Senile acute pancreatitis

　　Alcohol consumption and biliary tract diseases are two main causes of acute pancreatitis in young and middle-aged adults, but for elderly acute pancreatitis, the most common cause is biliary tract diseases, with other causes such as microthrombosis, tumors, and medications also being more common in the elderly.

　　1. Biliary diseases:Occupying 50% to 70%. Acute pancreatitis is closely related to biliary tract diseases because 80% of bile ducts and pancreatic ducts open into the Vater壶腹, and after merging, they enter the duodenum through a common channel that is 2 to 5mm long. If there is an obstruction in the ampulla, when the pressure in the gallbladder contracts and exceeds the pressure in the pancreatic duct, bile can reflux into the pancreatic duct to activate zymogen, causing self-digestion, which is known as the 'common channel theory'. The causes of ampulla obstruction include the most common being the impaction of common bile duct stones, obstruction by acute infectious secretions, spasm of the Oddi sphincter, and biliary ascariasis.

　　2. Idiopathic:In elderly acute pancreatitis, 23% to 30% are idiopathic, while in the general population, it is 10% to 15%. Recent studies have shown that about 74% of patients originally considered to have idiopathic pancreatitis are caused by bile sedimentation, cholesterol crystal suspension, biliverdin calcium salt particles, or due to abnormal pancreaticobiliary ducts such as ampullary duodenal diverticula, papillary stenosis, etc.

　　3. Surgical trauma:Acute pancreatitis caused by surgical trauma in the elderly accounts for about 12.5%. Any upper abdominal or retroperitoneal surgery may cause pancreatic injury. The massive supplementation of calcium during surgery, poor renal function before surgery, and hypoperfusion are important triggers of acute pancreatitis. The elderly have poor tolerance to hypoperfusion, and about 50% of severe hypovolemic shock patients may develop acute pancreatitis.

　　4. Pancreatic cancer:The elderly are a high-risk population for pancreatic cancer, with about 1% of acute pancreatitis secondary to pancreatic cancer.

　　5. Drugs:As early as the 1980s, drug-induced pancreatitis had attracted people's attention. Drugs that can cause pancreatitis include thiazides, furosemides, sulfonamides, estrogens, corticosteroids, methyldopa, procainamide, metronidazole, etc. The elderly are prone to multiple organ diseases and often take more medication, so drugs are an indispensable factor in triggering elderly pancreatitis.

　　6. Endoscopic retrograde cholangiopancreatography (ERCP):ERCP can cause a transient increase in blood amylase, and about 5% of cases of acute pancreatitis are caused by ERCP, but the risk of ERCP causing elderly acute pancreatitis is relatively high.

　　7. Others:Due to elderly atherosclerosis, in addition to other endocrine or metabolic abnormalities such as hyperlipidemia, hypercalcemia, diabetes, etc., thrombosis is much higher than that in young people, and microthrombosis leading to acute pancreatitis is also often seen.

　　In China, the incidence of complications of elderly acute pancreatitis reported is as high as 73%, which are common, including ARDS (acute respiratory distress syndrome), shock, electrolyte acid-base balance disorder, diabetes, heart failure, arrhythmia, renal failure, and severe gastrointestinal bleeding, etc.

　　In the elderly, the decline in organ function and autonomic nerve function disorder lead to an increased pain threshold, low sensitivity, and poor discriminative ability, resulting in atypical symptoms and signs, complex clinical manifestations, rapid progression of the disease, and early onset of shock and multiple organ failure.

　　1. Abdominal pain

　　Abdominal pain is often mild or without pain, and when present, it is usually dull, located in the upper abdomen. Typical severe upper abdominal pain is rare, and it is not easily relieved by general antispasmodic drugs.

　　2, Nausea, vomiting, and abdominal distension

　　More than 80% have nausea, vomiting, and abdominal distension.

　　3, Fever

　　Most patients have moderate fever, a few have low body temperature, and a very few can have high fever. Fever usually lasts for 3～5 days, if the high fever does not subside, it should be suspected of secondary infection (such as pancreatic abscess, peritonitis, etc.).

　　4, Shock

　　It can occur gradually or suddenly, even die quickly, with pale skin, cold sweat, thin pulse, and decreased blood pressure.

　　5, Jaundice

　　A few patients have jaundice, mostly due to bile duct inflammation or due to edema of the pancreas compressing the common bile duct.

　　6, Signs

　　Typical peritoneal irritation signs are often lacking, only mild to moderate tenderness, rebound tenderness, decreased bowel sounds; acute necrotic hemorrhagic pancreatitis can often lead to ascites, and ascites can be bloody. Bloody ascites can infiltrate into the subcutaneous tissue, and subcutaneous hemorrhage can appear on both sides of the abdomen or at the umbilicus. Ascites can enter the pleural cavity through the lymphatic丛 and the micropores of the diaphragm, causing pleural effusion, atelectasis, or pneumonia signs.

　　The prevention of elderly acute pancreatitis mainly focuses on the prevention of primary diseases. If prone to illness, mild cases only require fasting, rest, fluid replacement, and nutrition. Supportive and appropriate symptomatic treatment can be restored. Severe patients need to closely observe changes in pulse, respiration, blood pressure, heart rate, and actively prevent the occurrence of complications.

　　The symptoms and signs of elderly acute pancreatitis are atypical, so it is difficult to make a diagnosis only based on symptoms and signs, and a diagnosis can be made through the following examination results.

　　1, Blood leukocytes

　　The white blood cells can increase to (10～20)×109/L, and neutrophils are significantly increased.

　　2, Blood amylase

　　It starts to rise 8 hours after onset, reaches the peak at 24 hours, and lasts for 3～5 days, in acute pancreatitis it is >250U% (Somogyi method), and if it is >500U% it can be diagnosed. The level of amylase does not necessarily indicate the severity of inflammation, the mild ones may be very high, and the hemorrhagic necrotic type may be normal.

　　3, Urinary amylase

　　The increase of urinary amylase usually appears 12～24 hours after onset and can last for 1～2 weeks; the abnormal rate of urinary amylase in elderly acute pancreatitis is lower than that of blood amylase, which may be related to senile renal artery sclerosis and reduced renal clearance function; the normal value is 64U (Winslow method), >128U is significant, and it is often above 256U in acute pancreatitis.

　　4, Urinary amylase creatinine clearance rate

　　The normal value is 3.1%, it can increase by 3 times in acute pancreatitis.

　　5, Serum lipase

　　The normal value is 0.2～0.7U%, it is >1.5U% in acute pancreatitis and starts to rise after 72 hours of onset; for those whose blood amylase has returned to normal, serum lipase has reference value.

　　6, Serum methemoglobin

　　In acute hemorrhagic necrotic pancreatitis, due to internal hemorrhage, hemoglobin produced by red blood cell destruction is excessive, and it combines with albumin to form methemoglobin; it is negative in acute edematous pancreatitis and positive in necrotic type, which has reference value for diagnosis and prognosis.

　　7, Blood calcium

　　It can be reduced in hemorrhagic necrotic pancreatitis, such as

　　8, Other

　　The level of amylase in pleural effusion or peritoneal fluid is higher than that in blood and urine.

　　9. Abdominal flat film

　　It can be seen that there is intestinal bloating, chest X-ray shows pleural effusion, atelectasis, and electrocardiogram shows ST segment depression, flat or inverted T waves; the condition improves and returns to normal after recovery, and pancreas ultrasound or CT shows pancreas enlargement, necrosis or hemorrhage, abscess or cyst formation.

　　The dietary precautions for elderly patients with acute pancreatitis mainly include the following aspects:

　　1. It is advisable to eat light and nutritious fluid foods, such as congee, vegetable soup, lotus root starch, egg flower soup, and noodles.

　　2. In addition to liquid food, it also includes congee, plain noodles, vegetarian noodles, vegetarian wontons, bread, biscuits (low in oil), and minced soft vegetables, fruits, etc.

　　3. After the pain and vomiting are basically gone, and the white blood cell amylase decreases to normal, pure carbohydrate-free food without fat can be given, including congee, thin lotus root starch, almond tea, fruit juice, jelly, and other sugar-containing foods. These foods have no stimulating effect on the exocrine secretion of the pancreas and can be used as the main source of energy for acute pancreatitis.

　　4. It is advisable to moderately increase foods such as sieved congee, steamed egg white, and a small amount of soy milk soup.

　　5. Choose vegetable oils, and mostly use methods such as boiling, steaming, cold dressing, roasting, braising, pickling, and stewing for cooking.

　　6. General recovery usually takes 2 to 3 months, and to prevent recurrence, it is still necessary to avoid eating foods rich in fat for a relatively long time.

　　The principles of treating elderly acute pancreatitis include not only inhibiting pancreatic juice secretion, inhibiting pancreatic enzyme activity, actively preventing and treating complications, but also paying special attention to active supportive treatment, strengthening monitoring, and identifying the cause of the disease as soon as possible. When using drugs, it is advisable to choose drugs with small renal toxicity. Actively use broad-spectrum antibiotics. For those who have surgical indications, surgery should be performed as soon as possible.

　　1. Internal medicine treatment
　　1. General treatment
　　Active supportive treatment: Strengthening monitoring, through active treatment methods, the mortality rate of elderly acute pancreatitis has been reduced to 5% in foreign countries, with no deaths in mild and moderate cases.

　　Rescue from shock: The occurrence of shock is a sign of poor prognosis and should be actively treated. It is generally recommended to use a large amount of intravenous antiproteinase activity drugs early on, and to provide sufficient blood transfusion, plasma, human serum albumin, etc. Because inflammation and necrosis often result in the loss of a large amount of plasma and whole blood, which can reach 30% of body weight. It is necessary to measure the central venous pressure during fluid infusion and adjust the fluid volume according to pressure changes to avoid affecting cardiovascular and pulmonary function. Vasoconstrictor drugs can only have a temporary effect and should be used as little as possible. The effect of corticosteroids is not certain, it can reduce the ability to resist infection, increase blood sugar, and has the risk of triggering pancreatitis, so it is not recommended to use them.

　　The application of antibiotics: It is advisable to actively use broad-spectrum antibiotics. Elderly people have poor resistance and are prone to various infections. In the case of hemorrhagic necrotizing pancreatitis, the mortality rates are 10% and 30% with and without infection, respectively, indicating that preventing infection is very helpful for improving the prognosis. Since elderly acute pancreatitis is most commonly caused by biliary stones, it is recommended to use antibiotics routinely for elderly patients. If pancreas infection occurs, it is advisable to use antibiotics against anaerobic bacteria and Gram-positive bacteria, such as imipenem-cilastatin sodium (Tienam), ciprofloxacin, ofloxacin, which have strong penetration and are often used as the first choice of medication.

　　④ Correcting the balance of water and electrolytes: Due to vomiting, fasting, and gastrointestinal decompression, a large amount of water and electrolytes are lost, so they should be supplemented as soon as possible. 1000ml of 5% glucose and 2000ml of 10% glucose are needed daily, and the amount of fluid drained out by gastrointestinal decompression should also be compensated. Pay attention to changes in blood potassium and blood calcium, and supplement them in time if necessary.

　　⑤ Rescue from respiratory failure: When respiratory acceleration is found, blood gas changes should be monitored. If PaO2 decreases, it is a sign of respiratory insufficiency, and humidified oxygen inhalation should be given in time. Tracheotomy and artificial respiration with an oxygenator may be necessary if necessary.

　　⑥ Abdominal pain: Those with severe pain should be controlled as soon as possible. Severe pain not only affects the recovery of the disease, but also affects cardiac function. Atropine should be used together with pethidine or morphine to prevent spasm of the Oddi's sphincter. Pethidine 50-100mg or morphine 10mg intramuscular injection plus atropine 0.5mg intramuscular injection, repeated every 4-6 hours.

　　⑦ Abdominal lavage: This method can clear the pancreatic exudates in the abdominal cavity to reduce the stimulation of the peritoneum and reduce the absorption of toxic substances into the blood circulation. This therapy is suitable for patients with acute hemorrhagic necrotic pancreatitis. The lavage fluid is an isotonic balanced electrolyte solution containing 15g of sugar, 4mmol of potassium, 500U of heparin, and appropriate broad-spectrum antibiotics. In summary, it takes 15 minutes to infuse 2 liters of fluid into the abdominal cavity under gravity. It is retained in the abdominal cavity for about 30 minutes, and then drained out by gravity. This cyclic operation is repeated once every hour. It lasts for 48 hours to 7 days, depending on the patient's condition.

　　⑧ Control of hyperglycemia: Severe pancreatitis can cause hyperglycemia, insulin treatment should be given according to blood glucose or urine glucose. Insulin can be added to the intravenous glucose solution, and urine sugar should be checked once every 4 hours, and fasting blood glucose should be checked daily. Adjust the dose of insulin according to the results of blood glucose and urine sugar.

　　⑨ As soon as possible to identify the cause of the disease: unclear etiology is prone to recurrent acute pancreatitis, increasing the incidence and mortality rate of complications, so under possible conditions, systematic examination should be carried out to identify the cause. For those with calculus impaction, papillary muscle incision and stone extraction can be performed. For those caused by drugs, medication should be discontinued immediately.

　　2, Inhibiting or reducing pancreatic juice secretion:
　　① Abstaining from food and gastrointestinal decompression: It can not only reduce the promotion of gastric acid on pancreatic juice secretion, but also reduce the occurrence of paralytic ileus.

　　② Drugs for inhibiting secretion:

　　A, Antisecretory drugs: They can not only reduce gastric acid secretion and reduce the stimulation of pancreatic enzyme secretion, but also prevent the occurrence of stress-induced gastric mucosal lesions. Commonly used ones include omeprazole 40mg, intravenous injection, twice a day; cimetidine (cimetidine) 800mg, intravenous infusion, twice a day; famotidine 40mg, intravenous injection, twice a day.

　　The combined use of insulin and glucagon (glucagon): It has the effects of inhibiting fat necrosis and reducing pancreatic secretion. 20 units of insulin (regular insulin) are added to 1000ml of 5% glucose solution for intravenous infusion, and the infusion rate is determined according to the control of abdominal pain, usually using 2 liters of fluid within 24 hours. Glucagon (glucagon): The first dose is 1mg added to 100ml of normal saline for intravenous infusion, followed by 10-15mg/kg, which can be administered 2-4 times a day.

　　C. Somatostatin: This drug can antagonize胆囊收缩素-促胰酶素 (CCK-PZ), with organ and cell protective effects. Octreotide (Sandostatin): For acute pancreatitis, 0.1 to 0.2 mg, every 8 hours, administered subcutaneously for 3 to 7 days continuously.

　　D. Others: Such as calcitonin,胆囊收缩素受体拮抗药 (CCK receptor antagonists).

　　3. Application of antiprotease activity drugs
　　In recent years, there have been more and more trypsin inhibitors on the market. Some people emphasize that regardless of the type of pancreatitis, trypsin activity inhibitors should be used early, not only to prevent the conversion to severe cases but also to shorten the course of the disease. However, such drugs should be used early, as they cannot reverse severe lesions if they have formed. Common trypsin inhibitors include Aprotinin (Trasylol, Aprotinin, Iniprol), which are all polypeptides and can inhibit protein degradation, inhibiting trypsin, chymotrypsin, kallikrein, plasmin, and others.

　　①Aprotinin (Trasylol): Administered at a dose of 100,000 U each time, twice daily, by intravenous infusion.

　　②Aprotinin (Iniprol): Administered at a dose of 20,000 to 40,000 U each time, by intravenous infusion.

　　③Aprotinin: Administered at a dose of 100,000 to 200,000 U, even up to 500,000 U, twice daily, by intravenous infusion.

　　④Chlorophyll a: It has no ability to inhibit proteases by itself. After metabolism in the body, chlorophyll acid has a strong inhibitory effect on proteases. It is administered intravenously at a dose of 20 to 30 mg daily.

　　⑤Gabexate (Foy): A non-peptide synthetic agent that can inhibit proteases, kallikrein, thrombin, elastase, and other enzymes, with effects similar to antiproteinase (Aprotinin). Gabexate (Foy) 100 mg is equivalent to 50,000 to 100,000 U of Aprotinin. Depending on the condition, it can be administered intravenously at a dose of 100 to 300 mg dissolved in 500 to 1500 ml of glucose and saline solution at a rate of 2.5 mg/(kg·h). After 2 to 3 days, as the condition improves, the dose can be gradually reduced. Side effects may include hypotension, phlebitis, rash, and others.

　　⑥FL7-175: Similar in efficacy to Foy (Gabexate). It is 10 times stronger than Foy, with a dose of 10 mg, twice daily, administered by intravenous infusion.

　　⑦Micaclid: This is an updated pancreatic enzyme inhibitor compared to Foy (Gabexate), with strong inhibitory effects on trypsin, chymotrypsin, hyaluronidase, and creatine kinase; moderate inhibitory effects on carboxypeptidase, plasmin, and lipase; and slight inhibitory effects on elastase, intestinal kinase, and amylase. The drug can enhance the stability of lysosomal membranes and improve microcirculation, exerting an antishock effect. It is administered intravenously at a dose of 200,000 to 250,000 U, once daily, for 1 to 2 weeks.

　　⑧ Aminocaproic acid (6-aminocaproic acid, EACA), aminomethylbenzoic acid (p-carboxybenzylamine, PAMBA): They can inhibit bradykinin, enhance the activity of plasma antiprotease. Aminocaproic acid (EACA) 8-10g for intravenous infusion, 1-2 times a day. Aminomethylbenzoic acid (PAMBA) 0.4-0.6g for intravenous infusion, once a day.

　　⑨ Diphosphocytidine (nucleotide) choline (CDP-Choline): It has the effect of inhibiting phospholipase A2 and can improve the abnormal phospholipid metabolism that occurs during pancreatitis. The usage is to add 500mg to 500ml of 5% glucose for intravenous infusion, twice a day. According to the severity of symptoms, the medication can be continued for 7 to 14 days. A few cases may have mild rash, headache, and mild liver function abnormalities after taking this drug.

　　4. Improve pancreatic blood supply
　　During acute severe pancreatitis, the microcirculation of the pancreas is often impaired, with ischemic phenomena, which further aggravates the condition of pancreatitis. Dextran 70 and Naloxone (Naloxone) can improve the blood circulation of acute pancreatitis. Dextran 70: 500ml/d. Naloxone (Naloxone): 2mg/kg dissolved in glucose for intravenous infusion.

　　Second, surgical treatment
　　1. Indications for surgery: patients with clear biliary stone impaction and failure of endoscopic treatment; intrapancreatic abscess; pseudocyst infection; peripancreatic abscess.

　　2. Studies have shown that laparoscopic cholecystectomy at the initial stage of hospitalization does not increase any risk for patients with gallstone acute pancreatitis of any age, and it is a treatment option for most patients. Early surgical treatment for elderly patients with surgical indications can significantly improve survival rates, but due to poor healing ability in the elderly, the removal of drainage tubes should be appropriately delayed.

　　Ranson et al. listed 11 risk factors within 48 hours after admission to judge the severity and prognosis of acute pancreatitis. If the patient has only 1 or 2 risk factors, the mortality rate