Pancreatitis Chronic Flashcards
outline a typical presentation for chronic pancreatitis?
steatorrhea
bloating
DM ( due to destruction of langerhans cells)
epigastric pain
normal amylase but reduced faecal elastase
define chronic pancreatitis?
• Chronic inflammatory disease of the pancreas characterised by irreversible parenchymal atrophy and fibrosis leading to impaired endocrine and exocrine function and recurrent abdominal pain.
what is the triad for chronic pancreatitis?
steatorrhea
DM
epigastric pain
what are the risk factors for chronic pancreatitis?
alcohol
smoking
family history
coeliac disease
outline the aetiology/ risk factors for chronic pancreatitis?
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
summarise the epidemiology of chronic pancreatitis?
Annual UK incidence: 1/100,000
• Prevalence: 3/100,000
• Mean age: 40-50 yrs (in alcohol-associated disease)
what are the presenting symptoms of chronic pancreatitis?
- 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
what are the signs of chronic pancreatitis on physical examination?
epigastric tenderness
signs of complications- weight loss, malnutrition
what are the appropriate investigations for chronic pancreatitis?
bloods
abdominal ultrasound
ERCP
Abdominal X ray
CT scan
test for pancreatic exocrine function-> faecal elastase
describe what may be seen in blood tests in chronic pancreatitis?
high glucose ( endocrine dysfunction)- glucose tolerance test
amylase and lipase usually normal
High Ig (especially IgG4 in autoimmune pancreatitis)
what may be seen on a CT scan in chronic panncreatitis?
pancreatic calcification and pancreatic cysts
what are the tests for pancreatic exocrine function?
faecal elastase ( reflects pancreatic exocrine function)->not good for milder forms
what can be seen on MRCP or ERCP for chronic pancreatitis?
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
summarise the prognosis for chronic pancreatitis?
- Difficult to predict
- Surgery improves symptoms in 60-70% but results are often not sustained
- Life expectancy may be reduced by 10-20 years
what are the local complications for chronic pancreatitis?
o Ps eudocysts o Biliary duct stricture o Duodenal obstruction o Pancreatic ascites o Pancreatic carcinoma
what are the systemic complications of chronic pancreatitis?
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
what are the 4 subcategories in the management of chronic pancreatitis?
general
medical
endoscopy therapy
surgical
what is the general management for chronic pancreatitis?
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
what is the medical management for chronic pancreatitis?
- analgesia
- pancreatin (pancreatic enzymes) + O Omeprazole (PPI)
outline endoscopy therapy for chronic pancreatitis?
- Sphincterotomy
- Stone extraction
- Dilatation and stenting of strictures
- Extracorporial shock-wave lithotripsy (ESWL) is sometimes used to fragment larger pancreatic stones before removal
outline the surgical management for chronic pancreatitis?
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)
