Chronic pancreatitis Flashcards
Describe chronic pancreatitis?
- Chronic Inflammation
- Fibrosis and destruction of exocrine pancreatic tissue
- DM occurs in advanced stages
Causes of chronic pancreatitis?
- Chronic alcohol abuse (60%)
- Idiopathic (30%)
- Infection
- Autoimmune
- Cystic fibrosis
- Hyperlipidaemia, hypercalcaemia
- Pancreas divisum, annular pancreas
Describe the pathophysiology of chronic pancreatitis?
- Large duct disease
- Dilatation and dysfunction of large ducts => visible on imaging
- Fluid changes facilitate the deposition of calcium carbonate stones and cause pancreatic calcification
- More commonly found in males
- Small duct disease
- Normal imaging and no pancreatic calcification
- More common in females
Risk factors for Chronic pancreatitis?
- Excess alcohol consumption
- Smoking
- Also increased risk for pancreatic malignancy
Clinical features of chronic pancreatitis?
- Chronic epigastrium pain
- Radiates to the back, worse when eating
- Improved when patient leans forward
- Pain can be relieved by alcohol consumption in some cases
- Nausea/vomiting
- Erythema ab igne
- Can present with:
- Endocrine dysfunction (DM)
- Exocrine dysfunction (steatorrhoea/malabsorption)
What is stetorrhoea?
- Excretion of abnormal quantities of fat with the faeces
- Due to reduced absorption of fat in the intestine
Differentials for chronic pancreatitis?
- Acute cholecystitis
- Peptic ulcer disease
- Acute hepatitis
Investigations into Chronic pancreatitis?
- Bloods
- BM: raised glucose secondary to endocrine dysfunction
- Serum calcium: assess for hypercalcaemia
- LFTs: abnormalities may indicate hepatic aetiology
- Reduced faecal elastase
- Imaging
- CT is the principle investigation
- MRCP: identifies biliary obstruction and assesses pancreatic duct
Describe the initial management of chronic pancreatitis?
- Analgesia
- NSAID + opioid
- Tricyclic antidepressants (TCAs)
- Address complications of disease
- Pancreatic enzyme supplements
Describe more definitive treatments for chronic pancreatitis?
- Endoscopic treatments:
- ERCP
- Endoscopic US (EUS)
- Endoscopic pancreatic sphincterotomy
- Surgery
- Steroids can be used to reduce symptoms in people with AI cause
Describe the use of endoscopic ultrasound in chronic pancreatitis?
- Can facilitate the drainage of any pseudocysts
- Bile duct stent insertion can relieve distal duct stricture
- Short term due to blockage risk
Describe the use of an Endoscopic pancreatic sphincterotomy in chronic pancreatitis?
- Beneficial in patients with papillary stenosis
- Associated wtih high sphincter and pancreatic duct pressures
- Generally used for large duct pancreatitis
Complications that can occur with endoscopic procedures in chronic pancreatitis treatment?
Risk of inducing acute-on-chronic pancreatitis
Describe the use of surgical approaches to manage chronic pancreatitis?
- Relieve any obstruction and remove mass lesions whilest preserving pancreatic tissue where possible
- Lateral pancreaticojejunostomy
- Pancreaticoduodenectomy (whipples procedure)
- Total pancreatctomy
Describe a Lateral pancreaticojejunostomy procedure?
- Side to side anastomossis of the pancreatic duct to jejunum
- Provides reliev but pain tends to recur as the head of pancreas remains in situ
Describe a pancreaticoduodenectomy procedure?
- aka Whipples procedure
- Indicated in paraduodenal pancreatitis or is neoplasia cannot be excluded
- Resection of pancreatic head, gallbladder, bile duct, pyloric antrum and first and second parts of the duodenum
- The tail of the pancreas is anastomased with the duodenum
- The body of the stomach is anastamosed to distal duodenum
