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Chronic pancreatitis

  • Chronic inflammatory disease characterised by fibrosis and destruction of exocrine pancreatic tissue. DM occurs in advanced cases because islets of Langerhans are involved

Etiology

  • Alcohol – stimulates exocrine secretion, causes spasm of Ampulla of Vater
  • Hyperparathyroidism – hypercalcemia, stimulates exocrine secretion
    • Predisposes to precipitation of protein aggregates within the main pancreatic ductal system
  • Congenital anomalies of pancreatic duct – pancreatic divisium
  • Pancreatic trauma
  • Developing countries – tropical pancreatitis due to nutritional deficiencies

Pathogenesis

  • Hyper-secretion and stimulation of exocrine pancreas, plugging of pancreatic duct with protein precipitates
    • Causes hypertension in ductal systems

Clinical features

  • Pt has history of alcohol abuse. MC in 40s
  • 50% of pts have episodes of acute pancreatitis, with each attack resulting in a degree of permanent pancreatic damage
  • Abdominal pain – epigastric. Radiation to back
    • Some pts have unremitting pain
    •  Or recurrent episodes that resolves between attacks
    • Relived by leaning forwards or by drinking alcohol
  • Clinical tetrad – Abdominal pain, anorexia, insulin dependent diabetes, Steathorrea
  • First attack at head of pancreas
  • Second attack at body and tail – where the beta cells are
  • Peripheral neuropathy – related to DM and alcohol

Investigations

  • XR – pancreatic calcifications
  • CT – golden standard. Pancreatic calcifications , dilated major panc duct, pseudocyst formation
  • Endoscopic retrograde pancreatography ERCP – protein ppt, ductal dilation
  • Pancreatic function test – Lundh’s test
    • Meal of protein, carbs, fats injected into stomach
    • Sample of duodenal juice taken & activity of trypsin measured
    • Positive test – low trypsin activity means decreased exocrine function of the pancreas

Treatment

  • Alcohol avoidance
  • Pain relief – NSAIDs, opiates (pethidine [75mg])
  • Oral pancreatic enzyme supplements – suppress panc secretion, can reduce analgesic consumption in pts
  • Dietary fat restriction (need fat soluble vitamins – ADEK)
  • Lansoprazole [30mg b.i.d] to optimise duodenal pH for pancreatic enzyme activity
  • Celiac plexus neurolysis
  • Surgery

Complication

Aneurysm, splenic vein thrombosis, carcinoma

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