Chronic pancreatitis

Question 1

what are the causes of chronic pancreatitis?

Answer 1

chronic alcohol use
idiopathic
metabolic: hyperlipidemia and hypercalcemia
infection: HIV, mumps, echinococcus
autoimmune: SLE, autoimmune pancreatitis
obstruction: stricture / neoplasm
congenital : annular pancreas

Question 2

what is the pathophysiology of chronic pancreatitis?

Answer 2

large duct disease(more common in men):
dilation and dysfunction of large pancreatic duct –> seen on imaging
change in fluid composition –> deposition of calcium carbonate precursors –> pancreatic calcification

small duct disease (predominantly women):
no calcification or findings on imaging

Question 3

what are the clinical features of chronic pancreatitis?

Answer 3

• chronic pain (epigastrium radiating to the back) –> eased by leaning forward
• diabetes (endocrine dysfunction)
• steatorrhoea / malabsorption (exocrine dysfunction)

physical examination:

• epigastric tenderness
• epigastric mass –> pseudocyst or an inflammatory mass

Question 4

what are the investigations conducted in chronic pancreatitis and what are the findings?

Answer 4

lab tests:
BM - diabetes
serum calcium - hypercalcemia 
LFTs - may be abnormal in hepatic aetioloy 
*amylase and lipase rarely raised*
faecal elastase - abnormally low

imaging
Abdo USS - underlying cause (typically 1st line)
CT CAP- pancreatic calcification/pseudocyst/ dilation of ducts
MRCP - assess pancreatic duct + identify presence of biliary obstruction
ERCP - more accurate at eliciting anatomy of pancreatic duct + interventional with dilating strictures

Question 5

what is the management of chronic pancreatitis?

Answer 5

avoidance of precipitating factors
analgesia: simple analgesia + opioids
complications addressed as required
CREON - for pancreatic insufficency

endoscopic
ERCP - remove pancreatic duct stones
Endoscopic sphincterotomy: high sphincter and pancreatic duct pa
EUS - helps to facilitate aspiration of pseudocysts

surgical approach:

• whipple’s procedure (pancreaticoduodenectomy) for paraduodenal pancreatitis
• total pancreatectomy: poor morbidity

steroids
effective in chronic hepatites with autoimmune aetiology

Question 6

what are the complications of chronic pancreatitis?

how are they manage?

Answer 6

• pseudocysts
• steatorrhea and malabsorption: Creon + regular clotting function tests –> poor absorption of vit k as fat-soluble
• diabetes: insulin regime
• ascites and pleural effusion in disruption of the main pancreatic duct
• pancreatic malignancy

Question 7

what is the prognosis of chronic pancreatitis

Answer 7

significant morbidity
difficult to manage effectively
patients eventually ‘burn out’ because of the pain

1/3 die within 10 years