Pancreatitis, Chronic

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • 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

Laboratory Findings

• • 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

Imaging Findings

• • 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

• • 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

Rule Out

• • Pancreatic pseudocyst

  • Pancreatic adenocarcinoma

• • Serum amylase

  • Blood glucose

  • CT scan

  • ERCP

When to Admit

• • Acute exacerbation with severe abdominal pain

Surgery

• • Facilitates pancreatic drainage:

  • -Longitudinal pancreaticojejunostomy (dilated duct)

    -Pancreaticoduodenectomy (nondilated duct)

    -Total pancreatectomy (failure of other procedures)

Indications

• • Chronic intractable pain

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

Medications

• • Celiac plexus block

  • Pancreatic enzymes

  • Insulin

Treatment Monitoring

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

Complications

• • Pancreatic pseudocyst

  • Diabetes ...