Chronic pancreatitis is a progressive inflammatory disease of the pancreas characterized by irreversible destruction of pancreatic tissue. It commonly causes severe abdominal pain and can lead to exocrine and endocrine insufficiency over time. The most common causes are alcohol consumption and smoking. Diagnosis involves pancreatic function tests, imaging like CT or MRCP to identify changes in the pancreas and pancreatic duct. Treatment focuses on managing pain, treating underlying causes, nutrition support, and in some cases endoscopic or surgical interventions. The prognosis is often poor with declining health and function over time and an increased risk of pancreatic cancer with longstanding disease.

1. Chronic pancreatitis
Dr. Lala Robin, MS. Gen. Surgery,
Senior Resident,
CMC

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

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

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

19. THANK YOU