[42] Chronic Pancreatitis Flashcards
What is chronic pancreatitis?
Long-standing inflammation of the pancreas that alters the organs normal structure and functions
What can chronic pancreatitis present as?
Episodes of acute inflammation in previously injured pancreas, or chronic damage with persistent pain and malabsorption
Is the damage in chronic pancreatitis reversible?
No, unlike in acute pancreatitis
What is the underlying mechanism of disease in chronic pancreatitis?
Unclear
What is the most common theory as to the mechanism of disease in chronic pancreatitis?
Obstruction or reduction of bicarbonate excretion, which in turn leads to activation of pancreatic enzymes, which leads to pancreatic tissue necrosis with eventual fibrosis
What are the other theories as to the mechanism of disease of chronic pancreatitis?
- Epigenetic degeneration
- Alcohol-induced precipitation of proteins in the ductular structure of the pancras, leading to local pancreatic dilation and fibrosis
- Direct toxic effects of alcohol on the pancreas
What is the end result of the disease process in chronic pancreatitis?
The end result is pancreatic fibrosis
How long does pancreatic fibrosis take to develop?
Can take several years
What forms can chronic pancreatitis occur in?
- Large duct
- Small duct
What happens in large duct chronic pancreatitis?
There is dilation and dysfunction of the large pancreatic ducts
Is large duct pancreatitis visible on imaging?
Yes, on most
What happens to the pancreatic fluid in large duct pancreatitis?
It changes composition
What is the result in the changes in pancreatic fluid composition in large duct pancreatitis?
It facilitates the deposition of precursors to calcium carbonate stones
What does the deposition of precursors to calcium carbonate stones cause in large duct pancreatitis?
Diffuse pancreatic calcification
Who is large duct pancreatitis more commonly found in?
Males
Why is small duct pancreatitis difficult to diagnose?
Because it is usually associated wtih normal imaging and no pancreatic calcification
Who is small duct pancreatitis predominantly found in?
Females
What is the greatest risk factor for chronic pancreatitis?
Excess alcohol consumption
What % of people who are alcohol dependant develop chronic pancreatitis?
5-10%
What has emerged as a risk factor for chronic pancreatitis?
Smoking
Other than chronic pancreatitis, how else can smoking affect the pancreas?
Increases the risk of pancreatic malignancy
What are the causes of chronic pancreatitis?
- Chronic alcohol abuse
- Idiopathic
- Metabolic
- Infection
- Herediatry
- Autoimmune
- Obstruction of pancreatic duct
- Congenital
What % of chronic pancreatitis cases are caused by chronic alcohol abuse?
60%
What % of chronic pancreatitis cases are idiopathic?
30%
What are the metabolic causes of chronic pancreatitis?
- Hyperlipidaemia
- Hypercalcaemia
What are the viral causes of chronic pancreatitis?
- HIV
- Mumps
- Coxsackie
What are the bacterial causes of chronic pancreatitis?
- Echinococcus
What are the hereditary causes of chronic pancreatitis?
Cystic fibrosis
What are the autoimmune causes of pancreatitis?
- Autoimmune pancreatitis
- SLE
What can cause an obstruction of the pancreatic duct causing chronic pancreatitis?
- Stricture formation
- Neoplasm
What are the congenital causes of chronic pancreatitis?
- Pacreas divisum
- Annular pancreas
What is the major symptom of chronic pancreatitis?
Chronic pain
What might the chronic pain in chronic pancreatitis be complicated by?
Recurring attacks of acute pancreatitis
Where is the pain felt in chronic pancreatitis?
Typically in the epigastrum, and radiates to the back
What may ease the pain in chronic pancreatitis?
Leaning forwards
What may be associated with the pain in chronic pancreatitis?
Nausea and vomiting
What other symptoms may a patient with chronic pancreatitis present with?
- Symptoms of endocrine dysfunction, such as diabetes mellitus
- Symptoms of exocrine dysfunction, such as steatorrhoea or malabsorption
How is chronic pancreatitis investigated?
- Imaging
- BM
- Serum calcium
- LFTs
- Faecal elastase
Why is BM checked in chronic pancreatitis?
To check for raised glucose secondary to endocrine dysfunction
Why is serum calcium checked in chronic pancreatitis?
May be hypercalcaemia
What happens to LFTs in chronic pancreatitis?
They may be abnormal, especially if hepatic aetiology
What is typically the first line imaging in suspected chronic pancreatitis?
Abdominal USS
Why is an abdominal USS useful in suspected chronic pancreatitis?
- May show evidence of an underlying cause of pancreatitis,
- May show calcification of the pancreas
- Investigates for any other intra-abdominal pathology
What is the importance of the finding of calcification of the pancreas on abdominal USS?
It is diagnostic for chronic pancreatitis
What can a CT abdo-pelvis scan demonstrate in chronic pancreatitis?
Pancreatic calcification or pseudocyst formation
Why should a CT be avoided if possible in chronic pancreatitis?
Because people with chronic pancreatitis are often frequent attenders, and consideration should be made to the amount of radiation they recieve, especially if a diagnosis can be made clinically
What does MRCP stand for?
Magnetic resonance cholangioprancreatography
What can MRCP be used for in chronic pancreatitis?
It can identify the presence of biliary obstruction and assess the pancreatic duct
Does a normal MRCP appearance exclude chronic pancreatitis?
No
What does ERCP stand for?
Endoscopic retrograde cholangiopancreatography
What is the advantage of ERCP?
- It is a more accurate way of elliciting the anatomy of the pancreatic duct
- It is combined with intervention
What intervention can be delivered with ERCP?
Dilation of any strictures present
How is chronic pancreatitis initially managed?
- Analgesia
Appropriately addressing complications - Pancreatic enzyme supplements
What analgesia is given in the acute management of chronic pancreatitis?
Simple analgesia and opioid is usually sufficient
What should be avoided in chronic pancreatitis patients in long-term pain?
Strong opioid analgesics
Why should strong opioids be ideally avoided in patients with chronic pancreatitis in chronic pain?
Because they are often insufficient, and may lead to long-term dependance
What analgesia may be useful in chronic pain caused by chronic pancreatitis?
TCAs
What is Creon?
A pancreatic enzyme supplement
What is the purpose of Creon in chronic pancreatitis?
It is often trialed in an attempt to relieve the pain of chronic pancreatitis
When might Creon be particularly useful?
In small duct disease
What is the definitive management of chronic pancreatitis?
- Avoidance of the precipitating factor, such as alcohol
- Management of chronic pain and nutritional support, often with enzyme supplements
Is endoscopic and surgical management available for those with chronic pancreatitis?
May be in a select few patients
What do endoscopic and surgical management options target in chronic pancreatitis?
The underlying cause
What type of chronic pancreatitis is endoscopic treatments generally used for?
Large duct pancreatitis
What is the problem with endoscopic management of pancreatitis?
Many endoscopic procedures have a risk of inducing an acute-on-chronic pancreatitis, which patients must be warned about pre-intervention
What can ERCP be used for in chronic pancreatitis?
Diagnostic and therapeutic purposes
May be used to extract any pancreatic duct stones causing the chronic disease
What can an endoscopic ultrasound be used to facilitate?
- Drainage of any psuedocysts that have formed
- Placement of a bile duct stent to relieve a distal duct stricture
How long can bile duct stents be left in place?
4-6 weeks
Why can bile duct stents not be left in place for longer than 4-6 weeks?
They tend to become blocked
When might an endoscopic pancreatic sphincterectomy be beneficial?
In patients with papillary stenosis associated with high sphincter and pancreatic duct pressures
What is the purpose of surgery in the management of chronic pancreatitis?
Relieve any obstruction and remove any mass lesions, whilst preserving pancreatic tissue wherever possible
What is a lateral pancreaticojejunostomy?
A side-to-side anastomosis of the pancreatic duct to the jejenum
What is the advantage of a lateral pancreaticojejunostomy?
It provides relief in most patients
What is the disadvantage of a lateral panceaticojejunostomy?
Pain tends to reoccur
Why does pain tend to reoccur after a lateral pancreaticojejunostomy?
Because the head of the pancreas remains in situ
What is a pancreaticduodenectomy commonly termed?
A Whipple’s procedure
Where is a Whipple’s procedure indicated?
In a paraduodenal pancreatitis, or if neoplasia cannot be excluded
What does a Whipple’s procedure involve?
The resection of the pancreatic head, gallbladder and bile duct, the pyloric antrum, and the first and second portions of duodenum, with the tail of the pancreas anastomosed with teh duodenum and the body of the stomach anastomosed to the distal duodenum
What is a total pancreatectomy?
The removal of the entire pancreas
What is a total pancreatomy commonly associated with?
Morbidity secondary to the loss of pancreatic function and reduced quality of life
In what proportion of patients does a total pancrectomy not provide analgesia?
Approx. 1/3
When are steroids effective in reducing the symptoms of chronic pancreatitis?
In pancreatitis with autoimmune aetiology onmly
What regime is used in autoimmune chronic pancreatitis?
A high dose of prednisoline is used initially to bring symptoms under control. and then a low dose maintenance regime is used
What are the complications of chronic pancreatitis?
- Pseudocyst
- Steatorrhoea and malabsorption
- Diabetes
- Effusions and ascites
- Pancreatic malignancy
What causes steatorrhoea and malabsorption in chronic pancreatitis?
Poor exocrine function
How can steatorrhoea and malabsorption in chronic pancreatitis be treated?
Enzyme replacements (including lipase) such as Creon
When are enzyme replacements typically administered?
With meals
What are patients with steatorrhoea and malabsorption caused by chronic pancreatitis at risk of?
Being deficient in the fat soluble vitamins (A, D, E, K)
What is advised as a result of the risk of patients with steatorrhoea and malabsorption becoming deficient in the fat soluble vitamins?
Regular clotting function and bone density checks
What causes diabetes in chronic pancreatitis?
Loss of endocrine function
What kind of insulin regimes are usually preferred in diabetes caused by chronic pancreatitis?
Simple insulin regimes
Why are simple insulin regimes usually preferred in diabetes caused by chronic pancreatitis?
To avoid hypoglycaemia caused by deficiency of glucagon
When might effusions and ascites occur in chronic pancreatitis?
Where there has been disruption of the main pancreatic duct
What is often required to treat effusions and ascites caused by chronic pancreatitis?
Surgical intervention
Which chronic pancreatitis patients are at risk of pancreatic malignancy?
Those who have had the disease for 20 years or more
What is the result of those who have had chronic pancreatitis for 20 years or more being at increased risk of pancreatic malignancy?
New and evolving symptoms should undergo investigation
