Chronic pancreatitis Flashcards
What are the causes of chronic pancreatitis?
recurrent inflammation leading to destruction of exocrine & endocrine tissue -> fibrous scar
- alcohol
- gallstone
- congenital or acquired stricture of the pancreatic duct
- pancreas divisum
- tumor causing duct obstruction
- inflammation of papilla of Vater
- cystic fibrosis
- hypercalcemia
- idiopathic
What is the gross picture of chronic pancreatitis?
- early -> pancreas is enlarged, edematous, & indurated
- advanced -> small, reduced to cord with rubbery consistency
- > ducts are dilated but may be narrow & distorted
What is the microscopic picture of acute pancreatitis?
- early -> lesion are spotty, show dilatation of the acini with intra-lobular & peri-lobular fibrosis
- advanced -> fibrosis extends through gland but some lobules are still not completely affected
- most advanced -> pancreas is entirely replaced by fibrous tissue
- > cysts are found where the duct epithelium is destroyed
- > islets of Langerhans are hyperplastic & non functioning -> diabetes
- > perineural sheath of intrapancreatic nerves are irritated
What extrapancreatic involvement will occur due to chronic pancreatitis?
- CBD -> persistent constriction of duct due to head of pancreas inflammation -> stricture formation
- duodenum -> obstructed by inflammation of the head of pancreas
- colon -> partial obstruction in transverse colon or splenic flexure
What are the clinical features of chronic pancreatits?
- abdominal pain -> cramping dull, & aching in the epigastrium radiating to subcostal area & to the back
- > recurrent (several days to weeks)
- > spontaneous relief -> exocrine function is lost - weight loss -> malabsorption & decreased food intake due to pain
- steatorrhea & creatorrhea -> bulky offensive oily stool (floating)
- diabetes mellitus
What lab findings could be seen in case of chronic pancreatitis?
- early -> serum amylase & lipase increase during inflammation
- late -> normal
- abnormal liver function tests
What radiological features are seen in chronic pancreatitis?
X RAY -> pancreatic calcification
MRCP -> pancreatic cyst
-> biliary dilatation
CT -> ductal anatomy
-> pseudocysts & cystic communication with ductal system
-> biliary dilatation & level of duct obstruction
ERCP -> main pancreatic duct dilatation, stricture, cysts, & ductal calculi
-> angulation of distal CBD
What is the medical treatment of chronic pancreatitis?
- pancreatic insufficiency -> dietary restriction of fat (50gm) then increase till diarrhea appears
- > enzyme replacement - DM -> subcutaneous insulin -> fasting glucose level = 200 -> may cause hypoglycemia due to glucagon deficiency
- stop alcohol intake -> pain cessation
- minimize stimulus to secretion -> semisolids or liquid diet
- narcotic analgesia
What is the surgical treatment of chronic pancreatitis?
PANCREATICOJEJUNOSTOMY (PUESTOW PROCEDURE)
- only in enlarged duct (7mm or larger) -> drainage into jejunum
PANCREATICODUODENECTOMY (WHIPPLE)
DISTAL PANCREATECTOMY
What are the indications for Whipple’s procedure?
- inability to rule out presence of pancreatic cancer
- failure of previous pancreaticojejunostomy
- localized chronic pancreatitis
- pain relief
What are the indications of distal pancreatectomy?
- recurrent episodes of pancreatitis with multiple pseudocyst in pancreatic tail & splenic vein thrombosis
- recurrent episodes with stricture in the main duct in the body or tail
What should be done for pain relief in case of failure of narcotics & dependence?
DESTRUCTION OF THE CELIAC GANGLION