chronic pancreatits Flashcards
What is chronic pancreatitis?
inflammation of the pancreas with persistent and often progressive lesions. damage usually permanent
Etiologies of chronic pancreatitis
most common is alcohol
others include hereditary causes, cystic fibrosis, hypertriglyceridemia, autoimmune, fibrocalcific, pancrease divisum
How does EtOH cause chronic pancreatitis?
- changes the protein production by the pancreas: less lithostatin (which prevents stone formation); more proteins that promote stone formation.
- Reduces blood flow to the pancreas: localized ischemia
- Stimulates stellate cells to make more collegen, esp. when deficient in vitamin A.
Natural progression of alcohol related pancreatits
related to amt and duration of EtOH intake- usually 6-12 yrs. Starts as recurrent acute episodes in the first 5-6 yrs but progresses to chronic pain and/or endocrine/exocrine dysfunction
smoking and chronic pancreatitis
promotes both acute and chronic pancreatitis. accelerates its rate of progression. true for idiopathic and alcoholic pancreatitis
CF and chronic pancreatitis
thickened secretions; predisposition to ductal blockage. some pts have mutated CFTR genes even w/o other sx of CF. CF pts often have both diabtes and steatorrhea
hereditary pancreatits
autosomal dominant. 80% penetrance. pt mutations in trypsinogen and trypsin that make them resistant to degradation. usually Arg-His mutation. Leads to excess trypsin in the pancreas, which can activate other zymogens. frequent pancreatic calcification. Chronic pancreatitis typically begins before age 20. high incidence of pancreatic CA
autoimmune pancreatitis
most commonly in elderly men. begins with painless jaundice, then mild abdominal pain or pancreatic mass lesion. Elevated IgG4 levels and ANA positive. Pancreas: diffuse enlargement with irregularly narrowed pancreatic duct and stenosis. inflammatory lymphplastic infiltrate.
presentation of chronic pangreatitis
dull constant epigastric pain with radiation to the back. relieved by sitting with trunk forward or by lying prone. irritated by food intake. Pain may incr., continue, or disappear with disease progression
weight loss (from less eating from pain)
malabsoprtion and pancreatic diabetes: later manifestation.
steatorrhea- if pancreatic function less than 10%. related to less lipase production and to decreased bicarb and duodenal pH- inactivates lipase.
ascites, pleural effusion ,painful nodules on lower extremities.
Dx of chronic pancreatitis: exocrine testing
duodenal tub/secretin CCK stimulation test. pancrease is supposed to incr. bicarb secretion from 40 to at least 80 around food. put tube in stomach and tube in intestine below pancreatic opening. remove stomach acid for baseline readings, then give IV secretin. measure rise in bicarb- should be at least 80. rarely performed.
others : stool tests for fat, protease secretion; urine test for protease secretion.
Imaging in chronic pancreatitis:
What I will know: X-ray sees only calcifications and has low sensitivity and specificity. EUS is most sensitive and specific and good for mild disease. CT and ultrasound in the middle. ERCP gives good data but has risks so other options may be preferable.
complications of chronic pancreatitis
pain, endocrine/exocrine insufficiency, bile duct obstruction, pancreatic CA, splenic vein thrombosis, duodenal obstruction.
pancreatic excorine insufficiency with chronic pancreatitis. issues, tx
fat intake, medium chan tirglycerides, fat soluble vitamins, B12 deficiency. oral pancreatic enzyme replacement. with uncoated preps, give acid inhibition. good for steatorrhea (coated preps less good bc don’t dissolve until later in the GI tract).
When does enzyme replacement help with pain for chronic pancreatitis?
if given as uncolated enzyme in high doses for early disease in cases that aren’t caused by alcohol
options for pain in chronic pancreatitis
enzyme replace,ent, pancreatic duct stone tx, nerve block, surgery, remove part of the pancreas
