Hepato-biliary: Chronic Pancreatitis

Question 1

What is chronic pancreatitis?

Answer 1

Continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction and typically causing pain and/or permanent loss of function

Question 2

What is the pathogenesis of chronic alcoholic pancreatitis?

Answer 2

Chronic alcoholic pancreatitis is characterised by dilated pancreatic ducts filled with protein plugs which may be calcified due to impaired calcium regulation.

This leads to atrophy of the acinar tissue and fibrosis with relative preservation of islets.

Question 3

What are causes of chronic pancreatitis?

Answer 3

TIGARO

• Toxins/alcohol
• Idiopathic
• Genetic - Haemochromatosis, CF
• Autoimmune
• Recurrent/acute/severe pancreatitis
• Obstruction of pancreatic duct
• Familial
• Congenital - pancreas divisum

Question 4

What is autoimmune pancreatitis?

Answer 4

IgG4-related disorder where the immune system attack the pancreas. There are two types; Type 1 and type 2

Question 5

What are well recognised susceptibility genes implicated in chronic pancreatitis?

Answer 5

• PRSS1
• SPINK1
• CFTR

Question 6

What are symptoms of chronic pancreatitis?

Answer 6

Asymptomatic in early stages

• Epigastric pain boring through to the back - relieved by sitting forward or hot water. Sudden in onset, reaching max after a few hours. Worse 15-30mins post meal.
• Bloating
• Steatorrhoea - exocrine function
• Weight loss
• Brittle diabetes

Question 7

What signs might be seen in chronic pancreatitis?

Answer 7

• Weight loss
• Erythema ab ignes
• Jaundice - conjugated

Question 8

What is erythema ab ignes?

Answer 8

Erythema caused by exposure to heat - in the context of chronic pancreatitis

Question 9

What investigations would you consider doing in someone with suspected chronic pancreatitis?

Answer 9

• Bloods - Serum amylase/lipase (amylase may be normal), albumin, Ca2+, vit B12, LFTs (bilirubin, GTT), Prothrombin time, glucose
• Ultrasound +/- CT
• Faecal elastase
  
  • ​Reduced - exocrine function
• MRCP/ERCP
• EUS
• AXR

Question 10

What are you looking for on AXR?

Answer 10

Pancreatic calcification

Question 11

What are you looking for on AUS?

Answer 11

Pseudocyst

Calcifications, duct dilatations, irregular consistency, fluid corrections (SAME AS ON CT)

Question 12

What differential diagnosis would you consider in someone with features of chronic pancreatitis?

Answer 12

Pancreatic malignancy

Question 13

What features are you looking for in Endoscopic ultrasound/CT scan?

Answer 13

Pancreatic calcification

Question 14

How would you manage someone with chronic pancreatitis?

Answer 14

• Analgesia​
• Pancreatic enzyme replacement - Creon
• Insulin
• Dietary advice
• Surgery

Question 15

What dietary advice would you give someone with chornic pancreatitis?

Answer 15

• No alcohol
• Low fat diet
• Vitamin supplements
• Medium chain triglycerides
• May need insulin

Question 16

What are options for pain relief in chronic pancreatitis?

Answer 16

• Opiates - dihydrocodeine, pethidine
• Coeliac plexus block

Question 17

What surgical procedures are used for unremitting pancreatic pain?

Answer 17

• Pancreatectomy
• Pancreaticojejunostomy
  
  • ​Surgical resection combined with drainage of pancreatic duct into small bowel.

Question 18

What are complications of chronic pancreatitis?

Answer 18

• Local
  
  • Pseudocyst
  • Biliary obstruction (biliary strictures)
  • Local artery aneurysm
  • Splenic vein thrombosis
  • Pancreatic ascites
  • Pancreatic cancer
• Systemic
  
  • Diabetes
  • Gastric varices
  • Steatorrhoea
  • Chronic pain syndrome