- Chronic inflammatory disease of the pancreas
- Results in irreversible destruction of both the endocrine and
exocrine pancreatic tissue
- Early stages of the disease may be characterised by episodes of
acute pancreatitis
- Pancreas may appear macroscopically normal
- Late stage of disease is characterised by pancreatic fibrosis and
calcification
- Pancreatic duct dilatation and stricture formation occurs
- Cysts form within the pancreatic tissue
- Aetiological factors include
- Alcohol
- Tobacco
- Pancreatic duct strictures
- Pancreatic trauma
- Hereditary pancreatitis
- Tropical pancreatitis
- Male to female ratio is approximately 4:1
- Mean age of onset is approximately 40 years
- The incidence is increasing
- Chronic pancreatitis increases the risk of pancreatic carcinoma
Clinical features
- Pain is the principal symptom in most patients
- Usually epigastric, sub-costal and radiating to the back
- Pain may be continuous or episodic
- Often interferes with life and may lead to opiate abuse
- Weight lost may occur
- Loss of exocrine function produces malabsorption and steatorrhoea
- Loss of endocrine function results in diabetes
Investigation
- Serum amylase is often normal
- Plain abdominal x-ray may show pancreatic calcification
- CT or MRI is the most useful investigation for imaging the pancreas
- May confirm pancreatic enlargement, fibrosis and calcification
- ERCP has a high sensitivity for detecting chronic pancreatitis
Picture provided by Dr Luis Pinheiro, Hospital S
Teotonio, Viseu, Portugal
- MR pancreaticogram will outline the state of the pancreatic duct
- Pancreatic function test rarely provide useful information
- Direct tests - e.g. secretin-pancreozymin test, Lundh test
- Indirect tests - e.g. serum trypsin, faecal fat analysis
- On imaging criteria it can be difficult to differentiate chronic
pancreatitis from carcinoma
Treatment
- Low fat diet and alcohol abstention is essential
- Opiate analgesia should be avoided if possible
- Pancreatic enzyme supplements may
- Reduce steatorrhoea
- Reduce frequency of painful crises
- Surgery is associated with significant morbidity and mortality
- Does not arrest loss of endocrine and exocrine function
- If performed is aimed at:
- Removing any mass lesion
- Relieving pancreatic duct obstruction
- Mass lesion can be removed by pancreaticoduodenectomy or a Beger
procedure
- Duct obstruction can be relieved by pancreaticojejunostomy or Frey
procedure
- Disease confined to pancreatic tail may require distal
pancreatectomy
- Surgery relieves symptoms in 75% of patients
Bibliography
Braganza J M, Lee S H, McCloy R F et al. Lancet
2011: 377: 1184-1197.
Etemad B, Whitcomb D C. Chronic pancreatitis:
diagnosis, classification and new genetic developments.
Gastroenterology 2001; 120: 382-707.
Gupta V, Toskes P P. Diagnosis and management of chronic
pancreatitis. Postgrad Med J 2005; 81: 498-504.
Isla A M. Chronic pancreatitis. Hosp Med 2000;
61: 386-389. |