Chronic pancreatitis

Question 1

Define chronic pancreatitis

Answer 1

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

Question 2

Aetiology of chronic pancreatitis

2 causes + 2

Answer 2

ALCOHOL - 70%
Idiopathic - 20%

Caused by disruption of normal pancreatic glandular architecture due to chronic inflammation & fibrosis, calcification, parenchymal atrophy, ductal dilation & cyst & stone formation
Pain associated w/ raised intraductal pressures

Question 3

Epidemiology of chronic pancreatitis

prev/inc, age

Answer 3

Prevalence 3/100,000, annual UK incidence 1/100,000

Mean age 40-50 yrs (in alcohol-associated disease)

Question 4

Rare causes of chronic pancreatitis

7

Answer 4

Recurrent acute pancreatitis
Ductal obstruction
Pancreas divisum
Hereditary pancreatitis
Tropical pancreatitis
Autoimmune pancreatitis
Hyperparathyroidism

Question 5

Presenting symptoms of chronic pancreatitis

5

Answer 5

Recurrent severe epigastric pain
Pain radiates to back
Pain relieved by sitting forward
Pain can be aggravated by eating or drinking alcohol
Weight loss, bloating, steatorrhoea (over many years)

Question 6

Signs of chronic pancreatitis on physical examination

2

Answer 6

Epigastric tenderness

Signs of complications - weight loss, malnutrition

Question 7

Investigations for chronic pancreatitis

6

Answer 7

Bloods
US
ERCP/MRCP
AXR
CT
Pancreatic exocrine function

Question 8

Investigations for chronic pancreatitis - bloods

3

Answer 8

High glucose - glucose tolerance test
Amylase & lipase - usually normal
High Ig

Question 9

Investigations for chronic pancreatitis - ERCP/MRCP

2 early, 1 late

Answer 9

Early changes - main duct dilatation & stumping of branches

Late manifestations - duct strictures w/ alternating dilatation

Question 10

Investigations for chronic pancreatitis - AXR

Answer 10

May show pancreatic calcification

Question 11

Investigations for chronic pancreatitis - CT

Answer 11

May show pancreatic calcification & cysts

Question 12

Investigations for chronic pancreatitis - pancreatic exocrine function

Answer 12

Faecal elastase

Question 13

Management of chronic pancreatitis

3

Answer 13

General
Endoscopy therapy
Surgical

Question 14

Management of chronic pancreatitis - general

2

Answer 14

Treatment mainly symptomatic & supportive

Chronic pain management may need specialist input

Question 15

Management of chronic pancreatitis - endoscopy therapy

4

Answer 15

Sphincterotomy
Stone extraction
Dilatation & stenting of structures
Extracorporial shock wave lithotripsy - sometime sured to fragment larger pancreatic stones before removal

Question 16

Management of chronic pancreatitis - surgical

5

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 pancreatic duct & excavation of pancreatic head - Frey procedure

Question 17

Complications of chronic pancreatitis

2

Answer 17

Local

Systemic

Question 18

Complications of chronic pancreatitis - local

5

Answer 18

Pseudocysts
Biliary duct stricture
Duodenal obstruction
Pancreatic ascites
Pancreatic carcinoma

Question 19

Complications of chronic pancreatitis - systemic

4

Answer 19

Diabetes
Steatorrhoea
Chronic pain syndromes
Dependence on strong analgesics

Question 20

Prognosis of chronic pancreatitis

3

Answer 20

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