Chronic Pancreatitis

Question 1

What is chronic pancreatitis?

Answer 1

Irreversible pancreatic parenchymal atrophy + fibrosis leading to impaired endocrine + exocrine function + recurrent abdominal pain.

Question 2

Explain the aetiology of chronic pancreatitis

Answer 2

Disruption of normal pancreatic glandular architecture due to chronic inflammation + fibrosis, calcification, parenchymal atrophy, ductal dilation + cyst + stone formation
Pain is associated with raised intraductal pressures

Question 3

What are the 2 main causes of chronic pancreatitis?

Answer 3

ALCOHOL: 80%
other: 20%

Question 4

Give 2 genetic causes of chronic pancreatitis

Answer 4

Cystic fibrosis
Haemochromatosis

Question 5

List 3 causes of ductal obstruction leading to chronic pancreatitis

Answer 5

Tumours
Stones
Structural abnormalities inc. pancreas divisum + annular pancreas

Question 6

Summarise the epidemiology of chronic pancreatitis

Answer 6

Annual UK incidence: 1/100,000
Mean age: 40-50y (in alcohol-associated disease)

Question 7

Describe the pain in chronic pancreatitis

Answer 7

Recurrent severe epigastric pain
Radiates to the back
Relieved by sitting forward
Aggravated by eating or drinking alcohol
Over many years –> weight loss, bloating + steatorrhoea

Question 8

Give 2 signs of pancreatitis on physical examination

Answer 8

Epigastric tenderness
Signs of complications e.g. weight loss, malnutrition

Question 9

What bloods results are seen in chronic pancreatitis?

Answer 9

High glucose (endocrine dysfunction): glucose tolerance test may be performed 
Amylase + lipase usually normal 
High Ig (especially IgG4 in AI)

Question 10

Other than bloods, what investigations are performed for chronic pancreatitis?

Answer 10

CT/ MRI: pancreatic calcification + cysts
Endoscopic US
MRCP:
Early: main duct dilatation + stumping of branches
Late: duct strictures with alternating dilatation
AXR: pancreatic calcification
Faecal elastase (exocrine function) LOW

Question 11

List 7 rare causes of chronic pancreatitis

Answer 11

Recurrent acute pancreatitis
Ductal obstruction: strictures- trauma, stones
Pancreas divisum
Hereditary pancreatitis
Tropical pancreatitis
AI pancreatitis
Systemic: CF, Hyperparathyroidism

Question 12

Describe the medical management of chronic Pancreatitis

Answer 12

Symptomatic + supportive:
Dietary advice
Stop smoking/drinking
Treat diabetes
Pancreatic enzyme replacement: Creon
Analgesia

Question 13

What is given alongside pancreatic enzyme supplementation in patients still producing gastric acid?

Answer 13

PPIs
to improve the levels of the pancreatic enzymes making it to the intestines.

Question 14

What endoscopic therapy can be used in chronic pancreatitis?

Answer 14

Sphincterotomy
Stone extraction
Dilatation + stenting of strictures
Extracorporial shock-wave lithotripsy sometimes used to fragment large stones before removal

Question 15

When and what surgical methods are used in chronic pancreatitis?

Answer 15

If medical tx fails/ Ca suspected
Pancreaticojejunostomy
Pancreatic resection (Whipple’s)

Question 16

What 5 local complications may arise from chronic pancreatitis?

Answer 16

Pseudocysts  
Biliary duct stricture  
Duodenal obstruction  
Pancreatic ascites  
Pancreatic carcinoma

Question 17

What 4 systemic complications may arise from chronic pancreatitis?

Answer 17

Diabetes
Steatorrhoea
Chronic pain syndromes
Dependence on strong analgesics

Question 18

What is the prognosis for patients with chronic pancreatitis?

Answer 18

Surgery improves Sx in 60-70% but results often not sustained
Life expectancy may be reduced by 10-20y

Question 19

What are those with chronic pancreatitis at high risk of developing? How is this screened for?

Answer 19

Type 3c diabetes mellitus aka Pancreatogenic diabetes.
Annua HbA1c

Question 20

Why Pancreatogenic diabetes complex to manage?

Answer 20

Due to concomitant exocrine insufficiency resulting in malabsorption + malnutrition.