Chronic pancreatitis

Question 1

How common is it?

Answer 1

Based on the estimates from hospital discharge data in the United States, approximately 87,000 cases of pancreatitis occur annually.

Comparing the hospital admissions data from several cities around the globe, the overall frequency is similar.

Question 2

Who does it affect?

Answer 2

Alcoholics (80% of cases)

Question 3

What causes it?

Answer 3

Toxic-metabolic:

• Alcohol abuse
• Tobacco use
• Hypercalcaemia
• Chronic renal failure

Genetic:
- CF

Autoimmune

Recurrant acute pancreatitis

Obstructive:

• Ductal adenocarcinoma
• Intraductal papillary mucinous neoplasia
• Pancreas divisum
• Spincter of Oddi stenosis

Question 4

What risk factors are there (and how can they be reduced)?

Answer 4

Alcohol abuse
Tobbacco use
Previous acute pancreatitis
Infection
Malnutrition
Male sex

Question 5

How does it present? What symptoms should you look out for?

Answer 5

Abdominal pain, relentless and slowly progressive (35%)
May present like acute pancreatitis (acute on chronic) (50%)
No pain but diarrhoea (the rest)
Weight loss
Pain may be relieved by leaning forwards or drinking alcohol
Post postprandial
Steatorrhoea (90% exocrine tissue destroyed)
Protein malabsorption (in most advanced cases)

Question 6

What signs may the patient have on examination?

Answer 6

Examination often not useful
May have epigastric tenderness/mass
Signs of malnutrition

Question 7

Which other conditions might present similarly?

Answer 7

Ampullary Carcinoma
Cholangitis
Cholecystitis
Chronic Gastritis
Community-Acquired Pneumonia (CAP)
Crohn Disease
Intestinal Perforation
Mesenteric Artery Ischemia
Myocardial Infarction
Pancreatic Cancer
Peptic Ulcer Disease

Question 8

How would you investigate this patient?

Answer 8

Diagnostic tests:

• Ultrasound
• CT (may show atrophy, calcification or ductal dilatation)
• Abdominal X-ray (may show calcification)
• MRCP
• Endoscopic ultrasound

Tests of pancreatic function:

• Collection of pure pancreatic juice after secretin injection
• Pancreolauryl test
• Faecal pancreatic elastase

Question 9

What would you tell the patient and how would you explain the condition to them?

Answer 9

Their pancreas has become so damaged due to alcohol abuse etc, that it has become chronically inflamed. The damage is likely to be extensive and permanent.

Question 10

How do you think the patient and/or family might be affected by the diagnosis? Will it affect their
ability to work/care for themselves?

Answer 10

Given prognosis/severity it would be a very distressing diagnosis to receive.
Likely to have a long-term/lifelong impact on the patient
Particularly difficult if patient feels unable to give up alcohol (if this is the cause), which may cause feelings of guilt and/or anger

Question 11

What questions are they likely to have?

Answer 11

Why has this happened?
Will is go away if I give up alcohol?
Do I have to give up alcohol?
Will I ever be able to drink alcohol again?
Will this resolve completely?
Will this cause disability?

Question 12

What treatment/s (surgical, pharmacological and non-pharmacological) would you discuss with
them? What risks and benefits of treatment are there?

Answer 12

Alcohol avoidance
NSAIDs
Opiates (use may become heavy and addictive)

Endoscopic therapy:

• Dilatation or stenting of pancreatic duct strictures
• Removal of calculi (mechanical or shock-wave lithotripsy)
• Drainage of pseudocysts

Surgical methods

• Partial pancreatic resection, preserving the duodenum
• Pancreatico-jejunostomy