chronic pancreatitis

Question 1

definition of chronic pancreatitis

Answer 1

chronic inflammation of the pancreas

permenant structural changes = impaired endocrine and exocrine function and recurrent abdo pain

Question 2

aetiology of chronic pancreatitis

Answer 2

alcohol - main

idiopathic

smoking

autoimmune

rare:

• exogenous toxins
• CF
• haemachromatosis
• a1-antitrypsin deficiency
• pancreatic duct obstruction - acute pancreatitis, pancreas divisum, pancreatic duct anomalies, stones, tumour
• hyperparathroidism
• familial

Question 3

epidemiology of acute pancreatitis

Answer 3

annula Uk incidence - 1/100000

prevalence - 3/100000

mean age - 40-50s in alcohol associated disease

Question 4

sx of chronic pancreatitis

Answer 4

recurrent severe epigastric pain

• radiates to back
• relieved sitting forward, hot water bottles on epigastrium or back
• exacerbated by eating or after an episode of binge drinking

associated with bloating and pale offensive stools (steatorrhoea)

diarrhoea, weight loss, polyuria

sx relapse and worsen

Question 5

signs of chronic pancreatitis

Answer 5

epigastric tenderness

epigastric fullness - due to pseudocyts

bloating

signs of weight loss, malnutrition, alcohol abuse

brittle dm (hard to control dm)

erythema ab igne’s ottled dusky greyness - marks on skin from exposure to hot water bottles (not hot enough to = burns)

Question 6

pathology of chronic pancreatitis

Answer 6

disruption of normal glandular architecture due to chronic inflammation and fibrosis, calcification, ductal dilatation, cyst and stone formation

Question 7

Ix for chronic pancreatitis

Answer 7

bloods

USS - percutaneous or endoscopic

ERCP or MRCP

AXR - pancreatic calcification

CT scan - pancreatic cysts/calcification

tests of pancreatic exocrine function - faecal elastase

Question 8

bloods for chronic pancreatitis

Answer 8

glucose - high might indicate endocrine dysfunction

glucose tolerance test

amylase and lipase - usually normal

LFT - high if common bile duct obstruction

Question 9

ERCP or MRCP for chronic pancreatitis

Answer 9

early changes - main duct dilatation and stumping of branches

late - duct strictures qwith alternating dilataion - chains of lakes appearance

Question 10

levels of Mx of chronic pancreatitis

Answer 10

diet advice (low fat) and medium chain triglycerides (MCT oil) - no lipase needed but may worsen diarrhoea

alcohol abstinence

acute - analgesics

chronic

pain control

surgical

Question 11

chronic Mx of chronic pancreatitis

Answer 11

pain management may need specialist pain clinic

treatment of dm eg insulin - high or variable

pancreatic enzyme replacements - Creon (lipase), Pancrease

fat solubel vitamins

endoscopic stenting of strictures may be possible

Question 12

pain control for chronic pancreatitis

Answer 12

majority of sensory nerves to pancreas transverse the coelic ganglia and splanchnic nerves

both coelic plexus block and transthoracic splanchnicectomy offer pain relief

Question 13

surgical Mx of chronic pancreatitis

Answer 13

if medical failed, narcotic abuse, weight loss

proximal resection - pancreaticduodenectomy

or lateral pancreaticojejunal drainage (Puestow procedure)

Question 14

local complications of acute pancreatitis

Answer 14

pseudocysts

biliary duct stricture - bviliary obstruction

duodenal obstruction

pancreatic ascites

pancreatic ca

local arterial aneurysm

splenic vein thrombosis

Question 15

systemic complications of chronic pancreatitis

Answer 15

DM

steatorrhoea

hyperglycaemic coma

may develop chronic pain syndromes - become dependant on strong analgesics

gastric varices

Question 16

Px of chronic pancreatitis

Answer 16

surgery improves sx in 60-70% - results not sustained

LE is reduced by 10-20yrs

Question 17

Answer 17

chronic pancreatitis with calcification of the pancreas