Chronic pancreatitis Flashcards
Define chronic pancreatitis.
Chronic inflammatory disease of the pancreas characterised by irreversible parenchymal atrophy and fibrosis leading to impaired endocrine and exocrine function and recurrent abdominal pain.
What is the epidemiology of chronic pancreatitis?
- Annual incidence 1/100,000 in UK
- Prevalence 3/100,000
- Mean age 40-50 years in alcohol- associated disease
What are the risk factors for chronic pancreatitis?
- Alcohol - (70-80% of all chronic pancreatitis)
- Smoking
- FH - mutations in PRSS1, SPINK1, CFTR
- Coeliac disease –> IDIOPATHIC
Other: psoriasis, high-fat, high-protein diet
Which GI condition increases risk of developing any form of pancreatitis?
coeliac disease
What is the pathophysiology of chronic pancreatitis? Which cells are thought to be involved?
Chronic inflammation –> fibrosis and calcification, parenchymal atrophy, ductal dilatation, cyst and stone formation —> disruption of normal pancreatic glandular architecture
Pancreatic stellate cells - thought to play a role in pancreatitis by converting from quiescent fat storing cells to myofibroblast-like cells forming extracellular matrix, cytokines and GF in response to injury.
What is the pain in chronic pancreatitis thought to be associated with?
Pain is thought to be associated with raised intraductal pressure and inflammation.
What is the typical presentation of chronic pancreatitis?
- Recurrent severe epigastric pain, radiating to back, relieved by sitting forward and exacerbated by eating or drinking alcohol
- Weight loss
- Bloating
- Pale offensive stools (steatorrhoea)
- Other: painful joints, SOB, skin nodules (pancreatic lipase leaks into circulation and causes fat necrosis at non-pancreatic sites).
What investigations would you do for chronic pancreatitis?
1st tests: CT/MRI +/- USS
Bedside:
- Glucose - if high then endocrine dysfunction, GTT (glucose tolerance test)
- Amylase/lipase - normal
- Immunoglobulins - high esp IgG4 in autoimmune pancreatitis
- Faecal elastase - reduced in severe disease
Imaging:
- USS - percutaneous or endoscopic - hyperechoic foci with post-acoustic shadowing
- ERCP/MRCP - see next
- AXR - pancreatic calcification may be visible
- CT scan - pancreatic cysts, calcification
What does ERCP/MRCP show in early and late stages of chronic pancreatitis?
Early - duct dilatation and stumping of branches
Late - duct strictures with alternating dilatation (“chain of lakes”/beading appearance)
How do you manage chronic pancreatitis?
Conservative - alcohol and cigarette cessation
Medical
- Analgesics - if not sufficient → coeliac plexus block or transthoracic splanchnicectomy.
- Lifestyle modification
- Pancreatic enzymes (e.g. pancreatin/Creon) and PPI (e.g. omeprazole)
- Dietary modification - low-fat
Endoscopic - pseudocyst decompression, sphincterotomy, stone extraction, dilatation, stenting or strictures. ESWL for pancreatic stone fragmentation prior to endoscopic removal.
Surgical -
- drainage (modified Puestow procedure),
- resection (pancreaticoduodenectomy/ Whipple’s),
- limited resection (Beger procedure),
- combined opening of pancreatic duct and excavation of pancreatic head (Frey procedure)
What are the local and systemic complications of chronic pancreatitis?
Local - pseudocysts, BD stricture, duodenal obstruction, calcifications, pancreatic ascites, pancreatic carcinoma
Systemic - exocrine insufficiency, diabetes, steatorrhoea, reduced QOL, chronic pain syndromes, opioid dependence
What is the prognosis in chronic pancreatitis?
- Difficult to predict - may stabilise, worse, or improve
- Surgery improves symptoms in 60-70% but results are not sustained
- Life expectancy reduced by 10-20 years
- Pain decreases or disappears over time
