Chronic Pancreatitis

Question 1

What is Chronic Pancreatitis?

Answer 1

C.P is an inflammatory-dystrophic disease of pancreatic gland tissue with permeability passage tracts disturbance.

Question 2

Etiology of chronic pancreatitis

Answer 2

• Alcohol
• Gallstones and choledoch stones- the most frequent factor among women.
• Ulcer disease, duodenitis,chronic gastritis
• Mucovuscidisis(common in children)
• alpha antitrypsin insufficiency and genetic factors
• nutrition insufficiency
• viral infection
• allergic factors
• pancreas lesion during operation
• metabolic and dishormonic disturbances (essential hyperlipidermia, hypothyreosis)

Question 3

Pathogenesis of Chronic Pancreatitis

Answer 3

• pancreas parenchyma consists of endocrine and exocrine glandular tissue
• Acinar cells that form exocrine glandular tissue produce digestive enzymes in inactive form (zymogens) which are expelled to ducts that contain sodium bicarbonate and move to the small intestine where they are activated
• if this process takes place in the pancreas it may cause marked glandular destruction hence exocrine part of the pancreas has strong protective system of zymogen activity regulation
• when the protective system is damaged digestive enzymes cause direct damage of the parenchyma which in combination with immune response reveals pancreatitis with time
• this state favours cytotoxic damage of acinar cells in patients with chronic pancreatitis
• immune system activation is accompanied by anti-inflammatory response (production of IL and other substances )and the following stimulation of fibrotic process that proceed with participation of activated pancreatic Stella the cells,

For example alcoholic C.P
Causes direct damage of acinar cells and intraductal protein release with the following cell calcification
Secretion pressure increases and results in ducts widening
A cell inflammation, fibrosis, necrosis may develop
This causes development of pseudocysts and endocrine and exocrine pancreatic insufficiency

Biliary C.P
Leads to regurgitation of bile and duodenal content to pancreatic ducts.
This leads to activation of pancreatic juice enzymes,damage of acinar cells ,development of chronic inflammatory processes

Question 4

Classification of Chronic Pancreatitis

Answer 4

1.By ICD
Alcoholic CP

Other forms
Infectious
Continuously recurrent 
Reverse
Pancreatic cyst
Pancreatic pseudocyst
Other unspecified pancreatic diseases e.g
Atrophy 
Lithiasis
Fibrosis
Cirrhosis
Pancreatic infantilism
Necrosis-aseptic
                  Fatty necrosis 
Pancreatic steatorrhea

Clinical classification 
1.Chronic calcifying pancreatitis
Alcoholic 
Nutritional 
Hereditary
2.Chronic idiopathic pancreatitis 
Juvenile(under 35 years)
Senile(after 65 years)
3.Chronic obstructive pancreatitis 

By course
Mild
Moderate
Severe
1.Mild-rare short term exacerbations(not more than 1-2 a year) which are quickly and easily stopped, no signs of pancreatic insufficiency,body weight is not reduced, the patients general condition is satisfactory
2.Moderare- exacerbation 3-4times a year, pain is more intense and long lasting, pronounced phenomenon of enzymes(deviation) in blood, disorders of exocrine function, derangement of endocrine function are moderate and reversible, weight loss during the disease attack which is usually restored after relief
Severe- frequent and prolonged exacerbation (or continuously relapsing course)with persistent and severe pain and dyspeptic syndrome with symptoms of maldigestion and malabsorption “typical pancreatic “steartorrhea” , pancreatic diabetes and progressive emacistion of the patient

By morphology or stage
Normal- no visual changes in ERCPG, US,CT
Ambigous-less than 3changed ducts in ERCPG, dilation of main duct in CT and US
Mild can be in two ways-1. More than 3 changes ducts in ERCPG, diameter of cavities<10mm, duct roughness, focal acute pancreatitis in CT and US
2.More than 2 signs , parenchyma heterogeneity, increased echogenicity of ductal wall in CT and US

Moderate- abnormality of main duct and its branches, roughness of pancreas head and body contours in CT and U
Pronounced-abnormality of main duct and it’s branches in ERCPG, size of cavity more than 10mm, increase in pancreas cavity more than 2 times, intraductular defects or stones , obstruction or stricture of ducts in CT and US

By secretion
Hyposecretory-decreased production of enzymes, normal volume of bicarbonate secretion
Hypersecretory-decreased production of enzymes, normal volume of bicarbonate secretion
Obstructive type- divided into two
1.lower block reduction of secretion volume with normal concentration of bicarbonates and enzymes leading to decrease in their discharge (obstructive pancreatitis-papillitis,plugging with stone)
2.Upper block - reduction in secretion volume, increased enzyme concentration but their discharge is reduced , normal contents of bicarbonates(swelling of pancreas)

4.Ductular type- inflammation of ducts with impaired reabsorption of bicarbonate

Question 5

Clinical picture of chronic pancreatitis

Answer 5

-Pain(85%)
-Dyspeptic syndrome
-Malarbsoption syndrome
-Weight loss
-symptoms of intoxication- fever, weakness,arthralgia
-Endocrine deficiency syndrome(impaired tolerance or diabetes)
In 20-25% cases latent disease course is observed-

Pain syndrome 
Typical pain of circular character
Ulcer lime pains 
Pain by type if left sides renal colic
Pain in right upper quadrant which is accompanied by jaundice 
Can have dysmotoric character 
Might be widespread with no clead localisation, in sharpness of disease pain may be felt under rib 
Pain associated with food intake

Dyspeptic syndrome - nausea, eructation, multiple vomiting

Malabsorption syndrome- bloating , bone pain, diarrhea 3-4 times a day with polyfecslis,steartohea, creator-Rhea
Stool is grey,with unpleasant smell, well seen fat drops(stearttohea)o

Question 6

Results of physical examination during Chronic pancreatitis

Answer 6

General inspection
Bright red spots on the skin and abdomen, chest- symptom of red droplets
Grotts symptom- atrophy of subcutaneous adipose tissue in the area of projection of the pancreas
Jaundice or pale skin
Reduction of skin moisture and turgor
Dry tongue , smoothed lingual papilae
Abdomen enlarged incase of flactuence

Tenderness in
1.Chauffards zone- a triangular area that extends vertically for about 5-6com from the navel and corresponds to the projection of the first part of duodenum, head of pancreas and common bile duct
2.Mayo-Robson point-top of the angle lateral to rector spinal muscle and below the left 12th rib, Pain in left hypochondrion while pressing the left vertebral angle
3.Huberhyts-skulsky zone
4.Desjardins point- 5-7cm from the umbilicus on a line joining it to the right auxiliary. It lies over the head of pancreas.
5,Frenicus symptom

Question 7

Lab-instrumental diagnosis of Chronic pancreatisis

Answer 7

• ERCPG-the gold standard , to reveal deformations of main pancreatic duct, dilation ,
• CBC- increase ESR,CRP, leukocytosis
• US-to reveal pseudocysts,calcination,tumors,estimate duct diameter,pancreatic contours and their sizes
• CT
• Biochemical-serum amylase which increases at the sharpening of C.P and remains normal in remission
• ECG
• routine urine analysis
• feces lab test
• respiratory pancreatic test e.g C-triglyceride breath test-determines lipase activity in the lumen of the intestine and to differentiate psnrestic steartorrhea from intestine steartorrhea
  - protein breath test with C marked egg white reduced incase of CP due to lack of trypsin
  - amylase c corn starch breath test allows to determine deficiency of pancreatic amylase in duodenum
• pancreatic juice investigation with enzyme activity defining

To investigate pancreatic endocrine insufficiency
Static tests- blood glucose, insulin, C-peptide, pancreatic polypeptide, glucagon
Dynamic tests
Arginine test is more specific-determination of blood glucagon level after arginine infusion- changes present incase of pancreatic diabetes,

Question 8

Treatment of Chronic Pancreatitis

Answer 8

• antisecretory therapy- hunger during 1-3 days, H2 histamine blockers or Ppi, m-cholinolytics,antacids
• pancreatic secretion inhibition- sandostatin,
• protheolysis of pancreatic tissue inhibition-trasyol
• reestablishment of permeability-endoscopic canalisation of papilla Fateric
• pain-analgesics

Reopolyglukin,iv(400mg per day), hemodesis 300 ml, albumin 10% (100ml), 5-10% glucose (500ml per day) to decrease pain, intoxication, to prevent hypovolemic shock

For severe pain
Analgin(50%-2ml and papaverin 2%-2ml or synthetic analog of somatostatin-sandostatin (50-100mkg twice a day)

Enzyme preparations without bile acids e.g Creon(1 capsule during the main meal)
Pancreatin
For endocrine insufficiency insulin in sufficient dose

Indications for surgery
Strictures and stones that obturste pancreatic duct
Choledoch and duodenum narrowing
Persistent recurrent CP course with stable pain , resistant to conservative therapy
Segmental portal hypertension and GIT hemorrhages that recur

Question 9

Complications of Chronic Pancreatitis

Answer 9

DM
Pseudocysts formation 
Calcification of pancreas
Hermorrhage
Ascites 
Pleuritis 
Arthritis 
Obstructive jaundice 
Subhepatic portal hypertension 
Anemia
Encephalopathy
Pancreatic cancer