CHARACTERISTICS OF PAIN AS PREDICTOR OF FIBROSIS SEVERITY IN PATIENTS WITH FIBROTIC- DEGENERATIVE FORMS OF CHRONIC PANCREATITIS

Introduction. Chronic pancreatitis is a continuously progressing disease with atrophy and fibrosis as main features. The main clinical symptom of chronic pancreatitis is pain. The aim of our investigation was to define the type of pain as a predictor of the severity of fibrosis in patients with fibrotic degenerative forms of chronic pancreatitis. Material and methods. The results of surgical treat-ment of 69 patients with fibrotic- degenerative chronic pancreatitis were submitted. In all 69 patients chronic pancreatitis occurs after attack of acute pancreatitis, and 59 (85.5%) patients were alcohol abused. 21 patients had calculus's chronic pancreatitis, obstructive – 34, fibrosis – 2, cyst – 12. Patients with a cyst were those, where cyst were connected with degenerative main pancreatic duct. In all 69 patients during surgery procedure, we checked a tissue resistant pressure with Stryker tissue pressure monitor and pressure inside the main pancreatic duct. 39 patient underwent open approach surgical treatment. Results. Fibrotic –degenerative form of chronic pan-creatitis associated with parenchymal and ductal changes of the pancreas. Multiple strictures of main pancreatic duct were found in 50 (72.5%) patients (calcification form – 21, obstructive – 24, cyst – 5). Isolated stricture of main pancreatic duct were found in 17 (24.6%) (Obstructive – 10, cyst – 7). Dependence of pain type to chronic pancreatitis severity was checked in all 69 patients. 45 (65.2%) patients with calcification chronic pancreatitis, multiple strictures of main pancreatic duct, had B type pain at time of admission to the hospital. Patients with isolated strictures without calculus or multiple strictures of main pancreatic duct located in distal parts of pancreas had A type pain. One patient with fibrosis of the pancreas had type B and one – type A pain. All patients had rated their pain feeling according Brief Pain Inventory (Short Form) scale (BPI). There is significant difference between two groups in description of pain (7.65 vs 5.89, p<0.0001) and pain on the average (8.63 vs 6.32, p<0.0001). Other categories had no significant difference: pain at its worst (9.26 vs 9.05, p>0,05); functional interference caused by pain (7.79 vs 7.42, p>0,05). Patient with calcification (5) and obstructive chronic pancreatitis (multiple strictures of the main pancreatic duct) had tissue resistant pressure as high as >200 mm. Hg in all part of the pancreas indicating the total pancreatic fibrosis. In patients with pancreatic head alone stricture tissue resistant pressure was highest it the place of pancreatic duct stricture (>200 mm. Hg), as in other parts of the pancreas it decrease till 120 mm. Hg and lower. Ductal pressure was increased only in 22 (59,5%) patients. All patients histologically had 4 grade of fibrosis in the stricture place, and there was clear correlation with tissue resistant pressure and histological fibrosis grade. Histologically square of fibrotic fields in the specimen were 81,4±6,6 %. Conclusion: The nature of type A pain is the hyper-tonic crisis inside the main pancreatic duct (or cyst) with medium stage of pancreatic fibrosis. Type B pain is associated with severe stage of pancreatic fibrosis. The type of pain indirectly can predict fibrotic- degenerative forms of chronic pancreatitis. Surgical procedure should not only decrease ductal pressure and make local resection of the head of the pancreas but wide excision of the pancreatic stricture with the opening of the secondary and tertiary ducts. Moreover, excision should be performed in zone of maximal tissue resistant pressure (>200 mm. Hg), but in place lower 120 mm. Hg it is enough to do simple draining procedure. The pacemaker of CP should be considered as zone of maximal fibrosis that not always located in the pancreatic head.