Pancreatitis (Chronic)

Question 1

Define chronic pancreatitis

Answer 1

Chronic inflammation of the pancreas characterised by parenchymal atrophy and fibrosis ->
impaired endocrine and exocrine function and recurrent abdominal pain

Question 2

What are the causes/risk factors of chronic pancreatitis?

Answer 2

Causes
• Alcohol (70%)
• Idiopathic (20%)
• Autoimmune
• Cystic fibrosis

Risk factors
• Alcohol
• Smoking
• Family history

Question 3

What are the symptoms of chronic pancreatitis?

Answer 3

Symptoms
• Recurrent severe epigastric pain radiating to the back, relieved by sitting forward,
worse on eating
• Weight loss
• Anorexia (due to pain)
• Bloating
• Steatorrhea
• Jaundice (CBD compression)

Question 4

What are the signs of chronic pancreatitis?

Answer 4

• Epigastric tenderness
• Weight loss
• Malnutrition

Question 5

What investigation are carried out for chronic pancreatitis?

Answer 5

• FBC - normal
• U&Es - normal
• Glucose - elevated
• LFTs - may be deranged if there is an obstruction of the common bile duct –obstructive picture.
• Serology - elevated IgG4 in AI pancreatitis.
• USS Abdomen - percutaneous or endoscopic: Cavities, anatomical irregularities and calcification.
• AXR - pancreatic calcification
• CT Abdomen -pancreatic calcification, enlargement of the pancreas, ductal dilation, and/or vascular complications.
• ERCP/ MRCP - early: Duct dilation and the stumping of branches.
Late: Duct strictures with alternating dilations (chain of lakes appearance).
• Exocrine Function:
- Tests of pancreatic exocrine function:
- Faecal elastase –elevated
- Faecal fate –elevated
- Steatocrit –elevated
• Pancreatic biopsy - may be required for diagnosis: Increased CT, loss of acini, fibrosis and calcification.
Therapeutic Steroid Trial: Positive response in AI pancreatitis.

Question 6

What is the management for acute pancreatitis?

Answer 6

General:
• Dietary advice (low fat; medium chain triglycerides MCTs may be tried)
• Alcohol abstinence.

Chronic:
• Specialist pain clinic referral for chronic pain management.
• Diabetes treatment –insulin: long-acting; short-acting and mixed regimens.
• Pancreatic enzyme replacement: Creon; Pancrease; Lipase.

Interventional and Surgical:
• Endoscopic stenting of strictures may be beneficial.

Surgical:
• Indications: failure of medical management.
• Modified Puestow Procedure: Lateral pancreaticojejunal drainage.
• Whipple’s Pancreaticoduodenectomy: Resection
• Berger Procedure: Limited resection of the pancreatic head
• Frey Procedure: Combined opening of the pancreatic duct and revealing the head.

Question 7

What are the complications of chronic pancreatitis?

Answer 7

Local 
• Pseudocysts 
• Pancreatic Carcinoma 
• Duodenal obstruction 
• Biliary Duct stricture 

Systemic
•  Diabetes
•  Steatorrhoea
•  Chronic pain and reduced QoL
• Analgesic dependence