chronic pancreatitis

Question 1

what is chronic pancreatitis?

Answer 1

a chronic fibro-inflammatory disease of the pancreas, with progressive and irreversible damage to the pancreatic parenchyma.

Question 2

what are the causes of chronic pancreatitis?

Answer 2

• chronic alcohol abuse
• idiopathic
• metabolic e.g hyperlipidaemia, hypercalcaemia
• infection e.g Viral (HIV, mumps) or bacterial (echinococcus)
• hereditary e.g CF
• autoimmune e.g AIP and SLE
• obstruction of pancreatic duct e.g stricture or neoplasm
• congenital e.g annular pancreas/pancreas divisum

Question 3

what is the pathophysiology of chronic pancreatitis?

Answer 3

can occur in large duct or small duct form

• large duct disease = dilation and dysfunction of the large pancreatic duct = visible on imaging. Facilitates deposition of Ca carbonate precursor stones and causes diffuse pancreatic calcification. common in males
• small duct disease = normal imaging and no calcification, difficult to diagnose. usually in females.

Question 4

what are the risk factors for chronic pancreatitis?

Answer 4

excess alcohol consumption

Question 5

clinical features of chronic pancreatitis?

Answer 5

• chronic pain in epigastrium radiating to bak, eased by leaning forward
• recurring attacks of acute pancreatitis
• nausea and vomitng
• symptoms secondary to endocrine dysfunction e.g. diabetes mellitus or exocrine dysfunction e.g. steatorrhoea
• epigastric tenderness on palpation
• mass may be felt in epigastrium, suggesting pseudocyst of inflammatory mass

Question 6

what are your differentials?

Answer 6

• acute cholecystitis
• peptic ulcer disease
• acute hepatitis
• sphincter of odds dysfunction

Question 7

what lab investigations should be done?

Answer 7

routine bloods, but specifically for pancreatitis

• BM to check for raised glucose secondary to reduce endocrine dysfunction
• serum calcium to asses for hypercalcaemia
• LFTs in hepatic aetiology
• serum amylase and lipase levels are rarely significantly raised in established disease
• faecal elastase is sensitive and will be abnormally low in most cases

Question 8

what imaging can be done?

Answer 8

• abdominal USS for underlying cause and intra abdominal pathology
• CT AP after USS to show calcification or pseudocyst formation
• MRCP (Magnetic resonance cholangiopancreatography) - to identify presence of biliary obstruction and assess pancreatic duct. Normal appearance doesn’t mean no chronic pancreatitis.
• Endoscopic retrograde cholangiopancreatography (ERCP) - accurate way of seeing pancreatic duct anatomy. Can also combine with intervention e.g dilation for any stricture present.

Question 9

initial management?

Answer 9

• simple analgesia +opioid.
• pancreatic enzyme supplements, creon, can be given to relieve pain in chronic pancreatitis. May be especially useful in small duct disease.

Question 10

definitive management?

Answer 10

• avoid precipitating factor e.g alcohol
• manage chronic pain
• nutritional support with enzyme supplemements
• endoscopy for
  1) ERCP, diagnostic and therapeutic to remove stones and strictures.

2) endoscopic ultrasound to drain pseudocysts or place bile duct stent (last 4-6 weeks)
3) endoscopic pancreatic sphincterotomy in patients with papillary stenosis, associated with high sphincter and pancreatic duct pressure

Question 11

what is a lateral pancreaticojejunostomy?

Answer 11

side to side anastomosis of the pancreatic duct to the jejunum

provides relief in many patients but pain does tend to reoccur, as the head of the pancreas still remains in situ.

Question 12

what is a pancreaticoduodenectomy (commonly termed a Whipple’s procedure) ?

Answer 12

indicated in paraduodenal pancreatitis or if neoplasia cannot be excluded

involves resection of pancreatic head, gallbladder and bile duct, and first and second portion of duodenum

the tail of the pancreas is anastomosed with the duodenum and the body of the stomach anastomosed to the distal duodenum

Question 13

what is a total pancreatectomy?

Answer 13

removal of the entire pancreas

Question 14

how can steroids be used in chronic pancreatitis?

Answer 14

• can reduce symptoms with an autoimmune aetiology

- high dose prednisone can be used to bring symptoms under control, with a low dose maintenance regime

Question 15

what are the complications of chronic pancreatitis?

Answer 15

• pseudocyst
• steatorrhoea and malabsorption due to poor exocrine pancreatic function. can treat with enzyme replacements including lipase, such as creon, given at meals.
• patient at risk of fat soluble vitamin deficiency so regular clotting function and bone density checks
• diabetes. Loss of endocrine function = more vulnerable
• pancreatic malignancy i