Chronic pancreatitis

Question 1

Define chronic pancreatitis.

Answer 1

Chronic inflammatory disease of the pancreas characterised by irreversible parenchymal atrophy and fibrosis leading to impaired endocrine and exocrine function and recurrent abdominal pain.

Question 2

What is the epidemiology of chronic pancreatitis?

Answer 2

• Annual incidence 1/100,000 in UK
• Prevalence 3/100,000
• Mean age 40-50 years in alcohol- associated disease

Question 3

What are the risk factors for chronic pancreatitis?

Answer 3

• Alcohol - (70-80% of all chronic pancreatitis)
• Smoking
• FH - mutations in PRSS1, SPINK1, CFTR
• Coeliac disease –> IDIOPATHIC

Other: psoriasis, high-fat, high-protein diet

Question 4

Which GI condition increases risk of developing any form of pancreatitis?

Answer 4

coeliac disease

Question 5

What is the pathophysiology of chronic pancreatitis? Which cells are thought to be involved?

Answer 5

Chronic inflammation –> fibrosis and calcification, parenchymal atrophy, ductal dilatation, cyst and stone formation —> disruption of normal pancreatic glandular architecture

Pancreatic stellate cells - thought to play a role in pancreatitis by converting from quiescent fat storing cells to myofibroblast-like cells forming extracellular matrix, cytokines and GF in response to injury.

Question 6

What is the pain in chronic pancreatitis thought to be associated with?

Answer 6

Pain is thought to be associated with raised intraductal pressure and inflammation.

Question 7

What is the typical presentation of chronic pancreatitis?

Answer 7

• Recurrent severe epigastric pain, radiating to back, relieved by sitting forward and exacerbated by eating or drinking alcohol
• Weight loss
• Bloating
• Pale offensive stools (steatorrhoea)
• Other: painful joints, SOB, skin nodules (pancreatic lipase leaks into circulation and causes fat necrosis at non-pancreatic sites).

Question 8

What investigations would you do for chronic pancreatitis?

Answer 8

1st tests: CT/MRI +/- USS

Bedside:

• Glucose - if high then endocrine dysfunction, GTT (glucose tolerance test)
• Amylase/lipase - normal
• Immunoglobulins - high esp IgG4 in autoimmune pancreatitis
• Faecal elastase - reduced in severe disease

Imaging:

• USS - percutaneous or endoscopic - hyperechoic foci with post-acoustic shadowing
• ERCP/MRCP - see next
• AXR - pancreatic calcification may be visible
• CT scan - pancreatic cysts, calcification

Question 9

What does ERCP/MRCP show in early and late stages of chronic pancreatitis?

Answer 9

Early - duct dilatation and stumping of branches

Late - duct strictures with alternating dilatation (“chain of lakes”/beading appearance)

Question 10

How do you manage chronic pancreatitis?

Answer 10

Conservative - alcohol and cigarette cessation

Medical

• Analgesics - if not sufficient → coeliac plexus block or transthoracic splanchnicectomy.
• Lifestyle modification
• Pancreatic enzymes (e.g. pancreatin/Creon) and PPI (e.g. omeprazole)
• Dietary modification - low-fat

Endoscopic - pseudocyst decompression, sphincterotomy, stone extraction, dilatation, stenting or strictures. ESWL for pancreatic stone fragmentation prior to endoscopic removal.

Surgical -

• drainage (modified Puestow procedure),
• resection (pancreaticoduodenectomy/ Whipple’s),
• limited resection (Beger procedure),
• combined opening of pancreatic duct and excavation of pancreatic head (Frey procedure)

Question 11

What are the local and systemic complications of chronic pancreatitis?

Answer 11

Local - pseudocysts, BD stricture, duodenal obstruction, calcifications, pancreatic ascites, pancreatic carcinoma

Systemic - exocrine insufficiency, diabetes, steatorrhoea, reduced QOL, chronic pain syndromes, opioid dependence

Question 12

What is the prognosis in chronic pancreatitis?

Answer 12

• Difficult to predict - may stabilise, worse, or improve
• Surgery improves symptoms in 60-70% but results are not sustained
• Life expectancy reduced by 10-20 years
• Pain decreases or disappears over time