Chronic pancreatitis Diseases Symptoms Diagnosis and Treatment

Chronic pancreatitis Pregentation

• · Abdominal pain
• · Steatorrhea.

A form of pancreatitis that results from repeated or massive pancreatic injury, marked by the formation of scar tissue, which leads to malfunction of the pancreas

• Irreversible:
• Progressive destruction of the pancreas
• Results in both exocrine and endocrine deficiencies
• Pain, maldigestion, and diabetes mellitus (DM) are the major features.

Chronic pancreatitis Causes

• · Alcoholism
• · Cystic fibrosis
• · Genetic disease
• · Autoimmune.

Chronic pancreatitis Clinical Features

• Chronic pancreatitis typically presents as chronic unrelenting pain with episodic flares,
• Pain in abdomen may be continuous, intermittent or absent
• · Atypical pain, back pain, diffuse pain, chest pain or flank pain.
• · Persistent, deep-seated pain.
• · Pain after alcohol or heavy meal.
• · Weight loss.
• · Stools abnormal like malabsorption.
• · Abdominal tenderness.
• · Fever.

Diagnostic Tests and Interpretation

• Chronic pancreatitis:
• Tests sometimes normal
• Hyperglycemia
• Steatorrhea
• Flare-ups may mimic acute pancreatitis.
• Elevated alkaline phosphatase, bilirubin
• Hereditary pancreatitis: Mutations in PRSSI gene and SPINKI gene
• Autoimmune pancreatitis: Elevated serum IgI, autoantibodies to lactoferrin and carbonic anhydrase
• Chronic pancreatitis Differential Diagnosis :
  • Pancreatic cancer
  • Other malabsorptive processes
  • •Other cause of biliary obstruction
  • Disorders that may alter results:
• Biliary tract disease
• Penetrating peptic ulcer
• Intestinal obstruction
• Intestinal ischemia/infarction
• Ruptured ectopic pregnancy
• Renal insufficiency
• Burns
• Macroamylasemia, macrolipasemia

Chronic pancreatitis Diagnosis

• · Serum amylase and lipase may not be elevated.
• · Alkaline phosphatase levels increased.
• · Fasting hyperglycemia.
• · Triad of pancreatic calcification, steatorrhea and diabetes mellitus.
• · Decreased serum trypsinogen less than 20 ng/ ml, fecal elastase less than 100 I-lg/mg of stool.
• · X-ray – scattered calcification.
• · Ultrasound, CT and ERCP.
• Radiograph of abdomen: Pancreatic calcification
• Ultrasound and/or CT scan of abdomen: Pseudocyst formation/calcification
• ERCP/MRCP: Ductal deformity, retained common bile duct stone, pancreatic duct stones, and strictures
• Endoscopic ultrasound

Chronic pancreatitis Complications

• · Cobalamin malabsorption (8₁₂ deficiency) in alcoholic and cystic fibrosis.
• · It is corrected by giving pancreatic enzymes.
• · Diabetes mellitus, diabetic ketoacidosis
• · Pleural effusion
• · Pericardial effusion
• · GI bleeding
• · Portal vein thrombosis
• · Jaundice
• · Incidence of pancreatic carcinoma is increased.

Chronic pancreatitis Prognosis

• Acute pancreatitis: 85–90% resolve spontaneously; 3–5% mortality (17% in necrotizing pancreatitis). APACHE II scoring is most accurate but difficult to apply
• Ranson criteria (see below) have a sensitivity of ~40%.
• On admission: Age >55 years, WBCs >16,000/mm, blood glucose >200 mg/dL (11.1 mmol/L), serum lactate dehydrogenase (LDH) >350 IU/L, AST >250 IU/L.
• Within 48 h: hematocrit decreases >10%, serum calcium <8 mg/dL, blood urea nitrogen (BUN) increase >8 mg/dL, arterial PO₂ <60 mmHg, base deficit >4 mEq/L, fluid retention >6 L

Chronic pancreatitis Treatment

• Ensure alcohol abstinence.
• Persistent elevation of amylase weeks after acute pancreatitis suggests possibility of pseudocyst; perform imaging study.
• Avoid alcohol No fats
• Pain killers – narcotics
• Surgical interference – resection of pancreas Nerve blocks

Chronic pancreatitis:

• Analgesics
• Pancreatic enzyme supplements (Pancrease MT, Creon)

• H₂ blockers (reducing gastric acid, increases availability of pancreatic enzymes)
• Pancreatic enzymes
• H₂ receptor antagonist Sodium bicarbonate Proton pump inhibitors
• Antacids – Calcium carbonate, magnesium hy­droxide
• Supportive measures.
• Chronic pancreatitis—pain: Pseudocyst drainage

• Diet

• Acute pancreatitis: Begin diet after pain, tenderness, and ileus have resolved; small amounts of high-carbohydrate, low-fat, and low-protein foods; advance as tolerated; NPO or nasogastric tube if patient is vomiting
• Total parenteral nutrition (TPN) if oral is not tolerated (no lipids if triglycerides are increased)
• Enteral nutrition preferable to TPN if tolerated (less infection, decreased organ failure)
• Give oral pancreatic enzymes if necrotizing pancreatitis.
• Chronic pancreatitis: Small meals high in protein; adjust if DM is present.