Pancreatitis Chronic

Question 1

outline a typical presentation for chronic pancreatitis?

Answer 1

steatorrhea
bloating
DM ( due to destruction of langerhans cells)
epigastric pain
normal amylase but reduced faecal elastase

Question 2

define chronic pancreatitis?

Answer 2

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

Question 3

what is the triad for chronic pancreatitis?

Answer 3

steatorrhea
DM
epigastric pain

Question 4

what are the risk factors for chronic pancreatitis?

Answer 4

alcohol
smoking
family history
coeliac disease

Question 5

outline the aetiology/ risk factors for chronic pancreatitis?

Answer 5

ALCOHOL - 70%
trypsinogen in the pancreas is overproduced and/or prematurely activated, and/or degradation is inhibited.

• Idiopathic - 20%
• RARE: recurrent acute pancreatitis, ductal obstruction, pancreas divisum, hereditary pancreatitis, haemochromotosis, tropical pancreatitis, autoimmune pancreatitis, hyperparathyroidism

o Chronic pancreatitis is caused by disruption of normal pancreatic glandular architecture due to chronic inflammation and fibrosis, calcification, parenchymal atrophy, ductal dilation and cyst and stone formation

o Pain is associated w
ith raised intraductal pressure

Question 6

summarise the epidemiology of chronic pancreatitis?

Answer 6

Annual UK incidence: 1/100,000
• Prevalence: 3/100,000
• Mean age: 40-50 yrs (in alcohol-associated disease)

Question 7

what are the presenting symptoms of chronic pancreatitis?

Answer 7

• recurrent severe epigastric pain
• pain radiates to the back
• pain relieved by sitting forward
• pain can be aggravated by eating or drinking alcohol
• over many years- > weight loss, bloating and steatorrhoea

Question 8

what are the signs of chronic pancreatitis on physical examination?

Answer 8

epigastric tenderness

signs of complications- weight loss, malnutrition

Question 9

what are the appropriate investigations for chronic pancreatitis?

Answer 9

bloods

abdominal ultrasound

ERCP

Abdominal X ray

CT scan

test for pancreatic exocrine function-> faecal elastase

Question 10

describe what may be seen in blood tests in chronic pancreatitis?

Answer 10

high glucose ( endocrine dysfunction)- glucose tolerance test

amylase and lipase usually normal

High Ig (especially IgG4 in autoimmune pancreatitis)

Question 11

what may be seen on a CT scan in chronic panncreatitis?

Answer 11

pancreatic calcification and pancreatic cysts

Question 12

what are the tests for pancreatic exocrine function?

Answer 12

faecal elastase ( reflects pancreatic exocrine function)->not good for milder forms

Question 13

what can be seen on MRCP or ERCP for chronic pancreatitis?

Answer 13

o Early changes that can be seen include main duct dilatation and stumping of branches
o Late manifestations include duct strictures with alternating dilatation
o MRCP is preferred - ERCP should not be used as a purely diagnostic tool due to its significant complication rate. It is mostly a therapeutic procedure to retrieve retained common bile duct stones

Question 14

summarise the prognosis for chronic pancreatitis?

Answer 14

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

Question 15

what are the local complications for chronic pancreatitis?

Answer 15

o Ps eudocysts 
o Biliary duct stricture 
o Duodenal obstruction 
o Pancreatic ascites 
o Pancreatic carcinoma

Question 16

what are the systemic complications of chronic pancreatitis?

Answer 16

o Diabetes – Brutal Diabetes as with pancreatitis you lose both alpha and beta islet cells so no glucagon or insulin production – can crash into hypoglycaemia quite easily if they take too much insulin

o Steatorrhoea

o Chronic pain syndromes

o Dependence on strong analgesics

Question 17

what are the 4 subcategories in the management of chronic pancreatitis?

Answer 17

general
medical
endoscopy therapy
surgical

Question 18

what is the general management for chronic pancreatitis?

Answer 18

o Treatment is mainly symptomatic and supportive (e.g. dietary advice, stop smoking/drinking, treat diabetes, oral pancreatic enzyme replacement, analgesia)

o Chronic pain management may need specialist input

Question 19

what is the medical management for chronic pancreatitis?

Answer 19

• analgesia

- pancreatin (pancreatic enzymes) + O Omeprazole (PPI)

Question 20

outline endoscopy therapy for chronic pancreatitis?

Answer 20

• Sphincterotomy
• Stone extraction
• Dilatation and stenting of strictures
• Extracorporial shock-wave lithotripsy (ESWL) is sometimes used to fragment larger pancreatic stones before removal

Question 21

outline the surgical management for chronic pancreatitis?

Answer 21

o May be indicated if medical management fails

o Lateral pancreaticojejunal drainage (modified Puestow procedure)

o biliary decompression

o Pancreatic resection (pancreaticoduodenectomy or Whipple’s procedure)

o Limited resection of pancreatic head (Beger procedure)

o Combining opening of the pancreatic duct and excavation of the pancreatic head (Frey procedure)