Chronic Pancreatitis Flashcards
Define chronic pancreatitis
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
Aetiology of chronic pancreatitis
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
Risk factors for chronic pancreatitis
Alcohol
Smoking
Family history
Coeliac
Psoriasis
High–fat, high-protein diet
Tropical geography
Symptoms of chronic pancreatitis
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
Signs of chronic pancreatitis on examination
General:
Jaundice
Erythema ab igne - mottled dusky greyness
Skin nodules (pancreatic lipase leaks into the circulation -> fat necrosis)
Abdo:
Epigastric tenderness
Abdominal distension
investigations for chronic pancreatitis
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
Management for chronic pancreatitis
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
Complications of chronic pancreatitis
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
Prognosis for chronic pancreatitis
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
