Chronic Pancreatitis

Question 1

Explain what is meant my chronic pancreatitis

Answer 1

• Ongoing, persistent inflammation of the pancreas characterised by fibrosis and destruction of panreatic tissue.

Question 2

State major risk factors for chronic pancreatitis

Answer 2

• Alcohol (70-80%)
• idiopathic
• cigarette smoking
• high fat/high protein diet
• Autoimmune
• Genetic

Question 3

Explain the pathophysiology of chronic pancreatitis

Answer 3

Question 4

Further potential causes of chronic pancreatitis

Answer 4

Note cystic fibrosis.

SPINK1 - is gene enocding for PSTI - pancreatic secretory trypsin inhibitor protein that serves to

Autoimmune can be specific to pancreas or can be systemic

Question 5

Symptoms of chronic pancreatitis in initial stages, followed by symtpoms in later stages

People who stop what may experience a reduction in symptoms?

Answer 5

• Repeated episodes of abdominal pain - 80% of patients
  
  • pain usually in the middle of left side of the abdomen and can sometimes travel along your back
  • Some people also experience nausea and vomiting
  • People who stop smoking and drinking may lessen symptoms
• Advanced chronic pancreatitis
  
  • weight loss (often because eating makes pain worse), in addition to the abnormal function of the pancreas not releasing enzymes properly
  • loss of appetite
  • jaundice (10%)
  • steatorrhoea
  • symptoms of diabetes such as feeling very thirsty, tired, frequent urination
  • ongoing nausea and vomiting

Question 6

State potential complications of chronic pancreatitis

Answer 6

• Pseudocysts (fluid filled sacs containing pancreatic enzymes, blood and necrotic tissue)
• Panceatic ascites - stricture of pancreatic duct can cause pancreatic juices to leak into the duodenum
• Obstructive jaundice
  
  • Fibrotic pancreas can cause benign stricture of bile duct, causing post-hepatic jaundice
• Peptic ulcers
• Low-trauma fractures due to impairded bone density
  *

Question 7

What lab tests could you to check pancreatic function? (direct and indirect). Briefly explain them

Answer 7

• Direct
  
  • Secretin-pancreozymin test - gold standard but very invasive
    
    • use exogenous hormones (secretin and CCK) to synthetically stimulate pancreatic secretion and collect and measure levels of enzymes amylase, lipase and trypsin
    • They are measured by a cathetar in the duondeum
    • is however highly invasive
  • The lundh test basically nobody does this now

Question 8

State indirect pancreatic function tests.

Answer 8

• NBT-PABA test and the Pancreolauryl test
  
  • basically based on the fact that pancreatic enzymes should cleave an absorbable substance from a non-absorbable molecule
    
    • ​measure levels in urine to see if pancreas if functioning properly
• Neither test is now available in the UK

Question 9

Faecal tests are another indirect way of measuring pancreatic function. State some of these tests, what is typically mostly used today?

Answer 9

• Meauring fat levels in stool - now obsolete
• Measurement of pancreatic enzymes in faeces
  
  • ​Faecal chymotrypsin
    
    • ​​test looking for proteolytic enzymes
    • low value suggests pancreatic insuffiency
    • Lack of standardisation in techniques used
• • Faecal elastase - produced by the acinar cells of the pancreas
    * ​<200ug/g of stool incidcates exocrine insufficiency
    * may be useful in determining the amount of pancreatic enzyme replacement therapy required in patients with cystic fibrosis or chronic pancreatic insufficiency.

Question 10

What tests can be used to confirm a suspected chronic pancreatitis diagnosis?

Answer 10

• Ultrasound
• CT
• X-ray
• Magnetic resonance cholangiopancreatography
• Endoscopy

Question 11

What feature of suspected chronic pancreatitis can be shown when imaging the pancreas?

Answer 11

Calcification - seems to be when there is build up of protein material and ends up getting calcified

Question 12

Discuss treatments for chronic pancreatitis

Answer 12

• Alcohol avoidance is cruical in halting progression of the disease and reducing pain
• Analgesia
  
  • NSAIDs - however, opiate addiction is actually a relatively common outcome
  • Tricyclic antidepressants (amitripytline) and membrane stabilising agents (pregabalin) are also used for chronic pain releif
• Pancreatic enzyme supplements - often given with PPI to optimise pH for pancreatic enzymes which would normally be exposed to the duodenum only and not the stomach
• Dietary changes (covered in another card)
• Steroids if immune caused
• Insulin if diabetes

Basically if pain is still not relieved - then pancreotomy.

Question 13

Discuss dietary changes for chornic pancreatitis patients

Answer 13

• high protein, low fat
  
  • Aim for micro-nutrient dense diets
    
    • fruits, veg, whole grains, low fat dairy
    • Absitence from alcohol, fried foods
• Vitamin supplementation, as well as calcium, iron, folate can be common, since malabsorption can occur - which can lead to further problems like osteoporosis
  
  • patients frequently tested for nutritional deficienceis
• Pancreatic enzymes

Question 14

Discuss possible stratheies for improving patient compliance

Answer 14

https://www.nature.com/articles/bdjteam2015165