Chronic pancreatitis

Question 1

What is the epidemiology of chronic pancreatitis?

Answer 1

Age of presentation:

· Hereditary - 10-14 years.
· Juvenile idiopathic chronic - 19-23 years.
· Alcoholic chronic - 36-44 years.
· Senile idiopathic chronic - 56-62 years.

Affects men more than women.

Question 2

What is the pathophysiology of chronic pancreatitis?

Answer 2

Primary autoimmune or inflammatory reaction of pancreatic duct&raquo_space;> cytokine secretion&raquo_space;> cytokine and fibrogenic pancreatic stellate cells secrete collagen&raquo_space;> fibrosis&raquo_space;> chronic pancreatitis

Question 3

What is the prognosis for chronic pancreatitis?

Answer 3

· Pain decreases or disappears over time.

· 10-year survival after diagnosis is 20-30% lower than the general population.

Question 4

What is the aetiology of chronic pancreatitis?

Answer 4

· G - Gallstones
· E - Ethanol.
· T - Trauma.

· S - Steroids.
· M - Mumps.
· A - Autoimmune diseases
· S - Scorpion sting.
· H - Hypertriglyceridaemia.
· E - Enzymes
· D - Drugs.

Question 5

What risk factors are associated with chronic pancreatitis?

Answer 5

· Alcohol.
· Smoking.
· Family history.
· Coeliac disease.

Question 6

What are the signs and symptoms of chronic pancreatitis?

Answer 6

· Abdominal pain:

• > 80% of people.
• Epigastric, dull, back radiation.
• Diminishes by sitting forwards.
• Worsens approximately 30 minutes after food.

· Jaundice:

• 10% of people.
• Bile duct compression.
• Preceded by ALP elevation.

· Steatorrhoea:

• 8-22% of people.
• Due to injury, atrophy and loss of pancreatic exocrine tissue due to fibrosis and inflammation.

· Malnutrition:

• Fear of food due to pain.
• Malabsorption.
• Poor dietary intake due to alcohol abuse.

· Diabetes mellitus (later) and glucose intolerance (early):
- Hyperglycaemia in 47% of people.

· N&V.

Question 7

What investigations should you requested if you suspect someone has chronic pancreatitis?

Answer 7

· Blood glucose - may be elevated.
· Faecal elastase-1 - may be low.
· Faecal fat - increased.
· CT abdomen - pancreatic calcifications, pancreas enlargement, ductal dilation and/or vascular complications.
· Abdominal USS - pancreatic calcifications, cavities, duct and pancreatic irregularity. 
· AXR - pancreatic calcifications.
· ERCP.
· MRCP.

Question 8

Suggest some differential diagnoses.

Answer 8

· Pancreatic cancer.
· Acute pancreatitis.
· Biliary colic.
· Peptic ulcer disease.
· Mesenteric ischaemia.
· AAA.
· MI.
· Intestinal obstruction.
· IBS.
· Gastroparesis.

Question 9

What are the treatment options for chronic pancreatitis?

Answer 9

Acute episodic pain:
· 1st line - analgesia.

Chronic symptoms:
· 1st line - alcohol and smoking cessation with lifestyle modifications.
· Adjunct - analgesia.
· Adjunct - pancreatic enzymes plus PPI.
· Adjunct - dietary modifications + enteral feeding.
· Adjunct - octreotide.
· Adjunction - antioxidants.
· WITH PSEUDOCYSTS - pseudocyst decompression.
· WITH BILIARY COMPLICATIONS - biliary decompression.
· WITH INTRACTABLE PAIN AND MAIN PANCREATIC DUCT DILATATION - pancreatic ductal decompression.
· WITH INTRACTABLE PAIN AND PANCREATIC DUCT CALCIFICATIONS - extracorporeal shock wave lithotripsy.
· WITH INTRACTABLE PAIN AND SMALL DUCT DISEASE +/- PANCREATIC HEAD ENLARGEMENT - interventional procedures.
· WITH INTRACTABLE PAIN AND DISTAL PANCREATIC DISEASE - distal pancreatectomy.

Surgery:
· Pancreatectomy or pancreacticojejunostomy

Question 10

What complications can occur with chronic pancreatitis?

Answer 10

· Pancreatic exocrine insufficiency.
· Diabetes mellitus - 80% of people after 25 years.
· Pancreatic calcification.
· Pancreatic duct obstruction.
· Biliary obstruction.
· Pancreatic cancer.
· Pancreatic pseudocysts.
· Opioid addiction.
· Ascites.
· Fistula.