Chapter 54: Pancreas- Chronic Pancreatitis

Question 1

What is it?

Answer 1

Chronic inflammation of the pancreas region causing destruction of the parenchyma, fibrosis, and calcification, resulting in loss of endocrine and exocrine tissue

Question 2

What are the subtypes?

Answer 2

1. Chronic calcific pancreatitis
2. Chronic obstructive pancreatitis (5%)

Question 3

What are the causes?

Answer 3

1. Alcohol abuse (most common; 70% of cases)
2. Idiopathic (15%)
3. Hypercalcemia (hyperparathyroidism)
4. Hyperlipidemia
5. Familial (found in families without any other risk factors)
6. Trauma
7. Iatrogenic
8. Gallstones

Question 4

What are the symptoms?

Answer 4

Epigastric and/or back pain, weight loss, steatorrhea

Question 5

What are the associated signs?

Answer 5

1. Type 1 diabetes mellitus (up to 1/3)
2. Steatorrhea (up to 1/4)
3. weight loss

Question 6

What are the signs of pancreatic exocrine insufficiency?

Answer 6

• Steatorrhea
  
  • (fat malabsorption from lipase insufficiency—stools float in water)
• Malnutrition

Question 7

What are the signs of pancreatic endocrine insufficiency?

Answer 7

Diabetes (glucose intolerance)

Question 8

What are the common pain patterns?

Answer 8

1. Unrelenting pain
2. Recurrent pain

Question 9

What is the differential diagnosis?

Answer 9

• PUD
• biliary tract disease
• AAA
• pancreatic cancer
• angina

Question 10

What percentage of patients with chronic pancreatitis have or will
develop pancreatic cancer?

Answer 10

≈2%

Question 11

What are the appropriate lab tests?

Answer 11

1. Amylase/lipase
2. 72-hour fecal fat analysis
3. Glucose tolerance test (IDDM)

Question 12

Why may amylase/lipase be normal in a patient with chronic
pancreatitis?

Answer 12

Because of extensive pancreatic tissue loss (“burned-out pancreas”)

Question 13

What radiographic tests should be performed?

Answer 13

1. CT scan
   
   • ​​​Has greatest sensitivity for gland enlargement/atrophy, calcifications
   • masses, pseudocysts
2. KUB
   
   • ​​​​Calcification in the pancreas
3. ERCP
   
   • Ductal irregularities with dilation and stenosis (“chain of lakes”)
   • pseudocysts

Question 14

What is the medical treatment?

Answer 14

• Discontinuation of alcohol use
  
  • can reduce attacks
  • parenchymal damage continues secondary to ductal obstruction and fibrosis
• Insulin for type 1 diabetes mellitus
• Pancreatic enzyme replacement
• Narcotics for pain

Question 15

What is the surgical treatment?

Answer 15

• Puestow—longitudinal pancreaticojejunostomy (pancreatic duct must be dilated)
• Duval—distal pancreaticojejunostomy
• Near-total pancreatectomy

Question 16

What is the Frey procedure?

Answer 16

Longitudinal pancreaticojejunostomy with core resection of the pancreatic head

Question 17

What is the indication for surgical treatment of chronic pancreatitis?

Answer 17

Severe, prolonged/refractory pain

Question 18

What are the possible complications of chronic pancreatitis?

Answer 18

• Insulin dependent diabetes mellitus
• Steatorrhea
• Malnutrition
• Biliary obstruction
• Splenic vein thrombosis
• Gastric varices
• Pancreatic pseudocyst/abscess
• Narcotic addiction
• Pancreatic ascites/pleural effusion
• Splenic artery aneurysm