Chronic Pancreatitis

Question 1

What is it?

Answer 1

Continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction and typical causing pain and/or permanent loss of function

Question 2

What age group and gender does it mainly affect?

Answer 2

Males>Females

Age 35-50 years

Question 3

Due to the loss of exocrine and endocrine function, what may patients develop?

Answer 3

Severe malnutrition and diabetes

Question 4

What are the causes of chronic pancreatitis?

Answer 4

Alcohol (80%)
Cystic fibrosis (chronic pancreatitis in 2%)
Congenital anatomical abnormalities: annular pancreas, pancreas divisum
Obstruction of main pancreatic duct: tumour, sphincter of Oddi dysfunction
Hereditary pancreatitis: rare; autosomal dominant
Hypercalcaemia
Autoimmune
Environment: tropical pancreatitis (?decreased antioxidants in diet)

Question 5

What is the underlying pathogenesis?

Answer 5

Duct obstruction:
- Calculi
- Inflammation
- Protein plugs
?Abnormal sphincter of Oddi function:
- Spasm: increased intrapancreatic pressure
- Relaxation: reflux of duodenal contents
?Genetic polymorphisms
- Abnormal trypsin activation

Question 6

What is the pathology?

Answer 6

Glandular atrophy and replacement by fibrous tissue

Question 7

What are some complications that may occur?

Answer 7

Splenic, superior mesenteric and portal veins may thrombose -> portal hypertension
Insulin dependant diabetes
GI haemorrhage
Gastric varices
Pseudocysts
Pancreatic carcinoma
Biliary obstruction

Question 8

What are the clinical features?

Answer 8

Early disease is asymptomatic
Abdominal pain (85-95%):
- Most significant factor with respect to quality of life
- Exacerbated by food and alcohol
- Epigastric pain ‘bores’ through to back
- Relieved by sitting forward or hot water bottles on epigastrium/back (look for hot water bottle rash)
Weight loss (pain, anorexia, malabsorption)
Exocrine insufficiency:
- Late manifestation
- Fat malabsorption (steatorrhoea and decreased fat-soluble vitamins (A, D, E, L) and decreased Ca2+/Mg2+)
- Protein malabsorption (weight loss, decreased vitamin B12)
Endocrine insufficiency (diabetes in 30%)
Jaundice
Duodenal obstruction (uncommon)
Upper GI haemorrhage

Question 9

What investigations should be done?

Answer 9

Plain AXR: 30% have calcification of pancreas
Ultrasound: pancreatic size, cysts, duct diameter, tumours
EUS
CT scan
Blood tests:
- Serum amylase raised in acute exacerbations
- Decreased albumin, Ca2+/Mg2+, vit B12
- Increased LFTs, prothrombin time (fit K), glucose
Pancreatic function tests (Lundh, pancreolauryl)

Question 10

What are the management options with regard to pain control?

Answer 10

Avoid alcohol
Pancreatic enzyme supplements (usually help diarrhoea)
Opiate analgesia (dihydrocodeine, pethidine)
Coeliac plexus block
Referral to pain clinic/psychologist (not uncommon to find depression in this group)
Endoscopic treatment of pancreatic duct stones and strictures
Surgery in selected cases (e.g. pancreatectomy)

Question 11

What are the management options with regard to exocrine and endocrine functions?

Answer 11

Low-fat diet (30-40g/day)
Pancreatic enzyme supplements e.g. Creon, Pancrex; may need acid suppression to prevent hydrolysis in stomach
Vitamin supplements usually not required

Insulin for diabetes mellitus (oral hypoglycaemics usually ineffective)

Question 12

What is the prognosis?

Answer 12

Death from complications of acute-on chronic attacks, cardiovascular complications of diabetes, associated cirrhosis, drug dependence, suicide
Continued alcohol intake = 50% 10 yr survival
Abstinence = 80% 10 yr survival