Pancreatitis (Chronic) Flashcards
What is chronic pancreatitis?
Chronic pancreatitis is a chronic fibro-inflammatory disease of the pancreas, resulting in progressive and irreversible damage to the pancreatic parenchyma.
What are the causes of chronic pancreatitis?
The main causes of chronic pancreatitis are either chronic alcohol abuse (60%) and idiopathic (30%).
Less common causes:
- Metabolic (hyperlipidaemia, hypercalcaemia),
- Infection (both viral e.g. HIV, mumps, coxsackieand bacterial e.g. Echinococcus),
- Hereditary (e.g. cystic fibrosis)
- Autoimmune (e.g. autoimmune pancreatitis (AIP) or SLE)
- Anatomical (malignancy or stricture formation)
- Congenital anomalies (e.g. Pancreas divisum or Annular pancreas)
What are the clinical features of chronic pancreatitis?
The major symptom in chronic pancreatitis is chronic pain, which may be complicated by recurring attacks of acute pancreatitis (often termed “acute-on-chronic” pancreatitis). The pain is typically in the epigastrium and back, often associated with nausea and vomiting.
Due to the damage that has occurred to the pancreatic parenchyma, patients may also present with endocrine and exocrine insufficiency.
On examination, the abdomen will be soft, however the patient may be tender in the epigastrium. There may also be signs of cachexia and malabsorption.
How does endocrine insufficiency develop from chronic pancreatitis? And how does it present?
Secondary to damage to the endocrine tissue of the pancreatic gland (islets of Langerhans), there is subsequent failure to produce insulin, resulting in impaired glucose regulation or eventual diabetes mellitus.
How does exocrine insufficiency develop from chronic pancreatitis? And how does it present?
Secondary to damage to the acinar cells, resulting in failure to produce digestive enzymes, causing malabsorption, presenting with weight loss, diarrhoea, or steatorrhoea.
What investigations should be ordered for chronic pancreatitis?
Note: laboratory investigations
Most patients presenting with abdominal pain should have a urine dip and routine bloods, including FBC and CRP. Serum amylase or lipase levels are often not raised in established disease.
In suspected cases of chronic pancreatitis, ensure to also check blood glucose (secondary to endocrine dysfunction) and LFTs (to ensure no concurrent obstructive jaundice).
A faecal elastase level will be low in most cases of chronic pancreatitis with exocrine insufficiency, often can aid the diagnosis.
Why is faecal elastase used to measure chronic pancreatits?
The elastase enzyme is produced by the pancreas, being excreted into the bowel to aid with digestion, and importantly does not undergo any significant degradation during intestinal transit; as such, any exocrine dysfunction in chronic pancreatitis will present with low faecal elastase levels.
What investigations should be ordered for chronic pancretitis?
Note: imaging
CT imaging can often show pancreatic atrophy or calcification, as well as any pseudocysts present. Any overt causes for chronic pancreatitis, such as malignancy or congenital anomalies, may also be seen
The anatomy of the pancreas and the biliary tree can be determined using both ultrasound imaging or MRI imaging (specifically MRCP). However, a normal appearance of the pancreas on imaging does not necessarily exclude chronic pancreatitis.
Additional specialist tests, such as the secretin stimulation test or endoscopic ultrasound (EUS), may also be employed in cases of diagnostic uncertainty.
What is shown on the CT scan for chronic pancreatitis?
CT scans in chronic pancreatitis.
A- Calcification in the region of the pancreas.
B- Large psuedocyst formation
Briefly describe the management of chronic pancreatitis
Chronic pancreatitis can only be managed definitively by treating any reversible underlying cause. This can include alcohol cessation or statin therapy for hyperlipidaemia.
However, analgesia becomes the mainstay of management for most cases of chronic pancreatitis. Whilst the WHO analgesic ladder should be followed in acute cases, for those with long-term pain, opioid analgesia might be replaced with neuropathic analgesics instead.
How is exocrine deficiency treated in chronic pancreatitis?
Patients with malabsorption secondary to exocrine dysfunction may benefit from enzyme replacement (including lipases), such as Creon®, that can be taken with meals to good effect. Patients are also at risk of becoming deficient in fat-soluble vitamins (A, D, E and K), therefore ensure adequate vitamin supplementation and check bone density routinely.
What is the role of endoscopic management in chronic pancreatitis?
Endoscopic management is performed only in a select few patients where there is a targetable underlying cause. Surgical intervention is now rarely performed in cases of chronic pancreatitis, due to high morbidity and mortality, with limited symptomatic improvement.
Endoscopic retrograde cholangiopancreatography (ERCP) can be used for diagnostic and therapeutic purposes, including stone removal, stent placement, or sphincterotomy (especially in large duct pancreatitis).
Endosonography-guided celiac plexus blockade or thoracoscopic splanchnicectomy are interventions that be be performed purely for analgesic purposes.
What is the role of steroid treatment in chronic pancreatitis?
Steroids are effective at reducing symptoms in chronic pancreatitis with an autoimmune aetiology only. A high dose of prednisolone is used initially to bring symptoms under control; a low dose maintenance regime is then used.
What is the prognosis of chronic pancreatitis?
Chronic pancreatitis is associated with significant morbidity and reduced quality of life, as it can be a challenging condition to manage effectively.
In some patients, the disease may eventually ‘burn out’ after many years of pain, leaving residual endocrine and exocrine insufficiencies.
Pancreatic malignancy is a risk in those who have had the disease for 20 years or more; new or evolving symptoms should therefore undergo investigation.
