Chronic Pancreatitis

Question 1

Definition

Answer 1

3 months + of pancreatic detoriation = irreversible inflammation +/or fibrosis of the pancreas = progressive decline in endocrine and exocrine function.
Alcohol = 80% of cases

Question 2

Epidemiology

Answer 2

MALE
50

Question 3

Risk factors

Answer 3

Alcohol excess
Smoking
Family history
Ductal obstruction: gallstones, tumours, structural abnormalities (e.g. annular pancreas)
Genetic: cystic fibrosis and haemochromatosis
Autoimmune pancreatitis

Question 4

Aetiology

Answer 4

Alcohol
CKD
Gallstones
Autoimmune pancreatitis
Repeated bouts of acute pancreatitis
Cystic fibrosis (esp in children)
Tumours
Pancreatic trauma

Question 5

Pathophysiology

Answer 5

The exact pathogenesis is poorly understood
- initial insult is thought to occur in the pancreatic duct (e.g. gallstone) or the acinar cells (e.g. alcohol)
The outcome is an inflammatory reaction = ductal dilation and damages the pancreatic tissue. Obstruction of bicarbonate secretion in the pancreatic lumen causes early activation of trypsinogen to trypsin = autodigestion of pancreatic tissue with the end result of fibrosis and loss of function
Damage to islets of Langerhans = non diabetic hyperglycaemia

Question 6

Healthy pancreatic tissue replaced by…

Answer 6

Misshapen ducts
Fibrosis (via stellate cells)
Calcium deposits

Question 7

Signs

Answer 7

Epigastric tenderness (First feature)
Signs of liver disease (alcohol excess)
- e.g. jaundice and ascites
Skin nodules (rare)
- pancreatic lipase leaks into circulation and causes fat necrosis in soft tissue

Question 8

Symptoms

Answer 8

Epigastric pain
- dull radiating to the back
- improved by leaning forward
- occurs 15 to 30 minutes after eating
Steatorrhea
Nausea and vomiting
Weight loss and fatigue
Features of diabetes
- polyuria + polydipsia

Question 9

Diagnosis

Answer 9

FIRST LINE = Abdo USS = detects pancreatic calcification + dilated pancreatic duct
CT abdomen: if ultrasound is suggestive, CT should be conducted and may demonstrate:
Pancreatic calcifications (80% sensitivity and 85% specificity)
Pancreatic atrophy
Duct dilatation
Histology = inflammation, fibrosis, loss of acini, calcification
Bloods = lipase + amylase UNLIKELY TO BE HIGH IN IRREVERSIBLE CASES
* such a deficiency that there’s none left to leak out *
LFT’s = AST>ALT

Question 10

Treatment

Answer 10

FIRST LINE = Life style modication
- Alcohol cessation
- Diet = low fat, high-calorIe diet with soluble vitamin supplementation (A,D,E,K)
- Abdo Sx pain = NSAIDS
SECOND LINE =
- Endoscopic stenting
- Coeliac plexus nerve blocks
- Drainage of pseudocysts

Question 11

Complication

Answer 11

Malabsorption
Duct obstruction
Pseudocysts
Diabetes mellitus
Pancreatic cancer