Chronic Pancreatitis

Chronic Pancreatitis Background: Chronic pancreatitis is commonly defined as a continuing chronic inflammatory process of the pancreas, characterized by irreversible morphological changes

Chronic Pancreatitis Background: This chronic inflammation can lead to: ► chronic abdominal pain, ► and/or impairment of endocrine and exocrine function of the pancreas

Chronic Pancreatitis Background: Chronic pancreatitis usually is envisioned as: ► an atrophic fibrotic gland ► with dilated ducts and calcifications

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Chronic Pancreatitis Problems However, findings on conventional diagnostic studies may be normal in the early stages of chronic pancreatitis, as the inflammatory changes can be seen only by histologic examination

Chronic Pancreatitis Pathophysiology: The proposed pathologic mechanisms of chronic pancreatitis are as follows: ► Intraductal plugging and obstruction e.g.: ETOH abuse stones tumors

Chronic Pancreatitis Physiopathology Chronic alcoholism causes most cases of chronic pancreatitis but a few are due to: hypercalcemia hyperlidemia or inherited predisposition (familial pancreatitis)

Chronic Pancreatitis Physiopathology Direct trauma either: from external blow or from surgical injury can produce chronic pancreatitis, often localized to one section of gland

Chronic Pancreatitis Physiopathology ► Alcohol is thought to have:▼ a direct toxic effects on acinar cells and to increase the enzyme protein content of pancreatic secretions

In the development of alcohol pancreatitis, the protein in the ducts precipitates, obstruct the lumen, and eventually calcified

Chronic Pancreatitis General Considerations The calculi seen on plain x-ray films of the abdomen in patients with calcific pancreatitis are within the lumen of the duct

Chronic Pancreatitis General Considerations Pathological changes in gland: ► ► ► ► ►

Destruction of parenchyma Fibrosis, calcification Reduplication of smaller ducts Calculi And Ductal stenosis with up stream dilatation

Chronic Pancreatitis Frequency: In the US: Based on estimates from hospital discharge data in the United States, approximately 87,000 cases of pancreatitis occur annually Internationally: Comparing the hospital admissions data from several cities around the globe, the overall frequency is similar

Chronic Pancreatitis Sex: In population studies, males are affected more commonly than females (6.7 vs 3.2 per 100,000 population) Age: In aggregate, the mean age at diagnosis is 46 years, plus or minus 13 years

Chronic Pancreatitis Clinical Findings History: Clinically, the patient experiences intermittent attacks of severe pain ► often in the mid or left upper abdomen

and occasionally radiating in a: bandlike fashion or localized to the mid back

Chronic Pancreatitis Clinical Findings History: Remember

► The pain may occur either: * after meals or * independently of meals but it is not fleeting and tends to last at least several hours

Chronic Pancreatitis Clinical Findings History: Remember Unfortunately, patients often are asymptomatic for years before the diagnosis is established The average time from the onset of symptoms until a diagnosis of chronic pancreatitis is 62 months

Chronic Pancreatitis Clinical Findings History: Remember The delay in diagnosis is even longer in people without alcoholism, in whom the average time is 81 months from onset of symptoms to diagnosis

Clinical Findings History:

Pain The natural history of pain in chronic pancreatitis is highly variable Most patients experience intermittent attacks of pain at unpredictable intervals, while a minority of patients experience chronic pain In most patients, pain severity either decreases or resolves over 5-25 years

Chronic Pancreatitis Clinical Findings History: In alcohol-induced disease, eventual cessation of alcohol intake may reduce the severity of pain ► Variability in the pain pattern contributes to the: delay in diagnosis and makes determining the effect of any therapeutic intervention difficult

Chronic Pancreatitis Clinical Findings History: Other symptoms associated with chronic pancreatitis include: ► diarrhea and ► weight loss This may be due either: to fear of eating (eg, postprandial exacerbation of pain) or due to pancreatic exocrine insufficiency and steatorrhea

Chronic Pancreatitis Clinical Findings History: Remember A small percentage of patients (20%) have painless chronic pancreatitis and present with: signs or symptoms of pancreatic exocrine or endocrine insufficiency

Chronic Pancreatitis Clinical Findings Physical: In most instances, the standard physical examination does not help to establish a diagnosis of chronic pancreatitis; however, a few points are noteworthy

Chronic Pancreatitis Clinical Findings Physical: During an attack, patients may assume a characteristic position in an attempt to relieve their abdominal pain e.g.: lying on the left side, flexing the spine and drawing the knees up toward the chest

Chronic Pancreatitis Clinical Findings Physical: Funduscopic examination may reveal a milky white hue in the retinal blood vessels when hyperlipidemia is present

Chronic Pancreatitis

Clinical Findings Physical: Occasionally, a tender fullness or mass may be palpated in the epigastrium, suggesting the presence of: ▼ ► a pseudocyst ► or an inflammatory mass

Chronic Pancreatitis Clinical Findings Physical:

Patients with advanced disease (i.e. patients with steatorrhea) exhibit: ■ decreased subcutaneous fat, ■ temporal wasting, ■ sunken supraclavicular fossa and other physical signs of malnutrition

Causes: The cause of chronic pancreatitis usually is metabolic in nature ► Excessive alcohol consumption (60%) ■ Cystic fibrosis ■ Hyperlipidemia

■ Hypercalcemia

■ Medications (infrequent) ■ Idiopathic chronic pancreatitis ■ Obstruction (congenital)

Chronic Pancreatitis B) Laboratory Findings: 1) Amylase serum amylase and urinary amylase levels may be elevated, but most often are not

Chronic Pancreatitis

B) Laboratory Findings: 2) Tests of exocrine pancreatic function The most popular screening tests exocrine malfunction are the: ► secretin and ► CCK stimulation tests

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Chronic Pancreatitis B) Laboratory Findings: 3) Diabetes mellitus 75% of patients with calcific pancreatitis and 30% of those with no calcific pancreatitis have insulin-dependent diabetes

Chronic Pancreatitis B) Laboratory Findings: 4) Biliary obstruction Elevated: bilirubin or alkaline phosphate levels may result from bile duct obstruction by fibrosis

C) X-Ray Findings ►Endoscopic retrograde pancreatography (ERP) is establishing the diagnosis of chronic pancreatitis

►ERCP

helpful

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should be performed simultaneously to determine whether the common bile duct is narrowed by the pancreatitis

Chronic Pancreatitis Complications The principal complications of chronic pancreatitis are:

Pancreatic pseudocyst Obstruction Malnutrition Ascites Diabetes mellitus Blood clot in the splenic vein

Chronic Pancreatitis Treatment A) Medical Treatment The treatment include:

Diabetes (requires insulin) Steatorhea Malnutrition ►Patients with chronic pancreatitis should be strongly advised against the continues used of alcohol

Chronic Pancreatitis Treatment B) Surgical Treatment The best surgical candidates are those whose pain persists after alcohol has been abandoned

Chronic Pancreatitis Treatment B) Surgical Treatment ► Drainage procedure Sphincteroplasty

► Pancreatectomy Subpancreatectomy Total pancreatectomy

Chronic Pancreatitis Prognosis Except in advanced cases with continuous pain, alcoholics who can be persuaded to stop drinking often experience: relief from pain and recurrent attack of pancreatitis

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