Pancreatitis (chronic)

Question 1

Definition

Answer 1

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 2

Aetiology

Answer 2

• ALCOHOL - 70%
• Idiopathic - 20%
• RARE: recurrent acute pancreatitis, ductal obstruction, pancreas divisum, hereditary
pancreatitis, tropical pancreatitis, autoimmune pancreatitis, hyperparathyroidism

Question 3

Pathogenesis

Answer 3

EXTRA information about pathology/pathogenesis:

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 with raised intraductal pressures

Question 4

Epidemiology

Answer 4

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

Question 5

Presenting symptoms

Answer 5

• 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 6

Signs on physical examination

Answer 6

• Epigastric tenderness

* Signs of complications e.g. weight loss, malnutrition

Question 7

Investigations (bloods)

Answer 7

o High glucose (endocrine dysfunction) - glucose tolerance test may be performed
o Amylase and lipase usually normal
o High Ig (especially IgG4 in autoimmune pancreatitis)

Question 8

Investigations (others)

Answer 8

• Ultrasound

• ERCP or MRCP:
o Early changes that can be seen include main duct dilatation and stumping of
branches
o Late manifestations include duct strictures with alternating dilatation

• Abdominal X-Ray:
o May show pancreatic calcification

• CT Scan:
o May show pancreatic calcification and pancreatic cysts

• Tests of pancreatic exocrine function:
o Faecal elastase (reflects pancreatic exocrine function)

Question 9

Management plan (general)

Answer 9

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 10

Management plan (endoscopy)

Answer 10

Endoscopy Therapy:

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

Question 11

Management plan (surgical)

Answer 11

o May be indicated if medical management fails
o Lateral pancreaticojejunal drainage (modified Puestow procedure)
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)

Question 12

Possible complications (local)

Answer 12

o Pseudocysts
o Biliary duct stricture
o Duodenal obstruction
o Pancreatic ascites
o Pancreatic carcinoma

Question 13

Possible complications (systemic)

Answer 13

o Diabetes
o Steatorrhoea
o Chronic pain syndromes
o Dependence on strong analgesics

Question 14

Prognosis

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