chronic pancreatitis for 4th year medical students.. created by Dr ONYI

1. CHRONIC PANCREATITIS
 Chronic pancreatitis is a progressive
inflammation of pancreas related to the
process of autolysis, that presents by pain, by
violation of exocrine and endocrine functions
of gland with the result of fibrosis of organ
and high risk of malignization

2. ETIOLOGY AND PATHOGENESIS
 Gallstone disease is the most frequent cause
of chronic pancreatitis (70%).
 Pathogenesis of cholangiogenic pancreatitis
is hypertension in pancreatic duct and reflux
of infected bile or secretion of duodenum.
 Spasms and stenosis of the Vater's papilla
are instrumental in causing reflux. As result
occur activates the enzymes of pancreas and
progress inflammation. Development of
pancreatitis potentiates infection.

3. CAUSES
 The CAUSES of such violations are - due to
the attack of acute pancreatitis in past,
 alcoholism,
 traumas of gland,
 pathology of its vessels,
 gastroduodenal ulcers,
 gastritis or duodenostasis,
 hyperparathyroidism,
 hyperlipidemia,
 virus infections,
 idiopathic pancreatitis.

4. CLASSIFICATION AND ETIOLOGY
CHRONIC
CALCIFIC
PANCREATITIS
CHRONIC
OBSTRUCTIVE
PANCREATITIS
CHRONIC
INFLAMMATORY
PANCREATITIS
CHRONIC
AUTOIMMUNE
PANCREATITIS
ASYMPTOMATIC
PANCREATIC
FIBROSIS
ALCOHOL PANCREATIC
TUMORS
UNKNOWN Autoimmune
disorders (primary
sclerosing cholangitis)
CHRONIC
ALCOHOLIC
HEREDITARY DUCTAL
STRICTURE
SJOGREN'S
SYNDROME
Endemic in
asymptomatic
residents in
tropical climates
TROPICAL GALLSTONE OR
TRAUMA-
INDUCED
Primary biliary
cirrhosis
HYPERLIPIDE
MIA
PANCREAS
DIVISUM
HYPERCALC
EMIA
DRUG-INDUCED
IDIOPATHIC

5. CLASSIFICATION (by O.O. Shalitnov)
 Chronic fibrous pancreatitis without violation of patency
of main pancreatic duct.
 Chronic fibrous pancreatitis with violation of patency of
main pancreatic duct and hypertension of pancreatic
juice.
 Chronic fibrous-degenerative pancreatitis.
TAKING INTO ACCOUNT CLINICAL FEATURES
 Chronic recurrent pancreatitis.
 Chronic pain pancreatitis
 Chronic painless (latent) pancreatitis.
 Chronic pseudo tumor-like pancreatitis.
 Chronic cholecystocholangiopancreatitis (cholangiogenic
pancreatitis).
 Chronic indurative pancreatitis.

6. PATHOMORPHOLOGY
The morphological changes in pancreas in
chronic pancreatitis are mainly due to the
development of degenerative process and
atrophy of parenchyma

7. CLINICAL MANAGEMENT
 As the progress of the disease has cyclic
character with the periodic changes of
remission and acute exacerbations.
 Violation of exocrine and endocrine
functions of pancreas, determine
polymorphism of symptoms that are
characteristic of the period of
exacerbations pancreatitis

8. PAIN
 Patients with chronic pancreatitis complaining
on dull pain that is in the epigastric and radiates
to the back


9. PAIN
The pathophysiology of the pain
associated with increase
intraductal pressures, neural
inflammation, formation of
pseudocysts, bile duct
strictures, and duodenal
obstruction.

10. MALABSORPTION
With sufficient loss of functional exocrine pancreas,
diarrhea, steatorrhea, and azotorrhea can develop.
Because of the 10-fold reserve of exocrine
pancreaticenzymes, malabsorption occurs only after 90%
of the functioning exocrine cell mass is lost.
Pancreatic insufficiency resulting from alcohol-induced chronic
pancreatitis usually takes 10 to 20 years to develop. The
secretion of lipase is usually diminished earlier than the
secretion of the proteolytic enzymes, and as a result,
steatorrhea precedes protein-aqueous diarrhea.

11. CHRONIC UPPER ABDOMINAL PAIN AND WEIGHT
LOSS should suggest a diagnosis of chronic
pancreatitis.
Weight loss occurs with malabsorption, and of the
fat-soluble vitamins develop.
 Postprandial pancreatic bicarbonate secretion is
diminished. The duodenal pH may decrease (pH<4)
and an acidic milieu with precipitation of bile salts
and inactivation of pancreatic enzymes results in a
decrease intestinal digestion.

12. ENDOCRINE INSUFFICIENCY
Glucose intolerance frequently develops
early
 Endocrine insufficiency develops in up to
60% of patients, but in general not until after
the diagnosis of chronic pancreatitis has
been made.

13. STOOL EXAMINATION Steatorrhea and creatorrhea
are characteristic for Chronic Pancreatitis (plenty of
muscle fibres).
Examination of endocrine function includes:
1) determination of sugar in blood and urine
(hyperglycemia and glycosuria);
2) radioimmunoassay of hormones (insulin, C-peptide
and glucagon).
SKIAGRAPHY survey of organs of abdominal cavity in
two projections exposes the existent calculus in the
ducts and calcification of parenchyma of pancreas.
Relaxation duodenography. The development of
"horseshoe" of duodenum and change of its mucosa can
be seen
Cholecystocholangiography the purpose of diagnosis
of gallstone disease and damaging of biliary tract is
conducted

14. Ultrasonic examination
Sonography is one of the basic
methods of diagnosis. With the help
of symptoms of chronic pancreatitis it
is possible to expose inequality of
contours of gland, increase of density
of its parenchyma, it sizes, dilatation
of pancreatic duct and
wirsungolithiasis or presence of
calculus in parenchyma. It is
necessary to inspect gallbladder,
liver and extra-hepatic biliary tracts
for diagnosis of gallstone disease
and choledocholithiasis

15. Endoscopic retrograde cholangiopancreatography

16. Endoscopic retrograde cholangiopancreatography

17. CT-scan
showing multiple, calcified intraductal stones in a patient with
chronic pancreatitis

18. CT-scan

19. Routine Laboratory Findings
 Secondary anemia to malnutrition can occur in chronic
pancreatitis, to the steatorrhea of chronic pancreatitis are also
uncommon.
 Leukocytosis can occur during acute exacerbations of chronic
pancreatitis.
 Serum amylase and lipase concentrations may be elevated in
chronic pancreatitis. Even during an acute attack with
seemingly significant abdominal pain, the amylase and lipase
levels may be only slightly elevated because of depletion of the
exocrine pancreatic parenchyma.
 Abnormalities of liver function, manifested by elevations in the
liver enzymes, may be a result of either liver disease or
obstruction of the common bile duct.
 Fibrotic process may result from compression by a pseudo
cyst or mass in the head of the pancreas.

20. TESTS FOR CHRONIC PANCREATITIS
MEASUREMENT OF PANCREATIC PRODUCTS IN BLOOD
I A Enzymes
B Pancreatic polypeptide
MEASUREMENT OF PANCREATIC EXOCRINE SECRETION
II A Direct measurements
1 Enzymes
2 Bicarbonate
B Indirect measurement
1 Bentiromide test
2 Schilling test
3 Fecal fat, chymotrypsin, or elastase concentration
4 [14
C]-olein absorption
IMAGING TECHNIQUES
III A Plain film radiography of abdomen
B Ultrasonography
C Computed tomography
D Endoscopic retrograde cholangiopancreatography
E Magnetic resonance cholangiopancreatography
F Endoscopic ultrasonography
G Relaxation duodenogram

21. CLINICAL VARIANTS
 Chronic recurrent pancreatitis. The changes of periods of acute
attacks and remission are characteristic for it.
 Chronic pain pancreatitis. Intensive pain in the superior half of
abdomen with radiation to loins and region of heart is inherent for
this form. Also belt-like pain often appears.
 Chronic painless (latent) pancreatitis. In this patients the pain is
either absent in general or arises after the intake of spicy rich food
and can be insignificantly expressed Violation of exocrine or
endocrine function of pancreas present.
 Chronic pseudo tumor-like pancreatitis. Dull pain in the projection
of head of pancreas, dyspeptic disorders and syndrome of biliary
hypertension are its clinical signs.
 Chronic cholangiogenic pancreatitis. The features of chronic
cholecystitis and cholelithiasis and features of pancreatitis are
characteristic for this form.
 Chronic indurative pancreatitis. In patients with this diseases
symptoms of exocrine and endocrine insufficiency of pancreas are
present. With sclerosis of head of pancreas with involvement by the
process of common bile duct, development of mechanical jaundice
is possible.

22. COMPLICATIONS OF CHRONIC PANCREATITIS
INTRAPANCREATIC COMPLICATIONS
Pseudo cysts
Duodenal or gastric obstruction
Thrombosis of splenic vein
Abscess
Perforation
Erosion into visceral artery
Inflammatory mass in head of pancreas
Bile duct stenosis
Portal vein thrombosis
Duodenal obstruction
Duct strictures and/or stones
Ductal hypertension and dilatation
Pancreatic carcinoma

23. EXTRAPANCREATIC COMPLICATIONS
1.Pancreatic duct leak with ascites or
fistula
2.Pseudocyst extension beyond sac into
mediastinum, retroperitoneum, lateral
pericolic spaces, pelvis

24. SURGICAL METHODS OF TREATMENT OF CHRONIC
PANCREATITIS
The major indications for treatment are:
 1. Intractable pain;
 2. Fear of carcinoma;
 3. The development of structural complications
Indication to operation and its volume depend on
the form of pancreatitis. Acute exacerbation of
chronic cholangiogenic pancreatitis with presence
of gallstone disease must be seen as an indication
for operation in first 24 hours since the onset of
disease

25. OPERATIVE TREATMENT IS DONE IN CASES OF:
 calcinosis pancreas with the expressed pain syndrome;
 violation of patency of duct of pancreas;
 presence of cyst or fistula, resistance to conservative
therapy in 2-4 months;
 mechanical jaundice due to tubular stenosis of distal part
of common bile duct;
 compression and thrombosis of portal vein;
 gallstone disease complicated by chronic pancreatitis;
 ulcer disease of stomach and duodenum complicated by
secondary pancreatitis;
 duodenostasis, complicated by chronic pancreatitis;

26. CHOLECYSTECTOMY
is performed in presence of calculous cholecystitis and
secondary pancreatitis, acute destructive cholecystitis or
hydropsy of gall-bladder.

27. CHOLEDOCHOLITHOTOMY
is performed for patients with cholangiolithiasis:

28.  Papillosphincterotomy:
 a) execute transduodenal with papillosphinctero-
plasty;
 b) endoscopy is recommended in the isolated
cases or connected with choledocholithiasis
stenosis of large duodenal papilla, fixed calculus
of large papilla of duodenum.
 Wirsungoplasty is plastic of main pancreatic
duct. Lately in the isolated stenosis of entrance of
main pancreatic duct. Execute transduodenal or
endoscopic methods

29. Papillosphincterotomy, papillosphincteroplasty

30. PANCREATOJEJUNOSTOMY:
a) LONGITUDINAL (it is performed in considerable dilatation of pancreatic duct)

31. Technique of pancreaticojejunal drainage originally described by
Puestow and Gillesby. The distal pancreas was mobilized, the tail
amputated, the duct opened longitudinally, and the pancreas was
partially invaginated into a Roux-en-Y jejunal limb

32. RESECTION OF PANCREAS MAY BE:
 a) distal;
 b) pancreatoduodenal (PDR)
 c) total duodenopancreatectomy (execute
in case of fibrous-degenerative pancreatitis)

33. b) Distal (by Duval)
with the resection of distal part of pancreas

34. Procedure: Pancreatoduodenectomy

35. Operations on the nervous system
 are used in case of pain of chronic
indurative pancreatitis, resistant to
conservative therapy:
 a) left-sided splanchnicectomy;
 b) bilateral pectoral splanchnicectomy and
sympathectomy;
 c) postganglionic neurotomy of pancreas

36. Anatomic landmarks for videoscopic transthoracic left
splanchnicectomy. Diagram of the left plural cavity after
clipping and division of the splanchnic nerves, showing the
sympathetic chain, the intercostal vessels, and the aorta

37. CYSTS OF PANCREAS
 Cyst of pancreas is a cavity, filled by fluid
(pancreatic juice, exudation, pus), which
has epithelium on internal surface.
 Pseudocyst (false cyst) is a cavity in
pancreas which appears as a result of its
destruction, limited by capsule, that does
not have epithelium on internal surface

38. Etiology and pathogenesis
THE CAUSES OF PSEUDOCYSTS ARE:
destructive pancreatitis, traumas of pancreas, occlusion of
Wirsung's duct by parasite, calculus, tumors, innate anomalies
of development.
TRUE CYSTS ARE:
innate cysts which are anomalic in development; retention
cysts which develop as a result of obstruction to outflow of
pancreatic juice, cystadenoma and cystadenocarcinoma
The mechanism of development of pseudocysts consists
necrosis of gland, obliterated normal outflow of its secretions,
destruction of walls of pancreatic ducts, inflammation reaction
of surrounding organs which form the walls of pseudocyst

39. PATHOMORPHOLOGY
 Morphologically the cysts of pancreas are
divided into: pseudocysts, retention cyst,
single and multiple
 Pseudocysts are fresh and old. Epithelium
in pseudocysts is absent.
 Retention cysts is seen in connection with
an obturated duct
 Innate cysts are multiple and shallow.
 Rarely there are echinococcus cysts
localized in the area of head of pancreas

40. CLASSIFICATION (by A.N. Bakulev and V.V. Vinogradov)
 I. Innate cysts of pancreas:
 II. Inflammatory cysts:
 Pseudocysts
 Retention cysts
 III. Traumatic cysts:
 IV. Parasitic cysts:
 V. Neoplasty cysts:
 Pathomorphologically cysts are divided into:
 The true cyst
 Pseudocysts

41. CLINICAL MANAGEMENT
 PAIN (dull, permanent, cramp-like and belt-like). It is localized
in right hypochondrium, epigastric area, left hypochondrium
Pain radiates into the back, left shoulder-blade, shoulder and
spine.
 DYSPEPSIA characterised by nausea and vomiting.
 FUNCTIONAL INSUFFICIENCY OF PANCREAS by disorders of
exocrine and endocrine insufficiency, alternating diarrhea with
constipation, steatorrhea and creatorrhea, secondary diabetes
 COMPRESSION SYNDROME. As a result of compression of
neighbouring organs are: partial obstruction of common bile
duct (mechanical jaundice), veins (portal hypertension),
splenic vein (splenomegaly)
 During the CLINICAL EXAMINATION patients with large cysts
there is marked asymmetry of abdomen in the epigastria and
mesogastric areas.
 SONOGRAPHY examination shows echofree formation

42. SONOGRAPHY

43. A contrast-injected CT- scan reveals active bleeding
(B) into a pseudocyst (arrows)

44.  Contrast roentgenologic EXAMINATION OF STOMACH
and duodenum in the cyst of head of pancreas reveals
"horseshoe" duodenum
 CHOLECYSTOCHOLANGIOGRAPHY exposes
calculous cholecystitis and cholelithiasis
 RETROGRADE PANCREATOCHOLANGIOGRAPHY
exposes the deformed, extended pancreatic duct, there
can be cavity of cyst by the contrast matter
 LABORATORY EXAMINATIONS exposes
hyperamylasemia, steatorrhea and creatorrhea,
sometimes - hyperglycemia and glycosuria

45. COMPLICATIONS
 1. Perforation into free abdominal cavity and
peritonitis
 2. Perforation into stomach, duodenum, small or large
intestine is accompanied by decrease of size of cyst
 3. Suppuration of cystic fluid
 4. Erosive bleeding appears suddenly and is
accompanied by the symptoms of internal bleeding
(general weakness, dizziness, melena)
 5. Mechanical jaundice arises as a result of
compression of cyst on the terminal part of
choledochus
 6. Portal hypertension as a result of compression of
portal vein
 7. Reactive exudation pleurisy
 8. Malignization

46. DIFFERENTIAL DIAGNOSIS
 Cancer of pancreas.
 Aneurysm of abdominal
aorta
 The cyst of mesentery
 The cyst of liver
DIAGNOSIS PROGRAMME
 Anamnesis.
 Biochemical blood test
(amylase, sugar, bilirubin).
 Analysis of urine for
diastase.
 Coprograma.
 Sonography.
 Contrasting skiagraphy of
stomach and duodenum
 Retrograde
pancreatocholangiography.
 Computer tomography.

47. TACTICS AND CHOICE OF TREATMENT METHOD
Conservative treatment.
Treatment of acute or chronic pancreatitis
is conducted in accordance with principles.
Surgical treatment
Is the method of choice of treatment of
cysts of pancreas. The choice of treatment
method depends on the stage of
development of pancreatic cysts.

48. SURGICAL TREATMENT

49. MORE FREQUENTLY SURGEON MAKES CYSTOJEJUNOSTOMY
ON THE ELIMINATED LOOP OF SMALL INTESTINE BY ROUX

50. DISTAL PANCREATECTOMY, MARSUPIALIZATION
 MARSUPIALIZATION -
opening and suturing of
cyst capsule to the
parietal peritoneum and
skin is used infrequently
(because suppuration of
cyst is can lead to
sepsis peritonotis).
 External and internal
draining of cyst and
radical operations are
applied:
a) enucleation of cysts;
b) distal resection of
pancreas with cyst

51. CANCER OF PANCREAS
The cancer of pancreas is a malignant
tumor of epithelium tissue. Its incidence
among all malignant tumors is 10 %.
Etiology and pathogenesis
Shortage of vitamins, especially В and C,
harmful habits (alcohol, smoking), presence
of carcinogenic matters in food (nitrite,
nitrates) is one of etiological factors. The
cancer of pancreas can arise due to
prolonged chronic pancreatitis.

52. Molecular biology of pancreatic cancer

53. PATHOMORPHOLOGY
 The cancer is usually localized in the head
(80%). Rarely - in the area of body or tail.
 A tumor has resembles epithelium of
pancreatic ducts or epithelium of acinous
tissue, sometimes - the Langerhans' islet.
 Adenocarcinoma (60%) is exposed
microscopically, carcinoid (32-35%),
epidermoid cancer or skir is seldom met.

54. Classification of cancer of pancreas after the TNM
stages
 T1 - tumor size of diameter 2 cm, is confined interior parts of pan-creas.
 T2 - tumor, spreads the gland and spreads to surrounding cellular tissue
and duodenum.
 T3 - tumor, that spreads to neighbouring organs (stomach, spleen,
colon).
 N0 - absent signs of metastatic damage of regional lymph nodes.
 N1 - metastases in regional lymph nodes.
 M0 - absent signs of remote metastases.
 M1 - remote metastases present.
GROUP BY STAGES
 Stage I - Tl NO MO.
 Stage II - T2 NO MO.
 Stage III- T3 N0-1 MO.
 Stage IV is some T, some N, Ml.
 The cancer of pancreas metastasises rapidly by lymphogenic route
parapancreatic lymph nodes, and afterwards - into the liver. The
hematogenic metastases are into the lungs, bones, kidneys and brain
Also possible are remote metastases of Virhov's, Shnitsler's,
Krukenberg's.

55. Clinical management
 The symptoms of cancer of pancreas depend on
localization of tumor and the relations of pathological
process with surrounding organs.
 PAIN is a permanent symptom which affects 90 % of
patients. Pain localization in epigastria and radiation to the
back.
 The LOSS OF WEIGHT makes progress and in a short
duration of time becomes considerable enough.
 JAUNDICE is characteristic of the cancer of head of
pancreas, as a result of obliteration of common bile duct.
Bilirubinemia grows gradually, due to direct bilirubin.
 On palpation of abdomen COURVOISIER'S sign is positive
(large gallbladder).
 Obliteration of duct of pancreas causes DYSPEPTIC
DISORDERS: belching, nausea, vomiting, diarrhea.
 Distributions of tumor on duodenum and narrowing of its
lumen show up by the signs of STENOSIS (belching and
vomiting)

56.  By sonography examination and computer
tomography one can expose sign of mechanical
jaundice by localization the tumor in the head.
 Scanning is an informing method of examination
with the use of 75 Se-methionine.
 During laparoscopy is visualized dissemination
into peritoneum and its metastatic focus in liver.
 The changes of main duct of pancreas as
segmental stenosis or rupture are done on
retrograde endoscopic pancreatography
 Skiagraphy of gastro-intestinal tract can expose
the cancer of head of pancreas

57. Computer tomography, sonography

58. ENDOSCOPIC HOLANGIOPANCREATOGRAPHY

59. Radionuclide octreotide scan demonstrating pancreatic
endocrine tumor in the body of the pancreas (arrow).

60. TACTICS AND CHOICE OF TREATMENT METHOD
 Treatment of cancer of pancreas is
mainly surgical. The choice of method
and volume of operation depends on
localization of tumor, stage of process,
age of patient and his general condition.
 Radical surgical treatment performed
only in 15-20 % of patients.
Pancreatoduodenal resection is the
method of choice of operation in
patients with the cancer of head of
pancreas.

62. Pancreaticoduodenectomy (Whipple Resection)

63. PALLIATIVE OPERATIONS
 Surgical palliation in patients with cancer of
the head of the pancreas is directed toward
relief of obstructive jaundice, gastric
obstruction, and pain.
 Patients with cancer of body and tail are less
likely to have jaundice or duodenal
obstruction, but pain is often significant.
 Obstructive jaundice develops in about 70
percent of patients with pancreatic cancer.
Cholecystojejunostomy and
choledochojejunostomy are both safe and
are the procedures of choice to relieve the
biliary obstruction

64. Hepaticojejunostomy