Chronic Pancreatitis Flashcards

1
Q

Define chronic pancreatitis

A

Pancreatic inflammation characterised by recurrent or persistent abdominal pain and progressive injury to the pancreas and surrounding structures, resulting in scarring and loss of function.

Chronic relapsing pancreatitis: Patients have relapsing pain not recognised clinically as chronic pancreatitis (no hallmark features)

Established chronic pancreatitis: hallmark features of chronic pancreatitis are present - reduced pancreatic exocrine function, malabsorption, diabetes, and pancreatic calcifications

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2
Q

Aetiology of chronic pancreatitis

A

Metabolic/toxic: alcohol, haemochromatosis

Duct obstruction: gallstones, abnormal pancreatic duct anatomy, cystic fibrosis “mucoviscoidiosis”

Tumours

Idiopathic: autoimmune

Chronic inflammation with parenchymal fibrosis and loss of parenchyma (ascini become atrophic)
Duct strictures with calcified stones with secondary dilatations
Pancreatic calcifications are diagnostic of chronic pancreatitis

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3
Q

Risk factors for chronic pancreatitis

A

Alcohol
Smoking
Family history
Coeliac
Psoriasis
High–fat, high-protein diet
Tropical geography

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4
Q

Symptoms of chronic pancreatitis

A

Asymptomatic for years

Epigastric pain that ‘bores’ to the back
- Relieved by sitting forward or hot water bottles on the epigastrum or back
- Dull
- Worse 30 minutes post-prandially
- Either short episodes/relapsing (type A), or constant/prolonged episodes (type B)
Bloating
Steatorrhoea (foul-smelling)
Features of DM (polyuria, polydipsia)
Weight loss
Nausea and vomiting
Painful joint
SOB

Symptoms relapse and worsen

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5
Q

Signs of chronic pancreatitis on examination

A

General:
Jaundice
Erythema ab igne - mottled dusky greyness
Skin nodules (pancreatic lipase leaks into the circulation -> fat necrosis)

Abdo:
Epigastric tenderness
Abdominal distension

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6
Q

investigations for chronic pancreatitis

A

Faecal elastase: reduced (represents exocrine function)

FBC
LFTs
Albumin
Amylase
HbA1c
Bone profile
Glucose
Serum trypsin (low)

US abdo: Structural/anatomical changes e.g. cavities, duct irregularity, Contour irregularity of head/body, calcification
CT contrast: Pancreatic calcifications, focal or diffuse enlargement of the pancreas, ductal dilation, vascular complications, atrophy
AXR: pancreatic calcifications

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7
Q

Management for chronic pancreatitis

A

Conservative:
Alcohol and smoking cessation
Low fat diet (however may contribute to fat-soluble vit deficiency)
Medium-chain triglycerides (MCTs)

Reduce pain: analgesia e.g. tramadol/paracetamol
Reduce pancreatic steatorrhoea: Pancretic enzyme supplement CREON (pancreatin lipase + PPI omeprazole)
Correct weight loss and nutritional deficiencies: fat soluble vitamins
Maintain bone health
Treat diabetes and other complication
Screen for pancreatic cancer
Maintain/increase QOL.

Unremitting pain, narcotic abuse, weight loss -> pancreatectomy or pancreatojejunostomy

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8
Q

Complications of chronic pancreatitis

A

Local:
- Peripancreatic fluid collections (most common)
- Pancreatic necrosis
- Pseudocyst (mx: observe (12w) → cystogastrostomy / aspiration)
- Abscess: due to infection of pseudocyst, (mx: trans-gastric drainage / endoscopic drainage)
- Pancreatic haemorrhage
- Ascites
- Pseudoaneurysm
- Venous thrombosis
- Chronic pancreatitis
- Enteropancreatic fistulae
Systemic:
- Diabetes mellitus (late stage as endocrine parts survive much longer than exocrine components)
- Hypocalcaemia
- Hypoglycaemia
Pleural effusions - exudative

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9
Q

Prognosis for chronic pancreatitis

A

Pan decreases or disappears over time, regardless of the aetiology. Around 70% of cases.
Pain relief correlates with development of late complications of calcifications and exocrine/endocrine insufficiency

Most common cause of death varies with aetiology:
Juvenile - pancreatic carcinoma
Late-onset - cardiovascular disease and extra-pancreatic malignancy
Alcoholic - cardiovascular disease
Hereditary - malignancy

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