Chronic pancreatitis - Disorders of the pancreas

Chronic pancreatitis

Definition

Chronic pancreatitis is an inflammatory condition that results in irreversible morphological change and impairment of exocrine and endocrine function.

Age

Usually >40 years.

Sex

M > F

Aetiology/pathophysiology

Two patterns of chronic pancreatitis are seen, a chronic relapsing course with recurring acute pancreatitis and stepwise deterioration, or a truly chronic gradual deterioration leading to pancreatic insufficiency. Risk factors include alcohol abuse, hereditary pancreatitis, ductal obstruction (e.g. trauma, pseudocysts, stones, tumours), systemic lupus erythematosus and cystic fibrosis. Hypercalcaemia, hyperlipidaemia and congenital pancreatic malformations are recognised associations.

Clinical features

Patients may present with an acute episode of pancreatitis or an insidious onset with persistent or recurrent episodes of abdominal pain and weight loss. Late complications include impaired glucose tolerance, diabetes mellitus and malabsorption (steatorrhoea) associated with profound weight loss and oedema due to hypoal-buminaemia.

Complications

Predisposes to pancreatic cysts, pseudocysts and pancreatic cancer. Ascites and persistent obstructive jaundice may occur.

Investigations

Serum amylase fluctuates, but may be moderately raised on testing.

Plain abdominal X-ray may show calcification. Ultrasound and CT scanning demonstrates cysts, calcification and enlarged ducts.

Endoscopic retrograde cholangiopancreatography may show scarring of the ductal system and even stones in the pancreatic duct. Magnetic resonance cholangiopan-creatography is increasingly being used.

Management

Precipitating factors especially alcohol need to be removed. Adequate analgesia is required, thoracoscopic splanchnicectomy may be required in refractory pain not associated with main pancreatic duct dilatation. Steatorrhoea is managed with pancreatic enzyme supplementation and diabetes may need oral hypoglycaemics or insulin. Surgery is indicated for obstruction. Surgical techniques include sphincteromy or sphincteroplasty, partial pancreatectomy or opening the pancreatic duct along its length and anastomosing it with the duodenum or jejunum. Total pancreatectomy can be carried out, with replacement oral pancreatic enzymes and insulin.