Chronic Pancreatitis Flashcards
(47 cards)
definition
> > persistent inflammation and irreversible fibrosis associated with atrophy of the pancreatic parenchyma
> > associated with chronic pain and endocrine and exocrine insufficiency
MC cause and others
> > heavy alcohol consumption is the most common cause of chronic pancreatitis
> > chronic duct obstruction
trauma
divisum
cystic dystrophy of the duodenal wall
hyperparathyroidism
hypertriglyceridemia
autoimmune pancreatitis
tropical pancreatitis
hereditary pancreatitis
In up to 20% of patients, Idiopathic.
How does Alcohol cause chronic pancreatitis ?
- increases the total protein concentration in the pancreatic juice
- it promotes the synthesis and secretion of lithostathine
- it increases glycoprotein 2 secretion
- formation of protein plugs and eventually stones inside the pancreatic duct.
- predisposed to autodigestion
- fatty acid ethyl esters and reactive oxygen species, cause fragility of intraacinar organelles, such as zymogen granules and lysosomes,
- Acetaldehyde > direct injury
- enhanced NF-κB activity, intracellular calcium levels.
Response of Pancreatic stellate cells (PSCs)
> > specialized quiescent fibroblasts found at the base of acinar cells
differentiate into activated myofibroblasts
Examples of these proteins include collagen I and III, fibronectin, laminin, and matrix metalloproteinases.
chronic necrosis and inflammation (necroinflammation) induce the release of inflammatory mediators, such as platelet-derived growth factor, TGF-β, TNF-α, IL-1, and IL-6, which are known to activate PSCs.
> > chronic necroinflammation induced by ethanol activates PSCs and induces pancreatic fibrosis.
smoking Role ?
Increases the Risk
> > risk of pancreatic calcifications and diabetes mellitus is increased in patients who smoke
PRSS1 Gene
Mutations in the cationic trypsinogen gene, also known as protease serine 1 (PRSS1) gene
> > are common in hereditary chronic pancreatitis.
PRSS1 is located on chromosome 7 and regulates trypsinogen production
mutations in this gene are associated with intraacinar trypsinogen activation.
SPINK-1
> > SPINK-1 is a peptide secreted by acinar cells that regulates the premature activation of trypsinogen
> > they lower the threshold for chronic pancraetitis development and influence the severity of the disease.
> > SPINK1 mutations are more prevalent in alcoholic, hereditary, and idiopathic pancreatitis.
CFTR Gene
> > affect the normal secretion of bicarbonate, decrease pancreatic juice volume, and augment the concentration of pancreatic enzymes inside the pancreatic duct.
> > Homozygous CFTR mutations result in cystic fibrosis;
> > heterozygous mild mutations predispose to pancreatic exocrine insufficiency and chronic pancreatitis.
> > higher in patients with alcoholic, idiopathic, and hereditary pancreatitis
chymotrypsin C gene
> > chymotrypsin C protects against pancreatitis by degrading trypsinogen
Autoimmune Pancreatitis
> > Type 1, which is the pancreatic manifestation of an immunoglobulin G4-related disease
> > Type 2, a pancreatic specific disorder, not associated with immunoglobulin G4.
> > closely mimicking patients with pancreatic adenocarcinoma.
Type 1
> > Type 1 is the most common
> > it is characterized by dense, periductal lymphoplasmacytic infiltrates, storiform fibrosis, and obliterative venulitis
> > Plasmatic cells typically stain positive for immunoglobulin G4.
Type 2
> > the pancreas is infiltrated by neutrophils, lymphocytes, and plasma cells
Tropical Pancreatitis
> > particularly in India
> > associated with cassava ingestion and SPINK1 mutations
What Percentage of Gland needs to be dysfunctional before steatorrhea, diarrhea, and other symptoms of malabsorption develop
> > At least 90% of the gland needs to be dysfunctional before steatorrhea, diarrhea, and other symptoms of malabsorption develop
In severe cases, what they will have ?
> > diseases associated with fat-soluble vitamin deficiency, such as bleeding, osteopenia, and osteoporosis, develop
When will Diabetes Occur
> > 40% to 80% of patients will have clinical manifestations of diabetes mellitus, typically occurring years after the onset of abdominal pain and pancreatic exocrine insufficiency.
Complications of Chronic pancreatitis ?
> > Jaundice or cholangitis occurs in 5% to 10% of patients because of fibrosis of the distal common bile duct.
> > obstruct the duodenum, leading to severe nausea, vomiting, and abdominal pain.
The most common CT findings in chronic pancreatitis include
> > dilated pancreatic duct (68%)
parenchymal atrophy (54%)
pancreatic calcifications (50%)
Role of MRI
> > Alternative to CT
The sensitivity for the diagnosis of pancreatic calcifications is lower
MRCP with secretin injection is particularly useful to evaluate intraductal strictures and pancreatic duct disruption.
ERCP ?
- If CT and MRI Contraindicated or didnt Diagnose
- Therapeutic for :
» stricture, stone, pseudocysts, and biliary stenosis.
EUS ?
> > most accurate technique to diagnose chronic pancreatitis in patients with minimal change disease or in the early stages
> > Histologic evidence of inflammation, atrophy, and fibrosis is the gold standard for the diagnosis of chronic pancreatitis
Rosemont consensus-based endoscopic ultrasound features for diagnosis of chronic pancreatitis.
Parenchymal Features
» Major A Criteria
* Hyperechoic foci with postacoustic shadowing
> > Major B Criteria
* Honeycombing lobularity
> > Minor Criteria
* Hyperechoic, nonshadowing foci ≥3 mm in length and width
* Lobularity including three or more noncontiguous lobules in the body or tail
* Pancreatic cysts ≥2 mm in short axis
* At least three strands
Rosemont consensus-based endoscopic ultrasound features for diagnosis of chronic pancreatitis.
Ductal Features
» Major A Criteria
* Main pancreatic duct calculi
> > Minor Criteria
* Irregular main pancreatic duct contour
* Dilated side branches
* Main pancreatic duct dilation (≥3.5 mm in the body or ≥1.5 mm in the tail)
* Hyperechoic main pancreatic duct margin >50% of the main pancreatic duct in the body and tail
Functional Tests
> > fecal elastase 1 level is the preferred noninvasive study to diagnose pancreatic exocrine insufficiency.
> > using monoclonal or polyclonal anti–human elastase 1 antibodies
> > fecal elastase 1 concentration between 100 and 200 μg/g defines mild to moderate pancreatic insufficiency;
> > fecal elastase 1 concentration below 100 μg/g establishes the diagnosis of severe pancreatic exocrine insufficiency.
