Chronic pancreatitis

Question 1

What is chronic pancreatitis?

Answer 1

The process of healthy pancreatic tissue being replaced by misshapen ducts, fibrosis and calcium deposits, leading to decreased function.

Question 2

How can acute pancreatitis progress to chronic?

Answer 2

Repeated bouts of acute pancreatitis cause ductal dilatation and tissue damage. The healing process involves deposition of fibrotic tissue by stellate cells, which causes stenosis (narrowing) of ducts. This can lead to acinar atrophy.
Acute alcoholic pancreatitis also causes calcium depositions on protein plugs.

Question 3

Give 3 symptoms of chronic pancreatitis.

Answer 3

Intense epigastric pain lasting several hours, radiating to the back, may be associated with meals, relievedby sitting forward/hot water bottle.
Bloating
Steatorrhoea
Weight loss
Relapsing and remitting course.

Question 4

How would you confirm the diagnosis of chronic pancreatitis?

Answer 4

USS +/- CT - calcifications confirm Dx.

Question 5

Why would serum enzymes not be a good diagnostic test for chronic pancreatitis?

Answer 5

There may not be enough healthy tissue left to produce pancreatic enzymes.

Question 6

What are 3 complications of chronic pancreatitis?

Answer 6

Pancreatic insufficiency
Diabetes mellitus
Pseudocysts
Biliary obstruction
Local arterial aneurysm
Splenic vein thrombosis

Question 7

Describe the pathophysiology and symptoms of pancreatic insufficiency.

Answer 7

Acinar cells are impaired so they produce fewer enzymes. This causes malabsorption, leading to weight loss and deficiency of fat-soluble vitamins A, D, E and K. This causes stearorrhoea (greasy, smelly stools).

Question 8

How does pancreatitis cause diabetes?

Answer 8

Long-term pancreatitis causes inflammatory damage to alpha- and beta- cells of the pancreas, so there is decreased insulin and glucagon production, causing diabetes mellitus.

Question 9

How do pseudocysts form?

Answer 9

Ductal obstruction causes increased pressure and leakage, leading to accumulation of fluid in a pseudocyst.

Question 10

Describe the management of chronic pancreatitis.

Answer 10

1. Analgesia
2. Diet - no alcohol, low fat, wt loss.
3. Complications - pancreatic insufficiency (lipase, nutritional supplements) and diabetes (insulin). Beware hypoglycaemia.
4. Pancreatectomy: for unremitting pain, narcotic abuse, wt loss.

Question 11

Give 3 causes of chronic pancreatitis.

Answer 11

Common: alcohol, smoking, autoimmune

rare: familial, CF, haemochromatosis, obstruction, congenital.