Chronic Pancreatitis

Question 1

Define Chronic Pancreatitis?

Answer 1

Chronic inflammatory disease of the pancreas characterised by irreversible parenchymal atrophy and fibrosis leading to impaired endocrine and exocrine function and recurrent abdominal pain

Question 2

What is the aetiology of Chronic Pancreatitis?

Answer 2

Alcohol -70%

Idiopathic - 20%

Question 3

What are the rare causes of Chronic Pancreatitis?

Answer 3

Recurrent acute Chronic Pancreatitis
Ductal obstruction
Pancrease divisum 
Hereditary Pancreatitis
Tropical Pancreatitis 
Autoimmune Pancreatitis 
Hyperparathyroidism

Question 4

What is the pathology of Chronic Pancreatitis?

Answer 4

Chronic Pancreatitis is caused by disruption of normal pancreatic glandular architecture due to chronic inflammation and fibrosis, calcification, parenchymal atrophy, ductal dilation and cyst and stone formation
Pain is associated with raised intraductal pressures

Question 5

What is the epidemiology of Chronic Pancreatitis?

Answer 5

Annual UK Incidence: 1/100,000
Prevalence: 3/100,000
Mean age: 40-50 yrs (in alcohol-associated disease)

Question 6

What are the presenting symptoms of Chronic Pancreatitis?

Answer 6

Recurrent severe epigastric pain
Pain radiates to the back
Pain relieved by sitting forward
Pain can be aggravated by eating or drinking alcohol
Over many years leads to weight loss, bloating and steatorrhoea

Question 7

What are the signs of Chronic Pancreatitis on physical examination?

Answer 7

Epigastric tenderness

Signs of complications e.g. weight loss, malnutrition

Question 8

What investigations would you do for Chronic Pancreatitis?

Answer 8

Bloods 
US 
ERCP or MRCP
Abdominal X-Ray
CT Scan
Tests of pancreatic exocrine function

Question 9

What bloods would you do for Chronic Pancreatitis?

Answer 9

High glucose (endocrine dysfunction) - glucose tolerance test may be performed 
Amylase and lipase usually normal
High Ig (especially IgG4 in autoimmune pancreatitis)

Question 10

Why do we do an ERCP or MRCP for Chronic Pancreatitis?

Answer 10

Early changes that can be seen include main duct dilatation and stumping of branches
Late manifestations include duct strictures with alternating dilatation

Question 11

Why might we do an Abdominal X-Ray for Chronic Pancreatitis?

Answer 11

May show pancreatic calcification

Question 12

Why might we do a CT scan for Chronic Pancreatitis?

Answer 12

May show pancreatic calcification and pancreatic cysts

Question 13

What tests do we do to test pancreatic exocrine function?

Answer 13

Faecal elastase (reflects pancreatic exocrine function)

Question 14

What is the general management plan for Chronic Pancreatitis?

Answer 14

Treatment is mainly symptomatic and supportive
E.g.
Dietary advie 
Stop smoking/drinking 
Treat diabetes 
Oral pancreatic enzyme replacement 
Analgesia

Question 15

What is the Endoscopy Therapy for Chronic Pancreatitis?

Answer 15

Sphincterotomy
Stone Extraction
Dilatation and stenting of strictures
Extracorporial shock-wave lithotripsy (ESWL) is sometimes used to fragment larger pancreatic stones before removal

Question 16

What is the Surgical management plan for Chronic Pancreatitis?

Answer 16

May be indicated if medical management fails
Lateral pancreaticojejunal drainage (modified Puestow procedure)
Pancreatic resection (pancreaticoduodenectomy or Whipple’s procedure)
Limited resection of pancreatic head (Beger procedure)
Combining opening of the pancreatic duct and excavation of the pancreatic head (Frey procedure)

Question 17

What are the possible local complications of Chronic Pancreatitis?

Answer 17

Pseudocysts 
Biliary duct stricture 
Duodenal obstruction
Pancreatic ascites 
Pancreatic carcinoma

Question 18

What are the possible systemic complications of Chronic Pancreatitis?

Answer 18

Diabetes
Steatorrhoea
Chronic pain syndromes
Dependence on strong analgesics

Question 19

What is the prognosis for patients with Chronic Pancreatitis?

Answer 19

Difficulty to predict
Surgery improves symptoms in 60-70% but results are often not sustained
Life expectancy may be reduced by 10-20 years