Chronic Pancreatitis

DEFINITION

A fibrotic disease of the pancreas characterized by chronic abdominal symptoms and often malabsorption.

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EPIDEMIOLOGY

 
Fairly uncommon

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AETIOLOGY

Hereditary
AD condition; 2 relatives across at least 2 generations
- first attack usually in childhood
Alcohol abuse
- most common associated causal factor.
Nutritional
- tropical association; fibrocalcific pancreatic diabetes.
- it is a non-alcoholic form of calcific panc, occurring in young adults in low-income settings
Trauma
- can lead to a chronic form of distal panc.

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BIOLOGICAL BEHAVIOUR

Pathophysiology
Poorly understood; numerous mechanisms proposed
Hypersecretion theory says enzymes precipitate in ducts, causing plugging
Alternatively, plugs may form from intraductal mucoproteins, or clusters of desquamated epithelial cells
Alcohol has a direct toxic effect on pacreatic cells; recurrent low-grade necrosis causes gland fibrosis.
The head is almost always the epicentre, and if the head is not involved, consider more subtle causes.

Pathology
Gland usually fibrosed and atrophied.
Extensive clacification
Islet cells initially preserved; later, get progressive atrophy.
Duct gets strictures and post-stenotic dilatations.

Complications
Failure of gland secretions or hormones
Malabsorption
Diabetes

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MANIFESTATIONS

Recurrent abdominal pains, may radiate to back, can be prolonged periods of pain
With alcohol, may occur after bouts of drinking.
May become constant pain, may be debilitating and required substantial analgesia.
Varying degrees of malabsorption, steatorrhoea, and weight loss.

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INVESTIGATIONS

Characteristic presentation gives clues
Serum amylase may be entirely normal
Plain x-ray may reveal calcification.

CT may show atrophy and duct irregularities / dilations.
- a classification exists based on if main pancreatic duct abnormal (a bad sign)
- particularly bad if irregularity, strictures, poor filling.

ERCP is most specific test
- can show strictures and duct dilation; pancreatic calculi may be shown.

Used to do: Faecal fat
can show malabsorption
collect faeces for 3days and measure fat content in laboratory...

Now do faecal elastase; shows panc exocrine fx.

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MANAGEMENT

Principles
1. Every patient needs treatment for abdominal pain.
- pain relief is the primary goal
2. Few require complex treatment for fistula or come with steatorrhoea.
3. Surgery only used if endotherapy fails.
Treatment is very difficult.
Patients must abstain from alcohol.

Indications for Therapy
1. Must really have chronic panc.
- irreversible, persistent (despite removing triggers)
- check endocrine (HbA1c) and exocrine (elastase) fxs
2. Imaging studies must show a severe anatomical defect
- ie a bad main duct
3. Driver aetiology must have been removed
4. Pathologic anatomy fits a treatable pattern
- plans are only made from updated imaging.

Endotherapy
Has moderated need for resection.
Access through papillae, under EUS.
Sphincterotomies, guidewires
Must have a demonstrated benign stricture (full usual workup)
Dilation using catheter balloons.
Stent placed
Often resolves pain
- if not, surgical consideration may follow.
Pancreatic calculi may often be found, need removal.
Overall 60-80% response rate (pain relief); these patients will not need surgery
20% minor complication rate, few major complications

Surgery
Endotherapy has become so effective that these procedures are becoming rarer; salvage procedures.
Various procedures to open ductal obstruction +/- remove panc head problem area.
1. Puestow procedure
- lateral pancreticojejunostomy; sewing dilated duct onto a Roux limb.
2. Beger technique
- duodenum preserving panreatic head resection
3. Complete head removal and drainage to a Roux-limb
- ie pylorus-preserving pancreaticoduodenectomy (PPPD)
No good evidence to show what is best but PPPD has a proven track record for pain relief.
More limited head resections showing promise.

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REFERENCES
Tjandra
Cameron 10th.