1、CHRONIC PANCREATITIS,A 49-year-old man was admitted with a nine-month history of intermittent attacks of epigastric pain, jaundice and fever. These attacks usually last up to several days associated with nausea and vomiting. He was well in between attacks and had no loss of weight,What is your next
2、step?,Lab Results,AP =1017 GGT= 269 AST =103 ALT =186 TB =2 (DB= 1.1) Alb= 3.2 Lipase =33 (up to 244 during attacks) Amylase= 44,Hb =12 WBC= 5.7 Plts= 223 Na =141 K =4.2 Ur =15 Cr =0.9 Ca =8.9 FBS:178,What are arrows?,Pancreatic calcification,Transabdominal US: No gallstones or mass in head of pancr
3、easCT scan: The extrahepatic bile duct was mildly dilated and “generous pancreas“ was noted but there was no mass.,Endoscopic Ultrasound Diffuse hypoechoic enlargement of pancreas. Fine needle aspirate of the pancreas was negative for tumor.,ERCP There was a long segment of extrahepatic biliary stri
4、cture. The pancreatic duct was normal in size but irregular. Brushings, biopsies and bile aspirate were negative for tumor,The patient underwent Whipples operation Histology of the pancreas showed chronic pancreatitis, no malignancy,Two presentation: Episodes of acute inflammation in a previously in
5、jured pancreas Chronic damage with persistent pain or malabsorptionEtiology :same as acute pancreatitis “pancreatitis associated with gallstones predaminantly acute or relapsing-acute”More idiopathic types,Most common cause : In adults: alcohol intake In children: cystic fibrosisIdiopathic chronic p
6、ancreatitis is the leading cause of nonalcoholic chronic pancreatitis,PATHOPHYSIOLOGY,The events that initiate an inflamatory process are still not well understoodIn the alcohol-induced : suggested that the primary defect may be the precipitation of protein(inspissated enzyme )In fact ,shown that al
7、cohol has direct toxic effect on the pancreas,Clinical features,abdominal pain:may be continuous, intermittent or absent Pattern is often atypical RUQ or LUQ of the back Diffuse throughout upper abdomen May be referred to the anterior chest or flank Typical form: Persistent , deep-seated, Unresponsi
8、ve to antacids Worsened by alcohol intake or a heavy meal (especially fatty foods) Often need narcotics,Pancreatic insufficiency Weight loss Fat malabsorption: Steatorrhea: 15% of patients present with steatorrhea and no pain Pancreatic diabetes: Like DM1 needs insulin , but risk of hypoglycemia is
9、more than it (because alfa cells is also affected Fat-soluble vitamin deficiency rare,Lab data,Amylase and lipase : usually normalCBC ,electrolytes, and liver function tests are typically normalBilrubin and ALP may be increasedImpaired glucose intolerance and elevated fasting blood glucoseSudan stai
10、ning of feces or quantitative test for steatorrhea fecal elastase (Among pancreatic function tests, fecal elastase measurement is the most sensitive and specific, especially in the early phases of pancreatic insufficiency),Cont,Classic triad “ pancreatic calcification , steatorrhea , and diabetes me
11、llitus “usually establishes chronic pancreatitis Classic triad : found in fewer than one-third It is often necessary to perform secretin stimulation test (abnormal when 60% or more of pancreatic exocrine function has been lost) A decreased serum trypsinogen (20ng/ml) or a fecal elastase level of 100
12、ug/mg of stool strongly suggests severe pancreatic insufficiency,Imaging studies,Plain films : Pancreatic calcifications : % 30 most common with alcoholic pancreatitis, but is also seen in the hereditary and tropical forms of the disorder; it is rare in idiopathic pancreatitis.,CT, MRI, US,calcifica
13、tions ductal dilatation enlargement of the pancreas fluid collections (eg, pseudocysts),ERCP,Choice when calcifications are not present and there is no evidence of steatorrhea.a normal study should not rule out the diagnosis of chronic pancreatitis,ERCP,May provide useful information on the status o
14、f the pancreatic ductal system Abnormalities include :1)luminal narowing 2)irregularitis in the ductal system with stenosis, dilation,saculation,and ectasia3)blockage of the duct by calcium deposits,Endoscopic ultrasonography,The most predictive endosonographic feature is the presence of stoneOther
15、suggestive features include: visible side branches cysts lobularity irregular main pancreatic duct, hyperechoic foci and strands dilation of the main pancreatic duct hyperechoic margins of the main pancreatic duct.,Complications,pseudocyst formation bile duct or duodenal obstruction pancreatic ascit
16、es or pleural effusionsplenic vein thrombosis Pseudoaneurysms pancreatic cancer acute attacks of pancreatitis( particularly alcoholics who continue drinking),DIFFERENTIAL DIAGNOSIS,Pancreatic cancer (most important) older age absence of a history of alcohol use weight loss a protracted flare of symp
17、toms onset of significant constitutional symptoms pancreatic duct stricture greater than 10 mm in length on ERCP Markers such as CA 19-9 and CEApeptic ulcer disease gallstones irritable bowel syndrome Acute pancreatitis,TREATMENT,PAIN MANAGEMENT,General recommendations,Establish a secure diagnosis C
18、essation of alcohol intakeSmall meals,Pancreatic enzyme supplements,not very effectiveresponse may be better in young women with small duct disease.MECHANISM: suppression of feedback loops in the duodenum that regulate the release of cholecystokinin (CCK), the hormone that stimulates digestive enzym
19、e secretion from the exocrine pancreassix tablets of Viokase which contains: 16,000 units of lipase 30,000 units of protease 30,000 units of amylase.,Patients should also be treated with acid suppression (either with an H2 receptor blocker or a proton pump inhibitor) to reduce inactivation of the en
20、zymes from gastric acid.,Analgesics,if pancreatic enzyme therapy fails to control pain. short course of narcotics coupled with low dose amitriptyline and a nonsteroidal antiinflammatorySimultaneous short-term hospitalization, with the patient kept NPO to minimize pancreatic stimulation, may also be
21、of benefit in breaking the pain cycle.Chronic narcotic analgesia may be required in patients with persistent significant pain. Long-acting agents such as MS Contin or Fentanyl patches are generally more effective than short acting medications, which last only three or four hours.,Other medical thera
22、pies,octreotide :cannot be recommended for general use.Antioxidant therapy :vitamin C, E, methionine and selenium,Specialized approaches,Celiac nerve blocksEndoscopic stenting of the pancreatic duct or pancreatic sphincterotomyExtracorporeal shock wave lithotripsySurgery,Maldigestion management,Panc
23、reatic enzymes: Steatorrhea could be abolished if 10% of the normal amount of lipase could be delivered to the duodenum at the proper timePoor therapeutic results because of : Lipase is inactivated by gastric acid Food empties from the stomach faster than do the pancreatic enzymes Batches of commercially available pancreatic extracts vary in enzyme activity,Adjuants: H2 blockers Sodium bicarbonate PPIs,
