Chronic Pancreatitis

Question 1

What is the pathophysiology of chronic pancreatitis?

What are the consequences of this?

Answer 1

Chronic and irreversible inflammation and fibrosis of the pancreas which occurs due to recurrent episodes of acute pancreatitis

Compromised endocrine function:
-effects islets of langerhans= failure to produce insulin

Compromised exocrine function:
-effects acinar cells= failure to produce amylase or lipase

Question 2

What are the main causes of chronic pancreatitis?

Answer 2

Alcohol

Idiopathic

Smoking can accelerate the process

Cystic fibrosis

Some drugs= thiazide diuretics/azothioprine/TCA

Gallstones

Tropical

Question 3

How would someone with chronic pancreatitis present?

Answer 3

Epigastric pain radiating to back 
Worse when eating and relieved by sitting forwards 
N+V
Reduced appetite 
Diabetes 
Signs of loss of exocrine function
-malabsorption 
-weight loss
-diarrhoea 
-steatorrhoea

Question 4

What investigations would you do if you suspected someone of having chronic pancreatitis?

Answer 4

FBC
U+E
Creatinine
LFTs
Ca and Mg
Amylase (usually normal in chronic picture)
Glucose and HbA1c (assessing endocrine function)
CT
-calcification (due to calcium being deposited as part of destruction process/high cell turn over)
-atrophy
-duct dilatation
ERCP= only when 75% of pancreatic tissue is damaged
MRCP= when 60% of pancreatic tissue is damaged
-can be secretin enhanced i.e. stimulates the exocrine function of pancreas so that less invasive magnetic resonance required

Question 5

What forms part of the triad for chronic pancreatitis?

Answer 5

Pancreatic calcifications
Steatorrhea
Diabetes mellitus

(Note: strongly suggestive but are actually quite late signs)

Question 6

How do you manage chronic pancreatitis?

Answer 6

Analgesia (start low on analgesia ladder)

Creon= pancreatic enzyme replacement

Dietitian and diabetes input

Smoking + alcohol cessation

ERCP with stenting to try and open up ducts which have been obstructed by strictures

Question 7

What complications can occur with chronic pancreatitis?

Answer 7

Pseudocyst (can be complicated by necrosis)
Bile duct + Duodenal obstruction= due to strictures forming
-compromises bile and enzyme secretion
Local aneurysm
Splenic vein thrombosis
Pancreatic cancer