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Chronic Pancreatitis

 

Chronic pancreatitis (CP) is a benign inflammatory process of the pancreas characterized by progressive and irreversible damage to the organ that eventually leads to pain and/ or exocrine and endocrine insufficiency as well as malnutrition.

 

Etiologic factors: TIGAR-O classification

  • Toxic-metabolic (alcohol/tobacco)
  • Idiopathic
  • Genetic (Trypsinogen gene mutations)
  • Autoimmune
  • Recurrent and severe acute pancreatitis
  • Obstructive (divisum or tumor)

 

Clinical signs and symptoms:

  • Pain: Abdominal pain is most common and morbid symptom occurring in majority of patients (90%) and is responsible for most hospital admissions related to CP. The pain is located in the epigastric area, often radiates to the back, dull or boring in quality and worsens after eating
  • Endocrine insufficiency (diabetes mellitus): Endocrine insufficiency also occurs late in disease. It is reported to tune of 20–30% in various Indian studies. It can be controlled with diet, OHAs and insulin therapy.
  • Exocrine insufficiency: Pancreatic exocrine insufficiency may be mild, moderate or severe depending on stage of disease process, duration of disease and etiology. Clinically apparent steatorrhea (fatty diarrhoea) generally does not occur until 90% of pancreatic function has been lost.

 

Complications

Various complications include pseudocysts, biliary or duodenal obstruction, internal or external pancreatic fistulae, left-sided portal hypertension and pancreatic malignancy.

 

How to diagnose chronic pancreatitis?   

  • Biochemical Measurements: Isoamylase, lipase, trypsin, and elastase levels may be low, normal, or elevated in patients with chronic pancreatitis. In early or mild cases of chronic pancreatitis, it is difficult to make a definitive diagnosis based on serum enzyme levels alone.
  • Radiological Testing:
    • Plain Abdominal Film: A plain film of the abdomen is usually the first diagnostic test used to establish a diagnosis of chronic pancreatitis. Diffuse, speckled calcification of the gland may suffice as a positive finding
    • Transabdominal Ultrasound: This is a simple, noninvasive, and relatively inexpensive imaging technique. Findings of a dilated pancreatic duct (greater than 4 mm), calcification, and large cavities (greater than 1 cm) are associated with chronic pancreatitis (70% sensitivity and 90% specificity)
    • Computed Tomography (CT): More sensitive than transabdominal ultrasound, CT (computed tomography) scanning can demonstrate duct dilation, cystic lesions, and calcification. This technique is useful in discriminating chronic pancreatitis from pancreatic carcinoma
    • Magnetic Resonance Cholangiopancreatography (MRCP): It represents a major advance in the demonstration of pancreatic ductal anatomy. MRCP yields satisfactory pancreatograms in patients with chronic pancreatitis in whom a CT scan showed no abnormalities
    • Endoscopic Retrograde Cholangiopancreatography (ERCP): ERCP is an endoscopic technique for visualization of the bile and pancreatic ducts. This is a sensitive and specific diagnostic tool in chronic pancreatitis. ERCP shows details of the pancreatic ductal anatomy, including strictures, ductal rupture and pseudocysts
    • Endoscopic Ultrasonography (EUS): Endoscopic ultrasonography is the most sensitive imaging tool for the diagnosis of chronic pancreatitis, and has been proven to be more accurate than the CT scan.

 

Management Strategies in Chronic Pancreatitis

 The essential aspects of managing a patient with CP involve: (1) amelioration of pain; (2) maintain nutrition and control maldigestion; and (3) tackle complications.

Control of abdominal pain: The goal of therapy is to control pain to that level that it may not hamper patient’s life as complete relief of pain is not expected. The following modalities are used to control the pain:

  • Analgesics
  • Pancreatic Enzymes
  • Antioxidants
  • Pregabalin
  • Nerve Blocks: Celiac plexus blockade (CPB) and celiac plexus neurolysis (CPN) are the nerve block methods used to disrupt the signaling of the pancreatic pain afferents to the spinal cord.
  • Endoscopic Therapy: The aim of the endotherapy is to relieve pain by alleviating outflow obstruction of PD and decrease ductal hypertension. Endoscopic pancreatic sphincterotomy has been used to reduce pancreatic duct pressure and to facilitate other procedures such as pancreatic stent placement, tissue sampling, dilation of strictures, or stone removal.