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Management of labor/ delivery with pre existing hypertension 2 страница
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The icteric stage lasts 5-20 days and is characterized by the basic clinical signs, such as nausea, vomiting, liquid stool, pain in the right hypochondrium and epigastrium, weakness, headache, irritability, rheumatic pain in the body. Liver and spleen increase in size and become sickly.
In general, virus hepatitis A has no dramatic effect on the course of gestation. One of the most often complications at acute viral hepatitis A during pregnancy is abortion. In the II and III trimester of pregnancy the risk of discontinuing is much higher than in the first one. The development of late gestoses of pregnant, bleeding is possible too.
Viral Hepatitis B (VHB) with Pregnancy
Viral hepatitis B in pregnancy proceeds much more severely, and represents danger to mother and her fetus. Viral hepatitis B affects liver cells, is transferred from the patient or virus carrier with blood and other biological liquid (urine, saliva, milk, semen). The incubator period is long — from 6 weeks to 6 months. A prodromal stage is 1-4 weeks.
The preicteric stage proceeds from 5 to 30 days and is characterized by dyspepsia, allergy in a form of skin eruption, arthralgia, and significant intoxication.
The icteric period proceeds from 1 week to 2-3 months with exacerbation of intoxication, intensive itch, splenomegaly, hepatomegaly. There is discoloration of excrement; urine gets a dark, saturated color.
Clinical manifestations: nausea, vomiting, loss of appetite, pain in the right hypochondrium, hepatolienomegaly, arthralgias. Temperature rises seldom, and it is insignificant. With occurrence of icterus the intoxication increases, hemorrhagic signs occur. Acute hepatic failure, encephalopathy, hemorrhagic diathesis, disturbances of albumin synthesis and liver dysfunction, severe general intoxication develop. Massive necrosis of liver and death of the patient are frequently possible.
The convalescence occurs slowly, almost always results in development of chronic hepatitis.
In the stage of icterus augmenting the disease results in premature birth. Newborns in the process of labor are usually infected with HBV, subsequently in 80 % of children chronic hepatitis develops.
Hepatitis B virus (HBV) has a high rate of vertical transmission causing fetal and neonatal hepatitis. Additionally, maternally and neonatally transmitted HBV infection predisposes to liver cirrhosis and hepatocellular carcinoma in young adults.
Thus, in contrast to VHА, viral hepatitis B represents real danger to life of the mother, fetus and newborn. Acute VHВ produces an unfavorable effect on course of pregnancy. In its turn, pregnancy and labor exacerbate the course and prognosis of VHB. The aggravation of symptoms in the second half of pregnancy can be complicated with acute liver impairment with encephalopathy and coma, with high lethality. At development of the disease in the III trimester of pregnancy premature birth (in 47 %), anomaly of labor pains (in 19 %), bleedings — (in 12 %), fetus hypotrophy (in 22 %) frequently develop. Late forms of gestoses are also frequent. The perinatal mortality at acute VHВ makes up 140‰. Acute hepatic insufficiency and coma often develop.
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Labor in acute stage of VHB is conducted through maternal passages according to obstetrical situation.
Viral Hepatitis C (VHC) with Pregnancy
The causative agent of illness is hepatitis C virus, which is single-stranded, flavivirus-like RNA agent, 29-35 nm in diameter, and very changeable. The changeability of the virus leads to its rapid mutation, so significant immunity is almost absent in patients with VHC.
Contamination occurs by parenteral, infusion and sexual type.
The duration of incubatory period makes up 3-4 months.
The preicteric period lasts from 2 to 14 days and is characterized by gradual intensification of dyspepsia and asthenovegetative syndrome.
The icteric period lasts for 14-21 days with a moderate intoxication. It is very important that only 5 % of sick people have symptoms of intoxication and icterus, while the rest have an asymptomatic (masked) form of VHC.
Convalescence occurs slowly, a complete recovery takes place in 50% of patients, thus in 50-80% of them the disease terminates with the development of chronic hepatitis (more often in a form of active hepatitis or cirrhosis). Sometimes hepatocellular carcinoma may occur.
The most probable complications in pregnancy with VHC are:
· miscarriages,
· premature labors (immature infants), most often in 28-30 and 34-35 weeks of gestation,
· congenital anomalies of the fetus in case of happening of VHC in the 1st trimester of pregnancy,
· worsening of mother’s general condition in the 2nd and 3rd trimester of pregnancy.
Viral Hepatitis D (VHD) with Pregnancy
The causative agent of illness is hepatitis D virus, composed of ribonucleic acid (RNA), satellite viruses of plants, being 28-39 nm in diameter. Contamination occurs through blood, placenta; a sexual type is also possible.
Two variants of clinical course are distinguished:
· co-infection with VHB and VHD in patients without previous history of VHB,
· superinfection in established chronic VHB.
In case of co-infection the incubator period is 3-8 weeks. The clinical features of preicteric stage are similar to those at VHB, but more severe. A diphasic clinical course is characteristic of these patients; the phases are characterized by increased peak of transaminase activity, hyperbilirubinemia and exacerbation of general condition of patient. The interval between peaks is 15-32 days. There is an increase of icterus intensity, general intoxication in icteric stage. The outcome is favourable, as a rule.
In case of superinfection a severe course of VHD develops, fulminant hepatitis is not rare due to necrotic processes in the liver and occurrence of progressive acute hepatitis and cirrhosis. The incubator period is from 6 weeks to 6 months. The clinical picture is like in VHB, but more serious.
Convalescence occurs slowly, in a few months.
On the other hand, asymptomatic (masked) course of VHD is possible, and its incidence is 2 times more often in nonpregnant women than in pregnant.
Viral Hepatitis E (VHE) with Pregnancy
This form is widespread in tropical countries, Latin America and Asia.
The causative agent of illness is hepatitis E virus, composed of ribonucleic acid (RNA), 32-34 nm in diameter. Its antigenic structure has not been studied till nowadays.
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Contamination occurs by a fecal-oral type. The incubator period lasts for 1-9 days, but may be 30-40 days.
The course of VHE in pregnants is severe; 20% of patients die if the disease occurs in the 2nd half of pregnancy, the day before delivery or abortion.
The preicteric stage lasts for 1-9 days (on average 3-4 days). It is characterized by intensification of weakness (asthenia), lethargy, nausea, vomiting, pains in the right hypochondrium. Hyperthermia is possible.
The icteric stage proceeds for 1-3-weeks. The main symptoms are skin and mucous icterus, enlargement and morbidity of the liver, itch, etc.
In severe forms of VHE DIC develops and leads to intravascular hemolysis and acute renal-hepatic insufficiency.
Diagnostics of Viral Hepatitis
It includes:
· blood test
· urine test
· urobilin and bile acids in urine,
· biochemical blood test:
§ glucose in blood serum
§ residual nitrogen
§ cholesterol
§ total bilirubin, and its fractions
§ total protein and its fractions
§ transaminase, glutamic acid, aldolase and alkaline phosphatase activity
§ blood clotting activity
§ mercuric chloride and thymol tests
· Serologic markers of viral hepatitis
· US of abdominal cavity.
Management of labor With Viral Hepatitis
The following should be taken into account:
· Labor in acute stage of VHA does not threaten the parturient woman with any complications connected to hepatitis. So if labor proceeds without any complications any additional measures are not required.
· In case of VHB, C, D, E the rate of complications significantly increases:
· abnormalities of labor pains (the rate of primary and secondary weakness of labor pains is 19%), premature and early rupture of amniotic membranes (in 30-34%), intrauterine fetal hypoxia (25%), bleedings in the 2nd and 3rd stages of labor due to decrease of blood coagulability and uterine hypo- and atonia (for about 14-15%) are frequent.
· Labor in acute VH should be conducted with optimal analgesia and sedation (seduxen, promedol, baralgin, droperidol, nitrous oxide, epidural anaesthesia are widely used). Prophylaxis and correction of uterine contractility should be made. In addition to intrauterine infusion of oxytocin at the end of the 2nd stage of labor 1 ml of methylergometrine IV should be injected during the head disengagement for prophylaxis of maternal bleedings. As there is DIC due to acute VH frozen plasma, dicinon, aminocapronic acid should be administered intravenously.
During labor in acute stage of VH the fetus is always in the condition of hypoxia, therefore it is necessary to apply oxygenation and medicamental treatment of hypoxia of the fetus. At conducting labor in acute VH it is necessary to take into account the fetus general condition; most often premature delivery is preferable for saving life of the fetus, irrespective of duration of gestation.
· VH is not contraindicated for cesarean section depending on obstetric indication. Upon the whole, the rate of cesarean section in patients with VH is 2. 5%.
· The duration of fetus’ delivery should be shortened due to perineotomy (or episiotomy), application of obstetric forceps (by indication).
· In postpartum period at puerperas, who had acute viral hepatitis, the risk of development of puerperal septic diseases is high. Therefore preventive therapy is necessary.
From the moment of occurrence of icterus in pregnant woman, who was ill with VHА, she ceases to be dangerous to the environment, and her child is not dangerous to other children.
Pregnancy and Appendicitis
Appendicitis is an inflammation of vermiform appendix of the caecum. Its frequency at pregnancy makes up 0. 7-1. 4 %. Lethality of pregnant from appendicitis for the recent 40 years has decreased from 3. 9 to 1. 1 %; however it is higher than in nonpregnant women.
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Simple forms of acute appendicitis in pregnant women are encountered on average in 63 %, destructive forms — in 37 % of cases. The recurrent attacks of appendicitis are 3 times more frequent in the first half of pregnancy than in the second one and during labor.
Appendicitis complicates the course of pregnancy. In its second half there is no encapsulation of periappendiceal exudate at perforation of appendix, diffuse peritonitis develops. Commissures formed with uterus cause activation of contractile activity of the uterus that results in abortion at 2. 7-3. 2 % of women.
Clinical picture. The attack of appendicitis begins with an acute abdominal pain. The pain is localized in the field of belly-button, spreads to the whole abdomen, and later passes to the right ileal area. From the 5th month of pregnancy appendix with the caecum is pushed off by the uterus upwards and backwards. It changes the localization of pains. The sharpest morbidity can be not in the right ileal area (McBurney sign), but higher, in the hypochondrium. Pain during pregnancy is not so intensive as in nonpregnant patients. Patients quite often account for occurrence of pains in the abdomen by pregnancy, that is why they address a doctor late and it leads to late hospitalization and operation.
It is difficult to distinguish acute appendicitis during labor from labor pains; the muscle strain of the abdominal wall is weakly expressed. In this case it is necessary to pay attention to local morbidity, Sitcovsky’s symptom, and Bartomier-Michelson’s symptom, neutrophilic leukocytosis. Pain is followed by nausea; vomiting is possible. Temperature increases up to 38º С and over, but can remain normal. Pulse rate during the first day is accelerated up to 90-100 per minute. The tongue at first is slightly coated and wet, then becomes dry.
The protective strain of abdomen muscles on palpation of pregnant is poorly expressed, as the abdominal wall is overdistended, and appendix is located behind the uterus. Rovsing’s sign (intensification of pains in the field of caecum at pressure exerted over the left ileal area) and Sitcovsky’s sign (intensification of pains in the patient’s position on the left side) are not always of importance. The Bartomier-Michelson’s sign is frequently clearly marked, i. e. intensification of pain on palpation of the patient in position on the right side, when appendix is pressed down by uterus, but not on the left side, as in nonpregnant. The sign of irritative peritoneum (Shchotkin-Blumberg symptom) occurs early, its range of definition corresponds to spread of inflammatory reaction in the abdominal cavity. On blood analysis every 3-4 hours leukocytosis can increase up to 9x109/l — 12. 0x109/l; from the second day erythrocyte sedimentation rate (ESR) also increases.
Acute appendicitis should be differentiated from early gestosis, renal colic, pyelonephritis, cholecystitis, pancreatitis, acute gastritis, ectopic pregnancy, pneumonia and torsion of cystic pedicle. With the purpose of differential diagnosis the following should be researched: Pasternatsky’s sign (negative at appendicitis), urine (it should not contain any pathological elements), feces (character of stool); auscultation of the lungs is made (in doubtful cases roentgenoscopy should be performed); the pregnant is necessarily examined bimanually, chromocystoscopy is carried out (at renal colic the indigo carmine is not excreted from the blocked ureter).
During the first half of pregnancy an increased temperature, nausea and vomiting charactristic of early toxicosis can be also signs of acute appendicitis. In the second half of pregnancy, when appendix is located high, appendicitis is especially difficult to differentiate from right-side pyelonephritis. The onset of the disease is different: appendicitis always begins with pains, then temperature rises and vomiting occurs; pyelonephritis begins with chill, vomiting, fever, and only after that pains occur.
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Treatment is the same as without pregnancy: diagnosis serves the indication to obligatory operation. Simultaneously medicines should be administered to prevent abortion. When the clinical picture of appendicitis is not clear enough, a case monitoring for not more than 3 hours is possible.
During this time it is necessary to take differential-diagnostic measures. In case of confirmation of the diagnosis or impossibility to exclude it the operation is necessary.
Similar to non-pregnancy, at noncomplicated acute appendicitis appendectomy should be performed, and the wound sutured tightly. If the access to the appendix is complicated due to enlarged uterus, the woman should be turned to the left side. Any complication of appendicitis (periappendiceal abscess, peritonitis of any spread) is the indication to a good drainage of the abdominal cavity with the subsequent active aspiration and introduction of antibiotics into the abdominal cavity. Subsequent extent of treatment is defined by spread of the process: in pregnant, as well as in nonpregnant, acute appendicitis can be complicated by periappendiceal mass (periappendiceal abscess, local, diffuse or general peritonitis that determines surgical approach, treatment and prognosis.
After the operation the treatment preventing miscarriage is continued, including suppositories with papaverine, injections of magnesium sulfate, no-spa, vitamin Е, in the II-III trimester — partusisten intravenously. The incidence of abortions after the operation ranges within the limits of 0. 9-3. 8 %. If operation and postoperative period have passed without complications and signs of threatening abortion are not present, the woman is allowed to get up on the 4-5th day, but not on the 2-3rd day as in non-pregnancy.
The development of labor soon after appendectomy is undesirable. Contractions of the uterine musculature, changes of uterine configuration after birth disturb the process of exudate encapsulation, leading to development of generalized peritonitis. The question on volume of operation in these cases is decided individually. At diffuse purulent peritonitis caused by a phlegmonous or gangrenous appendicitis, a delivery is made by cesarean section with subsequent amputation or extirpation of the uterus. After that the appendix is removed, the abdominal cavity is drained. In other cases extraperitoneal cesarean section is made with preservation of uterus at proceeding treatment of peritonitis. At last, the treatment of peritonitis on a background of proceeding pregnancy is possible at its small term with the purpose of not so much to preserve pregnancy (further, after convalescence the abortion is possible), as to preserve a reproductive function. At term or almost term pregnancy (36-40 wk) in view of inevitability of labor on a background of peritonitis the operation is started with cesarean section, then after suturing of uterus and peritonization of the suture, appendectomy and treatment of peritonitis are provided.
Periappendiceal mass is treated conservatively at the surgical department up to its resorption or abscess formation. If resorption of periappendiceal mass takes place, appendectomy should be made in 6 months.
Pregnant women, who had appenectomy, should undergo abortion not earlier than 2-3 weeks after the operation at noncomplicated course of postoperative period.
Pregnancy and Cholecystitis
The diseases of the biliary system are high on the list of illnesses of digestive organs. Women suffer by 2-7 times more often than men that is, probably, explained by effect of pregnancy. Chronic diseases of liver and gallbladder are encountered in 3% of pregnant. The rate of cholecystectomy at pregnancy makes up 0. 1-3%.
Acute Cholecystitis
In its pathogenesis two factors are of great significance, i. e. infection and stagnation of bile, acting simultaneously, as a rule. In patients with acute cholecistitis the culture shows staphylococcus, colibacillus in bile. Hematogenous, lymphogenous and contact (from the intestine) ways of infection spread are determined. Cholestasis, caused by increase of intraabdominal pressure and hormonal imbalance in organism, changes of motor activity, position of gallbladder and ducts are of most importance in the development of acute cholecystitis during pregnancy. Hematogenous spread of infecton to biliary tract from organs of reproductive system is possible in pregnant.
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Chronic Cholecystitis
Chronic cholecystitis is a chronic recurrent disease related to the presence of inflammatory changes in the gallbladder wall.
A pain syndrome prevails in the clinical picture of disease (in 88% of cases). The pregnant complains of dull, arching, boring pains, (pain may be sharp depending on type of dyskinesia), more often in the right hypochondrium irradiating to the right shoulder-blade, right shoulder, clavicle, rarer they may irradiate to the epigastrium or left hypochondrium. In addition, the pregnant may have a sense of weight in the right hypochondrium, feeling of bitter taste in the mouth, bitter eructation, nausea, vomiting, heartburn, bloating, unsteady stool.
The occurrence or strengthening of pains after inadequate diet is characteristic; 25% of women in the second half of pregnancy explain pains on account of fetal movement, its position in the uterus (the second position). On objective examination the zones of skin hyperesthesia (tender Head’s zones) are determined in the right hypochondrium, under the right shoulder-blade; on palpation tenderness in the right hypochondrium, positive Kehr’s, Ortner’s, Murphy’s symptoms are marked.
The diagnosis of exacerbation of chronic cholecystitis during pregnancy is based on complaints, anamnesis, objective data and results of additional methods of examination. Duodenal intubation and ultrasound examination of gallbladder are used for diagnostics. Biochemical examination of blood shows the decrease of bilirubin, phospholipid and cholic acid concentration, increase of cholesterol level that testify to the inflammatory process in the gallbladder.
Effect of Cholecystitis on Pregnancy
Chronic cholecystitis exacerbates the course of pregnancy. Exacerbation of chronic cholecystitis (in 91. 1% of patients) develops in the III trimester of pregnancy. In 49. 1% of cases chronic cholecystitis is complicated by nausea, vomiting, and in 15% — by salivation. In 23. 3% of patients the vomiting proceeded for more than 12 weeks, and in 8. 8% — until 29-30 weeks of gestation.
The 2nd half of pregnancy is complicated by different forms of gestosis (edema, preeclampsia) in 10% of women. Cases of premature termination of pregnancy on a background of this disease are possible.
Effect of Gestation on the Course of Cholecystitis
Pregnancy deteriorates the course of chronic cholecystitis: of 120 patients only in 7 the symptoms of exacerbation of disease were absent.
Management of Pregnancy in Patients with Cholecystitis
Chronic cholecystitis is not an indication for termination of pregnancy.
In the period of exacerbation of cholecystitis the women are recommended bed rest during 7-10 days.
At hypokinetic biliary dyskinesia (prevailing during pregnancy) a prolonged bed regimen is undesirable. Principles of treatment of chronic cholecystitis in pregnant are the same as in nonpregnant. Dietotherapy is administered without any strict limitations at observance of optimal (for every term of pregnancy) ratio of proteins, fats and carbohydrates.
At the expressed pain syndrome spasmolytic and sedative drugs are administered: papaverine hydrochloride, baralgin, etc.
Oleandomycin phosphate (0. 5 g 4 times a day), ampicillin (0. 25 g 4 times a day), oxacyllin (0. 5 g 4 times a day), ampyoxis (0. 5 g 4 times a day) by courses of 7-10 days should be administered. From the II trimester of pregnancy antibiotics of cephalosporin group (cephalecsin, cephuroxim, claphoran, etc. ) can be used, as well as erythromycin (0. 25 g 4 times a day), linkomycin (0. 5 g 3 times a day), furazolidone, nevigramon. Bile-expelling agents should be obligatory used.
Labor should be conducted depending on individual course of the process.
Pregnancy and Pancreatitis
Acute pancreatitis in pregnant develops infrequently, proceeds severely and in 39 % of cases ends by death. Perinatal mortality at this disease reaches 39‰. Acute pancreatitis develops at any term of gestation, but more often in its second half; the maternal mortality from acute pancreatitis rises with increase in term of gestation.
Clinical picture. In 75 % of pregnant acute pancreatitis is clinically manifested by an acute excruciating pain in the upper part of the abdomen (epigastric area, left or right hypochondrium). Most often the pain is of a girdle character. Nausea, vomiting, collapse occur. At the beginning of disease the abdomen can remain soft, without any signs of peritoneum irritation; in future the phenomena of enteroparesis and intestinal obstruction become of most importance. More often than in non-pregnancy the painless forms of acute pankreatitis are observed. In this case the disease is manifested by shock and symptoms of affection of the central nervous sysem. A similar course of acute pancreatitis is an extremely unfavorable prognostic sign; a death rate in such cases makes up 83 %. At examination icteritiousness is sometimes revealed; the spontaneous petechias on the lateral surfaces of abdomen (Terner's symptom) or round the umbilicus can appear (Cullen's symptom). Fever occurs in half of patients.
In most cases of acute pancreatitis the level of amylase in blood rises in 8 hours after attack and reaches the peak in 24-36 hours. The content of amylase (diastase) in urine considerably increases; usually it rises in 24-48 hours after the onset of disease and remains increased for 10 days. The level of lipase increases a little bit later and remains increased longer than the level of amylase.
The estimation of calcium content in blood is of great diagnostic importance. The lowest levels of calcium at acute pancreatitis are observed between the 2nd and 4th day of disease. The decrease of calcium level in blood serum after the 2nd week of disease usually testifies to disease progress. In most women suffering from acute pancreatitis during pregnancy, leukocytosis and anaemia are marked.
Acute pancreatitis is accompanied by changes of glucose level in blood, often by hypo- and hyperglycemia. Hypoglycemia can be due to starvation or increased level of insulin. Hyperglicemia testifies to a severe course of disease, usually with lethal outcome. In 15-25 % of women diabetes mellitus develops after the attack of acute pancreatitis.
The treatment of acute pancreatitis consists in treatment of shock; the suppression of pancreatic function is achieved by nasogastric suction of gastric contents, exclusion of oral intake of preparations and foodstuffs (regimen of hunger and thirst), administration of anticholinergic drugs: atropine (1 ml of 0. 1 % solution subcutaneously), platyphyllin (1 ml of 0. 2 % solution subcutaneously), and also administration of enzymatic inhibitors — gordox, contrical, trasylol (at first 25, 000-50, 000 units intravenously, then 25, 000-75, 000 units intravenously droppingly in a 5 % glucose solution; the following days introduction of 50, 000-25, 000 units per day, reducing the dose in the process of improvement of clinical picture and laboratory results).
To decrease pain and spastic component, spasmolytic agents and anodynes are administered: no-spa (2-4 ml of a 2 % solution intramuscularly), papaverine hydrochloride (1-2 ml of a 1-2 % solution intramuscularly), analgin (1-2 ml of a 50 % solution intramuscularly), baralgin (5 ml intravenously or intramuscularly), novocaine (2-5 ml of a 0. 25 % solution intravenously). To patients with pancreatonecrosis antibiotics are administered with the purpose of prevention of suppuration. To decrease a secretory pancreatic activity and remove edema of pancreas, diuretics should be administered (1-2 ml of a 1 % lasix solution intravenously).
Besides, at treatment of acute pancreatitis the electrolyte balance should be maintained, by introduction of large quantity of fluid (3-6 l) with electrolytes. On revealing hyperglycemia insulin should be administered.
If an adequate conservative therapy turns out to be ineffective, there are doubts as for the diagnosis, there is a rapidly increased abscess, acute occlusion of bile ducts with stone and development of icterus, a surgical intervention is indicated.
Effect of Acute Pancreatitis on Pregnancy
One of the most frequent and widespread complications in patients with acute pancreatitis is premature labor, the cases of intrauterine death of the fetus are not uncommon. The development of weak contractile activity of the uterus is possible in labor, as well as asphyxia of the intrauterine fetus. In postpartum period the development of puerperal infectious-inflammatory diseases is possible.
Management of Pregnancy in Patients with Acute Pancreatitis
There are no convincing proofs that arresting of pregnancy in the I trimester or initiation of premature birth in the second its half improves prognosis for mother. At development of acute pancreatitis during pregnancy an adequate therapy should be started as early as possible; if the treatment is ineffective, the question on abortion and subsequent surgical treatment should be solved quite individually. The choice of method of delivery in pregnant with acute pancreatitis presents great difficulty. Most often a woman has weakness of labor pains and prolongation of labor. Cesarean section is undesirable, because it has to be performed in conditions of infected abdominal cavity, therefore the extraperitoneal cesarean section can be a method of choice.
Chronic Pancreatitis in Pregnancy
Chronic pancreatitis develops after the previous acute pancreatitis or as a primary chronic disease. Exacerbation of chronic pancreatitis during pregnancy is encountered as rarely as acute pancreatis. The clinical picture of exacerbation of chronic pancreatitis during pregnancy is to a great extent similar to exacerbation in non-pregnancy. Pain of a cramping or permanent character is the main complaint. More often pain occurs in the upper part of abdomen or in the epigastric area and irradiates to the left shoulder, shoulder-blade, neck or to the left iliac bone, sometimes having a girdling character.
Pain is not connected to taking meals, however it can considerably increase after eating fat food. In the majority of patients there are dyspepsia complaints, such as nausea, vomiting, eructation, loss of appetite, abdominal swelling, sometimes salivation. The excretion of plentiful, porridge-like, grayish, fetid “fatty” faeces (pancreatic steatorrhea) caused by dysfunction of pancreas is a characteristic symptom.
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