Chronic pancreatitis Flashcards
What is 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 are the risk factors for chronic pancreatitis?
- ALCOHOL - 70%
- Idiopathic - 20%
- RARE: recurrent acute pancreatitis, ductal obstruction, pancreas divisum, hereditary pancreatitis, tropical pancreatitis, autoimmune pancreatitis, hyperparathyroidism, hypertriglyceridemia
- Genetic factors such as cystic fibrosis
- Obstructive causes such as pancreatic cancer
- Metabolic causes such as elevated triacyglycerides
Describe the pathogenesis of chronic pancreatitis
- Chronic pancreatitis is caused by disruption of normal pancreatic glandular architecture due to chronic inflammation and fibrosis, calcification, parenchymal atrophy, ductal dilation and cyst and stone formation
- Pancreatic stellate cells are thought to play a role, converting from quiescent fat storing cells to myofibroblast-like cells forming ECM, cytokines and GFs in reponse to injury.
- Pain is associated with raised intraductal pressures and inflammation
Summarise the epidemiology of chronic pancreatitis
Annual UK incidence: 1/100,000
Prevalence: 3/100,000
Mean age: 40-50 yrs (in alcohol-associated disease)
What are the presenting symptoms of chronic pancreatitis?
- Recurrent severe epigastric pain
- Pain radiates to the back
- Pain relieved by sitting forward
- Pain can be aggravated by eating fatty food or drinking alcohol
- Over many years, symptoms of exocrine dysfunction –> weight loss, bloating and steatorrhoea
- symptoms of endocrine dysfunction, DM, thirst, polyuria
What signs of chronic pancreatitis can be found on physical examination ?
- Epigastric tenderness
- Signs of complications e.g. weight loss, malnutrition
What investigations are used to diagnose/ monitor chronic pancreatitis?
- Bloods:
- High glucose (endocrine dysfunction) - glucose tolerance test may be performed
- Amylase and lipase usually normal
- High IgG (especially IgG4 in autoimmune pancreatitis) - Ultrasound – can shown hyperchoic foci with post-acoustic shadowing
- ERCP or MRCP:
- Early changes that can be seen include main duct dilatation and stumping of branches
- Late manifestations include duct strictures with alternating dilatation - Abdominal X-Ray:
- May show pancreatic calcification - CT Scan:
- May show pancreatic calcification and pancreatic cysts - Tests of pancreatic exocrine function:
- Faecal elastase (reflects pancreatic exocrine function)
How is chronic pancreatitis managed?
- General:
- Treatment is mainly symptomatic and supportive (e.g. dietary advice – no alcohol, low fat, stop smoking/drinking, treat diabetes, oral pancreatic enzyme replacement, analgesia)
- Chronic pain management may need specialist input - Endoscopy Therapy:
- Sphincterotomy
- Stone extraction
- Dilatation and stenting of strictures
- Extracorporial shock-wave lithotripsy (ESWL) is sometimes used to fragment larger pancreatic stones before removal - Surgical:
- May be indicated if medical management fails
- Lateral pancreaticojejunal drainage (modified Puestow procedure)
- Pancreatic resection (pancreaticoduodenectomy or Whipple’s procedure)
- Limited resection of pancreatic head (Beger procedure)
- Combining opening of the pancreatic duct and excavation of the pancreatic head
What are the possible complications of chronic pancreatitis?
- Local:
- Pseudocysts
- Biliary duct stricture
- Duodenal obstruction
- Pancreatic ascites
- Pancreatic carcinoma
- Local arterial aneurysm
- Splenic vein thrombosis
- Gastric varices - Systemic:
- Diabetes
- Steatorrhoea
- Chronic pain syndromes
- Dependence on strong analgesics
Describe the prognosis for patients with chronic pancreatitis?
- Difficult to predict
- Surgery improves symptoms in 60-70% but results are often not sustained
- Life expectancy may be reduced by 10-20 years
