Chronic Pancreatitis

It is a chronic inflammatory condition characterized by fibrosis and destruction of exocrine pancreatic tissue.

Etiology

1. Alcohol
2. Hereditary pancreatitis
3. Idiopathic

Pathophysiology

• The secretion of viscid pancreatic secretion may allow protein plugs to form in the duct system and these plugs subsequently calcify to form duct stones.

• Impaired flow of pancreatic juice then leads to inflammation, stricture formation in the duct system, and progressive replacement of the gland by fibrous tissue.

• Loss of acinar tissue is reflected by steatorrhea and in time loss of islet tissue may lead to diabetes mellitus.

Clinical features

1. Pain is the outstanding feature in most cases. It is characteristically epigastric with marked radiation through to the back and is eased by leaning forward.

2. Weight loss is usual and reflects a combination of inadequate intake, poor diets, and malabsorption.

3. Steatorrhea is common, the bowel motion is pale, bulky, offensive, floating on water, and difficult to flush.

4. Diabetes mellitus develops in about one-third of patients

5. Other less common manifestations of chronic pancreatitis include: transient or intermittent obstructive jaundice, duodenal obstruction, and splenic vein thrombosis (leading to splenomegaly, hypersplenism, gastric and esophageal varices: compartmental, left-sided or sinistral portal hypertension that may cause massive upper gastrointestinal bleeding)

Complications of chronic pancreatitis

1. Exocrine insufficiency
2. Endocrine insufficiency
3. Malignant transformation ((PREMALIGNANT))
4. Jaundice due to compression of the distal CBD or tumor formation in the head of the pancreas
5. Left-sided (sinistral or compartmental) portal hypertension due to splenic vein compression or thrombosis
6. Gastric outlet obstruction due to duodenal compression

Investigation and diagnosis:

1. X-ray abdomen may show the scattered calcification in the area of the pancreas.

2. CT scan abdomen: It may show the speckled calcifications typical of chronic pancreatitis, inflammatory changes, tumor, pancreatic duct dilatation, or pseudocyst.

3. MRCP: to show the architecture of the pancreatic duct, especially if surgery or endoscopic intervention is required.

4. Pancreatic endocrine function is assessed by measurement of fasting and postprandial blood glucose levels that may be supplemented by a glucose tolerance test.

5. Pancreatic exocrine function can be assessed by measurement of fecal fat contents while the patient is on a fat-controlled diet with a fat content of 100g/day.

Treatment

A. Conservative treatment

1. Pain relief
2. Alcohol abstinence
3. Exocrine replacement enzymes
4. Endocrine treatment with insulin or oral hypoglycemic drugs
5. Nutritional support

B. Endoscopic treatment Pancreatic duct stenting is indicated sometimes when there is a dominant pancreatic duct stricture or with a disrupted pancreatic duct with pseudocyst or ascites formation.

C. Surgical treatment Drainage or resective surgical intervention is indicated for:

1. Intractable pain
2. Development of complications (pseudocyst, compression of the bile duct, duodenum, portal vein, or splenic vein that produce symptoms)
3. Tumor formation