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Chronic pancreatitis

  • 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

Chronic pancreatitis on CT scanning

  • May confirm pancreatic enlargement, fibrosis and calcification
  • ERCP has a high sensitivity for detecting chronic pancreatitis

ERCP showing 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

Apte M V,  Keogh G W,  Wilson J S.  Chronic pancreatitis:  complications and management.  J Clin Gastroenterol 1999;  29:  225-240

Etemad B,  Whitcomb D C.  Chronic pancreatitis:  diagnosis, classification and new genetic developments.  Gastroenterology 2001;  120:  382-707.

Isla A M.  Chronic pancreatitis.  Hosp Med 2000;  61:  386-389.

 

 
 

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