52. Chronic pancreatitis. Pancreatic cysts and fistulas

Question 1

Chronic pancreatitis definition

Answer 1

Chronic inflammatory disease where there is:

Irreversible destruction of pancreatic tissue.

Fibrotic tissue replacement,

Alteration of ducts (stricture + dilation)

Question 2

Chronic pancreatitis - Etiology

Answer 2

• Chronic alcoholism – causes edema + inflam of papilla of vater
• Hereditary
• Idiopathic
• Pancreatic duct obstruction e.g. stone/tumour
• Haematochromatosis = too much iron build up deposited in pancreas

Question 3

Chronic pancreatitis - Clinical presentation

Answer 3

Epigastric pain (elapsing pain) – radiates to back. Relieved by sitting forward or hot compress

N/V

Weight loss,

DM

Steatorrhea (due to decreased fat absorption – stool grey, bulky, smelly)

• Look for granny tartan rash – skin condition caused by long-term exposure to heat (infrared radiation) (aka hot water bottle rash

Question 4

Chronic pancreatitis - Diagnostic investigations

Answer 4

AbXR

CT = calcifications

ERCP = gold standard but involve

Serum amylase + lipase = not usually elevated

Question 5

Chronic pancreatitis - Diagnostic triad

Answer 5

DM
Steatorrhea
Calcifications

Question 6

Chronic pancreatitis Treatment - Medical

Answer 6

Analgesics

NBM (nil by mouth)

Pancreatic enzymes (creon) – inhibit CCK = decreased pancreatic secretions after meal

Insulin.

STOP alcohol.

Low fat meals

Question 7

Chronic pancreatitis Treatment - Surgical

Answer 7

Pancreaticjejunostomy =
pancreatic duct drainage procedure to decompress dilated pancreatic duct

o Whipples procedure –
pancreaicodudenectomy

Question 8

Chronic pancreatitis Complications:

Answer 8

Effusions (pleural/peritoneum)

DM

Carcinoma of pancreas.

Obstruction of CBD.

Pseudocysts
o “ED the COP has chronic pancreatitis”

Question 9

Pancreatic cysts

Types

Answer 9

– True (20%)
o congenital polycystic disease of pancreas

o retention – due to ductal obstruction by stone, tumour

o hydatid – tx by enucleation – when large distal pancreactomy

• False/Pseudocyst (80%)

o Collection of fluid (amylase rich) in lesser sac enclosed by wall of fibrous/granulation tissue

o Most freq in body + tail
After trauma
Following arcuate pancreatitis

Question 10

Pancreatic cysts - Clinical Presentation

Answer 10

Presents as firm.

Large, rounded upper abdomen swelling

Dysphagia

N/V

Anorexia

Weight loss

Question 11

Pancreatic cysts - Diagnosis

Answer 11

CT
US
MRI
X-ray

Question 12

Pancreatic cysts - Treatment

Answer 12

True cyst = surgical excision

False cyst = drainage

o Internally = anastomose with stomach

o Percutaneous under US control

Question 13

Pancreatic fistula - occurs when

Answer 13

Usually follows op trauma

or

complication of acute / chronic pancreatitis

Question 14

Pancreatic fistula - management

Answer 14

I.d. site of fistula + epithelial structure with which it communicates e.g. externally to skin, internally to bowel

• if uncertain about fluid from drain site in pancreatic measure amylase content

Question 15

Pancreatic fistula - treatment

Answer 15

• Drainage into stoma bag
• Need to know underlying cause – tx b4 fistula will close
• Frequently cause = obstruction of pancreatic duct so stenting/catheter endoscopically into pancreatic duct then wait for fistula to close
• Use octreotide to suppress pancreatic secretion