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.

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 %).

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.

Exploratory puncture under ultrasonic guidance is of extensive current use in the diagnosis of aseptic and septic pancreatonecrosis types at the early stage.

Our aim is to determine the role of ultrasonic tomography, including puncture biopsy of the pancreas under ultrasonic guidance, in the diagnosis and treatment of acute destructive pancreatitis.

We held one-day puncture biopsy examinations under ultrasonic guidance of 50 hospitalized patients suspected of destructive pancreatitis. The biopsy examination was multifocal: with the signs of the spare fluid the 4 spot intake was made from at least 2 parts of the pancreas and the omental bursa zone with the needle of the Chiba and Angiomed G 22-21 type. 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.

The analysis for infection of the pancreas and parapancreatic structures disclosed negative results with 44 patients. The results of the microbiological investigation of 10 patients were positive. Bacterial flora was presented by conditionally pathogenic gram-negative enterobacteria (E.coli, K.pneumoniae, B.cepacia, P.mirabilis) in 60 per cent of cases. The cases of infection by gram-positive agents (S.epidermidis, S.saprophyticus) covered 40 per cent. Sensitivity of the method used attained 91,7 per cent, specificity – 86,5 per cent, accuracy – 89,4 per cent.

Thus, the microbiological and cytological analysis of the aspirate taken by fine-needle aspiration under ultrasonic guidance allowed to determine the state of the pancreas objectively, to specify the pathologic process and its evolution, to verify the mode of tissue involvement in case of pancreatonecrosis.