Armando Hasudungan
Biology and Medicine videos

Chronic Pancreatitis

Chronic Pancreatitis copy

Summary of Chronic Pancreatitis Chronic pancreatitis is a syndrome involving progressive inflammatory changes in the pancreas that results in permanent structural damage. The main cause is chronic alcohol use. Signs and symptoms are similar to that of acute pancreatitis + diabetic signs and symptoms. Pathological change seen is fibrosis, scarring and atrophy. Management is to slow the progression of the diseases by stopping alcohol consumption, encourage a diet rich in antioxidants, diet modification (reduced fat). Surgical treatment include treating the reversible cause, complications that come with pancreatitis and pancreatoduodenectomy (partial or full)

Video: Chronic Pancreatitis Overview

 

Overview

Overview Chronic pancreatitis is characterised by recurrent or persistent abdominal pain arising from the pancreas. The inflammatory process results in irreversible destruction and fibrosis of the pancreas. Often associated with exocrine or endocrine pancreatic insufficiency.

Definition
Acute Pancreatitis: An inflammatory process in which pancreatic enzymes are activated and cause autodigestion of the gland.
Chronic Pancreatitis: Irreversible damage causing fibrosis and scarring to the pancreas, resulting in exocrine and endocrine dysfunction
Pancreatic pseudocyst: Cystic space within the pancreas not lined by epithelial cells, often associated with chronic pancreatitis.

 

Overview

Patient with abdominal pain worse with food and alcohol. Requests opioid for relief (addiction?)

Pancreas anatomy and physiology

Pancreatic anatomy Pancreas extends retroperitoneally across posterior abdominal wall. It means “All (pan) Flesh (Kreas)”. The pancreas consists of the following parts:

  • Head
  • Neck
  • Body
  • Tail

The head is encircled by duodenum and tail in contact with spleen. Pancreas has a poorly developed capsule & therefore adjacent structures (common bile duct, duodenum, splenic vein, transverse colon) are commonly involved in inflammatory process.

Blood Supply

  • Pancreatic branches of the splenic artery
  • Superior pancreaticoduodenal artery
  • Inferior pancreaticoduodenal artery

Venous drainage

  • Drains with the splenic vein → Superior Mesenteric → Portal vein

Nerve invervation

  • Parasympathetic → Vagus nerve → Stimulates pancreatic juice secretion
  • Sympathetic

Lymphatic drainage

  • Head and Neck → Pancreticoduodenal nodes →
  • Body and Tail → Pancreaticosplenic nodes →

Embryology

  • Fusion of the ventral and doral outpounchings of forgut

Normal Phys

Pancreatic physiology exocrine (98%) & endocrine (2%) functions

Exocrine: Pancreatic acinar cells produce digestive enzymes, which are stored in secretory granules. The Pancreatic exocrine secretion is regulated by cephalic, gastric & intestinal stimuli. Acinar cells secrete pancreatic juice made up the enzymes:

  • Amylase → Carbohydrate digestion
  • Lipase → Lipid digestion after bile has emulsified the fat
  • Proteases (MANY!) → Protein digestion

Exocrine section is stimulated by:

  • Vagus nerve
  • Secretin (hormone)
  • Cholecystokinin

Endocrine: Islets of Langerhans – clusters of hormone-producing cells secreted directly into circulation. Endocrine cells of the pancreas:

  • Beta cells → Insulin
  • Alpha cells → Glucagon
  • D cells → Somatostatin.
Cells of the Pancreas Secretion Function
Acinar cells secrete enzymes
into the duodenum
Nucleases Breaksdown nucleotides
Proteases Digests Proteins
Lipases Digests lipids
B-amylase Digests carbohydrates
Islets of Lagerhan secrete hormones
into the bloodstream
Glucagon Stimulates glucose release into the bloodstream from glucose stores
Insulin Increases cell uptake and storage of glucose

Risk Factors

Risk Factors
Alcohol
Smoking
Family history
Coeliac disease

Signs and Symptoms

Sands

Clinical Presentation of chronic pancreatitis is similar to acute pancreatitis but less severe. This include epigastric pain that may radiate to the back, nausea and vomiting. Patients may present to ED and require opiates. Pain is worse with food and alcohol. Exocrine features of chronic pancreatitis include weight loss and malnutrition (due to malabsorption of macromolecules) and also steatorrhea (due to fat malabsorption).

Investigations

 

  • Abdominal – X-ray may show pancreatic calcification
  • Abdominal ultrasound – may show cystic changes and duct dilatation within the pancreas.
  • Bloods – glucose (to assess pancreatic exocrine function) and serum amylase/lipase (which tend to be normal in chronic pancreatitis)
  • Pancreatic CT scan
  • ECRP
Ix1

CT scan of the pancreas may identify the cause and may show extent of the disease. It can show pancreatic cyst, calcifications, tumours.

Ix2

ECRP demonstrates irregularities of the pancreatic duct strictures, calculi, dilated segments (chain of lakes), and changes in first and second order branches and cyst formation. ECRP helps in showing extent of disease and useful for staging.

Aetiology

  • Recurrent acute pancreatitis of any cause, especially alcohol
  • Secondary to pancreatic ductal obstruction
    • Pancreatic head cyst, tumours
    • Cystic fibrosis
  • Associated with autoimmune disease (primary biliary cirrhosis, primary sclerosing cholangitis)

Pathophysiology

Pathological features

  • The process may affect the whole or part of the gland
  • The head tends to be the most severely involved part in chronic alcoholic pancreatitis
  • Features of acute pancreatitis may be present (fat necrosis, haemorrhage and/or oedema)
  • Chronic inflammatory changes include atropy, duct dilation, microcalcification and intraductal stone formation with cystic changes secondary to ductal occlusion.

Difference between acute pancreatitis and chronic pancreatitis

difference between acute and chronic

Management

Management

Management involve prevention of cause/progressive damage by stoping alcohol and smoking. Encourage diet rich in antioxidant. Controlling symptoms and complication involve dietary modification (low fat), pancreatic enzyme supplements, analgesia (may require opiates), insulin (for diabetes if develops). Surgical management includes percutaneous or endoscopic drainage to drain excess fluid in the pancreas that is causing obstruction. Pancreaticduodenectomy is performed to remove possible causes and complications.

Complications and Prognosis

Resectional surgery is associated with increasing risk of exocrine and endocrine pancreatic failure and high risk of complications

Complications

  • Pseuodocyst
  • Obstruction
  • Fistula
  • Infections
  • Portal hypertension
  • Diabetes Mellitus
  • Pancreatic calcification
  • Opiod addiction

Prognosis

  • Generally, pain decreases or disappears over time, regardless of aetiology
  • Ten-year survival after diagnosis is 20% to 30% lower than the general population.

References

UpToDate
Best Practice
Oxford Handbook of Clinical Medicine
Oxford Handbook of Clinical Surgery