chronic pancreatitis Flashcards
1
Q
definition
A
Chronic relapsing, aggressive, polyetiological inflammatory destructive disease manifested with obstructn of ducts, sclerosis, irreversible loss of exocrine & endocrine func & deterioration of pancreatic struc.
2
Q
etiology
A
- Alcohol intoxication
- Prob. Wit flow of bile
- Disease of biliary tract and liver: infection in lymphatic tracts, cholelithiasis, tumors, parasites, cholecystitis: regurgitation of bile to pancrease and activate enzyme and digest parencyme
- Disease of duodenum: Duodeno-pancreatatic reflux, oedema, duodenal ulcer, duodenitis, peptic ulcer below duodenal capillary - Obstruction pancreatic duct (stenosis, stones, carcinoma)
- Alimentary factors – Vit insuff & ↓protein in meals, chronic disease of gastrointestinal tract
- Drugs – Corticosteroids, Sulfanamides, NSAIDs, diuretics, cytostatics, glucocorticosteroids, immunosuppressive, a/coagulants, indomethacin, paracetamol, estrogens, tetracyclines
- Trauma of the pancreas
- Toxic chem. – mercury, arsenic
- Infectn – herpes, measles, parasites of GIT
- Allergy – food allergy
- Hormonal disorder- calcification due to ↑Ca (hyperparathyroidism)
- Hereditary -insuff of alpha-antitripsin, metabolic disorders in Wilson disease
- Hyperlipidemia, hypertriglyceride (deposition of fat under glands)
- Idiopathic
3
Q
pathogenesis
A
- Obstruction pancreatic duct - spasm in sphincter Odi (↓bicarbonate secretion, ↑protein concentration)
- Protein precipitation in tissue of pancreas leads to prob of flow of enz thus obstrucn of small ducts→ ↑P in pancreatic duct→oedema of pancreas→autodigestion by enz→fibrosis - ↓ inhibitory enz → Activation of enz in pancreas production → autodigestion
- abn production of juice - H2O , HCO3 , proton , lipase , tripsin , amylase
- abnormal drainage through lymph – edema of pancrease - Alcohol consumption
- prodn of pancreatic enz. cause deposition of protein plugs
- Obstrucn of small ducts→ ↑pressure in pancreatic duct→oedema of pancreas→autodigestion
- Decrease proteins and increase enzyme juice concentration, enzyme start digesting pancreas - Biliary tract disease → temporary gallstone → obstructn of Sphincter Odi/ ↑pancreatic duct P → inflamn → sclerosis-fibrosis
- Common bile duct - increase pressure in common bile duct - disturbance in the flow of juice of panc - stagnation of the enz containing juice cause destruction of panc tissue – autolysis - place of destruction, appear sclerosis and fibrosis development.
- Duodenitis/dystrophy or atrophy of duodenal mucosa → ↑secretin, cholecystokinin, pancreozitin prodn → ↑duodenum P → spasm of Sphincter Odi→↑P pancreatic duct →c-on of pancreatic juice→ deposition of prot plug formn → sclerosis-fibrosis
4
Q
classification
A
- acc to clinical stage : Relapsing, Algesia(pain), Latent
- acc to phase: Recurrent/relapse, Remission
- acc. to dev :
- 1st stage- no prob in endo&exocrine func
- 2nd stage – present endo&exocrine dysfunc
- 3rd stage- Diarrhea, LOW, Vit insuff - Rome classification
- Chronic calcifying pancreatitis (alcohol intoxication)
- Chronic obstructive pancreatitis (obstrucn of bile duct)
- Chronic fibrous in duration
- Fibrotic-sclerotic
- Chronic cystosis & pseudocystosis - According to pathophysiology:
- Chr obstructive pancreatitis
- Chr calcifying pancreatitis
- Infiltrative fibrotic /inflammatory
- Fibrotic sclerotic form
- Cyst type
- Retrograde flow - Primary / secondary
- Primary – inflammation of the panc tissue
- Secondary – result of other GIT diseases. - according clinical form and pancreatic function
- chronic relapsing pancreatitis
- chronic pancreatitis with permanent pain (algesia) syndrome
- chronic latent pancreatitis
- pseudotumour of the pancreas
- Sclerotic - Acc etiology
Primary:
- alcohol
- chronic obstruction of main pancreatic duct (stenosis,stones,carcinoma)
- infection
- drug-induced
- idiopathic
- hereditary
- Trophic - result of Kwashiorkor
Secondary:
- diseases of biliary tract
- hyperparathyroidism
- chronic disease of gastrointestinal tract
- hyperlipidemia, hypertriglyceride
- Acc morphology
- obstructive
- sclerotic arounds glands (calcified, alcoholic)
- atrophic (parenchymatous, inflammatory)
- Oedematous, Fibrous, Pseudo-cystic
5
Q
main syndrome
A
- Pain
- epigastric region, sharp spastic pain, belt like pain, 30-40 min after meal, hrs to days
- trigger factor - fatty food, alcohol, ice-cream, stress, physical exhaustion, when lie flat
- relieving factor - lie on R side wit leg pulled towards abdmn, avoid eating, cold application on epigastric region, spasmolytics, antacids, cholinolytics - Dyspeptic
- Gastric dyspepsia: nausea, vomiting, hypersalivation, belching, weight loss
- Intestinal dyspepsia: Diarrhea, constipation, meteorism, loss of apptte & weight, jaundice, dry skin - Inflammatory – Fever, lymphadenopathy, arthalgia, vasculitis
- Asthenic – weakness,↓activity to work, restless, malaise
- Malabsorpn (Q30 f, page 77)
- Hypoproteinaemia, hypoglycaemia, hypolipidaemia, electrolyte disorders, dehydration
- disturbed digestion by panc juice - Endocrinal insuff- hyperglycemia, glucose intolerance
- Exocrine insufficiency (destructn of pancreatic cells, obstructn of ducts)
- Pancreatic triad (Calcification, Steatorrhea, Exocrine pancreatic insuff) - Jaundice
6
Q
investigation
A
Objective examination
- Skin grey, dry, dirty color, red spot; enlarged nails, loss weight, muscle guarding, coated tongue, painful palpation on epigastric, weakness and fear of eating.
- Mayo-Robson‘s sign – Tenderness at L costovertebral triangle
- Kach‘s sign – Tenderness at L rectus abdominis, 5cm above umbilicus
- Shaffar zone (Degarden‘s point)
- Kerte‘s sign – muscular resistance of epigastric area.
Laboratory
- Blood – Leucocytosis L shift, ↑ESR, Normochromatic / hypochromic anemia, ↑enz in blood and urine: amylase, tripsin, lipase; ↑transaminase & urine amylase, hypercalcemia, glucosuria, bilirubin in blood
- Corprology : Steatorrhea, Amylorrhea, Creatorrhea
- Pancreatic juice examination
- Biochem - C-Reactive protein increase with mucoid, dysproteinemia
Instrumental:
1. U/sound - enlargement, form, density, edematous, fibrosis, cyst(stones) in the panc duct
- X-ray:
- Enlargement/deformed duodenum, ↑duodenal papilla, dislocation
- calcification (stones) in pancreas
- ↑ retrogastric space
- dilated ducts, central loop of small bowel, dilatation of transverse colon
- In contrast, double line seen. - Fibroduodenogastroscopy – stones, changes in Sphincter Odi, large papilla sphincter in tumor
- Endoscopic-pancreato-cholangiography- stones, stenosis of tracts
- Angiography- deformn+dilatation of arteries, abnorm distribution, disappearance of small arteries
- CT scan- size of organ, edema, calcification of pancreas, cyst, fibrosis, obstructn of biliary tract: stones, dilated vessels, differentiate wit tumor
- retrograde cholangiography
- ECG- tachycardia
- laproscopy and laparotomy – acute pancreatitis
7
Q
treatment
A
- Diet N.5, no triggering food (hot, cold, spicy, gassy, alcohol, fatty)
- Pain
Spasmolytics – Analgin, Baralgin , Noshpa, Atropine, Papaverin Analgesics –Pramidol, Meperidine Lidocaine/Novocaine Cold compression Cytostatic eg. 5-uracil - Treatment of maldigestion & malabsorpn - avoid eating 2-3 days
- insulin therapy
- substitution therapy to restore normal flow of bowel
- Etiological: due to infectn- A/biotics: Penicillin, cephalosporin, erythromycin, amoxicillin
- Pathogenetic:
- Antacids: almagel & pratop (salts-hydroxide of Al & Mg); phosphotical
- H2-antagonists: Famotidine,Ranitidine,Cimetidine - ↓ gastric & pancreatic secretion
- Proton pump inhibitor: Omeprazole
- M-cholinorcp blocker: atropine - Enzyme: (contains trypsin: Pancreatin, pancreamexin, Mezim, pancitrate, Festal); (lipase containing – Krion) - pancreatine, pancreatoazemine
- enzyme inhibitors: Contrical, Gardox, Tricivil, Aprotinin, Trasilol
- Diuretics
- Cytostatics to stop secretion
- Hormones: glucocorticoids
- Antitoxic therapy – ringer
- correction of exocrine - krion, Mizhil
- Surgical treatment - in acute phase, present complication, organic duodenal stasis
8
Q
complications
A
- Jaundice
- GIT (bleeding, enterocolitis, cholangitis, hepatitis, 2‘ peptic ulcer)
- DM
- Malignization
- stenosis of diff levels of tract
- local steato-necrosis in bones
- Ascites
- Abscess, cyst, stone
- HR pleurisy, polyarthritis, relaxation of L dome of diaphragm, hypotonic state
- Thrombosis of spleen veins
- stone in duodenal
