CHRONIC PANCREATITIS

RADWAN SHAKRA MB.BCh ,MS ,MD professor of surgery

Chronic pancreatitis:
A continuing chronic inflammatory process of the pancreas, characterized by irreversible morphological changes. This chronic inflammation can lead to chronic abdominal pain and/or impairment of endocrine and exocrine function of the pancreas.

Acut . pancreatitis
characters Acute pan

ch. pancreatitis
Chronic pan

Abdominal pain course

acute and severe pain

is acutely inflamed (neutrophils and edema),

chronic abdominal pain

chronic irreversible inflammation (monocyte and lymphocyte) that leads to fibrosis with calcification

Pan. enzymes

amylase and lipase) are elevated

normal or mildly elevated pancreatic enzyme chronic irreversible inflammation (monocyte and lymphocyte) that leads to fibrosis with calcification

prognosis

Full recovery is observed in most patients

p. enzymes presentation

Not affected Acute abdomen

Endo&exo .are lost Diabetes ,chronic diarrhea

 

Causes : 1-metabolic in nature. nature.



Excessive alcohol consumption Several inherited disorders also are considered metabolic in origin. Hereditary pancreatitis Cystic fibrosis, fibrosis,
Hyperlipidemia (usually type I and type V) also may cause chronic pancreatitis 2--Idiopathic chronic pancreatitis, which accounts --Idiopathic for approximately 30% 30%

 

3--obstruction of the flow of pancreatic juice Congenital abnormalities, Acquired obstructive accident,blunt abdominal truma,gall stones 4--Autoimmune pancreatitis --Autoimmune

Pathophysiology : The proposed pathologic mechanisms of chronic pancreatitis are as follows :  Intraductal plugging and obstruction (eg, alcohol abuse, stones, tumors )  Direct toxins and toxic metabolites: metabolites: These act on the pancreatic acinar cell to stimulate the release of cytokines, which stimulate the stellate cell to produce collagen and to establish fibrosis. Cytokines also act to stimulate inflammation by neutrophils, macrophages, and lymphocytes


 

 

Oxidative stress (eg, idiopathic pancreatitis) NecrosisNecrosis-fibrosis (recurrent acute pancreatitis that heals with fibrosis) Ischemia (from obstruction and fibrosis) . Autoimmune pancreatitis. pancreatitis. The disorder is associated with elevated immunoglobulin G4 (IgG4) concentrations. G4 (IgG4 While alcohol greatly influences the understanding of its path physiology because it is the most common etiology (60-70%), (60-70%), approximately 20-30% of cases are idiopathic 20-30% and 10% of cases are due to rare diseases . 10%

Frequency : 4.4/1000 hospital admission  Mortality/Morbidity :No data exist :No on the extent of the disability resulting from benign pancreatic diseases .  Race :Hospitalization rates for :Hospitalization blacks are 3 times higher than for whites in the United States .


Sex :  Males are affected more commonly than females (6.7 vs 3.2 per 100,000 (6 100, population) Rates in males peak at age 4545-54 years and then decline; female rates reach a plateau, which remains stable after age 35 years .  Age :In aggregate, the mean age at :In diagnosis is 46 years, plus or minus 13 years.





Clinical
History: 1) abdominal pain intermittent attacks of severe pain, often in the mid pain, or left upper abdomen and occasionally radiating in a bandlike fashion or localized to the mid back. The pain may occur either after meals or independently of meals, and tends to last at least several hours. Most patients experience intermittent attacks of pain at unpredictable intervals, while a minority of patients experience chronic pain. In most patients, pain pain. severity either decreases or resolves over 5-25 years.

2).diarrhea and weight loss. loss. This may be due either to fear of eating (eg, postprandial exacerbation of pain) or due to pancreatic exocrine insufficiency and steatorrhea.  painless chronic pancreatitis : A small percentage of patients (20%) (20%) have present with signs or symptoms of pancreatic exocrine or endocrine insufficiency.


Physical :  During an attack, patients may assume a characteristic position in an attempt to relieve their abdominal pain (eg, lying on the left side, flexing the spine and drawing the knees up toward the chest ) Funduscopic examination may reveal a milky white hue in the retinal blood vessels when hyperlipidemia is present.


Tender fullness or mass may be palpated in the epigastrium, suggesting the presence of a pseudocyst or an inflammatory mass in the abdomen. Patients with advanced disease (ie, patients with steatorrhea) exhibit decreased subcutaneous fat, temporal wasting, sunken supraclavicular fossa, and other physical signs of malnutrition.

 

DIFFERENTIALS Ampullary Carcinoma Cholangitis Cholecystitis Crohn Disease Gastritis, Chronic Intestinal Perforation Mesenteric Artery Ischemia Myocardial Infarction Pancreatic Cancer Peptic Ulcer Disease Pneumonia, Community-Acquired

Lab Studies :  Blood tests




Serum amylase and lipase levels may be slightly elevated in chronic pancreatitis; Laboratory studies to identify causative factors include serum calcium and triglyceride levels.
CBC, LIVER FUNCTIONS TESTS

Pancreatic function tests



Direct tests: These tests are the most sensitive and can be used to detect chronic pancreatitis at its earliest stage; however, they are somewhat invasive, labor intensive, and expensive .  Determination in duodenal aspirates: Determination in pancreatic juice: This test generally is performed in conjunction with an endoscopic retrograde cholangiopancreatography (ERCP).




Imaging Studies :
Abdominal x-ray: Pancreatic calcifications, x-ray: often considered pathognomonic of chronic pancreatitis, are observed in approximately 30% 30% of cases. Computed tomography scan: Computed scan: axial tomography scan has the advantage of providing images of the pancreas for the anatomical andpathological finding

Chronic pancreatitis. CT scans of the abdomen following an endoscopic transgastric pseudocystogastrostomy (see Image 4). mistaken for a pseudocyst.

Picture 2. Chronic pancreatitis. Abdominal CT scan showing that a pancreatic pseudocyst is responsible for the distortion of the ductal system

Pancreatic calcifications. CT scan showing multiple, calcified, intraductal stones in a patient with hereditary chronic pancreatitis.

Endoscopic retrograde cholangiopancreatography: cholangiopancreatography: ERCP provides the most accurate visualization of the pancreatic ductal system and has been regarded as the criterion standard for diagnosing chronic pancreatitis. Magnetic resonance ) cholangiopancreatography (MRCP) imaging provides information on the pancreatic parenchyma and adjacent abdominal viscera, and MRCP uses heavily T2-weighted images T2 to visualize the biliary and pancreatic ductal system.

This endoscopic retrograde cholangiopancreatography (ERCP) shows advanced chronic pancreatitis. The pancreatogram has blunting of the lateral branches, dilation of the main pancreatic duct, and filling defects consistent with pancreatolithiasis. The cholangiogram also shows a stenosis of the distal bile duct and a dilated biliary tree.

Chronic pancreatitis. Pancreatogram in a patient with a pancreatic pseudocyst. Note how the pancreatic ducts are extrinsically distorted by a mass lesion

The pancreatogram shows subtle blunting of side branches consistent with chronic pancreatitis. A stricture also is present in the body of the pancreas.

Chronic pancreatitis. This magnetic resonance cholangiopancreatography (MRCP) shows a healthy biliary system. with the pseudocyst. The endoscopic features were ideal for an endoscopic transgastric pseudocystogastrostomy

 

Histologic Findings : In the early stages of chronic pancreatitis, the parenchyma exhibits an increase in connective tissue around the ducts and between the lobules. The degree of inflammation is minimal to moderate, consisting mostly of T lymphocytes, and a patchy, focal process unevenly affects the pancreas.

With increasing severity, the connective issue progresses between the acini, which gradually become distorted and tend to disappear. In advanced disease, fibrous tissue replaces the acinar tissue, and the pancreas becomes contracted, small, and hard.




Medical Care .:
Behavior modification Cessation of alcohol consumption and tobacco smoking are important. .

 

Alleviation of abdominal pain Restoration of digestion and absorption



Although reduced fat intake is often recommended Medium chain triglycerides are directly absorbed by the small intestine without a requirement for digestion

surgical
pancreatic pseudocyst, abscess, fistula, ascites, fixed obstruction of the intrapancreatic portion of the distal common bile duct, stenosis of the duodenum with gastric outlet obstruction, and variceal hemorrhage due to splenic vein thrombosis. .

Chronic pancreatitis. This follow-up CT scan shows a percutaneous tube in the left upper quadrant that was used to drain the fluid collection (It was removed after 4 weeks. The patient returned to work, regained his weight, and has had no recurrence of abdominal pain or signs of a recurrent pancreatic leak.

Complications :  The most common complications are pseudocyst formation and mechanical obstruction of the duodenum and common bile duct. duct.


Less frequent complications include pancreatic ascites or pleural effusion, , splenic vein thrombosis with portal hypertension, and pseudoaneurysm formation of the splenic artery. artery.

Pancreatic pseudocyst

 

Prognosis : The prognostic factors associated with chronic pancreatitis are age at diagnosis, smoking, continued use of alcohol, and the presence of liver cirrhosis. cirrhosis. The overall survival rate is 70% at 10 years 70% and 45% at 20 years. The risk of developing 45% pancreatic cancer is approximately 4% at 20 years. years.

Chronic pancreatitis. This patient had a persistent postoperative leak from the site of a distal pancreatectomy enteric drainage using transpapillary stents placed into the pancreatic duct. While this changed the fluid dynamics in favor of healing the disrupted duct, some patients developed complications from this technique.

Chronic pancreatitis. The persistent postoperative leak from the site of a distal pancreatectomy now is healed at 1-month follow-up (see Image 6). However, after 4 weeks of transpapillary stenting, the pancreatogram now shows a stent-induced stenosis near the surgical genu (arrow). Based on this experience, the author stopped using pancreatic stents in this setting

Chronic pancreatitis. This patient developed abdominal pain several weeks after being hit with a baseball bat accidentally. A CT scan showed a large splenic hematoma, and he underwent a splenectomy. His postoperative course was notable for recurrent pain, abdominal distension, and elevation of amylase levels over the course of 2-3 months. This repeat CT scan shows postsurgical changes in the left upper quadrant and a large fluid collection.

Chronic pancreatitis. The pancreatogram shows a small leak from the tail of the gland

Chronic pancreatitis. A nasopancreatic tube courses through the esophagus, stomach, and duodenum and into the pancreatic duct. Externally, the end of the tube is attached to a suction bulb to decompress the ductal system and monitor its function on a daily basis. In contrast to patients treated with transpapillary stents, none of these patients ever has failed to return for a follow-up appointment. In addition, while stent obstruction and subsequent infection can occur with transpapillary stents, the author has not observed this complication while using nasopancreatic tubes.

Chronic pancreatitis. Nine days after placement, a pancreatogram is obtained via the nasopancreatic tube and shows the disruption is healed (see Image 10). The tube then was removed.

This pancreatogram shows a pseudocyst communicating with the main pancreatic duct in a patient with chronic pancreatitis and recurrent abdominal pain. He was treated endoscopically with a transpapillary stent placed into the pancreatic duct.

Four weeks after placement of a transpapillary stent, a patient with a pseudocyst communicating with the main pancreatic duct (chronic pancreatitis with recurrent abdominal pain) had not had a recurrence of pain. The CT scan showed resolution of the cyst, and the follow-up pancreatogram shows marked improvement. Transpapillary stenting of the pancreatic duct should be reserved for patients with established chronic pancreatitis.

This is an operative cholangiogram taken during a laparoscopic cholecystectomy. The common bile duct is of normal calibre and there is some emptying into the duodenum. There is reflux of contrast into the pancreatic duct. The patient presented with gall stone pancreatitis and there is a high incidence of pancreatic reflux in such patients, adding weight to the belief that such reflux does cause pancreatitis

The left picture is a percutaneous cholangiogram showing a cholecystduodenal fistula and on the right a barium enema shows a cholecystcolonic fistula. In both cases the underlying pathology was gall stones and both were managed entirely laparoscopically with separation of the fistula using an endoGIA stapling gun followed by cholecystectomy

cholecyst-duodenal fistula cholecyst-colonic fistula.