Chronic pancreatitis

Question 1

What are the causes of chronic pancreatitis?

Answer 1

recurrent inflammation leading to destruction of exocrine & endocrine tissue -> fibrous scar

• alcohol
• gallstone
• congenital or acquired stricture of the pancreatic duct
• pancreas divisum
• tumor causing duct obstruction
• inflammation of papilla of Vater
• cystic fibrosis
• hypercalcemia
• idiopathic

Question 2

What is the gross picture of chronic pancreatitis?

Answer 2

• early -> pancreas is enlarged, edematous, & indurated
• advanced -> small, reduced to cord with rubbery consistency
  - > ducts are dilated but may be narrow & distorted

Question 3

What is the microscopic picture of acute pancreatitis?

Answer 3

• early -> lesion are spotty, show dilatation of the acini with intra-lobular & peri-lobular fibrosis
• advanced -> fibrosis extends through gland but some lobules are still not completely affected
• most advanced -> pancreas is entirely replaced by fibrous tissue
  - > cysts are found where the duct epithelium is destroyed
  - > islets of Langerhans are hyperplastic & non functioning -> diabetes
  - > perineural sheath of intrapancreatic nerves are irritated

Question 4

What extrapancreatic involvement will occur due to chronic pancreatitis?

Answer 4

• CBD -> persistent constriction of duct due to head of pancreas inflammation -> stricture formation
• duodenum -> obstructed by inflammation of the head of pancreas
• colon -> partial obstruction in transverse colon or splenic flexure

Question 5

What are the clinical features of chronic pancreatits?

Answer 5

• abdominal pain -> cramping dull, & aching in the epigastrium radiating to subcostal area & to the back
  - > recurrent (several days to weeks)
  - > spontaneous relief -> exocrine function is lost
• weight loss -> malabsorption & decreased food intake due to pain
• steatorrhea & creatorrhea -> bulky offensive oily stool (floating)
• diabetes mellitus

Question 6

What lab findings could be seen in case of chronic pancreatitis?

Answer 6

• early -> serum amylase & lipase increase during inflammation
• late -> normal
• abnormal liver function tests

Question 7

What radiological features are seen in chronic pancreatitis?

Answer 7

X RAY -> pancreatic calcification
MRCP -> pancreatic cyst
-> biliary dilatation
CT -> ductal anatomy
-> pseudocysts & cystic communication with ductal system
-> biliary dilatation & level of duct obstruction
ERCP -> main pancreatic duct dilatation, stricture, cysts, & ductal calculi
-> angulation of distal CBD

Question 8

What is the medical treatment of chronic pancreatitis?

Answer 8

• pancreatic insufficiency -> dietary restriction of fat (50gm) then increase till diarrhea appears
  - > enzyme replacement
• DM -> subcutaneous insulin -> fasting glucose level = 200 -> may cause hypoglycemia due to glucagon deficiency
• stop alcohol intake -> pain cessation
• minimize stimulus to secretion -> semisolids or liquid diet
• narcotic analgesia

Question 9

What is the surgical treatment of chronic pancreatitis?

Answer 9

PANCREATICOJEJUNOSTOMY (PUESTOW PROCEDURE)
- only in enlarged duct (7mm or larger) -> drainage into jejunum

PANCREATICODUODENECTOMY (WHIPPLE)

DISTAL PANCREATECTOMY

Question 10

What are the indications for Whipple’s procedure?

Answer 10

• inability to rule out presence of pancreatic cancer
• failure of previous pancreaticojejunostomy
• localized chronic pancreatitis
• pain relief

Question 11

What are the indications of distal pancreatectomy?

Answer 11

• recurrent episodes of pancreatitis with multiple pseudocyst in pancreatic tail & splenic vein thrombosis
• recurrent episodes with stricture in the main duct in the body or tail

Question 12

What should be done for pain relief in case of failure of narcotics & dependence?

Answer 12

DESTRUCTION OF THE CELIAC GANGLION