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  • • Persistent or recurrent abdominal pain

    • Pancreatic calcification on x-ray in 50%

    • Pancreatic insufficiency in 30%; malabsorption and diabetes mellitus

    • Most often due to alcoholism

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Epidemiology

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  • • May be familial or due to chronic partial obstruction of the pancreatic duct which is either congenital (pancreas divisium) or following healing after injury (trauma) or inflammation (alcoholic chronic pancreatitis)

    • Over time, the parenchyma drained by the obstructed duct is replaced by fibrous tissue, and chronic pancreatitis develops

    • Pathologic changes in the gland include:

    • -Destruction of parenchyma

      -Fibrosis

      -Dedifferentiation of acini

      -Calculi

      -Ductal dilation

    • A dilated ductal system reflects obstruction, and when dilation is present, procedures to improve ductal drainage usually relieve pain

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Symptoms and Signs

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  • • Severe pain that is typically felt deep in the upper abdomen and radiating through to the back; it waxes and wanes from day to day

    • Malabsorption and steatorrhea

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Laboratory Findings

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  • • Serum amylase may or may not be elevated in acute exacerbations

    • Secretin and cholecystokinin stimulation tests detect exocrine malfunction

    • High glucose and/or low insulin levels

    • Elevated serum bilirubin and alkaline phosphatase levels resulting from entrapment of the bile duct

    • Thrombocytopenia due to hypersplenism secondary to splenic vein thrombosis

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Imaging Findings

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  • Abdominal x-ray: Calcification of the pancreas

    CT scan: Pancreatic calcification, stones in and dilation of the pancreatic duct and dilated bile duct if obstructed

    ERCP: Pancreatic ductal stones and irregularity, with dilation and stenoses, and occasionally ductal occlusion; bile duct dilation

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  • • Chronic pancreatitis may be asymptomatic, may present with signs and symptoms stemming from a complications, or it may produce abdominal pain, malabsorption, diabetes mellitus, or any combination

    • Splenic vein thrombosis, a complication of chronic pancreatitis, may present with secondary hypersplenism or gastric varices

    • Biliary obstruction, another complication of chronic pancreatitis, may present with jaundice

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Rule Out

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  • • Pancreatic pseudocyst

    • Pancreatic adenocarcinoma

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  • • Serum amylase

    • Blood glucose

    • CT scan

    • ERCP

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When to Admit

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  • • Acute exacerbation with severe abdominal pain

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Surgery

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  • • Facilitates pancreatic drainage:

    • -Longitudinal pancreaticojejunostomy (dilated duct)

      -Pancreaticoduodenectomy (nondilated duct)

      -Total pancreatectomy (failure of other procedures)

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Indications

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  • • Chronic intractable pain

    • Relief of pain with endoscopic stenting of the pancreatic duct may predict those patients who will benefit from an operation

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Medications

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  • • Celiac plexus block

    • Pancreatic enzymes

    • Insulin

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Treatment Monitoring

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  • • Patients with chronic pancreatitis have an increased risk of pancreatic adenocarcinoma and should be monitored for early symptoms

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Complications

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  • • Pancreatic pseudocyst

    • Diabetes mellitus

    • Pancreatic exocrine deficiency

    • Biliary obstruction

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