Chronic Pancreatitis

Question 1

What is chronic pancreatitis?

Answer 1

Chronic fibre-inflammatory disease of the pancreas with progressive and irreversible damage to the pancreatic parenchyma

Question 2

What are the causes fo chronic pancreatitis?

Answer 2

Chronic alcohol abuse
Idiopathic
Metabolic - hyperlipidaemia, hypercalcaemia
Infection - IGV, mumps, coxsackie
Hereditary - Cystic fibrosis
Autoimmune - anutoimmune pancreatitis, SLE
Obstruction of pancreatic duct - neoplasm, sstricture

Question 3

What is the pathophysiology of chronic pancreatitis?

Answer 3

Large duct disease:
Dilation and dysfunction of the large pancreatic ducts visible on most diagnostic imaging. Pancreatic fluid changes composition and facilitates the deposition of precursors to calcium carbonate stones and causes pancreatic calcification - males

Small duct disease - normal imaging, no pancreatic calcification - females

Question 4

What are the clinical features of chronic pancreatitis?

Answer 4

Epigastric pain, bores through to the back, relieved by sitting forward or hot water bottles on the epigastrium - erythema ab ignore
Nausea and vomiting
Bloating
Steatorrhoea
Weight loss

Symptoms secondary to endocrine dysfunction - diabetes mellitus
Exocrin dysfunciton - steatorrhea, malabsorption

Question 5

What investigations for pancreatitis?

Answer 5

BM for raised glucose

Bloods - serum calcium, LFTs

Imaging - abdominal USS - can show evidence of underlying causes

CT abdo-pelvis - to show calcification or pseudocyst formation

Magenetic resonance cholangiopancreatography (MRCP)
- presence of biliary obstruction and assess pancreatic duct

Endoscopic retrograd cholangiopancreatography (ERCP) - combined with treatment - e.g. dilatation of strictures

Question 6

What is the management of chronic pancreatitis?

Answer 6

Conservative:
Analgesia - simple + opioid
Diet: no alcohol, low fat
Nutritional support - enzyme supplements

Endoscopic:
ERCP - extract pancreatic duct stones
EUSS - facilitate drainage of pseudocysts
Dile duct stent to relive distal duct stricture
Risk of acute on chronic pancreatitis

Surgical:
Relive any obstruction and remove mass lesions
Lateral pancreaticojejunotomy - side to side anastomosis of pancreatic duct to jejunum
Pancreaticoduodenectomy (Whipple’s procedure) - resection of the pancreatic head, gallbladder and bile duct, pyloric antrum and first/second parts of the duodenum with the tail of the pancreas anastomosed to the duodenum and the body of the stomach anastomosed to the distal duodenum

Steroids in autoimmune pancreatitis

Question 7

What is Whipple procedure?

Answer 7

Pancreaticoduodenectomy (Whipple’s procedure) - resection of the pancreatic head, gallbladder and bile duct, pyloric antrum and first/second parts of the duodenum with the tail of the pancreas anastomosed to the duodenum and the body of the stomach anastomosed to the distal duodenum

Question 8

What are complications of chronic pancreatitis?

Answer 8

Pseudocyst
Steatorrhoea and malabsorption - due to poor exocrine pancreatic function - treated with enzyme replacement - risk of deficiency of fat soluble vitamins A, D, E, K - check clotting and bone density

Diabetes - loss of endocrine function
Insulin treatment - insulin treatment to avoid hypoglycaemia due to glucagon deficiency

Effusions - disruption of pancreatic duct

Malignancy