Pancreatitis, Chronic Flashcards
What re the risk factors of developing chronic pancreatitis?
Alcohol (70%). Idiopathic in 20%.
Rare: Recurrent acute pancreatitis, ductal obstruction, pancreas divisum, hereditary pancreatitis, tropical pancreatitis, autoimmune pancreatitis, hyperparathryroidism, hypertriglyceridemia.
Describe the epidemiology of chronic pancreatitis.
Annual UK incidence ~1/100 000;
prevalence ~3/100 000.
Mean age 40–50 years in alcohol-associated disease.
Describe the pathogenesis of chronic pancreatitis.
Inappropriate activation of pancreatic enzymes including trypsin oven leads to protein precipitation.
May progress to formation of plugs or stones.
Blockage of pancreatic ducts increases pressure and causes further damage.
Chronic alcohol intake is believed to increase trypsinogen relative to its inhibitor.
What would a patient with chronic pancreatitis describe in their history?
Recurrent severe epigastric pain, radiating to back, relieved by sitting forward, can be exacerbated by eating or drinking alcohol.
Over many years, weight loss, bloating and pale offensive stools (steatorrhoea).
What would be found on examination of a patient with chronic pancreatitis?
Epigastric tenderness.
Signs of complications, e.g. weight loss, malnutrition.
What investigations would you perform if you suspected chronic pancreatitis?
Bloods:
•Glucose (⬆️ may indicate endocrine dysfunction), glucose tolerance test.
•Amylase and lipase (usually normal),
•⬆️ immunoglobulins, especially IgG4 in autoimmune pancreatitis.
USS:
•Percutaneous or endoscopic: can show hyperechoic foci with post-acoustic shadowing.
ERCP or MRCP:
•Early changes include main duct dilatation and stumping of branches. •Late manifestations are duct strictures with alternating dilatation (chain of lakes appearance).
AXR: Pancreatic calcification may be visible.
CT scan: Pancreatic cysts, calcification.
Tests of pancreatic exocrine function: Faecal elastase.
How would you manage a patient with chronic pancreatitis?
General:
•Treatment is mainly symptomatic and supportive, e.g. dietary advice, —abstinence from alcohol and smoking,
—treatment of diabetes,
—oral pancreatic enzyme replacements, e.g. Creon,
—analgesia for exacerbations of pain.
**Chronic pain management may need specialist input.
The sensory nerves to the pancreas transverse the coeliac ganglia and splanchnic nerves, coeliac plexus block (CT or EUS-guided neurolysis) and transthoracic splanchnicectomy offer variable degrees of pain relief.
Endoscopic therapy:
•Sphincterotomy,
•stone extraction,
•dilatation or stenting of strictures.
•Extracorporeal shock-wave lithotripsy is sometimes used for fragmentation of larger pancreatic stones prior to endoscopic removal.
Surgical:
May be indicated if medical management has failed.
Options include:
•lateral pancreaticojejunal drainage (modified Puestow procedure),
•resection (pancreaticoduodenectomy or Whipples)
•limited resection of the pancreatic head (Beger procedure)
•combined opening of the pancreatic duct and excavation of the pancreatic head (Frey procedure).
What complications might you expect in a patient with chronic pancreatitis?
Local:
Pseudocysts, biliary duct stricture, duodenal obstruction, pancreatic ascites, pancreatic carcinoma.
Systematic:
Diabetes, steatorrhoea, reduced quality of life, chronic pain syndromes and dependence on strong analgesics.
What prognosis would you expect for a patient with chronic pancreatitis?
Difficult to predict as pain may improve, stabilize or worsen.
Surgery improves symptoms in 60–70% but results are often not sustained.
Life expectancy can be reduced by 10–20 years.
What is the definition of chronic pancreatitis?
Chronic inflammatory disease of the pancreas characterized by irreversible parenchymal atrophy and fibrosis leading to impaired endocrine and exocrine function and recurrent abdominal pain.
