increased the linear indices of intrapancreatic vessels gradually came down. During the reactive phase the linear speed of the blood flow in intrapancreatic vessels was not determined and reduced in adjacent vessels. The change of the resistance index and the pulsatory index were badly determined in adjacent vascular structures and were not determined in the parenchyma. The comparative analysis of doppler signals in the thickness of the pancreas and on its surface showed that hemodynamics decreases or disappears in case of necrotic fusion of tissues. In case of purulo-necrotic complications absolute and relative indices of hemodynamics are determined only in vessels adjacent to the pancreas. The dopplerographic picture of the pseudocyst of the pancreas was characterized by visualization of the avascular and hypoechoic zone with deformation of fine vessels at the periphery of the nidus. In adjacent vascular structures linear blood flow indices rose, indices in intraparenchymatous vessents could be determined indistinctly. Exacerbation of the chronic recurrent form was characterized by the decrease of the linear blood flow speed inside the pancreas, as well as in adjacent vascular structures. The resistance index and the pulsatory index tended to rise in adjacent vessels.

Purulent fusion of tissues of pancreatic infiltration is accompanied by a large number of fine irregularly placed echo-free structures with indistinct contours. During dynamic observation we can mark their fusion into larger inclusions of non-uniform density. Purulent fusion of tissues with formation of a cavity is traced approximately within 5-7 days. During formation of an abscess the augmentation of infiltration with an echo-free rim at the periphery is marked due to the gathering of liquid in the omental bursa. Diffusion of the process on adjacent tissues is accompanied with the loss of sharpness of their structure and illegibility of vessel contours.

During abscesses of the abdominal cavity and retroperitoneal space the common nidus of irregular shape and lowered echogenicity is determined. The internal structure of the abscess is non-uniform with individual regular or irregular fine echogenic inclusions. A strip of intensive reflections is marked behind the nidus. Echoginicity is reduced in the parts of the pancreas adjacent to the nidus.

The size of the pancreas is moderately enlarged or normal in case of cystous lumps. Cystous lumps with homogeneous hypoechoic structure up to 20-25 cm in diameter are determined in the parenchyma. During visualization the duct of the pancreac is crimped. The parenchyma surrounding the cyst had an apparent non-uniform structure. Some patients can have caval organs pushed off - the stomach, the duodenal with signs of gastro- and duodenostasis.

Echography shows that empyema of the cyst is heterogenic. On the homogeneous echo-free background the structures are more dense; they are suspended and look like flakes. Alongside with it the capsule is thickened and its internal border is loosened. The reactive process simultaneously develops in adjacent tissues.

In case of the necrotic form of acute pancreatitis (AP) the pancreas size exceeded the norm. Depending on the degree of affection there is the increase in size of different parts of the pancreas. The pancreas changes its shape when local affection is considerable. The contours are uneven, usurious, vague. Echogenicity of the parenchyma is reduced and the apparent heterogeneity of the acoustic structure with chaotic alternation of large parts of increased and decreased echogenicity is determined. The duct system is visualized unsatisfactorily and the liquid in the omental bursa is determined as echo-free lumps in different parts of the bursa.

Patients with infiltrative necrotic form of acute pancreatitis have a large pancreatogenic of irregular shape, uneven contours, increased echogenicity, heterogeneous structure, usually located in the projection of the greater omentum and the transverse colon. The sizes of the infiltration usually vary from 5 to 15-20 cm. In case of extension of infiltration in the retroperitoneal space, the length of massive affections located much lower than the pancreas is from 10 to 20 cm and even more. Adjecent vascular structures are hardly visualized.

All patients with the aseptic form of AP have vague contours of the pancreas all the parts of which are enlarged. The patients of this group have the following typical features: the heterogeneity of the internal pancreas structure, various echogenicity, unchanged sound conduction. Vascular structure and duct system of the pancreas in most cases are not determined. We can observe pathological foci as anechoic or hypoechoic formations with clear-cut or indistinct, more often uneven contours, irregular shape, often with heterogeneous structure and thickness of walls of about 0,2-0,4 cm.

Patients have various clinical forms of acute destructive pancreatitis (AP). Intensity and type of the clinical presentation depend on the phase of the pathological process. Thus, at early phases of acute destructive pancreatitis the signs of enzymatic toxemia prevail. Purulo-septic complications are typical of late phases of the desease.

The changes in blood properties during laboratory research (red blood colour, developed leukocytic formula, leucocytosis, increase in ESR) are auxiliary signs of the disease. The disfunction of the pancreas and liver at different phases of the desease is determined during biochemical investigation.

Ultasonic tomography (UST) is a fast, high-quality non-invasive method of direct diagnostics of acute pancreatitis. We’ve observed a number of sonographic variants of AP.

The enlargement of the pancreas proportionally to the edema is typical of the edematic form of AP. The visible contours of the pancreas are even and clear-cut. Echogenicity of the pancreas is educed diffusely and irregularly in different parts. The local decrease in echogenicity corresponding to the place of the maximum edema is typical of the segmental and local variants of affection. In most cases the echostructure of the parenchyma is homogeneous and the structure of stromal tissue elements was preserved. In case of diffusive affection we usually observe heterogeneity in all parts depending on the degree of the edema. When liquid gathers in the omental bursa we observe an echo-free area of different size as the distance between the back wall of the stomach and the forward surface of the pancreas increased.

Patients with various forms of destructive pancreatitis were examined. They all underwent a complex clinicolaboratory and instrumental investigation.

Among beam diagnostic methods applied were thorax and abdominal cavity radiography, ultrasonic research of abdominal cavity in the grey scale and doppler mapping mode, step-by-step computer tomography (CT). Standard US criteria were used to describe diffusive and focal affection of the pancreas. During fibrogastroduodenoscopy of patients with cystous lumps the opportunity of applying gastrocystostoma was considered. CT was used basically in case of patients with purulent complications before planned medical low-invasive manipulations (LIM) to specify the degree of the pathological process of abscess, phlegmon and pancreatic pseudocyst formation and to obtain information about peripancreatic and retroperitoneal tissue. Diagnostic and medical laparoscopy was carried out with patients with fermentative pancreatitis symptoms.

In order to increase diagnostic accuracy when detecting necrotic zones patients were examined by using color doppler mapping and energy dopplerography with Hitachi ultrasonic equipment. The US-investigation of the pancreas was carried by means of comparative assessment of the amount of doppler signals in the thickness of the pancreas and its surface. The pancreas was conditionally devided into equal parts.

Such separation is justified because of the optimal correlation between topographical anatomy of the pancreas, the opportunity of the maximal visualization of all doppler ultrasonic signals on the surface and in the parenchyma and subsequent spot puncture under ultrasonic guidance. A more than 50 % decrease in the number of doppler signals in a certain part of the pancreas in comparison with other parts serves as a marker of necrosis and gives reason to make spot puncture in this very part.

LIM of different extent under ultrasonic guidance were applied to all patients. For the purpose of morphological verification of the diagnosis multifocal diagnostic puncture biopsy (PB) under ultrasonic guidance was used. The program of biopsy was multifocal. In order to intake cellular material from the pancreas zone without contamination by gastric flora аn original method of step change of intaking multiplicity, duration and rate was applied. Besides, patients with complicated AP were examined by diapeutic and medical low-invasive interventions under ultrasonic guidance.

Bacteriological and cytological examination of the material taken during low-invasive manipulations was hold. The results of ultrasonic, cytological and bacteriological investigation were compared.

At present the general approaches to diagnostics and treatment of various forms of acute pancreatitis (AP) are determined. They assume a complex conservative therapy of abortive AP and refusal from early open operations in case of sterile pancreatonecrosis.

Usually purulo-septic complications of pancreatonecrosis indicate that surgical treatment is needed, however the question of the proper sanation method (open surgical operation, beam diapeutics, endoscopy) is debatable. Also the question of expediency of surgical sanation of sterile pancreatonecrosis remains. It is because of the variety of clinicopathologic forms of destructive pancreatitis and disagreements in differentiation between “sterile” and “infected” forms of pancreatonecrosis. The fact is that their clinical and laboratory manifestations are often similar, and traditionall methods of instrumental diagnostics not always allow to determine exactly the development of the infection in the affected zones of the pancreas (P) and/or retroperitoneal tissue.

At present taking into account the probabilistic nature of noninvasive ultrasonic tomography (UST) in verification of pancreatonecrosis, the early and reliable detection of its aseptic and septic forms can be possible only in case of microscopic and microbiological investigation of the material taken by diagnostic puncture under ultrasonic guidance.

We have analyzed lots of literature and come to the conclusion that the question of timely diagnosis of pancreatonecrosis and justified use of drainage and other low-invasive surgical methods at different stages of disease development is very urgent.