Альманах клинической медицины. 2016; 44: 654-660
Спорные вопросы Российского консенсуса по диагностике и лечению хронического панкреатита
https://doi.org/10.18786/2072-0505-2016-44-6-654-660Аннотация
Представлен ряд наиболее дискуссионных положений Российского консенсуса по диагностике и лечению хронического панкреатита (далее – Консенсус). Обсуждение проведено по инициативе Российского панкреатологического клуба по Дельфийской системе. Междисциплинарный подход обеспечен участием ведущих гастроэнтерологов, хирургов и педиатров. Данная статья открывает серию публикаций по вопросам Консенсуса. Представлены наиболее спорные положения Главы 5 «Лечение острых периодов» и Главы 8 «Тактика при болевом синдроме». При обсуждении традиционной рекомендации о соблюдении голода при появлении клинических симптомов обострения хронического панкреатита отмечено, что ранее это было практически единственным методом обеспечения физиологического покоя поджелудочной железы. Однако больные хроническим панкреатитом часто подвержены мальнутриции, поэтому при голодании возможно усугубление трофологической недостаточности, значимо влияющей на прогноз. Следовательно, показана ранняя нутритивная поддержка. В целях уменьшения секреторного напряжения поджелудочной железы целесообразно использование смесей для энтерального питания (элементные и полуэлементные смеси). Переход со смесей на традиционное питание должен сопровождаться назначением адекватных доз панкреатина. Дискуссионными оказались положения о роли панкреатических ферментов, спазмолитиков и ингибиторов протонной помпы в купировании болевого синдрома.
Список литературы
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Almanac of Clinical Medicine. 2016; 44: 654-660
The Russian consensus on diagnosis and treatment of chronic pancreatitis: points of debate
https://doi.org/10.18786/2072-0505-2016-44-6-654-660Abstract
The most controversial provisions of the Russian Consensus on Diagnosis and Treatment of Chronic Pancreatitis (hereinafter, the Consensus) are presented. The debate has been initiated by the Russian Pancreatic Club and performed with the use of the Delphi system, based on interdisciplinary approach with participation of leading gastroenterologists, surgeons and pediatricians. This paper is the first in the series of the Consensus-related publications. Here we discuss the most controversial issues of Chapter 5 "Treatment of acute episodes" and Chapter 8 "Strategies of pain syndrome management". While discussing the conventional recommendation of a period of starvation for patients with clinical symptom of exacerbation of chronic pancreatitis, it was noted that for a long time it had been virtually the only way to provide functional rest for the pancreas. However, patients with chronic pancreatitis are frequently in malnutrition, therefore, starving may aggravate nutritional deficit that significantly affects the prognosis; therefore, early nutritional support is indicated. To alleviate functional strain of the pancreas, it is reasonable to use enteral nutrition elemental and semi-elemental formulas. The transition from formulas to conventional nutrition should be accompanied by administration of adequate pancreatin doses. The role of pancreatic enzymes, spasmolytics and proton pump inhibitors in the management of pain syndrome was also controversial.
References
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5. Dominguez-Munoz JE. Pancreatic enzyme therapy for pancreatic exocrine insufficiency. Curr Gastroenterol Rep. 2007;9(2):116-22.
6. Hart PA, Bechtold ML, Marshall JB, Choud-hary A, Puli SR, Roy PK. Prophylactic antibiotics in necrotizing pancreatitis: a meta-analy-sis. South Med J. 2008;101(11):1126-31. doi: 10.1097/SMJ.0b013e31817ecbda.
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8. Frulloni L, Falconi M, Gabbrielli A, Gaia E, Graziani R, Pezzilli R, Uomo G, Andriulli A, Balzano G, Benini L, Calculli L, Campra D, Capurso G, Cavestro GM, De Angelis C, Ghez-zo L, Manfredi R, Malesci A, Mariani A, Mutig-nani M, Ventrucci M, Zamboni G, Amodio A, Vantini I; Italian Association for the Study of the Pancreas (AISP), Bassi C, Delle Fave G, Frulloni L, Vantini I, Falconi M, Frulloni L, Gabbrielli A, Graziani R, Pezzilli R, Capur-so IV, Cavestro GM, De Angelis C, Falconi M, Gaia E, Ghezzo L, Gabbrielli A, Graziani R, Manfredi R, Malesci A, Mariani A, Mutig-nani M, Pezzilli R, Uomo G, Ventrucci M, Zamboni G, Vantini I, Magarini F, Albarello L, Alfieri S, Amodio A, Andriulli A, Anti M, Ar-cidiacono P, Baiocchi L, Balzano G, Benini L, Berretti D, Boraschi P, Buscarini E, Calculli L, Carroccio A, Campra D, Celebrano MR, Capurso G, Casadei R, Cavestro GM, Chilovi F, Conigliaro R, Dall'Oglio L, De Angelis C, De Boni M, De Pretis G, Di Priolo S, Di Sebastia-no PL, Doglietto GB, Falconi M, Filauro M, Frieri G, Frulloni L, Fuini A, Gaia E, Ghezzo L, Gabbrielli A, Graziani R, Loriga P, Macarri G, Manes G, Manfredi R, Malesci A, Mariani A, Massucco P, Milani S, Mutignani M, Pasqua-li C, Pederzoli P, Pezzilli R, Pietrangeli M, Roc-ca R, Russello D, Siquini W, Traina M, Uomo G, Veneroni L, Ventrucci M, Zilli M, Zamboni G. Italian consensus guidelines for chronic pancreatitis. Dig Liver Dis. 2010;42 Suppl 6:S381-406. doi: 10.1016/S1590-8658(10)60682-2.
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13. Lerch MM, Bachmann KA, Izbicki JR. New guidelines on chronic pancreatitis: interdisciplinary treatment strategies. Chirurg. 2013;84(2):99-105. doi: 10.1007/s00104-012-2373-z.
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