33. Chronic pancreatitis Flashcards
what is chronic pancreatitis?
pancreatic inflammation lasting > 6 months with irreversible pancreatic changes documented by 1 of the following:
Abdominal imaging (inflammatory masses; calcifications; pseudocysts; ductal dilations/stenosis)
Functional studies
pancreatic exocrine insufficiency
endocrine insufficiency with diabetes mellitus [type 3c]
Histologic changes (atrophy, fibrosis, and/or sclerosis)
what are the risk for chronic pancreatitis ?
TIGARO
toxic metabolic = alcoholic , chroonic renal failure , hypercalciemia
idiopathic
genetic
autoimmune
recurrent and severe acute panreatitis - post necrotic , post irradiation , vascular ischemia
obstruction - pancrease divisium , sphintcer oddi tumor , duct tumor
more freq in men
80g of more dail ethanol 6-12 yrs
SMOKING
autoimmune pancreatitis are of two types what are they ?
IgG4 autantibodies - lymphoplasmacytic sclerorosing pancreatitis with systemic diseases
granulocytic epithelilal lesion - idiopathic duct centric pancreatitis
what is genetic/ heriditory cause for chronic pancreatitis ?
at childhood 5-23 years onset
with fam history for pancreatitis and pancreatic cancer
autosomal dom = genetic defect in cationic trypsinogen gene = PRSS1
or CFTR or SPINK1
chymotrypin C - CTRC
starting with recurrent acute pancreatitis = and has a major risk for tumor development
which type of pancreatitis is a major risk factor for tumor development ?
hereditary pancreatitis
what is the pathogenesis of CP?
inflammtion
glandualr atrophy
ductal change
fibrosis
what is the dagnostic criteria for chronic pancreatitis ?
atleast one of the following and NO OTHER DIAGNOSISI LIKLEY
recurrent pancreatic pain = the pain intesnity slowly dwindles after 5-10 years
elevation of pancreatic enzymes for more than one year , lipase = slowly dwindles in 5-10 years
pancreatic calcifications
hsitology of inflammation and fibrosis
change in pancreatic duct morphology
abnormal pancreatic function with maldigestion
it dips and resumes to be normal but by 10 years slowly dwindles
what is the clinical manifestation ?
characteristic pancreatic pain :
Midepigastric postprandial pain
radiates to the back
can sometimes be relieved by sitting upright or leaning forward
pain is episodic but becomes persistent as disease progresses
vommitting
setatorrhea
diarrhea = weight loss
muscle wasting
jaundice
diabates
metabolic bone disease
fat sol vit deficiency
how can we test for abnormal pancreatic function and maldigestion
steatocrit
72 hrs with diet on only 100g of fat
more than 7 g of fat per day in stool
fecal elastase - pancreatic lipase deficiency
less than 200mcg/g is abnormal
exogenous supplement does not alter results
secretin stimulation
peak biocarbonate conc less than 80mEq / l in duodenal secretion
serum tryspsinogen
less than 20ng/ml
: Cholecystokinin analog (cerulein) is administered intravenously, which stimulates pancreatic enzyme and bicarbonate secretion. This secretion is collected in a tube placed in the duodenum during endoscopy and analyzed.
whata re the all the imaginng modality used to diagnose chronic pancreatitis ?
abdominal us = dilated and sclerotic main pancreatic duct = string of pearls atrophies pancrease stones in pancreatc duct and pseudocyst
first DONE contrast enhanced US = calcification in pancreatic ducts pseudocyst ductal dilation thrombosis in splenic vein necoris atrophy
ENDOSCOPIC us = FIRST LINE to check high sentivity and specificity
combined with fine needle aspiration
EUS elastography
CECT
mri
MRCP
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blood test
igG4
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genetic testing
why is ercp not recommended ?
high risk of pancreatitis and hemorrhage and infection
what is the treatmnet for chronic pancreatitis
nutritional support
alcohol abstinence
small regular meals rich in
carbs and low in fat
pancreatic enzyme replacement
KREON gastroresistant capusle of porcine pancreatin = lipase
co treatmnet with acid suppressing drugs
vit d supplement
medical treatment : for pain - paracetamol then tramadol hydromorphine it has to be a ladder - nsaids and opoids
diabetes = metform and insulin administration
endoscopic treatment - pancreatc and billary sphinctereotomy
dilation and stent of pancreating duct
extracorporal lithotripsy = for pancreating stones
endoscopic ultrasound guided dariange of pseudocyts
EUS nerve block
surgical treatment
lateral pacreatociojejunostomy
duodenum preserving pancreatin head resection
whipple operation - pancreaticoduodenoectomy
complication in chronic pancreatitis which is seen MOST OF THE TIME
pseuodcyts pancreatic duct obstruction duodenal obstruction bile duct obstruction maluntriton PAIN SYNDROME
what is the treatmnet for autoimmune pancreatitis ?
Glucocorticoids (e.g., prednisolone); usually swift response
Immunomodulatory drugs: azathioprine/rituximab (for patients who do not respond to steroids
