Chronic pancreatitis

Question 1

Define

Answer 1

• Chronic inflammatory disease of the pancreas characterised by irreversible parenchymal atrophy and fibrosis leading to impaired endocrine and exocrine function and recurrent abdominal pain.

Question 2

What are the risk factors?

Answer 2

• ALCOHOL - 70%
• Idiopathic - 20%

• Key risk factors: alcohol, smoking, family history, coealiac disease

Question 3

Explain aetiology

Answer 3

o Chronic pancreatitis is caused by disruption of normal pancreatic glandular architecture due to chronic inflammation and fibrosis, calcification, parenchymal atrophy, ductal dilation and cyst and stone formation

Question 4

Epidemiology

Answer 4

• Annual UK incidence: 1/100,000
• Prevalence: 3/100,000
• Mean age: 40-50 yrs (in alcohol-associated disease)

Question 5

What are the presenting symptoms?

Answer 5

• Recurrent severe epigastric pain
• Pain radiates to the back
• Pain relieved by sitting forward
• Pain can be aggravated by eating or drinking alcohol
• Nausea and vomiting
• Over many years –> weight loss, bloating and steatorrhoea

Question 6

What are the signs?

Answer 6

• Epigastric tenderness

* Signs of complications e.g. weight loss, malnutrition

Question 7

What are the 1st investigations?

Answer 7

• Bloods:
o High glucose (endocrine dysfunction) - glucose tolerance test may be performed
o Amylase and lipase usually normal
o High Ig (especially IgG4 in autoimmune pancreatitis)
• Ultrasound
• structural/anatomical changes including cavities; duct irregularity; contour irregularity of head/body; calcification
• Abdominal X-Ray:
o May show pancreatic calcification
• CT Scan:
o May show pancreatic calcification and pancreatic cysts

Question 8

What are some investigations to consider?

Answer 8

• ERCP or MRCP:
o Early changes that can be seen include main duct dilatation and stumping of branches
o Late manifestations include duct strictures with alternating dilatation
• Tests of pancreatic exocrine function:
o Faecal elastase (reflects pancreatic exocrine function)

Question 9

How would you manage it?

Answer 9

• General:
o Treatment is mainly symptomatic and supportive (e.g. dietary advice, stop smoking/drinking, treat diabetes, oral pancreatic enzyme replacement, analgesia)
o Chronic pain management may need specialist input
• Endoscopy Therapy:
o Sphincterotomy
o Stone extraction
o Dilatation and stenting of strictures
o Extracorporial shock-wave lithotripsy (ESWL) is sometimes used to fragment larger pancreatic stones before removal
• Surgical:
o May be indicated if medical management fails
o Lateral pancreaticojejunal drainage (modified Puestow procedure)
o Pancreatic resection (pancreaticoduodenectomy or Whipple’s procedure)
o Limited resection of pancreatic head (Beger procedure)
o Combining opening of the pancreatic duct and excavation of the pancreatic head (Frey procedure)

Question 10

What are the possible complications?

Answer 10

•	Local:
o	Pseudocysts 
o	Biliary duct stricture 
o	Duodenal obstruction 
o	Pancreatic ascites 
o	Pancreatic carcinoma
•	Systemic:
o	Diabetes mellitus
o	Steatorrhoea
o	Chronic pain syndromes 
o	Dependence on strong analgesics

Question 11

What’s the prognosis?

Answer 11

• Difficult to predict
• Surgery improves symptoms in 60-70% but results are often not sustained
• Life expectancy may be reduced by 10-20 years