Chronic pancreatitis

Pathogenesis:

• Earliest change is deposition of protein plugs with the pancreatic ducts
• These then lead to ductular dilatation followed by acinar atrophy
• Eventually, only a few acinar and islet cells remain
• Intraluminal calcification of the protein plugs occurs, leading to stone formation

Causes of chronic pancreatitis:

• Alcohol (>85%)
• Idiopathic
• Tropical (nutritional)
• Hereditary
• Trauma
• Hypercalcaemia

Types of chronic pancreatitis:

Chronic calcifying pancreatitis:

• Most common form in developed countries
• Usually caused by alcohol

Tropical pancreatitis:

• Usually affects the young
• Primarily people from a region where there is protein and fat malnutrition

Hereditary pancreatitis:

• Rare condition
• Is a lack of a protein stabilizer, thus permitting the formation of calcifying plugs

Obstructive pancreatitis:

• Obstruction of the main pancreatic duct, owing to a:

Scar

Stricture

Tumour

• May regress if obstruction is remove

Clinical features:

• Epigastric pain radiating to the back, between the scapulae
• The pain can be severe (sometimes comparable to acute pancreatitis)
• Continuing episodes of pain may occur, sometimes mild and brief, sometimes there is chronic pain interspersed with acute episodes (relapsing pancreatitis)
• Steatorrhoea (occurs when secretion of pancreatic lipase is reduced by 90%)

Investigations:

• ERCP
• Endoscopic ultrasound
• CT

Differential diagnosis:

• Carcinoma of the pancreas (especially when the history is short)

Treatment:

• In alcoholic pancreatitis, the patient must be made to stop drinking
• Analgesia (often with narcotics – there is a frequent problem with addiction)
• Surgery (for the treatment of intractable pain)
• Steatorrhoea is treated with:
• Low-fat diet
• Pancreatic supplements (e.g. pancreatin 2-4g with each meal)

• Diabetes mellitus is treated with:
• Oral hypoglycaemics
• Insulin (if required)

Complications:

• Pancreatic pseudocyst (most common)
• Pancreatic ascites (usually in alcoholic ascites)