2. Definition
Chronic pancreatitis is a progressive inflammatory disease in which there is
irreversible destruction of pancreatic tissue.
Its clinical course is characterised by severe pain and, in the later stages, exocrine
and endocrine pancreatic insufficiency.
Chronic pancreatitis is defined as a continuing inflammatory disease of the
pancreas characterised by irreversible morphological change typically causing
pain and/or permanent loss of function
occurs more frequently in men (male: female ratio of 4:1)
mean age of onset is about 40 years
3. Aetiology
Alcohol - 60–70% of cases
Tobacco smoking
Hyperlipidaemia
Hypercalcaemia
Pancreatic duct obstruction
stricture formation after trauma , acute pancreatitis
pancreatic cancer
Congenital ---> pancreas divisum and annular pancreas with papillary stenosis
4.
5. Aetiology
Idiopathic chronic pancreatitis - 30% of cases
Hereditary pancreatitis
autosomal dominant, 80% penetrance
gain-of function mutation in the cationic trypsinogen gene (PRSS1)
chromosome 7
production of a degradation resistant form of trypsin
Cystic Fibrosis
Infantile malnutrition
Idiopathic pancreatitis
loss-of-function mutation in SPINK1
6. Aetiology
Tropical pancreatitis
begins at a young age
high incidence of diabetes mellitus and stone formation
Cassava intake, malnutrition, exposure to hydrocarbons
Autoimmune pancreatitis
diffuse and irregular narrowing of the main pancreatic duct
levels of the immunoglobulin subtype IgG4 are elevated
autoimmune cholangiopathy
7. Pathology
pancreas enlarges and becomes hard as a result of fibrosis
ducts become distorted and dilated with areas of both stricture formation and
ectasia
ductular metaplasia and atrophy of acini, hyperplasia of duct epithelium and
interlobular fibrosis
8. Clinical features
Pain
head of the pancreas --> epigastric and right subcostal pain
left side of the pancreas --> left subcostal and back pain
Weight loss
analgesic dependence
inability to work
Loss of exocrine function --> steatorrhea, diabetes
9. Investigations
Pancreatic function tests -
Lundh test
intravenous injection of a hormone such as secretin or CCK
nitroblue tetrazolium–para-aminobenzoic acid (NBT–PABA) test provides an indirect
measure of pancreatic function
low level of faecal elastase indicates exocrine insufficiency(fecal elastase 1 concentration
above 200 µg/g feces is normal)
10. Xray abdomen - pancreatic calcifications
CT - Calcification is seen very well on CT
MRCP - will identify the presence of biliary obstruction and the state of the
pancreatic duct
Secretin MRCP
ERCP - most accurate way of elucidating the anatomy of the duct
11.
12.
13. EUS - presence of four or more of the following features is highly suggestive of
chronic pancreatitis
presence of stones,
visible side branches,
cysts,
lobularity,
an irregular main pancreatic duct,
hyperechoic foci and strands,
dilatation of the main pancreatic duct and
hyperechoic margins of the main pancreatic duct
14. Medical treatment of chronic pancreatitis
Treat the addiction
Help the patient to stop alcohol consumption and tobacco smoking
Involve a dependency counsellor or a psychologist
Alleviate abdominal pain
Eliminate obstructive factors (duodenum, bile duct, pancreatic duct)
Escalate analgesia in a stepwise fashion
15. Nutritional and pharmacological measures
Diet: low in fat and high in protein and carbohydrates
Pancreatic enzyme supplementation with meals
Correct malabsorption of the fat-soluble vitamins and vitamin B12
Micronutrient therapy with methionine, vitamins C & E, selenium (may reduce pain
slow disease progression)
Steroids (only in autoimmune pancreatitis, for relief of symptoms)
Medium-chain triglycerides in patients with severe fat malabsorption (they are directly
absorbed by the small intestine without the need for digestion)
Reducing gastric secretions may help
Treat diabetes mellitus
16. Endoscopic Interventions
Endoscopic pancreatic sphincterotomy
stent across the stricture (stent should be left in for no more than 4–6 weeks)
Pancreatic ductal stone removal by ERCP and ESWL
Percutaneous or transgastric drainage of pseudocysts under ultrasound or CT
guidance
17. SURGERY IN CHRONIC PANCREATITIS
Aim of surgery is to overcome obstruction and remove any mass lesions.
mass in the head of the pancreas --> pancreatoduodenectomy or a Beger
procedure (duodenum-preserving resection of the pancreatic head)
duct is markedly dilated --> longitudinal pancreatojejunostomy (Puestow) or Frey
procedure
Patients with intractable pain and diffuse disease --> Total pancreatectomy and
islet autotransplantation
18. Prognosis
gradual decline in their professional, social and personal lives.
Development of pancreatic cancer is a risk in those who have had the disease for
more than 20 years