Chronic Pancreatitis.

  • Definition: Repeated episodes of acute inflammation lead to chronic damage and ductal obstruction
  • Etiology:
    • Alcohol (~70%)
    • Autoimmune, esp. associated w/ DM
    • Cystic Fibrosis (CFTR defects ID’d)
    • Idiopathic (~20% w/ bimodal distribution)

Classic Triad for Chronic Pancreatitis

  • Diabetes
    • Due to endocrine dysfunction
  • Steatorrhea
    • Due to exocrine dysfunction
  • Pancreatic calcifications

Clinical Presentation

  • Pain is the predominant symptom in 80%
    • Location & character ~ acute pancreatitis
    • Aggravated by: alcohol and large, high fat meals
  • Steatorrhea: increased excretion of fecal fat
  • Malabsorption: secondary to exocrine insufficiency
  • Weight loss (>50%)
    • Secondary to fear of eating, malabsorption

Diagnostic Studies

  • Amylase & lipase can be “normal”
  • Alkaline phosphatase may be elevated
  • Glucose is commonly elevated
  • US +/- CT
    • Helpful in ~ 70-90% of cases
  • EUS, MRCP require index of suspicion
    • Especially if pain is atypical or mild
  • Secretin stimulation test: abnormal if 60% of exocrine function lost Cumbersome, expensive, used infrequently

Radiographic Studies

Mettler, FA (1996). Essentials of Radiology

Picture1

  • Plain films might show scattered calcifications

CT scan of the abdomen is helpful to look for:

  • Calcifications
  • Ductal dilation
  • Pseudocysts

Picture2

ERCP, etc. for CP

  • ERCP can show “chain-of-lakes”
    • Classic finding but test used less frequently today
  • Endoscopic ultrasound – test of choice
  • MRCP – used with increased frequency

Picture3 Picture4

Management of CP Pain Control

  • Behavior modification:
    • Avoid alcohol, large, high fat meals
  • Pain medications:
    • Non-narcotics v. narcotics
  • Endoscopic procedures:
    • Ductal dilation, stenting, sphincterotomy
  • Nerve blocks: celiac plexus
    • Ethanol or bupivicaine

Management of CP: Steatorrhea/Malabsorption

  • Replacement of pancreatic enzymes
    • Lipase enteric or non-enteric-coated preparations taken with meals
    • H2 antagonists or proton pump inhibitors
    • Vitamin supplementation

Surgical Management of CP

  • Resection of ductal obstruction
    • Puestow procedure – pancreatico-jejunostomy
      • 80-90% have immediate relief
      • 75% have continued relief at 2 years
    • Resection of gland

Picture5

Complications of CP

  • Vitamin B12 malabsorption
  • Impaired glucose tolerance
  • Effusions (pleural, pericardial, peritoneal)
  • GI hemorrhage (erosions, gastritis)
  • Icterus
  • Pancreatic carcinoma
  • Narcotic addiction
    • Watch for drug-seeking behavior

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