Chronic pancreatitis

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