Chronic Pancreatitis Flashcards
defined based on clinical features (abdominal pain, exocrine insufficiency [steatorrhea], or endocrine insufficiency [diabetes mellitus]) or on imaging techniques including US, CT, EUS, MRI, MRCP, and ERCP
common in men and is most commonly a disease of middle age, with most patients diagnosed above the age of 40.
Chronic pancreatitis
perilobular fibrosis and ductal metaplasia, are also commonly seen in patients of advanced age without chronic pancreatitis, and in patients with long-standing diabetes mellitus
Autoimmune Pancreatitis that is more robust lymphoplasmacytic infiltrate, including plasma cells, is seen and these are usually positive when stained for immunoglobulin G subtype 4 (IgG4)
(Type 1)
Type of Autoimmune Pancreatitis that has idiopathic duct-centric chronic pancreatitis is characterized by neutrophilic infiltration and the absence of IgG4 positive plasma cells.
Type 2
Alcohol Chronic Pancreatitis
at least 5 years (and in most patients more than 10 years) of intake exceeding 4 to 5 drinks per day are required before the development of chronic pancreatitis
common in patients with alcohol-induced chronic pancreatitis,
is associated with an increased risk for pancreatic calcifications,
and smoking cessation after the clinical onset of chronic pancre-
atitis reduces the risk of subsequent calcifications
smoking
more common forms of chronic pancreatitis in certain areas of southwest India, although its incidence is decreasing
Tropical Pancreatitis
a disease of youth and early adulthood, with a mean age at onset of 24 years.
manifests as abdominal pain, severe malnutrition, and exocrine or endocrine insufficiency.
The pathology is characterized by these large intraductal calculi along with marked dilation of the main pancreatic duct and gland atrophy.
The pathophysiology of tropical pa
Tropical Pancreatitis
Lymphoplasmacytic infiltration
Dense periductal infiltrate without damage to ductal epithelium
Storiform fibrosis
Obliterative phlebitis
Abundant (>10 cells/HPF) IgG4-positive cells Fibroinflammatory process may extend to peripancreatic region
Male
60-70 years old
Type 1 AIP
Lymphoplasmacytic and neutrophilic infiltration around ducts
Destruction of duct epithelium by neutrophils (granulocytic epithelial lesion)
Obliterative phlebitis rare No IgG4-positive cells
associated with IBD
Type 2 AIP
type 1 AIP imaging
Typical imaging:
Diffuse enlargement of pancreas with delayed enhancement With or without rim-like enhancement or pancreas
IgG4 >2 × upper limit of normal
Definitive type 1 AIP
Response to steroids(0.6 to 1 mg/kg has been suggested.)
A common starting dose is 40 mg of prednisone daily.
Repeat pancreatic imaging at 2 to 4 weeks is prudent, to assess for clinical and radiographic response.
Relapse in Type 1 AIP
repeat course of glucocorticoids followed by maintenance at a low dose of prednisone (e.g., 5 to 10 mg/day)
Pancreas divisum
Pancreas divisum is a common normal variant, occurring in approximately 4% to 11% of the population
Dysfunction of the sphincter of Oddi, like pancreas divisum, is most often proposed as a cause of acute or recurrent acute pan- creatitis
Predictors of chronic pancreatitis
multiple relapsing attacks, smoking, and alcohol use.
Chronic pancreatitis abdominal pain
Pain is most commonly described as being felt in the epigastrium, often with radiation to the back.
Pain is usually described as boring, deep, and penetrating and is often associated with nausea and vomiting.
Pain may be relieved by sitting forward or leaning forward, by assuming the knee-chest position on one side, or by squatting and clasping the knees to the chest.
Pain may worsen after a meal and often is nocturnal.
a feature of far-advanced chronic pancreatitis, in which most of the acinar cells have been injured or destroyed, but may also be seen with blockage of the pancreatic duct, after pancreatic surgery, and after an attack of necrotizing acute pancreatitis.
Steatorrhea (Exocrine Pancreatic Insufficiency)
endocrine insufficiency is a consequence of long-standing chronic pancreatitis and is especially common after pancreatic resection and in tropical (fibrocalcific) pancreatitis
Diabetes Mellitus (Pancreatic Endocrine Insufficiency)
Chronic Pancreatitis EUS
EUS
Direct hormonal stimulation (with pancreatic stimulation by secretin or cholecystokinin or both): Using oroduodenal tube
Using endoscopy
chronic pancreatitis, this gold standard
pancreatic histology
most sensitive function tests for chronic pancreatitis.
Direct hormonal stimulation tests
tests require placement of a tube or endoscope in the duodenum, stimulation of pancreatic secretions (usually with secretin, but in some cases with CCK), and collection of pancreatic secretions for analysis (bicarbonate concentration in the case of secretin infu- sion, enzyme secretion in the case of CCK).
Ultrasonographic findings indicative of chronic pancreatitis
dilation of the pancreatic duct, shadowing pancreatic ductal stones, gland atrophy, irregular gland mar- gins, pseudocysts, and changes in the parenchymal echotexture
Grading of Chronic Pancreatitis by US or CT
Normal
No abnormal findings on a good-quality study visualizing the entire gland
Mild-moderate
One of the preceding findings plus at least one of the following:
Pancreatic duct dilatation (>4 mm) Pancreatic duct irregularity
Cavity (ies) <10 mm
Parenchymal heterogeneity Increased echogenicity of duct wall Irregular contour of the head or body Focal necrosis or loss of parenchyma
Severe
Mild/moderate features plus one or more of the following:
Cavity (ies) >10 mm
Intraductal filling defects Calculi/pancreatic calcification Ductal obstruction (stricture) Severe duct dilatation or irregularity Contiguous organ invasion
has been considered the most specific and sensitive test of pancreatic structure.
Pancreatography
Rosemont Criteria for EUS Diagnosis
Most consistent with chronic pancreatitis
1 Major A feature and ≥3 minor features or 1 Major A feature and 1 Major B feature or 2 Major A features
Major:
Hyperechoic foci with shadowing (Major A) Main pancreatic duct calculi (Major A) Lobularity with honeycombing (Major B)
Minor:
Lobularity without honeycombing Hyperechoic foci without shadowing Stranding
Cysts
Irregular main pancreatic duct contour Main pancreatic duct dilation Hyperechoic duct margin
Dilated side branches
Analgesics
Tramadol is a dual-action analgesic, with mu-opioid agonistic and monoaminergic proper- ties. High dosages of tramadol are equivalent to oral morphine in treating chronic pancreatitis, with fewer effects on gut motility.
Analgesics
pregabalin reduced pain at a dosage of up to 300 mg twice daily.
They occur in about 25% of patients with chronic pancreatitis, and are most commonly seen in alcoholic chronic pancreatitis
Pseudocyst
alcohol pancreatitis
Alcohol and its metabolites like FAEE have direct injurious effects on pancreatic acinar cells.
Pancreatic stellate cells are found in association with the acini.
The 2013 International Cancer of the Pancreas Screening (CAPS) consortium
individuals with 3 or more blood relatives with PC, with at least 1 affected FDR, should be considered for screening.
Those with at least 2 affected FDRs should also be considered for screening.
Individuals with 2 affected blood relatives with PC, with at least 1 FDR, can be considered for screening.
Patients with specific mutations should be considered for screening:
Peutz-Jeghers regardless of family history and BRCA2/PALB2/p16/ patients with Lynch syndrome who have an FDR with PC should be considered for screening.
screening modalities
Agreed-upon screening modalities include MRI/MRCP and EUS.
