Volume 03 Issue 10-2023
35
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
10
P
AGES
:
35-41
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
ABSTRACT
We used modern diagnostic methods of instrumental investigations. All patients in this work was divided to groups
depended on estimating patient statement with APACHE II and RANSON scale. Instead at this, we estimated multislice
computed tomography sings depended on Balthazar scale. This scale helped us to purpose existing and spreading of
the lesion in pancreas, prognoses course of the disease after diagnosing disease. We entered new diagnostic and
treatment algorithms, which helps to chose right surgical methods of treatment of acute pancreatitis in different
stages of disease. After using this tactics in patients with difficult forms of acute pancreatitis (total ball 3-9 on integral
scale RANSON and 9-20 on APACHE II scale) results was: mortality 25.9%, which conforms to low limit prognosing mor-
tality in this group.
KEYWORDS
acute pancreatitis, RANSON, APACHE II, Balthazar scale, surgical treatment.
INTRODUCTION
Acute pancreatitis (OP) is one of the most complex and
frequently discussed problems of modern surgery, the
relevance of which causes a steady increase in
morbidity. Among acute surgical diseases of the
abdominal cavity, acute pancreatitis ranges from 4.7 to
15.6%. In 15-25% of patients with acute pancreatitis,
severe infected forms occur, accompanied by various
complications, the mortality in which reaches 25-70% [1-
4,10,18]. According to most authors, conservative
therapy is effective in 75-85% of patients. Surgical
Research Article
MODERN METHODS OF DIAGNOSIS AND TREATMENT OF ACUTE
PANCREATITIS
Submission Date:
October 08, 2023,
Accepted Date:
October 13, 2023,
Published Date:
October 18, 2023
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume03Issue10-07
Tashlanov Boburbek Makhamadzhonovich
Andijan State Medical Institute, Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ijmscr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 03 Issue 10-2023
36
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
10
P
AGES
:
35-41
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
treatment is indicated with the ineffectiveness of
conservative
therapy,
increasing
endogenous
intoxication and the development of various purulent
complications. Early operations at the height of
endogenous intoxication and shock give a high
percentage of deaths in the early postoperative period.
At the same time, a prolonged delay in surgical
intervention may contribute to the development of
purulent complications, progression of pancreatic
tissue necrosis, and the increase in poly organ
insufficiency [2,3,7, 14,19,21].
Modern high-tech methods of medical imaging of the
pancreas (ultrasound and MSCT with a three-
dimensional image, laparoscopy) have reached a
qualitatively new level, which made it possible to
determine the severity of the pathological process,
assess the development of acute pancreatitis in real
time and conduct dynamic monitoring [2,7,8,13,15].
Currently, in a comprehensive assessment of the
severity of a patient's condition with acute
pancreatitis, depending on the equipment of the
medical institution, clinical and laboratory methods
(Ranson, Glasgow, APACHE II, MODS, SOFA scale
systems) and biochemical (C-reactive protein,
interleukins, neutrophil elastase) are used in different
accuracy and timing [1-3,14,17].
MATERIAL AND METHODS
The paper analyzes the principles of modern
diagnostics and approaches to the treatment of acute
pancreatitis in 54 patients admitted by the RCEMI AF
for the period from 2012 to 2013. There were 25 men
(46.2%), 29 women (53.7%). The majority of patients
(46) were of working age 20-59 years. A large number
of classifications of acute pancreatitis are known, the
generally recognized of which is the classification
proposed by H.J.Beger, adopted in Atlanta in 1992 and
subsequently modified by V.S.Savelyev et al. (2003).
This modified classification reflects in the most detail
all the features of the course and complications of
acute pancreatitis.
According
to
the
international
classification,
edematous pancreatitis was diagnosed in 21 (38.8%)
patients, acute severe pancreatitis with the
development of pancreatic necrosis
–
in 13 (24.1%). Of
these, sterile pancreatic necrosis occurred in 9 (16.6%)
patients, infected pancreatic necrosis - 11 (20.3%)
patients.
RESULTS AND DISCUSSION
The etiology of acute pancreatitis is determined by
biliary, autoimmune, angiogenic, alimentary (including
alcoholic), post-traumatic and postoperative factors.
Pathology of the biliary ducts was detected in 11 (20.3%)
of our patients, alimentary factor
–
in 7 (12.9%),
pancreatic injury
–
in 2 (3.7%), after endoscopic
interventions
–
in 3 (5.5%) patients. Total pancreatic
Volume 03 Issue 10-2023
37
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
10
P
AGES
:
35-41
SJIF
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FACTOR
(2021:
5.
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)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
lesion was diagnosed in 5 (9.2%) patients, focal in 17
(31.4%), subtotal in 9 (16.6%).
Diagnosis
of
acute
pancreatitis
should
be
comprehensive and include generally accepted and
special research methods. The combination of such
clinical manifestations as peripancreatic infiltrate,
resorptive fever, leukocytosis with a shift to the left,
lymphopenia, increased concentration of fibrinogen, C-
reactive protein, as well as characteristic ultrasound
and MSCT signs may indicate the presence of sterile
pancreonecrosis in the patient.
With sterile pancreatic necrosis, ultrasound can
visualize an increase in the size of the pancreas, the
fuzziness of its contours, the appearance of fluid in the
parapancreatic region.
The most informative method of diagnosing pancreatic
necrosis is currently considered to be multispiral
computed tomography, which most clearly reveals
signs of enlargement of the pancreas, the fuzziness of
its contours, the appearance of fluid in the
parapancreatic region. At the stage of infected
pancreonecrosis, clinical signs of purulent-necrotic
peripancreatitis, purulent omentobursitis, acute
abscess and retroperitoneal phlegmon are added.
Laboratory studies help to identify the progression of
acute inflammation, an increase in the level of
fibrinogen by 2 times or more, high levels of C-reactive
protein, procalcitonin.
With infected pancreatic necrosis, an increase in fluid
formations with inclusions is noted on ultrasound,
devitalized tissues are detected. The presence of gas
bubbles during multispiral computed tomography is
most likely to determine infected pancreatic necrosis.
The obtained MSCT signs were evaluated according to
the scale proposed by Balthazar (1990), according to
which the presence and extent of necrosis in the
pancreas can be assumed. The scale of evaluation of
MSCT signs allows predicting the course of the disease
and Computed tomography examination was
performed in 105 (85%) patients. The severity of the
patients' condition was assessed according to the
Ranson and APACHE-II scales. The Ranson scale, based
on 11 factors (5 at admission and 6 during the first 48
hours), allows you to differentiate the form of the
disease and predict its further course. The reliability of
the method reaches 96%. Dynamic daily assessment of
the severity of the patient's condition according to
APACHE II forms the basis for objectification of
indications for surgery and a differentiated approach
to the choice of an intensive conservative therapy
complex. According to APACHE II, the score is more
than 8 points
–
acute destructive pancreatitis, less than
8 points
–
moderate severity of OP; more than 15 points
–
severe complicated acute destructive pancreatitis
(EDP), unfavorable prognosis. The reliability of the
method is 76%.
Volume 03 Issue 10-2023
38
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
10
P
AGES
:
35-41
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
Today, the strategic directions of management of
patients with acute pancreatitis are:
-
dynamic objective assessment of the severity of
the condition of patients using integral scales
(Ranson, ARASNE);
-
determination of the scale and nature of the lesion
of the pancreas and retroperitoneal tissue
(ultrasound, MSCT, laparoscopy);
-
identification of infection (microbiological studies,
determination of procalcitonin concentration);
-
intensive therapy (maintenance of optimal oxygen
delivery, nutritional support, extracorporeal
detoxification);
-
antibacterial prevention and therapy;
-
adequate anesthesia;
-
blockade of the secretory function of the pancreas,
prevention of stress ulcers;
-
timely surgical rehabilitation.
Conservative treatment was effective in 17 (31.4%) of 54
patients. Basic therapy included:
-
hunger (3-7 days);
-
constant aspiration of gastric contents;
-
suppression of pancreatic secretion (octreotide);
-
prevention of stress ulcers and antisecretory
therapy (proton pump inhibitors and H2-adequate
anesthesia (NSAIDs, drugs);
-
infusion therapy;
-
anti-enzyme therapy (kontrikal, gordox in high
doses);
-
antibacterial therapy and prevention;
-
rheological preparations;
-
extracorporeal detoxification.
In severe acute pancreatitis, drugs were administered
through an intra-aortic catheter. Indications for
surgical treatment for pancreatic necrosis were
considered:
-
infected pancreatic necrosis and pancreatogenic
abscess;
-
septic phlegmon of retroperitoneal fiber;
-
purulent peritonitis;
-
persistent or progressive multiple organ failure;
-
persistent symptoms of a systemic inflammatory
reaction;
-
regardless of the fact of infection during
competent conservative basic therapy and its
ineffectiveness for 3-7 days.
37 (68.5%) patients were operated on at various times
from the onset of the disease.
Endoscopic papillosphincterotomy 3(8.1%).
Laparoscopic sanitation with drainage of the
abdominal cavity 5 (18.5%).
Laparoscopic cholecystectomy, drainage of the
choledochus according to Pikovsky-Halsted, sanitation
and drainage of the abdominal cavity 7 (18.9%).
Volume 03 Issue 10-2023
39
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
10
P
AGES
:
35-41
SJIF
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MPACT
FACTOR
(2021:
5.
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)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
Laparotomy, cholecystectomy, drainage of the
choledochus according to Pikovsky-Halsted. Opening
of the omentum bag, necrectomy, sanitation, drainage
and tamponing of the omentum bag, drainage of the
abdominal cavity 10(27%).
Laparotomy, cholecystectomy, choledocholithotomy,
drainage of the choledochus by Keru. Opening of the
omentum, necrectomy, sanitation, drainage and
tamponing of the omentum, drainage of the
abdominal cavity 7(18.5%).
Laparotomy, cholecystectomy. Opening of the
omentum bag, necrectomy, sanitation, drainage and
tamponing of the omentum bag, drainage of the
abdominal cavity 5(18.5%).
The key to the success of the management of patients
in the postoperative period, we consider adequate
drainage of the abdominal cavity and the omentum in
order to remove necrotic masses.
The drainage method allows for the lavage of the
omentum bag with antiseptic solutions already on the
10th
–
12th day. Our experience shows that the semi-
closed drainage method is sufficient for the
rehabilitation of the abdominal cavity and the
omentum. After removing the tampons (on the 10th-
14th day), we install thick drains (up to 10 mm in
diameter) in their bed, which also contributes to the
discharge of purulent-necrotic masses and provides
flow washing. In case of blockage of drains by necrotic
masses, they can be replaced with new ones.
Intensive therapy in the postoperative period is carried
out according to the same principles as before the
operation, taking into account the severity of the
patients' condition.
One of the main factors of successful management of
patients is rational antibacterial therapy depending on
the sensitivity of the microflora and the combined use
of broad-spectrum antibiotics.
The total mortality was 25.9% (14 patients),
postoperative mortality was 18.9%. 7 The analysis of
mortality depending on the indicators of the APACHE II
integral scale in the postoperative period in patients
with infected pancreatic necrosis revealed a direct
correlation between these indicators.
CONCLUSIONS
The active and expectant tactics of treatment of
patients with acute pancreatitis chosen by us must be
justified by the results of the examination, dynamic
monitoring, and a reliable assessment of the severity of
the functional state of vital organs according to the
Ranson and APACHE II system. As a result of the
application of the proposed tactics for the treatment
of patients with severe forms of acute pancreatitis
(total scores from 3 to 9 on the integral Ranson scale
and from 9 to 20 on APACHE II), the mortality rate was
Volume 03 Issue 10-2023
40
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
10
P
AGES
:
35-41
SJIF
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MPACT
FACTOR
(2021:
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(2022:
5.
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)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
25.9%, which corresponded to the lower limit of the
predicted mortality in this group of patients.
Despite the successes of modern pancreatology and
the emergence of high technologies in the diagnosis
and treatment of acute pancreatitis, in our opinion, the
following issues remain controversial:
-
early surgical interventions with the increase of
multiple organ failure and the absence of the effect
of conservative therapy;
-
the
expediency
of
using
programmed
relaparotomies;
-
the expediency of resection methods of treatment
in patients with acute severe pancreatitis.
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VOLUME
03
ISSUE
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P
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:
35-41
SJIF
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(2021:
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OCLC
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1121105677
Publisher:
Oscar Publishing Services
Servi
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