Chronic pancreatitis of biliary origin

　　Firstly, Etiology

　　The etiology of chronic pancreatitis of biliary origin has similarities with that of acute pancreatitis of biliary origin, but the pathogenic process is different. Various diseases of the biliary tract, such as calculi, infections, and stenosis, can all cause chronic pancreatitis. Most patients have chronic pancreatitis due to the extension of acute pancreatitis, and some patients develop the disease slowly, showing a chronic progressive course.

　　1. Biliary Calculi Biliary tract calculi can cause obstruction of the common bile duct, pancreatic duct, or ampulla of Vater, resulting in poor drainage of pancreatic juice and fibrosis of the pancreas.

　　2. Inflammation of the Biliary Tract During inflammation of the biliary tract, the inflammation spreads to the pancreas, and the pancreas is repeatedly infected with mild infections, forming chronic inflammation.

　　3. The basic pathological change of this disease is that the destruction of pancreatic cells is replaced by fibrous tissue.

　　Secondly, Pathogenesis

　　1. Gallstones become lodged in the ampulla of Vater, and bile flows backward through the common bile duct into the pancreatic duct, bringing infection with it.

　　2. During the process of bile stone excretion, it causes the Oddi sphincter to relax paralytically, leading to the reflux of intestinal contents into the pancreatic duct, causing pancreatitis.

　　3. The damage to the pancreatic tissue by toxic substances. They include: free bile acids, bacteria, unconjugated bilirubin, and hemolytic lecithin. Free bile acids are toxic and can damage the mucosal barrier of the pancreatic duct; bacteria can secrete glucuronidase (β-glucuronidase), which can decompose conjugated bilirubin into unconjugated bilirubin, and unconjugated bilirubin is toxic to the pancreas. Acute cholecystitis patients have hemolytic lecithin in bile, which can directly damage the pancreatic tissue.

　　1. Diabetes symptoms can manifest as polydipsia, weight loss, and generally呈 progressive worsening.

　　2. Liver cirrhosis, splenomegaly, and ascites.

　　3. Obstructive jaundice may occur when there is fibrosis of the pancreatic head, stenotic papillitis, and choledocholithiasis.

　　4. After pseudocystic pancreatitis causes large duct obstruction, it can lead to the expansion of small ducts and acinar cavities, accumulation of pancreatic juice, atrophy of epithelial cells, and the formation of pseudocysts. Ultrasound examination can diagnose cysts with a diameter of 2-3 centimeters or more.

　　5. Pancreatic ascites, pericardial effusion, and pleural effusion, with ascites being more common, are exudative and have an increased amylase concentration.

　　6. Up to 10-15% of peptic ulcers may occur due to a decrease in the secretion of sodium bicarbonate by the pancreas.

　　FirstSymptoms

　　1. Abdominal pain:This is the most common symptom of the disease. Initially, it may occur 1-2 times a day, and then the attacks become more frequent, eventually presenting as persistent pain. The pain is located below the xiphoid process in the upper abdomen and slightly to the left, deep in the location, radiating to the back. Drinking and eating fatty foods can induce and worsen the pain, which often wakes the patient up at night. The pain in the sitting position can be relieved, while general analgesics are ineffective.

　　2. Dyspepsia:After the pancreas becomes fibrotic, its exocrine secretion is insufficient, and combined with the existing biliary tract disease, it generally manifests as anorexia, fullness, aversion to greasy food, nausea, steatorrhea, and weight loss.

　　3. Diabetes symptoms:When the endocrine function of the pancreas is damaged, it may manifest as polydipsia, weight loss, generally呈 progressive worsening, and is more sensitive to insulin, while most other hypoglycemic drugs are not sensitive.

　　Second, signs and symptoms

　　This disease often lacks specific signs and symptoms. During the acute attack, symptoms such as peritoneal irritation and intestinal obstruction may occur. During the intermittent period, there may be only mild upper abdominal tenderness. In some cases of weight loss, the pancreas may be palpable as enlarged and hardened. When pseudocystic pancreatitis occurs, an unclear mass can be palpated in the upper abdomen. If accompanied by cholelithiasis, biliary tract infection, and liver cirrhosis, Murphy's sign, gallbladder enlargement, splenomegaly, ascites, and jaundice may occur during the acute attack. Fibrosis of the pancreatic head, stenotic papillitis, and choledocholithiasis may lead to obstructive jaundice.

　　1. Actively prevent and treat related diseases. Biliary tract diseases are common and frequent diseases in the elderly, and actively preventing and treating biliary tract diseases is an important measure to prevent chronic pancreatitis in the elderly. In addition, diseases related to the onset of this disease, such as hyperparathyroidism and hyperlipidemia, must also be actively prevented and treated.

　　2. Actively and thoroughly treat acute pancreatitis. A considerable number of elderly patients with chronic pancreatitis have a history of acute pancreatitis. It is speculated that the onset of this disease may be related to the incomplete cure of acute pancreatitis. Therefore, patients with acute pancreatitis must be treated actively and completely cured to avoid leaving any aftereffects.

　　3. Do not drink heavily, drink less. People who drink heavily for a long time are prone to chronic alcoholism, and alcoholism is one of the important causes of chronic pancreatitis. Therefore, it is necessary to develop the good habit of not drinking heavily or drinking only a little from a young age. If a person with chronic pancreatitis, in order to prevent the progression of the disease, must completely quit drinking.

　　4. Eat in moderation. Be careful with diet, prevent overeating, which is very important for preventing this disease. At the same time, the elderly should eat light, avoid spicy, greasy, and sweet foods, and avoid strong drinks to prevent intestinal heat and cause this disease.

　　5. Keep a cheerful mood, be happy. The elderly should avoid negative mental stimulation such as worry, melancholy, and anger, and being happy can regulate the Qi and blood circulation, and can prevent this disease.

　　1. Laboratory examination during acute attack

　　It is basically the same as acute pancreatitis, but most patients have dysfunction of pancreatic secretion, and serum amylase does not increase. During the intermission, quantitative analysis is used to determine the content of neutral fat in feces, fat absorption rate, or directly find muscle fibers, fat content under the microscope, which can often find steatorrhea.

　　2. Pancreatic function test

　　Can judge the status of exocrine function of the pancreas, including secretin (pancreozymin) test, BT-PAB (a kind of artificial peptide) test, dye fluorescence test, etc.

　　3. Glucose tolerance test

　　Can judge the endocrine function of pancreatic enzymes.

　　4. Other

　　When there is pleural effusion or ascites, it can puncture to determine the amylase content and perform cytological examination. Pancreatic puncture biopsy and selective angiography can also be performed.

　　5. B-ultrasound examination

　　Can show the shape, volume, pancreas cyst, pancreatic stone, biliary tract lesions of the pancreas.

　　6. Abdominal flat film

　　Can show pancreatic calcification or calculus shadow.

　　7. Barium meal examination

　　Can understand gastric duodenal lesions, duodenal hypotonic contrast, and can show straightening of the inner margin of the descending part of the duodenum, or the appearance of multiple spiny protuberances, and sometimes pressure marks.

　　8. Endoscopic Retrograde Cholangiopancreatography (ERCP)

　　Can show pancreatic duct dilation, stenosis, obstruction, pancreatic stones, gallstones, and changes in common bile duct, etc.

　　9. Computed Tomography (CT)

　　Can show pancreas volume, uneven fibrous hyperplasia, pseudocysts, and changes in peripancreatic fascia, etc.

　　First, dietary treatment for biliary chronic pancreatitis:

　　1. Fruit juice. White radish juice, watermelon juice, tomato juice, pear juice: water chestnut juice, mung bean sprout juice, etc., can be consumed. They have the effects of clearing heat and detoxifying, and can also supplement vitamins. They are suitable for patients with acute pancreatitis who are in the low-fat liquid food stage after fasting.

　　2, Chrysanthemum and portulaca herb drink. 30 grams of chrysanthemum, 30 grams of portulaca herb. Clean both ingredients, put them in a pot, add an appropriate amount of water, boil with strong fire, then simmer with low fire for 30 minutes, cool and store in a jar. It can be taken as tea, with the effects of clearing heat, detoxifying, and anti-inflammatory. It is suitable for the initial stage of pancreatitis when starting to eat liquid food.

　　3, Buddha's hand porridge. 15 grams of Buddha's hand, 50 grams of glutinous rice. Boil the Buddha's hand juice, discard the residue, add glutinous rice and an appropriate amount of water, cook into porridge, add an appropriate amount of rock sugar when it is about to be cooked, and eat the porridge. It has the effects of regulating Qi, relieving pain, and invigorating the spleen and nourishing the stomach.

　　4, Cassia twig and white peony root. 20 grams of cassia twig, 40 grams of white peony root, 12 grams of licorice root, 20 grams of ginger, 12 dates, boil the juice, discard the residue, add 100 grams of glutinous rice, and cook into porridge. Eat in several doses, it can invigorate the spleen and harmonize the stomach.

　　5, Cardamom porridge. 10 grams of cardamom, 10 grams of ginger, 50 grams of glutinous rice. First, cook the glutinous rice into porridge, then add the ground cardamom and ginger, and cook into porridge. It can regulate Qi, relieve pain, disperse cold, and is used to treat acute pancreatitis with cold symptoms.

　　6, Pork pancreas powder. Dry the pork pancreas over low heat and grind it into powder, encapsulate it, and take it in several doses daily. It contains various pancreatic enzymes and can act as a substitute therapy, effective for patients with indigestion and steatorrhea.

　　7, Hawthorn and lotus leaf tea. 30 grams of hawthorn, 12 grams of lotus leaf. Boil these two herbs in 2 bowls of water, reduce to 1 bowl, discard the residue, and take it in several doses. It can elevate the clear and resolve food retention, assist digestion, and can treat chronic pancreatitis with indigestion.

　　8, Kombu soup. 20 grams of kombu, 10 grams of cassia seed. Boil these two ingredients in 2 bowls of water, reduce to 1 bowl, take it all at once, and take twice a day. It is beneficial for the alleviation of chronic pancreatitis.

　　9, Dried ginger porridge. 3 grams of dried ginger, 3 grams of galangal, 50 grams of glutinous rice. First, boil dried ginger and galangal in water, discard the residue and take the juice, then add clean glutinous rice and cook into porridge. Eat in several doses. It has the effects of invigorating the spleen and warming the stomach.

　　10, Evodia fruit porridge. 2 grams of evodia fruit, 2 slices of ginger, 2 scallion whites, 50 grams of glutinous rice. Boil the glutinous rice in water, and when the rice is almost cooked, grind evodia fruit and ginger into fine powder, chop the scallion whites, and cook them into porridge. Eat in several doses daily. It has the effects of harmonizing the stomach and stopping vomiting, and regulating Qi and relieving pain.

　　11, Crucian carp porridge. 10 grams of amomum villosum, 10 grams of calamus, 10 grams of tangerine peel, one crucian carp, 10 grams of Sichuan peppercorns, 10 grams of pickled chili peppers, scallion, garlic, and salt to taste. Clean the crucian carp, put the above herbs and spices in the belly, and cook into porridge as usual, and take it in several doses. It has the effects of dispersing cold, regulating Qi, and relieving pain, and is used for chronic pancreatitis.

　　12, Areca nut drink

　　Usage: Wash 10 grams of areca nut and boil it in an appropriate amount of water for 30 minutes, then add 5 grams of amomum villosum and boil for another 5 minutes, discard the residue and drink the juice. Effect: Promotes Qi, resolves stones, harmonizes the middle jiao, mainly for chronic pancreatitis, dampness obstructing the middle jiao, with symptoms of decreased appetite, abdominal distension, sticky and difficult stools, greasy taste in the mouth, and heavy feeling all over the body.

　　13, Clear-braised crucian carp

　　Usage: Remove scales and internal organs from crucian carp, weighing about 300 grams, and wash it clean; wrap 10 grams of tangerine peel and 3 grams of amomum villosum in gauze, add 3 grams of refined salt, scallion whites, and an appropriate amount of vegetable oil. Add these ingredients to a sufficient amount of water, cook together until tender, then remove the medicinal bag and it is ready to eat. Effect: Promotes Qi, promotes diuresis, dries dampness, mainly for chronic pancreatitis in the elderly, with symptoms of abdominal distension and pain, and decreased appetite.

　　14. Amomum and Job's tears porridge

　　Usage: First, wrap 5 grams of amomum villosum in gauze; wash 100 grams of glutinous rice clean, add an appropriate amount of water, and cook it with 30 grams of Job's tears together into porridge; then add the amomum medicine bag and cook for another 5 minutes, remove the medicine bag and season to taste. Effect: Regulating Qi, drying dampness, and relieving pain, treating senile chronic pancreatitis with symptoms such as hidden abdominal pain, lack of thirst, and decreased appetite.

　　15. Codonopsis and Astragalus porridge

　　Usage: Wash 20 grams of Codonopsis pilosula, 15 grams of Astragalus membranaceus, and 100 grams of glutinous rice, then add an appropriate amount of water and cook them into porridge over low heat. Effect: Invigorating the spleen and Qi, treating chronic pancreatitis with symptoms such as hidden pain in the epigastrium and abdomen, fatigue, decreased appetite, and loose stools.

　　16. Dried tangerine peel and clove porridge

　　Usage: Cut 10 grams of dried tangerine peel into pieces, boil 8 grams of clove together, then add 100 grams of glutinous rice and cook them into porridge. Effect: Promoting Qi, drying dampness, and relieving pain, treating chronic pancreatitis with symptoms such as abdominal pain and discomfort.

　　17. Hawthorn and malt porridge

　　Usage: Wash 15 grams of hawthorn and 30 grams of malt, then cook them together with 100 grams of glutinous rice and take them as a medicine. Effect: Dissolving food and accumulation, promoting blood circulation, treating chronic pancreatitis with symptoms such as abdominal pain, decreased appetite, and discomfort in the chest and abdomen.

　　18. Chinese yam and Poria cocos porridge

　　Usage: Wash 30 grams of Chinese yam, 20 grams of Poria cocos, and 100 grams of glutinous rice, then add an appropriate amount of water and cook them together into porridge. Effect: Benefiting Qi and invigorating the spleen, treating chronic pancreatitis with spleen Qi deficiency, with symptoms such as epigastric and abdominal pain, decreased appetite, emaciation, fatigue, and loose stools.

　　Two, what foods are good for biliary chronic pancreatitis:

　　1. It is advisable to eat light, nutritious foods such as fish, lean meat, eggs, tofu, etc., and carbohydrates such as rice and noodles.

　　2. Vegetables such as spinach, broccoli, cauliflower, and radish can be eaten more, but they must be cooked, with fibers softened to prevent diarrhea.

　　3. Fruits such as peaches and bananas, which do not have a sour taste, can be selected.

　　Three, what foods should not be eaten for biliary chronic pancreatitis:

　　1. Alcohol is strictly prohibited, as are high-fat foods. Drinking alcohol and eating high-fat, fatty foods are important causes of acute exacerbation or persistent chronic pancreatitis, so alcohol should be strictly prohibited, and high-fat, fatty foods should not be eaten. There have been cases of death due to necrotizing pancreatitis caused by overeating.

　　2. Salt should not be consumed in excess, as it can increase pancreas congestion and edema.

　　3. Seasonings should not be too sour or spicy. Because they can increase the secretion of gastric juice, and increase the burden on the pancreas.

　　4. Foods that produce gas and cause bloating, such as fried soybeans, broad beans, peas, sweet potatoes, etc., should not be eaten.

　　1. Traditional Chinese medicine treatment

　　The clinical manifestations of this disease are relatively complex, with significant individual differences. At present, there is a lack of unified standards for dialectical differentiation, and it can be referred to the dialectical medicine for conditions such as 'Jaundice', 'Chest pain', 'Diarrhea', and 'Consumptive disease'. During the acute attack phase, it is treated according to biliary acute pancreatitis. During the remission period, it can be divided into three types: Qi and blood stasis, spleen and stomach weakness, and kidney Yin deficiency.

　　(3) Qi Stagnation and Blood Stasis: Disharmony between the liver and gallbladder, stagnation of Qi, as Qi guides blood, Qi stagnation and blood stasis, forming a mass under the diaphragm as a disease. Symptoms include mass in the abdomen, fixed and not moving, pricking pain, pain with a fixed location, dark complexion and emaciation, decreased appetite and fatigue, bluish purple tongue, and涩脉. Treatment should be to activate blood and resolve stasis. The formula is modified Ge Xia Ju Yu Decoction. Commonly used herbs include Danggui, Wu Yao, Yanhusuo, Gancao, Xiangfu, Honghua, Zhike, etc.

　　(2) Spleen and Stomach Deficiency: Disharmony between the liver and gallbladder, failure of the liver and gallbladder to perform their functions, horizontal and opposite invasion of the spleen, leading to the spleen losing its healthy function and the stomach losing its descending function, resulting in disease. Symptoms include diarrhea, indigestion, increased frequency of bowel movements after eating greasy food, decreased appetite, fullness and distension in the chest and abdomen, sallow complexion, fatigue, pale tongue with white coating, and thin, weak pulse. Treatment should be to strengthen the spleen and benefit the stomach. The main formula is Shenling Baizhu Powder. Commonly used herbs include Renshen, Baizhu, Fuling, Huaiyao, Jiegeng, Baibian Dou, Lianzi, Yiyiren, etc.

　　(1) Kidney Yin Deficiency: Prolonged weakness of the spleen and stomach leads to insufficient source of Qi and blood, unable to harmonize with the five internal organs and six bowels, 'When the five internal organs are injured, they will eventually affect the kidney'. The kidney loses the nourishment of the spleen and stomach, leading to kidney Yin deficiency, manifested as emaciation, frequent urination with large volume, dry mouth and chapped lips, restlessness and heat in the five heart regions, thin coating on the tongue, and deep, thin, rapid pulse. Treatment should be nourishing Yin and consolidating the kidney. The formula is modified Liu Wei Di Huang Wan. Commonly used herbs include Shanyao, Shengdi, Shudi, Qizi, Sangshenzi, Maidong, Danpi, Fuling, etc.

　　2. Surgical Treatment

　　Surgical treatment plays an important role in the treatment of this disease. The most common surgical indications are frequent attacks of abdominal pain, which are ineffective after internal medicine treatment. In cases with pancreatic duct stones, pancreatitis, and other pancreatic duct obstructions and strictures, as well as pancreatic cysts, pancreatic abscesses, pancreatic fistulas, or suspected pancreatic cancer, surgical indications can be considered. There are many surgical methods, and they should be chosen cautiously according to clinical practice, and corresponding surgeries should be performed based on the different biliary diseases. Some patients may gradually recover the pancreas after radical treatment of biliary diseases, but in cases where severe organic changes have occurred in the pancreas, pancreatic drainage, partial resection, or even total pancreatectomy should be considered according to specific conditions. For cases with refractory severe pain, consider performing sympathectomy and peripheral nerve resection around the pancreas.