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4УДК 616.37-002 ГРНТИ: 76.29.34
Krylova Elena Alexandrovna
Candidate of Medical Sciences, Senior Researcher, endoscopist, Center for Family Health and Rehabilitation Helios LLC ""Sky-Winner",
st. Yaselnaya, 18, Dnipro, 49023, Ukraine, Gravirovskaya Nina Georgievna Candidate of Medical Sciences, Senior Researcher, doctor of ultrasound diagnostics, LLC "Endotechnomed",
Dnipro, Ukraine.
STRUCTURAL FEATURES OF THE PANCREAS IN PATIENTS WITH VARIOUS CLINICAL AND MORPHOLOGICAL FORMS OF CHRONIC PANCREATITIS
Крылова Е.А.
кандидат медицинских наук, старший научный сотрудник, врач-эндоскопист, Центр семейного здоровья и реабилитации Гелиос ООО «Скай-Виннер»,
ул. Ясельная, д. 18, г. Днепр, 49023, Украина
Гравировская Н.Г.
кандидат медицинских наук, старший научный сотрудник, врач ультразвуковой диагностики, ООО «Эндотехномед»,
г. Днепр, Украина.
CТРУКТУРНЫЕ ОСОБЕННОСТИ ПОДЖЕЛУДОЧНОЙ ЖЕЛЕЗЫ У БОЛЬНЫХ РАЗЛИЧНЫМИ КЛИНИКО-МОРФОЛОГИЧЕСКИМИ ФОРМАМИ ХРОНИЧЕСКОГО
ПАНКРЕАТИТА
DOI: 10.31618/ESSA.2782-1994.2021.1.71.77 Abstract. The article presents the results of our own studies of structural changes in the pancreas according to computed tomography data in patients with various clinical and morphological forms of the disease. It was shown that the identification of structural changes in the pancreatic parenchyma using computed tomography with contrast (calcifications and calcifications, pancreatic cysts, fibrosis, expansion of pancreatic ducts) is a reliable confirmation of the diagnosis of chronic pancreatitis and allows to determine clinical and morphological form of the disease. Severe structural changes in the pancreatic parenchyma were found in 71.8% of the examined patients, in 18.5% of patients - moderate, in 8.7% - mild.
Аннотация. В статье представлены результаты собственных исследований структурных изменений поджелудочной железы по данным компьютерной томографии у больных различными клинико-морфологическими формами заболевания. Показано, что выявление структурных изменений паренхимы поджелудочной железы при помощи компьютерной томографии с контрастированием (кальцинаты и кальцификаты, кисты поджелудочной железы, фиброз, расширение панкреатических протоков) является достоверным подтверждением диагноза хронический панкреатит и позволяет определить клинико-морфологическую форму заболевания. У 71.8% обследованных больных установлены тяжелые структурные изменения паренхимы поджелудочной железы, у 18.5% больных - средней степени, у 8.7% -легкой степени.
Keywords: chronic pancreatitis, pancreas, clinical and morphological forms, computed tomography Ключевые слова: хронический панкреатит, поджелудочная железа, клинико-морфологические формы, компьютерная томография.
Introduction. Chronic pancreatitis (CP) is a progressive destruction of the pancreatic parenchyma and its replacement with fibrous tissue, which ultimately leads to irreversible disruption of the exocrine and endocrine functions of the pancreas [2, 4, 6, 7, 8, 9, 10].
In the recommendations of the American Society of Gastroenterology (ACG) specify that CP is a pathologic fibroinflammatory syndrome of the pancreas in individuals with genetic, environmental, and/or other risk factors who develop persistent pathologic responses to parenchymal injury or stress [7].
Diagnosis of CP is difficult, because there is no method that can be considered the "gold standard" for
diagnosing the disease. In addition, the diagnosis is made at the late stages of a progressive disease, when irreversible morphological changes with various clinical consequences have already developed [7]. CP is diagnosed using a combination of methods, including a thorough history and physical examination, risk factor analysis, imaging techniques, and direct and / or indirect pancreatic function tests [2, 4, 6, 7, 8, 9].
The initial methods of pancreas imaging are computed tomography (CT) and magnetic resonance imaging (MRI) [2, 4, 6, 7, 8, 9], invasive methods (endoscopic ultrasound and pancreatic functional tests) are not the primary research methods [7], so to make a diagnosis, the X-ray and endoscopic assessment of a patient with suspected CP should move from the least
UB
lasia
invasive to the more invasive method. For the patients with ambiguous or insufficient CT findings or refractory symptoms, additional tests are done -MRI/Magnetic Resonance Cholangiopancreatography with Secretin (sMRCP) or endoscopic procedures such as endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography (ERCP) and examination of pancreatic function [2, 4, 6, 7, 8, 9].
At the State Institution "Institute of Gastroenterology of the National Academy of Medical Sciences of Ukraine" we carried out work, which was a fragment of research work "To study the mechanisms of development of complications of chronic pancreatitis and to develop methods of diagnostics and surgical treatment using minimally invasive technologies", 2008-2010. (code VN. 25.01.001.08, state registration number No. 0107U012136) and "To study the mechanisms of development of fibrotic processes in chronic pancreatitis and improve the technology of their surgical correction", 2011-2013. (code VN. 25.01.001.11, state registration number No. 0111U001065).
This study was clinical, randomized, controlled, open-label, prospective. There were used research methods in the study: clinical, instrumental (ultrasound, CT, ERCP), functional (gastric intubation and duodenal intubation), morphological, biochemical
(determination of indicators of lipid peroxidation and antioxidant defense, average weight molecules, the level of total lipids, collagen synthesis products, bile acids, C-reactive protein), immunological (enzyme-linked immunosorbent assay for determining blood levels of interleukins TNF-a, TGF-01, REG-1a, lactoferrin, fecal elastase-1, methods of analysis of the immune status and nonspecific resistance of the organism), microbiological , dynamic (prospective observation), questionnaires, statistical.
During the study, the following results were achieved: it was proved that the development and course of clinical and morphological forms of CP depends on the ratio of the levels of cytokines and mediators of pancreatic fibrosis, factors of stone formation, apoptosis, oxidative stress and regulatory factors of the immune system; predictors of the progression of fibrotic changes, the formation of calcifications / calcifications have been established; defined markers for predicting the course of the disease; developed a method of treatment aimed at inhibiting the processes of fibrosis, apoptosis, stone formation in the pancreas, normalizing the cytokine profile of patients, the use of which helped to increase the effectiveness of treatment, lengthen remission, improve the quality of life of patients [3].
In this article, we present the results of our study on the study of the structural features of the pancreas in patients with various clinical and morphological forms of the disease according to computed tomography data.
The aim of the article. To study the structural features of the pancreas in patients with various clinical and morphological forms of the disease.
Material and methods. We examined 103 patients with CP, 87 men and 16 women. The age of the
East European Scientific Journal # 7(71), 2021 31 patients ranged from 31 to 65 years, the average age was (46.7 ± 0.7) years. In accordance with the Marseilles-Roman classification, patients were divided into 4 clinical groups: group I consisted of 14 patients (13.6%) with obstructive CP, II - 29 patients (28.2%) with calcifying, III - 34 patients (33.0%) with fibrotic -parenchymal form, IV - 26 patients (25.2%) with CP complicated by pseudocyst. Isolated forms of CP were detected quite rarely. More often, a combination of several variants of fibro-degenerative damage to the pancreas tissue was observed, and only the predominance of signs and clinical manifestations of one form or another gave the right to conditionally assign the patient to one of the identified groups. All patients signed voluntary informed consent. The study was approved by the ethical commission of the State Institution "Institute of Gastroenterology of the National Academy of Medical Sciences of Ukraine", protocol No. 5 of 09/10/2008. To diagnose pancreatic pathology, the CT method (with contrast) was used, which is based on the principle of X-ray scanning of internal organs with subsequent computer processing of the results and conversion of the data obtained into a flat image on the screen. On the film, as on the monitor, the internal organs are shown in a cross section with a given interval of the depth of the sections. The detection of calcifications in the parenchyma and calcifications in the pancreatic ducts is considered pathognomonic. Contrast-enhanced CT can detect pseudocysts, duct dilation, thrombosis, pseudoaneurysms, necrosis and parenchymal atrophy, pancreatic infiltration. The accuracy of the study ranges from 59-95%, depending on the type of tomograph and the criteria for diagnosis [10]. For the study, we used a Somatom-CR computer tomograph (Siemens, Germany).
Descriptive and inductive statistics were used to analyze the results obtained. In the case of quantitative data and subject to their normal distribution, the mean and standard error of the mean were used. To determine the significance of differences, the Student's t-test was used. In the absence of a normal distribution, the median, minimum, maximum, upper and lower quartiles were used, and the significance of differences was determined by the Mann-Whitney U-test. To describe the qualitative data, the frequency of detection of the feature (%) was used. In this case, the x test was used to determine the significance of differences between the groups. Differences were considered significant at p <0.05. Correlation and factor analysis were used. All calculations were performed using the SPSS 9.0 for Windows (or Statistica 6) program [1, 5].
Presentation of the main material. CT scan revealed structural changes in the pancreas, which were an indisputable morphological confirmation of the pathology of the pancreas (Table 1) and ultimately made it possible to compare the obtained indicators with indicators characterizing the development and course of CP and functional changes in the pancreas. According to CT, the size of the pancreas was increased in the majority of patients by 72.8%. An enlargement of the pancreas due to the head was observed in almost
half of the patients (46.6%), along the entire length - in a small part of patients (14.6%), the body of the pancreas and its tail - in a tenth of patients (8.7 and 11.7%, in accordance).
In the intergroup analysis, it was found that the sizes of the pancreas: were changed in the majority of patients in groups I and IV (78.6 and 76.9%, respectively) and in groups II and III (69.0% and 70.6%, respectively). The high frequency of enlargement of the pancreas in patients of groups I and IV is associated with an enlargement of the pancreas due to the formation of pseudocysts and their obstruction of the main pancreatic duct (MPD).
The frequency of pancreatic head enlargement did not differ significantly between groups, but in group I this sign was detected in 1.3; 1.6; 1.5 times more often than in II, III, and IV, respectively. According to the groups, the ratio of the frequency of increase in the size of the pancreas head was 1.56: 1.17: 1: 1.03, body -1.86 0.9 1.14: 1, tail - 1: 1.45: 2.07: 1.62, along the entire length - 1.43: 1: 1.47: 1.92, respectively. That is, an increase in the head and body was most often found in patients of group I, tail - in group III, but throughout the entire length of the prostate was more often increased in patients of group IV.
Table 1.
Changes in the size of the pancreas and the diameter of the main pancreatic duct in patients
Index Group of patient Total (n=103)
I (n=14) II (n=29) III (n=34) IV (n=26)
n % n % n % n % n %
pancreas size not increased 3 21.4 9 31.0 10 29.4 6 23.1 28 27.2
increase in the size of the pancreas head 9 64.3 14 48.3 14 41.2 11 42.3 48 46.6
body 2 14.3 2 6.9 3 8.8 2 7.7 9 8.7
tail 1 7.1 3 10.3 5 14.7 3 11.5 12 11.7
all over 2 14.3 3 10.3 5 14.7 5 19.2 15 14.6
main pancreatic duct not expanded 3 21.4## 6 20.7*** 17 50.0" 20 76.9 46 44.7
expanded 11 78.6 23 79.3 17 50.0** 6 23.1& 57 55.3
diameter, mm 7.83±0.61 7.19±0.81 5.98±0.55* 4.40±0.54*# 6.80±0.37
Notes:
1. * - significant difference between I compared with groups III and IV (p <0.05)
2. # - significant difference compared to groups I, II, III (p <0.05)
3. *** - x2 = 25.21, p = 9.62E-05 - significant difference with group IV;
4. ## - x2 = 12.23, p = 0.0005 - significant difference with group IV;
5. "- x2 = 3.45, p = 0.063 - significant difference with group IV;
6. ** - x2 = 4.61, p = 0.0318 - significant difference with groups I and II
7. & - x2 = 15.209, p = 9.62334E-05 - significant difference with groups I and II
Expansion of the MPD was detected in 55.3% of The MPD was tortuous, its walls were compacted in patients; its diameter was (6.80 ± 0.37) mm (Fig. 1). almost half of the cases.
Figure 1 - MPD diameter depending on the form of CP
In the intergroup analysis, it was found that the expansion of the MPD is characteristic of the overwhelming majority of patients in groups I and II (78.6 and 79.3%, respectively) and half of patients in group III (50.0%), in IV - this sign was established with a low frequency - 23.1% (p < 0.05). The expansion of
the MPD was significantly more significant in groups I and II, and the least pronounced was in group IV patients (p <0.05) (Table 1).
The diagnosis of CP was undeniable when calcifications of the parenchyma and calcifications in the pancreatic ducts were detected (Fig. 2).
Figure 2 - Computed tomogram. Calcifications in the pancreas head
Parenchymal calcifications were found in 35.0% of patients, and significantly more often in patients of group II (89.7%), compared with groups I, III, and IV
(p <0.05), which made it possible to diagnose calcific pancreatitis in them (Table 2).
Structural changes in the pancreas in patients
Table 2.
Index Group of patient Total (n=103)
I (n=14) II (n=29) III (n=34) IV (n=26)
n % n % n % n % n %
parenchymal calcifications 7 50.0# 26 89.7* 2 5.9 1 3.9 36 35.0
duct calcifications 9 64.3** 1 3.5 0 0 0 0 10 9.7
pseudocysts, up to 10 mm 2 14.3 1 3.5 1 2.9 1 3.9 5 4.9
pseudocysts, larger than 10 mm 4 28.6 10 34.5 8 23.5 25 96.2" 47 45.6
cyst size, mm 65.8±17.0? 22.9±3.0 21.4±2.4 54.7±6.4? 43.4±4.5
Notes:
1. # - x2 = 8.32-12.67, p = 0.004-0.0004 - significant difference compared with groups II, III, IV;
2. * - x2 = 40.39-44.48, p = 0.0001 - significant difference compared with groups I, III, IV;
3. ** - x2 = 19.58-26.90, p = 0.00001 - significant difference compared with groups II, III, IV;
4. "- x2 = 17.59-28.53, p = 2.73E-05-9.68E-08 - significant difference compared with groups I, II, III 4.? - p <0.05 - significant difference compared to groups II and III.
However, calcifications in the pancreatic ducts were found in 9.7% of the total number of patients, and more often in patients of group I - 64.3% (x2 = 26.90, p = 0.0001), which was the cause of obstruction.
Another cause of MPD obstruction in patients of group I were pseudocysts found on CT in 42.9% of patients. In 7.2% of patients in this group, the cause of
obstruction was a combination of the presence of calcifications in the ducts and a pseudocyst.
Small pseudocysts up to 10 mm in size were found in 4.9% of patients, most often in group I (14.3%), in other groups of patients, pseudocysts of this size were found in isolated cases (Fig. 3).
Figure 3 - Computer tomogram. Pancreas tail cyst
Large pseudocysts (from 10 mm to 135 mm, on average (43.4 ± 4.5) mm) were found in 45.6% of patients, significantly more often in group IV - 96.2% (x2 = 28.53, p = 9.68E-08). In groups I, II and III, the frequency of detection of large pseudocysts did not differ significantly (28.6%, 34.5%, and 23.5%, respectively). In terms of size, the largest pseudocysts were in patients in groups IV (p <0.05) and I (p <0.005), which led to duct obstruction in group I.
CT scan revealed changes in other organs of the abdominal cavity, primarily in the pancreatobiliary system (Table 3).
On the part of the liver and gallbladder, the changes accompanying CP were expressed mainly by the presence of signs of chronic cholecystitis (17.5%), cholelithiasis (5.8%) and signs of cholestasis (29.1%) with intrahepatic hypertension (3.9%). Changes of the gallbladder, signs of cholestasis and intrahepatic hypertension were more often found in patients of groups II and III - 31.0% and 23.5%, 31.0% and 44.1%, 10.3% and 2.9%, respectively.
The diameter of the common bile duct was normal in all patients of groups I, II and III, and significantly enlarged in patients of group IV, especially in cases when there was a cavity formation in the head region.
Table 3.
Changes in the abdominal organs in patients
Pathology Group
I (n=14) II (n=29) III (n=34) IV (n=26)
n % n % n % n %
chronic cholecystitis 1 7.1 8 27.6 5 14.7 4 15.4
cholelithiasis 0 0 1 3.4 3 8.8 2 7.7
intrahepatic hypertension 0 0 3 10.3 1 2.9 0 0
cholestasis 2 14.3 9 31.0 15 44.1 0 0
diffuse liver changes 0 0 4 13.8 3 8.8 5 19.2
focal liver formation 0 0 3 10.3 2 5.9 3 11.5
hepatomegaly 0 0 1 3.4 2 5.9 2 7.7
splenomegaly 0 0 1 3.4 0 0 0 0
cyst of left / right kidney 2 14.3 6 20.7 5 14.7 1 3.8
aortic plaque calcification 1 7.1 0 0 0 0 0 0
enlargement of regional lymph nodes 2 14.3 2 6.9 5 14.7 1 3.8
ascites 1 7.1 0 0 3 8.8 2 7.7
pyloric stenosis 0 0 1 3.4 0 0 0 0
Urolithiasis disease 0 0 1 3.4 0 0 0 0
ив Ш1
The data obtained made it possible to determine According to CT data, structural changes in the the severity of structural changes in the pancreas pancreas were found as mild in 8.7% of patients, according to the Cambridge classification (Table 4). moderate in 18.5%, and severe in 71.8%.
Table 4.
The severity of structural changes in the pancreas detected on CT _(according to the Cambridge classification)_
Severity Group of patient Total (n=103)
I (n=14) II (n=29) III (n=34) IV (n=26)
n % n % n % n % n %
mild 3 21.4 0 0 6 17.7 0 0 9 8.7
moderate 1 7.1* 4 13.8# 13 38.2 2 7.7** 19 18.5
severe 10 71.4 25 86.2# 15 44.1 24 92.3** 74 71.8
Notes:
1. # - x2 = 3.58, p = 0.059 - significant difference with group III;
2. * - x2 = 3.26, p = 0.071 - significant difference with group III;
3. ** - x2 = 5.79, p = 0.016 - significant difference with group III.
Intergroup analysis revealed a unidirectional distribution of patients according to this criterion in groups I, II and IV. Thus, in the overwhelming majority of patients in these groups, severe structural changes in the pancreas were revealed (71.4%, 86.2% and 92.3%, respectively). The frequency of detecting structural changes of moderate severity also did not differ significantly between the groups and amounted to 7.1%, 13.8% and 7.7%, respectively. Patients in group III had severe (44.1%) and moderate (38.2%) structural changes in the pancreas with almost the same frequency. Mild degree was determined only in patients of groups I (21.4%) and III (17.7%).
Conclusions.
1. Identification of structural changes in the pancreatic parenchyma using computed tomography with contrast (calcifications, pancreatic cysts, fibrosis, expansion of the pancreatic ducts) is a reliable confirmation of the diagnosis of chronic pancreatitis and allows to determine the clinical and morphological form of the disease.
2. Severe structural changes in the pancreatic parenchyma were found in 71.8% of the examined patients, in 18.5% of patients - moderate, in 8.7% -mild.
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