PANCREAS [pancreas (PNA, JNA, BNA)] — gland of the alimentary system possessing at the same time exocrine and endocrine functions; received the name by the situation — behind a back wall of a stomach.
- 1 The comparative anatomy
- 2 Embryology
- 3 The anatomy
- 4 Histology
- 5 Physiology
- 6 Biochemistry
- 8 Pathological anatomy
- 9 Pathology
- 10 Operations
- 11 Drugs of a pancreas
- 12 An artificial pancreas
The comparative anatomy
the Pancreas is available for all vertebrata. The exception is made acranial and cyclostomous. At the first a cell, homologous to exocrine and endocrine glandulotsita of the Item., are located in an epithelium of a gut, at the second accumulation of endocrine cells is placed in the thickness of her mucous membrane (sometimes around a vesical channel and in a parenchyma of a liver). Organ type of the Item. for the first time appears at cartilaginous fishes. Its exocrine part is constructed as at mammals, and cells of an endocrine part can surround output channels (an external epithelium), adjoining to them in the form of tyazhy, or to be located with separate islands. During evolution there is a replacement of an external epithelium and cellular tyazhy the isolated pancreatic islands, change of a quantitative ratio of the cells making them, change like secretion and a way of release of hormones. At the majority of vertebrate animals of the Item. — the compact body, only some species of rodents and fishes have loose type of a structure of the Item., when its segments are scattered in a mesentery of a small bowel.
The pancreas of the person develops from epithelial protrusion of a wall of that part of primary gut, from a cut the duodenum is formed (tsvetn. fig. 2). At the end of the 3rd week of an embryogenesis protrusion of an entoderm of its dorsal department growing in the form of a cellular tyazh between leaves of a mesentery — a dorsal rudiment is formed. On the 4th week similar process develops in ventral department (in the corner formed by a duodenum and its hepatic outgrowth) — a ventral rudiment (tsvetn. fig. 2, a). In process of growth epithelial tyazh get a form of tubes and branch. Rotation of a duodenum during an embryogenesis leads to rapprochement, and then to merge of both rudiments in uniform structure (tsvetn. fig. 2, b). At the same time the general system of channels forms; at the same time the proximal part of the canal of a dorsal bookmark is obliterated, and distal grows into the canal of a ventral rudiment of the Item. also forms a basis of a pancreatic (virzungov) channel (a pancreat duct, T.). If the obliteration does not occur, then gland has an additional channel — santoriniyev (an additional pancreat duct. T.). From a dorsal rudiment the body and a tail of the Item form., and from ventral — its head.
With 10 — process of differentiation of epithelial tubes begins 11th week. The group of cells located on their ends is differentiated in glandulotsita of exocrine type (acinous cells, or the exocrine pankreatsita) forming an acinus. From side sites of tubes epithelial kidneys which otshnurovyvatsya in the form of accumulations of the cells which are differentiated in various types of endocrine glandulotsit (insulotsita) grow. The group of insulotsit surrounded with an exocrine parenchyma reminds an island — from here and the name «pancreatic island» (Langergans's island). Their set makes an endocrine part of the Item., morfofunktsionalny formation a cut advances development of an exocrine part.
From tubes also output channels form. An essential role in development of the Item. belongs to the mesenchyma and blood vessels surrounding an intestinal tube.
Disturbance of an embryogenesis of the Item. leads to formation of various defects. So, the aplasia of a tail, and disturbance of process of a differentiation of a duodenum — education ring-shaped the Item can be a consequence of an underdevelopment of a dorsal bookmark. (when the head or all gland surround a duodenum). Chances of longitudinal splitting of a tail of the Item. or its unions with a spleen. Deviations in development of channels of the Item. are shown by preservation of an additional channel, narrowing or an atrophy of a pancreatic channel, and also its falling into a stomach.
the Pancreas has the form of the flattened, gradually narrowed tyazh located on a back abdominal wall in retroperitoneal space at the level of upper lumbar (I—II) vertebrae.
The body allocates three departments: head (caput pancreatis), body (corpus pancreatis), tail (cauda pancreatis).
Length of the Item. makes 14 — 23 cm, width of a head — 3 — 7,5 cm, bodies — 2 — 5 cm, a tail — 0,3 — 3,4 cm, the gross weight (weight) of body — 60 — 115 g.
Head of the Item. — its widest part — is located to the right of a backbone and wedged in an internal bend duodenum (see). From top to bottom the ankyroid shoot (processus uncinatus) departs from it. On border with a body cutting of the Item is formed. (incisura pancreatis), in a cut are located an upper mesenteric artery and a vein. On a front surface in the place of transition of a head of the Item. in a body the camber towards an omentulum called by an omental hillock (tuber omentale) is formed. Body of the Item. has front, back and lower surfaces, lies ahead of a backbone and to the left from it and gradually passes into the tail reaching a spleen. Front and lower body surfaces of the Item. are covered with a peritoneum. Behind a head of the Item. the lower vena cava, the beginning of a portal vein, the right renal artery and a vein, the general bilious channel are located (is more often in the thickness of the Item.). In the thickness of the Item. there passes the pancreatic channel (ductus pancreaticus) (tsvetn. fig. 1). It stretches from a tail of the Item. to a head after which escaping gets into a wall of a duodenum and opens at top of a big nipple of a duodenum — faterova of a nipple (see), previously having merged with the general bilious channel, more rare independently. In the absence of an obliteration of proximal department of a channel of a dorsal part of the Item. additional P. zh Canal falls into a cavity of a duodenum. (ductus pancreaticus accessorius).
Options of a deviation from a typical structure and an arrangement of the Item are known.: ring-shaped, club-shaped (oversizes of a head), molotkoobrazny (the form of a head is changed). Additional parts of the Item can meet. in a liver, a mesentery, walls of a stomach, a small bowel, the general bilious channel.
Behind a body of the Item. are a belly part of an aorta, limf, nodes, a part of a celiac texture, along a body of the Item. there is a splenic vein. Behind a tail of the Item. a part of a left kidney with a renal artery and a vein, the left adrenal gland lies. In front to the Item. the back wall of a stomach prilezhit. To a first line of a body of the Item. the root of a mesentery of a cross colon approaches. End of a tail of the Item. reaches a spleen, being located its collar is lower.
Blood supply of a head of the Item. it is provided from branches of the general hepatic artery (and. hepatica communis) and upper mesenteric (and. mesenterica sup.), and a body and a tail — from branches of a splenic artery (and. lienalis). Small arteries pass in interlobular connecting fabric and give branches in segments. In segments networks of the capillaries covering trailer secretory departments are formed. The arterioles suitable to pancreatic islands form balls of the sinusoidny fenestrirovanny capillaries of an island closely adjacent to insular cells. A venous blood flows through the veins of the same name in system of a portal vein.
Lymph drainage. Limf. capillaries form three-dimensional networks around a pancreatic acinus and islands (vokrugostrovkovy lymphatic network. T.) also the vessels forming in the thickness of the Item fall in limf. textures. The lymph drainage occurs through taking away limf, the vessels bearing a lymph in pankreatoduodenalny upper pancreatic, splenic and in lower pancreatic limf. nodes.
The innervation is carried out by the nerves going from splenic, hepatic, upper mesenteric and celiac textures and branches of a vagus nerve. In the thickness of the Item. the pancreatic texture is formed, intraorganic nerve knots are a part to-rogo. Around islands neuroplexes are formed, and between cells of islands nervous cells meet. Such educations are called neuroinsular kokhmpleksa.
Normal on pankreatogramm (fig. 1) the pancreatic channel can have the ascending, horizontal or descending situation, is more rare a S-shaped or loop-shaped form. Pankreatichesky Canal has equal walls, diameter it gradually decreases in the direction from a head to a tail of the Item. Besides, there is an anatomic narrowing on site of connection of pancreatic and additional channels. Length of a pancreatic channel fluctuates within 15 — 17 cm. Average diameter it in a head of the Item. makes 4 mm (3 — 6 mm), in a body of the Item. — 3 mm (2 — 4 mm), in the tail of gland — 2 mm (1 — 3 mm). Filling with a contrast agent of all pancreatic channel, and also its large, small branches and the smallest channels is normal noted. At administration of contrast medium under big pressure contrasting and an acinus is observed. But only the pancreatic channel is quite often contrasted that complicates interpretation patol, changes of gland.
Outside of the Item. it is covered with the thin connective tissue capsule (capsula pancreatis), cover branches, getting into depth of body, divide it into segments (lobuli pancreatis). In interlobular connecting fabric (interlobular partitions) vessels, nerves and output channels are located. Item. consists of two parts, various on morfofunktsionalny characteristics — exocrine and endocrine (tsvetn. fig. 2 and 3).
Exocrine part — the complex alveolar and tubular gland presented by system of trailer ferruterous departments (acinus) and output channels.
A pancreatic acinus (acinus pancreaticus) — the main structure of a segment of the Item. — is the place of development of the difficult secretory product containing the major digestive enzymes. It is created by group of ferruterous acinous cells (cellula acinosa), or exocrine pankreotsita (pancreocytus exocrinus), shaped the truncated cone turned by the basis (a basal part of a cell) outside, and top (an apical part) — to the center of an acinus. It gives to a pancreatic acinus a type of roundish or oval education.
In the center of each acinus there is a gleam in which acinous cells allocate a secret. The kernel and ground mass of organellas of an acinous cell are located in a basal part of a cell.
Special intensity is reached by development of a granular cytoplasmic reticulum (see. Endoplasmic reticulum ), among tanks a cut extended are located mitochondrions (see). Golgi's complex (see. Golgi complex ) it is localized preferential in nadjyader-ache areas, and near them in an apical part secretory granules of zymogen (fig. 2) are located. Thanks to dominance of structures of a granular cytoplasmic reticulum in a basal zone of a cell, and granules of zymogen — in apical, at a research by means of a light microscope the first looks homogeneous and is painted by the main dyes, and the second — has grain structure and is painted by acid dyes. The surface of an atsnnozny cell turned into a gleam of an acinus has short microvillis. In an apical part side surfaces are connected by a number of the lying acinous cells by means of dense contacts and desmosomes (see), and their basal departments — are diconnected by intercellular cracks. Outside an acinus is surrounded with the thinnest layers of the connecting fabric containing circulatory capillaries of fenestrirovanny type and nerve terminations. In the territory of an acinus, acting in its gleam, the small light cells which received the name cent-roatsinoznykh of cells (cellula centro-acinosa) are located. Consider that they belong to initial departments of the inserted channels which went deep into an acinus.
Functional value of tsentro-acinous cells is not finalized.
Output pancreat ducts remove, enrich (generally with bicarbonates) and liquefy the secret developed by acinous cells. They begin from an acinus inserted channels — the long narrow branching tubes, the cavity to-rykh is covered by a single-layer flat epithelium. Merging, inserted channels form intra lobular, covered by a single-layer cubic epithelium, cells to-rogo are supplied with microvillis. Intra lobular channels gather in interlobular, falling into the pancreatic canal. Gleams interlobular and pancreatic channels are covered by an odnoslokhshy cylindrical epithelium; its cells also have microvillis. In process of enlargement of channels as a part of an epithelium the quantity of scyphoid cells increases and there are endocrine cells, the connective tissue basis of a wall is thickened and the mucous membrane containing glands and smooth muscle cells forms.
An endocrine part is presented by set of pancreatic islands — insulae pancreaticae (islets of Langerhans). Each island is formed by group of the secretory cells located in the nezhnovoloknisty connective tissue stroma supporting network of circulatory sinusoidny capillaries of fenestrirovanny type. On the periphery of an island the vokrugostrovkovy limfokapillyarny network and vokrugostrovkovy neuroplexes are located. A form of islands preikhmushchestvenno roundish, the sizes considerably vary, the quantity them increases in the direction of a tail. Secretory cells (insulotsita) of pancreatic islands are located tyazha or groups along capillaries. Allocate four types of cells: the beta cells producing insulin; the alpha cells developing a glucagon; the δ-cells producing somatostatin; The PP cells producing pancreatic polypeptide. The quantitative ratio of insulotsit is subject to age and specific fluctuations. On average in pancreatic islands of the Item. the adult 70% beta klstok, 20% of alpha cells, 8% of δ-cells and apprx. 0,5% of PP cells contain. In the ultrastructural relation of an insulotsita are similar; their organellas are developed moderately, and at usual coloring of cuts of islands they have an appearance of light educations.
The main differences of secretory cells of different type are connected with structure of secretory granules: their size, density and the relation to a surrounding membrane (fig. 3, and —).
In the Item. the special type of cells — atsinoostrovkovy is found (mixed, transitional). They have structural and functional signs of at the same time exocrine and endocrine secretory cells. And one cells along with granules of zymogen contain the granules characteristic of beta cells (fig. 4), others — for alpha or beta cells. They are located with hl. obr. about pancreatic islands. Functions and their genesis are studied not enough.
Structure of the Item. it is subject to essential age changes. In a growth period of an organism (up to 20 — 25 years) the significant increase in mass of its exocrine part which is followed by decrease in content of connecting fabric, quantity of pancreatic islands per acre and change of a ratio between alpha and beta cells is observed. In the course of aging of an organism the volume of an exocrine part of gland decreases and the number of large islands is reduced, zapustevat a part of blood vessels, the content of connecting fabric increases.
item. performs two main functions: 1) exocrine (vneshnesekretorny), consisting in secretion in a duodenum of the juice containing a set of the enzymes hydrolyzing all basic groups of food polymers; 2) endocrine (intra secretory), consisting in secretion in blood of a number of the polypeptide hormones regulating assimilation of food and metabolic processes in an organism (see Digestion). Carrying out the functions, the pancreas participates in activity of various functional systems.
Beginning to systematic researches of physiology of the Item. it is necessary I. P. Pavlov (1879) who for the first time developed technology of imposing of a fistula of a pancreatic channel in hron, an experiment. Communication between meal and secretory activity of the Item. it is shown by K. Bernard (1856), Bernstein (J. Bernstein, 1869) and R. Geydengayn (1886). Nervous mechanism of regulation of the Item. it is for the first time shown by I. P. Pavlov with sotr. (1877). Analyzing the phenomenon found by I. M. Dolinsky (1894) and L. B. Popelsky (1896) who consisted in stimulation of pancreatic secretion salt to - that, entered into a duodenum, Beyliss (W. M of Bayliss) and E. Starling in 1902 discovered secretin. Stimulation of secretion of pancreatic enzymes the factor produced by cells of a mucous membrane of a duodenum, which received afterwards the name cholecystokinin (pancreozymin) is found in 1943 by Harper and Reyper (A. A. Harper, H. S. Raper).
The Vneshnesekretorny processes realized by the Item., are divided into two types: 1) secretion of macromolecules (synthesis, transport and release from a cell of high-molecular substances, including enzymes); 2) secretion of electrolytes (transport of water and ions through an epithelial layer).
Secretion of inorganic and organic components of pancreatic juice happens in different structural elements of the Item. Allocation of a liquid part of a secret, change of its ionic structure and quantity owing to a reabsorption and ion exchange happen preferential in cells of various departments of channels. Synthesis and secretion of organic components of a secret (proferments, enzymes, nek-ry peptide connections) are implemented in acinous cells (fig. 5 and 6) making up to 90% of lump of the Item. The volume of a secret of acinous cells is very small, and the amount of pancreatic juice generally is defined by secretion of cells of channels.
Endocrine function of the Item. consists in products of a number of the polypeptide hormones coming to blood and it is carried out by cells of pancreatic islands (Langergans). alpha Cells produce glucagon (see), beta cells - insulin (see), δ-cells — somatostatin, PP cells — pancreatic polypeptide.
Fiziol, value of insulin consists in regulation of carbohydrate metabolism and maintenance of necessary level of glucose of blood by its decrease. The glucagon possesses opposite action. Its main physiological role — increase in concentration of glucose in blood. Hormone exerts impact on metabolic processes in an organism. Somatostatin inhibits release of gastrin, insulin and glucagon, secretion salt to - you a stomach and receipt of ions of Ca in cells of pancreatic islands. RR-Kletki pancreatic islands and an exocrine part of a pancreas produce more than 90% of pancreatic polypeptide, on the effect being the antagonist cholecystokinin (see).
Control and regulation of functions of the Item. are implemented by several interconnected mechanisms: 1) intracellular; 2) nervous; 3) hormonal. Intracellular regulation is carried out by means of cyclic nucleotides and ions of Ca. The balance of cyclic adenosinemonophosphate (tsAMF) and a cyclic guanozinmonofosfat (tsGMF) in a cell is defined by activity of adenylatecyclases and guanylate cyclases, and also phosphodiesterases.
Distinguish three phases of secretion of pancreatic juice; complex-reflex, gastric and intestinal. Uslovnoreflektorny irritants of secretion are the look and a flavor of food, bezuslovnoreflektorny — chewing and swallowing. Under the influence of these factors secretion of pancreatic juice begins in 1 — 2 min. after meal. The center regulating secretion of juice is in a myelencephalon. The irritation of kernels of front and intermediate hypothalamic areas stimulates secretion, and back — slows down secretion. The gastric phase of secretion of pancreatic juice is connected with stretching of a greater cul-de-sac during the filling by its food and is followed by increase in release of water and enzymes. This effect is mediated by a vagus nerve. Stretching of a pyloric (peloric) part of a stomach at advance of food to intestines stimulates secretion of enzymes in pancreatic juice and is caused, obviously, by action gastrin (see), excreted by a stomach. This effect is not blocked at section of a vagus nerve. The main phase of secretion of pancreatic juice — intestinal — has the humoral nature and depends on release of two intestinal hormones: secretin (see) and cholecystokinin (pancreozymin). Secretin, peptide hormone, is emitted with a mucous membrane of an upper part of a small bowel in the form of prosecretin. Secretion of this hormone is stimulated with hl. obr. salt to - that, getting into a duodenum from a stomach, and also products of a partial proteopepsis and fats. Secretin, with a blood flow the reaching Item., stimulates secretion of a large number rich with bicarbonates and poor in chlorides and enzymes of juice. Decrease in pH in a duodenum at hit in it salt to - you stop, and as a result of release of pH bicarbonate of a small bowel becomes neutral. Besides, effect of secretin provides creation of the neutral environment that is necessary for activation of pancreatic enzymes. Cholecystokinin is the polypeptide hormone of an upper part of a small bowel synthesized in en-terokhromaffinny cells, exists in several molecular forms. This hormone is emitted in response to receipt in a duodenum of amino acids, fat to - t, products of a partial proteopepsis and in much smaller degree salt to - you. The pancreatic juice emitted under the influence of cholecystokinin is rich with digestive enzymes and is poor in bicarbonate. The pancreatic glucagon reduces the volume of juice and secretion of enzymes, but does not exert noticeable impact on secretion of electrolytes. Somatostatin, according to one data, increases secretion of enzymes, on others — inhibits secretion of enzymes and bicarbonate. Insulin stimulates secretion of enzymes, but does not influence release of water and bicarbonate. Pancreatic polypeptide inhibits secretion of enzymes and depending on a dose inhibits or stimulates an exit of bicarbonate.
Hormones of a hypophysis, thyroid and epithelial bodies and adrenal glands exert impact on secretory function of a pancreas.
Also dopamine, calcium, magnesium and their salts belong to stimulators of pancreatic secretion, salt bilious to - t, fats, proteins p products of their disintegration, gastrin, prostaglandin E. It is necessary to carry a calcitonin, vasopressin, adrenaline and noradrenaline, anticholinergic substances, the glucose entered intravenously to inhibitors, etc.
On secretory function of the Item. feedstuffs and their composition exert impact. Starvation leads to decrease in volume of juice and concentration of enzymes in it. Meal stimulates the secretion depending on character of food ingredients. The maximum quantity of juice is allocated prp consumption of bread, a little .menshy — meat and minimum — lyulo. The composition of enzymes of juice is defined by structure of a diet.
Specific reaction of the Item. on structure of food arises during rather early period of post-natal development and remains during all life. This adaptive reaction depends on a functional CONDITION of an organism, action of various extreme and other factors.
Biochemical structure of a pancreas. Water content in the Item. averages the person apprx. 71% (66,7 — 73,1%), proteins — 13% of the weight (weight) of crude fabric. Item. it is characterized by the high content of fast-synthesizable proteins with the period of updating apprx. 10 days. Content of fat in the Item. the person is made by 2,17% of weight of crude fabric at newborns and on average adults have 8% (2,9 — 20,4%), ashes on average of 1,2%, a DNA proteid — 0,013 — 0,024%, a RNA proteid — 0,018 — 0,08%. In 100 g of crude fabric of the Item. 2,1 g of nitrogen contain. Considerable part of protein of the Item. falls to the share of various enzymes, including digestive, adenozintrifosfataz, adenylatecyclases, cholinesterases, monoamine oxidase, etc. In sol of the Item. the person potassium, magnesium, manganese, phosphorus, lead, iron, copper, calcium contains. At laboratory animals at hypofunction of the Item. increase in content in its fabric of copper, cobalt and zinc is noted. Content of zinc in insular cells of the Item. (insulotsita) above, than in cells of an exocrine part. Depending on a functional condition of the insulin device the level of zinc in cells of pancreatic islands changes. Believe that this microelement plays an important role in the mechanism of secretion of insulin.
Biochemistry of secretion and composition of pancreatic juice. Pancreatic juice represents a transparent colorless liquid with alkali reaction (pH 7,5 — 9,0). The pH value of pancreatic juice depends on the speed of secretion: with a high speed the content in juice of bicarbonate and a pH value increase, and with a low speed of secretion of pH decreases to 7,5. At different types of animals the structure and secretion of pancreatic juice have the biol, features. Besides, the composition of juice changes depending on conditions of secretion. Amount of the pancreatic juice emitted to the Item. the healthy adult in 24 hours, is averaged by 600 — 700 ml and can vary from 30 to 2000 ml. Ud. the weight (density) of pancreatic juice makes 1,007 — 1,015. 98,7% (98 — 99%), on a share of dense substances — 1,3 — 1,5% fall to the share of water on average. Nearly 1/3 dense substances fall to the share of protein of enzymes. Organic content in pancreatic juice — 0,5 — 0,8%. Juice of the Item. izotonichen with a blood plasma.
Alkali reaction of pancreatic juice is defined by hl. obr. presence of an ion of bicarbonate at it (HCO 3 ). In formation of ions of bicarbonate plays a crucial role a karboangidraz (KF 188.8.131.52) — the tsinksoderzhashchy enzyme catalyzing reaction an otnyatiya of a water molecule from coal to - you. Bicarbonate together with other ions and water is emitted with the epithelial cells covering the channels going from an acinus. The marked-out amount of bicarbonate is enough for neutralization of contents of a small bowel, for creation and maintenance of the Item, optimum for effect of digestive enzymes. pH values. Other major anion of juice of the Item. Cl is - . Total ion concentration of bicarbonate and Cl-is usually constant, and relative concentration of these anions depend on the speed of release of juice. With low speeds (e.g., at rest, 0,5 — 1,0 ml/min.) strengthening of Cl-is observed, and with high speeds (to 3,0 — 5,0 ml/min.) concentration of bicarbonate increases. Secretagogues of bicarbonate and increase in volume of juice are secretin, salt to - that, ether, gastrin, and inhibitors — prostaglandin E, a glucagon. The main monovalent cations of pancreatic juice — Na + and K+. Their concentration approximately correspond to that in extracellular liquids. It is supposed that at the first stage of secretion of liquid of pancreatic juice there is active transport of Na + from plasma in the gleam of a pancreatic channel which is carried out by Na+ To +-ATF-azoy. Except this enzyme playing an important role in secretion of juice in the Item. the system activated by anions and connected, obviously with modification of composition of liquid at the level of P. zh Canal is found ATF-aznaya. The functional condition of a pancreas has significant effect on the content of electrolytes in a pancreas and pancreatic juice.
In pancreatic juice amino acids and sialine to - you are found, contents to-rykh is also defined by a functional condition of the Item. It is established that pancreatic juice in a small amount contains serotonin and a histamine. Vneshnesekretorny device of the Item. produces also a number of biologically active agents playing an important role in regulation of exchange and trophic processes. Item. produces the substances capable to influence blood supply and functional activity of a small bowel, in particular on functioning of her mucous membrane — intensity of processes of absorption and motor activity of fibers. These substances about a pier. it is powerful (weighing) more than 20 000 lose activity after boiling. In pancreatic juice a lab. animals biologically active low-molecular polypeptides capable to change a ratio of volumes of liquid between the extracellular environment and cells are found.
In an exocrine part of the Item. (acinous cells) there is exclusively bystry biosynthesis of set of the hydrolases emitted in the pancreatic juice interfaced to a high level of exchange and power processes in the Item. The cosecreted Items. enzymes take part in the course of digestion in a duodenal and small bowel, playing an important role in digestion of makromoleku-lyarny components of food. Besides, the hydrolases cosecreted by the Item., get to blood, and also to a lymph.
The digestive enzymes synthesized in an acinus gather in secretory granules, and then are removed to canals of the Item. Makromole-kulyarnaya a part of contents of granules consists hl. obr. from mix of hydrolases and their zymogens. Synthesis of the cosecreted enzymes happens on the ribosomes connected by a cytoplasmic reticulum and forming a so-called rough Endoplasmic reticulum. The secretory fermental proteins synthesized on free ribosomes of an acinus are transported through membrane cellular structures. On an endoplasmic reticulum they get to intra cisternal space where the selection proteolysis of molecules for removal of «alarm» peptides since the N-end is carried out, and then as a part of transport vesicles come to Golgi's complex. Here secretory proteins are exposed to sulphation, proteolysis and concentrate. In Golgi's complex the concentrating vacuoles (unripe granules), and then and mature zimogenny granules of big electron density which remain in an apical part of an acinus, between Golgi's complex and an acinar gleam are formed.
There is a hypothesis of participation in advance of secretory granules of the microtubules and (or) microfilaments containing aktino-and miozinopodobny kontraktilny proteins. By means of an exocytosis contents of granules are removed in a gleam of the Item. Synthesis of zimogenny granules borrows apprx. 40 min. Detection of high activity of hydrolases in soluble fraction of cells of the Item. led also to alternative idea of participation in intracellular transport of secretory enzymes (along with membrane structures) and cytoplasms. In processes of synthesis and secretion of enzymes of the Item. the important role is given to calcium ions. Contents Sa^ + in pancreatic juice depends on its content in extracellular liquid and a functional condition of the Item. Increase in secretion of enzymes is always followed by increase in maintenance of calcium ions in juice. Believe that release of intracellular calcium promotes secretion of enzymes, and extracellular calcium stimulates maintenance of secretion.
Many digestive, including proteolytic, enzymes are synthesized in the Item. in the form of inactive predecessors (zymogens) which in intestines turn into active forms of the corresponding enzymes. The digestive enzymes synthesized in the Item. in an active form, for manifestation of activity demand existence of the effectors which are in a duodenum. Synthesis of inactive digestive enzymes allows to prevent an autolysis of a pancreas.
Trypsin (see) it is allocated in a small bowel in the form of trypsinogen. Activation of trypsinogen consists in eliminating of hexapeptide since the N-end of its polypeptide chain. Trypsin, the most active concerning partially digested proteins, carries out a further peptidolysis and the proteins which are not treated to action of pepsin of a gastric juice. Trypsin holds key position among hydrolases of the Item., as it is capable to turn all proteolytic proferments of the Item into active forms., and also phospholipase.
Chymotrypsin (see) cosecretes in the Item. in the form of inactive chymotrypsinogen, transformation to-rogo includes splitting of a polypeptide chain of chymotrypsinogen in active chymotrypsin trypsin with education proteolytic active, but unstable I-himotrip-sina and the subsequent vyshchepleniye trypsin of two dipeptides with formation of alpha chymotrypsin, and then alpha chymotrypsin. Chymotrypsin, substrates to-rogo are products of a peptic and tryptic albuminolysis of food, preferably hydrolyzes the peptide bonds formed with participation of carboxyl groups of aromatic amino acids of tryptophane, phenylalanine and tyrosine and to a lesser extent bonds, formed by a leucine, methionine, asparagine and a histidine.
Item. cosecretes also ekzopeptidaza, carboxypeptidases A and B (see. Karboksipeptidaza ), acting on COOH trailer peptide bonds. The pro-carboxypeptidase A found in a secret of the Item., consists of three subunits, one of to-rykh under the influence of trypsin turns in carboxypeptide storage A. The carboxypeptidase A containing strongly connected atom of zinc in an active center hydrolyzes all COOH trailer peptide bonds, except those, in to-rykh COOH trailer amino acids the lysine or arginine and penultimate amino acid — proline are. Carboxypeptidase B works only on SOON-kontsevye the remains of a lysine or arginine.
In pancreatic juice also some other proteolytic enzymes is found. Pro-elastase under the influence of trypsin turns into active elastase (see), hydrolyzing peptide bonds between the remains of various amino acids, but especially active concerning elastin. Like trypsin and chymotrypsin, elastase is se-rinovy protease (i.e. contains the rest of serine in an active center).
The collagenase of pancreatic juice specifically splits the collagen which is not split by other proteases. Consider that the collagenase is responsible for a necrosis of fabric of the Item. at pancreatitis. Are found in pancreatic juice also an elastomukopro-teinaza and the kollagenmukoproteinaza splitting the corresponding mukoproteida. Kallikrein, proteolytic enzyme, vysvoboyachdayushchy physiologically active kinin from globulin of plasma, cosecretes a pancreas in the form of inactive pro-kallikrein, activation to-rogo is carried out with the participation of trypsin.
Item. cosecretes active forms of endonucleases: a deoxyribonuclease (see) and ribonuclease (see). In the Item. (and also in sialadens) activity of ribonuclease (Rnkaza) is higher, than in other fabrics. Rnkaza in pancreatic juice of ruminants is most active. Rnkaza from the Item. cattle consists of 124 amino-acid remains and is one of the most studied enzymes. Rnkaza attacks an ester group in molecule RNA between phosphoric to - that and 5' - the hydroxylic end of phosphodiester bridges if this phosphatic rest is connected with a pirimidinovy nucleotide. Intermediate products are cyclic a nucleoside-2', 3' - phosphates which then are split to Z '-nukleoti-dov. The optimum of pH for RNA elements makes 7,6. Enzyme differs in high heat stability. Deoxyribonuclease (Dnkaza) of the Item., using magnesium as a cofactor, splits an ester group between Z '-the hydroxylic end and phosphoric to - that in molecule DNA.
in an active form the lipase (see) which is carrying out hydrolysis of fats cosecretes in pancreatic juice. The maximum activity of a lipase is observed at pH 7,0 — 8,6 and in the presence of bilious to - t. The phospholipase of Ag is allocated in the form of inactive zymogen and activated by trypsin, and - Amiel the aza which is present at pancreatic juice on properties is close to enzyme of saliva and participates in an osakharivaniye of starch and a glycogen in a duodenum (see Amylases). a-Amilaza hydrolyzes and - bonds of carbohydrate chains in such a way that mix of glucose and a maltose as a result is formed. An optimum of pH for and - amylases from the Item. makes 6,3 — 7,2, enzyme is activated by ions of Cl-. Are present at pancreatic juice lactase (see. Galactosidases ), invertase (see) and maltase (see. Glucosidases ), the splitting lactose, sucrose and a maltose, and also esterases (see), alkaline phosphatase (see) and some other enzymes.
The fermental composition of pancreatic juice is thinly adapted to quantity and quality of the eaten food, depends on a diet, a ratio of animal and vegetable food, character of food and a type of a food irritant. At hron, starvation there is a decrease in content of RNA and proteins-enzymes, and also reduction of formation of a secret. At hron, proteinaceous insufficiency secretion of digestive enzymes decreases, and at the subsequent increase in protein content in a diet increase in activity of enzymes of proteolytic group is observed. At carbohydrate food the content of amylase and the speed of synthesis of enzyme increase in pancreatic juice, and the content of proteases decreases. At proteinaceous food the return phenomenon is observed. There is also a change of a ratio of proteases of pancreatic juice. These effects are result of regulation at the level of repression or induction of synthesis of digestive enzymes in cells of a pancreas.
The pancreatic enzymes which are emitted preferential in a gleam of a duodenum partially come to blood. Several ways of such penetration are supposed: 1) by means of an exocytosis of secretory granules through basolateral membranes acinous cells; 2) diffusion between epithelial cells of channels; 3) due to secretion by cells of morphologically transition type between the exocrine acinar device and endocrine cells of pancreatic islands; 4) by absorption by intestinal cells of intact molecules of enzyme from a cavity of a small bowel. Increase in concentration of pancreatic enzymes in blood at pathology can testify to a necrosis of cells of the Item. or about diffusion of enzymes between cells of channels as a result of an inflammation or obstruction of the last.
Change of activities of enzymes of pancreatic juice is observed at various pathology of the Item. and some other diseases. For the purpose of diagnosis define activity of amylase, trypsin, a lipase in biol, liquids (blood, urine), Calais, duodenal contents. Assessment externally - secretory ability of a pancreas is based on quantitative definition of these enzymes.
The enzymes cosecreted by the Item., find broad application in biochemical researches. Drugs of nucleases (Dnkaza and Rnkaza) are used in the analysis of the nucleotide sequence nucleinic to - t, and proteases (hl. obr. trypsin, chymotrypsin and carboxypeptidase) — in the analysis of the amino-acid sequence of polypeptides.
Inspection of the patient includes methods of inspection; analysis of complaints of the patient, collecting anamnesis, Physical researches, laboratory methods (functional research of extra-shnesekre-even and incretory function), immunological, tool and rentgenol, methods of a research. The most characteristic complaints of patients with diseases of the Item. are pain in an upper half of a stomach, it is frequent opoyasyvayush, its character; at damage of a body and tail of the Item. pain is preferential localized in the left upper quadrant, and in case of localization patol, process in a head of the Item. pain is noted in epigastriums and in right hypochondrium. Pains can be followed by vomiting, temperature increase, tachycardia (see), collapse (see).
Anamnesis. From anamnestic data data on a disease of bilious ways, injuries of a stomach, an alcohol abuse have a certain value.
At survey of patients with diseases of the Item. it is necessary to pay attention to outward of the patient and coloring of skin and mucous membranes. Existence of jaundice and weight loss are most characteristic of cancer of a head of the Item. and hron, sclerosing pancreatitis (see).
Percussion has a certain diagnostic value; so, at cysts of the Item. the big sizes adjoining to an abdominal wall the stupid percussion sound is defined, and in side parts of a stomach find tikhmpanit.
It is normal of the Item. it is palpated 2 — 3 cm above the lower bound of a stomach and big curvature in the form of the soft cylinder 1,5 — 2 cm thick having the transversal run.
Laboratory methods of a research
In diagnosis of diseases of the Item. laboratory methods of a research are very important, and sometimes the leaders having differential and diagnostic value.
Distinguish straight lines and indirect methods of a research of vneshnesekretorny function of a pancreas. Treat direct methods: 1) a research of pancreatic enzymes in blood serum (trypsin, a lipase, amylase, transaminases, deoxyribonucleases, a phospholinden-zy And, elastases, collagenases, krea-tinfosfokinaza, an alkaline phosphatase); 2) a research of pancreatic enzymes in duodenal contents and in blood using secretagogues; 3) a research of pancreatic enzymes in urine (amylase); 4) a research of pancreatic enzymes in Calais (trypsin, chymotrypsin); 5) test of Lund. Indirect methods include: 1) determination of weight calla; 2) macroscopic, microscopic and biochemical examination calla; 3) quantitative definition of fat in Calais; 4) RAVA-test.
Direct methods are based on bio-chemical research of enzymes of the Item. in duodenal contents and pancreatic juice, in blood and urine, Calais, pleural and ascitic liquids. Also microscopic, and also bio-chemical the research a calla is the cornerstone of indirect methods of a research. The observed changes of structure a calla are caused by disturbance of digestion and absorption of feedstuffs in intestines as a result of insufficient production of enzymes of the Item. The greatest distribution in clinic was gained by definition of amylase in blood and urine.
From the existing ways of definition and - amylases the most rational is Karavey's method based that and - amylase hydrolyzes splitting of starch with formation of the end products which are not giving staining reaction with iodine. On the speed of reduction of concentration of starch judge activity and - amylases. Amilazny activity of serum depends on extent of defeat of cells of an exocrine part of the Item., obstructions of pancreatic channels, breakdown rates of amylase, renal clearance. Increase in the general serumal amylases - ache activities it is not specific to defeat of the Item. also it can be observed at perforation or a penetration of stomach ulcer and a duodenum, intestinal impassability, parotitis, a salpingitis and a rupture of a uterine tube, a renal failure, a diabetic ke-toatsidoz, at use of drugs. For differentiation of a serumal hyperamilasemia at a renal failure from the hyperamilasemia caused by pancreatitis definition at the same time of amylase both in blood serum, and in urine, and also definition of a ratio of clearance of amylase of Sa to clearance of creatinine of Ss is reasonable. Increase in coefficient of Sa/Ss is characteristic of acute pancreatitis. At a renal failure the specified coefficient remains within norm (1: 4), since there is a parallel decrease in size of clearance of amylase and creatinine. At acute pancreatitis increase in amylase both in blood serum, and in urine is observed, and at a renal failure increase in content of amylase is noted only in serum. At acute pancreatitis and an aggravation hron. pancreatitis without damage of kidneys increase in amylase in urine is more expressed, than in serum; it remains within 8 — 10 days from the beginning of acute pancreatitis when already there occurs normalization of content of amylase in blood serum. The increase in content of amylase in serum which is not connected with defeat of the Item., poppy-roamilazemiyey can be caused, at a cut there is an aggregation of molecules of amylase or compound of amylase with globulin or a glucoproteid. For differentiation etiol. the reasons of a hyperamilasemia definition of isoenzymes of alpha amylase in globulinovy fraction of serum by method matters electrophoresis (see).
Level of a lipase in blood serum sharply increases at acute pancreatitis, sometimes more than by 5 times in comparison with norm, and longer period, than increase in activity of amylase keeps. Increase in a lipase in serum, as well as amylases, is not specific to defeat of the Item. also it can be observed at perforation of stomach ulcer or a duodenum, intestinal impassability, acute cholecystitis, a viral hepatitis and cirrhosis.
Definition of trypsin and other pancreatic proteases has limited diagnostic value. It is caused by the fact that blood contains several proteolytic enzymes capable to subject to hydrolysis the synthetic substrates used for definition of trypsin; besides, serum contains a significant amount of inhibitor of trypsin. In clinic most often definition of activity of trypsin is carried out by Erlanger's method to Shaternikov's modifications. The method is based on the principle that at effect of trypsin on synthetic substrate — N, alfa-benzoil-D, 1 arginine — p-nitroanilide are formed benzoil-D, 1 arginine and n-nitroanilide painted in yellow color; on intensity of coloring of solution judge activity of enzyme. Normal amounts: activity of trypsin of blood serum — 1 — 2 µmol/ml in 1 min., 60 — 120 µmol/ml at 1 o'clock; duodenal contents — 50 — 500 µmol/ml in 1 min., 3000 — 30 000 µmol/ml at 1 o'clock. Use of a radio immune method of definition of trypsin takes these samples of a pancreas, more sensitive for assessment of defeat.
Rather sensitive indicator of vneshnesekretorny insufficiency of the Item. test of Lund is. Patients receive the breakfast consisting of 18 g of vegetable oil, 15 g of casein, 40 g of glucose and 300 ml of water. Then enter the probe into a duodenum and define the peak of concentration or hourly release of trypsin, amylase or lipase. Results of a research depend on evakuatorny function of a stomach, production of gastroduodenal hormones. The deviation of test of Lund can be noted at a glyutenozavisimy enteropathy, cirrhosis, mechanical jaundice, diseases of bilious ways, a peptic ulcer of a stomach and a duodenum.
At diseases of the Item., followed by decrease in exocrine function, polyexcrements are observed. At pancreatic vneshnesekretorny insufficiency of kcal it is often colourless or clay and whitish coloring, has a putrefactive or musty smell, at survey it is possible to find fragments of not digested cellulose. At microscopic examination in case of pancreatic externally - secretory insufficiency the numerous not re-cooking muscle fibers with the rectangular terminations, cross and longitudinal strips are found. However the steatorrhea can be observed at the remained normal pancreatic secretion of enzymes. During the coloring by Sudan the III fats are painted in orange-yellow color, can take the form of drops of various size, sometimes form «fatty lakes»; crystals fat to - t and soaps are defined.
For assessment of vneshnesekretorny insufficiency of the Item. in clinic quantitative definition of fats in Calais by means of a method of trial diets and tests with use of marked fats is used. The method of the nutritious balance based that the amount of the fats emitted with a stake is compared to amount of the arrived fats in an organism of the patient is the cornerstone of quantitative definition. For these purposes the corresponding diet is used, against the background of a cut within 3 days appoint precisely weighed amount of fats. At the same time quantitative definition of fats is carried out to Calais. Normal the coefficient of release of fats with a stake is lower than 20%. In absolute numbers within a day release of fats shall not exceed 7 g. At diseases of the Item., the acinous cells which are followed by considerable reduction of quantity, the specified coefficient sharply increases.
Measurement of daily loss of fat with a stake can be carried out by means of the radio iodated triolein or radio iodated olein to - you (see. Fats ).
The clinic began to apply to recognition of exocrine pancreatic insufficiency so-called. The RAVA-test offered by Mitchell (Page J. Mitchell) et al. (1978), based on the principle that chymotrypsin selectively chips off paraaminobenzoic to - that from the sodium salt N accepted inside - benzoyl - alpha tyrosyl-r-aminobenzoic to - you are (RAVA). It is soaked up in intestines, conjugated in a liver and allocated with urine. At diseases of the Item., followed by decrease in release of chymotrypsin, decrease in allocation of RAVA with urine is observed. False positive results can be received at a renal failure, a sprue, hepatitises and cirrhoses of a liver, and also at reception of the pharmaceuticals containing arylamines.
From the existing methods of a research of pancreatic enzymes using secretagogues of pancreatic juice secretin-pankreoziminovy the test most was widely used. The research is conducted on an empty stomach. During 4 — days prior to a research would cancel sedative, antiacid and cholinolytic drugs. Two-or the three-channel probe is entered under rentgenol, control in such a way that one channel is installed in antral department (a lesser cul-de-sac, T.), and the second — in a duodenum. The gastric juice is collected constantly by means of a suction. The duodenal contents collected by means of manual aspiration (see. Sounding of a stomach , Duodenal sounding ), collect in the separate portions each 10 min. Three first 10-minute portions are basal. Then intravenously enter secretin in a dose of 1 PIECE/kg and each 20 min. within 1 hour collect duodenal contents. Determine the volume of all received tests, pH, concentration of bicarbonates. In an hour after administration of secretin enter pancreozymin in a dose of 1 PIECE/kg and again collect juice within 1 hour; the received fraction defines concentration of amylase, a lipase, trypsin and chymotrypsin. At hron. pancreatitis reduction of release of amylase, a lipase, trypsin, bicarbonates is observed. At the same time aberrations are qualitative since the volume of pancreatic juice does not change. At patients with heavy pancreatitis at death of a significant amount of acinous cells reduction of volume of pancreatic juice, bicarbonates and concentration of enzymes in it is noted. At cancer of the Item. changes in pancreatic juice have quantitative character. Owing to a prelum of a pancreatic channel tumor of a head or body of the Item. there occurs reduction of volume of release of juice at normal concentration of enzymes and contents of bicarbonates. Sekretin-pankreoziminovy the test is not specific to pancreatitis or cancer of the Item. Function of a pancreas, especially secretion of enzymes, is broken at cirrhosis, a diabetes mellitus, defeat of a small bowel, uraemia, a hypoproteinemia, hemochromatosis.
Diseases of the Item. quite often are followed by defeat of pancreatic islands, causing development of secondary diabetes. At adenoma of pancreatic islands the syndrome of a hyper dysinsulinism which is followed by signs of a hypoglycemia develops. To a research of carbohydrate metabolism apply definition of glucose in blood by a glyukozooksidazny method and a research of tolerance to glucose. Normal amounts of content of glucose: in blood — 56 — 94 mg / 100 ml, in plasma — 55 — 100 mg / 100 ml. Tolerance to glucose is determined by double loading sugar by a method of Shtauba — Traugotta. After capture on an empty stomach from a vein of blood on sugar the patient is given 50 g of glucose, in 1 hour — repeatedly the same amount of glucose. Then during 3 hours everyone half an hour define concentration of glucose in blood.
Immunological methods of a research have a certain value in diagnosis of diseases of the Item. Reduction of number of T lymphocytes of blood, and also emergence of antibodies and a sensitization of lymphocytes to the general fabric antigens of the Item is established. at acute and hron, pancreatitis.
Tool methods of a research
At duodenoskopiya (see) identification of indirect signs of defeat of the Item is possible. Often the superficial or atrophic duodenitis is found, limfoangiektaza, inflammatory infiltrates, polypostural growths of a mucous membrane of a duodenum, a diverticulum in the field of its big nipple (a faterov of a nipple), a papillitis, adenoma or a carcinoma of a faterov of a nipple are more rare.
A certain diagnostic value has tsitol, a research of duodenal contents, especially after administration of secretin, and more informatively a research of pure pancreatic juice at an endoscopic kanyulyation of a pancreatic channel. At the same time the cells of a cylindrical epithelium of various height with an oval or roundish kernel which are cells of a pancreatic channel normal are defined. Less often cells of a cubic epithelium are found, to-rymi proximal departments of small pancreatic channels are covered. At malignant new growths of the Item. in pancreatic juice it is possible to find tumor cells.
For differentiation of nature of a tumor, specification of localization patol. process, at intolerance of a contrast agent it can be applied transduodenal punk reatokholangioskopiya (see. Holedokhoskopiya ).
Importance in diagnosis of diseases of the Item. has ultrasonic investigation. Ability of separate structures of the Item is the cornerstone of a method. to reflect echo signals (see. Ultrasonic diagnosis ). Diagnostic opportunities of an ultrasonic method increased after implementation in a wedge, practice of the scanning ekhografiya with the scale allowing to define on the screen of an electron-beam tube up to eight shades of a black-and-white scale depending on density of structures of fabrics and bodies.
In the analysis of an echogram localization, a form, the sizes, character of contours, thickness, internal structure of the Item are defined., and also condition of surrounding fabrics and bodies. Normal fabric of the Item. represents continuous, homogeneous education. Increase in the sizes of gland is characteristic of acute pancreatitis. At hypostasis of the Item. clearly its contours, especially back are visible. At acute pancreatitis the pseudo-liquid ekhostruktura with trace amount of echo signals or semisolid with the echo signals scattered in fabric of the Item is observed. Heterogeneous structure of an echogram is noted at a pancreatonecrosis when liquid, semi-fluid and firm areas are defined.
Signs hron, pancreatitis on an echogram are: increase in the sizes of gland, wrong an echo structure with sites of the increased acoustic density, a prelum of an upper mesenteric and lower vena cava, sometimes visualization of the pancreatic (virzungov) canal expanded with uneven contours, a pseudocyst, in some cases expansion of bilious channels.
Radiological methods of a research
Radiodiagnosis of the Item. earlier was under construction hl. obr. on data of survey pictures of an abdominal cavity after imposing of a pneumoretroperitoneum (see) and artificial contrasting went. - kish. path. In 60 — the 70th the radiology was enriched with a number of the techniques which significantly expanded possibilities of presurgical recognition of diseases of the Item. Treat these techniques a computer tomography (see the Tomography computer), an angiography (tsvetn. fig. 3, 6, 9 and 12) (see. Mezenterikografiya , Tseliakografiya ), a relaxation duodenografiya (see. Duodenografiya relaxation ). The endoscopic retrograde pankreatokholangiografiya is very informative (see Pankreatokholangiografiya retrograde). At inspection of each patient, considering a wedge, yielded and results of ultrasonic scanning, choose an optimum complex rentgenol, techniques for the fullest research of the Item.
Acute pancreatitis (see) causes increase in the Item., a cut is defined especially clearly by means of a computer tomography (fig. 7).
In diagnosis hron, pancreatitis the endoscopic retrograde pankreatoduodenografiya has the leading value. According to this research, change of pro-current system at hron, pancreatitis it is conditionally possible to divide into three degrees. At the first extent of changes deviations in structure of lateral branches and intra lobular channels in the form of rigidity, uneven distribution, expansion or their stenosis in the field of a head, a body or a tail of the Item are observed isolated patol. (fig. 8). At the second degree diffusion changes of channels of all gland are noted. Pankreatichesky Canal quite often has the form of a thread. It is rigid, twisting, has stenoses and expansions; the same changes are found also in small branches. Cystic expansions of a rigid, twisting pancreatic channel are characteristic of the third extent of changes, sometimes in a channel stones are defined. Similar changes occur in small pancreatic channels. Because of an atrophy of a parenchyma of gland reduction of gland can be noted. Expansions of both a pancreatic channel, and its branches are usually unevenly expressed throughout the main channel and its branches. The prelum and narrowing of a pancreatic part of the general bilious canal is often observed. At the same time the channel is deformed, displaced, rigid, expanded.
Radio isotope research of the Item. it is based on ability of its cells to absorb methionine, marked selenium-75. Studying of its form, arrangement, receipt and distribution of radionuclide in it carry out with the help scannings (see) and stsintigrafiya (see).
Normal (tsvetn. fig. 1 and 2) on stsintigramkhma of the Item. is located under the left hepatic lobe, its form is very variable. Contours normal Item. accurate, flat, all departments are contrasted evenly, except for area of an isthmus where contrast is usually reduced that is caused by a prelum of this area of the Item. portal vein. Near the Item., in nek-ry cases is closer to a tail of body, the centers of accumulation of drug in a spleen are observed. At acute pancreatitis the increased accumulation of drug in the Item takes place. in the form of «the hot centers». At hron, pancreatitis are observed weak contrasting of all departments of the Item., an illegibility, blurring of its contours, uneven distribution of drug, delay of its accumulation to 1,5 hours (it is normal of 20 — 30 min.) and the accelerated emission of marked methionine in intestines (tsvetn. fig. 7 and 8).
Different types of dystrophy are observed both in acinous, and in an insular parenchyma of the Item. Muddy swelling of acinous cells is noted at various inf. diseases. At a submicroscopy it looks as swelling and damage of mitochondrions and membrane structures of a cell, increase in quantity of lysosomes. From other types of proteinaceous dystrophies in the Item. the hyalinosis of a stroma and capillaries of pancreatic islands and a fibrous stroma of gland is noted (see the Hyalinosis). At the general amyloidosis (see) in a wall of vessels, is more rare in own cover of an acinus, amyloid is laid. At a diabetes mellitus a peculiar homogenization and consolidation of islands due to deposits of paraami-loidny substances is observed. Also gidropichesky dystrophy of insulotsit (insular cells), a hyalinosis, a sclerosis, lipomatoz and petrification of islands is noted (see. diabetes mellitus ).
Disturbances of a lipometabolism are shown in the form of the fatty dystrophy of acinous cells and insulotsit which is characterized by accumulation in cytoplasm of a large number of lipidic drops (see. Fatty dystrophy ), or in the form of growth of fatty tissue in a stroma (lipomatoz glands, fig. 9, and, b). Distinguish two types of a lipomatoz: 1) vakatny growth of a fatty tissue at pancreatitis; 2) infiltrative growth of fatty tissue with gradual substitution of an exocrine part of the Item by it. The second type of a lipomatoz, perhaps, has genetic defects as it is observed also at children's age in the basis.
In the Item. hemosiderin can be laid that is especially characteristic for hemochromatosis (see). Along with hemosiderin in cells of an acinus, channels, walls of vessels and a stroma of gland also haemo fuscin is laid.
Damage of organoids and membrane structures of a cell is followed by the partial necrosis of acinous cells which is shown electronic microscopically formation of a set autofagosy and lysosomes (fig. 9, in — e). Deeper damages of a cell come to an end with her death, at the same time in connection with activation of the proteolytic enzymes which are contained in granules of zymogen there can be a chain reaction of a fermental autolysis (see) with involvement of all acinus, segment, share of gland (see. Pancreatitis ).
Characteristic type of damage both gland, and a fatty tissue at acute pancreatitis is the fatty necrosis (see. Fatty necroses).
Disturbances of blood circulation in the Item. are shown in the form of the congestive (venous) plethora observed at hron, heart failure and portal hypertensia owing to a pylephlebitis or cirrhosis. At long venous stagnation the Tsianotichesky induration of the Item can develop., microscopically characterized by gradual substitution of an exocrine part connecting fabric.
At an anemia of the Item. it is reduced in sizes, is dry, pale that is observed at hron, anemias and a cachexia. Very frequent manifestation of circulatory disturbances in the Item. the hemorrhages arising generally in the way are emigration (see). Small hemorrhages are possible at venous stagnation, inf. diseases (sapropyra), anemias, hemorrhagic diathesis. Extensive hemorrhages can arise also at a hemorrhagic necrosis of the Item. Less often hemorrhages in a pancreas are observed at a purulent inflammation of gland, corrosion of vessels by a tumor, a nodular periarteritis.
Fibrinferments and vascular embolisms meet quite often, however heart attacks of the Item. hemorrhagic and ischemic character — the phenomenon extremely rare in view of plentiful blood supply of gland from many sources. Hypostasis of fabric of the Item. it can be observed against the background of venous stagnation as display of an overhydratation of the noncellular sector (see. Swelled ). Such hypostasis does not cause, as a rule, signs of selective defeat of the Item. Other type of inflammatory aseptic hypostasis is connected with emission of granules of a fermental secret directly in a stroma. Such stromal hypostasis of the Item. it is, as a rule, combined with scattered micronecroses of an acinous parenchyma and can be a prestage subtotal) and a total pancreatonecrosis. Acute and hron, inflammation of the Item. has an enzymatic (aseptic) necrosis of an acinous parenchyma in the basis.
Tuberculosis of the Item. (see. Tuberculosis extra pulmonary ) it is observed rather seldom. It develops more often owing to hematogenous generalization of an infection at a pulmonary tuberculosis, being shown in the form of miliary tuberculosis of intersticial fabric, solitary tuberculomas and the diffusion granulating tuberculosis from the outcome in cirrhosis (tubercular cirrhosis of the Item.). Tubercular process can pass to the Item. also with limf, nodes of retroperitoneal space.
Syphilis of the Item. meets very seldom (see. Syphilis ). The intersticial sclerosing pancreatitis which is quite often combined with specific changes of a liver (a silicon liver) is characteristic of inborn syphilis. Microscopically in the Item. diffusion growth of connecting fabric with diffusion and focal limfoplazmokletochny infiltrates is found.
Find a large number of pale treponemas in the centers of fibrosis. Points out an underdevelopment of the acinous parenchyma presented by trace amount of segments of the Item the inborn nature of defeat. along with the numerous branching channels. Occasionally miliary and solitary gummas meet.
Existence of the small hillocks and large gummas sometimes having a diameter of 4 — 5 cm is characteristic of the acquired syphilis. Depending on prescription of a disease find this or that degree of fibrosis up to almost full substitution of gland cicatricial fabric (syphilitic cirrhosis of the Item.). As at the inborn, and acquired syphilis the sclerosis takes generally acinous parenchyma; endocrine part of the Item. it is represented a little changed, islands happen even hypertrophied.
Stones of the Item. are located in a pancreatic channel or its branches. Size varies them from the microscopic sizes determined by light microscopy to several centimeters in the diameter. A surface of stones uneven, rough, sometimes in places of contact of several stones fasetirovanny. Stones consist of the organic matrix formed by the condensed secret impregnated with calcium and calcium phosphate (see. Concrements ). Arising more often for the second time against the background of hron, pancreatitis, they promote stagnation of a secret, infection of canals and the progressing course of a disease.
Cysts of the Item. happen four types: 1) proliferatsionny; 2) dizontogenetichesky; 3) retentsionny; 4) false (see. Cyst ).
The multichamber cavities arising against the background of fibrosis owing to proliferation of channels, gleam concern to the first group to-rykh it is represented considerably expanded. Quite often have such educations a microscopic structure of cystadenomas. Dizontogenetichesky cysts arise owing to a malformation, most often happen multiple and are combined with cysts of a liver, lungs, kidneys. Sometimes the polycystosis of these bodies is combined with a focal angiomatosis of a head and spinal cord. The internal vystilka of such cyst is presented by a single-row cubic epithelium, contents of cysts serous, free of enzymes of the Item.
Retentsionny cysts arise owing to a prelum of outlet opening of a channel or its branches a stone, a hem or a tumor. However in an experiment it is proved that the isolated bandaging of a channel conducts only to nek-rum, besides to uniform expansion of channels, apparently, owing to a bystry rassasyvaniye of a secret. For formation of a cyst certain conditions, namely, blockade limf, vessels, arising most often against the background of a sclerosis of the Item are required. Because of expansion of a gleam usually there is a solitary cyst having sometimes a diameter of 10 — 15 a fir-tree. The multiple small cysts occupying the limited site of gland are frequent. Vystilka of such cysts is formed by the single-row cubic epithelium which is quite often exposed to a metaplasia in multilayer flat. In a gleam of a cyst — serous, sometimes a colloid look, contents about deposits of salts of calcium.
Adventitious cysts are formed owing to fusion and a partial rassasyvaniye of the large centers of a hemorrhagic necrosis of the Item. Further in connection with transudation of liquid the gleam of an initial cyst can increase considerably in sizes. At preservation of communication with the destroyed channel the cavity of such cyst constantly is replenished with a secret. In this regard there can be aseptic suppuration, an arrosion of a large vessel with secondary hemorrhage in a cavity, break of contents in a free abdominal cavity or in a gleam of a stomach and duodenum with formation of internal fistula (pancreatic fistula). The outside pancreatic fistula opening on skin of a front abdominal wall is much less often formed.
Formation of an adventitious cyst is promoted by a bystry otgranicheniye of the center of a necrosis a connective tissue cover. Being formed first in the field of a head, a body or a tail of the Item., such cyst eminates in a gleam of an omental bursa, reaching the considerable sizes. However more often the center of a necrosis of gland extends to the surrounding fatty tissue which is exposed to enzymatic fusion and therefore necrotic masses at once breaks in an omental bursa where are exposed to bystry encapsulation. Walls of such cyst are adjacent bodies (a stomach, a duodenal and cross colon, a spleen).
Microscopically walls of adventitious cysts are presented by dense fibrous fabric, among a cut separate fibrozirovanny ferruterous segments, channels, and also diffusion and focal limfoplazmotsitarny infiltrates with iri-mesyo histiocytes are found. Adventitious cysts of the Item. — quite permanent educations can also exist for a long time, being an accidental find during the opening. In a circle of cysts the extensive commissural process connecting bodies of the upper floor of an abdominal cavity in a dense cicatricial conglomerate is observed.
The pancreas has the broad range of compensatory and adaptive processes. In response to damage to it processes of an atrophy (see), hypertrophies (see) and a hyperplasia develop (see).
Atrophy of the Item. it is expressed by considerable reduction of its weight (to 30 g; it is normal of 60 — 115 g) generally due to decrease in volume, but not length of body. Microscopically the atrophy of a ferruterous, exocrine part of the Item is found. due to reduction of quantity and volume of the acinous cells turning into small roundish limfotsitopodobny elements with a piknotichny kernel. Atrophied exocrine part of the Item. it is replaced with fibrous fabric (a sclerous atrophy). At the same time endocrine pancreatic islands among fibrous fabric most often well remain and even hypertrophy. Atrophy of the Item. it is observed at a nutritional dystrophy, tuberculosis, a pituitary cachexia, long starvation, at senile age.
Regeneration of an acinus and pancreatic islands has some features. The bystry hypertrophy preexisting and formation of new pancreatic islands owing to proliferation of trailer departments of channels is characteristic. Any damage of an acinus or group of an acinus is replaced with a hem due to proliferation of a connective tissue stroma. Compensatory and adaptive reactions in acinous cells in response to damage are carried out by hypodispersion of loading within an acinus, a segment, a share and gland in general. At the same time the loss of structural energy potential connected with development of a proteinaceous secret quickly is compensated in a resting phase of the acinus exempted from a secret at the expense of intracellular regenerations (see).
Exocrine part of the Item. very quickly after death is exposed to an autolysis, scales to-rogo depend on a phase of a secretory cycle. The autolysis develops, undoubtedly, quicker and more intensively if death came at height of digestion, i.e. in 1 — 2 hour after meal when acinous cells work in an intense rhythm and contain a lot of fermental secret. Also the autolysis in the agonal period owing to activation of kalli-krein-tryptic system is possible. Macroscopically Item. at the same time looks plethoric, flabby, bulked up, in certain sites imbibirovanny blood that can simulate a picture of a hemorrhagic pancreatonecrosis. Microscopically the diffusion and focal diskompleksation of an acinus, disintegration of cells and kernels, destruction of intersticial fabric is defined. Lack of emigration of polymorphonuclear leukocytes and inflammatory hypostasis testifies to postmortem changes. Endocrine pancreatic islands are more resistant to an autolysis therefore they microscopically well are defined at gistol, a research.
Patomorfol. changes transplantirovanny Item. are studied generally in an experiment. These changes are caused by ischemia of body at the time of withdrawal for change, and also a circulatory unefficiency directly after transplantation. The changes inherent to reaction of graft rejection join it (see. Incompatibility immunological ). In the absence of a medicinal immunosuppression in a transplant disturbances of a hemodynamics are already during the first hours noted, to-rykh the progressing fibrinoid swelling and a necrosis of walls of vessels of a microcirculator bed, widespread aggregation of erythrocytes and a mural thrombosis is the cornerstone. In fabrics of gland there is a gradual decrease in content of enzymes of a tricarbonic acid cycle (see. Tricarboxylic acids cycle ) and increase in content of enzymes of anaerobic glycolysis (see) and lizosomalny enzymes.
Accruing ischemia (see) causes extended a diskompleksation), dystrophy, a necrobiosis and a necrosis of an acinus and segments that is followed by intersticial hypostasis and preferential perivascular inflammatory infiltration from polymorphonuclear leukocytes, to the Crimea already on 2 — the 3rd days join the limfoplazmokletochny elements reflecting formation of reactions of transplant immunity (see. Immunity transplant ). The insular device has considerably bigger resistance to a hypoxia therefore keeps the morfol, structure longer. In the first days after transplantation it looks even a little hypertrophied. However since 3 — the 5th days the accruing destruction and fibrosis of pancreatic islands are found. Destruction of an acinous parenchyma is followed by replaceable fibrosis and encapsulation of a transplant. All these changes designate the term «post-trance plantatsionny pancreatitis». By 10th days all transplant has an appearance of a cicatricial tyazh, in Krom single diskomplek-sirovanny segments and the sclerosed vascular trunks are visible. During the use of immunodepressants terms of rejection and fibrosis of allotransplant can be extended a little, but the basic essence of process remains to the same.
Malformations are caused: 1) a growth disorder of bookmarks usually the skeletotopicheska located the Item. (ring-shaped Item.); 2) heterotopy of fabric of the Item. (aberrant, additional Item.); 3) pathology of function of excretory glands (kistofibroz Item.).
Ring-shaped Item. — the inborn malformation arising on 4 — the 6th week of an antenatal life in connection with disturbance of uniform growth of dorsal and ventral laying of body. According to E. M. Borovy (1971), Danto and Bukovina (J. Danto, J. Bukovinsky, 1971), this malformation makes 3% of all anomalies went. - kish. path. The ring from fabric of a head of gland squeezes a duodenum in the average or descending part, in whole or in part interrupting its gleam (fig. 10, a). Less often fabric of gland covers a duodenum in the form of a claw (fig. 10, b). Additional channels of the Item are sometimes observed., falling into the narrowed department of a gut. Defect is shown by symptoms acute or hron, high intestinal impassability (see. Impassability of intestines ). Differential diagnosis is carried out with pylorospasm (see), pylorostenosis (see), inborn phrenic hernia (see. Diaphragm ), vomiting of neuropathic character, a cardiostenosis and a cardiospasm (see), a birth trauma of a brain (with - m. Birth trauma ). Absence nevrol, the symptoms caused by a birth trauma allows to exclude this diagnosis.
At a contrast rentgenol, a research went. - kish. a path find out that the ring-shaped pancreas causes limited circular narrowing of the descending part of a duodenum throughout 1 — 3 cm. Contours of narrowing equal, folds of a mucous membrane of a gut are kept. At endoscopic retrograde pankreatokhol an angiography branches of a pancreatic channel which surround a duodenum that serves as the direct proof of this anomaly come to light. In case of a sharp inborn stenosis of a gut already on 2 — the 3rd day after the birth of the child at rentgenol, a research find gastric flatulence and an upper part of a duodenum with existence of fluid levels in them. If at the same time via the probe to enter 2 — 3 ml of Iodolipolum into a stomach, then 10 — 15 min. later circular narrowing in the descending part of a duodenum is defined. Radiological and endoscopic methods of a research allow to confirm existence of high intestinal impassability. Treatment only operational (fig. 11, 12). The main objective of preoperative preparation — correction of disturbances of water and electrolytic balance. Operational treatment of intestinal impassability at newborns consists in imposing of a duodenoduodenoanastomoz more often or duodenojejunostomies (see). At children of advanced age apply bypass a duo-denoduodenoanastomoz more often.
Aberrant (additional) Item. — rare malformation. It represents a heterotopy of fabric of the Item. in a wall of a stomach, intestines, Mekkel's diverticulum. Is located in a submucosa, muscular or subserous layers in the form of a polyp or lobular consolidation. Microscopically ferruterous elements, output channels prevail, is more rare — pancreatic islands. Aberrant Item. serves as the reason of intestinal bleedings, an inflammation and perforation of an intestinal wall, impassability of intestines. Intestinal bleeding (see. Gastrointestinal bleeding ) begins suddenly, the plentiful chair pure blood or tar-like appears, the collapse develops, deterioration in the general state progresses, however abdominal pains are absent. The sudden sharp constant abdominal pain of uncertain localization, repeated vomiting, fervescence demonstrate the happened perforation. Differentiate this malformation with invagination (see. Impassability of intestines ), polipozy a large intestine (see. Intestines ), Peytts's syndrome — Egersa (see. Peyttsa — Egersa a syndrome ), Shenleyn's disease — Genokh (see. Shenleyna — Genokh a disease ), dysentery (see). At adults the disease proceeds behind a mask of a peptic ulcer, a polypose, gastritis, hron, pancreatitis, cholecystitis, appendicitis, a malignant tumor of a stomach.
Additional Item. comes to light radiological if it is located in a stomach, a duodenum or in a gall bladder. It causes roundish accurate defect of filling with a diameter of 1 — 2,5 cm, in the center to-rogo often it is possible to notice small accumulation of contrast weight in the mouth of an output channel additional the Item. In a gall bladder it also causes emergence of small defect of filling on holetsistogramma.
Anomalies of channels of the Item. are found only at a retrograde pankreatokholangiografiya and are expressed in changes of normal number, situation and form of a tsrotok or available small cystiform cavities on the ends of side branches of a pancreatic channel. Treatment only operational. Make a resection of the struck body.
Kistofibroz of the Item. develops at a hereditary ekzokrinopatiya of vneshnesekretorny glands — mucoviscidosis (see).
Damages, the Items caused by an injury., meet rather seldom. In peace time they make 1 — 3% of all injuries of abdominal organs that is substantially connected with a deep arrangement of the Item. Distinguish the closed and open damages of the Item., and also combined and isolated. The last represent an exclusive rarity.
The closed damages of the Item. arise after strong blow by a blunt object (a fist, a leg, a hoof of a horse) or at a perednezadny prelum of an upper half of a stomach during production accidents or road accidents, during the falling by a stomach on a firm subject. At the closed damages concussions, bruises and crushes of a parenchyma of the Item are observed., formation of subcapsular hematomas, hemorrhages in surrounding retroperitoneal cellulose. Small or significant gaps of fabric of gland with damage of its capsule are possible. During the falling on a firm subject a body of the Item. it is pressed down to a backbone therefore more often damage happens in this part of the Item., sometimes up to its complete cross separation.
Open injury of the Item. it is usually connected using fire or cold weapon or with wounds the cutting or pricking objects.
At direct wounds there are the different size and depth ruptures of the Item., sometimes its full breaks on several parts. Due to extensive hemorrhages and proteolytic influence of the pancreatic juice which is released at gaps also the total necrosis of the Item develops limited, and sometimes., extending to surrounding fabrics — a big epiploon, a mesentery thin and cross colonic guts, retroperitoneal cellulose. Accession of inflammatory changes causes extensive fusion of fabrics. In the absence of an otgranicheniye of process there can be diffuse peritonitis, as a rule, terminating letalno. At formation of inflammatory unions formation of an adventitious cyst
P.Zh. Klien, a picture of damage of the Item is possible. depends on the nature of an injury (opened or closed), damage rates of body, and also on expressiveness of traumatic shock (see), bleedings (see) and peritonitis (see), observed in these cases.
At the slight closed injury (the Item hurt.), followed by small hemorrhages in a parenchyma of body, the condition of victims can remain quite satisfactory. At a palpation of a stomach small morbidity comes to light, the expressed peritoneal symptoms usually are absent. Such damages do not constitute serious danger, and victims quickly recover. In nek-ry cases, later various time after an injury (from several hours to several days), against the background of the seeming wellbeing suddenly there are severe pains in a stomach, quite often surrounding character, the phenomenon of intoxication (frequent pulse, dry language) and peritonitis (a muscle tension of a stomach, a symptom of irritation of a peritoneum) caused by development of traumatic pancreatitis (see). At the same time increase in amount of amylase of blood and urine is possible.
At the heavy closed damages of the Item. (deep ruptures of a parenchyma of gland or a complete cross separation of body and channels) at victims the critical condition caused by shock, intra belly bleeding and peritonitis in connection with the expiration of a pancreatic secret in an abdominal cavity at once develops.
Patients complain on strong, sometimes the intolerable abdominal pains sometimes irradiating in a back are excited, quite often rush about in a bed. Language dry, pulse is speeded up (100 — 120 blows in 1 min.), weak filling. The stomach does not participate in the act of breath, is sharply painful and intense, symptoms of peritonitis are expressed, the delay of a chair and gases is noted. Body temperature is usually increased to 38 ° and more, heavy intoxication is observed.
Wedge, picture of open damages of the Item. it is in many respects similar to clinic of the getting wounds of a stomach (see) as in most cases they are combined with wound of other abdominal organs (a liver, a spleen, a stomach, intestines, a kidney).
Diagnosis of traumatic damages of the Item. presents great difficulties since the clinic of the last is characterized by lack of bright pathognomonic symptoms and usually differs from a wedge, pictures of wound of other abdominal organs a little. Diagnosis of open damage of the Item. it is facilitated at a possibility of definition of the direction of the wound channel passing through a projection of gland, or comparison of entrance and output openings at a gunshot wound.
From laboratory researches to recognition of damage of the Item. increase in a sugar content in blood (at the persons who are not suffering from a diabetes mellitus), the hyperamilasemia and a hyperamilasuria testimonial of disturbance inside - and vneshnesekretorny function of the Item can promote. Treatment of patients with traumatic damage of the Item., as a rule, operational.
The forecast is usually heavy, especially at the accompanying damages of other bodies. The absolute recovery of patients and recovery of working capacity, according to V. V. Vinogradov, is observed only at 1/3 victims. The lethality, according to G. M. Mazhdrakov, makes apprx. 50%.
After the operative measures made concerning damages of the Item., complications are possible: outside pancreatic svigts, abscesses of the Item., pseudocysts. Formation of fistulas is observed more often at open damages of the Item., abscesses and adventitious cysts — at closed. All these complications quite often demand repeated operations.
Features of fighting damages. At gunshot wounds of a stomach of damage of the Item. meet extremely seldom. According to «Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945», among all wounds of a stomach there are damages of the Item. were observed in 0,4 — 0,7% of cases. Gunshot wounds of the Item. usually are followed by damage of the next bodies and anatomic educations that defines weight a wedge, currents.
The first medical, pre-medical and first medical assistance is carried out, as at the getting wounds of a stomach (see. Stomach, stage treatment ). A task of the qualified medical aid is the final stop of bleeding, processing of wounds of gland and other bodies, drainage of an omental bursa.
Diseases. Among many diseases there is an Item. most often meet acute and chronic pancreatitis (see), cancer; more rare are its anomalies, calcification, cysts, tuberculosis, syphilis, etc. the Item. quite often is surprised also at acute inf. diseases, parasitic invasions, at collagenic diseases, heart failure, diseases of exchange.
The defeat of pancreatic islands arising owing to the various reasons leads to development of a diabetes mellitus (see. diabetes mellitus ). Rare pathology of an endocrine part of the Item. benign and malignant tumors which, developing from various cellular elements of pancreatic islands (α, β and δ-cells), differ on the morphology, a wedge, to a picture and a current are. Glucagonomas (see), insulomas (see) and so-called ulcerogenic adenomas of the Item belong to such tumors. (see. Zollingera — Ellisona a syndrome ).
Functional disorders of a pancreas quite often accompany other diseases of the alimentary system — a peptic ulcer of a stomach and a duodenum, hron, to gastritis, etc.
The major contributing factors for emergence of functional disturbances of the Item. at a peptic ulcer of a stomach and duodenum neuroemotional overloads, an aggravation of a peptic ulcer, its considerable duration and frequent recuring, the expressed dyskinesia of a duodenum, existence of a duodenitis, hron, gastritis are. Nature of functional changes of the Item. at a peptic ulcer at different patients it is various, but decrease of the activity of pancreatic enzymes in duodenal contents, moderate increase in their content in blood, and also the increased allocation with urine is more often observed. In a wedge, practice the hyperamilasemia and a hyperamilasuria usually come to light. Both laboratory signs are not specific since the hyperamilasemia and a hyperamilasuria of easy degree are manifestation of functional frustration of the Item., but can be observed also at her organic diseases, and also at diseases of other bodies — sialadens, kidneys etc. However the hyperamilasemia and a hyperamilasuria of considerable degree are characteristic of acute defeats of the Item., first of all for acute pancreatitis (see). It is necessary to consider that activity of amylase of blood considerably increases only if its receipt in blood exceeds renal clearance (see).
Functional disturbances of the Item. at a peptic ulcer and hron, gastritis are not followed by symptoms of a disease of the Item., quite often have reversible character, disappearing under the influence of treatment, are not followed morfol, changes of the Item. Functional disturbances at these diseases are explained by close functional interrelation of bodies of the alimentary system, disturbance of nervous and humoral control of the Item. In more exceptional cases at these diseases pancreatitis develops hron. Development of pancreatitis at a penetration of round ulcers in the Item is natural., and also at diseases of zhelchevydelitelny system.
Some researchers found functional, and sometimes and morfol. changes of the Item. at hron, hepatitis and cirrhosis. Emergence of functional disturbances of II is possible. at hron, the colitis which is shown dissociation of enzymes in duodenal contents (increase in activity of amylase, decrease in a lipase and trypsin), increase in activity of an atoksilrezistentny lipase in blood serum. These changes in the most part of cases have reversible character, as well as dysfunctions of an endocrine part of the Item.
Functional disturbances of the Item. are possible also at diseases of a thyroid gland, a diabetes mellitus, at diseases of a hypophysis and adrenal glands.
Differential diagnosis of functional frustration of the Item. it is carried out, first of all, with hron, pancreatitis, and also focal diseases of the Item. About the functional nature of defeat of the Item. lack of clinically expressed symptoms of a disease, and also signs morfol, changes of the Item testifies., the revealed by means of an ekhografiya, scanning and other tool methods of a research.
Treatment and prevention of functional frustration of the Item. consist in the healthy regular balanced nutrition, early detection and treatment of diseases went. - kish. a path, against the background of to-rykh perhaps secondary involvement of the Item. in patol, process.
Dystrophic processes in the Item. are quite often observed at exchange disturbances and diseases of closed glands. Defeat of the Item is most characteristic. at hemochromatosis (see). Item. process is quite often involved in patol, at amyloidosis (see). By data A. N. Podbelsky, the frequency of pancreatic localization of the general amyloidosis reaches 9,8%. As a rule, amyloidosis of the Item. develops against the background of the expressed amyloid defeat of other bodies that facilitates diagnosis. Clinically amyloidosis of the Item. it is shown by signs or incretory (see. diabetes mellitus ), or externally - its secretory insufficiency.
Disturbances of blood circulation vp.zh. can be caused by various reasons. Disturbances of venous outflow are observed at heart failure, portal hypertensia, a syndrome of a pulmonary heart at hron, diseases of lungs. Wedge, picture of defeat of the Item. usually the malokharakterna is also shaded by symptoms of defeat of other bodies. Research of enzymes of the Item. in duodenal contents allows to reveal insufficiency of its vneshnesekretorny function, the moderate hyperamilasemia and a hyperamilasuria at the same time quite often come to light.
Damage of a pancreas at atherosclerosis is observed rather quite often at persons 60 years, as well as at younger age, generally at the persons having alcoholism are more senior. At the same time sclerous changes in the Item develop., its excretory and incretory functions are broken that can be the cause of development of a diabetes mellitus (see a diabetes mellitus). In some cases there are thromboses and heart attacks of the Item., proceeding about a wedge, a picture of a pancreatonecrosis (see Pancreatitis).
Defeats of the Item. can take place also at a myocardial infarction. In mild cases they have functional character and are shown by only unsharply expressed disturbances of excretory and incretory functions. In some cases at a myocardial infarction there is acute thrombosis of vessels of the Item., proceeding about a wedge, a picture of hemorrhagic pancreatitis.
Diagnosis at various disturbances of blood circulation in the Item. it is difficult, it is possible to make only the presumable diagnosis if against the background of diseases, at to-rykh disturbances of blood circulation in the Item are possible., suddenly, without the special reasons there is acute pancreatitis or gradually the diabetes mellitus forms.
Treatment — as at acute pancreatitis and a diabetes mellitus. It is necessary to carry out treatment of a basic disease also.
Inflammatory diseases — see Pancreatitis.
Defeat of the Item is possible. at acute allergoses, and also at food allergy (to milk, meat etc.). Clinically it is shown by symptoms of acute pancreatitis. The diagnosis is facilitated if at the same time there are signs of allergic damage of skin and other bodies (a small tortoiseshell, a Quincke's edema, an asthmatic attack etc.). Treatment of damages of a pancreas at acute allergoses — see. Allergic diseases, Pancreatitis.
Defeats of the Item. are observed also at collagenoses. At a system scleroderma a wedge, a picture of defeat of the Item. the hypochondrium, weight reduction of a body is characterized by the dispeptic phenomena (a meteorism, frustration of a chair etc.), unsharp pains in left. Researches of enzymes of the Item. in duodenal contents, blood and urine in many cases reveal signs of its vneshnesekretorny insufficiency. By data A. L. Grebe-neva et al. (1980), at an ekhografichesky research almost at x / z patients with a system scleroderma symptoms of diffusion or focal fibrosis of the Item come to light.
At a system lupus erythematosus specific changes of the Item are sometimes observed., which are clinically shown by symptomatology of acute pancreatitis.
At a nodular periarteritis, according to G. M. Mazhdrakov, vessels of the Item can be surprised., at the same time the wedge, a picture forces to suspect acute or hron, recurrent pancreatitis.
Defeat of the Item., generally functional character, in some cases — as acute pancreatitis, it is observed in some cases at rheumatism, In more hard cases at rheumatism processes develop in the Item sclerous-atrofi-cheskiye., sometimes focal intra lobular sclerosis.
Defeats of the Item. at acute infectious diseases, apparently, meet considerably more often than are diagnosed as into the forefront symptoms of acute intoxication, a feverish syndrome and signs of defeat of other bodies usually act. Often defeat of the Item meets. at epidemic parotitis. In this case morfol, changes in the Item. are shown by inflammatory process, preferential intersticial. The wedge, picture is characterized by vomiting, a meteorism, pains in an anticardium and left hypochondrium. At a palpation of an anticardium sometimes the most expressed morbidity, as well as at other acute defeats of the Item., comes to light in the so-called painful point of Dezharden which is located on the conditional line connecting the right axillary hollow to a navel is 5 — 7 cm higher than the last. The considerable gigkheramilazemiya and a considerable hyperamilasuria are characteristic. Moderate degree the hyperamilasemia and a hyperamilasuria are quite often observed in more mild cases of epidemic parotitis, at absence a wedge, symptoms of damage of a pancreas.
Tuberculosis of a pancreas meets seldom (see Tuberculosis extra pulmonary). Even at patients with an active pulmonary tuberculosis it comes to light, according to various researchers, only in 0,5 — 2% of cases. According to section data, tuberculosis of the Item. comes to light in 0,03 — 0,1% of cases. Tubercular mycobacteria are included in the Item. in the hematogenous, lymphogenous or contact way. Wedge, picture of a polimorfn. In some cases clinically asymptomatic course of a disease can take place; only the ukhmeren-ny hyperamilasuria and a hyperamilasemia is observed. More often symptoms of tuberculosis of the Item. mask the expressed displays of a pulmonary tuberculosis and other bodies. In other cases patients show complaints to an eructation, a loss of appetite, nausea, pains in an upper left quadrant of a stomach, quite often surrounding character, ponosa, the increased thirst (at defeat of an endocrine part of the Item. — insular device and disturbance of intra secretory function of the Item.). Quite often found progressing exhaustion of patients can be a consequence as most tubercular process, and result of disturbance of vneshnesekretorny function of the Item. and arising thereof insufficiency of digestion and absorption (see Malabsorption a syndrome). Such symptoms as the increased perspiration, indisposition, feverish state, are defined by activity and prevalence of tubercular process. Skin of patients sometimes gets dark coloring, as at an addisonovy disease. At a palpation of the Item. morbidity is quite often noted, but to probe the Item. usually it is not possible.
The course of a disease generally is defined by weight of defeat of easy and other bodies.
Diagnosis of tuberculosis of the Item. it is difficult. It is possible to suspect it at the patient with pulmonary tuberculosis when there are symptoms stated above, or at laboratory researches the resistant hyperamilasemia and a hyperamilasuria comes to light. For confirmation of the diagnosis carry out an angiography, a retrograde endoscopic pankreatokho-langiografiya, scanning of the Item., research its external and incretion. Broad use of a method of an ekhografiya allows to reveal diffusion and focal changes of the Item. At severe defeats of the Item., followed by pankreatogenny ponosa, with the help koprologichesky researches reveal a steatorrhea, an amylorrhea and a creatorrhea. ROE is usually accelerated.
The differential diagnosis is carried out with nonspecific pancreatitis, malignant and benign tumors, cysts of the Item.
Treatment of tuberculosis of the Item. specific (see. Tuberculosis ). Appoint fractional 5 — 6-times food, a sparing diet with the limited content of fats, an exception of acute products and increase in protein content. At signs of vneshnesekretorny insufficiency of the Item. appoint Pancreatinum, panzinorm, festal and other fermental drugs.
Syphilis of a pancreas can be inborn and acquired. Specific defeat of the Item. it is found in 10 — 20% of the children having syphilis. More often the head of the Item is surprised. Syphilitic changes of the Item. are found in a fruit already in the second half of pregnancy.
The acquired syphilis of the Item. meets extremely seldom. For the first time it was described in 1861. To. Rokitanskim which observed specific gummous pancreatitis.
Klien, a picture is variable; perhaps asymptomatic current, forms which are shown clinic of a diabetes mellitus, hron, pancreatitis, a tumor of a pancreas. Frequent symptoms are pains in epigastric area and left hypochondrium, a meteorism, ponosa, weight reduction of a body. The diabetes mellitus arises at a sclerous form of syphilis of the Item more often. At the psevdoopukho-left form, in addition to characteristic symptoms (persistent pains and the dispeptic phenomena), sometimes it is possible to propalpirovat tumorous education in the field of the Item. At defeat of a head of the Item. owing to a prelum mechanical jaundice can arise infiltrate of terminal department of the general bilious channel that even more reminds a wedge, a picture of a malignant tumor of the Item.
To suspect syphilitic defeat of the Item. it is possible if symptoms of pancreatitis or a diabetes mellitus find against the background of other displays of syphilis (see). According to N. I. Leporsky, disappearance of the phenomena of diabetes during the performing specific therapy while usual treatment of a diabetes mellitus is inefficient is a diagnostic character. In diagnosis of a disease also results of serological researches are of great importance anamnestic yielded. Methods of ultrasonic diagnosis (ekhografiya) and scannings allow to establish existence of diffusion sclerous or focal defeat of the Item. and, thus, to specify morfol, the nature of defeat. The positive effect from specific treatment (functional tests improve, the centers of inflammatory infiltration and even a gumma resolve) finally confirms the lyuetichesky nature of defeat of the Item.
Treatment — specific (see. Syphilis ). At vneshnesekretorny insufficiency of the Item. appoint fermental drugs (Pancreatinum, panzinorm, festal, etc.), at incretory insufficiency of the Item. carry out the corresponding therapy.
Parasitic defeats pancreas meet seldom. First of all, it helminthoses (see). Cases of an invasion of ascarids (see the Ascaridosis) which, getting into canals of the Item are described., break outflow of pancreatic juice and can be an origin of acute pancreatitis, focal necroses and abscesses of the Item. In rare instances long finding of ascarids in channels of the Item. can lead to development hron, pancreatitis. Exclusively seldom to canals of the Item. the dwarfish tapeworm can get (see. Hymenolepiasis ) or trematodes of Fasciola hepatica (see the Fascioliasis) that also breaks outflow of pancreatic juice and serves as the reason of development of pancreatitis. Sometimes in the Item. trematodes of Opisthorchis feiineus and O. of viverrini parasitize (see. Opisthorchosis ).
The diagnosis facilitates detection of helminths in intestines, hepatic channels, and also repeated koprologichesky researches on eggs a worm.
Defeat of the Item is possible. alveococcosis and echinococcosis. Klien, a picture in these cases reminds hron, pancreatitis or a tumor of the Item. The diagnosis is made taking into account a natural ochagovost of the diseases given an ekhografichesky research of the Item., its scanning, an angiography, and also these specific laboratory tests (see. Alveococcosis , Echinococcosis ).
Stones of a pancreas, and also pancreatolithiasis and calcification of the Item. meet seldom. So, according to S. V. Lobachev, on 98 327 openings they were observed in 0,03%. However among patients with pancreatitis, by data A. A. Shalimov, N. I. Leporsky, J. Howard, Whyte (T. White), etc., find them in 2 — 7,4% of cases. They occur at men by 3 — 4 times more often than at women, usually at the age of 30 — 50 years, but can be also at children. Stones can be formed in any site of the Item., but are located in the field of a head, sometimes in the mouth of a pancreatic channel or in a fatero-vy nipple more often.
On chemical structure stones of the Item. for 85 — 95% consist of calcium and calcium phosphate. In them find also salts of magnesium, silicon, aluminum and various organic matters — cholesterol, soaps, pigments. The size of stones fluctuates from scarcely noticeable to several centimeters in the diameter, weight — from several milligrams to 60 g. The form of pancreatic stones is also very different: round, oval, pear-shaped, cylindrical, wrong with aculeiform outgrowths, sometimes in the form of mulberry berry or raspberry. Color from white to brown, brown or yellow at treatment by their bilious pigments.
There can be single concrements of various size which are located in larger pancreatic channels, and multiple, usually small. In addition, calcification of fabric the Item meets., diffusion calcification of the last is more often in the form of multiple calcificats, and.
Formation of stones of the Item. most of researchers connect with the postponed pancreatitis and the dysfunctions of body which arose in this regard, first of all outflow and vneshnesekretorny activity, and also change of character of a pancreatic secret. It becomes more dense, contains the increased amount of calcium and a desquamated epithelium that leads to loss of the proteinaceous masses which is becoming impregnated with salts of calcium.
Punk reolitiaza also disturbance of the general phosphorus-calcium exchange is the important reason. Development of calcification of the Item. it can be caused also by adenoma of epithelial bodies.
The concrements formed in a gleam of the main channels of the Item., in turn, promote a razvytiya of further disorders of outflow, to the perikanalikulyarny sclerosis and inflammatory changes in a parenchyma of gland leading to atrophic processes from the outcome in wrinkling of body. Calcification of the Item. it is more often observed at the persons who had acute pancreatitis that is explained with adjournment of salts of calcium in the sites of gland struck with necrotic process.
Pankreolitiaz and calcification Item. are constantly progressing diseases. They gradually lead to full functional and anatomic switching off of the Item., to a cachexia and a diabetes mellitus, sometimes being complicated by formation of a cyst, abscess, went. - kish. bleedings, development of obturatsionny jaundice. Also the malignancy of a pancreatolithiasis which is noted by data P. Mallet-Guy, in 12 — 15% of observations is possible.
Clinic of a pankreolitiaz and calcifications of the Item. it is diverse since depends on localization of concrements, their number, size, degree and the nature of changes the Item., and also liver and bilious ways. Quite often it is difficult to distinguish symptoms of this disease from hron, pancreatitis, and only in 5% of observations, according to N. I. Leporsky, it proceeds without any a wedge, manifestations and comes to light accidentally at rentgenol, inspection.
The leading symptom of a pancreatolithiasis are severe pains in epigastric area and left hypochondrium, irradiating in a back and a left shoulder-blade, quite often surrounding character. They arise in the form of attacks after disturbance of food (reception of greasy food, alcohol) or happen the constants amplifying after any meal. Pains are so intensive that it is necessary to resort to administration of drugs. After attacks there occurs remission, duration a cut can be various. Often pains are followed by nausea, vomiting and other dispeptic phenomena. At patients the breakdown, considerable weight loss is observed, up to development of an adynamy, a ponosa, steatorrhea (see), the phenomena of diabetes (see a diabetes mellitus) connected with the expressed disturbance of intra secretory function of the Item. Obturatsionny jaundice is caused by a prelum of distal department of the general bilious channel a head of a pancreas or obstruction of the mouth of the general bilious channel the concrement which left a pancreatic channel.
The palpation of a stomach at exacerbations of a disease is painful in epigastriums, quite often considerably, the muscle tension of a stomach can be expressed. At remissions the cyst or sharply condensed site of the Item is sometimes probed., usually to the left of a backbone, slightly above or at the level of a navel.
Diagnosis is complicated due to the lack a wedge, the symptoms specific to this disease. Data of laboratory researches are also not specific. In the period of an aggravation in blood serum find increase in content of trypsin and decrease in level of its inhibitors, and also the increased maintenance of a lipase and amylase of blood and urine. At considerable fibrosis of the Item. activity of these enzymes does not exceed normal figures. If at the same time a significant amount of pancreatic islands is involved in process, the typical picture of a diabetes mellitus develops. In a stage of remission when the content of enzymes in blood and urine usually normal, at a research of duodenal contents find decrease in products of pancreatic enzymes.
Great diagnostic value has rentgenol, the research allowing to reveal shadows of concrements of the Item. The X-ray analysis of an abdominal cavity (fig. 13) allows to differentiate stones of the Item., coming to light usually at the level I and III of lumbar vertebrae, from concrements in other bodies (a gall bladder, bilious channels, kidneys), and also from calciphied limf, nodes. Can help with doubtful cases a piyelografiya (see) and an endoscopic retrograde pankreatokholangiografiya (see. Pankreatokholangiografiya retrograde ), a computer tomography (see. Tomography computer ).
One of important displays of a disease is detection in Calais of the concrements consisting of calcium and calcium phosphate. An absolute diagnostic character is detection of concrements of a parenchyma of the Item. during a trial laparotomy by a palpation or by means of a pankreatokholangiografiya.
Treatment can be conservative and operational. In case of the easy course of a disease perhaps conservative treatment including a diet and medicamentous therapy as at hron, pancreatitis. At a diabetes mellitus appoint the corresponding treatment. Operational treatment is shown during the strengthening of a pain syndrome and increase of attacks, and also increase of pancreatic insufficiency or development of complications.
Cysts of a pancreas represent the meshotchaty educations containing liquid, which are located in the parenchyma of body or the fabrics surrounding it sacculated by a connective tissue cover. They can be single and multiple. Cysts of the Item. meet rather seldom; according to V. V. Vinogradov, they were found in 0,005 — 0,01% of the patients who were in hospitals and in 0,05 — 0,07% of openings. According to G. D. Vilyavin, in domestic literature from 1887 to 1971 771 similar observation were described, and slightly more often cysts are found in men at the age of 30 — 50 years. They occur also at children, and also at persons of advanced and senile age. Inborn cysts are more often observed at children's age, traumatic — at young faces, a cyst of inflammatory character — at middle-aged persons, and tumoral — at advanced age.
Origin of cysts of the Item. variously. Can be the reasons of their emergence an injury of a stomach, inflammatory and parasitic diseases of the Item., tumoral processes, disturbances of embryonic development of body. The most frequent etiol, factor of cysts of the Item., according to G. D. Vilyavin, destructive pancreatitis (59,4%), then traumatic damages of the Item is. (30,2%), others patol, processes make 10,4%.
Wedge, picture of cysts of the Item. differs in the variety connected with the polyetiological nature of a disease, the unequal mechanism of formation of cysts and their various arrangement in an abdominal cavity creating their various relationship with surrounding bodies. Symptoms can be caused by a basic disease, napr, pancreatitis, the cyst and complications of the last (gaps, suppuration, bleeding, formation of fistulas, a malignancy, etc.).
Often it is possible to learn from the anamnesis about postponed in last pancreatitis or an injury of a stomach. Cysts of the Item. seldom proceed asymptomatically. The leading symptoms are pains in an anticardium, right or left hypochondrium, existence of the probed tumor of a stomach, symptoms of a prelum of abdominal organs and disturbances external, and sometimes and internal secretory function of the Item.
Pains — the most frequent symptom which is found in 80 — 90% of cases. They are constant or in the form of attacks, the stupid or extremely sharp, not withdrawn drugs, have the surrounding character or irradiate in a back. At an arrangement of a cyst in a head of the Item. pains are localized in right hypochondrium or epigastric area, at its development in the tail of the Item. — in left hypochondrium.
The tumor in a stomach can be measured by eye in the form of protrusion of a front abdominal wall. It can be located in various departments of an abdominal cavity, in an anticardium, in right or left hypochondrium, in a navel (fig. 14). The consistence its plotnoelastichesky, sometimes is defined fluctuation (see. Zybleniye ). The tumor has a smooth surface, can be displaced at a palpation and a postural change of the patient, is usually poorly painful. At percussion over area of a cyst the stupid percussion sound is defined. The size of cysts happens various, sometimes they reach the huge sizes. Cysts can change the size, progressively increasing or, on the contrary, decreasing, sometimes before total disappearance at break it in hollow body (self-healing) or in an abdominal cavity with development peritonitis (see).
At a prelum obturatsionny can arise a choledochal cyst jaundice (see), a prelum went. - kish. a path is followed by a gastrostenosis, a duodenal staz, the phenomena of partial or full obstruction of intestines (see). At a malignancy of a cyst or neoplastic cysts the considerable lose of weight, a loss of appetite, nausea, vomiting, emergence of metastasises in limf, nodes, a liver and other bodies is quite often observed. In rare instances pancreatic cysts, squeezing a portal vein, can cause symptoms portal hypertensia (see) — ascites, gastric bleedings, increase in a spleen, etc. Vneshnesekretornaya insufficiency of the Item. it is clinically shown by the increasing weakness, emaciation, increased fatigue, excessive salivation, disturbances of a chair (alternation of locks and ponos). Development of a diabetes mellitus is observed seldom.
Among other complications of cysts there is an Item., the general frequency to-rykh makes, according to G. D. Vilyavin (1977), 32,4%, meet: bleedings in its gleam, went to bodies. - kish. a path or in a free abdominal cavity; the empyema of cyst proceeding as the isolated abscesses of an abdominal cavity or retroperitoneal space; formation of spontaneous pancreatic fistulas, outside or internal (is more often with a stomach and a large intestine).
Diagnosis of cysts of the Item. on the basis of physical data and laboratory researches it is complicated in connection with various a wedge, a picture and localization of cysts, and also thanks to lack of pathognomonic symptoms of a disease. Nevertheless suspicion of a cyst of the Item. shall arise in the presence of the palpated tumor of an abdominal cavity at the patients who had pancreatitis or an injury of a stomach. Great diagnostic value has rentgenol, a research went. - kish. path and tomography of the Item. at a pneumoretroperitoneum, allowing to specify size, localization and a ratio of a cyst with surrounding bodies, in particular deformation and shift of a stomach, duodenum, a cross colon, a liver, etc. (fig. 14). Cysts of the Item. clearly are defined on computer tomograms (fig. 15) which allow to judge number, situation, a form and size of cysts and their relation to the next bodies. Cysts can be located not only in gland, but also in surrounding bodies and fabrics. Without the aid of a computer tomography of a cyst it is possible to distinguish only in the presence in them calcifications or at their big sizes when the pushing off of the next bodies and impression on their walls is found. At a retrograde pankreatokholangiografiya (fig. 16) establish connection of a cyst with channels of the Item. At an angiography shift a cyst of surrounding arteries which as if bend around it is visible, but keep equal contours (fig. 17). In a parenchymatous phase the cyst causes emergence of well outlined avaskulyarny area having sometimes a rim of hyper vascularization on the angiogram.
Important role in diagnosis of cysts of the Item. has ultrasonic investigation (see. Ultrasonic diagnosis ), allowing to reveal in most cases a cyst and to establish its localization. Cyst of the Item. on echograms represents ekhonegativny education with the clear image of a back wall with the increased acoustic density (fig. 18). The isotope research of vessels of body (arterioskanirova-ny) allows to distinguish cysts from malignant tumors of the Item.
Differential diagnosis is carried out with cysts of a liver, adrenal glands, a stomach, spleen, ovaries, tumors of retroperitoneal space and kidneys; for this purpose apply a gepatoskanirovaniye, tseliakografiya (see), splenoportografiya (see), excretory urography (see), retrograde piyelografiya (cm), etc. (tsvetn. fig. 10 and 11).
Treatment of cysts of the Item. operational. Self-healing (spontaneous break of a cyst in hollow body) is observed rather seldom, and development of heavy complications (a prelum of abdominal organs, ruptures of cysts, bleeding, a malignancy, etc.) — is rather frequent.
Pancreatic fistulas can be outside and internal. Internal fistulas are usually reported with any hollow body, is more often with a cross colon, is more rare with lean, under-vzdoshnoi, a duodenum, a gall bladder, a pleural cavity and bronchial tubes. Perhaps also combination of outside and internal fistulas. Fistulas can be localized in any department of the Item.
Pancreatic fistulas in most cases result from damage of the Item. during operative measures, an injury or at acute destructive pancreatitis when there is a necrosis of a parenchyma of the Item. Important etiol, a factor, in addition to disturbance of an integrity of a wall of a pancreatic channel, is also the existence of an obstacle in the last (a stone, a stricture, a tumor) preventing normal outflow of a secret of the Item. in a duodenum. It can be located also in the field of a big nipple of a duodenum. Formation of internal pancreatic fistulas is observed at perforation of cysts of the Item. in the next hollow body.
Outside pancreatic fistulas arise usually on 5 — the 7th day after operation on the Item. Moderate pains in the field of an operational wound are followed by emergence of a swelling and erubescence. Then the small opening is formed, from to-rogo the transparent or serous and purulent discharge macerating surrounding skin begins to arrive. The amount of the emitted juice varies depending on character of food, time of day, reaching sometimes 1500 ml, and it contains sometimes small pieces of nekrotizirovanny fabric of the Item. (sequesters). At a significant amount separated an organism, in addition to enzymes, loses proteins and mineral substances (sodium, bicarbonates, calcium), and also it is dehydrated. Long existence of outside fistula of the Item. leads to a hypoproteinemia, anemia, a hypochloraemia and heavy exhaustion of the patient in connection with disturbance of processes of digestion (ponosa, a steatorrhea, etc.). Pancreatic fistula can periodically be closed that is followed by severe pains, temperature increase, a leukocytosis. At discovery of fistula all these phenomena disappear.
Internal pancreatic fistulas are not shown by characteristic symptomatology and quite often are found accidentally at rentgenol, a research went. - kish. path. If such fistula proceeds from a cyst of the Item., it periodically decreases in volume in connection with dumping of contents into intestines through fistula.
Diagnosis is not difficult if in separated from fistula find enzymes of the Item. With the help fistulografiya (see) it is possible to specify, besides, topography of fistula and to establish localization of its proximal end in relation to P. zh Canal. Recognition of internal pancreatic fistulas is possible only at rentgenol, a research went. - kish. a path on flowing of a contrast agent in the fistular course. To differentiate outside fistulas of the Item. follows with intestinal, first of all duodenal fistulas (see. Intestinal fistulas). The last have muddy contents, usually with impurity of bile, and sometimes and food masses.
Treatment in an initial stage in most cases conservative, and only if it is inefficient, resort to an operative measure. At conservative therapy the complex treatment including the general actions directed to elimination of dehydration and exhaustion (administration of liquids, electrolytes, vitamins, hemotransfusion and blood substitutes, etc.), and also on suppression of pancreatic secretion is carried out (a special diet, atropine, Vicalinum, pentoxyl, hydrosodium carbonate, a cortisone, AKTG, etc.). The diet for these patients shall consist preferential of fats (oil, fat cottage cheese, cream, milk, creams and is a little bread). It is locally necessary to carry out careful care of skin in the circle of fistula which is quickly exposed to maceration. For prevention of this complication drawing on it a thick coat of zinc oxide ointment or Lassar's paste is recommended. In fistula administer sclerosing the drugs (spirit of iodine, silver nitrate, sodium sulfate, etc.) and anti-fermental substances (Trasylolum, Contrykal). One of ways of conservative treatment is also the roentgenotherapy in the general dose to 500 is glad (with a single dose 40 — 60 I am glad). However at the same time it is necessary to consider that the full and complicated outside fistulas of the Item. usually will not respond to conservative treatment therefore it should be reduced to a minimum. Irrespective of the nature of fistula its long therapy (more than 4 weeks) which appeared inefficient serves as the indication for operational treatment.
Occupational diseases. Toxic defeats of the Item., caused by production factors, meet very seldom, generally they are possible only at violations of the rules of the accident prevention. By data A. A. Bashirova (1973), change of function of the Item is possible. at influence of a divinyl and styrene in the concentration, by 5 — 26 times exceeding admissible. F. B. Bulatova and L. I. Savvina noted «small symptoms» of defeat of the Item. at the working petrochemical productions which are affected by various hydrocarbons (existence of pain in left hypochondrium, tendency to a meteorism and a diarrhea, hyperamilasemias).
At occupational diseases a little more often than at defeats of the Item. other etiology, in patol, process are at the same time involved zhelchevydelitelny system and a liver that is clinically shown by dysfunctions of a gall bladder and hepatic and bilious channels, small increase in a liver and nek-ry changes of functional hepatic trials (a ge-patopankreatichesky syndrome). Its emergence is caused by a community of neurohumoral regulation of bodies of a gepatopankreatoduode-nalny zone, their close functional interrelation and the same reaction of a liver and the Item. on action of the same pathogenic factors.
Treatment of occupational diseases of the Item. consists in elimination of contact with etiol, the factor which caused damage to the Item.; a diet and medicamentous therapy, as at pancreatitis (see).
Prevention: accurate observance of the corresponding safety rules during the work on the productions connected with professional vrednost, systematic professional surveys with carrying out a research of excretory and incretory functions of the Item., ekhografiya, etc. that allows to reveal precursory symptoms of occupational diseases of the Item.
On the international histologic classification of tumors (WHO, 1979) tumors of the Item. are subdivided as follows:
I. Epithelial tumors.
A. High-quality: 1) adenoma; 2) cystadenoma.
B. Malignant: 1) adenocarcinoma; 2) planocellular cancer; 3) cystadenocarcinoma; 4) acinar cancer; 5) undifferentiated cancer.
II. Tumors of pancreatic islands.
III. Not epithelial tumors.
V. Not classified tumors.
VI. Hemopoietic and lymphoid tumors.
VII. Metastatic tumors.
To benign tumors of the Item. the new growths which are developing from different types of mature fabric of this body and characterized by high-quality growth belong. According to V. V. Vinogradov (1962), the frequency of benign tumors of the Item. on section material reaches 0,003%.
Numerous types of benign tumors of the Item. divide on a histogenesis, allocating the new growths developing from epithelial fabric — adenoma, a cystadenoma (see. Adenoma ) and not epithelial fabric: from connecting — fibroma (see Fibroma, a fibromatosis), a lipoma (see), myxomas and (see), from vascular — a hemangioma (see), a lymphangioma (see), from nervous — a neurinoma (see), a ganglioneuroma (see), from muscular — myoma (see), and also mixed, or teratoid, tumors — dermoids (see), enterokistoma (see).
It is necessary to distinguish tumors of the insular device from usual benign tumors: the insuloma (see) which is adenoma, coming from beta cells of both malignant, and high-quality character and also not beta kletochiye the tumors cosecreting gastrin and causing specific a wedge, the picture called Zollinger's syndrome — Ellisona (see. Zollingera — Ellisona a syndrome ). Benign tumors can have an appearance of solid or cystous educations, reach various sizes and occupy different departments of the Item. Growth their usually expansive without involvement in process of the next bodies. Despite various origin, these benign tumors have a similar wedge, signs. Small tumors can proceed asymptomatically, big cause a prelum of gland and the next bodies, being shown by pains, weakness, weight loss, disturbances of vneshnesekretorny function of gland. In addition to the physical methods of a research allowing to find fabric of a tumor of the Item. the considerable sizes, an important diagnostic role is played radiological also by tracer techniques of studying of the Item.
Benign tumors of the Item. have no specific rentgenol. pictures. They can be suspected only at a prelum of vessels on angiograms. Exception is the cystadenoma, edges is defined at an angiography as well vaskulyarizirovanny education in an arterial phase and gives a heterogeneous shadow (because of existence of cysts) in a parenchymatous phase. The tumor from insular fabric, in particular an insuloma, looks on angiograms as the roundish or oval center of hyper vascularization in the form of dense network of small gyrose vessels. In a parenchymatous phase in the same site during 10 — 12 sec. the intensive limited shadow remains.
At a radio isotope research signs of volume defeat of the Item. are rather various and depend on localization of the center, degree of its extent and involvement in patol, process of channels of the Item. At tumors of the Item. change of its form, the sizes and outlines, existence of one or several defects of accumulation (the cold center) is noted, and at total defeat — total absence of the image. At high-quality educations (a cyst of the Item.) on stsintigramma the defect of accumulation of drug surrounded with a so-called border of the activity corresponding to the functioning parenchyma on the periphery of a cyst comes to light.
A peculiar picture is observed at an insuloma: on a stsintigramma substantial increase of accumulation of drug in a zone of defeat — the so-called hot center is noted.
Treatment of benign tumors — operational. Most often they are deleted by enucleation of a tumoral node with economical excision of fabric of the Item. and sewing up of a tumoral bed. At the cystous nature of a tumor sometimes make marsupialization (see). The prelum of a pancreatic channel and impossibility to considerably remove a tumor can be the indication to a punk reatoyeyunostomii. At the big sizes of the tumor which is strongly connected with fabric of gland carry out a resection of the Item. or a pankreatoduodenalny resection (see. Pancreatoduodenectomy ). The long-term results of radical removal of benign tumors are favorable.
At nek-ry types of benign tumors (a lymphangioma, a gemangiolimfangioma) apply radiation therapy.
Cancer cases of the Item. makes 8,7 — 9,3 on 100 000 population. Kalberer (J. T. Kalberer, 1974) specifies that within the last 50 years the frequency of cancer of the Item. increased in the USA more than by 3 times. According to Kohn (J. Cohn, 1977), in the USA he takes the fourth place on mortality after cancer of a lung, a large intestine and a mammary gland. Established Seg (M. of Segi, 1977) that cancer of the Item. often meets in the USA and countries of Northern Europe, is much more rare — in Japan and Italy. And city dwellers are ill it more often than rural. Distribution of the diseased on a floor shows dominance of men — a ratio 1,5 — 2,5: 1.
Mankuzo and Attar (T. F. Mancuso, A. A. Attar, 1967) connect developing of cancer of the Item. with impact on an organism of a number of chemical agents (benzidine, r-naphthylamine, etc.). Ishiya (To. Ishii) with sotr. (1968) considers that alcoholism increases danger of a disease of cancer P.Zh. E. L. Wynder et al. (1973) suggest about possible communication of cancer of the Item. with diabetes and a cholelithiasis. D. F. The benefit types (1973) believes that hron, recurrent pancreatitis can be a pathogenetic basis for development of tumoral process in the Item.
Allocate the following a wedge, forms of cancer of the Item.: cancer of a head, body, tail and diffusion (or total) defeat. According to summary statistics Syurana, Bertrán (And. J. Ciu-rana, L. Bertrand, 1974), on 2205 openings at cancer of the Item. cancer of a head makes 63,8%, cancer of a body — 23,1%, a tail — 7,2%. From 346 patients operated concerning cancer of the Item. in All-Union oncological scientific center of the USSR Academy of Medical Sciences, cancer of a head met in 73,4% of cases, bodies — in 14,1%, a tail — in 6,6%, total defeat — in 5,9%.
Gross appearance of cancer of the Item. depends on localization, the sizes and type of a tumor. More often it is the single nodes located in fabric of gland, the irregular spherical shape, more dense consistence than surrounding ferruterous fabric. Surface of gland in some cases hilly. Tumors of a body and tail more massive. More rare the tumor happens diffusion, and then it is difficult to define its borders. The sizes of a tumor on length vary from 1 to 15 cm. At dominance of ferruterous fabric a tumor fleshy, elastic, light pink. At preferential development of a stroma — a tumor of white color, dense, cartilaginoid.
Cancer of the Item. often there are multitsentrichesk and is not single-step, and stadiyno. The Atipichesky hyperplasia passes into cancer of in situ (see Carcinoma in situ), and then — in invasive cancer (see). While cancer grows in epicenter of a tumoral node by an invasion, on its periphery oppositional growth can take place that explains the mechanism of a possible recurrence. In the sites of fabric of the Item, neighboring to a tumor. usually symptoms of congestive pancreatitis come to light (hron, an inflammation, fatty necroses, a sclerosis and an atrophy of gland) that creates difficulties in definition of exact borders of spread of a tumor at a macroscopic research. According to Lidbetter (A. Leadbetter) et al. (1975), the Vermont tumoral register allocates three stages of spread of a tumor: The I stage tumor is located within gland, the II stage — a tumor sprouts gland, extending to the next bodies, the III stage — a tumor gives the remote metastasises.
Germination of cancer of the Item. in the next bodies innidiation — in 45 — 70% of cases is noted in 30 — 50% of cases. The remote distribution happens in the hematogenous and lymphogenous way. Practically any body can be struck with metastasises what is connected with rich blood supply of the Item., and also with character of a structure okolopankreatichesky limf, systems. Hematogenous innidiation most often happens in a liver, is more rare in lungs, bones, adrenal glands and other bodies.
Developing, cancer of the Item. in most cases passes two a wedge, stages: dozheltushny and icteric. The Dozheltushny period is distinguished difficult that is connected with the indistinct and polymorphic symptoms more often having character of discomfort and pain in an upper half of a stomach. Wedge, picture of a developed cancer of the Item. it is characterized by the symptoms caused by actually tumoral process, and the symptoms connected with the anatomic relation of a tumor to output channels of the Item., hepatic both to the general bilious to channels and duodenum. The most characteristic symptoms of the first group are pains in an upper half of a stomach, increased fatigue, weakness, weight loss, anorexia, anemization. Other group of signs is connected with obturation pancreatic (pains, weight loss, disturbance of digestion of food, intestinal frustration, secondary diabetes) and extrahepatic bilious channels (jaundice, a skin itch, increase in a liver and gall bladder, an abnormal liver function, fever), and also with narrowing of a gleam of a duodenum (weight in epigastriums, vomiting).
The jaundice which is found at cancer of a head of the Item., is the observing sign approximately in 90%. A number of manifestations is characteristic of jaundice: skin itch, cholangitis, increase in a liver and gall bladder, change of a number of biochemical indicators and coagulant system of blood. The most typical for cancer of a head of the Item. Courvoisier's symptom — the increased (usually easily palpated) painless gall bladder in the presence of jaundice is. With increase in duration of jaundice and increase of its intensity a cholemia (see), the acholia, disturbance of functions of a liver and kidneys, coagulant system of blood, a nervous system develop.
Difficulties of early diagnosis of cancer of the Item. are connected with lack of symptoms, specific to it, especially in the dozheltushny period. It extremely complicates timely recognition and leads to the fact that quite often final diagnosis is established only on operation or even on opening. Diagnosis of cancer of the Item. it is carried out as if in several stages. The first consists in definition of nature of jaundice — mechanical, parenchymatous or hemolitic (see Jaundice). Use kliniko-anamnestic and biochemical, this allows to otdifferentsirovat in most cases mechanical jaundice from other types of jaundices. Klinikoanamnestichesky and standard rentgenol. researches allow to differentiate cancer of a pankreatoduodenalny zone with other diseases causing obturatsionny jaundice.
The most difficult is topical diagnosis, i.e. differentiation of cancer of the Item. with other tumors of a pankreatoduodenalny zone. The most informative researches at cancer of the Item. are a relaxation duodenografiya (see. Duodenografiya relaxation ), duodenoskopiya (see) with a retrograde pankreatokholangiografiya (see. Pankreatokholangiografiya retrograde ), the selection angiography of a celiac artery (see Tseliakografiya), scanning (see), peritoneoskopiya (see), a computer tomography (see the Tomography computer), a transdermal holangiografiya (see).
Especially important role in cancer detection of the Item. the computer tomography, an angiography and a pankreatokholangiografiya plays. Changes of channels of the Item. at cancer of the Item. Ogos (To. Ogoshi, 1979) divides into three types change: stenotic, cone-shaped and obstructive. At stenotic type there is a narrowing of the main pancreatic channel in the certain localized zone. Vetvi Canal around narrowing in whole or in part disappear, and contours of a channel equal. Pancreatic channels to the place of a stenosis at cancer of the Item. in the absence of pancreatitis are not changed, and channels behind a zone of a stenosis are expanded sometimes in the form of small cysts. Contours of expanded channels uneven. In the absence of the expressed stenosis of the main channel expansion of peripheral channels can not occur. The cone-shaped type of changes arises at a bigger prelum of the main pancreatic channel; on a pankreatogramma its gradual cone-shaped pointed narrowing is found. At this form there are no local stenoses and expansions. Branches of channels in the field of narrowing are not visible.
At obstructive type there occurs full obstruction of the main pancreatic channel. Vetvi Canal are contrasted in not changed part of the main canal, in the field of obstruction the wrong structure or a rupture of branches of channels is noted. On computer tomograms define increase in all in the Item. or its parts. Sometimes accurately the image of the tumor in the form of a node with uneven contours (fig. 19) appears. The shadow of a node can be heterogeneous because of sites of a necrosis. At obturatsionny jaundice expansion inside - and extrahepatic bilious channels comes to light. At an angiography four symptoms have the leading value: emergence in the Item. abnormal neogenic (so-called tumoral) vessels, an uzuration of walls of arteries, increase in a part of gland and an avaskulyarny zone in a parenchymatous phase.
Simpler techniques rentgenol. researches of bodies of chest and belly cavities also shall be applied at suspicion of cancer of the Item. They help identification of metastasises of a tumor in lungs, in bones of a skeleton, a liver, give the chance to find congestive increase in a gall bladder because of obturation of the general bilious channel, to ustanonovit deformation of a medial wall of the descending part of a duodenum at tumors of a head of the Item., expansion of a gleam of a duodenum (fig. 20), shift of a stomach and germination of a tumor in its back wall. Criteria of ultrasonic diagnosis of cancer of the Item. it is possible to consider local increase in the Item., rather homogeneous distribution of moderate intensity of echo signals, indistinct border between the subject fabrics; indirect signs are a compression lower hollow and upper mesenteric veins.
Cancer therapy of the Item. complex. The question of a possibility of performance of radical operation depends on age and a condition of the patient and a distributional pattern of a tumor. If germination out of limits of body takes place and metastasises are found, radical operation is impossible. Spread of a tumor dictates as well the choice of a method of palliative intervention.
A. A. Shalimov (1970), Poppies (T. Maki) with sotr. (1966) consider that advanced age of the patient, long jaundice, the expressed associated diseases (cardiovascular, pulmonary, diabetes, obesity) are a contraindication to radical operation.
The main radical operation which is applied hl. obr. at tumors of a head of the Item., the pankreatoduodenalny resection which is exclusively difficult and traumatic intervention is (see the Pancreatoduodenectomy). V. S. Da-tsenko (1965), E. S. Futoryan (1972) in general drop a hint of doubt in expediency of a pankreatoduodenalny resection at cancer of the Item. also recommend only a bypass anastomosis, pointing that the postoperative lethality at them is much lower, and average survival almost same, as after a pankreatoduodenalny resection. According to Herttsberg (J. Hertz-berg, 1974), the pankreatoduodenalny resection is shown only at tumors of the Item. the small sizes and also when it is not clear where the tumor — in a head of gland or a big nipple of a duodenum is located. By data A. A. Shalimov (1978), Warren (To. W. Warren, 1964), Hoffman (G. Hoffman, 1976), the operational lethality at a pankreatoduodenalny resection makes 10 — 20%. At the same time, on summary statistics of Herttsberg (1974), in most surgical institutions it makes 20 — 50%. Transition of a tumor of a head of the Item. on an isthmus and a body, innidiation in regional limf. nodes, retroperitoneal cellulose, limf, nodes in the field of a celiac trunk, on the course of a splenic artery are the indication to a pancreatectomy (see).
Achievements of surgery, resuscitation and possibility of replacement therapy led to the fact that the total pancreatectomy stopped being a rarity. According to Rimayn (W. H. Remine) et al. (1970), Hikksa (R. E. Hicks) et al. (1971), a lethality at a pancreatectomy makes 9 — 23%, and five-year survival of 14 — 21%.
At damage of a body and tail of the Item. the distal resection of gland is shown.
Low interest of operability (on average no more than 10%), great technical difficulties and high risk of performance of radical operations are the reason that to most of patients with cancer of a pancreas make the palliative interventions consisting in creation of a biliodigestivny anastomosis. Most often apply holetsistoenterostomiya (see) and an uoletsistogastrostomiya (see). The lethality at palliative operations makes 15 — 25%, and average life expectancy — 6 — 7 months. Approximately at 20% of patients an operative measure is limited to trial laparotomy (see).
Apply to chemotherapeutic treatment 5-ftoruratsit, Cyclophosphanum, a methotrexate. It is usually begun in 2 — 3 weeks after palliative operation when jaundice is liquidated. Repeated courses of chemotherapy are conducted with 4 — a 6 weeks interval at satisfactory portability of drug and lack of signs of progressing of process.
In view of high toxicity of therapeutic doses of chemotherapeutic drugs techniques of their regional vnutriarterial-ny introduction are developed that allows to bring them directly to a tumor and zones of regional innidiation. At cancer of a head of the Item. it is reached by introduction of a polyethylene catheter to an upper pankreatoduodenalny artery through the right gastrostuffing. At an intra arterial way of introduction course doses exceed by 2 — 3 times of a dose applied at system administration of drugs, and all-toxic manifestations are expressed more weakly. Life expectancy of the patients receiving regional chemotherapy, above than at system chemotherapy. Growth inhibition of a tumor or its regression can also achieve by means of radiation therapy (see). So, according to Hazlem (J. Century of Haslam) with sotr. (1973), at radiation in a dose 6000 — 8000 I am glad (60 — 80 Gr) increase in frequency of two-year survival of patients from 2 to 24% is noted. However possibilities of radiation therapy are limited because of early the coming beam reactions.
Due to the frequent recurrence after radical operations some surgeons recommend to carry out preirradiation in a dose 4000 — 5000 is glad (40 — 50 Gr) or to supplement radical operations with postoperative radiation in the same dose. In the 70th attempts of the combined himioluchevy cancer therapy P.Zh. Mertel were made (Page G. Moertel) with sotr. (1969) specifies that the combination of introduction of a 5-ftoruratsil to radiation therapy yields the best results, than separate use of these methods.
Thus, in the combined cancer therapy of the Item. the regional chemotherapy, the combined chemotherapy with use of antineoplastic means of the different mechanism and an action spectrum, the combined himioluchevy therapy with use of megavoltny sources of radiation are perspective.
Operations on the Item. make at damages it, inflammatory and parasitic diseases, concrements of channels and calcification of a parenchyma, cysts and tumors.
At the immediate surgeries undertaken concerning the closed damages or wounds of the Item., and also in connection with gaps or perforation of a cyst, bleeding from its wall, before an operative measure it is necessary to carry out antishock therapy (see. Shock ), transfusion is fresher than blood and blood-substituting liquids (reopoliglyukin, Haemodesum, 5 or 10% solution of glucose, etc.). All these events shall not be held more than 1,5 — 2 hours, if necessary they can be continued during operation.
At planned operative measures preoperative preparation shall include purpose of fortifying means, the diets rich with the easily acquired proteins, vitamins, iron preparations. At dehydration and exhaustion drop injection of physiological solution, blood, blood substitutes, proteinaceous drugs, plasmas is shown. At the constant pains exhausting the patient it is necessary to appoint analgetics, novocainic blockade (see) — vagosympathetic, perinephric, celiac nerves, etc., and also acupuncture (see). At disturbances of external secretion of the Item. therapy by fermental drugs — Pancreatinum, meksazy, festal is reasonable; disturbance of intra secretory function of the Item. demands special insulino-and a dietotherapy, providing normalization of carbohydrate metabolism. At the obturatsionny jaundice caused by a tumor of a head of the Item., prevention of cholemic bleedings and development of a gepatorenalny syndrome is necessary. For this purpose appoint intramuscular injections of Vikasolum, campolon, plasma transfusion, aminocaproic to - you and DR-
At operations to the Item., both emergency, and planned, use is the most reasonable inhalation anesthesia (see) with muscle relaxants (see). This type of anesthesia provides optimal conditions for carrying out technically difficult and in most cases long interventions.
The cuts offered for interventions on the Item., are various (fig. 21). At operations on a head of the Item. and on the bilious ways the most convenient is the slanting section which is carried out parallel to the right costal arch, offered by S. P. Fedorov. For approach to a body or a tail of the Item. often use midsection which is usually expanded by a cross section of direct muscles of a stomach (see. Laparotomy ). Bigger distribution was gained by cross and arc-shaped sections in an upper half of a stomach. The direction of a section at cysts of the Item. is defined by localization of the palpated education.
After a laparotomy approach to the Item. it can be carried out in various ways: through an omentulum, a gastrolic linking, a mesentery of a cross colon, and also by separation of a big epiploon from a cross colon (fig. 22).
Types of operations
At damages of the Item., both open, and closed, operation is made according to the emergency indications in connection with symptoms of internal bleeding or peritonitis. After a wide laparotomy make careful audit of abdominal organs, paying attention to existence of sites of a fatty necrosis and protrusion of an omental bursa that testifies to an injury of the Item. After an exposure of the last, usually through a gastrolic sheaf, start a careful research of the Item. Before it exempt a cavity of an omental bursa from the streamed blood mixed with a pancreatic secret, blood clots, freely lying pieces of the Item. and the smashed its fabrics. The damaged vessels of the Item. alloy. The small hematomas and hemorrhages which are formed as a result of a bruise of a parenchyma of the Item., are not subject to an operative measure. Subcapsular hematomas open and alloy the bleeding vessel. Superficial ruptures of gland take in together with the capsule noose sutures.
At deep ruptures of a parenchyma of the Item. with damage of the main pancreatic channels, and also at a full cross break its surgical tactics can be various.
Sewing together of gland separate P-shaped seams is possible. The damaged main channel at the same time also sew the end in the end by means of split on the end or the T-shaped tube, the ends enter a cut into proximal and distal parts of the main pancreatic canal.
At damages to area of a body of the Item, more considerable on an extent. after excision of the smashed fabrics impose an anastomosis between a small bowel and the formed defect of a parenchyma of gland and the damaged main pancreatic channel (a pankreatikoyeyunostomiya; fig. 23) with simultaneous At-shaped entero-enterostomy across Ru or enteroenteroanastomozy a side sideways according to Brown (see. Enteroenteroanastomoz ). It is also possible to anastomose damaged by the Item. with a stomach (pancreaticogastrostomy). Imposing of the pankreodigestivny anastomosis which is taking away pancreatic juice in intestines, more favourably, than a tamponade of the damaged site of the Item., fraught with formation of persistent outside pancreatic fistula.
At big destructions of the Item., its especially distal part, make a left-side pancreatectomy or a resection of a tail part of gland, usually together with a spleen. The remained proximal stump of the Item. take in P-shaped seams after bandaging of a pancreatic channel and cover with an epiploon on a leg. According to M. O. Michelson and M. A. Liyepinsh, after such operation vneshnesekretorny and endocrine functions of the Item. are not broken.
At cross ruptures of the Item. closer to a head reasonablly to sew up the proximal end of gland, and distal — to anastomose with the jejunum which is switched off across Ru (fig. 24).
At crush of a parenchyma of a head of the Item. with simultaneous injury of a duodenum carry out a pankreatoduodenalny resection (see. Pancreatoduodenectomy ). At the same time main channels of a stump of the Item. can be sealed up by the hardening silicone plastic, and the stump is taken in tightly without formation of a pankreatoyeyunoanastomoz, what is technically much simpler.
Operation at damages of the Item. finish with drainage of an omental bursa rubber trubna and introduction of the fencing-off tampons which enter through additional cuts of a front abdominal wall or lumbar area.
The forecast at damages of the Item. substantially depends on the terms which passed from the moment of an injury, the nature of damage of the Item. and other abdominal organs, and also timeliness of an operative measure. The best results were noted after the operations executed in the first the 12th hour. Extensive crushes of body, according to V. V. Vinogradov, lead to a lethal outcome in 60% of observations.
Operative measures at a pancreatolithiasis aim at removal of concrements and elimination of the reasons of their education, first of all a staz of a pancreatic secret which shall be liquidated or korrigirovan.
The operations which are applied for this purpose are various. At a single stone of the pancreatic channel which is localized in the field of a head or a body of the Item., carry out a pankreatikolitotomiya. At the same time cut a parenchyma of the Item. (pancreatotomy) and a wall of a channel (pankreatikotomiya) over a stone; the last is deleted then sew up dissect fabric with separate seams. To area of seams bring an outside drainage. Before performance of this operative measure make a puncture virzungografiya (see. Pankreatografiya ), with the help a cut define quantity of concrements, their localization and size, and also existence of strictures of a channel. Existence them is a contraindication for operation of a pankreatikolitotomiya; in these cases the longitudinal pankreatoyeyunosto-miya (virzungoenterostomiya) consisting in a section of a pancreatic channel lengthways throughout a tail and a body (to a head) is shown to the Item., removal of concrements and a section of all crossing points and the narrowed sections of the canal. Then Item. and the pancreatic channel is anastomosed with the jejunum which is switched off across Ru or according to Brown, a side sideways or the end in the end (fig. 25 and 26).
Results of similar interventions quite satisfactory. According to Pyustov (Ch. Century of Puestow), at 75% of the operated patients was observed favorable result.
At localization of concrements in a tail part of the Item. its caudal resection usually together with a spleen is shown, however only at preservation of outflow of a pancreatic secret in the natural way. If it is broken, then in addition impose an anastomosis with the loop of a jejunum (fig. 27) which is switched off across Ru.
During the finding of stones in the field of the mouth of a pancreatic channel removal them is made after a section and plastics of the last. Before it make a papillotomiya or a papillosfinkteroplastika (see. Faterov of pacifiers ). Then cut a front wall of a pancreatic channel, at the same time sewing edges of a mucous membrane of a section of a duodenum and a channel — a virzungoplastik (fig. 28). The Duodenotomichesky wound is sewn up, the general bilious channel is drained in supraduodenalny department.
At calcification of a head of the Item. some surgeons apply a pankreatoduodenalny resection, edges is followed, according to I. Littmann, 10 — 30% by a lethality. This operation is more shown at cancer of the Item., when the risk of intervention is more justified. O. B. Milonov at a prelum of the main pancreatic channel and distal department of the general bilious channel a calcific head of the Item. applies simultaneous internal drainage of a pancreatic channel and a gall bladder.
The total pancreatoduodenectomy is even more technically difficult and dangerous to the patient. Resort to it seldom because of a high lethality and development of heavy diabetes after operation. At the expressed pain syndrome some surgeons made denervation of the Item. (splankhnikektomiya, marginal and postganglionic neurotomy, etc.). Their results, however, without removal of concrements and elimination of pancreatic hypertensia in most cases were short-term or ineffective.
In cases of accession of complications of a pancreatolithiasis operative measures undertake only for the purpose of their elimination. At abscesses of the Item. make opening and drainage of an abscess, pancreatic cysts — the operations directed to their elimination at obturatsionny jaundices — imposing of a biliodigestivny anastomosis (see. Cholecystogastrostomy ).
Outcomes depend on a variety of reasons: character and prevalence patol. process — size, number and an arrangement of stones, expressiveness and the extent of calcification of a parenchyma of the Item., extents of disturbance externally - and intra secretory function of body, and also intensity and frequency of painful attacks, a condition of the patient and a type of the made operative measure.
For operational treatment of cysts of the Item. apply a number of operations: outside or internal drainage of a cyst, opening and sewing up of a cavity of a cyst, a resection of a wall of a cyst after vesicotomy, removal of a cyst (cystectomy), a resection of the Item. together with a cyst.
Outside drainage of cysts of the Item. it is carried out by means of various drainages (rubber, chlorvinyl, fungoid catheters of Pezzer, etc.) or operations marsupializations (see) — a podshivaniye of edges of the capsule of a cyst to a front abdominal wall. Enter a drainage or tampons into a cavity of a cyst, gradually bring up them and delete on 14 — the 20th day. These operations are followed by a low lethality and, according to Müller (N. Muller, 1962), make 3 — 12% though are usually carried out at patients in critical condition. Nevertheless because of often developing profuse bleedings from a cavity of a cyst, developing of not healing pancreatic fistulas, malignancies of walls of a cyst, formation of postoperative hernias apply outside drainage seldom (e.g., at an empyema of cyst, its insufficiently created capsule or at impossibility of carrying out more difficult operation).
Internal drainage of cysts of the Item., offered by Ombredann (L. Ombredanne, 1912), consists in imposing of an anastomosis between a cavity of a cyst and a stomach or departments of a small bowel. The most widespread is the last option of operation — a tsistoenterostomiya (fig. 29). After this operation usually 5 — 7 days later the cavity of a cyst decreases, and in 2 — 3 weeks is obliterated. If the cyst is reported with the main pancreatic channel, the existing anastomosis provides a decompression of the last and prevents a pelting of intestinal contents in a cavity of a cyst. Positive takes of this operation and a low lethality — according to Jordan (L. Jordan, 1960) 4,5% — gave the grounds to many surgeons to consider it method of the choice. It can be used also in the presence of several cysts.
Tsistogastrostomiya — imposing of an anastomosis between a cavity of a cyst and a stomach, the Piece pm for the first time executed (R. Jedlicka, 1921), is made at big cysts of a body of the Item., adjacent to a stomach. At an intimate spayaniye of a cyst with a back wall of a stomach Yurash (A. Jurasz, 1931) offered a chrezzheludochny tsistogastrostomiya. At the same time at first open a front wall of a stomach, and then after a puncture and emptying of a cyst through a back wall of a stomach anastomose it with a wall of a cyst (fig. 30). The front wall of a stomach is taken in. The joint capsule of a cyst shrivels after that, and her cavity is quickly obliterated. A serious lack of this operation is the possibility of formation of the stomach ulcers and an anastomosis which sometimes are complicated by profuse internal bleeding.
The transduodenal tsistoduodenostomiya similar on the equipment of a tsistogastrostomiya, is carried out at cysts of a head of the Item., directly adjacent to an internal wall of a duodenum. At multiple cysts an anastomosis with a jejunum or the combined operations when a cyst of a head of the Item is possible. anastomose with a duodenum, and a cyst of a tail — with a jejunum (fig. 31). At the considerable sizes of a cyst the combination of internal and temporary outside drainage of a cavity of a cyst is reasonable.
A cystectomy — removal of a cyst of the Item., for the first time executed by Bozmen (N. Bozeman, 1881), is the most radical and effective operation. It is shown at the small, mobile cysts having the created wall not spliced with surrounding bodies. These conditions meet at retentsionny, parasitic and benign tumoral cysts more often. After opening of an omental bursa the cyst is removed in a wound and deleted, crossing her leg. In the presence of unions in the field of a bed of a cyst consistently cut them. Operation is finished with sewing up of a bed of a cyst with leading of a drainage to it.
Partial removal of cysts of the Item. make in case of impossibility of full allocation of walls of a cyst from surrounding unions. After a resection of the freed site of a wall make electrothermic coagulation of the remaining part of a cyst either consecutive excision of the inner layer, or a tamponade an epiploon or gauze tampons. These operations are not radical, quite often after them persistent pancreatic fistulas are formed and there comes a recurrence of cysts.
The pancreatectomy together with a cyst belongs to the most radical ways of operational treatment. At its localization in a tail of the Item. carry out its resection. Thus after allocation of a cyst to its basis will mobilize the site of the Item which is subject to removal., to-ruyu then cross and delete together with a cyst and a spleen. At normal passability of a pancreatic channel a stump of the Item. take in with the shelter of the line of seams an epiploon on a leg. If the main pancreatic channel is blocked, a stump of the Item. it is necessary to anastomose with a jejunum. Operation is finished with drainage of area of a stump of the Item. and bed of a spleen.
At localization of a cyst in a body of the Item. make a resection of a body part together with a cyst. Having convinced of passability of a pancreatic channel, the proximal end of the Item. take in, distal anastomose with the jejunum which is switched off according to Brown or across Ru. The indication for these operations are multiple small cysts of a tail of the Item., the neoplastic or undergone malignancies of a cyst.
At cysts of a head of the Item. the pankreatoduodenalny resection can be justified only at the malignant nature of cysts proved with the help gistol, researches as these interventions are difficult and accompanied by big risk.
The choice of a way of operation depends on the reason of formation of a cyst, the sizes and its localization, and also on character of a course of a disease and the conditions created in a zone of an operative measure. At the same time also terms of performance of operation have important value. Surgical tactics in these cases shall be the adventitious cyst differentiated depending on extent of formation. In the initial stages proceeding 2 — 3 months when walls of a cyst are not created or consist of friable granulyatsionny fabric, operation is not shown. It is necessary to carry out vigorous conservative therapy as at acute pancreatitis, only outside drainage of a cyst is as a last resort possible. 3 — 12 months when the wall of a cyst well is created, becomes strong later, marsupialization or internal drainage of a cyst at the message of the last with channels of the Item is shown. In later terms when the cyst thanks to thinning of unions with surrounding fabrics and bodies under the influence of proteolytic enzymes becomes more mobile, radical operation — excision of a cyst is possible. G. D. Vilya-vin adheres to waiting tactics at sharply developing pancreatic cysts; however he recommends to monitor strictly development of process to be ready in a case of emergence of complications to an urgent operative measure.
At retentsionny (true) cysts of the most tactically justified perhaps earlier operation» preventing the progressing atrophy of a parenchyma of the Item is considered. under the influence of pressure of constantly increasing cyst, and also development of inevitable complications (bleeding, suppuration, perforation).
Results of operational treatment of cysts of the Item., according to most of surgeons, are regarded in general as favorable. At a timely and right choice of an operative measure the absolute recovery of patients with recovery of working capacity in 80 — 90% of observations, especially after more radical operations — an extirpation of a cyst, a resection of a distal part (tail) of the Item is observed. together with a cyst. However in connection with technical difficulties they are feasible only at 20 — 30% of patients. Pankreatoduodenalny resections at cysts of a head of the Item., considering danger of heavy complications and a high lethality, can be applied in specialized institutions at neoplastic cysts or a malignancy of a cyst.
Operations of internal drainage of a cyst in connection with availability for a wide range of surgeons and quite satisfactory results are considered by most of surgeons as a method of the choice though can be followed by complications: suppuration of a cavity of a cyst, massive internal bleedings, formation of round ulcers (see) and development of a recurrence of a disease. Palliative operations like outside drainage of a cyst are a little effective, but also, can be complicated by persistent outside pancreatic fistulas, bleedings from fistula; the malignancy of a cyst and a recurrence is possible. Nevertheless at certain situations this operation can be saving for the patient.
Echinococcal cysts of the Item. are subject to removal (see. Echinococcosis ). At the same time make an extirpation of a cyst without damage of its covers that works well seldom, or opening of a gleam of a cyst and consecutive removal of its contents (echinococcal liquid and affiliated bubbles) and covers (germinative and kutikulyarny). The residual cavity after formolation (2% solution in a liquid paraffin) is taken in or stuck, tamponed the remains of the fibrous capsule or an epiploon on a vascular leg or drained (see. Echinococcosis ).
Operational treatment of outside fistulas of the Item. consists in their elimination by excision, or a resection of the Item. together with fistula, or its anastamosing with one of bodies went. - kish. path. In the latter case after allocation of the fistular course throughout 3 — 4 cm from unions its distal end sew in a gleam of a stomach or the segment of a jejunum which is switched off across Ru or Brown by immersion by Vittsel's method with a nimbus of skin (fig. 32) or imposing of an anastomosis between them the end sideways. At localization of fistula in a head of the Item. for its internal drainage the duodenum can be used, to-ruyu anastomose with the released end of fistula.
At allocation of the fistular course quite often there are insuperable difficulties because of cicatricial changes of surrounding fabrics, and also an intimate spayaniye of its wall with nearby bodies (a stomach, a small or large intestine). Attempts of allocation of fistula in these conditions can be followed by damage of walls of the last, and also the specified bodies. Therefore in a similar situation it is more reasonable to use excision of pancreatic fistula. Before operation enter into its gleam under pressure solution of the methylene fistular course, blue for a prokrashivaniye of an internal cover, and elastic plastic or metal (more dangerous) the probe facilitating detection of the last after a laparotomy. Having opened a gleam of fistula, reach its basis in the open way. Having convinced by means of a fistulografiya (see) in passability of the main pancreatic channels, fistula is taken in at the place of an otkhozhdeniye from the Item. Fabrics of the fistular course, whenever possible, exsect, being guided on a prokrashivaniye their methylene blue. If in a zone of an arrangement of fistula there are covers of a cyst of the Item., they also shall be removed in order to avoid a recurrence. At extensive cystous, sclerous or tumoral defeat of the left half of the Item. it is resected together with fistula. The stump of gland is taken in tightly (at the kept passability of a pancreatic channel) or anastomosed with the switched-off segment of a jejunum. In some cases for elimination of distal fistula of the Item. use quickly hardening substance containing silicone elastomer, or medical glue.
Results of operational treatment of outside fistulas of the Item. at timely and technically correctly executed operation in general are favorable, the lethality does not exceed 5%. A recurrence and aggravations hron, pancreatitis are in some cases observed.
Postoperative maintaining patients depends on a type of pathology and the nature of the executed intervention. At traumatic damage of the Item. the actions begun before operation on fight against shock, blood loss and peritonitis continue. For suppression of pancreatic secretion and therapy of traumatic pancreatitis during the first 3 — 4 days after operation prohibit the patient food and drink, make constant suction of contents of a stomach via the thin nasal probe, carry out atropinization and anti-fermental therapy (Trasylolum, Contrykal, Gordoxum), (5-ftoruratsit) introduction of tsitostatik, cholinolytics, analgesic and antihistaminic drugs, etc. At peritonitis appoint antibiotics of a broad spectrum of activity, carry out hemotransfusion, Haemodesum, Polyglucinum, make peritoneal dialysis (see), an artificial diuresis, for prevention of insufficiency of the Item. appoint Pancreatinum. Gauze tampons delete on 8 — the 10th days, rubber drainages — on the termination of the receipt separated from a wound. At formation of outside pancreatic fistulas Volgemut's diet containing a large amount of fat, promoting reduction of department of juice, introduction to fistula of inhibitors of proteases is shown.
Operation for a pancreatolithiasis shall be combined with the conservative treatment directed to compensation of disturbances external and incretion of the Item.
After outside drainage of cysts of the Item. it is necessary to pay special attention to the prevention of infection of the fistular course and protection of skin against the corroding effect of the pancreatic juice which is quite often arriving in addition to a drainage. For this purpose use powder of gypsum, paste. Lassara, etc. At internal drainage of cysts of the Item. maintaining patients after operation is similar to that at stomach operations and intestines (see). The main objective at the same time consists in fight against paresis of intestines (early rising, to lay down. physical culture, pumping out of congestive contents from a stomach, the easily acquired diet, purpose of the means stimulating a peristaltics of intestines and so forth) and prevention of the insufficiency of seams of an anastomosis consisting in decompressive actions (drainage of the corresponding segments of intestines), aspiration of gastric and intestinal contents (see. Aspiration drainage). For the prevention of development of peritonitis carry out drainage of area of the put stitches of the Item. with active vacuum aspiration of a wound secret. At resections of the Item., in addition to the actions stated above prevention of an acute postoperative necrosis of gland is necessary. For this purpose irrespective of results of a research of amylase of blood and urine it is necessary to carry out intravenous injection of anti-fermental inhibitors of the Item to the first 2 — 3 days. and their introduction through a drainage to a stump of the resected body.
Change of a pancreas
Change of the Item. to the person is one of new methods of surgical treatment of a diabetes mellitus. In an experiment and clinic two models of change are applied: change of a fragment of the Item. (parts of a body or tail) p change of a pankreatoduodenalny complex. First change of the Item. in clinic it was carried out in 1966 Mr. of Kelly (T.K. by Kelly), and in the USSR — V. P. Shumakov, E. N. Wangqiang and A. A. Seid-Guseynov in 1971. Total number of the executed operations in various clinics of the world does not prevy-vyshat several tens. The indication for change of the Item. the juvenile diabetes mellitus in a stage of a diabetic nephropathy in this connection renal transplantation, as a rule, was at the same time carried out was. At technically correctly made transplantation of the Item. begins to function from the moment of recovery of a blood-groove. At the recipient the level of sugar in blood is normalized, development of diabetic vascular complications stops, and in some cases even there occurs their involution.
A serious obstacle for broad use of change of the Item. problems of a tissue incompatibility, immunological typing, difficulty of a fence of a transplant of gland, and also objective assessment of a functional condition of a transplant are. In this respect use of the methods of preservation developed in the USSR (see Conservation of bodies and fabrics) and estimates of viability of the Item is represented perspective., and also use of the microsurgical equipment (see. Microsurgery ).
Drugs of a pancreas
From the Item. receive hormonal drugs insulin (see) and a glucagon, (see), a number of fermental drugs and inhibitors of enzymes. To fermental drugs of the Item. belong a collagenase (see), ribonuclease (see) and a deoxyribonuclease (see), trypsin (see), chymotrypsin (see), chemical opsin (see). These drugs, having proteolytic activity, promote fusion of necrotic fabrics, a viscous secret, exudate, clots, purulent membranes. Apply them locally in the form of solutions for the purpose of acceleration of process of clarification of wounds from necrotic fabrics and strup at trophic ulcers, freezing injuries, burns. Some fermental drugs of the Item., napr, trypsin, decreases in viscosity and simplification of department of a secret at bronchitis, a bronchoectatic disease, pneumonia use in the form of inhalations for fluidifying, after lung operations, etc. Trypsin is recommended also for intramuscular introduction at a number of inflammatory processes (thrombophlebitis, antritis, otitis, periodontosis).
Fermental drugs of the Item. can cause allergic reactions. Therefore in the presence at patients of hypersensitivity it is impossible to apply them to them. It is reasonable to combine use of fermental drugs of the Item. with antibiotics (Neomycinum, streptomycin, levomycetinum). Some antiseptic agents (salts of heavy metals, compounds of iodine, nitrofurans) suppress activity of these enzymes. Drugs andekalin, dilminat, Increpanum represent the purified extract of the Item. lethal cattle. They expand peripheral blood vessels, increase permeability of capillaries, ABP reduce that is connected with availability of kallikreins in them. Andekalin apply at disturbances of peripheric circulation — a Raynaud's disease, Obliterating diseases of arteries, and also at a scleroderma, badly healing wounds and ulcers, etc.
Fermental drugs of the Item., the containing proteases, lipases, amylases and other enzymes, napr, Pancreatinum (see), panzinorm, apply at the disturbances of digestion connected with insufficiency of vneshnesekretorny function of the Item. (e.g., at hron, pancreatitis) or disturbances of digestion at diseases of a liver, gall bladder, stomach, intestines.
From the Item. receive also drugs with anti-fermental activity. Treat them pantripin (see), Gordoxum, Trasylolum (see), Contrykal, etc. They oppress activity of kallikrein, plasmin, trypsin, chymotrypsin. Suppression of activity of trypsin reduces risk of self-digestion of a pancreas, and the inhibition of kallikrein and collidine eliminates their hypotensive and toxic action. Use anti-fermental drugs at acute and hron, pancreatitis, and also as the means oppressing fibrinolysis (see).
An artificial pancreas
three groups of the devices called artificial by the Item are Experimentally developed. and intended for treatment of a diabetes mellitus:
1) stationary devices (dosers) for temporary correction of carbohydrate metabolism at a bed of sick (fig. 33),
2) parakorporalny devices (dosers) for prolonged treatment in a hospital and out-patient conditions which the patient carries on a body (fig. 34),
3) the implanted devices intended for long implantation in an organism of sick (fig. 35). Development of the devices «artificial pancreas» is begun in the USSR in 1970 at the initiative of B. V. Petrovsky in department of transplantation and artificial organs of All-Union research institute of clinical and experimental surgery of M3 of the USSR, and since 1975 — in laboratory of an artificial pancreas of scientific research institute of transplantology and artificial organs of M3 of the USSR under the leadership of V. I. Shumakov and A. A. Seid-Guseynov. Stationary artificial Item. consists of the analyzer with the sensor of glucose and system of continuous blood sampling; the computer with the control panel, registering and printing devices; the pump with system for infusion of solutions of insulin, glucose, etc. The pump of the analyzer carries out continuous blood sampling by means of a special catheter which is entered into a peripheral vein. In a gleam of a catheter there is a constant mixing of blood to solution of anticoagulants then mix moves to the electrochemical sensor of glucose. The electric output signal of the sensor will be transformed in the block of the analyzer to digital indicators of level of glucose which are transferred to the block of the computer calculating the speed of infusion of insulin or glucose on the basis of in advance programmed algorithms (see. Algorithm ).
Implanted artificial to the Item. has a tank with a reserve of insulin for a period of up to several months, power supplies, the microdosing timing unit, the device for gas station of insulin by a transdermal puncture. All these elements are located intrakorporalno. Dimensions of such device are limited to opportunities of surgical implantation and in the subsequent shall not reduce vital activity of the patient. Besides, there are systems of distance steering, control and a power subcharge.
Similar tiny devices (parakorporalny) use by outside connection with administration of insulin intravenously or subcutaneously.
First operation of implantation artificial Item. it was executed by V. Shumakov and A. A. Seid-Guseynov in 1975. In the subsequent operations of simultaneous renal transplantation and implantation artificial are made by the Item. to the patient with an end-stage of a diabetic nephropathy and simultaneous Implantation artificial the Item. and a pacemaker to the patient suffering from a diabetes mellitus and a full cross heart block.
The main indications to a wedge, to use stationary artificial the Item. acute diabetic ketoacidosis, a diabetic coma, heavy operative measures at patients with a diabetes mellitus, pregnancy and childbirth at the women sick with a diabetes mellitus are. The encouraging results of course use of these devices for patients with recently developed diabetes mellitus of juvenile type are received — permanent regress of a disease is established.
Works on a wedge, to use of devices of type artificial the Item. are carried out also in Canada, the USA, France, Germany and other countries.
Anatomy, physiology, biochemistry — Babkin B. P. Secretory mechanism of digestive glands, JI., 1960; Veremeenko K. N. Proteolytic enzymes of a pancreas and their use in clinic, Kiev, 1967; Yelets Yu. K. and Yaglov V. V. Evolution of the structural organization of an endocrine part of a pancreas of vertebrata, M., 1978; Lavrova 3. S. O biologically active agents of a pancreas participating in regulation of water-salt balance, Fiziol, zhurn. USSR, t. 57, No. 7, page 1014, 1971; Melman E. P. Functional morphology of an innervation of digestive organs, page 263, M., 1970; Pavlov I. P. Complete works, t. 2, book 2, page 210, M. — L., 1951; Poltyrev S. S. and Hens Qing of I. T. Fiziologiya of digestion, M., 1980; Rozin D. G. Mechanisms of correction of vneshnesekretorny activity of a pancreas, Usp. fiziol. sciences, M 4, page 98, 1977; The Teratology of the person, under the editorship of G. I. Lazyuk, page 202, M., 1979; Physiology of endocrine system, under the editorship of V. G. Baranov, L., 1979; Shevchuk I. A. and With and N d at l I to L. I. Content of zinc in a pancreas and its communication with functional activity of islets of Langerhans, Probl, endocrinins., t. 17, No. 6, page 113, 1971; Ciba foundation symposium on exocrine pancreas, Normal and abnormal functions, ed. by A. V. S. de Reuck a. M. P. Cameron, L., 1962; G at r N. E. Tests of exocrine pancreatic function, Bern, 1975; O r t e n J.M. N e u h an u s O. W. Human biochemistry, St Louis, 1975; Scientific basis of gastroenterology, ed. by H. L. Duthie a. K. G. Wormsley, Edinburgh a. o., 1979.
Pathology — Bairov G. A. Surgery of a pancreas at children, L., 1978; Blochin N. P., Itin A. B. and Klimenkov A. A. Pancreatic cancer and extrahepatic bilious ways, M., 1982; B about r about-vy E. M. Ring-shaped pancreas and duodenostaz, Vestn, hir., t. 107, No. 9, page 35, 1971; Varnovits-k and y G. I. Radiodiagnosis of diseases of a pancreas, M., 1966; Vasilyev Yu. D. and the Saddle of the Central Committee and I am T. N. A retrograde holangiopan-kreatografiya in diagnosis of diseases of bilious ways and pancreat ducts, Vestn, rentgenol, and radio-gramophones., No. 2, page 46, 1980; In both l I in and G. D., Kochiashvili V. I. N. and Kalta-e in K. K. Cysts and pancreatic fistulas, M., 1977; Vinogradov V. V. Tumors and cysts of a pancreas, M., 1959; At e r r and A. Ya c. Functional disturbances of a pancreas in clinic of internal diseases, Rubbed. arkh., t. 49, No. 2, page 92, 1977; 3ubovsky G. A. Gammastsintigrafiya, page 172, M., 1978; Clinical oncology, under the editorship of H. N. Blochina and B. E. Peterson, M., 1979; Clinical pharmacology, under the editorship of V. V. Zakusov, M., 1978; L e-porsky N. I. Diseases of a pancreas, M., 1951; M and at and P. M., etc. A differentiation of acinar cells at experimental canalicular hypertensia of a pancreas, Cytology and genetics, t. 12, No. 5, page 387, 1978; M and t of e in about with about in A. L. Arteriografiya and an arterioskanirovaniye of a pancreas, Vestn, rentgenol, and radio-gramophones., No. 5, page 48, 1979; Mashkovsky M. D. Pharmaceuticals, p.1 — 2, M., 1977; Medvetsky E. B. and Shalimov S.A. Structural meta - bolicheskiye features of pro-current cells and their role in development of pathological process in a pancreas, Klin, hir., No. 11, page 5, 1978; Millers R. A., Sukharev B. F. and H e-p and to O. F. About an additional share of a pancreas in a wall of a stomach, Vestn, hir., t. 108, No. 4, page 43, 1972; The Multivolume guide to pathological anatomy, under the editorship of A. I. Strukov, t. 4, book 2, page 439, M., 1957; The Multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 8, page 414, 467, M., 1962; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 12, page 233, etc., M., 1949; Residents of Perm N. K., Podolsk A. E. and Titov G. P. Ultrastructural analysis of a secretory cycle of a pancreas, M., 1973; Privezentseva T. V. and Markov I. N. An angiography at insulomas of a pancreas, Vestn, rentgenol, and radio-gramophones., No. 5, page 57, 1979; Use of radioactive nuclides in clinical trials, under the editorship of R. I. Gabuniya, page 68, M., 1979; Savchenko A. Item, Filimonov G. P. and P. V Zlemets. Angiographic symptomatology of chronic pancreatitis, Vestn, rentgenol, and radio-gramophones., No. 5, page 45, 1977; With e and d - at with e y N about in A. A. and d river. Comparative assessment of dynamics of insulin and sugar in blood at implantation artificial and transplantations of an allogenic pancreas a sick diabetes mellitus, in book: Transplantation of a kidney and artificial organs, under the editorship of V. I. Shumakov, page 218, M., 1976; Shalimov A. A. Diseases of a pancreas and their surgical treatment, M., 1970; Shalimov A. A., etc. Surgical treatment of malignant new growths of a pankreatoduodenalny zone, Vestn, hir., t. 121, No. 7, page 6, 1978; She to a log A. A ditch. Diseases of a pancreas, M., 1970; Shumakov V. I., etc. The implanted artificial pancreas for treatment of a diabetes mellitus, in book: Transplantation of a kidney and artificial organs, under the editorship of V. I. Shumakova, page 210, M., 1976; Shumakov V. I., etc. The first experience of a clinical use of the implanted artificial pancreas for treatment of a diabetes mellitus, in the same place, page 227; Shumakov V. I. and d river. 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Radiat., Oncol., Biol., Phys., v. 1, p. 141, 1975; Efficiency and limits of radiologic examination of the pancreas, ed. by H. Anacker a. o., Stuttgart, 1975; Endoscopic retrograde, cholangiopancreatography, ed. by T. Takemoto a. T. Kasugai, Tokyo — N. Y., 1979; F e r r u with with i J. o. Computed body tomography in chronic pancreatitis, Radiology, v. 130, p. 175, 1979; Freeny P. C. a. Ball T. J. Rapid diagnosis of pancreatic carcinoma, ibid., v. 127, p. 627, 1978; Gastroenterology, ed. by H. Bockus, v. 3, Philadelphia — L., 1976; H an a g a J. Reich N. E. Computed tomography of abdominal abnormalities, St Louis, 1978; K a 1 b e-r e r J. T. Cancer of pancreas, J. Surg. Oncol., v. 6, p. 1, 1974; L e a d b e t-t e r A., Foster R. S. a. H an i-n e s C. R. Carcinoma of the pancreas, Amer. J. Surg., v. 129, p. 356, 1975; Spiro H. M. Clinical gastroenterology, N.Y., 1977; Weill F. S. Ultrasonography of digestive diseases, St Louis, 1978.
A. L. Grebenev, O. B. Milonov; G. A. Bairov (it is put. hir.), R. I. Gabuniya (I am glad.), N. V. Gulyaeva (biochemical), I. I. Deryabin (soldier.), Yu. K. Eletsky (An.), S. I. Zolotukhin (pharm.), I. S. Klemashev, S. K. Ternova (mt. issl.), A. A. Klimenkov, A. B. Itin (PMC.), L. D. Lindenbraten (rents.), N. K. Permyakov (stalemate. An.), A. M. Ugolev, H. N. Iyezuitova (fiziol.), B. I. Shumakov (an artificial pancreas, change of a pancreas), S. A. Vasilchenko (stsintigramma — tsvetn, fig.), E. V. Krivenko (angiograms — tsvetn, fig.).