Chronic Pancreatitis

Kim Lin Ayuen

PGY-2, Community
March 27, 2009

What is it??
Progressive and irreversible
destruction of the pancreas
Results in the permanent loss of
endocrine and exocrine function

The Pancreas
Endocrine functions - production of
insulin and glucagon
Exocrine functions - fat and protein
digestion, alkalization of stomach acid

http://www.theholisticcare.com/cure%20diseases/Images/Pancreas.jpg

Causes
Alcohol abuse ~ 60 - 80% (although
only 5 - 10% of alcoholics will develop
chronic pancreatitis)

http://www.lifehacker.com.au/images/2008/06/beer.jpg

Causes cont
Idiopathic ~ 10%
- early onset: teens/twenties
- late onset: 50/60s
Pancreatic duct obstruction ~ 10%
- acquired: stones, stricture, tumor,
pseudocyst
-congenital: pancreas divisum
http://media.photobucket.com/image/question%2Bmark/kockneykapers/QuestionMark.gif

Causes cont

Hereditary ~ 1%
Autoimmune < 1%
Repeated acute pancreatitis
Developping world - tropical
pancreatitis (India, Africa, South
America)

Symptoms - Abdo pain

intermittent lasting several hrs, but may
become unrelenting with flares
epigastric
worse 15 - 30 min post parandial
radiates to back
relieved by sitting forward/upright

http://www.rd.com/images/content/2007/0711/StomachConditions.jpg

Symptoms
Steatorrhea
- loose, greasy, foul smelling stool
Fat soluble Vitamin deficiency (ADEK, B12) rare
* > 90% of pancreatic function has to be lost
before fat/protein deficiency becomes
clinically relevant
Glucose intolerance/diabetes

http://www.just-whatever.com/wp-content/uploads/2008/03/lego

~20 % of pts have exocrine/endocrine

insufficiency c/out abdo pain

Diagnosis
Challenging b/c lab tests/imaging are normal
in early disease
Blood work:
- lipase (sl elevated or normal)
- CBC, lytes, liver enz (normal)
- inc Alk phos/bili if obstruction
- inc Glu (endocrine dysfunction)
- inc ESR, ANA, RF, anti-smooth muscle
antibody (autoimmune)
Fecal elastase to test early exocrine dysfunc

Diagnosis cont
AXR - 30% have calcifications
CT abdo - N finding doesnt r/o CP, but can
r/o malignancy, pseudocyst
MRCP - MRI that is accurate and noninvasive; MRI to visualize parenchyma and
ductal system
ERCP - most accurate visualization of
pancreatic duct system - $, invasive, S/E
EUS (endoscopic us) - req very skilled GI

Diagnosis
AXR
CT
MRCP
ERCP

Goals of therapy
Pain relief
Fix pancreatic insufficiency
Manage complications

Pain relief
Lifestyle modifications:
- d/c etoh
- d/c tobacco
- eat frequent, small meals
- low fat diet

http://blogs.sun.com/bigadmin/resource/fastfood.gif

Pain relief cont

1st line - NSAIDS, acetominophen
Narcotics
Antidepressant adjuvant (e.g.
amitriptyline)

Pain relief cont

? Enzyme supplements (inhibits pancreatic
stimulation through negative feedback) - use
uncoated e.g. Viokase (lipase, protease,
amylase)
? Acid suppression - PPI/H2 receptor blocker
(may decrease pancreatic stimulation)

? = no great evidence, but may help some pts

Pain relief - Send them

away
Pain clinic referral
GI/gen surg referral

http://www.topcow.com/images/info/help.jpg

Pain relief - Things we

dont do
ERCP - if CBD or pancreatic duct
obstruction (stone/stricture), +/- stent
Surgery (when medical tx/ERCP fail)
a) decompression - if pancreatic duct
dilated
b) resection - if pancreatic mass or
disease only in tail/head

Things we dont do cont

? Celiac nerve block
? Extracorporeal Shock Wave
Lithotripsy

http://www.aafp.org/afp/20071201/1679.html

Treatment - exocrine
dysfunction
Steatorrhea:
- fat restriction (<20gm/day); dietician
- lipase supplement qmeal with an H2blocker or PPI
- +/- fat soluble vitamin replacement

Complications
Most pts develop diabetes within 5
years of diagnosis
Usually need treatment with insulin

Complications cont
Pseudocyst (10%)
- contains high [ ] of pancreatic enz
- most asymptomatic
- abdo pain (rupture/bleeding/infection)
- duodenal or biliary obstruction
- dx: CT/US

http://www.humanillnesses.com/original/images/hdc_0001_0003_0_img0191.jpg

Complications cont
Bile duct /duodenal obstruction (510%)
- 2ndary to inflammation/fibrosis or
pseudocyst
- duodenal: post prandial pain, early
satiety; dx by upper endo, CT
- bile duct: pain, abN liver enz; dx by
ERCP

Complications cont
Pancreatic ca - 4% with long standing
CP
Rare - pancreatic ascites, pleural
effusions, splenic vein thrombosis,
pseudoaneurysm

Take home
Main symptom of CP is pain. Other steatorrhea, hyperglycemia.
Diagnosis can be challenging combination of history, imaging, clinical
judgement
Treatment is stepwise (medical, ERCP,
surgery) involves many disciplines.
Monitor for complications

References

Freedman, S et al. Complications of chronic pancreatitis. Uptodate.com

Freedman, S et al. Treatment of chronic pancreatitis. Uptodate.com
Freedman, S et al. Etiology and pathogenesis of chronic pancreatitis in adults.
Uptodate.com
Freedman, S et al. Clinical manifestations and diagnosis of chronic
pancreatitis in adults. Uptodate.com
Nair, R et al. Chronic pancreatitis. American Family Physician, Dec. 15, 2007.
Obedeen, K et al. Pancreatitis, Chronic.
http://emedicine.medscape.com/article/181554-overview
Stevens, T et al. Chronic pancreatitis.
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastr
oenterology/chronic-pancreatitis/#cesec3
Warshaw, A et al. AGA technical review: Treatment of pain in chronic
pancreatitis. GASTROENTEROLOGY 1998;115:765-776.