Pathophysiology
Chronic inflammation of course will lead to chronic pancreatitis. This will ultimately result in fibrosis and impaired function of the pancreas.
Let’s quickly recap the function of the pancreas:
The pancreas has both exocrine and endocrine function:
- Exocrine function - is fulfilled by acinar cells secreting peptidases, lipases, nucleases, amylases into the pancreatic duct (leading into the major duodenal papilla at the descending duodenum).
- Endocrine function - is maintained by glucagon (alpha cells), insulin (beta cells), somatostatin (delta cells)
Let’s look at the causes of chronic pancreatitis
60% - alcoholism
30% - idiopathic
10% - rare causes such as metabolic insufficiency (hyperlipidaemia, hypercalcaemia), viral and bacterial infection (HIV, mumps virus, echinococcus), hereditary, autoimmune (SLE, AIP), anatomical (pancreatic divisum).
😷 Presentation
- Chronic epigastric pain - eased with sitting forward to with heat application. May be worse when eating.
- Tender abdomen - yet remains soft.
- Weight loss, diarrhoea, steatorrhoea - due to impaired exocrine function and malabsorption of nutrients
- Diabetes mellitus - due to impaired endocrine function. This is type 3c (pancreatogenic diabetes). Annual HbA1c measurements need to be taken.
- Pseudocysts + abscesses - collection of fluid containing pancreatic enzymes, blood, necrotic tissue within or adjacent to the pancreas. It cab become infected causing abscesses (often infected by e. coli). It may cause biliary obstruction or gastric outlet obstruction.
🔍 Investigations
Laboratory investigations:
1. Amylase or lipase - often not raised in chronic disease.
2. Faecal elastase - good in aiding diagnosis.
3. FBC & CRP
4. HbA1c - annual HbA1c measurements need to be taken.
5. LFTs - to ensure there is no obstructive jaundice present.
6. Urine dipstick
🧰 Management
- Abstinence from alcohol and smoking
- Low-fat diet
- Analgesia - such as pregabalin
- Creon - a lipase replacement
- Fat-soluble vitamin replacement (A,D,E,K)
- Subcutaneous insulin and HbA1C monitoring
- Steroids - if of autoimmune origin
- ERCP with stenting if there are any strictures or stones.
Imaging:
1. 🏆 CT pancreas - looking for pancreatic atrophy, calcification or pseudocysts. They may also show enlargement of the pancreas with or without pancreatic calcifications. IV contrast can be used to aid diagnosis.
2. Ultrasound or MRCP can be used to assess the biliary tree
A: calcification in pancreas B: large pseudocyst
Surgery may be useful for severe chronic pain, obstructions, pseudocysts, abscesses
1. Frey’s procedure - this involves coring out of the diseased portion of the pancreatic head as well as a lateral pancreaticojejunostomy (anastamoisis of the pancreatic duct and jejunum). This is indicated in cases of large ductal stones.
2. Whipple’s procedure - which is a pancreaticoduodenectomy if there is any malignancy of the pancreas as a result of the chronic inflammation/ causing the chronic inflammation.
3. Lateral pancreaticojejunostomy (alone) if there is a diseased pancreatic head with no ductal stones present.
Frey’s procedure
Whipple’s procedure