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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

• .
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 for
exocrine malfunction are the:

► secretin and
► CCK stimulation tests
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 helpful in
establishing the diagnosis of chronic pancreatitis

►ERCPshould 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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