Chronic Pancreatitis

Question 1

What is chronic pancreatitis?

Answer 1

An inflammatory condition which can affect both the exocrine and endocrine functions of the pancreas.

Question 2

What is the pathophysiology & consequences of endocrine insufficiency?

Answer 2

• Pathophysiology = Secondary to damage to the endocrine tissue of the pancreatic gland (islets of Langerhans)
• Consequence = Subsequent failure to produce insulin, resulting in impaired glucose regulation or eventual diabetes mellitus

Question 3

What is the pathophysiology & consequence of exocrine insufficiency?

Answer 3

• Pathophysiology - Secondary to damage to the acinar cells
• Consequence - Failure to produce digestive enzymes, causes malabsorption leading to weight loss, diarrhoea, or steatorrhoea

Question 4

What are the causes of chronic pancreatitis?

Answer 4

• Alcohol (60%)
• Idiopathic (30%)
• Genetics (e.g. CF, haemachromatosis)
• Ductal obstruction (e.g. gallstones, mass, ductal abnormality)
• Metabolic (e.g. hyperlipidaemia, hypercalcaemia)
• Infection
  
  • Viral (e.g. HIV, mumps, coxsackie)
  • Bacterial (e.g. Echinococcus)
• Autoimmune (e.g. autoimmune pancreatitis (AIP) or SLE)

Question 5

What are the risk factors?

Answer 5

• Alcohol
• Smoking
• Family Hx
• Coeliac disease

Question 6

What are the symptoms?

Answer 6

• Pain
  
  • Epigastric, dull, radiating to the back, diminished by sitting forwards & worse approximately 30 minutes post-prandially (After a meal)
• Nausea & Vomiting
• Weight loss
• Steatorrhoea (late symptom)
• Jaundice (rare)

Question 7

Why does steatorrhea occur?

Answer 7

Inflammation and fibrosis of the gland causes injury, atrophy, and loss of pancreatic exocrine tissue, leading to impaired digestion of fats.

Question 8

What would you typically find on examination?

Answer 8

• Epigastric tenderness possible
• Cachexia

Question 9

What bloods would you want to order with high suspision of chronic pancreatitis?

Answer 9

• Blood glucose
• FBC
• LFTs
• Faecal elastase (low)

Question 10

Why is blood glucose an important investigation to order?

Answer 10

Because glucose intolerance is an early occurance due to insulin resistance / insulinopenia

Question 11

What faecal elastase result would indicate severe disease?

Answer 11

< 200 mg/g

Question 12

What imaging modalities can aide a diagnosis of chronic pancreatitis?

Answer 12

1. CT abdo/pelvis

• More sensitive at detecting pancreatic calcification.
  2. Transabdominal USS of RUQ
• ONLY IF CT unavailable
  3. Abdominal XR
• Shows pancreatic calcification in 30% of cases
  4. Endoscopic ultrasound (EUS)
• May also be used in cases of diagnostic uncertainty.

Question 13

Give some differential diagnoses.

Answer 13

• Peptic ulcer disease
• Reflux disease
• Abdominal aortic aneurysm
• Biliary colic
• Chronic mesenteric ischaemia.

Question 14

What is the management of ongoing chronic pancreatitis?

Answer 14

1. Treat reversible underlying causes

• Drinking cessation
• Smoking cessation
• Statins (for hyperlipidaemic)

2. Analgesia (neuropathic)
3. Pancreatic ensyme supplements (Creon)
4. Vitamin supplements & regular bone density checks
5. Antioxidants: limited evidence base - one study suggests benefit in early disease

Question 15

What is the management of acute attacks of chronic pancreatitis?

Answer 15

1. Analgesia (following WHO analgesic ladder)

Question 16

What can be used to reduce symptoms of chronic pancreatitis caused by an autoimmune problem?

Answer 16

Steroids (Prednisolone)

High dose used initially to bring symptoms under control followed by low dose maintenance regime.

Question 17

How do you manage pancreatogenic diabetes?

Answer 17

Insulin regime alongside annual HbA1c review

Question 18

When would you manage chronic pancreatitis endoscopically?

Answer 18

In cases with a targetable underlying cause.

Question 19

What are the options with endoscopic management of chronic pancreatitis?

Answer 19

• ERCP
  
  • Used for diagnostic and therapeutic purposes (inc stone removal, stent placement, or sphincterotomy)
• Endosonography-guided celiac plexus blockade or thoracoscopic splanchnicectomy
  
  • Performed purely for analgesic purposes.

Question 20

What is the prognosis?

Answer 20

Chronic pancreatitis is associated with significant morbidity and reduced quality of life, as it can be a challenging condition to manage effectively.

In some patients, the disease may eventually ‘burn out’ after many years of pain, leaving residual endocrine and exocrine insufficiencies.

Question 21

Why should new / evolving symptoms in a patient with established disease (20+ years) be investigated?

Answer 21

Pancreatic malignancy is a risk in those who have had the disease for 20 years or more.