Liečba zápalu pankreasu

14.4.2012 , Jiří Dyntr

lecba-zanetu-slinivky-brisni.jpg - kopie
lecba-zanetu-slinivky-brisni.jpg - kopie
Liečba zápalu pankreasu spočíva predovšetkým v tlmení bolesti, zabezpečovaní dostatočného príjmu tekutín aj potravy, a to často aj vnútrožilovo. Všetky opatrenia by mali viesť k zabráneniu vzniku šokového stavu, ktorý pacienta ohrozuje na živote. V ďalšej fáze liečby zápalu pankreasu sa uplatňuje zmena pacientových stravovacích návykov a obmedzenie konzumácie určitých potravín. Aj cez všetku snahu špičkových pracovísk o liečbu zápalu pankreasu, stále viac ako polovica pacientov na následky ochorenia umiera.

Liečba zápalu pankreasu

Zápal pankreasu patrí k veľmi závažným ochoreniam a prináša pacientom mnoho nepríjemných ťažkostí. Radí sa medzi náhle príhody brušné a môže pacienta ohrozovať aj na živote. Je preto nesmierne dôležité, aby bol odhalený čo najskôr, aby mohla byť zahájená liečba a nastolený liečebný režim. Len tak je možné výrazne zlepšiť zdravotný stav pacienta a mnohokrát mu tiež zachrániť život. Či už sa jedná o akútny zápal pankreasu, alebo o záchvat chronického zápalu, vždy je nutná hospitalizácia a nepretržité sledovanie funkcií krvného obehu, dýchania a obličiek. K dôležitým úlohám lekárskeho tímu patrí zistenie závažnosti ochorenia, jeho príčin a rizikových faktorov, ktorým bol pacient vystavený. Až potom môže byť liečba správne nasmerovaná.

Vznik zápalu pankreasu

Zápal pankreasu, alebo pankreatitída, vzniká v dôsledku zadržania tráviacich enzýmov v pankrease. Tie sa tvoria v tzv. exokrinnej časti pankreasu, zatiaľ čo endokrinná časť tvorí hormóny inzulín a glukagón podieľajúce sa na metabolizme cukrov. Aktivované enzýmy vyvolajú v pankrease opuch a dochádza k samotráveniu pankreasu. Tento stav vzniká najčastejšie v dôsledku žlčového kameňa, ktorý sa zakliesni v spoločnom vývode pankreasu a žlčových ciest. Druhá najčastejšia príčina zápalu pankreasu je chronická konzumácia alkoholu, ktorá podporuje sekréciu tráviacich enzýmov.

Prejavy zápalu pankreasu

Zápal pankreasu môže byť akútny, či chronický. Akútna forma sa prejavuje silnými bolesťami v oblasti nadbruška, ktoré vystreľujú do chrbta a pod lopatku. Ďalej sa prejavuje nevoľnosťou, zvracaním, často vysokou teplotou, zrýchlenou srdcovou frekvenciou, zrýchleným dychom a môže dôjsť aj k dezorientácii. Chronická forma sa prejavuje rovnako bolesťou v podbrušku, obvykle po jedle a pacienti tiež strácajú hmotnosť.

Liečba zápalu pankreasu

U ľahších foriem zápalu pankreasu, ktoré tvoria cca 80% všetkých prípadov, stačí podávanie liekov proti bolesti a udržiavanie dostatočného objemu tekutín v tele. Ak je však pacientov život ohrozený rôznymi komplikáciami, prichádzajú na rad ďalšie liečebné metódy a poskytovaná starostlivosť musí byť komplexná a veľmi intenzívna. Nevyhnutná je podpora činnosti srdca a celého obehového systému rôznymi liekmi, ktoré zabezpečia dostatočné prekrvenie tkanív a zabraňujú vzniku šoku. Tiež sledovanie príjmu a výdaja tekutín a správnej funkcie obličiek patrí k významným úkonom, ktoré zabraňujú vzniku komplikácií zo zníženého objemu tekutín v tele. Väčšinou je potrebné tekutiny dodávať, ale vždy iba tak, aby nedošlo k preťaženiu srdca ich nadmerným množstvom.

Doplnenie tekutín

Doplnenie tekutín je nevyhnutným a prvým krokom v liečbe zápalu pankreasu. Je to nutné predovšetkým preto, že pri zápale pankreasu je prítomná porucha mikrocirkulácie a priepustnosti ciev. Tekutina sa tak dostáva mimo nich a znižuje sa objem kolujúci v cievach. V takom prípade hovoríme o hypovolémii a hypoperfúzii. Tkanivá sú tak v menšej miere zásobené krvou.

Výživa

Výrazný terapeutický význam má výživa hlavne pri akútnom zápale pankreasu. Potravu je možné pacientovi podávať ústami prakticky kedykoľvek, pokiaľ chorý potravu toleruje. Podáva sa po odznení bolestí a porúch pasáže čo najskôr. Pokiaľ nie je možné podávať potravu ústami, je možné zaviesť nazogastrickú sondu a podávať potravu touto cestou.

Antibiotická profylaxia

Pretože zápal pankreasu môže viesť behom 3-4 týždňov až k nekróze tkaniva, teda k jeho odumretiu, je na tomto teréne zvýšené riziko nasadnutia infekcie. Z tohto dôvodu sa profylakticky podávajú antibiotiká, ale väčšinou iba v prípadoch kedy dochádza k výraznému obehovému zlyhávaniu, k sepsii, či po traumatickom zápale pankreasu. Názory na užitie antibiotickej profylaxie pri zápale pankreasu sa rôznia.

Úprava stravovacích návykov

Okrem spomenutých liečebných metód a opatrení je tiež kladený dôraz na úpravu stravovania. Pacienti by sa mali vyhýbať alkoholu a mastným jedlám, predovšetkým v jednorazových vysokých dávkach. Zároveň sa odporúča dodržiavať zásady zdravej výživy, predovšetkým prijímať pestrú a vyváženú stravu, ale nezabúdať pri tom na určité obmedzenia, ktorá prináša pacientovi jeho choroba. Aj napriek intenzívnej liečbe a dobrej spoluprácu pacienta je totiž zápal pankreasu veľmi závažným stavom, ktorý aj pri hospitalizácii v špičkových nemocniciach, končí v 60% prípadov smrťou.

Farmakologická liečba

Farmakologická liečba spočíva v podávaní liekov, proti bolesti, tzv. analgetík. Najčastejšie sa podávajú opiáty typu, buprenorfín, pentazocín, alebo fentanyl. Pokiaľ je zápal dlhodobého charakteru, často je prítomna nedostatočná tvorba tráviacich enzýmov, ktoré je nevyhnutné nahradiť v liekovej forme. Vzhľadom k tomu, že môže byť postihnutá aj oblasť pankreasu, ktorá tvorí inzulín, je nevyhnutné korigovať aj tento hormón podávaním v injekčnej forme, či tabletkách.

Chirurgická liečba

Chirurgická liečba zápalu pankreasu spočíva v odstraňovaní nekrotickej oblasti orgánu, teda tej ktorá je už odumretá. Pokiaľ je príčinou zápalu pankreasu žlčový kameň zakliesnený v žlčových cestách, či v pankreatickom vývode, je nutné ho spriechodniť.

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