Chronic Pancreatitis

Question 1

Definition

Answer 1

Chronic, irreversible, inflammation and/or fibrosis of the pancreas, often characterised by severe pain and progressive endocrine and exocrine insufficiency.

Endocrine – damage to islets of Langerhans, failure to produce insulin DM
Exocrine – damage to acinar cells, failure to produce digestive enzymes maldigestion & malabsorption

Question 2

Prevalence

Answer 2

8.3 per 100,000

Question 3

Pathophysiology

Answer 3

Theories include oxidative stress, toxic-metabolic factors, ductal obstruction & necrosis-fibrosis.

Question 4

Causes

Answer 4

Alcohol (MAIN)
Idiopathic chronic pancreatitis for 25% of cases
Drugs – thiazide, azathioprine, tetracyclines, oestrogens, valproic acid, cimetidine and dipeptidylpeptidase-4 inhibitors (sitagliptin and vildagliptin)

Question 5

Risk factors

Answer 5

Smoking
Autoimmune (Sjörgen’s syndrome, IBD and 1° biliary cirrhosis)
Genetic
Obstructive
Tropical causes
Drugs – thiazide, azathioprine, tetracyclines, oestrogens, valproic acid, cimetidine and dipeptidylpeptidase-4 inhibitors (sitagliptin and vildagliptin)

Question 6

Clinical presentation

Answer 6

Pain – deep, severe and dull in epigastric region and may radiate to back. Intermittent, constant or continuous with superimposed acute flares. Relieved by sitting upright and leaning forward. Precipitated by eating and associated w/ nausea and vomiting.
Other: bloating, abdo cramps and excessive flatus.
Weight loss
Malnutrition
Steatorrhea
Diabete mellitus

Question 7

Signs

Answer 7

Signs of chronic liver disease
Epigastric tenderness
Jaundice due to concomitant liver disease.
Abdo distension due to pseudocyst, pancreatic ascites or pancreatic cancer.
Firm skin nodules due to disseminated fat necrosis.
SOB

Question 8

Differentials

Answer 8

Acute cholecystitis 
Biliary colic
Acute pancreatitis
IBS
Peptic ulcer 
Pancreatic cancer
Post-herpetic neuralgia
Gastroparesis
Intestinal obstruction
AAA
Thoracic radiculopathy 
MI

Question 9

Investigations

Answer 9

Blood tests – LFTs, intra-pancreatic bile duct compression.
Abdo ultrasonography e.g. gallstones and pancreatic calcification.
DEXA scan

Question 10

Management

Answer 10

Consider urgent admission.
Lifestyle advice
Pain relief: NSAIDs weak opioids
If pain is uncontrolled:
-Endoscopic therapy (remove stones or dilate strictures
-Surgery to relieve pain from obstructions e.g. pancreatic pseudocyst or gastric outlet obstruction
-Adjuvant: Amitriptyline, gabapentin or pregabalin
-Coeliac axis block, splanchicectomy
Diabetes screening, Osteoporosis screening
Pancreatic enzyme supplements
Corticosteroids for autoimmune chronic pancreatitis
Treatment of hypertriclyceridaemia, hypercalcaemia, DM

Question 11

Complications

Answer 11

Malabsorption
DM
Chronic pain
Opioid dependency
Osteoporosis
Pancreatic calcification
Pseudocyst formation
Duodenal obstruction
Biliary obstruction
Fistulae
Pancreatic cancer
Pseudoaneurysm
Splenic/portal vein thrombosis

Question 12

Prognosis

Answer 12

Chronic pain is common – intermittent, constant or continuous with superimposed acute flares. Pain changes over times.
Pancreatic exocrine insufficiency.
Pancreatic endocrine insufficiency.
Increased mortality chance