Chronic Pancreatitis

Question 1

Epidemiology

Answer 1

2-10 per 100000 per year

4 M : F 1

Average onset of 40 years

Question 2

Main causes

Answer 2

Chronic alcohol abuse (60%)

Idiopathic (30%)

Question 3

Other causes

Answer 3

Hyperlipidaemia and hypercalcaemia

HIV, mumps, coxsackie

Echinococcus

Hereditary like CF

Autoimmune like autoimmune pancreatitis or SLE

Malignancy or stricture formation

Congenital anomalies like pancreas divisum or annular pancreas

Acute pancreatitis recurrent

Question 4

Clinical features

Answer 4

Chronic pain that may be complicated by recurring attacks often termed acute-on-chronic

Pain is typically in the epigastrium and back

N+V

Question 5

There might be more systemic featrues of chronic pancreatitis

Which?

Answer 5

Endocrine insufficiency

Exocrine insufficiency

Question 6

Endocrine insufficiency in CP

Answer 6

Due to damage of the islets of Langerhans

Impaired glucose regulation and eventual DM

Question 7

Exocrine insufficiency in CP

Answer 7

Damage to the acinar cells

This leads to failure to produce digestive enzymes

This leads to malabsorption, weight loss, diarrhoea and steatorrhoea

Question 8

Examination findings

Answer 8

Abdomen is soft

Tender in epigastrium

There might be signs of cachexia and malabsorption

There might be jaundice due to pseudocysts

Question 9

Dx

Answer 9

Peptic ulcer disease

Reflux disease

AAA

Biliary colic

Chronic mesenteric ischaemia

Question 10

Lab tests

Answer 10

Urine dip + routine bloods including FBC and CRP

Amylase and lipids

Blood glucose

LFTs

Faecal elastase levels

Question 11

Lab test findings

Answer 11

Serum amylase or lipase levels are often not raised

Blood glucose can be high due to endocrine insufficiency

LFTs can be elevated

Faecal elastase levels might be low due to exocrine insufficiency

Question 12

Imaging

Answer 12

CT imaging

USS or MRI/MRCP

Question 13

CT findings

Answer 13

Pancreatic atrophy or calcification

Pseudocysts might be present

Question 14

USS and MRI/MRCP findings

Answer 14

The anatomy of the pancreas and the biliary tree can be shown on USS and MRI/MRCP

A normal appearance does not exclude CP

Question 15

If there is diagnostic uncertainty what special tests might be done?

Answer 15

Secretin stimulation test

Endoscopic ultrasound (EUS)

Question 16

Definitive management

Answer 16

Treating nay underlying cause which also includes alcohol cessation or statin therapy for hyperlipidaemia

Question 17

Mainstay of management

Answer 17

Analgesia with WHO ladder escalation to opioid analgesia or even neuropathic analgesics.

Question 18

Supportive treatment

Answer 18

Enzyme replacement such as Creon to get lipase.

Risk of becoming deficient in fat-soluble vitamins ADEK so vitamin supp should be given as well

Do a DEXA scan routinely as well.

Pancreatogenic diabetes should be screened for as well.

Question 19

When is endoscopic management indicated

Answer 19

Select few where there is a targetable underlying cause.

Question 20

Endoscopic management

Answer 20

ERCP for diagnostic and therapeutic purposes which includes stone removal, stent placement or sphincterotomy

Endosonography-guided celiac plexus blockade or thoracoscopic splanchnicectomy might be done as well.

Question 21

When might steroids be used?

Answer 21

Can reduce symptoms in CP if there is an autoimmune aetiology like AIP or SLE

Question 22

Complicaitons

Answer 22

Significant morbidity and reduced QOL

Endocrine and exocrine insufficiency

Pancreatic malignancy is also a risk in 20 years or more of disease.